‘Pinel of Istanbul’: Dr Luigi Mongeri (1815–82) and the birth of modern psychiatry in the Ottoman Empire

Introduction

In the classical age of the Ottoman Empire, the insane with uncontrollable and violent behaviours and the insane who were deemed dangerous to the social order were confined in various places (Mossensohn, 2009: 139–40) such as darüşşifas (general hospitals), tekkes (dervish lodges), monasteries, prisons or houses (Artvinli, 2013: 28). The rest of the insane were allowed to live freely in the community. ¹ Darüşşifas were built in city centres and were for people with all kinds of illnesses, including mental ones (Mossensohn, 2009: 135). The darüşşifas had separate rooms for mentally-ill people and medical staff to provide these patients with care and custody.

At the end of the eighteenth century, some of the old darüşşifa buildings were specifically assigned to mentally-ill people, and the buildings where the patients were given care and custody were called bimarhane, that is, lunatic asylum (Artvinli, 2013: 25). Süleymaniye Bimarhanesi was the central lunatic asylum in the Ottoman Empire at the beginning of the nineteenth century. Local and foreign visitors, travellers and physicians wrote eyewitness accounts of the poor conditions in Süleymaniye Lunatic Asylum. They wrote about its lack of modern doctors and hygiene, and how heavy chains with locks were put on the insane. ² The observations of Western travellers portrayed Süleymaniye as a place at the very centre of the city, yet tightly enclosed, forgotten and ahistorical (Artvinli, 2013: 38).

After the promulgation of Tanzimat – the Ottoman social and political reforms of 1839 – Ottoman medical institutions and asylums also received their share of the reforms. Süleymaniye Lunatic Asylum underwent minor modifications, and certain repairs were carried out during 1840 (Ünver, 1942: 205). For female patients a separate section was constructed, and the female patients in Haseki hospital were transferred to this section. The salaries of the asylum staff were increased, and the insane in other places in Istanbul were relocated to this central asylum (Prime Ministry Ottoman Archives (PMOA), C.SH. 25/1234, 9 Jan. 1845). Nevertheless, Süleymaniye still looked like a prison rather than a hospital. After Dr Luigi Mongeri was appointed there as the head physician in 1856, more reforms and changes ensued. In this article, I will examine the emergence of modern psychiatry in the Ottoman Empire through the biography and reforms of Luigi Mongeri.

Mongeri: from Pavia to Istanbul

Luigi [Louis] Mongeri (Figure 1), an Italian physician, was born in Milan on 16 November 1815. He was educated in the humanities and philosophy departments at the Gymnasium of Brera and at the Lyceum of Longone (Castro, 1882: 1). After graduation, he studied medicine at the University of Pavia. Here he studied nervous diseases, under the supervision of the renowned anatomist Bartolemeo Panizza (1785–1867), and he also conducted research on the aetiology of cholera in the general hospital in Milan. Mongeri completed his doctoral thesis in 1839 and graduated from the faculty. ³ He was offered a position at the school of medicine there, but he refused for political reasons. As a young student, he also participated in various revolutionary groups that opposed the Austrian occupation of Italy. Mongeri, whose country was occupied by foreign forces at the time, shared all the convictions and principles of the entire Italian youth with fervour and always considered himself in danger in political terms (Castro, 1882: 2–3).

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Figure 1.

Luigi Mongeri (1815–82); the photograph is from the private collection of Gianni Lapenna, and is reproduced with permission.

Mongeri came to Istanbul on 24 May 1839 and, almost as soon as he arrived, he became a physician in the Ottoman Army, which at the time was fighting the Egyptian forces in the Battle of Nizib (Castro, 1882: 3). Mongeri returned to Istanbul on 22 February 1840 and was employed in the Sinop branch of the International Quarantine Organization. ⁴ Mongeri stayed at Sinop for 20 months and organized the quarantine department there. He was then appointed as sanitary physician to the island of Crete, and served in this post until 1849 (PMOA, ŞD. 858/50; see also Castro, 1882: 3).

