Private and Public Medical Traditions in Greece and the Balkans

Deltos: Journal of the History of Hellenic Medicine

(Cover illustration: J.C. Back, La Grece et L’Ionie, ca. 1750)

Guest EditorMARIUS TURDA

PRIVATE AND PUBLIC MEDICAL TRADITIONS IN GREECE AND THE BALKANS

In memoriamChristos Papadopoulos (1949-2011)

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INTRODUCTION

Marius TurdaOxford Brookes University, Oxford UK

silient cultural and historiographic stereotype. Yet, whether or not accompanied by stereotyp-ical Orientalist representations (as wonderfully discussed by the historian Maria Todorova in her Imagining the Balkans), there is no doubt that until well into the twentieth century the Balkans were viewed through the lens of certain features alleged to be specific to this region. These features include illiteracy; pre-dominant rural environments; limited hygienic knowledge; malnutrition; frequent epidemics; numerous social diseases (such as alcoholism) and sexually transmitted diseases (syphilis, in particular); high levels of infant mortality; late adoption of modern ideas of medicine; and a persistence of traditional methods of healing. No historian of medicine would deny the his-torical accuracy of some of these descriptions, but there are grounds for caution. An appre-ciation of the complex interweaving of private and public medical traditions in Greece and the Balkans may well begin by recognizing these traditions as intrinsically meaningful within their own cultural locations, no matter how dif-ferent these locations are from the dominant Western “ideal-types.”

Surely it is the Balkans’ geographical diver-sity and multiplicity of languages and tradi-tions that makes this region so appealing intel-lectually. Yet the picture remains confused by this wealth of languages and traditions, and their jostling with each other can easily be seen in all branches of intellectual life in the Balkans. When these countries finally deposed their communist regimes after the 1990s, they were obliged to compete with each other for financial resources and political acceptance

The papers included in this special issue were first presented at the international workshop “Health and Society: Private and Public Medi-cal Traditions in Greece and the Balkans (1453-1920)” held in Athens between 8 and 10 Decem-ber 2010. This workshop was the third event in a series of scholarly meetings devoted to the history of medicine in the Balkans that began with a symposium dealing with “Medicine in the Balkans: Evolution of Ideas and Practices to 1945” held in London between 24 and 25 January 2008, and continued with a conference devoted to “Medicine within and between the Empires (Habsburg and Ottoman)” held in Vi-enna between 20 and 22 November 2008.

As these meetings highlighted, much still needs to be done in order to strengthen the position of the social history of medicine within historical scholarship more generally. The Bal-kan countries continue to be neglected. None of the books published in the prestigious Rout-ledge Studies in the Social History of Medicine, for example, deal with Greece and the Balkans. The justifications for this neglect are numerous, in-cluding the ideological segregation of the Cold War; the linguistic complexity of the region; and the persistence of outdated notions about the history of medicine itself. Sporadically, to be sure, chapters dealing with Balkan medicine have been published in edited volumes in the West, complementing the singular efforts of a handful of scholars who — for the past two decades — have repeatedly argued for the importance of this region in understanding wider European, as well as international, de-velopments in the history of medicine.

The image of a backward “Balkans” is a re-

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in the West. When it came to speaking about Greece and the Balkans — and indeed being in the Balkans — the cultural memory of a com-mon past and shared historical traditions was easily tossed away. The political borders may have been opened in the region, but academic programmes of genuine collaboration in the humanities and social sciences did not emerge overnight. In fact, the national traditions con-tinue to be narrowly defined and remain in opposition to one another.

This workshop on “Public and Private Medi-cal Traditions in Greece and the Balkans” has engaged with two theoretical frameworks:

Firstly, the acknowledgement that history of medicine is no longer confined narrowly to the writings of physicians. Social historians of medicine in the Balkans must shift their schol-arly focus from a single cultural site to networks of connections between cultures. Specifically their task is two-fold: they must combine differ-ent styles of writing, aiming to be conceptually and thematically innovative as well as atten-tive to hitherto un-researched topics; and they must challenge the purported uniqueness of their national cultures.

Secondly, the suggestion that historians in Greece and the Balkans themselves must broaden their understanding of what “his-tory of medicine” is so that it embraces more of that totality of living experience, both past and present, that they only identify with their

own field of study. The social history of medi-cine must ultimately be placed within its larger cultural and political contexts.

In comparison with the traditional historiog-raphy that is largely based on the narration of individual medical achievements in particular countries, social history of medicine suggests the need for a re-classification of medical think-ing about society based on synchronized read-ings of concurrent medical traditions across countries and regions. The short papers includ-ed in this special issue will – we hope – prompt the recognition of the need for a comprehen-sive comparative history of social medicine in Greece and the Balkans to emerge. This would ultimately require reconstructing the mean-ing of medical knowledge, of its symbolic and practical content, in each individual country.

Social historians of medicine in Greece and the Balkans should not just demote previous historico-medical scholarship, but they should see in their current work possibilities for conti-nuity as much as for change. The functions of scholarly engagement with medical traditions in the Balkans, private and public, and the con-cepts available for dealing with history more generally are very different now to those of the 1980s, or even the 1990s. Reflecting this schol-arly ambition, this special issue is intended as an illustration of the rich potential for historical analysis offered by the social history of medi-cine in Greece and the Balkans.

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ACKNOWLEDGEMENTS

viduals. Financial support also came from the Berendel Foundation and the Wellcome Trust. The latter’s Strategic Award not only enriched our academic life in the Centre for Health, Med-icine and Society at Oxford Brookes University, but also made it possible for us to expand our research into the social history of medicine in Greece and the Balkans. Finally, I would like to mention the editorial assistance provided by two dedicated students: Mark Galt and Simon Wilson. Their help was crucial in the final stages of this publication.

I would like to express my gratitude to Profes-sor George Antonakopoulos for his unfailing support in the publication of this special issue. It simply would not have happened without him. I am also grateful to Professor Catherine Morgan (British School at Athens) and Dr Kath-erina Gardikas (Faculty of History and Archae-ology, Kapodistrian University of Athens) for their generous support and hospitality before and during the workshop. That this workshop was an unforgettable event is due to these two wonderfully supportive institutions and indi-

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SOME ASPECTS OF THE RELATIONSHIP BETWEEN RELIGION AND MEDICINE IN EARLY MODERN PERIOD

Andrew WearUniversity College London, London UK

and death entered the world when Adam and Eve sinned and were expelled from paradise, becoming mortal. From the beginning, in the book of Genesis, the link was made between illness, death and sin. However, Christianity was a healing religion. Christian teaching declared that God was merciful to humans and it held out to them two forms of healing.

The first was supernatural or spiritual, above or beyond natural means. The other relied on natural means. The belief in the efficacy of su-pernatural healing was based on the example of Christ’s healing on earth. Christ came on earth, as the New Testament recounted, and healed the lame, the blind, the dumb, the maimed, and those who had plagues. Significantly also for the history of insanity Christ healed the insane by expelling the unclean spirits or the devils that possessed them and this served as a pat-tern for later beliefs in possession and exor-cism. The gift of healing was passed on to the twelve disciples: “And he ordained twelve, that they should be with him, and that he might send them forth to preach/ And to have power to heal sicknesses and to cast out devils.” (Mark 3, 14-15) As the Orthodox and Roman Catholic churches saw their priests to be the direct suc-cessors of the disciples they consider that the gift of healing was passed on to them. Protes-tants, especially Calvinists, denied this, declar-ing instead that the age of miracles was past and had ended with the death of the twelve disciples and that, moreover, the healing rituals of the Catholic Church had no effect.

It is worth paying attention to the divisions

Until recently, Christianity and medicine were closely interlinked, at least in the eyes of Chris-tian writers, and in this paper I want to bring out some of the basic doctrinal reasons under-lying this relationship. However, Christianity was not monolithic, and I will discuss the divi-sions within the Church and how they affected the relationship. In the later part of the paper I will broaden the discussion and look at the place of priests in the medical marketplace and at the relationship between the state, religion and medicine.

In what is for many a secular age, or at least a time when secularism is a growing force, as I think it is in Greece and the Balkans today, it is easy to forget how important the Chris-tian religion was in the early modern period (around 1550-1750). Though other forces and realities may have been at work, Christianity was a central factor in individuals’ lives and in the political life and social organization of a State. Wars were fought, heretics burned, ex-communications or anathemas issued, charity organized, and public and private moralities and laws created all in the name of religion. Birth, marriage and death, the stages of life, all came within the remit of Christianity and were given ceremonial structure and remembrance through Christian ritual. Given the way in which Christianity claimed to be able to reach into every aspect of individuals’ lives and beliefs, and into the ideologies of governments, it is not surprising that it claimed that illness and medicine also came within its influence and could be explained by its teachings. Illness

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within Christianity as they also led to different forms of charity for the sick poor and differing approaches to medical knowledge, in addition to differing rituals and doctrines. However, de-spite the divisions, and historians are too apt to focus on them as they tend to be interested in change rather than in continuity, the major Christian religions shared much in common, specifically; the Bible, agreement on the valid-ity of Christ’s teaching and for our purposes aiding of the ill, the importance of comforting the dying, and a concern for the sick poor. The forms that these concerns took, however, could vary along denominational lines. Natural heal-ing, using ‘means’ as the English Protestants put it, was accepted by all of Christianity. In Ecclesiasticus the reader is told that: “The Lord hath created medicines out of the earth; and he that is wise will not abhor them.” (Sirach 38. 4) And, in a verse that was popular among phy-sicians and often quoted by them, the reader is enjoined to: “Honour a physician with that honour due unto him [...] for the Lord hath cre-ated him.” The next verse was less quoted: “For of the most High (i.e. God) cometh healing...” (Sirach 38.1-2)

These verses make the point that curing ill-ness, whether by medicines, by physicians, or by both, ultimately came from God, although the means used might be natural. The early Church Fathers agreed; as Darrel Amundsen has pointed out, most of them believed that it was not sinful or a denial of God’s power to seek for natural cures from medicines and/or from physicians. Though to avoid any possible sin the ill person had to, in the view of theolo-gians, accept that the cure came from God, and pray to God that the medicine would work. In other words, religion incorporated naturalistic medicine into itself while also allowing medi-cine a separate existence; physicians were not priests and medicines were not prayers, even if Christian writers appropriated the language of medicine and could write metaphorically at

times of the medicine of prayer. On a formal level, in the eyes of Christian writers religion and medicine were intertwined, even if in real-ity many patients did not pray to God for the medicine to work. Not surprisingly, theologians set out the theoretical basis of the relationship between religion and medicine and in matters of religion there has often been a wide gap between the theory of what should happen and the practices of the population at large. Only empirical evidence can tell us what hap-pened in practice. There were however real consequences of this intertwining of religion, healing and medicine, whether in the super-natural or natural senses. Protestants might disbelieve in miraculous healing through the sacraments, the power of the saints or in any God-given powers of priests but they did be-lieve in the ability of God to act directly upon people on earth and bring on or cure illness. For the Orthodox and Catholics alike the intertwin-ing meant that it was natural for a priest and a church to be a focus for healing. They believed in the power of saints to bring healing and in the ability of priests to act as intermediaries between God and the sufferer, with the church acting as the ritual centre for the process of mediation between parishioners, clergy and God. This gave Orthodox and Catholic priests a degree of power and influence over parish-ioners.

That power was not lessened by any Protes-tant scepticism as to the existence of miracles that came about from the intercession of the saints or of the Virgin Mary. There was a rich and varied cosmology of supernatural powers set out in the Orthodox liturgy who could be appealed to for help. For instance, the Small Paraklesis or Supplicatory Canon written by Theosteriktos the Monk in the ninth century and still in use invokes a pantheon of powers able to intercede with God on behalf of the Orthodox:

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raise the Orthodox to glory, and shower us with your abundant mercies, through the interces-sions of our all pure Lady the Theotokos and ever Virgin Mary, through the power of the precious and life-giving Cross; through the protection of the honourable, heavenly bodiless powers; of the honourable, glorious prophet the Forerunner John the Baptist; of the holy glorious and all-praised apostles; of our holy fathers the great hierarchs and ecumenical teachers, Basil the Great, Gregory the Theologian….Spyridon bishop of Trimythous, the wonder workers; of the holy great martyrs George the triumphant, Demetrios the myrrh flowing…..(Translated by Demetri Kangelaris and Nicholas Kasemeotis, Greek Orthodox Diocese of America)

pre-reformation practices. It would be unwise, however, to underestimate Orthodox and Cath-olic ritual and prayer. The desperation of the ill adds force to such appeals. The link between the Orthodox Church and people is exempli-fied by the role of icons. Found in churches and houses, the sick and their relatives prayed to them as either a source of power or as conduits to healing power. They were visible emblems of the Church’s presence in people’s lives. But, they also gave people a degree of autonomy in seeking for a cure, whether this was by their own prayers to the icon or by promising silver or gold gifts to adorn the icon if a cure was forthcoming.

In the case of the Orthodox Church, its spe-cial position as a source of learning and knowl-edge for many Greeks during the Ottoman oc-cupation, its role in helping to preserve a Greek identity, and its later role in the revolt against the Turks would all have reinforced its author-ity. However, the Church’s role during the oc-cupation was not unproblematic; it was incor-porated into the process of Ottoman rule and it can also be argued that the Church helped to hinder and delay a Greek enlightenment that might have weakened its authority.

So far I have not mentioned the medical marketplace, a curious invention of Anglo-American historians that has had many useful functions and some drawbacks. It places all early modern practitioners on an equal footing; empirics, herbalists, wise women, astrologi-cal physicians, cutters for the stone, surgeons apothecaries and physicians are all seen as competing with each other directly. Historians

As long as people believed in such a host of heavenly powers there was no chance that the Orthodox Church would, by an internal process as occurred with Protestantism, be-gin “the disenchantment of the world” to use Max Weber’s famous phrase. The world and the heavens, being enchanted, contained beings and powers that acted as conduits to God and so served as sources of healing. In the Small Paraklesis as well as supplication to a wide variety of heavenly powers, the appeal to the Theotokos or Virgin Mary is most prominent. She can intercede with God on behalf of the sick and can also, through her own power, heal the sick: “with most serious ailments/ And with the passions so dark/ I am being tested, O vir-gin/ Come and bring help to me/ for I have known of you/ That you are without fail/ The endless treasure of cures/ only all blameless One.” Or, again: “I lie now on a bed of infirmi-ties/ And there is no healing at all for my body/ Except for you.” The Theotokos is also prayed to as someone with access to Christ: “And unto me grant health/ through your intercessions and your prayers.”

Historians of the English Reformation and of Protestantism have often, perhaps un-consciously, presented in a positive way the Protestant intensity of the new ‘one-to-one’ relationship between the individual and God, unmediated by Catholic priests and Catholic rituals, or by the saints and the Virgin Mary. In-fluenced by the rhetoric of early Protestantism, and by the links between Protestantism and the creation of a national identity, they have tended to dismiss the influence and power of

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who write of the medical marketplace do not put the university-educated physicians on top of the tree, nor do they accept at face value the rhetoric of the physicians against their compet-itors. In the space of the medical marketplace patients had access to a wide variety of healers and in it they could find multi-causal explana-tions of illness and be offered different types of treatment; herbal and/or chemical remedies, spells, prayer etc. Orthodox priests could also be viewed as part of the medical marketplace; they provided access to supernatural healing, and being literate were also sources of natu-ralistic medical knowledge, perhaps using the iatrosophic texts discussed in elsewhere in the workshop. The dual nature of religious healing, both spiritual and naturalistic, fitted well with a marketplace where patients and their fami-lies could choose between different types of explanation for an illness and different kinds of practitioners and treatments.

But how could a priest, a church, or Chris-tianity be part of a marketplace? The church saw it as its duty to care for the sick. It was part of the Christian ethic of charity, unknown to the classical world, that was extended to the hungry, the poor, to strangers and to those in prison, as well as to the sick (Matthew 25,35-39). It found expression in church run hospi-tals, in monasteries, and it formed part of the duty of priests. The Orthodox tradition of the Anargyroi-physician saints who took no mon-ey for their charitable services to the sick also reinforced the tradition of free treatment for the sick poor with no monetary transactions involved.

A cynical view might be that priests and the Church gained social capital within a commu-nity by caring for the sick, just as it might also be said that neighbours cared for neighbours so that they could gain social credit. Yet this is to deny the role of altruism or to deconstruct it away. It simplifies the nexus of social rela-tions and reduces them by analogy to a quasi-

financial transaction. This is in keeping with the ideological origins of the medical market-place, though ironically the personal politics of the historians were not right wing. The issue is that in trying to put all practitioners on an equal footing by placing them in a competi-tive commercial marketplace historians have over-reached themselves. The wide choice of practitioners existed partly because of eco-nomic reasons such as monetary competition, but other factors were also at play. As we saw, the care of the sick was part of the Church’s doctrinal teaching, without such teaching its existence would be doubtful.

Yet the Church and priests did take on them-selves a legitimating role in relation to practi-tioners and their practices within the medical marketplace. For instance, was it lawful for Christians to consult wise women? Could some healing practices be seen as witchcraft? Cer-tainly, the ability of the Church to offer coun-ter measures against maleficium increased its legitimizing and controlling roles. Exorcisms could expel devils and also offer, in the case of Greece, protection against exotica as well. In addition, anathemas or excommunications could be brought against anyone suspected of using witchcraft, for instance, by casting a spell and making a person ill. The Church could also be selective of the type of medical knowledge that it approved of. Hippocrates and Galen, though not Christians, had been assimilated into the West European universities in the middle ages. Yet the popular medieval saying of “Ubi tres medici, ibi duo Athei”, “where there are three physicians, there be two atheists” was long lasting and widespread. In the sixteenth and seventeenth centuries some Protestants preferred the medical theories and practices of Paracelsus because his medicine was explicitly Christian and charitable, in contrast to what they took to be the atheistic and uncharitably expensive medicine of the establishment uni-versity educated Galenic physicians. In Greece the Church-produced iatrosophic texts used in

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monasteries, and perhaps by priests, indicate an acceptance of classical authors albeit in a Christian setting and with content that is much more popular than classical.

I turn now to my last topic: the relationship between the State, religion and medicine. By and large the state in Western Europe did not concern itself very much with medicine, the individual and his or her family were expected to look after themselves. There were significant exceptions though. The licensing and policing of medical practitioners occurred at differing levels of intensity and efficiency in West Euro-pean countries, but nowhere was the policing of medical practice as efficient and widespread as it became in the nineteenth and twentieth centuries. In Ottoman occupied Greece it ap-pears to have been non-existent in the early modern period while it was present in the Ve-netian occupied territories. However, the care of the sick poor and plague are the two excep-tions that relate directly to this paper.

The interests of the State and of the Church-es intersected when it came to the care and support of the sick poor. Much has been writ-ten on the changes that took place in Prot-estant and Catholic attitudes to the poor and sick poor. The face-to-face charity of medieval Europe changed in the sixteenth century and was rendered more organized and less per-sonal in Northern Europe in both Protestant and Catholic towns. However, Luther’s rejec-tion of salvation through good works certainly encouraged Protestant states such as England and the Netherlands to develop national and civic financial structures to support the poor and the sick poor, rather than relying solely on individual charity, though local churches were often involved in the administration of this sup-port. In Greece, Cyril Loukaris’s Confession of Faith (1629 and 1633) argued for Luther’s doc-trine of salvation by faith alone together with a concept of predestination, but the Orthodox Church rejected Loucaris’s attempt to merge Orthodoxy with Protestantism. In Greece there

had certainly been organized care for the sick poor from the time that the Byzantine emper-ors had supported the creation of hospitals by the Orthodox Church, and personal face-to-face charity to the sick poor continued from the Byzantine period through the Ottoman occupation.

