Upon arrival at the Qasr al-ʿAyni Hospital in Cairo in 1908, a woman from a village in Qena province in Upper Egypt related her harrowing medical saga. It began when she developed a urinary fistula (nāsur bawlī) due to prolonged labor (a urinary fistula causes urine to leak from the bladder into the vagina, resulting in deep discomfort and social ostracism of those afflicted). She had gone to a hospital in the city of Qena, capital of the province with the same name, but medical officers there sent her to Asyut. There, in the government hospital, she underwent three operations without success, whereupon doctors instructed her to go to Qasr al-ʿAyni Hospital in Cairo to see Dr. Nagib Mahfuz (1882–1974), who had developed a reputation for his surgical prowess in treating fistulas.Footnote ¹ The woman from Qena traveled by foot, begging along the way, until, exhausted, she reached the city of Minya, halfway between Asyut and Bani Suwayf. There she was sent once again to the government hospital, examined, and once again told to go to Qasr al-ʿAyni.Footnote ²

The woman from Qena finally made it to Cairo, having been on the road for four months and walked hundreds of miles, only to learn that Dr. Mahfuz was leaving for Europe the next day and would be away for two months. Exhausted and in despair, she started sobbing and screaming until she passed out. When Dr. Mahfuz came upon her, she was lying on the floor at the entry to the building. He immediately recognized the problem, for “emanating from her was the repugnant odor that ascends from those stricken by urinary fistulas.” After wheeling her to the women's ward, Mahfuz asked the midwife Zaynab Gabara to prepare her for examination, during which he ascertained that she was fit for surgery. Delaying his trip abroad, he scheduled the operation for the next day. The surgery proceeded smoothly, the fistula being sutured successfully. Two weeks later, Mahfuz removed the stitches, giving back to his patient control of her bladder and her health.Footnote ³

What do the woman from Qena, fistulas, and Dr. Nagib Mahfuz all have to do with decentering Egyptian history? On the surface, this appears to be another story from the center—Cairo—and more particularly, Qasr al-ʿAyni, the hospital at the epicenter of the history of medicine in Egypt. Yet when striving to decenter Egyptian history we should not think only in geographical terms. Rather, we need to decenter imperial capitals and their presumed monopoly over knowledge production, default male bodies, and elite voices. But in shifting our attention to local forms of knowledge production, female bodies, and ordinary people, we need to remain cognizant of the center and its power, think relationally, examine the center (or centers) in relation to the periphery (or peripheries), and look at the flows and circuits of knowledge, bodies and body parts, and silenced subjects.

To start, a decentered history can only arise from a frank look at the questions we ask and the sources we use. Researchers have long faced obstacles to entering Dar al-Wathaʾiq al-Qawmiyya, the Egyptian National Archives, or have gained access only to be restricted in the range of documents made available, the topics eligible for research, and more recently, the number of days that can be spent there.Footnote ⁴ Yet we remain bedazzled by the state archive, seeing it as the gold standard. While acknowledging the wealth of materials in Dar al-Wathaʾiq, we need at the same time to be aware of the archive's limitations, including the real limits of using state-generated documents gathered to support a specific narrative; the obstacles to conducting research (if one is lucky enough to get in), as Lucia Carminati has so ably shown; and the lack of files for the postcolonial period.Footnote ⁵ Just as historians of other Middle Eastern countries whose state archives have been destroyed, declared off limits, or never existed have had to adapt, scholars of Egyptian history must adapt and be imaginative. This means identifying other archives and artifacts when writing history, or creating our own archives, from such places as the paper markets of Azbakiyya, which Lucie Ryzova captures so well.Footnote ⁶ There also are rich published sources that have been underutilized. As a field, we have only begun to scratch the surface in analyzing the scientific books and journal articles produced by Egyptian doctors, engineers, scientists, and social scientists, with scholars such as Omnia El Shakry and Jennifer Derr leading the way.Footnote ⁷

