Biomedicine as a Contested Site: Some Revelations in Imperial Contexts

Biomedicine as a Contested Site

Biomedicine as a Contested Site

Some Revelations in Imperial Contexts

Edited by Poonam Bala

LEXINGTON BOOKS

A division of ROWMAN & LITTLEFIELD PUBLISHERS, INC.

Lanham • Boulder • New York • Toronto • Plymouth, UK

LEXINGTON BOOKS A division of Rowman & Littlefield Publishers, Inc. A wholly owned subsidiary of The Rowman & Littlefield Publishing Group, Inc. 4501 Forbes Boulevard, Suite 200 Lanham, MD 20706 Estover Road Plymouth PL6 7PY United Kingdom Copyright © 2009 by Lexington Books All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher. British Library Cataloguing in Publication Information Available Library of Congress Cataloging-in-Publication Data Biomedicine as a contested site : some revelations in imperical contexts / edited by Poonam Bala. — 1st pbk. ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-7391-2460-4 (cloth : alk. paper) ISBN-10: 0-7391-2460-9 (cloth : alk. paper) ISBN-13: 978-0-7391-2461-1 (pbk. : alk. paper) ISBN-10: 0-7391-2461-7 (pbk. : alk. paper) 1. Imperialism—Health aspects—History. 2. Colonization—Health aspects—History. 3. Medicine—History—19th century. 4. Medicine—History—20th century. 5. Medical policy—History. I. Bala, Poonam [DNLM: 1. Health Policy—history. 2. Colonialism—history. 3. Delivery of Health Care—history. 4. History, 19th Century. 5. History, 20th Century. WA 11.1 B6155 2008] R149.B56 2009 610.28—dc22

2008024514

Printed in the United States of America

@ ™ The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI/NISO Z39.48–1992.

Dedicated To my father (late), Raghubir Narain, & my mother, Sharda, for their support and inspiration in academic pursuits

Contents

Acknowledgments Introduction: Contested “Ventures”: Explaining Biomedicine in Colonial Contexts Poonam Bala and Amy Kaler 1 Colonizing Mother Egypt, Domesticating Egyptian Mothers Hibba Abugideiri 2 “Defying” Medical Autonomy: Indigenous Elites and Medicine in Colonial India Poonam Bala 3 Medical Knowledge and Professional Power: From the Luso-Brazilian Context to Imperial Brazil Flavio Coelho Edler 4 The Invincible Generals: Yellow Fever and the Fight for Empire in Cuba, 1868–1898 Mariola Espinosa 5 The White Man in the Bedroom: Contraception and Resistance on Commercial Farms in Colonial Rhodesia Amy Kaler 6 Translations and TransFormations: Toward Creating New Men in Early Twentieth-Century China Angelika C. Messner 7 Rejected or Elected? Processes of Therapeutic Selection and Colonial Medicines in French Vietnam, 1905–1939 Laurence Monnais vii

ix 1 9

29

45

67

79

99

115

8

Articulating Medical Ideas: Medicine and Medical Education in New Spain Martha Eugenia Rodriguez

135

9 Disease, Doctors and De beers Capitalists: Smallpox and Scandal in Colonial Kimberley (South Africa) during the Mineral Revolution and British Imperialism, c. 1882–1883 153 Russel Stafford Viljoen 10 Submitting to Surgery in the 1890s: Four Vignettes Sally Wilde

171

Index

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About the Contributors

195

Acknowledgments

Collaborating with scholars in different parts of the world can be a formidable task when it comes to putting together essays in a volume. My experience with this volume, however, has proven it otherwise. I have been extremely fortunate to have worked with scholars who were very cooperative, and I thank them all for being responsive to long distance communications and facilitating this work. I am thankful to the Wellcome Trust (London) for awarding me a travel grant enabling me to complete major sections of my research. My thanks also go to the staff at the British Library (London), the University of Edinburgh Library (Edinburgh), the Ratan Tata Library (New Delhi), the Kelvin Smith Library at Case Western Reserve University (Ohio), and the University of Chicago library (Illinois), for their help in procuring books at short notice. At the Kelvin Smith Library, I am especially grateful to Angela Sloan for her help in accessing the Special Books collection, when required. To Neelam Gupta, I owe more than I can express in words here. Her help in “rescuing” my book files at a crucial stage of this work is gratefully acknowledged. Special thanks to Ruth Forrester for a much-cherished friendship and support. Finally, thanks to my family, with a special note of appreciation for my mother whose continuous inspiration goes a long way in making this work possible.

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Introduction

Contested “Ventures”: Explaining Biomedicine in Colonial Contexts Poonam Bala and Amy Kaler

An understanding of colonial discourses on medicine has, in recent years, been facilitated by discussions that open up new vistas on the unraveling of broader imperial ideologies.1 Defined in the context of power and inequality, such studies have also revealed the limits of colonial power in terms of authority and hegemony in colonial situations. Local responses to Western biomedicine ran the gamut from acquiescence to appropriation to outright resistance. For example, pioneering works by Sutphen and Andrews,2 and Arnold 3 assess the nature of resistance to medical power in colonial contexts, and the role this resistance played in shaping the “dialectics of power and knowledge.”4 From the sixteenth to the twentieth centuries, biomedicine and colonialism have co-evolved, extending their reach across people and places. Colonial expansions provided new territories for European-based biomedicine, while medicine also rendered colonialism possible, facilitating provision and maintenance of healthy workforces, protecting colonists from the pathogens of the new territory, and drawing colonized populations into colonial institutions. This juxtaposition produced hybrid and “eclectic” therapeutic economies across these territories in which biomedicine coexisted, often uneasily, with older and new forms of healing. The mutually constitutive nature of medicine and colonialism is, perhaps, best manifested in the discipline now known as “tropical medicine,” a discrete field of study which emerged from, and made possible, British and American colonial expansions into equatorial climates. Scholarly interest in studying power follows Michel Foucault’s work, in which control of bodies is key to gaining and maintaining power. Along these lines, some scholars, in explaining the implications of European medicine as a “tool” of imperialism, regard medicine as part of colonial ideologies. Viewed thus, medicine was used to “balance out the coercive features of 1

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colonial rule, and of establishing a wider imperial hegemony than could be derived from conquest alone.”5 These scholars treat European medicine as “an imperializing cultural force in itself, but also look at it as an expression of European commitments, variously to conquer or occupy or settle by the empire.”6 Both medicine and colonialism, as networks of institutions and fields of practice, are intimately concerned with what Foucault called “biopower”: the simultaneous exercise of control over both individual bodies and bodies in the aggregate (better known as populations). As Foucault emphasizes, this control need not take the form of oppression, but can also manifest itself as the introduction and application of new techniques for counting, diagnosing, and “fixing” the bodies that make up the population. David Arnold, in defining the role of medicine as “colonial” medicine enabling imperialism, argues that “the history of medicine in European and North American societies over the past two hundred years has been a history of growing intervention and a quest for monopolistic rights over the body.”7 While the intersection of colonialism and medicine is imbued with this form of power and knowledge, it is also fraught with that older form of power which Foucault named “sovereign power,” in which the wishes of one party are played out with or without the consent of other parties. This form of power requires social hierarchies to play out, and colonial societies became paradigmatic examples of hierarchy along racial, ethnic, religious, and gender lines. The stark and subtle force of these hierarchies is particularly evident in colonial contexts, which are themselves composed of unstable, yet forcefully maintained hierarchies. Imperial hegemony was expressed through a network of professional and colonial medical institutions, in the form of “bureaucracies, clinics and hospitals,” also seen as emerging from the processes of adaptations and accommodation that rendered Western culture and sciences difficult for representation in colonial cultures. In this respect, medical hegemony was not limited to the traditional norm of treating the infirm. The notion of clinical gaze, establishing authoritative facts about the human body through an institutional nexus, also signified medical power that was intended to be achieved through such establishments. Thus, power, seen in terms of the impact of the expansion of biomedicine in colonial contexts, was a form of cultural iatrogenesis, that created conditions of lack of autonomy and a “culture of passivity.”8 This is also evident from a recent study, by Watts, on the history of epidemic diseases in non-Western cultures, which portrays imperialism and imperial prerogatives as solely responsible for creating conditions of ill-health, disease, and epidemics.9 In the study of empires, thus, an important dynamics is one that underlies the impact they have had on the societies they colonized.10 By this definition, all medical conditions, including both “health” and “disease,”

Introduction

3

became an object of study and medical curiosity by Western medical men under colonialism. Both bio-power and sovereign power were at work in colonial medical settings, and the essays in this book engage power in both these guises. Despite the Enlightenment ideal of biomedicine as a collection of therapies and preventive practices, to be applied by disinterested healers to those in need, these articles demonstrate that biomedicine is rife with internal contradictions and external conflicts. In colonial contexts, these internal contradictions were entangled with efforts to restrict medical knowledge and power to “official” members of the medical professions. Medicine, thus, became a site for “deployment of diverse forms of expertise” in which the human being was not only to be known, but to be the subject of calculated regimes of reform and transformation, legitimation by codes of reason and in relation to secular activities.”11 If medical knowledge was part of colonial authorities’ armory of power over the indigenes, then lack of knowledge contributed to imperial decline. When related to the wider society, biomedicine, as a practical body of knowledge, demonstrates its efficacy by success in handling diseases of major health consequences. Mariola Espinosa highlights this relationship between knowledge of disease and colonial success in the Cuban experience of yellow fever where lack of knowledge of the disease led to imperial decline. Even within the European biomedical tradition, multiple approaches to disease and healing persisted, as Espinosa demonstrates in her account of differences between Spanish and American responses to yellow fever risk, and the implications of these differences for the eventual control of Cuba. Moving from medical knowledge to medical practitioners, ethical and impartial treatment of patients by doctors is the biomedical ideal that follows the essential traits of a profession. Unfortunately, as Russel Viljoen’s account of the interplay between doctors, patients, and the commercial and capitalistic enterprise in nineteenth-century Africa demonstrates, doctors sometimes acted more like “agents” of commercial and political expansion than like responsible members of the medical profession. Viljoen, in his piece on the collusion of medical authority and colonial capital in pre-apartheid South Africa, demonstrates how doctors were used to play down the threat of a smallpox outbreak in order to maintain the flow of African labor to the diamond mines, essential for the growth of white capital. The same collusion between medicine and capital is evident in Amy Kaler’s account of the introduction of contraceptives to colonial Rhodesian commercial farms, motivated more by white farmers’ interest in maximizing their workforce’s efficiency and output than by concerns for that workforce’s health and well-being. On

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the other side of the world, Espinosa claims an even more powerful role for biomedicine, arguing that the American domination of Cuba in the late nineteenth century rested on Americans’ ability to prevent yellow fever from decimating their ranks. In other cases, the connection between medicine and control was less explicit. Both Hibba Abugideiri and Angelika Messner show how medical authority was used to invoke the idea of “new women” (in Egypt) and “new men” (in China), representations which took on connotations of modernity and progress, creating new kinds of individuals as well as diagnosing and proscribing new pathologies. In colonial Zimbabwe, high fertility was redefined as a medical as well as political problem, according to Kaler, to be addressed with the trappings of medical authority as well as political rationalizing. Internal contradictions and established hierarchies in medical practice become obvious in situations of competing medical systems, or medical pluralism. In some situations, the colonial rulers entertained the idea of “using” local and influential social groups as agents for constructing medical knowledge, as reported by Poonam Bala and Sally Wilde. Both Bala and Wilde draw upon the elites, and the urban-educated social groups, as claiming rights to medical monopoly of traditional knowledge in a pluralistic situation, in colonial India and Australia, respectively. While elites and affluent social groups challenge medical authority, in the case of Egypt, as portrayed by Abugideiri, elites played a major role in the making of what David Arnold terms “colonial medicine,” primarily to subvert imperial interests and policies. Education and medical education, as acts of knowing, discovering, and expressing closeness to truth, were central to most colonial regimes. Expressed through a network of institutions, modern education was limited in its impact on the colonized populations, as demonstrated by Bala in her study on elites in colonial India. Bala contends that while Western education, confined to the newly wealthy and influential local elites, gave legitimacy to their high social status, it also created an infrastructure within which different forms of struggles for medical authority were expressed by local knowledge systems. It also “meant the renovation of their repertoire of skills” for the upper castes.”l2 Several other contributors, thus, explore the insular world of medical institutions and networks, and the struggles over what constitutes legitimate medical knowledge, and who authorizes that knowledge. The internal organization of medical institutions often reflected and reinforced the colonial hierarchies of race and class. In Martha Rodriguez’ account of State medicine in New Spain, only those deemed to be racially pure and of legitimate birth could aspire to the designation of doctor. Similarly, in Abugideiri’s account of medical institutions in late nineteenth-century Egypt, the distinction between “doctors” and “diplomats” in the ranks of gradu-

Introduction

5

ates from the leading medical school mapped on to the colonial distinction between Englishmen and “natives.” In the wake of the first world war, the “native” graduates came to identify themselves with, and consider themselves equal to, their white counterparts, as Egyptians delved deeper and deeper into the European corpus of physiology, anatomy, and medicine. In Flavio Coelho Edler’s account of nineteenth-century Brazil, licensing requirements were used to maintain the distinction between “high” medicine, as practiced by the physicians who attended the imperial elite, and “low” medicine practiced by barbers and others who lived among the mass of the population, and who syncretized local and European medical traditions. These requirements were also deployed toward the end of the nineteenth century in the interest of maintaining epistemological hierarchies, when practitioners of the old school of colonial medicine, using climatological etiologies for the ills that befell the transplanted colonial elite, were challenged by advocates of the “new” parasitology and infection paradigms (closely allied to the emerging field of tropical medicine); the latter followed a radically different approach to public health and preventive health. While biomedicine validated its authority through a network of colonial institutions devoted to the broad problems of health and hygiene, problematizing specific diseases also gave legitimacy to imperial control of the body. Within the parameters of educational and clinical institutions, Martha Rodriguez emphasizes the significance of institutional hierarchies in controlling major epidemics in eighteenth- and nineteenth-century Spain. Counterbalanced by practical training through clinical institutions, schools, and hospitals, Edler discusses how, despite formalization of medical education, tensions were generated between State medicine and the prerogatives of medical men. The clashes of interest between those who believed themselves intellectually qualified to prescribe and those who took healing as part of a wider administrative practice meant that divisions of labor and authority were often unstable and ambiguous. Commercial farms in colonial Rhodesia, illustrates Kaler, became an open site where new ideas on control of reproduction were created by colonial authorities, and gendered responses to these came to the fore. Such struggles between different physiological and medical epistemologies are apparent wherever biomedicine established its roots. For instance, Messner describes the treatment of people diagnosed as “mentally ill” by missionary doctors in nineteenth-century China, contrasting this diagnosis with the pre-existing Chinese nosologies, which did not connect aberrant behavior to pathologies of the brain. Western approaches to insanity as a state of being, which is fundamentally different from “normalcy” and “sanity,” were imposed over local traditions in which “insanity” was simply an excess of

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the bodily and psychic energies found in “normal” individuals. Similarly, in Laurence Monnais’ work on pharmaceuticals in colonial Vietnam, the range of conditions considered appropriate for pharmaceutical treatment was very different for the Vietnamese and for the French colonists. Many conditions recognized as treatable illnesses by medical staff trained in the European tradition, such as cholera, were located outside the realm of pharmacy by local populations, who turned instead to spiritual or cultural measures to alleviate their suffering. Patients’ agency was not limited to encounters with official or State-sanctioned medical institutions. These institutions, whether European or local in character, did not hold a monopoly on the production and circulation of knowledge about bodies, health, prevention, and treatment. Several contributors examine the ways in which medical knowledge escaped from the constraints of the “authorities” and disseminated through other networks. Wilde’s article on the negotiation of surgery in colonial Australia and the United Kingdom makes it clear that prospective surgical patients acted on their own (or their friends’) understandings of what surgery was about and when surgery was appropriate, despite the efforts of surgeons themselves to influence treatment decisions. As Wilde demonstrates, this autonomy is not reducible to race, class, or ethnicity; and individuals attempted to act on their own understandings of surgery across all social divides. Similarly, Kaler’s work on contraception in colonial Zimbabwe demonstrates that the Statesanctioned interpretation of birth control as benign, modern, and healthy was challenged by a very different understanding of these new technologies as dangerous and malevolent, an understanding produced and circulated by the Africans who were “targets” of birth control campaigns. The existence of medical pluralism and social groups limited the use of medicine as a “tool” for attaining absolute monopoly, thus subverting the overall hegemonic agenda of colonial power. Bala demonstrates that the limits also resulted from non-acceptability and defiance of medical autonomy. By the same token, Abugideiri’s study on Egyptian women highlights the resistance in accepting medical and colonial power controlling their sexuality. Similarly, Monnais identifies the existence of a wide range of therapeutics and popular representations as being “obstructive” to colonial propagations of Western therapeutics. The intimate, and significant, linkage between biomedicine and colonial power produces an equally intimate linkage between biomedicine and resistance. Not everyone embraced new medical innovations and technologies brought with colonial rule; and many actually refused the power of biomedicine, manifested in denunciation, sabotage, or simply the refusal to submit one’s body to particular medical regimes. Bala, Kaler, Monnais, and Wilde,

Introduction

7

all deal with different aspects of refusal and resistance by the “targets” of biomedicine, counterpointing the emphasis on medical power underlying other contributors’ work. Medicine engages power, resistance and agency at the most primal level— that of the individual body. Contestations over medical practices, thus, reveal much about the unstable and contested nature of power in colonial times and places. In view of this, thus, this book should be seen as part of the ongoing scholarly debates on colonial power and medicine, and it is hoped that this work will promote further studies on power, agency, and the contestation of biomedicine within the colonial domains. NOTES 1. Mark Harrison, Climates and Constitutions: Health, Race, Environment, and British Imperialism in India, 1600–1850 (Oxford/New York: Oxford University Press, 1999). 2. M. Sutphen and B. Andrews, ed. Medicine and Colonial Identity (London/New York: Routledge, 2003). 3. David Arnold, ed. Warm Climates and Western Medicine: The Emergence of Tropical Medicine, 1500–1900 (Amsterdam: Rodopi, 1996). 4. David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India (Berkeley: University of California Press), 1993. See also Poonam Bala, Imperialism and Medicine in Bengal: A Socio-Historical Perspective (Newbury Park, CA: Sage, 1991) for discussion on an interplay between indigenous and Western medical systems in a pluralistic medical encounter. 5. David Arnold, “Introduction: Disease, Medicine, and Empire,” in David Arnold, ed., Imperial Medicine and Indigenous Societies (Manchester, UK: Manchester University Press, 1988), 16. 6. Roy MacLeod, “Preface,” in Roy MacLeod and Milton Lewis, eds., Disease, Medicine, Empire: Perspectives on Western Medicine and the Experience of European Expansion (New York: Routledge, 1988), x. See also Spencer H. Brown, “A Tool of Empire: The British Medical Establishment in Lagos, 1861–1905,” International Journal of African Historical Studies 37, no. 2 (2004): 309. 7. Arnold, Colonizing the Body, 9. 8. Ivan Illich, Medical Nemesis: The Expropriation of Health (New York: Pantheon Books, 1976). 9. Sheldon Watts, Epidemics and History: Disease, Power, and Imperialism (New Haven, CT: Yale University Press, 1997). 10. See Durba Ghosh and Dane Kennedy, ed. Decentring Empire: Britain, India, and the Transcolonial World (New Delhi: Orient Longman, 2006) in which they see the impact of empires as “a force behind globalization that was ‘decentred’ by the transcolonial connections developed beyond the empire.” 11. See Nikolas Rose, “Medicine, History and the Present,” in Reassessing Fou-

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cault: Power, Medicine and the Body, ed. Colin Jones and Roy Porter (New York: Routledge, 1994) 48–72: 49, 51. 12. Krishna Kumar, “Colonial Citizen as an Educational Ideal,” Economic and Political Weekly (28 January 1989), 45–51.

1

Colonizing Mother Egypt, Domesticating Egyptian Mothers Hibba Abugideiri

In 1907, the British consul general of Egypt, Lord Cromer (1883–1907), wrote in his memoirs: On the whole, although of course much remains to be done, it may be said that, in so far as medical instruction and organization . . . an amount of progress has been realized which is as great as could reasonably be expected. The very capable Englishmen who have devoted their energies to the work of this Department, and who, like all other British officials in Egypt, have had great obstacles to encounter, have at all events succeeded in introducing the first commonplace elements of Western order and civilization into the country.1

Typical of the European imperialist era of the nineteenth century, British rhetoric, such as Cromer’s, revealed Great Britain’s sense of technological and cultural superiority over its “subject races.”2 Counted among the success stories of Britain’s civilizing mission was the modernization of Egyptian medicine, for modern science was believed to be the organizing principle around which an ordered and civilized society was built. Cromer’s suggestion that the English struggled much to bring modern Enlightenment to Egyptian society served to highlight native backwardness only to centerstage the nearimpossible achievement of British imperialism, a self-congratulatory rhetorical strategy typical of the time. In reality, Egyptian medicine was Britain’s “tool of empire.” Like steamers, quinine prophylaxis, quick-firing rifles, cables, and railroads, historians of imperial science have added medicine to Britain’s arsenal of nineteenthcentury technologies as it too allowed the English to penetrate and maintain imperial rule in Africa and Asia.3 In fact, early studies of “imperial tropical medicine” (ITM), driven by nineteenth-century scientists and colonialists who 9

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promoted its study in order to stop tropical colonies from being the “white man’s grave,” reveal ITM as “one of the most powerful tools of empire,” as it shaped the style and aims of colonial rule.4 More recently, historians have moved beyond ITM so that “the picture of medicine in the colonies that is now emerging shows its development as both mission and mandate: the missions of spreading Christianity and introducing modern (‘scientific’) rationality, and the mandate of consolidating colonial rule and promoting material development.”5 On each of these fronts, historians have begun to explore the responses of indigenous populations to imperial medicine.6 This study on colonial Egypt similarly understands medicine as a technology of power, not over the natural world, as did studies of ITM, but more significantly over people.7 It addresses how medicine allowed Britain to sustain Egypt as a colonial satellite by controlling its medical institutions and public health policies. Yet, ironically, the colonization of Egyptian medicine did not begin with the coming of the British in 1882. Rather it had its roots deeper in Egyptian history, in the early part of the nineteenth century under the Ottoman viceroy Muhammad Ali (1805–1848). In a bid for sovereignty from Ottoman rule and to establish his own dynasty in Egypt, coupled with his ongoing attempt to gain favor with his European trading partners, the Viceroy underwrote a far-reaching modernization campaign that affected the bureaucracy, military, agriculture, industry, and education. Ali’s making of modern Egypt would not have been possible without the development of medicine, as it guaranteed the health of Egyptians who constituted his modern army, tilled the lucrative cotton fields, and, after graduating from the newly created specialized schools, ran his modern bureaucracy. Instrumental to this campaign was the founding of Qasr al-Aini, Cairo’s then only school of medicine and teaching hospital. Borrowing European institutions to develop Qasr al-Aini, Ali’s approach demonstrates an indigenous mode of medical modernization based on a western model before the coming of “the West.” Nevertheless, his reforms reveal how the early Egyptian state colonized medicine, as would the British nearly a century later, by catering medicine’s development in the ongoing fight against epidemic disease to the regime’s politico-economic interests and not necessarily societal needs. Consequently, a new symbiosis between modern state building and medicine emerged, one created by Ali’s modernization program early in the century, but deepened with the onslaught of British imperialism.8 Indeed, medicine was at the heart of Britain’s empire building in turn-ofthe-century Egypt during which Qasr al-Aini’s role was rather determinative. This chapter uncovers the unprecedented transformation made to Egyptian medicine by colonial reform, but also unexpectedly by Egyptian medical elites. That is, Britain’s “mandate of consolidating colonial rule” is only

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11

half of the story of imperial medicine in Egypt. The other half is told by the often unrecognized role of natives in the making of what David Arnold calls “colonial medicine.”9 By employing Arnold’s construct to acknowledge the otherwise silent actors who stood between Victorian science in London and Egyptian medical practices in Cairo, this chapter highlights the intermediary roles of native doctors who helped negotiate this spatial divide. That is, far from being totalized colonial subjects, Egyptian doctors contributed to the making of colonial medicine, not to serve imperialist interests, but rather to undermine British colonialism altogether. “Medicine,” after all, “was too powerful, too authoritative, a species of discourse and praxis to be left to the colonizers alone.”10 As Egyptian doctors formed into an independent medical profession by the early twentieth century, the popular medical discourse they produced and the Egyptian press reproduced highlights an unexpected paradox. Namely, rather than eschew the imperial medical knowledge in which they were trained, Egyptian doctors reappropriated Victorian science’s rationale of sexual difference to forge their own indigenous discourse of “republican motherhood” during a period of intensifying anticolonial nationalism.11 The “modern Egyptian woman,” namely, that modern urban bourgeois feminine ideal that doctors popularized, but also justified in medical terms in the local press, was ultimately a nationalist trope of Mother Egypt. Ironically, this maternal archetype was essentially a modernized version of woman’s traditional role of mother, newly domesticated in the name of modern medicine, for the sake of the modern Egyptian nation. COLONIZING NATIVE MEDICINE BY ANGLICIZING QASR AL-AINI The British took over Qasr al-Aini almost a decade after invading Egypt. Priority during the early years of occupation (1882–1892) was given to Egypt’s economic instability, as this undermined Britain’s ability to secure its major trade route to India via the Suez Canal. Shifting their attention to sociopolitical problems after 1892, once financial solvency was attained and the question of withdrawal had been resolved, British imperial policy relied on a methodic and systematic campaign of Anglicization to entrench an English presence more definitively in Egypt. Cromer was determined to put the occupation on sounder footing . . . Cromer aspired to become the architect of British Egypt. To do so he needed to regularize and to institutionalize Britain’s presence in the country. During the final years in Egypt, Cromer took the British down these two roads, both of which led to a permanent occupation.12

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Anglicization entailed a structural process of modernizing Egyptian institutions based on an English model and appointing English personnel to key administrative positions. This meant British colonial authorities shed their de jure title of “Adviser” to instead exercise de facto power. The substitution of power was not instantaneous; rather, making British rule more direct was a gradual, top-down process. Once rooted, Anglicization left its most indelible imprint on Egyptian education; Qasr al-Aini simply details the far-reaching impact this colonization process had on professional training. Among the principal objectives of British educational policy, not to mention Cromer’s deep-seated fear of “manufacturing demagogues,”13 was that Egyptian instruction on all levels was to be utilitarian according to one’s station. Whether compressing the educational system from five levels of schooling to two, charging fees to enter and graduate from schools, instituting new certificates, or divesting the curriculum of all schools to be practical, a suite of imperial reforms worked collectively to limit mass and specialized education in the interest of the Empire. Primary education ensured that Egyptian cotton fields would not be stripped of what had increasingly become cheap labor. Secondary education, the real focus of colonial education, sought to create a small corps of qualified low-level Egyptian civil servants for public service. Finally, specialized instruction, including medical training, aimed to produce an even smaller number of “necessary” native professionals. In fact, Egyptian civil servants and professionals were produced based on British, not societal, demand, which in turn was decided by budgetary allotments designated for public health, irrigation, and education, along with British willingness to employ inexpensive natives over foreigners. Leaving little room for social mobility, these restrictions made education an individual privilege rather than a government responsibility for the vast majority of peasant families who could not afford it.14 Put simply, colonial education served to maintain Egypt as a cheap imperial satellite.15 What British educational reform changed most was the composition of the student body and the curriculum of schools on all levels.16 At Qasr al-Aini, these twin areas are what most transformed Egyptian medicine into colonial medicine since they reconfigured who was allowed to practice, and what type of medicine was practiced. Medical training, consequently, was rendered the privilege of an elite corps of Egyptian men who were urban, upper class, and English speaking. This new profile of the Egyptian doctor was attributed to mutually reinforcing policies. First was Britain’s minimal investment in educational development; until 1906, there were only three government secondary schools in the country and three professional schools (e.g., the Schools of Law, Medicine, Engineering, and, later, the Teacher Training College), all of which were located in Cairo. This meant that Egyptian secondary and specialized schools were largely urban-based.

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Second, the new policy of school fees restricted educational access to Egypt’s wealthier landed classes (with whom Cromer allied to finance the running of schools),17 and by implication to the higher track of education since only Egyptians of means could afford to finance their children’s education from the primary to specialized levels. In the eyes of the British, this served to “raise the moral standard” by not admitting “children of the class which sends its children to elementary schools” who would “harm their peers.”18 Figures show the exclusivity that professional training particularly assumed during the colonial period: between 1887 and 1922, there were only 3,666 total graduates, and the yearly average for each profession was forty-two in law, twenty-one in medicine, sixteen in engineering, and nineteen graduates in teaching.19 Correlated to a population in the millions, nine million in 1897 and twelve million by 1917, for example, these figures are the direct product of those colonial roadblocks, like tuition, placed largely at the primary and secondary levels, which ultimately shrunk the number of students eligible for specialized instruction. Egyptian doctors, thus, became members of an exclusive circle of colonially trained professionals. It would not be until the independence era that the professions enjoyed increased popularity. Finally, in 1898, English was made the official language of medical instruction since it was believed that Arabic would impede Western scientific instruction. “Arabic would appear to be an impossible medium for conveying modern human thought,” wrote one English scholar.20 Such a critique stemmed from a pervasive Orientalist view held by Europeans that Islam and Arab medicine were necessarily “antagonistic” to Western education and science.21 Together, these reforms had the unforeseen effect of creating a new kind of modern Egyptian doctor—an unprecedented transformation that contrasts drastically to the early nineteenth century when policies that affected Qasr al-Aini’s administration, curriculum, recruitment, and language of instruction considered rather than undermined traditional institutions when introducing Western reform.22 This is not to suggest that Muhammad Ali’s modernization campaign was motivated by benevolence toward Egyptians. We know, for instance, that the pasha relied heavily on brutal force for military conscription and corvée.23 In the case of education and vocational training, however, Ali relied alternatively on material incentives to attract students, including free tuition and room and board, in his aim to build a modern bureaucracy. To this end, the State recruited medical students from the urban poor and peasants of Upper and Lower Egypt; many in fact were initially recruited from the Islamic madrasah (university), al Azhar. Education was thus made more accessible to Egypt’s poor, providing some means of social mobility, despite the state’s self-interested aims. Arabic moreover was not discarded

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when French was introduced to bring Egyptians in line with Western scientific knowledge; rather it was used as a parallel language of instruction. Put differently, Qasr al-Aini followed a different kind of modernization model based on policies that were more inclusionist when compared to the exclusionist approach of the British, and this consequently produced different kinds of medical men. This precolonial experience offers a stark historical contrast to the transformative effects of Anglicization, the most noteworthy being changing the very identity of modern doctors in terms of their geography, class, and language abilities.24 Along with who practiced medicine, what was practiced was also reconfigured by the colonial encounter. A methodic campaign of Anglicization slowly infiltrated Qasr al-Aini’s administration in 1893 with the appointment of Henry P. Keatinge as its first English sub-director and later director, but took off in earnest after 1898 with the approval of the Perry Report. Commissioned by Lord Cromer to reorganize Qasr al-Aini’s administration and curriculum, Sir E. Cooper Perry, the Superintendent of Guy’s Hospital in London, wrote what was later called the “Perry Gospel.”25 His sweeping proposals represent a turning point in the history of Egyptian medical education since the Report was, essentially, the basis on which the constitution of the medical school and hospital were built until 1927 (when Qasr al-Aini was decreed the medical college of the newly founded Egyptian University, later Cairo University, in 1908).26 If a single reform had to be isolated as the definitive Perry policy to revamp Egypt’s medical program, it was the establishment of British-style clinical medicine—a vision brought by Perry from the Guy’s Hospital of London and fulfilled by Keatinge’s directorship. Clinical medicine was critical to changing Egypt’s medical grid of disease causation since it provided a conceptualization of bodily functions and malfunctions as a result of the discovery of various parasite-causing diseases. Surgical treatment and illness prevention were signposts of this new medical grid. While instruction in clinical medicine dates back to Qasr al-Aini’s founding, what was new was the British model used to create a “secure solidarity and harmonious working between the Hospital and the Medical School,” that is, between theoretical and practical medical training.27 Perry added new sub-fields of basic clinical medicine, such as medical and operative surgery, as well as elementary pathology, including bacteriology, in addition to adapting preexisting medical subjects to the modified program.28 As training in techniques of clinical medicine required a hospital-based, more practical curriculum, he mandated that advanced medical students earn hands-on experience at the hospital as dressers or clinical clerks in either the surgical or medical wards. The Report also condensed training in clinical medicine. Shortening the program from six to four years and three months was part of the colonial

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State’s attempt to limit the production of native doctors. “In my opinion,” observes Keatinge, “it is hardly possible to set loose on the country a more dangerous element than the needy medical man.”29 During the 1882–1922 period, 762 out of 3,366 total graduates were medical students.30 Isolating 1898–1919, namely Keatinge’s tenure as director, out of the 2,157 total professional graduates, 455 studied medicine. Clearly fewer Egyptians graduated from Qasr al-Aini during Keatinge’s directorship than at any other time during the colonial period. Once in place, maintaining the Anglicized curriculum was given the highest priority, a reform Keatinge easily managed throughout his twenty-five year tenure by importing handpicked English doctors from London to occupy the highest administrative and faculty positions. The Perry Report created a reorganized medical cadre with specific rights, duties, and salaries assigned to each rank. On top were the physicians and surgeons who were given added authority by the Report precisely because of the growing importance of clinical medicine itself. While Qasr al-Aini employed a healthy number of European medical professors throughout the nineteenth century, never did they outnumber Egyptians, so that when the British monopolized these positions in the 1890s, this was unprecedented. By contrast, Egyptians were appointed to faculty positions, but only as assistant professors, thus receiving the lowest salaries. Working in tandem with appointed English faculty were imported medical texts. While it is difficult to ascertain what specific textbooks were assigned as course requirements based on available archival sources, strong evidence suggests that medical texts were indeed imported from London. For instance, the Coptic doctor, Naguib Mahfouz who, having been trained in the Anglicized medical curriculum, cited several English medical texts, “to the teaching of which [he] is greatly indebted,” in order to diagnose his 1,300 specimens he collected from gynecological operations he performed and published in his highly acclaimed Atlas of Mahfouz’s Obstetric and Gynaecological Museum.31 Clearly, the reformed curriculum deeply influenced Egyptians, while the English language gave them direct access to the metropole, whether through medical missions to London or through medical texts imported to Cairo. While the London-based curriculum was imposed, what was remarkable was that Egyptian engagement with colonial medicine, like Mahfouz’s, unfolded on their own terms. Perry’s Gospel, in sum, created a new matrix of medical training and, therefore, a new type of diploma, namely, The Diploma of Proficiency in Medicine, Surgery and Midwifery, which offered Egyptian students medical proficiency, not a medical degree. Accordingly, graduates were referred to as “diplomats,” not “doctors” in the report.32 The reformed medical program

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functioned in a way to give Egyptians the medical credentials to qualify for, but not necessarily obtain, a medical degree. Put differently, the Perry Report rendered Qasr al-Aini’s curriculum an instrument of colonial control where Egyptians were made subordinate to English doctors. It was not until 1920, after Keatinge’s tenure, that an expansion program for medical faculty positions was proposed which changed the old structure of the faculty body where old positions were revamped and new ones created to redress this imbalance.33 In fact, Keatinge’s successor, Richard Owens, found it necessary after the 1919 Revolution to appoint Egyptians as full physicians and surgeons so that “the number of Egyptians appointed to the full staff posts became equal in number to that of their English colleagues. They were also made members of both school and hospital councils for the first time since the school came under English influence.”34 World War I facilitated this process since Qasr al-Aini became a military hospital and Egyptians filled key medical positions vacated by English medical volunteers in the service. Yet another opportunity for native practitioners was presented in 1925, when Law 27, providing compensation and pensions to all foreign officials of the Egyptian Government, was passed and many English staff members retired.35 Finally, despite their diplomas giving them limited medical credentials, wealthy Egyptians were given opportunities, albeit restricted, to pursue graduate and postgraduate medical degrees in London, and therefore were able to become full-fledged doctors with specializations and joined the reorganized medical cadre, despite appointment obstacles. Some even became members of England’s Royal College of Physicians and Surgeons (RCPS).36 Coupled with their overseas training, critical opportunities created by the 1919 Revolution and the Great War, among other historical circumstances, laid the groundwork for the formation of a native medical profession by the 1920s. This is best evidenced by the establishment of the Egyptian Medical Association (EMA), a medical society of 450 members, “all of them qualified medical men of Egyptian nationality.”37 It was hoped that “the work of Egyptian Medical Men which has been rapidly increasingly both in amount and value in recent years will be made known to all the World and thus Egypt will contribute its share in the promotion of medical science.”38 Indeed, by the turn of the century, Egyptian doctors increasingly saw themselves as autonomous medical elites on par with the English. They did not uncritically and automatically accept colonial medicine but often disagreed with their English colonizers about medical practices, often voicing their reservations and objections concerning diagnosis and treatment.39 No better demonstration of their perceived professional autonomy exists than the International Congress of Tropical Medicine and Hygiene, held in Cairo in 1928 for Qasr

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al-Aini’s centenary. In the presence of 2,000 doctors representing forty-four countries, Egyptians publicly presented themselves as equal interlocutors when discussing their medical research, which often clashed with English medical traditions.40 In sum, through a systematic process of Anglicization, Qasr al-Aini, with its British-modeled clinical program, ultimately constituted a site of colonial control where the English dominated and supervised the medical instruction and training of natives. Egyptians obviously lost out as the curriculum and faculty appointment process were stacked against them. The British were able to control state medicine as effectively as they did by transforming Qasr al-Aini medical positions to be commensurate with one’s degree of clinical training. That is, medical positions, and therefore medical authority, in Anglo-Egypt was ostensibly accorded to those most proficient in Victorianstyle clinical medicine. Yet just as clinical medicine gave the British the pretext to colonize Egyptian medicine, so too did it afford Egyptian doctors, paradoxically enough, the possibility of ascending the colonial medical hierarchy, once opportunities for greater proficiency arose. Once they assumed these key positions, Egyptian physicians employed their medical authority to undermine the colonial enterprise altogether.

THE RISE OF THE EGYPTIAN DOCTOR: FORGING EGYPTIAN REPUBLICAN MOTHERHOOD The colonial revamping of Cairo’s only medical school largely rendered medicine a specialized knowledge that only Qasr al-Aini doctors monopolized as they were the only licensed, thus legitimate, medical practitioners recognized by the colonial, and after independence, the Egyptian State. An 1891 promulgated decree regulated medical practice to those with a medical license, which, in turn, was contingent upon an awarded medical diploma from a government recognized medical school.41 This meant that the practice of traditional medicine by Egyptian barbers or folk midwives was illegalized. It also meant that a diploma was not legally enough to practice medicine; the government made this right even more exclusive through the controlled regulation of licensing. Out of the 2,409 licensed doctors authorized to practice medicine in Egypt, 1,830 were Egyptian in 1929.42 When compared to past figures, this number is significant; when compared to a population that totaled nearly 15 million, it becomes clearer just how exclusive native doctors became by the 1920s. Added to this was the significant development of sanitation measures (e.g., improved water supplies, land drainage, and cultivation), more hospitals

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and clinics, and an intricate system of strict inspections of institutions like schools and hospitals in order to maintain public health against disease epidemics.43 That doctors ensured that such sanitation measures were executed properly served to enhance their authority, and by implication, their social importance. Finally, they alone could treat and cure a desperate society from the “deadly trinity,” namely cholera, plague, and smallpox.44 Thus, the contingent relationship between state medical training and state-regulated licensing formed the basis of the doctor’s exclusive medical authority to practice, and by extension, to intervene in medical matters. What they said, in short, mattered. While a medical license constituted the doctor’s official badge to medically intervene in the name of the colonial State, it ironically became the basis of his authority to speak politically against it, and not coincidentally at a time of intensifying anticolonial nationalism. Their experiences of treating individual members gave them unique insights into the health of Egyptian society. How native doctors came to speak about Egypt’s collective body and especially about women’s bodies was, in their eyes, a logical extension of their professional expertise, but laid bare their political aspirations for the Egyptian nation. To extend their professional gaze to the female body was, indeed, a matter of nationalist importance. Since the late nineteenth century, the Egyptian press became the political battleground where Egyptian politicians, Islamic jurists, and women, among others, debated issues of modernity, anticolonial nationalism and Egyptian independence. Cultural questions of education and gender, or “the woman question,” proved most central, yet controversial, of the debated issues. Evidently, the Egyptian woman became a critical “site of contestation” of nationalist ideologies.45 After all, “the emergence of nationalism meant a reimagining of the community and ties of loyalty, and, by implication, a rethinking of the family and gender roles.”46 Among these literary interlocutors were Egyptian doctors who propagated their own ideas about women’s bodies and roles in what was a sea of competing discourses of Egyptian nationhood. What gave their discourse an edge over their competitors was the power and perceived objectivity of modern science. Even though Egyptian nurse-midwives were delivering most babies very often in the mother’s home, it was Egyptian doctors who claimed greater authority over women’s overall bodily functions, precisely because they, and not nurse-midwives, could resolve their gynecological malfunctions. In fact, their superior knowledge and life-saving abilities gave Egyptian doctors new medical jurisdiction over a previously female space: the domicile. Speaking authoritatively in the Egyptian press to Egyptian women about what to do with their bodies in their homes derived from the professional right, they

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already gained from attending medical emergencies in their home. These women, presumed to be housewives, were not simply the recipients of modern medical advice, popularized for public consumption in various journals and newspapers. They were its very subject matter, the scrutinized objects of colonial medicine and its meticulous gaze. By publishing their medical advice in various Egyptian periodicals, both old and new, Egyptian doctors ultimately produced a political discourse of “republican motherhood,” a scientific discourse that sought to nurture the maternal and domestic instinct in women for the political purpose of modern nation building.47 Why Egyptian mothers were targeted is partly explained by Egypt’s high infant mortality rate, and, to a lesser extent, contagious disease. The State looked to doctors as medical saviors to resolve these twin national “epidemics.” They in turn looked to each individual Egyptian mother, who, within the confines of her home, was required to carry out the exact same role as the doctor himself: to identify, treat, and prevent illness, and even death among her children. To prepare them for this “national duty,” doctors had to medically train Egyptian mothers in domestic medicine, a new brand of medicine that domesticated medical ideas to suit Egyptian everyday living, which housewives were to adopt to ensure the health of their families. When women read these articles, “which treats the everyday health and less serious medical issues, there [was] no need to call on a doctor.”48 Protected by the sanctity of modern science, doctors’ prescriptive advice rendered Egyptian mothers medical caretakers of the “modern” Egyptian family in what became through their supervision a “modern” Egyptian home. If every mother took domestic medicine seriously, it was thought, the establishment of a healthy modern nation was inevitable. The trope of the “modern Egyptian woman” that doctors popularized in the Egyptian press had three primary roles based on woman’s “natural” domesticity: mother, mistress of the home, and beauty queen. Concerning motherhood, there was no shortage of advice of how to be a nurturing and competent mother. For, it was “unnatural” that a woman ignored the dictates of Egypt’s “cultural environment,” namely to become a wife and mother who both breast-fed and raised her own children.49 Therefore, doctors’ prescriptive advice dealt largely with issues of pregnancy and child-rearing, and assumed the reader to be the mother herself. While the articles on pregnancy stressed the importance of the mother’s health for the sake of the infant, those on childrearing revolved around the child’s education, discipline, diet, grooming, entertainment and, above all, cleanliness, for the sake of the nation. All medical advice offered about motherhood was premised on the notion that a woman’s biological makeup was naturally weak. One Egyptian doctor

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explained: “In every country, the woman is distinguished from the man by her natural and physical weakness.”50 Why else would she endure more hardship in delivering babies than the peasant or tribal woman?51 In fact, in stark contrast to the tribal woman who could easily deliver her baby, “even while walking,” the urban bourgeois woman was prescribed a forty-day bed rest or else “she would get sick.”52 Not only was her physical strength seen as naturally weak, but so too her emotional state. So vulnerable was the pregnant or nursing mother that any imbalance in either state could potentially harm the child since “when she is physically or emotionally sick, so too is the fetus or newborn.”53 After all, in the case of the expectant mother, the child inherited the “weak constitutional makeup from the mother,” unless the mother took the necessary steps to be both physically healthy and emotionally stable.54 In the case of the nursing mother, “if she becomes fearful, sad, angry or undergoes any disturbance to her emotional state, her milk will spoil and may even turn poisonous.”55 In fact, one article related the story of a child’s death caused by the poisonous milk of his grief-stricken mother whose sister died suddenly.56 Because of her physical and emotional makeup, the role of the Egyptian mother in her children’s physical and moral upbringing (tarbiah) was crucial. Indeed, her first and foremost role as child-rearer was as teacher, suggesting that her reproductive capacity was at once biological and ideological. One article underscores the great importance of mothers as their children’s primary role models: Why can I not be my child’s teacher?” [The father] left this job for her, and she accepted to take his place to teacher her “future students.” This is a must for her, and she will be proud to do it. God is her witness to do this, as did her mother. And she will be a good role model as much as her strength allows. “I would not be his mother unless I teach him, as [the doctor] advised me. I will cooperate and do this serious task with all of my heart. You have guided me and I will do the work, and I promise to be strong. I will reach my goal by exercising and reading which will make me healthy both physically and mentally, in order to establish this great task. Forgive me, my intention is not to be better than I naturally am.57

Even if the child had a nanny, the mother was still encouraged to dedicate much of her time to teaching and supervising his behaviors, as exemplified by the Queen of England herself.58 Arguably, Egyptian doctors’ understanding of Egyptian motherhood had its basis in Victorian science, starting with its premise of woman’s weak constitutional makeup. Woman, nineteenth-century Victorian medical orthodoxy insisted, was starkly different from the male: physically, she was frail, her skull was smaller, her muscles were more delicate, and her nervous system

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was finer, “more irritable,” prone to overstimulation and resulting in exhaustion.59 By being smaller and more delicate in structure, a British physician explained, female nerves were endowed with greater sensibility and liable to more frequent and stronger impressions from external agents.60 Few, if any, questioned the assumption that in males the intellectual propensities of the brain dominated.61 “Thus it was only natural, indeed inevitable, that women should be expected and permitted to display more affection than men; it was inherent to their very being.”62 Accordingly those motherly and wifely roles that did not tax women’s physical and mental health optimized their “natural” affection. A woman who lived “unphysiologically,” or anything against her prescribed “natural” physical and emotional disposition, could only produce weak and degenerate offspring, since it was assumed that acquired characteristics in the form of damage from disease and improper life styles in parents would be transmitted through heredity.63 As far as child-rearing, Victorian science articulated a necessary relationship between woman’s peculiar biology and her social activities. Her roles were strictly consigned, not to the public sphere that was appropriated for men, but rather to the private sphere of the domicile where she could best display her “natural” psychology. This “model of femininity” provided the reason for excluding women from man’s domain (e.g., politics, business, organized labor, and the professions); it equally provided the pretext for defining the proper attributes of motherhood itself, most notably woman’s inherent morality. For, women were portrayed by Victorian scientists as repositories of traditional wisdom and knowledge, and their morality was often identified with maternal love.64 Clearly this English model of femininity shaped the maternal trope that Egyptian doctors medicalized in their discourse. When analyzing the second domestic role of the “modern Egyptian woman,” interestingly, we find that Victorian culture more than Victorian science anchored Egyptian medical discourse. This did not mean that Egyptian doctors did not find medical justifications for their endorsement of English domesticity. As the mistress of the home, Egyptian housewives were to oversee a number of domestic tasks, from organizing furniture to preparing meals. These various functions converged on one principal social value deemed necessary (and “modern”) by Egypt’s medical establishment: order. That everything from furniture to meals was to be fashioned in a way that was, first and foremost, clean and orderly, but also aesthetically pleasing, was the central message propagated by Egyptian medical discourse. The physical structure of the home was to be based on a rational method of organization. For example, certain rooms, like the bedrooms and the eating rooms, were to face the northeast direction so that the sun would light up

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these rooms, in the early morning, but not in the hotter evenings.65 Similarly the house was to face a certain direction, depending on its location, so that fresh air would ventilate the home.66 No less significant to an orderly home was the way in which the furniture was arranged, which women were encouraged to change and clean every so often in order to bring life to the home, yet arranged in such a way to ensure the room’s ventilation and easy cleaning.67 Dust was not to be hurled around with a duster. Instead a wet cloth, dabbed with a homemade treatment, was recommended to wipe down dusty and dirty furniture.68 In fact, many tips on how to make, and use, cleaning and household products were offered. While inexpensive in cost, these methods were intended to make Egyptian homes of all classes clean, odor-free and insect-free.69 In addition to an orderly home, the meals, prepared three times a day, were also to follow a certain logic in their arrangement and content, which was medically rationalized. Presentation could make foods considered to be very healthy but not quite tasty appear more appetizing. Also foods were to be prepared with the utmost care in order to eliminate any possibility of infection or food contamination. Tips moreover were given on how to preserve and store certain foods to prevent rotting, which apparently was a pervasive problem given the number of articles dedicated to this topic.70 Underlying the discussion of Egyptian housekeeping were themes of order, cleanliness, and physical presentation which doctors medically rationalized to uphold Victorian cultural values. Actually, those illustrated pictures that articles included to demonstrate domestic techniques bear a striking resemblance to those of Mrs. Beeton’s The Book of Household Management, “a founding text of Victorian middle-class identity,” which was known in Egypt by this time.71 Mrs. Beeton’s objective in her work echoed the Egyptian housewife’s mandate: “a mistress must be thoroughly acquainted with the theory and practice of cookery as well as all other arts of making and keeping a comfortable home.”72 With medicine’s stamp of approval, doctors rationalized bourgeois domesticity as the single normative model of modern healthy living. Finally, articles that discussed Egyptian women as beauty queens equally hinged on cultural, even racial, values of Victorian beauty rather than science. Striking is that aesthetic beauty and healthy grooming functioned as synonyms. Because beauty was inherited, says one article, not all women can be beautiful, but all women can still take measures to beautify themselves.73 Those primping measures outlined relied on three medical methods: cleanliness, exercise, and a healthy diet. Several articles detailed how to clean the body, to rid the body of any blemishes, like corns, or the face of acne. “One of the women wrote in a women’s magazine that the most important thing to a woman is that her face be clear, that her cheeks be red and free of any

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pimples. If women follow certain principles of cleanliness, inside and out, a perfect complexion is easy to attain.”74 This article, as do others, provided a program of how to attain and maintain “a perfect complexion.”75 No less important to this regimen was the centrality of fresh air since “the woman’s complexion will not clear or her cheeks will not be rosy unless her lungs are filled with good clean air.”76 The supreme method for women to maintain or enhance their beauty, however, was exercise. In fact, most prescriptive advice for exercise was preceded by a comment like, “the following advice, if applied, will help you maintain your beauty; and those who are not beautiful, it will still help enhance their beauty.”77 What followed was either ways of cleaning the body or exact exercises that “renew [women’s] youthful beauty.”78 One article suggested a walk of ten kilometers!79 Exercise not only made women beautiful due to the increased blood circulation that made their faces glow, exercise also made them thin, a trait that in counterdistinction to obesity was associated with good health.80 Part and parcel of her beautification regime was the woman’s social etiquette, which could either enhance or destroy the physical beauty she worked so hard to maintain. These social rules of interacting were based purely on English social customs, which these journals presented as the superior model of gender behavior: The Europeans have social rules that their women are accustomed to doing when interacting with one another. These women believe that these rules are the proper ways of behaving. It is mandatory for Egyptian women to know these rules and understand the objective behind these rules so that they can emulate them.81

Numerous articles listed the ways in which women (and sometimes men) were to greet one another, speak to one another while in the street or market place, speak to a stranger of a different class or social rank, dine when in each other’s company, and host a dinner party.82 This dramatic and medically sanctioned shift in women’s social image can only be appreciated in full in the backdrop of Egypt’s longstanding practice of gender segregation in upper-class society. Clearly, Egyptian women’s social manners were now predicated on modern medicine’s fundamental presumption of woman’s nature. Because women were medically proven to be physically weak, it logically followed that medical discourse of their physical appearance and social mannerisms reflect their delicate and refined nature. In conclusion, not before the early twentieth century did Egyptian doctors speak about Egyptian women’s social roles as rooted in their “biological providence,”83 arguably a historical development grounded in the making of

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colonial medicine and the rise of Egyptian nationalism. Evidently Victorian science’s rationale of sexual difference culturally translated into doctors’ class-based “re-imaginings” of Egyptian gender roles. Let us not forget that the very identity or social formation of Egyptian doctors as an elite professional class was itself based on class, urbanity, and a new cultural language of speaking and evidently behaving. Their medical view of biological sex was synonymous with their cultural worldview of gender; Victorian science in the formation of both was clearly not benign. Accordingly, their medical construction of the “modern Egyptian woman” indeterminately mixed medically rationalized behavior with bourgeois social etiquette in a way that obscured their entanglement, but certainly not their message: Egyptian mothers were the central cultivators of a modern Egyptian society. Doctors propagated a political discourse where membership in Egypt’s “modern” society required, even dictated, that each Egyptian adopt a modified grid of social organization, behavior, and, ultimately, culture. For Egyptian women, inclusion into this “modern” society necessitated, ironically enough, an exclusion of sorts: women could only be integrated as maternal nurturers, for such roles optimized on their biological nature. Otherwise, their contribution to the Egyptian nation was not dutiful, productive, or even natural, which in turn could threaten the very existence of nationhood. To be sure, colonial medicine as an ostensible force of benevolent change and enlightened progress, had the effect in Egypt of renaming traditional power relations between men and women, modern. NOTES 1. Lord Cromer (Evelyn Baring), Modern Egypt (New York: Macmillan, 1908), 2, 512. 2. See Earl of Cromer, “The Government of Subject Races,” The Edinburgh Review (January 1908). 3. See Daniel R. Headrick, The Tools of Empire: Technology and European Imperialism in the Nineteenth Century (New York: Oxford University Press, 1981). 4. Michael Worboys, “The Colonial World as Mission and Mandate: Leprosy and Empire, 1900–1940,” Osiris, Vol. 15 (2000), 207–208. 5. Worboys, “Colonial World as Mission and Mandate,” 208. 6. Worboys, “Colonial World as Mission and Mandate,” 208. 7. Headrick, Tools of Empire, 83. 8. Hibba E. Abugideiri, “Egyptian Women and the Science Question: Gender in the Making of Colonized Medicine, 1893–1929,” (Ph.D. diss., Georgetown University, 2001), 70–150. 9. “Colonial medicine” is a theoretical construct David Arnold developed from George Basalla’s typology of medical development in imperial colonies in order to

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elucidate more clearly the dialectical relationship between the scientific ideas and practices that emanated from the metropole and the local constraints and imperatives that modified them in India during the intermediary stage of colonial science. David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in NineteenthCentury India (Berkeley: University of California Press, 1993), 16. 10. Arnold, Colonizing the Body, 10. 11. See Londa Shiebinger, Nature’s Body: Gender in the Making of Modern Science (Boston: Beacon Press, 1993). 12. William M. Welch, Jr., No Country for a Gentleman: British Rule in Egypt, 1883–1907 (New York: Greenwood Press, 1988), 13–14. 13. Cromer, Modern Egypt, 2, 534–35. 14. For more on school fees, see Donald M. Reid, “Educational and Career Choices of Egyptian Students, 1882–1922,” International Journal of Middle East Studies 8 (1977), 356; Amira el Azhary Sonbol, The Creation of a Medical Profession in Egypt, 1800–1922 (Syracuse, NY: Syracuse University Press, 1991), 114; Michael R. Van Vleck, “British Educational Policy in Egypt Relative to British Imperialism in Egypt 1882–1922,” (Ph.D. diss., University of Wisconsin-Madison, 1990), 74. 15. Reid, “Educational and Career Choices,” 356. 16. Mona L. Russell, “Creating the New Woman: Consumerism, Education & National Identity in Egypt, 1863–1922,” (Ph.D. diss., Georgetown University, 1997), 213. 17. Reid, “Educational and Career Choices,” 357. 18. Russell, “Creating the New Woman,” 214. 19. Reid, “Educational and Career Choices,” 362. 20. Murray Harris, Egypt under the Egyptians (London: Chapman and Hall Ltd., 1925), 70. 21. Harris, Egypt under the Egyptians, 75. 22. Abugideiri, “Egyptian Women and the Science Question,” 70–307. 23. See Khaled Fahmy, All the Pasha’s Men: Mehmed Ali, His Army and the Making of Modern Egypt (Cambridge: Cambridge University Press, 1997). 24. Abugideiri, “Egyptian Women and the Science Question,” 70–150. 25. Sir E. Cooper Perry, Report Upon the Hospital and Medical School of Cairo (Cairo: National Printing Department, 1911). 26. David Chapin Kinsey, “Egyptian Education under Cromer A Study of EastWest Encounter in Educational Administration and Policy, 1883–1907,” (Ph.D. diss., Harvard University, 1965), 203; Amir Boktor, The Development and Expansion of Education in the United Arab Republic (Cairo: The American University in Cairo Press, 1963), 119. 27. Perry, Report Upon the Hospital and Medical School. 28. Ministry of Public Instruction, Règlement de l’Ecole de Médecine, de Pharmacie et de l'Ecole Médicale des Filles (Cairo: National Printing Department, 1892), 8; Perry, Report upon the Hospital and Medical School. 29. Cited in Reid, “Educational and Career Choices,” 370. 30. These figures were interpreted from data found in Table 2 of Reid’s study. Reid, “Educational and Career Choices,” 363.

