A Historical Review of Psychiatry in the Province of Quebec, Canada (From the 16th century to the 20th century)

In this paper QUEBEC shall be utilized as a “case method” example of a province which depicts a linear progression in a positive direction in the treatment and care of its mentally ill. Quebec is unique in that it was the first province in Canada to provide succor, care and treatment to the mentally ill. This provision of care for the mentally ill took on a very unique pattern even after services were provided in other provinces in Canada. The influence of the Roman Catholic Church was paramount. Services were “farmed out “to religious orders or proprietary interests which were not followed by the other provinces.

Notwithstanding this anomalous situation in comparison with the other provinces its humanitarian thrust for the time was not much different than that of the other provinces. A psychiatric historical review of services to the mentally ill in Quebec from the 15th century to the 20th century will be examined.

In the early 1700s, New France encompassed most of the eastern seaboard of Canada. The most important colony was at Québec, established by Samuel de Champlain in 1608. The name Canada was first applied to this colony. The settlements in Acadia, which is now the provinces of New Brunswick and Nova Scotia were even earlier, dating from the mid sixteenth century. Ile Saint Jean, now called Prince Edward Island, did not have permanent settlements until somewhat later. The French had a chain of trading forts in the Great lakes and down the Mississippi. New Orleans was a French colony until the late eighteenth century. North of New England, the British had only a colony at St. Johns on the eastern tip of Newfoundland and, by mid-century, a settlement at Halifax.

As early as 1639, the niece of Cardinal Richelieu of France, the Duchess d'Aiguillon, founded the Hotel Dieu (hospital) of Québec, which cared for the “indigent, crippled and idiots” [1]. Québec can also be credited with being the first jurisdiction in Canada to provide separate accommodations for the insane. In 1714, the second bishop of Quebec, Bishop St. Vallier, built a small structure of twelve beds for mentally ill women [2].

In French Canada, the care of the mentally ill was characterized by a “farming out” or “contracting out” to religious orders. These Roman Catholic religious orders were then reimbursed for their provision of care by the French colonial authorities, and interestingly by the British Crown after 1763. Institutional conditions under both regimes were, in a word, deplorable. These adverse conditions seemed even more so in the North American because they were based on models worked out for Continental conditions in the pre-modern period.

To the British officials, the contrast between a Protestant sense of social care and the prevailing conditions in the Roman Catholic hospitals of Québec was shocking, to say the least. Not a little of British superiority and Protestant distrust of Papacy was involved in this rhetorical dismay. But it was a case of the pot calling the kettle black. In those years, institutional conditions under both régimes, French and English were, in a word, deplorable.

In 1824, a committee chaired by John Richards (1755-1831), a Scot who entered public life as a member of the Quebec legislative council in 1792, reported that:

"The cells appropriated to the insane in this province are more likely to produce or increase insanity than cure it [3]."

The report further stated:

"The cells appropriated to the insane in this province, do not admit of properly applying either moral or medical treatment, with the hope to a mental cure of the unhappy persons confined therein [4]."

It is interesting to note that the role of John Richards’ committee reflected the purpose, nature and approach of the Select Committees established for the same reasons in England during 1807 and 1815. Included in the committee report was an architectural plan of the 120-bed Glasgow Lunatic Asylum and information about the latest developments in European asylums. This report, which was heavily influenced by British standards, has been referred to as the first “Royal Commission” on health services in Canada [5].

Almost fifty years late, with the asylum movement already started, an American social reformer, Dorothea Dix, who became an international crusader for humane institutional care of the mentally ill during the nineteenth century, visited Montreal and Quebec City in 1843 and 1844 respectively. She inspected the goals which housed the mentally ill and denounced the squalor, filth and mismanagement of the “patients”. She mentioned the Governor General of Canada, Sir Charles Metcalfe, in highly impressive terms as being associated with the first effective measures in Canada for “ameliorating and healing the sufferings of the insane” [6], In 1844 Sir Charles Metcalfe initiated government action to establish an asylum near Quebec City in Beauport, Quebec. The situation was bad to be sure, but corrective action was on the way.

