“Claiming the Mad”: Implications of the Introduction of the Mental Asylum in
Colonial Egypt
Introduction
When the British arrived to Egypt, in 1882, their presence was claimed to be
temporary, with the purpose of making Egypt fiscally solvent. The British authorities
faced a dilemma, however, in justifying their “civilizing mission,” which they propagated,
perhaps effortlessly, in other colonies through the establishment of “modern institutions.”
Education, law and medicine were the most cited gifts offered by the “munificent
colonizer” to the “barbaric and savage” indigenous. In Egypt, the situation was different.
Egypt had already gone through a rigorous process of modernization starting early in the
nineteenth-century, which revolved around Muhammad Ali’s efforts to build an army
strong enough to fulfill his expansionist ambitions. Whether intended or not, strong legal
and medical institutions came into being that by the 1860s, Egypt had developed a
complicated legal system with a full-fledged judicial institution and a body of law and a
strong medical tradition, modeled after its Western, mainly French, counterpart, was
created. Medicine, had achieved a considerable status due to its importance and centrality
to Muhammad Ali’s military establishment. It will not be an overstatement to claim that
the establishment of al Qasr al ʿAinī’s hospital represents the apotheosis of the relentless
process of modernization triggered by Muhammad Ali’s military and state building
ambitions.
With such a challenging existence of “modern institutions” the British had to
devise another novel “civilizing” element to be introduced to the newly occupied state.
The answer came in the form of a new institution that was not yet fully developed in
1
Egypt, though not altogether absent: the mental asylum. The mental asylum provided the
British with an institution which they could use to serve as their exclusive field of
expertise. The claim was to “scientific knowledge” with regards to curing and caring for
the mentally ill and the creation of an institution epitomizing the British humanitarian
efforts in Egypt and serving as a smokescreen to occupation.
A close study of psychiatric history of Britain clearly shows that by the time the
British came to Egypt, psychiatry and psychiatrists were far from having a clear
“scientific” recognition and were struggling to be recognized as a specialized profession.
Moreover, the British doctors’ claim to spreading the principle of “moral therapy,”1 and
humane treatment of the insane in the colonies is problematic since the introduction and
adoption of this principle in Britain itself, had witnessed a fierce resistance from no one
other than the British “mad-doctors” themselves.2 In fact, the principle of “moral therapy,”
was introduced not by doctors, but rather by laymen who came to be concerned with the
social, medical, and legal status of the mad. However, when the principle of moral
treatment had become morally, socially and legally backed by political and social
reformers, the doctors in Britain went through another battle over the appropriation of
this principle through a claim to “professional specialization” expertise, and “esoteric
1
The principle of “moral therapy” or “moral treatment” was developed in the 18 th century but came to a
fore in the 19th century when its proliferation reached Britain mainly and singularly through the efforts of
William Tuke (1732-1822), a Quaker coffee merchant, and his establishment of the York Retreat in 1796.
The philosophy behind “moral treatment” was the assumption that the mentally ill were not totally deprived
of their reason. The mentally ill, according to this assumption, had a better chance of recovery when treated
as children in need of learning to “internalize” the concept of “self-discipline” rather than being treated as
animals. The techniques used were nonmedical, based on Benthamite notions of surveillance, reward and
punishment.
2
Because psychiatry was far from being recognized as a specialized branch of medical science in Briatin,
the doctors working in the treatment of the mentally ill were either called “asylum superintendents” or
“alienists” by their proponents, or “mad-doctors” by their detractors.
2
knowledge” and hence monopolizing the institution dedicated for that purpose: the
mental asylum.
The proposed research topic is to study comparatively the developments in the
Egyptian and British societies that led to the introduction of the institution of mental
asylum, based on the principle of moral therapy, and the ideological function the
institution served in both countries. 3 This juxtaposition elaborates the wealth of
fascinating comparisons existing between the two cases. In comparing British and
Egyptian mental asylums, the following questions will be considered: How did the
asylum, in its “humane” form develop in both Britain and Egypt? Why was the need for
reform triggered in the first place and how was it addressed? What purpose did the
asylum serve in both societies? What was meant by “moral treatment” in Britain and did
its application differ in Egypt? If so, then how? What was the colonial element, if any, of
the asylum institution? How was the asylum managed? And can we speak of a “colonial
nosology”? 4 When applying the Foucauldian concept of “governmentality” with its
triangular structure of sovereignty, discipline and government, how does the mental
asylum as an institution controlled by the state fit in this equation and does the colonial
context make it any different?
The asylum, in its more humane outlook, served two different functions in the
metropole, Britain, and the colony, Egypt. In the former, it emerged in response to the
proliferation and adoption of Benthamite utilitarian ideas among laymen who were
interested in reform and a more humane treatment of the insane. The opportunity was
3
The British did not “introduce” the mental asylum as the institution existed in Egypt since the medieval
times and before the British arrival to Egypt there was one already existing in Būlāq. What the British did
was introducing new methods of therapy based on the principle of “moral therapy.”
4 Nosology is the branch of medical science, which deals with the classification of disease.
3
soon to be seized by the “mad-doctors,” the proto-psychiatrists, who turned the reform
into a battle to assert professional specialization and scientific expertise exclusive to
psychiatrists when treating the mentally ill. By contrast, in the colony the asylum served a
political purpose that mitigated the effect of colonialism by introducing an institution
serving as a microcosm, a maquette, elaborating the virtues of the British administration
of the country.
Most importantly the asylum constituted part of, what Gyan Prakash, drawing on
Foucault, eloquently calls “colonial governmentality” which developed in violation of the
liberal perception of the government as a complex, yet autonomous, interests secured by
law and liberty.5 Consequently, “a powerful process of bureaucratic expansion” whereby
“the population’s economic, demographic and epidemiological properties were surveyed,
enumerated, measured and reconstituted” in order to create “a colonial ‘complex of men
and things’” was set in motion. In other words, the population “constituted a subordinated
subjects, whose health, resources, productivity and regularities were the objects of
governance.” 6 The introduction of psychiatry and the mental asylum in Egypt can be
viewed as “a materialization of institutions and practices with which colonial power was
resituated and exercised as colonial governmentality.”7 For Prakash, it is the absence of
the aforementioned Foucauldian “governmentality” triangle- sovereignty, discipline, and
government, which explains the violence of “colonial governmentality.”8 Violence here is
not necessarily physical but rather it can refer to the violence in imposing and
5
Gyan Prakash, “Body Politic in Colonial India,” Questions of Modernity, Timothy Mitchell (ed.)
(Minneapolis: University of Minnesota Press, 2000),p. 192.
6
Ibid, 193.
7
Ibid.
8
Ibid.
4
implementing the colonizers’ ideas and “reform policies.” It is no longer a question of
repression but rather if asserting “authority.”
While the battle for the mad in Britain was between doctors, the Magistrate and
laymen reformers, in Egypt it was between the British medical institution, the asylum,
and the Egyptian medical institution and tradition. For the purpose of asserting their
superiority, the British took on to undermine the Egyptian and French efforts in the
development of medicine in the country criticizing the lack of expertise in psychiatry, and
the dismally deteriorated conditions of medicine in the country as a whole. Of relevance
was the severe bashing of the Waqfs, the Islamic religious endowments, which the British
spared no effort and missed no occasion to lambast. Moreover, while in Britain, the
lunacy reforms sought to push the state to assume a central role in caring for the mentally
ill, in Egypt, the mental asylum institution, under the direction of British personnel,
sought not only to keep the state intervention to the minimal, but also to ensure a degree
of independence from the state that reached its peak under Dr. Warnock, the director of
the ʿAbbasiya asylum 1895-1923, who had full control over the Lunacy Division and
could act freely aided by the absence of a state law regulating the admission and
incarceration of the mentally ill.
Why Colonial Medicine?
In the past two or more decades, far from celebrating the history of European
medicine, revisionist and post-colonialist historians have increasingly turned to critically
examine its effects and legacies both “at home” and in the colonies. The argument that
European (imperial) medicine can be understood as an “agent of empire” had become
almost a universally embraced premise. For example, Shula Marks, comments that “the
5
history of medicine in the colonies is often an illuminating way to examine aspects of the
power and limitations of colonialism and its ideas and discourses,” 9 while Lenore
Manderson argues that colonial medicine is “part of the front line of imperialism that
strove to dominate by care and cure” 10 . Historians have elaborated that medicine
represented the aim of colonial reform; it became an aspect of the “civic virtue” of
colonial settler societies “mimicking the grand configurations” of the metropoles. 11 In
1988, Milton Lewis and Roy Macleod introduced their significant work Medicine,
Disease and Empire, which closely examined the problem of medicine as part of the
imperial project. They argued that the period 1810- 1910 was a period of colonial
expansion, with medicine playing a role in the colonizing process. 12 Medicine did not
only “colonize.” Its character and presence in the colonies also signified the spread of
intellectual and scientific imperial “culture”:
Meeting similar patterns of disease, set against the foreign circumstances of
frontier life, colonial medicine eventually came to compare itself, and later
compete with, its professional parents. A common culture of medicine, sustained
by the image of science as the universal agent for progress, and scientific
medicine as its servant-became the hallmark of European empires throughout the
world.13
9
Shula Marks, “What is Colonial about Colonial Medicine? And What has Happened to Imperialism and
Health,” The Society for the Social History of Medicine, (1997), downloaded from
http://shm.oxfordjournals.org at New York University on August 23, 2010, p. 215.
10
Lenore Manderson, Sickness and the State: Health and Illness in Colonial Malaya, 1870- 1940
(Cambridge: Cambridge University Press, 1996), p. 14.
11
Jock McCulloch, Colonial Psychiatry and “the African Mind,” (Cambridge and Melbourne, Cambridge
University Press, 1995), p. 45.
12
Roy Macleod and Milton Lewis (eds.), Disease, Medicine and Empire: Perspective on Western Medicine
and the Experience of European Expansion (London and New York, Routledge, 1988).
13
Ibid, p.3.
6
Other historians have followed the same line of thought and argued that medicine,
is not a stagnant entity-but rather is of a dynamic nature that altered itself to fit various
different geographical and historical contexts- “refracted” in the colonial situation. 14
Moreover, in the colonial situation, medicine was enacted through and by the State, and it
was in this context that particular populations became the “object of medical
knowledge.”15
While there is abundant literature on colonial medicine, the study of the history of
medicine and colonial medicine in Egypt is by no means exhausted. There have been few
historians venturing into this virgin territory. One of the early attempts to document for
the institutional medical history of Egypt has been the work of Dr. Naguib Mahfouz, The
History of Medical Education in Egypt, where he gives a detailed account of the history
of Qasr al ‘Ainī Hospital and the attached School of Medicine.16 The book is a simple
chronology, with the sole purpose of documenting the important dates, events and figures
that directed and influenced the evolution of the institution.
Another important work is The Creation of a Medical Profession in Egypt, 18001922 by Amira El-Azhari Sonbol, where she studied, at the micro-level, the historical
trajectory of the medical profession in Egypt between 1800-1922, emphasizing the role
medicine played in the discourse of colonialism.17 While she credits the British for the
“physical” improvement of health facilities, she also criticizes, however, the colonial
claim of advancing the medical profession in Egypt. Arguing for the contrary, Sonbol
14
Megan Vaughan, Curing their Ills: Colonial Power and African Illness, (Cambridge, Polity Press,
1991), p.8.
15
David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth Century India
(Berkley and Los Angeles: University of California Press, 1993).
16
Naguib Mahfouz, The History of Medical Education in Egypt, (Cairo: Bulaq Government Press, 1935).
17
Amira El-Azhary Sonbol, The Creatoin of a Medical Profession in Egypt 1800-1922, (Syracuse, N.Y:
Syracuse University Press, 1991).
7
asserts that if anything, the medical profession deteriorated under British rule, became
less specialized and more commercialized. While the information and sources used in the
book were revealing, Sonbol’s argument is a tad vague and could not clearly pinpoint and
elaborate on the “colonial aspect” that dominated the profession under the British control
save perhaps her reference to changing the language of instruction from Arabic to
English, which cannot be considered “colonial” enough. The absence of any reference to
relevant work by Michel Foucault, such as The Birth of the Clinic and his ideas about
discipline, “docile bodies”, “bio-power” and “governmentality” makes her work in need
of revision.18 Also, absent was Timothy Mitchel’s work, Colonizing Egypt, which drew
on Foucault, and his notion of “enframing,” which could have helped further elaborating
and strengthening Sonbol’s argument.19
An interesting, important and updated work is Khaled Fahmy’s book al Jasad wal
Hadāthah: al Tibb wal Qanūn fī Misr al Hadīthah, (Body and Modernism: Medicine and
Law in Modern Egypt).20 In this work, Fahmy is as consistent as ever in his critique of
modernism. Digging in the Egyptian archives provided him with a closer look at the role
played by both medicine (public and forensic) and law (the existence of a “modern” body
of law independent from Shari’a)- drawing on Foucault’s power-knowledge binary and
the concept of “bio-power”- in further tightening the grip of the state over its citizens.
Fahmy dexterously shows how power, not necessarily oppressive, produced an
interaction between the people and the authority, which was not necessarily that of clash
18
Michel Foucault, The Birth of the Clinic: an Archeology of Medical Perception, (New York: Vintage
Books, 1975); Discipline and Punish: the Birth of the Prison, (New York: Vintage Books, 1995); The
History of Sexuality, (New York: Vintage Books, 1990); “Governementality,” in Graham Bruchell et al.
(ed.) The Foucault Effect: Studies in Governmentality, (Chicago: University of Chicago Press, 1991).
19
Timothy Mitchel, Colonizing Egypt.
20
Khaled Fahmy, Al Jasad wal Hadāthah: al Tibb wal Qanūn fī Misr al Hadīthah, (Cairo: Matbaʿat Dār alKutub w al-Wathā’iq al-Qawmiyya bil Qāhira, 2006).
8
and confrontation but rather of the people, the subalterns, using medicine and law for
their benefit. Despite Fahmy’s rich, pioneering and comprehensive research and findings,
his study focused mainly on the use forensic medicine (science) and law (mainly
criminal) in facilitating the “governmentality” of the “docile bodies” of the Egyptians in
the nineteenth century. Psychology and particularly “colonial” psychology was not part
of Fahmy’s research scope.
Another work that preceded Fahmy’s, and offered a critical study in the Egyptian state’s
management of the poor, is Mine Ener’s Managing Egypt’s Poor and the Politics of
Benevolence, 1800-1952.21 Her original work, which also made use of the material found
in the Egyptian archives, gives a compelling account of the poor and the care extended to
them by the state, mainly during 19th and early 20th century Egypt. By studying two of the
poor houses, the Mahal al Fuqarāʾ in the mosque of Qalāwūn, and Takiyyat Ibn Tūlūn,
which was located at the mosque with the same name, Ener adroitly traces how
benevolence to the poor, ihsān, a duty deeply entrenched in the teachings of Islam,
shifted from being a personal duty to become institutionalized by the state as a
mechanism to relief, control and contain “problem population.” The poor were not,
however, “objectified” as they managed to use the existing system of relief for their
interest, and Ener shows how some of them even sought admission to the poor houses
that the state had to be selective and meticulous in determining who would be eligible as
“deserving poor.” But again, although Ener brushed lightly on the mental asylums and
the attention foreign travelers paid to describing the conditions in the poor houses and
mental asylums, her study was mainly to elaborate on how the Egyptian government
21
Mine Ener, Managing Egypt’s Poor and the Politics of Benevolence, 1800- 1952, (Princeton and
Oxford: Princeton University Press, 2003).
9
management of the poor was used as a means to bring them under control to avoid any
prospective challenges and problems caused by the disenfranchised segment of
population.
Why the Asylum and Colonial Psychiatry?
But where do psychiatry and its history in the colonies, and particularly in Egypt,
fit in this story of medicine, public health and poor relief? As Roy Porter has argued, the
19th century was the period in which psychiatry was “made.”22 It was also then that it was
exported and became an “international enterprise.” Like other medical, and legal,
enterprises of this period, psychiatry sought to compile a “taxonomical” classification of
bodies and diseases in foreign places. Some of the histories of imperial/colonial medicine
(often used interchangeably) perhaps suggest a reading of the “colonial” setting where the
predominant indigenous population was managed by imperial institutional structures. 23
As psychiatry occupies a unique space among the social and natural sciences, the
discipline constitutes a crucial locus for study of the relationship between knowledge and
power in colonial domination. The asylum in any context functions as both hospital and
prison, and psychiatry’s medical applications render the mental institution the ultimate
“correctional facility.” Under colonialism, where the ruling state is in almost constant
tension with the population, the position of psychiatric knowledge becomes even more
complex. Colonial psychiatry allied itself closely to the “civilizing mission” as it
assembled knowledge about “indigenous psychologies” that facilitated rule. The asylums
therefore functioned as key symbols of the civilizing mission. As markers of European
22
See Roy Porter, Mind Forged Manacale: A History of Madness in England from Restoration to Regency,
(Cambridge, Massachusetts: Harvard University Press, 1987).
23 Waltraud Ernst, Mad Tales from the Raj: The European Insane in British India, 1800-1858 (London and
New York, Routledge, 1991); “European Madness and Gender in Nineteenth Century British India,” Social
History of Medicine, 9:3 (1996), 357- 82.
10
medical superiority, institutions propagated the myth of medicine as an important means
of colonization, despite their limitation in actually confining and treating patients.
Though the number of patients confined and treated was tiny, the asylum contributed to
the maintenance of the self-image of the colonialists as superior people whose charitable
humanitarianism and rational, scientific achievements mitigated the effects of colonial
rule and made it appear morally beneficial and legitimate.
Until recently, however, the colonial asylum has received minimal treatment by
historians. The relationship between colonialism and medicine and particularly psychiatry
was best described by Franz Fanon in A Dying Colonialism, in which he elaborated on
how medical officials and psychologists played an integral role in the oppressive and
interrogative practices of “a dying colonialism.” He also meticulously explained the
Algerians’ reaction to the French insertion of “modernity” and the severity by which the
French imposed their own “knowledge” in the field of psychology that the Algerians only
reacted as aggressively by embracing century old habits that the French were constantly
lambasting.
24
Aside from Fanon’s pioneering work on the role of the asylum and
psychiatry in consolidating colonialism, some interesting and comprehensive studies had
appeared tackling the asylums in Australia, Fiji, Canada and India. 25 In these studies,
scholars have begun to investigate the close connections between colonial medicine,
power and the production of knowledge.
24
Franz Fanon, A Dying Colonialism, New York: Grove Press, 1965.
See Jacqueline Leckie, “Modernity and the Management of Madness in Colonial Fiji,” Paideuma, Bd.
50 (2004), pp. 251-274; Jock McCulloch, Colonial Psychiatry and the African Mind, (Cambridge
University Press, 1995); Megan Vaughan, Curing Their Ills: Colonial Power and African Illness, (Stanford,
California: Stanford University Press, 1991); Waltraud Ernst, Mad Tales From the Raj: Colonial
Psychiatry in South Asia, (London; New York: Anthem Press, 2010); Bernard Harris and Waltraud Ernst
(eds.), Race, Science and Medicine, 1700-1960, (London; New York: Routledge, 1999); Lee-Ann Monk,
Attending Madness: At Work in the Australian Asylum, (Amsterdam; New York: Radopi, 2008); Edwin
Fuller Torrey and Judy Miller, The Invisible Plague: The rise of Mental Illness from 1750 to the Present,
(Piscataway, New Jersey: Rutgers University Press, 2003).
25
11
However, when it comes to Egypt, there has rarely been any comprehensive study
on psychiatry and the history of the asylum in Egypt.26 Even more problematic is the lack
of a comparative approach to asylum history, which would both underline the dynamics
of colonialism and also free this history from its usually parochial perspective, as Linda
Bryder has suggested. 27 The relationship between “colonial state policy” and “lunacy
policy” was important as they combined to produce colonial order, through creating
mechanisms and institutions to deal with “problem populations.” As John Harley Warner
suggests, the value of the comparative perspective where the colonial context is being
examined, lies in the fact that “comparison” is part of the very articulation of histories of
colonialism.28 In this respect, the inflections of ideas “at home” and the development of
the British asylum itself become crucial to the perceived role of the asylum in the
colonies. Significant developments in medicine, legislation and administration which
dealt with “madness” occurred in 19th century Britain, addressing the problem of how
madness was to be contained, who were eligible to be asylum “inmates” and would in
turn make the asylum’s “patient population.” The asylum experience as a response to the
problem of madness in Britain and the principle of “moral therapy” for the management
of the mentally ill had become models to be followed in the colonies. But were they? And
did the colonial asylum serve the same purpose it served “at home”? Was the raison
d’être and significance of the asylum the same in both the metropole and the colony?
26
Save perhaps Marilyn Anne Mayers unpublished PhD dissertation, “A Century of Psychiatry: The
Egyptian Mental Hospitals,” Diss. Princeton University,1984. Otherwise there were scattered articles on
the mad but not on the institution of the asylum itself and its implication); Michael W. Dols, Majnun: The
Madman in Medieval Islamic Society, (Oxford: Clarendon Press; New York: Oxford University Press,
1992); Eugene Rogan, “Madness and Marginality: The Advent of the Psychiatric Asylum in Egypt and
Lebanon,” Outside In: On the Margins of the Modern Middle East, Eugene Rogan (ed.) (London; New
York: I.B. Tauris Publishers, 2002).
27
Linda Bryder, qtd in Diane Kirkby and Catherine Coleborne (ed.), Law, History, Colonialism: the Reach
of Empire, (Manchester; New York: Manchester University Press), p. 3
28
John Harley Warner, quoted in Ibid.
12
Were the management, admission procedures and “mad” legislation, if any existed, the
same?
Different patient populations provoked different medical responses and
experienced medicine in different ways in the colonial environment. This in no way is
clearer than in the etiology and nosology of madness in Egypt, which centered around
cultural and racial assumptions rather than on proven and medically tested facts. As
Foucault argues, the transition to modernity brought the dialogue between sanity and
madness to a standstill and the power of reason thereafter identified, categorized and
dominated the irrational “other” within European society. 29 This assertion takes a
particular bent when applied in a colonial context as this sanity/madness binary becomes
especially problematic in defining the relationship between the colonial power and the
colonial subject. The knowledge produced in the psychiatric encounter with the colonized
often reinforced the mandates of the civilizing mission, but in other ways it called
European superiority into question. Yet the existing scholarship has neglected the tension
between psychiatrists’ expectations and the unexpected results turned up in their research.
In the British Isles, civilization itself had been made accountable for what was
perceived as a rising incidence of mental illness, since it was held that in less developed
and less sophisticated countries, people lived a simple, contented life and were
consequently less prone to mental problems. If the “colossus” of madness was seen to
stride with confidence only among the highly civilized, then how could it be explained
that those called the natives in British colonies were generally prone to a weakness of
intellect and possessed an easily deranged mind?
29
Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason, (London;
Sydney: Tavistock Publications, 1967).
