A medical trailblazer in the Ottoman Empire: The legacy of Dr Caroline Frances Hamilton (1861

Abstract

This article explores the life and work of Dr Caroline F. Hamilton, one of the pioneering female physicians sent from the USA to the Ottoman Empire in the late 19th century. Over a career spanning three decades, Hamilton provided critical medical care, especially to women, at the Azariah Smith Memorial Hospital in Aintab, overcoming legal, cultural, and political obstacles to become one of the first women licensed to practise medicine in the region. Her contributions, particularly in treating Muslim women who had limited access to male doctors, were significant in advancing healthcare in a conservative society. Hamilton’s role extended beyond direct patient care, she also trained local health workers, contributing to long-term improvements in healthcare. Her efforts during times of war, epidemics, and humanitarian crises exemplified her resilience and dedication. This article highlights Hamilton’s broader legacy, examining how her work reflects the intersection of gender, medicine, and missionary activity in a complex geopolitical context while also contributing to the introduction of Western medical practices in the Ottoman Empire.

Keywords

Medical missions women in medicine female physicians ABCFM Ottoman Empire

Introduction

The convergence of medicine and missionary work in the late nineteenth and early twentieth centuries created significant opportunities for women in the medical profession and global humanitarian efforts. Dr Caroline F. Hamilton (1861–1944), an American physician and missionary, played a significant role in advancing healthcare in the Ottoman Empire, particularly in Aintab (modern-day Gaziantep). A New York Women’s Medical College graduate, Dr Hamilton overcame various legal, cultural, and political challenges to become one of the first women licensed to practice medicine in the Ottoman Empire (Figure 1).

Her work at the Azariah Smith Memorial Hospital¹ was incredibly impactful as she provided medical care to a diverse population, including Muslims, Christians, and Jews. Dr Hamilton’s contributions reflect women’s evolving role in medicine and demonstrate how Western medical practices were introduced into Ottoman society through transnational missionary efforts. This article examines her career, focusing on the intersections between gender, medicine, and missionary work, and highlights the broader socio-political context in which she operated.

Early life and education

Caroline F. Hamilton was born on 18 September 1861 in West Hartford, Connecticut.² She completed her education at West Hartford High School in 1880 and studied at Smith College, graduating in 1885 at the age of 24.³ While at Smith, Hamilton developed a deep interest in medicine, an aspiration that took shape when she was around thirteen or fourteen. By her second year at Smith, she had firmly decided to pursue a medical career to apply her skills internationally.⁴

Hamilton was admitted to the New York Women’s Medical College, a trailblazing institution founded in 1863 to provide women with access to medical education.⁵ Under the mentorship of Dr Clemence S. Lozier (1813–1888), the college’s founder, Hamilton navigated the challenges of studying medicine in an era when women had limited opportunities in the profession. She earned her Doctor of Medicine degree in 1888, becoming one of 219 college-trained women. After completing a year-long internship, Dr Hamilton co-founded and worked as a staff physician at the Rivington Street Settlement in New York City,⁶ a facility providing care to people experiencing poverty, while also teaching at her alma mater and serving as a resident physician at the New York Infant Asylum, which cared for abandoned infants and offered obstetrical services to unmarried or indigent women.⁷

Although her career in New York thrived, Dr Hamilton felt a renewed sense of her original mission to work abroad. In March 1892, she experienced what she described as ‘a divine calling’, prompting her to accept a position to serve as a missionary doctor in Aintab in the Ottoman Empire (Figure 2).⁸ This decision marked a turning point in her life and career, realigning her focus with her early aspiration to practise medicine internationally.