What happened to the xenodoheia for the poor and sick poor after the fall of Constantino-ple? How far was the Orthodox millet allowed to organize its own welfare arrangements? What if any was the influence of the Ottoman rulers? How influential was the ecumenical pa-triarch in Constantinople in relation to charity in the old orthodox regions of the Ottoman Empire? And when nationalist sentiment and nationalist churches challenge the patriarchal approach of a universal Orthodox church, does this lead to different forms of welfare for the sick poor?

Perhaps the most dramatic occasion for state intervention in medicine came with plague. Social cohesion, economic well-being, and the rule of law were all threatened by plague. The response of the Italian city-states was the most organized, seeing the organisation of public health boards and magistrates of health. The Church also played a role. Its explanation for plague was that it was God-given, a punish-ment for the sins of the whole community, while other illnesses were caused by the sins of the individual patient. The remedy was therefore mass prayer and repentance. The state could, as in England, also appoint days of prayer and humiliation, whist in Italy a city might agree to a church procession around the city’s walls with the relics of its patron saint. But the secu-lar government remedy for plague in Western Europe was preventive quarantine, isolation of victims and the cleaning up of the environment and this policy sometimes, but not often, came into conflict with the gathering of people in churches or in processions, but normally there was co-operation between Church and State in implementing plague measures.

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While the role of the Church in the case of plague was concerned with the divine, and that of the State was concerned with natural means of prevention and cure, a degree of dualism remained in Catholic and Protestant teaching on plague. God, it was believed, could send plague directly, supernaturally, or He could also work through natural, secondary means to produce plague through the same causes believed in by governments. The explanations given by religious writers and by physicians and governments showed also some unity at the level of analogy. The spiritual and moral

pollution or dirt of sin caused plague, and dirt in the form of cesspits, putrid air etc. generated plague at the physical level; the religious and naturalistic explanations shared some similari-ties. In the case of Greece and the Balkans, an area occupied by two different powers, namely Venice and the Ottoman Empire, the situation was complex, particularly the relationship be-tween religion and medicine. One theme in particular has been the way in which religion claimed powers of both spiritual and natural healing and brought natural healing within its ambit and control, at least in theory. Moreover,

priests were able to offer spiritual and physical healing and in so doing helped to integrate religion further into the life of their communities, and made their presence felt in the medical marketplace.

FURTHER READINGS: D. Amundsen, “Medicine and Faith in Early Christianity,” Bulletin of the History of Medicine 56 (1982): 236-

250.O. Grell and A. Cunningham, eds., Medicine and the Reformation, London, 1993.K. Parry, ed. The Blackwell Companion to Eastern Christianity, Chichester, 2010.Andrew Wear, “Religious Beliefs and Medicine in Early Modern England,” in H. Marland and M. Pelling, eds.,

The Task of Healing: Medicine, Religion and Gender in England and the Netherlands 1450-1800, Rotterdam, 1996, 145-169.

marius

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ANCIENTS AND MODERNS: THE RISE OF SOCIAL HISTORY OF MEDICINE IN GREECE AND THE BALKANS

Marius TurdaOxford Brookes University, Oxford UK

particularly during the 1970s and 1980s, medi-cal scholarship became increasingly vitiated by a political agenda.

Finally, the third explanation that must be mentioned is the history of medicine’s relation-ship with state nationalism. Modern Greece, Serbia, Romania, and Bulgaria were all estab-lished in the nineteenth century; an indepen-dent Albania was proclaimed in 1912 and Yu-goslavia was created after the First World War. During this often-turbulent period in Balkan history, medicine was viewed as essential to the process of state and nation-building proj-ects, assisting other disciplines in the search for the nation’s former glory, both culturally and politically. The Balkan countries, more-over, were and are religiously and ethnically heterogeneous. Not surprisingly, perhaps, then that nationalism figured prominently in the dominant medical discourses elaborated during the nineteenth and twentieth centuries. Under these circumstances, medicine became part of a larger nation-building agenda, serv-ing as a vehicle for transmitting a social and political message that transcended opposing ideological camps.

One of the most important corollaries to these developments was the physician’ exten-sive social and national involvement. Starting with the mid-nineteenth century, a physician became more than just a healer caring for pa-tients (as during the Enlightenment); he (and increasingly she) was a social activist, express-ing a new form of professional loyalty, one through which medical knowledge addressed moral and ethical questions pertaining to the

Why has the social history of medicine been so slow to develop in Greece and the Balkans? To answer this question fully would take more time than the compass of this short paper per-mits. In the following, I will focus, briefly, on three explanations.

The first is academic. Social history of medi-cine, as many authors have convincingly ar-gued, is not a single clearly defined intellectual strategy, but arises in a number of variations: geographical, cultural and political. Tradition-ally, the history of medicine in Greece and the Balkans has focused exclusively on the life and activities of important physicians. This Whig-gish interpretation, chronicling the triumphal progress of medicine, is only to be expected, considering that in these countries, the his-tory of medicine has been largely written by physicians, and from the perspective of the nation-state paradigm. As long as the history of medicine was dominated by an internal, national perspective there was little point in comparing medical developments in neigh-bouring countries. When not able to place it within its own national context, one simply traced the growth of a medical tradition to a Western environment, mostly France, Germany and Britain.

The second explanation is far more political-ly charged. Dogmatic Marxism contaminated most of the medical scholarship produced dur-ing communism in countries like Yugoslavia, Romania, Bulgaria and Albania. Far from invis-ible, the dominance of ideology challenged all claims to objectivity to which scholarship has always aspired. As political pressures hardened,

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health of the nation and society. To an extent that has not been fully acknowledged, the cur-rent fetishisation of the medical profession in the Balkans, the hallmark of most histories of medicine produced in these countries, is to be found in the symbiotic relationship between the nation-state and its medical elites. The point is therefore not to talk about the emer-gence of the medical profession in the Balkans in isolation, but to locate it within those cur-rents of thought and institutional efforts that most compellingly produced canonical inter-pretation of national history in this region.

During the nineteenth and the first half of the twentieth centuries, medicine contribut-ed to the formation, consolidation, and con-firmation of national identities in the Balkans as much as other disciplines. Physicians pro-jected medical ideas onto the national body, but they did so by assuming the existence of a distinct national character. New regimes of health and hygiene were instituted in the Bal-kans, beginning with the nineteenth century, within which state intervention in the name of the nation was normalized. It was assumed that with the help of the state, health experts could control and regulate the nation’s bio-logical life. This form of scientific management based on medical education and schemes of hygiene and public health became central to the professionalization of medicine in Greece and the Balkans.

To be sure, the process of embracing mod-ern theories of health and hygiene did not occur simultaneously across Greece and the Balkans, nor was the spread of medical educa-tion — let alone the extent of medical institu-tionalization — similar. To give a few examples: the Ionian Academy was founded in 1824 in Corfu and included a faculty of medicine; the Imperial School of Medicine was established in Istanbul in 1827, and it soon became a centre for medical training for generations of physi-cians in the Balkans. The first medical faculty in modern Greece was founded in 1837 in Athens;

a National School of Medicine and Pharmacy was established in 1856 in Bucharest. Yet the rest of the countries in the region had to wait until the twentieth century: in Serbia, the first medical faculty opened only in 1905; in Bul-garia, in 1918; and in Albania in 1952.

Until these institutions were established, there was a consistent lack of trained medical personnel in these countries; physicians need-ed to be trained abroad, and many could only afford this elite education through scholar-ships, initially private, from various benefactors. Well into the twentieth century, generations of medical students from Greece and the Balkans benefited from this transfer of knowledge by way of studying under leading specialists of distinct medical disciplines in various Europe-an universities. Often these medical students would later engage with private initiatives in combating diseases and epidemics, as well as contributing to the building of national health systems in their own countries. To some ex-tent, the values of Western medicine became the standard against which medical traditions in Greece and the Balkans were ultimately as-sessed.

I hasten to note that no transfer of knowl-edge is unilateral. The Balkans have undoubt-edly recurrently absorbed external medical knowledge, but regions and cultures are both interrelated and interdependent. The process of adopting medical values and practices was a horizontal movement, not a vertical one with the West on top as the unique source of knowl-edge and power. The emergence of modern medicine in Greece and the Balkans should therefore be seen as part of larger European labyrinth of intertextual and existential rela-tions. It is only when private and public medical traditions in Greece and the Balkans are viewed in a comparative framework that one can sug-gest a more integrative interpretation, one that is equally attentive to historical idiosyncrasies and regional similarities.

What is needed now is a comparative theo-

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retical framework, so that different histories and stories about these different medical tradi-tions can be unveiled and critically examined. Monographs and edited volumes are gradually being published both in and about the coun-tries in the Balkans, a trend not only driven by the emergence of a new generation of medi-cal historians but with equal importance one that is defining the crystallization of social his-tory of medicine as a discipline in the region. A number of factors contribute directly to this process, including improved access to archives, the influx of Western scholarship and, most im-portantly, scholars from the Balkan countries studying abroad.

In pursuit of its new identity, social history of medicine in Greece and the Balkans should not only bring together significant themes and developments in medicine as part of social history, political demography and cul-tural anthropology, but should also forcefully engage with some of the most central topics pertaining to the historical traditions of these countries more generally. This recourse to his-torical memory is essential if, on the one hand, the Balkan countries are to be reconciled with their troubled pasts and if, on the other, the history of medicine more generally is to be systematically analysed through its appropri-ate local, regional, national and international contexts.

Social history of medicine’s importance to the general historiographic traditions in this region is yet to be acknowledged, but the fact that an increasing number of historians in the Balkans are interested in the history of medi-cine is already noticeable. Compared to the pre-1989 period, this emerging scholarship claims not to be vitiated by ideological ma-nipulation and biased interpretations, though it remains to be seen whether these new intel-lectual projects will have the desired impact on

the discipline of history in general, and on the history of medicine in particular.

Current debates and contestations accru-ing around the meaning of national history in Greece and the Balkans yield eloquent exam-ples of the ability of scholars in the region to produce different, almost competing, readings of the past. Social history of medicine too is currently undergoing a remarkable transforma-tion — one defined on the one hand by soci-ety’s need to engage with scientific advances and the ethical dilemmas they raise, and by the inclusion of hitherto marginalised case studies on the other. The inclusion and juxtaposition of histories of medicine in Greece and the Bal-kans with their well-known Western European counterparts thus lies at the heart of the more ambitious historiographic project, a project that strives not only to yield original and timely archival research on neglected national case studies, but also to redefine and diversify the overarching debate on the centrality of medi-cine in modern European history.

The time has finally come for the social his-tory of medicine in Greece and the Balkans to be firmly situated within its own historiograph-ic canon. To be sure, there remains room for im-provement, especially in terms of methodology and access to archival collections. Above all, it is imperative that works of comprehensive synthesis are produced — studies that move away from narrow definitions of medical his-tory and are theoretically and analytically ro-bust. Besides the task of mediating between the local historiographic canons in the Balkans and their international context, there is a press-ing need to tackle these phenomena within a framework of the region’s entangled history, more specifically to look at Greece and Balkan medical traditions, both private and public, from a cross-national perspective.

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FURTHER READINGS:Marius Turda, “Focus on Social History of Medicine in Central and Eastern Europe,” Social History of Medicine

21 (2008): 395-401.Idem, (with Steve King), “Journeying across Empires: An Agenda for Future Research in Central and Southeastern

European History of Medicine,” in D. Sechel, ed., Medicine Within and Between the Habsburg and Ottoman Empires, 18th and 19th Centuries, Bochum, 2011, 235-242.

Idem, “History of Medicine in Eastern Europe, including Russia,” in Mark Jackson, ed., The Oxford Handbook of the History of Medicine, Oxford, 2011, 208-224.

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It is difficult to write a history of Albanian medi-cine during the post-Byzantine period due to the lack of archived documentation or other materials concerning the health service. Under these circumstances, in order to carry out our research we worked on a number of historical domestic and foreign publications. There are studies written by well-known Albanian doc-tors including S. Simonidhi, A. Ashta and A. Mihali. We also relied on publications by main heads of clinics such as those by Fejzi Hoxha, Kërçiku Kadri, Mantho Nakuçi, Flamur Tartari and Mikel M. Nakuçi. Other important and valu-able sources are reports and books written by various missionary doctors who lived in the Albanian territories such as F. Pukeville , H. Hol-land, A. Bue, J. Muller, F. Nopcsa etc.

Health Development in ShkodraThe city of Shkodra is one of the most impor-tant cities in northern Albania. During the pe-riod of about two centuries (1747-1947) this ancient city had regular registers for births,

marriages and deaths, and documents about various diseases and epidemics survived, which were held mainly by the Catholic Church. Prof. Kërçiku in his 1962 book published lists and a rich information on national and foreign health personnel (doctors, nurses, pharmacists) who served in this city. In addition to information about health and development of the earliest hospitals in the city and the whole province of Shkodra, there is also an attempt to compare health development in Shkodra with other cit-ies and regions in Albania.

The 1861 report states that the city of Shkodra has a Catholic population of about 6,500 persons, while according to the reports of 1898, 1901, and 1904 the population was about 8,000 persons. Two-thirds of that population were Mohammedan and one-third Catholics. A reliable source for the history of this city are the parish registers of Shkodra which reflect the demographic movement of the city’s popu-lation, and the dynamics of marriages, births and deaths.

THE HISTORY OF ALBANIAN MEDICINE, 1800s to 1920s

Mikel Nakuci, Asllan ZemaniInstitute of Dermatological Studies, Tirana, Albania

Marriages in Shkodra

Years General no of marriages Average per year1747-1772 198 7.61786-1811 451 17.31812-1837 542 20.81838-1863 880 33.81864-1889 1,179 45.01890-1922 1,367 52.61923-1947 1,521 58.5Total 6,138 33.9

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Births and deaths of the Catholic population in Shkodra

Years Births Deaths1747-1792 1,549 5421793-1819 3,481 1,3211820-1845 4,858 1,0681846-1871 5,181 3,1601872-1897 5,957 5,3351806-1930 6,080 5,4391931-1947 4,455 3,379Total 31,561 20,244

Another epidemic, which is encountered in these documents (though somewhat later), is the smallpox. There were approximately 18 outbreaks of this infectious disease in the city and in its suburbs. The greatest epidemic of smallpox in relation to annual deaths occurred in 1885, with about 97 deaths per 10,000 in-habitants. During this period other infectious diseases including measles, pertussis, scarlet fever, diphtheria, and abdominal typhus, have caused a number of deaths too. Tuberculosis was endemic during the period between 1906 and 1916. The annual mortality from this dis-ease was 31.3%.

The first case of leprosy was registered in 1790, reappearing in 1852, 1884 and again in 1894. Malaria, which had existed since ancient times, was widespread in the 1400s in Shkodra, especially when the lands east of the city were turned into swamps that favoured its spread. In the first siege of Shkodra (1400s) “20,000 Turk-ish soldiers out of 60,000” died from malarial fe-ver. Malaria continued to be widespread during the Austro-Hungarian occupation (1916-1918) and consequently patients suffering from this disease have been reported by Austro-Hungar-ian doctors working in the city hospital dur-ing the years 1905-1906. Cholera also ravaged Shkodra during the period between 1831 and 1918, accounting for 3-6% of the city’s total mortality.

Tables of births, deaths and marriages in-dicate that the number of inhabitants was on the rise. Infant mortality data from the Catho-lic Church shows the following: during 1842 – 1878, 15.7% of babies under the age of 1 died, while during 1877–1911, children made up 15.2% of annual deaths. The highest rate of mortality occurred in 1842 (26%), and was reached again in 1858-1859 (26-28%).

Epidemics and Commerce The temporary migration of workers or peas-ants; the drafting of young Albanians in the Ottoman army; Muslims travelling to Mecca; the establishment of the Ottoman Army in the Albanian territories; and numerous wars all contributed to the spread of many major epidemic diseases including, but not limited to plague, smallpox, and malaria in this period.

In his work, The Siege of Shkodra, Marin Bar-leti shows that when the Turks attacked the castle of Drishti, Albanians fought heroically even though the plague was spread in the cas-tle. Epidemics that were prevalent in Europe and the Ottoman Empire have affected Alba-nia too. The registers of the Catholic Church in Shkodra record 12 epidemics within 60 years. The epidemics of 1763, 1797, 1798 resulted in a mortality rate of about 4-6%, while in other cases deaths from plague vary from 15% to 55% as was the case during the 1819 epidemic.

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Empirical MedicineMarin Barleti was the first to discuss empirical medicine in his two works History of Skander-beg and The Siege of Shkodra. Moreover, for-eign scholars who studied Albanian ways of life, like Edith Durham, also mentioned “Alba-nian healers” (the xherahs) of several varieties. Those healers used a large number of medici-nal plants in various preparations such as in-fusions or ointments for treatment. It should be emphasized that empirical medicine in Al-bania reached its highest level in the surgery practiced by the xherahs, who transmitted their knowledge from generation to generation. They conducted surgery on tonsils, eye cata-racts, fractures, hernias and bladder stones. Many foreigners who have written about Al-bania have discussed these exceptional skills. Pukevil (French consul to Ali Pasha’s court) noted that: “They make some surgical opera-tions without knowing the anatomy, with such a success and skill that surprised even the most skilled surgeons.” Whereas Dionisis Piros in his 1848 Practical Medicine wrote: “There are some practitioners called Strange Doctors, who with the greatest care can cure even great and in-curable diseases in people.” Furthermore, Edith Durham described a case in which a healer suc-cessfully treated a patient’s leg after a foreign doctor had resolved to cut it off.

The xherahs of Buali Karma and Preza, for example, were famous. They taught their craft to their children, who were deemed competent only when they proved their ability in front

of other people. Besides the popular doctors in the Permeti districts, Zagoria, a village in Ioannina (Greece), is mentioned for its suc-cessful empirical medicine during the Otto-man conquest. The practitioners of this village were best known for curing diseases, rather than surgeries. It is estimated that Zagoria’s xherahs knew 219 different medicinal plants and created some codes to their craft. Thus, the above evidence on empirical medicine and surgery included the entire area of Epirus (Albania-Greece).

Surgeries Performed by the XherahsIn Albania, empirical surgery was developed as a result of historical and social conditions dur-ing the period of Ottoman occupation. Empiri-cal surgery was one of the ways in which the Albanian people demonstrated its talent, even in the toughest conditions. The skill of popular surgeons has often been greater than that of other graduated doctors. Below are some ex-amples of surgical interventions carried out by Albanian native xherahs:

The Cataract

For the removal of cataracts the xherahs used silver needles. At 1cm from the needle’s tip they put a wax ring to prevent its penetration deep into the eye. When the needle reached the lens, by making up and down movements the clouded lens could be removed, thus allow-ing light to pass through to the retina.

Surgical tools used by the xherahs Silver needle used for cataract removal

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Fractures

The xherahs performed used frame pieces to perform jointing, with skin of cherries or splints (minced soap, oil, egg white and goat wool). They broke bones, which did not join well and rejoined them after straightening them cor-rectly. In cases of great damage they used dog bone as alloplastic material.

Surgical interventions for kidney stones

The patient sat with their hands tied to their feet, tied against a log so that he wouldn’t move. The xherah cleaned his hands and tools with a strong brandy (raki) and began operat-ing with or without anaesthetics (brandy given to the patient half an hour before the surgery). The xherah then put his two left hand fingers into the patient’s rectum, while squeezing the bottom of the abdomen with his right hand, helping to catch the stone with the left hand fingers, drawing it out through the left or right urinary canal. He would cut the perineum be-tween the fingers with a razor, thrust a hook through the formed hole and pull the stone out. Blood flow would interrupt itself and the xherah’s opinion was that the wound would close quickly. After two to three days, water could be passed through the urinary canal.