13
The understanding of mental illness in Egypt, as in the colonies in general,
underwent a significant change with the introduction of the modern European asylum in
1884. The definition of madness changed to conform to European definitions rooted in
the “new science” of psychiatry. By 1907, the Cairo Lunatic Asylum of ‘Abbāsiyya was
full to capacity and a second asylum, the Khānkah hospital, was opened in 1912 to
accommodate the patients’ overflow. It would be very cynical to doubt that the modern
asylums represented an improvement over earlier facilities. If there is something
objectionable about these developments, “it is the imposition of norms and definitions
based on spurious claims to modern scientific knowledge.”30 The self-proclaimed “men
of science” barely knew little more about the causes of insanity than the men of religion.
Yet, their jargons and idioms of medicine and the promise of cure, earned them a degree
of acceptance and an authority derived from the claimed expertise. Consequently, the
mentally ill became “objectified” by the “experts” while simultaneously they became
stigmatized that the appropriate place for them was no longer in society but in an
institution, which remains an enduring legacy of colonial medicine.31
Thesis Division
Since this study is a comparative one between asylums in both the metropole and
the colony, the first chapter is dedicated to survey the evolution of the mental asylum
institution in Britain and the simultaneous development of the principle of “moral
treatment” and the subsequent battle to universalize the principle and how it came to
signify a shift as well as a tool of “governmentality.” This chapter attempts to recap what
30
Eugene Rogan, “Madness and Marginality: The Advent of the Psychiatric Asylum in Egypt and
Lebanon,” Outside In: On the Margins of the Modern Middle East, Eugene Rogan (ed.) (London; New
York: I.B. Tauris Publishers, 2002), p.122
31
ibid.
14
already exists in the vast literature on madness in Britain, as the scope of this research is
limited to the Egyptian context, but to do so, a mise en scène of the context in the
metropole, England, has to be furnished.
The second chapter gives a glimpse and a background on the general medical care
in Egypt on the eve of the British occupation. The discussion will cover the evolution of
medical care and the Egyptian medical institution, represented by al Qasr al Aini and the
attached medical school, and the care extended to the mentally ill before the
establishment of the Abbasiyya asylum in 1884. The purpose of this chapter is to argue
for the existence of a “modern” medical institution in Egypt, which posed a threat to the
British claims to the “civilizing mission.” Also, the aim is to show that the mentally ill
were not completely ignored by the government as the British authorities came to claim
later. As in Britain itself until mid-nineteenth century, there was a difference in
perception of whom to assume responsibility for caring for the mentally ill. Until that
time it was the family and parochial relief who cared for the insane and the state only
intervened on behalf of the pauper lunatics for whom no one cared. The Egyptian
government’s medical priorities (and expenditure) were to combat epidemics, such as
Cholera and universalize vaccination, particularly against smallpox.32 Also the general
debt and insolvency problems affected the state’s willingness to assume full
responsibility for the mentally ill, allowing their families, and the community, a freer
hand in caring for them.
The third chapter is devoted to studying the establishment of the mental asylum
under the British occupation, the British discourse on the care for the mentally ill before
32
LaVerne Kuhnke, Lives at Risk: Public Health in Nineteenth Century Egypt, (Cairo: The American
University in Cairo Press, 1995).
15
and after the occupation, and the attempts to study mental and psychological diseases
peculiar to Egypt, which takes us to a discussion of what we can call “colonial nosology,”
how precise it was and what purpose it served. Another idea that is discussed in this
chapter is the independence the British doctors managed to secure from the Egyptian
government and how the creation of the Lunacy Division epitomized these efforts,
bringing both the ‘Abbāsiyya and the Khānka asylums fully under the control of Dr.
Warnock and almost independent from the jurisdiction of the Egyptian government. The
chapter also deals with the related point of Waqfs. The argument here is that the criticism
to the Waqfs was not merely due to the poor service it offered to the poor and the
mentally ill. Rather, there had been an ideological element to this criticism. The fact that
there had been an institution with vast resources not accessible to or supervised by the
colonial authorities must have been irksome to the British, leading them to adopt a hostile
approach toward the Waqf institution and seeking to urge it to spend more in caring for
pauper lunatics, while not claiming authority over them.
Most historical writings on lunacy reform perpetuate the illusion that the whole
process represented progress towards enlightenment, the triumph of rational, altruistic,
humanitarian response over ancient superstitions; the dawn of a scientific approach to
insanity. Yet this is a perspective made possible only by concentrating on the rhetoric of
intentions while neglecting the facts about the establishment and operation of the asylum
system. Even a superficial acquaintance with the functioning of 19th century mental
hospitals reveals how limited was the asylum’s concern with the human problems of its
inmates, and how the number of the actually cured patients was very limited, that the
asylum became a mechanism for sequestration and confinement rather than treatment and
16
cure. The move toward an institutionalized and centralized social control apparatus must
be seen as primarily the product of closely inter-related structural changes; the main
driving force behind these changes being the advent of colonization and the obsession
with creating “order” where there should exist institution that contain this element of
“problem population” that did not fit in prisons, workhouses and poor shelters.
Although, as will be shown in the next sections, the Egyptians made use of the
newly established asylum to dispose of their mentally afflicted relatives and rid
themselves of legal liability, for treatment purposes, Egyptians still resorted to folk
medicine and even embraced the then newly imported zār rituals. Early studies appearing
towards the end of the 19th century and early 20th century suggest that the phenomenon of
zār was gaining momentum. Abdel Rahman Ismail’s book Tibb ar-Rukka, or Folk
Medicine, (1892), and Muhammad Umar’s Hadir al Misriyyin wa Sir Ta’akhurihim, or
The Present State of the Egyptians and the Causes of their Retrogression (1902), were
among the first works to tackle, and attack, the then new zār phenomenon.33 Although
both authors did not view the zār favorably, their works are indicative of the popularity
and spread of zār in Egypt as a healing mechanism used in the treatment of those
perceived as mentally disturbed. This resort to alternative folk interpretation of
behavioral abnormalities can be also viewed as a mode of subversion; a defensive
mechanism where the subalterns challenge “cultural hegemony” imposed on them by the
government, colonial authority and the intellectual elite, such as Ismail and Umar, who
33
Abdel Rahman Ismail, Folk Medicine in Modern Egypt, (New York: AMS Press, 1980); Muhammad
Umar, Hādir al Misriyyīn wa Sir Ta‘khurihim, (Cairo: al-Maktab al-Misṛī li-Tawzīʻ al-Matḅūʻāt, 1998).
17
held the Egyptian subalterns responsible for the state of backwardness and retrogression
in Egypt.34
Research Method
This research is done through a meticulous study and analysis of both primary and
secondary sources, in Arabic, English and French. Most of the primary sources used in
this research will be mainly the memoirs, reports and testimonies of officials and doctors,
articles and reports published in relevant periodicals, mainly The British Medical Journal
(BMJ), the Lancet, and the Journal of Mental Science (The British Journal of Psychiatry).
Also, a report issued by the Lunacy Division, Qism al Amrād Al ʿAqliyya, in 1933 will
be the source of most of the figures provided in the thesis as it covers the period roughly
between 1893-1933.
34
The term “Cultural Hegemony” refers to the domination of a culturally diverse society by the ruling class,
who manipulate the society’s culture by imposing the “appropriate” beliefs, explanations, perceptions,
values, mores and taste of the society. In Prison Notebooks, Antonio Gramsci explained that in perceiving
and combating cultural hegemony, the working class and the peasantry depend upon the intellectuals
produced by their society to which ends Gramsci distinguishes between bourgeois-class intellectuals and
working class intellectuals, the earlier being the proponents and the latter are the opponents of the imposed
culture and social status quo.
18
Chapter I: The British Model: the Asylum and the Profession
“No medical advance, no humanitarian approach was responsible for the fact that the mad were
gradually isolated, that the monotony of insanity was divided into rudimentary types. It was the
depths of confinement itself that generated the phenomenon; it is from confinement itself that we
must seek an account of this new awareness of madness” (Michel Foucault, Madness and
civilization, p. 224).
The importance of institutional and professional history had for long been
understudied by historians and researchers until Michel Foucault unleashed the wealth
and importance of such studies in his research pertaining to modern state disciplinary,
curative and corrective institutions such as the prisons, clinics and the asylums. As
elaborated in the introduction, this study zooms in on one institution and discusses its
origins, roots, development and characteristics comparatively in both the metropolitan
and colonial settings. Before discussing the institutional history and evolution of the
mental asylum in Egypt and the introduction of psychiatry as a new profession and
science through it, it is imperative that we study the evolution of the same institution and
profession in nineteenth century Britain, to be able to understand the nature and
circumstances in which both asylums developed and what makes them different and what
colonial bend, if any, the asylum took in Egypt.
In Britain, the nineteenth century had been the century of medical specialization
and professionalization par excellence. This trend was simultaneous to the rise of a strong
middle class, following the industrial revolution. In her book The Medical Profession in
Mid-Victorian London, M. Jeanne Peterson attributes the rise in authority of the medical
profession to academic institutions since “the medical schools provided an independent
base for physicians and surgeons who began to expand their powers of patronage and
19
influence, not only within the schools, but within the hospitals as well.” Moreover,
“authority came to the experts as the public was increasingly closed off from the
knowledge of their work. The power of the experts was not the power to do, but the
power to know,”35 or more accurately, the power to “claim” knowledge.
This trend for professionalization, facilitated, if not necessitated, the adoption of
an institutional response to all sorts of “problem populations.” 36 By making separate
institutional provisions for a troublesome group, like the insane, a source of potential
danger and inconvenience to the community could be removed to a place where such
people could no longer pose a threat to the social order. So, by the early 19th century,
many were becoming convinced of the need for specialized institutions.37 This is not to
say there was no lunatic asylum before that time. Throughout the 18th century there
existed a large number of privately run asylums. However, what was emerging at the end
of the 18th century was a growing market of “lunacy-trade” or “mad-business”; and those
trading in this thriving market were at work in a social context in which claims to possess
expertise and special competence were on general grounds likely to find a receptive
audience. It comes as no surprise that the development and consolidation of institutional
means of coping with madness paralleled the rise of a professionalized group of
managers of the mad, for it was the existence of the institution, which permitted, or
perhaps it might be more accurate to say, provided the breeding ground for this emerging
“professionalism.” On the one hand, and particularly once the state was made to interfere
35
M. Jeanne Peterson, The Medical Profession in Mid-Victorian London (Berkeley: University of
California Press, 1978, p. 3 qtd in Amira El-Azhary Sonbol, The Creation of a Medical Profession, 14.
36
“Problem populations” is a term used by historians and writers specialized in studying the Victorian era,
in reference to the middle class perception of the rogue elements in their society who were perceived as
potentially troublesome. Examples of “problem populations” include the unemployed, the criminals, and
the insane, who belonged mostly to the lower classes of society
37
Andrew Scull, Museums of Madness: the Social Organization of Insanity in Nineteenth-Century England,
(New York: St. Martin’s Press, 1979), p. 41
20
directly in the asylum solution, the asylum institution provided the incentive for the
experts’ to offer their services, because of the existence of a guaranteed market. On the
other, the asylum institution provided a context within which, isolated from the
community at large, the proto-profession could develop empirically based craft skills in
the management of the deranged whose minds had been unhinged. 38 This was a selfreinforcing system for the key claim to expertise of the emergent profession came to
revolve around questions of institutional management. The very heart of the experts’
approach lay in their emphasis on order, rationality and self-control, which could only be
achieved, according to Max Weber, through an institution monopolizing all legitimate
coercive power.39
“The Lunacy Business”
One has to be careful, as it might be misleading to speak of early nineteenthcentury privately owned madhouses in Britain as a well-established asylum system. There
was no uniform structure or a system to be found in all the madhouses and their policies
depended on their owners who differed in their approaches and management. Not until
the end of the 1840s did a network of state run and financed asylums assume a dominant
position in the institutional management of the mad. 40 Due to the state’s parsimony,
absence of legal restrictions and regulations on the entry to and discharge from
madhouses and the fact that no attention was paid as to the proper conduct and
management of such private institutions, inmates suffered from barbarity, neglect,
inhumane and violent treatment. The use of mechanical restraint and physical violence
38
Andrew Scull, Museums of Madness: the Social Organization of Insanity in Nineteenth Century England,
(New York: St. Martin’s Press, 1979), p. 43
39
Max Weber, Economy and Society: An Outline of Interpretive Sociology, Vol. I, (Berekely; Los Angeles;
London: University of California Press, 1978), p.337
40
Scull,Museums, 50.
21
was a natural consequence to the aforementioned conditions. In these overcrowded
establishments “fetters and chains, moppings at the morning toilet, irregular meals, want
of exercise, the infliction of abusive words, contemptuous names, blows with the fist or
with straps, or with keys, formed an almost daily part of the lives of many unprotected
beings.”41
The Reformers
These dismal conditions of the asylums and mad houses in the early decades of
the nineteenth century provided a working ground for reformers who were mostly upperclass gentlemen interesting themselves in projects of social reform. Like almost all
Victorian social reformists, those interested in lunacy reforms were heavily influenced by
two contemporary, yet competing, philosophical paradigms that were, in effect, social
movements: Benthamism and Evangelicalism. The Evangelicals were a group of selfrighteous proselyte religious reformers who sought to “convert” the society as a whole
from disorder and vice to discipline and conformity. They were “moral entrepreneurs”
41
John Conolly, The Treatment of the Insane Without Mechanical Restraints, (London: Smith Elder& Co.,
1856), p. 143. Conolly was what can be called a “reform maverick.” He did not call for improvement of
asylum conditions, as he was a staunch critic of the very idea of sequestration and confinement as a
working and acceptable treatment of the insane. The deficiency, he believed, of the asylum as a curative
institution was inherent in its very structure, and hence could not possibly be removed by any conceivable
reform. It did not matter if the asylum doctors were men of intelligence and humanity; nor did it matter that
they may point to the spaciousness of their grounds, to the variety of occupations and amusements prepared
for their patients; to the excellence of their food and the convenience of their lodging; and brag that as little
restraint is employed as is compatible with this safety, the fault of the association of lunatics with each
other, and the infrequency of any communication between the patient and persons of sound mind taints the
whole design and makes such an environment a pathological and self-defeating one. It is one of the ironies
of institutional existence that those who manage this transition most effectively are at the same time
reducing their ability to function in the outside world. “After many hopeless years, such patients become so
accustomed to the routine of the house, as to be mere children; and are content to live their, as they
commonly do, until they die. A continued residence in the asylum was gradually ruining the body and the
mind” (John Conolly, An Inquiry Concerning the Indications of Insanity, 1830, pp. 31, 21). Despite these
plausible drawbacks, which Conolly convincingly pointed out, there was no alterative scheme. Only the
asylum plan offered the advantage of allowing a scope for the exercise of humanitarian impulses, without
requiring any fundamental changes in the structure of society. Surrendering to the inevitable, the antiinstitutional Conolly became a leading and zealous advocate of county asylums for pauper lunatics.
22
and lunacy reform to them was a “mission.” Their “moral imperialism” was directed at
the lower class to rescue them from sin and social degradation.42
If Evangelicalism drew its followers from among those who loathed certain
“vicious” aspects of the emerging society, Benthamism (Utilitarianism) was the creed of
a class of administrators, who were the product of this new society. The Benthamites
belief in the need for a “science of government” and their emphasis on the replacement of
the amateur by the “expert” made the principle of utility (a proto- cost and benefit
analysis) the core to their “rational” method for deciding between different policies and
actions whose implementation must, by definition, produce the greatest happiness to the
greatest number.43 Such an approach inevitably emphasized the necessity of centralized
professional administration. Somehow, the Benthamite proved himself a better moral
entrepreneur than his Evangelical counterpart. His emphasis on institutional mechanisms
in pointing out and treating social maladies and his “rational” formula of inquiry,
legislation, execution, inspection, surveillance and report proved more useful and
effective in promulgating new laws and establishing institutions throughout the
nineteenth century reform and lunacy reform was no exception.44
Initially, however, notwithstanding their early efforts and revulsion by the
condition in the asylums, the reformers lacked a well-defined perception of the best
institution to care for the lunatics, a working plan to ameliorate conditions in the
madhouses and most importantly how to perceive of the lunatics and the best way to
manage and treat them. It was the notions developed by the Tuke family at the York
42
Scull, Museums, 56.
See Jeremy Bentham, An Introduction to the Principles of Morals and Legislation, (Canada: Batoche
Books, 2000).
44
Scull, Museums, 58.
43
23
Retreat, which became almost synonymous with the very notion of reform. The probable
reason behind the establishment of the retreat was a local scandal that involved the death
of a Quaker patient at the local charity York Asylum, which was built in 1772 in
Yorkshire to ensure the placement of and care for the mentally ill in a suitable institution.
William Tuke, a local tea and coffee Quaker merchant, urged his “Community of Friends”
to build their own facility, serving their “Friends” who were “deprived of the use of their
reason.” Samuel Tuke, his grandson, published an account of the retreat and the method
of treatment pursued in it in his book Description of the Retreat an Institution near York
for Insane Persons of the Society of Friends, where he described the retreat, its
philosophy and method, which came to be known as “moral treatment.”45
One cannot summarize in a phrase or two the meaning of what “moral treatment”
is for it is not particularly a well-defined technique. Rather, it is a general, pragmatic
approach making use of anything, which appeared to work and aiming at minimizing
external, physical coercion; and it has therefore usually been interpreted uncritically as
“kind” and “humane.” Restraint might be necessary to prevent physical injury but it
ought to be applied as a last resort and was never to be imposed arbitrarily for the
convenience of the attendants. While Tuke did not believe that restraint could be entirely
done away with, he did insist on doing away with its most objectionable forms- such as
chains and manacles- and his refusal to employ them, as a routine measure, was a
departure from prevailing practices. This made a profound impact on contemporary
reformers who saw Tuke’s success as a proof that the insane could be managed without
what were now seen as harshness and cruelty.
45
Samuel Tuke, Description of the Retreat an Institution near York for Insane Persons of the Society of
Friends, (London, 1813).
24
Aside from its barbaric nature, the problem with physical restraint was that while
it managed to impose an outward coercion it never succeeded in “internalizing” moral
standards. It failed to inculcate morality and teach the patient self-discipline. By all
reasonable standards, the Retreat was an outstandingly successful project. It had
demonstrated, to the reformers’ satisfaction at least, that the supposedly continuous
danger and frenzy to be anticipated from maniacs were actually the consequence of,
rather than the justification for, harsh and misguided methods of management and
restraint.46 The insane were to be restored to reason through the Benthamite notion of
“rewards and punishments,” a clear evidence of the deep impact these ideas had on the
lunacy reformers.47
Few months before the publication of Tuke’s book, Godfrey Higgins, a Yorkshire
magistrate, had become aware of the mistreatment of a pauper lunatic whom he had
ordered to be committed to the York Asylum (not to be confused with the York Retreat).
He managed to initiate an official investigation and inspection of the institution, through
the formation of what came to be known as the 1815-1816 Select Committee. The
investigation results revealed a wide range of violations and abuses that included, but
were not exclusive to, embezzlement, physical violence, rape and murder.
Simultaneously, other revelations of similar abuses at Bethlem asylum, the oldest mental
asylum in all of Europe, were discovered. Bethlem, or its corrupted form “Bedlam”, had
for centuries been synonymous with the idea of a separate institution for the insane. It’s
respectability had been attested to by the presence of a Board of Governors who were
46
47
Scull, Museums, 69.
Jeremy Bentham, The Rationale of Punishment, (Elibron Classics, 2003).
25
almost exclusively of aristocratic background; and its physician, Thomas Monro, was
himself something of a society figure.48
Despite the upper-class administration, however, most of Bethlem’s patient
population was of pauper lunatics crammed together in a derelict structure, which was
acknowledged to be in need of replacement. With only four keepers employed to
supervise 120 inmates, the inspecting party found that many patients continued for weeks
and months at a time to be chained to the walls of their cells.49 A number of the patients
were left naked and there was no effort to classify the patients and they were distributed
haphazardly among the mild and convalescent cases. 50
Both the Committee itself and those reform activists, who disseminated its
findings to a wider public, interpreted these revelations as proof of the need for more
institutions but they have to be under public control, as well as an improved system of
inspection and supervision of all receptacles within which lunatics were confined. 51 At
the close of the inquiries in 1815, therefore, the Committee had uncovered evidence that
neglect and maltreatment of lunatics was endemic in all the various types of institutions
in which they were incarcerated, and its members were convinced that legislative
intervention was urgent.52
The delay of adopting a legal bill of reform came from a number of sources that
viewed such a bill with suspicion. First, the owners of private madhouses feared for their
48
Scull, Museums, 73-74.
The most notorious of all the cases found was that of James William Norris and his iron cage. Norris was
a former American marine who was detained, or more accurately encaged, in the asylum in an iron cage
custom-designed for him, for 12 years. The horrifying account of Norris’s case was given by Lunacy
reformer Edward Wakefield who was a member of the Committee that investigated the conditions of the
madhouse and released its report in 1815.
50
“Report of the Select Committee on Madhouses,” April 1815 http://www.bible.ca/psychiatry/reportfrom-the-committee-on-madhouses-in-england-1815ad.htm
51
Scull, Museums, 77.
52
“Report of the Select Committee on Madhouses.”
49
26
business and profit and such threats of intervention through inspection and the calls for
state-run and financed asylum compromised their position. Second, doctors saw the
reformers’ proposals as an assault on their medical “professional prerogatives” by
encouraging lay interference in technical decisions concerning the proper treatment of the
insane. Third, and perhaps most importantly, there was a much more broad-based
powerful political opposition coming from a more local level represented by the British
society’s general aversion to the concentration of power at a national level, and the
entailed threat of “absolutism.” This made the British gentry view the Benthamites and
their calls for professional centralization and administration as a threat to their position. A
fourth factor, which stiffened resistance to the lunacy reformers’ proposals was the fact
that the parsimonious local authorities were alarmed by the prospects of heavy
expenditures resulting from the plan’s making the establishment of a county asylum
compulsory. A final factor was the local magistrates who continued to accept the
traditional social perception of insanity as “demonological and bestial”, unable to
comprehend the reformers’ criticism of the treatment of the insane. 53
All these factors contributed to the blocking of the 1819 bill, after three years of
Parliamentary debates on the findings of the Select Committee on Madhouses of 18151816. A brief hiatus ensued, until interest in the issue was renewed in 1827 with another
Parliamentary inquiry, which ended successfully with the passing of the 1828 Madhouses
Act. This Act stipulated the first legal requirements with respect to medical attendance in
asylums, as it became compulsory that asylums guarantee a medical visit to the patients
at least once a week.54 Between 1828 Madhouses Act and the 1845 Lunatics Act, which
53
54
Scull, Museums, p. 83-6.
Scull, Museums, p. 163.
