Professional Documents
Culture Documents
Medicine Modernity
Medicine Modernity
44 (2012), 799–807
doi:10.1017/S0020743812000931
R E V I E W A RT I C L E
Nancy Gallagher
In recent decades historians specializing in the Middle East and North Africa have studied
endemic and epidemic diseases as well as evolving medical and public health knowledge
and policy to better understand major historical transformations. The study of gender
and empire, class and ethnicity, and civil society and government in the determination
of medical and public health policy has yielded new insights into questions of state
power, colonialism, imperialism, nationalism, modernity, and globalization. Historians
have asked why, when, and how Western medicine took root in Muslim societies, which
had their own complex and longstanding medical traditions.
In the early modern era, new understandings of scientific knowledge led to the sys-
tematic study of natural phenomena and to new ideas about disease control. Colonial
or tropical medicine aimed to advance the study of diseases unknown in the West and
their prevention and cure. In Muslim majority societies, Galenic-Islamic, prophetic, and
customary medical systems competed with and sometimes complemented new medical
knowledge and practice. Colonial authorities and local rulers feared endemic and espe-
cially epidemic diseases that could depopulate whole regions, leading to a decline in
Nancy Gallagher is a Professor in the Department of History at the University of California, Santa Barbara,
Santa Barbara, Calif.; e-mail: gallagher@history.ucsb.edu
the number of laborers and therefore revenue. For this reason, they actively sought new
preventative and curative medical interventions. Advocates of empire often justified their
imperial ventures by arguing that Western medical intervention improved the health of
the colonized. During the imperialist era of direct colonization, medicine became a tool
of empire that facilitated the penetration of local societies. Over time, Western-trained
medical practitioners, indigenous or foreign, gained moral authority over indigenous
bodies, which now were controlled and regulated by state public health policy. Doctors
and police enforced new laws that regulated women’s reproductive capabilities, soldiers’
bodies, the vaccination of children, and the incarceration of the physically and mentally
ill.
The books under review illustrate these trends in the social history of medicine
and suggest new directions for further research. I review the books chronologically by
historical period.1 The first book, on Ottoman medicine from 1500 to 1700, sets the
stage for the encounter with Western medicine. The second, an edited volume, addresses
complex and often elusive questions of modernity in the Ottoman Empire and the Middle
East. The third and fourth books take up questions of gender, empire, and nationalism
in medical reform in Egypt, Syria, and India. The final two books discuss the politics of
malaria eradication in British Mandate Palestine and the treatment of mental illness in
colonial North Africa.
Ottoman Medicine: Healing and Medical Institutions, by Miri Shefer-Mossensohn,
contains four well-researched chapters on preventative and curative medicine, health
and illness, medical charity, and medical institutions. Her sources are the records of
the ruling elite in the three Ottoman capitals of Bursa, Edirne, and Istanbul: waqf
endowment documents, annual reports of waqf foundations, firmans, medical treatises,
travel accounts, .tabaqāt (biographies), and miniatures illustrating medical scenes. She
explains that the Ottoman Empire was comprised of diverse cultures with medical
systems that both complemented and competed with one another. Medical practices
varied from region to region and were predictably more elaborate for the wealthy than
for the poor. As elsewhere in the Middle East and Europe, humorism (the Hippocratic
theory that a person’s temperament and health are influenced by an excess or deficit
of four bodily fluids: black bile, yellow bile, phlegm, and blood) underlay medical
understanding. To restore the humoral balance and bring the patient back to good
health, the author explains, Ottoman physicians generally began with dietary adjustments
followed, if necessary, by medication. Surgery was high risk and only a last resort.
Religious or prophetic medicine was based on hadith and was widely practiced among
all classes. Customary or popular medicine, unlike humoral and prophetic medicine, did
not derive from a written tradition; it was much used among the non-elite because it
entailed inexpensive home-based remedies rather than compound medicines and other
interventions prescribed for the elite. The three systems were often used simultaneously;
physicians and patients alike were willing to try humoral medicine, religious medicine,
and customary medicine in hopes that something would prove effective.