Scientific MedicineAt the beginning of the nineteenth century Ali Pasha of Tepelen sent two Albanian stu-dents to study medicine in the universities of Naples and Vienna, from this point the number of Albanians studying abroad began to rise, particularly in the second half of the century. An important factor that influenced the devel-opment of scientific medicine in Albania was the foundation of Istanbul Medical School in 1835, and the Faculty of Medicine in Athens in 1837. A considerable number of Albanian doc-tors graduated from these two centres.

Grave economic and social conditions often forced Albanian doctors to work abroad where

they would contribute to the development of medical science in these respective countries, and to the world more generally. For example, Besim Omeri, professor at the Istanbul Military Academy and rector at the University of Istan-bul played a key role in the organization of Turkish healthcare and founded the Turkish Red Cross. He also established some medical magazines and wrote over 50 medical works. Also in Turkey worked Ibrahim Lutfiu, Mustafa Buda, and for some time Bilal Golemi and Rifat Frashëri.

Around the middle of the nineteenth cen-tury, hospitals were established in the Albanian lands such as the one in Shkodra (1876) which was used by the Turkish military for its own pur-poses, followed by the one in Durrës (1903), Ti-ranë (1919), Vlorë (1914), Korçë (1916), Elbasan (1919), Gjirokastër and Berat (1914-1919). The hospitals in Peshkopi, Përmet were established after the declaration of independence. How-ever they had a limited bed-capacity and were not able to meet all local requirements.

It is worth mentioning that Albanian doc-tors, pharmacists, and nurses worked heroically during battle of Vlora in 1920; on the initiative of Dr. Petraq Popa (who like many other Alba-nian doctors came from Turkey) a sanitary team was organised which established the hospital in Llakatund of Vlora and provided first aid to all wounded in the battle. This team was led by Petraq Popa, and included his brother Mar Popa, pharmacist Mir Caku, Zekije Krasta, Xha-fer Gica and Ymer Lala. The 1920 Congress of Lushnja made an effort to organize the Alba-nian health care system with Professor Rifat Frasheri appointed as its head. In 1924 the bac-teriology laboratory was established in Tirana and transferred to Durres in 1925. It was first run by Bernard Dodi, a French bacteriologist, followed by Bajram Emiri. In 1928, the labora-tory was transferred back to Tirana upon the request of Bilal Golemi and joined the veteri-nary lab. Despite these developments, special-ist areas of medicine and specialized wards in

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existing hospitals started to emerge gradually, however, the number of doctors and specialists

remained too small to meet the growing needs of the newly created country.

FURTHER READINGS:N. Çabej, Nga historia e zhvillimit të shkencës shqiptare, Tiranë, 1980M. M. Nakuçi, Figura të shquara të mjekësisë, Janinë, 1995M. Barleti, Rrethimi i Shkodrës, Tiranë, 1982.

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BALKAN MEDICAL EDUCATION AND BULGARIAN PHYSICANS, 1840s-1920s

Georgeta NazarskaState University of Library Studies and IT, Sofia, Bulgaria

particularly those in Istanbul in 1827, Athens in 1837, and Bucharest in 1857/1869.

Around the creation of the modern Bulgar-ian state in 1878 the number of native phy-sicians was 127. They were educated in the Ottoman Empire (53), Western Europe (30 in France, Austria, Italy, Germany, and Switzer-land), Romania (28), and Russia (16). Valcho Kurtev maintains that at least 284 physicians had been prepared during the same period. They graduated in the Ottoman Empire (114), in Romania (90), in Western Europe (40), in Rus-sia (34), and in Greece (6). Nikolay Genchev argues that during the National Revival Pe-riod Bulgarian physicians represented 1.8% of Bulgarian intellectuals. He accounts for 339 individuals with complete medical education, 192 of which were working on their specialty. Physicians were also the most compact group among the Bulgarian intelligentsia with sec-ondary and higher education. 94 of them had attended the Medical School in Bucharest (55 of them graduated); another 58 had studied at the Medical Faculty there (43 completed); 146 had attended the Military School in Istanbul (66 completed); and 13 studied at the Medical Faculty of the University of Athens (5 of them completed).

For my research I created a prosopographical database. It details all 311 persons who studied in these three centres. It was used to produce a statistical analysis of a cluster sample. The database includes data on the year of birth; birthplace; social background; educational level and their place of study; professional experience before education; professional ca-reer after graduation; fields of specialism; and

This paper discusses the problem of intercul-tural communication in terms of the develop-ment of modern medicine in Greece and the Balkans during the nineteenth and twentieth centuries. The paper will focus on Bulgarian physicians, in particular graduates of the fa-mous centres of medical education in the Bal-kans: Athens, Bucharest, Constantinople (Istan-bul) and Belgrade. Based on primary and sec-ondary sources, and by means of methods of prosopography, the paper discusses the social profile of students attending these institutions; their education and professional migrations; the place of female students; the professional career of alumni and their contribution to the creation of a modern Bulgarian health care and medical science; their work as practitioners and managers; and finally their membership in sci-entific networks.

Medical Centres in the Balkans: Bucharest, Constantinople/Istanbul, Athens, and BelgradeThe creation of Bulgarian medical intelligentsia in the early nineteenth century is a product of different factors, including reforms in the Ottoman Empire during the time of the Tan-zimat; the process of consolidation within the Bulgarian nation; the emergence of the bour-geoisie within Bulgarian diaspora (in Istanbul, Bucharest, Odessa, and Vienna); the creation of modern cultural institutions (schools and community centres); and the policies of the Great Powers (particularly Russia and France). An important factor was also the establishment of educational medical centres on the Balkans,

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public performance (political activities, liter-ary activity, and participation in organizations). Here I present some of the results.

Three major periods in the training of Bul-garians in various Balkan medical centres can be outlined. The first covers the period between 1848 and 1878, when Bulgarians at-tended the medical schools of Istanbul, Bucha-rest and Athens. Istanbul trained the greatest portion of these students (47.5%), followed by Bucharest (40.9%) and Athens (5.7%). Stu-dents were mainly born in the 1840-1860s. They came exclusively from bourgeois families; craftsmen (22.9%); traders (18.8%); and intel-ligentsia (15.6%). A large part of them (12.5%) were born to families of doctors and pharma-cists. After 1860 many poor boys and orphans studied medicine and were funded by local municipalities. Medical students were born in Bulgarian trade and craft centres known for their advanced education and active bour-geoisie, namely Tarnovo (21.6%); Stara Zagora and Kotel (7.8%); Kalofer; Koprivshtitsa; and Sliven (5.9%). Almost all students during this period were men. There was only one woman, Stephana Kuleva, who studied at the School of Nursing at the Medical Faculty of the Bucharest University (1877). Overall, young people com-pleted primary schools in their homeland, but acquired secondary education in foreign Greek schools in Bucharest, Istanbul and on the island of Andros at the famous Robert College, due to the lack of Bulgarian schools.

The second period covers the years 1878-1920 when there was no Medical Faculty in Bul-garia (the first one opened in 1917) and the gov-ernment urgently needed medical profession-als. For this reason a number of scholarships for medical students were granted annually. The Bulgarian students were directed not to the Balkans, but to France, Russia or Austria-Hun-gary. Students studying at their own expense targeted Balkan countries. Initially there was a period of withdrawal of Bulgarian citizens from Balkan medical centres (1878-1895), probably

related to political events (Unification of the Principality of Bulgaria with Eastern Roumelia in 1885, Serbian-Bulgarian War 1885). After 1895 it was mostly members of the Bulgarian ethnic minorities who went to Balkan medical centres while Greeks of the diaspora preferred to study in Athens; Armenians and Jews in Bu-charest; Turks and Armenians in Istanbul. These medical centres had remained attractive places for students of medicine and pharmacy. All of the students were male and came from cities with the status of multiethnic centres: Plov-div, Varna, Shumen, and Sofia. Almost equally they were graduates of the Bulgarian state and private secondary schools. Their average age was 23 years

The third period covers the years 1921-1944. In the 1920s Balkan medical educational cen-tres lost their attraction due to several factors, including the establishment of the Medical Fac-ulty at Sofia University (1917); the economic difficulties of the post-war crisis, strengthened internal migrations, and strained international relations within the Balkans in the 1920s. Nov-elty was attracting Bulgarian students to Istan-bul where they were drawn to the study of den-tistry, a subject missing from the curriculum at the University of Sofia. This trend explains their professional mobility in the late 1920s and the early 1930s. The presence of women students can also be observed. Many Bulgarian, Turkish, Armenian and Jewish girls studied dentistry in Istanbul. From the middle of the 1930s until the end of the World War II another transformation occurred. After 1938 Belgrade became the pre-ferred educational centre for Bulgarian medi-cal student as a result of their migration from occupied Austria and Czechoslovakia after the onslaught of Nazi Germany. Thus, the Medical Faculty of the University of Belgrade attracted many Bulgarian citizens, including Jews. After 1940, when Bulgaria received the Southern Do-brudja from Romania and exchanges of popu-lation took place, a group of graduates from the Faculty of Medicine in Bucharest arrived in

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Sofia. Available information indicates that most of the Bulgarian physicians who had gradu-ated until 1878 made their career in the field of medicine, but a few became teachers, clerks, priests, etc. Most of them were employed in the Ottoman Empire and Romania.

Professional Careers of Bulgarian Physicians in the Ottoman Empire (up to 1878)

The first steps towards the professionalization of medicine in Bulgaria coincided with impor-tant changes to the healthcare in the Ottoman Empire during the Tanzimat era. From the 1830s to the 1870s the following institutions were established: the Quarantine Office with its branches in countryside (1831-1847); the Sanitary Board (1840) which controlled medical practice, ensured public hygiene and fought against epidemics; and the Department of Public Health (1869). During this period several regulations were issued that dealt with medical qualifications, the practice of urban doctors, the organisation of urban pharmacies among other topics.

A change in public attitudes was another favourable factor. The urban population that formed the backbone of the bourgeoisie had preferred specialized medical attention to tra-ditional healers, and science and methodical treatment to tradition and improvisation. Last but not least, the military reforms and Russo-Turkish wars of the nineteenth century em-phasised the need for military doctors and the construction of military hospitals, in particular in the Balkan provinces of the Empire.

According to my database, most Bulgarian doctors who graduated from the Military School in Istanbul became military doctors in the Ot-toman army. They had served as divisional or regimental surgeons in different garrisons in particular those in: Bosnia, Albania, Montene-gro, Asia Minor, Iraq, Egypt, or alternatively had been working in military hospitals elsewhere.

The first military hospital on Bulgarian soil was founded in Shumen in 1837. Its pioneers were Nikolaki Bey and Todoraki Bey, alumni of Is-tanbul and Athens respectively. Over the years the Shumen hospital began to serve the civil-ian population as well, establishing male and female wards, and becoming exemplary for its care and the innovative treatments that its staff applied. It also employed mainly Istanbul graduates. A majority of Bulgarians engaged in military service during the Serbo-Turkish War (1876) joined the Romanian or Russian health missions. During the Russo-Turkish War (1877-1878), Bulgarian doctors conscripted into the Turkish army managed to escape and enrol in the Russian army, where they applied their ex-perience and skills.

The database also shows that a small pro-portion of Istanbul’s alumni worked as civilian doctors. Some of them were employed by the famous Istanbul hospitals, Malpete and Hai-dar Pasha, or became founders of other local hospitals such as St. Petka Urban Hospital in Tarnovo. Others were employed as urban doc-tors in larger cities, or had started in private practice by serving their fellow Bulgarians. These who could not complete their Medical Schooling served as doctors’ assistants and pharmacists.

Almost all Bulgarian physicians returned to work in their home regions and opened their own pharmacies; Chr. Bodurov and N. Bay-ryakov in Stara Zagora (1866); V. Gromnikov in Pazardjik (1870) are examples of this. They had enjoyed prestige among the local popula-tion and municipal authorities, and often be-came promoters of a number of health innova-tions: home visits on call; medical insurance; adoption of health regulations, among others. They began giving lectures on health topics to adults and students, compiled and issued prescription collections (“Lekarstvenik”, 1845) and translated medical books.

Two Bulgarian doctors became famous. Because of their qualities they had been ap-

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pointed as professors at the Military School in Istanbul. Dr. Georgi Valkovich (1833-1892) became head of the Surgical Clinic and profes-sor of surgery at the Military Medical School in Istanbul as a young doctor in 1857 but it was after 1865 that he started to make his real contribution to the Ottoman military surgery and education. He was sent to the chief medi-cal officer of the Central Military Hospital in Damascus, and the next year he was brought to the Department of Surgery at the Military Medical School, later in 1870 he was elected as a professor of surgery and as a Director of Haidar Pasha Hospital in Istanbul. Valkovich contributed greatly to the construction and arrangement of military hospitals, and to the organization and development of surgical assistance throughout the Empire. After the Serbo-Turkish War (1876), during which he served as a head of Turkish military hospital in Nish and Sofia, he was promoted miralay-bey. In May 1878 Valkovich resigned and returned to Bulgaria where he began his active public and diplomatic activity. Dr. Christo Stambolski (1843-1932) taught students of anatomy and histology. Over three years he was the head of the Clinic of Skin and Venereal Diseases, also making contributions to medical science. He is the author of Atlas of Anatomy (1867) and the manual The Key to the Anatomy, as well as books on anatomy, parasitology and epidemiology. Moreover, he had tried to adapt the terminol-ogy of anatomy from old Arabic to the Turk-ish language and created a nomenclature of anatomy in Turkish (1876). He was the very first doctor to have described the parasitic disease Philariasis (1877).

Professional Career of Bulgarian Physicians in Romania (up to 1878)In the first two decades of the nineteenth cen-tury, Bulgarian doctors who had graduated in Vienna, Paris and Würzburg began to practice in Romania (Athanas Bogoridi, Vasil Hadjistoy-

anov-Beron, Georgi Atanasovich). During 1830-1840s the French alumnus Nicholas Piccolo had become a chief inspector of the Romanian hos-pitals. Most graduates of the Bucharest Medical School and the Medical Faculty who graduated after 1862 worked as civilian doctors. They had founded private practices in various regions of the country: Bucharest, Izmail, Turnu Severin, Pitesti, Calafat, Craiova, Braila, Tulcea. Others had become hospital doctors and their ap-pointment in metropolitan hospitals was an acknowledgement of their skills. For instance, Dr. G. Stransky worked as an intern at Colentina Hospital in Bucharest; D. Atanasovich at the Children’s Hospital; and Peter Protich headed the Psychiatric Department of the Marcuta Hospital (1853-1857). Others were district physicians and school inspectors. Many Bul-garians also served as military doctors in the Romanian army. 14 Bulgarians participated in the Romanian health mission in the Serbo-Turkish War (1876), for example. During the Russo-Turkish War (1877-1878) some Bulgar-ian doctors worked in the Romanian military field hospitals.

Two Bulgarians became respected lectur-ers at the Medical Faculty of Bucharest Uni-versity. Shortly after his graduation from Paris, Dr. Peter Protich (1822-1881) was appointed physician of the prisons in Muntenia Region (1851). Later he became an inspector of all hos-pitals for venereal diseases, and a municipal doctor in the Marcuta Hospital in Bucharest. In 1857 he was elected both as a professor of surgery at the medical school and as a head of the department of surgery. Dr. Protich was a member of the Romanian Supreme Medical Council. He was the founder and treasurer of the Romanian Scientific Medical Society and of the journal Romanian Doctor. His biggest contribution was to collect materials for the Romanian Pharmacopoeia.

Dr. Georgi Atanasovich (1821-1892) was ap-pointed as a toxicologist in Bucharest in 1849,

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a year after his successful doctorate in Paris. Following an invitation from Dr. Carol Davila he was appointed as a Professor of pathology at the medical school in Bucharest in 1856. From 1861 to 1869 he became the founder, professor and head of the Department of the Forensic Medicine and Toxicology at the University of Bucharest. Atanasovich made diverse contribu-tions to Romanian health care, medical educa-tion and science. He had published articles on forensics, on children’s hospitals, on poisoning with arsenic acid, on epidemiology and on hy-giene. Atanasovich had held other positions of responsibility in Romanian health care as: founder and vice-chairman of the Romanian Scientific Medical Society (1863); member of the Romanian Supreme Medical Council (1862-1879); municipal physician at the Children’s Hospital; a forensic doctor and a head of the Municipal Health Service of Bucharest; and member of the pharmacy charges.

Professional Career of Bulgarian Physicians in Bulgaria (1878-the 1920s)After the Liberation of Bulgaria in 1878 good career opportunities developed for Bulgarian doctors. The Russian occupation authorities and the Bulgarian government established a coherent state organised and centralized health care system of the Russian pattern. It was based on hospitals (civilian and military), and on county and district doctors. Bulgar-ian doctors, graduates of the Balkan medical schools, had returned home and become the pioneers of home health care and Bulgarian science. Most of them had been enrolled in the newly established hospitals: the Alexandrovska Hospital in Sofia, in Pleven and Sliven. Initially appointed as interns, they eventually reached managerial positions: Dimitar Kalevich in So-fia, Nacho Planinski in Sliven, Vicho Panov in Shumen, Ivan Enchev in Silistra, Angel Piskyu-liev in Varna, Stat Antonov in Plovdiv, Stefan Pentchev in Tarnovo. As managers, they were

characterized by entrepreneurship and a desire to introduce modern methods of treatment, to develop of the hospital departments, and to turn these institutions into real health centres of the cities and the regions.

A large part of the Balkan graduates had been hired as full-time doctors in the cities (Var-na, Shumen), in districts (Stanimaka, Bourgas, Plovdiv, Sliven, Razgrad, Targovishte, Yambol, Anhialo, Bourgas, etc.) or in counties (Varna, Veliko Tarnovo, Plovdiv, Gabrovo, etc.). By work-ing directly with the population they had an obligation to visit homes and their inhabitants to teach them the benefits of hygiene; to per-form vaccinations; to give lectures on health topics; to treat most common diseases; and to combat epidemics.

A third group of Balkan alumni had been working in the field of military health care, based on their previous experience and attract-ed by the stable status and good pay. They were distributed in large garrisons (Varna, Shumen, Kyustendil), as well as in the divisional hospi-tals established in 1892 on a proposal by Dr. Georgi Sarafov. He initiated and had prepared a number of normative documents relating to military health care in the late 19th century: rules for food of the sick, structure of the infir-maries etc. The biggest divisional hospital in Sofia was managed by the graduates of Istan-bul Medical School, Dr. Yosif Ljubenov and Dr. Petko Dimitrov, during the period 1894-1897. They had opened surgical and ophthalmology departments, and had performed operations under general anaesthetic. Yosif Ljubenov was also an author of the first textbook on Univer-sal Military Hygiene, published in Bulgaria in 1902.

Graduates of the Balkan universities were involved in the management of Bulgarian health care. Two of them, A. Piskyuliev and Ch. Stambolski, had managed the Health Care Directorate affiliated with the Ministry of In-terior (1902-1903). At least nine of them were

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members of the Supreme Medical Council, an advisory body of experts: P. Protic (1879-1880), Ch. Stambolski, G. Atanasovich (1883-1885), A. Piskyuliev (1892-1894), P. Minchovich (1895), G. Sarafov, Y. Angelov, D. Valkovich, D. Kalevich. They also prepared drafts of the Sanitary Acts in 1884-1888.