Mongeri was interested in the cholera epidemic, which at the time was the most important health problem on the island. He became notorious for his introduction of the strict isolation of patients; these measures disturbed the Supreme Council of Health in Istanbul and, as a result, he was dismissed by the government in 1849 (Castro, 1882: 4; Taşkıran, 1973: 8). Mongeri published his cholera experiences in Crete in the form of several articles, which were collected in a book following the Istanbul cholera epidemic of 1865 (Mongeri, 1866). After his dismissal, Mongeri began to practice private medicine and surgery on the island. In 1850 he left Crete for Istanbul and became the physician of Mustafa Naili Pasha, the Cretan who was the governor of the island, and continued in his service until 1856 (PMOA, ŞD. 858/50). Mustafa Naili Pasha was steadily promoted in the Ottoman bureaucracy during these years, and he also held the office of Grand Vizier (sadrazam) in 1853–4 and in 1857.

Avram de Castro, ⁵ who had been Mongeri’s assistant for many years, recorded the following observations in the short biography he wrote about the years Mongeri spent in Crete, and about his personality:

His benevolence, his knowledge, his honest heart made him dear to the Cretans who regarded him as their benefactor. Every persecuted patriot, every Italian immigrant was sure to find somewhere to lay his head, a table at his house and often an open pocket to meet all his needs. His hospitality was proverbial and to those who could practice a profession he generously provided the first funds that were required. There were tailors, shoemakers, pharmacists who were able to settle down on the island by successfully acquiring a position thanks to his assistance and benevolence. His humanitarian feelings were so developed that he always felt a profound sorrow for witnessing the daily sale of slaves. He frequently acted under the guise of a buyer so as to experience the happiness of liberating the slaves and he helped them regain their freedom. Such traits abounded in his life. (Castro, 1882: 4–5)

In 1851 Mongeri was appointed as the private physician for the treatment of Adile Sultan, the sister of Sultan Abdülmecid (1823–61). Having established a close relationship with the Ottoman court, Mongeri visited and inspected the hospitals in Istanbul as part of his assignment. It was at this point that he first saw Süleymaniye Lunatic Asylum, where, according to Castro, Mongeri witnessed misery, maltreatment, lack of hygiene, and chains. He was deeply influenced by the miserable state in which the patients were left, so although he received several offers to work as a physician in the major hospitals of Istanbul, he declined all of them, asking only to manage the bimarhane. His close friends and his patron tried in vain to dissuade him from this persistent desire, but in 1856 he was appointed as the chief physician of the bimarhane (Castro, 1882: 6).

Before his appointment to the post, Mongeri wrote a petition to the government setting out the need to reform the lunatic asylums in accordance with European standards. When asking to be appointed to the post at Süleymaniye Asylum, he had given his relevant studies in Italy as credentials. He noted that the medical communities in Europe were now discussing the need for a special kind of care for the insane. In this petition, he pointed out the fact that the bimarhane differed from the other hospitals; that the insane men and women who came here were unable to know right from wrong due to their illness, and hence they were literally like children, therefore it was a humanitarian duty to help them as much as one could (PMOA, İ.DH. 341/22460, 30 Mar. 1856).

The ‘Pinel of Istanbul’

When Mongeri took up the position in Süleymaniye Lunatic Asylum in order to make the reforms he promised, the institution already had two existing physicians, namely Ata Efendi and Nazif Efendi (PMOA, İ.MVL. 313/13117, 25 Aug. 1854). Nazif Efendi, who had graduated from the School of Medicine in Istanbul (Mekteb-i Tıbbiye), noted that the number of the insane sent from various Ottoman provinces to the asylum was increasing day by day and the total number of male and female patients was more than 100 (PMOA, A.MKT.NZD. 129/98, 28 Jan. 1855). The treatment in Süleymaniye was essentially based on the classical medical practices of the Ottomans: baths, bloodletting, and dietary adjustments were the principal components of the treatment, and baths were particularly important in the context of mental illnesses. Madness was then considered to be a result of dryness in the patient’s body and baths were thought to regulate the moisture of the body (Mossensohn, 2009: 82–4). The change in the secretion of black bile (sevda), which was thought to be in the brain, had an influence on a person’s psychic state; therefore, separate dietary regimes and treatment methods were applied in accordance with the amount of black bile. Since nutrients were counted as first-line drug therapy, treatment of the patients through diet was regarded as highly important. The aim of the treatment was to eliminate from the body the element that was assumed to have caused the illness in the first place (Sarı, 1988). Methods such as blood-letting, emetics, enemas, cupping and perspiration were utilized as required (Sarı, 1982: 110). Various herbal remedies were also used in Süleymaniye Lunatic Asylum. In the nineteenth century, before Mongeri’s appointment as the head physician there, the care and treatment that were offered to patients had gradually worsened, especially as a result of overcrowding.

