2—
Response:
Establishment of the Egyptian School of Medicine

Although contemporary European observers tended to view the Egyptian School of Medicine as a hybrid growth during its early years, the institution conformed to the pattern of hospital-affiliated training centers that had become the norm in France and England by 1830.^[1] In aims and administration, however, Egypt's medical school was similar to the eighteenth-century military hospital-allied schools training officers for the armed forces of European monarchs. It resembled most closely the hospital school founded in Moscow in 1707 to serve Peter the Great's army, one of the prime instruments in his Westernizing program.^[2]

Dr. Clot had all the requisites to carry out the viceroy's mandate. The son of one of the veterans of Napoleon's army in Italy, he was a self-made man who enriched his background by drawing on several of France's medical traditions: he trained at the Hòtel-Dieu Hospital in Marseille, apprenticed himself to a barber to learn phlebotomy, studied Latin with a local priest to gain admission to the university, and won doctorates in both medicine and surgery at Montpellier, France's oldest school of medicine. Clot had a genius for organization, thorough familiarity with the successful innovations of the French military medical corps, and considerable skill in bureaucratic politicking, military or civilian. He first enlisted the cooperation of

court physicians who were close to Muhammad Ali by involving them in an advisory body that would channel his recommendations to the War Ministry with high-level endorsement. Headed by the viceroy's chief private physician, the Medical Council adopted the French model for a military medical corps and approved the establishment of a permanent military hospital near Cairo for the army training camp, another at Alexandria for the navy, and field hospitals for each regiment. The army establishment became a new model facility about 15 miles from Cairo between the villages of Khanka and Abu Zabel. Clot's design included a pharmacy, a botanical garden, and an amphitheater for lectures and demonstrations, for he was determined that the new hospital should be the site as well of the first medical school in Egypt.^[3]

Only by training Egyptian physicians could the needs of the armed forces be met, Clot wrote Muhammad Ali. "In order to be lasting, useful institutions should be national and independent of the cooperation of foreigners." He therefore proposed to give a five-year course of medical training at the new military hospital to one hundred Egyptian young men who must be proficient in Arabic and arithmetic.^[4]

The requirement that they be well versed in Arabic meant that the first students for the new medical school were almost exclusively drawn from al-Azhar, an Islamic college, and mosque schools (madrasah ). Because the principal purpose of the Islamic college was the transmission of the Koran, its language, and related religious studies, al-Azhar's curriculum had not changed essentially since the twelfth century. Arabic language, grammar, rhetoric, literature, Koranic exegesis and readings, sacred tradition, canon law, and theology were the primary subjects; studies not related to religion were logic and mathematics.^[5] The logical choice of Azharites thus seemed to Dr. Clot to dictate preparatory studies that would provide a transition from classical, tradition-oriented learning in theology and law to the spirit of critical inquiry that was held to animate Western scientific studies. Before undertaking any medical subjects, the entering class received instruction in geometry and natural sciences, emphasizing physics and astronomy to stimulate their interest in observing the natural world. The walls of the study hall were painted with geometric figures and diagrams and sketches of geographic and astronomical phenomena. A collection of natural history specimens supplemented the botanical garden in the school courtyard, and in default of apparatus that did not arrive until the course

of studies was under way, instructors improvised experiments to demonstrate basic principles of physics. Finally, to provide a medium for continuing their studies after graduation, the students plunged immediately into learning French.^[6]

At the same time, to relate their new studies to the Islamic classics and to lend legitimacy and prestige to the enterprise, the great figures of medieval Arab science were evoked. A well-known picture of the turbaned medical students watching a demonstration in the anatomical amphitheater at Abu Zabel shows the walls inscribed with the names of famous Arab scientists: Abu Musa Jaber, Ibn al-Ainy, Abu al-Qasim, Ibn Zubayr, lbn al-Faris, Ibn al-Baytar, Abu al-Faraj, and others.^[7]

After the introductory first year, the students followed a four-year medical curriculum modeled on the one in force in France at that time. The core studies were anatomy, pathology, and materia medica, progressing to increasingly advanced levels throughout the four-year course. Physiology, surgery, and therapeutics entered the curriculum in the second year. The third and fourth years introduced clinical training in internal medicine and surgery, plus hygiene, toxicology, and forensic medicine.^[8]