27
is discussed in more detailed later in this chapter, the reformers continued their battle on
two fronts. The first, and the most visible, was political, where the reformers astutely
used parliamentary maneuvering and inquiries to keep the issue alive in the mind of the
public and to wear down their opponents. The second was less visible, yet more effective,
represented in the propaganda for a more pro-institutional ideology designed to rally
public support for the reformers’ plan. These factors allowed for the passing of a bill in
1828.
The “Mad-Doctors”
For the “mad-doctors,” the name given to the “proto-psychiatrists” by their
detractors, the threat to their “professional prerogatives” was clear, and so was the need
for a vigorous and convincing defense. In the aftermath of the findings of the 1815-16
Select Committee, the reformers in the Commons made a sustained effort to push their
double agenda of establishing state-run asylums and the establishment of a permanent
inspection commission. Each of the draft bills they introduced to give effect to this plan
empowered boards of laymen to inquire into the treatment and management of the
patients. Such proposals to introduce lay control and evaluation of “expert” performance
must clearly be seen as of enormous strategic importance; and as likely to provoke
intense opposition from those threatened by such control, namely the doctors in the “mad
business.”55 William Bynum argues that, “moral treatment” represented a rather damning
attack on the medical profession’s ability to deal with mental illness.56
55
Scull, Museums, 145.
William F. Bynum, Jr. “Rationale for Therapy in British Psychiatry, 1780-1835,” Andrew Scull (ed.),
Madhouses, Mad-Doctors and Madmen, (Philadelphia, Pennsylvania: University of Pennsylvania Press,
1981), pp. 35-57.
56
28
Despite the failure to pass the 1819 bill, the doctors remained vulnerable to
charges of lack of expertise based on scientific and/or practical knowledge. Therefore, if
they were ever to surmount this vulnerability, they had to develop a more sophisticated
justification for their claimed privileged position. Moreover, they became convinced that
reform was inevitable and they decided to join the reform movement, but they had their
own plan, as they were not willing to give “mere laymen” an upper hand in their own
respective field. The two decades following the reform bill of 1828 witnessed the
emergence of a class of professional asylum administrators, producing accounts of the
advantages of the asylum as a response to insanity. 57 A spate of books and articles
claiming to be medical treatises on the subject of the treatment of insanity made their way
to the public and professional circles, claiming that instruction in its treatment formed a
part of the normal curriculum of medical training, which had been made by an earlier
generation of “mad-doctors.” Dr. Francis Willis, grandson of the very doctor who was in
charge of “treating” King George III’s madness, perceived of his treatise as an endeavor
rendered “the more necessary, because derangement has been considered by some to be
merely and exclusively mental disease, curable without the aid of medicine, by what are
termed moral remedies; such as travelling and various kinds of amusements.”58 John and
Thomas Mayo used a more defensive and elaborate language when proclaiming that the
purpose of their Remarks on Insanity was “to vindicate the rights of [our] profession over
insanity, and to elucidate its medical treatment.” 59 Moreover, Prichard developed a
57
See W.A.F Browne, What Asylums Were, Are and Ought to Be, (Edinburgh: Adam and Charles Black;
London: Longman et al., 1837). Browne, a surgeon, was the medical superintendent of the Montrose
Asylum, before which he was the president of The Royal Medical Society in Edinburgh. This book is
mainly an accumulation of five lectures he delivered before the managers of the Montrose Royal Lunatic
Asylum.
58
Francis Willis, A Treatise on Mental Derangement, (London, 1823), p. 2
59
John and Thomas Mayo, Remarks on Insanity, (London: Underwood, 1817).
29
complicated nosology of insanity that impressed the average layman. 60 The mere
existence of a large body of what purported to be technical literature passing on the
scientific knowledge about the management of the insane gave a seemingly impressive
substance to the claim of expertise, regardless of its empirical usefulness and credibility.
The Medical appropriation of “Moral Treatment”
Since “moral treatment” lacked a well-defined philosophical rationale for why it
should work, it was easy to lay claim to and even be appropriated by doctors later on.
Since the beginning, Tuke had explicitly eschewed any desire to develop a theoretical
account of the nature of mental disturbance, and had refused to categorize “moral
treatment” into a rigid “scientific” paradigm, and vindicated a more flexible and
pragmatic approach instead. He boasted that he “happily [had] little occasion for theory,
since [his] province is to relate, not only what ought to be done, but also what in most
instances, is actually performed.” More importantly, he refused to choose between a
psychological and somatic etiology of insanity, arguing that “whatever theory we
maintain in regard to the remote causes of insanity, we must consider moral treatment of
very high importance.” If its origins lay in the mind, “applications made immediately to it
are the most natural, and the most likely to be attended with success;” if it is the body,
“we shall still readily admit, from the reciprocal action of the two parts of our system
upon each other, that the greatest attention is necessary, to whatever is calculated to affect
the mind.”61 Despite this evasion and aversion to theory and dogma, the moral treatment
advocates were more inclined towards a mental rather than a somatic interpretation of
60
James Cowles Prichard, A Treatise on Insanity and the Other Disorder Affecting the Mind, (London,
1835).
61
Samuel Tuke, Description of the Retreat, pp. viii, xxii, 138, 131-32.
30
mental illness. 62 The doctors reacted by adopting a strict somatic interpretation of mental
illness. The problem was that they lacked the empirical evidence linking mental illness to
somatic causes.
In an effort to save face, the doctors invented an ingenious metaphysical argument
disguised in scientific trappings, using the Cartesian philosophic/religious doctrine of
“dualism” between the mind and the body. The soul here is represented by the mind,
which is immortal, while the body is represented by one of its faculties, the brain, which
is mortal and hence is susceptible to disease and dysfunction.63 This explanation proved
highly appealing to a Christian audience who willingly adopted it. By establishing, and
adopting, this somatic etiology of insanity, the medical profession consolidated its claim
and jurisdiction over the treatment of the mad and “moral treatment” was absorbed as one
of the numerous medical techniques used in lunacy treatment. This left the physician as
the only legitimate authority to dispense the medical treatment. This authority is best
represented in the fact that a resident physician had been appointed to run the previously
lay-run York Retreat, where “moral treatment” had originally developed.64
The 1845 Lunacy Act
By 1845, the reformers had been successful in accomplishing their two key
demands -the establishment of public run asylums and the establishment of permanent
inspection commission- with the passing of two bills on 4 and 8 August 1845. The first,
the Lunatics Act of 1845, established a permanent national lunacy Commission, with the
power to make detailed and frequent inspections of all types of asylums, public, private
or charity foundations. The second Act, the County Asylum Act, made the erection of
62
Scull, Museums, 159.
Ibid.
64
Ibid., 162.
63
31
county and borough asylums to house pauper lunatics compulsory. In order to ensure that
the presence of large numbers of chronic cases would not interfere with the asylum
doctor’s ability to produce the cures they had promised, counties were authorized, though
not instructed, to erect separate, less costly buildings for chronic lunatics. Although
initially this had been viewed as a long-awaited-for victory, optimism about the future
was soon to prove hasty. As early as 1845, the economies imposed by the cost conscious
local authorities and the impact of an overwhelming lower-class clientele were clear signs
of the collapse of the very things the reformers thought were indispensible to the success
of the whole enterprise. 65 The asylum doctors themselves contributed to this process.
Bowing to political and social realities, the medical superintendents of county asylums
began to compromise and lower their requirements, always consoling themselves with the
thought that “the worst asylum that can at this day by possibility be conceived, will still
afford great protection” to the poor lunatics, compared to the treatment he would get
elsewhere.
Moreover, and perhaps ironically, the long-fought-for reforms came to
consolidate the doctors’ position and compromise that of the lay reformers, by giving the
former a bureaucratically and legally backed authority in lunacy treatment and asylum
management. Both the Madhouse Act of 1828 and the 1845 Lunatic Act, made this
possible with the former stipulating the mandatory arrangement for each asylum to have a
doctor visiting at least once a week, and the latter committing each asylum to keep a
Medical Visitation Book and a record of the medical treatment of each patient in a
Medical Case Book. Furthermore, from 1846 onward, the Lunacy Commissioners, who
had amongst their ranks a considerable number of doctors, had become hostile as ever to
65
Ibid., 113
32
non-medically run asylums, making sure to drive competing lay people out of the field or
at best subjugating them to their authority.66 Both Acts relinquished to the doctors the
“exclusive” right to manage and treat the insane; henceforward the doctors’ concern was
not to obtain a monopolistic professional legal recognition but rather to maintain it.
The Asylum and the Validation of Medical Authority
Despite their bureaucratically and legally backed position as the sole authority in
treating the mad, the doctors failed to score any progress in the treatment for the insane,
using every possible tool in their medical armamentarium,67 so much so that towards the
last decades of the nineteenth century they remained as far as ever from possessing any
real scientifically based knowledge about treating and curing the insane. 68 Consequently,
the medical superintendents were obliged to cling to the only remaining claim to
expertise: their “knowledge” of “moral treatment,” which by then, as it had always been,
meant the efficient, and humane management, of a large number of asylum inmates.
Fortunately, however, for the medical superintendents, their inability to produce
cure to the insane by no means exhausted their usefulness as asylum doctors. Eliot
Freidson when talking about the profession of medicine in general argued that “a
significant monopoly could not occur until a secure and practical technology of work was
developed.”69 In the case of the doctors and the psychiatric profession in Britain the case
was different. It was the institution itself (the mental asylum) that lent a legal recognition,
professional backing and social acceptance to doctors and not vice versa. The
66
Ibid., 163.
R. A. Hunter and I. MacAlpine, Three Hundred Years of Psychiatry, (London: Oxford University Press,
1963), p. 743 qtd in Scull, p. 171.
68
Scull, Museums, 171.
69
Eliot Freidson, Profession of Medicine: A Study of the Sociology of Applied Knowledge, (Chicago:
University of Chicago Press, 1988) p. 21.
67
33
profession’s monopoly over the asylum (the only authorized and recognized institution
for the treatment of insanity) shut out all potential competition and opposition. Moreover,
the asylum institutional base armed the doctors with a powerful leverage over the
community, who by seeking to utilize their services, unknowingly and indirectly
strengthened these doctors’ professional authority, adding an aura of legitimacy
surrounding their activities. Seeking the help of the doctors did not necessarily reflect the
community’s acceptance of the doctors’ claim to professional specialty and “esoteric
knowledge,” but it was a working solution they were ready to adopt to rid themselves of
the responsibility for the insane and infirm family members, and throwing it instead onto
the state. It is safe here to conclude that when it comes to psychiatry, psychiatrists and the
mental asylum, the situation is best reduced to something similar to “bureaucratic office,
limiting the freedom of the clients and even coercing them into compliance.”70
The institution was the almost exclusive arena in which the new profession plied its trade.
The structure of “moral treatment” was such that the asylum was also perceived by
doctors as one of their crucial therapeutic instruments; that is the asylum itself was a
major weapon, if not the major weapon, in the struggle to claim “cure” and jurisdiction
over the insane. Organized psychiatry originated precisely in a partly entrepreneurial
response to the opportunities offered by the creation of an asylum system rather than as
the “logical” institutional expression of an expanding body of knowledge or the
crystallization of particular therapeutic techniques.71
70
Ibid, 131.
Andrew Scull, Mad-Doctors, Madhouses and Madmen: The Social History of Psychiatry in the Victorian
Era, (Philadelphia: University of Pennsylvania Press, 1981), p.17.
71
34
Chapter II: Medical and Psychiatric Care on the Eve of British Occupation
General Medical Care
When the British arrived to Egypt in 1882, following the defeat of ‘Urābī and the
end of the army mutiny, the situation in Egypt was shaky on both the political and
economic fronts. Although the British initially claimed that their intention was to stay in
the country until the leavening of Egypt’s economic insolvency, their presence lasted for
another seven decades. Unlike the situation in most of the other British colonies, where
political colonial actions were justified on “moral” grounds, mainly the “spread of
civilization” and the introduction of medicine, law and education through “modern
institutions,” the situation in Egypt was different. Egypt had gone through a rigorous
process of modernization starting early in the nineteenth-century, as a result of
Muhammad Ali’s (1769-1849) efforts to build an army strong enough to fulfill his
political and territorial ambitions. Whether intended or not, a strong medical tradition was
created and achieved a considerable status due to its importance and centrality to
Muhammad Ali’s military establishment. The Qasr al-ʿAinī hospital and the attached
medical school were the pinnacle of this modernization.
Following the British arrival to Egypt in 1882, a cholera outbreak led to the
appointment of a Medical Commission of 12 members, among whom was Dr. Fleming
Mant Sandwith (1853-1918), who would in 1884 assume the directorship of the
“Department of Public Health” which replaced the Sanitary Department. Upon the
assumption of the new post, Dr. Sandwith reported on the conditions in the Qasr al ʿAinī
hospital lamenting that “the hospital and school were in an unspeakably filthy condition
and few patients went there except under compulsion…Refractory patients were punished
35
by confinement and chains, anklets and handcuffs.”72 Moreover, “there was no nursing,
the attendants consisting entirely of worn-out old soldiers, who had been dismissed from
the Army with of course, no moral control over the patients.”73
While it would be highly inaccurate, cynical and unfair to claim that a British
doctor such as Sandwith did not really care about sanitary conditions and was only
motivated to serve political ends, it would be equally erroneous to ignore the colonial
context in which Sandwith worked, where the case was usually that the power of the
“experts,” here the colonizer, was based on an exclusive “claim” to knowledge. This
“claim” to knowledge established itself on the power to control, claim and “do” and not
necessarily on “real knowledge.” The British discourse on evaluating “modernization”
and “modern institutions” in Egypt was that of vehement denial of any positive
achievement, at worst, and undermining all previous attempts to create and enhance
institutions and services, at best. There had been claims that modern medicine was
established under the British administration and that whatever the British failed to
achieve must be blamed on the indigenous population’s resistance to change.74
Nobody represents this line of thought better than Evelyn Baring (Earl of Cromer
1841-1917), henceforth Lord Cromer, whose evaluation of medical care and services
shows how he perceived of the arrangements and developments achieved prior to the
British occupation as rudimentary. There was “of course much remains to be done”
awaiting the Englishman who “had great obstacles to encounter,” but “succeeded in
introducing the first commonplace elements of Western order and civilization into the
country.” Simultaneously, Cromer accused the indigenous Egyptians of hindering
72
Sandwith quoted in Mahfouz, History, 44.
Ibid, 47.
74
Valentine Chirol, The Egyptian Problem (London: Macmillan, 1921), p. 212.
73
36
sanitary reform because of their inherent aversion to hygiene and intrinsic “indifference
to sanitation,” which “constitute almost inseparable barrier to rapid progress.”75 It is true
that Cromer admitted that “the School of Medicine still existed,” but he retorted, “the
instruction afforded the students was very defective” and “the greatest number of the
medical officers serving under the Egyptian Government were ignorant and
incompetent.”76 By overstating the poor condition of Egypt’s health facilities prior to the
British takeover, such statements as Cromer’s exaggerated the British accomplishments.
These statements gave the impression that since the British had practically started from
point zero, they should be admired for what they had achieved rather than criticized for
not having done more.
It might be argued that because of the aforementioned reasons, Cromer’s policies
in ruling both Egypt and India were almost the same, with the purpose of keeping the two
people for the longest time under British control.77 But the experience and progress in
medical education and services in both countries are different. In India, medicine and
modern education were introduced, financed and promoted by the British, whereas Egypt
had already gone through its medical reform experience almost sixty years before the
75
Lord Cromer, Modern Egypt, (Eliborn Classics, 2005) Vol. II, p.512.
Ibid, Vol. I, p.507-8.
77
For more details see Roger Owen, “The Influence of Lord Cromer’s Indian Experience on British Policy
in Egypt 1883–1907,” in Albert Hourani, ed., St Antony’s Papers, 17: Middle Eastern Affairs, 4 (London:
Oxford University Press, 1965); Roger Owen, Lord Cromer: Victorian Imperialist, Edwardian Proconsul,
(New York: Oxford University Press, 2004). Owen studies the imperial career of Evelyn Baring, Lord
Cromer, which included serving in, along with Cairo, Calcutta, Malta, and Simla. Baring’s imperial debut
was in India where he served two intermitting stints in the 1870s and 1880s. Between his two assignments
in India, he served in Cairo from 1877-80 on the Caisse de la dette publique, which controlled Egypt’s
finances. After his brief sojourn in Egypt, Baring returned to India for his second assignment there only to
be called upon back to Cairo in the wake of the events caused by the Urabi Mutiny, which ended with the
British occupation of the country in 1882. Baring was then reinstated as Consul-General of Egypt. But it
was in India, under the patronage of his cousin, the then Viceroy of India Northbrook, that Baring learned
the importance of low taxation, of sympathy with the peasant population, of keeping just in advance of
local public opinion, and of listening carefully to the uncensored views to be found in the vernacular
newspapers." For him, the best way to rule Egypt, unlike the British Raj in India, was through indirect
control.
76
37
British takeover. Besides, medicine and Western education were introduced to Egypt
according to the plans of the Egyptian rulers and foreign help was sought only in the
drawing of the general plans and borrowing techniques, and this help was mostly nonBritish, particularly French.78
In order to test the validity of the British claims, represented by Cromer, that an
enhanced medical care was only possible when the British ruled the country, it is
imperative to review the development of medical care in Egypt before the arrival of the
British and their “reform” of medical services, care and education. Prior to the
establishment of Qasr al-ʿAinī hospital in 1827, the two most important māristāns,
hospitals, built in Egypt were bimāristān “al-ʿatīq” (the ancient) which was built by Salah
ad-Dīn Yūsuf Ibn Ayūb, Saladin (1137/38-1193), in A.D. 1172 and bimāristān “al
mansūrī” built by Sultan Qalāwūn (1222-1290) in 1283 A.D.79 More ancient than these
two hospitals was the bimāristān built in Fustāt in A.D. 872-874 by Ahmad Ibn Tūlūn
(835-884) who took a great interest in the hospital and paid it weekly visits of inspection
on Friday. These visits were however suspended after he was attacked by one of the mad
inmates.80 During the French Expedition to Egypt (1798-1801), René Nicolas DufricheDesgenettes (1762-1837), the Principal Medical Officer of the French Army, reported on
the state of the Qalāwūn māristān in 1798. According to him, the māristān was composed
of 8 principal rooms that can accommodate a hundred patients. Four were reserved for
men and four for women. He counted 25 wooden beds covered by miserable mattresses.
78
Sonbol, The Creation, 17.
Mahfouz, History, 10
80
Ibid. It should be noted that this hospital is different than the mosque that was used as a Takiyya of which
no trace exists today. For a full record on the history of the mosque/Takiyya of Ibn Tūlūn, see Mine Ener,
Managing Egypt’s Poor and the Politics of Benevolence, 1800- 1952, (Princeton and Oxford: Princeton
University Press, 2003).
79
38
Fifty more beds were built of stone. He found 27 patients and 14 lunatics and was
afterwards led to courts where seven men and seven women were locked up for
insanity.81 The hospital remained functioning until the reign of Said Pasha (r. 1854-1863)
when the building fell into ruins, and all patients deserted the hospital with the exception
of the insane. The māristān remained the Cairo Lunatic Asylum until 1856 when the
patients were removed to a warehouse in Būlāq. From Būlāq they were again moved in
1880 to ʿAbbasiyya.82
Muhammad Ali’s obsession with building a strong army created another
obsession with medicine, not for the benefit of his subjects per se as much as it was
aiming at universalizing vaccination, preventing and containing the outbreak of
epidemics and maintaining healthy army personnel. These imperatives prompted
Muhammad Ali to seek assistance and advisers from France. He recruited doctors to
initiate smallpox vaccination efforts as early as 1819. This increased concern for the
Egyptian population and its health was most noticeable in the military. 83 But as LaVerne
Kuhnke has argued, Muhammad Ali’s interest in the health of the military personnel also
applied, perhaps not intentionally, to the civilian population.84 On December 22, 1824, Dr.
Antoine Barthélemy Clot (1793-1863), henceforward Clot Bey, signed a contract of
service under Muhammad Ali, for 5 years, with a salary of 8000 francs a year. 85 The
81
Degenettes, Memoires sur L’Egypte, (Paris, 1803), p.49,.quoted in Sandwith, “Cairo Lunatic Asylum,”p.
474.
82
Sandwith, “Cairo Lunatic Asylum,” 475-76.
83
For an extensive account of Muhammad Ali’s army building and the ensuing medical services see
Khaled Fahmy, All the Pasha’s Men: Mohamed Ali, His Army and the Making of Modern Egypt, (Cairo;
New York: the American University in Cairo Press, 2002).
84
LaVerne Kuhnke, Public Health in Nineteenth Century Egypt, (Cairo: The American University in Cairo
Press, 1992), p.134.
85
Jacques Tagher, Memoires de A. B. Clot Bey, Le Caire: L’institut Français D’Archéologie Orientale, 28.
39
following year, the “Health and Hospitals Council” was established which a few years
later (1834) was renamed “The General Health Council”.86
Muhammad Ali ordered the establishment of an army hospital in Abū Zaʿbal, to
the north-east of Cairo, with an attached medical school and the capacity to accommodate
more than 1500 patients. In February 1827, study started in the medical school with Clot
Bey presiding over it, assisted by 100 students, with each of them receiving a monthly
stipend of 100 piasters and employment upon completion of medical training. 87 The
School of Medicine was later transferred, however, to its present site al Qasr al ʿAinī in
1837.88 The school’s original purpose was to provide the government’s health services
with the medical personnel they needed. There was no thought of a future profession
independent of government service. 89 Along with the newly established government
hospital, few private clinics run by European and Levantine doctors offered medical
service to those who could afford it. To the majority of the Egyptian public, the only men
practicing medicine were either barbers or charlatans, who used a form of tibb ilāhi
(spiritual healing) that relied on recitation of the Quran and other holy scriptures. 90 This
situation was not unique to Egypt. In 19th century Britain, people depended on home
remedies. What made all the difference between Egypt and Britain was the fact that in the
latter, at the beginning of the 19th century, medicine was developing and growing into a
specialized profession and a private business (mainly family business), and medical
education took the form of medical apprenticeship.91
86
Amīn Samī, Taqwīm el Nīl, Vol.II, (Cairo: Dar el Kutub el Masriyya, 1928), p. 327.
Ibid., p. 326.
88
Mahfouz, History, 35
89
Sonbol, The Creation, 86.
90
Ibid, 35.
91
Peterson 41, quoted in Sonbol, The Creation, 36; see chapter 1 for more details.
