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Female patients, patrons and practitioners

In in the medieval Islamic world

 

– Written by Peter E. Pormann, UK

 

Women constitute roughly half the population. This is true now as it must have been during the heyday of the Islamic medieval period. The sources from this time, however, whether medical writings, histories or works of literature, were mostly written by men, for men. Male doctors sometimes even vilified women and put them into the same category as charlatans, the proverbial ‘medical others’. It is therefore not surprising that the woman’s voice only reaches us faintly across the centuries. And yet, by combining a range of variegated sources, we can tell an interesting tale of how women sponsored healthcare as patrons, how they provided medical care in various roles and how they received treatment.

 

FEMALE PATRONS

Patronage played a powerful role in the provision of health services. In ‘Abbasid times, caliphs, viziers and other high-ranking officials sponsored the building of hospitals, the digging of wells and in one case even the improvement of access to medical services in prisons and remote areas. It was not only men, however, who financed these charitable activities. Women occasionally rose to some prominence in the palaces of the powerful. For instance, Khayruzan (d. 789) and Zubayda (d. ca. 831), mother and wife, respectively, of the caliph Harun al-Rashid (r. 787-809), had wells and drinking fountains set up in Mecca and Medina. Shuja‘, the mother of the caliph al-Mutawakkil (r. 847-61), increased the endowment of the hospital founded by Badr al-Mu‘tadidi (d. 902), the commander-in-chief of the caliph al-Mu‘tadid (r. 892-902).

 

The Mistress

The most powerful woman in ‘Abbasid times, however, was Shaghab, the mother of the caliph al-Muqtadir (r. 908-32). Her son became caliph at the tender age of 13 and remained devoted to his mother throughout his life. She turned the harem into a separate female court that influenced the fate and fortunes of the empire. The harem stewardess, installed by Shaghab, mediated between the different parties and kept the lines of communication open. Shaghab wielded such tremendous power that she was simply called the ‘Mistress’ (al-Sayyida).

 

The Mistress also enjoyed significant income from land holdings that she obtained from her son, the caliph, and that she continued to buy up. As these holdings increased, she required her own accounting office (diwan) to administer them. This wealth enabled her to embark on a vast programme of philanthropic works. She set up a number of pious endowments (awqaf), notably to help the poor during the pilgrimage to Mecca. One of these endowments funded a hospital that she founded. At her behest, Sinan ibn Thabit (d. 931), a prominent intellectual and physician, set up the ‘Hospital of the Mistress’ (Bimaristan al-Sayyida) in the area of John’s Market (suq Yahya) on the bank of the River Tigris in Baghdad. It opened its gates on 14 June 918. The Mistress contributed to the physical well-being of the population through these acts of Islamic charity1.

 

Yet, even during her lifetime Shaghab was often vilified; the male elite simply could not abide by the idea of a woman determining the affairs of the state. In the end she met with a cruel fate. After the death of her son she was imprisoned and tortured and died shortly after her release. More generally speaking, physicians and philosophers in the medieval Islamic world regarded women as inferior, as did their Greek predecessors and their Christian contemporaries. This can be exemplified by the view expressed by a 10th century author of a text on medical anthropology, called Abu Ja‘far Ahmad ibn Abi l-Ash‘ath (d. 970). He described women as the weaker gender, saying:

 

“For the creator, great and exalted, did not intend women to have wisdom, nor to engage in arts, crafts and agriculture, nor to protect the cities and the lives [of their inhabitants]. He only intended them for the purpose of procreation; therefore, their mixture is most appropriate for reproduction and procreation2.”

 

Women were not, however, content with just producing babies. Despite their perceived biological limitations, some women such as Shaghab, the Mistress, rose to power and influence. Others practised medicine and offered medical care in various ways.

 

WOMEN PRACTITIONERS

If we peruse the histories of medicine written during the medieval Islamic period, we find very few women. For instance, in his monumental history of physicians, called Essential Information about the Classes of Physicians (‘Uyun al-anba’ fi tabaqat al-atibba’), Ibn Abi Usaybi‘a (d. 1270) only mentions one female doctor (tabiba): the legendary Zaynab, physician of the Banu Awd tribe, who is said to have treated ophthalmia. Even if women are largely absent from medical historiography, we know about them from indirect sources.

