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More than a Disease: The History ofGeneral Paralysis of the Insane in TurkeyFatih Artvinliaa Department of Medical History and Ethics, Acibadem UniversitySchool of Medicine, Istanbul, TurkeyPublished online: 03 Apr 2014.

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More than a Disease: The History of GeneralParalysis of the Insane in Turkey

FATIH ARTVINLI

Department of Medical History and Ethics, Acibadem University School ofMedicine, Istanbul, Turkey

This article explores the history of general paralysis of the insane (GPI) and its treat-ment in Turkey. GPI was considered as “a disease of civilization” at the end of thenineteenth century. From the early years of the twentieth century, Turkish psychiatristsdiscussed and interpreted the causes of GPI and followed the European diagnosticand treatment methods of the disease. Austrian psychiatrist Julius Wagner-Jauregg(1857–1940) introduced and developed “malaria fever therapy” for general paraly-sis in 1917. Malaria fever therapy spread to other countries and, during the 1920s, thetreatment was also used in Turkey. This article not only aims to illuminate an unnoticedaspect of the history of psychiatry in Turkey but also uses GPI as a model to illustratehow psychiatry in Turkey was influenced by the developments in Europe.

Keywords general paralysis of the insane, malaria fever therapy, Turkish psychiatry,Toptası Asylum

Introduction

General paresis, also known as general paralysis of the insane or paralytic dementia, is aneuropsychiatric disorder affecting the brain and central nervous system, caused by syphilisinfection. It was originally considered a psychiatric disorder when it was first scientificallyidentified around the early-nineteenth century. General paralysis of the insane (GPI) wasfirst identified as a distinct disease by Antoine Laurent Bayle in the 1820s (Brown, 2000).French psychiatrists like Esquirol and Georget were also studying GPI in these years notingthe increasing number of cases (Brown, 1994).

By the mid-nineteenth century, the physical and mental symptoms considered charac-teristic of GPI were placed in medical textbooks. The disease generally progressed throughthree stages. In the first, patients would exhibit slight defects of speech, uncoordinated facialmuscles, pupil irregularities, and mental exaltation. Unless the patient died of exhaustionor convulsions, he or she would be expected to pass into the second stage, characterizedby increased muscular incoordination, paralysis, and mental enfeeblement. The final stagewas said to be one of fairly complete paralysis and “mental extinction,” the complete lossof intellectual and physical functions culminating in certain death (Davis, 2012).

Originally, the causes were believed to be hereditary, head trauma, excessive cold,fright, alcoholism, venery, or exhaustion (Pearce, 2012). While Esmarch and Jessen hadasserted as early as 1857 that syphilis caused general paresis, the general acceptance by

Address correspondence to Fatih Artvinli, Department of Medical History and Ethics, AcibademUniversity School of Medicine, Icerenkoy Mh. Kayisdagi Cd. No. 32, 34752 Atasehir-Istanbul,Turkey. E-mail: fatih.artvinli@acibadem.edu.tr

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the medical community of this idea was accomplished by the syphilologist Alfred Fournier(1832–1914), who linked statistically a primary syphilis infection to the later appearanceof general paresis and tabes dorsalis (Shorter, 2005, p. 193). In 1913, all doubt aboutthe syphilitic nature of general paresis was finally eliminated when Noguchi and Mooredemonstrated the syphilitic spirochaetes in the brains of patients with GPI (Brown, 2000).

At the turn of the twentieth century, new optimism was fostered by scientific discover-ies, in particular, the neurobiological etiology of GPI. The attitudes regarding the hopelessprognosis of and treatments for GPI changed (Warren, 2000, p. 68). Although antisyphilitictreatments such as mercury and potassium iodide and later salvarsan and neo-salvarsanwere recommended for GPI treatment, the first therapeutic breakthrough was introducedby the discovery of malaria fever therapy.

