Historical research at its best is a treasure hunt for the past, illuminated in lost documents that turn up in unexpected ways and in surprising places. Jonathan Andrews and Andrew Scull were alerted to the case book of John Monro, an 18th-century "Mad-Doctor," in the course of research on Bethlem, or Bethlehem, Hospital, even now the best-known mental hospital in the English-speaking world. They found it among a trove of family papers in the custody of descendants of the Monro family, who had presided as physicians to the Bethlehem Hospital from 1728 to 1853. The case book records clinical information about 100 of Monro's patients during one year, 1766. Uniquely among similar antique records, it describes patients Monro saw in his outpatient practice, either in their homes or in his office, rather than in the hospital. The book has two parts. In the first part, the authors have extracted themes from the case book to illustrate the kinds of patients Monro saw, the ways in which he conducted his consultative practice, his approaches to establishing diagnoses and treating patients, and the ways in which his patients viewed their own illnesses. The authors discuss the themes with a scholarly depth that is based on their understanding of medical and psychiatric history. This section of the book is presented in stately prose, which is elaborate and somewhat turgid. It is crammed with information and complex ideas that double back on themselves at times and end up at some distance from their starting points, leaving readers puzzled about where they have been and forcing them to reread a sentence from the beginning in order to understand what the authors intended to convey. The second part of the book is a reproduction of the case book. Here the clinical realities come alive. Monro's terse sketches of his patients are colorful and engaging. The authors' notes provide a useful context concisely and with authority. Monro paid close attention to his patients' patterns of speech as well as to the content of their speech. Physical signs and symptoms were very important. Fevers, skin color, and the state of the patients' bowels and bladder were frequently noted, as were convulsions and paralytic symptoms. Many of the case histories begin with accounts of emotional upsets. Clearly, Monro understood that disappointment, loss, and emotional trauma could be causative factors, and he often commented on the history of mental illness in patients' families. There is no suggestion that Monro, practicing as he did during the Enlightenment, regarded mental illness as religious possession; on the contrary, he tended to view religious fervor as a reflection of madness. In treating patients, Monro favored management over medical treatment. He counseled restoring the healthy habits of living; there is relatively little in the case book about bleeding, purges, or opiates. He suggested ways of improving sleep, restoring good appetite, taking proper exercise, and developing habits of temperance and regularity in daily routines. For violent patients, Monro found that confinement or restraints were indicated, and he was not reluctant to prescribe them, at least temporarily. A number of his patients required hospitalization and were sent to Bethlehem or to one of the private mental hospitals that had sprung up in London and its suburbs. The case book is printed in a modern typeface but with Monro's marginal notes, addenda, and original numbering system reproduced intact. His brief sketches of patients are surprisingly vivid, although they are clearly intended simply to remind him of the cases and perhaps to serve as a guide to billing. In their extensive annotation of the case material, the authors supply fascinating additional details to amplify Monro's jottings. When Monro alludes to other physicians, the authors add background information about them and about the London medical community, which was torn by fierce competition over miraculous cures, countered by allegations of quackery. Surprisingly often, the authors can identify the patients, and in those cases they elaborate on the clinical sketches with background information about the patients, their families, and their London neighborhoods. They even fill in a number of the patients' subsequent case histories by consulting records at Bethlehem and other hospitals. The result is a richly detailed picture of the nature of psychiatric practice in 18th-century London. Customers and Patrons of the Mad-Trade offers a rare opportunity to look over the shoulder of a professional ancestor as he goes about his practice. It also provides a rich picture of the conditions of life and medical practice in 18th-century London, a picture of Hogarthian dimension and character. Its authors are uniquely qualified to add substantially to the reader's experience, and they do so with great style and reassuring scholarship.
Miles F. Shore, M.D.Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