This brings us back to Dr. Mahfuz. Born in the Delta town of Mansura, Mahfuz grew up comfortably until his father's death resulted in the loss of much of his family's wealth. Undaunted, Mahfuz followed his childhood passion for science, sparked by reading in al-Muqtataf of Charles Darwin's theories and Robert Koch's discoveries, and pursued his dream of becoming a doctor. He enrolled at the Qasr al-ʿAyni Medical School in 1898, the year the British anglicized instruction. Taking every opportunity to learn and push himself, including going to an Upper Egyptian town to track down the source of cholera during an epidemic, Mahfuz settled on an interest in gynecology and obstetrics after attending a delivery gone awry. Upon graduating, he took up an appointment in Suez for a year and then returned to Qasr al-ʿAyni to practice and produce research, in tension and in teamwork with the imperial doctors who ran the institution.Footnote ⁸ He was a prodigious practitioner, writer, and teacher, churning out works in multiple forms—scholarly articles, textbooks, a history of medical education, an atlas, and memoirs—in both Arabic and English.Footnote ⁹

Histories of modern science tend to focus on European and American practitioners and producers of knowledge, ignoring Egyptians and other Arabs. Focusing on local knowledge production decenters a paradigm that suggests that knowledge flowed in linear fashion from the imperial center to outer regions, or from foreign experts, who used Egypt as a colonial laboratory, back to the center. There are other ways of depicting these flows, whether as exchanges, sometimes intimate ones, with knowledge shared, translated, and adapted in both directions, or as circuits of knowledge, which sometimes bypassed the center and moved between peripheries.

In December 1928, twenty years after he had operated on the woman from Qena, and by then a professor of obstetrics and gynecology at the University of Cairo, Dr. Mahfuz delivered a paper on “Urinary and Recto-Vaginal Fistulae in Women” before the International Congress of Tropical Medicine and Hygiene, held in Cairo to mark the centenary celebration of the School of Medicine. His paper appeared the next year in the Journal of Obstetrics and Gynaecology of the British Empire, drawing on data from the series of surgeries which he and his colleagues had performed over twenty-one years (1907–28) at Qasr al-ʿAyni, the Coptic Hospital, and Kitchener Memorial Hospital. The woman from Qena underwent one of 234 operations on urinary fistulas that Mahfuz had performed; the paper also included another 42 surgeries by his colleagues Professor Roy Dobbin and Dr. Ahmad Shafik, bringing the total to 276.Footnote ¹⁰

Focusing, even for a moment, on fistulas serves to decenter the default male body in historical and medical writing (although men do get fistulas, usually for different reasons than women do.Footnote ¹¹) With the female body as our subject, or more precisely, certain body parts—vaginas, uteruses, bladders, urethras, and so on—we have an opportunity to listen to the stories that girls’ and women's bodies tell and hear their voices. Fistulas reveal, for example, the dangers surrounding childbirth in the early 20th century, as well as the pain accompanying early sex and surgery. Although fistulas seemed rare, they were not as rare as one might think, and fistula surgery kept Mahfuz busy. He notes that, before 1919, “the number of cases was so great that I devoted a ward of 10 beds to urinary and faecal fistulae and the beds were always full.”Footnote ¹² There is no evidence to suggest that Mahfuz went out in search of patients to practice his craft, but rather the contrary, that they eagerly came to him for relief. And Mahfuz and his colleagues were not the only surgeons operating on fistulas in Egypt or even in Cairo, where doctors at private hospitals also operated on them. The woman from Qena had already had three surgeries in Asyut, and another woman had had five unsuccessful operations before appearing at Qasr al-ʿAyni. In the latter's case, there was a stone encysted in a pouch in the bladder; Mahfuz crushed the stone, and the fistula closed on its own.Footnote ¹³