The relationship between fever and madness was a subject of medical inquiry espe-cially at the end of the nineteenth century. In 1887, Julius Wagner-Jauregg (1857–1940) hadproposed that it might be possible to treat psychosis through the use of fever. He injectedtuberculin into several patients whose psychotic symptoms were caused by GPI, with theaim of giving them a tuberculous fever. He discontinued his experiments with tuberculinbecause it was considered to be toxic. Then he returned to the possibility of giving patientswith GPI a fever with malaria, which, unlike other possible infections, had the advantageof being controllable with quinine (Shorter, 1997, p. 193).

In 1917, Julius Wagner-Jauregg discovered that infecting GPI patients with malariacould halt the progression of general paresis. While World War I was raging, a soldierfrom the Macedonian front was admitted to the hospital in Vienna. The soldier had tertiarymalaria with chills, sweating, and regular attacks of fever, and Wagner-Jauregg consid-ered the possibility of using the soldier’s blood to induce fever in the hospital’s patientswith general paralysis. On June 14, 1917, he drew blood from the soldier during an attackof fever and injected it subcutaneously between the shoulder blades of two patients withparalysis. Then he used the blood from the two patients to inoculate a new group of par-alytic patients. The patients’ first fever attack occurred about a week after the blood wasinjected. After having 7 to 12 fever attacks, the patients were given quinine to terminatethe malarial infection (Whitrow, 1990). In 1918, Wagner-Jauregg reported a remarkablesuccess rate: 67% improvement in treated patients (Braslow, 1997, p. 75).

News of malaria fever therapy spread to other countries, and, in the early 1920s, thetreatment was used not only in Europe but also in South America and the United States(Kragh, 2010). In 1927, Wagner-Jauregg won the Nobel Prize for his discovery of the ther-apeutic value of malaria inoculation in the treatment of general paralysis of the insane(Shorter, 2005, p. 194).

GPI was known and diagnosed already in Turkey much like in European countries atthe end of the nineteenth century. Ottoman and Turkish psychiatrists also discussed andinterpreted the causes of GPI and followed the new diagnostic and treatment methods ofthe disease. Malaria fever therapy started to be used in Turkey in 1922 and became pop-ular among Turkish psychiatrists. This article aims to search the history of GPI in Turkeyand use GPI as a model to illustrate how psychiatry in Turkey was influenced by thedevelopments in Europe.

General Paralysis of the Insane in the Late Ottoman Period (1859–1923)

The history of GPI in Turkey can be researched as a specific part of the history of mod-ern psychiatry in Turkey. The institutionalization of psychiatry started in the OttomanEmpire at the middle of the nineteenth century. An Italian physician/alienist Luigi Mongeri

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(1815–1882) who was called “Pinel of Istanbul” (Mahmud, 1910, p. 28) or “Pinel of theTurks” (Uzman, 1941, p. 78) was the pioneer of modern psychiatry in Turkey (Erkoç &Artvinli, 2011). He was appointed in 1856 to Süleymaniye Bimarhanesi [SuleymaniyeLunatic Asylum] that was the most important and central lunatic asylum of Istanbul, theOttoman capital, in the nineteenth century. The first attempts to institutionalize psychia-try took place in this asylum; however, the greater transformation and practices occurredafter the transfer of the mentally ill patients from Suleymaniye to Toptası1 at the end of1873 (Artvinli, 2013, p. 63). As the head-physician of the Suleymaniye Lunatic Asylumand later Toptası Asylum, Mongeri published the asylum statistics and psychiatric casereports. While Mongeri witnessed numerous patients with GPI, his assistant Avram deCastro (1829–1918), who became the head physician of the Toptası Asylum after thedeath of Mongeri, published more detailed statistics of the asylum (Artvinli, 2012) thatalso included the numbers of patients diagnosed as GPI.

