0010.1177/0957154X221094689History of PsychiatryWu research-article2022 Madness and Psychiatry in East Asian Countries in the Modern Period: Article Relaying station for empires’ outcasts: managing ‘lunatics’ in pre-World War II Hong Kong History of Psychiatry 1–14 © The Author(s) 2022 Article reuse guidelines: sagepub.com/journals-permissions https://doi.org/10.1177/0957154X221094689 DOI: 10.1177/0957154X221094689 journals.sagepub.com/home/hpy Harry Yi-Jui Wu National Cheng Kung University Abstract This article explores how ‘lunatics’ emerged and how they were managed beyond the capacity of institutionalization in colonial Hong Kong in the second half of the nineteenth century and the first half of the twentieth century. The story contests the conventional historiography about madmen that focuses on institutions. Unlike in Britain or in other East Asian colonial cities, inpatients stayed at the asylum only for very short periods. Instead of psychiatric admission, they were then transported by ship, either to Canton in China or to London for further care until after World War II. This article analyses how this was done to maintain a ‘clean’ city-scape, as well as an instrument to ensure the smooth operation of the port city. Keywords Colonialism, Hong Kong, Kerr’s Refuge, lunatics, repatriation On 16 September 1927, a man attempted suicide by jumping into Victoria Harbour, and was soon spotted by a sailor on a ferry. According to the report, the ferry was not fast enough to catch up with the suicidal man, who swam away. Later, the man was arrested by an Indian police officer, but he escaped. When the man was again restrained, he told his story. Originally a farmer, the man had come to Hong Kong from Nanjiangkou, an agricultural town in Canton Province, to make a living. However, he did not wish to become either a coolie or a policeman. With all his plans and hopes dashed, the man had decided to end his life. After his capture, he awaited the magistrate’s decision either to put him in the hospital or send him back to China.1 This was a common story in Hong Kong newspapers during the first half of the twentieth century. In 1927, Hong Kong had only one mental hospital, Victoria Hospital, available to admit ‘lunatics’. Victoria Hospital was established as a custodial facility in 1925, but its purpose was changed to treating mental patients of both European and Chinese origins. The hospital had only 23 beds, not nearly enough to treat those in need among a population of over 725,000 (Lo, 2003).2 At this time, Hong Kong began to receive rapid influxes of Chinese migrants, mostly labourers who sailed to the port city to earn a better Corresponding author: Harry Yi-Jui Wu, Cross College Elite Program, National Cheng Kung University, No. 1 University Road, Tainan City, 701. Email: [email protected] 2 History of Psychiatry 00(0) living for themselves or their families. These labourers went on strike from time to time, because of low wages and poor working conditions in the early twentieth century during Hong Kong’s first phase of industrialization (Carroll, 2007). Compared with records for infectious diseases, records on mental patients from the period are relatively scarce and incomplete (Yip, Huang and Liang, 2018). Thus, indepth insight into the mental illnesses and their causes cannot be determined. Most patients, after a short hospitalization, were sent back home to the government hospital for long-term care, if necessary, or, if they were Chinese, to the John Kerr’s Refuge, a mental hospital built in Canton in 1897. European patients were mostly repatriated back to London for care or further hospitalization. The history of ‘lunatics’ in Hong Kong cannot be understood simply by looking at asylums, for institution admissions do not reflect the full picture of how those of unsound mind were managed. The term ‘lunatics’ was commonly used, but a precise or detailed medical definition is unavailable during the time frame in this article. Historically, the establishment of asylums and the formation of psychiatric disciplines have served as convenient lenses through which authors in psychiatry can view the how empires or other authorities treated individuals who were deemed unfit to navigate regulated modern life (Mahone and Vaughan, 2007). Two decades ago, Richard Keller appealed for an investigation of the combined impact of Michel Foucault and Edward Said on psychiatry in colonial settings, but he did not include East Asia (Keller, 2001; Ma, 2015). In the context of China, historical accounts have proliferated over time, analysing the formation of various Chinese mental institutions, mostly in large cities, such as Peking, Shanghai and Guangzhou (Baum, 2018b; Wang, 2019). These institutions share several common characteristics: modern hospitals built by Europeans or Americans, who were mostly missionaries, as evangelical or philanthropic projects in China; these hospitals provided mental health care for Chinese patients and introduced modern psychiatric knowledge. Like the man described