Mongeri worked in Süleymaniye from 1856 to 1873 and carried out significant reforms in the treatment of the insane and the management of the asylum. As a result, the foreign press dubbed Mongeri the ‘Pinel of Istanbul’ (Mahmud, 1910: 28) or ‘Pinel of the Turks’ (Uzman, 1941: 78), comparing him to the prominent French alienist Philippe Pinel. One of the founders of modern psychiatry, Pinel was famous for removing chains from patients in Bicêtre Hospital in 1793 following the French Revolution. Pinel also introduced various psychological treatments called moral treatment in general (Shorter, 2005: 221).

What were the specific qualities and properties of Mongeri that made him a reformer or Pinel of Istanbul? To analyse this, one needs to go back to three significant developments in the history of psychiatry in the nineteenth century: moral treatment, the non-restraint movement, and professionalization.

The term moral treatment was coined in the eighteenth century and was used by Vincenzo Chiarugi and by Pinel in their textbooks. Pinel explained this term in 1801 as ‘the general principles to follow in psychological treatment’; he recommended winning the patients’ confidence by talking with them and treating them fairly, and by organizing daily life in the asylum, involving patients in various kinds of tasks and giving them regular meals (Shorter, 2005: 180). The non-restraint movement refers to the treatment of patients without any mechanical restraints or the removal of those restraints, and also improving the living conditions of the insane. It was thought that patients should be classified in accordance with their particular condition so as to receive the appropriate treatment; they should be employed in different activities; appropriate clothing and bedding should be provided for them; and all the patients should be treated with kindness and be supported to restore their sanity (Piddock, 2007: 42–3).

Throughout the nineteenth century, a process of professionalization in psychiatry also began to take place in Europe. Asylum superintendents like Mongeri published articles and books on insanity, formed professional associations to promote their common interests, and established journals for the dissemination of expert knowledge (Shepherd and Wright, 2002: 187–8). ⁶ By the nineteenth century, the ideas of moral treatment and the non-restraint movement had spread throughout Europe, including the Ottoman Empire.

Mongeri’s reforms and contributions to psychiatry can be evaluated against this background. Similar to other European reformers who followed the example set by Pinel, Mongeri also abandoned the use of shackles and chains in Süleymaniye Asylum. A document from January 1857, just a few months after his appointment to the Asylum, indicates that the insane had to be brought by zaptiye (policeman), and zangoç (vergers) were not supposed to use chains during the transfer of the insane from their homes or the streets to the asylum (PMOA, HR.MKT.174/26, 19 Jan. 1857). In 1863, Mongeri replaced güllabis, the traditional, non-educated asylum attendants, with new staff: caregivers (PMOA, İ.MVL. 500/22607, 25 Oct. 1863). Güllabis represented the old confinement regime in which beatings, whips and chains were common practices (Artvinli, 2013: 52; Pakalın, 1971: 686).

For Mongeri, the key question was not how to eliminate the asylum system, but how to modify it by making treatment more humane. He transformed Süleymaniye Lunatic Asylum from an antiquated and inadequate building into a medical space where patients were regularly visited by physicians and classified according to their symptoms. Other significant reforms include the introduction of the straitjacket, and the provision of regular meals and beverages, clothing, heating and so on (Castro, 1882: 6–7; Erkoç and Artvinli, 2011: 60).

Insanity in the Orient: Mongeri’s patient statistics and commentaries

Mongeri prepared and published the annual statistics of Süleymaniye Asylum between the years 1857 and 1867 in the Gazette Médicale d’Orient and later published them in a book (Mongeri, 1867). ⁷ These were the first statistics from the newly emerging discipline of psychiatry in the Ottoman Empire. ⁸ Following Pinel’s principles, Mongeri collected patient data for clinical purposes and used them for classifying mental illnesses and treating patients with various mental illnesses.