So what caused most fistulas in women? “Before 1919 the overwhelming number of fistulae met with in Egypt was a sequel of neglected labour.”Footnote ¹⁴ By “neglect,” Mahfuz meant that there was no modern medical intervention, no specialist called in to perform a cesarean section or some other procedure. The vast majority (259 of 276 of Qasr al-ʿAyni's cases from 1907 to 1928) suffered from “pressure necrosis,” which was related to a long and difficult labor that caused sloughing of tissue. Long meant three or four days of contractions, pushing, and pain, usually at home attended by a village midwife or female family members. In the balance of cases, he noted, the fistulas had been caused by sexual penetration of girls with vaginal atresia, surgeries with bad outcomes, or bilharzial infections.Footnote ¹⁵

Women who had fistulas were often turned away by surgeons due to the complicated nature of the surgery. At Qasr al-ʿAyni, all patients were examined to see if surgery was possible; this was the first step taken with the woman from Qena, who had been immediately wheeled into the women's ward and prepared for examination. “We have only rejected cases in which the urethra and sphincter were totally destroyed, and cases in which the bladder wall left was not sufficient to form a sufficient bladder.”Footnote ¹⁶ In addition, Mahfuz did not operate on women with malignant diseases. He did not like to operate unnecessarily and preferred to wait until two months after labor to see if the fistula would heal naturally, in time extending the waiting period to three months. In the surgeries performed from 1907 to 1928, 238 fistulas were cured, 28 relieved, and 10 left unresolved, a success rate of 86.5 percent. Mahfuz admitted that in the beginning, his success rate was not as high, but over time it improved; the more surgeries he performed, the sharper his skills as a surgeon became. In short, the women that Mahfuz operated upon helped build his expertise, and his last 500 fistula surgeries had a success rate of 100 percent.Footnote ¹⁷

Women who knocked on the doors of Qasr al-ʿAyni desperate for fistula repair had to be prepared for the fact that their surgeries were not private affairs. This was a teaching hospital, with students and sometimes foreign doctors looking on in the surgical theater during the procedure. The operation floor itself was crowded, with surgeons assisting (Mahfuz had female assistants at the Coptic Hospital and Kitchener Hospital), and surgical nurses arrayed around the body, as evidenced in photographs and films.Footnote ¹⁸

Mahfuz learned about fistulas, including rare ones, through the surgeries that he performed and operations that he observed as well as through his extensive reading on the topic. He also performed a series of dissections on ten women who died undelivered due to rupture of the uterus during labor; their bodies provided him with invaluable information.Footnote ¹⁹ Although these procedures and others helped propel his career, making him the doctor of choice for many elite Egyptian and foreign women, Mahfuz continued to attend to the working-class and peasant women who made up the bulk of gynecological and obstetrical patients at Qasr al-‘Ayni. If he learned from the bodies of poor women, he gave back to this community, trying to diagnose and cure their problems.

Although ruptured uteruses were extremely rare, their occurrence spoke to another set of dangers in childbirth. Some of these uteruses had afterlives as specimens in Mahfuz's Obstetrics and Gynaecological Museum, which was launched in 1932 after the positive reviews his “pathological gynaecological and obstetrical collection” elicited at the 1928 centennial conference. The exact conditions under which the specimens were collected is not clear, but they were used primarily as teaching tools for medical, midwifery, and nursing students, replacing wax casts and preceding the use of colored slides and films. They were immortalized in detailed drawings by the Russian watercolor painter Nicholas Strekalovsky, who often sat with patients before surgery. These drawings were reproduced as plates in the Atlas of Mahfouz's Obstetric and Gynaecological Museum and also appeared in Mahfuz's scientific articles.Footnote ²⁰ Mahfuz continued to update colleagues on advances in fistula surgery in numerous lectures and in the pages of the Journal of Obstetrics and Gynaecology of the British Empire, with three articles appearing in the 1930s.Footnote ²¹

