David Skae: resident asylum physician; scientific general practitioner of insanity.

Introduction

David Skae was resident physician of the Royal Edinburgh Asylum (hereafter REA) from 1846 to 1872. Despite a pioneering article about him by Frank Fish, Skae remains a liminal figure in the history of psychiatry.1 He is usually seen as an asylum-based practical medical instructor of more important figures such as Thomas Clouston.2 Although he lectured on insanity in the Edinburgh extra-academical school of medicine, it was not his stepping-stone to a university professorship. As a result, Skae’s reputation has fared less well in comparison with others such as Thomas Laycock, professor of the practice of physic at the University of Edinburgh.3 When placed in the wider historical tradition of British alienists who also taught and wrote, his significance is by no means evident.4 In the absence of a major textbook or monograph, his scattered journal articles can appear sporadic, if not eclectic. Against this backdrop, descriptions in obituaries of his sterling professional conduct and likeable personal qualities can be read as glosses upon an unspectacular provincial career.5 Well-known exchanges in the professional journals shortly after Skae’s death also cast a pall over his controversial classification of insanity.6 Over forty years have passed since Fish’s article and it is time for a fresh look, one that takes into account scholarship in the history of psychiatry since then, especially with respect to asylums and their alienists.7

The argument throughout is that Skae is better understood as a scientific general practitioner of insanity rather than as a resident asylum physician and mental disease specialist. It is advanced in relation to selected historiographic themes including: the relationship between medical training and asylum alienists’ careers; engagement with phrenology; diagnosis, medical treatment and classification of insanity; asylum superintendence and lunacy reform. A wide range of historical sources are brought to bear, the most important of which is a holograph manuscript of Skae’s lectures on insanity.8 Some new aspects of Skae’s personal circumstances are also noted. However, he is viewed mainly from a range of professional, institutional, intellectual, and lunacy reform perspectives in order to locate and understand Skae’s alienism in its mid-nineteenth-century local Edinburgh context of use.

Medical Training, Alienist Career?

Skae’s appointment at the REA is generally assumed to have transformed his career from general medicine into the much narrower specialized path of alienism.9 Viewed from his perspective, however, it was more a matter of seizing a timely professional opportunity for which he was able to show some general aptitude than an achievement predetermined by mastery of specific knowledge, skills and expertise. The ways Skae sought to make a medical living after he qualified reflect the typical opportunities and constraints of the nineteenth-century British medical marketplace as described and analysed by Irvine Loudon and Anne Digby.10 He started out as a general practitioner and then became surgeon to the Edinburgh Lock Hospital.11 Skae had a similar role in another public charity, the Eye Dispensary, and also provided gratis medical advice to the poor of the southside of Edinburgh where he lived—probably through becoming a visiting physician to a local public medical dispensary there. He also had charge of sick prisoners in the Edinburgh Bridewell for three years.12 During the 1840s Skae sought a remunerated institutional position to consolidate his career. Public practice was seen as a reputable means of attracting private patients.13 He applied unsuccessfully first to become a surgeon in ordinary at the Royal Infirmary of Edinburgh in 1844 and then a parochial district surgeon of St Cuthbert’s Parish in 1846.

From around the 1820s onwards, the modus vivendi of competition for public positions in Edinburgh was to print and circulate addresses to patrons supported by numerous personal testimonials.14 Such documents testify to the pell-mell of competition for scarce posts among large numbers of medical men. For the Infirmary job Skae’s practical skills as an anatomist and operator were highlighted. His teaching in the extra-academical school and early publications also featured prominently. For the parochial one, the emphasis was upon his long-standing record of active, practical and kind charitable work in a locality where he also resided.15 In so far as his teaching was referred to, it was the medical police or jurisprudence aspects. It is instructive to compare the latter testimonials with ones Skae produced for the ordinary managers of the REA only a few months later.16 In the prefatory address to them he drew attention to his liberal and extended literary education at St Andrews University prior to studying medicine at Edinburgh.17 He emphasized how insanity had been prominent in his “Forensic Medicine” courses (notwithstanding the fact that he had recently given these up in favour of teaching anatomy). He claimed that an address given to the Royal Medical Society (RMS) nine years previously evinced his long standing interest in “Mental Alienation”, and indicated that several of his published articles since had also dealt with aspects of “Insanity”. Skae averred that he had treated more cases of it during his extensive and well-established private practice than were routinely encountered. Concerned to meet the telling point that he had never resided or practised in an asylum, Skae stressed the favourable opportunities he already had for “acquiring a practical knowledge of the phenomena and treatment of general disease”, and argued that residence in an asylum could not have provided this by itself. He “would be enabled to enter upon the duties of Physician to such an Institution, experienced in the means of discovering those obscure diseases with which Insanity is so frequently complicated, and on which alone it in many instances may depend”.18

Skae’s implicit argument about the need to connect general and asylum practice was explicitly underscored by several of his testifiers.19 As well as offering to give up his practice in favour of “the Physiology and Pathology of the Brain”, Skae considered he was well placed to deliver clinical lectures on insanity should the managers ever desire to strengthen its ties with “the great Metropolitan Medical School” on its doorstep.20