 

In pre-Islamic and early Islamic poetry, we can find examples of female carers. One warrior boasts that he has left many opponents behind who are mortally wounded and describes the scene of women trying in vain to cure them. Another warrior brags that he does not care that the wounds he inflicted make a female physician (asiya) shudder. Moreover, in the Tradition of the Prophet, the Hadith and the Sunna, we find occasional reports about female carers. In the entourage of the Prophet Muhammad, women such as Umm Qatiya or Umm Sulaym provided medical care to his male companions. Incidentally these instances then provided a precedent for medical contact between men and women in the Islamic legal tradition: provided that there was necessity (darura), men could examine women intimately and vice versa3.

 

Literature can also serve as a source. The mesopotamian judge and litterateur al-Tanukhi (d. 994) relates the episode of a man who contracted a disease that resulted in pustules on his leg. As the man is in the countryside and no male physician is available, he consults an old woman who uses magic to treat him (‘ajuz tarqi fi hadha). The old woman not only uses magic, but also applies a dressing made of myrtle and oil to the affected spot. She enjoins her male patient to leave the dressing for three days. He does as he is bidden and when he takes off the dressing, the pustules have disappeared4.

 

Male views on women practitioners

Old women such as the one mentioned by al-Tanukhi, were not always viewed with a favourable eye by their male competition. Different male authors lamented the fact that patients often sought the advice of such women in cases of medical problems. For example, Abu Bakr Muhammad ibn Zakariya’ al-Razi (d. 925) wrote a (now lost) treatise with the eloquent title: Epistle on the reason why the ignorant physicians, the common people, and the women in the cities are more successful than men of learning in treating certain diseases, and the physician’s excuse for this. Additionally, in his Treatise on the causes why most people turn away from excellent physicians towards the worst ones, only preserved in Hebrew, he repeatedly lambasted women for their incompetence and tried to persuade his readers not to consult them5.

 

Documents from later times, and especially Egypt, also show that there were some female physicians (tabiba). In one case, a papyrus preserves a letter by a mother to her daughter with medical advice; the mother writes:

 

“I had written to you, my beloved daughter, a letter before this one and sent with it a paper [cone] containing a remedy for your stomach. Write to me that you have received [it] and that my letter has reached you, that you have drunk it [sc. the remedy] and benefited from it. Write to me, so that I can be in good spirits [again], for [at the moment] I am extremely worried about you. I ask God to grant me relief6.”

 

This is a poignant testimony to the fact that many women, whether as mothers, wives, aunts or neighbours, provided medical care to their family and relations. The Christian physician Sa’id ibn al-Hasan (d. 1072), however, deplored the fact that people generally sought the counsel of their female relatives and neighbours and exclaimed that it is a wonder that anybody got cured at all. Yet this is again evidence for the fact that it was women who often provided most of what modern historians of medicine call bodywork – the basic medical care needed in so many instances.

 

All in all, however, we have very little information about these female practitioners. In Muslim Spain (al-Andalus), the great physician and surgeon al-Zahrawi (fl. ca. 1000) complained about the difficulty caused by this lack of female doctors. When discussing the surgical removal of bladder stones, he says:

 

“The treatment is indeed difficult and is hindered by a number of things. […] You will not find a woman who will expose herself to a [male] doctor if she be modest or married. […] You will not find a woman competent in this art, particularly not in surgery. […] If necessity compels you to undertake this kind of case, you should take with you a competent woman doctor. As these are very uncommon, if you are without one, then seek a eunuch doctor as a colleague or bring a midwife experienced in women’s ailments or a woman to whom you may give some instruction in this art. Have her with you and bid her to do all that you instruct7.”

 

This quotation highlights not only the rarity of fully trained female surgeons, but also the woman’s experience in being treated by a male doctor. Although we mostly do not know the details of how women treated other women and men, we possess more information about how male practitioners treated female patients.

 

FEMALE PATIENTS

Examination by male physicians

Al-Razi wrote a letter to one of his students in which he admonishes a young protégé about to embark on a high-flying career that will lead him to the palaces of the powerful. Al-Razi lays down some general guidelines as to how to behave at court, but also offers specific advice about how to interact with female patients. He says:

 

“Know, my son, that the physician ought to be gentle to people, preserve their confidences and guard their secrets, especially of those in whose service he is. Someone may suffer from a disease that he hides even from his most intimate friends and family such as his father, mother or son. They keep it secret from these close connections, while they necessarily share it with the doctor. If he treats one of the women, slave girls or slave boys, he ought to keep his glance in check and not stray past the location of the disease. The doctor Galen said in his testament to his students – and upon my life he was right – that one should surrender to God and avert one’s eyes from women endowed with beauty and good looks and abstain from touching any part of their bodies. If he wants to treat them, he should focus on the place of the proposed treatment and not let his eyes wander to the rest of her body8.”