In 1956, nearly a half-century after the woman from Qena appeared at Qasr al-ʿAyni, Mahfuz, by now a Master of Surgery, fellow of the Royal College of Surgeons, Royal College of Physicians, and Royal College of Obstetricians and Gynaecologists of England, and recipient of numerous Egyptian awards, delivered the William Meredith Fletcher Shaw Memorial Lecture in London. Although he was an expert on multiple topics, he decided to present on fistula repair, accompanying his talk with a film illustrating the surgeries. The next year the article “Urinary Fistulae in Women” appeared in the Journal of Obstetrics and Gynaecology of the British Empire.Footnote ²² Medicalization of childbirth in Europe meant that fistulas there were less often a by-product of faulty obstetrics and increasingly the result of surgical interventions gone awry.Footnote ²³ Yet in parts of the world where large numbers of women labored in rural areas far from clinics and hospitals, the lack of medical intervention in difficult deliveries meant that fistulas still occurred regularly in childbirth, and Mahfuz's expertise was eagerly sought. When Australian doctors Catherine and Reg Hamlin launched their Addis Ababa Fistula Hospital in 1959, they turned to him as one of the most knowledgeable surgeons in the world on correcting fistulas.Footnote ²⁴

By the end of Mahfuz's career, the unnamed woman from Qena was one of nearly a thousand women on whom he had performed fistula surgery, and her decentering of Egyptian history seems obvious. She was from Qena, not Cairo; from Upper Egypt, not the Delta or Canal Zone; and from ordinary people, not the elite. Yet she was in fact quite extraordinary. She set out on a quest in search of a surgical procedure to cure a debilitating health condition, undergoing three initial operations before embarking on a further journey on foot over hundreds of miles, with no money or support, eventually making her way not just to any hospital but to Egypt's premier medical institution. Once there, in Mahfuz's hands, her fourth operation proceeded smoothly.

Thirteen women who faced fistula surgery at Qasr al-ʿAyni from 1907 to 1928 had to endure multiple surgeries once there. Seven women underwent two operations, two were operated on three times, two operated on four times, one operated on five times, and one six times before being cured.Footnote ²⁵ These rates may seem high, but in fact pale in comparison with those of Dr. James Marion Sims (1813–83), whose 1852 article in the American Journal of Medical Sciences described his experiments to find a cure for fistulas. Sims honed his surgical skills by practicing for five years (1845–49) on eleven enslaved Black women in the hospital he started on his slave labor plantation in Alabama. He operated on the three women—Anarcha, Betsey, and Lucy—forty times without anesthesia until he perfected a cure. When his assistants deserted him, he turned the enslaved women, the subjects of his experimentation, into nursing assistants.Footnote ²⁶

Mahfuz was no Sims: he has never been accused of operating on women without their consent, without anesthesia, or under harsh conditions. To the contrary, he is known to have gone out of his way for patients, looking out for their interests and treating them with the greatest respect. And for this he acknowledged the debt he owed to the woman from Qena. After her surgery, he checked on her every day, removing her stitches after two weeks, once he was assured that she had healed properly. She wanted to thank the doctor who had operated on her, and at first did not believe that the young doctor who made the daily rounds was her surgeon. She asked Mahfuz his name and that of his mother and then, according to his recollection, said, “Naguib, son of Mariam, I ask God to reward you, to place a jewel on your forehead and a piece of sugar on your tongue.” Her words touched him, he recalled, bringing tears to his eyes. “Since then I have always tried to meet my patients with a pleasant smile and to be kind in talking to them, remembering always the simple wish of a simple woman.”Footnote ²⁷ Simple but tenacious and determined.

Knowledge about fistulas was produced mostly by male surgeons with and through women's bodies, which helped establish the surgeons’ careers and sometimes made the women whole again. It was also made with and through parts of women who died tragically—like the ten women whose uteruses ruptured—with body parts preserved in medical museums.Footnote ²⁸ We do not know what happened to the woman from Qena, but we do know that she played no small role in the life of one of Egypt's most famous surgeons and a role in the production of knowledge about curing fistulas. An examination of Mahfuz's scientific research and discovery challenges the hierarchy of colonial medicine, in which local everyday people are depicted as consumers and not producers of knowledge. And focusing on fistulas helps to decenter the default male body, suture the gaps, and address some of the silences in Egyptian history.