It is relatively easy to see how Skae’s application appealed to the broad coalition of university professors and extramural teachers who were prepared to testify on his behalf. It could well have resonated to a degree with progressive members of the REA’s Medical Board, the two ordinary managers who were medically qualified and the REA’s visiting physician.21 However, it is much harder to see why his distinctive stance towards insanity would appeal to a majority of the remaining ten managers who represented the law, the municipality and local parishes. Although commending a clinical anatomical approach to insane brains, his application made no mention of what the managers referred to as the “system of humane and gentle treatment of the insane” introduced by Dr William M’Kinnon, the REA’s first resident physician.22

Fish cites the autobiographical recollections of Professor Robert Christison respecting the politics of Skae’s election. An ordinary manager at the time, Christison noted the appointment was made in opposition to the dominant party of managers led by the REA’s Treasurer, John Scott WS. Unfortunately, Christison offered no further information about how this actually came about.23 The Minutes reveal that, on the advice of the Medical Board, the post was initially offered to the medical superintendent of the Crichton Royal Asylum, Dumfries, W A F Browne, who declined it.24 Only then was it publicly advertised in selected general and medical presses. The unanimity between the ordinary and medical managers then broke down. No further discussion was minuted and no other applicants were even mentioned when the eventual outcome was recorded. Skae’s appointment was noted with extreme brevity and without any further explanation.25 Afterwards, the irregularity of both the process and the outcome of the election were deplored in local papers. The main accusation was that previous asylum experience had been publicly advertised as necessary.26

The circumstances surrounding Skae’s appointment confirm the observations of Andrew Scull about other alienists such as Browne and John Conolly.27 Recruitment was unpredictable and there was a lack of consensus about the required education and training, the role of previous medical experience and teaching, and the necessary personal qualities to become a resident asylum physician. All three men had different educational backgrounds. They had experience of teaching, but in the quite different settings of an extramural medical school, a university and a mechanics’ institute. The circumstances in which they practised medicine were also very varied. Browne was seeking to establish himself in general practice when he was first appointed to Montrose Royal Asylum. Conolly’s practice was believed to be failing when he went to Hanwell. Skae claimed he had successfully built his up over a ten-year period. Against this background of contingency and uncertainty, Skae’s stance seems all the more distinctive. He argued that experience as a practitioner of scientific general medicine was the decisive consideration and outweighed familiarity with asylum practice. Skae presented himself as a scientific general practitioner of insanity, able to work effectively in a public asylum setting, a hospital, a dispensary or in patients’ homes.

Although the battle over the moral treatment of insanity fought along anti-restraint lines by Conolly, Browne, M’Kinnon and others was well underway, it was by no means won. Nor was it taken for granted that the medical hand was the only means of dispensing the benefits of moral treatment to asylum patients. In fact, a letter from Andrew Combe, written to the REA’s managers at the time of M’Kinnon’s resignation, suggests that some retrenchment might have already taken place.28 He expressed complete opposition to asylum lay superintendence, using arguments already advanced in his influential work on mental derangement.29 Skae clearly believed in asylum medical superintendence too, but he took it further. He aimed to treat insanity scientifically according to the clinical anatomical method which he claimed to have applied successfully in general practice. This informed his subsequent approach as an alienist, in which mental derangement was viewed as an aspect of general medical practice, not a specialty.30

Skae and his supporters sought to annexe the asylum as an outpost of scientific medicine. Within a few years of his appointment, they succeeded in putting a “clinique” within the REA, where the treatment of insanity could be taught as well as practised. The connection between the Edinburgh metropolitan lunatic asylum and its medical school helped to achieve this. Yet a range of factors subsequently came into play that retarded the success of the Edinburgh metropolitan asylum clinique. Foremost in Skae’s lifetime was the relentless transformation of the REA after 1845 into an institution largely driven by the demands of pauper, as opposed to private, lunacy provision. Initially this was beneficial, since it was easier for Skae to draw his clinical illustrations from pauper than private patients. Later, when Skae was overworked and undervalued, the pedagogical aspects of his role tended to be overlooked. He never achieved academic distinction in his subject despite teaching it for nearly fifteen years and personally training many asylum medical superintendents.31 Dogged by ill health from the outset of his appointment, his family life thrown into disarray by a wife whom he feared might be intermittently insane, disappointed in his attempts first to move asylums and then to become a lunacy commissioner, his combined salary, teaching income and private consultation practice proved insufficient to prevent him from posthumously being declared a bankrupt.32

Phrenology, Evidence, Scientific Method

During the 1970s and 1980s the relationship between theories of mind, brain and the practice of alienism during the first half of the nineteenth century was explored by, for example, W F Bynum, R J Cooter, Scull, and L S Jacyna.33 While there is a limited amount of commentary on Skae’s ideas, he is firmly placed in the anti-phrenological camp, in contrast with his alienist near-contemporaries such as William Ellis, Combe, Conolly and Browne. Skae’s hostility to phrenology, belief in the “physical basis of insanity” and his use of a form of moral treatment in which asylum patient labour prevailed over attending each insane individual’s unique mental functions are seen by Cooter as closely connected. Given Skae’s rejection of a key tenet of the “phrenological psychiatry” advocated in particular by Combe, Cooter also considers it was not “incidental that in November 1846 he had written the hostile article on phrenology in the British Quarterly Review”.34 However, the view that Skae’s anti-phrenological stance fed directly into his approach to the care of the insane is open to criticism.