 

Al-Razi’s advice could not be clearer – the physician should avoid any indecent behaviour when dealing with female patients. He justifies this injunction with a reference to Galen (d. ca. 217), the great Greek doctor.

 

Al-Razi observed that patients perceive some diseases as so shameful that they do not even talk about them with their closest family. Al-Tanukhi relates a story that can illustrate this point. Once, the daughter of a high-ranking official suffered from a pain in her private parts. This pain worsens over time. At first, she tells no-one, but as things get worse, her father notices that something is wrong and she confides in him. He too does not immediately seek medical help and only turns to a (male) physician when his daughter is at ‘death’s door’. The physician then first talks with the girl, taking her history. Through clever deduction in a Sherlock Holmes-like fashion, he discovers that the reason for her pain is a tick. The physician asked the father to allow him to see the spot and examine it. After some hesitation he consents to the examination, given the dire circumstances. The physician has the girl pinned down and removes the tick. She then asks that he leave immediately, as she is now well. This episode not only highlights the shame that female patients could feel when examined by male practitioners, but also the problems that the latter faced when doing so: they had to avoid any hint of impropriety, for otherwise they would have incurred the censure of the woman and her family9.

 

Case histories

A major source of how actual women were treated is al-Razi’s case histories as they are preserved in his Book of Experience (Kitab al-Tajarib). From them, it would appear that women routinely consulted male physicians. Here we find some general topics where more case histories of women than of men are related – in the case of headaches and migraine, for instance, he lists 11 female and 10 male patients and their complaints. One chapter on ailments of the womb exclusively deals with women, listing 26 cases. Sometimes, women complained about burning, pain or roughness in their private parts or about discharges (e.g. yellow liquid or just a liquid). A number of times, women consulted al-Razi because of complications after delivery. In one case, the placenta did not come out during birth, in two others the patients suffered from excessive bleeding and in another there was reduced menstruation. An excess of menstruation or the absence thereof occurs quite often. One patient had fits of raving madness like an epileptic during her periods of menstruation and another had secreted mostly watery blood. In a few cases, women sensed that their menses moved up in their body. One woman is reported as having an illness during pregnancy, whereas another suffered from constipation, leading to a pain that goes up from the belly to the back. Finally, in one case, a woman had an ulcerous swelling in her womb.

 

One issue that preoccupies patients then and now is fertility. Al-Razi discussed it in his Doubts about Galen. Basically, Galen thought that only women could be responsible for infertility. Al-Razi disagrees with Galen’s opinion:

 

“This is not true… I have seen many such men [suffering from infertility] who changed women often out of a desire to procreate, but that was of no use to them. One of them bought slave girls according to my advice, so that they would be opposite to him in mixture. I had a indefatigable neighbour with a warm and moist mixture. He went to great lengths in changing slave girls, but to no avail10.”

 

This passage is interesting for a number of reasons. It shows al-Razi critically engaging with Galen, but it also offers an interesting vignette of elite social life. Owing to his experience, al-Razi knows that some men are infertile, no matter who their partners are. The Galenic concept of opposite mixtures, however, makes rich men hope to be able to find a slave girl with whom they could have a baby.

 

CONCLUSIONS

Women faced significant difficulties as patrons and practitioners. When they rose to power like the Mistress Shaghab, they incurred the criticism of men. Likewise, as providers of healthcare, the medical elite sometimes viewed them with an unfavourable eye and resented the competition. This difficult situation was not unique to the world of Islam. After all, Galen developed a medical anthropology that partly explained women’s inferiority by their sexual organs, and doctors – among them Ibn Abi Ash‘ath – adopted these and other misogynistic Greek ideas in their conception of women. Moreover, the segregation of women could lead to a limited access to (male) medical care, as their bodies were controlled by men.

 

This somewhat bleak picture should not detract from the fact that it was women who provided the majority of bodywork – they cared for the members of their family in case of illness and some could offer efficient cures to the wider public. Many women also had access to elite male practitioners such as al-Razi. They obviously felt shame when intimate examinations became necessary, yet even these were occasionally carried out by male physicians. The literature also suggests that women consulted al-Razi and his colleagues in cases of female conditions such as those relating to menstruation and childbirth, and the same could be said for questions about lactation. Yet women also provided advice in medical matters to other women, both orally (as one can deduce from comparative anthropological studies) and in writing. In this way, a complex picture of the place of women in the medical marketplace emerges in the medieval Islamic world. Although marginalised, they could occupy such a prominent position that male doctors became quite alarmed by their female competition.