At the beginning of the book, Mongeri explicates the importance of statistical studies with regard to mental illnesses and points out Pinel as one of the champions of humanity in the field of mental health (1867: 1). Mongeri’s statistics show that between 1857 and 1867 a total of 312 female and 1193 male patients were admitted to Süleymaniye Lunatic Asylum (p. 9). He accounted for the relatively low number of female patients as due to the unwillingness of the families to send women to an asylum. He explained the low number of insane patients in the Orient in general as follows:

… the number of people admitted to asylums is far from expressing the actual number of the insane people existing in the country; and the reason is easy to grasp. People from the upper classes are never supposed to be afflicted with madness; they love silence and solitude; they are in a habitual bad mood (melancholy); they suffer from nervous attacks (mania); have tics, traits of originality (monomania); but in their case, no one dares to pronounce the word madness. Within this class, there is an excessive repugnance toward asylums, which are only used as a last resort. Up to that point, the state of mental alienation is carefully concealed. It is to some extent the same with poor people who never send the insane to the asylum at the beginning of the illness, and who only become resigned to it when they hear the claims of their neighbours, who fear … that there will be a fire accident or that the dangers that run in the sick’s person’s own family will continue. … Most of the insane people are brought to us by the police who catch them during their vagrancy at night or arrest them due to their behaviour in disrupting public order. (pp. 47–8)

In the nineteenth century, especially in France, alienists discussed insanity in the Orient and they generally agreed that the number of insane in the West was much higher than in the East because of urbanization and civilization. In the 1840s, the French psychiatrist Jacques-Joseph Moreau de Tours (1804–84), who visited lunatic asylums in Istanbul and Cairo, noted that few inmates were housed in asylums and the real number of the insane remained unknown (Tours, 1843: 14). According to him, a man in the East enjoyed a simple life that did not include intellectual activities, but a man in the West had a civilized life and his intellectual capacity was more developed. Mongeri argued that a man’s mental state was also complex in the East, but he shared Pinel’s and Tours’s ideas with regard to the relationship between insanity and civilization. Mongeri believed that insanity was on the rise in the West as a result of civilization:

European civilization, as we understand it, involves two main elements: the progress of society and the progress of individual. The first one is acquired by promoting unity by all available means: the aggregation of the masses so that by their combined forces their action may be more powerful and more lasting. The influence that the mere concentration of the population exerts on the development of madness is a fact. Also, it was precisely the great centres of population which proportionately supplied the greatest number of insane people; for it is in the great cities that commerce and industry, education, and training are joined at every level; influences which act all at once and as a power which engenders the predisposition to madness, and as a cause that can directly determine it. (Mongeri, 1867: 42)

From Mongeri’s perspective, there were certain specific circumstances in the East that led to insanity such as the extreme practices of religion. Mongeri wrote that Islam, like all religions, was absolute in its principles; it did not authorize discussion, and it commanded faith and belief. He argued that on the one hand its rigid principles prevented one from madness; on the other hand, the extreme practices that involved asceticism and violence could provoke mental disturbances or cause insanity (pp. 46–7).

Regarding sexual connotations of madness, Mongeri claimed that the advance of civilization caused mental disorders among women, and he underlined the differences between female insanity in the West and in the East from the ‘civilization’ perspective. According to Mongeri, women in the West and in the East have certain physiological conditions, such as menstruation, pregnancy, childbirth, the puerperal state. In the case of European women, the physiological evolution and the physiological conditions are more difficult than in Oriental women and, under the influence of Western civilization, they cause more mental breakdowns in the European women who play an important role in society (1867: 50–1). According to Mongeri, childbirth in Europe could constitute a problematic psychological experience that may cause mental breakdowns, whereas in the East it is treated differently:

When it comes to Oriental women, the physical influences which we have indicated as pernicious do not exist; so the evolution of the above-mentioned physiological states is usually accomplished with great ease, and without any particularly unpleasant consequences.

The ordinary women in particular attach so little importance to these different states that they never change their regimen or habits. Thus, neither the appearance of the periods and their cessation, nor the pregnancy are accompanied by this excessive impressibility and by these strange perversions of the nervous system, which are so frequent among European women. As for childbirth, this difference becomes even more evident. Among Oriental women, childbirth is so easy and so natural that as soon as the baby is born, the mother herself stands up to wash her child and manage the usual work of her household as if nothing extraordinary had happened. (p. 52)

Mongeri published not only patient statistics, but also details of cases. In particular, he published forensic psychiatric cases in the Gazette Médicale d’Orient. ⁹ His forensic case reports include five sections: preamble, the statement of the facts, direct examination, scientific discussion and conclusion (Mongeri, 1881: 51–2). These case reports were written in a language that was quite intelligible, clear and exact. As Castro (1882: 8) says, ‘In Istanbul, actually even in the whole of Turkey, there was not a single case of insanity in which Mongeri wasn’t consulted; all the physicians responsible for treating similar cases sought his confirmation’.