For the Ottomans, Shefer-Mossensohn informs us, human beings were at the center of
the universe and custodians of the natural world. They should both use and maintain the
world that God created and aspire to maintain all forces—physical, material, spiritual,
and divine—in a cosmic balance. The Ottomans were great sponsors of medical aid and
other forms of charity. Assisting the sick was a religious duty incurring the gratitude
Medicine and Modernity in the Middle East and North Africa 801
and obligation of the recipients and thus in turn helped reinforce existing hierarchies
as well as social harmony. Ottoman authorities preferred to found hospitals and other
institutions of public welfare in the centers of major cities, where populations were
dense and the need was concentrated. The facilities in Istanbul were especially large and
well designed, with tranquil gardens and spectacular views.
The author explains that medical and food aid were generally dispensed on the bases
of social standing and vocation. Travelers without family nearby might seek care in
hospitals, which perhaps in part explains why most patients, according to the existing
hospital records, were Muslim men. There was, however, at least one hospital, located
in Cairo, exclusively for women. Women closest to the sultan were greatly restricted
in medical care; the male physician was not allowed to speak with them or to examine
them directly, and surgeons were not allowed to treat them at all. Woman medical
healers, however, were able to serve the women of the palace. Shefer-Mossensohn
cautions that the Ottoman concept of balance should not be confused with the Western
concept of holistic medicine. For Ottoman healers, the human body must be understood
as existing in both a physical and a spiritual environment. Physical health and mental
health were closely related: when one was out of balance, the other would be as well.
Physicians therefore tried to bring the patient back to balance by considering external
and internal elements. Music was considered a particularly effective treatment: hospitals
sometimes had a pavilion where musicians could serenade patients with music selected
for their particular medical conditions. Water was also viewed to be therapeutic, and
most hospitals contained a hammam, or bath, where the patient’s humoral balance could
be restored. A wide variety of foods and amulets were also used for preventive and
curative purposes. Ottoman authorities were not in agreement about the existence of
contagion. They built hospitals near mosques, which might afford protection against
miasmas, but generally did not isolate the physically or mentally ill from the healthy,
with the exception of lepers. The wealthy often fled plague-sicken areas, but most stayed
put and trusted in providence.
In the introduction, the author tells us that she chose to focus on the period from 1500
to 1700 because it covered the transition from medieval Ottoman to modern medicine.
At the beginning of the era, hospitals were typically part of larger complexes (külliye)
that were endowed by Ottoman elites and included mosques, soup kitchens, and other
benevolent institutions. At the end of the era, new hospitals were modern stand-alone
facilities with larger and more specialized medical personnel. The author tells us that
the empire was very diverse, as were its medical systems, but generally treats Ottoman
medicine as a single system. We do not learn about Greek Orthodox, Coptic, Armenian,
or Jewish medical traditions, though they may have been of great importance in some
areas. Were there other religious medical traditions similar to Prophetic medicine? She
also states that medicine was to be a prism through which she would reconstruct social
and cultural realities. Although we learn a great deal about Ottoman medicine and health,
we do not get a sense of the wider social and cultural realities or how they changed over
time.
In her conclusion, Shefer-Mossensohn states that Ottoman medicine was distinct
from Galenic-Islamic medicine in general because scholars wrote in Ottoman Turkish
rather than Arabic and because hospitals took on the characteristics of the Ottoman
bureaucracy and hierarchy. She then asks if Ottoman medicine was “successful.” She
802 Nancy Gallagher
argues that the Ottomans took preventive medicine very seriously and that it was very
effective. This might be a topic for future research. When illness did occur, the sick
believed in the ability of physicians and their medicines to heal them but realized
that medical treatments often failed. Physicians were paid less than religious scholars
in medreses; many physicians were from Jewish, Greek, Armenian, or other minority
communities, perhaps, she suggests, because of the relatively low status of the profession.
This explanation seems contradictory, however, because the author has already told us
earlier in the book that physicians were held in high esteem; perhaps the physician’s
social standing varied by time and place. In her final comment, she observes that
Ottomans accepted illness and death as part of the life cycle; physicians and medicine
were not expected to cure all but rather to do no harm. Again, this seems to contradict
the author’s earlier statements about popular views of medical efficacy.
Ottoman Medicine is a well-written and richly detailed monograph that will become
a standard source for specialists in Ottoman and medical history. It is the first social
history of Ottoman medicine in English and is written in a delightfully accessible style.
As the author states, it is not the final word on Ottoman medicine and society but rather
brings together in one compact monograph much information that points the way to
further research.