Foreign Medical Doctors and the Transfer of KnowledgeAt the beginning of the twentieth century the foreign doctors (Greeks, Armenians, and Jews) made up 19% of district, and 43% of county doctors. A whole team of Greek doctors, all graduates of the University of Athens, worked in Varna. The Greek Leonidas Georgiev opened a pharmacy in Sliven (1858), and later in Stara Zagora. He created a prototype for municipal health insurance. Another Greek, Leonidas Antipas opened the first pharmacy in Shumen (1864). In the 1870s several foreign doctors had been working too, e.g. Grigor Moriatis, Aleko Christis, Michael Crispis, Heliopolis, and others. Dr. Giannopoulos, Valendas and Papadopou-los worked at the public hospital, the Greek Private Hospital “Paraskeva Nicolau” and as private practitioners. They had succeeded in limiting the cholera epidemic in 1881 along the Black Sea coast. Together with their Bul-garian counterparts they created a Scientific Medical Society (1883). Its goal was to study local conditions, to spread medical knowledge, and to issue its own magazine, Zdravie [Health]. Periklis Madamas had become the first doctor in the city of Pazardjik (1885-1886), who agreed

to work under special rules drawn up by the municipal council, i.e. against fixed salary, to treat the poor for free, and to give medical ad-vice to citizens.

ConclusionsThree periods in the preparation of Bulgarian doctors in the Balkan medical centres were briefly discussed here: the 1840s until 1878, 1878 into the 1920s, and the 1920s until 1944. In the first period the largest proportion were graduates of the medical schools in Istanbul, Bucharest, and Athens. During the second period Istanbul dominated with its attractive specialties, including pharmacy and dentistry. During the third period most part of students were directed to University of Belgrade.

Balkan medical centres actually had cre-ated a core group of Bulgarian doctors before the Liberation in 1878. In the Ottoman Empire and Romania they had received considerable experience as military and civilian doctors. In Bulgaria this group had initiated the Bulgar-ian health care system and domestic medical sciences. Moreover, Balkan medical education was very important for the education of the Bulgarian minorities and Bulgarian women. It qualified them for a for well-paid occupation associated with greater social respect. Balkan medical education was thus an agent of social modernization through the creation of profes-sional groups among Bulgarian intellectuals, and in introduction of modern health stan-dards in modern Bulgaria.

FURTHER READINGS:N. Gentchev et al. eds., Balgarskata vazrozhdenska intelligentsia. Entsiklopedia, Sofia, 1988.V. Kurtev, Balgarskoto voennomeditsinsko delo. Sofia, 1990, 5-77.V. Stefanov, Balgarskata meditsina prez Vazrazhdaneto. Biografii I trudove na belezhiti meditsi, Sofia, 1980, 63-

79 and 149-216.E. Siupur, Balgarskata emigrantska intelligentsia v Rumania prez 19 vek. Sofia, 1982.

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THE MIGRATION OF ROMANIAN MEDICAL STUDENTS TO PARIS IN THE NINETEETENTH CENTURY

Valentin-Veron TomaFrancisc Rainer Institute for Anthropology, Bucharest, Romania

the nineteenth century Paris started to attract a large number of foreigners aiming to study medicine, law, literature, theology or pharma-cy who would compete for the same degrees as the French. This pattern of migration was surprising in the fact that the migrants were not citizens of the neighbouring countries of France. Instead, they were coming from Eastern Europe, the Balkans, Egypt and the Ottoman Empire. This group added to a large cohort of students originating in the French, English and Spanish colonies. From a statistical point of view, the proportion of foreign students en-rolled at the faculty of medicine in Paris in the late nineteenth century was quite significant; between 1890 and 1900 it averaged around 16.75% of all students. Of these, 3.8% were women. As for the situation of doctoral ad-mitted, their number remained around 10.6% between 1870 and 1900. Unfortunately, regular statistics relating to foreign students admit-ted to medical school were only available since 1890. However, P. Moulinier attempted to pro-vide an overview of the migration of medical students to Paris from 1870-1900 using several criteria: nationality, gender, age for admission to college etc.. Thus we can see that Serbs rep-resented 1.26%, Bulgarians 1.38%, Turks 9.90% and Romanians 13.48% of the total number of medical students (P. Moulinier 2006: 3). In turn, Daniel Panzac, analyzing the dynamics of the migration process of students originating from “Eastern” (Oriental) countries including the Bal-kans, identified a very uneven growth in the number of degrees in medicine conferred to this category of foreigners by the Faculty of Medicine in Paris during the nineteenth cen-

Long before the emergent nation-states from the Balkans organised their educational sys-tems and offered diplomas to young medical doctors, a tradition had been established which continued up until the Second World War. This tradition allowed future medical practitioners to familiarise themselves with what was per-ceived at the time to be the state-of-the-art in clinical education. As a consequence of this ‘ritual migration’ to Paris and other important medical centres in Europe, a new elite formed that became the driving force of the Europe-anisation of medicine in their own countries. The aim of the present paper is to describe the peculiarities of this ‘migratory tradition’ dur-ing the second half of the nineteenth century, focusing on the Romanian Principalities. The migration of Romanian medical students to Paris was initially connected with the arrival in Bucharest during March 1853 of a very young French medical doctor named Carol Davila (1828-1884). He had performed, for several decades, the leading role in the organisation of the country’s public health system, and was the founder of the National School of Medicine and Pharmacy in Bucharest in 1857, the first medical school in the Romanian Principalities. As soon as this new educational system pro-duced its first generation of secondary school level medical students, Davila sent them to Paris (some of them were also sent to the Uni-versity of Turin) in order to pass the necessary examinations needed to obtain a valid and highly desirable diploma.

In his 2002 Quand le Quartier Latin accueillait la jeunesse étudiante du monde (1814-1914), the French historian Pierre Moulinier noted that in

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tury. The author distinguished four phases of this process during 1833-1889; the first phase (1833-1846) marked the beginning of recruit-ment. During this period, to come to Paris to study was still an adventure, an outstanding achievement. There was a total of 22 “Oriental” doctors in 14 years. The second phase (1847-1865) marked an increase in the number of de-grees, reaching the number of 77 doctors in 14 years. The third phase (1866-1877) recalled the previous high growth until 1874, being followed by a rapid decrease until 1877. The total number was 76 doctors in 13 years. The fourth phase (1878-1889) was characterised by a dramatic increase in the number of diplomas issued. One could count a number of 154 theses in 12 years. Thus, young doc-tors coming from the Balkans, or from the overseas, ”were no longer a curiosity but a familiar element in the halls of hospitals [in Paris]” (D. Panzac 1995: 298).

Patterns of Student MigrationsHow can student migration in Europe from the end of the nineteenth century into the early twentieth century be conceptualised for our research purposes? According to the French historian Nicole Fouché, for example, one can distinguish at least two simplified models for student migrations. Since the late nineteenth century until 1914 one can speak of a substitu-tion or improvement migration (migration de substitution ou de perfectionnement) in a pe-riod when the national university systems were non-existent, weak, or discriminated against certain ethnic and religious minorities. The elites of some Balkan countries, for instance, were entirely formed abroad, which greatly influenced the cultural and social develop-ment of the countries in question. After the Second World War a second model emerged, one termed disguised emigration (émigration déguisée) when people fled, firstly, the dis-crimination and the statutes of numerus clausus imposed by the national universities, and sec-

ondly the consequences of the Soviet revolu-tion. Victor Karady, identified two other major models for foreign students in the West. The first model described foreign students dedi-cated to obtaining a degree that allowed them to settle permanently either in their country of origin or in the host country where they stud-ied, or to adopt a strategy of permanent im-migration in another Western country of their choice. The second model included university degree holders considering their improvement stays (séjours de perfectionnement), finalised or not, with a university degree such as a Ph.D. or other postgraduate degree (V. Karady 2002). However some students, as Karady shows, came only for a short stay of one or two se-mesters, with no aim to get a university degree. In the author’s opinion, this pattern is a part of a broader strategy of itinerant studies un-dertaken in Germany or France, given the fact that the students’ presence during a semester in one country was recognised and validated by the other, so that finally, one student could obtain the desired degree by adding the re-quired number of validated semesters which allowed him or her to enrol for the final exams. It also happened that students from the Bal-kans would go to Western countries not only to study but also to affirm that they were there “symbolically,” even if for a short period of time. The logic of these trips, according to Karady, cannot be properly understood without under-standing the symbolism of “travelling to the West” among East Europeans.

Analysing patterns of migration into France during the nineteenth century, Pierre Moulinier described the more pervasive phenomenon of Francophilia and a desire for a mimesis with the Western mirage. He also used the terms of “le-gitimating cultural studies” or even of “cultural tourism” when referring to students coming from the wealthy families of Romania, Russia and other francophone countries. In conclu-sion, at this stage, we consider that, for our

marius

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research, the following analytical distinctions are relevant: a) the purpose of study trips to Paris (obtaining a first degree in medicine or migration for improvement); b) the sources of scholarship funding (State bursaries, family expenses or the students’ own income); c) the decision to return to the country of origin or to permanently remain in France; d) the social background and the socio-economic status of young medical students travelling to Paris (important differences have been described in this respect between rich students and poor students). These conceptual distinctions have enabled us to better understand the prominent features of the migration of medical students originating from the Romanian Principalities af-ter Carol Davila’s arrival in Bucharest in 1853.

Romanian Medical Students’ Migration to ParisThe first stage of systematic medical relations (as opposed to the more sporadic previous relations) between the Romanian Principali-ties and France also began with the “migra-tion” of a French doctor named Carol Davila (1828-1884) from Paris to Bucharest with the support of the then consul of France in Bucha-rest, Louis Béclard. The second stage of medical relations between the Romanian Principalities and France refers to the Romanian students sent to Paris in order to pass their final exams and to get an M.D. New regulations were issued in the Principalities during the late nineteenth century stipulating the conditions required for Romanian students to travel abroad for medi-cal licensing examinations. It was only after the famous agreement of 1857 that the first generation of four graduates was sent to Paris. In 1862 the next generation of graduates of Carol Davila’s School of Medicine also went to Paris (C. D. Severeanu 2008). The third stage is characterised by the relationships between the medical faculties of the Principalities (and after 1866 from the Kingdom of Romania) and

France. As a matter of consequence, a long history of immigration to France (especially to Paris) has been thus established for young Romanians studying medical sciences. These young people could either study entirely in France, from where they could get their degree (license) or migrate to Paris after the comple-tion of the undergraduate studies at other fac-ulties in the Balkans (Athens, Constantinople, etc.) in order to get a second degree, such as a PhD. Some of them could also travel to Paris to defend the doctoral thesis in medical sciences. This “tradition of medical migration” lasted un-til the first half of the twentieth century, so the number of Romanian students, compared with the total number of students from other Balkan countries, was very high, being based according to some authors on a “privileged re-lationship” between the two countries.

Carol Davila’s RoleShortly after his arrival in Bucharest on 13 March 1853, Carol Davila’s organisational initia-tives were directed towards the creation in the capital city of the Romanian Principalities of the following institutions dedicated to medical education: The School of Minor Surgery, situ-ated in the back yard of Spitalul Mihai Vodă; Prince Michael’s Hospital (1855); the National School of Medicine and Pharmacy (1857); and the Faculty of Medicine (1869). The extern-ship and internship were introduced in 1859 while the degree of primary physician was in-troduced in 1868. The first internship in 1859 (this generation included 12 graduates of the Bucharest medical school) was followed by the decree of 16 July 1860 issued by the Prince Alexandru Ioan Cuza. As a consequence of this decree Davila was sent to France to study the appropriate French medical legislation. He was accompanied by the first generation of students of his school that were supported to study in Paris (4 students) and Turin (2 stu-dents). From Paris, Davila brought the famous

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anatomist Alphons Lebiez, a former colleague at the Faculty of Medicine in Angers. From 1860 to 1866, as the head of the anatomical depart-ment and director of the anatomical museum, Lebiez performed a significant role in the de-velopment of anatomy at the School of Medi-cine in Bucharest.

Another significant investment Davila made while in Paris, consisted of books and modern didactic material for his school. The stake of these serious investments and competitions, following the successful and much admired model provided by the Parisian Faculty of Med-icine, was to establish meritocracy in the medical professional body from the Principalities, and to create a new tradition, a consequence of this being the replacement of the old morality with a new one entirely based on professionalism and competition. As acknowledged by his former students, one of the most important objectives Davila had in mind was to favour the young Romanian-born doctors against the older generation of practitioners lack-ing professional education, and to set criteria for competence and professional ethics.

Institutional AgreementsWith regard to the agreements between the Romanian Principalities and France, the rules of the School of Medicine were adopted by the Decree No. 1092 issued as early as 16 August 1858. The Decree No. 1788 from December 18, 1857 completed by the Decree No. 1230 from September 7, 1858, both signed by Prince Al-exandru Demetriu Ghica, Deputy Ruler (cai-macam) of the Principality of Wallachia, also played a significant role in the early phases of the establishment of medical education in the Principalities. Based on these documents, stating that the Romanian baccalaureate exam was equivalent to the corresponding exam in France and Italy, the diploma was recognised in these countries, which opened the way for the continuation and completion of university courses by Romanian students in France and Italy.

Once the problem of the legal framework had been solved an entirely new problem arose; how to fund the students to travel abroad. The majority of students were poor or from middle class families with no resources to support such an important financial effort. This is the reason why, in 1862, Davila made huge efforts to get a stipend for the first five scholarships awarded to students to travel abroad and study medi-cine. In May 1864 again he got funding for an-other scholarship, but in this case from private sources. These were followed by other schol-arships, which allowed for new departures of his students to France and Italy. Some of these students benefited from state stipends, others made use of their salary as a holiday payment, and still others travelled abroad at their own expense.

As for the rights enjoyed by these graduates of the School of Medicine in Bucharest, C. Dim-itrescu-Severeanu noted in his Memoirs that, by virtue of the decrees and regulations men-tioned earlier, former students of the Medical School returning from France and other Euro-pean countries holding an MD degree were al-lowed to pass the exam for the free practice in the Romanian Principalities. As a consequence, after several years a large number of them oc-cupied important positions in the medical hi-erarchy. Some of them, holding a doctorate in medicine, could also teach in different faculty departments not only in Romania but also in other Western European states like France and Italy. Most important though was the right and the incentive to come back to their country and build a career in some of the best hospitals and clinics, and to become founders of the medi-cal and surgical disciplines at the Faculty of Medicine in Bucharest.

ConclusionThe peculiarities of the “migratory tradition” established in the Romanian Principalities in the second half of the nineteenth century can be best conceptualised as a “substitution or

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improvement migration” or, in the formulation of Victor Karady, a migration with the purpose to obtain a diploma (V. Karady 2002). There is no way to consider what happened with this generation of medical students as ‘itinerant education’ or ‘cultural tourism’. In the Roma-nian case migration was somehow considered as a necessity by Carol Davila and other physi-cians of the time like N. Kretzulescu and Gh. Polizu. It was codified from the very beginning as a top priority, given the precarious situation of the current healthcare system, on its way towards modernisation and Europeanisation. Davila’s central idea was to create the space for young physicians with excellent degrees to gradually replace the older generation of practitioners who had no specialist training (i.e. the barbers), or had only average medical studies (magistrates, medical assistants, etc.). This process was lengthy and conducted in a succession of several phases, the first being the generation of a greater number of medical as-sistants (‘felceri’ in Romanian), followed by an increased number of health officers and phar-macists and only afterwards by physicians hav-ing received the degree of Doctor of Medicine (M.D.). Since no Romanian school of surgery or medicine and pharmacy could grant the M.D. degree, Romanian students were sent to Paris and other French cities (also to Turin, Italy) to pass the required exams and obtain the medi-cal degree. This was possible through the as-

similation of these new medical schools based in the Principalities to the medical secondary schools in France (and also, in Italy) followed by the recognition of the Romanian baccalaureate by the same countries. The number of people who went to study abroad increased gradually in the following years, so much so that by the year 1869 a total of 32 students went to univer-sity at their own expense in different cities from France and Italy in order to get their degree in medicine. A large number of young Romanian physicians benefited from the breakthroughs made possible by Carol Davila’s organisational and financial efforts.

Davila also raised the awareness in France to the needs of medical education in the Prin-cipalities and helped make the Romanian di-plomas equivalent to the French baccalaureate diploma, without which the required final level exams at the Faculty of Medicine in Paris would not have been possible. Davila’s other strategic move, the advantages of which would benefit the greatest number of young medical doctors returning from Paris, was to open to Romanian students of medicine the prospect of a long and solid career in clinical teaching and prac-tice in the best hospitals in Bucharest. There is no doubt that these professional development opportunities significantly contributed to the increased level of repatriation of Romanian students who studied medicine in Paris in the nineteenth century.

FURTHER READINGS:V. Karady, “La migration internationale d’étudiants en Europe, 1890-1940,” Actes de la recherche en sciences sociales 145 (2002):

47-60. P. Moulinier, “Les étudiants étrangers à Paris au XIXe siècle,” Organon 35 (2006): 129-142. L. Nastasă, Itinerarii spre lumea savantă. Tineri din spațiul românesc la studii în străinătate (1864-1944), Cluj-

Napoca, 2006. D. Panzac, “Les docteurs orientaux de la Faculté de médecine de Paris au XIXe siècle,” Revue du monde musulman

et de la Méditerranée 75-76 (1995): 295-303. C. D. Severeanu, Din amintirile mele (1853-1929), Bucharest, 2008.

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THE ROYAL MEDICAL COUNCIL OF GREECE, 1834-1922

George N. AntonakopoulosFaculty of Medicine, University of Thessaly, Larissa Greece

welcomed by the Greek people, who neverthe-less dethroned him thirty years later in 1862. He brought in several Bavarian bureaucrats and scholars to organize his new country. Unfortu-nately, the sheer number and complexity of the problems they faced, combined with their own inflexible attitudes, made their task almost im-possible. Some progress, however, was made in public health, hygiene, medical education and the construction of infrastructure.

The Ivil and Military hospitals were built in Athens, which became the capital in 1834. In 1835 the Medical Society of Athens was founded and the following year Aesculapius, the first Greek medical journal appeared; the Medical School of the National University was established in 1837, while the Royal Medical Council was established by the Act of 24 July 1834 (see fig. 1).

Its main tasks were to tackle the numerous health and hygiene problems, to examine doc-tors, surgeons, dentists, vets, pharmacists and midwives and to issue licenses to practice. In addition it would provide forensic opinions and advise the Ministry of Internal Affairs on matters of public health and hygiene. The first members of the Royal Medical Council ap-pointed by the King were Carl August Wibmer (president), Bernard Roeser (vice president), Anastasios Leukias, Ioannis Nicolaides- Le-vadieus, Panagiotis Hippitis, Mann, Heinrich Treiber, Demetrios Mavrocordatos and Xavier Landerer.

Landerer, a brilliant pharmacologist who wrote the first Greek textbooks of pharmacol-ogy and toxicology, also examined in detail the mineral and spring waters of Greece. More

In 1828 the newly founded Greek State consist-ed of the Peloponnese peninsula, the Roumeli district (including Attica), the large island of Euboea (Negreponte), and several small Ae-gean islands. The population, crushed by the harsh conditions that prevailed during the War of Independence, lived mainly in small villages dispersed throughout the hilly and mountain-ous parts of the country. The few flat, low-lying regions such as the Copais district, although fertile were extremely unhealthy and almost uninhabitable due to malaria. The countryside, especially that of the Peloponnese, lay in waste, having been burnt by the troops of Ibrahim Pa-sha. Poverty and disease were widespread and mortality, particularly among the numerous or-phan children, was extremely high. The newly liberated population, instead of increasing, was in decline. Outbreaks of severe epidemic diseases were frequent. Spyrocolon, a kind of endemic syphilis, was also taking its toll, while blindness due to ophthalmia trachomatis was frequent.

John Capodistrias, the first governor of Greece, was faced with the task of trying to turn an impoverished ex-Ottoman province into an organized state while fighting out-breaks of epidemic disease as well caring for numerous orphans with the help of the Greek Orthodox Church. He tried to install a sewage system in Nauplion, the capital at the time, and to supply it with clean water. Unfortunately the sons of the chieftain of the Mani peninsula assassinated him in September 1831.