Mongeri compared the different perspectives of the insane in the East and in the West in various essays that he wrote at different times. In 1877, he thought that ‘the Eastern’ approach used to be quite superior concerning these aspects, but it was now ‘lagging behind’:

The Orient has always displayed the greatest solicitude for the unfortunates deprived of their reason, and in this respect has preceded Europe by a few centuries. While in Europe those people were regarded as guilty creatures of the devil, and religion permitted that they could be burned alive and subdued, in the Orient, insane people were gathered up and placed in establishments that were intended for their maintenance and treatment in particular.

The remains of these establishments in Constantinople and in the provinces confirm our claim. Unfortunately, time and decline struck them with their blows. Only one, Süleymaniye, has been saved from the combined influence of these destructive elements by the noble and persevering efforts of the government. However, notwithstanding the many improvements that have been carried out here, the mental hospital falls short of providing any of the circumstances that today’s science requires, as a result of the considerable increase in the number of insane individuals, and the inadequacy and the inappropriateness of the facility. For this reason, we have requested for quite a long time that the building should be changed or a new one constructed. (Mongeri, 1877: 6–7)

Mongeri’s comments on the statistics of Süleymaniye Lunatic Asylum and the aetiological explanations of insanity in the Ottoman Empire reflect in some respects the theory of nineteenth-century French alienists. As Edward Said noted, like people, ‘ideas and theories travel from person to person, from situation to situation, from one period to another’ and sometimes this ‘circulation of ideas’ may take the form of ‘acknowledged or unconscious influence, creative borrowing or wholesale appropriation’ (1983: 226). Mongeri’s intellectual perspective and comments on insanity were not only derived from Western psychiatry or ideas in circulation, but also from his clinical observations in the Ottoman asylum.

Mongeri had two main projects: construction of a new and modern mental hospital, and establishing law/regulation in the mental health field. He proposed these two projects to the Ottoman government in 1870, but he did not receive a positive or negative reply for years (Mongeri, 1877: xi). In his 1877 booklet Le Régime des Aliénés, he included the petition he had written in 1870 to the Grand Vizier, Ali Pasha. In this, Mongeri states: ‘I know that a lot of people find my insistent impatience regarding the fate of the insane exaggerated and almost ridiculous; I don’t mind their views because it seems that they don’t attribute any value to intelligence’ (p. ix). At the end of this emotional petition, he emphasizes that his greatest goal in life is to prepare a law on mental illnesses:

Dear Grand Vizier, please forgive me for the boldness of my approach, which is dictated by the ardent desire to see this beautiful country progress, where I have spent two-thirds of my life honoured with a reputation that was more than I deserved. Now that my career is drawing to a close, I can assure you that I will depart without leaving any desire unaccomplished if I can complete this humane work on which I have been working for so many years under the auspices of the Grand Vizier. (p. x)

The bill that Mongeri had prepared in 1870 with regard to mental illnesses took effect only in 1876. However, the project for a new mental institution did not materialize. Nonetheless, he shut down the Süleymaniye Lunatic Asylum, which was trying to operate in quite antiquated and inadequate conditions, and moved it to a new institution. The capacity of Süleymaniye Lunatic Asylum was extremely limited, and the number of insane people in it was increasing on a daily basis. Mongeri had several times requested the construction of a new mental asylum in Istanbul, but his project was rejected on the grounds of financial setbacks. For him, the ideal asylum would be similar to the ones in Europe; therefore it had to be out of the city centre (beyond the city walls) and should have adequate land for work therapy (PMOA. İ.ŞD. 27/1285, 30 July 1873). An outbreak of an epidemic in Süleymaniye Lunatic Asylum provided Mongeri with a suitable opportunity to realize his desire.