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31. Naguib Mahfouz, Atlas of Mahfouz’s Obstetric and Gynaecological Museum (London: John Sherratt and Son, 1949), vii. 32. Sonbol, Creation of a Medical Profession, 14. 33. Abugideiri, “Egyptian Women and the Science Question,” 243–44. 34. Naguib Mahfouz, The History of Medical Education in Egypt (Cairo: Government Press, 1935), 57. 35. Abugideiri, “Egyptian Women and the Science Question,” 253–254. 36. Abugideiri, “Egyptian Women and the Science Question,” 275. 37. al-majallah al-tibbiyyah al-misriyyah, January 1928. 38. al-majallah al-tibbiyyah al-misriyyah, January 1928. 39. Abugideiri, “Egyptian Women and the Science Question,” 288–89. 40. Abugideiri, “Egyptian Women and the Science Question,” 294–301. 41. Sonbol, Creation of a Medical Profession, 110. 42. Annual Report on the Work of the Department of Public Health for 1929 (Cairo: Government Press, 1932), 35. 43. Abugideiri, “Egyptian Women and the Science Question,” 286. 44. Arnold, Colonizing the Body, 10. 45. See Michel Foucault, Power/Knowledge: Selected Interviews and Other Writings 1972–1977, ed. Colin Gordon (New York: Pantheon Books, 1980). 46. Beth Baron, The Women’s Awakening: Culture, Society, and the Press (New Haven, CT: Yale University Press, 1994), 14. 47. See Shiebinger, Nature’s Body. 48. al-majallah al-sihiyyah, January 1901. 49. al-muqtataf, January 1902. 50. al-balagh al-isbuci, April 1927. 51. al-muqtataf, January 1902. 52. al-muqtataf, January 1902. 53. al-muqtataf, April 1900. 54. al-muqtataf, January 1902. 55. al-muqtataf, April 1900; November 1911. 56. al-muqtataf, April 1900. 57. al-muqtataf, March 1900. 58. al-muqtataf, April 1913. 59. Charles E. Rosenberg and Carroll Smith Rosenberg, “The Female Animal: Medical and Biological Views of Women,” in No Other Gods, ed. Charles Rosenberg (Baltimore, MD: John Hopkins University Press, 1976), 55. Also see Cynthia E. Russett, Sexual Science: The Victorian Construction of Womanhood (Cambridge: Harvard University Press, 1989). 60. Rosenberg and Rosenberg, “Female Animal,” 55. 61. Rosenberg and Rosenberg, “Female Animal,” 55. 62. Rosenberg and Rosenberg, “Female Animal,” 55. 63. Rosenberg and Rosenberg, “Female Animal,” 58. 64. Ornella Moscucci, The Science of Woman: Gynaecology and Gender in England, 1800–1929 (Cambridge: Cambridge University Press, 1990) 36–37. 65. al-muqtataf, April 1907; August 1907.

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66. al-muqtataf, April 1907; February 1917; al-majallah al-sihiyyah, January 1905. 67. al-muqtataf, February 1901; September 1901; April 1906; al-majallah al-sihiyyah, March 1901; June 1902. 68. al-majallah al-sihiyyah, January 1905. 69. al-muqtataf, August 1901; October 1901; January 1902; October 1903; November 1902; al-majallah al-sihiyyah, March 1901. 70. al-muqtataf, March 1900; September 1900; October 1900; July 1901; August 1901. 71. See Isabella Beeton, The Book of Household Management (London: S. O. Beeton, 1861). 72. Beeton, Book of Household Management, x. 73. al-muqtataf, May 1902. 74. al-muqtataf, November 1913; al-majallah al-sihiyyah, February 1901; January 1905. 75. al-majallah al-sihiyyah, January 1901. 76. al-muqtataf, November 1913. 77. al-muqtataf, May 1902; al-balagh al-isbuci, February 1927. 78. al-muqtataf, February 1911; November 1919. 79. al-majallah al-sihiyyah, April 1901. 80. al-muqtataf, July 1906; September 1907; November 1913; al-majallah al-sihiyyah, June 1901. 81. al-muqtataf, January 1902. 82. al-muqtataf, March 1901; January 1902; April 1903; January 1906; February 1906; January 1911. 83. See Cynthia E. Russett, Sexual Science: The Victorian Construction of Womanhood (Cambridge, MA: Harvard University Press, 1989).

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“Defying” Medical Autonomy: Indigenous Elites and Medicine in Colonial India Poonam Bala

The rise of the Western-educated elites in colonial India restrained the use of Western medicine as a “tool” for controlling the Indian mind. New alliances developed as a result, and new patterns of support marked the colonial rule. Besides, the existence of several competing medical systems challenged the professional autonomy of medicine at a time when Western medicine and medical men had accepted its near monopoly and universal acceptance. Consequently, the patient-physician relationship within the Western medical system became “a mere provider-consumer relationship rather than as a sacred trust requiring awe and deference.”1 This chapter attempts to analyze the significant role played by the local elites and social groups who, as prime benefactors and staunch patrons, defied medical hegemony at a time when Indian systems of medicine encountered opposition from Western medical science; the existence of various medical systems, medical pluralism, reinforced these challenges.

ELITES AND WESTERN EDUCATION Western education in colonial India was seen as having a major objective of shaping the character of the Indian population—an objective that was validated in the post-1835 educational reforms, limiting government patronage to I would like to thank the Wellcome Trust (Wellcome Institute for the History of Medicine), London, for awarding me a travel grant, facilitating research for this paper. I am also thankful to the staff at the British Library for accommodating my book requests during my brief stay in London (UK). 29

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Western education. During the early years of the twentieth century, there was a tendency to lament the extant system of education, which seemed to contribute to the “moral decline” and “moral crisis” of the educated Indian. The benefits accrued from Western education attracted small sections of the Indian population, especially in the Bombay and Bengal Presidencies. Training in Western-style institutions and employment in the British administration were two major benefits that the colonial administrators hoped to provide. The Native Medical Institution (NMI), founded in Calcutta in 1822, was the first “formalized” effort by the British toward educating the local population of India. However, policy changes and demands for educational reforms abolished the NMI with the orders of William Bentinck, the then Governor General of Bengal; Bentinck’s orders were also based on a “dissatisfactory” report from the members of the Committee of Public Instruction appointed to look into the status of education at the time. The demise of the NMI in 1835, and its replacement by the Calcutta Medical College, provided new educational opportunities for the urban elite in Bengal, the Bhadralok, comprised of the upper Hindu castes of Brahman, Kayastha, and Baidya. A majority of these were wealthy landlords with their income derived partly or wholly from rents paid by their tenants. While some of them were professionals, including doctors, lawyers, or even priests, a small percentage worked as clerks in the government or under landlords carrying out administrative services. With the passage of time, the Western-educated elites became socially and politically visible so as to challenge the autonomy of the medical world. By the end of the nineteenth and early twentieth centuries, the British administrators decided to reformulate their policies in India. And since the emergence of the educated social elites was seen as a sequel to the “colonial project of re-forming Indian subjects,”2 the latter were seen as a “threat” to the imperial autonomy and ideologies. During the late nineteenth and early twentieth centuries, India was defined by a unique pattern of medical consumerism in the form of indigenous patrons representing the upper echelons of Indian society. One group identified, thus, was the urban, Western-educated group represented by Parsis. As the most highly educated and Western-bred section of the population, and as a result of early and close alliances with the British, Parsis remained most sought after, and hence were best placed to take advantage of the educational provisions of the British in Bombay. A British guidebook indicated the close ties Parsis had established over a period of time. It noted that “among the many strange people, who accepted the Company’s offer of hospitality, none was more welcome than the Parsi and none has become so completely identified with the fortunes of the city.”3

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Bombay, home to some of the most successful Parsi traders, bankers, and industrialists, was a favorable place for the development of scientific and medical education. The first group of Parsis went to India in the tenth century A.D. following the Arab conquest of Persia. They were descendants of Zoroastrians, and made their impact in India as the most successful lawyers, bankers, and medical entrepreneurs during colonial India. In a country where the caste system justified all social interactions, perhaps, the casteless status of Parsis facilitated easy interactions with the British.4 They “vowed” to be friends to the whole of India, and proved so through their involvement in various social and literary activities in India. One such engagement was in promoting literary endeavors among the local population. They were seen to have adopted the “colonial ideology of progress and superiority, of Westernization as a means to advancement, and of the British as an agent of positive change.”5 Elsewhere in the erstwhile Presidency of Bengal, the social group well placed under the colonial rule was represented by the Bhadralok. Their dominant position in society contributed to the ease with which they could acquire a privileged status in the colonial echelons. Thus, while colonial India and indigenous elites provided a suitable arena for an insatiable pursuit of exploring science and medicine by the British, by the late nineteenth and early twentieth centuries, the impact of such opportunities remained confined to the upper echelons of Indian society. While the Parsis and Bhadralok provided support to British policies, it seemed unlikely that one or either of them would use these alliances against the British during the nationalist struggle for freedom. This leads us to another major theme of the chapter, which is to locate the trajectories by which local elites, as the prime beneficiaries of Western education, and also of medicine, not only proved their loyalty to the empire as ardent patrons and consumers of Western medicine, but as Westernized Indians used these experiences as part of the revivalist efforts in favor of indigenous culture during the nationalist and anti-imperial movement. If Western sciences and medicine were used as a “tool” to justify colonial imperatives, then the rise of indigenous elites and their increasing entry into the Western professions, including medicine, put constraints to their usage. Explanations of Western or biomedicine as instrumental in combating disease situations also indicate the professional control Western medicine has over the human mind. Viewed thus, biomedicine can also be detrimental as an institution of total dependence.6 While Western medicine and its practitioners tried to establish themselves in colonial India, the indigenous medical traditions, called Ayurveda (Ayu meaning life, and veda meaning knowledge) and Unani (Greco-Arab

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medical system introduced into India by the Muslim rulers in the ninth century A.D.), limited the impact of these endeavors. As a repository of ancient Indian knowledge of medicine, and as a profession in itself, Ayurveda was seen as an important part of Indian culture. Viewed thus, in later years, both Ayurveda and Unani got support from their practitioners, indigenous elites, nationalists, and the State. Thus, the rise of indigenous elites in colonial India also altered the conflicting relationship as a result of a struggle for power in a plural medical system. Power also was part of the high status and prestige accorded to Western medicine,7 seen as part of “medicalization thesis” wherein medicine becomes “a major institution of social control, superseding the influence of religion and law as a repository of truth.”8 With a Western-style education, and a broader vision of how India could be shaped, the Parsis and the Bhadralok galvanized the move to provide directions to reviving and revisiting India’s cultural heritage. And they were successful in doing so, for “they were themselves a product of the translation that gave them agency.”9

PARSIS AND BHADRALOK: LITERARY AND MEDICAL ENGAGEMENTS The desire to acquire and promote knowledge through the medium of English as well as the vernaculars among the Parsis can be gauged by their involvement in initiating some of the leading newspapers and magazines in the late nineteenth century. The first newspaper in Gujarati, Bombay Samachar, for instance, was started by Fardunji Marzbanji, alongside the first Gujarati magazine by Narozji Fardunji. The first composition in English was also by a Parsi; the first Indian to lead an English newspaper was a Parsi; Parsis were also foremost in promoting vernacular newspapers in Bombay. As ardent supporters of the English language, Parsis also figured in some of the prominent English newspapers in colonial India. The Times of India, for instance, had leading Parsis among its proprietors. In addition, special literary writings were devoted solely to honor the involvement of Parsi women in philanthropic avocation and other social activities. The Parsis: The English Journal of the Parsis and a High Class Illustrated Monthly, for instance, was one such journal that devoted a special page, Ladies Page, to Parsi women and their social involvement, and a section called A Parsi Lady’s Noble Work, honoring Mrs. Cama’s convalescent home for Parsi women and children at Bandora. Other sections that found prominence in the Monthly journal included scientific and medical progress and literature, as a means to convey the achievements of the Parsis.

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As close associates of the British, Parsis were known as distinguished philanthropists, politicians, patriots, scholars, and industrialists. While they are known for their pioneering role in commerce and industrial enterprise, which also facilitated successful relations with their British counterparts, there were special writings honoring this relation that were made part of special occasions during the turn of the twentieth century. Khan Sahib Manek Hormasji Dadaachenji presented the royal coronation in book form to the department of Oriental Printed Books in London in the year 1937, with a section on The Unflinching Loyalty of the Parsee Community to the British Crown. Here is how the ending note of loyalty was dedicated: In conclusion, tendering humble and loyal greetings to their Majesties and the Royal Family on this auspicious occasion, I pray to the Almighty to strengthen the binds of good-will and friendship between India and Great Britain leading to the fulfillment of India’s cherished ambition to become an equal partner in the great and glorious British commonwealth of nations, linked together by a common bond of loyalty towards the British Crown. God Bless the King-Emperor and the Queen Empress.

So significant was the loyalty of the Parsis to the royal family that, in 1871, the news of the illness of His Royal Highness disturbed the community; special ceremonies and prayers were organized in fire temples in Bombay. In return, the British, eulogizing the works of Parsis, rewarded them with financial, bureaucratic, and mercantile security and benefits from employment. The prosperous Parsis, thus, remained a largely successful social group, dominating Bombay for more than a century. 10 The Parsis became a significant part of the various charity funds not only in India but also in England during the early part of the nineteenth century. Special funds were raised for the Patriotic Fund and for the Scottish Corporation in 1807; the latter was established in London by Charles II. As closely allied to the British, and the British royalty, the Parsis also were staunch patrons of Western sciences and medicine. Their generous contributions to special funds for the London Hospital, for the benefit of families of soldiers who fell at the battle of Waterloo, and for the distressed during the potato crop failure in Ireland in 1822, speak well of the benevolent social involvement of the Parsis. Identified by their notable achievements in the nineteenth century, they became pioneers in Indian industry, dominating, and becoming the “symbol of Indian entrepreneurial class.”11 When opportunities for medical instruction were introduced in Bombay, the Parsis were quick enough to take advantage of it. The first medical college in Bombay, the Grant Medical College, was opened in 1845. Known as a premier institution training local elites in Western-style education, between

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1845 and 1884, several Parsis graduating from the college successfully qualified as physicians, and about 14 entered the Indian Medical Service (IMS), which required qualifying in an examination in London. Dhanjisha Narozji Parakh was appointed by Sir James Ferguson, the then Governor of Bombay, to the Chair in Midwifery, and to Surgery at the Jamshedhji Jejeebhoy Hospital. They utilized their fortunes for progressive purposes in the form of educational opportunities and health care. 12 Among the Parsi families, that of Jejeebhoy deserves a special mention. Known for its pioneering work in commercial, education, and social activities, Byramjee (born 1822) was one of the few prominent Indians in Bombay to take part in the ceremonial Durbar (coronation ceremony) of Queen Victoria in Delhi. The Queen also conferred upon him a special honor of Companionship of the Most Exalted Order of the Star of India in 1876. 13 Philanthropic activities of the Parsis started in the early eighteenth century, with Rustom Manock (1635–1721) and his family as the leading commercial family of the time. As a broker to the East India Company, Rustom earned encomiums by expanding his trading and commercial activities with private merchants and company members. 14 Byramjee took great interest in funding medical schools in various towns and cities of the Bombay Presidency. He also founded a dispensary in memory of his wife, Maneckbai, and devoted special funds toward the foundation of a charitable clinic, called the Byramjee Jejeebhoy Charitable Institution, which remained his most notable contribution. Successive generations of Byramjee continued to provide financial support to various charitable institutions, including clinics, dispensaries, and medical schools. In Bombay, families of Parsi practitioners were known for the financial support they provided to medical institutions. Some also set up private practice earning huge fortunes. Drawing a large clientele, Pestanji Ratanji Tamna (1757–1822), Kavasji Ratanji Tamna (1761–1818), and Behramji Bhika, Sohrabji Jamshedji Doctor (1791–1852) did very well in their medical practice. Some were employed in Company hospitals in recognition for the services they offered to the British. As close allies of the British, the Parsis benefitted economically at the same time that they made financial contributions toward promoting Western medical sciences. Sir Jamshedji Jejeebhoy, the first baronet in British India, for instance, funded the first charitable dispensary in Bombay. The dispensary was run by Dr. Mackie, who had a successful private practice in Bombay. As an ardent advocate of medical sciences, generally, Jamshedji Jejeebhoy later funded medical research at the Grant Medical College in 1845. The first Parsi to join the college was Fardunji Jamshedji, and the first Parsi to receive a medical diploma in 1851 was Meherwanji Sorabji Kharas. It is interesting to note that the medical in-

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terests of the Parsis were not confined to Western sciences. They also valued indigenous medical sciences, and often got the support of local princes to promote native medical sciences. The usual way of expressing their appreciation was to dedicate medical writings to the local royalty.15 Engagement in philanthropic activities and gifting, identified the Parsi elites from the rest of the community, at the same time maintaining and defining the boundaries of the Parsi community. As gifting was one way of strengthening social ties between the elites and the “commoners,” it also meant “the construction and maintenance of social order . . . conditioned on the development of some combination between the organizational structure of division of labor and the institutional construction of trust, meaning and legitimation.”16 In addition, it also signified the social power of a group that had been socially, politically, and economically successful under the aegis of the colonial rule. As successful business entrepreneurs providing financial support to medical institutions, the Parsis were also known for their prominence in the profession of medicine, and also in law and engineering. And as keen seekers of knowledge, as successful practitioners, they continued to rely heavily on European medicine as a treatment option, promoting it at the same time. They were skilled bone-setters. One such family of bone-setters, or Hadvaid bone physician, was the Suralivala family from Surat region in Gujarat. Practitioners from the family often offered their services in the newly founded clinics, but occasionally made home visits to treat the infirm. By the late nineteenth century, there were forty-six native graduates of medicine who had a lucrative practice. These excluded assistant surgeons, and other physicians attached to local clinics and dispensaries. Most of these practiced in areas that were predominantly inhabited by the Parsi population in the Fort Market, Khetwady, and Dhobee Talao divisions. In addition, there was another enterprising social group of Khojas (belonging to the Shia sect of Muslims) that was successful in medical practice.17 Another group that made a noticeable mark in colonial India was represented by the Bhadralok, the new intelligentsia in Bengal. The group was by no means an economic or occupational category, but an analytical one that included elements of economy and occupation. According to Weber’s definition of “open” and “closed” groups, the Bhadralok were more akin to being an open group, for entry was possible by education.18 The involvement of the Parsis in Bombay, and Bhadralok in Bengal has had historical links with the educational institutions that were established in the two Presidencies. These institutions disseminated Western liberal and scientific knowledge because that was presumed to be superior to indigenous systems of knowledge. The involvement became more evident with the establishment of the Hindu College in Bengal in 1816 (which was

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renamed Presidency College in 1855) by none other than the local elites who sought Western and English education for their sons and future generations. The college was a major institution that not only socialized this section of the population, but also opened up space for expressions of their subjectivity. The foundation of the Hindu College as a new center for teaching new European sciences was a landmark in the history of Western education in colonial India. By the 1830s, the college had become “home to a rationalist and ‘skeptical movement,’ led by Henry Louis Vivian Derozio, a charismatic leader”19 who taught rather “radical” ways of Western life and inculcated ideas of independent thinking and debates. While for the most part during Derozio’s tenure, the group of Young Bengal students ridiculed Hindu traditions and culture, advocating atheism and agnosticism, one Kashi Prasad Ghose, despite his Western training, openly defended Hindu beliefs, against James Mill’s History of British India (1819); he became the first student of Young Bengal to do so publicly. Students trained at the Hindu College represented a new social group of Young Bengal, and rejected the religious and cultural heritage of India, identifying themselves with Western ideals. Advocating agnosticism, the group came under strong criticism, thus ending the “first waves of European enlightenment into the new education system”20 that were introduced and shaped by Derozio. Protests from parents of Hindu College students and official deliberations eventually led to the dismissal of Derozio in 1831 by the Calcutta Society. The Hindu College “acted as a key socialization agency for . . . (an) earlier generation of bhadralok.”21 The emergence of English language and writing in Bengal, and of the intelligentsia also marked Bengal as the major and, perhaps, the premier institution of European-style learning in Asia. Special courses in general medicine and anatomy were introduced at the college. Maintaining close ties with the British, the Bhadralok were able to establish themselves in the political realm in Bengal, identified as one of the first areas where indigenous voices were clearly visible. And because, initially, in the early part of the eighteenth century, they were seen as a successful group of prominent Indians, the British relied on them for political and commercial purposes. This was evident in the concessions made by Morley-Minto Reforms, which stated that, “we must do our best to make English rulers friends with Indian leaders, . . . and at the same time train them in habits of political responsibility.”22 Not surprisingly, then, the new social groups remained at the helm of most reform movements. Thus, there was an increasing involvement of indigenous elites in the political and social affairs at the time. By the early decades of the twentieth century, however, “moral crises” had become a major concern for the colonial administrators, thus calling for continued de-

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bates and discussions with the aim of finding corrective measures. This concern was a sequel to the increasing consciousness of the Western-educated Indians that threatened imperial hegemonic power. The new British policies were sought in view of this with the main aim of subverting the newly acquired power of the elites. Hence issues of “moral crisis” were not an issue in the true sense—but by posing them as one, the British authorities were only trying to subvert the influence of the elites. There were regular criticisms of the British perception and diagnosis of “moral decline” by educated Indians, which the latter saw as “expressions of alarm at the rising agitation.” Inasmuch as the British authorities convinced them that “their diagnosis was not simply a way of pathologizing and belittling the phenomenon of nationalist unrest,” 23 educated Indians continued to debate over diagnosis of “indiscipline” and general moral decline. The rise of the printing press in Bengal publicized the scientific and social developments not only in India but also in Europe, thus keeping the Indian masses abreast of significant issues. At the same time, colonial policies were framed by different of the colonial state at different levels. While the latter acted on the basis of their perceived conceptions of certain social groups, they were also using these notions to gather relevant information about these groups.24

NATIONALISM AND ELITES While Western education brought encomiums to the new Bengali intelligentsia, it also gave rise to an “intellectual proletariat”25 that remained unemployed as a result of the imbalance between the numbers graduating and employment opportunities available. Members of the urban educated class also became exponents of Hindu cultural nationalism. In Bengal, dominating the professions of medicine, law, and teaching, the educated elites held the British colonial policies as anti-Indian, and hence responsible for the social and cultural decline.26 The move to revive traditional medical systems, thus, became a part of the overall nationalistic fervor. Considered as the “highest tribune for all decisions,” and the sanctioning authority, the elites gained supremacy by virtue of their Western-style education and medical education. As a result, they were at the helm of all nationalistic events during the late nineteenth and early twentieth centuries. They exhibited an unabated commitment and participation in the national movement. This was specially so among the lawyers and doctors who “refused to work for patients and clients that opposed Swadeshi,”27 thus “emulating the traditional service castes” and occupational severity and limitations.28

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Although changes in the social and political environment alongside developments at the turn of the nineteenth century facilitated “different British groups and their respective indigenous collaborators together in a formalized institutional context,” they also produced a system of knowledge that was considered to be of superior quality. It was through the College of Fort William in Bengal that various “knowledge traditions and their corresponding skills were brought together, standardized, and rendered teachable.”29 By the end of the nineteenth century, the Bhadralok had begun to assume that Indian culture was on the decline. However, two major events intensified the feelings and the passion with which anti-British sentiments were expressed. First, the anti-plague policies of the municipal officials in 1898 led to widespread opposition by the workers, especially in the jute mill towns of Calcutta. The move to destroy their slums and to coerce slum dwellers into hospitals intensified their resistance to plague policies. As a further reaction to this, however, and for fear of further opposition from the “respectable” political elite leaders, and professional elites, physicians, and lawyers, the British did not apply the same stringent measures to them. Instead of quarantine wards, special arrangements for private hospitals in houses or private “garden compounds” were promised by the lieutenant governor, even providing special facilities for their family members by converting their houses into ward hospitals.30 The discriminating policies led to further agitations, which were then directed against the government “policy of segregating ‘lower class’ patients while it also abandoned its drive to make plague inoculation compulsory in the city.” Thus, “Calcutta workers emerged as a powerful political force, which successfully prevented the government from enforcing decisions against their wishes.”31 The other event that changed the Bhadralok mind and their relations with the British was the partition of Bengal in 1905. This created a feeling of loss of identity and respect not only among the Bhadralok but in all sections of the Indian population. The turn of the twentieth century, rife as it was with political and social changes, became an era of explicit expressions of anti-British sentiments following these major events. And the usual way of reaching the public was through the press. The Bhadralok-managed press made serious inquests into the official policies on public health measures, conducting a campaign against the regulations on plague. Hitavadi, a leading Bengali daily, and Sanjivani, a Bengali weekly, acted as active “crusaders” against plague regulations. It was reported that a quarter of the population of Calcutta fled the city for fear of plague regulations that were framed in Bombay to effectively combat plague. While the educated and rich elites and the professional elites expressed their “indebtedness” to the colonial policy makers for

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the concessions offered to them, it was not long before the same social group turned against the British policies during the turn of the twentieth century. Revival of indigenous medicine, Ayurveda and Unani, occupied a prominent place in the new agenda. This was also the period during which indigenous medical men were keen to have an independent status for indigenous medical science. The nationalist movement provided the framework for these expressions. Professional bodies were formed to regulate medical practice. Practitioners of Ayurveda, vaids, were listed, and hakims (practitioners of Unani or Greco-Arab medicine) were taken care of by the Mahomedan Literary Society and the National Mahomedan Association in Bengal. The Ayurvedic movement, seeking political legitimacy and professional status defied the medical autonomy and the medical monopoly of European medicine in colonial India. For the movement was one of “an educational interest group which has attempted to acquire legitimacy and professional status through political methods.”32 Much of the pressure from Ayurvedic proponents, the Bhadralok and educated elites, to provide support to Indian systems of medicine found expression in the early decades of the twentieth century. The period between 1860 and 1920 saw the development of both indigenous and Western medicine toward a professional model. Royal support in the form of encouraging native sciences was symbolic of their social recognition. Thus, the seventh session of the All India Ayurvedic Conference, held in Madras in 1915, had a special popular appeal with the following opening remark by King George V: “you have to conserve the ancient learning and simultaneously to push forward western science.”33 At the same session, in his speech, the president of the conference, Kaviraj Jamnibhushan Roy Kaviratna, highlighted the medical and surgical marvels of Indian medicine, ensuring facilities for a systematic study of Ayurveda through institutional support. This also provided an opportunity for him to express his resentment about the treatment meted out to Indian physicians for their association with Ayurvedic institutions. In particular, Dr. Roy lamented the action taken by Western physicians in removing the names of one of the governors of a charitable Ayurvedic dispensary, Dr. Krishnaswamy Iyer, from the Madras Medical Council. Similar incidents took place in Bombay where any association by Western-educated Indian physicians with Indian medicine was frowned upon. This was also a sequel to the rising nationalist consciousness when colonial policies were endangered at the slightest provocation of the indigenous masses. Nevertheless, in 1917, for the first time, the colonial administrators acceded to this pressure and appointed a committee in the Madras Presidency to assess how best indigenous medicine could be revived. It is not surprising that this may have been due to extreme political pressure from Indian nationalists for whom Ayurvedic revival was of prime importance. Between the

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Montagu-Chelmsford Reforms of 1919 and World War I, Ayurvedic revival began to be increasingly linked with the all-pervasive nationalist movement. While Western medical men feared pressure and threat to medical monopoly, Indian elites and professionals made sure that Indian medicine could be professionalized in the light of its Western counterpart. In 1931, Indian medical practitioners formed the General Council and State Faculty of Ayurvedic Medicine in Bengal to regulate courses and medical instructions in Ayurveda. Besides, the establishment of the Gobinda Sundari Ayurvedic College in 1922, the national university of Bengal, Gaudiya Sarvavidyayatana, and Viashawantha Ayurveda Mahavidyalaya, with royal support also added to the successful steps toward professionalization of Indian medicine. The Registration Acts between 1912 and 1919 to regulate and register the medical practice of Western-educated medical personnel in itself had a limited impact. Since a large part of the Indian population still formed a willing clientele to Indian medicine, the Acts met with severe criticisms and opposition from the elites, the public, and the professionals. Fearing further reactions, the government decided to wait until Western medicine had gained a strong foothold in terms of the number of medical men, the quality of research, and influence. Encouraging an independent medical profession seemed the most viable option at that stage even though it meant bringing about changes in policies to regulate the government medical machinery, the IMS. The professional dominance, autonomy, and monopoly were visibly shaken with the increasing responsibility of the State toward promoting Indian medicine, as well as the increasing involvement of indigenous practitioners, elites, and other professionals in providing a direction to this. The latter established institutions, colleges, and medical schools with a regular period of training to meet the requirements and standard of the profession. Individual efforts by Ayurvedic practitioners also added to promoting the cause of indigenous medicine. Thus, in 1878, Chandrakishore Sen opened a dispensary with the idea of selling Ayurvedic drugs. Encouraged by his success in dealing with this, he published inexpensive books to propagate the rich knowledge contained in the Ayurveda. Following him, other practitioners actively sought to undertake large-scale production of indigenous drugs, so that by the turn of the twentieth century, Indian medicine and its drugs had found acceptability among the hinterland of Bengal Presidency. The rapidity with which the Indianization of the IMS took place in the early part of the twentieth century became an issue of serious concern for the British officials. For this meant an overall increase in the number of Westerneducated Indian men, as English education was a prerequisite for entry into the colonial bureaucracy. Between 1872 and 1885, the Bhadralok established and funded several institutions to meet the increasing demand for English

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education. The new consumerist orientation in the Bhadralok, as patrons and also consumers, challenged the power of medicine. Large numbers of Indian medical graduates and license holders, from medical schools in the Bengal Presidency were seen to defy the Western medical profession. The fear was justified when, among the several changes and shifts in medical policies as a result of the political environment, issues of health and medicine were transferred to Indian ministers. The transfer was allocated under the dyarchy or dual-government system under the Montagu-Chelmsford reforms, which created two categories—“transferred” and “reserved.” In the aftermath of these reforms, health, medicine, and medical services became a “transferred” subject, readily accepted by the Indian ministers. The rise of the national consciousness among the Indians was concomitant with the spread of Western education. In the early part of the twentieth century, anti-British sentiments became so intense that English education came to be associated with political unrest at the time. The rapid Indianization of medical services then became an issue of concern and threat to professional autonomy of Western medicine.34 In sum, the existence of Parsis and Bhadralok in colonial India indicates a duality in the functioning of European medicine, as was also the manner in which the two social groups interacted with their British counterpart. While colonial India and economic benefits provided an impetus to the Parsis to assimilate British culture, they created conflicting positions with the Bhadralok in Calcutta. As politically and economically influential, the Bhadralok used their education and potentials as a “tool” to dislocate the imperial and medical hegemonic power, with the support base of indigenous medical practitioners, nationalists, reformers, and the State. The marked difference was also visible in their relations in the medical encounter in colonial India. Thus, while the Parsis were active patrons and consumers of European medicine, and of indigenous sciences, their claims to the richness of Indian culture and medicine were more deep-seated. In addition, by definition, Indian medicine met the professional requirements that classified it as a “profession.” The system of training, entry requirements, regulation of medical practice, regulation and control of qualified physicians, were traits that identified Indian medicine. Thus, if the State provides medicine the right for monopoly, and medical dominance by virtue of its scientific character, then Indian medicine had it all. This then was medical pluralism at its best so that no single system could have complete monopoly over the other. In colonial India, thus, “power relations by patients, physicians in the medical encounter” occupied “a range of shifting positions.”35 The medical encounter in nineteenth and twentieth-century colonial India displayed dynamic power relations between the Indian and Western medi-

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cal sciences, through a continuous process of challenges, rejection, and acceptance of medicine and its monopoly by its practitioners.36 For Western medicine, the real challenge to its established autonomy was the emergence of the urban, Western-educated indigenous elites, each playing a different, yet crucial role in relation to European medicine. If Western-education is seen as “colonizing the minds”37 of the new social groups in colonial India, then “alienation” and subjectivity were inherent in elite representations as agents of change and social and cultural reforms. While the Parsis in colonial Bombay had little to negotiate by way of accepting Western medicine and its ideals, the Bhadralok in Bengal constantly did so while defining their identities in the medical encounter. As a result, the State-controlled medical profession in Bombay, and the consumerist support displayed a lesser degree of power imbalance than in Bengal where the Bhadralok, as “Western-bred” consumers, and by virtue of their position, challenged the dominant role and power invested in Western medicine. The existence of medical pluralism reinforced this challenge, collapsing the legitimate the medical authority of European medicine. If Western medicine was “dislocated from its functioning as a form of alien power” 38 in colonial India, then, the emergence of the newly influential social groups, and medical pluralism, made it well nigh impossible for Western medicine to be translated in a form that could be enforced on the Indian population. NOTES 1. See Marie Haug and Bebe Lavin. Consumerism in Medicine: Challenging Physician Authority (Thousand Oaks, CA: Sage Publications, 1983). 2. Gyan Prakash, Another Reason: Science and the Imagination of Modern India (Princeton, NJ: Princeton University Press,1999), 35. 3. H. A. Newell, The Gate of India (London: Harrison, 1914); cited by T. M. Luhrmann, “The Good Parsi: The Postcolonial ‘Feminization’ of a Colonial Elite,” Man, New Series, 29, no. 2 (June 1994): 333–357, 336. 4. Luhrmann, “The Good Parsi,” 336. 5. Luhrmann, “The Good Parsi,” 334. 6. Ivan Illich, Medical Nemesis: The Expropriation of Health (Berkeley: University of California Press, 1975). 7. E. Friedson, Professional Dominance: The Social Structure of Medical Care (Chicago: Aldine, 1970). 8. See Zola in Deborah Lupton, Medicine as Culture: Illness, Disease and the Body in Western Societies (London: Sage, 2001). 9. Prakash, Another Reason, 85. 10. T. M. Luhrmann, The Good Parsi: The Fate of a Colonial Elite in a PostColonial Society (London: Sage Publications, 2003).

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11. Luhrmann, “The Good Parsi,” 337. 12. Dosabhai Framjee, Karaka, History of the Parsis (London: Macmillan, 1884), vol. I, 97. 13. Anonymous, Famous Parsis:Biographical and Critical Sketches of Patients, Philanthropists, Politicians, Reformers, Scholars and Captains of Industry (Madras: G.A. Natesan, 1930) 45. 14. David L. White provides interesting details on Rustom Manock’s wealth as a broker to the East India Company. See David L. White,”From Crisis to Community Definition: The Dynamics of Eighteenth-Century Parsi Philanthropy,” Modern Asian Studies, 25, no. 2 (May 1991):303–20, 304. 15. Rustomjee Naswrwanjee Khory and Nanabhai Navroji Katrak, The Bombay Materia Medica and Their Therapeutics (Bombay; Times of India, 1903). This is courtesy of the Wellcome Institite for the History of Medicine Library, London. See also P. Bala, Medicine and Medical Policies in India: Social and Historical Perspectives (Lanham, MD: Lexington Books), 88. 16. S. N. Eisenstadt, Patrons, Clients and Friends: Interpersonal Relations and the Structure of Trust in Society (Cambridge: Cambridge University Press, 1984), 21. See also David White. “From Crisis to Community Definition,” 306. 17. Heerajee Eduljee, History of the Medical Art: Past and Present (Bombay: Education Society Press, 1880). Heerajee Eduljee was a graduate of the Grant Medical College, Bombay, appointed as a medical officer to the Manockjee Nusserwanjee Petit’s Charitable Dispensary, Bombay. 18. H. H. Gerth and C. Wright Mills, eds., From Max Weber: Essays in Sociology (New York: Oxford University Press, 1958): 405. See also J. H. Broomfield, Elite Conflict in a Plural Society: Twentieth-Century Bengal (Berkeley: University of California Press, 1968). 19. Sanjay Seth, Subject Lessons: The Western Education of Colonial India (Durham, NC: Duke University Press, 2007): 50. 20. Thomas Edward, Henry Derozio (New Delhi: Rupa and Company, 2002). 21. John McGuire, The Making of a Colonial Mind: A Quantitative Study of the Bhadralok in Calcutta, 1857–1885 (Canberra: Australian National University, 1983): 47. 22. J. Buchan, Lord Minto: A Memori (London, 1924): 289. See also Broomfield, Elite Conflict in a Plural Society. 23. Seth, Subject Lessons, 53. 24. See R. Dasgupta and D. Chakrabarty, “Some Aspects of Labour History in the Nineteenth Century: Two Views,” Occasional Paper 40 (Calcutta: Centre for Studies in Social Services, October 1981). 25. Sumit Sarkar, The Swadeshi Movement in Bengal (New Delhi: People’s Publishing House), 150. Sarkar points out that the term “intellectual proletariat” was first used in the Bengal District Administration Report, 1913–14 (Calcutta, 1915). They were unable to find employment within the imperial dispensation. See also Dhruv Raina and S. Irfan Habib, “ The Moral Legitimation of Modern Science: Bhadralok Reflections on Theories of Evolution,” Social Studies of Science, 26, no. 1 (Feb., 1996): 9–42.

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26. See P. Bala, Medicine and Medical Policies in India (Lanham, MD: Lexington Books, 2007), 94. 27. The term used for the nationalist or independence movement during colonial India. 28. R. Guha, Dominance without Hegemony: History and Power in Colonial India (Delhi: Oxford University Press, 1998), 118. 29. K. Raj, “Colonial Encounters and the Forging of New Knowledge and National Identities: Great Britain and India, 1760–1850,” in K. Raj, Nature and Empire: Science and the Colonial Enterprise (Chicago: University of Chicago Press/on behalf of the History of Science Society, Osiris, 2nd Series, 2000), 15: 119–34, 127. 30. The Englishman, 30 April 1898. See also S. Basu, “Strikes and Communal Riots in Calcutta in the 1890s: Industrial Workers, Nationalist Leadership and the Colonial State,” Modern Asia Studies 32, no.4 (Oct.1998): 949–83, 975–76. 31. Basu, “Strikes and Communal Riots in Calcutta, 973. 32. S. H. Rudolph and L. I. Rudolph, eds., Education and Politics in India (Cambridge: Cambridge University Press,1972), 342–43. 33. Proceedings of The All India Ayurvedic Conference, Seventh Session, Madras, 1915 (Allahabad: Pandit Jagannath Prasad Sukh, 1916). 34. Proceedings of the Conference of Provincial Representatives, Simla, 24–30 June 1930. See also Bala, Medicine and Medical Policies in India, 86–87. 35. D. Lupton, Medicine as Culture:Illness, Disease and the Body in Western Societies (London: Sage Publications, 2001), 121. 36. P. Bala, Imperialism and Medicine in Bengal: A Socio-Historical Perspective (New Delhi: Sage Publications, 1991). 37. Prakash, Another Reason, 64. 38. Prakash, Another Reason, 6.

3

Medical Knowledge and Professional Power: From the Luso-Brazilian Context to Imperial Brazil Flavio Coelho Edler

The emotional and physical suffering, and the care dispensed to the sick in the Luso-Brazilian context (1500–1822), and by its symbolic “heir,” academic medicine in Imperial Brazil (1822–1889), comprised a field marked by social conflicts. The knowledge, skills, institutions, and therapeutic practices in this field were constantly provided and contested by various groups, from family members and community curandeiros (folk-healers) to professional doctors. This chapter analyzes the political and discursive strategies of legitimation developed by classical medicine in the Luso-Brazilian and Imperial Brazil contexts. The colonial period examines the extent to which the privileges conferred upon official medical institutions clashed with the pragmatism of local authorities more concerned with optimizing economic development and tax collection than defending the corporate interests of the scarce representatives of the medical arts. And the period that follows political independence (1822) examines the process by which the Brazilian medical leaderships, instructed by hygiene and French hospital medicine, constructed the basis of their professional authority vis-à-vis the model of European medical institutions. The emphasis here is on the active role played by the Imperial medical elite in appropriating theoretical instruments of European medicine to focus on the production of original medicine for the pathology of the tropical Empire. Two other correlated aspects of this same process include the attempt to neutralize, discredit, and circumscribe the medical heritage left by institutions and therapeutic practices (popular or classical) of the colonial period,1 and the production of a hygiene agenda directed to the solution of sanitary problems in the main cities and ports in accordance with the strategies of the constructors of the Imperial State to affirm the bases of their territorial power and impose seigniorial order on a rigidly hierarchical society.2 45

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In 1822, Brazil politically emancipated itself from Portugal. The struggle for independence had achieved a new dimension with the sudden transfer of the Portuguese Court to its American colony in 1808, fleeing from Napoleon’s troops. That event had enormous consequences for the construction of medical institutions on national bases. Never before then had the city of Rio de Janeiro, capital of the colony, experienced such transformations in its physiognomy. The end of the Portuguese commercial monopoly with the opening of its ports to “friendly nations,” in January 1808, which mainly benefited England, was one of the first acts to have a strong modernizing impact. The Portuguese fleet brought with it a printing press, the government archives, and various libraries that would form the basis of the National Library of Rio de Janeiro. A degree of cultural excitement was, thus, introduced with access to previously prohibited books, and a considerable degree of circulation of ideas. In addition to the immigrants of various European nations, who came to comprise a middle class of professionals and qualified artisans, foreign scientists and artists arrived in Brazil. The capital also concentrated on scientific institutions such as the Royal Military Academy, the origin of the Polytechnic School of Rio de Janeiro (1874), the Royal Garden (1808), later renamed the Botanical Gardens, conceived as a place to acclimatize plants of African or Asiatic origin, and the Mineralogy Office (1810), which would be the nucleus of the Imperial Museum (1818). In 1812, the Practical Chemical Laboratory was founded with the aim of strengthening the professional potentials of candidates to work in apothecary shops. This continued until special courses in pharmacy were framed in 1832. The professional organization and regulation of medical teaching in Brazil, as activities distinct from those practiced by blood-letting barbers, practitioners, and curandeiros, thus only began in the nineteenth century. At that time, D. João VI, held hostage in his own overseas redoubt, initiated a series of reforms of a liberal stamp. In the field of medicine, he created two courses in surgery and anatomy at the military hospitals of Salvador and Rio de Janeiro (1808), putting an end to the era of physicians and surgeons educated exclusively in Europe. Thus was begun a strong clinical tradition marked by the figure of the family doctor, who functioned as clinician, surgeon, and hygienic adviser, as the occasion called for. In 1832, the two Medical-Surgical Academies were transformed into the Medical Colleges of Rio de Janeiro and Bahia. The same decree instituted courses in medicine, pharmacy and childbirth. The new colleges followed the French model, oriented by the Society for Medicine of Rio de Janeiro (1829–1835)—the embryo of the Academia Imperial de Medicina (1835–1889). The configuration of medical institutions during the imperial period (1822– 1889) was marked by a series of initiatives that inaugurated profound changes

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in the panorama of medical assistance, sanitary legislation, the formation of professionals, and the means of producing and validating medical knowledge on health conditions in the tropical Empire. The consequences of these transformations, and the relationship with European medical institutions, in the context of the colonial contributions of Africa and Asia, will be discussed in the second part of this chapter. It will also present some determining aspects of colonial medical practice.

PURGING SUGAR, SINS, AND DISEASES: THE COLONIAL HERITAGE Studies of the colonial period, which extends from the sixteenth to the eighteenth centuries, have pointed out that in the European imagination, while the nature of America and its riches (sugar, tobacco, gold, and wood) were acclaimed as paradisiacal, its population, formed of Indians, blacks, and poor colonists achieved diabolical connotations. Colonial “heretics” and “witches,” “filthy,” and “incestuous” Indians with “brutal,” “cannibal,” “polygamous,” “pagan,” and “lazy”manners and habits, and “stupid,” “cunning,” and “pagan” blacks, all had to fit into an authoritarian political order, in which slavery imposed itself not only as an economic solution, but also as a form of pedagogy. A purgatory, where the whites were sent to pay for their sins, and a colonial territory opened itself to the catechizing action of the Catholic Church on the black and indigenous population. According to the metropolitan project, while “medicine for the soul” ought to be ministered by priests, members of the secular clergy, or religious orders and be concerned with cleanliness and the expiation of pernicious and diabolical elements, physicians, surgeons, and apothecaries were responsible for employing their knowledge and skills to alleviate the sufferings of the body and improve general health conditions. Although they competed to provide medical services, the religious orders, especially the Jesuits—the first and most influential missionaries of Lusitanian Catholicism—were fundamental allies in affirming the power of official medicine by denouncing popular healing practices as demoniac. The Jesuits believed that the Indians, with their eating habits, their way of life and dress, and their beliefs and gestures, were the devil’s people, who lacked reason because they were unaware of God. According to historian Laura de Mello e Souza, “evident in their habits and life, confirmed by their magic practices and witchcraft, the demonizing of colonial man expanded from the figure of the Indian—its first object—to that of the slave, finally reaching the remaining colonists.”3 With the advance of the colonizing

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process, the different magical conceptions of the world, shared by Indians, blacks, and whites from different social classes, merged into a fusion of beliefs and practices producing a popular brand of Catholicism of syncretic and multifaceted manifestations tolerated, encouraged, or combated by the colonial elite. Although supported by Portuguese legislation, the professional prerogatives of the agents of metropolitan medicine were not protected by the local authorities, which were very pragmatic in the fluid colonial life. The popular therapeutics ministered by Indians, Africans, and half-breeds amply dominated healing practices. Eliminating evil forces or spirits through blowing or sucking, the use of amulets and the employment of magic words, together with the application of potions, unguents, and bottled liquids, harmonized with the syncretic spiritual universe. The religious rigidity propagated by the Tribunal of the Holy Office and the strict Lusitanian sanitary legislation expressed in Royal Letters or by the Philippine Ordinances, strongly contrasted with the tenuous cultural frontiers that grouped therapeutic practices, blessings, witchcraft, spells, and prophecies in the same semantic field. Witch doctors and curandeiros were summoned to resolve a wide range of problems concerning daily tensions and conflicts, where therapeutic cure and neutralizing spells possessed the same symbolic meaning: restoration of a broken harmony.

LUSO-BRAZILIAN SOCIETY: ITS DISEASES AND SANITARY CONDITIONS When the Portuguese arrived here in 1500, they encountered an indigenous, semi-nomadic population, with little heterogeneity in cultural and linguistic terms. Tupis-guaranis, tapuias, goitacazes, aimorés, and other ethnic groups were dispersed along the coast and interior. Among the diseases suffered by the indigenous people at the beginning of the colonization of Brazil, historian Lourival Ribeiro4 cites “fevers,” dysentery, skin diseases, pleurisies, and endemic goiters as being the most prevalent maladies. Following the period of coastal exploration, whose principal economic activity was the extraction of brazilwood, the Portuguese crown initiated the process of colonization and territorial occupation with the expedition of Martin Afonso de Souza (1530– 1533). This period is marked by exaltation of indigenous Brazil. It seemed that disease rarely afflicted the inhabitants of America. The truth is that by the end of the colonial period, the few Indians that lived under Portuguese domination belonged to the lowest class of society. The enslavement and killing of the Indians due to captivity and forced removal from their land contributed less than imported diseases to what historians call the demographic

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catastrophe of the indigenous population.5 The Indians were victims of such diseases as measles, smallpox, scarlet fever, tuberculosis, typhoid fever, malaria, dysentery, and influenza, brought by the European colonizers and for which the Indians had no immune defenses. Together with the African slaves, the colonizers also brought a new type of malaria to American soil. The health conditions of the black population were equally deplorable. The situations experienced and activities performed by the African slave varied widely, as did the treatment they received from their owners. The chroniclers of the colonial period remarked that the blacks who labored on the land, were repeatedly beaten and poorly fed. Labor in the mines was entirely different from working in the sugar mills. The mining business required more specialized labor, allowing the captives relative freedom of action and greater opportunities than in other regions of Portuguese America.6 At the peak of gold production in the middle of the eighteenth century, the slave population corresponded to three quarters of the inhabitants of Minas, and the risks to the health of the slaves were increased with the gradual complexity of the labor involved in the search for gold that was becoming scarce. Erário Mineral—a pharmacopoeia written by surgeon Luis Gomes Ferreira after extensive therapeutic experience in the mining region—records “rheumatic crises,” “cold-related fevers,” and “open leg sores” that attacked the gold digging slaves, obliged to remain with their bodies half submerged in the cold and rocky river beds for hours, diving, removing gravel, and panning. Under such conditions, the average life expectancy was estimated to be seven years. In the main urban centers, such as Olinda, Recife, Salvador, and Rio de Janeiro, their activities ranged from being domestic servants and handicraft makers, to itinerant commerce and carrying freight and merchandise. Ancylostomiasis, or oppilation, and deficiency diseases, such as scurvy, tuberculosis, and diarrhea, did not distinguish between the black slave population and the remaining population of mulattos, poor whites, and cafuzos (Indian/black) that lived at the base of the social pyramid.7 Generalization regarding the health conditions of the white population is impossible, owing to the variety in the situations encountered in this period, irrespective of one’s social position. Thus, to be noble or plebeian, to live in the large urban centers or sheltered in mills and plantations, to be a businessman, doctor, lawyer, or a regular category; to live in convents or villages in the arid hinterland, or to settle in the mining region or drive cattle, all had an effect on the rhythm of life, eating habits, and health standards. It is obvious that lower-level civil servants, peddlers, artisans, mechanics, muleteers, foremen, traders, enlisted-rank soldiers, beggars, and the rural poor did not live in conditions much better than some categories of slaves and well below the white elite, mill owners, nobility, clergy, and merchants.