In 1832 the Great Powers appointed his suc-cessor, the young Bavarian Prince Otto. Otto became the first king of Greece and was warmly

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tional healers, druggists and midwives as well as practical exercise of the new professional doctors (Royal Act of 18 May 1835).

2) On the practice of phlebotomy (Royal Act of 30 January 1835).3) On the trade of leeches (Royal Act of 19 Feb-ruary 1836).4) On the medical recompense (Royal Act of 5 March 1835).5) On protection from epidemic disease (Royal Act of 31 December 1837).

In 1839 Wibmer, the president of the Coun-cil, left Greece and was replaced by Leukias. In 1854, during the Crimean War, French and British troops bombarded the Palace and oc-cupied Piraeus and Athens, bringing cholera with them. Despite all efforts of the Council to contain the ensuing epidemic, one tenth of the local population perished. During this time several new members were added to the Council: Andreas Anagnostakis, one of the most brilliant ophthalmologists of his era; Theodore Afentoulis professor of Pharmacology, a bril-liant academic teacher, a revolutionary, a poet and mayor of Piraeus; and Theodore Aretaios, a professor of surgery. In 1862 the law “on the establishment of mental hospitals” was passed. Unfortunately, psychiatric patients had to wait several decades before receiving the protec-tion and medical support they needed, and until quite recently treatment of the mentally ill by the Greek State and Greek society has been less than satisfactory.

In 1881, soon after the Congress of Berlin, the Great Powers placed Thessaly and a narrow strip of Epirus under Greek jurisdiction follow-ing an unsuccessful insurrection in the region in 1878. As a result of the transfer Greece ac-quired the wheat-producing area she so des-perately needed, but the newly acquired terri-tory brought the Royal Medical Council more problems to solve, as Thessaly was notoriously malarial. Furthermore, a considerable propor-tion of its population were nomadic Vlach and Saracatsan people who crossed the new border

Fig 1: The Royal Degree of Establishing the Royal Medical Council

than a century before the discovery of the an-tibiotics and the corticosteroids, these waters were extensively used with some success for the treatment of a wide spectrum of diseases. Soon after Landerer’s appointment Ioannis Bouros, professor of internal medicine at the National University Medical School, became a member of the Council and its president for many years.

Some of the edicts of the Council became law and were published in the Government Ga-zette. One of the first of these formed the basis of the Royal Act of 4 April 1835, which made small-pox vaccination compulsory. Among the other edicts of the Council were the follow-ing:

1) On the establishment of theoretical and practical school of Surgery, Pharmacology and Midwifery for the education of the tradi-

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twice a year, moving between winter shelters and summer pastures, thus increasing the inci-dence of epidemics and the spread of diseases among humans and livestock.

In 1902, Constantine Savvas, professor of microbiology at the National University was appointed Member of Council and became its president in 1908. It was a most successful choice not only because he was an excellent scientist but also because his service coincided with better understanding of the role of mi-crobes in disease and the increased availabil-ity of vaccines and drugs. Savvas was a close associate of Sir Ronald Ross, the Nobel Prize laureate who elucidated the life cycle of the plasmodium parasite. In collaboration with other members of the Anti-Malarial Society of Greece he started the campaign that eradi-cated the disease which had devastated the country. A supply of unadulterated quinine was made available, and pamphlets containing in-structions for health workers on disinfection, sterilization and anti-malarial measures were published.

Particular care was taken to immunize soldiers of the Greek Army against epidemic diseases, giving it a major advantage over its opponents and contributing to Greek victo-

ries during the Balkan Wars of 1912-1913. In 1918, the Royal Medical Council commenced the publication of the Bulletin of Hygiene. This journal featured articles by the most distin-guished Greek doctors of the early twentieth century. Its issues contain a great quantity of information, including reliable statistics and informative maps.

The most important documents of the Royal Medical Council of Greece, however, are its un-published hand-written Proceedings (see fig. 2).

These records survive in the form of bound volumes and contain a wealth of information on the following subjects:

a) Epidemics and epizootics (animal diseases), which were breaking out in Greek provinces, in other Balkan countries, and in the Near East, especially in ports. The Council was kept constantly informed by the Greek con-sulates of the main Mediterranean ports, as well of other, often remote, places about epidemics and epizootics breaking out there.

b) The measures taken by the Council to con-tain such diseases or keep them out of Greece. Special care was taken concerning the raw hides destined for tanning, noto-

Fig. 2: Example of the Royal Medi-cal Council’s Proceedings. Author’s personal collection

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cessful mission of the Royal Medical Council had come to an end.

ConclusionTo summarise:1) The Royal Medical Council of Greece was

established in 1834, a few years after the foundation of the Greek State and func-tioned until 1922.

2) Its members were among the most eminent members of the medical profession.

3) Their contribution in fighting epidemics, as well as in the immunization of the popula-tion against lethal contagious diseases was significant, considering the adverse social, cultural and financial difficulties.

4) Its publications constitute a valuable source of information.5) The surviving unpublished proceedings of

the Royal Medical Council contain a vast quantity of information not only related to the medical and social history of modern Greece but also to the history of the Balkans as a whole.

rious for spreading epidemics, especially plague.

c) The steps taken to improve the standards of hygiene throughout Greece, a very diffi-cult task, as the infrastructure was minimal and the majority of the population impov-erished and illiterate. Particular care was taken to improve the standard of hygiene in the medicinal baths, on which, later on, the tourist industry of Greece was going to be built.

d) After examinations the Council supplied pharmacists, dentists and midwives with licenses to practice, a fact that gradually re-duced the activities of practical healers and crooks, especially in the Provinces where they were overtly active.

In 1922 the public sector was reformed. It was the year of the humiliating defeat of the Greek Army in Asia Minor, as well as the abrupt and bloody end of Hellenism there. The Royal Medical Council was abolished and replaced by a rather similar organ, the High Commit-tee of Hygiene, which was answerable to the Ministry of Health. The long and largely suc-

FURTHER READINGS:Β.Π. Ρόζος: Αι πρώται εν Ελλάδι μέριμναι περί της Δημοσίας Υγιεινής, της Ιατρικής Αντιλήψεως και της Κοινωνικής

Προνοίας (1821-1862). Αθήναι, 1976.Υγειονομικόν Δελτίον Ιατροσυνεδρίου. Έτος πρώτον 1917. Εν Αθήναις, 1918.

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HYGIENE AND FOOD REGULATIONS IN PIRAEUS, 1835-1914

Lydia Sapounaki-DracakiPanteion University, Athens, Greece

The newly established Greek state adopted the institutional framework for public health from abroad. The system was monitored by the state and structured in three hierarchical levels. The Health Department, a special branch created by the Ministry of the Interior, was responsible for the prevention of outside threats and city hygiene (water system, foodstuffs, markets, slaughterhouses, sewer system, etc.) and was supervised either by municipalities or prefec-tures according to level.

At the beginning of the twentieth century health legislation and health services were in-adequate. However, doctors, hygienists and in general people involved in the field of health kept on promoting initiatives, in order to reor-ganize the system of public health. The Greek state tried to improve the public health by monitoring disease, food and construction sites (health police, market police and construction police). The police and the Town Hall had to supervise the sanitation of the food market, to remind buyers and vendors of the health ordinances, to impose fines on violators, and to eliminate anything harmful or hazardous to health.

The first clauses of the Decree for the Mar-ket Inspection Police (1835) refer to prices by weight, bread quality and bakers’ profession. Bakers had to produce good bread, beneficial to health, and in case of violation of hygiene rules they were threatened with prosecution. Municipalities had to determine the place where meat markets should dispose of their waste. Meat from pigs infected with leprosy or scabies was not to be sold. Thus, pigs that were intended for slaughter had first to be

checked for pustules on the tongue, while after slaughter their entrails were checked. Local au-thorities were to supervise slaughterhouses for the adequacy and quality of meat; they were entitled to confiscate spoiled and diseased meat and appointed to control the sanitation of butchering, storage areas and pens. Con-sumers were also allowed to slaughter animals for their own use; however, they had to follow the health and sanitation code pertaining to professionals.

In medium-sized and large municipalities it was the Town Hall that determined the location of slaughterhouses, which had to be built out-side the town for reasons of sanitation. Namely, according to the Law for Hygienic Construction of Cities and Buildings, slaughterhouses had to be located in areas with clean water and plac-es where, as a rule, odours could be averted. Municipal slaughterhouses’ construction and operation could be financed by the municipal tax for the animals slaughtered. To this end the Police had to inspect both the markets and the storage areas frequently. If two doctors identified humidity or unhygienic conditions, the Mayor or his Deputy had to ban the sale of products or the milling as well bread pro-duction. As for dairy products, the sale of milk adulterated with water or egg yolk as well as spoiled butter or mixtures of butter with stale butter was also officially and legally prohibited; moreover heavy fines were imposed on sellers. This also applied to fishmongers who sold fish with a strong odour or adulterated with lime, or smoked dried fish that was spoiled before processing.

The Medical Inspection Service of the Min-

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istry of the Interior, a branch of the Office of Public Health, could not cope with the extent of the public health issues. For example, lax health police inspection and measures led to profiteering mainly by dairy merchants. The daily ongoing analyses of milk, butter, oil and flour, practices that were in place mainly in France, were rarely carried out. Thus, the sani-tarians recommended on the one hand obliga-tory analysis of milk threatened with penalties and on the other hand adoption of awards for the most hygienic creameries and dairy farms. As in Switzerland, emphasis had to be given to milk and cows suffering from tuberculosis. Official relevant statistics, which did not exist until the second decade of the twentieth cen-tury, were also to be established.

At the beginning of the twentieth century, Dr. Antonios Papadakis, the former head of the Department of Public Health, referred to unsafe meat and milk that spread diseases like trichi-nosis to humans. Special reference was made to poisonous meat and viral diseases of animals, such as rabies, meat smallpox, hoof-and-mouth disease, anthrax, tuberculosis, diphtheria, ty-phus, infectious pneumonia, which make meat unsuitable. Finally, Dr A. Papadakis mentioned the rotten and dangerous meat as well as un-safe milk that were responsible for scarlet fever, hoof-and mouth disease, enteritis, diphtheria, diarrhea in children, tuberculosis and cholera and recommended precautionary measures for milk. It is worth noting that he based his find-ings on similar works by French doctors and hygienists: Proust, Arnould, Langois, Brochard, and Baillière.

In 1846 the municipality of Piraeus circu-lated a regulation with clarifications about the Food Decree of 1835, according to which bakers had to produce bread from clean and high-quality flour, with potable water and to bake only as much as necessary, in order to be beneficial to health. Bread had not only to be properly weighed; its price should be equiva-lent to its quality and within the price limits

specified by the municipal authorities. After 1849 the Administrative Police issued circu-lars that interpreted and determined the food market law. The quality of the ingredients used for the making of bread was important for the health of the population, whereas the method of baking was not of great importance, since may households consumed homemade bread and ready-made bread was only sold in big cities. Thus, health efforts were mainly geared towards grain merchants, flour grinders, bakers and pasta industry, in order to avoid the use of rotten grains or grains adulterated with stones or sand. This health policing, however, did not bring about the desired results. Flour, sold to consumers, was made very often from legume powder and inappropriate mixtures. It is not surprising that neither legislation nor police circulars, nor municipal regulations referred to the protection of olive oil, since its adulteration was not profitable.

The fact that in Piraeus the areas of author-ity of the authorities often overlapped caused confusion and distress in the market. The Medi-cal Inspector (Astyiatros) should have been the person to decide on whether a product, e.g. fish, was to be confiscated as harmful to the public health, due to its scientific nature, whereas the Police Officer should only act in a supervisory role.

Piraeus’ Central SlaughterhouseAlong with the establishment of the municipal-ity of Piraeus, the structures and facilities for handling of food were organized and contin-ued to expand as long as the town was grow-ing. The municipal Market operated unofficially from 1836 with 25 shacks that the municipal-ity rented to merchants; however, the central stone municipal market and a second market were built in 1862-63 and 1868 respectively.

Although the need to create a municipal slaughterhouse arose at the beginning of the 1840s, when the municipality counted more than 2,000 residents, the first organized slaugh-

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terhouses were built many years after. The pur-chase of ten hectares beyond the borders of the city, near the cemetery, for the construction of municipal slaughterhouses was decided in 1881, whereas in 1883 was decided the con-struction of a tank for them. Credit was ob-tained for the repair of slaughterhouse build-ings and the construction of a new road that would facilitate access. However, the slaugh-terhouses that began to operate proved to be lacking in modern standards of hygiene.

In 1892, A. Metaxas, the municipal architect, sent a report to the municipality, documenting the construction of a new slaughterhouse to replace the old ones, which were hazardous and did not meet the current needs of a grow-ing city. He also proposed the co-exploitation of the Athenian slaughterhouses and those of Piraeus, in order to ensure the medical ex-amination of every single animal and better supervision of meat sellers. In an attempt to persuade the municipal council, he placed great emphasis on arguments that had already led modern states to create public slaughter-houses and abolish private ones that endan-gered public health. In public slaughterhouses every single animal was strictly examined be-fore slaughter and consumption, rotten water and entrails were eradicated, and cut meat was much better preserved. The report also stated the specifications, according to which slaugh-terhouses had to operate. They had to be lo-cated in a specific, sufficiently isolated area and have enough space for the examination of animals destined for slaughter; their skinning, disembowelling and preparation of entrails; for analysis of fat and tallow; for drying and storing of skins, but also for disinfection and removal of impurities and waste. All these jobs required a large space, continuous ventilation, compli-cated machinery and high operational costs. Slaughtering has always been a big issue for the municipal authorities; however, the main issue has never been hygiene and safeguard-ing of public health. For several reasons it was

proposed to locate slaughterhouses between Athens and Piraeus, near the railroad lines. The report stated that slaughterhouse areas should be kept clean, the municipality should secure certain amounts of free water supply, and that essential equipment for contiguous jobs af-ter slaughter should be provided. Moreover, slaughterhouses had to be connected with the railroad lines and the Railway Companies re-quired to put on two trains per day specifically for the transportation of meat. This would put an end to the transportation of slaughtered meat with viscera and entrails by cart, which led to vitiation due to high temperatures. This report also stated recommendations concern-ing the reimbursement of the investment and operation, and stressed the necessity of slaugh-ter in specific slaughterhouses and of relevant tax rate stability.

Cattle fair should be created nearby, allow-ing for the animals to be examined twice, while allowing merchants and meat sellers to avoid the expenses of preserving meat and price fluc-tuations. With regard to the rights of slaugh-ter, Metaxas compared them with those of the large slaughterhouses in Paris, Lyon, Marseilles, Rouen, Geneva, and Genoa and Budapest, the most famous slaughterhouse in Europe. It is noteworthy that in these years the cheapest slaughterhouse was located in Berlin. Prices were determined according to each slaugh-terhouse’s needs and the special conditions on the market. Nevertheless, only efficient inspec-tions could guarantee the security of revenue from tax for the animals slaughtered and safe-guarding of public health. According to sta-tistics preceding the establishment of slaugh-terhouses, inspections were insufficient even in the “civilized” countries, although “miasmic” diseases, such as anthrax, tuberculosis, leprosy, trichinosis and erysipelas could be spread. For this reason public slaughterhouses’ legislation was extremely strict and inviolable. The rel-evant German Law of 1868 was even stricter than the French one of the same year, since it

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provided severe fines, and even imprisonment. No agreement was ever concluded between the Municipality, the Company founded by Metaxas, and the investors with respect to the concession and exploitation of Piraeus’ central slaughterhouses. However, it is interesting to see what this agreement provided for. It made provisions for special burning equipment for the skinning of pigs, and separate stables for animals to be slaughtered on the same day. The Company committed itself to construct and equip chilling rooms for the preserva-tion of meat, spruce up and plant trees in the surrounding areas, but also to maintain the buildings throughout the concession period. On the other hand, the Municipality had to set up two telephone booths for the public in or-der to connect slaughterhouses by telephone to the city.

The Greek Medical Council not only had con-trol over the supreme medical supervision of municipal slaughterhouses and the cattle fair, but also appointed the resident public veteri-narian and his deputy, i.e. the slaughterhouse veterinarian. Meat sellers kept books, in which the examination of animals for sale had to be certified, otherwise fines were imposed on them until they proved they had followed po-lice ordinances on public health and sanita-tion.

The negotiations failed and soon the meat sellers in town protested against the tax on animal slaughter and refused to use slaugh-terhouses, characterizing them as totally im-proper. The Prefect required a slaughterhouses’ inspection on the spot to be carried out by the municipal committee and the municipal engi-neer. The results were disappointing. The road to the slaughterhouses was in fact a rising car-riageway, hard to pass in winter unless strewn with gravel. The lighting was by oil rather than gas; the space for the meat shops was inad-equate. The two tanks that collected rainwater for drinking and washing the animals before slaughtering were empty. There was also no

pump to bring in seawater for washing the slaughterhouses. Additionally, there was no drinking water.

In the following years priority was given to the improvement of the roadway network that led to the slaughterhouses, to the cemetery and to the repair of buildings. Works on the city slaughterhouse began in 1900: special machinery was installed to pump in seawater for the cleaning of sewers. Five years later the municipal disinfection plant operated in the surrounding area. However, the sellers were still discontented and refused to pay taxes. The Government ordered the immediate operation and improvement of related shortcomings; a veterinarian and an engineer supervised the works that were carried out. After the com-pletion of works there was clean water in the tanks, the road had been repaired, and follow-ing an agreement concluded with the Electric Company in Piraeus, there was to be electric lighting. The demands of the meat sellers had finally been met; thus, after 1910 the slaughter-houses began to operate systematically, which actually “glorified” the then Mayor of Piraeus, Dimosthenis Omiridis Skylitsis.

The Outcome: The Condition of Public Health in PiraeusFrom 1835 until 1862 the development of Pi-raeus was based mainly on its port facilities, which were used for commercial trading. From 1860 onward, the port of Piraeus began to serve the industry of the town. This new industrial function gave a fresh impulse to its develop-ment. Until at least the 1880s, public health in Piraeus was due to domestic immigration and epidemics that were caused by visiting sailors. Later, however, these circumstances played a smaller role since hygiene measures for the health of the local population became of greater importance. The causes of death in Piraeus in the last decade of the nineteenth century were almost the same as in other Eu-ropean port-cities. That is, predominantly re-

40


spiratory diseases and tuberculosis, followed by contagious diseases and digestive disorders. Many people died of gastroenteritis, which was attributed to the consumption of spoiled fruit, fish or meat; to the poor quality of food that was sold without controls by the small grocery stores of the town; to infected water occasion-ally sold by water sellers. A large number of diseases were attributed to bad conditions of public hygiene associated with the rapid growth of the city.

At the beginning of the twentieth century, the local press, referring to the hygiene mea-sures that had to be taken in order to stave off the danger of epidemic, especially to cholera, reported on the improvement of water sup-ply, sanitation and the effective maintenance of hygienic conditions in the food market. The fact that the cases of digestive disorders and especially typhus epidemic were reduced in Pi-raeus was primarily attributable to the quality of water and food. From 1899 to 1908 Piraeus

placed eighth among the twelve Greek towns and below the national average for deaths due to abdominal typhus. This was again at-tributed to the fact that municipal authorities took the necessary measures in public health and hygiene.

Public health policy in Piraeus had an ad-hoc character; epidemics acted as powerful cata-lysts. Furthermore, The Department of Food Inspection lacked efficiency. The need of public hygiene measures in Piraeus was advocated by doctors and chemists located in Athens; however, the greatest effort at spreading the measures for the protection of foodstuffs and public awareness came from the Society of Hygiene. The fact that there was no munici-pal laboratory responsible for the analysis of foodstuffs and beverages, and that the duties of the supervising offices were often unclear, was crucial in the developing city of Piraeus. Ultimately, it was the market’s free competition that protected consumers.