Moral treatment, non-restraint and the regulation of mental asylums

On 27 October 1873, a gastroenteritis epidemic, similar to cholera, broke out among the patients at Süleymaniye, the cause of which was not definitely determined; it claimed the lives of 29 patients within 8 days. On 14 November 1873, Mongeri provided information regarding the outbreak of the epidemic at the meeting of the Ottoman Imperial Medical Society and stated that the asylum, which had a capacity of 100–130 patients, had 375 patients at the time (Taşkıran, 1973: 17). He informed the government and requested the reorganization of Toptaşı Asylum as a new place for patients. This epidemic thus provided Mongeri with a long-awaited opportunity. Following the outbreak of the epidemic, Süleymaniye Asylum was abandoned and its residents were transferred to Toptaşı, which was located in Üsküdar, the Asian part of Istanbul. This asylum became the central mental asylum of the empire (Artvinli, 2013: 67). However, like Süleymaniye, Toptaşı Asylum quickly faced increasing numbers and overpopulation.

John H. Davidson, medical superintendent of the Cheshire Asylum in Britain, visited Toptaşı Asylum in 1875 and wrote on the living conditions in the asylum (Davidson, 1875: 411). He noted that the restraint regime in the asylum had been changed:

The Asylum preserves as historical curiosities the chains, collars, fallaca (bastinado), and other instruments of restraint formerly in use. These have been replaced by the camisole [straitjacket], but except in very turbulent cases, little recourse is had to it, as the heat of the country renders its employment painful, and even dangerous. Reil’s belt is, however, sometimes used to restrain the masturbators, and certain melancholics with well-ascertained suicidal tendencies. To subdue excitement, a prolonged bath of ten or twelve hours is the treatment most frequently adopted. Besides the Turkish bath, the institution is well supplied with baignoires couvercles, like the ones that are encountered in the asylums of France and Belgium. (p. 412)

Davidson also noted that work therapy, which was commonly practised in European asylums, was in restricted use at Toptaşı:

The employment of the patients is exceedingly restricted, owing to want of space, for beyond the performance of a few domestic duties and a little tailoring, the patients have really nothing to do. The amusements consist of the games of backgammon and chess, in which a few engage: many prefer to smoke narghillé or chibouque quietly, but the majority give themselves up to the pleasures of kief and dolce far niente. (p. 412)

According to Davidson’s account, the physician-superintendent visited the asylum patients three times a week in ordinary circumstances. The visits were made at fixed hours and all patients, except those engaged in domestic duties or confined to bed, had to be at the place of inspection at the appointed hour. Davidson also described a doctor’s visit:

The Doctor, accompanied by his medical assistants and the inspector and head attendant, slowly proceeds along the line of patients, occasionally stopping to make interrogations. The patient generally rises to reply to the questions addressed to him, which chiefly refer to his health, his wants, and his conduct. In certain circumstances, and especially as regards new admissions, care is taken to conduct them into the Physician’s private room, where they are subjected to a long and minute examination, for the purpose of ascertaining the nature and extent of their physical disorders. (pp. 411–12)

Davidson presented historical knowledge, based on Mongeri, about Süleymaniye Asylum, which was built in the sixteenth century, and at the end of his article he reached the following conclusion:

When Dr. Mongeri assumed the direction of the establishment [Süleymaniye], he had many difficulties and prejudices to contend with, but these have, in a great measure, been happily overcome by his unflagging energy and indomitable perseverance, and the patients now confined in the Timarhane [lunatic asylum] experience a judicious and humane treatment. (p. 415)

The treatment was based on a non-restraint approach and included a limited moral component. But were there any other treatments in the Toptaşı Asylum at the time? Like Süleymaniye Asylum, it also had a pharmacy (Etker, 2010: 18). The list prepared in 1878 by the asylum’s pharmacist, Yanko Efendi, mainly includes herbal drugs, some of which were processed into formulations such as tinctures, decoctions, oils and extracts. Cinnamon, bitter orange, sage, linden, clove and melissa were among the herbal drugs (Artvinli, 2010: 27–8). Certain drugs with sedative and hypnotic effects seem to have been preferred in the management of mental conditions.

