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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

Jonathan Andrews (Author), Andrew Scull (Author)

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This book is a lively commentary on the eighteenth-century mad-business, its practitioners, its patients (or "customers"), and its patrons, viewed through the unique lens of the private case book kept by the most famous mad-doctor in Augustan England, Dr. John Monro (1715-1791). Monro's case book, comprising the doctor's jottings on patients he saw in the course of his private practice--patients drawn from a great variety of social strata--offers an extraordinary window into the subterranean world of the mad-trade in eighteenth-century London.

The volume concludes with a complete edition of the case book itself, transcribed in full with editorial annotations by the authors. In the fragmented stories Monro's case book provides, Andrews and Scull find a poignant underworld of human psychological distress, some of it strange and some quite familiar. They place these "cases" in a real world where John Monro and othersuccessful doctors were practicing, not to say inventing, the diagnosis and treatment of madness.
List of Illustrations
Preface
Acknowledgments

Part 1. Managing Lunacy in Eighteenth-Century London
1. Customers, Patrons, and Their Mad-Doctor
2. A Rare Resource: John Monro’s Case Book
3. Profiling Patients and Patterns of Practice
4. The Craft of Consultation: Managing Patients and Their Problems
5. Diagnosing the Mad
6. Religion, Madness, and the Case Book
7. Treating Patients and Getting Paid
8. Being Mad in Eighteenth-Century England: Patients’ Views of Their Own Illnesses

Part 2. John Monro’s 1766 Case Book

Notes
Bibliography
Index
Jonathan Andrews is Senior Lecturer in the School of Humanities, Oxford Brookes University. His publications include The History of Bethlem (1997) and "They're in the Trade of Lunacy" (1998). Andrew Scull, author of Social Order/ Mental Disorder (California, 1989; 1992) and The Most Solitary of Afflictions (1993), among other books, is Professor of Sociology at the University of California, San Diego. They are coauthors of Undertaker of the Mind (California, 2001), a wide-ranging study of the place of madness in eighteenth-century culture and society, seen through the prism of John Monro's life and career.
“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.”—Elaine Murphy Medical History
“This is an intriguing book which should be of interest to both the specialist and the general reader.”—Kevin Purday Metapsychology Online Review
“Offers a rare opportunity to look over the shoulder of a professional ancestor as he goes about his practice. ... Its authors are uniquely qualified to add substantially to the reader’s experience, and they do so with great style and reassuring scholarship.”—New England Journal Of Medicine
"The authors/editors have performed an invaluable service not only to the scholarly community, but to anyone who cares about the treatment of those we call mentally ill. Their transcription and editing of the candid case book of a prominent mid-eighteenth-century physician provide an extraordinarily circumstantial and illuminating glimpse into a vanished world of private psychiatric practice, at once alien yet surprisingly familiar."—Charles E. Rosenberg, author of The Care of Strangers

Chapter 1

Customers, Patrons, and Their Mad-Doctor

  The history of psychiatry, as David Ingleby wittily remarked some years ago, once resembled "the histories of colonial wars[: it told] us more about the relations between the imperial powers than about the 'third world' of the mental patients themselves."1 In recent years, his gibe has lost some of its sting, as historians belatedly have begun to make efforts to uncover the fates and the experiences of patients and their families.2 Still, it is remarkable how much less we know of these customers and patrons of the mad-trade than we do of those who managed, cared for, and confined the (putatively) insane. Nor, until recently, have we learned much about the nuts and bolts of psychiatric practice and therapeutics3—about what the alienist and the madhouse-keeper actually did to and for their patients—a neglect equally manifest in the history of medicine more broadly construed.4 The difficulties presented by each of these enterprises are manifest and major. They are not insurmountable, however, and the distortions of understanding that flow from avoiding these tasks are at least as apparent and as significant.

This book is centrally about patients and their families and their interaction with the mad-doctor who managed their troubles and who provided for their care and (in some instances) confinement. Concerned, nonetheless, to offer a balanced, multifaceted account, it also explores in some depth the reactions of the physician to the stories he heard from and about the insane, and the nature of the interventions he recommended and employed in the course of his daily practice. The patients and families whose lives and travails we explore here were all attended by the same mad-doctor, John Monro (1715ñ91), Physician to London's Bethlem (or, as it was popularly known, "Bedlam") Hospital for most of his professional career. Monro was perhaps the most prominent of the emerging coterie of medical men specializing in the management of the mad in Augustan England. With only rare exceptions, however, the patients we deal with here were not among the ranks of Bedlam's mad-folk. Rather, they constituted a sample of those Monro treated in his private practice, which was far more financially rewarding and consumed far more of his time, energies, and talents than did his more visible involvement with the inmates of what for centuries has been the most celebrated (and anathematized) hospital for the insane in the English-speaking world.