87
40
A protégé of none other than the Viceroy himself, Clot Bey strove to “nationalize
medicine” and establish a profession based on the ancient Arab and Pharaonic medical
glory of the country. 92 He disapproved of Egyptian graduates of the medical school
teaching at the preparatory school opened at the māristān Qalāwūn and had that school
closed down. He managed instead to have them appointed as assistants to foreign doctors
as “repététeurs” of the lectures delivered by foreign professors.93 As Sandwith remarks,
“of all Europeans attached to Egypt during the last half of the 19th century, no one was
more fortunate than Clot Bey in impressing upon modern Egypt the durability of his
works. He found chaos and created therefrom hospitals, schools of medicine, pharmacy
and midwifery, sanitary and quarantine departments, all of which in an improved form
still exist. One of his greatest services was the introduction of vaccination throughout the
whole country.”94
Clot Bey’s medical services were interrupted, however, when he was forced to
retire in 1849 following “la mort d’Ibrahim Pacha,” and the accession of “Abbas Pacha,
son successeur,” who “pris en main les rênes du gouvernement” and “n’eut rien de plus
pressé que de démolir, pièce à pièce, l’édifice des grandes et utiles institutions fondées
par Mohamed Ali et continuées par son fils (Ibrahim).”95 The death of Abbas I and the
succession of Said Pasha in 1854 revived a new hope and Clot Bey returned to Egypt at
the end of the same year, only to deliver the inaugural speech for the Medical School
reopening in 1856. Two years later, he retired for health reasons.96
92
Clot, Memoires, 64.
Mahfouz, History, 33.
94
Sandwith, quoted. in ibid, 38.
95
Clot, Memoires.
96
Ibid
93
41
Due to Clot Bey’s efforts in advancing the medical services and teaching in Egypt,
the country boasted the existence of a number of functioning hospitals. Two of them were
for the European communities residing in Egypt, one located in ʿAbbāsiyya, known as
the European Hospital, and the other located in the city of Ismailiyya, and known as the
Princely Hospital (isbītalya al birinsāniyya?). Other hospitals were operated and owned
by the Egyptian Government. The first was al Qasr al ‘Ainī Hospital, which was attached
to the School of Medicine. The second Egyptian hospital was the Lunatic Asylum in
ʿAbbāsiyya, endowed by Khedive Tawfiq, including two sections, one for men and the
other for women.97 Another hospital was the Jewish Hospital, located in Haret el Yahūd
(the Jews’ Alley), in Old Cairo.98
Registration procedures of qualified medical practitioners had been instituted in
the 1850s under Said Pasha and developed further under Ismail although the number of
licensed practitioners remained quite small. Under Said Pasha, rules and regulations
concerning medical practice were issued. A health council, made up of foreigners, was
responsible for reviewing the credentials of any person, whether European or Egyptian,
wishing to practice in Egypt as a physician. Ismail accepted these rules and established
penalties (including revocation of the license to practice) for doctors guilty of dishonesty
or misdemeanors.99
The Health Council objected to giving diplomas to Egyptian graduates from Qasr
al ʿAinī (foreign graduates were awarded medical diplomas) despite repeated petitions
from the School of Medicine. The government’s policy, presumably, aimed at keeping
97
There was a third government hospital in Cairo in the quarter of Azbakiyya called the Civil Hospital, but
it was closed down before the British advent to Egypt.
98
Ali Mubarak, Al Khitat al Tawfiqiyya al Jadida le Misr, Vol. I, (Cairo, 1980), p. 239
99
Mayers, 45.
42
graduates in government service since without a medical diploma, they would be barred
from setting up private practice. In the 1870s, however, government policies concerning
the medical school had changed. Mostly for financial reasons, non-boarding Egyptians
were allowed during Ismail’s rule to obtain the coveted medical diploma. 100 Towards the
close of the 1880s, prior to the British reorganization of the school, medical education at
Qasr al ʿAinī was still operating according to the French system. According to Naguib
Mahfouz, by the time the British occupied Egypt, all but one of the faculty at Qasr al
ʿAinī were Egyptians who had completed advanced medical training in Europe.
By the time of the British arrival to Egypt in 1882 the School of Medicine at Qasr
al ʿAinī, had already gone through various problems since its creation in 1827, and was in
a shaky position due to Egypt’s bankruptcy and the general budgetary cut in accordance
to the British programs to reduce government spending. Simultaneously, the British
interest in the School had grown steadily, and eventually a British doctor, Dr. Keatinge,
was appointed Director of the School in 1889. By 1893 the school administration was
completely taken over by the British who proceeded to reorganize it and “raise its
standard to that of Western schools.” Of all Egyptian educational institutions, the school
of Medicine received exceptional propaganda and was cited most often in proclaiming
the benefits of British rule. The curriculum was updated, the buildings restored, the
attached hospital efficiently organized, and the standard of the students raised.101
But aside from this managerial and exterior varnishing, there were some adverse
effects brought by British “occupation” on the School of Medicine. First, medical
specialization was stalled in 1898, allowing certified students to be only general
100
101
Sonbol, The Creation, 88-93.
Ibid., 106.
43
practitioners and any post-graduate work done could only be towards training students to
serving as “[a]s assistant in the Infectious Hospital; as assistant in the Lunatic Asylum; as
assistant to Sanitary Inspector; as assistant to the professor of Hygiene or Pathology at
Qasr al ʿAinī or other hospital.” 102 The refusal to implement academic specialization
must have contributed to the shrinking number of enrolled students in the medical school
at Qasr al ʿAinī as these students realized that upon graduating they would not be able to
stand the competition with their foreign counterparts who were academically specialized
and were granted license to practice.
A second adverse effect brought by the British occupation on both the medical
education and services was the fact that both were “privatized.” The trend toward
creating a medical elite was accelerated by the charging of fees to enroll in the School of
Medicine, which were instituted for schools at all levels of the educational system. When
the British took over the School of Medicine, they established a fee of £15 per annum per
student (an immense financial burden according to the measures of that time), excluding
the cost of books, medical and surgical equipment the students were required to own.103
Consequently, while the need for European doctors receded after the inauguration of Qasr
al ʿAinī and the graduation of trained Egyptian doctors, the refusal of the British
administration to license the Egyptian doctors, and the relatively high fees of medical
education, reduced the number of local doctors, giving a free hand to European doctors
who almost had no domestic competition.
At the same time, the British issued a new regulation stipulating that at no time
can the number of scholarship exceed 10% of the student body as opposed to 73% in
102
Extracts from the Report of Dr. Perry, Approved by Ministerial Order, 15 th June 1898 (Cairo: National
Printing Office, 1989), p.14 quoted in Sonbol, The Creation, 113-14)
103
Sonbol, The Creation, 119.
44
1885.104 As per patients, the British divided the one-class hospital system into five classes,
of which only the lowest allowed any form of free service. The psychological impact of
such a classification and the acceptance of subjugation it imposed need to be emphasized.
This multiclass system was not restricted to medical care. It was applied everywhere
under the British except perhaps in mosques.105
Psychiatric Care
In 19th Egypt, “mental disorder” was conceptualized in terms articulated by
Islamic theology, medicine, jurisprudence and popular culture. Explanations of “mental”
illness, like other afflictions, referred to coexisting and mixed worldviews, which
reflected animistic beliefs, humoral theory, Pharaonic remnants, Coptic strains as well as
European medical ideas.106 Social differentiation between types of disorders referred to
social and legal restrictions rather than to medical theory or problems. In other words,
“insanity was conceptualized primarily in legalistic terms and social categories and only
rarely did it designate medical assumptions.”107
The categorization of a person as insane (majnūn) was important in determining
his/her legal capacity (ahliyya) in cases of inheritance, transactions, civil and criminal
offenses, guardianship and marriage. Legal capacity to enter into binding contracts was
restricted to “interdicted persons.” Causes of interdiction included slavery, minority, debt
and prodigality, lunacy and imbecility. The insane person in Islamic law possessed the
status of a minor unable to discriminate and was denied competence to enter into
contractual relations, or to have his witness testimony taken as valid by a judge.
104
Ibid.
Ibid, 140.
106
For a full account on the perception of the mentally ill and mental illness in the medieval period check
Michael Dols, Majnūn: The Madmen in Medieval Society, (Oxford: Clarendon Press, 1992).
107
Mayers, 28.
105
45
According to Islamic law, the insane, like minors, are not considered fully liable for their
actions and the qadī (judge) also had to make sure that a criminal was sane before
holding him accountable and passing a judgment.108 Mental disorders were thought to be
caused by physiological malfunctions occurring because of creation abnormalities
(khilqa) or supernatural factors such as demons and jinn.109
Imbeciles and the mentally deranged, known in Arabic as majadhīb, 110 were
perceived in the popular classical tradition, as possessing saintly attributes. They were
believed to be closer to the spiritual and metaphysical world than ordinary people. Part of
their insanity had been accounted for as being the result of their exposure to “revelations”
and “visions” of the divine and the supernatural world that the ordinary mind cannot
perceive. As such, they themselves possessed a certain amount of “baraka” (roughly
translated as blessing and sainthood) and even divinity. Lane noted that in Egypt, an idiot
was regarded as a “being whose mind is in heaven, while his grosser part mingles among
ordinary mortals.” The dangerous lunatics were kept in confinement while harmless
insane were “generally regarded as saints” and most of the reputed saints” were in fact
“lunatics, idiots or imposters.” Such persons (known as Sheikh, waliyy or murābit) were
left to wander at will and were supported by alms.111 From birth to young adulthood, the
family was the first bulwark of safety and security and the primary site of socialization
108
See Majid Khaddurri and Herbert Liebesny, Law in the Middle East, (Washington: Middle East Institute,
1955); Joseph Schacht, An Introduction to Islamic Law, (Oxford: Clarendon Press, 1964) for a full
discussion of criminal responsibility and legal capacity with regards to such persons
109
For an account on the folk beliefs concerning metaphysical powers and demonic possession, see Hasan
el-Shamy, Religion Among the Folk in Egypt, (Westport: Praeger, 2009).
110
The etymology of the word “majdhūb” suggests that it is derived from the Arabic root “Jadhaba” which
means to pull. Derivatives of this root indicate pulling, attraction, both physically and emotionally. In this
case it basically means those pulled to or attracted by the divine and/or the metaphysical world.
111
Edward William Lane, Manners and Customs of the Modern Egyptians, (New York: Cosimo Classics,
2005), 229; William Yates, The Modern History and Conditions of Egypt: Its Climate, Disease and
Capabilities, Vol.1 (London, 1843), p. 331-32.
46
and financial support. That is why the care for the insane was left to the families of the
inflicted or, in case of financial difficulty, parochial relief, mainly the Waqfs.112
With Muhammad Ali’s relentless modernization and centralization efforts, the
state took over from religious authorities the task of health care provision, including
mental health. Muhammad Ali’s projects were distinguishable from those of earlier rulers
in that he paid close attention to medicine and health care services, and his approach was
preventative aiming at nipping in the bud the outbreak of diseases and epidemics through
vaccination efforts and the application of quarantine strictures. 113 His efforts also
involved state expenditures to recruit foreign medical experts, send students to Europe for
training, and construct new hospitals. The very act of separating the various functions of
the māristān represents the modernization of services. By the 1840s, the Egyptian
government, through its health officials, began to distinguish between different categories
of people needing assistance and to create distinct institutions for their care. In this
manner, state-sponsored facilities replaced the multifunctional role Islamic hospitals had
once played with more specific, category-centered institutions. 114 While the Viceroy’s
interest and investment in these forms of medical relief and assistance can be perceived
as a form of charity and part of the ruler’s obligations towards his subjects, they also
reflected the state’s knowledge of the importance of public health and the increasing
intervention of the medical authorities and the police in the lives of Egypt’s inhabitants, a
112
Ener, Managing, p. 2.
Ibid., 42.
114
Ibid., 46.
113
47
typical application of Michel Foucault’s neologisms of “bio-power” or “bio-politics” and
“governmentality.”115
The Dabtiyya, the police authority, was responsible for stopping, arresting and
referring those poor, mentally ill and those in need of medical assistance to the proper
shelter, hospital or asylum. Some people even voluntarily resorted to the Dabtiyya, such
as “family members and the relatives of insane persons,” requesting that “the insane be
admitted to government-run asylums.”116 This is in line with Judith Tucker’s explanation
of how economic changes during this period had weakened the peasant family’s role and
ability to support its nonproductive and infirm members, weakening the family’s role in
favor of an increasing state intervention.117 Arresting individuals found by the police in
urban and rural areas and those committed by their families, testify to the interest of the
government in clearing public spaces of individuals who might pose a threat to the
society at large. In this regards, “the Dabtiyya served to link the state with the
populace.”118
The criticism directed to the medical conditions and care extended to the
medically ill was not an exclusive domain to foreign politicians, such as Cromer. Foreign
political and economic intervention in Egypt did not simply start with the British
occupation of the country. It had started as early as the French Expedition to Egypt
(1798-1801), but even before that, travelers had been roaming the land of Egypt, along
with other parts if the Ottoman Empire, for religious, touristic and political reasons. The
115
Michel Foucault “Governmentality,” The Foucault Effect: With Two Lecture by and an Interview with
Michel Foucault, Graham Burchell et al (ed.) (Chicago: University of Chicago Press, 1991), p. 100. Also
see Foucault’s discussion of bio-politics in The History of Sexuality, (New York: Vintage Books), p. 13940.
116
Ener, Managing, 42.
117
Tucker, Women in 19th century Egypt, (Cambridge University Press, 1985) pp. 102-03.
118
Ener, Managing, 44.
48
result of these trips was a mélange of ethnographies and travelogues and literary works
that reflected two contradictory sentiments; an infatuation with the relics and mystique of
the ancient civilizations and a repulsion by the inferior political and cultural state of the
“Orient.” But throughout the nineteenth century, the first sentiment gradually subsided,
giving ample room for the second to take over. The British in particular, who had played
an advisory role in the administration of Egypt’s finances in the 1870s until occupying
the country in 1882, regarded Egypt’s beggars and the pauper insane “as an eyesore, a
nuisance, and carriers of filth and disease.”119 To them, these infirm figures symbolized
the “diseased,” “impoverished” and “dependent” status of Egypt.
Foreign travelers had the liberty to visit Egypt’s medical facilities, inspect them
and write their own accounts, which were mostly negative. The lunatic asylum had been a
favorite “attraction” included in the itinerary of most of these travelers and became part
of their commentary. In their portrayals of Egypt’s poor and insane, European visitors,
medical doctors, missionaries and statesmen, focused on two concepts: “the
omnipresence of Egypt’s indigent in public spaces” and the utter lack of regard that
Egyptians and their government had for the poor and others in desperate need.120 Most of
these accounts were tainted by political motives directed against Egypt’s rulers and
government to assert the country’s inherent backwardness, the rulers’ despotism, and
Egypt’s inability to self -rule.
The frequency with which travelers made authoritative reference to the insane and
the ease with which travellers entered institutions such as the lunatic asylums of Cairo
points to a particular privilege enjoyed by European men and women who had the
119
120
Ibid., 76.
Ibid, 84.
49
freedom to transgress the boundaries between the public and the private realms, and
rendering a “medical gaze” so penetrating and authoritative. Like the women and men of
London’s West End (West-Enders) who easily crossed the boundaries between the rich
and the poor, travelers to Egypt commented on the activities of a group of people whom
“they identified as belonging to a separate category of humans.”121 As the upper classes
in Victorian England set forth their own ideas about how the poor could best learn to
improve themselves, travellers to Egypt arrived with fixed ideas about the proper care for
the “deranged Easterners.”
As mentioned earlier in this chapter, the bimāristān, or māristān, of Qalāwūn
included a section for the mentally ill. Foreigners/orientalists who visited this institution
in the early 1840s, noted that it hosted the insane as well as the infirm, and illustrated
how the māristān functioned as a shelter along with its original role as a hospital and an
insane asylum.122 By the early 19th century, the quality of care and the number of patients
in the hospital had diminished and the hospital had fallen into disrepair. According to
Amīn Samī, Muhammad Ali ordered his deputy to transfer the inmates to the Civilian
Hospital in Azbakiyya. However, due to the lack of logistics and the fact that the hospital
was not yet prepared to accommodate the mentally ill, the plan was postponed 123 but
apparently they were eventually transferred to the Civilian Hospital in Azbakiyya in the
1840s as they were spotted by Gustav Flaubert there in 1849.124 The māristān remained,
however, the principal Cairo Lunatic Asylum until 1856. The patients were removed to a
121
Ener, Managing, 87.
Yates, The Modern History, p.330-36. Yates account of the mūristān, is extremely negative. The
“mouritan,” a misnomer of mūristān, was used as a dumping ground for the insane who were seen as
“incurables.” See below for further details.
123
Amin Sami,Taqwīm, Vol. II, p. 178.
124
Francis Steegmuller (trans. and ed.) Flaubert in Egypt, (Chicago: Academy Chicago Publishers, 1979),
p.67.
122
50
warehouse in Būlāq (the Gūkh warehouse), which was not properly equipped to
accommodate the mentally ill. From Būlāq they were again moved in 1880 to ʿAbbasiyya.
The asylum of ʿAbbasiyya was built on the renovated ruins of the “Red Palace,” which
was built by Khedive Ismail but which was later burnt down in 1878.125
William Yates’ account, The Modern History and Condition of Egypt, is typical of
negative accounts given by foreign travelers on the general deterioration of the medical
conditions and the lack of care for the mentally ill in Egypt. A British medical doctor and
a Baptist missionary, who served most of his tenure in India, Yates launched on a trip to
Egypt to survey its climate, diseases, religious beliefs and social life. During his sojourn
in Egypt, he visited the māristān Qalāwūn, which he heavily criticized as filthy and
inhumane. Using his discussion of the lack of care for the insane, the aged and the poor
as a means for launching a broader condemnation of the despotism of Muhammad Ali’s
rule in Egypt, Yates mirrored the perceptions of other British residents and statesmen
who vilified Muhammad Ali’s actions and viewed the “East” and “Easterners” with utter
resentment and despise. Yates noted that “notwithstanding the talked of doing of Clot
Bey on medical subjects,”126 the condition of the insane and the population in general
remained dismal due to the ruler’s despotism and negligence. Such critique also reflected
the British attempts to belittle the French, as represented by Clot Bey, whose opinion and
help were more sought by the Viceroy as opposed to their British counterparts. Moreover,
Yates could not hide his contempt for Muslims and voiced his belief that Islam is
inherently defaulted and barbaric. Accordingly, that was why the Qalāwūn, asylum which
was built on “Mohammadan notions,” failed to rescue the demented souls of the insane
125
126
Ali Mubarak,al Khitat, p. 240.
Yates,The Modern History, 333.
51
and the only way to reverse the situation is by British intervention. He urged the
“counsels of the English” to seek the abolition of this “execrable lazaret,” and found in its
stead a hospital based on “Christian principles.”127 He further likened the māristān to a
prison because all of the insane were kept in cells.
Another traveler who provided a negative account of medical care in Egypt was
Richard Robert Madden (1798-1886). A contemporary of Yates, and a prominent British
doctor, writer, abolitionist and civil servant, Madden paid a visit to the māristān Qalāwūn
in 1826, through which he remarked on the inhumane treatment the insane received at the
hands of their keepers. He even tried to persuade “the keeper” to introduce more humane
treatment, but his advice was ignored. 128 Another dissatisfied traveler was James
Augustus St. John (1795-1875) who while visiting the māristān in the 1830s admitted that
while madhouses were horrendous everywhere in the world, there could be nothing “so
terrible, so disgusting, [to] be witnessed as the madhouse of Cairo, where, as maybe
certainly inferred from the ferocious aspect of the keepers, and appearance of the victims,
lacerated and covered with wounds, scenes of cruelty and suffering occur not elsewhere
exhibited out of hell.”129
The common factor in the accounts of the aforementioned travelers was their
perception of the inherent “political despotism” in the “East,” reflected in the barbaric
and inhumane treatment of the mentally ill. Political despotism was not only attributed to
the autocratic rule of Muhammad Ali, but rather was discussed as an inherent cultural
trait that was responsible, along with others, for the continued suffering and destitution of
127
Ibid, 335.
Richard Robert Madden, Travels in Turkey, Egypt and Palestine, (London: H. Colburn, 1829) Vol. 1 p.
309-10.
129
James Augustus St. John, Egypt and Muhammad Ali or Travels in the Valley of the Nile, (London:
Longman, Rees, Orme, Brown, Green& Longman, 1834), Vol. 2, p.310.
128
52
Egypt’s inhabitants. Although Marsot argued that the negative commentaries about
Muhammad Ali emerged within the context of British industrial competition with and
contempt for Muhammad Ali’s policies, their continued use illustrates that such
representations were not confined to Muhammad Ali’s reign but fitted into a larger
scheme that created a dichotomized binary distinguishing the “despotic Orient” from the
“enlightened West.”130
Even the account given by the renowned British artist William Henry Bartlett
(1809-1854), which had been viewed by historians of the Middle East as favorable and
positive, is a tad tricky when not taken at face value. In the 1840s, Bartlett visited Egypt
as part of a prolonged trip he made to the Middle East. He paid a visit to the then new
asylum in Būlāq and noted that “thanks to European influences upon the naturally
humane feelings of Muhammad Ali, [it] has replaced the old ‘Morostan’ with its horrors,
which was so long a standing subject for description with Egyptian tourists.”131 It is true
that unlike the aforementioned accounts this one gives a favorable depiction of the new
asylum and the care extended to the insane. However, this would not have happened, as
Bartlett suggested, without the “European influence” without which the Viceroy’s
“naturally humane feelings” would not have moved.
Within thirty years, however, another account on the Būlāq asylum appeared
which was not particularly favorable of the facility. It is either the conditions Bartlett
viewed as positive deteriorated sharply during this three decades period, or his criteria
were much more compromised than his successors. Medical doctors A.R. Urquhart and
130
For further details see ʿAfāf Lutfī el Sayyid- Marsot, Egypt in the Reign of Muhammad Ali, (Cambridge;
New York: Cambridge University Press, 1984). For a full critique of the discourse of Orientalism and the
“East/West” binary, see Edward Said, Orientalism, (New York: Vintage Books, 2003).
131
William Henry Bartlett, The Nile Boat or Glimpses of the Land of Egypt, (London: Hall, Virtue, 1849), p.
51.
53
William Liam Samuel Tuke, a descendant of the famous Tuke family, visited the Būlāq
asylum in the late 1870s. During his visit to the asylum in 1877, Urquhart harshly
criticized “Mohammedanism” for overlooking the welfare of the insane.132 He lamented
that Egypt still had not met its “Conolly” (in reference to John Conolly the British lunacy
reformer). He bitterly remarked on the absence of trained physicians and attendants, the
presence of “decaying” bedding, and the continued use of chains for some inmates. The
stench, the squalor and the lack of hygiene were all ubiquitous and appalling. He
concluded his report with a dramatic depiction of the insane following him with pleading
eyes, as he could see them “discernible through the cracks.” 133
Upon visiting the asylum one year later, Dr. W. L. S. Tuke was better able to
assess the population in this institution, estimating its number at 200; he was also much
more impressed by the attempts that Dr. Muhammad Tagroi, the principle medical officer,
made to care for the insane, despite the budgetary constraints resulting from Egypt’s
declaration of bankruptcy in the very same year 1878. Tuke rejoiced upon noticing that
the only restraints employed were strait waistcoats.