Securing a work permit and professional endeavours in Azariah Smith Hospital

In 1892, following her extensive medical training and clinical experience in New York, Dr Hamilton was sent to the Ottoman Empire by the American Board of Commissioners for Foreign Missions (ABCFM) (Figure 3).⁹ Though she had not yet been formally recognised as a missionary under the Board,¹⁰ her work was financially supported by a benefactor referred to as a “Boston lady”.¹¹ Upon her arrival, Dr Hamilton encountered significant challenges in obtaining the necessary permits to practice medicine. The Ottoman authorities, adhering to regulations that effectively excluded women from the medical profession, restricted her ability to work as a doctor. As a result, Dr Hamilton's early activities in the region were limited to midwifery, and she assisted Dr Fred D. Shepard (1855–1915) during this period.¹²

Dr Hamilton’s struggle was not an isolated case. During the same period, another American female doctor, Mary P. Eddy (1864–1923),¹³ also sought authorization to practise in the Ottoman Empire but faced similar bureaucratic obstacles. Both women’s cases shed light on the broader legal and political difficulties foreign female doctors seeking medicine in the Ottoman Empire faced. Diplomatic correspondence between the U.S. State Department and the American Embassy in Istanbul revealed the situation's complexities.¹⁴ Securing permission was lengthy and arduous, lasting from July to November 1893, and required considerable diplomatic intervention. U.S. Ambassador Alexander Watkins Terrell (1827–1912) played a central role in these efforts, persistently advocating for the right to practise. His diplomatic engagement with the Ottoman authorities eventually led to a significant breakthrough.¹⁵ A report from the Ottoman Council of Ministers in October 1893 alluded to the cases of two female doctors, though their names are not mentioned explicitly. They were undoubtedly Dr Hamilton and Dr Eddy. The Council’s deliberations resulted in an amendment to the legal provisions regulating foreign doctors, allowing women with proper qualifications to apply for medical licenses. At that time, foreign doctors had to register their diplomas with Mekteb-i Tıbbiye (the Imperial School of Medicine), pay a fee, and pass a medical examination. Prior to the legal amendment, women were effectively barred from this process. However, a key argument in favour of the change was the need for female doctors to treat women suffering from certain conditions, reflecting a growing recognition of the critical role women could play in the medical profession.¹⁶ Despite this progress, the authorities were cautious, fearing foreign physicians might gain access to private households and be exploited by ‘seditious individuals’ or political dissidents. As a result, stricter background checks were introduced to ensure foreign doctors had no subversive affiliations.¹⁷ This marked a significant shift in the Ottoman authorities’ approach, reflecting their cautious stance towards foreign influence and a broader recognition of the need to regulate women’s participation in the medical field.

The Ottoman government relaxed its restrictions on female doctors thanks to Terrell’s persistent efforts, granting Hamilton and Eddy special authorisation to practise. Terrell reported to U.S. Secretary of State Walter Q. Gresham (1832–1895) that the regulation barring women physicians from practising medicine in the Empire had been overturned, primarily due to Eddy’s case. Eddy was summoned before a medical committee, submitted her credentials, and was subsequently granted permission to practice.¹⁸ This legal change allowed Eddy to practice in Beirut and enabled Dr Hamilton to work in Aintab. Contemporary accounts, including reports in Harper's Bazaar and The British Medical Journal, celebrated this regulatory shift as a significant milestone. Harper's Bazaar reported that the Sultan had permitted women doctors to practise in the Ottoman Empire, with Dr Hamilton being the first to receive this honour. She soon established a hospital for women and children in Aintab, funded by her Boston benefactor, while Eddy departed for Beirut.¹⁹

A separate report in The British Medical Journal confirmed the authorisation granted to Hamilton and Eddy, noting that only women who presented valid medical qualifications and passed the required examination at the Imperial Medical School were permitted to practise. The report commended the Grand Vizier, Cevad Pasha (1851–1900), for his progressive stance. The approval from the Ottoman Sultan to allow Hamilton and Eddy to practice medicine was a direct result of Terrell’s efforts, marking a turning point for women in the medical profession within the Ottoman Empire.²⁰ Dr Hamilton’s success in securing a licence represented a rare achievement in a period where such opportunities were minimal, and her work in Aintab was a significant step forward for female medical practitioners in the region.