It was, of course, John Monro's family connections and his long association with Bethlem that accounted, in substantial measure, for his standing at the very head of a newly emerging eighteenth-century profession. Monro was the second of a veritable family dynasty who continuously presided over London's Bedlam from 1728 to 1853. His tenure as the hospital's physician began in June 1751, barely a year before the death of his father and predecessor, James, and extended over four decades, to within a few months of his own demise. On the foundation provided by the limited income but extraordinary visibility his hospital appointment generated for him, and building upon his father's reputation and contacts among the aristocracy and well-to-do, John created a remarkably extensive and extremely lucrative practice ministering to the mad. He acquired madhouses of his own, obtained substantial retainers and consulting fees from his contacts with a range of establishments owned and operated by others, and provided advice and treatment to a wide array of nervous and distracted patients in more domestic settings. The wealth and property he accumulated secured the family's fortunes, and his professional prominence made the Monro name virtually synonymous with the specialty that he did much to create and consolidate.

Bethlem itself was a monastic foundation dating from as early as 1247, and it had been involved with the care of the lunatic since at least the early fifteenth century, early acquiring and never losing an identity almost isomorphic with the institutional treatment of the insane. In its corrupted form, "Bedlam," the institution's very name became identified in the English-speaking world with chaos, tumult, danger, and disorder. In John Monro's day, the institution was one of the sights of London, visited regularly and in substantial numbers by metropolitan sophisticates and country bumpkins alike. A staple of the stage at least since the age of Shakespeare (1564ñ1616) and Ben Johnson (1573[?]ñ1637), it surfaced as a cliché in Grub Street novellas, as a satirical weapon in the poetry and prose of men such as Swift and Pope, in the paintings and prints of Hogarth and Rowlandson, and in repeated (if often throwaway) references among the diaries and letters of the English elite.

The inmates of Bedlam—both literally, in the eyes of those who came to gawp at them, and metaphorically, in a variety of literary renditions of insanity—gave seeming substance to long-standing cultural stereotypes of mad behavior. They stood (or squatted) as an indictment of the lunatic, seen variously as the embodiment of extravagance, incoherence, incomprehensibility, melancholia, menace, and ungovernable rage. The cells and galleries of the ancient foundation—ironically, the smallest, most specialized, and least affluent of the great London hospitals of the Georgian age—were emblematic of Unreason, their occupants both unwilling and performing actors in a theater where the throngs of visitors might inspect the product (and price) of immorality, the wreck of the human intellect, the dolor of the downcast, and the rages of the raving. Once housed in the modest accommodations provided by an old monastic building at Bishopsgate that Henry VIII had granted to the City of London at the time of the dissolution of the monasteries that formed part of the English Reformation, Bethlem had grown dilapidated and boxed in by the encroaching city by the early seventeenth century. It moved, however, to its Moorfields location in 1676, occupying an externally ornate edifice designed by Robert Hook and constructed (with little regard for the long-run integrity of the building itself, but with symbolic appropriateness) on the liminal space just beyond the City of London wall, built upon the uncompacted accretion of discarded rubbish and effluvia that had filled up the old moat. Here was a spectacular new palace designed to display the benevolence and solicitude of the capital's citizens and to symbolize the Restoration of royal and civic unity and to connect it to the restoration of reason. Its architecture was conceived preeminently as fund-raising rhetoric rather than for its present and future inmates, whose interests took distinctly second place. As late as the mid-seventeenth century, there were between thirty and fifty madmen (and madwomen) at the old Bishopsgate site. However, with the 120 cells that comprised new Bethlem soon fully occupied, and a series of further extensions from the late 1720s (when provision was made for more than 100 "incurable" patients in newly constructed wings) onward, the hospital's population multiplied many-fold. In the new building, both internal and external arrangements were manipulated and compromised to achieve the higher goals of impressing upon both the institution's patrons and the public at large the virtues of civic pride and Restoration renewal. Contemporaries could be relied upon to point out the ironic contrast between the sober splendor of the hospital's exterior and the impoverishment and chaos that lurked within. Yet—and again the qualification makes salient another important facet of the ambivalent place occupied by madness and the mad in early modern England—notwithstanding all its contradictions between inner and outer, ditch and palace, deprivation and ornament, as Christine Stevenson has shown, new Bethlem was still planned with a firm (if subordinate) attention to "therapeutic efficacy." In terms of air, light, and space, it was fundamentally designed for the restitution of its inmates' health and to exploit the advantages of its bright and airy Moorfields location. And, undoubtedly, new Bethlem represented a rather impressive and grandiose application of resources by its governors to the creation of a new lunatic hospital, bringing it "a new dignity among London's charitable institutions and international renown."5