After the patients were transferred to Toptaşı Asylum, Mongeri, to some extent, achieved one of his aims since the conditions there were better than those in the Süleymaniye Asylum. In 1876, he began to implement his second project: Bîmârhânelere Dair Nîzamnâme (Regulation on Mental Asylums), which took effect on 15 March 1876. It consisted of 22 articles that set out the permission, administrative process, and responsibilities of the asylums; the rules regarding transfers from the provinces to the centres; the admission and discharge of patients in the asylum; and their records and treatment processes (PMOA. İ.ŞD 30/1453, 14 Mar. 1876). ¹⁰ This regulation is an abridged version of the French Law of 1838 (Loi des aliénés) with only minor changes and adaptations (Artvinli and Etker, 2013: 5).

The Regulation on Mental Asylums defined and organized the mental health domain in the Ottoman Empire. Mongeri’s reason for preparing such a regulation was to protect the rights of the Ottoman subjects and, in justification, he cited the existing abuses that arose due to the lack of legal regulation in this field. For example, the hospitals for non-Muslim populations, situated in different parts of Istanbul, would accept patients with the permission of their spiritual leaders. However, since there were no existing laws, procedures and regulations, many patients had unpleasant experiences (Artvinli, 2013: 73). Mongeri also stated that all the institutions, with the exception of Süleymaniye Lunatic Asylum, confined the insane without a physician’s signature or any documentation. Because of this, a complete arbitrariness prevailed in this area. For him, the absence of such a law meant that the individual liberties, properties and even the lives of all the Empire’s subjects were at risk (Mongeri, 1877: 17).

The enactment and implementation of the regulation was a highly significant step in the medicalization of madness in the Ottoman Empire (Artvinli, 2013: 73). It also paved the way for the institutionalization of modern psychiatry in the Empire. The first article of the regulation specifies the role and authority of the government regarding issues of mental health: ‘No one from any nation will be able to open a mental asylum as long as a formal permit document is not acquired from the government’; and ‘all the mental asylums will be under the control of the government.’ The second article says that ‘if required, families must tie up the insane member of the family and inform the government right away’. The fourth article says that mental asylums will not accept any patient without formal medical documents. The seventh article states that ‘The confinement of the insane is exclusively under the authority of the government’. The 22nd article forbids unlawful confinement: ‘If the manager of the asylum gives permission to confinement of a person who is not insane and has been sent by relatives or other people because of showing resistance to religious conversion or marriage, the manager will be punished accordingly’ (PMOA, İ. ŞD 30/1453, 14 Mar. 1876). The other articles of the regulation set out the admission and discharge processes in detail, as well as standards for confinement and everyday practices in a mental asylum.

Along with the Regulation on Mental Asylums, Mongeri prepared a 20-question survey form in order to obtain detailed information about the people sent to an asylum. The physician or relevant person was requested to fill in this form, which included general information (age, marital status, current address, etc.) about the patient and information as to how the patient was sent to the asylum (Was he taken from his home? Did the police find him in the street or was he sent from the provinces?). The rest of the questions were aimed at describing the medical history of the patient, and particularly his symptoms of madness and type. Some of the questions in this survey were as follows:

Did this patient ever wish to destroy himself, and in that case what means did he employ? Did he want to hang himself, cut his throat, drown, etc.?

What are the probable causes of this state?

Has he had any epileptic seizures since birth or after?

Does he use alcoholic beverages, opium, hashish and since when?

Are there any people in the family suffering from insanity or epilepsy? Who are these people?

If it is as a result of an illness which has caused the insanity, what is this illness (typhoid fever, intermittent fever, syphilis etc.)? Or else if it is as a result of a fall, blow on the head, woman abuse, masturbation, etc.?

(PMOA, ŞD. 1282/10, 7 Feb. 1876; also Mongeri, 1877: 20–3)

The enactment of the 1876 Regulation on Mental Asylums led to overcrowding in the asylum, because local governors and courts began to send insane people from other cities to the Toptaşı Asylum (Artvinli, 2013: 96). Among the problems encountered in the process of implementing the articles of the regulation, the main one was the lack of the stipulated infrastructure in the provinces. In this period there were too few physicians and they were not present everywhere, and there were no regional mental asylums to which the insane could be sent. So the provinces, which were actually supposed to confine the insane within their own boundaries, sent them to Toptaşı Mental Asylum. Due to the lack of infrastructure and the idealized nature of the articles, the Regulation on Mental Asylums did not function efficiently during the following decades and, indeed, discussion of the need for a new mental health law still continues today (Artvinli and Etker, 2013: 31).