According to the statistics of Castro, there were seven males and three females patientswith GPI,2 in Toptası Asylum in the 1898–1899 period (Castro, 1900a, p. 174). The ratioof patients with GPI in the asylum was 2.18% in males and 2.34% in females in the year1898. The number of deaths from GPI was very high: six of seven male patients and allthree female patients with GPI died in the asylum. This means that the total death ratiofrom GPI was 90%. One year later there were six male patients and one female patient withGPI and the ratio of patients with GPI was 2.26% and 0.91%, respectively (Castro, 1900b,p. 200). Three of the six males and the one female patient died from GPI and the death ratiowas 57%. In 1901, there were five male and no female patients with GPI in the asylum andonly one patient died (Castro, 1901, p. 744).

GPI was known and diagnosed in Turkey much like in European countries at the end ofthe nineteenth century. Dr. Luigi Mongeri (psychiatrist and son of Mongeri),3 after his longpractice in Istanbul, published an article about general paralysis in Turkey. Mongeri, basedon 144 cases, concluded that “general paralysis is invariably preceded by syphilis.” Thepatients of Mongeri were representative of various nations owing to differences in religionand mode of life and varied greatly in their susceptibility to syphilis and alcoholism.4

Turkish psychiatrists of the nineteenth century were clearly influenced by Frenchpsychiatry.5 Mongeri and Castro followed European psychiatry mostly in French and they

1Toptası is a neighborhood at Scutari (Uskudar) that was located in the Anatolian side ofIstanbul. Toptası Lunatic Asylum was a part of Valide-i Atik Complex built in 1583. The placewas used as general hospital, military barracks, and military hospital before 1873 (Artvinli, 2013,pp. 64–67).

2Castro used the French term paralysie progressive des aliénés for GPI. Castro’s statistics werepublished in Gazette Medicale d’Orient, the most important medical journal in the late OttomanPeriod. The journal began to be published in 1857 as an official publication of the Société Impérialede Médecine de Constantinople that was founded by European physicians.

3L. Mongeri (jun.) worked 12 years in Istanbul as psychiatrist (medico alienista) at varioushospitals like the Italian Hospital, Surp Agop Armenian Hospital, and International La Paix Hospital.Mongeri wrote several books, one of which is a psychiatric texbook: Patologia special delle malattiementali (Milano, U. Hoepli, 1907).

4See Bernard Hart, 1907, p. 181.5This was largely related to the use of French in the teaching of medicine in Turkey. The language

of instruction in the Imperial School of Medicine that was opened in 1839 was French until 1867.Ottoman physicians were sent to France at the second part of the nineteenth century for medicaleducation and specialization in medicine. For example, Hilmi Kadri (1866–1920) was sent to Parisin 1890 for the education of neurology and he studied with Jean-Martin Charcot. In the same years,Dervish Pasha (1859–1909), physician at Toptası Asylum, started to translate Emmanuel Régis’ book,namely Précis de la Psychiatrie, into Turkish.

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sent their articles and case reports to Annales Médico-Psychologiques. French influences inTurkish psychiatry started to diminish in the early-twentieth century and German influencesincreased.

Rasid Tahsin (1870–1936; see Figure 1), who studied with Emil Kraepelin in Germany,could be called the father of academic psychiatry in Turkey (Özaydın, 1999; Erkoç &Kutlar, 2001). More physicians learned about GPI by his academic courses on psychia-try, which began at the Imperial School of Medicine in 1896. As chief of the psychiatricclinic of the school, he mentored a group of Turkish neuro-psychiatrists at that time. RasidTahsin participated in the 4th International Psychiatry Congress in Berlin in 1910 as theOttoman delegate and presented a detailed report about mental diseases in Turkey. He alsomentioned general paralysis in Turkey:

The rate of “general paralysis” in Turkey is low if you compare with Europeancountries. The percentage of GP in big cities and coast cities is higher thanrest of the country. There are hardly any GP cases in villages and ruralTurkey, because of the healthy and religious life styles of villagers. This dis-ease is generally seen in upper socio-economic classes and especially amongsome professions like merchant, lawyer, poet, philosopher etc. (Tahsin, 1910,pp. 22–23)