Although modern scholars acknowledge the racism in the comments of European
observers, we cannot entirely disregard these comments merely as being quintessentially
biased and serving certain political objectives, for two reasons. First, beside reflecting the
line of thought and argument used in the political and diplomatic colonial circles at that
time, they served as a social barometer of what the indigenous people living at that period
saw as mainstream and socially acceptable. Second, these accounts serve as historical
records in showing how particular traits or aspects of everyday life in Egypt- such as
132
A. R Urquhart, “Two Visits to the Cairo Asylum, 1877, 1878,” Journal of Mental Science, 25: 43-53,
1879- 1880, p. 43
133
Ibid, 47.
54
poverty and lack of hygiene- became an “internalized knowledge on knowledge” and
expressed in most of the travelogues, that during the 19th century, the impressions and
perceptions travelers had of Egypt, were built on previously conceived notions of the
country and its people, especially the poor.134 Such criticism largely implied a natural
inability of “Easterner Muslims” to care for their own indigent and insane. Consequently,
as visitors to the insane asylums of the māristān Qalāwūn and Būlāq noted, it was only
thanks to Christian countries’ interventions that the insane of Egypt received better care.
It is interesting to note that all these negative accounts on the conditions of the
mentally ill in Egypt were given throughout the 19th century, the same time when the
wind of change regarding the treatment of the mentally ill was blowing in Britain. As
David Arnold suggests, the introduction of new ideas to the colonies should be seen in
parallel to their counterparts at home to determine the existence, or not, of a colonialist
element in them. In the introduction to his account of the polemic and practice of
medicine in colonial India, Colonizing the Body, David Arnold warns we should be wary
of establishing too rigid a barrier between colonial and metropolitan medicine:
It would be pointless to deny that much of what is described here in a colonial
context has its precedents and parallels in nineteenth century Europe particularly
Britain itself. . . . The diverse array of ideological and administrative mechanisms
by which an emerging system of knowledge and power extended itself into and
over [the] indigenous society [was] in many respects characteristic of bourgeois
societies and modern states elsewhere in the world. . . . There is indeed a sense in
which all modern medicine is engaged in a colonizing process. . . . It can be seen
134
Ibid, 88.
55
in the increasing professionalization of medicine and the exclusion of 'folk'
practitioners, in the close and often symbiotic relationship between medicine and
the modern state, in the far-reaching claims made by medical science for its
ability to prevent, control, and even eradicate human diseases.135
Accordingly, failure to live up to the measures and criteria of the colonizer
deemed the colonized “uncivilized,” “barbaric” and “inhumane.” But interestingly, the
practices witnessed by foreign travelers and featured in their negative accounts on the
care extended to the mentally ill were still practiced at Britain and were medically
sanctioned by the “mad-doctors” that the latter went through numerous rows with lay
“lunacy reformers” over the applicability of the more humane principle of “moral
treatment.” What was then so irksome about the colonial context? The difference
between the travelers’ perception of the violence practiced against the mentally ill at
home and in the colony is that in the former, the mentally ill were the responsibility of
“specialized professionals” while in the latter, according to foreign travelers and officials
such professionalism was nonexistent. As shown earlier in this chapter, the British
discourse on medical care services in Egypt prior to their advent was that of denial or at
best undermining. To admit to the existence of such services and professionalism would
amount to depriving colonialism of one of its main raison d’être; i.e. the spread of
science and medicine.
135
D. Arnold, Colonizing the Body. State Medicine and Epidemic Disease in Nineteenth-Century India
(Berkeley, Los Angeles and London, 1993), pp. 9-10.
56
Chapter III: Claiming the Asylum, Claiming the Mad
“It is not for us, who so recently kept and made a show of our own madmen
to reproach the people of Egypt for their inhumanity as manifested in
cruelties practiced on the insane but they might at least be candid and not try
to hide their practices…it is not for us to blame, but rather to pity, and try to
help the mad-doctors of Egypt to a better state of enlightenment and more
humane practice” (F. M. Sandwith, “The Cairo Lunatic Asylum, 1888”).
“So difficult was it to situate madness in a social sphere that was being
restructured” (Michel Foucault, Madness and Civilization, 240).
Because of the inherent frustration of British psychiatric practice and limited
professional opportunities in Britain itself, a career in the colonies must have offered an
attractive, if unusual, alternative to ambitious young specialists. By 1890, India alone had
25 lunatic asylums, opened and operated by British physicians. Other asylums scattered
throughout the British colonies—in British Guiana, Barbados, Bermuda, Burma, Ceylon,
Malta, Mauritius, New South Wales, Tasmania, New Zealand, Australia, and Canada.136
Experienced asylum superintendents went to all corners of the earth to bring “enlightened”
care to the insane. The “non-restraint” movement, with its application of the non-violent,
self-disciplining “moral treatment” technique in the treatment of the mentally ill, fostered
and legitimized expansion of asylum systems both at home and abroad. One has to be
mindful, however, of how particular biases and (mis)representations worked to justify the
British intervention in “rescuing” the mentally ill from the “barbaric” treatment they have
been receiving from their fellow countrymen.
136
For a comprehensive review on the colonial and foreign asylums see Henry C. Burdett, Hospitals and
Asylums of the World, Vol. I, (London, 1891).
57
Upon their arrival to Egypt, the British proclaimed, their intention to stay
temporarily, until order and financial solvency were restored. Egypt’s inability to selfrule, however, came later to justify Britain’s continuing and consolidating control over
the country. Within the constraints imposed by the priority given to payment of the debt,
the British sought to establish a very particular system of order based on “liberal British
values and norms.” Again, Britain’s “civilizing mission” featured prominently as the
ideological foundation legitimizing the continued British presence. But Egypt offered a
challenge to the British colonial authorities, as unlike other colonies, a process of
“modernization” had been taking place and “modern institutions” of education, law and
medicine existed. To undermine the Egyptian resistance to British control, therefore, it
was imperative for the colonial authority to provide a clear evidence of British moral and
administrative superiority in governance. It is within this context that the British policy
regarding the asylum management and treatment of the insane fits. While in Britain the
asylum was appropriated by the doctors -whose claim to “special esoteric knowledge”
was unfounded and at best spurious- to justify and safeguard their profession, in Egypt, it
was appropriated by the colonial authority to justify their “civilizing mission” and the
Egyptians’ inability to care for their insane, let alone ruling their country.
From the onset of the British rule in Egypt, the ‘Abbāsiyya asylum received an
unusual degree of official attention and financial investment, all the more striking in view
of the budgetary cuts other government departments (including the Sanitary
Administration) experienced. 137 This could only happen because ‘Abbāsiyya, from the
start, served an important ideological function, justifying British control over Egypt’s
137
For a detailed study on the British public health administration in Egypt see Robert Lee Tignor,
Modernization and British Colonial Rule in Egypt, 1882-1914 (Princeton: Princeton University Press,
1966), pp. 319-357.
58
internal affairs. On a symbolic level, it exemplified the benefits British rule could bring to
Egypt; a clear indication of their having brought order and light out of chaos and
darkness. Given the “Victorian” preoccupation with lunacy reform and against arbitrary
incarceration, admission and certification procedures for the insane would be an obvious
point in need of reform. The asylum, as a microcosm of society at large, exemplified all
the moral deficiencies of what the British saw as unenlightened despotic rule.
Concealment of evil practices, the shirking of civic responsibility on the part of officials,
inertia and general abuse of power were themes, which the British would level against the
Egyptians time and again. The British claimed that since their arrival, and after years of
the greatest financial difficulties, which made Egypt very near bankruptcy “the hospitals
were little better than prisons, over-crowded and unsanitary; and the lunatic asylums were
like wild beast cages, only, unlike the beast, the lunatic was half starved.”138 This attitude
on the part of the British was absolutely necessary to maintain if they were to reform the
country in good faith.
As shown in the previous chapter, the British assessment of medical services and
facilities in Egypt, including the mental asylums and the treatment of the insane, was
anything but positive. What the British thought they found when they assumed direction
of Egyptian medical services was a proto-asylum system modeled after the French lunacy
practice. As in France, the Ministry of Interior through the Sanitary Administration, was
responsible for the maintenance of government lunatic asylums. Although less formalized
than in Europe, admission to the Egyptian asylum was through compulsory detention by
order of the police. Only those considered violent or dangerous to public order and safety
were detained. A commission which met in early 1884 decided to replace the previous
138
Stanley Lane-Poole, Cairo: Sketches of Its History, Monuments and Social Life, (London, 1898), p. 196.
59
Sanitary Board (Conseil de Santé), that had been established in 1881, by a new Direction
des Services Sanitaires et d’Hygiène Publique headed jointly by an Egyptian and a
European. Dr. Hassan Pasha Mahmud, former president of the Quarantine Board at
Alexandria, and Dr. F.M. Sandwith, a British medical officer who had been active in
combating the cholera epidemic of 1883, were chosen to fill these two posts.139 It seems
that the dissolution of the Sanitary Board was authorized by Clifford Lloyd, the counselor
and administrative chief, since, according to him, the Board had failed to undertake the
reforms he recommended due to financial restraints. 140 Lord Lloyd was principally
concerned with the defects in the police forces and conditions in the prison system, but he
was also keenly aware of the deficiencies of Egypt’s sanitary services. All his efforts at
reform rested on the basic assumption that the personal security of the Egyptian citizen
was threatened by the arbitrary rule of the Egyptian authorities. He therefore looked upon
prison reform as a reform of the first order, giving, as it does, to the people, security
against arbitrary confinement.141 This applied to the treatment of the insane as much as it
did to the treatment of prisoners. While Lloyd recognized the financial aspect causing the
deterioration of Egypt’s sanitary administration (which was also responsible for the
government lunatic asylum), he declared that this deterioration was due more to a general
lack of moral integrity on the part of the Egyptian officialdom. Sandwith was very close
to Lord Lloyd, and his appointment to the Sanitary Department ensured the execution of
139
“Egypt,” The British Medical Journal, Vol. 2, No. 1195 (Nov. 24, 1883), p. 1042; F.M. Sandwith, “The
Cairo Lunatic Asylum,” The Journal of Mental Science, Vol. XXXIV, No. 148 (January, 1889), p. 476.
140
“Egypt,” Ibid.
141
For a detailed account on how the British brought the ministry of interior under their control in the
1890s, see Harold H. Tollefson Jr., “The 1894 British Takeover of the Egyptian Ministry of Interior,”
Middle Eastern Studies, Vol. 26, No. 4 (Oct. 1990), pp. 547-60.
60
Lloyd’s plans. The development of lunacy administration along British lines were thus
part of a much larger picture dictated by Britain’s general policy in Egypt.
Soon after assuming his new post, Sandwith directed his attention to the
lunatics. 142 Within the considerable financial restraints imposed by Egypt’s financial
situation, Dr. Sandwith was expected to reform the Sanitary Department’s services as
much as possible. One area in which rapid and obvious improvement could be made was
in the conditions of care at the government asylum. He carried sufficient authority to be
able to introduce a new system of care and treatment at ‘Abbasiyya. His inspections of
the asylum found that the inmate patients were maltreated, ill dressed, and those
considered dangerous were chained. The dungeons where the dangerous inmates were
kept were unhygienic, badly lit, and ill ventilated. Moreover, Sandwith noted that official
visits and inspections were at best rarely paid and at worst nil. There was no resident
doctor on the grounds of the asylum, and the head doctor was an Italian Jew, with no
relevant medical expertise, or even a diploma, who, probably for diplomatic reasons, was
never excused from his post. Sandwith’s mistrust of the “corrupt” Egyptians, made him
strongly inclined to look for an English resident physician, familiar with lunacy to
institute reform. But the pay offered and the “prospect were so small that no first class
man could be obtained.”143 Therefore, Sandwith resorted to hiring an Egyptian doctor
who had just returned from Paris with a medical diploma, but who was soon to be
dismissed on ethical and misconduct grounds.144
Sandwith was determined to rectify what he saw as a miserable situation in
‘Abbasiyya. The asylum staff was increased by the addition of a surgeon, a clerk,
142
Sandwith, op. cit., 476.
Ibid, 476-7.
144
Ibid., 477.
143
61
storekeeper, a native midwife to supervise the female section, a gardener, a carpenter,
mat-maker and attendants “of a younger and more intelligent type” at a ratio of one for
every 10 insane patients, a standard which was rather generous for public asylums even
by British standards at that time. The annual budget to cover the cost of the staff,
medicine, food, maintenance, and repair mounted to 7800 LE, not an inconsiderable sum
given the Sanitary Administration’s pressing need for funds.145
Sandwith also saw it fit to recommend certain measures to help improve the
situation in the ‘Abbasiyya asylum. One of these measures was encouraging “visits at
unexpected hours by any English officer in uniform.” Moreover, the lunatics were
removed from their dark rooms to better ventilated ones, “where they had the advantage
of breathing.” A dramatic symbolic gesture was further made when Sandwith had all the
chains removed from the asylum, leaving only one, however, as a memento of the
conditions existing prior to his reform.146 He wanted to maintain the image that under
him, and by implication the British rule, the patient emerged, literally and figuratively,
from darkness to light.
Serious efforts were made by Lord Lloyd to centralize the authority of the
ministry of interior concerning the arrest of those considered “potential criminals.” A law
had been passed authorizing the arrest of vagabonds, which also applied to pauper
lunatics. This set an important precedent in establishing a centralized control concerning
the detention of deviants within the ministry of interior. Moreover, the detention of such
persons was justified as a “preventive” measure, rather than a reaction or punishment to a
crime committed by the person involved. Ironically, these reforms caused quite a stir
145
146
Ibid., 479.
Ibid., 478.
62
against Lloyd and with his position compromised, Sandwith, who was closely connected
to Lloyd, resigned from his post in 1884 to be succeeded in 1885 by Brigadier Surgeon
Greene.147
Greene was very critical of the Egyptian doctors and he lamented that there was
“no qualified medical aid whatever.” While he thought it might be possible “in time” to
obtain good native doctors, he felt this would require reforming the existing school of
medicine. 148 He deplored that the Direction des Services Sanitaires (as the sanitary
administration was still called) had no supervisory or financial control, over the School of
Medicine, a problem which was finally rectified when Dr. Keatinge assumed the
directorship of the Medical School in 1893.149
Perhaps Greene’s most important contribution to the reform was organizing the
process of admission to the asylum. Although comprehensive reforms in admission and
administration of the asylum did not materialize until 1895, certain steps were made to
pave the way. Prior to 1886, patients were admitted directly to the asylum without special
147
Clifford Lloyd was an outspoken and rumbustious ex-magistrate from Ireland, who in September 1883
was given the newly invented title of “Director General of Reform’ in Egypt, a post of great power,
nominally. He took his post seriously and reached the conclusion that in order to undertake “reform” he had
to fight for “exclusive authority” that he clashed with both his countrymen, Evelyn Baring and Benison
Maxwell, and Nubar Pasha, the then minister of interior in the Egyptian government. His attitude and
quarrels were centered on the question of whether the British “advisors” in Egypt were or were not to have
executive powers, or in other words, “whether the Egyptian ministers were to be treated as mere
figureheads.” Although Nubar was a supporter of the British presence in Egypt, he was no stooge. No
sooner did Nubar accept the post of the minister of interior in January 1884, than he clashed with Lloyd.
The two men did not necessarily see eye to eye when it came to the administration of the Ministry of
interior. Lloyd had already devised a plan whereby the newly organized police force would be entirely
placed under British control in all matters of discipline. Nubar saw these stipulations as a conspicuous
social revolution. It is true that he was a proponent of the British occupation in Egypt, but only as long as
the army refrained to interfere in the civil administration. Therefore, Nubar spared no effort in fighting
Lloyd’s new measures and because he was seen by the British as indispensible at that time and his foe had
his issues with his own countrymen, Nubar won. Peter Mansfield, The British In Egypt, (New York: Holt,
Rinehart& Winston, 1972), pp. 85-7; Also see Cromer, Modern Egypt, II: 482-8 on Clifford Lloyd and the
feuds he had with his compatriots and Nubar and Cromer’s opinion about him lacking experience and his
sharp uncompromising temperament.
148
Mayers, op.cit., 73.
149
Mahfouz, op. cit., 54.
63
certification, having been sent by the mudirs of the police. Thereafter, special letters, for
purposes of admission, were supposed to be written by the police about each admission.
Under Greene, certain transfer procedures began to become more formalized. The police
and/or the patients friends and family would have to first contact the head government
director or the province to request the examination of the patient who shows signs of
madness. The patient would be examined by two doctors who would provide a detailed
account of the symptoms and diagnosis of the case in the issued certificate. By the end of
1886, the number of resident patients reached 233. The following year the admission
tripled in number reaching 460 of whom 67 died. The discharged patients numbered 359
of whom 310 were reported “cured” and 49 “uncured,” who were mainly harmless feeble
minded and many of them were admitted to the asylum of the incurables in Turah, which
was maintained by the Waqfs. 150
Although regular inspection by officials from the sanitary service was rare, if
nonexistent, British officers paid inspection visits to the asylums. One such officer was
Sir James Dormer, commanding in Egypt, apparently, used to undertake annual visits to
the asylums during the Bairam holiday when he used to distribute gifts among the
inmates. During one of these visits he expressed satisfaction that “everything was found
in order and perfectly clean and well-kept.” 151
In 1891 Dr. Rogers succeeded Dr. Greene and under him, the British intervention
in government health services and medical training intensified especially that another
cholera epidemic hit the country in 1894 which gave the British an opportunity to
increase their control within the Sanitary Administration while simultaneously continue
150
Sandwith, op. cit., 486.
“Egypt”, British Medical Journal, Vol.1, No. 1435 (Jun. 30, 1888), pp. 1408-9; “Egypt,” The British
Medical Journal, Vol. 2, No. 1489 (Jul 13, 1889), pp. 103-4.
151
64
their severe criticism of the health care provided by the Waqfs. To the British the Waqf
asylum in Turah, came to represent what the British officials and medical professionals
saw as an evidence of the typical and inherent Egyptian negligence in providing efficient
and satisfactory public health services. Dr. Rogers went as far as proclaiming that “we
tremble to think of the country if it were not for the handful of English medical men
attached to the sanitary service of Egypt.”152 In the 1893 Annual Report of the Sanitary
Service, Rogers expressed his hope to obtain permission to have an English psychologist
appointed “in order to study lunacy as seen in Egypt” and also to introduce some form of
“necessary employment and exercise for the patients.”153
Rogers apparently did not consider promoting as director of the asylum the
Egyptian doctor already working there who had a degree at the Salpetrière. This
reluctance may have been prompted by his general attitude regarding Egyptian medical
incompetence. This reluctance can also be explained by taking into consideration the
enduring French/British rivalry for influence over Egypt’s health services and the need to
undermine the French influence as dysfunctional and ineffective since the latter’s
influence had compromised the British claims to medical superiority. At any rate, Rogers
appointed a British doctor, Dr. John Warnock, as director of the Abbasiyya asylum in
1895, to be his successor.
Warnock arrived to Egypt in 1895 and remained in his office as director of the
asylum for the following twenty-eight years. The “application of British lunacy methods
to a partially civilized race in a hot climate” was Warnock’s ultimate contribution to the
152
153
“Report from Egypt,” Lancet, Vol. 145 (January 5, 1895), p. 59 qtd in Mayers, 81).
Ibid., 58.
65
establishment of “colonial psychiatry” in Egypt. 154 As far as the British medicopsychological profession was concerned, his reforms, mainly administrative, enhanced
the position of the British among other European countries, not necessarily in the
scientific and therapeutic achievements but more when it comes to the management of
the asylum as an institution. In Britain, as discussed in chapter one, the mental asylum
institution helped give legitimacy and strength to the then vague and fragile profession
and science of psychiatry. Warnock’s efforts were both appreciated in Britain, where he
was awarded a C.M.G. (the Order of St. Michael and St. George) in 1917, and in Egypt
where the government awarded him a Second Class Order of the Nile upon his
retirement. 155 Before serving in Egypt, Warnock had spent eight years as a medical
superintendent in two asylums in Britain. His education, medical training and
professional affiliation to the British Medico-Psychological Association, played an
important role in shaping his philosophies and policies concerning the treatment of the
mentally ill and asylum management.
What struck Warnock the most when he assumed his new post was, first, the lack
of general order represented in the absence of a proper classification of patients based on
their degree and type of insanity, the lack of clear rules and laws regulating the admission
of pauper patients to public asylums and the deteriorating conditions of the buildings and
facilities of the asylum; second, the use of mechanical restraint and the absence of “moral
treatment.”156 During his post as director of the asylum, Warnock managed to whitewash
154
John Warnock, “Twenty Eight Years of Lunacy Experience in Egypt 1895-1923,”Journal of Mental
Science, Vol. 70, (London, 1924), I, p.234.
155
The Order of St. Michael and St. George is awarded to men and women who render outstanding nonmilitary service to the British Crown in foreign or Commonwealth affairs and countries.
156
This is in contradiction to Sandwith’s report on the lunatic asylum, released 6 years prior to Warnock’s
appointment to the asylum, in which Sandwith boasted the demolition of all chains and tools used for
mechanical restraints and the existence of padded rooms and the overall good physical condition of the
66
it both literally and figuratively. Buildings were renovated, the green area surrounding the
asylum was expanded, a network system for phone lines was installed, and many other
services and facilities were ameliorated, such as laundry, bakery, kitchen and the system
of drainage and sewage. The staff number grew more than seven fold to be 698 in 1923
up from only 73 in 1895. 157 The rate of admission almost tripled during the same
period.158
Under Warnock, the asylum further legitimized Britain’s gradual assumption of
control over the sanitary administration. The asylum, therefore, bore greater political and
social significance beside its medical role. The constant claims of reform, as opposed to
the former “dismal conditions” can only provide a justification for the ideological attack
Britain was launching against the Egyptian government. An improvement in the asylum
services and conditions could only serve as a symbol of British political and ideological
potency.
The publicity given to Warnock’s work further served to stress the ameliorated
medical services under the British and by extension, served to legitimize Britain’s
continuing control over Egypt, in general. The Lancet commented on his efforts by
saying that:
It is really wonderful to witness the peaceful revolution, which Dr. Warnock has
brought about during the last fifteen months. More than 200 new windows have
been opened in the wards and no longer is there any animal smell, though the
wards are more crowded than ever, chiefly because by caring for the sick in a
asylum and staff that such conditions were even considered high according to the standards applied in the
British asylums in the metropole.
157
Warnock, “Twenty-eight”, Vol. II, July, 1924, p. 389 .
158
Check Table III of the “Lunacy Division Report for the Year 1933, Including the Mental Hospitals of
Abbasiyya and Khanka, and Khanka Criminal Asylum,” (Cairo: Bulaq Government Press, 1935).