at the beginning of this article, inmates stayed in these institutions only temporarily, typically from several hours to days, without professional assessment or treatment In other words, current historical studies of colonial and Chinese psychiatry are insufficient to explain the treatment for lunatics in Hong Kong. In the British crown colony of Hong Kong, mental asylums developed relatively slowly from the mid-nineteenth to the mid-twentieth century, in ways that apparently reflect the old saying about the free port as a place of ‘borrowed place and borrowed time’. Compared with those in nearby cities and in the British motherland, the asylums remained small and their therapeutic functions were restricted. According to David Wright, the Western world saw a rapid growth in mental asylums from 1800 to 1914, with 300,000 individuals committed therein in England and Wales (Wright, 1997: 137). Madness came to be defined exclusively and unambiguously as a medical illness, and patients were kept in asylums for long periods of time. Unlike in Britain, inpatients in Hong Kong stayed in an asylum for only brief periods, during which they were not treated specifically for psychiatric illnesses. When medical historian Mark Harrison (2015) raises the idea of a ‘global turn’, he breaks away from conventional historiography, which sees the globalization of medicine through diffusive patterns. Rather, he cites examples from the past two centuries, noting that much scholarship considers medical traditions within colonies or nation states. Harrison proposes a broader perspective by looking at how ‘Western medicine’ has emerged in the non-West through a global market that has allowed trajectories of disease transmission to develop in tandem with commodity exchange. This notion can be put to the test in the development of Hong Kong’s mental health services, for several reasons. First, psychiatry plays a limited role in shaping mental health services. Second, the visibility of the mentally ill has emerged along with increasing economic activities in the growing port city. Third, the short stays and ongoing flow of patients in and out of mental asylums matches the map of the global Chinese labour supply chain. According to the available data from the Hong Kong Government Gazette between 1875 and 1939, the number of residents in Victoria Hospital and the other asylums never exceeded 30 people 3 Wu (Table 1). These patients were admitted for various reasons, but were not offered specialized psychiatric care until after World War II. The present article aims to explain the situation of those who unfortunately became lunatics in Hong Kong, either before or after their admission to mental institutions. At a time when psychiatric professionals were not yet available, such management of mental patients was considered as a measure to maintain a ‘clean’ city-scape, as well as an instrument to ensure the smooth operation of the port city. This arrangement was not only shaped by the geopolitics of the colony regarding the varying Sino-British relationship, but was also supported by a larger, inter-imperial project to remove so-called lunatics for obvious commercial and administrative reasons. Table 1. Statistics of patients in Hong Kong’s mental asylums and the Victoria Hospital, 1875–1939. *(Res. = Residents; Admiss. = Admissions; C, R, T = Cured, Relieved/Treated). Year Res. Admiss. C,R,T Died Year Res. Admiss. C,R,T Died 1875 1876 1877 1878 1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 0 0 0 1 0 1 2 1 0 0 2 5 5 3 3 4 5 10 18 16 n/a 12 9 6 9 15 13 11 17 22 17 22 18 0 0 0 4 6 9 10 8 8 6 16 10 5 4 5 8 13 41 22 31 n/a 116 127 82 69 94 77 109 138 144 160 162 204 0 0 0 3 4 8 11 8 8 4 13 10 7 2 3 6 7 29 19 38 n/a 103 118 73 54 88 71 90 121 136 n/a n/a n/a 0 0 0 2 0 0 0 0 0 0 0 0 0 2 1 1 1 4 5 6 n/a 16 12 6 9 6 8 13 12 13 7 9 13 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 21 18 26 26 30 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 191 123 169 194 243 259 169 201 217 214 217 182 224 300 235 309 347 308 290 267 250 252 293 288 277 316 307 310 376 359 424 436 n/a n/a n/a n/a 202 224 111 117 102 204 217 185 206 270 234 306 0 281 274 229 236 239 282 285 260 306 301 304 347 334 334 373 11 13 9 14 26 17 15 4 6 10 7 8 3 8 1 3 7 9 16 18 20 20 8 7 11 9 3 3 21 20 31 36 *Between 1875 and 1895, numbers show those who were admitted to the temporary asylum. Starting from 1905, numbers of ‘cured and relieved’ patients were no longer counted; instead, only ‘treated’ patients were recorded. In 1906, the Legislative Council passed the Asylum Ordinance. Source: The Hong Kong Government Gazette, 1875–1939. 