A difficulty of Cooter’s argument is the timing of Skae’s post in relation to his anti-phrenological article. It was published a month after his contentious appointment at the REA, and only seven months after he had applied for an entirely different parochial position unconnected with insanity or alienism. The article reviewed recent phrenologically-inspired works by James Straton and Daniel Noble.35 While it appears to be coterminous with his appointment, Skae used the review as a vehicle to publish quantitative findings he had presented in a Royal Medical Society dissertation nearly ten years previously.36 Therefore, a second difficulty is that the roots of Skae’s opposition to so-called phrenological psychiatry began much earlier and related more to his student than his asylum days.

In his RMS dissertation Skae posed the question: are phenomena of mental alienation consistent with phrenology? Arguably, it was more focused upon alienism than the British Quarterly Review article, although he by no means entirely abandoned the insanity theme in the latter. The common denominator and main preoccupation of both, however, was the nature of scientific method and evidence. Skae began the RMS dissertation by drawing attention to the long philosophical tradition of reflection, commencing with Locke and ending in Kant, that established the existence of mental faculties prior to the phrenological classification of them by Franz Joseph Gall.

If it is presumed, then, that the mind consists of a plurality of faculties [and] that we have arrived, or may arrive at any knowledge of them by consciousness or by observing the differences between the mental manifestations of different individuals, it may certainly be deemed in the highest degree probable, that, by observing the morbid manifestations of the mind, in the state of insanity, we shall be able to correct or verify our ideas regarding these faculties …37

However, the subsequent discussion was weighted far more towards normal rather than insane behaviour. What he termed “the Argument from Observation” took up the bulk of it and concerned the evidence that had been advanced in support of phrenology. Skae explained how he derived standardized quantitative “necroscopical observations” of the capacity and surfaces of cranial casts in order to compare and contrast the alleged physical manifestations of mental faculties of the famous and notorious with what was known of their lives and deeds in general.38 He drew upon his liberal arts education to display his proficiency in historical, literary and forensic biography by comparing the cranial casts of four murderers (Haggart, McKaen, Pollard and Lockey) with those of Burns, Swift, La Fontaine, Robert the Bruce, Héloïse and Stella. The succeeding, more medical, “argument from Pathology”, and his concluding discussion of evidence from “different forms of mental alienation”, especially monomania, occupied the final six of a 65-page discussion.

Like so many other young medical men trained at Edinburgh during the 1820s and 1830s, observed facts, quantification and inductive reasoning in order to arrive at “truth” were prominent in the manifesto of scientific method Skae professed. They are just as evident ten years later in his British Quarterly Review article. Although, in Skae’s view, phrenology was largely discredited, “a few men of eminence” still supported it due to “some uncertainty in the nature of that evidence upon which the system rests”.39 He considered the ways phrenology had been challenged on metaphysical, anatomical, developmental and pathological grounds, as well as by experiments on living animals, before returning to the theme of insanity found in the pathology section of his dissertation.40 The bulk of the discussion reiterated the earlier argument from observation. However, one of the few lines of thought that are new seems to have been related to his REA post.

The improved methods of treating the insane have been but too recently introduced; and it is but too lately, and far too imperfectly as yet, that the unhappy subjects of this malady have been removed from the mere keeper, and placed under the care of those whose habits of observation and scientific attainments could lead us to anticipate discoveries in this quarter. But when this department of pathological enquiry shall have been cultivated with the same industry and skill, and with the same aids and appliances as others, we may reasonably anticipate a rich harvest of truth.41

The details of Skae’s recasting of phrenological evidence in conformity with the “precision and accuracy” required by “inductive science” are less important than understanding the methodological commitments underlying it. The inductive stance has been widely noted with respect to aspects of later eighteenth- and early-nineteenth-century Edinburgh scientific and medical culture.42 A connection between Edinburgh medically trained alienists and later Scottish Enlightenment “Whig” thought has also been noted, but how this may have affected discourse about insanity is seldom discussed.43 Skae’s application of the inductive method to insanity from the general standpoint of scientific medicine informed all his subsequent thinking as a practising alienist. His clinical anatomical approach was already long-standing by 1846. It, rather than a continuing reaction to phrenology, informed his medical practice at the REA. There is no evidence either in the timing or the content of his criticisms of phrenology to suggest that the form of moral treatment he adopted there was conceived in direct opposition to the individualized form of it favoured by phrenologists such as Combe. However, Skae’s critical response to phrenology does reveal a great deal about his approach to what he understood scientific medicine to be.