For teaching staff, Clot was able to draw on numerous Italian physicians and pharmacists who had staffed the Egyptian military medical corps before his arrival, as well as many of his own countrymen.^[9] Syrian Christians fluent in French or Italian as well as Arabic served as interpreters and Azharite shaykhs subsequently recast the translations of instructors' lectures in literary Arabic to serve as the first textbooks. When the question of technical terminology arose, professors, interpreters, and shaykhs agreed to adopt from the outset the Greek and Latin nomenclature standard in Europe.

To facilitate comprehension of unfamiliar subject matter, the school adopted the Lancaster method of student monitors, dividing the class into ten groups of ten, each headed by one of the brightest students, who repeated each lesson with every member of his group.^[10] Although visitors from abroad applauded this method as a European innovation, it was in fact the time-honored tutorial system of al-Azhar's student hostels (riwaq ) where good students earned spending money by coaching their colleagues studying the same legal system or compatriots from their home province.^[11]

In view of the key role played by pathology in medical studies in Europe at this time, introducing postmortem dissection was as im-

portant as breaching the language barrier. Egyptians' repugnance to mutilation of corpses was well known. It was said to be rooted in a Pharaonic belief that the individual continues to experience sensations after death, fortified by the Muslim eschatological expectation, in common with Jews and Christians, of the resurrection of the body for the last judgment. In his memoirs, Clot described dramatically how he resorted to misrepresentations, ruses, and bribes to break down resistance among students and Muslim shaykhs, but the dissections had to be carried on in secret until 1829, when one of the students attacked Clot with a knife. He treated the attack as an inconsequential interruption, he claimed, and necropsies remained unchallenged thereafter in the regular teaching routine.^[12]

Clot was equally determined to enforce what he called "unity of doctrine," to spare the students the contradictions in theory he believed plagued the medical profession in Europe. To obviate the confusion that might result from a diversity of medical opinions among the professors, he wrote, "I laid down that instruction should be consistent in theory and practice, based on the principles of the physiological doctrine." He would not tolerate mere "symptomatic" treatment.^[13] Clot's dogmatism, which may have been one of the reasons for the rapid turnover in the medical school's European staff in its early years, illustrates the adherence of European practitioners to speculative systems of physiology and pathology in the early nineteenth century.

Two of these systems, Brownism and Broussaisism, apparently were introduced into the Egyptian medical school. John Brown of England held that illness was the result of either excess tension or abnormal laxness of the nervous and vascular systems. Treatment called for remedies that would either increase tone by stimulation or lessen it by relaxing tensions. Gout, for example, was considered a condition of fiaccidity requiring stimulation: application of heat, friction, counterirritants, robust diet, and strong drink. In France, François Broussais elaborated a rival system, "physiological medicine," which made him a leader of the Paris school. Broussais's theory was ahead of his colleagues' views in rejecting the idea of specific disease entities as "ontology"; disease was not a foreign element but simply a change in function. Unfortunately, Broussais could not identify the cause of malfunction, and he fell back on an old theory of an "irritation" that spread from one organ to another by way of the sympathetic nervous system and caused generalized in-

flammation. Most diseases either started or ended as gastroenteritis; therefore, it was the key to pathology. Since disease was hyperirritation characterized by inflammation, therapeutics called for inflammation-reducing, "antiphlogistic" measures, such as the generous application of leeches to the affected area and a diet of soothing liquids.^[14]

Because citizens in Paris before sanitary reform drew their drinking water from the Seine and enteric ailments were endemic, Broussais found ample vindication for his theory in the evidence of autopsies he performed in Parisian hospitals, and it seems likely he elaborated his theory on the basis of observations at the dissecting table. Clot also must have found abundant confirmation of Broussais's fixation on gastroenteritis in his autopsies in Egypt's military hospitals. He had abandoned the "old school" Mediterranean doctrines of Montpellier when he became acquainted with the "physiological doctrine," and he remained attached to Broussaisism throughout his medical career.