It is clear that Rasid Tahsin identified GPI as a “city disease,” “disease of rich people,”and its cause was an “immoral” or “bohemian” lifestyle. Rasid Tahsin’s comments on GPIreflect the common ideas of European physicians of the time. At the International MedicalCongress in 1897, Austro-German psychiatrist Richard von Krafft-Ebing (1840–1902),suggested that the combination of “syphilization and civilization” was the cause of GPI. Heand other European scientists argued that GPI was more common among “brain workers”who could only be found in civilized countries. The following sentences from A ReferenceHandbook of the Medical Sciences (1900), written by various authors and edited by AlbertH. Buck, summarize the dominant paradigm about the causes of the disease at the turn ofthe twentieth century:

Exciting Causes: The exciting or immediate causes of paresis are numerous,but one stands pre-eminent; that is, mental overstrain and worry, including thestress and anxiety of business and the struggle for existence under conditionsof modern civilization. The best proof of this is the fact that paresis is almostexclusively a disease of civilization and almost unknown among barbariansand populations living under simple conditions; it is a disease of cities, wherethe struggle for life is keenest, and rare in rural districts and away from thetemptations and excitement that abound in the great centres. (Buck, 1900, p. 87)

Rasid Tahsin emphasized that he had not seen this disease among women. On thebasis of 10 years of clinical research, Tahsin reported that the ratio of the patients admittedwith GPI to his institution was around 7% and generally the disease lasted for 4–6 years.According to him, Greek people had the highest rate of GPI because syphilis and otherinfectious diseases were more common in the Greek community. Armenians had twice asmuch GPI than Muslims and, similar to Muslims, GPI was rarely observed among Jews(Tahsin, 1910, p. 23; see Figure 2).

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Figure 1. Rasid Tahsin (1870–1936), the father of academic psychiatry in Turkey (color figureavailable online).

GPI entered Turkish psychiatric textbooks at the beginning of the twentieth century.6

Fourteen patients were diagnosed as felc-i umumi-i müterakki-i mecanin [progressive gen-eral paralysis of the insane] at Toptası Asylum in 1910. Twelve patients died from GPI inthe asylum in the same year (Muessesat, 1911, pp. 60–61).

There are different reasons for the low number of patients with GPI at ToptasıAsylum during the nineteenth and the early-twentieth centuries. Mazhar Osman Uzman(1884–1951; see Figure 3), student of Emil Kraepelin in 1910 and the last head physi-cian of Toptası Asylum, diagnosed 32 male and six female patients with GPI in 1923.Emphasizing the high rate of GPI, Uzman argued that the number of cases of GPI is notreally much lower in Turkey than in Europe. The real reason for the low number of GPIcases in Turkish statistics is related to missed diagnoses. According to Uzman, there hadbeen many cases of GPI before, but there were not enough physicians and laboratory teststo diagnose them (Uzman, 1925a).

6Different terms including “felc-i umumi,” “felc-i umumi-i müterakki,” “felc-i umumi-imüterakki-i mecanin,” and “cümle-i asabiye frengisi” were used in the Turkish language to the paral-lel terms “general paralysis,” “progressive general paralysis,” “progressive paralysis of the insane,”and “neurosyphilis.”

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Figure 2. The title page of Rasid Tahsin’s pamphlet about the mental diseases in Turkey (color figureavailable online).

Mazhar Osman Uzman challenged Krafft-Ebing’s “syphilization and civilization”theory (Uzman, 1935, p. 25). He criticized the “Orientalist discourse”7 produced byWestern physicians, who associated syphilis with civilization and described Turkey asa noncivilized or non-Western country. Unlike Rasid Tahsin, Uzman argued that GPI iswidespread among people in Istanbul and Anatolia regardless of their social or religious

7I used the term “Orientalist” in the sense of Edward Said’s conceptualization of Orientalism:“Orientalism is a style of thought based upon ontological and epistemological distinction madebetween ‘the Orient’ and (most of the time) ‘the Occident’. Thus a very large mass of writers, amongwho are poets, novelists, philosophers, political theorists, economists, and imperial administrators,have accepted the basic distinction between East and West as the starting point for elaborate accountsconcerning the Orient, its people, customs, ‘mind’, destiny, and so on” (Said, 1978, pp. 2–3).