 

 

Peter Pormann M.A., M.Phil., D.Phil., F.R.A.S.

Director of the John Rylands Research Institute and Professor of Classics and Graeco-Arabic Studies

School of Arts, Languages and Cultures

University of Manchester

Manchester, UK

Contact: peter.pormann@manchester.ac.uk

 

Further Reading

1.         Peter E. Pormann. Islamic Hospitals in the Time of al-Muqtadir. Ed John Nawas In: Abbasid Studies II: Occasional Papers of the School of ‘Abbasid Studies, Leuven, 28 June - 1 July 2004. Orientalia Lovaniensia Analecta 177 (Leuven; Dudley, Mass: Peeters: 2010). p.337-82. Reprinted in Islamic Medical and Scientific Tradition, Critical Concepts in Islamic Studies.London: Routledge 2011. i. 136-78.

2.        Oxford, Bodleian Library, MS Hunt. 534, fol. 402a, lines 6-8; see Remke Kruk, ‘Ibn abi-l-Ash‘ath’s Kitab al-hayawan: a Scientific Approach to Anthropology, Dietetics and Zoological systematics’, Zeitschrift für Geschichte der arabisch-islamischen Wissenschaften, 14 (2001), 119-68; reprinted in Pormann, Islamic Medical and Scientific Tradition, ii. 342-384.

3.        Peter E. Pormann. Islamic Medicine Crosspollinated: A Multilingual and Multiconfessional Maze. In: AA Akasoy, JE Montgomery, PE Pormann eds. Islamic Crosspollinations: Interactions in the Medieval Middle East. Oxford: Oxbow 2007. p.76-91.

4.        Nadia Maria Al-Cheikh. Women’s History: A Study of al-Tanukhi. In: M Marín, R Deguilhem eds. Writing the Feminine: Women in Arab Sources.  London, New York: I. B. Tauris 2002. p.129-148, on p. 140-41.

5.        Peter E. Pormann. The Physician and the Other: Images of the Charlatan in Medieval Islam. Bulletin of the History of Medicine 79 (2005), 189-227, reprinted in Pormann, Islamic Medical and Scientific Tradition, ii. 203-39.

6.       Ed. Yusuf Raghib, Marchands d’étoffes du Fayyoum au IIIe/IXe siècle d’après leurs archives (actes et lettres), Supplément aux Annales islamologiques: cahier nos. 2, 5, 14, 16, 5 vols (Cairo: Institut français d’archéologie orientale, 1982-96), vol. 2, nº 28, lines 3-5; see Joel. L. Kraemer, ‘Women Speak for Themselves’, The Cambridge Genizah Collections: Their Contents and Significance, Cambridge University Library Genizah Series 1. Cambridge: Cambridge University Press 2002.  p.178-216.

7.        Albucasis On Surgery and Instruments. A Definitive Edition of the Arabic Text with English Translation and Commentary. MS Spink, GL Lewis eds. Berkeley/Los Angeles: University of California Press 1973. p.420-21 (translation slightly modified).

8.        Al-Razi, Risala ila Ba‘d Talamidhihi (Letter to One of his Students), ed. ‘Abd al-Latif Muhammad al-‘Abd, Akhlaq al-Tabib (The Ethics of the Physician). Cairo: Maktabat Dar al-Turath 1977.  p.27-29.

9.       Julia Bray. The Physical World and the Writer’s Eye: al-Tanukhi and Medicine. In Bray ed. Muslim Horizons: Writing and Representation in Medieval Islam. London: Routledge 2006. p.215-250, on p. 224-6; reprinted in Pormann, Islamic Medical and Scientific Tradition, i.343-80, on p.353-355.

10.     Ed. ‘Abd al-Gani, Mustafa Labib, Kitab al-Shukuk li-l-Razi (t. 320 h. / 932 m.) ‘ala kalam fadil al-’atibba’ Jalinus fi l-kutub allati nusibat ilayhi (Cairo, Dar al-Kutub wa-al-Watha’iq al-Qawmiya, al-Idara al-Markaziya li-l-Marakiz al-‘Ilmiya, Markaz Tahqiq.

 

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