Customers and Patrons of the Mad-Trade: The Management of Lunacy in Eighteenth-Century London, With the Complete Text of John Monro's 1766 Case Book (review)

In the 1980s, Tavistock Press published a series of books under the title 'Classics in the History of Psychiatry'. These publications involved eminent medical historians editing significant psychiatric treatises from centuries past. At that time it must have seemed like the demand for works in the history of madness was limitless, and with the quality of scholarship from Roy Porter, Michael MacDonald, and others, Tavistock must have felt the reproductions of relatively obscure medical texts were worth the financial risk. Unfortunately, the series sold poorly—apparently there weren't many specialized researchers who were willing to pay significant sums to have a private copy of texts they could simply access in major deposit libraries. Routledge, who took over Tavistock in 1987, eventually cancelled the series in 1991.

Customers and Patrons of the Mad-Trade can be seen in part as an attempt to resurrect the now defunct Tavistock series. But rather than reprint a publicly-available and (previously published) medical treatise, Andrews and Scull sought to reproduce a private medical diary of one of the leading mad-doctors i eighteenth-century England. One half of Customers and Patrons constitutes a transcription (with detailed annotation) of a case book of Dr John Monro, the physician to the Bethlem Asylum and the proprietor of several madhouses in the London region. The manuscript—recovered by Andrews from a descendent of the Monro family—discusses 100 cases under the care of this famous proprietor during the year 1766. The authors rightly insist that this is an unusual discovery, one that details a physician's private thoughts about the treatment, social and medical characteristics, and payment of the patients under his care. The other half of the book offers up a complementary and detailed re-construction of the context of Monro's practice and a meticulous analysis of the practice of early-modern psychiatry derived both from the casebook itself, and also from Andrews' and Scull's impressive knowledge of eighteenth-century mad-doctoring.

So what does the case book reveal? The 'majority' of Monro's clients were either from the 'middling' or 'lower ranks' of society or from the nouveaux riches. There were slightly more women than men, and most of those afflicted were in the prime of their lives. One quarter were consigned to madhouses; the remainder were treated in the 'community'. A surprising number had connections to the 'London Art World'. Patients varied from the demented, to the depressed, to the delusional. Although the authors are very guarded in the conclusions that can be drawn from one year's notes of a solitary Georgian mad-doctor, the interpretations tend to reinforce accepted historiographical positions, including Roy Porter's argument that there was no 'great confinement' in Georgian England and Michael MacDonald's thesis that suicide was secularized during this era. Consistent with other research challenging the 'top down' medicalisation of madness at this time, social and psychological causes were attributed by Monro more commonly than 'biological' ones. Finally, in a manner reflective of recent historiographical trends, patients' families figure prominently as "the prime arbiters in determining treatment" (p.94). Ultimately, Monro's approach was more one of mild management than aggressive treatment.

The authors claim that Monro's 1766 case book is a "document of considerable historiographical interest." (p.27). One wonders, however, whether the enthusiasm of these scholars for their own work has exaggerated their beliefs in the wider value of one year's entries for a single (and exceptional) medical practitioner. After reading Undertaker of the Mind, a full-length monograph on Monro and the mad-doctoring trade in Georgian England by the same authors, much of the contextual section of Customers and Patrons strikes one as repetitive. Moreover, the elegance of the writing is undermined somewhat...