Anne Marie Moulin and Yeşim Işıl Ülman ambitiously title their edited volume
Perilous Modernity: The History of Medicine in the Ottoman Empire and the Middle
East from the 19th Century Onwards. It is based on the proceedings of a conference held
in Istanbul (no date given). In their introduction, “The Particular Place of Medicine in
the Debate on Modernity and Modernization in the Middle East in the 19th and the 20th
Centuries,” Moulin and Ülman lay out the central arguments of the collection: that the
history of medicine, more than that of other fields of knowledge, enables historians to
challenge the notion of an unbridgeable divide between East and West; that moderniza-
tion is ongoing; and that modernity is “a permanent quest for solving the global issues of
science, society, and power” (p. 21). The volume’s articles, which are for the most part
original and interesting, tend to be short research papers in English or French that make
tentative suggestions for further research, the sorts of papers given at conferences for
comment and scholarly exchange. We get titles such as “Some Methodological Issues
Concerning the Sciences at the European Periphery,” “Some Preliminary Thoughts about
the Tanzimat and the Idea of Nature,” and so forth. Despite the title of the book, not
all the articles focus on medicine; I will focus on those dealing with medical history,
the topic of this review essay. M’hamed Oualdi, in his article, “Du hakim renégat au
praticien européen: Mutations d’identité des médecins de cour et modernization du
service rendu aux beys de Tunis, du milieu du XVIIe siècle au milieu de XIXe siècle,”
shows that the status of Italian and French doctors who practiced medicine at the court
of the Regency of Tunis improved over time. In the 17th century, European physicians
in Tunis would have been expected to convert to Islam, but by the mid-19th century this
was no longer the case. Rather, they were becoming more independent and gaining in
status. When the bey had a European physician thrown into prison and bastinadoed in
the early 19th century for announcing an outbreak of plague, public opinion roundly
opposed the punishment.
In “Glimpses of Relationships between Hospital, State, and Medicine in Nineteenth-
Century Iran,” Hormoz Ebrahimnejad considers the meaning of modernization in the
Medicine and Modernity in the Middle East and North Africa 803
Syria, Egypt, and India but begins with Lady Wortley Montagu’s account of her stay in
Istanbul from 1716 to 1718. In Istanbul, Montagu, as wife of the British ambassador, was
invited into elite Ottoman women’s homes and was much impressed by their hospitality
and customs. She learned of the practice of variolization and had her son inoculated.
She herself had survived the disease in London and when she returned home introduced
variolization to her circles. Her account of her trip greatly influenced later British women
travelers who also sought access to local women’s private lives,
Hassan explains that in the 19th century, British women travelers to the Middle
East and India often learned to treat themselves and their families with medicines they
had brought with them. A few then began to treat local women and their families,
thereby gaining unprecedented access to local domestic life and a higher status than
was possible at home. Some of these women, who were not medically trained at all,
called themselves “doctresses” to enhance their medical authority. In Egypt, Lady Lucy
Duff-Gordon, wife of Alexander Duff-Gordon, a well-known British civil servant and
baronet, established herself as a great healer of rural inhabitants and later happily worked
under the direction of a European-trained Egyptian physician. She adapted to Egyptian
culture, was befriended by a local Egyptian family, and elected to spend the remainder
of her life in Egypt. Isabel Burton, wife of Richard Burton, was an untrained medical
healer who treated twenty to fifty patients a day in Syria for simple ailments.
In India, British women doctors, mostly trained in medical schools at home, gained
professional experience and built relationships with local women, some of whom were
also educated in Western medical schools. British, Middle Eastern, and Indian women
doctors became advocates of reforms such as the expansion of female education, new
medical and public health systems, and restrictions on child and forced marriages.
They were also, according to Hassan, agents of empire, whose access to private families
enabled them to present a positive image of imperial power and serve as useful mediators.
Memoirs of these women were wildly popular in Victorian England, and British
novels glorified the British women “doctors” who treated natives and found adventure
and romance abroad. A number of Middle Eastern and Indian women doctors trained in
Western medicine also wrote memoirs; Hassan briefly mentions several in an epilogue.
Again, this might be a topic for another study.