4 History of Psychiatry 00(0) Resituating Kerr’s Refuge Institutional power has always been a concern of medical historians in Hong Kong. Most writings consider hospitals and charitable organizations either as facilitators of modern medicine or as prisons that are a by-product of modern urban life. However, this historiography is not easily applicable to the development of mental health. Free services were provided at the Alice Memorial Hospital, built by the London Missionary Society in 1887, and later at Tung Wah Hospital, established in 1872 to provide traditional Chinese medical care. These institutions were vital for Chinese residents’ access to and familiarity with hospital care (Sinn, 1989: 19–22). The establishment of the Bacteriological Institute also laid the foundation for medical research in Hong Kong (Leung and Furth, 2010: 75); today, its legacy is still being carried out through the time of SARS and COVID19. Regarding the development of psychiatry, most historians agree that John Kerr’s Refuge was the prototype of the mental hospital in southern China, which indirectly eased the burden in Hong Kong (Blum and Fee, 2008). John Glasgow Kerr (1824–1901) was an American missionary doctor and philanthropist who arrived in Canton from Ohio in 1854 to work on vaccination projects in the ophthalmic hospital of missionary Peter Parker (1804–88), before lobbying for a refuge for the mentally ill (Anderson, 2006). From the perspective of institutional design, Kerr’s Refuge was a gem that combined the beauty of Eastern and Western architectural philosophies (Szto, 2014). Yet, similar to asylums in other Chinese cities, such as Peking and Shanghai, most historical accounts describe Kerr’s Refuge as one example in a series of medical experiments spanning two civilizations. This perspective fails to consider the uniqueness of Kerr’s Refuge as part of a broader interimperial network. Regarded as the original model for the mental hospital in modern China, Kerr’s Refuge was born as part of a strategic plan to convert the Chinese to Christianity within the niche missionary market-place of Hong Kong and the inadequate care capacity of its colonial government. In 1890, during its first assembly, the Medical Missionary Society drafted a proposal to study the possibility of establishing an asylum for the insane in the Chinese empire. In the late nineteenth century, various missionary task-forces planned their work in different parts of China. The proposal was first sent to Chang Chih-Tung (1837–1909), the Viceroy of the late Qing, who was influential due to his advocacy for controlled reform to modernize China. Yet, despite his three-decade effort in the Westernization Movement and his close relationship with the Hong Kong government, Chang did not fully support the proposal. John Kerr then insisted that the building of the mental asylum should become an international effort.3 He first used his money to obtain a 17-acre plot of land in Fang-tsun, a village in southwest Canton facing the Pearl River.4 The construction could not be completed without financing from Hong Kong sources. In contrast to Tung Wah Hospital, which was a dungeon-like facility, Kerr’s Refuge was: [a] large two-storey building, with wide verandahs and iron bars, looking out on a large lawn, and overlooking the grounds of the Civil Hospital. . . . Each cell, with a heavy door and grating, was fitted with a comfortable bed, the large room being the dining room.5 The doors of the Refuge opened in 1892. However, its expansion in the early twentieth century relied on the influx of inpatients from Hong Kong. Who were the ‘lunatics’? The designation of ‘lunatics’ for Hong Kong’s outcasts existed long before any mental institution was built. Over time, their status, together with that of other unwelcome individuals, had been Wu 5 characterized within various ordinances as primary legislation. Without a medical definition, those who did not participate in society in common ways were grouped as one of the outcast categories, to ensure efficient operation of the entrepôt without having to waste public funds on their care. In 1854, an ordinance was passed ‘to Invest Her Majesty’s Consuls in the Ports in China with Jurisdiction over the Persons and Property of Lunatics and Persons of Unsound Mind, as also with the Power inherent in the Office of Coroner’.6 Very soon, another ordinance incorporated Hong Kong and Shanghai Banking Corporation’s indenture to define categories of individuals who were unable to become shareholders, such as married women, bankrupt people, infants, ‘idiots’ or ‘lunatics’.7 Later, in 1873, insane individuals were ‘not allowed to produce evidence at court’ (Hong Kong Government Gazette, 1873). Similar to the modern legal concept of interdiction, these ordinances were made for commercial reasons to prevent insane individuals from conducting business in the crown colony. During the1890s, with mounting public disturbances caused by people arriving in the free port, it was observed that living spaces in the old prison were already larger than those in common households (Tsai, 2001: 59). The colonial government attempted to deal with the ailing social order by keeping problematic individuals out of sight. The Imbecile Persons Introduction Ordinance (1904) required: The owner, charterer, agent, consignee, and master of every vessel from which is landed without permission from the Principal Civil