By the time John Monro succeeded his father, James, as Bethlem's physician, however, the hospital had long since lost its distinction as the sole specialized establishment for the confinement of the mad in the metropolis. When Thomas Guy left his fortune to endow one of the rapidly proliferating new charitable hospitals that graced the capital,6 one of the stipulations of his will was the setting aside of a sum of money to endow a ward in his new institution for the chronically ill, including the insane. And in the very year that John succeeded to "the throne of folly," St. Luke's Hospital, another charity asylum dedicated entirely to the care of the insane, was founded in London, partly at the initiative of one of Bedlam's governors (and one of Monro's major rivals in the mad-business), William Battie.7 Moreover, these were only the most visible manifestations of a transformation in the management of madness that had been gathering steam in England since the Restoration.

For the growing affluence of London and its hinterland was fueling an expanding marketplace for all manner of goods and services, as the rich found ever more extensive (and expensive) ways of expending their surplus, and the middling sort hurried to ape and emulate their "betters."8 The entrepreneurially inclined soon realized that a lucrative living could be derived from the provision of all manner of novelties, not least finding ways to relieve the well-to-do of the burdens of life's (and even death's) unpleasantnesses. If undertakers could make death the occasion for profit, helping to invent and then satisfy a whole array of new wants, so too were there fresh prospects to earn lucre from the care of lunatics, and a thriving business speculating in this variety of human misery had begun to establish itself several generations before John Monro appeared on the scene.9 A growing demand on the part of the upper classes for some system of private care that would relieve them of the burden of their troublesome and unmanageable relations and sequestrate them from public view, together with the ability of the rich to provide substantial rewards for those who obliged them in this way, was a crucial catalyst for the development of an expanding array of "madhouses." To an increasing extent parish authorities also got in on the act, paying small sums to those willing to provide places of confinement for difficult characters of a meaner sort. In Bethnal Green, in Hoxton, and in Hackney, men such as Matthew Wright took leases on large old houses and converted them into places to which one could consign the most disturbed and disturbing.10 And west of the city, in the village of Chelsea, still another cluster of madhouses now emerged, including Michael Duffield's madhouse, a handsome building erected by a Mr. Mart that was located between Lord Shaftesbury's house and Lord Wharton's park.

Nor was the "trade in lunacy" confined to the institutional care of the seriously disturbed. If madhouses provided one mechanism for drawing a discreet veil over the madman's very existence, families often recoiled from taking advantage of such sinister silences (for the reputation of these places was dire almost from the outset). Demonstrably, most preferred to seek other solutions to the problems their mad relations posed, and, if affluent, they possessed the wherewithal to do so. Hence, those who sought to minister to minds diseased often found themselves treating the mad in family or community settings.

Not that the mad-doctors of the age reacted purely passively to the demands of their customers and patrons. Many of them, on the contrary, actively sought to expand their practices to encompass all sorts of "nervous" troubles and distress. Here were protean disorders of uncertain provenance and even more uncertain extent, diseases whose very existence the doctors helped to establish and legitimize—the fashionable hyp (or hypochondria), hysteria, the spleen, and the vapors proving at least as rewarding and attractive an arena for the display of their professional talents as the more alarming and urgent manifestations of Bedlam madness. The fashionable Scottish physician George Cheyne's lucubrations about "the English Malady"11 were but one especially visible manifestation of a far wider marketplace for the services of the specialist in mental disorders than a traditional historiographic emphasis on the growth of an institutional sector would lead us to expect. And John Monro, as one of the leading actors in this particular morality play, provides us with a revealing and intimate set of insights into the multifaceted clinical realities of the age.

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