On September 15, 1845, when the Beauport Asylum opened its doors to accommodate 120 patients, “Lunatics in the charge of the religious ladies of the General Hospital of Quebec” were sent to the asylum [7]. This was not a state institution but a “propriety” institution operated by Drs. Douglas, Fremont and Morrin, under the “farming out” system, whereby the state made per diem payments to the proprietors via Orders in Council.

James Douglas (1800-1886) was born in Scotland and came to Quebec on March 13, 1826 [8]. He had received his medical training at Edinburgh before going on to London to pursue a degree in surgery. It was Douglas who founded the Beauport Asylum in 1845 with the help of his colleagues, Drs. Fremont and Morrin. Four years later, he gave up his general medical practice to devote all his time and energies to the care of the mentally ill, refusing to accept the then current notion that nothing could be done to remedy the condition of the insane. An activist and a reformer, he was appalled by the conditions in which the mentally ill found themselves [9].

The new attitudes and ideas which Dr. Douglas brought to Quebec with regard to the care and treatment of the mentally ill were a reflection of the prevailing British ideological paradigm of the Romantic Period, with its stress on individual integrity and deep introspection. The difference was of course, that in Canada these ideas which bright young men like Douglas had imbibed in Edinburgh and London from teachers who espoused enlightened medical theories of the new age could be more swiftly and extensively put into practice than in the Old World metropolis. What were these new ideas?

Dr. Douglas advocated exercise, music, dancing and employment in the open air-typical moral treatment prescriptions. James Douglas, Ll.D. of New York, son of Dr. Douglas, stated:

In his medical treatment he put little faith in drugs as specific curative agents in mental disease... He was opposed to their administration when it tended to react directly on the nervous system. He confined his treatment to maintaining his patients in as perfect a state of health as possible, and directing their thoughts from their diseased channels by work and amusements…[10].

Dr. Douglas was, thus, one of the many “alienists” [11] in Canada who advocated moral therapy. Yet as we shall see, advocacy and successful implementation are two different things. Canadians on the whole, like other nineteenth-century North Americans, were not yet prepared for alienists or moral therapy.

In 1850, the Beauport Asylum was renamed the Quebec Lunatic Asylum when a new building with 275 beds was opened. Due to the eventual overcrowding of this institution, the St. John’s Asylum was established in 1861. In that same year, inspectors commenting on the St. John’s Asylum remarked that it was a makeshift arrangement and added:

There are still to be provided for hundreds of insane, scattered through the Lower Province, some in jails, others in charitable institutions, and not a few with families, who have neither the means or the appliances for their proper treatment [12].

In addition, the 1864 Colonial Office report advised:

It is to be desired that immediate steps should be taken to transfer the inmates of the St. John's Asylum to some better structure... It is impossible to convey by words an adequate idea of the miserable conditions of the Asylum. Its condition is so bad that the interrogatories are said to be inapplicable [13].

This institution represented the first attempt at total state care in Quebec in that it was not run by a religious order, charitable institution or proprietor. It ceased functioning in 1875 and a new asylum run by the Soeurs de Charité de la Providence was erected that year. This institution, which was known as Longue Pointe Asylum and more recently as Hôpital St. Jean de Dieu, had its historical roots in structures dating back to 1845 in Montreal and Longue Pointe.

An 1864 Report of the Board of Inspectors of Asylums, Prisons, &c.. , commented on the conditions of asylums throughout Quebec, stating that the insane were:

...congregating at night in cribs erected in badly ventilated rooms, under such circumstances, consented to what as professional men, they condemned [14].

In 1865 the same inspectors further stated that the farming out or contract system was “..objectionable”. As they saw it:

Here it is plainly in the interests of the proprietors or contractors to spend as little as possible upon the food and maintenance of the patients... A system can hardly be expected to work satisfactorily where the interests of the parties concerned are so essentially at variance [15].”