Although Clot was too diplomatic to make invidious comparisons in his writings, a compatriot who had preceded him in Egypt asserted that the Italian physicians in the medical corps were "tainted with an extreme Brownism." He applauded Clot's success in enforcing physiological medicine as standard treatment in the Egyptian military hospitals.^[15] The Italian Brownists were at least partly avenged a generation later when the German pathologist, Wilhelm Griesinger, was appointed director of the medical school in 1850. Griesinger remarked with annoyance that Clot had enforced Broussaisism as a national system of medicine in the interests of "unité de la doctrine." Hence, Egyptian physicians still tended to identify all possible types of acute illness as gastroenteritis; "something like that cannot be uprooted in a couple of years," Griesinger complained.^[16]

While Clot was able to maintain a unified approach in teaching Egyptian medical students, their lives and careers were subject to government policies that evolved under the pressure of events and were often erratic and inconsistent. Although the Egyptian medical school acquired new objectives and operated under changed circumstances over a quarter century of evolution, it never lost its character as a service agency for the military establishment during Muhammad Ali's governorship.

Conscripted into a service organization for the armed forces, Egyptian medical students were subject to organizational and opera-

tional patterns that remained a permanent legacy for the nineteenth-century medical profession. Like their counterparts at Moscow's military medical academy a century earlier, Egyptian medical students were expected to finish training within a prescribed five-year curriculum. Unlike the Russians, however, who sometimes prolonged their studies to eight or ten years, the Egyptians were washed out rigorously after each annual examination. Those who failed were dismissed from the school, assigned the rank of private in the army, and transferred to orderly duty in the hospitals. The medical school was directly under the jurisdiction of the Ministry of War, and its supervisor was a Turkish army officer. Students wore army uniforms and received food, lodging, and an allowance of 100 piasters a month. They also were subject to military discipline, the Turks' time-honored punishment of bastinado, beating the soles of the feet, sometimes with disabling effect. Clot had attempted to enforce a system of fines levied on students who cut lectures, failed to prepare assignments, flunked quizzes, or were absent without leave from hospital rounds, but as soon as a sizable sum accumulated, he wrote, it was appropriated by the War Ministry.^[17] The ministry's subverting of petty funds was symptomatic of the government's serious failure to place the administrative bureaucracy on a sound fiscal basis, which could have regularized salaries and discouraged corruption. All government salaries were chronically a year or more in arrears. Moreover, the medical school and the army medical corps labored under penny-pinching bureaucratic regulation in minutest detail. The school and regimental hospitals had to request authorization from the ministry's executive council to purchase leeches, for example, or candles for the interpreters who worked on students' manuals far into the night.^[18]

Among other disadvantages, graduates of the medical school entered the army at a lower rank and salary than Europeans. A European assistant medical officer received 350 piasters a month, while an Egyptian at the same grade received 150 piasters, only 50 piasters more than his student allowance. European physicians headed each regimental medical unit, where ample staffing apparently made their responsibilities relatively light, as one French medical officer with the Egyptian army in Syria wrote: "I have a deputy and four assistants who do all the work, I have to make only one short round of an hour in the morning, and I have the rest of the day free."^[19]

Since salaries were perennially in arrears, all government physicians, including Europeans, found it necessary to seek private clientele; but the majority of Egyptians who could afford the services of a private physician were upper-level government functionaries who apparently expected to receive care from state physicians gratis. Even Clot complained that the wealthy considered him obliged to treat them free of charge because he was employed by the viceroy.^[20] Well-off Egyptians would be even more inclined to expect free treatment from the neophyte Egyptian government medics.

The greatest disadvantage for Egyptian students attached to the military in wartime was the recurring demand for personnel, which meant they were transferred to active duty before they had completed training. Those eighty students who were assigned to duty as regimental aides during the campaign in Syria, for example, later had to face charges that they were inadequately trained. Eventually, it became necessary to devise a system of continuing education and to require annual examinations for medical officers seeking qualification for promotion.^[21]

Some of the medical students in that first class also must have been casualties in the great cholera epidemic of 1831. According to Clot, he withdrew sixty of the advanced students from the medical school, issued instructions in Arabic and a supply of medicines and lancets, and assigned the young men to care for the stricken in different quarters of the city.^[22]