Medical Officer or Health Officer any person not ordinarily resident in the Colony who, being at the time of landing, lunatic, idiotic, or imbecile, shall become within a period of 3 months from the date of landing a charge upon the public or upon any public institution, shall be liable to repay to the Government any expense on account of such person by reason of his care, maintenance, or repatriation, unless such owner, charterer, agent, consignee, or master can prove that such person became lunatic, idiotic, or imbecile, after embarkation. at the port or place from which he shipped: Provided that such expense shall in no case exceed the sum of 5,000 dollars in the aggregate. The authorities were thus able to shirk the responsibility for paying any costs due to disturbances caused by these individuals. The most convenient way to manage themwas to take them into temporary custody. During the first two decades of the twentieth century, the influx of migrants caused various social, economic and health-related problems. In the 1920s, the growth of left-wing politics in Britain altered the Hong Kong government’s ‘non-interventionist’ approach to the colony’s governing policies. Voices became louder to consider residents’ social welfare. However, the Chinese elites and government strategists at the time agreed more with the tactic to spend less on the planning of social welfare systems (Goodstadt, 2004). Regarding medicine and health, the colonial government still faced a tumultuous society as a more pressing challenge, and it did not want to improve the city’s insalubrious conditions. The industrialization of the port city led to extensive tensions between labour and management, resulting in episodes of unrest. Thus, the government’s emphasis on social order rather than on residents’ health became the norm (Tsai, 2001: 121–172). Medical and health officials had little to do with producing or enforcing sanitation rules until 1936, when consideration was finally given to assigning local responsibilities for health-related agenda under the newly formed Urban Council (Gauld and Gould, 2002: 38). Nevertheless, in the 1930s, with the population of Hong Kong continuing to grow, the Immigration and Passports Ordinance stated that those classified as ‘diseased, maimed, blind, idiotic, lunatic, or decrepit and without the means of subsistence – while possibly being hindered by their state from earning a livelihood’ were prevented from landing in the port or would be expelled.8 6 History of Psychiatry 00(0) In the late nineteenth and early twentieth century, psychiatric or psychological sciences were commonly incorporated into the British empire’s controlling governance over its colonies. Individuals were often deemed mentally disabled due to having a reduced capacity in accordance with then-popular racialized scientific theories. However, in Hong Kong, such prejudiced practice was not apparent. On the contrary, amid the utter lack of development in the psychological or psychiatric sciences, the concept of lunacy was only a small part of the operation chain involving different sectors, including asylums, to deal with various social disorders. Despite the introduction of the Asylum Ordinance in 1906, no practical medical treatment was available for the mentally ill in Hong Kong. In the ordinance, ‘asylums in Hong Kong’ actually meant any institutions, or places the governor might declare as such, for the ‘detention, custody, and care of persons of unsound mind’.9 To designate an individual as a lunatic, the authorities did not need to consult any medical opinion. Before standard operating procedures were developed, measures taken to manage lunatics were harsh and inconsistent. The ignorance of government and society, whether intentional or not, resulted in a disparity between the ways in which lunatics were managed and the medical effects. Against the backdrop of Hong Kong’s incapacity to care for lunatics, the city started to repatriate them to their home countries and also to collaborate with other governments. In the 1860s and early 1870s, due to the lack of asylums in the colony, insane patients were either confined in the Victoria Gaol or sent to the Government Civil Hospital, from which they were to be sent on to their native countries.10 Insane individuals were often remanded by a magistrate when they arrived in Hong Kong by sea. The ‘mentally ill’ were sometimes sent to the Civil Hospital, but if it was overcrowded, they were unfortunately sent to the Victoria Gaol. After 1875, when the temporary mental hospital opened, news reports on lunatics began to proliferate, such as suicidal individuals captured on the Praya (the promenade) and European seamen turning aggressive before reaching the shore of Hong Kong (Wu, 2021). This category of the mentally ill was often connected with the unique city-scape surrounded by ocean. With the function of mental asylums still limited, transport by sea naturally became the most convenient way for the colonial government to handle lunatics. Politics