Upon arriving in Aintab, Dr Hamilton began to serve at the Azariah Smith Memorial Hospital, a pivotal institution in the region. The hospital's operations were centred on three key areas: direct medical care, training of local health workers, and evangelistic activities connected with the medical services.²¹ Dr Hamilton’s primary responsibility was providing healthcare to women, a critical role given the cultural and religious sensitivities that often prevented Muslim women from seeking treatment from male doctors. Her presence in the region was vital in addressing these barriers and offering much-needed medical services to a population with limited healthcare access.

Dr Hamilton arrived in Aintab after nurse Elizabeth M. Trowbridge (1865–1967), and quickly became essential to the medical efforts there. After only one night of rest, she immediately began work with the help of an interpreter, continuing without pause except during holidays.²² Her presence as a female doctor was especially significant in the region, where cultural and religious sensitivities within the Muslim community often led to a preference for female doctors to treat female patients.²³ Reflecting on her early days, Dr Hamilton noted the overwhelming need for specialised care for women in Turkey. She treated forty to fifty patients a day, often working alone for hours until exhausted. Although a male doctor would have been a relief, Muslim families often insisted on female care for their wives. Dr Shepherd stated that the greatest need was for a foundation to teach medicine and midwifery, as there was a shortage of trained Christian doctors and no trained midwives.²⁴ Female doctors like Hamilton brought a new dynamic to healthcare in the Ottoman Empire, particularly in rural areas where cultural and religious barriers prevented women from seeking treatment from male physicians. Their presence was crucial in addressing the neglected health needs of women, helping to break down long-standing taboos.²⁵ Beyond providing care, doctors like Hamilton became trusted figures in the communities they served, playing a pivotal role in transforming healthcare access for women (Figure 4).

Dr Hamilton's arrival marked a turning point for the hospital, particularly in its service to women. Under her supervision, the hospital's Women's Clinic saw 2300 new patients in 1894, with a majority receiving free or reduced-cost treatments. Most of the patients were Muslims, including Turks, Arabs, Kurds, and Circassians, who travelled from various regions of the Ottoman Empire to receive care. Dr Hamilton personally treated over 700 patients that year, contributing significantly to the hospital’s overall 2000 patient visits. The clinic’s reach extended far beyond Aintab, as people across the Empire, from Harput in the north to Aleppo in the south, sought better healthcare.²⁶ Following Dr Hamilton’s arrival, the hospital's activities expanded significantly, becoming a critical service in the region. Due to the inadequate healthcare infrastructure in Anatolia during the late Ottoman period, many sought treatment at better-equipped facilities such as the hospital in Aintab.²⁷

Dr Hamilton's contributions were well documented in the Life and Light for Woman periodical, where she provided detailed accounts of the hospital's work.²⁸ One of her most notable articles, ‘Turkey: At the Hospital in Aintab’, published in 1899, described the hospital’s modest facilities and the challenges of delivering medical care with limited equipment and supplies. Despite these difficulties, Hamilton emphasised the hospital’s resilience, noting that natural remedies like fresh air and sunlight often helped where medicines were in short supply. She also highlighted the complexities of cross-cultural communication, recounting stories of patients who spoke Kurdish, Arabic, or other local languages unfamiliar to the hospital staff. For example, she described a young Arab girl who spent several weeks at the hospital, and while she picked up a few Turkish words, much of the communication between her and the staff occurred in what Hamilton called ‘the language of smiles’.²⁹ Hamilton’s work in Aintab significantly expanded the hospital’s activities, transforming it into a vital regional healthcare hub. Her presence addressed a critical gap in the medical care of women, especially in rural and conservative areas where female patients were reluctant to consult male doctors. Beyond her clinical work, Hamilton’s efforts helped to overcome social taboos, establishing a foundation for women’s healthcare in the Ottoman Empire during a time when such opportunities were rare.

In Medical Work in Aintab, Dr Hamilton described the far-reaching reputation of the Azariah Smith Memorial Hospital, which became a vital healthcare hub in the region.³⁰ She remarked that anyone within a 200-mile radius would hear about the ‘Khasta Khanu’ (home of the sick), demonstrating the hospital's central role in providing medical care. Patients travelled not only from Aintab but also from distant villages, towns, and the plains beyond the Euphrates River. A diverse range of ethnic and religious groups – including Arabs, Kurds, Armenians, Jews, and Gypsies – sought care at the hospital. Despite its limited capacity of only 33 beds, the hospital attracted large numbers of patients, many of whom arrived by foot, on mules, or in makeshift stretchers, desperate for medical treatment. Some came without enough money for food or lodging, highlighting the dire circumstances many faced.