67
well-appointed infirmary, the death-rate has been diminished by half. New baths
have been built, the garden has been furnished with verandas and new cells have
been constructed for excited patients. Best of all, instead of all the men sitting idly
upon their beds all day, some 200 out of a total 500 are working every day, mostly
as masons and carpenters. I have the authority of the Public Works Department
for stating that the work turn out is extraordinarily good and all the improvements
so far have only cost LE 2000. Work for another LE 2000 is planned for in the
present year.159
It is interesting to know that the report was citing these accomplishments while
wondering if the Khedive would still insist that Dr. Warnock would only serve for two
years, a question whose answer was that Warnock stayed in Egypt for twenty-eight years
as director of both the ‘Abbāsiyya and the Khānkah asylums. In 1899, the MedicoPsychological Association of Great Britain praised Warnock’s achievements, especially
with regards to the difficulties he had been facing and the fact that he had to start from
point zero in his reform efforts. In the same year, moreover, ‘Abbāsiya Hospital was
recognized by the University of Cambridge as offering the practical experience required
of candidates for the Diploma in Psychological Medicine from Cambridge.160
In contrast to the strong publicity given to Warnock, the Lunacy Division Report,
issued by the Lunacy Division in 1933 states that back in 1895 the treatment method had
consisted of “low-dieting, violent purging, blistering, padded rooms, straight waistcoats,
physical restraint and seclusion; with a high death rate and may accidents.” 161 One would
159
“Report from Egypt,” Lancet, June 27, 1896, p. 1835
“Egyptian Government Hospital for the Insane,” Journal of Mental Science, (January, 1909), p.170.
161
“Lunacy Division Report for the Year 1933 Including the Mental Hospitals of Abbasiyya and Khanka,
and Khanka Criminal Asylum,” (Cairo, Bulaq: Government Press, 1935), p. 1.
160
68
think that the report would give a positive account of the following years after Warnock.
But the report proceeds explaining that after 1896, and contrary to the very principle of
“moral treatment,” confinement in secluded cells replaced the aforementioned treatment.
Moreover, the patients’ self-image was that of prisoners, “resenting their detention and
treating the staff as their gaolers,” that “incendiarism assaults and determined efforts to
escape and to suicide were frequent.”162
The discrepancy between the two reports, the 1896 Lancet “Report from Egypt” and that
of the “Lunacy Division Report for the Year 1933,” can be explained due to several
reasons. First, there was the difference between the two types of publications. While the
report of The Lancet was written by a reporter, whose access to the asylum and
information were restricted and directed by the asylum British officials and
superintendents, the Lunacy Division Report of 1933 was issued by the Egyptian
government, as by that time the Division had been already under Egyptian control since
the Egyptian nominal independence in 1922. The second reason behind the reports’
discrepancy was the difference in purpose and in audience. While The Lancet report
addressed the British public in general and the British medical circles in particular with
the purpose of veneering the British political and medical achievements in Egypt, the
Lunacy Division report was issued by and for the benefit of the Lunacy Division,
providing facts and statistical records for official documentation purposes, with no need
to aggrandize the British achievements.
162
Ibid., 2.
69
Warnock’s Freehand and the Absence of Lunacy Laws in Egypt
Warnock was aware of the absence of lunacy legislation in Egypt, comparable to
those found in Britain. 163 Although Warnock initially deplored the absence of laws
prohibiting “arbitrary” incarceration of the mentally ill, he did not lobby for the
promulgation of laws regulating the admission and discharge of the mentally ill. In fact,
like his medical superintendent counterparts in British asylums, Warnock believed that
the arrest and confinement of alleged lunatics was appropriate and justified action by the
authorities. The question here is who is to be invested with this “authority”? Warnock
was fortunate in being largely free of the legal constraints, which hampered the work of
his counterparts in Britain, who had been struggling, as explained in chapter one, with the
Magistrate and the lay reformers in laying claim over jurisdiction pertaining to the
mentally ill. While the British were ceaselessly claiming that their lunacy reforms were
directed against arbitrary incarceration, Warnock and his predecessors seem to have
preferred a freehand approach in managing the asylum. In fact, Warnock took advantage
of the absence of regulatory laws to increase the physician’s control over admission
procedures. Facile detention of the mentally-ill and short admission procedures were
some of the guiding aims and underlying principles of Warnock’s reforms. Instead of
seeing this as an infringement upon the patients’ right, Warnock claimed that these
measures were taken to protect the patient from abuse since as far as Warnock and other
asylum physicians were concerned, popular forms of treatment were injurious to the
patient and his admission to the asylum should be as fast as possible. The protection of
163
See chapter I for a further discussion of the Lunacy and Asylum bills and acts in Britain in the early and
mid-nineteenth century.
70
public health and safety from dangerous lunatics, who might cause a serious disruption to
public order, was cited as another reason for rapid admission.164
Those patients who made their way to the asylum were at first invariably brought
by the police. Gradually, families began bringing their relatives directly to the asylum to
be diagnosed and treated. Unless they had obtained proper medical certification
beforehand, however, Warnock turned such people away.165 Warnock believed that the
function of the doctor at the asylum was not to issue certificates for the inmates but to
treat, or more accurately to manage, patients already certified, in keeping with the British
medical practice. Within a decade of Warnock’s assuming control over ‘Abbāsiyya, the
asylum was overcrowded in terms of bed capacity and adequate patient/staff ratios: in
1915, the number of beds available was 1550, accommodating 2040 resident patients,
with no room for the newly admitted 936 patients.166 While there was a fluctuation in
admission rates, the overall tendency was to accumulate patients, particularly the chronic
insane. What to do about the excessive number of patients soon became one of the most
pressing problems facing the asylum.
To relieve overcrowding, the asylum administration was obliged to discharge
“uncured cases,” usually the chronic insane and the “feeble-minded,” only to readmit
them not long after. In 1901, a man had been reported to be admitted to the asylum for
the 47th time, because he had always been discharged uncured for lack of space.167 Even
this measure soon proved to be unhelpful as the number of admission continued to
increase due to economic and cultural factors. Families became less tolerant of their
164
Mayers, op. cit., 98.
Ibid., 100.
166
The Lunacy Division Report of 1933,” op. cit., Table III.
167
Ibid., 4.
165
71
mentally ill relatives due to economic restraints and were culturally and socially less
reluctant to have their relatives admitted to the asylum to relieve themselves from the
social, legal and economic burdens associated with caring for the mentally ill. As a result
of the increasing number of the admitted patients, medical officers were ordered to send
only those urgent cases to the ‘Abbāsiyya asylum. 168 Hence, the necessity for more
mental asylums became a matter of fact. The inauguration of the Khānkah Hospital in
1912 was a partial solution to this dilemma. Unable to build other asylums in other
Egyptian provinces due to financial restraint, the Khānkah asylum was to host the chronic
cases, which could not be discharged. It ended up hosting the criminally and acutely
insane, who were classified as violent cases.169
With the expansion of the asylum network that accompanied the establishment of
the Khānkah asylum, Warnock became all the more vigilant when it came to his
autonomy and that of the asylums, that he managed to lobby for the establishment of an
independent Lunacy Division within the Ministry of Interior. With the establishment of
the Lunacy Division, both asylums, ‘Abbāsiyya and Khānkah, came directly under
Warnock’s control through the central office of lunacy affairs established at ‘Abbāsiyya
in 1914. Warnock wanted to ensure that the Lunacy Division would not only be
independent from other sanitary and health divisions but to also be “free to put forward
its claims to other ministries without their being modified by an over department with
different aims and different methods.”170
168
Department Order #22, 16 April, 1907, from H.H. Pinching, Director General of the Department of
Public Health qtd in Mayers, op. cit., 105.
169
“The Lunacy Division Report,” op. cit., p. 1-2.
170
Warnock, op.cit., Vol. I, p. 255.
72
Lambasting the Waqf and the Egyptian Government for Negligence
Warnock’s attempts to ensure his freedom from legal constraints and
independence from rules imposed by the Egyptian government, and mainly the Ministry
of Interior which was responsible for the detention and arrest of the pauper lunatics,171
were consistent with the British colonial medical discourse centering on the belief that
Egypt was incapable of providing sufficient and humane medical care for its patient
population and that British expertise was inevitable for any progress to take place. During
the first decades of the British occupation, the British medical authorities as well as
British journalists argued that Egyptians’ disregard of their own poor and their inability
to care for the impoverished and insane citizens indicated that British expertise was
crucial in public health and social welfare and the Egyptians were not ready for
independence and self-governance.
172
Such tropes of Egypt’s poverty and the
government’s lack of regard for the poor and the insane were key features of the
foreigners’ perception of Egypt. Consequently, the British turned their attention to the
Egyptian government-run religious endowments, the Waqf, which was religiously,
historically and customarily responsible for providing relief for the poor and pauper
lunatics. The British officials perceived of the Waqfs as an institution with numerous
financial resources, but run parsimoniously and rife with corruption.
During the previously discussed problem of the overcrowded ‘Abbāsiyya asylum,
a suggestion was made to transfer the “quiet” patients to the Tikiyya of Turah, the
principal poorhouse run by the Waqfs, to leave room for more agitated and dangerous
171
For a detailed account on how the British brought the ministry of interior under their control in the
1890s, see Harold H. Tollefson Jr., “The 1894 British Takeover of the Egyptian Ministry of Interior,”
Middle Eastern Studies, Vol. 26, No. 4 (Oct. 1990), pp. 547-60.
172
Ener, op. cit., 14
73
patients to be hospitalized in the ‘Abbāsiyya asylum. Following the government’s
approval, the Minister of the Interior gave orders that delegates from the Waqfs and the
Sanitary Department should visit Turah and report the applicability of the suggested
patients’ transmission. The British Medical Journal reported the Sanitary Department
concluded that the conditions at the tikiyyah were inadequate, asserting that the tikiyyah
was “not fit to keep animals in, let alone human beings.” The Journal further added that
the head of the Sanitary Department preferred that the poor lunatics would be better off
“lying on mats in the corridors at the asylum” rather than being “under the tender mercies
of the Waqfs.”173
The political tone of the report cannot be missed. Behind the criticism directed to
the conditions in the Waqf sponsored poorhouses, comes a larger one targeting the fact
that the Waqf, along with the School of Medicine, remained out of the bounds of total
“European leaven among the administrators”, and hence “both are equally in need of
reorganization.” It was very irksome to the British officials that a large public body with
enormous land revenues such as the Waqfs, was beyond their control at a time when the
declared purpose of their presence in Egypt was to end the Egyptian insolvency. The fact
that the Waqfs had to “furnish no balance sheet and declined systematically to give an
account of their stewardship” promoted the suggestion that “a commission should be
named to hold a searching inquiry into the manner in which their trusts are administered”
using accusations of flagrant corruption and rampant embezzlement as a justification.174
While both the British officials and reporters sometime relieved the sanitary
administration from the “deplorable” conditions of health care due to the lack of funds,
173
174
“Egypt,” The British Medical Journal, September 28, 1889, No. 1500, p.738
Ibid.
74
they mounted a fierce attack on the Waqf, with its “immense estates” and “the most
valuable properties under its control.”175 Since the Sanitary Administration was limited
by financial constraints, and since the health services provided by the Waqfs were
“deplorable”, the solution that was seen most viable to the problem of underfunding, was
to reform the Egyptian system of medical training in such a way as to make it less costly.
This effectively meant shortening the curriculum in the Qasr al ‘Ainī Medical School
from six years to only four. It was left to Dr. Keatinge, the director of the School from
1897-1919, to bring about this drastic cut effectively halting the nascent trend towards
medical specialization, in spite of the students petitioning for specialization. 176 In
addition to the need to be frugal, the British authorities did not view specialization
favorably, as they believed that the government desperately needed general practitioners
rather than specialized doctors. Furthermore, the British approach to clinical training in
determining the practice and specialization of the physician rather than academic training,
which emphasized academic specialization during school years, should be viewed in
parallel with the medical trend in Britain itself, which was less “academically specialized”
than both Germany and France, the two countries after whom the Qasr al Aini had been
modeled.
Under these circumstances, the specialization in psychiatry came to center around
institutional vocational training exclusive to the ‘Abbāsiyya asylum rather than an
academic training received at Qasr al ‘Ainī, a monopoly of knowledge and a claim to an
exclusive right to its practice and dissemination. As mentioned earlier in chapter II,
student specialization was limited to four areas: “[a]s assistant in the Infectious Hospital;
175
176
British Medical Journal, July 29, 1893
See Sonbol for further details, op. cit.
75
as assistant in the Lunatic Asylum; as assistant to Sanitary Inspector; as assistant to the
professor of Hygiene or Pathology at Qasr al ʿAinī or other hospital.”177 The key word
here is an “assistant” and not a “practitioner”, in order to ensure that specialization in this
field along with the other three, was exclusive to European doctors, and specifically, in
the case of mental illness, to British doctors.
Despite the unfavorable recommendation reported by the Sanitary Department
concerning conditions in the Turah asylum, the “quiet” lunatics were transferred there
anyways. However, in 1894, the Department ordered the transfer of 120 lunatics then
residing in the Turah asylum, maintained by the Waqf administration, back to ‘Abbāsiya
on the grounds that sanitary conditions at Turah were unsatisfactory. As the problem of
overcrowding became all the more ubiquitous, Warnock prodded the Waqf, yet again, to
assume financial responsibility for building a new asylum as the Ministry of Interior was
unable, or unwilling, to provide further financial support. In 1913, the Waqf
Administration proposed building a hospital for incurables. Warnock turned down this
idea, however.178 Warnock’s refusal of the offer could have been due to the fact that he
was afraid that control of such a facility, specialized in caring for the insane would render
medical-psychologists subordinate to non-psychiatric administration. More importantly,
he might have feared that caring for the insane would not be an exclusive domain of the
European and the colonial administration, since the Waqf, and the services offered by it,
were not under British control. His idea of Waqf contribution in establishing a new
asylum was purely exclusive to the Waqf Administration as a financier; that the new
177
Extracts from the Report of Dr. Perry, Approved by Ministerial Order, 15th June 1898 (Cairo: National
Printing Office, 1989), p.14 quoted in Sonbol, The Creation, 113-14)
178
“1917 Annual Report of the Lunacy Division,” p. 84 qtd in Mayers, op. cit., 106)
76
facility should only be run by “authorities duly qualified in the subject of mental
disease,”179i.e. British and European doctors.
Social, Geographic and Class Distinction
While the establishment of the Khānkah asylum came as a response to the
problem of patients’ overflow in ‘Abbāsiyya, the admission of patients in both asylums
was not based solely disease nosology and etiology. Social, economic and geographical
factors were taken into consideration in distributing the patients. The proper status of a
patient was determined at ‘Abbāsiyya. Male non-paying and pauper patients from rural
governorates and criminal lunatics were mostly placed in Khānkah, while their urban
counterparts who belonged to all social classes would typically be placed in ‘Abbāsiyya.
All paying patients, female patients and foreign patients were also sent to ‘Abbāsiyya for
therapy.180
It is important to know that the privatization of medical service was not exclusive
to ‘Abbāsiyya as a similar process had been taking place in al Qasr el ‘Ainī hospital.
Furthermore, all paying patients sent to ‘Abbāsiyya, were categorized into first, second
and third class sections depending on the amount of money paid for their treatment. 181 In
1897, the first villa for paying male patients was built to separate upper class patients
from the rest.182 Although by 1910 85% of the mentally ill patient population received
free treatment, the paying wards were accruing a revenue of almost LE 4000 per annum.
Although the number of paying patients was much lower than their non-paying
counterparts, an aura of pride was created surrounding the very existence of such paying
179
Ibid.
“Lunacy Division Report For the Year 1933,” op. cit., 10.
181
Mayers, op. cit., 112.
182
Warnock, op.cit., I:p.242
180
77
patients, who, according to Warnock’s propaganda and interpretation signified the
success of the treatment and managerial methods of the asylums, and hence confidence in
Warnock himself and on a larger scale success for the British psychological medicine and
administration policy of the country as a whole. This was nowhere more obvious than in
an editorial published in The Lancet bragging that “in the old days, the asylum was
regarded with horror by all inhabitants of Egypt and it is now satisfactory to know that
during 1907, 16 voluntary patients were admitted on their written application.”183
Needless to say such a statement could hardly be accurate as the voluntary
admission might not have been out of confidence and satisfaction as much as being the
result of a loophole that allowed well-to-do families, to repudiate their legal and moral
responsibilities towards their mentally afflicted relatives. Even if assumed that people
really trusted the asylum, this in no way gave credit to colonialism and how beneficial it
was to the backward” natives. Fanon described such erroneous assumptions from the part
of the colonizing power and how it translated the natives’ recognition western medicine
as recognition of colonialism, stating that “in certain periods of calm, in certain free
confrontations, the colonized individual frankly recognizes what is positive in the
dominator’s action. But this good faith is immediately taken advantage of by the occupier
and transformed into a justification of the occupation. When the native, after a major
effort in the direction of truth, because he assumes that his defenses have been
surmounted says ‘that is good. I tell you so because I think so,’ the colonizer perverts the
meaning and translates ‘don’t leave, for what would we do without you?’”184
183
“Report from Egypt,” The Lancet, August 15, 1908, p. 496.
Fanon, 122.
184
78
In any event, the “voluntary” admission gave the ‘Abbāsiyya an outlook close to
that of a normal hospital that received patients on their own personal request. This gave
credit to the institution that both the Department of Public Health and Ministry of Interior
could not but acknowledge the medical superiority and absolute authority of the mental
hospitals.185
Colonial Nosology and Etiology186
Having seen in the previous section how admission to both the ‘Abbāsiyya and
Khānkah asylums was determined by social, economic and geographic factors along with
disease classification, it is now important to turn to discuss mental illness nosology and
etiology, as perceived by the British doctors in Egypt. Some of these doctors came with
the purpose of studying mental diseases peculiar to Egypt. The result of these doctors’
research shows an inclination to attribute mental diseases in Egypt to the presence and
practice of certain cultural, dietary and religious habits. Definitions of mental normality
and pathology preoccupied medical and lay colonizers. Megan Vaughan has remarked in
Curing their Ills that “the power of colonial medicine lay not so much in its direct effects
on the bodies of its subjects . . . but in its ability to provide a “naturalized” and
“pathologized” account of those subjects.”187 In 1992 Charles Rosenberg explained the
areas, which he felt had been of concern to professional historians of medicine over the
past couple of decades. Of these, “perhaps the most widely influential”, according to
Rosenberg, has been an interest in “the way disease definitions and hypothetical
etiologies can serve as tools of social control, as labels for deviance, and as a rationale for
185
Mayers, op. cit., 116.
While “nosology” is the branch of medical science that deals with the classification of disease, “etiology”
is the study of the cause(s) of diseases and disorders.
187
Megan Vaughan, Curing Their Ills, p. 25.
186
79
the legitimation of status relationships.” This categorization in turn has been associated
with the swing towards a social constructionist view of disease and is an aspect of the
wider concern with the relationship between “knowledge, the professions and social
power” in the social sciences.188 This is congruent with Foucault’s “discourse,” which
describes the particular kind of language “specialized knowledge” has to conform to in
order to be regarded as true. In this way, discourse always involves a form of violence in
the way it imposes its linguistic order on the world; knowledge has to conform to its
paradigms in order to be recognized as legitimate.189
In this regard, it would not be an overstatement to say that Warnock’s most
important contribution during his long tenure in Egypt was to construct the “medical”
identity of both the ‘Abbāsiyya and Khānka asylums in the sense that the asylum would
no longer be viewed as a “dumping ground” for the infirm and insane, but would rather
be viewed as a place where the treatment of mental illness was a possibility. This
“medical identity” would not be possible without the establishment of a nosology for
mental illness. As soon as he undertook his duties in Egypt, Warnock began to systemize
records of patients according to standard disease categories formulated in Britain
psychological medicine. Most importantly, he was intent on identifying those types of
insanity, which he thought were common or peculiar to Egypt. He developed a theory,
though lacking a sound empirical proof, concerning the existence of certain types of
insanity associated with social conditions predominating in Egypt such as poverty, the
consumption of cannabis, namely hashish, and the “Easterners libidinous promiscuity.”
188
Charles E. Rosenberg, 'Introduction. Framing Disease: Illness, Society, and History', in C. E. Rosenberg
and Janet Golden (eds.) Framing Disease. Studies in Cultural History (New Brunswick, NJ, 1992), p. xv
qtd in Marx, 209-10
189
Foucault, History of Sexuality, op.cit.
80
Warnock noticed that there were two new types of insanity, hashish and pellagrous
insanity. His perception of mental disease in these terms deemed social problems, such as
malnutrition and the smoking of drugs, medical, and therefore calling for public health
solutions.
Pellagra
British doctors practicing in Egypt were convinced that the dietary system of the
Egyptian peasantry left them highly susceptible to pellagra. Although the exact cause of
pellagra remained undecided, doctors seemed to agree that it was caused by certain toxins
combined with nutritional deficiency that, in turn, were caused by eating moldy, inedible
maize-bread. Dr. Sandwith was the first to make such a remark and assert a connection
between the disease and maize-based diet.190 Pellagra’s occurrence in the countryside was
so commonplace that it was considered a normal rather than a pathological condition and
Sandwith, in researching its incidence in one village found that almost 62% of the male
population examined there displayed symptoms of the disease. What struck him the most
was the men’s denial that they had any physical problem and their assertion that the
disease had not affected their physical health and stamina for work.191 While there is no
doubt that pellagra sometimes causes insanity, it is far from certain that every person
suffering from Pellagra will necessarily become insane. 192 However, if neglected, the
symptoms might ravage the body and the mind causing insanity and physical debility,
which in turn would render the afflicted unfit for work. Warnock managed to diagnose
pellagrous insanity clinically as melancholy, or acute mania passing into dementia, (a
190
F.M. Sandwith, “How to Prevent the Spread of Pellagra in Egypt,” The Lancet, March 14, 1903, p. 723;
for more information on Pellagra, its history and etiology see Edward Jenner Wood, A Treatise on Pellagra,
for the General Practitioner, (New York& London, 1912).
191
Ibid.
192
“Lunacy Division Report for the Year 1933,” op. cit., 4.
81
kind of “confusional insanity”)193 accompanied by emaciation, anemia and diarrhea. By
1913, Warnock declared that pellagra had become the main cause of insanity in Egypt,
arguing that out of 206 admitted lunatics to ‘Abbāsiyya, 193 showed signs of the disease
and it also had become the major cause of deaths among the insane patients.194
The prevalence of the disease among the peasants and the fact that it, at the least,
caused physical debility, which rendered many fellahs unfit to work did not cause only
medical concerns. The possible social and economic consequences resulting from the
diminishing labor force posed a direct threat to the state itself. 195 Furthermore, the
insanity nosology in Egypt, where pellagra featured prominently, made it possible for
Warnock to give some class prejudices a medical validity asserting that the “poorest class
supplies thousands of insane and criminals.”196 The parallel search for a “criminal gene”
among the “underclasses” in the metropole suggests that the dialogue between home and
the colony is far from simple.197
Hashish
Hashish, a.k.a. Indian hemp, or cannabis indica as referred to in medical circles,
was considered to be the second cause for insanity, after pellagra. According to Dr.