Since journals and letters have not come to light yet, one can only speculate on the Egyptian medical student's daily life in that historic first class. The sudden transformation from theological student at al-Azhar to medical trainee at an army hospital in the desert must have been traumatic for many. As an Azharite, the student's schedule had been unstructured and open-ended. He could return to his village as a preacher after a half dozen years of study or he could remain a theological student indefinitely, as long as his family responsibilities could bear the strain of penury. Nothing was more alien to the spirit and practice of the medical school than such a relaxed, laissez-faire attitude. In Clot's view, the task of training Egyptian physicians was a high-priority crash program, with not a moment to be wasted. He abandoned the traditional three-month summer vacation that prevailed in European schools and restricted the Egyptian students to a single month recess during Ramadan, the period of fasting, when

they would be unlikely to apply themselves strenuously to studying in any event.

To arouse a spirit of competition among the students, Clot also arranged public examinations to judge their accomplishments at the close of each academic year. Exercising his flair for the dramatic to the fullest, he invited high-ranking military officers, leading shaykhs, European consuls, and any distinguished visitors who happened to be in Egypt at the time. To lend éclat to the event, the study hall was decorated and a band was summoned from the music school. The medical students were called on to answer orally questions they drew by lot from an urn. Whenever a student gained applause from the examiners for his response to a question, the band delivered a triumphant fanfare. The examinations lasted five days and divided students into three groups according to their performance—fail, pass, and superior. Those who distinguished themselves were rewarded by a double raise in allowance. Those who failed were assigned as orderlies in the military hospitals or later joined barbers as vaccinators in the provinces.^[23]

Students who successfully completed the five-year program of studies entered the armed forces as medical officers with the rank of second lieutenant. In lieu of a diploma and as a guide to future professional conduct, Clot had translated into Arabic and presented to each graduate a copy of the version of the Hippocratic oath used at his alma mater, the Montpellier Faculty of Medicine.^[24]

Clot's efforts aimed at developing the students' esprit de corps, a sense of professionalism, and a competitive drive by psychological incentives—invocation of the great figures of medieval Islamic science, ceremonial recognition of accomplishment at public trials, the inspiring rhetoric of the Hippocratic oath, and monetary rewards for outstanding performance in competitive examinations. As the students transferred into the military medical corps, he also sought to ensure that their salaries, ranks, and prerogatives would match those of their peers in other branches of the military service, and he fought for distinctive insignia on the regulation second lieutenant's uniform.

On one point, however, Clot remained adamant: he refused to permit graduates of the medical school to assume the title "Doctor." The French officiers de santé appeared to Clot to be the appropriate model for Egypt's medical school, and its graduates were designated senior health officers in the government service, with or without an accompanying military rank.^[25]

"Egyptianization" of the Medical School

The twelve members of the class of 1832 selected to study for the doctorate in Paris were the object of special recognition; they were expected to become the nucleus of the medical school's future Egyptian teaching staff. It had long been recognized that the weakest aspects of training were transmitting instruction through the medium of interpreters and the lack of texts in the students' own language. Consequently, members of the group sent abroad in 1832 were ordered to acquire the doctor's degree, a sufficiently advanced level of accomplishment in a specialized field to enable them to teach it, and proficiency in French adequate for translating scientific works. In groups of two, the students were assigned to six areas of study that were to become their teaching specializations: natural history, physics and chemistry, pharmacy and materia medica, anatomy and physiology, pathology and internal medicine, and surgery. In Paris, Clot arranged for the students' admission to three leading hospitals and charged a French commission to hold quarterly examinations, to make appropriate modifications in their instruction, and to report their progress to the viceroy.^[26]

Five members of the group returned to join the faculty of the medical school in 1836 after receiving the doctorate; the others remained in internships or residencies in Paris hospitals an additional two years. With the addition of Egyptians to the faculty, instruction in Arabic increased, and after 1839, all courses were conducted in Arabic without interpreters serving as intermediaries.^[27] Translation and publication of textbooks in Arabic also accelerated after 1836. Between 1833 and 1840, the number of works translated rose from 12 to 24, and when Abbas succeeded Muhammad Ali as viceroy in 1849, the Egyptian staff members and Dr. D. M. Perron, director of the medical school, had translated 55 titles in anatomy, physiology, internal medicine, surgery, obstetrics, gynecology, pediatrics, and dermatology, and undertaken the collective publication of a scientific lexicon.^[28]