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During the first three centuries of Brazilian colonization, white society resorted indiscriminately to cures brought from Europe or those that the diverse ethnic groups with which they were in constant contact utilized to fight the illnesses that attacked them. Even the opulent Portuguese, although using their doctors, surgeons, and barbers from Portugal, did not hesitate to utilize the copaíba oil used by the indigenous people for this purpose. With the arrival of African slaves, they also accepted certain cures related to magic, as evident from the documentation of the inquisitional visits of the Holy Office. Medicine in Portugal in the twelfth and thirteenth centuries was practiced by ecclesiastics. When the Jesuits arrived in Brazil, they maintained this tradition of combining spiritual and corporal assistance in their catechism work. In addition to prescribing, bleeding, operating, and delivering babies, they created infirmaries and pharmacies. As drugs of European and Asian origin were rare and exorbitantly priced, they used indigenous medicines. That was how Europe learned the virtues of Peruvian quinine and Brazilian ipecac, which also enjoyed great success. The Jesuit apothecary shops were almost always the only ones present in cities or villages. Thirteen Jesuit apothecary shops were set up in Brazil in the 1600s and another thirty in the eighteenth century. The convent pharmacies are alleged to have contributed to the penury of the lay apothecary shops. In the hands of the Jesuits, Triaga Brasílica, a panacea composed of elements of native flora, became the second largest source of income for the Jesuit order in Bahia, achieving international fame. The Jesuits can be credited with pioneering the initial interchange between these two universes of medicine, since they also absorbed the knowledge of physicians, surgeons, and apothecaries, applying them in the precarious Santa-Casa da Misericórdia hospitals.8

SANITARY REGULATIONS Regarding sanitary legislation, since 1430 the king of Portugal had required that all those who practiced medicine be examined and approved by his doctor, also called physician. In 1448, the king of Portugal passed a law, the Regimento do Cirurgião-mor, which explicitly included among the duties of the position, regulation of the practice of medicine and surgery through licensing, legalization, and inspection of pharmacies. The Philippine Ordinances of 1595 (Ordinances of the Kingdom of Portugal recompiled by order of King D. Felipe, the First), which dealt with all matters of the Crown, also dictated rules regarding the functions of doctors, surgeons, and apothecaries. In 1521, duties were divided between the two major health authorities: the Físico-mor and the Cirurgião-mor, both playing roles similar to a surgeon-

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general in Brazil. The Fisicatura was a tribunal; the Físico-mor, a judge. Thereafter, the figure of the commissioner judge appears in the kingdom and its dominions. At the time Portuguese administration was established in the Luso-Brazilian Empire in the sixteenth century, there licentiates for the position of physician (doctor) were appointed in the city of Salvador. Where there was no examining physician, a representative of the Físico-mor, practitioners of the art of healing, had to request a letter from the Físico-mor, with a certificate from the local councils attesting to their experience and knowledge. If they passed the examination, they received a license to engage in medicine, limited to the location where they practiced and valid for a specific time period. Legal letters, permits, and regulations addressed individual situations, such as violations of sanitary legislation and abuses against the interests of the subjects.9 Until creation of the Royal Protomedicato in 1782, the Físico-mor was responsible for supervising apothecary shops and the quality and price of medicine, with the help of approved apothecaries. The law established that the separation between physicians, surgeons, and apothecaries be complete, each group with attributes restricted to their domain. The definition of the limits to exercise each activity adhered to the hierarchy of importance gradually established among them. A permit of the sixteenth century prohibited physicians and apothecaries from entering into commercial partnership in the apothecary shops. The Regulations of 1744, prepared by the Físico-mor for his representatives in Brazil, indicated the growing importance that Portugal gave to the American states. All the legal provisions, which sought to make the Fisicatura omnipresent by creating a heavy bureaucratic apparatus, and the constant complaints regarding the interference of the commissioners, indicate that the Crown’s central concern was with public revenue. The administration of justice in the medical area was thus exerted both in supervising the supervisors and punishing violators. However, failure to observe the Fisicatura Regulations almost became a norm in colonial times.10 Not only did barbershops and apothecary shops sell remedies in Brazil, but goldsmith establishments, bakers, and other shops also sold specific remedies. Despite the royal permit of 1561 prohibiting them from preparing and selling drugs, the doctors themselves prepared and sold their own prescriptions. While surgeons dispensed medicine and doctors issued their prescriptions, apothecaries prescribed on their own account or when requested by curandeiros.11 The legislative zeal of the metropolis was not limited to mercantile activities. Before the Pombal period (1750–1777) and the reign of Dona Maria I (1777–1808), when the Minister of the Navy and Overseas Possessions, D. Rodrigo de Souza Coutinho (1755–1812), outlined a policy to emphasize

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the natural products of Portuguese America and natural history research, the interest of the Crown in plants that might have medicinal use was already evident.12

THE HOLY HOUSE OF MERCY: MEDICAL ASSISTANCE AS CHARITY Another powerful tradition that had influenced the shaping of the heteroclitic medical culture that marked the colonial period came from Portuguese Catholicism, through the regular clergy, religious orders, and the brotherhoods and sisterhoods. Numerous diseases and epidemics afflicted the colonists, and the indigenous and black population. Smallpox, dysentery, malaria, typhoid and paratyphoid fevers, yaws, maculo (anal fistula), syphilis, leprosy, Arab elephantiasis (filariosis), and ancylostomiasis were most prevalent, with a majority treated at home. The poor chose that option, and the wealthy also treated diseases at home with doctors and surgeons or charlatans and curandeiros, while religious or lay orders treated their own brothers and sisters. Poor whites, people of color, whether slaves or not, soldiers, sailors, and foreigners in general, received spiritual and medical assistance in the hospitals of the Brotherhood of Mercy. For the Christian culture, physical well-being was secondary to spiritual salvation. Moreover, illness could be perceived either as an expression of sin or divine grace. The body as the repository of the immortal soul remained as a legitimate object of care. Biblical teachings and the example of Jesus indicated that devotion to the sick was a divine blessing not limited to trained practitioners. The Christian faith emphasized that caring and healing should be a popular vocation, an act of conscious humility, and, consequently, a vital component in Christian caritas. At the end of the sixteenth century, Benedictines, Carmelites, and Franciscans established themselves in Brazil. In addition to their seminaries and pastoral work, charitable work, especially treatment of the ill, was an essential part of their duties. The cult of the saints also protected against the vicissitudes of life or a defense against demons; many were invoked for their healing quality. In the processions organized by the brotherhoods and sisterhoods, in the churches or at home, orations and prayers solicited the intervention of the saints, each according to his or her specialty. A daily cortege, the viaticum, comprised of devotees intoning liturgical prayers, proceeded through colonial cities visiting the infirm, with churches tolling their bells as the procession passed. In difficult situations, the Church encouraged the faithful Brazilian to join brotherhoods and sisterhoods, formed according to social categories, to find

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solutions that would open the gates to eternal salvation. Offering a refuge in life, security against death, pleasure in demonstrating ostentation and social position in a rigidly stratified society, the brotherhoods and sisterhoods also ensured care for the sick and posthumous masses for the comfort of the soul. The oldest lay brotherhood in Brazil was the Brotherhood of Mercy, which, inspired by corporal commitments, carried out works devoted to feeding prisoners and the hungry, redeemed the captive, cured the sick, clothed the naked, provided rest for pilgrims, and buried the dead. Maintained by socially prominent people, the order benefited from the legacies left by their members and also funds received directly from the Crown. The four hospitals opened in the eighteenth century by the third orders of San Francisco and Carmo were devoted to housing exclusively members of the sisterhood. The hospitals of the Santa Casa da Misericórdia, almost all modest and in a permanent state of penury assisted the sick population since the sixteenth century in fifteen Brazilian cities. As the Brotherhood of Mercy spent less on its hospitals than on religious festivals, the institution lived in poverty.13 The therapeutics administered in its hospitals were limited to a diet of chicken soup, bloodletting, and purges conducted by barbers, blood-letters, and, when short of money, even slaves; a doctor and a surgeon oversaw the work occasionally.

CLASSICAL AND POPULAR KNOWLEDGE IN COLONIAL MEDICINE Throughout the Luso-Brazilian Empire, doctors, surgeons, and graduate apothecaries comprised a small proportion of the entire therapeutic community. Formally occupying the apex of the professional pyramid, in addition to competing with each other, they maintained a regulatory and vigilant attitude over popular therapeutic activities. The authority of doctors with diplomas was still embryonic; generally the patients themselves or popular therapists tried to cure serious diseases, or even solve problems of a surgical nature. The legal hierarchy was not respected. Relatives, friends, and by-standers gathered beside the patient’s bed did not hesitate to criticize a doctor, propose other treatment, or suggest the name of another, more efficient practice for the case. Differences regarding the origins of diseases were considerable. God, witches, malign spirits, and the stars counted as much as natural causes. The remedies were accordingly based on praying, purging, exorcism, magical formulas, herbs, minerals, and substances of an animal origin. While in some situations, the patients invoked multiple explanations (divine intervention did not exclude the action of natural causes) to call upon therapists of all types.

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Physicians and surgeons, for the most part New-Christians (recent Christian converts) of Jewish origin, did not occupy an important position in society until the middle of the eighteenth century when, as graduates of European universities and members of literary academies, they acquired a more privileged status. They often worked for free with their financial rewards not equally advantageous, causing many professionals to seek clients in other locations. To guide their prescriptions, they adopted European pharmacopeia of notable medicinal plant treatises of prescriptions published in Portugal. In addition to cutting hair and beards, barbers practiced bloodletting, applied suckers, leeches, and administered enemas. As with apothecaries, barbers needed a Letter of Examination to qualify them as practitioners. Barbers were generally Portuguese and Castilian, many of them New-Christians; blacks and mestizos were also found in this profession. Of all therapeutic practices, the use of Brazilian medicinal herbs had the greatest popular legitimacy, and their use had mystical connotations. Certain minerals and parts of animal bodies were used as medications or amulets. Although anthropophagy was looked upon with horror by Europeans, the use of saliva, urine, and feces, human or animal, was shared as a therapeutic resource, with culturally distinct meanings. While sucking or blowing to drive out evil spirits, fumigation by tobacco, baths, rubbing with ashes and aromatic herbs, and ritualistic fasting were disparaged as barbaric elements, the theory of signatures, postulated by the classical episteme,14 believed that each region contained the antidote for its own diseases and authorized the assimilation of popular empirical pharmacopoeia. Although classical and popular knowledge were inseparable at different social levels, the representatives of the official art fought against those who practiced informal healing. Demanding control over the sick body for itself, official medicine took useful aspects from popular therapeutic knowledge, reinterpreting it in the light of classical knowledge. The fluidity between the domains of medicine and witchcraft, which used human and animal cadavers associated with the diabolical universe to produce remedies, imposed on those with diplomas the task of distinguishing “scientific” procedures from popular “superstitious” beliefs. In this task, they found support from the Church and the Ordinances of the Realm. The influence of licensed doctors on those governing did not guarantee regulation. No group achieved the monopoly intended of diagnosis or treatment. Medical practices as diverse as catimbó and calundu coexisted, generating difficulties. Apothecaries, barbers, midwives, bone setters, and enema appliers officiated over a mechanical and servile art, while the physician, with a dogmatic and doctrinal education, possessed the honors of the nobility, with the right to recognition in the use of arms and silks—symbolic distinctive

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ornaments of noble status in the public mind. Among the agents involved in healing practices, apothecaries and surgeons, thus, occupied a subordinate position in the professional hierarchy. The task of diagnosing, prescribing, and following the treatment of the sick person, in accordance with doctrinal learning of canonic texts in Latin, was reserved for the doctor. This liberal art—conducive to the status of free men—enjoyed supremacy over the work of the surgeon and over the preparation and sale of medicines. Physicians were expected to supervise the preparation of all drugs that contained opium, pastes, pills, and tablets. Apothecaries were responsible for crushing and mixing the drugs previously selected and weighed by the doctors, while surgeons were expected to limit their therapeutic action to the fixing of broken bones and the treatment of certain wounds. In the colonial world, meanwhile, the rigid hierarchy between physicians, surgeons, and apothecaries proved to be innocuous. When applied, complaints were received from the representatives of the Crown in the name of colonial reality. The exercise of medicine in Brazil up to the creation of the Royal Promedicato in 1782 in the reign of D. Maria I (1734–1816) was only permitted to doctors and surgeons bearing a certificate of qualification and licensed by the medical authorities of the Realm, the Cirurgião-mor and Físico-mor. Initially residing in large settlements, the royal representatives were seen with commissioners in villages and cities in later years. Physicians, although numerically insignificant, were doctors to the Crown, the Council, and troops in the main cities and villages, as seen in Recife, Salvador, and Rio de Janeiro. They were responsible for examining, diagnosing, and prescribing for patients, while surgeons were assigned manual duties, considered socially inferior, that required the use of lancing tools, scissors, scalpels, cauterizers, and needles, thus limiting their activities to bloodletting, application of blood suckers, and curing wounds and fractures. They were prohibited from administering internal remedies, the privileged domain of doctors graduated from Coimbra, Portugal. The foundation of surgical schools in 1808 broke this restricted practice, creating new doctors in Brazil, and of the faculty of the medical-surgical schools in 1826 control the issuance of diplomas for the practice of medicine.

ACADEMIC MEDICINE AND PRODUCTION OF THE NOSOGRAPHIC MAP OF THE EMPIRE The post-independence period saw no visible changes in the demography of Brazilian society. The heteroclitic cultural heritage maintained the same standard in providing medical services. With a limited scope for this chapter,

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it may not be feasible to discuss the role of the imperial medical elite and their struggle for different initiatives for alternative institutional projects. Suffice it to mention that in the early 1870s, an important split arose between doctors educated in the strictly clinical and climatological tradition, and representatives of the nascent medical parasitology—helminthologists and bacteriologists—who would, together with other specialists, fight for reforms in the field of public health and medical instruction, raising the banner of experimental medicine and the Germanic teaching model as an antidote to the French matrix of official medicine. Thus, when the Academia Imperial de Medicina was created in 1829, hygiene and anatomo-clinical medicine were given a strategically placed position that would weaken the influence of the old Portuguese surgeons and of those from Medical-Surgical Schools of the Court and of Bahia.15 In this period of dependency of pathology and therapeutics on environmentally circumscribed climatic-telluric factors, rejection of the colonial heritage of the Fisicatura and the legacy of the medical information, as described in medical treatises of the colonial period or by lay cults or naturalist travelers, imposed itself as a precondition for affirmation of the new professional ethos. Through the Academia de Medicina, the medical elite produced original knowledge regarding Brazilian pathology akin to the program of the nascent medical geography. From its creation to the middle of the century, it monopolized itself as an instrument of imperial policy for public health, and became the principal arbiter of medical-scientific innovations, sanctioning innovations in diagnosis and therapy, concerned with Brazilian pathology. Like the Academy of Medicine of Paris, it offered prizes in annual competitions, collected and examined epidemiological information, administered smallpox vaccinations, and assisted the government in the subject of medical education, hygiene policy, and public health. The comparison between the two can be extended to some of their successes and failures. In the two institutions, the production, coordination, and arbitration of medical knowledge, oriented toward public health, resulted in the organization of the medical profession (much more precarious in the Brazilian case), seeking to constitute a network of information and data collection that had to be processed, analyzed, and eventually applied by the academics. Thus, regional inequalities were geared to the benefit of the medical elites of the capital, the direct beneficiaries of their proximity to the sources of state power. On the other hand, both were equally defeated in their intent to centralize policymaking power in the health field. A corps of modest experts would be useful to the government, while one having excessive administrative pretensions could become a political embarrassment. The academics wanted administrative powers, but only obtained

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an advisory role. The creation of a Central Public Hygiene Board in 1850 did not represent the apex of political power of Brazilian hygienists, as some historians believed.16 In addition to stripping the Academia de Medicina of its power, creation of that body subordinated official initiatives in public health and medical policy to the more general political and administrative agenda, resulting in complaints by academics and the independent medical press in the Court and Bahia.17 These reverberated until the reforms of medical teaching and sanitary legislation, coinciding with the decline of the Empire in the 1880s.

THE MEDICAL GEOGRAPHY RESEARCH PROGRAM Geographic pathologization, carried out by the medical topographies of the eighteenth century under the influence of neo-Hypocratism, achieved a new dimension in the Age of Empires. A group of medical professionals, almost all military doctors who practiced in regions politically, culturally, and economically subordinated to the principal European colonial powers, headed this enterprise. They were responsible for defining medical-hygienic problems and establishing the parameters for their solution in the inhabited zones peripheral to the main centers of medical culture.18 A broad commercial interchange, coupled with European colonial policy, introduced a clear understanding of the global as well as limited patterns of occurrences of diseases. The experience of colonial armed forces doctors generated an intense interchange of facts and medical theories, among the scientific centers of the Old World and the emerging medical communities of the periphery. The dominant version in the historiography of tropical medicine claims that medical geography was based on a body of fossilized knowledge (climatological theories and ancestral raciologies), with no reference to scientific practice and anchored on a scientific criterion that was displaced by contemporary currents of investigative medicine.19 This view is wrong. It was a dynamic medical force that motivated a research program involving doctors practicing anatomo-clinical and statistical medicine—incorporating parasitology—at the periphery of the main centers of European medical culture. The history of the genesis and development of medical knowledge under the aegis of medical geography in the middle of the nineteenth century was inseparably linked with the expansion of contemporary European medical culture to the periphery of the empires, and to the post-colonial regions. The construction of the idea of the singularity of tropical pathology and therapeutics was not limited to doctors that practiced there. A similar epistemological discourse

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with the same basis of pathological causality and representations on the rules that ought to produce and validate medical knowledge, governed the clinical practice of academic medicine in the main European medical centers.20 The internal division of medical work between national and regional molds was a vertical hierarchical division that expressed itself in terms of professional power and scientific prestige. Thus, the effort to redefine the medical problems of the tropics, based on an appreciation of environmental factors of endemicity, was broadly conditioned by jurisdictional competition internal and external to the medical profession. A number of hygiene doctors, who occupied administrative positions21 and were responsible for institutionalization of the techniques of statistics in French medicine in the 1830s, delineated the initial bases of a research program that sought to establish a nosographic map of the world. They were succeeded by doctors of the French navy, prominent agents in the construction of this discipline in the second half of the nineteenth century. Together, they acted strategically—as did their Brazilian, English, German, and other colleagues—to create a system of scientific authority (medical-scientific associations, medical schools, publications, treatises, and compendia, and the medical geography sub-specialty) that would give them legitimacy vis-à-vis the State (colonial administrations, ministries of the navy, the Ministry of Health). This also enabled them to defend their professional status against other hierarchically superior institutions—the hygiene chairs and clinics of the principal European colleges, the Academy of Medicine of Paris, the Annals of Public Hygiene and Legal Medicine, the National Committee of Public Health of France, and the classical treatises of general pathology. Encouraging research on tropical nosology, constructing a global nosological map, and coordinating the new knowledge was fundamental for achieving this objective. Affirmation of the notion of geographic specificity for pathology and therapeutics thus harmonized with the interests of doctors interested in the tropics, benefiting from this supposed “natural” monopoly to demand their privileges in the production, control, and application of a regionally circumscribed knowledge. An assessment of the activities of the Academia Imperial de Medicina reveals a lack of justification in the interpretation that identifies medical climatology with a fatalistic determinism. The notion of hygiene, as opposed to the idea of “natural region,”22 serves as an antidote to the morbiferous factors of climate. There is a wide range of positions that would analyze the epistemological and ideological bases of the beliefs sustained by the sources of disciplinary authority identified during the period. These include the treatises of medical geography or tropical climatology, frequently cited as classics,

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and the Archives de Médecine Navale, the main institution that undertook to organize the field between the 1860s and the 1880s. Another work23 played a crucial role as an alternate route to scientific legitimation for emerging medical groups in the Brazilian medical panorama.

REINVENTING BRAZILIAN PATHOLOGY In the academic work published in the Propagador das Sciências Médicas, Diário de Saúde, Semanário de Saúde Publica, and the Revista Médica Fluminense—the last two being organs of the Academia Imperial de Medicina—malarial fever was highlighted as the dominant illness of the national pathology.24 In accordance with the theories in the context of the sociocognitive experience of anatomoclinical medicine and the climatological paradigm, this conviction was scientifically grounded. Such an epistemology presupposed the existence of institutions, such as the Academia de Medicina, that regulated a territorially defined collective practice, for data on clinical observations encompassing the description of the diagnoses, etiologies, and therapeutics and post-mortem anatomo-pathological examinations. This necessarily presupposed the commitment of the local corporate medical body to produce knowledge limited to its own environmental jurisdiction. In addition to other endemic diseases discovered by medical professionals, including filarasis, leprosy, and hemorrhoids, several other diseases, including smallpox, influenza, chickenpox, and tetanus, to name a few, became noticeable in their weekly sessions. Nevertheless, the overall evaluation in the first half of the 1800s was that the country enjoyed good health conditions. Wishing to monopolize the dialogue on national medical problems before the Imperial Government and European medical-scientific centers, the Academia de Medicina undertook the task of translating and updating the contemporary European hygienic and anatomo-clinical agenda, to legitimize the interpretation of Brazilian pathology. In the face of these issues, consecrated by medical geography, Brazilian doctors presented responses, opposing the old racial stigmas circulated in European medical compendia. They also produced a positive evaluation regarding Brazilian pathology, where some of the most feared diseases, such as yellow fever, the plague, and cholera had no claim to call their home. Some of these original solutions were gathered together by one of the founders of the Academia de Medicina, a doctor of French origin, Xavier Sigaud.25 Among the climatic-telluric factors, the academics attributed a predominant role to heat and humidity in Brazilian pathology, describing their pathogenic action (miasmas) on the human economy, and prophylactic

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ways to avoid their deleterious action. Meanwhile, according to the medical consensus of the time, the decisive morbiferous factors were related to hygienic habits. Thus, the “first agents of mortality” in Brazil would be “the dietary regimen” and abuse of the “venereal act.” A healthy attitude focused on excluding these predisposing factors would result in attenuation of the main instigating climatic agents, namely heat, humidity, and miasmas.26 The academics also presented a generous evaluation on the problem of acclimatization linked to issues of European immigration, seen by eminent politicians as a solution to the end of black slave traffic imposed by England.27 And they did so, condemning certain European customs imported indiscriminately. The presentation of a hygienic prescription book, adapted to the new climatic conditions, should be interpreted as a victory credited to national doctors in their efforts to revise European treatises on pathology and hygiene and create a local medical culture. As a result, both the work of theoretical revision, related to downgrading the role of meteorological agents and temperament in the hierarchy of the production of diseases due to good habits, as well as recommending these secular habits of “cold baths,” “alcoholic beverages,” “the use of milk,” and “the tendency to follow Paris or London fashions would be contrary to healthy hygiene,” indicated the effort of the national medical culture to conform to the precepts imposed by the exclusively Brazilian pathology.28 Another example to suggest the originality of Brazilian doctors in the first half of the 1800s that was considered sacred in European medicine may be explained here. Contradicting the opinion of European colleagues, who attributed the emergence of new diseases nonexistent in the European pathology to ‘a mixture of the races,’ the Academia de Medicina asserted that “the diseases that each of the races brought to the country had not degenerated after transmission to other races” (...). Yaws, imported from Africa, the syphilis of the indigenous people and smallpox from Europe were identical to what they had been three centuries before. Only the pathological secret of the country could be ascribed to the ‘nature of the locations’ and the ‘regimen of the populations.’”29 A good part of these scientific beliefs was not consensual, remaining an object of fierce dispute among academics. Despite being polemical in some aspects, description of the nosographic map of the Empire was a spectacular triumph of the Academia Imperial de Medicina. By adapting European medical knowledge to Brazilian climatic-telluric conditions, it came to control the nosographic map, monopolizing all dialogue with hegemonic medical institutions until the middle of the nineteenth century. Meanwhile, three events jeopardized the social position that the Academia Imperial de Medicina had achieved in its first quarter century of existence. First, the unexpected eruption of two outbreaks of the most feared epidemics known to man, namely yellow fever (1849) and cholera (1855), afflicted the capital of the Empire

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and other important coastal cities. Yellow fever, which had last appeared in the seventeenth century, soon became the main public health issue in Brazil.30 The event was decisive in changing the health profile described by Sigaud, and contributed to the second event, the creation of the Central Public Hygiene Board, which removed the central role it had until then played in public health from the Academy. The Board restrained the administrative pretensions of the Academy, making it subservient to government directives during the increased political centralization of the Empire following the short liberal experience of the regencies (1831–1840). The third event was the epistemological dislocation caused by experimental medicine, which resulted in the appearance of competing societies and medical publications of the 1860s. These new avenues of scientific legitimation would break the monopoly enjoyed by the official medical publications of the Academia de Medicina. In Bahia and Rio de Janeiro, medical journalism enabled the growth of scientific interchange and consolidation of a research agenda directed mainly to knowledge of national medical material (phytotherapy), pathology, and therapeutics. This stimulated incipient individual medical research initiatives, setting the stage for the legitimation of new disciplinary fields demanded by the reformers of medical teaching. In addition to the Gazeta Médica da Bahia (1866–1915), the following Court publications were also relevant in the work of scientific emulation: the Gazeta Médica do Rio de Janeiro (1862–1864), the Revista Médica do Rio de Janeiro (1873–1879), the Archivos de Medicina (1874), the Progresso Médico (1876–1880), the União Médica (1881–1889), the Gazeta Médica Brazileira (1882), and the Brazil Médico (1887–1946). Beginning in the 1870s, an inflection would occur in the medical research program now captained by the above-mentioned publications. New groups of doctors began to pursue pari passu, the institutional reform movement that, under the impact of the dynamics of experimental research, subverted the medical hierarchy headed by clinical medicine and hygiene. The emergence of disciplines that were labeled experimental medicine, and new clinical specialties, made the curricular reform of medical teaching imperative. This contemplated a redefinition and expansion of the old body of knowledge. Convulsed by the demand for new specialized professionals, the academic territory saw its old jurisdictional borders fragmented. However, it was realized that the new clinical and statistical knowledge of the coroners, toxicologists, physiologists, pathologists, and hygienists—concerned with new subjects, such as specific pathologies, limited areas of the human organism and certain age groups—would have to be adapted to Brazilian medical problems, as one of the leaders of the victorious movement for reform in medical teaching in the 1880s stated,

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applying experimental means, the illumination we receive from development of the art, we must study the illnesses that afflict us, according to the modifications our customs and the special character of our race imprint upon them, not only in terms of topography, but also of climatic influences.31

Meanwhile, a research program of this kind lacked the scientific stamp for the Pasteurian medicine that would triumph over theories of parasitical etiology of diverse diseases previously associated with the climate, and the ontological conception of diseases, thereby revoking all the legitimacy of the climato-telluric démarche. The shift from scientific facts to beliefs or myths at the end of the nineteenth century corresponded to an alteration in the rules for producing facts, which meant a change in the status of practices in the groups that sustained them, and in new definitions of hierarchies and socioprofessional values. In this process, the scientific interchange started by the Archives de Médecine Navale favored legitimation of the new knowledge.32 CONCLUSION Thus, there were significant aspects of the Brazilian medical past that have inscribed themselves on historical studies regarding colonial medicine as well as on the new problems that have begun to receive the attention of historians since the middle of the 1980s, and can be grouped under the heading Medicine and Empire, or post-colonial studies. The nuclear problems covered here include those related to the center-periphery relationship, concretely translated as the relationships between metropolitan and colonial medicine and between popular medical knowledge and academic medicine, respectively, in the postindependence period (1822). The discussion also reveals the forms by which sustained medical knowledge, by the Portuguese Empire, or by its successor, the Brazilian Imperial State, interacted with popular therapeutic practices, trying to circumscribe them within strict limits when they could not eliminate them. Tensions were generated by the monopolizing tendencies of the official medical knowledge over medical assistance, and in maintaining the legal prerogatives conferred upon the doctor, pharmacist, and surgeon. In both contexts, such privileges were contested by various groups, from religious representatives of the various ethnic groups that comprised the multi-cultural environment of the age to curandeiros, barbers, priests, midwives, and innumerable popular therapists. In the field of therapeutic arts, knowledge, skills, and institutions were constantly supplied and rejected by the diverse heteroclitic groups of the imperial Brazilian society. At this juncture, the rhetoric against charlatanism ran up against the pragmatism of the political elites that sought to accommodate the diverse interests in play to the imperative of law,

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in a context of little capacity to supervise and limited punitive power, making sanitary legislation a legal fiction. In the field of public and private hygiene, imperial academic medicine developed a specific political and epistemological policy, seeking to legitimize itself before the State and model European medical institutions. The description of the nosographic map of the Empire was hailed as a major success for the Academia Imperial de Medicina, when it acclimatized European medical knowledge based on a nucleus of universal medical disciplines (anatomy and physiology) to Brazilian climatic-telluric conditions, becoming its guarantor and controller, practically monopolizing the dialogue between central medical institutions. In order to impose a monopoly of dialogue on Brazilian medical problems before the imperial government and European medical-scientific centers, the Academia strove to translate and update the contemporary European hygiene and anatomo-clinical agenda, which would make it the legitimate interpreter of Brazilian pathology. Given the issues sanctified by medical geography, Brazilian doctors, thus, presented original responses, some of which opposed the old stigmas supported by racial and climatic determinism. NOTES 1. On the disbarring of popular therapists in the first half of the nineteenth century, see T. S. Pimenta, “Terapeutas populares e instituições médicas na primeira metade do século XIX,” in Sidney Chalhoub et al., Artes e Ofícios de curar no Brasil, Campinas, ed. Unicamp, 2003, 307–30. On the lack of popularity of academic medicine in the same period, see L. O. Ferreira,“Medicina Impopular: ciência médica e medicina popular nas páginas dos periódicos científicos (1830–1840)” in Chalhoub et al., Artes e Ofícios de curar no Brasil, 2003, 101–22. For a more extensive evaluation of the conflicting relationships between surgeons, doctors, apothecaries, and curandeiros in the nineteenth century in the province of Minas Gerais, see B. G. Figueiredo, A arte de curar: cirurgiões, médicos, boticários e curandeiros no século XIX em Minas Gerais, (Rio de Janeiro: Vício de Leitura, 2002). 2. The most significant works on the topic of the medicalization of imperial society are those of R. Machado et al., Danação da norma: a medicina social e a constituição da psiquiatria no Brasil (Rio de Janeiro: Graal, 1978), and J. F. Costa, Ordem médica e norma familiar (Rio de Janeiro: Graal, 1979). Other approaches on the construction of the professional power of doctors and their relationship with the Imperial State are referred to in Edler,“A medicina brasileira no século XIX: um balanço historiográfico,” Asclépio, L, no. 2(1998): 169–86. 3. Laura de Mello Souza, O diabo na terra de Santa Cruz (São Paulo: Companhia das Letras, 1994), 70. 4. Lourival Ribeiro, Medicina no Brasil colonial, Rio de Janeiro, Ed. Sul Americana, 1971, 187.

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5. Maria B. N. da Silva, “A cultura implícita,” in O império luso-brasileiro (1620–1750) ed. Frédéric Mauro (org.) (Lisboa: Editorial Estampa, 1991), 265–365. 6. Maria B. N. da Silva, “A cultura implícita,” 283–93. 7. F. C. Edler, “Boticas e boticários no Brasil Colonial,” in Boticas e Pharmacias: uma história ilustrada da farmácia no Brasil, ed. Flavio Coelho Edler (org.) (Rio de Janeiro: Casa da Palavra, 2006). 8. Vera R. B. Marques, Natureza em boiões: medicinas e boticários no Brasil setecentista, ed. (Campinas: Unicamp, 1999). 9. R. Machado, et al., Danação da norma, 20–43. 10. R. Machado, et al., Danação da norma, 29. 11. Vera R. B. Marques, Natureza em boiões, ch. III. 12. Maria Cristina Cortez Wissenbach, “Gomes Ferreira e os símplices da terra: experiências dos cirurgiões no Brasil-Colônia,” in Belo Horizonte: Fundação João Pinheiro, ed. L. G. Ferreira, Erário Mineral (org. Júnia Ferreira Furtado) (Rio de Janeiro: Fundação Oswaldo Cruz, 2002), 112–13. 13. Lourival Ribeiro, Medicina no Brasil Colonial (Rio de Janeiro: Ed. Sul Americana, 1971), 40–41, and A. J. R. Russell-Wood, Fidalgos e filantropos: a Santa Casa da Misericórdia da Bahia, 1550–1775 (Brasília: Editora Universidade de Brasília, 1981). 14. M. Foucault, As palavras e as coisas – uma arqueologia das ciências humanas, (São Paulo: Ed. Martins Fontes, 1999), Ch. II. 15. Luis Otávio Ferreira, O Nascimento de uma instituição científica: os periódicos médicos brasileiros da primeira metade do século XIX, São Paulo, Doctoral Thesis, FFLCH-USP, Dept. of History,1996. 16. R. Machado et al. Danação da norma. See also J. G. Peard, The Tropicalist School of Medicine of Bahia, Brazil, 1869–1889, Dissertation information, Michigan, Columbia University, 1990. 17. On the French Academy of Medicine, see George Weisz, The Medical Mandarins: The French Academy of Medicine in the Nineteenth and Early Twentieth Centuries (New York: Oxford University Press, 1995). On the Academia Imperial de Medicina, see Flavio C. Edler, As Reformas do Ensino Médico e a Profissionalização da Medicina na Corte do Rio de Janeiro 1854–1884, São Paulo, Masters thesis, FFLCH-USP, 1992), and Lorelai B.Kury O Império dos miasmas: A Academia Imperial de Medicina (1830–1850), Niterói, Masters Dissertation, Post-Graduate degree in History Universidade Federal Fluminense, 1991 and Ferreira, Luis Otávio Ferreira, O Nascimento de uma instituição científica: os periódicos médicos brasileiros da primeira metade do século. 18. F. C. Edler, A constituição da medicina tropical no Brasil oitocentista: da climatologia à parasitologia médica, Doctoral Thesis, Rio de Janeiro, IMS-Uerj, 1999. 19. On such arguments, see David Arnold, “Introduction: Tropical Medicine before Manson,” in Warm Climates and Western Medicine: The Emergence of Tropical Medicine, 1500–1900, ed., David Arnold (Amsterdam, Atlanta, GA: Rodopi, 1996) (Clio Medica 35 The Wellcome Institute Series in the History of Medicine, 1996), 1–19. 20. For a similar interpretation in the American historiography on Southern medicine during the War between the States, see John Harley Warner, “The Idea of South-

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ern Medical Distinctiveness: Medical Knowledge and Practice in the Old South,” in Judith Walzer Leavitt and Ronald L. Numbers, Sickness and Health in America (Wisconsin: The University of Wisconsin Press, 1985), 53–70; On colonial medicine in India, see Harish Naraindas, “A genealogy of the advent of Tropical Medicine,” in Anne-Marie Moulin. Médecines et Santé, vol. 4, Paris, UNESCO (1994): 31–56. 21. Boudin was chief doctor of the Marseille hospital. Becquerel and Lévy held various administrative posts. On the topic, see: Bernard P. Lecuyer,“Médecins et observateurs sociaux: Les annales D’Hygiène publique et de médecine légale (1820– 1850),” in Pour une histoire de la statistique, Tome I, Paris, INSEE, 1977, 445–76 and Ann F. Berge,“The early nineteenth-century French public health movement: the disciplinary development and institutionalization of hygiène publique,” in Bulletin of History of Medicine 58 (1984): 363–79. 22. On the opposition between social statistics and the notion of natural region, see Roger Chartier, Au Bord de la Falaise (Paris: Alban Michel, 1998), 213. 23. F. C. Edler, “Keeping an eye on Brazil: medical geography and Alphonse Rendu’s journey,” História, Ciências, Saúde – Manguinhos VIII (supplement), (2001): 925–43. 24. See L. O. Ferriera, O Nascimento de uma Instituição Científica: os periódicos médicos brasileiros (1827–1843), Doctoral Thesis in History, USP, 1996. 25. J. F. X. Sigaud, Du Climat et des Maladies du Brésil ou Statistique Médicale de cet Empire (Paris: Chez Fortin, Masson et Cie, Libraires, 1844). 26. Sigaud, Du Climat et des Maladies du Brésil, 59. 27. Theoretical debates on acclimatization in Rio de Janeiro, see Sidney Chalhoub, Cidade Febril: Cortiços e Epidemias na Corte Imperial (Companhia das Letras São Paulo, 1996). Optimistic evaluations on climatic adaptation (acclimatization) of the Europeans in Brazil are in Edler, “A constituição da medicina tropical no Brasil oitocentista.” 28. Sigaud, Du Climat et des Maladies du Brésil, 100. 29. Sigaud, Du Climat et des Maladies du Brésil, 157. 30. On yellow fever, see the works of J. L. Benchimol, Dos micróbios aos mosquitos. Febre amarela e a revolução pasteuriana no Brasil (Rio de Janeiro: Editora Fiocruz/Editora da UFRJ, 1999); see also Chalhoub, Cidade Febril, 1996. 31. The parasitologist Julio de Moura (1839–1892), still in the 1870s, in Edler, 1992, 87. 32. See Edler, A constituição da medicina tropical no Brasil oitocentista, 71–79.

4

The Invincible Generals: Yellow Fever and the Fight for Empire in Cuba, 1868–1898 Mariola Espinosa

By the second half of the nineteenth century, Spain had lost most of its American empire and was determined to maintain control over the few colonies it had left. Cuba was the gem of this diminished empire—the pearl of the Antilles. Following the Haitian revolution, the island had experienced an economic boom as a sugar supplier. Although many in Cuba were loyal to Spain, and economic stability encouraged political stability, most Cubans wanted a different relationship with their colonial ruler. Spain was economically strapped after losing wars both in Europe and abroad, but when unrest in Cuba erupted in the Ten Years War in 1868, Spanish authorities fought hard to quell the disturbance. By 1878 the war was over, with the Spanish government promising the Cubans some autonomy and representation in the Spanish courts. However, the peaceful situation did not last long. Some in Cuba refused to recognize the end of the war and continued to fight for complete independence. Eventually, it became apparent that Spain was unwilling to fulfill its promises of Cuban autonomy, and in 1895 war broke out again on the island. This time, the Cuban insurgents refused to accept Spanish promises, and the war was fought ruthlessly on both sides. In 1898, the United States intervened in the conflict. Spain lost Cuba along with the rest of its empire, and the United States became the dominant force on the island. Yellow fever played a crucial role in these events. During the nineteenth century, the disease was frequently epidemic in the Caribbean and around the Gulf of Mexico, and it was always present in Cuba. For the victim, it begins like any tropical fever, with a sharply elevated temperature. The high fever is accompanied by severe body pain, headaches, weakness, and muscle and joint pain. The victim also suffers chills, nausea, and very low blood pressure. After a few days, most victims begin to improve, with full recovery in 67

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about a month. However, in the worst cases, the fever returns and internal organs begin to fail. In such cases, liver failure causes the victim’s skin and eyes to turn yellow, the symptom which gives the disease its name. Internal hemorrhaging begins, and the victim bleeds from the nose, eyes, mouth, and stomach, vomiting black coagulated blood uncontrollably, and eventually succumbing to the disease. Between 20 to 40 percent of yellow fever victims typically die this horrible death. Later scientists would learn that yellow fever is caused by a virus transmitted by a mosquito, but at the time of the Cuban fight for independence from Spain, this was still not known. A lack of understanding of yellow fever precipitated the collapse of Spanish imperial rule in Cuba. Ignorance of the causes and behaviors of the diseases endemic to the island led to high rates of morbidity and mortality among the troops sent to put down Cuban insurgency during the Ten Years War and the War of Independence of 1895. Spanish garrisons were stationed in the centers of Cuban cities, where they were easy prey for the housebound mosquitoes that were later confirmed to transmit yellow fever. The lack of segregated wings for yellow fever patients in Spanish military hospitals further ensured that nearly all of the sick and wounded soldiers would quickly also become infected with yellow fever. Spanish neglect of basic sanitation during wartime only provided additional breeding places for disease-carrying mosquitoes. The Cuban insurgents, the majority of whom were immune to yellow fever through childhood exposure, knew of this Spanish weakness. During both conflicts, they quite successfully made it a central component of their strategy to combat their more disciplined and far better equipped foe. The insurgents, already in control of the countryside, avoided large engagements with Spanish troops and attempts to capture the cities they held. Instead, they allowed yellow fever to be their principal weapon. As Cuban General Máximo Gómez pointed out, “the invincible Generals June, July, and August”—the months that marked the height of the yellow-fever season in Cuba—fought on the side of his Cuban Liberation Army. In contrast, the U.S. forces that dispatched the already decimated remnants of the Spanish army in 1898 suffered little from yellow fever. Even without knowledge of the exact mechanism by which the disease was transmitted, U.S. military doctors and other field officers had learned simple but effective precautions from earlier experience during epidemics along the coast of the Gulf of Mexico and in the Mississippi Valley. Troops, they understood, must never be quartered in urban areas susceptible to yellow fever. They also knew that, in the event of an outbreak among the ranks, relocating the encampment to higher ground would prevent any additional cases. These two insights kept U.S. soldiers free of significant infection during the war against Spain and the occupa-

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tion of Cuba that followed. Some historians of colonial public health argue that advances in medical understanding during the late nineteenth century reduced the mortality in European armies caused by disease and thereby allowed the maintenance of empires in the inhospitable environment of the tropics. Others contend that it was the successful establishment of colonial rule that brought improvements in public health and so the decline in death rates among European troops. This chapter demonstrates that ignorance of disease prevented the Spanish from maintaining colonialism in Cuba, and public health measures, rudimentary but effective, allowed the United States to quickly achieve domination of the island. In the Cuban experience through 1898, it was improvements in public health that enabled empire, not the other way around.

THE SPANISH ARMY AND YELLOW FEVER IN CUBA With the outbreak of war in 1895, the Cuban insurgents adopted a strategy that had proven deadly to the Spanish during the Ten Year War: control the countryside, avoid direct conflict, and allow yellow fever to kill the troops garrisoning the island’s towns and cities. “The Cubans laugh at soldiers being sent over from Spain,” it was soon reported: “They say that it is almost certain that yellow fever will kill half of any number that Spain may send over.”1 The Spanish, apparently, were not worried. One Spanish diplomat went so far as to assert that yellow fever would in fact provide the Spanish army with the tempering it needed to wage war in the tropics: “The ‘green’ troops will, of course, have the yellow fever. They will need it to become acclimatized so that they can equal the rebel negroes in endurance.”2 By the end of the year, 7,085 Spanish soldiers had fallen ill with the disease, and 2,796 of them had died as a result, a mortality rate among those stricken of nearly 40 percent.3 The high mortality rate among the soldiers afflicted with yellow fever and the evident spread of the disease among patients alerted the Spanish army’s doctors to the condition of the military hospitals. The Chief of the Sanitary Corps of the Spanish army in Cuba, Major General Cesáreo Fernández de Lozada enacted changes meant to address the issue soon after arriving on the island in November 1895. He closed the filthy San Ambrosio Military Hospital, which adjoined Havana’s notoriously insalubrious harbor, and relocated its patients to a new facility named Alfonso XIII, situated on a breezy hill on the outskirts of the city and isolated from other buildings. Alfonso XIII provided separate wards for yellow fever victims, a measure not employed elsewhere that reduced the chances of spreading infection among other patients and contributed to the lowest mortality rate of Havana’s military hospitals for the duration of the war.4

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But these measures were insufficient for meeting the problem of yellow fever. With the Spanish army unable to provoke the Cuban insurgents into a decisive confrontation and the war dragging on, more and more soldiers were sent to the island during 1896: from 90,000 at the beginning of the year, the Spanish forces numbered 110,000 by April, 130,000 by September, and 200,000 by November. In March of that year, before the start of the yellow fever season, Fernández de Lozada foresaw the consequences of concentrating so many people who had never been previously exposed in an area where the disease was present. “I anticipate an unhealthy summer,” he said, “There are so many unacclimatized soldiers here, much sickness, due to the climate, is inevitable. I fear that yellow-fever will be epidemic.”5 Yellow fever’s toll was even worse than he predicted. During the year, some thirty thousand Spanish soldiers contracted yellow fever.6 The existing military hospitals were overwhelmed. San Ambrosio was reopened, and the army emptied Havana’s civilian hospitals for its own use. Two large warehouses in Regla, across the harbor from Havana, were converted into a military hospital. The army even appropriated an orphanage, turned out the children, and crammed it full of beds for the sick troops.7 Yellow fever caused 7,309 deaths in the military hospitals in 1896. Cases treated elsewhere were not included in the official casualty count, but if they suffered a similar mortality rate, then the disease claimed the lives of roughly 2,000 additional soldiers that year.8 Lacking the ability even to provide beds for all of the sick soldiers, in 1897 Spanish military doctors responded to pressure to reduce the number of yellow fever deaths among the troops by employing one of the few measures available to them: they began reporting the deaths as having been caused by other diseases. W. F. Brunner, the inspector of the U.S. Marine Hospital Service stationed in Havana, reported that according to the official Spanish statistics on yellow fever, it appeared “that this disease is decreasing. This appearance is not real. [T]he deaths from yellow fever are being absorbed by those credited to other diseases,” especially “pernicious” fever and malarial fever.9 The pernicious fever, previously unknown among the troops, became a common diagnosis—declaring a case to be pernicious fever had been a favorite means of hiding yellow fever (and temporarily delaying the panic it provoked) for doctors across the U.S. South for decades.10 In a personal investigation, Brunner found that “deaths from pernicious fever should also be counted as yellow fever.”11 Ángel Larra y Cerezo, head of the Alfonso XIII hospital, pointed out that malaria in Cuba, though extremely widespread and debilitating, was only very rarely fatal and caused just 306 deaths in 1896—a mortality rate of less than 1 percent of the cases severe enough to be hospitalized.12 Nevertheless, pernicious and malarial fevers were attributed with killing approximately 7,000 Spanish troops in the military hospitals in 1897.13

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Further, as Brunner noted, the official records for 1897 “did not include hundreds of deaths that occurred among certain troops sent back to Spain” in the final stages of the illness: “Having observed those departures from Habana, I can safely say that 10 per cent of the 30,000 invalided home were destined to an early and positive death.”14 Judging from the outrage in the Spanish press over the “cemetery ships” arriving from Cuba laden with soldiers dying of yellow fever, it seems that his estimate was indeed conservative.15 Only in 1898 did yellow fever actually begin to decline among the Spanish troops. With the army beginning to evacuate the island in August, few new troops arriving before then, and most of the Spanish soldiers still present in Cuba having already contracted the disease, the size of the vulnerable population was dramatically smaller than in the preceding two years. Still, counting officially recognized cases as well as the specious diagnoses of “pernicious” or malarial fevers, some 2,100 deaths can be attributed to yellow fever in the military hospitals of Havana alone that year.16 Over the full course of the war, it is very likely that well over 30,000 Spanish troops lost their lives to yellow fever, or about one of every six soldiers sent to the island. The destructive power of yellow fever broke the Spanish army and doomed its efforts to keep Cuba under the Spanish flag.

THE U.S. ARMY EXPERIENCE WITH YELLOW FEVER In contrast to the minimal concern for yellow fever evidenced by the Spanish command, the U.S. military was very conscious of the need to avoid the disease. Although they did not know exactly how it spread, the U.S. Army officers did understand that relatively simple measures could keep yellow fever out of the ranks. Their experience with yellow fever in 1846 in Veracruz during the Mexican-American War, and across the U.S. South in the latter half of the nineteenth century, had demonstrated that yellow fever was a disease of cities and towns and so could be kept at bay by keeping troops stationed outside of cities and, when possible, at higher elevations. This knowledge allowed the United States to take and occupy Cuba with few losses from yellow fever. The U.S. Army’s first wartime experience with yellow fever occurred during the Mexican-American War from 1846 to 1847. The initial invasion from Texas had met with great success on the battlefield but had not compelled the Mexican government to surrender the northern half of the country. Determined to force this outcome, the Polk administration ordered a second invasion, this one to strike from the Gulf of Mexico and take Mexico City. Major General Winfield Scott was charged with planning and leading the at-

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tack. The threat of yellow fever was his foremost consideration. Scott pointed out to his superiors: To reach the heart of the country, from the gulf coast, there is a difficulty in three quarters of the year, more formidable than the artificial defences [sic] of other countries; I allude to the vomito.17

Veracruz was the only port on the gulf with suitable roads to the capital and so, despite its strong fortifications, was the obvious target. The city would have to be taken quickly, he warned. Failing to do so, “by running into the season of the vomito, might quadruple the waste of life, and cause the invading army to lose a campaign.”18 Scott judged that the expedition should be undertaken with 15,000 troops, and that 10,000 would be the absolute minimum required, but that it would be better to set off with 8,000 than wait for a full complement and risk failing to capture Veracruz by the start of the yellow fever season in late April.19 Various delays and confusion led him to nearly his worst-case scenario: he arrived at Veracruz on March 5, 1847, with just 8,600 soldiers. The troops landed without incident and quickly encircled the city, and after a brief siege, a joint bombardment by army and navy guns prompted the surrender of Veracruz on March 27. As Scott had planned, the U.S. soldiers were able to quickly advance inland to the safety of the mountain town of Xalapa before yellow fever arrived in Veracruz. The need to keep Scott’s forces provisioned with food, ammunition, and other supplies as they marched on Mexico City, however, meant that Veracruz would have to be held for the duration of the campaign. As the crucial link in a supply line that stretched back across the gulf to ports in the southern United States, the city was occupied not only by thousands of latearriving volunteers on their way to the front, but also by a large contingent of quartermaster’s troops. Cases of yellow fever slowly multiplied through April and May in Veracruz, and by early June a full-fledged epidemic had erupted that raged throughout the summer. Second Lieutenant Josiah Gorgas, commanding officer of the ordinance depot at Veracruz and himself among the early cases of the disease, described the consequences: A great many deaths have occurred here, chiefly among that class of people who neither have the means nor care to take pains about health—such as Q[uartermaster’s] men & soldiers—they have died by the hundred of yellow fever.20

Records from the war are incomplete, making it difficult to estimate the number of casualties caused by yellow fever in the port city. It is revealing,

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though, that of the 4,818 volunteer troops who served under Scott’s command, 1,930—a staggering 40.1 percent—died of disease; elsewhere, the death rate from disease among the volunteers was just 6.3 percent.21 Many of these losses were due to yellow fever. The fate of these soldiers further demonstrated to the U.S. Army the importance of keeping troops outside urban areas susceptible to the disease. After the war, this point was scrupulously observed among Army officers stationed in those parts of the southern United States where yellow fever was often epidemic during the summer months. As Thomas Lawson, Surgeon General of the U.S. Army, reported in 1855, “the troops stationed at New Orleans Barracks are transferred during the sickly season to some point on the shores of the lakes or gulf” well away from the city. “This will account,” he noted, “for the small number of cases of yellow fever reported, particularly in 1853 and 1854, when that disease proved so terrible in New Orleans.”22 Outbreaks among soldiers based in cities less frequently visited by the disease were countered by relocating to the countryside. “Yellow fever does not spread by contagion when carried from a city to the country,” confirmed one army doctor after the 1852 epidemic at Fort Moultrie in Charleston, South Carolina.23 These procedures were used to keep soldiers safe during the epidemics that swept the South roughly once each decade during the latter half of the nineteenth century. Even during the terrible Mississippi Valley epidemic of 1878, which sickened 100,000 people and claimed over 20,000 lives, the army suffered just 5 cases and 2 deaths—all within a single 12-man detachment left behind to guard the barracks in New Orleans when its regiment relocated.24 When the U.S. government decided to intervene in the Cuban struggle for independence, keeping yellow fever out of the ranks was a foremost concern of U.S. military planners. In fact, the commander of the U.S. Army, Major General Nelson A. Miles, initially argued against an invasion of Cuba on the grounds of yellow fever. “In my opinion, it is extremely hazardous, and I think it would be injudicious, to put an army on that island at this season of the year, as it would undoubtedly be decimated by the deadly disease,” Miles wrote to the Secretary of War. Instead, he proposed a naval blockade of Cuba; the navy, he argued, could compel the surrender of the Spanish while keeping U.S. troops off the island and so avoiding any exposure to yellow fever.25 However, arguments that U.S. forces could operate in Cuba while minimizing the risk of yellow fever ultimately carried the day. Although these arguments proved correct, the U.S. Army did not remain free of disease during the war. Inadequate sanitation in the camps established to quarter the troops waiting to embark for Cuba led to a major epi-

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demic of typhoid in which over 20,000 soldiers fell ill and more than 1,500 died.26 Malaria also took its toll. The troops besieging the major port city of Santiago de Cuba—the first and only substantial U.S. military engagement on the island—started falling ill soon after their arrival. Although the epidemic initially caused panicked reports that yellow fever had struck the army, the malaria at Santiago mainly incapacitated the soldiers and was very rarely fatal. Fortunately, for the U.S. military, the Spanish were suffering from yellow fever within the city and surrendered after only a short siege. The sickened U.S. troops were then able to evacuate to Long Island, New York, to recover. The extent of the malaria epidemic was publicized after the surrender of Santiago de Cuba in the infamous Round Robin letter written by Theodore Roosevelt and signed by all of the U.S. generals present.27 Although the McKinley administration feared this news would encourage Spain to fight on elsewhere in Cuba, these concerns proved unfounded. Hostilities effectively ended after the fall of Santiago de Cuba, and peace was made within a month. There was one small outbreak of yellow fever among U.S. troops during the war, in the town of Siboney along the U.S. supply line to Santiago de Cuba, but it was quickly halted. The U.S. Army doctors knew that yellow fever could only spread in an urban setting. Strategic considerations prevented the removal of U.S. soldiers from the area of the town; so to remove any chance of infection, the town was burned to the ground.28 With the end of the fighting, the U.S. troops built camps near, but outside, Cuba’s cities and towns, and were safe from yellow fever. A short-lived exception occurred in Santiago de Cuba. That city was initially occupied by specially formed volunteer regiments made up entirely of men who had declared themselves immune to yellow fever due to previous exposure.29 Most of these volunteers, however, had not actually had yellow fever and therefore remained susceptible to the disease. Not surprisingly, a yellow fever epidemic swept through the troops the following summer. The army again employed its time-tested solution: “All soldiers and clerks etc. were removed from the city, scattered about in camps from three to twenty miles from the city and the disease very promptly disappeared from among them.”30 Unlike the Spanish, U.S. forces suffered very little from yellow fever in Cuba. Even in 1900, the worst year for yellow fever during the U.S. occupation of the island, only twenty-four cases and seven deaths from the disease occurred among the military personnel in and near Havana and fewer still elsewhere.31 Its knowledge of yellow fever, though quite limited, allowed the U.S. Army to seize Cuba from the Spanish and establish U.S. domination over the island.