of repatriation For a government that wished to express its humanitarian concern about the welfare of lunatics, but also to avoid expensive, resource-intensive accommodation or treatment, the best strategy was to send patients to more specialized care elsewhere. This mentality of keeping lunacy ‘out of sight, out of mind’ lasted for a century (until the end of World War II), reflecting – and reflected by – three aspects of the increasingly problematic situation. First, the capacity of various asylums was nowhere near the level needed to accommodate the growing number of lunatics. Although voices were then being raised more frequently in favour of providing humanitarian custody for the mentally ill, reform was slow and heedless. Second, Kerr’s Refuge in Canton continued to expand; many of its inpatients did not come from the Chinese inland but were sent north from Hong Kong. Third, when paying the ship fare for the repatriation of the insane, the manner in which bills were to be settled, by ordinance, clearly revealed the colonial government’s wish to remove them as soon as possible. Conflicts about repatriation often arose with the Hong Kong consulates of various countries when they refused to pay the bills for shipping the insane. Rather than spending additional money to put the mentally ill into institutions, the Hong Kong government often paid to send away ‘lunatics’ of various nationalities, even though the ordinance stated that their fares should be paid by the companies owning the ships that had brought them to Hong Kong. The transfer of the city’s ‘outcasts’ began with convicts. To keep Hong Kong peaceful and orderly, the government exercised surveillance, detention and deportation of troublesome people before the free port developed its capacity to resort to coercive measures (Holdsworth and Munn, Wu 7 2020). The route used to transfer criminals away from the various British colonies was much discussed. Although they were sent from different ports in Asia – for example, Shanghai, Singapore, and different ports in India – Hong Kong became the ‘relaying station’, not only deporting individuals but also receiving those rejected by other places. Being the most important entrepôt in Asia and geographically close to China’s first mental hospital in Canton, Hong Kong naturally became the ideal place to receive and deport both Chinese and non-Chinese lunatics, compared with other port cities such as Shanghai in China and Singapore in the Strait Settlements. For example, in 1924, the British Supreme Court in Shanghai ordered two British Indian natives be sent to serve their life sentences at a prison in India. The pair eventually landed in Hong Kong, after the government of India refused their entry.11 By 1937, the work of deportation reached its peak with over 17,000 people dispatched from Hong Kong: among them were approximately 9,000 discharged prisoners, 3,000 beggars and 2,500 people with ‘bad characters’ who were not sufficiently liable for court prosecution.12 Repatriation began almost as soon as mentally-ill individuals began to surface in Hong Kong. The non-Chinese were mostly transferred via different routes to London, while the Chinese were sent to Canton after Kerr’s Refuge was completed. This arrangement often faced immense resistance from the destination countries, resulting in the requirements of complex procedures before the removal of patients. In the second half of the nineteenth century, the governors of Hong Kong continually sent requests to Britain’s Secretary of State for the Colonies, expressing a wish to repatriate European lunatics to their own countries. One reason given was a then-popular, racialized belief in bodily degeneration caused by the tropical climate. In 1877, the 8th Governor, Sir John Pope Hennessey (1834–91), wrote to Earl of Carnarvon, saying: there [were] no proper means for treating lunatic patients in this Colony, and while therefore on the simple ground of humanity it is highly important owing to the nature of the climate that European and American pauper lunatics should be sent as soon as possible to their own countries, it is doubly necessary where the Hospital accommodation is lamentably deficient and unsuitable for their detention.13 By contrast, European consulates in Hong Kong often rejected collaboration with various excuses. For instance, a Norwegian consul expressed his regret at not being able to take charge of a lunatic passing by the Strait Settlements en route to Europe. He required the individual to obtain a certificate of nationality from the government before dispatching him.14 Intergovernmental disputes over the repatriation of lunatics lasted for decades. In Hong Kong, despite a temporary facility finally becoming available in 1875, the colonial government did not have adequate resources to provide long-term care for lunatics, nor had it invested in developing specialized psychiatric expertise due to a lack of administrative support in healthcare. In 1912, the 15th Governor of Hong Kong, Sir Francis Henry May (1860–1922), expressed his vision of care for the mentally ill. Similar to the above requests, he wrote to Secretary of State for the Colonies, Lewis Harcourt (1863–1922), that ‘Hong Kong has never done more than provide a temporary place of detention for lunatics pending their repatriation to their country of origin’. He also noted his wish that in cases ‘in which the colony itself is the country of origin it is prepared to pay whatever charges may be made by the country with which the lunatic is identified racially’.15 Disputes on who should pay for repatriation were ongoing. The colonial government first sought help from family members of the mentally ill before defraying the cost using its funds. As noted above, conflicts among governments often arose.16 For example, a German criminal was first taken into custody for larceny in 1897. He was then found to suffer from ‘general paralysis of the insane or delusional Insanity’ and the Gaol Medical Officer suggested he should be relocated to the mental 8 History of Psychiatry 00(0) asylum. After the patient had spent more than three years in confinement, Governor May wrote to the next Secretary of State for the Colonies, Joseph Chamberlain (1836–1914), to complain about the German government’s refusal to pay the sum of US $3,321 for the patient’s transfer.17 In 1903, another dispute over the responsibility for care and payment arose in the case of a manic German sailor who worked on a French ship. The man attempted suicide by jumping overboard when the ship arrived in Hong Kong. German authorities were responsible for the care of French sailors who fell sick while in the service of a German ship, and vice versa.18 In this case, the cost should thus be settled by French authorities. However, if no inter-consulate agreement was reached, the Hong Kong government often provided temporary custody and covered the expenses. From the perspectives of different governors, arranging for repatriation was a way to ensure that patients could receive the best care and treatment. In the distant colony of Hong Kong, in the midst of each patient’s winding journey of repatriation, professional treatment and care was understandably unavailable. According to Francis Henry May, who expressed his view in a legislative council meeting, ‘Ships [are] very unwilling to take away a lunatic, and the negotiation with a foreign government for the reception of such lunatics into their own countries are very difficult and protracted’.19 As a result, mentally-ill individuals who were refused entry elsewhere were left in Hong Kong, and several of them unfortunately became permanent inmates in places of detention, including gaol. Among 12 attempts at repatriation to various countries, the case of an Indian native was cited as a detailed example, as described in the man’s own agonized letter. The man was conveyed on a vessel to take him to Ceylon,20 which however refused his arrival. The vessel then carried him to the Red Sea, met an outward-bound ship of the same company, which transferred him back to East Asia. He was eventually dumped in Hong Kong. As the nexus of cross-country transportation, Hong Kong often became the final destination where others sent the insane. For example, in 1917, James W. Jamieson, the British Consul in Shanghai, wrote to Claud Severn, an administrative officer in Hong Kong, planning to transfer a patient suffering from mental deficiency and degeneration. The patient had stayed at Shanghai’s Victoria Nursing Home for four months and was now to be sent to Hong Kong due to a shortage of charity funds.21 Thus, patients arrived in Hong Kong because the available funds in Britain’s other colonies were insufficient to cover longer periods of stay. Yet patients were unlikely to find better care in Hong Kong, where even fewer resources and less support were available. Chinese lunatics were at times directly escorted by the police to the authorities in Canton, a practice that was commonly described as kai seng. In Cantonese, kai means ‘to send under guard’; seng, originally meaning the ‘province’, refers specifically to the province of Canton in the discourse of Hong Kong’s history. One news article reported that nine lunatics arriving in Hong Kong via a ferry were all sent straight back to Canton.22 In 1898, after Kerr’s Refuge in China began to receive patients, the Hong Kong government’s plan to send lunatics there did not always go smoothly. The Refuge had difficulties in admitting patients because the Chinese tended to keep their insane family members in their homes until they had become a public nuisance (Baum, 2018a). Starting in 1909, the colonial government began to pay the Refuge a stipend to accept its lunatics on a routine basis. This decision faced opposition from within, along with other sociopolitical factors. In 1910, an anonymous person, Z. Z. Z., wrote a letter to complain about the British ConsulGeneral soliciting funds to support the care of lunatics in Kerr’s Refuge. ‘What has a lunatic asylum in Canton to do with us in Hong