Scull suggests that phrenology’s reform agenda appealed to alienists like Conolly and Browne during training at Edinburgh and in their early careers, but then its attraction as a professionalizing strategy began to wane from the late 1830s.44 Skae’s anti-phrenological stance accords well with this, yet he also seems to have been steadfast in his opposition to phrenology from the outset. Although Skae’s family background was less distinguished than those of Conolly and Browne, it is clear that phrenology did not appeal to him on Whig-inclined, reform-minded, social grounds. This is all the more surprising given an early interest in insanity that parallels theirs.45 There is, however, a phrenological dimension relevant to Skae’s appointment, but it is likely to have been contingent, local and political, rather than general and ideological. The REA Medical Board members Combe and Dr John Scott belonged to the Edinburgh Phrenological Society. The REA’s first Treasurer, William Scott WS, was one of its founders, a sometime proprietor of the Phrenological Journal and contributor of many articles about phrenological character.46 Yet there is no evidence that any of them made allegiance to phrenology a criterion for M’Kinnon’s appointment in 1839.47 By the time of Skae’s appointment, the reins of REA administration were in the hands of John Scott, William’s son. Although Combe wrote to the ordinary managers about M’Kinnon’s successor, he had taken no active role as a medical manager for many years, if he had ever done so. Thus while Skae’s opposition to phrenology was insufficient to stop his appointment, Browne’s asylum experience at Montrose, together with his earlier phrenological loyalties, were probably the main factors that brought the managers and Medical Board to their unanimous decision to offer him the post first.

Diagnosis, Medical Treatment, Classification

How did Skae’s commitment to scientific medicine feed into his REA-based practice between 1846 and 1872? The following discussion of Skae’s evolving approach to diagnosis, medical treatment and classification takes three contingent factors into account. Firstly, he inherited a majority of REA diagnoses made by M’Kinnon and his assistants. Secondly, like many nineteenth-century physicians, he by no means considered treatment to follow automatically from the “advancement of psychological science”, and referred instead to “the art of treating insanity”.48 Thirdly, he did not make his preferred classification of insanity public until he had practised as an asylum physician for seventeen years.

Data found in asylum case books, admissions registers and related records have been used to study patterns of diagnosis.49 A major difficulty of all such approaches is to identify the input of individuals into diagnostic processes that were collective. For example, Skae acknowledged that diagnoses contained in his first annual report had been collected by the senior assistant physician, Dr Irvine, who had also deputized during M’Kinnon’s absence.50 Even after Skae became more familiar with the REA’s records system of registers and case books devised by his predecessor, it remains unclear how much he controlled diagnostic procedures. Shortly before his death, he reflected that there had been strikingly different diagnostic practices amongst different groups of his assistant physicians in the late 1840s to early 1850s compared with the early 1860s.51 Even though the latter group had probably been trained by him to a much greater degree, this raises further questions about how REA diagnostic data were created, not to mention their subsequent uses in REA annual reports and other publications.52

Skae commented more generally about diagnosis in a manner that is very suggestive of his early direct encounters with patients. In the introduction to his first course of clinical lectures on insanity, he drew attention to its broader social significance.

The diagnosis of the particular form of insanity is of great importance. There are many cases of transient but acute hysterical excitement, which very closely resemble maniacal attacks. How distressing it must be for a young female to be hurried into a lunatic asylum, while labouring under such an attack, and to recover after a few days, to find her prospects for life perhaps destroyed, by the stamp of insanity having been irrevocably attached to her name.53

Skae’s reflection concerned what the general practitioner needed to know in order not to make mistakes concerning the diagnosis of insanity. Skae’s REA experience revealed such pre-admission shortcomings only too well. For example, he cited cases of typhus sent there because the patient had been certified.54 When diagnosing insanity it was necessary “to make out the whole features, history, and progress of each case sufficiently to establish [an] opinion on the sure basis of a scientific diagnosis”.55 Although he considered this was rarely done by general practitioners, one of the main aims of his teaching was to equip his students with the means to diagnose insanity more effectively. In terms of Skae’s own evolving diagnostic practice there is unlikely to have been a straightforward switch from indirect and theoretical textbook knowledge to direct face-to-face encounters with patients. Rather an interaction took place, one that continued throughout his entire period at the REA.

The historiography of the treatment of mental disease in the nineteenth-century British asylum is sharply divided between medical and so-called moral approaches, with most attention given to the latter.56 The former remains under-researched. Hence an important interface between mental and general disease, and between the alienist and the general practitioner, is less well understood. As a self-professed scientific practitioner of medicine, Skae was probably more confident applying his pre-existing medical skills to treat insanity inside the asylum walls than diagnosing the precise forms of it he encountered there. Having trained in the 1830s, his stance reflected the widespread movement away from earlier depletive or antiphlogistic “heroic” therapies, especially those involving bloodletting.57 He was suspicious of single drug use to bring about specific cures and his publications show very little interest in their application to insanity, although he did investigate the use of chloroform as a sedative.58 Instead, he trusted in the vis medicatrix naturae, or healing power of nature, another aspect of the prevailing therapeutics of the time.