When the army training camp at Abu Zabel was vacated during the Syrian campaign in 1832, the military hospital's raison d'être vanished and it became necessary to transfer the medical school. Theoretically, the hospital continued to serve the garrison in Cairo, but the distance from the city made transporting seriously ill soldiers impractical. More important, the medical students no longer had

access to a large hospital for clinical training.^[29] The new military hospital, Qasr al-Ainy, located on the Nile between Bulaq and Old Cairo, was accessible to the Cairo garrison by land and by river. It also replaced Cairo's former garrison hospital, Ezbekiyah, which became the first civil hospital founded in Egypt in 400 years and played an important role in the evolution of a health care system to serve the civilian population.^[30]

It is difficult to assess contemporary European observers' judgments of the Egyptian School of Medicine, for they often were colored by an individual's biases or even the perennial Anglo-French rivalry in the Ottoman Empire personalized in a clash between antagonistic French and British nationals. European observers' partisan views of the school most often reflected their reactions to the school's founder, Dr. Clot. Muhammad Ali awarded Dr. Clot the title of "Bey" for his unflagging service during the fearsome cholera epidemic in 1831. He apparently learned to speak Arabic and adopted the exotic garb of an Ottoman higher official. Clot adjusted to Oriental-style living with such ease that he was challenged frequently to refute rumors that he had "turned Turk," that is, converted to Islam.^[31] His flamboyant personality and flair for dramatic gesture did nothing to allay the resentment and criticism generated by his autocratic drive to dominate the entire medical establishment, including the Italian-run pharmacy service and the veterinary school headed by a French rival. Even one of his compatriots who applauded his establishment of the medical school cautioned that improvement in the quality of instruction would be necessary if the school were to merit the "somewhat too brilliant" reputation claimed by its founder. Another who visited in the early years of development observed that the school's operations appeared handicapped by "imported" as well as "local jealousies." A visiting English physician was bluntly explicit: "The establishment does credit to Clot-Bey," he said, "however much envious Franks may sneer at his crimson trowsers [sic ] and red morocco boots."^[32]

The single issue that drew the sharpest criticism from outsiders was nationalization of the school—adopting Arabic as the language of instruction and replacing foreign faculty members with Egyptians. The appearance of Egyptian faculty only ten years after the school's foundation caused some observers to question whether it was possible to create an Egyptian School of Medicine taught by Egyptians. The Russian consul general was unequivocal in his negative judgment.

The medical school left more to be desired than any of the schools established because it was ill-conceived from the outset, he wrote:

The broad learning which may be rightfully demanded of a good physician is too far above the common intelligence of Arabs to allow any expectation of seeing them succeed in this branch of human knowledge. It might have been better perhaps to send a few distinguished students to study in the European universities [rather] than to create a medical "wash-house" [buanderie] in Egypt, for which the country cannot offer even the basic requirements.^[33]

If the diplomat was referring to the chronic lack of preparatory training for medical students, his observation was well taken. The most serious weakness in the enterprise was the failure to create any system of general education in Egypt from which medical school candidates could be drawn.^[34]

In Egypt, for more than a generation, until Ismail succeeded to the khediviate in 1863, the only institutions of learning to prepare students for medical training were the Koranic schools (kuttabs ) and mosque colleges and a growing number of private schools established for Christian communities.^[35] But the Russian consul general's comment probably reflected the educated upper-class European's view that only training in the Greek and Latin classics could fit a young man to undertake medical studies. Most European physicians who traveled in Egypt, as well as diplomats, were well-to-do gentlemen with a traditional humanistic education. In Germany, graduates of secondary schools that emphasized instruction in the natural sciences rather than the classics were still denied admission to medical schools as late as 1879. The nineteenth-century Viennese historian of medical education, Theodor Puschmann, declared unequivocally that nonclassical gymnasium students were excluded from medical school because the medical profession was concerned to preserve its elevated social position.^[36]