The hospital operated for nine months of the year, consistently filling its beds during the peak seasons of autumn and spring. Due to space constraints, the majority of patients were treated as outpatients. Surgical wound dressings were administered outside in the mornings, and general clinics were held in the afternoons. Dr Hamilton particularly emphasised the need for specialised care for women, and the hospital ran dedicated women’s clinics three times a week. In addition, two or three surgeries were performed each week. By 1897–1898, the hospital was staffed by two American doctors, an American-trained nurse, two Armenian doctors, a pharmacist, and a surgical assistant. That year, the hospital recorded 4272 new patients and provided 29,300 treatments and examinations. Of the 184 patients admitted to the wards, the hospital performed 385 major surgeries, with a success rate of 364 recoveries. Despite the challenges of inadequate surgical instruments and poor sterilisation, the hospital achieved remarkable outcomes due to the dedication and skill of its staff.

One of the hospital’s most striking features was its patients’ social and demographic diversity. Dr Hamilton observed that patients from various racial and religious backgrounds – Turks, Armenians, Muslims, Protestants, Jews, and Catholics – were treated side by side. She described how pain and suffering united individuals who might otherwise be divided by profound social and cultural differences. It was common to see a Turk helping an Armenian or a Muslim assisting a Christian, demonstrating the hospital’s role in fostering a sense of shared humanity. This environment of mutual care transcended the ethnic and religious tensions that often characterised the region.³¹ Dr Hamilton’s reflections offer valuable insights into the hospital’s operations and its role as a centre for healthcare in the Ottoman Empire. The hospital provided a critical service to a population with limited access to medical care, and it was one of the few institutions where Western medical knowledge and practices were introduced to the local population. The facility improved healthcare access and helped bridge cultural divides in the region through its inclusive approach.

By 1906, the Azariah Smith Memorial Hospital had expanded significantly, now staffed by five doctors, two of whom were American. The hospital extended its operations to twelve months, no longer limited to the previous nine-month schedule. That year, the hospital treated 3372 patients in the general clinic, and Dr Hamilton personally attended to 966 patients in the women’s clinic. The hospital recorded 58,563 patient visits for treatments, dressings, and other medical services, excluding the work of the dispensary and assistants. Additionally, 4606 home visits and 486 surgical operations were conducted. The hospital’s surgical work had evolved, with more straightforward procedures being carried out by local doctors, while the hospital handled more complex cases.

The demographic breakdown of the hospital’s wards in 1906 reflected the diverse population it served. Of the 258 patients admitted, 163 were Armenian, 59 were Turkish, and 22 were Kurdish. Among the Armenians, 114 were Armenian Orthodox (Gregorian) and 44 were Protestant. The hospital admitted 150 men and 108 women, and patients spent 5895 days there. Many of these patients received their treatment free of charge, while others paid a modest fee. The hospital’s capacity increased slightly with the addition of six beds to the men’s ward to meet growing demand.³² That year, the hospital reached a record of 54,248 treatments, the highest for any American Board hospital at the time. Out of 656 primary surgical operations performed, only 15 patients succumbed to their conditions, a testament to the high standard of care despite challenging conditions. Nearly half of the hospital’s inpatients were Muslim, demonstrating the facility’s importance in serving the wider community.³³

In addition to her medical endeavours, Dr Hamilton participated in the first medical conference organised by missionaries in Turkey, where she presented a paper on ‘Eclampsia’ at the 1908 ‘Medical Missionary Association of Turkey conference’ held in Aintab.³⁴ Beyond her clinical work, she strongly emphasised training local health workers. While the hospital provided care six days a week, she also organised educational classes to improve the medical skills of local women. These efforts contributed to developing a local healthcare workforce, with trained assistants going on to serve in key cities across Turkey, strengthening the region’s healthcare services.³⁵ Although Dr Hamilton had initially served at the hospital without formal missionary status, in 1910, the ABCFM officially appointed her as a missionary. She submitted annual reports on the Aintab hospital, albeit not consistently.³⁶ This marked a significant shift as Hamilton’s medical and educational work became fully integrated into the broader religious mission. Her appointment signalled her commitment to continuing her medical work within a more structured framework, ensuring the hospital’s mission of providing healthcare and spreading Western medical practices would endure.