FURTHER READINGS:Historical archives of the Municipality of Piraeus Minutes of the meetings of the municipal council, 1835-1914.

Folders, 1835-1914 and Reports of Accounts, 1865-1914.C. Stéphanos, “Géographie médicale,” Dictionnaire Encyclopédique des Sciences Médicales, 2nd vol., Paris, 1884,

363-581.K. Pim, and L. Sapounaki-Dracaki, “Health Care in Greece and the Netherlands in the Nineteenth Century. A

Tale of Two Cities,” Gesnerus 60 (2003): 188-219.P. Antonios, Υγιεινή, διεθνής, δημόσια και ιδιωτική. Προφυλακτικά μέτρα κατά των λοιμωδών νοσημάτων, Athens,

1900.L. Sapounaki-Dracaki, Οικονομική ανάπτυξη και κοινωνική προστασία: η γέννηση των υπηρεσιών υγείας στον

Πειραιά και το Τζάνειο νοσοκομείο, Athens, 2005.

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EDUCATING HEALTH PROFESSIONALS: THE ROLE OF ATHENS MUSEUM OF CRIMINOLOGY

G. Loutsidis, Z. Sakki , M. Stefanidou, S. Athanaselis, C. Spiliopoulou, C. Maravelias

Department of Forensic Medicine and Toxicology, School of Medicine, University of Athens, Greece

The Athens Museum of Criminology belongs to and functions in the ground of the Faculty of Medicine of the National and Kapodistrian University of Athens. Created by law 5343 of 1932, it is housed under an appropriately ar-ranged space in the building of the Labora-tory of Forensic Medicine and Toxicology at the University of Athens, and constitutes the first University museum in Greece dedicated to Criminology and to Forensic Sciences in general.

John Georgiadis (1874-1960), an avid collec-tor of criminalist evidence and paraphernalia and a distinguished Professor of Forensic Medi-cine, founded the Museum. Since 1912, and during the forty-year period that he was a full Professor of Forensic Medicine and Toxicology, he collected, organized, registered and exhib-ited heterogeneous items related to criminal acts in a very systematic manner, exhibiting caution and diligence, and providing the basis for the establishment of the Museum. His suc-cessors, Professors of Forensic Medicine and Toxicology, Gr. Catsas, C. Iliakis, G. Agioutantis, Ant. Coutselinis, C. Maravelias and M. Stefanid-ou-Loutsidou, the new director, enriched those collections in cooperation with the police au-thorities, the district Attorney authorities and the Greek army.

The Museum is a non-profit institution, providing services to the community, while its main purpose is the multi-level support of the Faculties of Medicine and Law, as well as the Police Academies, educating students and staff, and providing a concise picture of

the criminal actions committed during the late nineteenth and early twentieth centuries in Greece. It is a centre for training, research, culture, study, promotion and scientific devel-opment. The Museum’s collections record the history of crime in Greece, together with the annotation, exposition, preservation and pub-lication of criminal activity evidence.

The Museum also supports the educational task of the National and Kapodistrian University of Athens in undergraduate and postgraduate level, as well as the broader support of the sci-entific research in the relevant fields. Further-more, the Museum aims to transmit academic knowledge to the wider university community, as well as its diffusion to the whole society.

CollectionsThe Museum’s collections number more

than one thousand and five hundred items of historical value that were involved in spe-cific violent activities that took place in the provinces of Athens and in the countryside of Greece, as well as in various prisons, shedding light on the perpetrators’ personality. These are items of unique historical value. In addition, it is possible to associate these collections with events and individuals having definite roles in the history of modern Greece. The collections are divided into four categories:

Collections related to CriminologyMilitary Equipment Collection: Includes objects – evidence of criminal activities and military conflicts in the territory of Greece (see fig. 1).

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Fig. 1. Revolver of Lefaucheux 1860-1870 type, 7 mm calibre

Fig. 2. Wooden guillotine from the era after the Independence of Greece

-The Weaponry Collection, consisting of more than 500 exhibits. This is the largest of Muse-um’s collections. -The only guillotine ever used in Greece (see fig. 2)-Tools and canes-Explosives and ammunition-Military equipment. Including objects-evi-dence of criminal activities and military con-flicts in the territory of Greece. -Collection of handguns of historic value-There is a large collection of short and long barrel hand guns some of them dated back to early 18th century.-Collection of knives and swords Ritual Artefacts Collection: includes objects from sites where rituals were performedForged (counterfeit) Banknotes Collection: in-cludes banknotes and stamps from Greece and other European countries

Collections related to Forensic MedicineHuman Remains Collection: includes various human remains of great interest to researchers and scientists. The collection is divided into the following sub-collections:

Dried Specimens:

- Tattoos on human skin.- Mummies, mummified foetuses (see fig. 3), mummified hands and legs (see fig. 4), em-balmed heads of 12 bandits (early twentieth century).-Animal remains collection: It includes vari-ous dry animal remains of great interest to researchers and scientists.

Formalin Preserved Specimen:These are preserved human tissues, foetuses and neonates, some of them presenting body abnormalities from rare cases.

Objects of general Forensic Medicine interest: The collection is divided into:-Sado-masochist objects -Other objects

Models collection: Includes models of real objects, used exclusively for educational pur-poses. The collection is divided into:

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Fig. 3. A mummified foetus Fig 4. Section of left upper limb of a woman, consisting of forearm and arm, which holds a bedside lamp, responsible for death due to electrocution

-Mushroom models-Wax models of wounds and injuries concern-ing violent death cases.These models have been crafted over 70 years ago presenting with every little detail these wounds and injuries concerning all kinds of violent death i.e. homicide, suicide, accident cases and sexual transmitted diseases. These models very often are used for educational purposes.-Other models

Loops collection: Includes self-made loops for hanging in cases of suicide or homicide.

Footwear collection: Includes footwear evi-dence of accidental deaths that certify elec-trocution or falls from height.

Collection of objects of general forensic medi-cine interest

Collections related to ToxicologyDrugs of abuse collection: This particular col-lection includes samples of narcotics and hal-lucinogens, normally street samples, usually used by drug abusers.Poisoning evidentiary items collection: In-

cludes objects-evidence of poisoning casesChemicals and pharmaceuticals collection: In-cludes reagents and medicines

Collections of general interestTables collection: includes collective inspec-tion tables of criminology and other context (bullets, ropes, hair, etc.)Printed material collection: Includes various documents, in some cases connected with other museum exhibits. The collection is di-vided into:-Documents-Magazines-Photographs – draws – x-ray photographs

Museum History Collections: Objects con-nected to the Museum’s foundation and ex-pansionAs can be seen from this overview, the Athens Museum of Criminology has unique artefacts relating to the history of medicine in Greece that deserves to be preserved for future gen-erations of scholars.

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FURTHER READINGS:J. A. Bamberger, G. E. Howe, G. Wheeler, “A Variant Oddy Test Procedure for Evaluating Materials Used in Stor-

age and Display Cases,” Studies in conservation 44 (1999): 86-90.R. Boano, “The School of Palaeopathology of Turin: From the Histology of Mummified Tissues to the Monitoring

and Programmed Conservation of the Mummies of the Egyptian Museum and the Anthropology Museum,” Med Secoli 18 (2006): 831-841.

G. Thomson, The Museum Environment, 2nd edition, Oxford, 1986.

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‘THE ART OF CREATING BEAUTIFUL CHILDREN’: SOME REMARKS ON EUGENICS IN EARLY TWENTIETH-CENTURY FRANCE AND GREECE

Despina KarakatsaniUniversity of Peloponnese, Corinthos Greece

The English scientist Francis Galton, a cousin of Charles Darwin, coined the term eugenics in 1883, although there were numerous philo-sophical and medical texts that put forward theories aiming at improving man before the 1880s. This paper outlines some of these ‘pre-eugenics’ writings and concerns and analyzes their different connotations; special tribute is devoted to the French and Greek cases. Moreover, this paper probes the impact that French eugenics had on the Greek physicians by looking into the work and influence of the Greek obstetrician Moisis Moisidis, who played a crucial role in the discussion about eugenics in Greece at the beginning of the twentieth century.

The late nineteenth century witnessed, though for different reasons, a widespread belief that the human species was in various stages of deterioration and decline. Much of this pessimism came from observations in the social and political domain. British eugenicists, for instance, were concerned with the high fe-cundity and the inherited mental degeneracy of the urban working class, those character-ized or considered as paupers or the residuum. However, American eugenicists dealt mainly with the number of the mentally retarded and the feebleminded that had “swarmed” the pris-ons and asylums, attributing this situation to urbanization and industrialization. They were also deeply concerned with the genetic defi-ciencies and peculiarities of the immigrants that reached America. In Germany, eugenicists were alarmed by the high percentage of the mentally retarded, the psychotic and the psy-

chopaths, and had attempted to counter the problem. In France, on the other hand, public health measures and intervention in the con-text of child-breeding and mild eugenics were considered the most effective means to deal with racial degeneration.

For some French intellectuals and physi-cians, eugénique was synonymous with elite or good heredity, while eugénisme was introduced in 1887-8; various other suggestions included: “good birth”, “conscious procreation”, “puéricul-ture”, “human selection”, “hominiculture”. The French supporters of human improvement had difficulty in finding a single word to de-fine eugenics. Prior to the nineteenth century, the most recurrent reference was to a poem entitled Callipædia: or, the Art of Getting Beauti-ful Children, written in Latin by the physician Claude Quillet in 1655 (the second edition was entitled Pædotrophiæ or the Art of Nursing and Breeding up Children). It prescribed the rules of the progenitors’ selection: the author laid emphasis on anything that went against com-mon sense: disproportion of age, defects eas-ily detected and absence of beauty. He also highlighted the appropriate conditions for procreation: hour, season, and position of the stars, the need to take care of pregnancy and childbirth, the principles that should guide the child’s early education. Callipædia was con-sidered a work which was not limited to the procreative act, but lying within and beyond, and could help people bear beautiful children. Callipædia had been a great success: it was translated for the first time in French in 1749 and was very often discussed by eighteenth

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century authors; a case in point is Dr. Andry, whose Orthopédie was considered as a sequel to Callipædia.

In 1756, the founder of the Journal of Medi-cine, Charles Auguste Vandermonde, published the Essai sur la Manière de Perfectionner L’ Es-pèce Humaine and attempted to define medical consensus about moral decline and degenera-cy. Moving beyond moral hygiene and physical education, Vandermonde believed that sexual education could improve humanity. As he put it, “if chance can degenerate the human species, medicine {l’art} can also perfect it”. Unlike the eighteenth century writers on sexual educa-tion, Vandermonde’s work was specifically ad-dressed to those doctors and bureaucrats who were concerned with fertility as the primary agent of state power. For him, French hygiene urgently needed sexual hygiene, because luxu-ry and libertinism had exerted a bad influence on the natural characteristics and caused the degeneration of species. When he spoke of per-fecting the race, he implied that people should regain the primordial virtuous body they had lost when abandoning the state of nature. He also underlined how heredity could transmit particular diseases from parents to children and he emphasised the fact that individuals should choose their partners with an eye for height, weight, size and temperament, and that those with similar physical deformities should avoid marrying entirely. Quillet’s work was primarily addressed to potential parents who were in search of advice in order to bear good offspring. Compared to him, Vandermonde, though he proposed similar strategies, wanted to create a perfect humanity and spread the practice among breeders.

In general, doctors believed that people could regenerate society through self-assis-tance and demanded social and moral reform. The revolutionary period coincided with a new type of pre-eugenic discourse orientat-ed towards the common good. In 1799, when Bonaparte came to power, this tendency was

reinforced. Louis Joseph Marie Robert laid the foundations of a science called Mégalanthro-pogénésis. The theory and practice were laid down in his Essai, first published in 1801 and reedited in 1803. Robert presented his Essai as a totally new work although he saw the simi-larities with baroque style procreation. Howev-er, Robert was not completely concerned with the particularities of conception. He was mainly concerned to determine which elements could secure greatness the way he put it, which ac-cording to his opinion could ensure the viabil-ity of the French nation. Though he recognized that natural tendencies determined individual abilities and potential for greatness, he held that this in itself was not enough. In the second part of his plan, he stressed the importance of education and offered appropriate examples. For this reason, he recommended that big pub-lic schools be set up, one for boys and another for girls; these he named ‘Athenees’. Robert’s Megalanthropogenesis provided a plan for the reform of the ideal citizen according to medi-cal and hygienic principles. His approach went hand in hand with the pro-eugenics views and proposals of his predecessors and rendered them clearly political.

Cabanis’ physiological theories also played an important role in this discussion. He be-lieved in the basic malleability of the human or-ganism and the perfection of the human form. His work Rapports du physique et du moral de l’homme (On the relations between the physical and moral aspects of man, 1802), provided a systematic account of variables such as diet, climate, temperament, sex and age, which were considered very important for the de-velopment of individual character, talent and aptitudes. The best exploitation of these fac-tors constitutes the basis of Cabanis’ hygienic program for perfecting both the individual and the humanity as a whole. Although Cabanis is more close to an open/ended meliorist model, he underlines the difficulty to establish a clear demarcation between meliorist and fixist con-

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ceptions of the human body. Cabanis promotes a theory of human perfectibility, but he also puts limits to the degree to which the individ-ual physiological synthesis can be modified.

In 1800 Jacques Andre Millot publishes L’art de procréer les sexes a volonté in which he underlines the utility for the French nation to create his treatise on reproduction and the na-tional utility of conjugal hygiene. There had also been strong scepticism towards legisla-tion. This absolute faith in hygiene was severely undermined in the successful work of Lucas between 1847-1850 (Traite philosophique et physiologique de I’heredite naturelle). Lucas had studied the mechanisms of hereditary trans-mission and proposed practical applications. Until 1840 Robert and Millot remained the basic sources although there were also some opponents and those who were really sceptical considering this discussion a utopia.

Two more authors entered the eugenic dis-cussion, proposing practical solutions. Doctor Francis Devay, who published in 1846 his most successful Traité d’Hygiène des Familles and Al-exandre Debay, who wrote Hygiène et Physi-ologie du Marriage, reedited several times be-tween 1848 and 1888. Their writings mirrored the contradictions of the discussion concern-ing procreation. Debay spoke of calligénésie and adopted a rather pessimistic approach: the influence of bad marriages combined with a bad education was the main cause of prob-lems and misery. A better hygiene and a better procreation combined with a better education were the solution; however, the choice of the procreators, who must be callipaediques, was the most important of all factors considered. Debay linked calligenesis with calliplastie, cos-metics and orthopaedics and stressed the ne-cessity of a prenuptial certificate.

Two tendencies are then discernible in this pre-eugenic discourse during the nineteenth century. One was more directive and normative as well as more relevant to later eugenics, while the other was more pragmatic, and placed the

problem within the domestic sphere. During this period, specialists of legal medicine par-ticipated in the formulation of a discourse on the need of legislation for couples and of good offspring inside marriage. Around the end of the nineteenth century, a more coherent de-bate on this subject can be detected.

In the second half of the nineteenth century the physicians who specialised in child treat-ment or the art of birth were involved in the discussion that led to the twentieth century eugenics in France. Later these doctors formed a group under the leading eugenics figure Adolphe Pinard. Their discourse was different from those who talked about megaloanthro-pogenesis and callipaedia. They spoke of the choice of prospective mothers, the hygiene of the pregnancy and the way of raising a child. These first paediatricians – the term was coined later – were interested in taking care of the imperfect children, the product of procreation and finding the hereditary problems so as to fight pathology.

In 1859, Cantel published a book about the Hygiene of Child from conception till weaning. He, thus, opened up the new field of caring before the procreation. He was to make the link with puériculture, or the science of rais-ing the child in a hygienic and physiological way. Pinard was the one who brought back in use the term puériculture, and introduced it in the Académie de Médecine in 1895. Puéricul-ture was a plan that included medical checks conducted at three stages: in the period before procreation; during pregnancy; and during the period after birth. Despite its rapid and wide acceptance, puériculture would have been little more than a call for prenatal care and breast-feeding without its hereditarian con-notations. Pinard’s puériculture added the ele-ment of heredity – not only the producing of healthy babies – which linked the well-being of the infant not just with the mother’s health but to previous generations and those yet unborn. He first mentioned heredity in 1899

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when he spoke about the idea of puériculture before procreation. He understood heredity in neo-Lamarckian terms involving the hereditary transmission of acquired characteristics. Ac-cording to him, puériculture signified the posi-tive measures that would improve the quality of infants, stressing the negative measures to eliminate defectives.

In Greece, the views held by the obstetri-cian Moisis Moisidis ran in parallel with Pinard’s views. Moisidis was member of the Gynaeco-logical Society of Paris, of the French Eugen-ics Society and the International Institut d’ Anthropologie de Paris, director of the journal Υγεία (Health) and author of several books that popularised medical knowledge for mothers. In his speech delivered in front of the Greek Literary Society of Constantinople, on 11 De-cember 1911, he linked the research and the admiration of the beauty with the intention to create a beautiful race, though he wondered if it was ever possible to create beautiful chil-dren. He also directly referred to Pinard in order to give the following explanation: the research of knowledge related to the conservation, the maintenance and the betterment of the hu-man species. Following Pinard’s views, when he described puériculture before conception, Moisidis found similarities with ancient Greek callipaideia, which was promoted not only by doctors but also by women and was strongly connected with cosmetics. Moisidis also di-vided puériculture into three stages: before conception, during pregnancy and after birth. He justified his opinion resorting to Pinard’s assumption that the future of the race depend-ed on puériculture before conception. Moisidis also used some texts from the Review of Puéri-culture in order to consolidate his arguments about the significance of procreation and the importance of healthy progenitors and parents. Moisidis underlined that one must consider as a dishonest criminal the man or the woman who, although he or she knows the risks, gives birth to a monster or a crippled person. Finally,

Moisidis also favoured the introduction of the prenuptial certificate.

In 1934, in the midst of an intensified de-bate on eugenics, Moisidis published Eugenic Sterilization: Principles, Methods, Application, following the passing of the sterilization law in Germany. The book provided an account of the international and Greek debates on steril-ization Moisidis’ attitude towards sterilization was rather ambiguous because although he accepted the key principles of eugenics, yet he was unable to side with one of the parties involved without running the risk of confront-ing the others. Despite his initial scepticism, Moisidis sided with the moderate eugenicists advocating voluntary and remedial steriliza-tion with the assent of the persons involved, on the condition that it would contribute to combating degeneration and protecting the race.

At the end of the 1920s, Greek paediatricians linked the absence of any health policy for chil-dren, “from the mother’s womb until they enter the army,” with the risk of racial degeneration. The importance of protecting motherhood and childhood was highlighted in the debate con-cerning the prenuptial certificate. Even though most of the participants – doctors and jurists – were in favour of passing such a measure, they set out their doubts, which rested on emotional, moral and social principles. They claimed a period of time would be required to prepare public opinion in order not to abol-ish the implementation of such a measure in practice. Educating the public on their eugenic duties was considered to be the main measure that would gradually lead to a voluntary medi-cal examination of couples seeking to marry. Instead of a mandatory examination that could potentially lead to family tragedies and put the measure in ill repute, they proposed to culti-vate a sense of moral responsibility in couples intending marriage, a sense of duty to the col-lective biological capital.

In conclusion, the French Eugenics School,

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and especially the eminent French eugenicist Pinard, exerted considerable influence on the proposals put forward by the Greek paedia-tricians, Moisidis in particular. The neo-Lama-rckian heredity of puériculture was attractive to a wide array of specialists concerned with infant health and in particular to the Greek physicians, who had studied obstetrics and paediatrics in France. French eugenicists were sceptical about the imposition of sterilisation, justifying such a stance on the grounds of indi-

vidual freedom, humanism and medical ethics. Their cautious attitude towards the adoption of negative measures, shared also by Moisidis during the first two decades of the twentieth century, can be attributed to: the dispute over hereditary laws as the sole determinant of im-paired individuals; the insistence on safeguard-ing doctor/patient confidentiality, the belief in individual liberty and the dominant trend of puériculture in France and Greece during the early decades of the twentieth century.

