Jonathan Andrews and Andrew Scull, 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, Medicine and Society, Berkeley and London, University of California Press, 2003, pp. xvi, 209, illus., £29.95, US$44.95 (hardback 0-520-22660-7).

Abstract

Psychiatry today has three salient features: first, the profound uncertainties and ambiguities in the scientific knowledge base which masquerade as facts; second, the pervasiveness of conflicting ideas and values; and third, the complexity of the group process involving professionals, family, the state and the individual by which we come to an agreement about what to do. Evidence, paradox and consensus are the stuff of modern practice. How reassuring then to discover that John Monro's 1766 case book, his jottings or “aide-memoire” about new and returning patients, suggests that the practice of eighteenth-century mad-doctoring was beguilingly similar in its pragmatic eclecticism and yet fascinatingly different in the detail. The reviewer was reminded of the psychiatric house officers' shorthand “admission notes” from twenty years ago, when detailed description of symptoms and signs took precedence over personal comment on the status of delusional ideas and aetiological origins. But the modern shrink reading Monro's jottings has to beware the diverting but ultimately sterile pleasure of translating eighteenth-century symptoms into DSM-IV diagnoses. Far more important is what his case book tells us about the practice of one of the best known mad-doctors of his day and about the world in which he operated. These then are the themes explored by Jonathan Andrews and Andrew Scull in this second volume about John Monro. The first, Undertaker of the mind: John Monro and mad-doctoring in eighteenth-century England (2001), established the context and professional history of a man who sat at the pinnacle of mainstream, solidly successful, middle-class practice. The John Monro who emerges from this second book is not the Bethlem physician, a post he held from 1751 for four decades, which tenure conferred professional prominence but relatively modest financial reward, nor the wealthy mad-house proprietor who secured the prosperity of his descendants for the next century, but rather the private physician to respectable moneyed, but not necessarily exceptionally wealthy, families who consulted him on a day to day basis. Monro's complex web of business relations with madhouses at Hoxton and elsewhere, his roaming domiciliary visits, the patients who returned with recurrent episodes of psychosis and the significance of his approach to case management and treatment are scrutinized here by Andrews and Scull in a highly readable and refreshingly immediate narrative. The essential foundations of the critical authority of medical practitioners like Monro, the social roots of their economic success and their subsequent intellectual imperialism over the lives of the mad emerges successfully but so too do the origins of the stigmatized social position of those associated with the dread lunatic. Monro's fame made him the target of lampooning cartoons and the butt of high society jokes as well as a lucrative practice. Fear and revulsion of the insane still affects the status of professionals in the trade. The book has relevance for anyone interested in the later and until now rather better researched nineteenth-century alienists and the Victorian asylum, and also in the origins of twentieth-century office psychiatric practice. Much has been written about John Monro and other Monros before but never in this detail and never with Monro's own rather stolid clinical self speaking directly to us. The authors' impeccable scholarship in the detail is singularly impressive. This and its companion volume are essential reading for social historians of the eighteenth century. My only quibble is, why on earth two books when one would have done? The case book lies at the heart of both and without it the first to be published was rather like a birthday party without the cake. But that aside, the value of these two complementary volumes is without a doubt the confirmation that within the social class milieu in which he worked, an eighteenth-century mad-doctor's management objectives for his patients and their families were in many respects similar to his nineteenth- and twentieth-century counterparts. No sudden ideological leap separates the approaches to personal mad-doctoring this past three centuries.