Hibba Abugideiri begins her book, Gender and the Making of Modern Medicine in
Colonial Egypt, by explaining that British reformers in late 19th-century Egypt brought
the school for women medical practitioners (h.akı̄mā), founded by Muhammad Ali
in 1832, under the authority of the all-male Qasr al-Aini medical school, founded by
Muhammad Ali in 1827. The new British-appointed all-male faculty taught male students
the practice of medicine. The male faculty also presided over an all-woman faculty
that trained the female students in the practice of midwifery and nursing only. British
authorities appointed British physicians and administrators to the highest positions, while
Egyptian physicians remained at the lower ranks; many of the Egyptian physicians
became active in the nationalist movement. As Abugideiri comments, after nominal
independence was won in 1923, Egyptian physicians formed the Egyptian Medical
Association and, following both colonial and patriarchal patterns, reserved the most
lucrative fields for themselves, consigning Egyptian women medical workers to remain
at the lowest levels. Egyptian physicians advocated training women to manage their
homes scientifically, arguing that women should learn modern ideas of hygiene in order
Medicine and Modernity in the Middle East and North Africa 805
to raise healthy children. Doctors exhorted women, especially those who were pregnant
or nursing, to eat healthfully and exercise daily. They came to consider themselves as
the scientifically educated guardians of women’s health, reproduction, and sexuality
and accordingly the defenders of Egypt’s moral identity. Both Hassan and Abugideiri
are much influenced by historians of gender and empire such as Fred Cooper, Ann
McClintock, Mary Louise Pratt, and Ann Stoler.
Sandra M. Sufian, in Healing the Land and the Nation: Malaria and the Zionist Project
in Palestine, 1920–1947, explains that during the British Mandate era in Palestine,
Zionist physicians and engineers believed themselves to be rescuing the land of Palestine
from disease. Their efforts would save Jews from the unhealthy ghettos of Europe and
bring them to Palestine, where they would build healthy bodies by farming the newly
reclaimed land. Sufian tells us that because they thought diseases from the “natives”
might be dangerous, Zionist leaders encouraged mandate authorities to enact public
health policies that would remove “natives” from the land and separate them from the
Zionist settlers. In the view of the Zionists, the indigenous population was backward,
unproductive, and without real attachment to the land.
Sufian relates that the Zionist colonizers considered malaria, which was prevalent
in parts of the country, to be caused by neglectful agrarian practices of the indigenous
population, whose watering holes and leaky irrigation ditches made ideal places for
mosquitoes to breed, rather than by a natural environmental problem. The Zionists
called for the removal of the Palestinian Arab peasants from the land that they had long
used for pasture and to which under Ottoman law they held traditional grazing rights.
The Zionist leadership then claimed that because they had drained the swamps and pools
to eradicate the mosquitoes and thereby redeemed the land, they were entitled to replace
the Palestinian Arabs with Zionist immigrants.
Palestinian Arabs, with their own sense of national identity and well aware of Zionist
intentions, tried to counter Zionist claims that they were backward or that they neglected
their land. Among them, according to Sufian, was Dr. Tawfiq Canaan, a Palestinian Arab
who was a prominent physician before and during the Mandate era and who lectured
about malaria in German and English to scientific audiences. In a report to the Mandatory
authorities, Canaan stated that Palestinian Arabs carried out their own swamp-drainage
projects and worked as laborers in government malaria-control projects. Palestinian Arab
landowners distributed quinine to their workers and supervised the drainage projects.
They were, Canaan argues, quite able to take care of their land and their communities
according to modern public health guidelines. When Zionist authorities claimed that their
own efforts had improved the health of Palestinian Arabs, Canaan countered that the
health of Arabs had begun to improve well before the Zionist projects began, that the main
improvements in health were in Arab communities farthest from the Zionist settlements,
and that Zionist settlements had no effect at all on the decreased infant mortality rate
of Arabs anywhere in Palestine. Sufian’s well-researched book demonstrates the close
connections between disease, colonization, and nationalism.
In his complex and nuanced study, Colonial Madness: Psychiatry in French North
Africa, Richard C. Keller explains that French psychiatrists at the turn of the 20th century
came to North Africa to study and practice in what they considered an experimental space
outside the bounds of civilized metropolitan society. French colonial authorities held
that Morocco, unlike France’s other territories in North Africa, was to be ruled indirectly,
806 Nancy Gallagher
with indigenous institutions functioning alongside modern ones for Europeans. French
psychiatrists accordingly advanced a dual standard: substandard mental health facilities
for Moroccans and modern ones for Europeans. French colonial authorities contrasted
a maristan (from the Persian, bimaristan, a hospital often for the mentally ill), where
mental patients were in chains, with a French-built psychiatric hospital founded in
1920, where patients were housed behind locked doors with tiny windows for frequent
inspection. Keller observes that Moroccan patients had been liberated from their chains
but were now housed in a harshly alienating prisonlike institution.