The first [and] most important point is to place the patient in the most favourable circumstances for becoming cured by the efforts of nature—or the ordinary laws which regulate the economy of life—the exciting cause of deranged action, being removed. It is astonishing what nature can do for the cure of disease—if she is left alone [and] not interfered with by too much Doctoring. It is well known that all acute diseases tend towards a cure, exciting causes [and] sources of irritation being removed.59

Skae’s exemplars of the vis medicatrix naturae at work outside the asylum were medical diseases, such as pneumonia and phthisis, and surgical fractures. He considered that applications of this therapeutic principle to mental disease were more extensive, given the range of exciting moral as well as physical causes conventionally invoked to account for the onset of insanity.

… the great principles to be attended to in the management of the insane either in an Asylum or out of one—are the removal of the cause of their complaint—whether it be an external cause or a bodily one—the former by removing the p[atien]t from the source of Excitement, the latter by medical treatment on general principles calculated to remove the local disease.60

Skae also sought to accommodate all insanity treatment to the standard model of therapeutics based on the “indications of cure”. Thus removal of exciting causes was the first indication, followed by placing a maniacal patient, for example, in appropriate circumstances with regard to secluded accommodation, nursing, and bodily exercise. Thereafter, Skae turned to the value of physical and pharmacological, secondary medical “cures” such as cold, heat, counter-irritation, purgatives, emetics, opiates, sedatives, anti-spasmodics and the like. Skae was circumspect and cautious in a manner that emphasized the art of treatment in specific cases. He noted that several substances in older pharmacopoeias had failed to live up to expectations during asylum-based trials. Throughout, the main thrust was that:

Mania must be treated on the gen[era]l principles of Medicine—local diseases must be removed—suppressed evacuations restored … suppressed eruptions healed up, sores either brought back or their place supplied by a blister, seton or other drain on the System. Worms must be evacuated from the bowels if there are reasons to believe in their presence …61

In general, Skae continued to apply the perspective of the scientific general medical practitioner to the medical treatment of all forms of insanity.62

The classification of disease in the history of medicine has a complex historiography of its own. Michel Foucault gave it a central structuring role in his account of the birth of the nineteenth-century clinic.63 It is closely implicated in the notion of the framing of disease advanced by Charles Rosenberg.64 Within the history of psychiatry Jan Goldstein has emphasized its wider cultural and symbolic importance for understanding the development of alienism in early-nineteenth-century France.65 German Berrios approaches the evolution of psychiatric classifications from the standpoint of conceptual history.66 He argues theoretically that they are cultural products with definite historical contexts as well as being informed by stable natural “invariants”. He illustrates this empirically with reference to a Société Médico-Psychologique debate about classification that took place in 1860–61.67

Most recent historical studies of nineteenth-century British asylums reject the kind of retrospective classification on the basis of present-day criteria that Fish drew upon to discuss Skae’s clinical interests. Yet they also tend to side-step complex issues that arise from alternative historiographies of psychiatric classification. Either classification is treated as an empirical pattern of diagnosis in specific institutions, or standard textbook descriptions of the symptom-based nosology adopted by Philippe Pinel, Jean-Etienne Esquirol and their successors are rehearsed.68 Both approaches implicitly assume that physician superintendents and their staffs accepted and used the traditional mania, monomania, melancholia, dementia, idiocy, general paralysis classifications in similar ways. Skae’s remarks suggest that this is false: “[T]here are no two asylum reports published in the empire in which the same rules and distinctions are rigidly observed in tabulating the forms of insanity under treatment.”69 What alternative did Skae propose, and what led him to adopt radical and controversial views about classification?

Skae’s first definition of insanity in print appeared in a lecture on the legal relations of insanity he gave to the Royal College of Surgeons of Edinburgh in 1861.70 He adopted the increasingly common position of medicine, metaphysics and phrenology that “insanity is a disease of the brain affecting the mind”, arguing that it had the merit of being a practical starting point that did not compromise any existing theories of mind or brain.71 Skae then sought to show that insanity expressed itself as symptoms, not eccentricities of character or strange beliefs, making those who exhibited them “proper objects for medical care and treatment”.72 Having framed insanity professionally, Skae formalized his definition as “an (apyretic) affection of the brain in which emotions, passions, or desires are excited by disease (not by motives), or in which conceptions are mistaken for acts of perception or memory”.73 It distinguished insanity from fevers that also affected the brain. Another noticeable feature was that although the language Skae used implied an underlying theory of mind, the latter was entirely taken for granted rather than being either explained or philosophically justified.

Skae’s definition of insanity originated as a critical reflection upon previous attempts in works of metaphysics as well as medicine. His experience as a teacher and author on medical jurisprudence and his practice and teaching at the REA then informed its development and refinement as, increasingly, he sought to make it an intellectually rigorous justification for medical and moral treatment, especially in asylums. Throughout this process, there seems to have been a relatively easy accommodation between the respective claims of tradition and clinical expertise. The opposite was the case when it came to the classification of insanity.