A generation later, in 1884, Dr. D.H. Tuke, a world-renowned Quaker alienist from London, England visited the asylums of Quebec. He too condemned the contract system as one which "involved the possibility of their [the patients] being sacrificed to the interests of the proprietor [16]." Yet this system persisted until the middle of the twentieth century. Tuke then went on to say that contracting-out (equivalent in modern parlance to public hospital boards purchasing services from private providers) had the disastrous tendency:

To keep the dietary as low as possible ... inducing want of proper attention [17].

Tuke also commented on the Longue Pointe Asylum which was operated by a religious order in Quebec:

In the course of seven and thirty years, I have visited a large number of asylums in Europe, but I have rarely, if ever, seen anything more depressing than the condition of the patients... at Longue Pointe [18].

While it is hard to judge whether the statements made in this Report are purely objective or are part of a polemical argument to force reforms on the system, nevertheless it is clear that reformers like Tuke were deeply committed to seeing the new ideas of the asylum movement put into effect in British North America. He went on to opine:

… it is amazing to reflect that although the superiority of the human mode of treating the insane inaugurated nearly a century age has been again and again demonstrated and has been widely adopted through the civilized world, a colony of England, so remarkable for its progress and intelligence as Canada can present such a spectacle as I have so inadequately described as existing in the year of grace 1884, in the Montreal Asylum [19].

Clearly, Tuke here is amazed not just at the backwards conditions of the hospital run by religious authorities in Quebec but at the fact that a British colonial administration turned a blind eye to these conditions, something they would not have allowed to continue at home in England. Tuke, noting the excessive use of restraints and the lack of power vested in the government visiting physician, wrote a report leading to a series of resolutions condemning the conditions of the asylums in Quebec. The words of this Quaker reformer for once it seems fell on fertile ground.

In 1885, an Act was passed which placed the medical control of these asylums under Government supervision. The government gained the power to appoint the Medical Superintendent and assistant physicians in all the asylums in the province. Nevertheless two years later, in 1887, a Royal Commission found that conditions at Beauport Asylum were worse than those in other countries. Six years later when the proprietary contract was not renewed, Beauport was transferred to the Sisters of Charity in Quebec.

In comparison with the rest of Canada, religious orders in Quebec were in an unique position with respect to the housing of the mentally ill. The contracting out system was also unique in that it established a partnership between the government and religious orders in the care of the mentally ill. Notwithstanding the criticisms levied against this system, the contracting out system should not be viewed as the sole, or primary source of the deleterious features of the system in Quebec. The lack of adequate resources (human, fiscal and physical) militated against a humane institutional approach in this province, as well as in the other provinces of Canada. As too often would happen, practice did not keep up with theory, just as emotional and fiscal commitment lagged behind fine words.

However, this did not prevent reformers from trying. In 1881, Fred Perry (1820-1900), a well-known citizen of Montreal, was instrumental in securing” An Act to Incorporate the Protestant Hospital for the Insane” in the legislature of the Province of Quebec [20]. The notion of a separate institution for the Protestants of the Province of Quebec is credited to Perry, and conventional wisdom puts this down to his disillusionment with the farming-out system and the custodial nature of care given by Catholic orders in the province. Around 1875, Perry had already begun to devote his energy to the task of a Protestant institution. According to Hurd, Perry, a man of strong will, energy and purpose, resolved that at least the Protestant community should be freed from both the farming out system and the custodial systemoperating in Quebec [21]. In 1881, the Act was passed. With a Board of Governors comprised of Protestants, the hospital admitted its first patient on 15 July 1890.

This represents an early instance of the demise of the contracting out system between the religious and government of Quebec, just as it also portrays a different partnership between the government and the management authority of an institution for the psychiatrically disabled. While Perry's group identified with a particular religious group, there was no linkage with the Protestant churches and certainly none with the Roman Catholic Church, predominant and active in the province’s political and civil life. This development may also be viewed as the beginning of the secularization of care to the mentally ill in Quebec. I would like to end this presentation on a lighter note. In 1885, protests had been made by farmers owning land surrounding the proposed site of the Protestant hospital, who feared that their livestock might catch mental illness from the patients.