In Tunisia, according to Keller, Guy de Maupassant visited the Sadiki hospital in 1887
and wrote eloquently about its horrors. Many other French writers wrote similar sensa-
tional and terrifying accounts of their visits to maristans or other mental hospitals; such
accounts were extremely popular with the reading public. Antoine Porot, a progressive
and reform-minded French psychiatrist who had practiced general medicine in Tunisia
since 1907, urged colonial authorities to establish an asylum designed especially for
Tunisian patients, both for their own good and for public safety. He further argued that
through medicine France could extend its penetration into its colonial territories. The
project was repeatedly stalled because settler leaders were reluctant to approve funds
for Tunisians, but construction finally began in 1927.
In 1925, Antoine Porot moved from Tunis to Algiers to take up a chair in psychiatry
at the medical faculty. He lobbied to build a state of the art psychiatric hospital for
Muslims that was suited to the culture, economy, and geography of North Africa. Like
the asylum in Tunisia, the projected hospital was considered expensive, particularly by
settler officials, but was finally approved and opened in 1930 as a showpiece to celebrate
and advertise France’s beneficence to its colonies during the centenary of the 1830
conquest of Algiers. With Porot as its central figure, Algiers became a major center
of psychiatric study. The “Algiers school of psychiatry” argued that Algerians were
neurologically inferior because of the stunted evolution of the cerebral cortex.
Keller observes that unquestioned assumptions about the inferiority of the native
underlay the “Algiers school of psychiatry” that Porot founded. Since the 19th century,
French settlers had considered the indigenous peoples to be inherently fatalistic, super-
stitious, debilitated, amoral, violent, and pathological because of their climate and race.
French psychiatrists absorbed these views and assumed that North African Muslims
were not compatible with more “civilized” settlers, so the two communities had to be
separated, especially in hospitals. Keller argues that even progressive psychiatrists with
utopian visions, like Porot, were (perhaps unwittingly) an integral part of a militantly
racist colonial order. Colonial authorities forcibly confined many Algerians to asylums
for being drug or alcohol abusers or nationalist activists. Algerian Muslims understood
that the asylum was a locus of state control and avoided committing themselves and
their relatives in it unless absolutely necessary.
Keller also discusses Franz Fanon and other interrogators of the colonial encounter
such as Albert Memmi and Kateb Yassine. Fanon had pointed out that by prohibiting the
sale of medical supplies to Algerians, using doctors and psychiatrists as torturers, and
requiring physicians to report the wounded, the French turned medicine into a weapon
during the Algerian Revolution. After independence in 1962, French-educated Muslim
staff physicians were promoted, and new physicians were trained. French-educated
Algerian psychiatrists began to challenge the racist stereotypes of the colonial era.
Medicine and Modernity in the Middle East and North Africa 807
In postindependence Tunisia, in a formerly French hospital that had fallen into decay,
French-trained Tunisian reformers had patients remove their confining doors, introduced
art and dance therapy, and opened a market where patients could sell agricultural products
to the local community. They sought common ground where doctor and patient could
meet on equal footing. This method would not have worked in colonial times, when the
goal was to preserve a hierarchical order and the privileges of the settler community;
and it resulted in a happier, safer, and more efficacious medical facility.
Taken together, the books reviewed here illustrate new directions in the social history
of medicine. In addition to bringing together extensive information, Ottoman Medicine
exemplifies how medicine and public health can be used as a prism on the early modern
era, pointing the way for further research. Perilous Modernity offers new views on
modernity and medicine as well as new sources, from x-rays to epitaphs. Diagnosing
Empire and Gender and The Making of Modern Medicine in Colonial Egypt build on the
work of earlier historians to show how women and gender impacted the development
of modern medicine in Egypt. The final two books, Healing the Land and the Nation
and Colonial Madness, demonstrate that in the only two settler societies in the region—
Palestine and Algeria—unquestioned notions of superiority enabled the colonizers to
inflict great injustices on the indigenous peoples. In both cases, the local populations
appropriated and adapted the public health and medical policies of the colonizers as a
form of resistance.
N OT E
1 I previously reviewed Hibba Abugideiri’s book in American Historical Review 117 (2012): 3; Sandra