From my own personal experience, then, and from what I have observed in the practical experience of others … it has always struck me that the moment [young men] came into actual personal contact with the insane, all their preconceived notions of insanity, derived from our systematic works, were found to be vague, misty, and purely conventional descriptions of what they actually saw.74

Precisely how Skae’s ideas on classification evolved over time is unknown. Their first expression in print, subsequent development, and some aspects of the early critical response, is more accessible to historical scrutiny. After making classification the subject of his 1863 presidential address to the Association of Medical Officers of Asylums, two slightly different versions of the table representing his views appeared in print soon afterwards. Twenty-seven forms of insanity were specified in an off-print of his address.75 Twenty-three appeared in a Journal of Mental Science reprint of it.76 A third version, also in tabular form, appeared posthumously in the first of his ‘Morisonian lectures on insanity’ ten years later.77 It now contained thirty-four forms, or thirty-five if “sthenic idiopathic insanity” and “asthenic idiopathic insanity” are counted as two rather than one. The names of some of the same forms of insanity in the different tables also vary.78 Another important reference point is his published article on general paralysis, a disease he regarded as an exemplar of his general approach to classification.79 Former pupils’ use of Skae’s ideas, for example in relation to phthisical and puerperal insanity, are also relevant.80 As well as inspiring and facilitating REA-based research by his assistant physicians, Skae also incorporated some of their findings into his scheme. After 1863, Skae increasingly used it as a framework for data he presented about the incidence of different forms of insanity in his REA annual reports.81 In the mid-1860s he embarked upon a complete re-write of his lectures that reflected it more fully.82 Subsequently, Skae’s classification was discussed at quarterly Scottish meetings of the Medico-Psychological Association held in Glasgow and Edinburgh in the early 1870s, and in print shortly after his Morisonian lectures were published.83

Skae re-titled his Journal of Mental Science article ‘A rational and practical classification of insanity’. This suggests he found the traditional way of classifying using observable mental symptoms to be irrational and impractical in some way. However, Skae’s publications, lectures, reports and ad hoc remarks never amounted to a full and detailed critique of symptom-based classifications. Nor did he attempt to refute the latter using evidence drawn from the case histories of particular patients. Instead, his objections were behaviourally focused upon how practitioners actually operated when they diagnosed insane patients.

The next point which has struck me in my experience … is the mode in which we all very soon come to look at any new case. … What we are solicitous to know is the natural history of the disease before us, and its cause. Is it a congenital disease? Is it one associated with epilepsy, caused by masturbation, by parturition or protracted lactation, or some other debilitating cause, or by hard drinking? Is it a case of organic brain disease, of general paralysis? Is it one connected with phthisis, with the critical period, or with the atheromatous vessels of the senile dement?84

The classifications they arrived at collectively were “instinctively and practically the data upon which we classify the cases, which are placed under our care, in our own minds”.85 The rationale of medical consultation was also used to criticize traditional approaches that ignored it. Skae argued that practitioners never asked “what the particular nosological name of [a patient’s] particular form of Insanity is”. Nor had any present and past systems of classification “yet found their way into general practice”.86

Why, then, should we adopt another ground of classification in our tables and text-books? And why should we perpetuate a nomenclature so indefinite and conventional, and which has no other foundation upon which to rest than an imperfect, if not an obsolete, system of psychology?87

For Skae to speak of a natural history of insanity was to make an advantageous use of language already familiar to all physicians. He equated it with the idea of a “variety” rather than “species”, a term he seems to have avoided.88 To general practitioners, natural history implied speaking about the “origin, course and probable termination” of a disease. The forms of insanity were “natural orders” or “families” or “natural groups”, not species.89 Skae argued that wherever there was a distinct natural history of a form of insanity, it was always referred to its natural order “without reference to the character of the mental symptoms” exhibited by psychological or mental disorder.90 He considered the most obvious examples were how epilepsy, puerperal mania and general paralysis were classified, not only by general practitioners but also by alienists in charge of asylums. One of Skae’s main contentions was to argue that more forms, or diseases, like these existed than his fellow alienists were aware of. His classification scheme was a non-hierarchical list of all the different forms, or varieties, or families, or groups, or diseases of insanity that had definite natural histories.

… we have now twenty-five natural orders or families, having each its natural history—its special cause and morbid condition, a certain class of symptoms more or less peculiar to each—its average duration—and probable termination. In fact, each may be described as a separate disease, of which mental derangement is the most salient feature; and each may be described as a disease, presenting a certain variety and kind of mental symptoms, varying in different cases, and varying at different times in the same case, but still varying within certain limits only, so as to give to each variety its own special psychological character, sufficiently marked and peculiar to make out a distinct physiognomy for each group.91

To determine what Skae regarded as the appropriate place of mental symptoms, or what he sometimes described as “psychological lineaments” in the natural history of a distinct form of insanity, he reasoned analogically about the role delirium played in diseases without insanity. In general practice:

we do not describe acute or violent delirium, or muttering delirium, or fugacious and wandering delirium … as diseases … [W]e describe, accordingly, inflammatory fever, typhus and typhoid fevers, phthisis … of which these different forms of delirium are only symptoms. … Why should we attempt to group and classify the varieties of insanity by the mental symptoms, and not, as we do in other diseases, by the bodily diseases, of which those mental perversions are but the signs?92

Causality is normally the main focus of discussion about Skae’s classification of insanity.93 However, his understanding of the role of how scientific general practitioners interacted during consultations is arguably more important. Despite operating in a highly institutionalized asylum setting after 1846, he still considered himself as a general rather than a specialist practitioner.94

Asylum Superintendant, Lunacy Reformer?