Frederick Peterson, who visited Egypt and reported on the care for the mentally ill, of the
two hundred and forty eight patients in ‘Abbāsiyya, sixty men and four or five women
were insane from the excessive use of hashish. Acute cases, which recovered and were
discharged, were almost sure to return. 198 According to Peterson, hashish caused a
193
“Lunacy Division Report for the Year 1933,” p.4.
“1913 Annual Report of the Lunacy Department”, qtd in Mayers, 129.
195
“1909 Annual Report of the Lunacy Division,” qtd in Mayers, 128.
196
Mayers, op. cit., 130
197
Marx, op. cit., 211.
198
Frederick Peterson, Medical Notes in Egypt, (New York, 1893), p. 27.
194
82
distinctive form of madness, ranging from intoxication, lasting for a day or two, to acute
mania, which could linger on for months. The symptoms produced are disorder of the
alimentary canal, increased appetite, dilation of the pupils, drooping eyelids, anemia,
general debility and delirium. Some cases might even result in chronic insanity, dementia
or death. 199 Unlike pellagra, which was mainly found in the countryside, hashish
consumption was mostly rampant among city dwellers. Warnock noted, moreover that
hashish smoking was predominantly a male habit. Warnock further made a bold assertion
that “in quite a considerable number of cases, [hashish] is the chief if not the only cause
of mental disease.”200 It comes as no surprise to know that Warnock had impressed upon
Cromer the importance of passing a stricter law prohibiting hashish consumption.201 It
seems that Egyptian authorities crackdown on hashish consumption has been effective
since that same year The Lancet declared that the percentage of patients treated from drug
induced insanity dropped to 16% when compared to 35% in 1897.202
But can this form of “temporary delirium” caused by the consumption of hashish
be considered a form of insanity? Alcoholic intoxication was cited as a possible cause for
brain damage, and Sandwith managed to record few cases suffering from this condition at
the ‘Abbāsiyya asylum. 203 However, being “drunk” did not amount to madness. Why
then was being temporarily drugged as a result of hashish smoking considered a form of
madness? A spate of op-eds in the British Medical Journal reflected a rift between British
laymen on the issue of the use and consumption of hashish in Egypt. A contributor with
199
Ibid., 28.
J. Warnock, “Insanity from Hashish,” Journal of Mental Science, 1903.
201
Mayers, op. cit., 133.
202
“Report from Egypt,” The Lancet, November 26, 1904, p.1533; also see Liat Kozma, “Cannabis
Prohibition in Egypt 1880-1939: From Local Ban to League of Nations Diplomacy,” Middle Easter Studies,
vol 47, No. 3 (May 2011), pp. 443-460.
203
Sandwith, op. cit., 483.
200
83
the pseudonym Pyramid warned the British authorities in Egypt from the repercussions of
banning hashish consumption while leaving unharnessed the trade in alcohol; a measure
that he feared might be “paving the way for the ruin of the [Egyptian] people.” 204 The
same contributor, Pyramid, was very skeptic of a medical report attributed to a certain Dr.
Thomas Ireland, a British doctor and a member of the British Medical Association. This
report argued that “the excessive use of Indian hemp was a very prolific cause of insanity
in eastern countries.” 205 While Pyramid admitted that “there [could] be no doubt
whatever that many lunatics [were] found amongst users of the drug” it by no means
follows “that the disturbance of their mental equilibrium was owing to the habit [of
smoking hashish].”206 The causal relationship between hashish and insanity as established
by Dr. Ireland was seen by Pyramid as a fallacy. Pyramid, claimed that during his sevenyear sojourn in Egypt he “traversed every province more than once without hearing of or
meeting lunatics under private control, and the number of idiots was surprisingly
small.” 207 Pyramid further warns from the repercussions of banning hashish, as the
fellahin will fall as an easy prey to drunkenness. Therefore, he made a suggestion that
instead of prohibiting the use of hashish in Egypt altogether, the authorities should direct
their attention to the “refinement and purification” of hashish use.208
The argument made by Pyramid, concerning the claim that the use of hashish
induces insanity, were contemporaneous to and consistent with the findings stated in
“The Indian Hemp Drug Commission, 1893-94” report, concerning the use of Indian
204
“Indian Hemp and Insanity in Egypt,” The British Medical Journal, Vol. 2, No. 1722 (Dec. 30, 1893), p.
1452.
205
“Indian Hemp As a Cause of Insanity,” The British Medical Journal, Vol. 2, No. 1708 (Sep. 23, 1893), p.
710.
206
Ibid.
207
Ibid.
208
Ibid.
84
hemp and the allegation of the plant causing insanity in India.209 The Report concluded
that
In respect to the alleged mental effects of the drugs, the Commission has come to
the conclusion that the moderate use of hemp drugs produces no injurious effects
on the mind. It may indeed be accepted that in the case of specially marked
neurotic diathesis, even the moderate use may produce mental injury. For the
slightest mental stimulation or excitement may have that effect in such cases. But
putting aside these quite exceptional cases, the moderate use of these drugs
produces no mental injury. It is otherwise with the excessive use… it has been
shown that the effect of hemp drugs in this respect has hitherto been greatly
exaggerated.”210
The findings of the “Indian Hemp Drug Commission” were hence at odd with the
allegations and attempts made to establish a causal relationship between hashish
consumption and mental illness.
General Paralysis
The third cause of mental illness as perceived by the British doctors was general
paralysis. The statistical and etiological reports on general paralysis in particular,
however, are extremely contradictory. The long established assumption of a correlation
between general paralysis and syphilis had preoccupied the mind of lunacy experts in
209
“The Indian Hemp Drug Commission” was formed in 1893 to address the British House of Commons
concerns over the use of Indian hemp in India and the allegation that the plant induces insanity. Presided
by Mr. Macworth Young, the Commission produced a more than 3000- page report, which was the result of
year-long investigation into the matter, after listening to testimonies given by almost 1200 witnesses,
ranging from doctors, fakirs, yogis and heads of lunatic asylums. For the full report see “The Report of the
Indian Hemp Commission 1893-94,” Vol. I the National Library of Scotland online
http://digital.nls.uk/indiapapers/browse/pageturner.cfm?id=74574070
210
Ibid., 264.
85
Egypt. Sandwith noted with bemusement that while syphilis had a free play in Egypt
surprisingly there was no proportionate number of general paralysis cases.211 And even
when general paralysis cases were detected, the disease afflicted more those “of better
circumstances, who eat meat freely, use their brains more than their hands and are not
strict teetotalers.”212 Warnock initially adopted Sandwith’s opinion concerning the rarity
of general paralysis among lunatics admitted to the asylum and the absence of a
relationship between general paralysis and syphilis. Sandwith further noted that out of the
29 general paralysis cases admitted in 1896, only one was a peasant while the rest were
urban city dwellers. This led Sandwith to the conclusion that general paralysis was more
linked to the stress and pressure associated with “advanced stages of civilization,” 213
which is inherently psycho-pathogenic.
Later, however, Warnock repudiated his former assertions concerning general
paralysis’s rarity and irrelevance to syphilis, arguing for the contrary. In a letter to one of
his colleagues in Britain, a certain Dr. Mott, Warnock said: “the number of patients
suffering here from syphilis is proportionately greater than among the poorer classes in
England. When I wrote my 1895 report, I believed that syphilis was not an important (the
all-important) factor in the causation of general paralysis. In later reports I have changed
that opinion and from experience here I am coming round to the idea that general
paralysis is caused by syphilis and probably only by syphilis. I doubt if alcohol, sexual
excess, worry, fast life have anything to do with general paralysis.” 214 Warnock did not
provide statistical or clinical evidence supporting his conclusion and change of opinion.
211
Sandwith, “Cairo Lunatic Asylum,” 488.
Ibid.; Peterson, op. cit., 29.
213
“Report from Egypt,” The Lancet, April 24, 1897. p. 1158.
214
“Syphilis and General Paralysis in Egypt,” The British Medical Journal, Vol. 2, No. 2030 (Nov. 25,
1899), p. 1500.
212
86
He failed to explain the high rate of syphilis infections among the Egyptians with no
corresponding rate of general paralysis cases. Warnock’s insistence on connecting
general paralysis exclusively to syphilis, while failing to produce empirical evidence to
support his assumptions, can only be understood as a case of “knowledge building on
knowledge;” an attempt to give a medical façade to a cultural and racial judgment.
Religious excitement
Religion had often been cited as a possible cause of insanity, although not as
frequently as Pellagra, Hashish and general paralysis. But when cited, the criticism to
religious excitement was not directed against the extreme practice of some observing and
practicing Muslims that might lead to insanity, but rather to the nature of Islam itself as
intrinsically breeding mania and delusions. Dr. Frederick Peterson gives an interesting
etiological interpretation, to mental illness in Egypt based on geographical essentialism.
According to him, one would expect that “a religion which so commonly gives rise to
extremes of fanaticism, to the orders to be seen in Cairo of howling and dancing
dervishes to the desert pilgrimages to Mecca to constant poring over the Koran and the
like, would have a more than usually bad effect upon the mental balance.”215 Moreover,
such a “desert” religion gave rise to “so many false prophets.” The desert has the
peculiarity of “developing thoughts in great luxuriance, even if nothing else grows there.
If there is anything morbid in one’s mind it will grow like an exotic there where there is
nothing else to think about.” As such, it is of no surprise to find “a great many false
prophets in the Cairo asylum” when “Mahomet” the founder of Islam, was one
himself.216
215
216
Peterson, op. cit., 28.
Ibid.
87
According to the discussed nosology and etiology of mental illness in Egypt, it is
arguable that there was a big cultural element to it, which cannot be overlooked. Most of
the observations, remarks and conclusions made by doctors were based on previously
formed assumptions that they simply came to prove with no chance to refute. In this
context, native spiritual beliefs and national heritages were commonly labeled as
“barbaric”, “uncultured” and “uncivilized.” At best, Egyptians were described,
patronizingly, as “grown-up children, and when insane they are almost invariably easy to
manage”217 naturally endowed only with a poor mental capacity and a mind possessed of
a “feeble texture” that could easily become unhinged. Although eminent colonial figures
trusted that, with a little help from the British, enlightened ideas and education might
civilize even the natives, the talk of racial inferiority came to predominate. Obsession
with phrenology, and its heir craniology, (although different they are usually used
interchangeably), made the Cairo asylum a good place for a study of racial
characteristics.218
While it is true that the British administration of the mental asylums in Cairo
brought about managerial and administrative improvements compared to the previous
conditions, claims to use and “produce” scientific knowledge in the diagnosis and
treatment of the mentally ill made by the asylum’s British directors and doctors, however,
were anything but spurious.219 Dr. Sandiwith, the first director of the ‘Abbāsiyya mental
asylum, admitted once to be “even more ignorant in psychology than of Arabic.” 220
217
Sandwith, op. cit., 485-6.
Peterson, op. cit., 28; Sandwith was obsessed with measuring the heads of the patients at Abbasiyya, to
prove the predominant racial theory predominant at his time concerning the level of intelligence in
relevance to the head shape and size and that certain races were more endowed with intelligence while
others inherently lacked it.
219
Rogan, op. cit., 112.
220
Sandiwth, op. cit., 483.
218
88
Accounts of mental disease nosology and etiology provided by British doctors were
based on post hoc ergo propter hoc aphorisms. The fact that the excessive use of hashish
can lead to mental disturbance to an already “feeble mind,” or that syphilis might be a
cause of general paralysis, or that pellagra could lead to mental disturbance or that
religious excitement can lead to mania, do not provide a scientific evidence that
whenever these factors exist, mental illness should entail.
The early statistics from the Cairo Lunatic Asylum sought to demonstrate that
mental illness was a curable disease. It sought to reinforce the claim that psychiatry held
the key to cure mental illness. Yet by time, the ‘Abbāsiyya became more of a place of
confinement rather than of treatment; an asylums rather than a hospitals. It was a state
facility, “most of whose patients were committed through the agency of the
police.”221The growth of the facility over subsequent decades reflected British concerns
for order rather than an increasing demand from society for psychiatric services, as a
huge number of uncured cases had been discharged since 1895, most of whom were
“quiet” insane, making room for patients who were believed to pose a threat to public
order and safety.222
The science of “mental disease” as it developed in the asylum would always be
only of the order of observation and classification. 223 It is true that the doctor/patient
relationship was not of repression, but rather of authority.224 Within the asylum itself, the
doctor takes a preponderant place, insofar as he converts it into a medical space. However,
221
Rogan, op. cit., 113-114.
The year 1895 when Warnock assumed the directorship of the asylum witnessed the admission of 726
patients and the discharge of 192 uncured patients. In 1923 the dramatic increase in the discharged patient
in relation to the admitted cases proves that the asylum became a place for incarceration more than medical
treatment as the number of cases discharged as uncured reached 703 in favor of 1179 admitted new cases
(Lunacy Division Report for the Year 1933, Table III).
223
Michel Foucault, Madness, 250.
224
Ibid., 251.
222
89
the doctor intervention is not made by virtue of a medical skill or power that he possesses
in himself and that would be justified by a body of objective knowledge. It is not as a
scientist that homo medicus has authority in the asylum. If the medical profession is
required, it is as a juridical and moral guarantee, not in the name of science. 225 The
British in running the lunatic asylum in Egypt did not introduce science, but a personality,
the psychiatrist or asylum superintendent, “whose powers borrowed from science only
their disguise, or at most their justification.” 226
225
226
Ibid., 270.
Ibid., 271.
90
Chapter IV: Folk Medicine As Subaltern Subversion
The hope for the British was that the “staging” of science in exhibitions, museums
and hospitals would force the “marveling natives in the colonies” to acknowledge the
justness of British rule. And yet, such acknowledgment could only come from one
capable of reason already. In discussing the relationship between the Indians and their
British colonizers, Gyan Prakash argued that while “seeking from Indians the recognition
of Western knowledge’s authority” the British were “unwilling to acknowledge them as
knowing subjects.” In the colonies, the British had to regard, and propagate, their subjects
as always “less than adequate, always lacking some key attributes.” This justified
colonial dominance, but it also conceded that the colonial project would never achieve
complete success; the colonized would remain unconquerable in the last instance.227 As
part of the civilizing mission, science played two contradictory roles in colonial discourse,
at once making clear to the “natives” the kind of knowledge they lacked (whose absence
justified colonialism itself) while simultaneously denying them the hope that such
knowledge could be theirs.
As natives were denied the status of knowing subjects in terms of scientific
knowledge, colonial discourse became filled with the utterances of subjects knowing little
concrete knowledge, but speaking much, spreading rumors and adapting universal
knowledge to the specific demands of indigenous religion. Even if ruled out to be less
than appropriate, the native reaction could not be ignored. 228 In this regard, Humi
Bhabha’s notion of the inevitable failure of colonial “mimicry” and the hybrid
227
Gyan Prakash, Another Reason: Science and the Imagination of Modern India, Princeton: Princeton
University Press, 1999, p 48.
228 Gyan Prakash, “Science ‘‘Gone Native’’ in Colonial India,’ Representations, 40, Autumn 1992, pp
153-178, p.172
91
subjectivities to which such failures give rise is particularly useful.229 These ideas are in
accordance with Fanon’s observations and conclusion concerning the Algerians’ reaction
to the French medical and psychiatric institutions in French Algeria. Fanon noted that in a
great number of cases, the practice of tradition had been a disturbed practice; the
colonized being unable to reject completely modern discoveries and the arsenal of
weapons against diseases possessed by their colonizers but at the same time he/she insists
on following the treatment prescribed by the healer of his/her village or district.230 In this
manner “every pill absorbed or every injection taken invites the application of a
preparation or the visit to a saint...There is always an opposition of exclusive worlds, a
contradictory interaction of different techniques, a vehement confrontation of values.”231
In this context, one can understand how ordinary Egyptians sought another
explanation and treatment for mental ailments and behavioral disturbances, derived from
their own religion and cultural heritage. Pilgrimages to a sanctuary, the making of
amulets and charms were seen as complementary to Western medicine. Just as neglecting
a ritual duty or transgressing a given taboo causes the disease to break out, “so
performing certain actions or following the medicine man’s or the sorcerer’s
prescriptions are capable of expelling the disease and restoring the equilibrium between
the different forces that govern the life of the group.”232
The zār was perhaps the most infamous form of popular treatment designed to
deal with behavioral disturbances and physical ailments. 233 The zār ceremony is basically
229
Homi Bhabha, “Of Mimicry and Man: The Ambivalence of Colonial Discourse,” in The Location of
Culture, London: Routledge, 1994, pp 85-92.
230
Fanon, 130.
231
Ibid, 130
232
Ibid, 149-150.
233
The introduction of zār rituals to Egypt is usually attributed to the slaves brought from Abyssinia or
tropical Africa. Evidence points that the advent of zār to Egypt happened towards the end of the nineteenth
92
a dance ritual designed to ascertain and satisfy the desires of the Jin (‘afārīt or asyād
also used interchangeably) possessing a person (usually a woman). A zār could be public
or private. The private zār, as the name suggests, would be held on behalf of a particular
possessed individual (sahbit ez-zār). It required a large outlay of expenditure to pay for
the services of the musicians and “kudya” (the female leader conducting the zār), ritual
food and sacrificial animals. Such zārs were held periodically as a prophylactic or
treatment measures. Public zārs, on the other hand, occurred on a regular (usually
weekly) basis in cemeteries and other public sanctuaries and included men as well as
women.234
By pleasing and placating the spirits through music-making and gift-offering, the
zār was considered one means of preventing the spirit from tormenting the possessed
person. Each spirit was thought to respond to particular musical modes and rhythms.
When the appropriate song, rīh, was played, the woman possessed began to respond by
dancing. Through dancing, she entered a trance state in which the spirit could make
known its desires and demands, which in turn had to be satisfied by the possessed person
century as the ceremony is absent from almost all the travelogues and ethnographies written before the
second half of the 19th century, mainly Clot Bey’s Aperçu Generale, and Lane’s Manners and Customs.
234
For a full documentation and early studies on the zār rituals in Egypt see Muhammad Umar, Hādir al
Misriyyīn wa Sir Ta‘khurihim (Cairo: al-Maktab al-Misṛī li-Tawzīʻ al-Matḅūʻāt, 1998). For later academic
studies, see Brenda Z. Seligmann, “On the Origin of the Egyptian Zar,” Folklore, Vol. 25, No. 3, Sep. 30,
1914, pp. 300-323; Hager El Hadidi unpublished PhD dissertation, “Survival and Surviving: Belonging to
Zar in Cairo,” Diss. University of North Carolina at Chapel Hill, 2006; Mohamed Mahdi Qenawi, Tuqūs
az-Zār: Ru’ya syko-thaqāfiyya, (Cairo: Markaz el Hadāra el ‘Arabiyya, 2012); John G. Kennedy, “Nubian
Zār Ceremonies as Psychotherapy” in John Kennedy, ed., Nubian Ceremonial Life, (Berkeley: University
of California Press, 1978), pp. 203-223; Ahmed Okasha, “A Cultural Psychiatric Study of El-Zār Cult in
U.A.R,” The British Journal of Psychiatry, 112 (1966):1217-1221; M.F. El Sendiony, “The Problem of
Cultural Specificity of Mental Illness: The Egyptian Mental Disease and the Zār Ceremony,” Australian
and New Zealand Journal of Psychiatry 8 (1974): 103-107; Hassan M. El Shamy, “Mental Helath in
Traditional Culture: A Study of Preventive and Therapeutic Folk Practices in Egypt,” Catalyst, 6(1972):
13-28.
93
or her family. Otherwise, the spirit would “punish” the woman. If it were satisfied,
symptoms of illness would subside.235
Although the ceremony and ritual of zār itself is not sanctioned in the teachings of
Islam, it made its way to Egypt easily as the people did not find trouble in confounding
the spirit possession with jinn, who have their place in Muslim cosmology. 236 The
practice of the zār by late nineteenth and early twentieth-century had become a distinctive,
contrarian social phenomenon and subculture in its own right; so rampant was it that it
evoked alarm and action among both the Orthodox Muslim ‘ulama’ and westernized
social reformers. In a letter addressed to the Ministry of Interior in 1895, the ‘ulama’ of
al-Azhar urged the government to forbid and incriminate the “unorthodox” practice of zār,
which, they protested, violated the principles of religion and morality code.237
For the government officials and Egyptian elite reformers alike, the zār
symbolized and perpetuated Egypt’s “backwardness.” According to Chakrabarty, elites
within colonized nations, while rejecting the notion that science was imported from the
West, often shared such sentiments about science’s positive and transformative powers,
and spoke a “language of modernity,” that, however uneasily, allied them with imperialist
officials. 238 For them, curative folk practices as performed by the common Egyptians
were continually shunned as harmful, mistaken, and mischievous. No work represents
this line of thought better than Abdel Rahman Ismail’s Tibb ar-Rukka, or Folk Medicine,
(1892), and Muhammad Umar’s Hadir al Misriyyin wa Sir Ta’akhurihim, or The Present
235
Seligmann, 310.
Ibid, 305.
237
Letter No. 1 of the Ulema of the Azhar University Mosque of Cairo to the Egyptian Ministry of the
Interior, 10th Shaaban, 1312 A.H. (Feb., 1895) quoted in Seligman, pp. 304-06n6.
238
Dipesh Chakrabarty, Habitations of Modernity: Essays in the Wake of Subaltern Studies, Chicago:
University of Chicago Press, 2002, pp 68-79.
236
94
State of the Egyptians and the Causes of their Retrogression (1902).239 Abel Rahman
Ismail hailed from a village in the Delta and had been trained as a doctor at the
government medical school in Cairo. The purpose of his book was not simply to discredit
the local practitioners of healing among the poor, mainly women -- though all of them
were roundly condemned as “impostors,” “charlatans,” and “public robbers” -- but to
offer an alternative idiom of explanation and an alternative medical practice. The author
admitted, in fact, that many of the remedies of folk medicine were successful, but
explained that these remedies succeeded “not from any therapeutic peculiarities in them,
but from the play of the imagination and nervous volitional influence, which according to
biologists in most recent times, has a very dangerous action upon the constitution.” 240 In
other cases, he admitted that the local remedy was scientifically sound, but attacked the
local understanding of how it worked upon the body, replacing this with “the true
explanation” which accounted for its working in an alternative idiom drawn from late 19th
century medical science.
Unlike Ismail who had a medical training, Muhammad Umar was an employee at
the Egyptian postal service. His book was an attack on both the upper and lower classes,
which he viewed as the main cause behind retrogression and backwardness of Egyptian
society. The author set apart members of his own class -- the middle class, which lives off
income from property, emoluments or inheritance -- together with those who worked as
239
Abdel Rahman Ismail, Folk Medicine in Modern Egypt, (New York: AMS Press, 1980); Muhammad
Umar, Hādir al Misriyyīn wa Sir Ta‘khurihim, Cairo: al-Maktab al-Misṛī li-Tawzīʻ al-Matḅūʻāt, 1998).
