Book Review

Undertaker of the Mind: John Monro and Mad-Doctoring in Eighteenth-Century England

N Engl J Med 2002; 346:2097June 27, 2002

Article

Undertaker of the Mind: John Monro and Mad-Doctoring in Eighteenth-Century England
(Medicine and Society. Vol. 11.) By Jonathan Andrews and Andrew Scull. 386 pp., illustrated. Berkeley, University of California Press, 2001. $35. ISBN: 0-520-23151-1

This book about the work of John Monro, a doctor in 18th-century England, is based on a newly discovered case book of his (which is being published separately). Monro is best known for his work at Bethlem, or “Bedlam.” Bethlem — a contraction of the name of the public asylum at Bethlehem Hospital in London — was the only public insane asylum in 18th-century England. The growing affluence of England was accompanied by geographic mobility, a flourishing of service occupations, and as Andrews and Scull write, a “commercialization of existence” that decreased the willingness and ability of families to care for their mentally ill relatives at home. The alternative was the asylum. The one at Bethlem was infamous because Londoners went there for entertainment. Some of William Hogarth's engravings depicting this macabre form of amusement are reproduced in this book. John Monro (1715 to 1791) was the physician at Bethlem at the time. He was the best known of the Monro family, four generations of whom had occupied the position of visiting physician at Bethlem. The family also had professional and financial interests in private “madhouses.”

In Undertaker of the Mind, several of Monro's cases are described in detail. One of his patients was Alexander Cruden, a remarkable man who was interested in the Bible, Milton, political office, righting the wrongs done to others, observance of the Sabbath, and pamphlet writing. He created a large and valuable concordance to the Bible, still in use today, with more than 200,000 entries. He wrote it in just over a year but spent much of the rest of his life correcting it. On occasion, he was a public nuisance and was confined in Bethnal Green, where his attending physician was James Monro, John Monro's father. Cruden escaped from Bethnal Green by sawing his way through the leg of the bed to which he was bound and then leaping through a window. Five years later, in 1743, he was confined at Bethlem, and in 1753 he was confined at a small asylum in Chelsea, where John Monro was the physician. Cruden worked as a proofreader and wrote about his life in pamphlets, which he happily called “The Adventures of Alexander the Corrector.”

Undertaker of the Mind also recounts the misadventures of the third Earl of Orford and his uncle, Horace Walpole, son of a former prime minister and author of the well-known Gothic novel The Castle of Otranto. Thanks to Walpole's prolific pen, we have abundant detail about the illness and treatment of the third earl. There is also the story of Margaret Nicholson, who tried to kill George III in August 1786. John Monro and his son, Thomas, examined Nicholson over the course of several days and decided that she clearly was insane. Just one week after the attempted murder, she was transported to Bethlem, where she stayed until her death 41 years later. Justice seems to have moved quickly in those days.

Gothic novels about innocent young women who were locked up in madhouses for life and treated with great cruelty because they were intent on marrying the wrong person contain misleading exaggerations. The actual treatment of the mad may have been less horrible. Both Cruden and the third Earl of Orford, for example, were confined against their will several times but were also released. During Nicholson's time at Bethlem, she seems to have been treated gently, and many visitors described her as being well dressed and as often reading Shakespeare and writing letters.

John Monro himself is a shadowy figure in comparison with the unambivalent and energetic Cruden and the delusional Nicholson. He wrote very little. He did publish a riposte to William Battie's attack on the management of Bethlem by his father. Whether Monro or Battie won this battle of opposing monographs is still debated today.

Physicians of the 18th century struggled to be recognized as gentlemen who did not get their hands dirty. Monro would often diagnose his patients' illnesses from a distance, unlike surgeons and apothecaries, who were of a lower class and actually touched their patients. Monro and his colleagues were quite open about their inability to treat their patients. The accounts of their patients' illnesses will intrigue psychiatrists who may wonder about 21st-century diagnoses.

Frances Rachel Frankenburg, M.D.
Bedford Veterans Affairs Medical Center, Bedford, MA 01730
frances.frankenburg@med.va.gov