FURTHER READINGS:D. Kevles, In the name of Eugenics. Genetics and the Uses of Human Heredity, New York, 1985).C. Promitzer, S. Trubeta and M. Turda, eds., Health, Hygiene and Eugenics in Southeastern Europe to 1945, Bu-

dapest, 2011. W. Schneider, Quality and Quantity: The Quest for Biological Regeneration in Twentieth-Century France, New

York, 1990.

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LAY NARRATIVES OF MENTAL ILLNESS AT THE DROMOKAITEIO HOSPITAL, 1900-1920

Despo Kritsotaki, Vasia LekkaUniversity of Crete, Rethymnon University of Athens, Greece

During the past decades, there has been a remarkable trend among historians to focus on people’s lived experience. This interest has also been shared by historians of medicine, particularly, since the publication of Roy Por-ter’s highly influential article entitled “The pa-tient’s View. Doing Medical History from Below” (1985). Porter succeeded in putting forward a series of important issues for the social history of medicine, including an emphasis on the ar-gument that ‘the history of healing is par excel-lence the history of doctors’ and the need for a patient-oriented history, or more precisely, ‘for a sick people’s or sufferer’s history’.

Of course, there are great difficulties with this perspective. In our view, these difficulties are by far greater when we are dealing with the lived experience of the mentally ill. Some scholars have also argued that there could not be any ‘real’ patient to study, considering the contested notion of the patient as a specific medical, social, political construct. As David Armstrong has put it, “the patient’s view is an artefact of socio-medical perception”. In fact, we argue that the role of the patient is, among other things, a reflection of social expectations and norms. However, if we try to distance our-selves from the various discourses on patients and turn our attention to their own writings, we might manage to listen to the patients’, not more authentic, but undoubtedly different, discourse on their illness and their afflictions. Within this context, we have investigated lay perceptions of mental illness, and more par-ticularly, the ways in which mental patients at the Dromokaiteio Hospital, during the period

1900-1920, experienced their illness and con-finement. Our sources include patients’ writ-ings, mainly letters, and a series of documents written chiefly by the patients’ relatives.

First, a few words about the Dromokaiteio Hospital. It was built in 1887 in Athens, follow-ing a donation from a businessman, named Zorzis Dromokaitis. Despite its private charac-ter, the institution provided some accommoda-tion for paupers. It was advertised as a modern institution, with specialised medical staff and up-to-date equipment. Nonetheless, at the be-ginning of the twentieth century, Dromokait-eio was already overcrowded and faced serious financial problems. Αs a result, its therapeutic capacity was seriously undermined and it was gradually viewed with distrust by both medical circles and the general public. However, due to the considerable lack of specialised medical institutions in Greece, Dromokaiteio continued to play an important role in the care for the mentally ill. These factors, along with its large patient population from a variety of social and economical strata, render it a significant case study for the examination of the patients’ ex-perience.

Let us now turn our attention to the patients’ writings at the Dromokaiteio Hospital, during the period 1900-1920. First of all, we should stress that our material is quite selective, since it consists only of letters that had not been sent to their recipients. Supposing that a number of letters did actually reach their destination, then a part of the patients’ correspondence is missing from our analysis. A second caveat: obviously not all patients wrote letters. For in-

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stance, women and patients from the lower so-cial strata are considerably under-represented, as their great majority was illiterate.

Patients’ letters were mainly addressing to family members. In some cases, patients wrote to the asylum’s medical superintendent, Dr. Mi-chail Gianniris. In addition, some letters were addressing to eminent people or public au-thorities, such as members of the Royal Family, the Prime Minister and the Public Prosecutor. Finally, apart from letters, there were other types of patients’ writings, such as poems or even autobiographical texts.

For the purposes of our research, patients’ writings are divided into three main, interre-lated categories. First, there are those writ-ings, where the patients are expressing their thoughts and feelings concerning their con-finement, and, quite often, they are accusing the medical and nursing staff of improper be-haviour. Second, there are writings where pa-tients are describing their relatives’ attitudes towards them. A third category consists of writ-ings that appear quite incomprehensible and delusional.

Let us begin with the first category of pa-tients’ writings; that is, those describing the experience of their confinement. The following excerpt from a letter from 1900 is quite indica-tive: “It is an urgent need to send someone to collect me, as I suffer extremely here; they let all madmen free and keep me, a sane man, confined in my room, from dawn till dusk. […] Imagine Yago that until now I have three times (forgive me) shitted on me; the secretion was wet”. The patient concluded by threatening to commit suicide if he stayed in the hospital any longer.

In another letter from 1908, the patient ad-dressed his nephew, calling him an idiot. He was very upset and cursed his nephew for not visiting. He described the conditions of his con-finement in Dromokaiteio and depicted his life in the asylum as miserable. He concluded: “I want to get out from here, I suffer and I beg of

you to come within this week and arrange for my departure”.

In fact, this was the recurrent theme in most letters. At first, the patients were depicting their life within the asylum walls as sad and unbearable. They were complaining about the poor quality and quantity of food, the unhy-gienic conditions and the lack of cigarettes and rest. More significantly, they were depicting the distress of being tied down, the insuffer-able sadness of being confined and lonely. One patient wrote that he was being deprived of life, while another considered himself as “the most unfortunate person in the world”, and a third called the hospital “Hades”. In addition, some patients likened their confinement in Dromokaiteio to the confinement of criminals in prison or of beasts in cages.

Taking this into consideration, it should not surprise us that many patients were persistent-ly asking to be discharged. They believed that their health had deteriorated due to their con-finement and their mixing with the mentally ill. There was even a patient who was stressing the need to be discharged, saying that: “the condi-tion of my health requires specialised services and care that this sanatorium does not provide”. Some could not understand why they were in a mental hospital at all, as they thought they had not been ill in the first place, while others claimed that they were wrongfully confined. They reported that they had been admitted to the hospital by fraud or force and asked for help from their family, public authorities and eminent people. Some even “filed” lawsuits against those whom they deemed responsible for their confinement. Others described their confinement and treatment as damaging not only to their physical and mental health but also to their honour. Nevertheless, we should note that some patients requested to be dis-charged on the basis that their condition had considerably improved.

Of great interest are the letters accusing the nursing staff of improper behaviour. The fol-

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lowing excerpt from a letter, dating from 1909, is quite indicative: “he put his hand upon my chest as if I were a woman [. . .] Next, as I moved away, he put his hand upon the buttons of his trousers, holding his hand upon his genitals, while he was staring at me. [. . .]. As the afore-mentioned is an act to be punished by law, I would appreciate if you could morally com-pensate me and, if you judge it more severely, I could testify the above incident to the Public Prosecutor”.

However, allegations for sexual abuse were rare. More common were letters accusing the staff of indifference, insults and ill-treatment. Some patients complained that the medical and nursing staff did not pay enough atten-tion to their troubles, that they used to open their mail, or that they were constantly insult-ing and mistreating them. Similarly, a number of patients stressed the innuendos that they were hearing from their attendants.

It is almost impossible to deduce with cer-tainty whether these complaints corresponded to reality or not. Indifference to the patients’ problems and needs was a common feature of the overcrowded asylums of the nineteenth and early twentieth centuries. We may also infer that there would have been conflicts between nursing staff and patients. As Erving Goffman has highlighted, both the staff and inmates of the so-called “total institutions” use certain codes of behaviour and language and create their own “underlife”, in order to cope with the reality and difficulties of either working or be-ing confined within an asylum. Some of the innuendos mentioned above could probably be included in this category.

In any case, even if the patients’ griev-ances stemmed from their delusional ideas, they indicate their feelings and experiences in Dromokaiteio. In our view, these letters do actually illustrate, to a certain extent, the mis-erable conditions within Dromokaiteio, as well as within most institutions and asylums, at the beginning of the twentieth century. They high-

light the great difficulties that patients usually faced in coping with their illness and in accept-ing their confinement and isolation.

Νext to these descriptions of asylum life, pa-tients’ narratives reveal many aspects of family life, at least from their own point of view. A let-ter of a 26-year-old to his father, dating from 1907, is illustrative in this sense. The patient described how his father claimed that he was mad only after he began showing disrespect towards him and after he stole some money. In another letter from 1907, a patient wrote to his father: “Devious Sir (Father)??? I answer to your last letter and I call you a devious fag and I challenge you to settle our disagreement with a pistol, if as a fag, you consider yourself insulted. Instead of the usual I worship you I express my last wish, get lost!! Skunk”!

Similar letters with abusive language were rather rare. However, many letters depict the conflicts between patients and their families. The following letter from a patient to his wife is quite illuminating: “My dear wife, Theodora, I kiss you and my beloved children. I do not know the reasons why you were forced to treat me like this and confine me within this reformatory sanatorium [...] maybe you want to take revenge on me because I treated you with roughness and I slapped you […]”. Then, he asked her to get him out of Dromokaiteio, negotiating his release: he reminded her all that he had offered to their family and promised her that, if she let him out, he would not oppose her anymore, unless she did something wrong.

From this perspective, could we actually as-sume that mental asylums like Dromokaiteio had been used as a means of isolating family members who misbehaved and diverged from established social norms? Although it is dif-ficult to give a definite answer, it appears that some patients experienced their confinement as a punishment, feeling isolated and neglect-ed. The fact that a number of patients were imploring their relatives to visit reinforces this assumption. On the other hand, some patients

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were writing in a loving tone to their relatives referring to their visits and the money, food and cigarettes they had brought them. Hence, we could infer that there was a variety of fam-ily attitudes towards the mentally ill. While some abandoned their relatives, others were supporting them, both emotionally and eco-nomically.

A third category of patients’ writings con-sists of letters, poems and other writings that appear rather incomprehensible. Some of these writings were obviously expressing the patients’ delusions and hallucinations. For in-stance, in a letter dating from 1910 the patient addressed the king of Greece, asking him to inspect the Greek nation. At the top of another text from 1920, it was written: “faith enlightens the people through worshiping from memory as the word of the ancient Latin ‘Listo’.” Then, the patient was providing a kind of table, in order to work out a mathematical problem – probably invented by him. At the end, he had written the following postscript: “whoever finds the answer, bravo”.

However, it should be stressed that incoher-ent writings were relatively few in comparison to those written in a rather lucid manner. There were even patients who wrote long texts de-scribing their life and illness in a quite coher-ent way. In addition, even writings that may seem delusional at first sight can reveal the patients’ thoughts and feelings. They can pro-vide an insight into the patients’ suffering, or they can help us detect the patients’ opinion of the medical profession and the asylum’s regime. For instance, in a letter full of threats and incomprehensible phrases we read: “a rope and gibbet are more honourable than being a medical psychologist. [...] I am not a subject of Gianniris, who says to my guardians take him on a trial basis and if he doesn’t suit you bring him back”. In any case, even if some of the patients were not always intelligible, they did find a way to express themselves. The im-portance of these writings consists exactly in

the fact that they provided an outlet to the patients’ feelings and anxieties. To some extent these letters were a cry for escape from con-finement and for return to society, be it often figuratively.

Next to the patients’ writings, there were writings by the patients’ relatives, which can be designated as ‘reports’, a term used by many of the authors. Most reports uncovered a rath-er different reality than that depicted by the asylum’s inmates, and had a common content. Family members gave ample information on the patients’ personal and family history. They reported on the patients’ physical and mental development, their habits and character and referred to alcohol consumption and previous illnesses, with a special emphasis upon sexually transmitted diseases. Moreover, family mem-bers described the alleged causes, the first signs and the course of the patients’ mental illness. Sometimes, they asked the doctor to do his best and promised to provide all the necessary information requesting in turn to be kept informed. On the whole, reports bring to the fore the willingness of the family to inform doctors about the patients’ condition. In this way, reports highlight the wide network that surrounded the mentally ill, as well as the di-versity and, more importantly, the interrelation of discourses on them.

Finally, reports furnish valuable insights into lay understandings of mental illness. They refer to heredity, accidents, sexually transmitted dis-eases, masturbation, as well as work and family problems, as the most commonly perceived causes of mental disturbance. Mental illness was usually designated in non-medical terms, such as ‘losing one’s mind’ and ‘going mad’. However, some medical terms, especially from the nineteenth century, were also used – for example, ‘persecutory mania’, ‘erotomania’ and the late nineteenth century nerve terminology, like “nervous attack” and “nervous breakdown”. Moreover, the most frequently detected signs of mental illness resembled those usually men-

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tioned by medical men: eating and sleeping problems; sadness and absent-mindedness; fears; suicidal attempts; and disruptive behav-iour. In general, the mentally ill are described as talking and behaving absurdly. This includ-ed a variety of attitudes, such as a son’s hate for his father or a monk’s interest in ancient Greek philosophy. In order to explain the fact that the patients’ relatives adopted a number of psychiatric categories and often described mental illness in a medical-like way, it is safe to assume that the asylum’s doctors, to whom the reports addressed, asked the patients’ fami-lies for specific information. On their behalf, patients’ relatives, through their encounter with medical men, had the opportunity to as-similate some medical terms and explanatory frameworks.

All in all, through this brief analysis of lay narratives at the Dromokaiteio Hospital, during the period 1900-1920, several points deserve highlighting. First, patients’ writings demon-strate the patients’ need to be heard and re-spected. The detailed – at times, even exagger-ated – depiction of asylum life reveals, above all, the desperation experienced by the asylum’s inmates. Subsequently, patients’ writings offer some insight into family attitudes towards the

mentally ill. On the one hand, one can detect signs of disdain and a trend towards their isola-tion and marginalisation. On the other hand, one can also detect signs of support and affec-tion towards the mentally ill, as well as of inter-est in their illness. In addition, although many patients appeared disappointed and angry towards their relatives, some expressed their love and gratitude towards them. Finally, our research reveals a number of common aspects between lay and medical perceptions of mental illness. Nevertheless, patients’ writings unveil a rather different reality than that presented by the established medical discourse.

It is important that historians of medicine realise the significance of exploring the world of the mentally ill. Apart from the formality and rules of any institution, historians need to dive into the patients’ unexplored, deep ocean and bring to the surface their intimate thoughts and feelings, their own lived experience. For, in order to write a social history of medicine, it is important to try to listen to the patients’ own discourse. That is, to listen to what the poet Ro-mos Philyras, himself confined at Dromokaiteio in 1927, called “a cry from my chaos, within the Madhouse, a cry from the grave, a cry of agony cracked by illness and strain”.

FURTHER READINGS:D. Armstrong, “The Patient’s View,” Social Science & Medicine 18 (1984): 737-744.F. Condrau, “The Patient’s View Meets the Clinical Gaze,” Social History of Medicine 20 (2007): 525-540.Dromokaiteio, Case Books, 1900-1920.E. Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, Garden City, N.Y.,

1961. R. Porter, “The Patient’s View. Doing Medical History from Below,” Theory and Society 14 (1985): 175-198.

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CARING FOR TB PATIENTS: THE FIGHT AGAINST TUBERCULOSIS IN EARLY TWENTIETH-CENTURY GREECE

Vassiliki TheodorouUniversity of Thrace, Alexandroupoli Greece

Tuberculosis occupies a distinct place in the social history of medicine, offering a privileged field of study in which medical theories and attempts to confront the patients’ social prob-lems intersect. Despite a plethora of studies in English and French, published in particular dur-ing the 1990s, the lack of a Greek monograph devoted to this topic, deprives us of the ability to understand, in depth, not only an impor-tant aspect of the history of public health, but also a variety of issues related to perceptions of the disease held by the wider public, together with demographic behaviour and mentalities. Based on primary and secondary sources, this contribution looks into the first efforts to man-age the disease in Greece, undertaken by the National Association against Tuberculosis and the Sotiria Sanatorium. Furthermore, it exam-ines how the transition from voluntary anti-TB agencies to state intervention took place in early twentieth-century.

The first attempt to record the disastrous effects of TB in Greece was made at the First Pan-Hellenic Medical Congress, which took place in Athens in May 1901. At the turn of the century, high mortality rates due to TB in combination with the lack of measures to ad-dress it, gave rise to growing concern among doctors. Until then, apart from a handful of beds, available in three hospitals in Athens, no particular measures had been adopted for the treatment of TB patients. The Congress’ par-ticipants condemned the state’s indifference. Vassilis Patrikios had been entrusted by the Greek Medical Council to present a paper on the progress of TB in Greece during the con-

gress and the feasibility of founding sanato-riums. Patrikios, who would later distinguish himself as an authority on the fight against TB, was the Secretary of the Greek Medical Council. He had studied medicine in Athens and Paris and as such was well-informed about current trends in the fight against TB among European medical circles. Using data on TB mortality in urban centres, collated from state statistical services and charities, Patrikios came to the conclusion that in the 1890s various forms of TB had killed at least 50,000 people, while suf-ferers “sewing the seeds of the disease far and wide”, were estimated to be around 20,000. Av-erage annual mortality was 21.48 per 10,000 inhabitants.

Nevertheless, the optimism expressed at the Congress was thwarted by the fact that while in other European countries, mortal-ity rates demonstrated a downward trend, in Greece the opposite was the case. In particular, the proportion of consumption sufferers was higher in Athens, Patra and Ermoupoli com-pared with other European and American cities accommodating greater populations. TB was responsible for 1/6 of all deaths: In Athens, the proportion was 16.85%, while in Ermoupoli it reached 18.43%, thus making TB the primary cause of death. The disease attacked especially young people. The damage to the young gen-eration was reflected in the 10% of army re-cruits excluded from conscription, due to the disease. According to Patrikios, in the 1890s TB had caused more deaths in Greece than the great epidemics – the plague, yellow fever and cholera – which had haunted Greek society for

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generations. He also stressed that the official numbers were below the real figures, since in some cases the illness went undeclared for reasons of social sensitivity and medical con-fidentiality. Patrikios reached the conclusion, widely accepted at the time among his circles, that this was a scourge, against which doctors and the state must begin a “crusade”.

The proposed precautionary measures to fight this scourge were related to the extent of medical knowledge on the nature of the illness, and the interpretation of its causes. The 1890s was the turning point as regards the finalization of medical perceptions of TB. Until the middle of the nineteenth century, the disease was addressed using the methods suggested by Hippocratic medicine. In 1882 Koch’s discovery that the disease was contagious and born of a bacterium (tubercle bacillus), marked a turn-ing point and defined the means of its treat-ment until the end of the 1940s. The fatalistic approach, deriving from the theory that the disease was hereditary, was in decline towards the end of the century – although a number of doctors still had reservations – when it was replaced by panic, once the ways in which the bacillus spread became known. Phtisiophobia replaced indifference.

Attempts to mitigate public anxiety came from the conviction that since the disease was not hereditary, it could be avoided. Vulnerabil-ity to infection played an important role and depended on such factors as: predisposition, the “soil”, physical shape, stamina, as well as living and social conditions. Whatever reduced resistance, generated susceptibility to the dis-ease: Epidemic illnesses that plagued Greece such as malaria, smallpox, measles, influenza, drink, syphilis, unhealthy dwellings, “poverty in general”, Patrikios added, concluding that “social and economic inequality was the main cause for TB”. Both the causes of the illness and its effects were social. However, accord-ing to Patrikios, the spread of the disease was

not caused by the destitute living conditions of the working class, as was the case in other densely-populated European cities, but rather due to unhealthy buildings — such as schools, factories, printing houses, tobacco-cutting fac-tories, prisons, public buildings and shops in general - where hygiene and precaution regu-lations were unknown. Another factor contrib-uting to the spread of the disease was the lack of state concern about the frequent outbreak of epidemics (influenza, smallpox, measles and whooping cough) that plagued Greece, weakening those individuals with vulnerable constitution.