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DISEASE, PUBLIC HEALTH, AND EMPIRE The relationship between disease, public health, and empires forms a longrunning debate in the history of colonial medicine. Most earlier works on the topic maintained that it was advances in the understanding and treatment of disease that made the conquest and colonization of tropical lands possible. The most prominent example given was the gradual adoption of regular doses of quinine as a prophylaxis against malaria in the 1840s, which these works credited with allowing the expansion of European empire in Africa in the latter half of the nineteenth century.32 Later, though, most scholars argued that the relationship was, in fact, the opposite of that originally supposed: it was not advancements in protecting the health of the armies that enabled empires to expand in the tropics, but rather the growth of empire that caused the improvements in morbidity and mortality among the troops. The diligent use—and, therefore, the effectiveness—of quinine was vastly overstated, at least outside the British military. Even late in the nineteenth century, disease often took a terrible toll on would-be colonizers. But because nonfatal cases of yellow fever convey lifetime immunity, and the often-deadly strains of malaria common in tropical Africa provide to survivors some temporary resistance to the illness, soldiers suffered the highest death rates from disease during their first year in the tropics. Establishing a colonial foothold created a seasoned body of troops who did not suffer as much from disease as new arrivals would have, and these men were deployed to conquer additional territory. Moreover, it provided a source of indigenous laborers who served as soldiers and porters, greatly magnifying the strength of even small imperial forces. Even when death rates were initially high, the actual numbers of imperial troops involved were relatively small, so the price of empire was modest. Once colonies were established, garrisoned soldiers enjoyed better food and housing than they did while they were on campaign.33 The often-disastrous mortality rates from disease during the acquisition of new colonies prompted not only a renewed attention to these basic health needs as well as sanitation more generally, but they also spurred on medical research. In short, this new view maintained, successful conquest generated improvements in tropical medicine, not the reverse.34 The experiences of the Spanish and U.S. armies during Cuba’s struggle for independence, however, demonstrate how the ability to protect troops from disease could and did have a powerful influence on empire. Because the Spanish army did not know how to prevent the spread of yellow fever through its ranks, it could not stop the Cuban insurgents’ invincible generals—the worst months of the yellow-fever season—from killing tens of thousands of its troops and from incapacitating many, many more. Weakened in this way,

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Spanish forces were unable to put down the Cuban rebellion and, ultimately, unable to maintain control of the colony. On the other hand, the understanding of the disease gained by the U.S. military over decades of experience with yellow fever around the rim of the Gulf of Mexico, though incomplete, was sufficient to keep the illness from impeding its operations in Cuba, and allowed the United States to establish its dominance over the island with little difficulty.

NOTES 1. “Cuban Notes,” Los Angeles Times, March 31, 1895, 14. 2. “Ridicule for Rebels,” New York Times, 22 May 1895. 3. Ángel de Larra y Cerezo, Datos para la Historia de la Campaña Sanitaria en la Guerra de Cuba: Apuntes Estadísticos Relativos al Año 1896 (Madrid: Imprenta de Ricardo Rojas, 1901), 37–38. 4. José A. Martínez-Fortún Foyo, “Historia de la Medicina en Cuba (1840– 1958),” Cuadernos de Historia de la Salud Pública 98, no. 1 (2005); W. F. Brunner, “Morbidity and Mortality in the Spanish Army During the Calendar Year 1897,” Public Health Reports 13, no. 17 (April 29, 1898): 409. 5. “Five Thousand Are Sick,” Chicago Daily Tribune, March 14, 1896, 4. 6. Larra y Cerezo, Datos para la Historia de la Campaña Sanitaria, 38. 7. “Cuba Scourged by Yellow-Fever,” Chicago Daily Tribune, October 12, 1896, 8; “Bad State of Havana Hospitals,” Chicago Daily Tribune, December 18, 1896, 3; Brunner, “Morbidity and Mortality in the Spanish Army,” 409–10. 8. Larra y Cerezo, Datos para la Historia de la Campaña Sanitaria, 38–39. Larra y Cerezo estimated that six to seven thousand cases of yellow fever were treated outside of the military hospitals. The 30.1 percent mortality rate for cases in the military hospitals that year implies that 1860 to 2170 of those soldiers died of the disease. 9. W. F. Brunner, “Sanitary Report from Habana,” Public Health Reports 12, no. 34 (August 20, 1897): 882. 10. When yellow fever was present in a southern town, it was common that “all cases of the disease, until it becomes epidemic, are reported as ‘pernicious malaria,’ ‘bilious intermittent,’ or some other kind of fever, so that strangers may not be frightened away and in order that the commerce of the locality may not be jeopardized by the establishment of quarantines.” “Result of the Autopsy: Prof. Proctor Died of Yellow Fever,” New York Times, September 17, 1888, 1; see also Jo Ann Carrigan, “Privilege, Prejudice, and the Strangers’ Disease in Nineteenth-Century New Orleans,” Journal of Southern History Vol. 36, No. 4 (1970), 568–78 at 574. 11. W. F. Brunner, “Sanitary Report from Habana,” Public Health Reports 12, no. 39 (September 24, 1897): 1028. 12. Larra y Cerezo, Datos para la Historia de la Campaña Sanitaria, 41–43. 13. Brunner, “Morbidity and Mortality in the Spanish Army,” 411. 14. Brunner, “Mortality and Mortality in the Spanish Army,” 411.

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15. “Un Barco Cementerio,” El Imparcial, October 19, 1897, 1. 16. W. F. Brunner, “Deaths in Habana from January 1 to October 13, 1898,” Public Health Reports 13, no. 43 (Oct. 28, 1898):1221, and Brunner’s weekly reports for the remainder of the year. 17. Major General Winfield Scott, “Vera Cruz and Its Castle,” in Messages of the President on the Subject of the Mexican War, House Executive Document no. 60, 30th Congress, 1st Session (Washington, DC: Wendell and Van Benthuysen, 1848), 1268. 18. Winfield Scott, “Vera Cruz,” 1269. 19. Scott’s estimates are recounted in William L. Marcy, Secretary of War, “Projét,” in Winfield Scott, “Vera Cruz,”1275–77, 1276. 20. Josiah Gorgas to his mother, August 6, 1847, quoted in Frank E. Vandiver, “The Mexican War Experience of Josiah Gorgas,” Journal of Southern History 13, no. 3 (1947): 373–94, 382. 21. Figures calculated from “Statistics of the War with Mexico,” in Thomas Lawson, Surgeon General, U.S. Army, Statistical Report on the Sickness and Mortality in the Army of the United States, Senate Executive Document no. 96, 34th Congress, 1st Session (Washington, DC: A.O.P. Nicholson, 1856), 605–21. 22. “Southern Division,” in “Statistics of the War with Mexico,” in Thomas Lawson, Statistical Report, 257. 23. Surgeon John B. Porter, “Medical Topography and Disease of Fort Moultrie,” in Thomas Lawson, Statistical Report, 241. 24. “Report of the Surgeon General,” in Report of the Secretary of War, House Executive Document No. 1, 45th Congress, 3rd Session (Washington, DC: Government Printing Office, 1878), 426. 25. Nelson A. Miles to Russell Alger, Secretary of War, April 18, 1898, in United States Congress. Senate, Report of the Commission Appointed by the President to Investigate the Conduct of the War Department in the War with Spain, 8 vols., 56th Congress,1st Session (Washington, DC: Government Printing Office,1900), 872–73. 26. Walter Reed, Victor C. Vaughan, and Edward O. Shakespeare, Report on the Origin and Spread of Typhoid Fever in the U.S. Military Camps During the Spanish War of 1898, 2 vols. (Washington, D.C.: Government Printing Office, 1904), 1, 675. For the reforms triggered by this epidemic, see Vicent J. Cirillo, Bullets and Bacilli: The Spanish American War and Military Medicine (New Brunswick, NJ: Rutgers University Press, 2004). 27. “Nine Men Out of Ten Sick: Col. Roosevelt Declares the Whole Army in Danger Unless Moved North at Once,” New York Times, August 5, 1898, 7. 28. “Burning of Juraguicito: The Torch Applied by Our Soldiers Under Orders of the Military Health Authorities,” New York Times, July 14, 1898, 1. 29. “Immunes to the Front: Two Fever-Exempt Regiments Ordered to Garrison Santiago—Speculation as to Their Immunity,” New York Times, July 15, 1898, 2. 30. Brigadier General Leonard Wood to the Adjutant General, Division of Cuba, August 9, 1899, File 1899/4636, Letters Received, 1899–1902, Records of the Military Government of Cuba, Record Group 140, National Archives, College Park, MD.

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31. William C. Gorgas, Report of Vital Statistics of the City of Havana, Year 1900, File 1900/275, Entry 10, Records of the Military Government of Cuba, Record Group 140, National Archives, College Park, MD. 32. See, among many others, Philip D. Curtin, “‘The White Man’s Grave’: Image and Reality, 1780–1850,” Journal of British Studies 1, no. 1 (1961), 94–110, and Daniel R. Headrick, The Tools of Empire: Technology and European Imperialism in the Nineteenth Century (Oxford: Oxford University Press, 1981), 58–79. 33. These counterarguments were first introduced by William B. Cohen, “Malaria and French Imperialism,” Journal of African History, Vol. 24, No. 1 (1983), 23–36. 34. Philip D. Curtin, Disease and Empire, 227.

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The White Man in the Bedroom: Contraception and Resistance on Commercial Farms in Colonial Rhodesia Amy Kaler

In an earlier work, I claimed that contraceptives “are unique in their ability to stir up trouble—trouble between men and women, between generations, and trouble of all sorts.”1 This troubling and troublesome quality of contraception arises because contraceptives are about power—the power to determine whether and under what circumstances a new person will come into being. Control over human reproduction is eternally contested, in zones ranging from the comparative privacy of the conjugal bedroom to the political platforms and programs of national polities. In those zones in which the distribution of power is asymmetrical and unjust, as in colonial and postcolonial societies, struggles over reproduction are particularly intense, yet often indirect and subversive, not confrontational. This chapter examines the troubles that contraceptives caused in one such zone—the commercial farms of white-ruled Rhodesia during the 1960s and 1970s. The main argument is that the contestations over family planning on commercial farms, epitomized by the specter of a white man invading the bedroom to proffer pills and injections to African women, not only epitomize the trouble-making power of contraceptives, but also serve as an inspiration to complicate the concept of the “contact zone,” close to recent work on colonial and post-colonial societies. COMMERCIAL FARMS IN COLONIAL RHODESIA Until 1979, colonial Rhodesia (now called Zimbabwe) was under the control of a white minority government, the Rhodesian Front, similar to that of apartheid-era South Africa. On the white-run commercial farms, the racial 79

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relations of ruling were intensified by the near-absolute power that farm owners had over their African workforce, thus providing a particularly appropriate setting to examine power and trouble as they coalesce around contraception; for they were saturated with asymmetries of power, extending and deepening the asymmetries that characterized most social settings under the Rhodesian Front. These asymmetries occurred along many intersecting axes. Superficially, the most obvious axis is race, as the white minority who owned and ran the farms were legally, politically, economically, and in nearly every other way dominant over their African workforce. However, racial polarization does not exhaust the complexity of power relations on the farms. Within the small and enclosed world of the commercial farm, men sought to exert control over “their” women; subaltern figures such as “boss-boys” held authority over ordinary workers, and even among those workers, the native Zimbabwean “sons of the soil” held themselves above the “outsiders,” migrant workers from Malawi and Zambia who could make no ancestral claim on Zimbabwean land. Outside the enclosed world of the farm, the political hierarchy of white-dominated colonialism was being shaken by insurgent African nationalist forces, and the reverberations from this political struggle echoed in the lives of farm owners and workers alike. In the 1960s, oral contraceptives were introduced into this complex mix. They were brought in by the Family Planning Association of Rhodesia (FPAR), a white-run charitable organization with close, though sometimes conflicted, relations with the government Ministry of Health.2 The rationale for promoting contraceptive pills and injections was welfarist and developmentalist, with neo-Malthusian concerns lurking among some of the political supporters of the FPAR. Nonetheless, the FPAR itself took as its official line the argument that effective contraception was a benefit to the physical and social health of African families, enabling women to avoid unintended, undesired, and potentially debilitating pregnancies, and enabling parents to have children in a quantity and configuration that fit their means. For commercial farm owners, the benefits of family planning were calculated differently. Having workers on the pill meant reduced loss of laborpower due to pregnancy; greater flexibility in managing the reserve army of labor comprised of women farm workers; and less responsibility and pressure on the farm owner to provide minimal amenities for the economically unproductive children of farm workers. Among farm workers themselves, opinions about contraceptives split along gender lines, much as they did elsewhere in Zimbabwe.3 For many women, the pill and the injection were welcome new technologies that helped them control their childbearing. For many men, however, the same quality represented a threat to their masculine prerogative of control over the deployment of their wives’ and daughters’ wombs. For

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both men and women, the issuance of these contraceptives from the hands of the white oligarchy carried the threat that these technologies were the newest weapons in the ongoing struggle of whites against Africans and would render Africans unable to reproduce themselves and their societies.

REPRODUCTION IN THE CONTACT ZONE In a recent work on colonial, postcolonial, and neocolonial encounters, the notion of the “contact zones” represents a way of denoting an encounter of groups in geographical, political, and imaginary contexts. Thus, contact zones are conceptualized as “the space of colonial encounters, the space in which peoples geographically and historically separated come into contact with each other and establish ongoing relations, usually involving conditions of coercion, radical inequality, and intractable conflict.”4 Or, they may be physical spaces in which physical contacts take place—a sports field, a red light district, a sitting room—but they may also be metaphorical “spaces,” circumscribed by the operation of particular discourses of power. As Rutherdale and Pickles argue in their work on contact zones in the colonization of Canada, the metaphor of the contact zone opens up ground for documentation and analysis.5 By speaking of zones of contact, they move away from the oversimplified narrative of the ever-expanding frontier of colonial control, as well as the narrow dialectic of oppression and resistance as a means of telling colonial stories, which sets limits on accommodation, negotiation, and subversion. The trope, explicit or implicit, of the contact zone has been taken up with particular enthusiasm by scholars of medicine and health, especially in the area of reproduction.6 This chapter fits into the growing body of literature, although, as argued in the conclusion, the application of the contact zone trope to the study of reproduction complicates and expands the heuristic possibilities of that trope. In view of the above, this chapter examines the nexus of power asymmetries on white commercial farms, by looking at the ways that this nexus was troubled by the introduction of contraceptives. The archival sources of the Rhodesian Ministry of Health, and interviews (on social and political aspects of fertility control) with whites and Africans who worked for the FPAR as family planning promoters, provide a necessarily oblique view of tensions over contraceptives on commercial farms, as neither farm workers nor farm owners were directly represented here; they also highlight contemporary and retrospective descriptions of the motivational and clinical work on farms. It would be difficult to represent the subjectivity of these two groups. However, a focus on the displays of power and resistance on commercial farms, as re-

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corded by those who were observers (although not disinterested observers), rather than direct participants provides a feasible explanation; extrapolations as to subjectivity and the interior world of owners and workers should be made at the reader’s own risk. COLONIAL EUGENICS: PRO- AND ANTI-NATAL Reproduction, birth, and babies are finally being given their due in the social history of Africa. Nancy Rose Hunt, a prominent historian of gender in central Africa, speaks of “a huge outpouring of material on…colonial eugenics and the medicalization of female bodies, citing different authors on different aspects of the social organization of pregnancy and childbirth, from abortion to maternity homes.7 A large part of this work is cited in historical contexts in which the “eugenics” described by Hunt was implicitly or explicitly pronatal. Colonial powers focused their attention on enabling African women to have more and better babies, rather than fewer. Carol Summers, for instance, focuses on colonial fears of a population implosion in colonial Uganda, leading to vigorous anti-syphilis campaigns (to reduce syphilis-linked infertility) and the promotion of birthing in clinics, rather than at home, to reduce the infant mortality rate.8 This white-run Social Purity Campaign to reshape sexual and reproductive practices was based in pro-natalism, and the belief that Africans needed to have more babies, which Summers dubbed “intimate colonialism.” She quotes a speech promoting the campaign: The glory of the nation is its people. A strong prosperous nation is one where … the population is growing year to year and the number of births greatly exceeds deaths. If Uganda is to be judged by these standards, it is a dying nation.9

Elsewhere in Africa, pro-natal eugenics was driven by concerns about dwindling labor supply.10 If African women were unable or unwilling to have more babies, the labor-intensive industries underpinning colonial economies were threatened, particularly in light of labor migration southward, to Rhodesia and South Africa. Reducing the incidence of sexually transmitted diseases (and the non-monogamous sexual practices that presumably spread them) and lowering the infant mortality rate were the preferred measures, not only to fulfill the colonial mandate of benevolent stewardship of African lives, but also to keep the labor supply constant. By contrast, mid-century Rhodesian interventions in African reproduction were also eugenic, but with a decidedly anti-natal inclination. The demands for African workers were more easily sated in Rhodesia, which drew immi-

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grants, legal and illegal, from across the region. Fears of demographic submersion in an African sea quickly overtook concerns about too few African babies in the minds of most whites. The FPAR took pains to present itself as an organization for uplifting living standards for Africans, through smaller and better-spaced families, but it was perceived by blacks and whites alike to be an instrument of anti-natalism.11 The “intimate colonialism” involved in shaping African reproductive practices thus took a somewhat different course in mid-century Rhodesia than it did in the cases documented in the new scholarship on reproductive politics—a course that brought it into sharper conflict with the people on whom it was practiced, very few of whom wanted their numbers of children to be reduced.

THE SOCIAL DYNAMICS OF RHODESIAN COMMERCIAL FARMS The particular contact zones at issue in this chapter are the commercial farms of colonial Rhodesia. If reproductive management is a form of “intimate colonialism,” these farms were among the most intimate settings for colonial power. The farm workers were arguably the most impoverished and oppressed of all Africans in Rhodesia, and experienced white control in its most pervasive and totalizing form. In the 1970s, 40.1 percent of all land in Rhodesia was reserved for the use of whites, “of which the vast bulk is farms [usually tobacco, cotton or citrus].”12 Commercial farm workers made up between 20 percent and 25 percent of the African population in the 1960s and 1970s, and the total number of official farm employees peaked at 358,000 in 1974.13 However, this figure does not include family members and dependents of employees (mainly women), and does not take into account the number of illegal migrants, “under the table” workers, and unreported casual workers, which pushed estimates of how many people actually depended on commercial farm labor upwards of one and a quarter million. This workforce consisted of permanent employee/residents with a mix of contract/casual laborers (mainly from outside Rhodesia), labor tenants, and illegal migrants. The proportion of non-Rhodesians among registered farm employees declined through the 1960s and 1970s, from 50 percent in 1961 to 33 percent in 1971.14 However, non-Rhodesians made up the bulk of the illegal, non-registered workers, so that 20 percent of the male labor force was Malawian in 1972, with Mozambicans “only slightly fewer in number,” and Zambians making up 3.4 percent, suggesting a total foreign workforce of closer to 40 percent.15 Regardless of national origin, only 12 percent of

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all workers had any form of right to reside on land anywhere else, whether through a traditional land title system or through ownership of a plot. The other 88 percent were landless, entirely dependent on their employer for a place to live as well as for subsistence. For commercial farm residents, the 1960s and 1970s were years of impoverishment. Real wages of farm employees actually declined from 1948 to 1972, and this pattern continued through the 1970s.16 Chikanza et al. estimated average monthly family income (which could include the earnings of more than one worker) in the Bindura area in 1979 at $28.09 for a 54-hour workweek, while a monthly income of $91.73 was estimated to be necessary to bring those families up to the poverty datum line.17 Social services were similarly inadequate. Chikanza et al. reported that on the farms in their study, only 40 percent of children of school-going age attended school; and 75 percent of people of all ages had never been to a clinic or hospital.18 The estimates of poor health and undernutrition that they obtained using various measures were comparable to those in the most remote and underdeveloped Tribal Trust Lands in Rhodesia and were much worse than working-class African urban townships.19 They also found that 9 percent of all children born to workers on commercial farms died within one month and that only 17 percent of all children on commercial farms were ever immunized, indicating a hazardous and uncertain environment for mothers and children in particular.20 Clarke described the Rhodesian commercial farm as a “total institution,” in which the owner is nearly a one-man government. The owner’s position also allows for the dispensation of privilege and patronage in labor policies as well as penalties and fines. His control extends beyond the workplace, over the private lives of the workers in the compound … [and] there is a lot of personal contact with workers, in terms of a master-servant relationship. Varying degrees of benevolent authoritarianism can be found, the distribution of which partly compensates against the effect of low wages. 21 White commercial farmers saw themselves as benevolent authorities, like an institutional paterfamilias, albeit with very limited knowledge of its subordinates.22 The farm owners professed to believe in a degree of well-being among their workers which was not corroborated by more objective measures: The farmers … estimated undernutrition in this group of children [of farm workers] to be zero or negligible. The survey estimated undernutrition at 19.8% to 68.8% [depending on what measure was being used] . . . . The interviews with farmers revealed a large variability in their knowledge of the worker communities health, educational and socio-economic status, with a tendency to overestimate their well-being. For example, the average family income was estimated at $45 per month, the percentage of school age children attending school at 50% - 100%, and the percentage of children immunized at 0% - 90%.23

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Clarke concluded that the model which best described relations between owners and workers, in terms of the organization of both labor and private life, was feudalism: Farm labor relations involve a high degree of non-cash and non-labor commitment on both sides of the contract. Worker links to the plantation are almost all encompassing. These links are not simply economic but also involve a high degree of personal sociopolitical subordination and dependence. … The landowner is not only the sole employer of the worker’s family, but is also the landlord of his worker-tenants. … Workers also rely on extensively on employer-initiated welfare policies which often reinforce dependency links. The provision of education, the supply of rudimentary medical aid, the hope of “retainer status” after retirement, the prospect of obtaining intermittent cash loans and the local authority of the employer for discipline, order and obedience are dependent often on employer decision and inclination. In this respect workers are “tied” to the land. 24

The total control that the farmer could exercise over the lives of his employees led to acts of lese-majeste, in which the farmer’s power could reach into the domestic and personal life of the worker to maximize labor extraction and ensure obedience. Clarke provides a gallery of criminal cases brought against white farmers for assaulting their workers with cattle prods, sjamboks, hammers, and pistols, or interfering in their domestic life through destroying family property, burning homes, or exacting retribution for the alleged misdeeds of family members. Rutherford also notes the paternal reach of the white farmer, arguing that white farmers were encouraged by the Rhodesian State to see themselves as benevolent, fatherly autarchs, who, together with their wives (the farm “madams”), oversaw both the domestic and the public lives of “their” Africans.25 This “institutionalized paternalism” manifested itself in the form of rudimentary health care, often provided by the madam; small loans for marriage payments or the purchase of items like bicycles, and rations of oil, rice, or other basics to supplement the small wages. Such patriarchal preoccupation with the intimate organization of workers’ lives set the stage for conflicts over workers’ ability to reproduce in the 1960s and 1970s.

THE FAMILY PLANNING ASSOCIATION OF RHODESIA The institutional agent that brought contraceptive troubles to the commercial farms was the FPAR, and its white and African community workers. The FPAR was founded in 1959 by a group of liberal white women, following a

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visit from an American representative of the Pathfinder Fund, an organization that vigorously promoted birth control to defuse a global population explosion. Throughout the decades before independence, the FPAR had a rocky relationship with the white governments of the day. Promoting smaller families and contraception to African women was perceived by white authorities as politically incendiary, threatening the fragile cooperation between white authorities and elite African men on which the maintenance of Rhodesia’s stability depended. At the same time, neo-Malthusian concerns about the rapid growth in the African population, and the demographic and political threat to white superiority inherent in the rising tides of African babies, led to calls for aggressive and rapid expansion of contraceptive services for population control. The Rhodesian Front government, which came to power in 1963 on a platform of strict racial separation and hierarchy, funded and actively supported the FPAR, despite episodic objections from white civil servants working directly in African communities, who complained that the Africans under their jurisdictions were opposed to contraception being promoted to their women. Interviews with former white leaders of the FPAR did not indicate any motivation by the same racial anxieties about population that obsessed the white government. The leadership of the FPAR subscribed to a socialwelfarist, even proto-feminist, interpretation of contraception, treating it as a means for Africans in general, and African women in particular, to improve their living standards and gain greater control over their biology. The FPAR’s promotional material was replete with images of contented, well-educated, economically empowered small families, with nary a mention of overpopulation or excessive birth rates. FPAR leaders also went head-to-head with their political leaders, in both public and private venues, over the Front’s desire to pursue population control more aggressively. However, the Rhodesian Front’s concern with overpopulation was well known and publicly articulated in media accessible to Africans as well as in whites-only policy circles.26 The distinction between the political agenda for birth control advocated by the Rhodesian Front, and the more benign agenda espoused by the FPAR, would have been lost on most Africans, who viewed the FPAR as an arm of the government (and indeed, while the FPAR was nominally independent, it received the vast majority of its funding from the RF government).

FAMILY PLANNING ON WHITE COMMERCIAL FARMS Although commercial farmers were early and staunch supporters of family planning, Family Planning Workers (FPWs) expressed their dislike about vis-

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iting commercial farms to deliver family planning education and motivational talks. Their discomfort with farm visits stemmed from the strain of being caught in the undeclared conflicts between the white farmers and their African tenants; between men and women, and between the voluntaristic, rationalist ideals of the FPAR and the oppressive conditions prevailing on the farms. In the discourse of the FPAR, “family planning education” was imagined as a voluntary, rational process of providing information about new contraceptive technologies to receptive potential users, who would then make an informed decision about adopting these technologies. However, on the farms, this model of open communication was distorted by forced exposure of African workers to new, and unsettling, information about family planning. White farm owners compelled African workers to attend education sessions, although in written FPAR accounts of educational work on the farms, this coercive power appears in the guise of white “enthusiasm” for family planning among their workers: 27 European farmers [in Banket district] are in nearly all cases very enthusiastic and co-operative, one or two worried about the reactions of their labour if told they must attend, but other made no bones about saying it was a compulsory affair as it was in their paid working hours. (Report of a visit by Mrs. Elizabeth Teubes, 15–20 April 1967). 28 The most difficult question I am always faced with from the Europeans is “what do we do now [about family planning for workers]?”.Some of them would gladly purchase the pills and issue them to their employees themselves. I always have to point out that a doctor’s prescription is required in the first place. (Report of a visit by Mrs. Hilda Kranzlin to Macheke commercial farming area, June 1968)

Or, as Mrs. Kranzlin more cynically and laconically put it, after her tour of Concession farming area, “All the farmers we visited were very enthusiastic. The same enthusiasm was not so evident in their laborers” (Report, June 1968). This enthusiasm translated into pressures applied to the workers, both to attend lectures and film shows on family planning and also to use, or to require their wives to use, the pill and the Depo injection. Reports of educational visits to the farms are filled with descriptions of the strategies used by the farmers to be sure their laborers attended the talk. Mr Hayter had let it be known that he expected his laborers to attend and had laid on transport from distant [residential] compounds. The clerk and official policeman exhorted the crowd to pay attention to what was being said and to laugh only when laughs were called for. (Report of a visit by Hilda Kranzlin, 20 August 1968)

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[At Grand Chase Farm] people did not turn up because they were frightened. Mr Nethersole, who was determined that his laborers should have the benefit of our talk, had resorted to fairly drastic measures by threatening to dismiss all those who did not turn up. He himself had brought a carload over and was pleased to see that the others came also. The threat must have worked. He had also promised them that they were allowed to run for it the moment either of us brandished a knife or a syringe but not before then. There was certainly a considerable degree of uneasiness in our audience and many hesitated at the entrance, especially the women. … after the initial apprehension the relief on finding that there really was nothing sinister about our talk was so great that we had a particularly enthusiastic audience. (Report of a visit by Hilda Kranzlin, 16 October 1968) On this farm [Mtunzi] not only the women were afraid to come to the family planning talks but also the men. They said that had been told by the farmer that they should have muti [Shona, “medicine”] for family planning which they took to mean they would have it whether they wished or no. Most women, when rounded up from the compound, hung in the doorways and refused to come and sit down in front of the bioscope … [in the men’s meeting] only 11 men arrived, the rest had fled straight from the field to the compound and announced to the boss boy that nothing would induce them to come and hear about family planning. The farmer sent the boss boy off again primed with horrid threats and 38 men eventually sulkily took their places. This was not the ideal atmosphere and it was rendered even less auspicious by the attitude of the farmer’s cook, a gentleman with two wives and 20 children, who sat in the front row with his eyes shut and his head bowed during the proceedings; he had apparently told the farmer’s wife that he would do this, in protest, if he had to attend. (Report of a visit by Elisabeth McCarthy, 19 March 1968)

In my interviews with FPWs, all of those who had visited the farms said that they believed farmworkers were coerced not just to attend talks about family planning, but to actually practice it. In the farming areas most of the mothers worked and so it was a burden to have children all the time. And the farmers wanted strong workers, so they used to provide some transport in tractors or lorries to ferry the women to the nearest health center to get some contraceptives. In the farming communities it was far better because whether they liked it or not the farmers themselves were already motivated and they were motivating their workers to be on family planning. The farmers kept on saying “If you want to be on my farm, I want strong workers. If you have children year after year you are not going to be very strong, or else I can chase you from work”. So they [female farm workers] were motivated in that way that they were frightened … each time they were due for the next

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Depo [injection] I used to go around the farms reminding the farmers to bring them to the clinics according to the roster which we have for the clinics … the farmer will provide transport to go to the clinic so that his production won’t suffer. In the farms, the farmers would just tell their workers that their wives must go, some were frightened to see that “if my wife doesn’t go for family planning [I] will be chased away from work”, but it is just a question mark there [i.e. it is not clear whether anyone actually was chased away from the farm for not using contraception]. [Family planning promotion] was easy there [on the farms] because we got the support from farmers. They had problems with population on their farms and so they had to support us. … they would say “After you have done your clinic tell me who are those who have taken family planning”, and they would say [to those workers who had not accepted family planning] “Why haven’t you taken family planning? Why didn’t your wife take contraceptives?”. It was due to the population around their farms … [AK: Doesn’t that give family planning a bad name?] It does, but we were sort of explaining “Never mind that the boss thinks you are overcrowded, at the same time think of your wife’s health, that is important. Think of your children, if they die from malnutrition it is the same as if you never had a child”. So that was how we would neutralize the situation. Farm owners’ enthusiasm for family planning backfired, in the opinion of the FPWs, making their own work more difficult, as the workers suspected and resented their employers’ interest in their private lives. I was working in the farms and the farmer would call his workers and say “Now look, family planning is very nice, very good, listen to what this man is going to tell you, it will help you. You John, you have got too many piccaninnies [derogatory term for African children], you John you have too many”. That was the approach that would make them [farm tenants] say, “To hell with it, why is he saying that?”. So it was very difficult to motivate them that this is something good. On farms the boss used to give education to his workers. … [AK: Did the farmers use coercion to force the workers to go on family planning?] Yes, they used to do it everywhere. But as time went on I had to sit down myself with the farmer and tell them “I think you scare the people. They can take the pills and just throw them in the river or bury them in the soil….they have to understand that they benefit from family planning. They must understand that they benefit from family planning a b c d.” The farmers used to think that it would work if they forced the workers, but in my area I had to sit down with Mrs Mowbray, and talk to her and discuss the problems.29

Gender politics, in domestic and institutional forms, were central to farmworkers’ resentment and hostility towards family planning. The hard-sell approach to promoting contraception on the farms was taken as evidence that the white farm management, in league with the FPAR and the Rhodesian government, was attempting to strip African men of one of the few forms

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of power they still possessed, the power to manage and control their wives’ fertility. The promotion of contraception marked the furthest reach of white power into African lives, subverting husbands’ and fathers’ prerogative of organizing the reproductive life of his family: [At Chomkuti Farm] a number of serious questions were asked and objections were raised on the grounds that women would practice family planning without the knowledge or consent of their husbands. (Report of a visit by Hilda Kranzlin, 25 September 1968) [At Rustington Farm]at question time the general feeling seemed to be coming around to our way of thinking until a man vehemently introduced the prostitute question then opinion veered and the men said that while they agreed family planning was a good thing they feared the methods for women and only wanted Durex [condoms] so they could control the thing themselves … David [the African assistant educator] remarked that although the men didn’t seem to accept it well the wives had expressed their intention of going to the clinic and he thought some would get their way. (Report of a visit by Elisabeth McCarthy, 28 March 1968)

As the last quote suggests, women did not necessarily share their men’s concerns about the impact of contraception on gendered balances of power. Like women elsewhere, many female farmworkers and farmworkers’ wives wanted the new methods to limit their family size, and the burdens that this growth imposed on mothers and wives. 30 This led to a complex interplay of power on many farms whereby wives attempted to evade their husbands’ control of their reproductive capacities, while at the same time the husbands sought to evade the white “bosses’” control of their prerogative of having children. One African FPAR employee described the form this pattern of evasion and subversion took on one particular farm that she visited: The farmers were insisting that “If you have more than five children here I will chase you out of the farm”. So they [farmworkers] would say “If I am sent away with five children I have had, these children here, going to Malawi, how can I live?” That’s when they were forcing matters and they [farm workers] said “No, instead give us Durex [condom brand name]”. And you know what was happening? They [women] were getting pregnant. Men would keep the Durex and tear it at the end, so they could say “I am using a Durex”, but the women started reporting to us that the Durex are torn. They took it so they could say [to the white boss] “Look, I am using, but now my wife is pregnant, the Durex has failed”, and women would say the Durexes are torn. Now what will be the remedy? The Durex must be kept by the wife. [AK: Would the men allow their wives to keep the Durex?] It is the farmer who will say “Now the Durexes are going to be kept by your wife, I want to see, because there are too many pregnancies going on”.

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It was harsh. He said “It’s too much feeding you and too many children, where are we going to keep those children?” Until they [women] come up saying “Let us have pills”, and they started having pills.

Such dynamics led to a tacit alliance across racial lines between African women farm workers and their white bosses. Employers would often provide means for their workers’ wives and female workers to use contraception without the men’s knowledge, and made surreptitious contraception possible by providing access to birth control pills and later, Depo-Provera injections. However, this cooperation was not always based on white farm owners’ sympathy for their female tenants’ reproductive predicaments, but often mixed with women’s fear of the boss (and his wife). Although gender relations were central to farm workers’ hostility toward contraception, gender does not tell the whole story. Racialized relations of power, between African and white polities, meant that efforts to shape African reproductive behaviors were much more than intrusions into family life. The grinding, flaring low-level conflicts between whites and Africans reached into the realm of family planning, and men’s opposition to the FPAR was exacerbated, as it was elsewhere in southern Africa, by suspicions that the white government was using family planning as a political tool to cut down Africans: [At Rocklands Farm] men at this farm had a very wrong idea of our message to them. I heard them saying this man is coming to tell us not to have children because the government has seen that Africans are too many. When I addressed them I said I am sorry that you talk about things which you don’t know. We are not telling you that you must do this but we can assure you how to plan the number of children which you can afford to care for well, above all is education for all. After I have said this one man stood up and give apologies for their words which they have said before they heard a talk. At last they understood the message well. (Report of a visit by David Chibvongodze, 25 April 1968)

These fears were buttressed by external forces, including both the nationalist movement and the local white community itself: With regard to the great reluctance, particularly amongst the women, of farm workers to attend film shows and talks in the Banket-Mutorashanga area, the foreman on Mr Braunstein’s farm said that Zambia Radio [probably the state radio service of Zambia, which supported the African liberations movements] was broadcasting reports that the Rhodesian government was sending people around the country sterilizing Africans so they could not have any more children. Counter-propaganda on Harari Radio [the Rhodesian government-owned radio service targeted at Africans], especially at times when men can hear the

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program, might be a way to reassure people about family planning visits. As most of those who are influenced in this way are from Malawi or Portuguese East Africa [now Mozambique] such reassurance would be most effective repeated in those dialects. (letter from Elisabeth McCarthy to the Information, Education and Communication Department of the FPAR, no date but probably late 1968 31)

Rumors about the pills and Depo injections proliferated, conveying the intense political suspicion about these technologies. Most rumors concerned the likelihood that women or men would be permanently sterilized, by taking contraceptives into their bodies or even simply by exposure to the apparatus of the educational teams, including film projectors and pamphlets. 32 FPAR reports are filled with references to the wildfire spread of these rumors. The most persistent rumor was that anyone who attended an educational film show or talk was going to be forcibly sterilized—exacerbated by the FPAR’s practice of holding information meetings separately for women and for men. Some examples may illustrate this argument: [At Onamatapi Farm] there had been considerable misgivings amongst the audience about what we were going to do to them and the women were very hesitant to come in at all. One brighter man, possibly a tractor driver, when he saw the projector set up delightedly recognised it for what it is and delightedly urged the women to come in as it was after all only a film show they were letting themselves in for. (Report of a visit by Hilda Kranzlin, 8 October 1968) [At Crocodile Pool Farm] the farmer arrived and dispatched the foreman to round up women from the compound. These were as terrified as those of other farms that they were to get injections (Report of a visit by Elisabeth McCarthy, 28 February 1968)

When FPAR staff investigated the sources of these rumors, they frequently traced them back to white employers, which only added to the rumors’ credibility. Elisabeth McCarthy, in a 5 April 1968 report, complained about the damage done to her credibility by white farmers who “put their employees off with crude jokes about sterilization,” and Hilda Kranzlin expressed annoyance with the “ill-timed jests” of white farm managers which convinced workers that they were about to be sterilized by the FPAR (report of a visit to Crottier Farm, 18 October 1968), and expressed general exasperation with “all this wretched talk about sterilization” (report of a tour of commercial farms in the Marandellas North area, October 1968). Kranzlin stated that rumors which began as jokes by employers were particularly destructive in a political climate characterized by African distrust of white motives:

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The Africans are only too willing to believe everything bad rather than anything good. In an atmosphere like this, a thoughtless jest like “You better have a last fling today because after tomorrow you won’t be able to33” most obviously have disastrous results.

In addition to circulating rumors, farm workers found other ways to subvert their bosses’ desires to promote contraception, including forms of physical evasion, such as hiding in the woods, sequestering wives and daughters, or even symbolic strategies of twisting or subverting the words of the white educators when translating.34 According to one of the white administrators of the FPAR, white educators who did not speak Shona learned to be very attentive to the body language of their translators on the farms, which could be deliberately used to convey a meaning different from what the educators had in mind. She mentioned the act of picking up and snapping a twig, which, she said, was a code for “What this woman is saying is rubbish and should not be followed.” An African educator recounted a similar incidence when the intended message of the white boss through his nurse to “space children using family planning” was changed by his foreman to “the old lady has come to tie up the wombs,” without the knowledge of the white “boss.” The African educators and their assistants often bore the brunt of these rejections of contraception, because, as fellow Africans, they were culturally and physically accessible to the farm workers in a way that the white educators were not. During their tours of the farms, African educators were expected to eat and spend the night in the workers’ compound, while their white counterparts were put up in the bosses’ homes. This exposed the African farm workers to lack of hospitality and outright rebukes by people who objected to their work. One early African educator in the farms of Manicaland, reported in his monthly reports that he was having a great deal of difficulty finding anywhere to sleep in farm compounds, as farm workers refused to let him into their huts; he ended up “sleeping rough” on the grounds of local police camps, or other government facilities. In interviews, other African FPWs recount petty acts of rudeness and discourtesy by farm workers.35 One of the most striking such incidents occurred to an African field educator assisting a white FPAR employee at Mtunzi Farm on 19 March 1968, when “ the cook, on being asked to give [the African educator] food at lunch, presented him with a pot containing the dried remains of the cat’s porridge, in mute protest against our visit. (Report of a visit by Elisabeth McCarthy). 36 In sum, the contact zone of the commercial farms was a space of coercion and contestation across multiple axes of inequality. However, in examining issues of fertility control and control over reproduction, there is a double

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contact zone, with the intersection of both corporeal and geographical space as the site of this coercion and contestation. At first glance, the encounters between African workers and white farm owners and “family planners” (and their African staff) appear as an example of colonial encounters in a literal, geographically-defined contact zone. On the physical territory encompassed by the commercial farms, given over to white control by white political rulers, whites met Africans, each group possessing multiple conflicting agendas for the encounter. In these spaces, in the tobacco drying sheds or “community” meeting halls, white farmers and FPAR personnel tried to encourage African farm workers to take up pills and injections to ward off pregnancy; among Africans, some embraced while some refused the new technologies, a majority remained ambivalent. I argue, however, that the case of family planning promotion on white farms is an example of a double not a single contact zone. The “doubling” is produced by the existence of two separate yet superimposed sites of contestation—the physical space of the farms, and the equally physical, equally literal, space of women’s bodies. These new technologies did not merely affect the operation of bodies but put directly into those bodies. The very corporeal nature of family planning meant that the sites in which struggles were joined over contraception encompassed not just the spaces that bodies occupy, but the bodies themselves. As indicated earlier, this is part of the uniquely troubling and troublesome nature of contraception, that it renders bodies into terrains of struggle and contestation. These doubled contact zones engaged a double set of power relations, which are analytically distinct although deeply entwined. If farms are taken as contact zones, the power relations in these zones, producing the dramas of resistance and rejection were those which produced Africans’ disenfranchisement within racialized institutions, a microcosm of African disempowerment in Rhodesia as a whole. If, however, with a focus on female bodies as the primary zones of contact, the dominant power relations were those surrounding control over women’s reproductive capacities, which may also be seen as a microcosms of broader gender struggle over authority and command of resources (a theme which I have not had the space to fully develop in this chapter). It would be too simplistic to suggest that the racial-political aspect of hostility towards contraception belongs to the geographic contact zone, the commercial farm in apartheid Rhodesia, while the gendered aspect of anticontraceptive discourse and actions emanates from the bodily contact zone. The doubled contact zones produce doubled, and intertwined, analytic fields, encompassing racial politics and gender politics, the national and the domestic, the public world of farm efficiency, and white minority governance and

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the private world of childbearing and sexuality. The idea of a white man in the bedroom, proffering pills and injections to African women, took on its particularly repellent connotations from its location at the conjunction of the corporeal and the political contact zone.

NOTES 1. Amy Kaler, Running after Pills: Gender, Politics and Contraception in Colonial Zimbabwe (Portsmouth: Heinemann, 2004),1. 2. Kaler, Running after pills. 3. Kaler, Running after pills. See also Amy Kaler, “Who has told you to do this thing?: Towards a feminist interpretation of contraceptive diffusion in Rhodesia, 1970-1980,” Signs: journal of women in culture and society 25 (2000): 677–708. 4. Mary-Louise Pratt, Imperial eyes: Travel writing and transculturation (London: Routledge, 1992), 6. 5. Katie Rutherdale and Myra Pickles, ed. Contact zones: Aboriginal and settler women in Canada’s colonial past (Vancouver: University of British Columbia Press, 2005). 6. See Rachel Chapman, “A nova vida: The commoditization of reproduction in central Mozambique,” Medical Anthropology 23 (2004): 229–61; Durba Ghosh, Sex and the family in colonial India ( London: Cambridge University Press, 2006); Nancy Rose Hunt A colonial lexicon: of birth ritual, medicalization and mobility in the Congo (Durham, NC: Duke University Press, 1999); Sheryl Nestel, “(Ad)ministering angels: Colonial nursing and the extension of empire in Africa,” Journal of Medical Humanities (1998) 19:257–77; Adele Perry,“Metropolitan knowledge, colonial practice and indigenous womanhood: Missions in 19th century British Columbia,” in Pickles and Rutherdale, 109–30; and Elish Renne, Population and progress in a Yoruba town (Edinburgh: Edinburgh University Press, 2003). 7. Nancy Rose Hunt , “Fertility’s fires and empty wombs in recent Africanist writing,” Africa (2005) 75:421–35, 428. 8. Carol Summers, “Intimate colonialism: The imperial production of reproduction in Uganda, 1907–1925” (Special Issue: Women, Family, State, and Economy in Africa),” Signs 16 (1991):787–808. 9. Summers, “Intimate colonialism,” 798. 10. See Bryan Callahan, “Veni, vici VD?: Reassessing the Ila syphilis epidemic,” Journal of southern African studies 23 (1997):421–41; Nancy Rose Hunt, A colonial lexicon: Of birth ritual, medicalization and mobility in the Congo. (Durham, NC: Duke University Press, 1999); and Lynn Thomas, Politics of the womb: Women, reproduction and the state in Kenya (Berkeley: University of California Press, 2003). 11. Kaler, Running after pills; Kaler, “Who had told you to do this thing?” 12. D. G. Clarke, Agricultural and plantation workers in Rhodesia—a report on their conditions of labour and Subsistence (Gwelo [Gweru]: Mambo Press,1997), 21. 13. Clarke, Agricultural and plantation workers, 24.

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14. D. G. Clarke, “Settler ideology and African underdevelopment in postwar Rhodesia,” Rhodesian Journal of Economics (1975) 8, 17–38, 31. 15. Clarke,“Settler ideology,”32. 16. Clarke,“Settler ideology.” 17. L. D. Chikanza, D. Paxton, R. Loewenson, and R. Laing, “The Health Status of Farm worker Communities in Zimbabwe,” Central African Journal of Medicine (1981) 27, 88–91. 18. Chikanza et al., “The Health Status of Farm worker Communities.” 19. Chikanza et al., “The Health Status of Farm worker Communities.” 20. Chikanza et al., “The Health Status of Farm worker communities.” 21. Clarke, Agricultural and Plantation workers, 146. 22. See Blair Rutherford, “Settlers” and Zimbabwe: Politics, Memory, and the Anthropology of Commercial Farms during a time of Crisis,” Identities 11 (2004): 543 (20) for retrospective accounts by white farmers of their self-perception as benevolent, engaged citizens. 23. Clarke, Agricultural and Plantation Workers, 89–90. 24. Clarke, Agricultural and Plantation Workers, 51–2. 25. Blair Rutherford, “Another Side to Rural Zimbabwe: Social Constructs and the Administration of Farm Workers in Urungwe District, 1940s,” Journal of southern African studies 23 (1997):107–27. 26. Amy Kaler, “Fertility Running Wild: Elite Perceptions of the need for Birth Control in White-ruled Rhodesia,” in Contraception Across Cultures:Technologies, Choices and Constraints, ed. Elisa Sobo Andrew Russell, Mary Thompson (New York: Berg, 2000), 81–102. 27. These commercial farmers are the same group who are criticized in Annual Reports of the Ministry of Health from the 1950s and 1960s for impeding the attempts of the Ministry to bring various preventive health measures other than family planning to their tenants, on the grounds that such measures interfered with the flow of labor to the farms or cut into the farmers’ profit margins. Provincial Medical Officers of Health complained that commercial farmers failed to respect cordons sanitaires instituted to control outbreaks of cholera and smallpox, and that they did not allow workers to observe quarantines when smallpox was reported. The conjunction of this reluctance with commercial farmers’ enthusiasm for family planning suggests that many farmers may have been motivated as much by economic considerations—in the case of family planning, to limit the number of dependents on their farms and to free women for labor—as by concerns for the health of their workers. However, in my conversations with white women who were farmers’ wives during this period, they stressed their own sense of sympathy with the workers’ wives and their pleasure at being able to help these women through giving them means to avoid having a child every year. As one woman said, “Most of them [workers’ wives] had quite a few and most of them came [for family planning] because they wanted either not to have more children or to wait a while. I would phone up my neighbours’ wives and we would talk [about family planning services for employees’ wives] …Back in the 1970s it was just a case of what the farmer’s wife did. Some did nothing, some were very good. Those [white farmers] that had nurses as

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wives did a lot, and others were very interested in the welfare of their employees, they did as much as they could.” 28. All reports of visits made by FPAR education officers (David Chibvongodze, Hilda Kranzlin, Elisabeth McCarthy, Elizabeth Teubes, and Norah Warburton) are from file NAZ B/137/3 in the National Archives of Zimbabwe (Harare, Zimbabwe). Except for Mr. Chibvongodze, all the education officers who filed the reports preserved in this file were white women, as was the usual FPAR practice for liaison with the white agricultural sector. Although the women were usually accompanied by a male African assistant to translate and to run the film projector, it was the education officer herself who filed the reports, especially in the early days of the FPAR’s education programs. As time went on and more Africans were promoted to education officers duties, reports were presumably filed by Africans, but files from these later days have unfortunately been lost. 29. The Mowbrays appeared to be enthusiastic proponents of family planning among their workforce, according to a report from a white educator who visited the Mowbrays’ Chipoli Farm near Bindura on 14 February 1968: “Mr Mowbray … repeated his willingness to transport candidates at the drop of a hat” (report of a visit by Elisabeth McCarthy). 30. See Kaler, “Who has told you to do this thing?” for a detailed analysis of contraception and subversion of gender hierarchies in Zimbabwe. 31. McCarthy included with her letter an undated clipping from a Zambian newspaper saying that: Black Rhodesians have been told that birth control in Rhodesia is a white plot. This weeks’ issue of the Zimbabwe Review, organ of the Zimbabwe African People’s Union [an exiled African nationalist organization fighting the Rhodesian Front], says the Smith dictatorship wants the African population to remain static while the white population rises higher and higher. The weekly warned every Zimbabwean about the activities and effects of a family planning organization touring Rhodesia.

32. According to one African FPAR worker, some farm workers were suspicious of the film projector and the educational literature which he brought with him on his visits. Some said, “if we see the films we are going to be blind. Sometimes it was misinterpreted, especially in the farming areas where they speak this chilapalapa [a simplified pidgin used for communication between boss and workers]. They [farmworkers] say “We are now going to see the films, if you see the films, you are not going to be having children.”That’s what the boss said. So they were frightened by the boss in some areas. … Even the pamphlets, to give them the pamphlets, they were throwing [away] the pamphlets, they say “If you hold this pamphlet, they [the FPAR[have put the injection in the pamphlet, in the ink.” 33. Possibly a reference to castration, in addition to sterilization? 34. Other forms of symbolic rejection of family planning include the use of body language or interjections during films and talks. See the references above to audiences being exhorted to “laugh only when laughter is called for” and to audience members sitting with their eyes closed and heads bowed during the presentation. 35. Ethnicity may have played a role in this discourtesy. Most early educators were Shona while many of the fieldworkers were Nyanja speakers from Malawi (or speak-

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ers of other languages from Mozambique or Zambia). The friendly relation between the Shona and the Nyanja speakers still exists; in both reports of farm visits and in interviews, FPWs expressed that the Malawians were a bit thick. (“[The African FPAR assistant]’s opinion is that we should do a lot better to concentrate on the reserves talking to the Shona people, rather than slogging away at the farms trying to get the idea through the Malawi minds” [Report of a visit to Glendale farming area by Elizabeth Teubes, October 1967]). However, in my interviews no one referred explicitly to these ethnic differences per se as sources of suspicion or dislike of family planning: the main terms of reference were “African” and “white.” 36. I interviewed the educator in question more than 25 years after this incident. This FPW was very talkative and interested in my project and remembered many stories from their long history with the FPAR in detail, but unable to recall the cat food incident. Perhaps, his silence may indicate distress in receiving such a message of the person as a domestic animal or a pet of the whites, from another African.