An article published in The Pennsylvania Medical Journal in June 1912 highlighted the significant contributions of the Azariah Smith Memorial Hospital in Aintab, where Dr Shepard, Dr Hamilton, and their local assistants worked tirelessly for three decades. Despite the hospital’s limited resources, inadequate hygiene, and overwhelming workloads, the surgical outcomes were remarkable, often matching those of the best-equipped hospitals in the USA. The hospital achieved notable success in procedures such as cataracts, urinary calculi, and abdominal disorders. However, the article underscored the urgent need for more funding to enhance the hospital’s operations. Issues such as the cost and danger of heating the hospital with wood-burning stoves, the lack of additional hospital rooms, a nurses’ residence, and an adequately equipped operating room were all cited as critical areas for improvement. The hospital required a stable annual income to support these necessary upgrades.³⁷

By 1913, the hospital, under the leadership of Dr Shepard and with support from Dr Hamilton, three local physicians, two American doctors, and seven local nurses, treated 394 inpatients from six different religious backgrounds. Additionally, the hospital served 5492 outpatients and made 2220 home visits that year. The medical team performed 656 primary surgical operations, and remarkably, two-thirds of the hospital’s running costs were covered by patient fees. Alongside the medical care provided, the hospital shared the Gospel with those who came through its doors. In 1914, the hospital received a $10,000 grant, which was vital in enabling the much-needed expansion of its facilities. This grant allowed for additional hospital rooms and an upgraded operating theatre, improving the hospital’s ability to meet the growing medical demands of the diverse population it served.³⁸

During World War I, the hospitals in Aintab and Adana were repurposed for military use but remained under the supervision of the American mission. Both facilities were quickly filled, treating wounded soldiers amidst the chaos of war. A typhus epidemic became a severe threat in the region, and both Dr Shepard and Dr Hamilton contracted the disease while treating soldiers, though both eventually recovered.³⁹ The hospital in Aintab faced further strain as it became overwhelmed by an influx of refugees, forcing it to operate well beyond its intended capacity. The hospital's staff, including Dr Hamilton, faced immense pressure as they provided care under increasingly difficult circumstances.⁴⁰ Aintab was a particular focal point of the humanitarian crisis, unlike some northern mission stations, as it was inundated with displaced people fleeing war and ethnic tensions.

Despite the immense challenges, Dr Hamilton and other dedicated missionaries, such as Mr Merrill (1872–1960), Mrs Trowbridge, and Mrs Norton (1874–1966), persevered to provide medical care. They continued their work resiliently, even as the region’s crises worsened. On 15 December 1918, the arrival of British forces in Aintab brought much-needed relief to Dr Hamilton and the rest of the mission staff. This marked a turning point, as British forces helped stabilise the area and alleviated some of the intense pressure on the hospital. The region began a slow recovery, and the hospital staff, now supported by the British, could begin to restore normal operations after years of war and hardship.⁴¹

Dr Hamilton, a pioneering female physician and missionary, frequently returned to the USA during her career in Aintab, taking sabbaticals in 1898, 1904, and 1909–1910. After years of service, she returned to the USA in 1919 but returned to Aintab in 1921 to continue her mission. However, amid the turmoil that began in 1920 caused by Turkish resistance against British and French forces, Dr Hamilton and her team had to abandon the hospital.⁴² She then spent 18 months in Beirut, where she directed an orphanage caring for 300 children, before returning to Aintab in 1922 to resume work.