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Figure 3. Mazhar Osman Uzman (1884–1951) a leading figure in psychiatry in Turkey (color figureavailable online).

bases (Uzman, 1925a). He diagnosed GPI both in men and women, married and single,elderly and young, hodjas and priests, rural and urban, religious and nonreligious people(Uzman, 1925b, 1929). Fahreddin Kerim Gökay (1900–1987), former assistant of Uzman,also noted that “we found more GPI patients who are not ‘brain workers’ and ‘illiterateones’” (Gökay, 1939, p. 63).

Most of the earlier psychiatrists diagnosed patients with GPI according to patients’social class or lifestyles. As Davis argued, “GPI was not recognized initially in somepatients because they did not fit the ‘social’ profile of the disease” (2008, p. 240). Thediversity in the social profile of patients, which Uzman supported as well, can be observedin the professions of patients (Table 1). Workers, artisans, small traders, and civil servantswere the most affected groups and it shows that GPI was usually a “middle class” diseasein Turkey (Gökay, 1929). This “middle class” character of the disease does not reflect the

Table 1Profession of Male Patients with GPI

Type of Profession Number of Patient The Ratio

Workers 41 21.35Artisans and small traders 32 16.66Sailor and boatman 10 5.20Naval officer 4 2.08Soldier 8 4.16Civil servant 32 16.66Teacher 2 1Doctor 1 0.5Merchant 3 1.56Farmer 5 2.60Beggar 4 2.08Unknown 20 10.51

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Table 2GPI Statistics of Toptası Asylum

Number of Entrance Number of GPI Patients

Year Male Female Total Male Female TotalThe Ratio

of GPI

1920 220 113 333 16 4 20 5.91921 259 140 399 10 6 16 41922 288 156 444 21 4 25 5.61923 453 235 688 32 6 38 5.51924 556 255 811 29 7 36 4.41925 694 308 1002 54 3 57 5.6Total 2470 1207 3677 162 30 192

Table 3GPI Statistics of Bakırköy Mental Hospital

Year Entrance Male Patients with GPI Female Patients with GPI Total

1928 951 98 15 1131929 849 83 14 971930 1045 112 17 1291931 1144 96 20 1161932 1359 122 32 1541933 1674 146 37 183

truth as a whole, because there were hundreds of people not within the asylum, who couldnot be diagnosed as GPI or died in their homes. The hospitalization of people with GPI wasstill low and there were few mental asylums in Turkey other than the Toptası Asylum. Thenumber of patients diagnosed as GPI increased in Toptası Asylum in the 1920–1925 period(Gökay, 1929; see Table 2) and in Bakırköy Mental Hospital in the 1928–1933 period(Uzman, 1935, p. 407; see Table 3). The number of patients with GPI also increased inother mental hospitals in 1920s and 1930s. On the other hand, general admissions to mentalhospitals also increased during this period.

GPI and Its Treatment in the Republican Era (1923–1950)

After the foundation of the Turkish Republic in 1923, Toptası Asylum was transferred toBakırköy Mental Hospital8 in Istanbul and the new hospital served as the most impor-tant psychiatric institution in Turkey from 1924 (Erkoç, Kardes, & Artvinli, 2010). In theRepublican era, there were two assistants of Mazhar Osman Uzman who especiallystudied GPI: Ahmed Sükrü Emed (1898–1970; see Figure 4) and Fahreddin Kerim Gökay(1900–1987).

8Bakırköy is a district on the European side of Istanbul. Bakırköy Mental Hospital was foundedin 1924 and today serves as the largest psychiatric hospital of Turkey under the name of Prof. Dr.Mazhar Osman Research and Training Hospital for Mental Health and Neurological Diseases.