Both books attempted to trace the reasons behind the backwardness of the Egyptians, following the book
genre of their time such as Juji Zaydan’s translation of Samuel Smile’s Self Help and Ahmed Fathi
Zaghloul’s translation of Demolin’s A Quoi Ttient la Supériorité des Anglo Saxons. The translation of such
works tried to convey to the Egyptian reader the message that the Egyptian character or mentality could be
treated as a distinct and problematic object, the object upon which society and its strength were said to
depend. The very occupation of the country by the British could be blamed upon defects in the Egyptian
character, defects whose remedy was Egypt’s political task.
240
Ismail, Folk Medicine, 16.
95
scholars and writers, from the rest of the population by their sense of “order.” They were
not afflicted with the indolence found among both the poor and the very rich. This, as the
book emphasized, was thanks to the “order” introduced by the British, which had given
them self-confidence and initiative in their affairs. Umar dedicated a full section in his
book to discuss the then new zār ritual. According to him, the women’s belief that they
were possessed by the jinn simply obfuscate the zār’s real purpose, which was to satisfy
sinful lusts (shahwa radiyya), lusts that could not be satisfied except through cunning and
subterfuge (hīla). He blamed the zār for throwing families into an abyss of misery, which
eventually drifted them apart. Umar attributed the zār phenomenon to two sets of causes.
The general and indirect ones included the lack of proper education and moral upbringing
as well as the misunderstanding of “proper” Islam. The direct cause of zār, however,
according to Umar, was marital unhappiness and the women’s desire for vengeance from
their controlling husbands.241
Both Ismail and Umar represent the quintessential Egyptian patriarchal elite,
fearing the insidious, and destructive, power of women with the zār -- an essentially
women’s business where men were unquestionably excluded. Both authors blamed
women for spreading backwardness and hindering progress through maintaining the ageold folkloric habits and conducting zār rituals.
Regardless of how the zār and other forms of folk medicine were viewed by
Egyptians officials and intellectuals, the British, and the religious institution represented
by al-Azhar, it remains a fact that they all failed to understand the implication and
symbolism of the spread of such trends. While they blamed these “backward” habits to
241
Umar, 275.
96
the lack of education and proper religious and moral upbringing, they failed to see the zār
in its own terms, namely, as an outlet for people’s subversion and a challenge to the
cultural hegemony of the middle and upper classes, with their versions of
institutionalized religion, and acceptable social decorum. While both western medicine
and zār were foreign practices imported to Egypt (the former being commissioned by
Mohamed Ali early in the 19th century, and the latter infiltrated via the African slaves
who were imported to Egypt towards the end of the 19th century), the zār’s increasing
popularity suggests that the phenomenon has more to it than mere superstition, as
described by backlashers back then.
By ignoring the significance of the then new phenomenon of zār, the colonial
authority and the Egyptian intellectuals understood what was in fact the assertion of a
distinct identity, a concern with keeping intact few shreds of national existence, as mere
religious and magical fanatical behavior. Recent studies on the zār rites, however, have
increasingly treated the phenomenon in its own right, focusing on its epistemic value.
Hager el Hadidi’s work is typical of such studies where the focus is on “that spirit
possession through the lenses of local contexts, focusing on cultural logic and human
imagination and human creativity.”242 In this sense, the phenomenon of zār is, as put by
Fritz Kramer, a manifestation of the marginalized “cultural other” who rejects imitation,
conformity and the mainstream.243
As El Hadidi points out, many accounts and studies on zār are merely descriptive
and contain reiterated misunderstandings. They tend to ignore the complexity and
multifaceted nature of the practice, reducing it, at best, to the healing and cathartic
242
243
El Hadidi, 29.
Fritz Kramer, The Red Fez: Art and Spirit Possession in Africa, (London& New York: Verso, 1993).
97
aspects of the cult. Most scholarly works on the zār in Egypt have also overlooked its
symbolic aspect, its clear representation of “otherness.” A great number of scholars
concentrated on the psychological and therapeutic functions of the cult. They viewed the
cathartic aspect of the zār ritual from its religious aspect, and defined zār as
psychotherapy without accounting for its healing mechanisms or its social aspects. 244
Most of the scholars who have focused on rendering the phenomenon intelligible to a
Western audience, by rationalizing away from the cult’s own terms, rather than building
on deep understanding. That is to say, shallow accounts present zār as an exotic cultural
survival, a psychotherapeutic ritual complex. The models used in these accounts are
highly rational while zār simply is not.
Taking a new take while criticizing earlier accounts of Egyptian zār produced by
native commentators -- who were mostly men, who were critical of the practice and who
quite often wrote within a discourse of nationalist reform against colonialism (as seen in
the writings of Umar and Ismail) -- Hager el Hadidi traces and analyzes the phenomenon
of zār as an important cultural form, despite more than a hundred years of state repression,
and despite rapid, uneven social change and criticism from both the nationalist and
religious discourses. Janice Boddy shares El Hadidi’s approach by elaborating on how
zār offered a leeway for subversion and breaking social constructions. In Boddy’s view,
the zār is an “indigenous text that unfolds anew with every ritual performance” with both
exoteric and esoteric meanings. Moreover, Boddy interprets zār as a counter-hegemonic
allegory 245 where the disenfranchised is elevated and celebrated in a Bakhtinian
244
El Hadidi, 32-3.
Janice Boddy, Wombs and Aliens Spirits: Women, Men and the Zar Cult in Northern Sudan (New
Directions in Anthropological Writing), (Madison: University of Wisconsin Press, 1989).
245
98
“carnivalistic” sense. 246 In other words, zār offers “a counter-reality, wherein salient
social values and cultural orientations are played with, repressed, weighted differently
than in everyday life, opened up to other interpretations.”247
In his book, Rituals of Rebellion in South-east Africa, Max Gluckman describes
the ritual reversal in African societies he observed as an expression of dramatized
structural conflicts. According to Gluckman, “every social system is a field of tension, of
ambivalence, of co-operation and contrasting struggle.”248 El Hadidi adds that the rituals
of zār create “a community with a shared experience of ‘otherhood.’” Members of this
community “buffer each other’s pains and misfortunes through friendships, mutual
sympathy, communal dance, entertainment outside the immediate kin group.”249 In this
regard, zār is a dynamic system understood, interpreted, and performed with infinite
possibilities. Zār can be construed, using Levi-Strauss’s word, as a “bricolage” of signs
and symbols that are continuously tailored to fit the needs of its participants and tinkered
to create meaning in response to local and global forces.250
Zār is a mode of experience and a concept of reality, which may fulfill many and
multiple functions. For the purpose of this research the zār can be seen as a healing
indigenous ritual, parallel to Western psychotherapy; 251 a muted counterhegemonic
ritual252 and, as el Hadidi states, a tayfa (guild) that provides “a sense of belonging” by
establishing deep connections between the afflicted and the zār leaders. These
In his works Problems of Dostoevsky’s Poetics and Rabelais and His World, Mikhail Bakhtin points out
that the carnivalesque in literature resembles the type of activity that often takes place in the carnivals of
popular culture. In the carnival, social hierarchies of everyday life—their solemnities, pieties and etiquettes,
as well as all imposed truths—are profaned and mocked by the subaltern suppressed voices and energies.
247
Boddy, 156-7.
248
Max Gluckman, Rituals of Rebellion in South-East Africa, (Manchester University Press, 1954), p. 127
249
El Hadidi, 44.
250
Claude Levi-Strauss, The Savage Mind, (Chicago: Chicago University Press, 1966).
251
El Shamy, “Mental Health”; Kennedy, “Nubian Zar.”
252
Gluckman, Rituals of Rebellion; Boddy, Wombs and Aliens Spirits.
246
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connections are very personal, and are marked by acceptance and sympathy unlike the
mechanic and formal relationship between the mental doctor and the mentally-ill.
Rather than focusing exclusively on the hegemonic power and ideological role of
Western medical discourse in the making of colonial medicine and psychiatry in Egypt, a
‘de-centered’ perspective was deployed in this chapter that focused on the subaltern
responses and the various forms of resistance, or at least alternatives, displayed by the
colonized and marginalized subjects. Moreover, throughout the previous chapters, the
analysis of colonial psychiatry in Egypt has come to show that while Western psychiatric
discourse may have flourished as rhetoric, it failed to a great extent to deliver in practice
its promise of improved health care and supreme cure efficiency for colonial subjects,
and hence the resilient resort to indigenous medical systems and folk practices, contesting,
or at least offering substitutes to, the hegemony of the western psychiatric discourse.
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Conclusion
In recent years, the history of psychiatry has become an extraordinarily creative
and controversial field. This owes much to Michel Foucault’s idiosyncratic and
pyrotechnic writings, particularly his relevant and important work Madness and
Civilization, where he traces the rise of the mental asylum in Europe as the sole solution
to deal with the problem of insanity through confinement. The paradox of Foucault’s
work is that his analyses seem particularly appropriate to the colonial arena, and yet
colonialism itself does not figure in his writings, a fact that led Gayatri Spivak to
comment:
[s]ometimes it seems as if the very brilliance of Foucault’s analysis of the
centuries of European imperialism produces a miniature version of that
heterogeneous phenomenon: management of space—but by doctors; development
of administrations—but in asylums; considerations of the periphery—but in terms
of the insane, prisoners and children. The clinic, the asylum, the prison, the
university—all seem to be screen allegories that foreclose a reading of the broader
narratives of imperialism.253
In light of this statement and the pervasive Foucauldian effect on the studies of
institutional history, this research comes as an effort to trace the rise and evolution of the
mental asylum in both Britain and Egypt. The main purpose has been to pinpoint the
“colonial” implication, if any, in the establishment and management of the Cairo Lunatic
Asylum of ‘Abbāsiyya. In order to do so, a comparative study between the asylum
253
Gayatri Chakravorti Spivak, “Can the Subaltern Speak?,” Rosalind C. Morris (ed.) Reflections on the
History of an Idea: Can the Subaltern Speak, (Columbia University Press, 2010), p. 227-36.
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institution both at home, Britain, and the colony, Egypt, had to be conducted. Such a
comparison is imperative to highlight the difference between the asylum experiences in
both countries.
Chapter I has provided a background and a discussion of the evolution and rise of
the mental asylum in Britain and the symbiotic relationship between the “mad-doctors,”
or the proto- psychiatrists, and the institution of the mental asylum. In this regard, the rise
of the asylum came in consequence to a long struggle between British laymen reformers
and British “mad-doctors” over the perception of mental illness and claim to the
treatment and “management” of the mentally ill. The principle of “moral treatment” was
appropriated by the emerging psychiatric profession to support the claims to
“professional expertise” and “esoteric knowledge.” The principle did reflect a
fundamental transformation in the basic paradigm or perception of insanity. It was not
based on a more “scientific understanding” of the subject; rather it represented from one
perspective at least, a novel administrative technique, a more efficient means of
management. The essence of this innovation lay in its emphasis on order, rationality, and
self-control.
The Victorian age saw the transformation of the madhouse into the asylum into
the mental hospital; of the “mad-doctor” into the psychiatrist; and of the madman/woman
into the mental patient. It is a grave mistake to confuse semantics with reality and it is
also an error to view these verbal changes as mere euphemism. These verbal changes
reflect the changing social order, perception and meaning of insanity. In Britain, the state
apparatus came to assume a greater role in handling insanity that eventually the asylum
became the only officially approved response to this segment of “problem population,”
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the mentally ill. Madness became something that could be authoritatively diagnosed,
certified and treated only by a group of legally recognized experts. Those experts were of
course men of medicine, increasingly organized, with a claim to expertise and “esoteric”
knowledge. But as these doctors failed to produce empirical knowledge supporting their
claims to scientific method in treating the mentally ill, their legitimacy was only asserted
through their claim to the practice of “moral treatment,” or more accurately, “moral
management” in the mental asylum institution. These men were known to their detractors
as “mad-doctors” and among themselves as “medical superintendents of asylums for the
insane.” Andrew Scull suggests that the clumsiness of the title “captures the extent to
which their professional identity was bound up with their institutional status.”254
While chapter I has dealt with the British context in which the mental asylum and
the profession of psychiatry evolved, chapter II has attempted to give an overview of the
general medical care services in Egypt on the eve of the British occupation. The purpose
of this chapter has been twofold. First, this chapter has attempted to trace the evolution of
a “modern” medical tradition in Egypt, which had developed as part (a very important
one) of Muhammad Ali’s rigorous process of modernization. Second, while providing an
account of medical care and medical institutions in Egypt in the 19th century, chapter II
has elaborated the colonial discourse on medicine, not solely through the eyes of the
British administrators and officials, but also through some of the foreign travelers’
accounts, which had preceded the British “occupation” to Egypt. The accounts provided
by both the British officials and foreign travelers (mostly British travelers in this study),
attempted, to negate, or at best undermine, the presence of a “modern” medical tradition
254
Andrew Scull (ed.), Mad-Doctors and Madmen: The Social History of Psychiatry in the Victorian Era,
(Philadelphia, Pennsylvania: University of Pennsylvania Press, 1981), p.6.
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in Egypt prior to the British occupation. According to these accounts, the poor medical
services and derelict conditions of hospitals and insane asylums at the 19th century were
interpreted as symptoms of the despotism of Egypt’s rulers. As David Arnold argues,
such accounts do tend to indicate that medicine “gave expression to Europe’s faith in its
innate superiority, its mastery over man as well as nature.” 255 After all, together with
Western education, medicine has not only been considered an adequate recompense for
the hardships and injustices of colonial domination but has also been glorified as a
formidable, if not the sole, “excuse for colonialism.”
Yet, “modernization” and the (ab)use of medicine as excuses for colonialism
could not be employed to Egypt as easily as they did in other colonies. Therefore, the
British doctors came up with yet another decisive and lasting contribution to the colonial
cause: the introduction of the mental asylum. Chapter III has discussed the implication of
the introduction of the mental asylum in Egypt in 1884. By creating a great colonial myth
that British psychiatry was practically and clinically efficient and effective, the British
introduced the mental asylum not only as an excuse, but also as a solution to the
hardships and social problems concomitant with colonial domination. It is of course, not
intended to suggest here that the raison d’être of the British presence in Egypt grew
stronger simply and exclusively on myths such as that of medical and psychiatric
supremacy. It is however important to point out that such myths were essential elements
of the colonial discourse and, as such, facilitators and components of colonial dominance.
British physicians who came to Egypt as official members of Britain’s occupying
forces conceived their task as advancing civilization in a “backward” country, one
suffering from incompetent and morally inadequate leadership on all levels of society.
255
David Arnold, Imperial Medicine and Indigenous Societies, (Manchester University Press, 1988), p. 17.
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Sandwith, Green and Rogers drew on Victorian models and values to legitimize their
medical and lunacy reforms. Thus, they established the rudimentary procedural
framework which Warnock then elaborated. Under British administration, ‘Abbasiyya
even became a model institution of its kind. Lunatics from all over Egypt were, orderly,
transferred via the police and medical authorities to ‘Abbasiyya. The maintenance of
order at the reformed insane asylum helped validate the British’s claims to have brought
enlightened and civilized rule to Egypt. The idleness of the patients, the filth, hunger and
chains were replaced by a well- ordered system under medical supervision.
British reform under Rogers militated against academic specialization, a
development then gaining momentum among European medical faculties. Meanwhile,
the mental asylum constituted its own system and extended its own institutional power.
Warnock, an exemplary “colonial psychiatrist” reformed the burgeoning psychiatric
system by enforcing British standards of care. Supervision was intensified and extended.
Mechanical restraint was replaced by seclusion, and attendants were subjected to rules
and penalties. But ‘Abbasiyys began to accumulate chronic and criminal patients, a
pattern familiar to that of the England’s asylums and the colonies. Such an accumulation
consequently weakened the hospital’s therapeutic claims and threatened the asylum’s
medical identity by establishing as criminal a conspicuous portion of the inmate
population. This in turn undermined further the medical status of psychiatry, which, by
lacking an academic base, was already in jeopardy.
To preserve and enhance the medical nature of the hospital, Warnock established
khanka, a mental hospital as modern in design as any then in Europe. The patients
confined at Khanka were more amenable to control as the violent and criminal patients
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continued to be held exclusively in ‘Abbasiyya. However, overcrowding in Khanka seem
to be inevitable and rather than allowing the patients to wander freely in the vicinity, the
administration resorted to impose seclusion due to the fact that the asylum was
understaffed.
Since there were only these two “proper” asylums under British administration,
Warnock wanted to ensure that they followed Victorian ideals and that social rank and
class considerations were observed. Therefore, upper class patients “naturally” had to be
segregated from the poor, criminal had to be isolated from non-criminals and of course
men and women were put in different wards. Despite his ambitions, Warnock’s plan to
establish a network of asylums, each serving a different category of patients went
unrealized due to Egypt’s insolvency and fiscal crisis. He managed, however, to establish
special subdivisions for upper class and criminal patients at ‘Abbasiyya and Khanka.
The insistence on issuing medical certification for mental patients served to
establish and claim the medical identity of the asylum. The detention of violent pellagra
patients, hashish addicts, general paralytics and other lunatics at ‘Abbasiyya and Khanka
presupposed, and imposed, the view that such persons were sick individuals requiring
medical attention, despite failing to establish a direct causal relationship between the
consumption of hashish, pellagra and general paralysis on the one hand, and mental
illness on the other.
A pivotal figure in this system of relations has been the director of the lunacy
administration. Certification, admission, and discharge procedure emanating from his
office have determined the role of the family, police, courts, and government medical
services in dealing with person officially designated as insane. Psychiatric expertise,
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under Warnock’s influence, was given juridical primacy in determining criminal
responsibility for prisoners and accused persons suspected of insanity.
Abbasiyya and Khanka, like their institutional counterparts in Britain, operated on
the presupposition that mental illness is fundamentally a medical problem requiring a
medical solution. To the extent that the mental hospital has “failed” to cure patients, the
fault has been presumed to lie in the inadequacy of funding and resulting overcrowding.
The relatively low ratio of doctors and attendants to patients has been interpreted as a
failure to maintain international health standards of care, paying no attention to cultural
factors in defining mental/psychological disturbances.
But was there such a thing as “colonial psychiatry” in Egypt? As David Arnold
suggests, the introduction of medical ideas and institutions in the colonies should be
viewed in parallel to similar developments taking place in the metropole. 256 However,
what distinguishes medicine in the colonial context, according to Arnold, is the exclusion
of the “folk” medical interpretation. Along with this notion of excluding the “indigenous”
medical practice, comes another element to colonial medicine and colonial psychiatry,
which is the “authority” to provide “naturalized” and “pathologized” medical accounts of
the colonial subjects. The British in Egypt managed to establish a full control in the
administration of the mental asylum of ‘Abbāsiyya, and later the Khānkah asylum, by
claiming the “production” of psychiatric knowledge, and its application in the treatment
of the mentally ill. To ply these claims and establish an uncontested authority over the
treatment of the mentally ill, the British doctors and directors of the lunatic asylum in
Egypt had to come up with an innovative nosology (disease classification), that would
256
David Arnold, Colonizing the Body. State Medicine and Epidemic Disease in Nineteenth-Century India
(Berkeley, Los Angeles and London, 1993), p 9.
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identify certain types of madness peculiar to Egypt.
The disease classification provided, included a list of causes inducing mental illness.
The most cited causes of mental illness in Egypt were pellagra, hashish consumption,
general paralysis (and Warnock’s desperate attempts to connect it to syphilis) and
religious excitement. All these causes had a cultural significance as they were connected
to dietary, smoking, sexual and religious habits. The British psychiatrists in Egypt,
especially Dr. Warnock failed to provide an empirical evidence to an existing correlation
between these listed factors and habits and the induction of the mental illness. However,
the British were very assertive about their claims using a post hoc ergo propter hoc and
inductive logic to translate their “cultural prejudice” into medical theories regardless of
their scientific validity. These attempts to establish a causal relation between certain
cultural habits and mental illness contributed to the definition and re-enforcement of
group-appropriate behavioral norms. Such attempts also potentially provide for the
implementation of adequate and narrowly circumscribed sanctions for deviant behaviors
should an urgent need for disciplinary measures be seen as justifying considerable
government expense, such in the case of hashish consumption and the attempts to push
the Egyptian government to impose stricter measures in combating hashish consumption.
Together, ‘Abbasiyya and Khanka’s formation constituted part of Britain’s larger
project of gradual assumption of control over Egypt’s internal affairs. The institution of
British power in Egypt required developing institutions that could generate and
perpetuate their own system of order and meaning. The previous discussion shows the
degree to which Britain succeeded in reordering Egyptian society. By exemplifying
society’s relative degree of order, or disorder, and thus symbolizing the society’s general
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need for change, the mental asylum have thus been used to legitimize British rule.
Although Warnock managed to obtain the authority to detain the mentally disturbed and
subject them to the asylum authority, official efforts to manage and control the mentally
ill were still circumscribed by the continuing strength of popular healers and beliefs. Thus,
in 19th century Egypt, the interpretation of mental illness, as practiced in the asylum, had
been in competition with other social interpretations of “mental illness.”
The most prevalent alternative approach to mental illness was the metaphysical
approach; the interpretation of behavioral disturbances in terms of spirit anger and
possession. The study of zār as possible subaltern interpretation, treatment and response
to mental illness has been thus of utmost relevance. The zār was seen by the British
doctors, officials and the Egyptian middle class as the clearest manifestation of “Western
medical and scientific discourses” clashing with mere folk religion and superstitious
irrational beliefs. One has to be careful, however, not to fall in the trap of relying on
seemingly clear-cut binaries and dichotomous categories, such as the ubiquitous stanza of
‘colonial medicine’ (assumed to be based purely on science) versus ‘indigenous/folk
healing’ (assumed to be “unscientifically” based on popular religion and magic), since,
terms that are based on preconceived, seemingly plausible assumptions such as those can
be elusive. Not only is the epistemological status of ‘science’ to be subjected to inquiry in
the same way as the knowledge-base of allegedly unscientific approaches; the very extent
to which science can be demarcated from the realms of popular belief, social conventions
and religion – as if there existed a litmus test that could clearly separate the one from the
other –needs further critical scrutiny. It is this kind of critical inquiry that leads us to pose
questions about authority: who is to decide what is to count as science or non-science, as
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orthodoxy or heterodoxy, as proper medicine or mere superstition? Which evidence is to
be relied on and whose story is to be told? This very authority to define and appropriate
knowledge while excluding alternative “folk” medical interpretation, is precisely what
David Arnold defines as “colonial” in colonial medicine.257
In running the lunatic asylum in Egypt the British did not introduce “science” but
rather an improved system of management and administration of the mental asylum.
Moreover, the British managed to produce a personality: the psychiatrist or asylum
superintendent. With the introduction of psychiatry and the institution of the mental
asylum, Egypt came to have two controller-generals: a political controller-general
residing in Qasr el Dūbara and another, asylum controller-general (the British asylum
director) residing in ‘Abbāsiyya.
257
Arnold, Colonizing the Body.
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