6

Translations and TransFormations: Toward Creating New Men in Early Twentieth-century China Angelika C. Messner

The Shanghai Dianshizhai huabao 咲⷇唞⬿ฅ (The Lithographer’s Pictorial)1 in 1892 contains an article named 㽓်㹿ぬ (A Western Woman in Distress). See figure 6.1. The illustration is divided into two scenes. On the right hand side we see a young woman with tousled hair, half naked, half clothed within lumps, people crowding around her are obviously amused and observe the scene which is going on right now. Children are looking curiously. A man, obviously belonging to the building, a temple—talking to her might show her the way home. Her crossed arms indicate that she somehow appears to detest his suggestions. In front of the picture, there are two men talking to each other—but not necessarily about those standing behind them. A man coming from behind turns toward the second scene (on the left of the picture) where obviously a tumult is going on. The above is the description of the illustration. The text tells the story about a woman, who, after suddenly having become mad (diankuang ⱆ⢖) was standing [for a long time] in front of the temple. A Jieshizhe 㾷џ㗙 (one with understanding and experience) come by giving her cloths. One day another mad person, a male one (fengnanren ⯟⬋Ҏ), came to the temple implanting himself vis-à-vis the woman. One day two Westerners came by, a man and a woman,

This chapter is based on my book Medizinische Diskurse: Medizinische Diskurse zu Irresein in China (1600-1930) (Stuttgart: Franz Steiner Verlag, 2000) and my contribution “On ‘Translating’ Western Psychiatry into the Chinese Context in Republican China,” in Mapping Meanings: The Field of New Learning in Late Qing China, ed. Michael Lackner and Natascha Vittinghoff (Leiden: Brill, 2004), 639-57. 99

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credit: Dianshizhai huabao 17–26.4. [1892], 16. Figure 6.1. The Shanghai Dianshizhai huabao

when the mad man approached the [Western] woman and beset her. At this moment a child carrying a basket with a bottle of oil come along. The mad man took the bottle, began to laugh loudly and poured the oil on the head of the [Western] woman. The Western man threatened wildly with his umbrella-stick without success. Only when other people came by to help the Westerners could escape.2

The author states that this story could also be part of a collection of jokes (xiaolin ュᵫ). That is why he reported the story. What is important for the following remarks is that the story shows people suffering from madness were moving freely in the public sphere. It is not the place here to speculate about the “hidden” messages regarding the role of Westerners and their clumsy and at the same time threatening behavior when being confronted with unexpected situations on Chinese streets. Important for our concern is the suggestion that the gesture of acceptance of helpless people was a quite normal phenomenon among people in late Imperial China. The quoted text is about madness. Madness does not appear as a specific problem, however. People appear as being more concerned with the fact that the woman was naked than with her “inner” situation. In opposition to that,

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madness in nineteenth-century Middle European and North American societies increasingly became perceived as a major “social problem” that had to be solved with urgency. This was the background of the Presbyterian medical missionary, John Glasgow Kerr’s (1824–1901) attempts to establish the first Hospital for the Insane3 in China. In 1898, only a few years after the abovequoted story was published, the first insane patient was brought to his asylum in Canton: The philanthropic, medical, and political discourses reflecting missionary attempts to convert Chinese people to Christianity essentially aimed at changing them into “civilized human beings.”4 This was connected with the Western “project of modernity”5 which was propagated as the only way and the only direction human beings had to develop. Although China, compared to the situations of colonial domination elsewhere, was successful in restricting the foreign powers to a minimum of possible influences, the Chinese experience of substantial breakdown in early twentieth century is impossible to tell without referring to western powers on the Chinese mainland beginning with the Opium wars in 1840–1842. By 1895, when China suffered the defeat at the hands of the Japanese (Treaty of Shimonoseki), attempts to save the old order became connected with the struggle for renewing the society. Reform proposals by Kang Youweiᒋ᳝⚎ (1858– 1927) and Liang Qichao ṕẼ䍙 (1873–1929), released in 1898,6 included demands for an indigenous (Chinese) industry, an army according to Western models, a modern postal system, and a banking system run by the State. After the Boxer Rising (1900),7 the court launched reforms in 1905,8 with the purpose of the total renovation of the Chinese order of life, ending up with the replacement of the empire by the Republic of China in 1911. This summary is a brief sketch of the socio-political background for the following analysis.

VARYING PERCEPTIONS OF MADNESS This chapter focuses on the rhetoric and social activities aiming at changing the Chinese “Selves.” Being part of the hegemonic contacts between western powers and China from the late nineteenth century until the 1930s, these activities are steeped in the “project of modernity.” More specifically, the focus in this chapter is on a small fragment of the “project of modernity.”9 The newly introduced view in the early twentieth century identifying the (Chinese) nation as a sick person by referring to sickness, mainly as “insanity”; the relatedness of the “project of modernity,” the “propagation of the Christian message,” “modern Western medicine”10 and the human body. Madness was well known within indigenous Chinese medical systems before, but this knowledge hardly resembled the newly introduced conception of

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insanity by medical missionaries in the early twentieth century.11 The Chinese perception(s) of madness at the time and before can be outlined by three basic constants: First, the lack of any institutionalization of care for the insane. Second, the judicial concept of “Three Pardonables” (san she ϝ䌺) which was to ensure the specific lenient treatment (te bei aiqin ⡍ᚆᛯ㽾) of offenders who were very young, very old, or mad: Already the Zhouli ਼⾂ (Rites of the Zhou)12 paid attention to the “ignorant and imbecile” (zhuangyu ៛ᛮ): In the case of offence they should be treated with clemency.13 This specific lenience appears as a persistent feature within judicial codices until the early twentieth century.14 Third, at the epistemological level, the complex nature of the “medicine of systematic correspondences” did not allow the extraction of any single organ or aspect as sole location or cause for the outbreak of illness. The central concept of madness (diankuang ⱆ⢖15) within the medicine of correspondence was that of disharmony (madness due to yinyang-imbalance, disturbances in body fluids connected to qi ⇷-disturbances inside the body, e.g., qi-reversal, states of repletion (shi ᆺ) and depletion (xu 㰯), blockages of qi within the various organ-systems). Hence, although “mental” symptoms and “mental” illness were not known among Chinese physicians, madness was not described in terms of “mental” symptoms and “mental” illness. The respective descriptions by no means formed a single and separate category in opposition to a single physical category. This is also evidenced by various medical theories appearing in late imperial China, such as the prominent role of the study of the heat (heat as the origin of all diseases, and hence also for madness) as well as different attempts to locate the cause of madness (and/or kuang ⢖16 for instance) as “fire in the yangming 䱑ᯢ-meridian,” or in the spleen-organ system, or in the liver and gallbladder, or in the heart (the heart-holes). The partial accumulation of sputum or wind within a certain place within the human body was seen as causing madness as well as sudden frights. Even approaches which (since the seventeenth century) attempted to subsume different forms of madness under the category “shenbing ⼲⮙” (life-force diseases), indicating a beginning of conceptual extraction of madness from other illnesses, eventually remained within the general systematic approach of correspondences both in diagnosis and treatment. The two fundamentally interwoven spheres (physical and mental) were not divided and cannot simply be reduced by an exclusion of a single element from the whole. Hence, madness figured as any other disease rather as a “quantitative” alteration of normal health; in this, madness did not differ from other illnesses and was not considered a different state, which would imply a fundamental “qualitative” difference between insanity and health. Thus, the “indigenous” medical discourses on various forms of madness obviously neither based on exclusive etiological terms for explaining madness nor can we observe attempts to exclude the sufferer from his own

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environment for healing. Medical explanations of madness did not require an exclusive epistemology to define it.

PROFESSIONAL INSIGHTS: MADNESS RE-DEFINED Fragments of newly introduced medical nosologies from the Western hemisphere, however, sporadically appear in early twentieth century as part of discourses by Chinese doctors trained in Western medicine.17 They accused Chinese physicians for proclaiming “absurd” and “totally wrong” conceptions on insanity, knowing nothing about “psychological” (xinli ᖗ⧚) on the one hand and “physiological” (shengli ⫳⧚) causes for insanity on the other. Wang Wanbai ⥟ᅠⱑ, a Christian physician who also worked as a missionary, speaks of jingshenbing ㊒⼲⮙, indicating “insanity,” meaning “mental disease.” The scientific medical knowledge that insanity ultimately would always be a disease of the brain (naobing 㜺⮙) should replace the “absurd” concept of “sputum which blocks the heart holes” or the concept of “demons and ghosts” believed by dumb people (wuzhi yumin ⛵ⶹᛮ⇥).18 Chinese people, according to Wang, were not aware that ex-prisioners and bandits stirring up trouble everywhere (raoluan defang zhi feitu ᫒іഄᮍП ࣾᕦ) and idiots (chunyu 㷶ᛮ) are actually in general a disguised kind of mad people (fengren ⯟Ҏ) who have to be cured in special hospitals. Demands for a nationwide construction of such hospitals based on the argument that these institutions would protect society from the handicapped (canzei Ⅼ䊞), dumb (yu ᛮ), and weak (ruo ᔅ) in as much the reproduction of all these could be prevented.19 Among the most prominent Chinese intellectuals propagating the brain as the area where all intellectual, mental and psychic activities would take place was Tan Sitong 䄮ஷৠ (1865–1898), who, as a son of a high official, was educated in the conventionalist Confucian ethics and philosophy. But, after having read the Chinese translation of Henry Wood’s (1834–1909) “Ideal Suggestion through Mental Photography” (1893)20 in 1896 he was eager to propagate the necessity to found a school devoted to the study of mind (the power of the heart (xinli ᖗ࡯).21 “We can say that senses (knowledge, zhi ⶹ) come from the heart. But as the heart controls the circulation of the red and purple blood, how can you see the so-called senses (knowledge) there? They must, then, come from the brain.”22 Tan Sitong was among the reformers who in 1898 between June 11 and September 21 succeeded in Beijing at the Court to implement reforms based on Russian and Japanese models. Yet, after only one hundred days, conservative powers gained the upper hand: Tan Sitong and other five

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intellectuals were executed in September 1898. His vision was of a renewed society and the whole world partly based on the concept of “electricity”: Believe me, the brain is electricity. At first I thought that its movement was without a pattern; later I learned that this is not so. When thousands of thoughts are clear and limpid, they stay motionless in the brain and cannot be seen. When a thought emerges, there immediately arises an electrical phenomenon. When the thoughts emerge one after the other, the movement of the brain nerves becomes continuous and incessant. When there is a change in thought, there is also a corresponding change in movement.23

The electric movements are called naoqi zhi dong 㜺⇷Пࢩ (literally: movements of the brain-qi). In the case of madness (fengdian ⯟ⱆ) the brain-qi are moving in a chaotic and disorderly way. One must avoid chaotic movements of the brain-qi in order to prevent this disease. The notion that all intellectual, mental, and psychic activities would take place exclusively in the brain was alien to the traditional medical discourse in China.24 Within Tan Sitong’s writings, the brain-qi figure as an epistemological fundament for his moral demand for reformation at the political level and the reformation in the sense of everybody [self] cultivation. He propagates the power of the heart, e.g. mental or psychic power (xin li ᖗ࡯), as the general healing power which can be made use of not only by a single person but it would be the solution for the desolate situation of the Chinese nation as well. In this respect, Tan’s views resembled the above quoted views of the physician Wang Wanbai, who merely adopted Western conceptions of insanity, which in his eyes were the only objective and scientific solution. Others, like Zhang Xichun ᔉ䣿㋨ (1860–1933), one of the leading Chinese physicians of this time, educated in both Western and Chinese medicine, were questioning this “objectivity.” His main concern obviously was the “fact” that the brain cannot think by itself: It essentially needs the heart, which traditionally was both, the seat of thinking and of feeling. In his opinion, there is an endless circular connection of a silk thread between heart and brain. The Western insight of “the brain receiving one seventh of the whole blood by heart function” served as another confirmation for his connection-paradigm.25 DEALING WITH INSANITY Within the Chinese context of the time, we hardly find a similar alertness for madness as it was the case in industrialized Europe and North America in the nineteenth century. Herein lies one of the reasons for the general disinterest

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in John Glasgow Kerr’s (1824–1901) demands to establish “Hospitals for the insane” in China since the 1870s. Thus, he had no associates when he finally succeeded in establishing the first “Hospital for the lunatics” in China in 1898.26 His view, that insanity was a major problem in China, was neither shared by other missionaries in China nor by the Chinese government.27 Eventually, he was supported by an anonymous missionary in India who donated enough money for the acquisition of land and the erection of two buildings. Kerr’s philanthropic engagement for people who in his eyes were suffering from various forms of insanity was challenged by his younger assistants who favored a more clinical view. One among them, namely Charles Selden,28 supervised the institution until 1927 when he had to close the doors because the communists assumed control.29 Selden reports that within the first ten years of the existence of the hospital the patients were mostly recruited from converted families or their friends from Canton and its hinterland. Afterwards, people came even from Hong Kong, including uprooted vagabonds, but also from well-to-do families.30 According to puritan-protestant ethics besides hydro-therapy and calmative formula, the therapy methods mainly consisted in work (occupational therapy),31 order, hygiene, a detailed day’s schedule in addition to hours of prayer and Bible study.32 Starting from 1909, restraint methods were applied: In special cases people were kept in strait jackets and in metal cages in a horizontal position.33 The “John G. Kerr Hospital for Lunatics” in Canton served as a point of crystallization for various “Mental Hygiene campaigns” in the 1920s34 which were intended to diffuse Western views on health of body and mind. Now the time obviously was ripe for the insanity to be viewed as a major medical and social problem which was based on the epistemology characterized by an intense faith in the capacity of “science” (kexue ⾥ᅌ) to dismantle “tradition” and to achieve its opposite, “modernity.”35 The elimination of all possible disturbing factors within the society would lead to a healthy society. The matrix for this view was the metaphor of the nation as a sick body-person. In the first campaign in 1921, initiated by Robert M. Ross and his wife Margareth Taylor Ross,36 the building was opened for five days for everybody was eager to listen to the representations of the physicians as well as of the police, the senate, and the governor of Canton, deputies of the Board of Trade who were invited as speakers.37 The patients themselves were locked away during these days. Only one year later, the same organizers conducted the second campaign for mental health, especially for Chinese people who were studying Western medicine. This campaign aimed at instructing the Chinese auditorium in “mental health facts” as for instance the “necessary racial purity” in order to prevent insanity; the “necessity to educate the young to an orderly, clean social life without sexual excess—

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syphilis was considered a major cause for insanity.38 For the proposed segregation of all problematic individuals from society, again the necessity of over 1,000 Hospitals for the Insane was proposed.39 The third campaign for mental health in Canton, the so-called Purity Campaign, was organized by the “Canton Christian Council” under the auspices of Dr. F. Oldt,40 and was supposed to serve especially to the explanation of what “prostitution” meant and about the inner connection between prostitution, criminality, and insanity.41 During three months this campaign animated about 3,000 Christians to participate in prayer groups and Bible reading courses with a special focus on elucidation about the danger of prostitution as a source of insanity. Ten years later the monograph Social Pathology in China 42 (1934) appeared pretending to be a handbook about the major problems in China for Chinese students: North America is designed as the standard-example in segregating the insane from their families. In opposition to that, the Chinese attitude to keep such patients at home was characterized as an emblem of an uncivilized country.43 These discursive activities are accompanied, followed, or even preceded by political decisions on various levels: At the beginning of the twentieth century, the police of Canton, for instance, were already starting to pick up stranded people from the streets and to bring them to the hospital; in 1909 the police granted a huge amount of money for the expansion of the institution. In 1913 Yuan Shikai 㹕Ϫ߅ (1859–1916), the fifth President of the Republic of China (reg. 1912–1916), ordered the official recognition of Western medicine, and, in 1915, Western medicine was disposed as the only examination subject within the medical curriculum.44 This decree also signified the sanction of dissecting human bodies.45 In 1913 Canton officially established a health office, followed by Shanghai and Beijing in the 1920s. As part of the police reform in 1901, following the Meiji Reform model in Japan (1868), which again was an adoption from Prussian and French models of centralized, bureaucratic command systems, the Beijing Police Academy was founded by a Japanese “self-taught China expert named Kawashima Naniwa”46 and meant to specifically train and properly equip the police. Whereas the police in nineteenth-century London, Paris, and other large cities systematically operated along the category of “dangerous classes” reflecting a deep social split and defining urban violence as deviance, Chinese police reformers obviously presumed, that beggars, roamers, criminals, and rioters intrinsically were part of urban life: Deviance was thus seen as an inevitable aspect expected in cities in turbulent times.47 Thus, the social aspect of police activities in early twentieth-century China should not be confounded with the specific disciplinarian activities in nineteenth-century Europe and North America. The notion of “dangerous classes” was clearly connected to

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medical conceptions that served again as argumentative foundation for activities in favor of the elimination or isolation of such persons. The idea of the “definition of the human being as brain,” that is, the determination of the qualities of the human being through the brain, can be seen as one of the most “effective terms of modernity for the definition of the human being,”48 and this idea is one of the concepts crucial to the specific Western psychiatric discourse at that time. To sum up, psychiatry in China had its origins as Western psychiatry. In the early twentieth century, Chinese physicians were confronted with Western explications of insanity, which focused on the brain as the place of the development of insanity. Among those struggling for the total renewal of society Chinese physicians argued in favor of the new epistemology and thereby legitimized their demand for establishing thousands of hospitals for the insane in China. Others would hardly accept the view that insanity was a qualitatively different state from any other disharmonic bodily states. This was also reflected by the fact, that within indigenous medical texts no single book is to be found which exclusively deals with insanity. The various philanthropic missionary activities attempting to renew Chinese society were all connected to the project of “modernity”: China was supposed to follow the example of the western civilizations. Despite various discursive activities and political decisions in favor of this project, until the end of 1949 “only” six “Hospitals for Insane” were established. Under the Communist leadership they changed into kind of “reception camps” for homeless people. However, the creation of “a psychiatry with Chinese characteristics”49 is still a work in progress.

NOTES 1. The Dianshizhai hua was a popular pictorial magazine appearing every ten days since 1884; it was normally made up of eight folios, entirely without advertisement. On authorship and circumstances of distribution see Roswell S. Britton, The Chinese Periodical Press 1800-1912 (1933) (Taibei: Ch’eng-wen publishing, 1966), 69ff; Ye Xiaoqing, Popular Culture in Shanghai 1884-1912 (1933) (Canberra: The Australian National University); Yu Yueting ֲ᳜ҁ, “Wo guo huabaode shizu: dianshizhai huabao chutan ៥೟⬿ฅⱘྟ⼪,” Xinwen yanjiu ziliao ᮄ㘲ⷨお䊛᭭, 1981, 5. It was a “typical product of nineteenth century China coast culture” (See Eric Zürcher, “MiddleClass Ambivalence: Religious Attitudes in the Dianshizhai huabao,” Études chinoises, XIII, 1-2, printemps-automne 1994: 109-43). On authorship and circumstances of distribution, see Roswell S. Britton, The Chinese Periodical Press 1800-1912 (1933) (Taibei: Ch’eng-wen Publishing, 1966), 69; Ye Xiaoqing, Popular Culture in Shanghai 1884-1912, Ph.D.Diss. (Canberra: The Australian National University, 1991).

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2. See Dianshizhai huabao, 17–26, 4. (1892), 16. 3. I here use “Hospital for the Insane” and “Asylum for the Lunatics” interchangeably. Kerr himself throughout speaks of an asylum, but others called it a hospital. 4. On this issue see Paul Cohen, “Christian Missions and Their Impact to 1900,” in The Cambridge History of China, Vol. 10, Late Ch’ing, 1800-1911, Part I, ed. John K. Fairbank (Cambridge: Cambridge University Press, 1978), 543–614; Peter Buck, American Science and Modern China 1876-1936 (Cambridge, Cambridge University Press 1980), 8-43. 5. I refer to the definition in Prasenjit Duara, “Knowledge and Power in the Discourse of Modernity: The Campaigns against Popular Religion in Early Twentieth-Century China,” The Journal of Asian Studies, 50, 1 (February 1991): 67–83, 67: “[…] a discourse which structures the perception of the world not only cognitively through the categories of rationality and science, but also by means of such values as progress and secularism, which are often inseparably entwined with the former.” 6. This reform stopped after a very short time (Hundred Days Reform). 7. This uprising resulted from manifold factors like catastrophic flood and drought in North China, and after the occupation of Qingdao and its hinterland by the German army of occupation; in total there were 229 foreigners killed. See Joseph W. Esherik. The Origins of the Boxer Uprising (Berkeley, Los Angeles, London: University of California Press, 1987); Mechthild Leutner and Klaus Mühlhahn (eds.), Kolonialkrieg in China. Die Niederschlagung der Boxerbewegung 1900-1901. (Band 6 der Reihe “Schlaglichter der Kolonialgeschichte”) (Berlin: Christoph Links Verlag, 2007). 8. These reforms can be seen as the most radical attempts within the Chinese history until the modernizing policy launched by Deng Xiaoping in the 1980s. The abolition of the traditional examination system for instance now forced many young people to study at foreign universities; Japan, Germany, and North America were among the most frequented countries. Among the many fields of reform, as for instance the police reform, which began in 1901, the law reform, the demand for the fundamental renovation of the Chinese education system obviously was the most drastic one, since it meant to “renew” the individual. See Douglas R. Reynolds. China, 1898-1912: The Xinzheng Revolution and Japan (Cambridge, MA: Harvard University Press, 1993). 9. Hutchison characterizes North American missions in terms of an “activistic and civilizationizing” approach. See William R. Hutchison, “A Moral Equivalent for Imperialism: Americans and the Promotion of ‘Christian Civilization’, 1880-1910,” in Missionary Ideologies in the Imperialist Era: 1880-1920, Papers from the Durham Consultation, 1981, ed. Torben Chistensen and William R. Hutchison (Aarhus: Christensens Bogtrykkeri, 1982), 167–77. For an overview of the missionary activities in late Imperial China see Paul A. Cohen, “Christian missions and their impact to 1900,” in Cambridge History of China, 10, 543–90; Jerome Ch’en, China and the West, Society and Culture 1815-1937 (London: Hutchison, 1979). 10. China was the first country where medical-missionary projects took place. Rev. Dr. Peter Parker (1804–1889) was the pioneer within this field. In 1835, when he arrived at Canton, about 100 missionaries worked at 60 different stations in China, mostly in Canton (North American Protestants), in Peking (Jesuits) and in Macao

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(Portugiese Catholics). Protestant mission in Canton was conducted by the “American Board,” the “American Bible Society,” the “United Foreign Missionary Society” and the “American Colonialization Society.” See Kenneth S. Latourette, A History of Christian Missions in China (New York: The Macmillan Company, 1929), 615–21. Parker himself was a member of the Presbyterian Mission, like John G. Kerr. Together with Dr. Colledge and Rev. Bridgeman Parker established the “Medical Missionary Society” in 1838. See Edward V. Gulick, Peter Parker and the Opening of China (Cambridge, Massachusetts: Harvard University Press, 1973), 44; Chimin K. Wong and Lien-teh Wu, History of Chinese Medicine [1936] (Taibei: Chengwen publisher, 1977), 307. Different to the hospitals and drugstores which have been erected before by missionaries (for missionary colleges only), the hospital established by Peter Parker especcially should serve mainly Chinese patients. In 1887 the first medical journal “in heathen lands” was established: “The Medical Missionary Journal.” See Chimin K. Wong and Lien-teh Wu, History of Chinese Medicine [1936] (Taibei: Chengwen publisher, 1977), 465-66. 11. Madness (diankuang ⱆ⢖) in a most general sense was seen as a manifestation of either depletion or repletion of Qi ⇷. See my Medizinische Diskurse zu Irresein in China (1600–1930) (Stuttgart: Franz Steiner Verlag, 2000), 78–194; Martha Li Chiu, Mind, Body, and Illness in a Chinese Medical Tradition, Ph.D. diss. (Harvard University, reprint Ann Arbor, UMI), 1981. 12. The Zhouli is one of four extant collections of ritual matters of the Zhou Dynasty ਼ (from about 400–300 B.C.).The final redactional work on these books took place during the Han Dynasty (202 B.C.– 220 A.C.). Three of them were incorporated into the Canon of Confucian Classics: Liji ⾂㿬, Yili ‫⾂۔‬, and Zhouli. The fourth, the Da Dai Liji ໻᠈⾂㿬, has only survived in fragments and was almost forgotten for centuries. 13. “The first [amnesty] is [for] young and weak (youruo ᑐᔅ), the second [amnesty] is [for] old and senile (laomao 㗕㗘), the third [amnesty] is [for] ignorant and imbecile (zhuangyu ៛ᛮ). See Zhouli, in Shisanjing कϝ㍧ ⊼⭣. Compiled by Ruan Yuan 䰂‫ܗ‬. [Photomechanic reprint from woodblock-print 1816] (Taibei, Xinwenfeng chuban gongsi, 1988), 3, juan 36, 540. 14. Of course, this is no answer to the question of how such people in reality were treated. The same is even true for legal case stories from the seventeenth and eighteenth centuries. Vivien Ng in her study Madness in Late Imperial China: From Illness to Deviance (Norman: University of Oklahoma Press, 1990), attempts to answer this question. Yet, she fails, since her instrument of analysis completely relies on predefined insights from the history of Western psychiatry: One of these predefinitions regards the relief of “insane people” in 1793 (when Philippe Pinel in the hospitals Salpêtrière and Bicêtre freed the patients from their chains) which might be interpreted as a sign of humanism. Ng’s interpretation fails on three points: Her thesis “from illness to deviance” is based on the shift that Michel Foucault generally stated for Middle Europe around 1800. By transfusing this presumption on the Chinese context—she also equates Western theology with Chinese “philosophical orthodoxy” in the early seventeenth and eighteenth centuries—Ng identifies the Chinese medical discourse with the Western medical discourse. She uses insights from

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the Middle European history in the sense of normative heuristic conceptions for the analysis of Chinese history. See Vivien Ng, Madness in Late Imperial China: From Illness to Deviance (Norman: University of Oklahoma Press, 1990), 32 and 170. When Ng commiserates for instance that no physician within the Chinese context of the seventeenth and eighteenth centuries was allowed to diagnose “insanity” before the court, she clearly misinterprets the Chinese context in favor of the insights into the Western history of psychiatry, because she interprets the starting cooperation between the court and medical authority in nineteenth-century Europe and North America [See Roger Smith, “The Boundary between Insanity and Criminal Responsibility in Nineteenth-Century England,” in Andrew Scull (ed.), Madhouses, Mad-Doctors, and Madman. The Social History of Psychiatry in the Victorian Era (London: Athlone Press, 1981), 363-84. 15. Diankuang was the most common term for madness. 16. Generally translated as “mania.” 17. It is not the place here to dwell on related translations in the seventeenth and eighteenth centuries. See Angelika C. Messner “Some Remarks on Semantics and Epistemological Categories in early Scientific Translations,” Monumenta Serica Journal of Oriental Studies, LIII (2005): 429–59. 18. Wang Wanbai was engaged in the public recognition of Western medicine in China. In the 1920s, he founded a hospital in his hometown of Changzhou where he dedicated himself to the distribution of the smallpox vaccination. Later on at Suzhou he founded a small Insane Hospital (fengrenyuan ⯟Ҏ䰶). See Wang Wanbai ⥟ᅠ ⱑ,Fengrenyuan zhi zhongyao yu biyi ⯟Ҏ䰶П䞡㽕㟛㺼Ⲟ (On the importance and benefit of lunatic asylums), Zhonghua yixue zazhi 3 no. 5: 127–31. 19. See Wang Wanbai ⥟ᅠⱑ, “Fengrenyuan zhi zhongyao yu biyi ⯟Ҏ䰶 П 䞡㽕㟛㺼Ⲟ” (On the importance and benefit of lunatic asylums), Zhonghua yixue zazhi 3, 5: 127. 20. The translator was John Fryer (1839–1928). He was employed at an English college in Hong Kong in 1861 for two years were he learned the Cantonese language. In 1863 he began to teach English in Beijing for another two years. In 1865 he left the School for Shanghai and in 1868 he started to translate scientific books at the Jiangnan Arsenal. Between 1870 and 1880 he published about 34 translations on natural science and technology. See Jonathan Spence, The China Helpers, (London: The Bodley Head, 1969), 140–54; Adrian Arthur Bennett, John Fryer: The Introduction of Western Science and Technology into Nineteenth-Century China (Cambridge, MA: Harvard University Press, 1967); Wang Yangzong ⥟᦮ᅫ, Fulanya yu jindai Zhongguo de kexue qimeng ٙ㰁䲙㟛䖥ҷЁ೟ⱘଳ㩭 (Fryer and the Enlightenment in Modern China), (Beijing: Kexue chubanshe, 2000); Rune Svarverud, “The Formation of a Chinese Lexicon of International Law 1847-1903,” in Mapping Meanings: The Field of New Learning in Late Qing China, ed. Michael Lackner and Natascha Vittinghoff (Leiden: Brill, 2004), 507–36, 516–18. 21. Xinli can also be rendered as “power of the mind” or as “psychic power.” See Tan Sitong, Renxue ҕᅌ (An Exposition of Benevolence) [1896] in An Exposition of Benevolence: The Jen-hsüeh of T’an Ssu-t’ung, translated by Chan Sin-wai (Hong Kong: The Chinese University Press, 1984), 61 and 285. On the influence

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of Wood’s book on Tan Sitong see Richard H. Shek, “Some Western Influences on T’an Ssu-t’ung’s Though,” in Paul A. Cohen and John E. Schrecker, eds., Reform in Nineteenth-Century China (Cambridge, Massachussetts: East Asian Research Center, Harvard University, 1976), 194–203. 22. See Tan Sitong, Renxue ҕᅌ (An Exposition of Benevolence) [1896] in An Exposition of Benevolence: The Jen-hsüeh of T’an Ssu-t’ung, translated by Chan Sinwai (Hong Kong: The Chinese University Press, 1984), 251 and 96. 23. See Tan Sitong, Renxue ҕᅌ (An Exposition of Benevolence) [1896] in An Exposition of Benevolence: The Jen-hsüeh of T’an Ssu-t’ung, translated by Chan Sinwai (Hong Kong: The Chinese University Press, 1984), 290 and 209. 24. On the history of this complex question see Angelika C. Messner, Medizinische Diskurse zu Irresein in China (1600-1930), (Stuttgart: Franz Steiner Verlag, 2000), 198–211; Angelika C. Messner, “On ‘Translating’ Western Psychiatry into the Chinese Context in Republican China,“ in Mapping Meanings: The Field of New Learning in Late Qing China, ed. Michael Lackner and Natascha Vittinghoff (Leiden: Brill, 2004), 639–57, 649. 25. See Zhang Xichun ᔉ䣿᯹, Yixue zhongzhong canxi lu 䝿ᅌ㹋Ёগ㽓䣘 (The assimilation of Western and Chinese medicine) [1918-1934] (Hebei: Kexue jishu chubanshe, 1995). This book appeared between 1918 and 1934, published in 7 parts (in 30 juan). Zhang served as military physician at the end of the Qing dynasty, and from 1918 was head of a hospital in Liaoning. From 1928, he lived in Tianjin running ‘correspondence courses’ for traditional medicine. 26. Already in the 1870s he articulated his philanthropic driven desire for helping insane people in China, after traveling back to North America for several times in the late 1860s. During the following sojourns in North America in the late 1870s, the mid 1880s, and the early 1890s he collected money for China. Moreover, his attempt to equalize the situation for insane patients in China to that in North America led him to the calculation that China would need 300 hospitals for 1,000 patients each. J. G. Kerr, “‘The Refuge for the Insane,’ Canton,” The China Medical Missionary Journal 12, no. 4 (1898): 178. For an analysis of the situation in an asylum in Beijing in the 1930s, see Hugh Shapiro, The View from a Chinese Asylum: Defining Madness in 1939s Peking, Ph.Dissertation (Harvard: UMI) 1995. 27. Zhang Zhidong ᔉП⋲(1837–1909), one of the two governors who controlled the middle and lower Yangzi-region, simply stated: No interest in this matter. See C. Selden, “The Story of the John G. Kerr Hospital for the Insane,” The China Medical Journal 52 (November 1937): 713. 28. Charles Selden originally came to China in order to establish an orphanage. 29. The communist party launched nineteen regulations for all hospitals (including both foreign and Chinese managed) in regard to the insurance for the whole personnel. Selden could not meet the demands. In the 1930s the hospital was taken over by Chinese doctors. See Charles Selden, “The Story of the John G. Kerr Hospital for the Insane,” The China Medical Journal 52 (November 1937): 713; “China Medical Association Section, The John G. Kerr Hospital for the Insane, Canton,” The Chinese Medical Journal, XLI (January 1927): 164–65. For a general overview on the situation of medical missionaries working in China at this respective time, see John Z.

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Bowers, Western Medicine in a Chinese Palace: Peking Medical College, 1917-1951 (New York: Josiah Macy, Jr. Foundation, 1972). 30. Charles Selden, “Work among the Insane and Some of Its Results,” The China Medical Missionary Journal 19, 1 (January 1905): 17. 31. Work as therapy indeed was a foreign implant. See Mary Brown Bullock, An American Transplant, The Rockefeller Foundation and Peking Union Medical College (Berkeley: University of California Press, 1980). 32. Selden, “Work among the Insane, 1–17; Charles Selden, “Ill Treatment of the Insane,” The China Medical Journal 23, 6 (November 1909): 373–84; Charles Selden, “The Need of More Hospitals for the Insane,” The China Medical Journal 24, 5 (September 1910): 330. 33. Selden, “Work among the Insane,” 9. 34. Medical missionaries at the beginning mainly called attention to the necessity of clean water and food (See for instance A. Stanley, “Hygiene in China,” The China Medical Missionary Journal 20 (November 1906): 235–41; In the 1920s prevailed the discourse on “Social evil.” See Robert M. Ross, “The Insane in China: Examination hints,” The China Medical Journal 24 (1920): 514–18. 35. On the application of the concept of science in twentieth-century China see Wang Hui, “The Fate of ‘Mr. Science’ in China: The Concept of Science and Its Application in Modern Chinese Thought,” Positions East Asia Cultures Critique 3, 1 (spring 1995): 1–68. 36. She served as a doctor at the David Gregg Hospital where Charles Selden worked as an instructor. See Chimin K. Wong and Lien-teh Wu, History of Chinese Medicine [1936] (Taibei: Chengwen publisher, 1977), 689. 37. These cooperative activities between police and physicians could be interpreted as equivalent activities to the situation in nineteenth-century North America and Middle Europe. 38. The 1899 conference on social hygiene in Brussels discussed the “problem” of venereal diseases. As a remedy the confinement of prostitutes within special hospitals was proposed. See “Brussels Conference of Social Hygiene,” The British Medical Journal 2 (1899): 676–78. 39. Robert M. Ross, “Mental Hygiene,” The China Medical Journal, Vol. XV (January 1926): 12. 40. See especially the article “The Demi-Monde of Shanghai,” The China Medical Journal (August 1923): 782–88, where various forms of prostitutions are differentiated in order to show the complexity of the phenomenon. 41. Oldt demanded special “Hospitals for veneral diseases.” See F. Oldt “Purity Campaign Canton,” The China Medical Journal (August 1923): 777. 42. See Herbert Day Lamson, Social Pathology in China (Shanghai: Commercial Press, 1934). 43. Lamson, Social Pathology in China, 383 and 385. 44. See Chimin K. Wong and Lien-teh Wu, History of Chinese Medicine [1936] (Taibei: Chengwen publisher, 1977), 436–38. 45. In 1922, however, traditional Chinese medicine was allowed again as an examination subject, yet her status was relatively low. See Ralph C. Croizier, Tradi-

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tional Medicine in Modern China: Science, Nationalism and the Tensions of Cultural Change (Cambridge, MA: Harvard University Press, 1968), 47. 46. See David Strand, Rickshaw Beijing. City People and Politics in the 1920s [1989] (Berkeley, Los Angeles, London: University of California Press, 1993), 67. 47. See the discussion in David Strand, Rickshaw Beijing. City People and Politics in the 1920s [1989] (Berkeley, Los Angeles, London: University of California Press, 1993), 89-95. 48. See Michael Hagner, Homo cerebralis: Der Wandel vom Seelenorgan zum Gehirn (Berlin: Berlin Verlag, 1997), 293. 49. See Veronica Pearson, Mental Health Care in China: State Policies, Professional Services and Family Responsibilities (London: Gaskell, 1995), 4.

7

Rejected or Elected? Processes of Therapeutic Selection and Colonial Medicines in French Vietnam, 1905–1939 Laurence Monnais In the early twentieth century, in their monthly reports to their superiors, French doctors posted in Vietnam described, and condemned, acts of refusal on the part of indigenous people towards the medicines they were being offered. For such doctors, this refusal was an expression of mistrust, even of deplorable ignorance, in the face of the benefits of modern Western medicine. Yet, even before World War I, the same doctors, along with their Vietnamese colleagues, also reported enthusiasm among their patients for particular pharmaceutical products, an enthusiasm they presented as undeniable proof not only of the success in their mission to medicalize, but also of its popularization. What can one make of this double discourse? Surely, it cannot simply be the product of time. How could the Vietnamese, in just a few years and in a context of political subjection, have suddenly yielded to the medicalizing intentions of these western(ized) doctors? In an attempt to analyze the dissonance in these discourses, the hypothesis followed in this chapter is that the Vietnamese made complex choices in their recourse to colonial therapies.1 Indeed, throughout the first half of the twentieth century, some therapeutic products were accepted, often with surprising ease and rapidity, while others were rejected, at times quite forcefully so. This made some practitioners uncomfortable, and also accounts for the contradictions I find in medical and administrative records. It is on this process of selection that I focus here first identifying its patterns, and then interrogating the reasons behind it. Even heavily biased sources, administrative and medical, which virtually neglect the voices of sick people and consumers of therapy, provide a glimpse into these reasons. Drawing on additional littleused sources, in particular the Vietnamese popular press from the interwar period, I have been able to make out three broad factors acting on therapeutic 115

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choices: pre-colonial popular representations, the therapeutic relation that was imposed by the colonial system, and the gap between the ideal and the actual provision of medicines within the colonial system of healthcare.

COLONIZATION, MEDICALIZATION, AND MEDICINES The history of modern medicines2 in Vietnam is embedded in the French domination of Indochina (1858–1954),3 and in the project of medicalization with which it was associated. Indeed, this association manifested a powerful synchronism: the scientific medicine4 that emerged in the nineteenth century became a tool of empire, that is, a political, economic, and humanitarian instrument that was dedicated to the cause of pacification and then of exploitation and of mise en valeur—the rational development of human and natural resources5—of this region. By 1905, this endeavour was structured by a formal healthcare system designated under the generic heading Assistance Médicale Indigène [Indigenous Medical Assistance] or AMI. This system was grounded in a desire to demonstrate the alleged scientific nature of European medicine and the power of public health and of its promoters. Among its core priorities were massive vaccination campaigns (with an emphasis on smallpox), in continuity with previous interventions deployed as early as the first Cochinchina conquests of the 1860s, and the provision of hospital care, for which a network of institutions was rapidly extended and diversified: by 1936, there were over 600 health facilities in the Vietnamese region, or which at least two thirds were small clinics, dispensaries, and infirmaries.6 This system was based on the principle of free healthcare provision for “indigents”—a segment of the population that was probably not insignificant— and for agents of the colonial State. It placed special emphasis on the twopronged objective of prevention and the propagation of rules of hygiene; this double priority was used to justify attempts to transform local social norms and intrusions into people’s intimate lives. Indeed, metropolitan legislative frameworks were quickly imposed, particularly in urban areas, to regulate a wide range of domains, from the appropriate adduction of drinking water to the cleanliness of buildings, funeral rites, and the control and surveillance of prostitutes and the contagiously ill. Still, real efforts were made to adapt this “French-style” health system to Vietnamese realities. Signs of adaptation became visible during the interwar period, as colonial medical actors were able to better grasp the geographical and pathological, and to a lesser extent socio-cultural, environment in which they worked. This willingness to adapt was concretized in qualitative as well as quantitative shifts: institutional care was provided for sufferers of “social diseases” (venereal, pulmonary, ocular,

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and cancerous affections); social and sanitary protection was extended to mothers and children; the diffusion of “essential care” into rural areas was prioritized; and the number of medical, especially subaltern, personnel was increased considerably, primarily through a process of “vietnamization.” By 1939, about 3,500 indigenous nurses and midwives worked for the AMI. This set of shifts thus constituted a polymorphous movement of indigention.7 How important were medicines in this system? What functions were they attributed, and did these functions change over time? The available medical and administrative sources consistently speak very little about this issue. For a long time, pharmaceuticals seem to have been relegated to a secondary role, and were tacitly assimilated, as minor medical tools, to the provision of hospital care. Only vaccines, elected by the Pastorians, whose heavy presence in Indochina was unrivaled in any other colonial territory,8 and supported by a logic of collective prevention in the face of regional epidemic and endemic threats, made it to the forefront of each policy plan. The little importance medicines were given in this colonial context can be explained by a combination of general and specifically colonial factors: first, the position of therapeutic scepticism9 adopted by western doctors—in the Metropole as much as the colonies—out of awareness of the limits of their therapeutic arsenal, at least until the introduction of arsenobenzols and of Salvarsan (606) in 1910;10 and second, the priority colonial doctors felt compelled to nearly always give to mass prevention over individualized treatment in the face of endemic and epidemic tropical diseases that were not only devastating, but about which, in some cases, they knew very little. As a result, it was only with World War I that I see the emergence of a discourse on the value of medicines, and of their civilising potential. This discourse gathered strength in the 1920s and especially the 1930s, when antibacterial sulphonamides were introduced.11 And yet, since 1905, the legislative and institutional framework of AMI had defined the contours of the population’s access to pharmaceuticals. It regulated the importation of pharmaceutical substances, particularly those containing toxic substances,12 the conditions for obtaining some medicines—such as those requiring a prescription—and the distribution of free medicines to indigents, government agents, and several groups deemed to be “at risk” or underprivileged. In the margins of this public system, wealthier Vietnamese could go to the doctor or pharmacist as they wished, as long as they could afford the price of a consultation and prescription, or simply the price of non prescription drugs. The rural population was erratically visited by medical circuits; these often involved distributions of free basic medicines. From 1909, a State quinine service [Service de Quinine d’État] provided inhabitants of regions with a high prevalence of malaria with opportunities to obtain free or subsidised quinine.13

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Most notable, however, was the creation, authorized by a law of April 18, 1920, of basic medicine stores [dépôts de médicaments]. As an upshot of the interwar reorientation of health policies and of a new faith in therapeutics, these stores launched a broader diffusion of basic medicines in communities further than 10 km from an AMI facility or a private pharmacy. Vietnam is the only country in Southeast Asia to be part of the Confucian world—a consequence of nearly 1,000 years of colonization by its powerful neighbor—has developed rich and complex medical traditions, within which a distinction is usually made between the “Northern medicine” (Thuôc bac) or Chinese medicine and “Southern medicine” (Thuôc nam) or Vietnamese medicine, referring to a more popular tradition of healing that draws on a rich local biodiversity.14 Thuôc translates as tobacco, remedy, as well as medicine or healing; its multiple meanings illustrate the centrality of medicinal substances in the double-stranded medical heritage it designates—poorly translated as Sino-Vietnamese or Sino-Annamese in colonial-era documents—in which drug therapies are indistinguishable from the art of healing, and have long constituted the core of actions on illness and sick individuals.15 It seems reasonable to believe that colonial medicines might have been rapidly adopted by the population, at least more so than other kinds of interventions into health that were less familiar in terms of local cultural references.

THERAPEUTIC SELECTION: SOME MANIFESTATIONS The reality was certainly more complex; throughout my period of study, I have observed wide contrasts in reactions to therapy ranging from categorical rejection to expressions of enthusiasm that were virtually instant and unconditional. One of the most striking features of medical discourses dating from the early years of AMI was the expression of a particularly vehement refusal, or at least an obvious recalcitrance, by the Vietnamese in response to the first biomedicines diffused in this region, that is vaccines. Rejected Medicines Smallpox vaccination was imposed on the population of Cochinchina from 1871, an obligation that was extended to the rest of Vietnam in the 1880s.16 Soon produced locally thanks to the perseverance of the Pastorians, the vaccine was the core component of massive prevention campaigns that indeed seem to have elicited clear reactions from the Vietnamese. In one village at the turn of the twentieth century, anyone who was summoned to a vaccination session, and who had a little money to spare paid to have themselves

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replaced; in another, mothers sucked on their babies’ arms to extract the noxious substance from their bodies.17 Similarly, plague, and later anti-cholera vaccination campaigns gave rise to varied expressions of discontent, some even escalating into large-scale anti-French protests.18 Introduced in Saigon schools in 1921, the tuberculosis vaccine BCG was perhaps the first vaccine to arouse more interest than dissension. However, its use would remain circumscribed, and was accompanied by the distribution of information about the procedure, as well as social and financial support to families affected by pulmonary tuberculosis.19 Vaccination, which was not only compulsory but was also clearly a preventive measure, was, for a long time, held up by colonial doctors as the symbol of Vietnamese refusal of modern medicines. These practitioners also lamented the rejection of quinine, especially for the prevention of malaria. As the prime cause of morbidity in Indochina throughout the period of domination,20 malaria was seen as a major public health problem, especially because it affected populations who had been put to work for the exploitation and economic development of the region. Besides their reluctance to take medicines when they were not sick, the Vietnamese seem to have refused to consume substances that induced side effects, or at least perceptible bodily reactions. Thus, the use of copper sulphate to treat trachoma, “the application of which, in addition to being very painful, often provokes an intense reaction of the conjunctiva” would also be massively vetoed by sufferers in the 1920s. During the same period, leprosy treatments consisting of chaulmoogra oil injections, known to be very painful and to provoke nausea and high fever, probably boosted leprosaria escape rates. Similarly, patients reportedly rejected the dairy diet prescribed for dysentery. They complained about the discomfort it caused, probably as a consequence of lactose intolerance in most cases, or categorically refused to consume foods, which, in fact, were completely absent from their usual diets.21 In addition, some AMI doctors constantly complained that Western medicine and its agents were being sought out as a “last resort,” that is, after trying to obtain relief from traditional therapists and other available remedies. This tendency was interpreted by French doctors and some Western-trained Vietnamese practitioners of the school of medicine opened in Hanoi in 1902 with the first class graduating in 1905 as an expression of preference for a “crude empiricism” rooted in ignorance and fear.22 They saw it as an obstacle to their own therapeutic interventions, producing conditions under which these were more difficult and less effective. It may be appropriate to suggest that this tendency was, by and large, a manifestation not so much of a refusal of modern therapies but of mutating practices of medical pluralism.

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Changing Visions: Medicines Accepted and Demanded Indeed, from World War I, numerous medical reports drew attention to the success encountered upon offering some Western medicinal treatments. Other sources confirm this enthusiasm for biomedical therapies, perhaps less directly, but also more convincingly (the truthfulness of reports that government-employed doctors were obliged to submit to the administration to which they were accountable is open to question). Among these are documents issued by judiciary and customs services, in which I find statements of violations of laws regulating the practice of medicine or pharmacy, reports of cases of theft of medicines from AMI hospitals or of lucrative black market trading of certain substances,23 as well as a plethora of advertisements for commercial specialties and patent medicines that abound in the local press, published in French and in quoc ngu.24 More specifically, the most prominent feature of this enthusiasm is the popularity of several dozens of commercial specialties in urban environments. Upon consulting contemporary magazines and newspapers,25 I was struck by the strong presence of French private pharmacies in this media landscape and by the efforts they deployed to praise, often in Vietnamese language, the merits of a plethora of products that were allegedly highly popular in colonial society and, for the most part, in metropolitan society as well. While making a direct link between this publicity and the consumption of featured products would certainly be problematic, the vietnamization of trademark names—for example, Gastrol (for stomach pains) was referred to as Ga-TòRôn, while Morrhuol (a cod liver oil based remedy for colds and bronchitis) as Mo ru ôn—does seem to indicate a certain level of local familiarity with some of the remedies being advertised. Additional evidence for this interpretation is provided by a growing number of seizures of counterfeit French products, produced locally or in China at lower cost,26 and by the local manufacture, by French pharmacists in small laboratories adjacent to their shops, of products destined for the Vietnamese market.27 For example, the Pharmacie Montès in Hanoi marketed its own “cachets antiseptiques” [antiseptic tablets], while the Pharmacie Chassagne produced a “collyre jaune selon la formule du Dr Casaux” (yellow eye-drops based on the formula of Dr. Casaux, a colonial ophthalmologist who was the director of the Hanoi Ophtalmological Institute in the 1920s), which was allegedly tailored for the “native constitution.”28 It is significant that Pharmacie Chassagne also owned a magazine for the popularization of health information, the Vê sinh Bao, Journal de Vulgarisation d’Hygiène. With a monthly circulation of 13,000 copies from 1926 to 1933, the publication was used by Chassagne’s successors, the pharmacists Lafon and Lacaze, as an advertising platform,

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as well as to diffuse knowledge and basic principles concerning matters of health, prevention, and self-care. Advertised remedies were indicated for a variety of conditions. Often portrayed as panaceas but sometimes also as specifics,29 they usually promised relief for various symptoms: from cough and pains to “generalised weakness,” anemia, anxiety and insomnia, digestive discomfort, fever or dermatological affections. As for their cost, owing to a lack of extensive information, there is some evidence that these medicines were relatively inexpensive (0,30 piastre ($) for eye-drops; 0,40 for a bottle of Gastrol) and thus accessible to a relatively high proportion of households.30 On the other hand, the modest cost of this type of commercialised product does not, in and of itself, constitute an argument “for” or “against” extensive recourse to Western medicines: while the high cost of French medicines was often brought up by associations of traditional therapists in the 1930s as an argument against restricting their practice, other sources convey the idea that the Vietnamese were accustomed to paying a high price for some Chinese medicines. Outside urban areas, enthusiasm for colonial medicines would be directed toward some of the products distributed in basic medicines stores, which were soon beset by chronic shortages across the country.31 These products, according to a law of 1920, were “ready to use,” in that should not require any manipulation or preparation on the part of the distributor,32 as well as non-toxic, and could be sold without a prescription. It was required only that they be accompanied by a notice describing their therapeutic indications. Among the medicines found in these stores were quinine, purgatives (sodium sulphate), analgesics and antipyretics (sodium salicylate, Pyramidon, Antipyrin, Aspirin), ointment for scabies (pommade d’Hélmerich), pills for diarrhoea (pilules de Second), emetine hydrochloride for dysentery, several types of eye-drops, copper sulphate, two or three antiseptics and anthelminthics (santonin, thymol) as well as a few syrups and expectorants. Thus, as with the advertised medicines, these were, for the most part, indicated for the treatment of common symptoms—fevers, diarrheas—and of minor but recurring infections—worms, parasites, benign eye infections—and meant to be sold at very low cost: a dose of Antipyrin, for example, cost 0,1–0,2$ in a basic medicines store in 1930. Finally, there are a few pharmaceuticals, which, in the 1930s, seem to have elicited immediate enthusiasm pretty much everywhere they were distributed. Unlike most advertised remedies and the basic medicines sold in rural stores, these products could only be legally obtained with a prescription; they were considered to be highly toxic and to carry a risk of therapeutic accidents when used without medical guidance. The introduction of Salvarsan in 1911 seems to have instigated a growing recognition of the efficacy of specific chemical

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treatments against several devastating or previously incurable affections. The class of medicines that exemplified this third movement of enthusiasm for biomedicines, however, was the sulphonamides, and especially Dagénan, which was used in Tonkin from 1938 to treat gonorrhea, pneumonia, as well as some forms of urinary infection and meningitis. A large black market developed around this class of drugs, growing dangerously during World War II, to the extent of implicating French military personnel, as well as employees in pharmacies and doctors’ houses who had access to their employers’ prescription pads.33 These three movements of pharmaceutical enthusiasm clearly indicate that the therapeutic choices made by Vietnamese people did not easily fit into, and often sought to bypass, the rules governing the distribution of medicines upheld by colonial doctors. An analysis of the potential determinants of this selection, which is attentive to diverging opinions and interpretations of medicines’ functions and of the conditions under which they could be obtained, helps to better understand its basis and confirms its political, economic, and above all cultural dimensions.