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Ahmed Sükrü Emed studied more than a year at Kraepelin’s psychiatric clinic inMunich with Felix Plaut (1877–1940)9 and at other neuro-psychiatric clinics and serologylaboratories in Vienna and Paris. After returning to Turkey, he founded a serology labora-tory at the Toptası Asylum and started to use laboratory tests, especially the Wassermannreaction, to diagnose GPI (Emed, 1977, pp. 116–117). He brought a rabbit infected withsyphilis from Frankfurt and inoculated hundreds of rabbits. He began experiments on neu-roimmunology and the treatment of GPI (Emed, 1929). Fahrettin Kerim Gökay studiedwith Kraepelin in Munich for a year and with Wagner-Jauregg in Vienna for seven months(Gökay, 1950, pp. 2–3). Emed and Gökay followed the discussions and literature about thetreatment of GPI and contributed to the discussion after their experiences of malaria fevertherapy.

During the first half of the nineteenth century, the authorities on the treatment ofsyphilis were divided into mercurialists and non-mercurialists (Pearce, 2012). Mercuryhad been the oldest known treatment for syphilis, and it remained the primary medicineto treat syphilis in Turkey. The ointment form of mercury was used in Toptası Asylumin the nineteenth century (Artvinli, 2010). At the beginning of the twentieth century, dif-ferent compounds of iodine, bromine, and barbiturates were used in the asylum not tocure neurosyphilis but to diminish the symptoms (Etker, 2010). After the discovery ofSalvarsan (arsphenamine) in 1909, it was also used in Turkey. But even Salvarsan and,later, Neosalvarsan, had little effect on the mortal progression of the GPI (Braslow, 1997,p. 74). Like European physicians, Mazhar Osman Uzman and Turkish psychiatrists hadlittle trust in these arsenicals.

Malaria fever therapy started to be used in Turkey in 1922 at Toptası Asylum (Gökay,1939, p. 280) and became popular among Turkish psychiatrists during the 1920s and the1930s. Gökay explains the typical malaria fever therapy that they used in 1920s and early1930s as follows:

Before inoculating a patient with malaria-infected blood, the proper strainof malaria should be obtained. Although there are other strains to use, theideal one is Plasmodium vivax. Initially, a malaria strain should be obtainedfrom a patient incidentally infected. After medical clearance, the patientshould be injected intravenously with malarial blood. The incubation period is3–5 days on average. The fever usually peaked at about 39–40 degrees Celsius(102–104 degrees Fahrenheit). Treatment is complete following 8–10 febrileepisodes around 39–40 C, usually for a total febrile period of 50 hours. Afterthe bouts of fever, quinine sulfate should be given to the patients to termi-nate the infection. Finally, it is required to support the treatment with a courseof neo-salvarsan starting from 0.15 to 0.45 and totally not more than 5 gr.(Gökay, 1934, p. 225)

The malaria fever therapy described above was similar to the standard therapy usedin Europe and the United States, yet, there were local differences. The first difference wasthe technology used. Adequate equipment to preserve the blood infected with malaria and

9Felix Plaut was the director of the Department of Serology at the Deutsche Forschungsanstaltfür Psychiatrie in Munich. His book The Wasserman Sero-Diagnosis of Syphilis in its Applicationto Psychiatry (originally published in German in 1909 as Die Wassermannsche Serodiagnostik derSyphilis in ihrer Anwendung auf die Psychiatrie) was translated in 1911. Plaut is remembered forhis research on the syphilitic origin of general paralysis, as well as his work with August vonWasserman (1866–1925) in the development of a serological test for syphilis. Plaut performed exten-sive research of syphilis and its correlation to psychiatric disorders and conducted early studies inneuroimmunology involving the brain’s immune reaction to syphilitic infiltration.

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Figure 4. Ahmed Sükrü Emed (1898–1970) studied more than a year at Kraepelin’s psychiatricclinic in Munich (color figure available online).

to produce artificial fever was lacking. Turkish psychiatrists inoculated their patients withmalaria-infected blood obtained from other patients that were incidentally found (Uzman,1934).