In spite of the rapid spread of the disease, determined hygienists did not lose their op-timism. They all stressed that the plague was both curable and preventable, if treated in time. However, methods of treatment did not advance much in the first decades of the twentieth century. Doctors began gradually to turn their attention from treatment methods to means that strengthened the immune system; the medical community resorted to preventa-tive measures. A holistic, natural method, com-bining hygiene and dietetics, was acclaimed as the means of prevention and cure, par ex-cellence, combined with a healthy diet, air treatment, disinfection, rest and an easy and moral life constituted the means of treatment. Adopting the triptych detection-precaution-isolation, most European countries founded sanatoriums for the working class, based on the Brehmer and Detwiller model, and estab-lished a network of dispensaries to identify suspicious cases and educate the sufferers.

Patrikios placed particular emphasis on the latter. Informed about the progress made in other European states and of the meagre means allotted to public health in Greece, he proposed that the anti-TB campaign focus on public enlightenment. The French model, fre-quently referred to by Patrikios, had turned its attention to the prevention of the disease

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both for financial and social reasons. The Con-gress, indeed, proposed a committee be set up, comprised of doctors who would establish an association to fight TB and found a public sanatorium. During the same period, the Min-istry of the Interior charged Patrikios to visit sanatoriums in Austria, Germany, Switzerland and France, in order to study their organiza-tion and propose the most appropriate model for Greece. The five-year period that followed was particularly productive in organizing the anti-TB campaign.

The National Association against Tubercu-losis, established at the end of 1901, set as its goal the dissemination and implementation of precautionary measures, the scientific study of TB, as well as the establishment of institu-tions for the care of sufferers. The Association, as described in its Articles and activities, fol-lowed the models of similar associations set up in France, in the 1890s: small dynamic teams, active around a key medical figure. Merchants, industrialists, businessmen of the diaspora and politicians were among its members and pro-vided financial support to the Association. Nev-ertheless, the majority were physicians, among them university professors who had published on issues related to TB, or doctors working in the dispensary of Athens.

As soon as it was set up, the Association un-dertook the task of enlightenment, both suffer-ers and healthy potential victims. This anti-TB campaign included translations and publica-tion of popularized books, like the one by the German Knopf, leaflets and guidelines, such as the “ten commandments” of TB, which included the main precautionary measures. Through these publications, distributed free of charge to public services, the army and schools, the Association’s physicians attempted to per-suade, teach, even to propagate the basics of medical knowledge of the time, but mainly to uproot prejudice and erroneous perceptions. Schoolchildren and soldiers were considered

to be the main groups through which the doc-tors’ message could reach lower-class fami-lies. Signposts were put up in public places, carrying the prohibition, “Do not spit on the ground”. This prohibition was bound to become the main motto of the anti-TB cause as it elo-quently summarized the doctors’ undeclared war against bacteria included in the sufferers’ sputum. The education included new rules of personal and domestic hygiene, nutrition and interpersonal relationships. This popularized material attempted to exercise total control over the behaviour of citizens and introduce a new attitude towards the body.

In 1907, assisted by the Hellenic Red Cross, the Association set up the first anti-TB dispen-sary in Athens, based on the French model of Calmette in Lyon. The dispensary was consid-ered the most appropriate means to fight the disease. Being a medical and social institution, the dispensary, carried out diagnosis, detected suspicious cases, treated, enlightened, disin-fected and provided financial assistance to the sick. In the first three years, three wings oper-ated – pathological, laryngological and micro-biological – while after 1922, radiology and TB surgery units were annexed, and in 1926, the last year of its operation, introduced the artifi-cial pneumothorax and BCG anti-consumption vaccination of newborns. The public visiting the clinic for examination underwent ‘anti-TB education’, namely was given oral and written instructions, and was provided with spittoons and disinfectants, restoratives, thermometers and medicines. The doctors saw that the homes of those consumptive who had died, be disinfected. They also offered material as-sistance, following assessment of household conditions such as coupons for soup kitchens, bed covers, pillows, underwear and mattresses, to meet basic hygienic conditions, as well as foodstuff, such as milk, butter and meat.

The Association did not create a public sanatorium. Patrikios considered that the num-

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ber of TB sufferers in need of hospitalization, amounted to between 8 and 10 thousand, a number that was an overwhelming economic burden for such an effort, with questionable results, since many sufferers were in the final stages of the sickness. Despite the fact that the doctors expressed concerns that the sanato-rium would function as an asylum, a group of middle-class ladies took the initiative to found a charitable organization, whose purpose was to collect money for the construction of the first sanatorium, nearby Athens.

In May 1902, the Articles of Association of the Sotiria Sanatorium were approved and 6 of the ladies who had funded it served on its Administration Board. It was expected that revenue for the institution would come from donations and benefactions, as well as collec-tions and medical costs paid by patients. Large donations came mainly from Greek merchants of the Diaspora and members of the Adminis-tration Board, while smaller sums, in the form of subscription, were given annually by mem-bers of the Athenian middle classes. It should be noted though that a very small number of doctors participated in this charitable orga-nization. This venture forms part of the well-known tradition of female charity work in the nineteenth century, which also informed the foundation of other hospitals and charitable institutions in Athens.

Sofia Sliman, the widow of the well-known archaeologist, played a crucial role in the foun-dation of the sanatorium. Aware of the dreadful medical care of TB sufferers in the public hos-pital in Athens, and urged by Dr M. Sakorrafos, she allocated a significant sum of money to the construction of the first wing. An area at the foot of Mountain Ymittos, a short distance from Athens, was chosen for the construction of the Sanatorium. It fulfilled the necessary sanitary conditions, ie. clean air, lack of dust, water, a small pine orchard accessibility. Continuous pine tree-planting, during the first years, com-pensated for the lack of forest in the area.

It seems that the initial goal was to set up a small sanatorium for the care of wealthy TB sufferers. The first two wings built by 1905, one funded by Sliman and the other by a Greek merchant of the Diaspora, Kyriazis, offered 40 and 15 paid beds respectively. Until 1917, the medical staff of the Sanatorium consisted of Professor of pathology, N. Makkas, and two doctors, well-known for their publications on consumption: M. Sakorrafos and Sp. Kanellis. The Sanatorium open its doors in the summer of 1905, initially for 6 patients. Over the follow-ing years their number rose to reach around 500 patients a year in 1914. In addition to hy-gienic and dietetic treatment, pneumonotho-rax operations were performed since 1914.

One of the most important problems faced by the Sanatorium’s management was its in-ability to respond to the pressure of applica-tions by patients, as many of them were poor. The need for expansion led the Board to seek resources, secured from collections, donations from wealthy Greeks of Diaspora and contribu-tions from municipalities and societies, as well as a state grant. In 1909, the 15-bed Abetio Wing, funded by a donation from Nikolas Abet from Alexandria, was built, followed in 1910, by the People’s Wing, with a donation by Ms Al. Mela, member of the Administration Board, with 20 beds to accommodate poor and needy sufferers was added.

The year 1911 saw the start of construction of the so-called Triantafyllaki Wing, with funds from a collection, providing 30 beds also for the poor and needy. In 1913 the military wing with 50 beds was added. Its construction was fund-ed by collections for the treatment of soldiers and officers who had caught the disease during the Great War. Finally, in 1914, the Spiliopoulio Wing, hosting 50 beds, was built, financed by a member of the Administration Board. With the exception of the Abetio and Spilopoulio wings, characterized by the luxury of having balconies, bathrooms and central heating, the remainder buildings were simple and did not

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meet the standards set for sanatoriums at the time. Over time, due to pressing needs, the number of poor and needy patients increased. Thus, circa 1915, 40 out of the 200 beds avail-able in the Sanatorium were provided free of charge; 25 were funded by the Municipality of Athens and around 20 by the Central Wel-fare Committee set up during the Balkan Wars, while the remainder were paid beds. Never-theless, despite the increase in the number of beds, the Sanatorium could not keep up with demand for hospitalization.

Statistics published by the Sanatorium be-tween 1905 and 1918, recorded the condition of the sick, their age, profession and place of residence. As far as geographical origin was con-cerned, the majority of the patients came from the capital and Piraeus. A significant proportion of around 30%, however, came from the prov-inces, areas under Ottoman rule and Greek colo-nies abroad. The majority were male, unmarried, aged between 15 and 30 years. As to their oc-cupation, the majority came under the category of “housework”, apparently reported by most of the women (this category represents about 1/5 of the total), followed by workers, public and pri-vate sector employees, carpenters, shoemakers, tailors, seamstresses, servants, tobacco-workers, soldiers, hatters, barbers, coffee-house owners, shoe cleaners, printers, teachers and a variety of other manual occupations. Schoolchildren of both sexes also accounted for a significant proportion of sufferers

Between 1905 and 1918, a total of 4,451 pa-tients were treated in the Sotiria Sanatorium; only 120 were cured (2.69%), while 40% were in stable condition, and the remainder died. The Administration Board was deeply concerned about the high percentage of mortality, rang-ing from 52% to 68%, which was put down to the fact that many patients resorted to the Sanatorium when they had already reached the 2nd or the 3rd stage of the illness – that is, when their condition was irreversible. However, as the institution served a dual purpose, being

at the same time a treatment centre and an asylum, it was expected that some cases would turn out badly. During the first decade of the twentieth century, the issue of reception of pa-tients in the final stages of the disease was of particular concern to the medical community and most physicians argued that they should not be hospitalized.

These discussions came to a head during World War I, when the number of victims rose significantly, as in other European countries. In Greece the causes of this increase were at-tributed both to the lack of health services in the army and the effects of war. Due to inad-equate medical examination, many TB sufferers went undetected and were recruited. When the disease broke out, others were also infected, mainly those of a weaker physical constitution. The hardships of captivity and expatriation in-creased the number of victims, who, in turn, also infected members of their families on their return home. A selection service set up on the Front, organized the expulsion of around 4,000 reserves who had been infected. Even so, the hospital infrastructure could not cope with the number of cases.

The deficiencies in hospital care of Army members led to an increase in the annual state grant to the institution and a change in op-eration regulations. The new Articles of the Association, passed in 1917, reflected the gov-ernmental involvement in the management of the institution. The new organizational infra-structure meant an increase in the scientific staff, as well as a change of the Administration Board. Only Sofia Sliman, as founder of the sanatorium, retained an honorary position. The remaining members of the Board were re-placed by professors from the Medical School, managers of health services, bank managers and other state officials. At the same time, a detailed set of rules attempted to regulate the behaviour of the patients, limiting their move-ments in the area and imposing fines on those who broke the rules. The obedience of patients

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to doctor’s orders, in relation to nutrition, rest, personal hygiene and entertainment, was laid down in great detail. These limitations and pro-hibitions reflected the authoritarian and harsh attitude towards carriers of the disease that characterized post-war public health policy in Greece and elsewhere. The parliamentary debate that preceded the passing of the 1919 law to tackle TB, when certain PM proposed negative eugenic measures, such as a ban on marriage or vasectomy, was characteristic of the strict attitude towards TB sufferers.

Just as in other sectors of public health, the Great War revealed deficiencies in health and sanitation services that tackled endemic dis-eases. During the years 1918-1920 the Liberal government put forward the framework of state supervision over health legislation in the following years. This political decision reflected the influence of the views held by the doctors of the Association, expressed both in the two TB congresses they organized in 1909 and 1912

and in the annual reports of the Association. Thus, the law No 1979 of 1920 provided for the establishment of dispensaries, hospitals, convalescent homes and sanatoriums in moun-tainous areas. Complementary laws made pro-vision for doctors to be sent “for specialized ed-ucation in TB treatment” to Switzerland and the establishment of dispensaries in major cities. In the same spirit, in 1919, the Sotiria Sanatorium came under state control, while the govern-ment grant was raised to 800,000 drachmae per annum. The participation of the president of the Anti-TB Association in the Administra-tion Board of the sanatorium may be indicative of the state’s recognition of the contribution made by the Association to the anti-TB cause between 1900 and 1920. Although these leg-islative regulations were later modified, and deficiencies in the hospitalization and care of TB sufferers were still detected in the following years, nevertheless, state intervention signified the end of an era.

FURTHER READINGS:Proceedings of the First Congress on TB, Athens 6-10 May 1909, Athens 1909.V. Patrikios, The Sanatoria, Athens 1903.National Association against Tuberculosis. Minutes of the Association (1907-1926).Sanatorium ‘Sotiria’, Annual report for the year 1915, Athens, 1916.Κ. Katis, The “Sotiria” Hospital for the Treatment of Chest Diseases, Ph.D. thesis, Athens, 1984.V. Theodorou, “The Physicians’ Attitude towards a Social Question: The Fight against TB at the Beginning of the

20th Century,” Mnimon 24 (2002): 145-178.

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THE SOCIAL HISTORY OF PUBLIC AND PRIVATE MEDICINE IN GREECE AND THE BALKANS

Paul J WeindlingOxford Brookes University, Oxford UK

The public and private have taken diverse forms in the provision of medical care. The Balkans and Greece in their transition to modernity are no exceptions with their rich diversity of their forms of health care. Both the providers of care and the forms of care have been complex and variegated over the long term. The question arises as to what is distinctive to the various cultures and national contexts, and what inter-national models have been adapted and un-der what circumstances? The balance between public and private raises questions of the place of health in the transformation of social struc-tures and interactions with the wider world.

The Making and Remaking of Social History of MedicineThe paradigm of a social history of medicine has itself undergone radical change and re-conceptualisation. Henry Sigerist first articu-lated the idea of a social history of medicine in 1940, although he had a long-standing inter-est in the patient rather than just the physi-cian. Sigerist tied social history to an agenda of socio-political reform – he hoped to extend not only medical and social insurance, but also the social competence of the physician. He looked admiringly at the Soviet Union in his tract of 1937 on Socialised Medicine in the Soviet Union and critically at the United States with regard to the lack of social provision of health care.

Another classic author, George Rosen, took a similar view in his History of Public Health. The physician’s role was essentially a public one, and should be involved with socialisation of

service provision. Rosen took a view of medicine as applied social science, and as concerned with the social production of health and disease. He saw public health history as concerned with the social causes of disease and of different preven-tive strategies.

Rosen was a progressive, committed to medi-cine as providing a range of socialised services. Yet his scientific progressivism was accompa-nied by a somewhat uncritical positivism as can be seen in his volume on From Medical Police to Social Medicine. Here, he regarded eugenics as part of social medicine both positively and positivistically, and from a non-racial viewpoint. Rosen was certainly open to economic and so-ciological approaches; yet he subordinated these to his medical interests - so that we re-main within the medical history of medicine. This idea of the doctor as a social leader can already be seen in Sigerist’s idea of the great physician. The physician was an inspirational and charismatic figure. Indeed, Sigerist appears at one stage to have taken a Nietzschean view of the physician as an agent of modernity. His-tory of medicine was the basis for planning for the future.

The question arises as to the place of the patient in this historiography. Already in the late 1920s another radical historian – like Si-gerist associated with the pioneering Leipzig Institute of the history of medicine. In 1932 Erwin Ackerknecht wrote in his pioneering and critical analysis of famine fever in Upper Silesia in 1848, “the patient is mute” (in its original Ger-man “Der Patient bleibt stumm”). Ackerknecht provided a critique of the liberal and progres-

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sive–minded physician Rudolf Virchow. Siger-ist in 1929 had already written insightfully on “the special position of the sick”. Here are the origins of the history of the patient.

Yet in other ways today’s social history of medicine would look critically at the values of such founding fathers of the social history of medicine as Sigerist, Ackerknecht and Rosen. Today’s research is in a very different paradigm, and appraises critically the modernist value structures of the 1940s and 50s. There were blind spots as regards gender, medical science, service provision and culture. The whole ten-or was expert-driven and positivistic. Science was presumed to be a force for enlightenment, rather than potentially two-edged. Social con-structionism and prosopography offered new ways forward in terms of looking at how social interests were constituted. This would translate into studies of the distribution and types of medical practice in any period.

Britain became a crystallisation point in the developing of a new social history of medicine from the mid 1970s onwards. The initial spur was the ending of the Medical Officer of Health, and a desire of public health professionals to document their achievements. In this sense this represented a continuing of the Sigerist-Rosen agenda of social history as advancing socialisation of health services. It also repre-sented an historical approach to problems of social administration as adopted by Richard Titmuss and by his collaborator and successor at the London School of Economics, Brian Abel-Smith, who published books on Hospitals and Nursing, and had a global interest in develop-ing health services studying numerous countries and contexts.

The sustained argument for what has been called “unified medical services” has continued to dominate the subject. This developed into studies of service provision and social inequali-ties. Yet there was also a broadening of histori-cal approaches with the dismantling of public health structures with the shift to social services

and social work. Thomas McKeown (in his ‘A So-ciological Approach to the History of Medicine’ (the Inaugural Lecture on 8 May 1971 of the So-ciety for the Social History of Medicine) took up Sigerist’s theme of planning for the future. He argued for an operational approach, taking up issues confronting medicine today.

Historians urged the use of the values and techniques of the new social history. But what sort of social history was to emerge? This was the age of E. P. Thompson and the take-off of a populist approach to history. An immense polar-ity emerged between socially engaged visions of social history, and scientifically objective for-mulas. More academic and detached, the Cam-bridge Group for the History of Population and Social Structure came to exert an increasing influence with statistical models of population dynamics. Charles Webster at the Oxford Well-come Unit (where the author also worked) pio-neered the shift away from the physician to the “medical practitioner”. Roy Porter and others supported this new approach. Here one finds a wide diversity. Clearly people liked choice and would shop around. The study of every-day medical practice opened new historical horizons.

These perspectives would open the way to a cultural highly diverse cultural anthropology of health. Clearly such locations as a Greek is-land would be ideal for historical and culturally sensitive research. There is a long tradition of health and religion in Greece. At the confer-ence Andrew Wear highlighted the role of the priest, and health as a religious discourse. There are rich possibilities for such research. Clearly, it is necessary to widen our ideas of the Renaissance medicine and the classical tradi-tion. Sigerist recognised the value of health in classical Greece. Given the multiplicity of cultural influences in South East Europe, not least the Byzantine and the Venetian, a broader view of the medieval and Renaissance periods is necessary, and to see these beyond that of a transition to modern values.

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A wider cross-cultural view is also required. At times Western philanthropy and medicine intervene. One might see this with the Ser-bian Child Welfare Association at the close of the First World War, which was important in shaping the preventive medical activities of the Milbank Memorial Fund. Similarly the Croatian Andrija Stampar was an international public health figure. Edwardian philanthropy showed a remarkable dynamism with the move of Muriel Paget from the East End of London to Eastern Europe, where she worked in such locations as Romania.

Yet this was a two-way process. The Croatian Andrija Stampar developed the health clinic known as a Zadruga, which was to be managed by the local lay representatives. The transfer of this model for rural health was taken up by the Rockefeller Foundation and the Milbank Memorial Fund-sponsored Mass Literacy Move-ment of Jimmy Yen at Ding Hsien in China. This example shows how the Balkans has a wider significance when seen internationally. Neither localised nor detached, social history of medi-cine reveals a rich cultural variety of forms of both public and private health care.

FURTHER READINGS: G. Rosen, A History of Public Health, Baltimore, 1993.Henry Sigerist, ‘The Social History of Medicine’, The Western Journal of Surgery, Obstetrics and Gynaecology

(1940): 715-722.P. Weindling, “Research Methods and Sources,” in Information Sources in the History of Science and Medicine,

London, 1983, 173-194.Idem, “American Foundations and Internationalizing of Public Health,” in Murard, Solomon and Zylberman, eds.,

Shifting Boundaries of Public Heath. Europe in the Twentieth Century, Rochester, 2008, 63-86.