MAKING CHOICES: PROCESSES IN THERAPEUTIC SELECTION The seemingly contradictory attitudes elicited by quinine offer us a key for understanding, in this case, the factors that came into play in processes of therapeutic selection. While colonial doctors remarked on a tenacious resistance against its ingestion for preventive purposes, triggered, they suggested, by a fear of lethal suffocation,34 they also observed a growing tendency to seek it out as a treatment for bouts of fever. This apparent inconsistency may in fact, I suggest, be symptomatic of a set of factors bearing on therapeutic choices: the influence of pre-colonial representations; the challenges experienced by doctors in getting their patients to comply with the therapeutic rules they sought to impose; and more concrete conditions arising from a considerable gap between the ideals and realities of therapeutic provision in colonial Vietnam at that time. The Influence of Representations Reflecting on popular representations of illness, health, the body, but also of therapy, it is possible to hypothesize that an earlier conception of malaria as a devastating and incurable scourge in Vietnam may have facilitated the progressive acceptance of quinine-based treatments. The recognition of

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quinine’s efficacy may have been accelerated by close medical control over its use in certain “closed” environments, for example among plantation workers. Representations and explanatory models of other illnesses also seem to have influenced patterns of recourse to therapy. For example, some diseases categorized by biomedicine as circumscribed morbid entities did not figure in similar nosological terms within local popular conceptions. Cholera, for example, which was traditionally seen as a manifestation of revenge by an evil spirit, was interpreted as having supernatural origins; in this case, purely medical interventions were considered to be ineffective. Smallpox, on the other hand, was viewed as a necessary rite of passage: according to a Vietnamese proverb, the child who has not yet had smallpox has not yet been born. In the case of both these conditions, the conversion to biomedical interpretations took place only slowly and partially, especially because, for a long time, many colonial doctors played down the significance of such beliefs in approaching local people. This was especially the case when populations were to be intervened upon collectively and anonymously, as in campaigns of vaccination—the favored, sometimes exclusive weapon in the fight against these infectious diseases. By the same definition, one can assume that some biomedicines, whether patent or “ethical,” may have been more easily rejected or integrated into therapeutic practices on the basis of their therapeutic indications. Thus, when the actual effects of a therapy were promised, or were translatable into terms that resonated with notions, such as the hot and cold dichotomy or the principle of balance, that were fundamental in Confucian medical cultures, it was probably more readily accepted by the Vietnamese. This was the case of tonics, and indeed, even now, tonics still represent the class of drugs with the highest consumption in Vietnam.35 The impact of other types of analogies merit closer attention, such as the possible rejection (or acceptance) of medicines on the basis of prior familiarity with their active substances, that is, according to whether their components were customarily included in the Sino-Vietnamese pharmacopoeia or local diets. In this respect, the popularity of remedies derived from animal products (such as hormone extracts) is a fascinating example.36 Rejection or acceptance may also have been influenced by an experience of the shape, packaging, or even the taste37 of a product, although probably not independently of its effects. Along these lines, I might suppose that the emergence of pill and tablet forms, unfamiliar before colonization, played a significant role in the diffusion of certain products as well as in the instigation of a movement of commodification of health as well.38 In these forms, medicines are more easily transported, consumed, and preserved, which reduces the risk of being altered and losing their effectiveness.

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The Vietnamese, nevertheless, seem to have sustained a clear preference for substances having a curative action. This is not to say that prevention did not exist in Vietnamese culture.39 However, the refusal of preventive therapies may have arisen from a dissonance between the intentions of those who provided them, that is, to prevent a targeted disease, most often a contagious one, and the conceptions of disease causation and prevention by those who were meant to take these medicines. For the latter, disease represented a state of disequilibrium; its origins, precipitating factors, and manifestations could not necessarily be predicted or identified precisely, and yet it might be avoided through healthy eating. In the absence of direct and tangible evidence, further discussion on this issue is limited. However, there are indications that the Vietnamese were not keen on the idea of long-term, much less chronic, therapies. For them, a remedy must have rapid and measurable effects that occurs within hours—might this account for the tremendous enthusiasm for anthelmintic medications repeatedly reported by district doctors?—40or, at most, within days.41 Such beliefs may, in any case, account for the frequent complaints on the part of medical authorities about patients’ behaviors of non-compliance and therapeutic pluralism. Of course, these representations must have changed over the course of the period French colonization. Attitudes towards toxic medicines, such as the synthetic derivatives of quinine that were in high demand and short supply during the 1930s, as well as of methods of administration that accelerated or intensified their effects, such as the intravenous injections introduced with the arsenobenzols and increasingly used to administer sulphonamides,42 may be indicative of such change. However, although several medical reports describe popular fears of overly “strong” therapies and beliefs according to which these were not adapted to Vietnamese bodies and “temperaments,” one must not forget the longstanding tradition of recourse to products containing mercury, arsenic or nux vomica that were imported from China and known to be particularly toxic.43 Thus, while attitudes towards therapy did change during the colonial period, this change seems to have reflected an integration of colonial medicines into pre-existing logics of syncretism, such as the distinction between gentle, slow-acting medicines for benign symptoms and diseases, and strong, toxic, fast-acting medicines for serious diseases, rather than a reconfiguration of traditional cognitive categories. Nor did prior understandings of how to obtain and consume remedies seem to have disappeared, as suggested by the ways in which the Vietnamese sought to avoid the therapeutic relationship imposed by AMI, and by the clash they seem to have experienced it as.

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The Therapeutic Relationship as a “Shock” In the colonial context, the provision of healthcare was particularly authoritarian. Compulsory vaccination, intrusions into private life and into public spaces in the name of the risk of contagion: such measures reinforced an inextricable link between colonization, biomedicine, and social control.44 Yet, one often forgets another colonial encounter that may, in and of itself, have seriously hampered the development of an indigenous affinity for biomedicine and its therapies, and thus have constituted a major obstacle for the colonial enterprise of medicalization: the therapeutic relationship. With the establishment of AMI, access to medicines was codified and obligations were imposed: individuals wanting to obtain a biomedical therapy that either contained toxic substances or was free of cost were obliged to submit to the biomedical framework of the therapeutic relationship. It is not difficult to see the authority and rigid standardization entailed by this framework, which permeated both the procedure of the medical consultation and the follow-up of the prescribed treatment. First, there was an obligation to abide by the doctor’s availability and respect the consultation schedule. Most dispensaries and hospitals were open to the public only a few hours each day, sometimes only a few hours per week. From rural areas, it was often necessary to travel long distances at dawn in order to be sure not to find a closed door. After having their name inscribed in a register, which provided permission to wait in line, patients were granted access into an aseptic but often archaic, and certainly impersonal consultation space. When the size of the building allowed for it, this space was separate from rooms dedicated to surgery and bandaging; the latter room, when there was one, was usually where medicines were dispensed.45 Following the shock of entering this space, which had to be done alone,46 often without knowing what or who to expect, the patient had to submit to the diagnostic ritual (undressing and physical examination, which were perceived as humiliating) and to the eventual, unilateral proposition of a treatment.47 In addition, the patient was often not even entrusted with the prescribed medicine: they were made to consume it right there, in front of the nurse or even a warden.48 Several reasons explain this desire to maintain a close watch on medicine taking: a concern not to waste medicines (clinics’ supplies were often meagre and not easily renewed) but especially, worries about their inappropriate use. Indeed, the maximum quantity in which toxic products were dispensed was the dose prescribed to be taken over a limited period, 24 hours at most. Underlying this practice was a perception of the patient as ignorant or, perhaps, untrustworthy, in any case incapable of managing his or her own health. Regardless of the reasons behind it, it is not difficult

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to imagine that this tight control may have been badly received by patients, particularly when they were required to come back for their next dose. Here, again, we are a long way from local cultural references. In precolonial Vietnam, there was such a thing as a therapeutic relationship, but it was not obligatory nor was it highly formalized. It involved some kind of dispenser of remedies, who had different possible functions49 and forms of training; these varied according to clients’ financial means, obviously, but also according to their expectations and interpretations of a condition (particularly, whether an illness was deemed to have natural or supernatural causes). It was also a relationship of trust, initiated by clients’ wishes rather than imposed by the therapist, and which unfolded on the basis of a shared conviction that each case of illness was unique and called for a tailored treatment. This belief in the specificity of individual cases inevitably widened the gap between traditional and biomedical care, which was increasingly tending towards the standardization of treatment and its alignment with duly diagnosed pathologies or symptoms. In its aspiration to “convert” its participants to a “superior” form of medicine and its expectations of an immediate allegiance, the highly formatted biomedical encounter may have produced the opposite effect. That is, it may have contributed to maintaining parallel recourse to traditional therapists, particularly among those who lacked the means to call upon private physicians and thereby obtain more convivial conditions of consultation. And who knows whether some AMI doctors may possibly have gone as far as to refuse patients who confessed to first having tried several local remedies, that is, when the consultation even took place in a language spoken by both protagonists.50 Colonial authorities never directly legislated Sino-Vietnamese medicine, for reasons ranging from the highly pragmatic—how could they regulate something they knew so little about?—to the highly political—fear of uprisings fuelled by demands for the right to choose one’s own medicine according to one’s convictions and means.51 Yet, it is known that some Sino-Vietnamese therapists were quick to appropriate biomedical techniques in order to respond to their clients’ demands. Although they were deemed to be acting illegally because they injected their own recipes or dispensed pills that looked remarkably similar to French medicines,52 they proved themselves to be much more flexible than colonial services in their provision of healthcare. Provision of Care: From Theory to Reality The persistence in the provision and use of Sino-Vietnamese medicine highlights and reflects the wide gap that existed between the theory and reality of therapeutic provision in colonial Vietnam. Indeed, this persistence must be

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seen as the product not so much of a colonial conviction in the value of traditional therapies as of necessity to address the limitations of a public healthcare system that ultimately never had the means, financial or ideological, and to match its ambitions. Before World War I, Vietnam became the destination of an exponential, and probably, rapid diffusion of pharmaceutical products exported from France and other Western countries. In parallel and in response to this movement, which raised a variety of issues, colonial authorities sought to impose increasingly strict rules on the importation and distribution of these products.53 Guided by clearly protectionist interests, but also by concerns to protect public health, they searched for ways to drastically limit access to an ever increasing number of toxic substances (decree of December 27, 1916).54 Such strictness must have matched poorly with the lively atmosphere or rapid therapeutic expansion and diversification, in which a growing number of protagonists and their varied logics were colliding. One might think, in particular, of the frustrated objectives of French pharmaceutical manufacturers, such as Spécia Rhône-Poulenc, which, at the time, were seeking to take advantage of overseas markets while at the same time hoping to eliminate foreign competition.55 Nor did this increasing rigidity respond well to the budgetary realities and chronic personnel shortages that plagued AMI, and which may have created a mismatch between what Vietnamese patients sought to obtain and what could realistically be offered to them. What I am suggesting here is that biomedical authorities’ condemnation of a Vietnamese refusal of therapy may, in some cases, have masked a lack of accessibility. Biomedical therapies were, thus, not sought because of imposed barriers rather than rejected out of conviction. Although I have somewhat detailed data on the size of this gap, some doctors—both French and Vietnamese—were remarkably frank about the shortcomings of the system. They noted that many of their colleagues were overworked, and unable to offer good care. Some practitioners admitted to turning patients away without treatment on account of shortages—pharmaceutical supplies were mainly imported from the Metropole, a system that saved money but was often unreliable—or because the appropriate treatment was too costly and, therefore, not provided by AMI.56 Others reported that they had to “dilute” certain products in order to economize, even if they risked weakening the effectiveness of their treatment.57 Others still deplored their own inability to personally follow up on their patients’ care; they were constantly being reassigned to new posts in an ultra-bureaucratised system, and could therefore hardly become familiar with the inhabitants of a particular district, nor provide them with any kind of extensive knowledge of biomedical therapies even if they expressed a willingness to do so.58

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In contrast, here again, Sino-Vietnamese therapists were more numerous, certainly more available, and perhaps also better supplied in remedies than AMI doctors. In 1931, a commission for the inspection of Indochina’s pharmacies estimated that at least 1,700 merchants of medicines were practicing in Tonkin, not including itinerant vendors who were impossible to count. In the same year, there were only 65 Western-style pharmacies and basic medicines stores according to the official repertory of the inspection of health services and about a hundred doctors affiliated with AMI, amounting to about one doctor for 100,000 potential patients, that is, proportionally 45 times fewer than in metropolitan France in 1911.59 The obvious persistence of popular recourse to Sino-Vietnamese therapists and the undeniable gap between colonial intentions concerning the distribution of medicines and its realities (illicit networks, shortages, costs that were beyond AMI’s means) would eventually lead, in the 1930s, to legislative amendments as well as some improvements in the healthcare system. There were increases in the training and appointment of Vietnamese medical personnel; nurses and midwives were granted limited rights to prescribe; Vietnamese doctors obtained the right to enter private practice; and rural stores of commercial pharmaceuticals, which could be managed by traditional druggists, were authorized. Some colonial doctors also learned a lesson in humility from this tropical environment, in which the superiority of their art was challenged, and often failed. Some even went as far as to envisage the possibility of establishing “partnerships” with traditional therapists, or accepted to provide their patients with local remedies in order to avoid losing them. Just before World War II, the tendency to condemn the rejection of colonial medicines thus gave way to a genuine reflection on how, given Vietnam’s political, economic, and cultural realities, to best carry on diffusing the benefits of modern western medicine. And some doctors, mainly Western-trained Vietnamese practitioners, but also including a few French colonial doctors, were even ready to accept therapeutic pluralism as a necessary path toward achieving this diffusion.

CONCLUSION The three determinants of therapeutic selection, as much of rejection as of acceptance, described here for Vietnamese populations under French rule would facilitate in understanding realities and behaviors that clearly continue to resonate in the present: the multifarious influence of accessibility on the selection of medical treatments, and the significance of popular representations and practices in determining the success of policies of medical-

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ization; the deep cultural—or simply human?—roots of practices of therapeutic pluralism and of self-medication. To conclude, it should be pointed out that when biomedical professionals denounce therapeutic practices they deem to be deviant, they are denouncing a lack of faithfulness to scientific medicine, judged to be superior and, therefore, imposable. This does not leave open a space for lay initiatives claiming the right to choose one’s own treatment, according to one’s own representations of illness and health. Yet, the model of healthcare developed in colonial Vietnam, which prefigured the construction of an integrative health system held up as exemplary by the World Health Organization, has revealed the extent to which this exclusivist position can be ineffective, particularly as a framework structuring recourse to medicines. NOTES 1. By “colonial” medicines or “colonial” therapies I mean medicines brought to Vietnam along with the process of colonization. 2. By “modern medicine” I mean any pharmaceutical product, whether made up of chemical or natural components, which is industrially produced. This includes commercial specialties (modernized patent medicines sold without a prescription and profusely advertised directly to the consumer) and medical specialties or “ethical medicines” (produced and experimentally tested according to scientific principles, sold with a prescription) (Sophie Chauveau, L’invention pharmaceutique: la pharmacie française entre l’Etat et la société au XXe siècle [Paris: Sonéfi-Synthélabo, 1999], 19–21). 3. Indochina was a territory made up of five countries (Cochinchina, Annam, and Tonkin, which comprise Viêt nam, Cambodge, and Laos); its domination by the French was begun with the conquest of Saigon (1858), and ended with their defeat at Dien Biên Phu (1954). Naming it French Indochina formalised its administrative and political foundation in 1887, which conferred extensive powers to the Governor General at its head (Pierre Brocheux and Daniel Hémery, Indochine, la colonisation ambiguë, 1858–1954 [Paris: La Découverte, 2001 (1994)]). 4. Although I am aware that the terms “scientific medicine,” “modern medicine,” and “biomedicine” are not strictly synonymous, I will use them interchangeably here; my purpose is not to revisit their respective meanings or to discuss their equivalence. 5. Alice Conklin, A Mission to Civilize: The Republican Idea of Empire in France and West Africa, 1895–1930 (Palo Alto, CA: Stanford University Press, 1997). 6. Laurenc Monnais-Rousselot, Médecine et colonisation. L’aventure indochinoise, 1858–1939 (Paris: CNRS Editions,1999), 177–225. 7. Laurence Monnais, “‘De la reproduction d’une idéologie à la naturalisation d’un système. Essai sur la médecine moderne au Viêt nam avant la Deuxième guerre mondiale, ’” Outre-mers. Cahiers d’histoire (2006), 352–53: 171–208.

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8. Monnais-Rousselot, Médecine et colonisation, 400–40; Annick Guénel, “The creation of the first Overseas Pasteur Institute, or the beginning of Albert Calmette’s Pastorian career,” Medical History, no.43 (1999): 1–25. 9. Bert Hansen, “New images of a new medicine: Visual evidence for the widespread popularity of therapeutic discoveries in America after 1885,” Bulletin of the History of Medicine, 73 no.4 (1999): 629–78; Evelyan B. Ackerman, Health Care in the Parisian Countryside, 1800–1914 (Piscataway: Rutgers University Press, 1990). 10. Replacing mercury in the treatment of syphilis, Salvarsan was the first antiinfectious drug to be extensively tested in Vietnam beginning in 1911. 11. Sulphonamides were the first generation of antibiotics, introduced from the second half of the 1930s. 12. Based on the metropolitan model, the legislation on toxic substances would determine the conditions under which a certain number of French and foreign pharmaceuticals containing them could be stocked, manipulated, and distributed—under medical prescription only—by qualified pharmacists as defined by the law of 21 Germinal an XI (April 11th 1803). Importing foreign pharmaceuticals that figured in the French pharmacopoeia was indeed allowed, but subjected to high customs duties. In order to apply this legislation, the Governor General decreed the creation in October 1908 of a commission for the inspection of pharmacies that was entrusted the task of verifying the conditions under which medicines were sold in all pharmacies and drugstores, both French and indigenous (Vietnam National Archives I, Hà N.oˆi (VNA-I), RST 48339). 13. Malarial zones were classified according to their rate of malaria prevalence; this rate then determined whether quinine was distributed free of charge or sold at low cost. 14. The boundaries between these two “bodies” of medicine are neither clear nor fixed, and both follow similar rules and therapeutic formulae. 15. David Marr, “Vietnamese attitudes regarding illness and healing,” in Death and Disease in Southeast Asia. Explorations in Social, Medical and Demographic History, ed. Norman G. Owen (Oxford: Oxford University Press, 1987), 162–86. 16. It is relevant to note that compulsory vaccination was only imposed in metropolitan France by the Loi de santé publique de février 1902 [Public health law of February 1902]. (Monnais-Rousselot, Médecine et colonisation, 121–38). 17. Dr. Mougeot, La vaccine en Cochinchine et les idées chinoises sur la variole et la variolisation (Saigon: Imprimerie L. Ménard,1901), 20–24. 18. CAOM, Fonds du Gouverneur général (Gougal) 6738–39. 19. François Guérin, Paul Lalung-Bonnaire, and Michel Advier, “‘Premiers résultats de l’enquête sociale sur la tuberculose dans les écoles de Cholon ,’” Archives des Instituts Pasteur d’Indochine, 1 (1925): 189–212. 20. Monnais-Rousselot, Médecine et colonisation, 51–54. 21. CAOM, Fonds de la Résidence Supérieure du Tonkin, Nouveau Fonds (RST NF) 4024/ 3823/ 4007. 22. Medical officers reported that many traditional therapists diffused messages of counter-publicity, telling their patients that French medicines were harmful for their constitutions and that French doctors performed surgery “just for the pleasure of cutting into human flesh” (CAOM, RST NF 4014).

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23. CAOM, RST NF 3710; Nouveau Fonds Indochine (NFI) 2298; Gougal Service économique (Gougal SE) 219. 24. Quoc ngu is a romanized version of Vietnamese that was imposed as the written language of the colonial administration and education system. One of the known consequences of this imposition was the rise in rates of literacy and, with it, of written medias including the press. (Shawn F.McHale, Print and Power. Confucianism, Communism, and Buddhism in the Making of Modern Vietnam (Honolulu: Hawaii University Press, 2004), 28; David Marr, Vietnamese Tradition on Trial, 1925–35 (Berkeley: University of California Press,1981), 44–50). There were up to several hundred serials in Vietnam in the 1920s and 1930s. 25. The systematic consultation of these sources, currently in progress thanks to the financial support of the Social Sciences and Humanities Research Council of Canada (2006–09) concerns a dozen of serials dealing with matters of health and science, both for general and specialised readership, that were published in Vietnam both in French and quoc ngu between 1914 and 1945. These periodicals were chosen on the basis of their period of publication and the extensiveness of their circulation. 26. CAOM, Gougal 18751; ANV, Centre n° 2 (Ho Chi Minh Ville) (ANV–II), Fonds du gouvernement de la Cochinchine (Gougoch), IA-8/237 (4). 27. A similar trend is to be found in neighboring countries such as China (Sherman Cochran, Chinese Medicine Men. Consumer Culture in China and Southeast Asia [Cambridge, MA: Harvard University Press, 2006]). 28. The fact that about 15 French pharmacists were established in Hanoi and Saigon in 1940, while only a few thousand Europeans were settled in these cities, indicates that they must have had a Vietnamese clientele. 29. The term “specific” designates a substance with a targeted action on a specific disease or symptom. Conversely, a “panacea,” often portrayed as a “miraculous remedy,” promises to heal multiple ills and symptoms, most often those which are neglected by official medicine or which its treatments fail to relieve (Olivier Faure, Les Français et leur médecine au XIXe siècle (Paris: Belin, 1993). 30. In the 1930s, a syrup made up of local plants was priced at 0.50$, while a dose of a sulphonamide such as Dagénan (Spécia Rhône-Poulenc) could cost up to 30$ on the black market. At that time, a Vietnamese secretary was paid between $40 and $60 per month. 31. CAOM, RST NF 4024. 32. The manager of each store was authorised by the administration after having produced a certificate of good morals and followed a minimal training on the art of dispensing medicines (CAOM, Gougal 6530). 33. “Correctionnelle indigène. Le boy docteur,” La Dépêche d’Indochine, July 2, 1942. 34. CAOM, gougal 65324. 35. David Craig, Familiar Medicine. Everyday Health Knowledge and Practice in Today’s Vietnam (Honolulu: Hawaii University Press, 2002), 47–49. 36. Called opotherapeutic products, these medicines were made up of substances extracted from animal organs (such as Carnine Lefranc, Hémoglobine Montès) and blurred the boundary between medicine and food. They were most often presented

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as fortifying substances for the restoration of the human organism within an openly holistic and global approach to health. I find abundant advertisements for these products in the press. 37. In 1930, Dr Massias was in contact with the French drug company Laboratoire Byla and sought to obtain a preparation containing vitamin B, called Vitaminol, which apparently had a taste reminiscent of Vietnamese flavors and would enable him to treat them for beriberi (Charles Massias, “Le traitement du béribéri par une preparation contenant Vitamine B et acides amines (Vitaminol),” Bulletin de la Société Médico-chirurgicale de l’Indochine, 11 (1933): 389–91). The popularity of vitamins is confirmed by the amount of advertising space they took up in the press during the interwar period, along the same lines as the publicity for opotherapeutic products. 38. Sjaak Van der Geest, Susan Whyte and Anita Hardon, “The Anthropology of Pharmaceuticals: A Biographical Approach,” American Review of Anthropology 25 (1996): 163–64. 39. Preventive practices were and are still considered to be important in Vietnamese society, but these practices consist mainly in dietary and “lifestyle” interventions rather than drug treatments. 40. CAOM RST NF 3682/ 4003/ 4007/ 4014/ 4019. 41. It should be specified that traditionally, the payment of Chinese or Vietnamese therapists was due only once the patient was cured and was generally calculated according to the difference between the predicted and actual duration of treatment. 42. This may be one of the reasons for the current popularity of injections that constitutes a major public health problem in various developing countries including Vietnam. 43. Used to treat serious or dramatic diseases, on which local remedies failed to have the desired effect, the manipulation of these toxic substances was limited to a minority of therapists who had the knowledge of how to use and prepare them. Emperor Gia Long’s Code (1812) advocated the punishment of medical negligence that resulted in cases of poisoning (Albert Sallet, L’officine sino-annamite. La médecine annamite et la préparation des remèdes (Paris: Imprimerie Nationale, 1931). 44. Biswamoy Pati and Mark Harrison, eds. Health, Medicine, and Empire: Perspectives on Colonial India (Hyderabad: Orient Longman, 2001), 3–4. 45. CAOM RST NF 4014. 46. The notion of a one-on-one relationship between patient and doctor is assumed in the West but goes against Vietnamese customs in which social networks play a valued part in the management of episodes of illness. Several medical reports complained about the challenge of making hospitalized patients and their families understand the concept of limited and regulated visiting hours. 47, R. Debusmann describes similar attitudes of resistance to medical consultation, and particularly to hospitalization, synonymous with discipline and rules that are often very different from Cameroonian references (Robert Debusmann, “Médicalisation et pluralisme au Cameroun allemand : Autorité médicale et stratégies profanes, ’” Revue française d’Histoire d’Outre-mer 90 no.1 (2003): 225–45. 48. CAOM, RST NF 4003.

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49. Traditionally, in Vietnam, the boundaries between the roles of therapists, prescribers, and sellers of remedies were easily blurred. This juxtaposition incited some colonial doctors to declare that the Vietnamese customarily view the doctor as a mere “automatic distributor of medicines” (CAOM, RST NF 4014). 50. The colonial administration did attempt to make the ability to speak an Indochinese language into a requirement for its agents, but this failed. Training Vietnamese doctors from 1902 was meant, among other things, to provide a solution to this language problem. 51. CAOM, Gougal SE 213; NFI 2298. 52. CAOM, Gougal SE 219. 53. Laurence Monnais, “Des poisons qui en disent long: les fonctions de l’arsenal thérapeutique du Vietnam colonisé,’” Frontières 16 no. 1 (2003) : 12–19. 54. This text, modelled on the metropolitan law of July 1916, ratified the rules on access to substances figuring in tables A (toxic substances), B (narcotics) and C (dangerous substances) for the French colonies. Through this decree, the authorities in Hanoi restricted the freedom of Sino-Vietnamese medicine, forcing its therapists to give up any preparation that figured on one of these lists. Despite the fact that this law could never truly be enforced, it nevertheless represents a step towards relegating traditional medicine to a secondary role, redefining it as limited to inoffensive or “gentle” interventions on minor ills. 55. Although I was unable to obtain access to the Indochina archives of Spécia Rhône Poulenc, I was able to make out some of its links not only with locally established pharmacists and store managers (whose stores the company apparently had no compunction in illegally flooding with its products) but also with the General Inspection of Health Services, on which it regularly put pressure to proceed to experimentations of its products in AMI hospitals. 56. In 1915, only 6 percent of the budget of a provincial hospital was dedicated to purchasing medicines (CAOM, RST NF 4003). Although this percentage reached 25 percent of the budget of a rural dispensary around 1930, this amount would barely cover the cost of a single aspirin pill per patient (CAOM, NFI 2303). 57. CAOM, RST NF 4003/ 4014. 58. CAOM, RST NF 3683. 59. Van Thê Hoi, “La valse des médecins auxiliaires indigènes,” L’Echo annamite (11 September 1920)

8

Articulating Medical Ideas: Medicine and Medical Education in New Spain Martha Eugenia Rodriguez

The Viceregal period began in the year 1521, with the Spanish conquest of the city of Mexico Tenochtitlan, inhabited by the Mexicas. Following this, during the next three centuries when the country remained a colony of Spain, until 1821, it came to be called New Spain. The period of the sixteenth century was the most tumultuous one, for it witnessed several phases of merging of cultures and their adjustments in the new social and political milieu. While the new authorities tried to build and rebuild the city they were to rule, they introduced new labor ways of doing so. Thus, rebuilding the city to suit the Spanish style dislocated the native population from their homes, rendering them homeless. Under such conditions, abject poverty and lack of a healthy social environment affected the health of a large population. New types of illnesses from both the Old and the New worlds added to the great damage, and a high degree of mortality. Ever since the sixteenth century epidemics became a reality, which was frequent in New Spain, epidemics appeared practically at the moment of the Conquest itself, leaving a special impact on the American population, with important demographic, social, and economic damages. Among the illnesses registered during the period in question, mention should be made of matlazáhuatl or typhus, influenza, yellow fever, pleurisy or rib pain, measles, plagues, and smallpox; the latter brought about “disgrace” and fear among the inhabitants, due to recurring outbreaks in various areas. Repeated outbreaks of smallpox occurred in 1520, 1537–1538, and 1544–1546, of measles in 1531 and 1596 of cocoliztli in 1576, and of matlazáhuatl, typhus, or sunstroke in 1544–1545, later in 1575–1577. According to Francisco Flores, two thirds of the native population1 was killed as a result. 135

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Once the conquest was completed, the viceregal authorities were forced to pay attention to the sanitary environment. The need for health and medical care services called for the development of a wide range of medical personnel, including doctors, surgeons, pharmacists (druggists), and even traditional healers. Hospitals were established for colonial rulers as well as the indigenous population; some doctors are known to have specialized in blood-letting and midwifery, treating a large population. Native physicians were not only tolerated, they even treated some Spaniards. This was a situation in which both cultures found themselves merged with elements of prehispanic and European medicines. As far as Prehispanic medicine was concerned, superstitions were set aside, while Mexican herbalists were popular for their expertise and knowledge, so much so that the conqueror Hernán Cortés said to the king of Spain that there was no need for him to send Spanish doctors to New Spain, since the natives were highly efficient. However, in spite of Cortés’ suggestion, there was a continuous influx of Spanish doctors.2 Speaking of Mexican herbs, the oldest book of medicine known was called The Libellus de Medicinalibus Indorum Herbis, better known as the Códice de la Cruz Badiano. The compendium was written by a native physician, Martín de la Cruz, later translated from the nahuatl language into Latin by Juan Badiano. The herbarium was written in 1552 as a gift to the king of Spain, existing as a valuable document for the study of the therapeutic resources of Prehispanic nahuatl medicine.3 Medicine throughout the viceregal period, thus, was practiced by a range of medical men, and regulated by specific institutions such as The Royal Protomedicate Court, the Town Council or City Hall, and the Church. While these institutions did much to organize the medical profession, it was the hospitals, health committees, and more specifically, the School of Medicine of the Real y Pontificia Universidad de México and the Royal College of Surgery, that played a major role in consolidating it. During the fifteenth and sixteenth centuries, New Spain evolved in accordance with Spanish dispositions; however, by the middle of the eighteenth century, the situation changed. The intellectual isolation which prevailed in New Spain as a Spanish colony was left behind, in order to participate in Europe’s Enlightenment philosophy. This was due to the introduction of the Bourbon Reforms carried out by the kings Charles III and Charles IV, who engaged themselves in promoting the knowledge, intellectual life, progress and of the well-being of everyday life of the people. This was primarily done through cultivating and encouraging education at all levels. Medical education formed a significant part of these attempts. It was then that the first step was taken toward the secularization of education, culture, and science

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through scientific communities, through institutions, academic societies and through popularization of printed matters via newspapers and books.4 The effects of the above changes were marked. The Creole population (those born in New Spain from Spanish parents) became increasingly interested in European advancements at the same time, providing scientific inputs from various disciplines, thus constituting a reduced “multidisciplinary scientific elite.” These included José Mariano Mociño in natural sciences, Joaquín Velázquez de León in the mining sector, Antonio de León y Gama in astronomy, and José Antonio Alzate. At the same time, a group of Spaniards reached New Spain and joined forces with the local community; among them were Andrés Montaner y Virgili, Martín de Sessé, Vicente Cervantes, and Fausto de Elhuyar, who are known to have contributed a great deal to the study of anatomy and physiology, to the new chemical nomenclature, and the taxonomy of the natural kingdom. Thus, this was one of the first steps toward an institutionalization of science which was a result of the combined interest and efforts of Spaniards and creoles; institutionalization also meant creating new scientific academies, institutions to carry on the process.

HOSPITALS AS AGENTS OF CHANGE Ever since the establishment of the Spanish rule, interest in establishing hospitals and infirmaries for the people of New Spain, both natives and Spaniards, was kept alive. The creation of these institutions resulted from the dark epidemiological panorama which originated with the encounter of both cultures, the American and the European. One of the first laws issued by the Spanish Crown was to create hospitals and orphanages, as evidenced by the Recopilación de las leyes de los Reynos de las Indias (Compilation of the Laws of the Kingdoms of the Indies), which states thus, “we hereby order our Viceroys, Audiences and Governors to take the necessary provisions, so that in every town within their jurisdictions, whether Spanish or Indian, hospitals be built where the poor may be cured of their illnesses and Christian charity may be exercised.”5 There were three reasons for establishing hospitals—to comply with royal indications, to face epidemiological problems, and to put into practice the religious precepts; the latter was important since the Church was responsible for providing medical aid to the natives by establishing hospitals for medical care. In addition, religious orders played an important role in the creation of hospitals in Mexico in the sixteenth century. With the main purpose of evangelizing the natives, in 1523 the first Franciscan monks arrived in New Spain, followed by the Dominicans in 1526, and later the Augustinians and as the

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Jesuits toward the second half of the sixteenth century; their main foundation, however, was the principle of integral Christianity, where the soul’s needs were taken care of before the body’s requirements. And in order to fulfill this objective, a physical space that could accommodate church, monastery, and hospital6 had to be constructed. While philanthropic work characterized the period, continuity in foundation of hospitals for the same posed difficulties when these were created according to the population—native or European—and the kind of pathological situation presented. The first hospital devoted exclusively to the Europeans was founded by Hernán Cortés around 1524, followed by the Hospital de la Purísima, or of Nuestra Señora de la Concepción de María Santísima, known since 1663 as Hospital de Jesús, specialized in treating all kinds of illnesses, except syphilis, insanity, and leprosy; Pedro López, and surgeon, Diego de Pedraza, the first physicians to arrive in New Spain, practiced medicine in this hospital. It is noteworthy that this hospital still exists and is fully functional. Another institution devoted to the Spaniards was the Hospital del Amor de Dios, founded by Bishop Fray Juan de Zumárraga in 1540, for those who suffered from venereal diseases. At the same time, the Franciscans built small infirmaries in their convents. As far as the natives were concerned, they were treated at the Hospital Real de Indios or Hospital Real de Naturales, founded in 1553 under the aegis of the Spanish Crown which made this “concession” as a responsibility to address the health needs of the Indians. The Real de la Epifanía y Nuestra Señora de los Desamparados hospital, founded by Doctor Pedro López in 1582 focused on the most impoverished population among the mixed races. Specialized hospitals, namely, San Lázaro for treating leprosy, and San Hipólito to treat the mentally challenged, and the Hospital del Amor de Dios for syphilitic patients also had a popular appeal in terms of the specific disease situations they handled. Quite often, hospitals would be established under extreme conditions of a sudden calamity. San Andrés Hospital was, thus, opened in 1779 during the smallpox epidemic with support from Archbishop Alonso Núñez de Haro y Peralta. The hospital became popular over the years because of its principle of treating all “alike,” becoming the most important general hospital throughout most of eighteenth century.

THE UNHEALTHY ENVIRONMENT: SOME CONCERNS Health, hygiene, and illness were important aspects of the medical profession in the eighteenth and nineteenth centuries, when an “unhealthy environment” became an issue of concern for the sanitary authorities which they believed

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generated by garbage in the streets, stagnant and open waters which became garbage dumps, and pig pens established in the core of the capital of New Spain, or, perhaps, public places where people had established “make-shift” market places for ready meals leading to unhealthy conditions. In view of the city’s insalubrious conditions and foul air, it became necessary to initiate programs to control these. Several men of science, chroniclers of the time, physicians, officials, and viceroys concerned over the prevailing conditions, joined, thus. The idea of “public health” also was initiated at the time by the second Count of Revillagigedo, Viceroy from 1789 to 1794, followed by Marquis de Croix, Azanza and Branciforte.7 Nevertheless, it was Revillagigedo who remained at the helm in giving public health and sanitation the top priority in all his policies. To this effect, he issued edicts where he forbade the use of palm leaf mats or throwing dead animals over the balconies; he stated that public toilets, which “offended the senses of both smell and shame” should be used and cleaned for common welfare; he ordered the withdrawal of the permanent coat of slime present on the fountains which provided “drinking water” to the neighborhood; he announced that carts pulled by mules would cross the city in order to collect wastes and garbage and, to that effect, inspectors were appointed to pay “unexpected visits.”

UNDERSTANDING EPIDEMIOLOGY: MEDICAL CHALLENGES The eighteenth century which, on the one hand, contemplated growth and scientific progress, on the other hand witnessed a dark panorama—that of the occurrence of epidemics with a strong demographic, social, and economic impact. The most devastating ones were typhus, smallpox, and the “mysterious” fevers or plagues which appeared in the years 1761–1762, 1779–1780, 1784–1787, 1797–1798, and in 1813.8 Despite the serious nature of public health hazards and epidemics, medical practitioners were unable to handle them successfully. Although the concept of contagion or transmission was somewhat known, a clear knowledge and understanding of the disease impeded handling disease of major consequences. Physicians in New Spain were sure that illness was transmitted through water, personal contact, or polluted air. Professor José Ignacio Bartolache said: “Smallpox is always conveyed from person to person. So that, if as of today Mexico had no trade or communication whatsoever with people elsewhere, there would be no smallpox.”9 Physicians of the eighteenth century had an idea of causality with regard to illness, but without establishing a relation between microorganisms and illness. This made it impossible to fight against the actual causes of the disease. Accordingly, medical action went only as far

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as the implementation of preventive measures, such as quarantine, the creation of leper hospitals, or the prohibition to sell or pawn the objects which had belonged to anyone suffering from a contagious illness. Throughout the period, the intangible cause of illness was more important that the tangible one. It was considered that miasmas, or contagion through gas or particles suspended in the air, were some kind of poison to which nobody ever got used to. Miasmas had a strong pathological force and hence needed to be eliminated through a clean environment. In view of the fact that epidemics affected the entire population, American or European, young and old, rich or poor, civilian or members of the church, several oraganizations joined together to fight against them. The Royal Protomedicate Court, the Public Health Committees, the Church, the Town Council and the Viceroys were equal participants in all. The epidemics stretched beyond the frontiers of the capital of New Spain. And in the opinion of the great man of science, José Antonio Alzate, the treatments applied during the epidemic of 1761 were not adequate at all, leading to a high death rate. According to Alzate,10 out of nine thousand patients who entered the Hospital Real de Indios in that year, only two thousand survived. With regard to smallpox, José Ignacio Bartolache was disturbed by the frequent occurrence of the disease, commenting that “it usually appears every ten, fifteen or twenty years.”11 There were two outstanding and unprecedented facts in the treatment of the smallpox epidemic in 1779—the preventive inoculation with variolic pus, and the foundation of a specialized hospital, the Hospital de San Andrés built by Archbishop Alonso Núñez de Haro y Peralta with 300 beds, and attended by qualified physicians, surgeons, nurses, and priests. In view of the rapidly spreading smallpox, Viceroy Marquis de Croix issued an edict for the epidemic of 1797. The most important points make reference to isolating individuals suffering from the illness, interruption of communication with infected towns, establishment of cemeteries far from urban zones and, finally, inoculation, which was left as a last and totally voluntary resource.12 Branciforte accepted the authorized method of inoculation, conveyed through an edict dated April 19, 1797. The acceptance of the “procedure” by the Viceroy surely meant an important step and interest toward public health concerns in the form of preventive medicine. However, the above method was soon to be substituted by the smallpox vaccine.

THE EXPEDITION OF THE SMALLPOX VACCINE As mentioned above, the period of the eighteenth century witnessed three significant smallpox epidemics New Spain—of 1762, 1779, and 1797. During

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the second epidemic, efficient preventive measures were taken in accordance with the suggestions of Dr. Esteban Morel who used the first inoculations with smallpox pus. For the epidemic of 1797, once more the practice of inoculating was popular. However, the discovery of the smallpox vaccine by Edward Jenner in 1796 brought the practice to a temporary halt. Jenner demonstrated that the application of the smallpox lymph of the cow protected against human smallpox. This fact was published in 1798, spreading the news throughout Europe. Consequently, surgeon Francisco Gil translated Jenner’s text into Spanish to get more insights into the practice. The significant breakthrough in medical science did not go unnoticed by the royalty, and Charles IV was prompt enough to introduce the vaccine in all his domains. He organized an expedition with the support of an eminent surgeon, Dr. Balmis of Alicante. This was, perhaps, the first sanitary expedition of a preventive and not of an exploratory nature. The vaccine expedition left the port of La Coruña on November 30, 1803, heading for the Canary Islands, and continuing on its way toward the Antilles, to Venezuela and, finally, New Spain. It crossed the Pacific Ocean on its way toward the East and then back to the metropolis. Some medical assistants joined the expedition headed by Balmis, besides Doña Isabel Cendala y Gómez, head of the Casa de Niños Expósitos de La Coruña (House for Foundlings of La Coruña), who would be in charge of twenty children between eight and ten years old, who were also aboard the ship. Since the children were considered the main reservoir for the vaccine during the voyage, her duty was to confined to injecting the smallpox pus from arm to arm.13 The voyage was seen as successful under the leadership of Balmis. He was even encouraged to visit other regions in New Spain to carry the smallpox lymph of the cow and open a Vaccine House to preserve the vaccine pus. Elsewhere, in the city of Mexico, surgeon Miguel Muñoz carried on the work with equal enthusiasm. Preventive medicine, thus, became a reality in Mexico with the efforts of the two outstanding doctors.

THE ROYAL PROTOMEDICATE COURT While medical practice kept pace with scientific accolades, the Royal Protomedicate Court regulated the practice of general medicine. The Court was consolidated in the metropolis in 1477, and in New Spain in 1628, even though there were appointments of representatives of the Protomedicate in earlier years. The Protomedicate had multiple responsibilities. It supervised medical education and teaching, study plans, and working methods specific to medicine. After having complied with the academic program and examination at the University, the Court examined every professional in health who

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wished to practice either as a physician, surgeon, pharmacist, “blood-letter,” or a midwife, although theoretically, nobody could work without a title to certify that he was a specialist. Also, the Court incorporated the titles of the sanitary professionals who came to live in New Spain. The Protomedicate also made regular visits to pharmacies every two years, and occasionally took a complaint or accusation. It also supervised and ensured quality regulation of medicinal drugs and their supply in pharmacies, in addition to keeping a check on the professional title of the pharmacy owner. The Court, as a regulatory institution, also solved epidemiological problems and investigated the etiology of the illness, and followed curative and preventive measures, necessary to maintain environmental hygiene. In common practice, however, the Protomedicate Court acted only as an advisory institution, especially as far as epidemiology was concerned. In the later part of the century, however, its efficacy and behavior surprised the progressive scientific community. While the Court took a modern attitude by defending the practice of inoculation in the presence of smallpox, confronting the Viceroy and the clergy, on the other hand, it showed a most conservative attitude with regard to the reforms proposed in medical teaching. The Protomedicate objected to changes in textbooks and the curriculum, and to the two new establishments—The Royal College of Surgery (1770) and the Royal Botanic Garden (1788), both of which were founded as a complement to the medical studies at the University. These objections may have been a result of the challenge posed by the new establishments; for the Court feared that its efficiency and functioning were repeatedly questioned by the scientific focus of the two, and by the sanitary committees which performed their job only in times of “crises.”

HEALTH COMMITTEES AND THE COURT: CONFLICTING SITUATIONS Health committees emerged as a result of the smallpox epidemic of 1797 and typhus. The most prominent in the former was called the Main Charity Committee, headed by Archbishop Alonso Núñez de Haro y Peralta, while the Superior Health Committee was formed to regulate typhus epidemic of 1813; yet another committee, the Municipal Health Committee of Mexico handled the issue of the continuing plague of 1819. During the nineteenth century, more health committees were created, with some variations in their respective titles.14 In addition, some health committees were formed solely with a philanthropic avocation but these functioned only temporarily, for the duration of the epidemic. These committees included physicians, priests and civilians

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and, sometimes, nurses (both male and female) providing help to the poor and the needy. The health committees had the onus of surveying the infected places—a task made easier by dividing the city of Mexico into quarters or blocks. It was also imperative for them to have information on the condition of the sick people and the availability of health services. The next step was to distribute the physicians geographically so as to cover the entire city for medical care, with special emphasis on faraway regions where there were no physicians. Maintaining a statistical profile on the incidence of the disease was of prime importance. Provisional hospitals were established, with instructions on sanitary regulations for the healthy as a means of prevention. All these activities were in some way institutionalized in that they were portrayed through edicts, regulations and ecclesiastical sermons. Although, the presence of the Health Committees was highly indispensable in controlling epidemics, they were not totally accepted by the Protomedicate Court which resulted in occasional professional conflicts. The fact remains that the Court never understood that the committees took action only when the number of ill people surpassed those generally attended.

THE FACULTY OF MEDICINE OF THE ROYAL AND PONTIFICAL UNIVERSITY: AN INSTITUTION FOR “MEDICAL REFORM” As far as education was concerned, the most important institution during the Viceregal Period was the Royal and Pontifical University of Mexico, which opened its doors in 1553, and the Faculty of Medicine in 1578, where, gradually, a program similar to the one of the Spanish universities developed. This program was made up of five “chairs” created during the sixteenth and seventeenth centuries, and which remained in force throughout the entire Viceregal Period: the Primary Medicine, that studied the healthy body, anatomy, and physiology; the Vespers of Medicine, mainly focused on the study of an ill body; the Medendi Method, analyzed therapeutic procedures and pharmacy; Anatomy and Surgery, which taught various surgical procedures and, finally, Astrology and Mathematics, which included subjects such as geometry, physics, geography, chemistry and several others; the last subject trained students of architecture, geographers, in addition to physicians. The Constitutions of 1645, which regulated the university, were approved in 1775, with the idea of utilizing traditional teaching methods based on the readings of Hippocrates, Galeno, and Avicena. On its part, the Royal Protomedical Court stated in 1751 that professors should consult the works of the above mentioned ancient authors, “…reading, initially,

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the meaning of the chapter in question; The professor should take the book, and the students study the context and understand that these are the grounds and foundation which should remain as an important part. Also, it is imperative for the professor to read the doubts and questions submitted as to the contents and which both, professor and students, find useful for the knowledge of the essence of illnesses, the causes thereof, signs, prognosis and cure.”15 The first four subjects required reading Hippocrates, Galeno, and Rhazés. As far as Hippocratic treatises are concerned, the students read the Aphorisms, Epidemics, and On Airs, Water and Places, among others, using Latin editions of the same. From the works of Galeno, they read De Elementis, De Temperamentis, De Humoribus, De Diebus Decretoriis, among others. Very few books were introduced during the eighteenth century, among them was the one written by Marcos José Salgado, the Cursus Medicus Mexicanus, in 1727. Its contribution consisted mainly on the fact that it dealt with the subject of physiology. It commented on blood circulation discovered in England by William Harvey, and dedicated some pages to iatrochemistry (medical chemistry) and iatrophysics (medical physics), which interpreted physiology from the chemical or physical point of view, respectively. Salgado’s book had the merit of presenting a modern galenic physiology, that paved the way for further discoveries in medicine in New Spain. On the other hand, José Ignacio Bartolache wrote his Lectures on Mathematics, which was read both in Astrology and in lectures on Mathematics. As far as the teaching of physiology was concerned, the university had a limited view of the vastness in medical sciences. Harvey, Boerhaave, and Haller figure as among those men who demolished the ancient world of the hyppocratic-galenic ideas. Their teachings were founded more on living facts than on doctrine. This necessitated the use of lecture rooms not only as classrooms, but as investigation centers. Harvey, an anatomist, botanist, embryologist, and, above all, a physiologist, preferred animate anatomy which intended to find, in an experimental way, the functions of anatomic arts. Haller himself initiated, on his own, what nobody had ever tried to do before: a general exploration of physiology, and his work reached Mexico before it became independent.16 With regard to clinical teaching, medical students were accompanied by their professors during their visits to clinical wards to oversee hospitalized patients and submitted reports to the university. Their final qualification depended upon an assessment by the professors. Regarding practice, the constitutions elaborated by the Visitor of the University, Don Juan de Palafox y Mendoza ordered that every four months, anatomies should be made at the “Hospital Real de Indios,”

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which should be attended by all the professors in Medicine, as well as students thereof . . . and that all the instruments elaborated to that effect, be kept in the place appointed by the University, together with the skeleton, table and all the necessary instruments, and the anatomy or surgery professor should keep the key to such place.17

Dissection and anatomical studies became complicated for the university when several “justifications” were provided to explain their inadequate development. The shortage of dead bodies, and the distance between the hospital and the university were seen as an impediment to their progress. Concerned about this deficiency in medical education, the study of human anatomy and pathology was rendered indispensable by the university, at meeting on February 4, 1780. The University requested Viceroy Martín de Mayorga to order all city hospitals in Mexico to provide human cadavers for purposes of anatomical studies at the university; the hospitals of San Juan de Dios, Real de Indios, and de Jesús were the first to indicate interest for medical cause. Medical students also studied an additional subject, Botany, established after the opening of the Royal Botanic Garden of Mexico to study the curative properties of plants. It also became obligatory for students of medicine, pharmacy, and surgeons. As far as the organization of the study plan, Viceroy Branciforte made the creation of a Chair of practical medicine imperative in exactly the same way in which it had been carried out in Madrid’s General Hospital. The Chair was authorized by king Charles IV and legalized by the university teaching staff as an optional subject in 1806; two years later, it became an obligatory subject for medical students. Legalization of the subject also meant that oppositions to its study would be minimal. While regular reforms and changes marked medical education, the university became the most controversial institution. On the one hand, it defended its traditions and remained rigid as far as any proposal of modification was concerned, presenting ideological, political, and economic obstacles, according to the testimony of Professor Juan de la Peña. The introduction of Botany destroyed many statutes of the university, for it entailed different teaching methods. The University Council, on its part, was also resistant to any changes toward modernizing the curriculum. The Inquisition was, of course, most watchful regarding these innovations. The Court censored any thesis that aroused the minimum suspicion of contradicting the Catholic faith; this was ratified by José Ignacio Brizuela, priest and professor and head of the Department of Medicine at the Royal and Pontifical University of Mexico. Brizuela pointed out that the Inquisition had to corroborate that the probationary teachers were not persuaded by French modern mental-

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ity.18 In 1798, two doctors, who were members of the Inquisition—Mariano Aznárez and Francisco Mada—analyzed a thesis which was to be defended at the University of Guadalajara, because it quoted the prominent Dutch clinic Hermann Boerhaave, who talked about blood circulation discovered by William Harvey which was promoted in New Spain by Salgado. As far as the revised thesis was concerned, the examiners from the Inquisition stated that the conclusions arrived at were common in the field of medicine. For the term “breath,” it was indicated “there is, undoubtedly, breath, vapor and odor in the blood recently taken from blood vessels, thus the phrase breath of the blood is very adequate.” The period of the nineteenth century witnessed conflicting opinions and suggestions on how best to alter the medical curriculum at the university. Most of these, however, favored reforms as a necessary step toward this. In 1803, Viceroy Marquina left written instructions for his successor, Iturrigaray, that “according to the intelligent people, there was a need for some modification in the mode of the studies and in the way of celebrating grades and other literary functions. I also understand that he has no cubicle or office and that his library is somewhat scarce as far as good modern works are concerned.”19 This left the university in a continued state of instability in its functioning as an educational institution. There were, however, opposing views on this. While the Protomedicate Court pretended that the already existing study plan be respected by including the classic authors, some professors, on the other hand, took special care in modernizing education. In 1815, don Antonio Serrano, headmaster of the School of Surgery, expressed to Viceroy Calleja that he detected many differences between the university and the school. The former remained under the same academic program of earlier periods, with the studies reduced to their minimum expression. He added that “the students of the University needed to learn and study, while the students of the School required not to forget and to continue with their studies.”20 In 1824, with the intention of modernizing education, several lectures were added to the study plan, such as the Anatomie Générale appliqué a la physiologie et a la medicine, by Xavier Bichat, who spoke about the notion of tissue, Hermann Boerhaave’s book, Instituciones medicae, aphorismi y elementa chemiae, as well as the work by Ignacio Lacaba and Jaime Bonells, the Curso complete de anatomìa del cuerpo humano. At the same time, some professors also expressed their interest in updating the academic studies at the university. Prominent among these was José Ignacio Bartolache, who taught Prime of Medicine, Medendi Method and Mathematics, as well as Luis José Montaña, head teacher of Vespers of Medicine. The contents of their classes went beyond what the constitutions dictated, since they favored clinical teaching, supporting the union of medicine with physics, chemistry,

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and botany, pointing out the importance of observing the patient and his environment. The most significant reform proposed by these professors consisted in combining medicine and surgery, which became effective only after New Spain obtained its independence from the mother country. In spite of the fact that the independence of Mexico took place in 1821, several institutions, including the university, continued to function for some years. It was not until 1833 when the government decree ordered the abolition of the university to replace it with the Establishment of Medical Sciences, as an institution where medical education was carried out as per a “modern” study plan; medicine and surgery were given special emphasis in these attempts at modernizing medical education.