The second difference was that patients in Turkey developed a kind of immunityagainst malaria. As Gökay underlined, irregularity in recurrent fever observed in somepatients caused the discontinuance of treatment in these cases. Wagner Jauregg, with whomGökay discussed the reasons for this absence or irregularity of fever, explained that thepatients might have been infected with malaria already previously (Gökay, 1934). Uzmanagreed and opined that people in Turkey probably had a kind of immunity against thisdisease because most had been infected by malaria previously (Uzman, 1934).10

Malaria therapy was widely regarded as the most successful form of therapy for GPI,prior to penicillin. During these years, fever therapies were used not only on patients withGPI but also in schizophrenic patients. A truly effective treatment for syphilis was foundin 1943 with the introduction of penicillin by Mahoney, Arnold, and Harris (1943). One

10Malaria was one of the most significant public health problems of Turkey in the earlyrepublican era in the 1920s (see Evered & Evered, 2011).

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year later, it was clear that penicillin was also successful in the treatment of neurosyphilis(Stokes et al., 1944). Malaria was used in the United States most frequently during the1940–1944 period but was rapidly replaced by penicillin in the subsequent five years(Patterson et al., 2012).

The rate of GPI decreased dramatically after the introduction of penicillin treatment.In 1935, the rate of GPI at Bakırköy Mental Hospital was 8.5%, but the rate decreasedto 1.2% in 1951. In the same period, the rates of GPI at the Psychiatry Clinic of IstanbulUniversity Medicine Faculty decreased from 9% to 0.88% (Aksel, 1959, p. 58). The totalnumber of registered syphilis patients in Turkey was 161,753 in 1935 and 104,941 in 1951.

Turkish psychiatrists continued to use malaria as the only treatment choice until themid-1950s. The general tendency among certain psychiatrists was to use both methods andcombine them. Penicillin reduced the number of admissions of paralytic patients in Turkey.At the second half of the 1950s, the malaria-treatment era was over and penicillin was usedmore frequently. In the late 1950s and the 1960s, the incidence of GPI declined steadilyand today GPI is quite rare in Turkey.

Conclusion

GPI has been surprisingly neglected by historians (Davis, 2012). It was of capital impor-tance in the history of psychiatry, because it often announced itself clinically in the form ofpsychiatric symptoms (Shorter, 1997, p. 53) and it is the first psychiatric illness of whichthe biological nature was determined with certainty (Braslow, 1996). It was formerly called“progressive paralysis” or “general paralysis of the insane,” because neurosyphilis pro-gressed from psychiatric symptoms to neurological symptoms accompanying lesions incentral nervous tissue (Shorter, 2005, p. 193).

The interpretation of the causes of GPI varied due to the institutional, social, and cul-tural context, in which it was examined and discussed by psychiatrists. GPI was considered“a disease of civilization” at the end of the nineteenth century. Ottoman and Turkish psy-chiatrists also discussed and interpreted the causes of GPI and followed the new diagnosticand treatment methods of the disease. The history of GPI in Turkey not only shows theadaptation of Turkish psychiatry to European psychiatry within the context of a specificdisease but also demonstrates the internalization of and resistance to social interpretationsthrough GPI as observed in orientalism and civilization debates. As Edward Said notedthat, like “people,” “ideas and theories travel — from person to person, from situation tosituation, from one period to another.” Said suggested that this “circulation of ideas” maytake the form of “acknowledged or unconscious influence, creative borrowing or whole-sale appropriation” (Said, 1983, p. 226). Ottoman and Turkish psychiatrists had acceptedWestern psychiatry and used its tools and methodology, but at the same time they criticizedthe Orientalist discourse about GPI produced by Western physicians. This very short his-tory of general paralysis of the insane in Turkey can be read also as the story of Westernpsychiatry, as a medical science in a different cultural sphere.

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