Skae’s generation of alienists reaped the benefits of an earlier campaign about the care of the insane.95 By the time he took over from M’Kinnon, moral treatment was already in place at the REA. Skae offered a deeper understanding of it from the perspective of the scientific general practitioner and he applied it in a more systematic, holistic and medically supervised way. Both are evident in lectures he gave on asylums and moral treatment rather than in his asylum reports.96 Skae emphasized the need to make every aspect of asylum life fall within the resident physician’s gaze. Medical superintendence stretched from the construction of asylum buildings to the comparative merits of different types of mattress fillings, from the physiology of the brain and mental psychology to the keeping of parrots. Moral treatment depended “upon what the physician already knows, [and] upon his possession of that natural tact in the use of his resources, which no teaching can impart to him if he has it not”.97

Skae did not view isolation, rule following and discipline as the main components of asylum based moral therapy, although each had its role to play. Rather, the scientific general practitioner knew moral therapy as an important application of “a therapeutic rule—treating the patient physiologically—by placing his brain at rest—removing all causes of disturbance, so as to enable it by natural processes to recover health”.98 Although Skae did not explicitly refer to the vis medicatrix naturae here, the equivalent phrase “natural processes” strongly implied it. Those he had in mind lessened congestion and repaired any waste by a regime of bodily rest and good nutrition. Therefore, Skae’s scientific physiological perspective stressed that by “moral treatment must be understood the bringing to bear upon the mind moral agencies which tend to the restoration of sanity”.99 Skae had a definite psychological theory about how the agencies of moral treatment rested the diseased parts of patients’ brains. By engaging the mind in new trains of thought, such activities brought into play its healthy parts. In other words, forms of moral treatment served as “distractions”, not in a trivial sense but physiologically and psychologically.100 This, rather than just isolation and removal of exciting causes, was the main object of moral treatment; and Skae sometimes implied the asylum was itself a massive engine of distraction. The “insane person” is

surrounded by new scenes—by strange faces—by a number of odd looking people, doing [and] saying odd things;—a new train of thoughts necessarily passes thro’ his mind—he wonders at the absurdities he sees and hears … he is overawed by the discipline of the Establishment … the simple fact that he is in an Asylum sometimes suffices to rouse him into a state of Sanity.101

Unsurprisingly, therefore, at least one of his medical friends considered Skae to be a “manufacturer of pleasure [and] occupation”.102 Clearly, Skae had reflected in depth about his role as the REA’s resident physician. Yet his distinctive approach to asylum superintendence appears to have encountered considerable opposition from some managers. The REA managers’ minutes give an indication of some early flashpoints, but their causes are more difficult to discern.103 It is likely that the animosities surrounding his appointment persisted for some time afterwards and to such an extent that, less than three years after he was appointed, Skae applied to become resident physician to Glasgow Lunatic Asylum. In the event, he was unsuccessful, coming second to Dr Alexander Mackintosh.104 Although Skae seems to have settled—and was more appreciated—in his REA post thereafter, it was not the end of his attempts at career advancement. In 1857 he applied to be a medical member of the General Board of Commissioners in Lunacy for Scotland. Once again, it is instructive to look at comments made about him in the published testimonials.105 Whereas Skae’s previous attempt to move was borne out of conflict, in this instance it appears to have been inspired more by his commitment to a new phase of lunacy reform then about to begin in Scotland.

The condition and management of the Pauper Insane, and the evils arising out of the present defects in our legal provisions for them, have occupied a large share of my attention. They have been to a great extent brought before the public in my Annual Reports of this Asylum, and have been also urged by me at various times upon the attention of the authorities, with a view to obviate some of those evils exposed by the late Commission of Inquiry[.] I may add that I laid those evils fully before miss dix on her arrival in this country, and encouraged her to bring them under your notice, so as to obtain the inquiry which was subsequently instituted.106

Skae’s various testifiers once again drew attention to his thorough medical education, medico-legal interests, his successful practical asylum experience, acuteness in consultation, vigour of mind and body and “commitment to systematic and humane asylum polity”.107 However, it was John Goodsir, professor of medicine and anatomy at the University, who particularly stressed Skae’s “ample practical acquaintance with the treatment of disease in general”, and the manner in which Skae had attended to “those scientific principles which must form absolutely essential elements in the discriminative functions of the responsible office for which he is a candidate”.108

The two medical commissioner posts eventually went to Sir James Coxe and Browne. Comparing Skae’s seven surviving letters to Dorothea Dix with the three by Browne, some differences in their respective approaches to Scottish lunacy reform emerge. Browne deplored the Royal Commission and its legislative approach to insanity; more especially because public chartered asylums were to come under scrutiny alongside private establishments.109 He considered that the 1815 Act to Regulate Madhouses in Scotland was still fit for purpose as far as private asylums were concerned, provided it was properly implemented by the shrievalty.110 Despite Browne’s earlier radicalism as a materialistically inclined phrenologist and asylum reformer, his response to prospective legislation was deeply conservative. Yet this did not inhibit him from applying for one of the medical commissioner posts created by the 1857 legislation.111 In contrast, Skae’s response appears to have been more liberal.