THE ROYAL SCHOOL OF SURGERY: TRANSFORMING SURGERY The establishment of The Royal School of Surgery at the Hospital Real de Indios, authorized by the Crown in late eighteenth century was a significant step in modernizing education as part of the Bourbon Reforms of the metropole and its colonies. For it changed the social status and academic ranks of surgeons, especially Latin surgeons, who were considered inferior to physicians. Dictated by the rules of the Crown, the School of Surgery of New Spain was expected to function in a way similar to the schools of Cádiz and Barcelona. The rules dictated that the chief authority of the establishment who was, in this case, an Army Surgeon, Andrés Montaner y Virgili, would teach anatomy and physiology to medical students. On the other hand, Manuel Antonio Moreno, chief of surgery at the school at Cádiz was to teach pathology. The School of Surgery had Latin surgeons whose practice was determined by a proper education at the university and a two-year practice with a doctor previously approved or with a hospital surgeon. Besides, they were to be old Christians, with a student’s Baptism Certificate, clean of “bad race,” be sons of legitimate marriage, and guarantee obtaining the necessary books and surgical instruments for practice from a reliable person. There were also surgeons who could practice surgery with less stringent requirements. An adequate knowledge of grammar, a two-year practice in a hospital, and a threeyear apprenticeship under a surgeon were required of these surgeons; interestingly, no proof of “clean blood lineage” was necessary.21 The initial years of the school, however, saw a decline in the number of students admitted. This was because knowledge of Latin was considered as a prerequisite to admission; this is why they do not appear in the school records of the nineteenth century.22 Students could only practice surgery after a four-year medical

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career with experience in anatomical and surgical operations. The merit they acquired during this period was stated through certification, when required. They also had to go through an examination in anatomy, physiology, therapeutics, and pathology, followed by practical training. Among the statutes of the school, one that draws attention is the importance given to daily visits to the Hospital Real de Indios, for the care of the sick. Those excelling in this were to be appointed as medical assistants, instead of nurses, at the hospitals. The assistants would work in medicine and surgery wards, applying topicals, bloodlettings, “vejigatorios” and suction pads, besides attending theoretical lessons. It was the obligation of both, Latin and Romancist surgeons, to grant free assistance to the poor, as well as attend the wounded, when needed. Despite the progressive reforms created by The Royal School of Surgery under the aegis of the Spanish Crown, there was some antipathy among the academic community of New Spain on the consequences of the stringent rules made by the school. This led to disagreements between the authorities of the school and the Faculty of Medicine. While Montaner and Virgili stated that the university taught a “galenic” physiology, the Royal Protomedicate Court fully approved the existence of the school, and refused to approve the statutes proposed by Montaner and Virgili. Despite these differences, it is apparent that the School of Surgery marked a definite direction in the evolution of surgery as a specialty, strengthening anatomical studies and the practice of dissection in a high quality academic program in accordance with the advances in European surgery.

THE BOTANIC GARDEN: NEW DIRECTIONS IN THERAPEUTICS An outstanding feature of the eighteenth and nineteenth centuries was the curiosity of medical men to know more about their environment. Natural history, thus, became a field of general interest in Spain and its colonies; biology and botany consolidated and became of utmost interest to medicine. As a result, the Royal Botanic Garden of Madrid organized scientific expeditions to its dominions. José Celestino Mutis took a trip to the coasts of South America (1785 to 1810); Ruiz y Pavón traveled to Peru and Chile, (1777 to 1787), and Martin de Sessé y Lacasta organized the expedition to New Spain (1787 to 1803). The latter expedition was organized in eight exploration voyages in order to collect the flora of New Spain and foster the study and teaching thereof; it also intended to continue with the works that Francisco Hernández, member of the Protomedicate, had undertaken two centuries before. The expeditionary group remained interdisciplinary in its approach with the inclusion of Martìn

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de Sessé as the head of the expedition as well as of the Botanic Garden, and Vicente Cervantes as a specialist in Botany, Longinos Martínez as an expert in zoology and mineralogy, and José María Maldonado, as a practicing surgeon. The main aim of the group was to identify plants which had medicinal value, and could be used in therapeutics. The university and the Protomedicate, however, did not fully understand the significance of the project in the career of a physician, placing political interests before academic ones. The presence of botanists in New Spain stimulated medicine and the teaching thereof with a modern focus. José Mariano Mociño, Vicente Cervantes, and Luis José Montaña carried out pharmacological studies, proving the therapeutic qualities of various plants. They visited various hospitals with the intention of providing botanical assistance and counsel to the surgeons and pharmacists.23 A result of the expedition, as well as teaching and investigation at the Botanical Garden of New Spain was the introduction of biology as an autonomous discipline, but also related to medicine. This correlation was best seen in printed works, such as Flora Mexicana, published by Sessé and Mociño in 1801, and Flora de Guatemala, written by Mociño, in 1802–1803, and of Cervantes in 1803 on rubber, ipecacuana and other medicinal plants in Mexico; some reputed herbalists accompanied them on their return to Spain in the early nineteenth century.

CONCLUDING REFLECTIONS The study of viceregal Mexico presents two most contrasting moments: the sixteenth century which gives rise to a new way of life, and European standards some of which were difficult for the native population to adapt to, and a new series of institutions including those of a sanitary character, which governed three centuries of colonialism. On the other hand, the second half of the eighteenth century which breaks with the impenetrability that had characterized life in New Spain as a Spanish colony and starts participating in the modernity of the Age of Enlightenment. In terms of epidemiology, these were three difficult centuries not only for the native population, who were most prone to epidemics, but also for the Spanish population who showed an increasing interest in the well-being of its colony. Sanitary measures were initiated as a result of this. While the hospitals, and the university and the School of Surgery, created health professionals at various echelons, the Botanical Garden enriched medical resources, and the Protomedicate regulated medical education and practice as a whole. As part of this “acculturation” process, Mexico received the medical knowledge and practice as prevalent

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in Spain and, in turn, contributed to its development by enriching therapeutic resources by way of strengthening botanical studies. NOTES 1. Francisco Flores, Historia de la medicina en México, Facsimilar ed. (México: Instituto Mexicano del Seguro Social, 1886), 2, 214–20. 2. Hernán Cortés, Cartas de relación, (México:Espasa Calpe, 1972), 70–6. 3. Martín de la Cruz, Códice de la Cruz Badiano. Libellus de medicinalibus indorum herbis, Facsimilar ed. 1552, (México: Instituto Mexicano del Seguro Social, 1964), 1–5. 4. Martha Eugenia Rodríguez and Xóchitl Martínez ed. Historia general de la medicina en México, IV: Medicina novohispana, siglo XVIII, (México: Academia Nacional de Medicina, Facultad de Medicina, Universidad Nacional Autónoma de México, 2001), 1–20. 5. Recopilación de leyes de los Reynos de las Indias mandadas imprimir y publicar por la majestad católica del Rey Don Carlos II nuestro señor, Facsimilar ed., 1791, (Madrid: Consejo de Hispanidad, 1943), Libro I, Título Quarto, Ley primera. 6. Josefina Muriel, Hospitales de la Nueva España, I: Fundaciones del siglo XVI, (México: Instituto de Investigaciones Históricas and Cruz Roja Mexicana, 1990), 13. 7. Martha Eugenia Rodríguez, Contaminación e insalubridad en la ciudad de México en el siglo XVIII, (México: Departamento de Historia y Filosofía de la Medicina, Facultad de Medicina, UNAM, 2000), 60. 8. Donald B. Cooper, Las epidemias en la ciudad de México 1761–1813, (México: Instituto Mexicano del Seguro Social, 1980), 8. 9. José Ignacio Bartolache, Mercurio volante (1772–1773), Roberto Moreno ed., (México: Universidad Nacional Autónoma de México, 1979), 195. 10. Cooper, Las epidemias, 72. 11. Bartolache, Mercurio volante, 195. 12. Instrucción para inocular las viruelas y método de curarlas con facilidad y acierto, (Puebla: Imprenta de Pedro de la Rosa, 1797), 37. 13. Francisco Fernández del Castillo, Los viajes de don Francisco Xavier de Balmis, (México: Sociedad Médica Hispano Mexicana, 1985), 46. 14. Martha Eugenia Rodríguez, “Las juntas de sanidad en la Nueva España. Siglos XVIII y XIX,” Revista de Investigación Clínica (mayo–junio 2001), 277. 15. Miguel Muñoz, Recopilación de las leyes, pragmáticas reales, decretos y acuerdos del Real Protomedicato, (Valencia: Imprenta de la Viuda de Antonio Bordazar, 1751), 144. 16. Rómulo Velasco Ceballos (selección preliminar), La cirugía mexicana en el siglo XVIII (México: Archivo Histórico de la Secretaría de Salubridad y Asistencia, 1946), 16. 17. Constituciones de la Real y Pontificia Universidad (México: Archivo General de la Nación, 1775), 248, XXXVI.

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18. Inquisición, (México:Archivo General de la Nación, 1798), 1387, 185. 19. Instrucciones que los virreyes de Nueva España dejaron a sus sucesores II (México: Imprenta de Ignacio Escalante, 1873), 629. 20. Rómulo Velasco Ceballos, ed., La cirugía mexicana en el siglo XVIII (Mexico: Archivo Histórico de la Secretaría de Salubidad y Asistencia, 1946) 372. 21. Velasco Ceballos, La cirugía, 90. 22. Ignacio de la Peña, “El Real Colegio de Cirugía en la Nueva España,” in Historia general de la medicina en México, IV: Medicina novohispana, siglo XVIII, Martha E. Rodríguez and X. Martínez, 396. 23. Miguel Angel Martínez Alfaro, “La real expedición a la Nueva España en el siglo XVIII: su aporte al desarrollo de las ciencias biomédicas,” in Temas médicos de la Nueva España, ed. E. Cárdenas de la Peña, (México: Instituto Mexicano del Seguro Social e Instituto Cultural Domeq, 1992), 601.

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Disease, Doctors, and De Beers Capitalists: Smallpox and Scandal in Colonial Kimberley (South Africa) during the Mineral Revolution and British Imperialism, c.1882–1883 Russel Stafford Viljoen Give doctors the honour they deserve, for the Lord gave them their work to do. Their skills came from the Most High, and kings reward them for it. Their knowledge gives them the position of importance and powerful people hold them in high regard. He gave medical knowledge to human beings, so that we would praise him for the miracles he performs. The chemist mixes these medicines, and the doctor will use them to cure diseases and ease pain. Call the doctor—for the Lord created him—and keep him at your side; you need him. The doctor’s prayer is that the Lord will make him able to ease his patients’ pain and make them well again.. Jesus Sirach 38:1–3, 6–8, 12 & 14: The Apocrypha, Good News Bible.

The impact of smallpox on early Cape colonial society has always been a point of debate among scholars. As a result, its impact was either exaggerated or understated.1 An outbreak of smallpox in Kimberley, South Africa, during the early 1880s,2 became contentious when doctors disagreed on whether or not the virus was smallpox. Dr. Leander Starr Jameson, an influential doctor, who shared strong links with diamond capitalists, suggested that the virus was phemphigus,3 far less threatening than smallpox, while Dr. Hans Sauer, an equally able doctor with credible medical qualifications, believed it to be genuine smallpox (variola). The debate was soon complicated by the involve-

This chapter first appeared in Kleio, 35 (2003), 5–18, under a different title, and its original text has been substantially revised. It has been republished with kind permission of the editors and publishers of the former Kleio, now known as African Historical Review. The author wishes to acknowledge the comments and assistance of Professors Cuthbertson and Du Bruyn. 153

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ment of influential diamond capitalists, such as Cecil John Rhodes, and the resulting cover-up attracted such attention that it led in the words of Dr. Hans Sauer to the “greatest medical scandal in the long and honourable history of British medicine.”4 Although the episode is documented, most scholars either made cursory reference to its importance or devoted a few paragraphs to it.5 In revisiting an event that Edmund Burrows called the “most diabolic uses to which the medical profession was put,”6 this chapter reinvestigates an episode of “deception” and denial in the history of the medical profession at the Cape and the British Empire. In her book, Divided Sisterhood, the eminent historian Shula Marks correctly suggests that the mineral revolution not only transformed the lives of thousands of people, but it also “transformed South Africa’s disease patterns and its medical care.”7 Though Kimberley had emerged as a leading producer of diamonds during the latter half of the nineteenth century, its public health sector remained undeveloped. The lack of hospitals, poorly trained staff, and inferior medical facilities had rendered Kimberley unfit to combat epidemic diseases effectively. The first qualified medical doctor to arrive on the diamonds fields was Dr. B. W. Hall. He arrived in 1868, and remained in Kimberley for seven years. Following his departure to Basutoland, where he became medical officer during the Basuto wars, saw the arrival of more qualified doctors in Kimberley, namely Drs. Otto, Dyer, and Josiah Wright Matthews. These doctors opened private practices and rendered invaluable medical care to diggers and the growing population of Kimberley. The establishment of a hospital gradually developed as the town developed. In 1871, the missionary and Catholic priest, Father Hiddien, erected a tent and treated diggers who fell ill. In 1871, the community erected an iron and brick structure and called it Diggers Central Hospital. This was a private initiative, and, in 1874, the local government erected another hospital and named it Carnarvon Hospital. The arrival and appointment of nurses, in particular, those belonging to the St. Michael-and-all-Angels and the arrival of Henriette Stockdale in 1879 changed the face of hospital medical care on the diamond fields. In 1882, the Diggers Hospital and Carnarvon hospital merged into one hospital and was named Kimberley Hospital.8 Already by the late 1870s, Denis Doyle, Sanitary Inspector of Kimberley, expressed the view that an epidemic could ruin Kimberley. In order to combat future intrusion of communicable diseases, Edward Arthur Judge, the Civil Commissioner of Kimberley chairman of the Board of Health, convened a meeting with the Sanitary Inspector and board members to appoint a medical officer of health tasked to monitor the situation and implement precautionary and preventative measures.9 At that stage, efforts to appoint a state doctor proved fruitless, largely because established doctors seemed unwilling to

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abandon their lucrative private practice. The post remained vacant and was filled in 1882, when Hans Sauer was appointed to the position. Smallpox infiltrated Kimberley in November 1883 when Mozambican migrant laborers en route to the diamond fields were stopped and placed in isolation in a vacant building on Fealstead’s farm, some distance from the diamond town.10 The Medical Board acted swiftly and with the approval of Edward Judge, commissioned six senior Kimberley doctors to investigate the situation at Fealstead’s farm. On their return to Kimberley, doctors “unanimously reported that the disease . . . was smallpox.” Jameson added later “that the disease was undoubtedly smallpox” and affirmed that “two or three were beautiful cases of smallpox.”11 Though correctly described as variola (smallpox) by Kimberley doctors, it was a mild form of smallpox, scientifically known as variola minor. Dr. Murphy described the variant as “a severe form of Kafir pocks.” “Amaas” or “Kafir pox” is the native word for various skin eruptions that included smallpox and chickenpox.12 At a special board meeting convened on November 3, 1883, to discuss their findings and how best to control smallpox, the six doctors offered contradictory medical opinions. First to report to the Medical Board was Dr. Jameson. He retracted an earlier statement and significantly amended his diagnosis to such an extent that it contradicted an earlier opinion. He claimed that it was not a contagious disease nor lethal. This statement baffled everyone, especially the medical fraternity. He stressed that it was not smallpox, but a “bulbous disease of the skin allied to pemphigus.” Dr. William Murphy confirmed that it was a “severe form of Kafir pocks, pure and simple”13 and described it as extremely infectious to Africans. Dr. J. W. Matthews concurred with Jameson and stated that the disease was not contagious. Drs. Otto, Smith, and District Surgeon, William Grimmer, agreed unanimously that it was “variola (smallpox) or a disease allied to smallpox.”14 Grimmer voiced a much stronger opinion saying that “it was genuine smallpox modified by the life led by natives who are affected.”15 Incorrect diagnosis of smallpox, confusing it with chickenpox, also occurred in other parts of the British Empire, namely, the Australian port cities of Sydney and Melbourne. In his paper recounting the reactions to the appearance of smallpox in the colonial cities of Sydney and Melbourne in 1881–1882, Alan Mayne, writes that during “the dreadful scourge” doctors and the medical fraternity appeared divided on whether or not it was smallpox or chickenpox. Inexperienced Australian doctors and health officials turned to British medical sources and expatriate doctors who had encountered and treated cases of smallpox in London a decade earlier. As the debate evolved, and eventually ended, on whether the virus was smallpox or chickenpox, Australian doctors admitted that lack of experience and not ulterior motives

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were the underlying reason for the initial disagreement. The Medical Board of New South Wales, concurred that “few practitioners in this colony, and especially graduates . . ., have seen, or will see cases of small-pox”; therefore, the opinion of a few experienced doctors who have “seen a very great deal of small-pox, having been in practice in London during the severe epidemic of 1870–71” would be respected and accepted.16 The Sydney Morning Herald, which covered the story, reported that “the origin of small-pox is wrapped in mystery and the same may be said of the laws by which it does its deadly work. There is, perhaps, no malady about which even medical specialists are so much in the dark.”17 In Melbourne, during the epidemics of 1869 and 1884, Mayne argues that, “dissatisfaction was widely voiced at doctors’ hesitancy, disagreements, and mistakes in diagnosing smallpox.”18 Again, public confidence reached a low point in the medical profession, as the inability of doctors to diagnose smallpox correctly was severely criticized. In critiquing their inability, “to distinguish between smallpox and chickenpox,” one resident of Melbourne wrote: “what is the good of them I should like to know?”19 At the same meeting, arranged by the Kimberley Medical Board, the question of quarantine was also raised. Again, medical opinions differed. Dr. Jameson viewed quarantine completely “unnecessary,”20 while Dr. Murphy considered quarantine as crucial, especially for newly arrived African migrant laborers. Drs. Otto, Smith, and Grimmer suggested that all patients, including African laborers, be placed under quarantine. After much deliberation, the Medical Board and the six doctors finally concurred that all smallpox sufferers should be quarantined. A week later, without the approval of the Medical Board, Dr. Jameson and his cohorts printed and distributed flyers, or so-called pink slips, all over the diamond fields, with the inscribed message that “the disease of Fealstead’s farm is not smallpox, [but] a bulbous disease of the skin allied to pemphigus.” It was signed by Drs. L. S. Jameson, Matthews, Crook, Harris, and Wolff. The signatures provided some kind of legitimacy to their cause as most of them belonged to prominent doctors in Kimberley. Doctors had hoped that the message would appease the public, especially claim-owners and their African laborers. The Medical Board seemed baffled and embarked on a serious mission of damage control.21 Meanwhile, in Cape Town, prominent Cape politicians criticized those who challenged the opinion of the majority. “It does not seem to matter much,” wrote John X. Merriman, “as it is deadly and contagious whatever they call it.”22 But the question we need to pose at this point is why Dr. Jameson undermined the Medical Board and declared that the disease was not smallpox, but pemphigus. One could argue that Jameson was entitled to alter his

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opinion. However, there is a strong suggestion that his medical opinion was clouded by his close links with the diamond elite who generally feared that an epidemic could ruin the entire diamond industry. Moreover, in Kimberley, Jameson was by far the most qualified doctor holding an MD degree while his peers obtained medical diplomas.23 Since he was rated as one of the best-qualified doctors of his generation by his peers, many refrained from challenging his medical opinion. Dr. J. W. Matthews, for example, described Jameson as “one of the most able physicians in the Diamond Fields.”24 The biographer Ian Colvin concurs and explains how Jameson’s “skill was considered marvellous, not only by laymen, but by his fellow-practitioners; he was a master of the latest methods and was far more highly trained than any other doctor in the camp.”25 As a result, less qualified doctors felt obliged, if not intimidated, and sided with Jameson. He had become an “untouchable” medical man, or so it seemed. The manner in which Jameson reasoned suggests that a definite code of medical ethics was non-existent among Cape doctors in British South Africa. S. S. Gilder concurs, and he argues that by 1884, “in South Africa, it was not a question of amending medical ethics but creating them.”26 This suggests that although certain doctors may have been extremely skillful and talented, they clearly lacked a sense of medical ethics. Such doctors became a law unto themselves. Ironically, in July 1883, four months before the smallpox scandal hit the diamond fields the South African Medical Association was established in Cape Town. As a newly formed association, its operations were very lowkey, and the association was hardly in any position to act upon its members. In Kimberley, doctors were also keen diamond entrepreneurs and owned claims. “The medical man on the Fields,” wrote Seymour Fort in 1918, “need not confine himself to the exercise of his profession. If he sort on his claim, his tent should be pitched not very far from the latter, and he can have a particular flag flying on his claim with a notice to patients.”27 Based solely on credentials, Dr. Jameson and Dr. Matthews were not only respected by the medical fraternity of Kimberley, but also gradually established themselves as the vital link between the world of medical science and the growing sphere of mining capitalism. However, the real “force” behind the conspiracy of silence and the smallpox scandal was the powerful diamond elite and the private wealth of one individual, namely, Cecil John Rhodes. As far as they were concerned, the industry had already suffered too many setbacks and closure of the fields would ruin Kimberley.28 The involvement of Cecil John Rhodes, described as the “hidden hand” and the person “pulling the strings while keeping entirely out of sight,”29 gave a new twist to the smallpox saga. Though exonerated by the biographer Robert Rotberg in his latest work on the mining magnate,

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evidence suggests that Rhodes had indeed played a vital role in the denial of smallpox.30 Though based on the recollections of a certain Mrs. Tiny Hickman, a conversation between Rhodes and Dr. James Alexander Smith illustrates his involvement all too well. “Mr Rhodes,” said Dr. Smith to Rhodes one day, “I am sorry to tell you that smallpox had broken out in one of the compounds.” Rhodes then replied, “Don’t be a fool. It’s chickenpox,”31 Smith then delivered a piece of skin in a bottle with full particulars to the Medical Superintendent of the South Eastern District Fever and Smallpox hospital, Dr. John MacCompie, for diagnosis. Weeks later, MacCompie wrote: Your diagnosis is perfectly correct: “Smallpox”. You are to be congratulated on the measures you have taken to combat the spread of the disease and in spite of the opposition of a certain section of the community your efforts have been rewarded with a large amount of success. The concealment of the mine-owners of cases of smallpox amongst natives in their employ is a practice which calls for the severest censure.32

Despite being congratulated on combating smallpox and exposing the opposition, Smith backed down and refused to go public with the results. A few days later, Rhodes appointed him medical officer of the compounds and earned a salary package of £600 per annum.33 In a short while, James Smith was also drawn into the widening network of doctors and mining entrepreneurs denying the presence of smallpox. When Rhodes insisted that the disease be called chickenpox and not smallpox, he reasoned like an entrepreneur and capitalist. However, he also knew what local Africans and African chiefs thought of smallpox. “We will not get wood from the Basuto women, and the mines will have to close down, as we have no coal here,” said Rhodes to one of his associates at the time of the crisis.34 Since the discovery of diamonds in Kimberley trade with Basutoland had flourished. By 1873, grain and wool was exported from Basutoland to Kimberley on a regular basis. Trade links with the Basotho people soon included the provision of migrant labor. “By the end of the 1870s,” writes Paul Maylam, “about 5000 southern Sotho adult males were employed on the diamond fields.”35 For Rhodes, the entrepreneur, these risks were simply far too great. Thus, with his remark that “the mines will have to close down,” Rhodes knew exactly what was at stake. In his opinion, the entire Cape economy and future of Kimberley would no doubt be affected. This imperilment of people in favor of financial gain undoubtedly constituted a low point in the history of mining capitalism in colonial South Africa. Johannes (Hans) Sauer, the young Afrikaner medical doctor who received his medical training in Edinburgh, immediately questioned the denial of smallpox. Sauer arrived in Kimberley in 1882 with the hope of opening a

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private practice. When his enthusiasm was dashed by the fact that he entered a saturated medical market, Dennis Doyle offered him a job as State doctor, which Sauer accepted immediately.36 Within weeks, Sauer rose to prominence when he successfully safeguarded Kimberley from the smallpox scourge, which struck Cape Town in 1882. A proponent of quarantine and vaccination, Sauer established a quarantine station at Modder River outside Kimberley. Here travelers were vaccinated and fumigated before entering Kimberley.37 Although these preventative measures infringed on personal liberties, their success rate was remarkable. No fewer than fourteen cases of full-blown smallpox were detected as a result. Of the fourteen, only two sufferers died and the rest staged full recoveries.38 The implementation of preventative measures by the Sanitary Board and Sauer paid off handsomely when a major outbreak of smallpox was successfully averted. On his return to Kimberley from Lydenburg, where vaccination stations were erected by Sauer to combat smallpox, he was handed a pink pamphlet stating that the virus was pemphigus and not smallpox. This baffled Sauer, especially since the local authorities asked him to return to Kimberley to combat what they regarded as a fresh outbreak of smallpox.39 In order to clarify matters for himself and rectify the confusion, Sauer consulted his medical textbooks and read that pemphigus was a very rare skin disorder, but that it did not resemble smallpox even in its remotest form. Since pemphigus was a rare disease, Sauer was convinced that none of the co-signatories of the “pink slips,” with the exception of Jameson, had knowledge of it.40 The examination of a few smallpox sufferers the following day confirmed in Sauer’s view that “it is smallpox.”41 A report was compiled and telegraphed to the authorities in Cape Town. A few days later, Hans Sauer was appointed Medical Officer of Health in Kimberley.42 Weeks later, smallpox was detected among African migrant laborers employed on the diamond fields near Du Toitspan. Congested compounds and poor living conditions no doubt accelerated the dissemination of smallpox.43 Inadequate accommodations, a poor diet, and substandard medical care invariably meant greater susceptibility to smallpox. Apart from smallpox, other infections such as pneumonia, dysentery, and typhoid were rife among migrant workers.44 Prior to the outbreak of smallpox, Dennis Doyle released startling figures and reported that one in every fifteen laborers had fallen ill in 1883.45 Patrick Harries estimated that between 1883 and 1884 about 600 black workers died of smallpox and inadequate sanitation.46 It did not take the De Beers capitalists very long to attach racial connotations to the prevailing smallpox epidemic. Mining capitalists stressed that smallpox was essentially a black disease brought to the diamond fields by African migrant laborers. Smallpox was soon stigmatized and linked to a particular

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lifestyle led by African people. In 1883, one doctor, for example, diagnosed the type of smallpox detected among African laborers “as smallpox modified by the life led by the natives.”47 However, the death of white diamonddiggers brought about a sudden urgency to combat smallpox. The Medical Board acted quickly and established a lazaretto outside the town. Henceforth, all smallpox sufferers who could not be quarantined in their homes were transferred to the lazaretto. The board did its utmost to monitor and combat the spread of smallpox. Kimberley’s poor medical infrastructure and general lack of public health policies forced the local authorities to deal with the epidemic in a radical manner. They formulated a policy regarding vaccination, quarantine, and the fumigation of all smallpox sufferers.48 Apart from building and furnishing the lazaretto with the necessary equipment, the board still lacked many essential resources to ensure swift action in combating the disease. For example, it had to acquire ambulances and horses, employ drivers and appoint people willing to assist in various capacities. In cases where patients could not be taken to the lazaretto, their houses had to be quarantined and guarded day and night. Doctors, nurses, and other assistants demanded higher wages than usual owing to the risk involved in treating smallpox sufferers.49 Moreover, the board was constantly sabotaged by the efforts of Drs. Jameson and Matthews who maintained that it was not smallpox, nor was it contagious and infectious. As a result, Kimberley residents acted carelessly and failed to take precautionary measures to combat smallpox.50 As the funds of the Medical Board began to run dry, opposition toward its activities escalated. The Kimberley press criticized the Board for its inability to handle to crisis. Disagreement among doctors was no longer confined to board rooms, hospitals, and smallpox sufferers, but it became public knowledge. Smallpox became a matter of public debate and was widely publicized in the Kimberley press. The rapid increase in the mortality rate among whites triggered an unprecedented attack on the Medical Board by The Diamond Fields Advertiser. The newspaper accused the Board of neglecting its responsibilities to the public. In the response, the Board argued that their efforts to combat the epidemic were undermined by external factors beyond their control, namely, the disagreement among doctors and lack of funds. As the rift among Kimberley doctors widened, the Cape authorities too doubted the authenticity of the diagnosis provided to them thus far.51 In order to settle the dispute, they commissioned Dr. Falconer, a smallpox specialist to investigate the matter. On his way to Kimberley, an unidentified person offered Dr. Falconer a bribe. “At De Aar,” Falconer recalled later, “I was met by someone who offered me a large bribe to say that the disease is not smallpox.”52 Falconer, however, could not be bribed and his report to the Medical Board declared unequivocally “that the disease was undoubtedly genuine smallpox.”53

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Despite Falconer’s conclusive report, diamond magnates urged doctors “sympathetic” to their cause to reject the contents of the report. Described in one source as “one of the Directors,” Jameson successfully lobbied for a re-investigation. Dr. Edmund Sinclair Stevenson, a Cape Town doctor, and Jameson headed the re-investigation and “pronounced it chicken-pox” as any other diagnosis according to them “might have led to serious trouble.”54 The promulgation of the Public Health Act in 1883 made no immediate impact on the epidemic other than forcing doctors to report all cases of smallpox to Sauer and his staff. “Pink slip” doctors, however, continued to call it “Fealstead disease,” pemphigus.55 Armed with the Public Health Act, Sauer soon discovered how deep the conspiracy of silence was rooted. Dr. Henry Wolff, the acting resident surgeon, and Sister Henrietta Stockdale, matron of the Kimberley hospital, “were in sympathy with the views of Drs. Jameson and Matthews.”56 Evidence gradually mounted against the “pink slip men.” First, there was the case of Mrs. Greenhough, a smallpox sufferer. Both Wolff and Rutherford Harris falsified her death certificate, stating that pneumonia was the cause of death, when she had in fact died of smallpox. When Sauer re-examined the corpse, he discovered that the patient died of “smallpox of the most severe type.”57 Acting on a tip-off that several people had died of smallpox and that hospital staff had concealed their bodies, Sauer investigated the matter and informed the Public Prosecutor of these irregularities. Sauer visited the hospital but was refused entry by Sister Stockdale. Stockdale only changed her mind when her entire nursing staff was threatened with quarantine. Despite her strong personality and the fact that she ran a “strict regime,”58 Stockdale was, nevertheless, powerless when it mattered, as she was often “overruled by the doctor in charge.”59 But, as Shula Marks remarked, “Sister Henrietta’s loyalty to the medical and mining establishment in Kimberley seems to have overridden her professional judgement.”60 After the hospital scandal, Dr. Wolff was sacked, but Sister Henrietta kept her job. The private vaccination of medical staff, particularly those who denied the existence of smallpox, which included Sister Stockdale, was not only unethical, but also a case of medical hypocrisy. Even Dr. Harris had taken sufficient precaution against contracting smallpox.61 Had Sauer not caught him disinfecting himself, or demanded, as in the case of the Kimberley nurses, to show him the vaccination marks, it would have remained a secret. The introduction of public health regulations by the local authorities introduced a new form of state control in Kimberley. Compulsory smallpox vaccination forced upon minority communities, violated certain civil liberties, notably religious freedom. The Malay62 population of Kimberley that totaled about 600 by the mid-1880s faced a serious religious dilemma. Anti-

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vaccinationists protested in public against compulsory vaccination. One Malay smallpox sufferer was carried against his “will to the lazaretto.” The violent removal of another patient caused quite a stir in central Kimberley as he was dragged “amidst the hoots and execrations of an infuriated mob through the streets into an ambulance.”63 In 1882, similar protests were staged in Cape Town when the Malay community refused on religious grounds to be vaccinated against smallpox. Using the slogan “religion is superior to the law,” they expressed “strong objection to hospitalisation, vaccination, quarantine and fumigation.”64 Apart from religious objections, concealment of sufferers posed a major challenge to Sauer and his staff as they attempted to control the outbreak. Indian and Malay fruit and food traders often concealed smallpox sufferers in order to protect their businesses from closure. For example, in 1884, it was discovered that an Indian fruit trader had concealed a woman who later died of smallpox in his house where he conducted his business. The Medical Board took strong action against the trader and shut his business. Once the body was removed from the shop, health officials were instructed “to burn everything in the house and shop, and then fumigate the premises.”65 When the trader later demanded £200 in compensation, he heard that he had contravened the law by concealing a smallpox sufferer and forfeited compensation for his loss. Meanwhile, days after the scandal broke of Sauer being denied access to the hospital, a serious case of smallpox was reported at Bultfontein involving a young married white woman, Mrs. Sarsfield. She died of smallpox after having contracted the virus from her friend, Mrs. Greenhough, twelve days before. As Mrs. Sarsfield was pregnant and not prepared to run the risk of contracting any virus, she was assured by Dr. Wolff that her friend Mrs. Greenhough only “had a mild form of pneumonia.”66 Taking the word of the doctor to heart, she visited her friend and contracted smallpox, dying twelve days later. The untimely death of Mrs. Sarsfield and her unborn infant attracted considerable attention. It also provided Hans Sauer the required breakthrough to solve the medical fiasco. Piecing the evidence together, he discovered that the patient in question “had been infected . . . as a direct consequence” of contact with a smallpox sufferer.67 Sauer requested that criminal charges be instituted against Dr. Wolff. Charged with murder, Wolff appeared in court, but the presiding judge pointed out that Mrs. Sarsfield could also have contracted smallpox from another source and exonerated Wolff from any wrongdoing.68 Meanwhile, attention shifted toward Jameson, the principal architect of the crisis and confusion. Driven into a corner, Jameson sought refuge in his medical credentials. Armed with a university degree (Doctor of Medicine), he

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believed that “his opinion overrode that of all other doctors on the Fields.”69 Denigrating his fellow doctors in public and questioning their professional competence points to what the historian Robert Rotberg regard as Jameson’s “lack of integrity.”70 Jameson also accused Sauer of making money out of smallpox and both parties subsequently brought libel charges against each other in the High Court. Both were found guilty and ordered to pay each other £2000 in damages. To counteract Jameson’s claim that most Kimberley doctors were unqualified and incompetent to diagnose the virus accurately, Sauer insisted on the appointment of another independent Medical Commission or a respected doctor. Parliament agreed and appointed Dr. G. Saunders, an MD graduate and leading smallpox specialist, to head the investigation. He confirmed that the disease was “smallpox pure and simple.”71 Jameson and his associates within the medical and entrepreneurial field had little choice but to accept the outcome of the investigation. In parliament, smallpox sparked some degree of debate. Rhodes protested “against these attacks on the character of medical men of the highest standing, who had suffered pecuniary loss through adherence to their convictions, whether these convictions were mistaken or not.”72 J. X. Merriman’s comment in his address to the Cape Assembly was much more hard-hitting. “The spread of the disease,” he said, “was entirely the fault of the inhabitants who had behaved in a disgraceful way.”73 In the end, however, it came to light that Rhodes and the mining elite had acted on “assumptions.” Sauer himself best summarized this when he wrote, “eventually the presumption turned out to be entirely groundless, for even when, some months later, the epidemic was at its climax, not a single native labourer left Kimberley on account of the disease.”74 Mining capitalists not only misunderstood African culture but also underestimated their medical practices. Exposed to smallpox for centuries, African societies developed their own methods to counteract smallpox through inoculation. Although not regarded as the safest method at the time, inoculation did provide African societies with lifelong immunity against smallpox. Documentary evidence suggests that inoculation had been practiced in Africa since 1706, but it is believed that this practice existed for a much longer period. The site of inoculation varied but was commonly done on the forehead, arms, or legs.75 As Sauer explained, African societies had inoculated themselves against smallpox76 for centuries before Western medicine was introduced by missionaries. The missionary, David Livingstone, observed how the Bakwena people inoculated themselves against contracting smallpox. “For smallpox,” explained Livingstone, “the natives employed in some parts inoculation in the forehead with some animal deposit; in other parts they employed the matter of the smallpox itself.”77

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The implementation of preventive measures finally brought smallpox under control. Toward the end of 1885, the epidemic subsided completely and allowed Hans Sauer to give the entire province of Griqualand West, including Kimberley, a clean bill of health. Of the estimated 2,300 cases reported, only 700 individuals died, while the rest staged full recoveries. Of the victims who perished, 51 were whites and the rest (649) were persons of color.78 Taking into consideration that the Kimberley population totaled well over 20,000 by 1884,79 the overall mortality rate was more or less 3.5 percent. In her book The Trouble with Doctors: Fashions, Motives and Mistakes, Ann Dally highlights in one chapter, entitled “Doctors’ Motives,” how motives of doctors were and are not always pure, sincere, and admirable. As a result, the accepted adage that doctors invariably “act only in their patients’ interest,” has proved to be a myth, as every physician has their own agenda for administering or not administering medicine to patients.80 As the “hidden motives” of doctors are brought to the fore, the smallpox saga and subsequent scandal that unfolded during the early 1880s in the diamond-rich village of Kimberley, remains a good example of how colonial doctors, under the spell of imperialism and material capitalism, twisted the truth and facts of a deadly disease. They had done this because they had the political power, financial resources, and medical expertise to do so. Thus, by allowing themselves to be manipulated by the De Beers capitalist elite, certain doctors compromised their profession and, in the words of the biographer G. S. Fort, stood “accused of deliberately sacrificing the public health to capital interests.”81 While the infamous “pink slip doctors” and the ethos they represented, disgraced and damaged an otherwise revered profession, the smallpox saga of 1882–1883 underscores exactly how influential doctors had become at the height of the mineral revolution in South Africa. Moreover, it highlights the prevalence of corruption within a local community and the dangers thereof, when big business, politicians, and medical men become cozy bedfellows. The currency of the pound rather than public health outweighed the primary concern of a doctor, namely to act in the interest of the patient. The medical profession was clearly in crisis, desperately in need of stricter control measures as far as medical ethics and the role of the doctor was concerned in the fast-evolving medical profession and medical science. The “smallpox war” also unveiled the skill and medical knowledge certain colonial doctors possessed to diagnose, treat, and combat smallpox. Unlike their Australian counterparts, who remained “ignorant” in combating recurring smallpox outbreaks, many British and Cape-born doctors based at various hospitals throughout the Cape Colony raised the bar and took medical science, the available technology of vaccination, and treatment techniques to a new level. Many began to specialize in smallpox prevention, immunization

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and treatment. Many of these doctors were known in the medical profession as “smallpox specialists.” During the epidemic of 1882–1883, we were introduced to at least three such smallpox specialists, namely, Drs. Saunders, Falconer, and MacCompie. Though highly qualified in the field of medicine, the real interests of Dr. Leander Starr Jameson and his cohorts seemingly lay elsewhere. His credibility as a doctor is best described by one of his former patients, Elsa Smithers. In her autobiography, she writes that Jameson “was considered more of a politician than a doctor, as he never seemed interested in his patients.”82 His initiating the Jameson Raid ten years later and entering politics suggest that Jameson saw himself as a politician rather than a doctor. Fortunately, not all doctors allowed themselves to be bribed. A proponent of sound medical ethics, Hans Sauer and other smallpox specialists succeeded in restoring the tainted image of the medical profession in a significant way. Even the editor, of the newly founded South African Medical Journal, established in January 1884, Dr. William Darley-Hartley, who later became a medical journalist, attacked Jameson and those doctors of his generation for disgracing the medical profession and their obstructionist attitude during the “smallpox war.” In the July 1886 issue of the South African Medical Journal, Darley-Hatley outlined his low regard for the generation of doctors that had compromised their profession in favor of material wealth. “The old generation of Kimberley doctors,” writes Darely-Hatley, “would never be missed. With a few honourable exceptions their homes were bars, their principal occupation swearing and gambling, and their main claim to success an unlimited capacity for advertising themselves and slandering their confreres.” His intention, as a medical practitioner, was to “fearlessly guide, direct and defend the common interests of the profession and the ethical proprieties of its individual members.”83 Modern medicine, advanced surgical procedures, and scientific knowledge to combat and better yet, eradicate life-threatening diseases have been shown to prolong life.84 The medical advances of a modern world thus dictate to a large extent that all human beings have the right to be protected by a medical profession against the dishonest, and often evil, conduct of certain doctors, such as Dr. Jameson and his cohorts. Therefore, as modern South Africa and Africa confront life-threatening diseases such as cholera, malaria, tuberculosis, and HIV/AIDS, the “smallpox war” raises awareness about honesty and openness in the medical profession, government, and the public health sector. South Africa can ill afford the near calamity of a century ago when doctors, colonial officials, and capitalists denied and silenced the presence of smallpox in favor of economic growth and accumulation of personal wealth. But, on the other hand, as history has shown and continues to show, disease was and will always be a merciless leveller of class, culture, race, age, and gender.85

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The smallpox scandal of 1882–1883 and the behavior of certain colonial doctors, reminds us of the words written by John Aubery who lived during the seventeenth century. Quoting a contemporary of his, one Dr. Ridgely, he wrote: “If the world knew the villainy and knavery of the physicians and apothecaries, the people would throw stones at ‘em as they walked in the streets.”86

NOTES 1. R. H. Elphick, “The Khoisan to c.1770,” in The Shaping of South African Society, 1652–1820, eds. R. H Elphick and H. Giliomee (Johannesburg: Longman, 1979), 22–23; R. Ross, “Smallpox at the Cape of Good Hope in the Eighteenth Century,” African Historical Demography, 1 ed. C. Fyfe and D. McMasters (Centre for African Studies: University of Edinburgh, 1977), 416–22; A. Smith, “Khoikhoi susceptibility to virgins soil epidemics in the 18th century,” South African Medical Journal, 75, 1 (1989): 25–26; R. S. Viljoen, “Disease and Society: VOC Cape Town, Its People and the Smallpox Epidemics of 1713, 1755, 1767,” Kleio, XXVII (1995): 22–45. 2. S. Marks, Divided Sisterhood: Race, Class and Gender in the South African Nursing Profession (Johannesburg: Witwatersrand University Press, 1994), 38–40; B. Roberts, Kimberley: Turbulent City (Cape Town: David Philip, 1984), 218–25; I. Colvin, The Life of Jameson, vol. 1 (London: Edward Arnold, 1922), 25–36; R. Rotberg, The Founder: Cecil Rhodes and the Pursuit of Power (Johannesburg: Southern Book Publishers, 1988), 186–87; A. Thomas, Rhodes (London: BBC Books 1996), 159–60; H. Sauer, Ex Africa (London: Geoffrey Bles, 1937), 67–92; J. W. Matthews, Incwabi Yami: Or Twenty Years’ Personal Experience in South Africa (New York: Rogers and Sherwood , 1887), 108–11. 3. In medical terms, pemphigus is described as a skin condition characterized by the appearance of highly infectious large blebs. 4. Sauer, Ex Africa, 74. 5. Sauer, Ex Africa, 67–92; E. H. Burrows, A History of Medicine in South Africa up to the End of the Nineteenth Century (Cape Town: A. A. Balkema, 1958), 258–62; Roberts, Kimberley, 218–25; Marks, Divided Sisterhood, 38–40; Rotberg, The Founder, 186–87; Thomas, Rhodes, 159–60. 6. Burrows, A History of Medicine in South Africa, 259. 7. Marks, Divided Sisterhood, 16. 8. N. Kretzmar, “On the Diamond Fields around Kimberley,” South African Journal of Medical History, 46 (30 September 1972): 1448–50. 9. BC 500 Judge Edward Arthur Papers, B 76 “An Autobiographical Account of his Life in South Africa—Edward Judge” (UCT Manuscripts and Archives Department, Jagger Library, University of Cape Town), 403. 10. Matthews, Incwadi Yami, 425. 11. Sauer, Ex Africa, 73. 12. Though the origin of the word amaas is unknown, it may have been derived from the Dutch word masels or mazelen. According Dr F. Arnold, District Officer of

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Health of Lydenburg in the district of Northern Transvaal in 1908, the word Amaas is the native word for various eruptions, including smallpox and chickenpox. During the late nineteenth and early twentieth centuries, there had always been a difference of opinion regarding the nomenclature of the disease. In Volksrust, two local doctors called it “amaas or Kaffir pox,” meaning that the disease was not smallpox but a third disease of a pustular nature midway between smallpox and chickenpox. See Colonial Secretary (CS) 543 Correspondence Files, no 1064–1121, 1905. “Amaas in Lydenburg Goal, 20 July 1908; “Smallpox in Volksrust, November 1905” report by Medical Officer of Health, Dr. J. R. Briscoe. 13. BC 500 Judge Edward Arthur Papers, B 76, “An Autobiographical Account of his Life in SA - Edward Judge.” Report of the Proceedings of the Medical Commissioner on the cases under treatment at Felstead’s farm. (UCT Manuscripts and Archives Depot, Jagger Library), 404. 14. BC 500, Judge Papers, B 46, 404–405. 15. BC 500, Judge Papers, B 46, 404–405. 16. A. Mayne, “‘The Dreadful Scourge’: Responses to Smallpox in Sydney and Melbourne, 1881–2,” in Disease, Medicine and Empire: Perspectives on Western Medicine and the Experience of European Expansion, ed. R. Macleod and M, Lewis (London and New York: Routledge, 1988), 225. 17. Mayne, “‘The Dreadful Scourge,’” 230. 18. Mayne, “‘The Dreadful Scourge,’” 230–31. 19. Mayne, “‘The Dreadful Scourge,’” 231. 20. BC 500, Judge Papers, B 46, 404–405. 21. Matthews, Incwadi Yami, 425. 22. P. Lewsen, ed., Selections from the Correspondence of J.X. Merriman 1870– 1890 (Cape Town: Van Riebeeck Society, 1960), 147. 23. E. B. van Heyningen, “Leander Starr Jameson,” in E. J. Carruthers, ed., The Jameson Raid: A Centennial Retrospective (Johannesburg: Brenthurst Press, 1996), 181–82. See also Sauer, Ex Africa, 75. 24. Matthews, Incwadi Yami, 425. 25. Colvin, The Life of Jameson, 26–27. 26. S. S. B. Gilder, “South African Medicine in the 1880s,” South African Medical Journal, 66 (August 1984): 248. 27. G. S. Fort, Dr Jameson (London: Hurst and Blankett, 1918), 60. 28. R. V. Turrell, “Kimberley: Labour and Compounds, 1871–1888,” in S. Marks and R. Rathbone, eds., Industrialisation and Social Change in South Africa: African Class Formation, Culture and Consciousness 1870–1930 (London: Longman, 1987, 3rd edition), 57–58. See also W. H. Worger, South Africa’s City of Diamonds: Mine Workers and Monopoly Capitalism in Kimberley 1867–1895 (Johannesburg: A. D. Donker, 1987), 103; Lewsen, Selections from the Correspondence of J.X. Merriman 1870–1890, 121. 29. Sauer, Ex Africa, 42. 30. Rotberg, The Founder, 186. 31. MSS.AFR.t.11. “Reminiscences of Mrs Tiny Hickman,” 21–33. Rhodes House Library (Oxford), CJR 11, 1955.

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32. MSS.AFR.t.11.”Reminiscences of Mrs. Tiny Hickman,” 21–33. 33. MSS.AFR.t.11.”Reminiscences of Mrs. Tiny Hickman,” 21–33. 34. MSS.AFR.t.11.”Reminiscences of Mrs. Tiny Hickman,” 21–33. 35. P. Maylam, A History of the African People of South Africa: From the Early Iron Age to the 1970s (Cape Town: David Philip, 1989, 3rd edition), 118. 36. Sauer, Ex Africa, 37. 37. Sauer, Ex Africa, 37. 38. Sauer, Ex Africa, 38. 39. Sauer, Ex Africa, 73. 40. Sauer, Ex Africa, 74. 41. Sauer, Ex Africa, 75. 42. Sauer, Ex Africa, 75. 43. R.V. Turrell, Capital and Labour on the Kimberley Diamond Fields 1871– 1890 (London: Cambridge University Press, 1987), 138ff; Worger, South Africa’s City of Diamonds, 100; F. Fenner, et. al, Smallpox and Its Eradication (Geneva: World Health Organization, 1988), 202–205. 44. Worger, South Africa’s City of Diamonds, 100. 45. Turrell, “Kimberley: Labour and Compounds, 1871–1888,” 64. 46. P. Harries, Work, Culture, and Identity: Migrant Labourers in Mozambique and South Africa, c.1860–1910 (London: James Currey, 1994), 64. 47. BC 500, Judge Papers, B 46. Report of the Proceedings of the Medical Board, 405. 48. BC 500 Judge Papers, 405. 49. BC 500 Judge Papers, 413. 50. BC 500 Judge Papers, 405. 51. BC 500, Judge Papers, B 76, 406–407. 52. BC 500 Judge Edward Arthur Papers, B 76 “An Autobiographical account of his Life in South Africa - Edward Judge,” 407. 53. BC 500, Judge Papers, B 76, 407. 54. E. S. Stevenson, Adventures of a Medical Man (Cape Town: Juta & Co, 1925), 13. 55. Sauer, Ex Africa, 81. 56. BC 500 Judge Papers, 408. 57. Sauer, Ex Africa, 84. 58. HKB 2/1/1 Kimberley Hospital Correspondence. `Recollections of the Old Kimberley Hospital, 1890–1894 by Colleen Paul (Ross). 59. Marks, Divided Sisterhood, 39. 60. Marks, Divided Sisterhood, 40. 61. Sauer, Ex Africa, 83. 62. Malays refer to people who subscribe to the Islamic faith. 63. Matthews, Incwadi Yami, 408. 64. A. Davids, “`The revolt of the Malays’: A study of the reactions of the Cape Muslims to the Smallpox Epidemics of Nineteenth Century Cape Town,” in eds. C. Saunders, E. van Heyningen, and V. Bickford-Smith, Studies in the History of Cape Town (Cape Town: UCT Press, vol 5, 1984), 63.

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65. BC 500 Judge Papers, 410. 66. Sauer, Ex Africa, 87. 67. Sauer, Ex Africa, 89. 68. Sauer, Ex Africa, 89. After his acquittal, a complimentary dinner was arranged in honor of Dr. Wolff by his fellow doctors that included Matthews and Jameson. See The Diamond Field Advertiser, April 7 and 25, 1884. 69. Sauer, Ex Africa, 89. 70. Rotberg, The Founder, 187. 71. Sauer, Ex Africa, 91. 72. Cape Hansard, July 4, 1884. 73. Cited in Roberts, Kimberley, 225. 74. Sauer, Ex Africa, 78. 75. Fenner, Smallpox and Its Eradication, 246, 257–58. 76. Sauer, Ex Africa, 78. 77. D. Livingstone, Missionary Travels and Researches in South Africa (London: J. Murray, 1857), 113. 78. Matthews, Incwadi Yami, 110. 79. Worger, South Africa’s City of Diamonds, 136 nt 57. Thanks to Dr. Bridget Theron for pointing out this reference. 80. A. Dally, The Trouble with Doctors: Fashions, Motives and Mistakes (London: Robson Books, 2003), 38–54. 81. Fort, Dr Jameson, 74. 82. E. Smithers, March Hare: The Autobiography of Elsa Smithers (London: Oxford University Press, 1935), 137. 83. Editorial, “A century of the Journal,” South African Medical Journal, 66, no.7 (August 1884): 241. 84. Dally, The Trouble with Doctors: Fashions, Motives and Mistakes, 236. 85. D. M. Fox, “The Politics of Physicians’ Responsibilities in Epidemics: A Note on History,” in AIDS: The Burden of History, eds. M. Fee, and D.M. Fox, (Berkeley: University of California Press, 1988), 86–94; J.N. Hays, The Burdens of Disease: Epidemics and Human Response in Western History (New Brunswick, NJ: Rutgers University Press, 1998). 86. Quoted in Dally, The Trouble with Doctors, 45.