It would take time for even his own countrymen to accept the Egyptian "homegrown" physician. And at mid-nineteenth century, the most generous judgment to be expected from an outsider was exemplified by a visitor who found the Egyptian replacements for European faculty "much too hasty"; nevertheless, he conceded that "several of these professors are demonstrating themselves to be not completely beneath their task."^[37]

In addition to their medical studies and clinical training, graduates

of the Egyptian School of Medicine mastered French, translated technical literature, pursued research in health-related subjects, and assumed teaching and administrative responsibilities after their return to the school. Were they indeed handicapped by their earlier education at al-Azhar, as critics of the school have claimed? It should be remembered that the clinical training that was becoming normative in the formation of physicians was as new a departure in Europe as it was in Egypt. While Bichat was narrowing the focus of pathology studies from organs to tissues, his colleague in Paris, Pinel, was following a more familiar line of investigation, attempting to create a meganosology by classifying all diseases according to symptoms. In this premicroscopic era when natural science studies were still largely taxonomic, students trained at al-Azhar were at no great disadvantage. Nineteenth-century Europeans who declared that Egyptian students lacked the essential background of Western learning to succeed in medical studies were referring to the classical humanities; the association of scientific method with medical training was only emerging in Western education.^[38]

Decline, Recovery, and Decline

By focusing on presumed deficiencies in the students' preparation and abilities, European critics of the School of Medicine failed to ask the appropriate and relevant question: had the school succeeded in nationalizing and institutionalizing the study of Western medicine securely enough to survive the neglect that followed the disappearance of Muhammad Ali's patronage? Continuing support was required in three essential areas, lacking which the medical school would inevitably decline: first, expansion of general education to provide a pool of student candidates with adequate preparatory training for medical school; second, consistent and substantial economic and administrative support for the school's operations; and third, regular study missions abroad to keep the medical students in touch with the accelerating pace of discoveries in the basic sciences that had direct application to medicine.

None of these requisites received sufficient attention during the nineteenth century. Under retrenchment in the 1840s and 1850s, reports of miserly payment of students and graduates, familiar during

the school's early years under the War Ministry, reappeared, and in 1848, the Ministry of Education acknowledged that the students had received no salaries for six months. The following year, the ministry attempted to rationalize medical officers' substandard salaries by reducing the rank of new appointees to government employment. Henceforth, graduates would be commissioned second lieutenants only after two additional years in aspirant or cadet rank; thus, the government was able to continue paying them only a slight increase over their student allowances for two years after graduation.^[39]

Like other minor government agencies, the School of Medicine also became rife with rivalries and intrigues, and politicization undermined its character as an educational and public service institution. However, the conventional view that Abbas Pasha subverted the school's effectiveness by replacing French leadership with German and Italian faculty is debatable. It is not clear what changes the German, Austrian, and Italian faculty members introduced into the medical school curriculum or whether the changes survived repeated reorganization. We do know that they were interested in clinical research. Griesinger, for example, during his tenure as director of the school between 1850 and 1852, rediscovered and definitively identified ancylostomiasis as the cause of the widely prevalent anemia called "Egyptian chlorosis." Theodor Bilharz, a former student who followed him to Cairo and a teaching position at the School of Medicine, became more famous for his discovery of schistosoma haematobium, the parasite that had been preying on Egyptians since Pharaonic times, causing the debilitating disease subsequently named for him, bilharziasis.^[40]

Evidently neither the German nor Italian administrators who followed Dr. Clot had his skill or taste for exercising political influence, which had enabled him to promote the School of Medicine successfully in spite of indifference or hostility among high-ranking government functionaries. Perhaps more important, at this time their native lands were politically insignificant among international powers. Unlike the French or British who could rely on the prestige and support of their respective empires' ambassadors, Italians and Germans were represented by consular officials of relatively minor states and principalities. Also, top-level support from the viceroy was crucial for the medical school's success or failure. The low point in the

school's fortunes occurred when the new viceroy, Saïd, suspended the school's operations in 1855 and dispersed all the students among various army units to serve in the Crimean War.^[41]