I feel deeply interested in the subject you have taken so warmly in hand, [and] the more I reflect upon the general apathy regarding it, the miserly penuriousness of those deeply interested bodies—the Parochial Boards—[and] the many other obstructives [and] obstructions in the way of a reform proceeding from ourselves—the more I feel convinced it is your special mission to draw public attention to the Subject in such a way that Government will provide an efficient remedy for existing evils.112

Skae agreed that all private asylums required efficient surveillance, but he thought public ones had nothing to fear from a well constituted commission. Nevertheless, for Scotland, he favoured a toning-down of the powers that the equivalent English commissioners already had, “public Asylums being to a great extent regulated well by their own Managers [and] their publicity”.113

In other letters to Dix, Skae described the visit of the commissioners to the REA and his more detailed views on reform were subsequently published.114 Skae also wrote privately to Dix about the failure of his candidature:

You must have long ago consigned me to forgetfulness—[and] put me in your catalogue of very rude Scotsmen … [a]t the time of receiving your letter I was busily engaged canvassing for an appointment as one of the two Medical Commissioners under the new Lunacy Act for Scotland which followed upon the Report of your Commission to Parliament—I was disappointed, [and] Dr Browne of the Dumfries Asylum & Dr Coxe were appointed. They have been working very hard since 1st Jany [and] have a great deal of work before them—but it will be one or two years before the Great Object of the Bill is effected—namely the erection of new Public Asylums so as to remove all the pauper patients from those miserable private houses which you visited.115

Conclusion

Skae’s work illuminates a number of themes in the history of psychiatry, especially with reference to Edinburgh and broader Scottish developments. Those concerning the historical understanding of mental disease practice, psychiatric scientific naturalism, Scottish lunacy reform and the classification of insanity are most pertinent. As a scientific general practitioner of insanity, Skae insisted upon the pervasive connection between the practice of medicine and the practice of psychiatry. This has frequently been lost sight of in sociological and some social historical approaches in which alienism is presented as a distinct specialty sooner than it probably was. Here the emphasis has been less on specialist psychiatry and more on general medical practice. The latter remained Skae’s main preoccupation and this may have been so for others too.

Skae’s approach to the care of the insane took very little from phrenology. Nor did it draw much upon degenerationist fears about increases in insanity that appear to have motivated Clouston and many other alienists of the next generation.116 What connected the medical and the social aspects of Skae’s work was a far broader ideology about the role of the medical man that developed in nineteenth-century Britain. This has been termed scientific naturalism, although most studies of it focus upon its natural philosophical and wider cosmological aspects rather than its application to medical or mental disease practice.117 A task ahead for the history of psychiatry is to investigate how asylum medical men committed to psychiatric medical naturalism attempted to organize and deliver care to their patients in a society dominated by alternative ideologies of increasingly powerful central and municipal government agencies and the law.

In their zeal to reform pauper insanity, Scottish asylum physicians exculpated public chartered asylums from improprieties of any kind. In their eyes, medical and administrative governance and strong connections with local communities of supporters inhibited the kind of abuses Dix had found in Scottish private asylums. Despite some clear differences with Browne, Skae’s stance towards reform was entirely typical in this respect. He believed that the science and art of medical superintendence in Scottish chartered asylums was truthful, self-evidently good, and socially virtuous. His faith in new Scottish pauper asylums to come was similarly based.118 Yet the 1857 Act and its successors were probably of less significance to him than an on-going professional and ideological dispute about how care of the insane should be determined by medical not financial need. Skae’s entire superintendence at the REA took place under the long shadow cast by the new Scottish Poor Law of 1845. How this affected his scientific medical work, and that of other nineteenth-century Scottish asylum resident physicians, deserves further investigation. This could offer another perspective on the important question of what, if anything, was distinctive about the history of Scottish psychiatry at this period.119

Skae’s attempt to reform how physicians classified insanity was not adopted outside a small group of his pupils, who themselves began almost immediately to modify its categories.120 This is unlikely to have concerned him much during the decade marked by the first public airing of his views and his death from cancer of the oesophagus. He always regarded this part of his work as “a skeleton theme”, yet one “full of interest to all” and expected his successors to flesh it.121 It is certainly possible to connect Skae’s classification of insanity to other so-called “Somato-Etiological” schema emerging in Britain, Europe and America around the same time.122 Here, however, it has been viewed as a distinctive expression of a long line of inductivist thinking about natural order. Berrios has identified a need for studies of psychiatric classification from a social historical point of view.123 Skae’s description of “laying down [his] ideas synthetically as [he had] formed them” about the classification of insanity is an invitation to retrace his steps and find wider social significance in them.124 The uses made of his views by Scottish followers and English critics provide important signposts for understanding the historical meaning of contested classifications of insanity. They were representations informing a debate that extended beyond the professional role of alienism and the nature of mental disease practice to how the mind, brain and mental illness were to be conceived and treated within later-nineteenth-century British society.