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)

Customers and Patrons of the Mad-Trade is the outcome of a chance discovery by Jonathan Andrews who, during his research into the history of Bethl(eh)em Hospital in London, identified a cache of papers relating to the Monro family who presided over that hospital from 1728 to 1853. Included in the haul was a Case Book for 1766 belonging to John Monro, the second member of the dynasty and physician to Bethlem for four decades after 1751. The Hospital itself has a "mythical and mystical" past that "historians have recently sought to replace . . . with a more prosaic portrait" of what "it really was" (p. xiii). For the most part, however, the Case Book covers not Monro's institutional practice but his treatment of private patients, who were not only more lucrative but also more demanding of his "time, energies, and talents" (p. 6).

In putting this valuable resource into the public domain, Andrews and his coauthor, Andrew Scull, have written a lengthy introduction that forms the first part of the book. Devoted to the management of lunacy in eighteenth-century London, this part places the Case Book in historical context with chapters on themes like customers and patrons, the profile of patients and patterns of practice, the craft of consultation, the diagnosis of madness, religion, treatment, remuneration, and the experience of being mad. Each chapter engages with existing research, drawing liberally on Monro's cases. Part 2 then presents the Case Book in facsimile, with comprehensive endnotes. Individual patients spring to life as their symptoms—physical as well as mental—are described in intimate detail. Miss Hume, for example, "a young lady" of twenty-four, "talk'd extremely incoherent" and "laugh'd & cried at times, but both without reason" (pp. C-13–C-15). Mrs Cookson, "a Maiden lady about fifty," had "blasphemous thoughts, & imagines herself, to have been very wicked, she does not sleep well, . . . nor does she go to stool: but her appetite tolerable" (pp. C-31–C-34). Capt. Robinson, "fancying himself infected with the Venereal distemper," believed that he had "infected his wife's mother aged about 90, and pretended to shew the marks of its eruptions upon her face"; the day before Dr. Monro visited him, "he had fairly hanged himself but was cut down by the maid" (pp. C-48–C-50). Whereas such symptoms were carefully cataloged, treatments were little recorded, confirming that Monro was disinterested in therapeutics and experimentation, and "remained steadfastly conservative in . . . [his] espousal of the standard evacuative and antiphlogistic remedies" (p. 92).

The historical significance of the Case Book is unquestionable. However, though Andrews and Scull argue that it gives "direct and unmediated insight" into Monro's practice, can we really be sure that "the original manuscript was intended purely for private purposes and was never expected to see the light of day" (p. xii)? The claim that the volume is essentially about the interaction of patients and their families with the "mad-doctor" is also debatable. The authors concede that in order "to offer a balanced, multi-faceted account" they examine "in some depth the reactions of the physician to the stories he heard from and about the insane" (p. 5). In a source that is generated by a medical practitioner, is not this perspective most likely to prevail, frustrating attempts to write a genuine "history from below"? Yet despite these quibbles, John Monro was Augustan England's most renowned "mad-doctor," and he played a pivotal role in the development of the nascent psychiatric profession. Therefore, the publication of his Case Book, with the editors' substantial introduction and meticulous notes of interpretation, is a...