The following year, Clot was recalled from France to reopen the School of Medicine and to launch a second "French period" in direction. Failing health caused him to retire definitively in 1858; there was a rapid turnover in directors and the school did not regain a healthy operating level until it passed under Egyptian leadership in 1863. A French physician who visited the school in 1862 attributed its evident decline to lack of continuity and stability. The school has been reorganized three times in five years, he observed; it had not yet recovered from its closure six years earlier and had only 25 students. Parents were reluctant to send their sons to the school because medical careers held few advantages for Egyptians. As government medical officers, Egyptian physicians enjoyed no prestige and no assured vacations; nor was it possible for them to earn a living in private practice.^[42]

Shifting graduate medical students to schools other than Paris was a constructive change, however, since the French lost ground rapidly after mid-century to universities that emphasized training in the basic sciences. To Abbas's credit, of 41 students assigned to study abroad during his viceroyalty, 31 were sent to study medicine in Munich, Edinburgh, Pisa, Berlin, and Vienna. Under Saïd Pasha, an additional 30 medical graduates went abroad for specialized training, but we are told that many of them were recalled after only one year's study. At least 20 of 172 students who traveled to Europe during Ismail's khediviate were medical graduates, but the study missions have not been investigated yet.^[43]

The outlook for the School of Medicine improved considerably during Ismail's viceroyalty. Besides sponsoring graduate study missions abroad, the government provided consistent financial and administrative support, and it promoted general education. Most important was a revitalization of the Koranic village schools, the kuttab system, primarily by private initiative—Egyptian notables and shaykhs who feared the rapid expansion of schools for foreigners, often run by Christian missionaries, threatened Egypt's Islamic culture. In November 1867, the government assumed responsibility for control, reform, and expansion of the kuttab system. At the same time, it required community support, involving a commitment from

parents for their children's instruction. In provincial centers, new schools began to offer at least an intermediate level of instruction for those who had completed the elementary curriculum in the kuttabs. Thirty-three such intermediate schools arose between 1868 and 1879, and an institute to train Koranic teachers in secular subjects opened in 1872 to meet the increased demand for instructors.^[44]

Ismail followed his grandfather Muhammad Ali's example by expanding the armed forces, establishing military academies to train the officer corps, and providing them with infirmaries. He also increased career opportunities for Egyptian physicians by revitalizing the military medical corps to serve with the armed forces in campaigns to consolidate Egypt's position in Africa. During Ismail's reign, the School of Medicine enjoyed its most illustrious period under Egyptian leadership. The director of the school between 1863 and 1876 was Muhammad All al-Baqli, who had been the youngest and brightest member of the first postgraduate study mission sent to Paris in 1832. After his return, al-Baqli first became famous as a surgeon at Qasr al-Ainy hospital, but as director of the medical school, he encouraged research in all areas and launched the first Egyptian medical journal, Ya'sub al-Tibb (the Queen Bee of Medical Science). During his tenure at the school, all but one of twenty instructors were Egyptians who had received specialized training abroad.^[45] At this time, the 175 resident students received complete maintenance as well as schooling and in return they were committed to enter military service or some public health agency after graduation. Twenty "volunteers," whose parents paid their living expenses, were free to pursue private practice after graduation if they wished.

Unfortunately, the medical school's most capable director, alBaqli, died in 1876 while serving with Ismail's military forces in Abyssinia. During the financial crisis in the late 1870s, the system of state support for students was abandoned. Mandatory payment of fees caused enrollments to plummet, and by 1896, there were only 27 students in the School of Medicine. Without high-level support, the school repeatedly became an object of political intrigues and pressures. Politicization of the school's administration became so flagrant and caused such obvious decline that its takeover by British occupation authorities in 1893 was a rescue operation.^[46]

During Muhammad Ali's time, however, graduates of the medical school provided the majority of personnel in the military medical

corps for about a decade. And following demobilization, the viceroy broadened their mandate to serve the civilian population in urban and rural health centers. For, in addition to the chronic, endemic diseases that crippled the armed forces and aroused Muhammad Ali's concern initially, two devastating epidemics had claimed thousands of victims and heightened his alarm over the loss of people. We shall describe first the murderous cholera pandemic of 1831.