Kong? And why should I spend my money on keeping Chinese idiots alive?’23 Soon afterwards, in 1912, the repatriation plan was disrupted by the political turmoil preceding the Republic’s establishment.24 Beginning in the 1920s, Chinese patients were more frequently escorted to Kerr’s Refuge, partly because of a tighter social and commercial bond between Hong Kong and Canton (Tsai, Wu 9 2001: 161). Although the repatriation was at times hampered by political turmoil, the colonial government saw a growing necessity to develop cooperation with China because its prosperity increasingly depended on the accessibility of the mainland market (Goodstadt, 2004). Lunatics certified by the Sanitary Board temporarily stayed in Hong Kong before being sent by ferry to Kerr’s Refuge under Guangzhou City’s authority.25 The second half of the 1920s also saw an unstable relationship between the two authorities, which for years overturned the plan to escort patients to Canton. The Canton-Hong Kong strike lasted over a year, starting in June 1925, as an angry response by the Chinese people to the massive killing – under British command – of anti-imperialist protesters in Shanghai. In 1925 and 1926, only 15 cases were sent to Canton among 290 patients admitted to Hong Kong’s lunatic asylums.26 In 1926, the Governor of Hong Kong and the Trustees of Kerr’s Hospital agreed to send back to Canton only those patients who were not born in Hong Kong.27 By the 1930s, when the medical infrastructure in Hong Kong became more established, lunatics received a certain degree of ‘treatment’ at the government’s Civil Hospital before being escorted to Kerr’s Refuge. By doing so, the colonial government could continue its commitment on the social well-being of the Chinese majority without having to develop mental health care facilities. The arrangement continued until World War II, partially because Sino-British relations improved after the Nanjing government was established in 1928 (Miners, 1994). The map of repatriation was broad, possibly matching the trajectories of the countless Chinese who became either merchants or coolies in the Americas and Australia via the North or South Pacific Oceans (Sinn, 2013). In 1914, for example, 22 insane Chinese from the Oregon State Asylum for the Insane were brought from Seattle to Portland and then to Hong Kong. This was carried out according to negotiations between the Asylum’s Senior Superintendent and the Hong Kong colonial government, and the decision that a patient who was expected to live for over 10 years would be sent back to China. The admission of some Chinese coolies to psychiatric hospitals in Australia was also documented. In the mid-nineteenth century, Chinese indentured labourers were used by Britain to help to build the infrastructure for Australia as another colony (Mountford, 2016: 41). Most of these labourers had arrived there via Hong Kong. Tragically, several were admitted to hospitals due to miscommunication, and some stayed there for life, often dying eventually of infectious diseases, as there no arrangements to take them back home. For example, one coroner reported the death from dysentery of a 45-year-old Chinese man after 17 years at Yarra Bend Hospital in Victoria.28 Conclusion In a recently published chapter, I have sketched out the landscape of Hong Kong’s mental health care history by commenting predominantly on various developmental phases of mental asylums and other means to maintain the public order in Britain’s most important colony in Asia (Wu, 2021). From the mid-1870s onwards, different mental institutions were available, but their size and care capacity were far from sufficient to accommodate the growing number of individuals in need of mental treatment. Such strategized incapability of care resulted in the drifting of Hong Kong’s ‘lunatics’, and their fate of meandering in the ocean did not begin to find an anchor until the end of World War II, when the government began to consider providing specialized health care by building large-scale mental hospitals. Trained psychiatrists began to teach at the university, to see patients in mental hospitals and to cooperate with the colonial government in settling court cases related to insane criminals. Whether the introduction of modern psychiatry improved the mental well-being of Hong Kong residents is also questionable. Born in Malaysia and trained at Cambridge, Pow-Meng Yap 10 History of Psychiatry 00(0) (1921–71) was one of the most important early figures who laid out the blueprint for the development of modern psychiatry in Hong Kong. In the 1950s, with Yap’s assistance, Castle Peak Hospital was planned to provide specialized psychiatric services in the New Territories. However, the development represented several ironies. First, in 1949, with the further influx of migrants to Hong Kong, an ordinance was passed to control the colony’s population through the expulsion of ‘undesirables’. By law, ‘undesirables’ included the ‘diseased, maimed, blind, idiot, lunatic, or decrepit not having the