10

Submitting to Surgery in the 1890s: Four Vignettes Sally Wilde

The setting for this chapter is the rapid late-nineteenth-century rise of surgery in Britain and Australia. Most work on this period has focused on doctors and the reasons why they wanted to operate increasingly often.1 But whatever the details of the complex set of factors that drove the growing popularity of surgery from the doctor’s perspective, this was only one side of the story. Patients, especially paying patients, also had to be convinced that surgery was in their best interests.2 The focus in what follows is on patients, and the circumstances under which they agreed to allow themselves to be made unconscious while strangers went to work on them with knives. While charity patients in public hospitals played an important role in the development of scientific medicine, often as passive subjects for the medical gaze, there is now a very considerable body of research that highlights the rather different sorts of nineteenth-century relationships negotiated between medical practitioners and their paying patients.3 The four vignettes in this chapter have been chosen to illustrate the experiences of women who were not well off and lived on the margins of poverty, sometimes able to pay for their medical care, and sometimes treated in public hospitals. But despite their economic circumstances, it emerges that these women and their families were able to make important choices about their medical care, often resisting medical authority in the process. These stories of one English and three Australian women illustrate how doctors sometimes had difficulty imposing their authority, even on working-class patients. The late nineteenth century was a transitional period between the conceptualization of health care as a commodity, bought and sold under market arrangements, and the contrasting conceptualization that health care decisions should be the special province of experts. Patients were moving from the idea 171

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of “buyer beware” in their relationships with health professionals to the idea of “doctor knows best.” As Mark Schlesinger recently pointed out, markets, including for services provided by proponents of a range of health beliefs, were the nineteenth-century norm.4 Similarly, Rima Apple has argued that ideas about scientific motherhood in the nineteenth century required mothers to seek out information for themselves. In contrast, in the early twentieth century women were increasingly being exhorted to “follow the directions of their physicians.”5 The combination of increasing technical complexity and professional closure contributed to a new dominance by allopathic professionals, and the assumption that they would make decisions on behalf of patients. By the 1930s, the argument that medical care was not a commodity, and that the public were incompetent to make treatment decisions on their own behalf, had become widely accepted. However, this was not yet the case in the 1890s. In the period covered by this chapter, most patients still made, and were expected to make, their own decisions about treatment. Characteristically, this was in the context of advice from family and friends, as much as from medical practitioners.6 It has been customary in studies of colonial medicine to emphasise the differences between periphery and metropolis, but when examining the circumstances surrounding the decisions of patients to submit to surgery, many important similarities emerge between Britain and Australia. At least partly, this is because patients in both countries were subjected to very similar repertoires of treatments by doctors trained under a very similar (and sometimes precisely the same) system. In the nineteenth century, the vast majority of Australian doctors did at least some of their training in Britain and held British qualifications.7 All doctors were entitled to operate, but many of those who chose to specialize in surgery went to considerable trouble to acquire further expertise. Travel for postgraduate experience and sometimes also qualifications was a regular feature of the careers of Australian surgeons, including round the world study trips taken in Britain, North America, and possibly also France and Germany. From at least the 1890s, elite Australian surgeons typically held a fellowship from one of the British colleges of surgeons. They also set up patterns of hospital routines and rituals in Australia that emulated those “at home.” Australian surgery was never isolated from events elsewhere.8 At the turn of the century, most Australians who operated on a regular basis had spent time training in Britain, and they compared their own standards to surgery in England and Scotland, especially at the larger teaching hospitals. It is therefore possible to directly compare the surgical experience of British and Australian patients. That experience varied enormously by place—whether the surgery was performed by a general practitioner in a small town, for instance, or by a specialist surgeon in a major

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city—but it varied just as importantly with a range of other factors, including the ethnicity, gender, and economic circumstances of the patient, as well as with the experience (and competence) of the surgeon. For those patients who agreed to submit to surgery, their economic circumstances and social background had just as important an impact on the process as whether the surgery took place in Britain or Australia. This is not in any way to argue that surgery in Australia was the same as surgery in Britain, but rather to point out that location was only one of very many variables affecting the sort of surgical experience that patients could expect.

VARIATIONS IN PATIENT AUTONOMY AND AGENCY IN SURGERY When someone is sick or injured, they have a range of options. They can do nothing; they can consult family and friends; they can try various remedies from family, friends, memory, or books; they can try remedies suggested by advertisements, including visiting a pharmacist or using mail order; they can consult a medical practitioner who advertises; or they can consult a medical practitioner who does not advertise. Only the last option on this list involves consulting a regular allopathic doctor. In the 1890s, the medical profession in Australia was still struggling to have its members regarded as the first and most obvious people to consult for medical advice, and published case reports are full of stories about patients who took alternative advice, before, during, and after consulting an allopathic doctor. For instance, in 1895, a doctor in country New South Wales was called to see a two-year-old boy with empyema (pus in the pleural cavity). “The parents refused private or hospital operative treatment in any form and sent the boy to his grandmother where he was seen by my friend Dr. McKillop, of Goulburn. Appropriate treatment was again refused, and in April I learned from the father that the grandmother was using poultices. Later I heard that the abscess had burst.” By May, the abscess had healed. “The child has had no symptoms since, and in August and January was apparently in rude health.”9 As this example demonstrates, we cannot take it for granted that when someone was sick they would consult a regular doctor, let alone agree to surgery. The trust implied when they decided to do so has to be explained. A key feature of surgery in the 1890s was that only a minority of surgeons were experienced experts. No special training or qualifications were required, and all qualified medical practitioners were legally entitled to perform surgery. Many operations were performed by general practitioners, who might well be performing that particular operation for the first time. For a patient, therefore,

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the experience of undergoing surgery could vary enormously depending on the expertise of the doctor concerned. Surgery is the extreme case illustrating faith in allopathic medicine. But before patients could be expected to trust surgeons, surgeons had to have confidence in themselves, and published case reports from the 1890s contain many examples of doctors who, for very good reason, were reluctant to operate. For instance, a Townsville doctor reported the following case in 1895: Under my advice [Mrs K] went into the hospital so that her case might be carefully observed and a correct diagnosis arrived at. She remained in hospital about five weeks, during which time all the medical men in Townsville saw her, but I think I am correct in stating all hesitated to give a definite opinion on the case. She then left the hospital and came under my hands again, the haemorrhage being now almost continuous. Ergot was sufficient, however, to keep it under control . . . [the] patient soon taking two grains of morphia daily . . . Mrs K having heard while in hospital that an operation was possible with a remote chance of saving her life, now insisted that it should be done; and the risks connected with such a formidable undertaking having been made clear to herself and her husband, the operation was performed on August 13 with the kind assistance of Dr. Clatworthy and Dr. Bacot.10

Mrs. K died forty-eight hours after the operation. “The cause of death I could only regard as septicaemia,” wrote Dr. Nesbit, “but the first bad symptom seemed to be a rise in temperature, which followed an altercation with her husband, who had been allowed to sit with her for a short time during the night, to give the nurse a few hours’ well-earned rest.” Dr. Nesbit showed Mrs. K’s uterus to the meeting of the North Queensland Medical Society.11 The growth of surgery did not just require surgeons with the confidence to operate. It depended on patients like Mrs. K, and their friends and families, who were prepared to trust doctors and, in the phrase used at the time: “submit to surgery.” As case notes from the 1890s repeatedly demonstrate, doctors were not only dealing with patients, but also with their families. The following example, for instance, illustrates the doctor’s version of what was clearly a major row: Case 2. rupture of uterus . . . a fine young primipara . . . Placenta not expelled . . . On exploration of the fundus uteri I was horrified to feel the breadth of my hand pass through a rent near the left cordu, and my fingers to be slipping among coils of intestine. . . . I had kept the danger a close secret, and maintained a cheerful demeanour; but, as symptoms of cinchonism12 developed, the patient’s mother, who had been objectionably officious, became more and more abusive, accused me of poisoning her daughter, and compelled me to constrain the husband to eject her from the house. . . . The house was damp and leaky,

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situated on swampy ground, and the weather bad. To this cause I attribute rise of temperature, with rigors, which occurred that night . . . The patient was overexcited by her mother, who had again interfered.13

In Australia, as well as in Britain, doctors routinely divided patients into at least two distinct classes—those who paid and those who did not—but they also tended to approve of some paying patients more than others.14 “Attendance on the servants of the rich . . . especially if paid for by the latter, at the master’s residence, will not enhance your reputation much,” wrote Dr. Jukes de Styrap in his guide to the Young Practitioner, which was popular in both Britain and Australia. 15 “People who, in their minds, associate you professionally with their servants,” he continued, “are apt to form a low opinion of your status, and of the nature and class of your practice.” Jukes de Styrap repeatedly expressed the opinion that treating the poor was different from treating the rich: You will probably find hospital and dispensary patients, soldiers, sailors, and the poor, much easier to attend than the higher classes; their ailments are more definite and uncomplicated, the treatment more clearly indicated, and the response of their system is generally more prompt. With the wealthy and pampered, on the other hand, there is often such a concatenation of unrelated or chronic symptoms, or they are described in such indefinite or exaggerated phrases, that it is somewhat difficult to judge which one symptom is most important. With hospital patients, sailors, soldiers, etc., there are but two classes—the really sick, suffering from affections of a well-marked type, and malingerers.16

These passages are almost direct quotes from an American volume of advice entitled the Book on the Physician Himself, which, together with Percival’s Medical Ethics, form (as Dr. Styrap freely acknowledges) the basis of his manual.17 Advice to the young doctor on this subject seems to have been regarded as equally applicable throughout the English-speaking world. The view that the poor only called on orthodox medical advice when they were very sick or when they were malingering is, however, suggestive that those who were not poor called on medical advice more often and for a greater range of problems. This impression is confirmed by British surgeon Lawson Tait, who wrote: The public . . . like the idea of a new discovery, especially the upper classes, and I am told by men practising near the dwellings of the princes of the land and at fashionable watering places that the great burden of their lives is to keep up with the new drugs and the new dodges.18

In Australia, there were also assumptions about different treatment for different classes. R. B. Duncan, for instance, in an article on inguinal hernia,

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divided his patients into four classes, each with its own mode of treatment.19 These “classes” combined socio-economic and clinical characteristics. The first was “young people desirous of entering some of the services” [“operate without any hesitation”]; the second was “that class of patients who are in fairly good circumstances, and can command medical advice, who are thoroughly conversant with the use of a truss” [“no patient belonging to this class, save in exceptional circumstances, ought to be operated upon at all”]; “the third class comprises men engaged in manual labour, whose intellectual capacity or understanding is not so high as that of the former class” [“there ought to be no hesitation in resorting to an operation”]; “In the fourth class, I would place all cases in which hernia is on the increase” [“no hesitation in resorting to operative measures”].20 In the 1890s, an important reason why an ordinary working-class family would call for a doctor, was because there was someone in the family who was imminently expecting to give birth, or who was already in labor and having a difficult time. This, in turn, made such women subject to gynecological examinations. As a result, working-class women were more likely to be diagnosed as requiring gynecological surgery than other kinds of surgical intervention. Those women who were relatively well off might consult a doctor for a far greater range of problems and, hence, have a wider range of surgical procedures suggested to them. Even when poorer families did call for medical assistance, it was likely to be later rather than sooner, as B. Poulton, surgeon to the Adelaide Hospital, noted in 1891: A woman, unfortunately pregnant in one of her fallopian tubes, may not, especially if belonging to the poorer classes, take early medical advice; and probably if she does the exact condition of affairs may not be at once recognized, so that early radical operative measures are not perhaps resorted to as often as occasion demands. 21

Dr. Poulton made it clear that the woman in question, and her husband, both members of the “poorer classes,” were in no hurry to take his advice, even after they had asked for it. “She declined to be removed to the hospital for operation,” he wrote. “I . . . advised an operation at once. I had taken out everything necessary to operate on the spot, but the surroundings of the home being unfavourable, we sent her to the hospital. Only after long persuasion would her husband consent to any operative measures.”22 Surgery was an enormously diverse experience, and the degree of autonomy enjoyed by patients, as well as the attitudes and treatment recommendations of medical practitioners, varied considerably. However, there was a fairly obvious underlying pattern to this variation, and we should not be surprised that wealthy white men had more choices about their medical treatment than

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poor black women or children. Some Australians like to think that they live in a relatively classless society, at least compared to Britain, but in the 1890s all social classes with the exception of the aristocracy were well represented. In addition, all the Australian colonies relegated the Aboriginal inhabitants to an underclass, to which little or no allopathic medical care was available, while making some racially segregated care available to members of another underclass: Pacific Islanders.23 Consequently, in order to simplify the picture by controlling for five of the important variables in patient autonomy (ethnicity, class, gender, age, and the seriousness of their medical problem), all the examples that follow relate to adult working-class white women with potentially fatal conditions. The picture that emerges is that a considerable degree of patient autonomy extended a long way down the social scale, even for those who were very sick. Medical authority was regularly contested, despite the efforts of doctors to persuade patients to take their advice. Whether in Britain or Australia, in the late nineteenth century, working-class women and their friends and families were generally making choices about their surgery. Only the very sick without family support regularly had decisions made for them by doctors. An English Example Working-Class Women and the Women’s Cooperative Guild Survey, 1915 Some idea of how working-class women made choices about their medical care can be gleaned from the letters on maternity from 160 working women, published by the Women’s Cooperative Guild.24 At the beginning of World War I, the Guild sent out a survey on the experience of maternity to about 600 of its current and past officials. It received 386 replies, of which 160 were subsequently published. These letters provide a rare instance of the publication of the words of working-class women, writing about their own and their neighbors’ experiences of maternity. The overall impression is that doctors’ expert authority was used by the women for their own purposes. They were not the passive recipients of treatment, but actively sought out and assessed medical assistance, often in conjunction with friends and family. Further, once they had received medical advice they sifted through it and selected what suited their own purposes in the stories they told about their health. Seven of the women whose replies to the Guild survey were published (1 in 23), wrote that they had undergone more major surgical intervention than the use of forceps to deliver their babies or the stitching of perineal tears. The following story is from letter 95, and it illustrates some of the ways in which this working-class woman and her husband made choices about her care. Neither was the subject of medical dominance; surgery was refused when it was

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first suggested; some doctors were trusted, some were not; private medical care was regarded as superior to charitable/public provision; and this couple were prepared to undergo considerable financial hardship in order to pay for private hospital care. Initially, this woman and her husband engaged the services of a newly qualified doctor who, they had heard, “was very clever in maternity.” With the aid of a nurse, he set out to deliver a premature baby: The rest of that night is too terrible to go through even now after twenty-eight years. Suffice it to say that next morning there was a poor little baby boy with a very large swollen head dreadfully cut, and a young mother dreadfully cut also.

After the birth, she had repeated attacks of pain, calling in both the doctor and the nurse again, until finally after eighteen months: My husband called another doctor in, and I was ordered into the B. Infirmary at once. I got better. I was home three months, when I was carried in again. They said it was ovarian trouble. They wanted to operate. My husband asked them how long I might live as I was. They said I might live for years, but I would always be subject to these attacks. He told them he would rather keep me as I was than risk an operation. . . . I went on in much the same way until my boy was ten years old. Then I had to be operated on. It was a case of life or death then. But if I went into the Infirmary I could not choose my doctor.

In the event, the surgery was performed in a private hospital, the doctor waived his fee, although the cost of the hospital was considerable at £3.3s. a week for three weeks, plus the cost of a second nurse. The implication is that they pawned the contents of their home (“Our home went then a thing at a time”) to pay the bills. After leaving hospital I was in bed for three months, but it was a complete cure, though no one except my husband expected me to get over it. Dr.—told me I could not have gone through a more serious operation unless I had had my head taken off.

Surgery for this woman was one of the defining events in the hard luck story she told the Women’s Co-operative Guild, redeemed by her relationship with her husband (“the pain was never quite so bad when he was near”). But she makes it clear that she is telling the sort of story that she thinks the Guild wants to read. “I think this is what you want,” she writes. But it is not the only way that she could tell the story of her life, as she points out: Of course things are very much better with us now, and have been for the last twelve years, both in health and finance. I just want to add that although the

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first half of my married life was so hard and painful, I would not have missed one bit of it, because it has all helped to make me understand things that matter from a practical point of view. If there is anything more I can help in I shall be pleased to do so.

This is, then, a narrative consciously shaped to meet what she believed were the political requirements of the Women’s Co-operative Guild. It was also, of course, one of the ways that she chose to present her life story for public consideration. The characters include a caring husband, an incompetent young doctor, a benevolent doctor who “offered to do the operation free” (a particularly potent way of gaining trust), and a woman who learned through long suffering how to “understand things that matter from a practical point of view.” Surgery was incorporated into her life, but only after long consideration. Working backward from the date of the survey in 1915, her son was born twenty-eight years earlier in 1887. An operation for her “ovarian trouble” was proposed in about 1889 or 1890 but not performed until her son was ten years old, in the late 1890s. By then both she and her husband had presumably had sufficient time to discuss the idea and come around to the view that surgery might be an acceptable way to try and end her pain. They also seem to have been told at that point that “It was a case of life or death then.” The decision to have the surgery performed privately, so that they could choose the surgeon, rather than in the Infirmary where they could not, is particularly interesting, given their financial circumstances. The text very much suggests that this woman and her husband did not trust doctors in general. On the contrary, she thought she had made a mistake in having an inexperienced doctor for the birth of her son, and seems to have held the doctor partly responsible for her subsequent trouble. They did, however, trust the doctor who they eventually allowed to perform the surgery, or rather her husband did. His role within the relationship seems to have been to look after her: “my husband has always been husband, nurse and mother,” and this included choosing, and finding the means to pay for, her medical care: “my husband insisted that Dr.—was to do the operation, and by letting everything else go he managed to get the money together by the time I came out.” Overall, the women who responded to the questionnaire from the Women’s Co-operative Guild seem to have adapted to the advice of doctors for their own purposes, and to have found it especially useful in supporting their own wish not to have anymore children. Doctors who provide what the patient regards as inappropriate or ineffective treatment, or who don’t pay sufficient attention to the patient, do not necessarily lead these women to distrust doctors as a whole. They make up their own minds about their treatment on a case by case basis, but within a framework that seems to have been generally

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trusting of both the good intentions and the expert knowledge of doctors as a whole. We see here agency and resistance as well as cooperation with doctors and nurses. Surgery was a rare event, and in four of the seven stories where it appears as a personal experience, the operation is credited with bringing an end to pain. This is in marked contrast to the often critical assessment of the other medical care that these women received. Australian Examples A Failed Attempt at Medical Domination of a Woman from Rural Victoria Doctors could be quite outspoken about the class characteristics of behavior of which they did not approve. In the case of a woman with an ectopic pregnancy, for instance, a doctor describing himself as Surgeon-Major, Victorian military forces, Echuca, Victoria, wrote the following: Remembering that I had curetted this uterus some four years previously for the cure of chronic endometritis. . . I had very grave suspicions that this was a very unusual case . . . I laid the case before those interested, but the desired consent to operative delivery was not obtained until the following morning . . . the usual antiseptic precautions . . . opened abdomen and delivered healthy girl. . . . Everything went on satisfactorily, the patient being able to urinate, and also had several movements of the bowels daily, and taking and retaining nourishment well, until the tenth day, when the patient, out of morbid curiosity, removed the antiseptic coverings “to see what her innards was like,” and got badly flyblown in consequence. This indiscretion was repeated more than once; the utter indifference of the woman herself as to the ultimate result, the poverty, absence of skilled, or for the matter of that of any nursing, and various undesirable and insanitary surroundings proved too much, the patient dying on December 7th, of toxic poisoning and exhaustion, exactly seventeen days after operation. This was a miserable termination to what might, and would under other or even ordinary circumstances [have been] a brilliant result of obstetric surgery.25

More than a hundred years later, the economic and social gulf between doctor and patient comes over very clearly, but what is also apparent is that this doctor tried, and failed, to impose his will upon the patient. She and her friends and family did not immediately agree to the doctor’s proposal to attempt to deliver her baby by the new and dangerous method of caesarean section, and after the operation, she ignored his advice not to look under her bandages. We can draw our own conclusions about the surgery, if it was possible for her to “see what her innards was like” ten days after the operation, and also about a surgeon who blamed the patient for robbing him of “a brilliant result of obstetric surgery” by dying. Such remarks also

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highlight particularly vividly the obvious point that case reports only present us with the doctor’s side of the story. A Carpenter’s Wife from Brisbane Making Choices In contrast, Mrs. Cann’s story was recorded at an inquest into her death, and in the associated newspaper reports.26 We do not have Mrs. Cann’s own views about her treatment, but we do have the views of a range of people, including some of her friends and members of her family. Sarah Cann, the wife of a carpenter, was admitted to the Brisbane Hospital in November 1889. This was against the advice of her doctor, who thought she had a slight attack of gastric fever and would be better off at home.27 Mrs. Cann was treated for typhoid for three months, using the cold bath method introduced by Dr. F. E. Hare early in 1887.28 This treatment, which was also used at hospitals in Baltimore, Montreal, and Stettin, among other places, involved reducing the temperature of patients with fever by placing them in cold baths several times a day. When Dr. Hare left the hospital at the end of 1896, the treatment was continued by Dr. Eugen Hirschfeld, although he favored rather warmer baths at 85° F.29 Dr. Hirschfeld hinted at some of the differences in the relationships between doctors and their patients in private, compared to hospital, practice when he noted that “very few private patients could be persuaded to submit to regular cold bathing.”30 The Brisbane Hospital typhoid, or rather “fever” patients were treated in two special wards, one for men and one for women. All visitors were supposedly excluded, because they were regarded by Dr. Hare as having a “baneful influence” on the patients, raising their temperatures. Hare noted that before each bath, patients were “made to pass water,” as otherwise the shock of immersion in the cold water gave them “an almost irresistible desire to urinate in the bath.”31 This was a controversial treatment, as even Hare acknowledged, citing the British Medical Journal to the effect that the treatment was “very much disliked by patients and their friends.” Some patients, Hare noted, refused to submit to the treatment, especially in the first year he employed it, but keeping all fever patients together on the same ward helped to overcome this resistance. “No difficulty is met with in overcoming the common initial prejudice of patients against cold water in a ward where all alike are submitted to it,” he wrote.32 The treatment was systematically carried out on all fever patients admitted to the hospital, providing “an abundance of clinical material, more than sufficient indeed definitely to prove the value of the treatment without having recourse to statistics from elsewhere.” 33 Mrs. Cann died on April 12, 1890, from “sloughing from operation.”34 The inquest into her death offers a window on the cold bath treatment from a rather different point of view, providing a messy and complex contrast with

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Hare’s disciplined patients and tidy statistics. Despite Dr. Hare’s prohibition on visitors, Mrs Cann’s husband, William, did manage to see her several times and noted that she was very ill and had lice in her hair.35 William Cann decided to “try and get her home.” He stated that when he took her out of hospital, she was dirty and “had an abscess [in her groin] that was running which appeared to him not to have been dressed for several days, and the smell from it was sickening.”36 Bodily odor was a heavily loaded concept by the late nineteenth century, associated not only with uncleanliness but also with the working class.37 There were also medical connotations.38 By the 1890s, ideas surrounding germ theory had almost everywhere replaced the idea of “miasma” (which incorporated the concept of smell as a marker of danger), in understandings of disease causation.39 Nevertheless, it is likely that the smell from Sarah Cann’s abscess would have been considered potentially “sickening” literally, as well as metaphorically. Her other marked symptom was that both legs were contracted under her, so that she was unable to stand, and on 6th February her husband called in Dr. Southam, who practiced as a homeopathic and hydropathic doctor. Dr. Southam reported Mrs. Cann as saying that her: Condition was the result of the cold water baths. . . . The deceased said they took her out of the water and laid her on a bed and then put a sheet over her and left her shivering, and the reason she got in her present position was that she doubled herself up to try and keep warm, and she had asked for a blanket but could not get one.40

Dr. Southam called on the advice of Dr. Marks, who was one of the Honorary Surgeons at the Brisbane Hospital. Dr. Marks and Dr. Southam visited Mrs. Cann at her home in Vulture Street on February 25. They decided that she needed surgery to straighten her legs so that the abscess in her groin could be properly dressed, but they also decided to delay the operation because she was too weak. Dr. Marks tried to shift at least part of the blame for the patient’s condition to her own behavior, arguing that: “the contraction of the deceased’s legs resulted through her having a relapse and refusing to have her legs straightened.”41 Mrs. Cann was not held responsible for the abscess, but she was held partly responsible for the fact that it could not be properly cleaned and dressed and therefore emitted a “sickening” smell. Both doctors saw her again on March 28th, and Dr. Marks “advised further delay in performing the operation; but the deceased was anxious to have something done.” So Dr. Marks and Dr. Southam forcibly straightened Mrs. Cann’s legs under chloroform and fixed them to a splint. How much experience had Dr. Marks had with such cases? Had he ever performed an operation like this before? Had anybody ever performed an operation like this before? The Mag-

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istrate did not ask questions of that kind about the surgical treatment (which was presumably carried out at the Canns’ home in Vulture Street). This is despite the fact that the skin around the joints tore and began to slough a few days after the operation, and Mrs. Cann died two weeks later. The omissions in the questioning of treatment at the Brisbane Hospital are also interesting. Neither Dr. Marks nor Dr. Southam disagreed with the cold bath treatment, and the Magistrate said that: “the only question worth inquiring into further was as to whether the deceased was kept clean while in hospital.”42 The Brisbane Hospital’s advocate at the Police Court, Mr. Mansfield, set out to establish not that Mrs. Cann was kept comfortable, or was appropriately treated, but that she didn’t smell and if she had head lice, it was because she refused to allow the nurses to cut off her hair.43 Nurse Irene Handley and Mrs. Cann’s friend, Rose Heaton, were both questioned as to whether Mrs. Cann had head lice, and whether her body was clean, at the time she was admitted to hospital.44 Overall, the inquest into the death of Sarah Cann was not used as a way to find out what went wrong with her treatment and how the death of similar patients might be avoided. Rather, it was used to blame at least part of her problems on her own behavior, and to cast very public aspersions on her personal hygiene in a social setting in which being clean was about claiming both virtue and social position. That the case was manipulated by a legal representative of the Brisbane Hospital, an organization rather more powerful than Mr. and Mrs. Cann, is unsurprising, especially as the Cann family seems to have had no equivalent legal support. But the case also raises rather less obvious questions. Why did Sarah Cann not only agree to, but also apparently ask for, the surgery to straighten her legs? She had clearly had a bad experience at the Brisbane Hospital, so why did she have confidence in the homeopath, Dr. Southam, and the orthodox surgeon, Dr. Marks? She and her husband did not just go along with whatever the medical establishment suggested. Her husband took her home from the Brisbane Hospital, and the family were involved in making decisions about how Mrs. Cann was going to be treated. Mrs. Cann was not only a public hospital patient. She was also a private patient, consulting doctors privately both before and after her treatment at the Brisbane Hospital, and choosing at least three different doctors to call in to see her at home. A Domestic Servant from Melbourne without Family Support The final vignette is of a woman with virtually no choice about her treatment, and it is taken from the case notes made by a junior doctor working with Mr. Syme at St Vincent’s Hospital in Melbourne. In 1897, George Syme performed emergency surgery on a young woman admitted with

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symptoms of intestinal obstruction. In this instance, urgency was given as the reason for not discussing treatment with the patient. According to the junior doctor’s notes: “There was no time to take a history before operation. Abdominal section was performed by Mr. Syme.”45 Things did not go well, and the woman died a few hours after the operation. There was no postmortem, but the young doctor was clearly interested in the case and drew a diagram of the twisted jejunum in the notes. He showed where a loop of ileum had passed through a hole in the mesentery and noted that there was general peritonitis. “The hole in the mesentery was apparently congenital,” he wrote. Tucked into the case book is a folded sheet of paper in a different hand. This is a case history that may have been written by the woman’s general practitioner. It contains the following information on the young woman’s sick career: When 4 years old had an attack of “spasmodic colic.” She suddenly got violent and intense spasms of colic referred to the umbilical region with vomiting and constipation. For treatment they were giving her injections “all the time”; she was 4 months ill at this time. She was strong and well after this till she was 21 (April 27/91) when she was living in E. Melbourne; she had been constipated for 5 days & she took a large dose of salts; on going down the yard she suddenly had a violent abdominal pain & fell down unconscious; she remembered nothing till they were carrying her upstairs. Dr McColl called in Dr Moore & Dr Fitzgerald who wished to operate but this was refused & she recovered; since then she had been well although subject to constipation. She would often swell up and get much stouter than usual. Her last illness began with constipation pain in abdomen vomiting & some slight feverishness at first. Calomel and enemata refused to act and she was sent to hospital.46

This woman’s story contains a number of features that should by now have become familiar to the reader. She consulted multiple doctors over a period of time, refused surgery when it was first suggested, and was only operated upon when she was too sick to object. Stories like this gave considerable ammunition to surgeons who argued that refusal to consent to surgery was often not in the patient’s best interests. Surgeons, they argued, were the people in the best position to make the complex technical decisions about whether or not it was wise to operate. An operation might prove successful if it was performed when first advised, but it was less likely to be able to help if the patient put off agreeing to surgery until their symptoms were extreme. Over time, the public in general came to accept this surgical point of view, and the associated confidence in surgery that went with it. But in the 1890s, many patients still agreed with “MC” in distrusting the idea of surgery when it was first suggested to them.

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CONCLUSION While the doctor’s perspective on surgery invites attention to a series of operations, a flow of patients past the medical gaze and under the surgical knife, the patient’s perspective invites attention to a longer span of time for each patient, to the events which preceded and the events which followed surgery, as well as to the unconscious moments while submitting to surgical interference. These glimpses of the past remind us that for patients, surgery was incorporated into their lives in ways that cast long shadows and was likely to be the subject of considerable discussion among friends and family both before and after the event. When deciding whether or not to have an operation and negotiating treatment with doctors, the support of others was clearly important. In the case studies discussed above, husbands in particular played a significant role, while the woman who was alone was the one whose treatment decisions were dominated by doctors. But the cost of surgery was prohibitive for most people, quite apart from the question of whether doctors were believed to be able to help. Instead, many people turned to less expensive sources of comfort, including the kind of medicines that were widely advertised and readily available. In this context, surgery emerges as an extreme measure, both in terms of the cost and in terms of the circumstances under which it might be considered to be of any use. Attitudes to surgery, therefore, are attitudes to extraordinary events. When doctors decided to recommend surgery, it was by no means certain that the patient and their friends would agree, and the case records published in the 1890s are full of laments by doctors about patients who refused surgery until it was “too late.” Surgery was an enormously diverse experience. It varied, of course, with the seriousness of the medical problem, but it also varied with the experience of the surgeon, the place where the operation was performed, and the ethnicity, gender, social circumstances, and family support of the patient. Overall, it would seem that doctors in the late nineteenth century may have attempted to impose their will upon their patients, and sometimes they may have succeeded, but it is clear that they could not take patient compliance with their wishes for granted even among their working class clientele, let alone among those of their patients whose medical choices were not constrained by price.

NOTES 1. Thomas Schlich, “The Emergence of Modern Surgery,” in Medicine Transformed: Health, Disease and Society in Europe, 1800–1930, ed. Deborah Brunton (Manchester: Manchester University Press, 2004), 61–91; Christopher

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Lawrence, ed., Medical Theory, Surgical Practice, Studies in the History of Surgery (London: Routledge, 1992); Owsei Temkin, “The Role of Surgery in the Rise of Modern Medical Thought,” Bulletin of the History of Medicine 25 (1951): 218–50; Sally Wilde, “See One, Do One, Modify One, Prostate Surgery in the 1930s,” Medical History 48 (2004): 351–66; Wilde, “The Elephants in the Doctor-Patient Relationship,” Health and History 9 (2007): 1–26. 2. Consent article; Morris J. Vogel and Charles E. Rosenberg, eds., The Therapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia: University of Pennsylvania Press, 1979). 3. Michel Foucault, The Birth of the Clinic, An Archaeology of Medical Perception, trans. A. M. Sheridan Smith (Paris: Presses Universitaires de France, 1963; London: Routledge, 2003); Erwin Ackerknecht, Medicine at the Paris Hospital, 1794–1848 (Baltimore, MD: Johns Hopkins Press, 1967); Anne Digby, Making a Medical Living: Doctors and Patients in the English Market, 1720–1911 (Cambridge: Cambridge University Press, 1994); Nancy Theriot, “Negotiating illness: doctors, patients and families in the nineteenth century,” Journal of the History of the Behavioural Sciences, 2001, 37: 349–68; Judith Walzer Leavitt, Brought to Bed: Childbearing in America, 1750–1950 (New York: Oxford University Press, 1986); Regina Morantz-Sanchez, “Negotiating power at the bedside: Historical perspectives on nineteenth-century patients and their gynaecologists,” Feminist Studies, 26 (2000): 287–309; Christopher Crenner, Private Practice in the Early Twentieth-Century Medical Office of .Dr. Richard Cabot (Baltimore, MD: Johns Hopkins University Press, 2005); Nancy M. Theriot, “Women’s Voices in Nineteenth-Century Medical Discourse: A Step Towards Deconstructing Science,” Signs, 19 (1993): 1–31; Kathleen E. Powderly, “Patient Consent and Negotiation in the Brooklyn Gynecological Practice of Alexander J. C. Skene: 1863–1900,” Journal of Medicine and Philosophy, 25 (2000): 12–27; 4. Mark Schlesinger, “The dangers of the market panacea,” in Healthy, Wealthy, & Fair; Health Care and the Good Society, eds. James A. Morone and Lawrence Jacobs (New York: Oxford University Press, 2005), 91–135. 5. Rima D. Apple, “Constructing Mothers: Scientific Motherhood in the Nineteenth and Twentieth Centuries,” Social History of Medicine (1995): 161–78. 6. Wilde, “Elephants.” 7. Donald Simpson, “The Adelaide Medical School 1885–1914, A study of Anglo-Australian Synergies in Medical Education” (MD, University of Adelaide, 2000); Laurence M. Geary, “The Scottish-Australian Connection 1850–1900,” in The History of Medical Education in Britain, eds. Vivian Nutton and Roy Porter (Amsterdam: Rodopi, 1995); Anne Crowther and Marguerite Dupree, “The Invisible General Practitioner: The Careers of Scottish Medical Students in the Late Nineteenth Century,” Bulletin of the History of Medicine 70 (1996): 387–413; K. F. Russell, The Melbourne Medical School 1862–1962 (Melbourne: Melbourne University Press, 1977); Diana Dyson, “The medical profession in colonial Victoria, 1834–1901,” in Disease, Medicine and Empire, eds. Roy Macleod and Milton Lewis (London: Routledge, 1988), 194–216. 8. David Wade Chambers and Richard Gillespie, “Locality in the History of Science; Colonial Science, Technoscience, and Indigenous Knowledge,” Osiris

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15 (2000): 221–40; David Wade Chambers, “Does distance tyrannize science?” in International Science and National Scientific Identity, Australia Between Britain and America, R. W. Home and Sally Gregory Kohlstedt, eds. (Dordrecht: Kluwer Academic Publishers, 1991); idem, “Locality and Science: Myths of Centre and Periphery,” in Mundializacion de la ciencia y cultura nacional, Actas del Congreso Internacional Ciencia, descubrimiento y mundo colonial, A. Lafuente, A. Elena and M. L. Ortega, eds. (Madrid: Doce Calles, 1993); David Knight, “Tyrannies of Distance,” in International Science, Home and Kohlstedt, eds.; Roy Macleod, “On Visiting the ‘Moving Metropolis’: reflections on the Architecture of Imperial Science,” in Scientific Colonialism: A Cross-cultural Comparison, Nathan Reingold and Marc Rothenberg, eds. (Washington, DC: Smithsonian Institution Press, 1987). 9. Gerald S Samuelson, “Notes from a Country Practitioner, Kangaroo Valley NSW,” The Australasian Medical Gazette, 14 (1895): 229 10. Dr. Nesbit, “A case of total extirpation of the uterus for cancer—death,” The Australasian Medical Gazette, 10 (1890–1891): 50–51. 11. Dr. Nesbit, “A case of total extirpation of the uterus for cancer—death,” The Australasian Medical Gazette, 10 (1890–1891): 50–51. 12. Presumably from the quinine, which Dr Spencer appears to have prescribed in large quantities. 13. Walter Spencer, “Notes from a Tasmanian case-book,” The Australasian Medical Gazette, 14 (1895): 225–26. 14. “Class” is used here not in a Marxist sense of a particular relationship to the mode of production but in a cultural sense, drawing on evidence of how people categorized themselves and others. 15. Jukes de Styrap, The Young Practitioner: With Practical Hints and Instructive Suggestions as Subsidiary Aids for His Guidance on Entering into Private Practice (London: H. K. Lewis, 1890), 3627. 16. Jukes de Styrap, The Young Practitioner, 38–39. 17. D. W. Cathell, Book on the Physician Himself and Things that Concern His Reputation and Success (Philadelphia: F. A. Davis, 1890), 9th edition; Thomas Percival, Medical Ethics; or A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons (Manchester: J. Johnson, 1803), reprinted with an introduction by Edmund D. Pellegrino (New York: Classics of Surgery Library, 1997). 18. “Abridged report of the address in surgery delivered to the meeting of the British Medical Association in Birmingham by Lawson Tait, F.R.C.S. Edin., President of the Mason College, Birmingham,” Lancet 135 (1890): 220–24, 224; Dorothy Porter and Roy Porter, Patient’s Progress, Doctors and Doctoring in Eighteenth-century England (Palo Alto, CA: Stanford University Press, 1989). 19. R. B. Duncan, “The Radical Cure of Inguinal Hernia,” Intercolonial Medical Journal of Australasia 5 (1900): 387–95. 20. Duncan, “The Radical Cure,” 390. 21. B. Poulton, “Notes on a case of tubal pregnancy—rupture—operation—death,” The Australasian Medical Gazette, 10 (1890–1891): 144.

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22. B. Poulton, “Notes on a case of tubal pregnancy—rupture—operation—death,” The Australasian Medical Gazette, 10 (1890–1891): 144. 23. For an example of the sort of medical treatment that was provided to Aboriginal people see: Diary of George Blanchard, 1888–1889, OM82-4, box 9159, Queensland State Library; Wendy Selby notes that as late as the 1920s, separate wards or “sheds” for Aboriginal women were added to government maternity hospitals in country areas. Japanese and Chinese women, however, were allowed to share the wards with whites: Wendy Selby, “Motherhood in Labor’s Queensland 1915–1957” (Ph. D. Thesis, Griffith University, 1992); for medical care for Pacific Islanders, see: Clive Moore, Kanaka: A History of Melanesian Mackay (Boroko: Institute of Papua New Guinea Studies, 1985), espec. pp. 235–44; Kay Saunders, ‘The Pacific Islander hospitals in colonial Queensland: the failure of liberal principles,’ Journal of Pacific History 11 (1) (1976): 28–50. 24. The Women’s Cooperative Guild, Maternity, Letters from Working-Women (London: G. Bell and Sons Ltd, 1915), republished in The English Working Class, ed. Standish Meacham (New York and London: Garland Publishing, Inc., 1980). 25. Geo. Reginald Eakins, “A case of ectoptic gestation,” The Australasian Medical Gazette, 14 (1895): 90–91. 26. Coroners Court, Record of Depositions Taken and Enquiries During 1890, case no 209, Queensland State Archives. 27. Brisbane Courier (12 May 1890); Evening Observer (10 May 1890): 4. 28. F. E. Hare, The Cold Bath Treatment of Typhoid Fever, the experience of a consecutive series of nineteen hundred and two cases treated at the Brisbane Hospital (London: Macmillan and Co., 1898). A similar treatment had been popular in parts of England a hundred years earlier, but then went out of fashion until revived by Dr. Brand of Stettin in 1861: John M. Forrester, “The Origins and Fate of James Currie’s Cold Water Treatment for Fever,” Medical History, 44 (2000): 57–74. 29. Eugen Hirschfeld, “The Tepid Bath Treatment of Typhoid Fever,” Australian Medical Gazettes, xix (1900): 22–25. 30. Hirschfeld, “The Tepid Bath Treatment of Typhoid Fever,” 25. 31. Hare, The Cold Bath Treatment of Typhoid Fever, 26. 32. Hare, The Cold Bath Treatment of Typhoid Fever, 14. 33. Hare, The Cold Bath Treatment of Typhoid Fever, vi, 13. 34. Hare, The Cold Bath Treatment of Typhoid Fever. The records of the actual inquest are missing and what follows is based on the almost identical reports in the two local newspapers. 35. Nurse Handley noted that it may have been possible for visitors to see patients without her knowledge, when they were out on the veranda of the fever wards, although William Cann clearly did sometimes see his wife on the ward. Evening Observer (13 May 1890): 5 36. Brisbane Courier, 12 May 1890; Evening Observer (10 May 1890): 4 37. George Orwell, The Road to Wigan Pier (Victor Gollancz, London, 1937); the classic work on smell in France is: Alain Corbin, The Foul and the Fragrant: Odor and the French Social Imagination (Cambridge, MA: Harvard University Press, 1986); see also: Georges Vigarello, Concepts of Cleanliness: Changing Attitudes in

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France since the Middle Ages, trans Jean Birrell (Cambridge: Cambridge University Press, 1988). 38. For some of the overlapping ideas about cleanliness, health, and buildings see: Annmarie Adams, Architecture in the Family Way, Doctors, Houses, and Women, 1870–1900, (Montreal: McGill-Queen’s University Press, 1996). 39. On some of the complexities surrounding the adoption of germ theory see: Michael Worboys, Spreading Germs, Disease Theories and Medical Practice in Britain, 1865–1900 (Cambridge: Cambridge University Press, 2000); Margaret Pelling, “The Meaning of Contagion: Reproduction, Medicine and Metaphor” in Contagion, Historical and Cultural Studies, eds., Alison Bashford and Claire Hooker (London: Routledge, 2001). 40. Brisbane Courier, 12 May 1890; Evening Observer, 10 May 1890, 4. 41. Evening Observer, 10 May 1890, 4. 42. Evening Observer, 10 May 1890, 4. 43. According to the testimony of nurse, Irene Handley, Mrs. Cann had her hair washed with carbolic lotion every morning after she was admitted to the hospital but refused for five weeks to have it cut off. Evening Observer, 13 May 1890, 5. 44. Evening Observer. 45. St Vincent’s Hospital, Surgical Case Books, Book 1, Mr. Syme, p. 165, St Vincent’s Hospital, Melbourne, Archives. 46. Loose sheet in Book 1, Mr. Syme, St Vincent’s Hospital, Surgical Case Books, Book 1, Mr. Syme, 165, St Vincent’s Hospital, Melbourne, Archives.

Index

Academia de Medicina, 56; anatomoclinical agenda of, 59–60 Academia Imperial de Medicina, 58, 61; and nosographic map, 63 Archives de Médecine Navale, 59; and scientific interchange, 62 Academy of Medicine of Paris, 56 Academia de Medicina, 59 Africa: smallpox outbreak in, 3 African education, 93 Alfonso XIII, 69 Alfonso de Souza, Martin, 48 Angel Larra y Cerezo, 70 anglicization, 12 Assistance Medicale Indigene, 116, 118, 124–25, 127; doctors and local remedies in, 126; hospitals of, 120; legislative and institutional framework of, 117 Australian surgeons, 172 Ayurveda, 32; revival of, 39 Ayurvedic movement, 39. See also Ayurveda Bhadralok, 32, 35, 42 Benedictines, 52 Bengal: medical profession in, 37; partition of, 38

biomedicine: authority of, 5 biomedical therapies, 127. See also Vietnam biopower, 2 Boerhaave, Herman, 146 Bombay Samachar, 32 “boss-boys,” 80 Boxer Rising, 101 Brazil: medical teaching in, 46; colonization of, 50 Brazilian hygienists, 57. See also Central Public Hygiene Board Brazilian medicinal herbs, 54 Brisbane hospital, 182 Brotherhood of Mercy, 53 Cape colony: medical science in, 164. See also Colonial Cape doctors Carmelites, 52 Central Public Hygiene Board, 57 chickenpox, 158 Chinese medical systems, 101 College of Fort William, 38 colonial Cape doctors, 157; and society, 153 colonial Egypt, 10; doctors in, 12, 23–24 colonial India, 4; elites in, 4 191

192

colonial power, 1; and biomedicine, 6; and monopoly, 6 colonial Rhodesia, 6, 80; gendered responses in, 5 colonial Uganda: population explosion in, 82 commercial farms: power asymmetries in, 82; power and resistance on, 81; as total institutions, 84 “contact zones,” 81, 83; and power relations, 94 contraceptives, 79; introduction of, 80 Count of Revillagigedo, 139 Cuba: colonialism and disease in, 68; rebellion in, 76; Spanish authorities in, 67; yellow fever in, 4, 67–68, 71–72; American domination of, 4 cultural iatrogenesis, 2 Dennis Doyle, 154, 159 diamond-diggers, 160 Diego de Pedraza, 138 Dominicans, 137 Dr. B. W. Hall, 154 Dr. F. E. Hare, 181 Dr. James Alexander Smith, 157–58 Dr. Mackie, 34 Dr. McKillop, 173 dyarchy, 41 education: and anatomical studies, 145; reforms in, 12 Egyptian Medical Association, 16 Egyptian medicine, 9–10 elites, 29; and indigenous patrons, 30; as western-educated, 29. See also colonial India epidemics, 140; and Edward Jenner, 141; and smallpox, 142 epidemiology, 139 family planning, 80; and education, 87; hostility toward, 89; on white farms, 86; promotion of, 94

Index

Family Planning Association of Rhodesia, 80, 83, 91–92. See also contraceptives, family planning Fisico-mor, 51; and apothecary shops, 51 Franciscans, 52 Grant Medical College: medical research at, 34 Guy’s Hospital, 14 Hanoi Opthalmological Institute, 120 health committees, 142 Henry Louis Vivian Derozio, 36. See also Young Bengal Hernán Cortés, 136, 138 Hindu College, 35; foundation of, 36. See also Presidency College Hitavadi, 38 Hospital de Amor de Dios, 138 Hospital for the Insane, 101, 107 Hospital Real de Indios, 144, 148 Hospital de Jesús, 138 hygiene doctors, 58. See also Brazilian hygienists imperial Brazil, 45 imperial China, 100 imperial elite, 5, 45–46; and Brazilian pathology, 56 Imperial Tropical Medicine, 9–10 Indian Medical Service, 34; Indianization of, 40 Indochina, 116 insanity, 106. See also madness International Congress of Tropical Medicine and Hygiene, 17 James Mill, 36 John Glasgow Kerr, 101, 105 John Glasgow Kerr Hospital for Lunatics, 105 Kimberley Medical Board, 156; and public health policies, 160

Index

Latin surgeons, 147 madness, 100; and indigenous Chinese medicine, 101; Chinese perception of, 102 malaria, 70, 74 medical authority, 177; and domination, 180 medical autonomy, 29, 42 medical education, 4 medical elite, 45 medical nosologies, 103 medical orthodoxy, 20 Medical Surgical Academies, 46 medical teaching: regulation of, in Brazil, 46 medicalization thesis, 32 Meiji Reform Model, 106 Mental Hygiene Campaigns, 105 Mexican-American War, 71 miasma, 182 middle class, 46 military doctors: and yellow fever, 68; and military hospitals, 69 Native Medical Institution, 30 New Spain: hospitals and infirmaries in, 137; physicians in, 139; and epidemics, 140; medicine in, 4 North Queensland Medical Society, 174 nurse-midwives: in Egypt, 18 opium wars, 101 Pacific Islanders, 177 Parsis, 30, 32, 42; and British royalty, 33; as patrons of medical science, 33, 35 Pathfinder Fund, 86 patient autonomy, 173, 176 Patriotic Fund, 35 Pharmacie Chassagne, 120 Pharmacie Montes, 120 “pink-slip”doctors, 161, 164 Portugal: medicine in, 50

193

Portuguese: domination, 48; in Brazil, 48; Catholicism, 52 Presidency College, 36. See also Hindu College pro-natal eugenics, 82 Psychiatry, 107 Public Health Act, 161 Qasr al-Aini, 10, 12, 17; reorganization of, 14 “reception camps,” 107 Registration Acts, 40 Rhodes, Cecil John, 157–58 Rhodesian Front, 79 Rhodesian Ministry of Health, 81 Rodrigo de Souza Coutinho, D, 51 Royal Botanic Garden, 148 Royal Military Academy, 46 Royal Protomedicate, 51; creation of, 55 Royal School of Surgery, 147–48 Salvarsan: introduction of, 121 San Ambrosio Military Hospital, 69–70 San Andrés Hospital, 138 Sanjivani, 38 Scottish Corporation, 33 Sino-Annamese, 118 Sino-Vietnamese medicine, 126; therapists in, 128 smallpox, 153; in Kimberley, 160 “small-pox war,” 164–65 Spanish crown, 137 Spanish military doctors, 70 Spanish rule, 68. See also Cuba St. Vincent’s hospital, 183 State Faculty of Ayurvedic Medicine, 40 surgery: rise of, 171, 174; in Australia, 172 swadeshi, 37 Syme, George 183 Tait, Lawson, 175 Tan Sitong, 103–104

194

Tribal Trust Lands, 84 tropical pathology, 57 tropical nosology, 58 typhoid, 181 U.S. Marine Hospital, 70 U.S. Army: and yellow fever, 71 vaccination, 119 viceregal period, 135; medicine in, 136 Vietnam, 115; French doctors in, 115, 119; modern medicine in, 116; therapeutic selection in, 122, 128. See also biomedical therapies

Index

Wang Wanbai, 103 W. F. Brunner, 70–71 Women’s Cooperative Guild, 177–79 Xavier Bichat, 146 Xavier Sigaud, 59 Xiaolin, 100 Xichun, Zhang, 104 Young Bengal, 36. See also Henry Louis Vivian Derozio Youwei, Kang, 101 Zhouli (Rites of the Zhou), 102

About the Contributors

Hibba Abugidieri is an assistant professor in History at Villanova University, Pennsylvania. Her research interests include gender and medicine, although she has published extensively on women in Islam in Daughters of Abraham and Islamic Thought in the Twentieth Century, Gender and History, and The Muslim World, and has collaborated with John L. Esposito and Yvonne Y. Haddad on The Islamic Revival since 1988. Her new publication is her forthcoming book Gender and the Making of Medicine in Colonial Egypt. Poonam Bala is a Reader in Sociology at the Delhi School of Economics, University of Delhi, Delhi (India), prior to which she taught at Case Western Reserve University in Ohio. She has published extensively on the history of medicine in colonial, and pre-colonial India, including articles in the Encyclopedia of Cancer and Society; her most recent publication is Medicine and Medical Policies in India: Social and Historical Perspectives. She is also the author of Imperialism and Medicine in Bengal: A Socio-Historical Perspective. Flavio Coelho Edler is an associate professor in History of Sciences and Health at The Casa de Oswaldo Cruz – Fiocruz at Rio de Janeiro, Brazil. He has published extensively on the history of clinical and laboratory research in nineteenth-century Brazilian medicine and on public health. His major publication includes Boticas e Pharmácias. Uma história ilustrada da farmácia no Brasil. Ilust, with recent work on the relation between psychiatry, legal medicine and criminal law in Brazil (1860–1930). Mariola Espinosa is an assistant professor in History, and Director of Latino and Latin American Studies at Southern Illinois University in Carbondale. 195

196

About the Contributors

Her work focuses on the history of disease, public health, and colonial public health in Cuba and the Caribbean. She has written for the Journal of Southern History, and her book Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878-1930, is forthcoming in 2009. Amy Kaler is an associate professor in Sociology, and an adjunct associate professor at the School of Public Health at the University of Alberta, Edmonton in Canada. She has published widely on gender, fertility, sickness, and social history in southern and eastern Africa in several journals, including the Journal of Family History, Social Science History, Social Science and Medicine, Journal of Southern African Studies, Culture, Health and Sexuality, and Journal of Gender Studies. Her major publication is Running After Pills: Politics, Gender and Contraception in Colonial Zimbabwe. Angelika C. Messner is an associate professor in Chinese Studies at the University of Kiel, Germany. Published widely on the history of madness in late Imperial and Republican China, and on a range of topics related to emotions (including investigations on literary, medical, and scientific views and paradigms), with research interests in material culture and the history of science in China. Her main publication includes Medizinische Diskurse zu Irresein in China (1600-1930) (Medical Discourses on Madness in China (1600-1930). Laurence Monnais is an associate professor in History at the University of Montreal in Canada, holding a Canada Research Chair in Health Care Pluralism. Written extensively on the history of medical traditions in Southeast Asia, her major publications include Le Médicament: Vecteur deMédicalisation ou Révélateur de Socialisation ? Regards Croisés sur un Objet Complexe (co-edited with J. Collin and M. Otero, Ste Foy : Presses de l’Université du Québec, 2006), and Médecine et colonisation. L’aventure indochinoise (Paris: CNRS Editions, 1999). Martha Eugenia Rodríguez is a professor in History and Philosophy of Medicine at the Facultad de Medicina, Universidad Nacional Autónoma de México in Mexico, and former president of the Mexican Society of History and Philosophy of Medicine (2005–2006). Her recent publications include Cincuenta años de la Sociedad Mexicana de Historia y Filosofía de la Medicina (coauthored) (México: Editorial Medicina Familiar Mexicana, 2006), and Medicina novohispana, siglo XVIII. Historia General de la Medicina en México (México: Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), 2001), with her La Escuela Nacional de Medicina 18331910 forthcoming in 2008.

About the Contributors

197

Russel Stafford Viljoen is an associate professor in History at the University of South Africa in Pretoria. He has published extensively on smallpox, and indentured labor in Cape colonial society, in Kleio, Itinerario: International Journal on the History of European and Global interaction, and South African Journal of Art History. His recent publication is Jan Paerl: A Khoikhoi in Cape Colonial Society, 1761-1851. Sally Wilde is a Fellow (Australian Research Council) in History, Philosophy, Religion, and Classics, at the University of Queensland, Brisbane in Australia. Her research interests focus on the history of surgery in Australia, history of medicine and health-care systems in relation to moral economy and trust in Australia. Some of her major publications include Joined Across the Water: A History of the Urological Society of Australasia and From Driver to Paramedic: A History of the Training of Ambulance Officers in Victoria.