Several events shaped Quebec psychiatry in the second half of the 20th century. In the immediate post-war period (1945-1960) the developments were mostly private, mostly in the large cities mostly serving the Anglophone population. The Francophone population with mental health problems was left largely to the parish priest and the huge overcrowded and neglectful mental hospitals. After the Quiet Revolution changes occurred rapidly, with the provincial government actively involved. In the 1960s, the province was divided into regions and regional mental hospitals were opened in many areas. Legislation was passed requiring physicians to serve outside large cities and this resulted in an exodus of physicians and psychiatrists, both Anglophone and Francophone. There was a period when psychiatrists were in short supply and great efforts were made to train and attract psychiatrists to the province. Models of care which did not depend on psychiatrists were developed similar to this trend elsewhere in Canada.

While all the Canadian institutions professed a moral treatment approach, overcrowding, the rather crude biological, psychological and social treatment methods of the time, and the lack of adequate resources-human, fiscal and physical-militated against humane institutional conditions by today's standards in all the provinces of Canada. But can one put all the blame on external conditions? Perhaps, as we have started to show, there are other kinds of explanation, reasons inside the mentality of the public, the provincial governments, and even the professionals which resisted the newer ideas about the mind and the treatment of its illnesses already well advanced by 1914.

References

1. Hurd Henry M (1916) The Institutional Care of the Insane in the United States and Canada. Johns Hopkins Press, Baltimore, Maryland. 1: 446.
2. Department of Health (1934) The Hospitals of Ontario - A Short History. King's Printer, Toronto. 236.
3. Report from the Special Committee of the Legislative Council of the Province of Lower Canada (1824). 254.
4. Report from the Special Committee of the Legislative Council of the Province of Lower Canada (1824). 255.
5. Staiwick HN (1969) A History of Asylum Administration lunacy legislation in Canada before Confederation. Ph.D. thesis, University of London. 276.
6. Hurd Henry M (1916) The Institutional Care of the Insane in the United States and Canada. Johns Hopkins Press, Baltimore, Maryland. 1: 486.
7. Burgess TJW (1898) A Historical Sketch of Our Canadian Institutions for the Insane. Transaction Section IV, Royal Society of Canada. 48.
8. www.biographi.ca/en/bio/douglas_james_1800_86_11E.html
9. Hurd Henry M (1916) The Institutional Care of the Insane in the United States and Canada. Johns Hopkins Press, Baltimore, Maryland. 4: 564.
10. Hurd Henry M (1916) The Institutional Care of the Insane in the United States and Canada. Johns Hopkins Press, Baltimore, Maryland. 4: 176.
11. alienist - definition. 1. Specialist in the treatment of mental diseases. (Webster's Dictionary,1987) 2. A "mad doctor". (Oxford English Dictionary, U.S.Edition, July 1987) 3. A former term for a psychiatrist. (Dorland's Illustrated Medical Dictionary, W.B. Saunders Co., Philadelphia, 1981) An etymological search revealed that people first used the term alienation to refer to mental illness circa 1790. "Alienists" were those who treated people suffering from "alienation". In the 20th century, certainly by 1914, it was no longer used to refer to" asylum" doctors.
12. Report of Board of Inspectors of Asylums, Prisons. Ontario and Quebec (1861). 37.
13. Public Record Office (1864). 29.
14. Report of the Board of Inspectors of Asylums, Prisons & c (1864). 58.
15. Fifth Annual Report of the Board of Inspectors of Asylums, Prisons (1865). 6.
16. Tuke DH (1885) The Insane in the United States and Canada. H.K. Lewis, London. 200.
17. Tuke DH (1885) The Insane in the United States and Canada. H.K. Lewis, London. 202.
18. Tuke DH (1885) The Insane in the United States and Canada. H.K. Lewis, London. 203.
19. Tuke DH (1885) The Insane in the United States and Canada. H.K. Lewis, London. 204.
20. Andrew Jackson Downing, The Architecture of country houses (New York, D. Appleton,1854). 353.
21. Hurd Henry M (1916) The Institutional Care of the Insane in the United States and Canada. 4: 583.