The year 1876 was not only important in terms of history of psychiatry in the Ottoman Empire, but it was also a critical year in Ottoman political history. Mongeri practised medicine during the reigns of four Ottoman Sultans: Abdülmecid (1839–61), Abdülaziz (1861–76), Murad V (1876) and Abdülhamid II (1876–1909). The Regulation of Mental Asylums was passed on 22 March 1876, during the last days of Sultan Abdülaziz’s reign. He was deposed by a coup on 30 May 1876, and Murat V replaced him; four days later Abdülaziz was found with the veins in his arms slashed. His death – by murder or suicide – deeply affected Murad V, whose mental condition deteriorated dramatically. Murat V remained in power for only 93 days and was deposed on the grounds of mental illness. Mongeri played a crucial role during this period; he was among the physicians who examined Sultan Murad V and signed his medical report (Uzunçarşılı, 1946: 332–3).

Until his death, on 25 November 1882 (Biffi, 1882: 1), Mongeri continued to work as the head physician of Toptaşı Asylum and La Paix Hospital, the only private mental hospital in Istanbul at the time. ¹¹ He was not only the most renowned alienist in Istanbul but also the most renowned Ottoman alienist in Europe, where he was an active member of several medical societies. ¹² His son, who had the same name – Luigi Mongeri, also worked for 12 years in Istanbul as a psychiatrist (medico alienista) at various hospitals such as the Italian Hospital, Surp Pırgiç Armenian Hospital and La Paix Hospital. Mongeri (junior) returned to Milan in 1906 and published many articles and books, and, like his father, contributed to Italian and European psychiatry. ¹³

Conclusion

Between 1856 and 1873, Luigi Mongeri (senior) worked in Süleymaniye Lunatic Asylum, and he tried to reform the asylum by abolishing the use of shackles, forbidding maltreatment and beating of the patients, ameliorating the physical conditions, and ensuring the regular supply of food and clothing. These reforms changed, to a certain extent, the perception of madness and mental asylums, just as his contemporaries did in Europe. While the birth of modern psychiatry is linked to Pinel’s ‘unchaining’ of the insane, Mongeri, similarly, was the pioneer of modern psychiatry in the Ottoman Empire through his efforts to replace the maltreatment and chaining of the insane with a more humane, moral approach.

Mongeri was the first physician in the Ottoman Empire to emerge as a professional alienist in the modern sense of the word. He published patient statistics and patient cases in the Gazette Médicale d’Orient. These cases were mostly forensic psychiatric cases, and Mongeri discussed the nature of insanity in them. He also demonstrated that some of these insanity cases were due to biological or organic causes. As one of the founders of Cemiyet-i Tıbbiye-i Şahane (The Ottoman Imperial Medical Society), he presented neuropsychiatric cases at the regular meetings of the Society.

Having transferred the patients and the staff present at Süleymaniye Asylum to Toptaşı Asylum in 1873, Mongeri continued to practise the non-restraint regime in this new institution; however, it was known that moral treatment, and work therapy in particular, were in extremely limited use. In 1876, Mongeri prepared the first legislation on matters regarding mentally ill people and asylums, namely the Regulation on Mental Asylums.

State control of insanity through this Regulation provided new bureaucratic procedures and excluded other actors, such as religious and local organizations, in the long term. It also paved the way for the emergence of a group of physicians at the end of the century who claimed sole authority on the management of mental asylums and the treatment of insanity. Mongeri as a physician had not had any psychiatric training at university, but he practised as a medical expert on insanity or as an alienist for 26 years in Ottoman mental asylums in Istanbul. It was only in 1896 that the first psychiatry lectures were added to the curriculum at the School of Medicine, and the first professional organization of Ottoman neuropsychiatrists was established in 1914.

In this article, I have examined the Regulation on Mental Asylums, in terms of the medicalization of madness, the involvement of the central state in the mental health domain and its management, and the definition of the asylum physicians’ and staff’s duties and responsibilities; this study has shown that the Regulation marked the end of a traditional period and the beginning of a new one. The article has also tried to describe how Mongeri made significant contributions to the formation of modern psychiatry as a field in the Ottoman Empire. His most important contribution was probably to tell the Ottoman government, bureaucracy, medical circles, and society that madness was an illness and the mad/insane individual was a patient requiring affection and assistance.