means of subsistence and may be hindered by his state from earning a livelihood’.29 Also prevented from entering Hong Kong were vagrants, beggars, prostitutes, unemployed, people receiving charitable benefits, patients with contagious diseases, or individuals who might promote sedition or cause a disturbance of public tranquillity.30 Second, the growth of institutions in Hong Kong contradicted the international trend to de-institutionalize mental patients. Facilities that made the best use of Hong Kong’s archipelagic nature to isolate lepers on Happy Healing Island and drug addicts on Shek Ku Island further embodied the unique geopolitics of the ‘Pearl of the Orient’ in early post-war history. Third, records show that patients sent to John Kerr’s Hospital before World War II were still under care at the expense of the Hong Kong government until 1959, when Kerr’s Hospital stopped sending them invoices for unknown reasons, and several patients went missing from the institution.31 A recent historical study of Hong Kong mentions two major challenges during the city’s post-1949 transformation: migration and inequality, which hampered the affluent accumulation of financial and social capital (Hamilton, 2021). Such challenges, as divulged through this story, should be historicized as the expulsion of problematic new arrivals as a crucial measure to ensure the entrepôt’s affluence since the 1850s. Unlike other colonies held by the European or East Asian empires, such as Japan, in the free port city of Hong Kong, ‘movement itself was a self-perpetuating source of profit and an interest to be defended’ (McKeown, 1999: 320). The removal of those suffering from mental health challenges was thus seen as a means for the colonial authority to maintain the normal functioning of the port, especially in business matters. Much of this intervention was passive, at times taking the form of mere practical management after crises. Movement itself, including repatriation, became a legitimate mega-plan to safeguard the port operations. In this sense, the smooth operation and abundant cash flow in the port city can be seen as a kind of ‘profit’, in McKeown’s (2001: 77) words, for the colonial government. Whether or not they profited financially from transporting the insane requires more primary sources for further analysis. However, it is clear that mental illness in Hong Kong cannot be portrayed simply through the lens of institutions. The ways in which the mentally ill were managed in this atypical colonial city reflect the multiple interests of the British Empire and other foreign stakeholders beyond the immediate colonization purposes. The development of psychiatry partially reflects newly emerging historiographies, from the millennium onwards, which view Hong Kong as an entity at the edge of British and Chinese empires, an ‘in-between place’ that involved frequent transits and detours of overseas Chinese, a concept within the discourse of Canton Pacific (Carroll, 2005; Sinn, 2013: 166; Yu, 2011a, 2011b). The ways in which human subjects moved in and out of Hong Kong could also be assessed against the negotiated network among treaty ports, which was the financial circle emerging in maritime Asia before colonialism (Hamashita, 2003). The conventional historiography of colonial psychiatry emphasizes the social, political, technological and professional power of colonized people. In Hong Kong, this power reified the stereotypes of racial classification under the colonial gaze. Yet, before the psychiatric profession emerged in the mid-1960s, the demarcation between sanity and madness was not drawn under a clinical gaze; nor were lunatics predominantly managed through confinement and therapy. Rather than focusing on the conditions in mental asylums, this article underscores the value of 11 Wu considering institutions outside the colonial territory and the networks among different empires. In addition, the journeys of ‘lunatics’ in Hong Kong are dignified, from a ‘ship of fools’ to ‘the great confinement’ to modern psychiatry. In the absence of modern psychiatry, confinement was transient as the mentally ill were left adrift on a ship without anchor, at least in Hong Kong prior to World War II. Acknowledgements The author thanks Gabriel Sze Man Chan for compiling Table 1. Declaration of conflicting interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is supported by the General Research Fund, Gerda Henkel Stiftung. AZ 26/V/21 under the project title: Sad Waters: Lunatics of Hong Kong and Beyond. ORCID iD Harry Yi-Jui Wu https://orcid.org/0000-0002-0884-9311 Notes 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. The China Mail (16 Sep. 1927) Lunatic jumps into water. 725,000 was theapproximate number in 1925. The China Mail (21 Feb. 1890) An asylum for the insane. The place is nowadays known as Fangcun in pinyin. Report on the Tung Wah Hospital by The Honourable T.H. Whitehead. SP 1896. In: Hong Kong Legislative Council Sessional Papers. 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