Dr Hamilton, whose career in the Ottoman Empire and early Republican Turkey was marked by tireless dedication to providing medical and social services in challenging conditions, is described by Sarafian as ‘the first woman missionary physician, diligent, dignified, serious, dependable, successful, and friendly’, serving as the women’s doctor in Aintab for 35 years.⁴³ She left her post in 1928 and returned to the USA in 1932, retiring in Holyoke, Massachusetts, where she lived with her close friend Elisabeth Trowbridge. Despite retiring, she remained active in her local church and community, continuing to contribute until her later years. She maintained a strong connection with her home church, the First Congregational Church in West Hartford, which had supported her throughout her missionary career. After returning to the USA, she continued to share her missionary experiences, inspiring others with her stories of dedication. Dr Hamilton died on September 16, 1944, at 83, in White Plains, New York.⁴⁴ Her death was a profound loss to the missionary community and the many women and children whose lives she touched. She is remembered as a trailblazer in healthcare and missionary work, whose legacy of service and compassion continues to inspire.

Conclusion

Dr Caroline F. Hamilton’s career is a significant example of the broader patterns of missionary work during the late nineteenth and early twentieth centuries, particularly in her achievement as one of the first women to secure official permission to practise medicine in the Ottoman Empire. This milestone, enabled by persistent diplomatic efforts, marked a significant shift in Ottoman policies towards women in the medical profession. Dr Hamilton's success, alongside Dr Eddy, illustrated the growing recognition of the role female physicians could play in addressing the healthcare needs of women, particularly in a society where cultural norms often barred women from seeking treatment from male doctors.

At the Azariah Smith Memorial Hospital in Aintab, Dr Hamilton’s work was especially critical in the women’s clinic, where she treated hundreds of patients yearly. Her contributions helped break down cultural taboos surrounding women’s healthcare, improving access to medical services for women in the region. Her role in securing medical licences for women in the Ottoman Empire set an important precedent for future female practitioners, legitimising women’s work in the medical field. While her career was part of a more considerable collective effort by American missionary doctors, Hamilton’s achievement was a significant breakthrough for women in medicine, allowing future generations to follow in her footsteps. Although her contributions did not radically reshape the medical landscape, they were crucial in introducing Western medical practices to the region. Dr Hamilton’s inclusive approach to healthcare, treating patients from diverse ethnic and religious backgrounds, and her efforts in training local health workers, further highlight the impact of her work.

In conclusion, Dr Hamilton’s career represents an important intersection of gender, medicine, and missionary work during significant social and political change in the Ottoman Empire. While part of a collective mission, her achievements mark a crucial step forward for women in medicine, particularly in providing essential healthcare to marginalised populations. Though not revolutionary, her legacy lies in pioneering the role of women in healthcare and contributing to long-term improvements in the region’s medical services.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Zeynep İskefiyeli

Fikrettin Yavuz

Author biographies

Zeynep İskefiyeli is an Associate Professor in the Department of History at Sakarya University. Her research focuses on the late Ottoman period, particularly on the governance of non-Muslim communities, with a special emphasis on Armenians. She also explores the influence and activities of Protestant missionaries in the Ottoman Empire, providing valuable insights into interfaith and intercommunal relations during this transformative period.

Fikrettin Yavuz is an Associate Professor of History at Sakarya University, with a broad research interest in the late Ottoman and early Republican periods. His work examines the challenges faced by the Ottoman Empire, including separatist movements and the evolving dynamics of Ottoman-American relations. He has also conducted research on Armenians in Ottoman history and the role of Protestant missions, exploring how these topics intersect with questions of identity, ideology, and state policies during critical historical junctures.

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Fikrettin

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There were no Muslim doctors in Antep besides a single municipal physician (if present). The first Turkish hospital, constructed in 1897 and known as the “Blue Hospital,” was followed by the “Yellow Hospital” (Nîsâiyye), specialising in women’s health. However, Armenian doctors were staffed in both hospitals and were less well-equipped than the American Hospital. Güllü Ramazan Erhan. Antep Ermenileri – Sosyal Kültürel ve Siyasi Hayatı/The Armenians of Antep – Their Social, Cultural, and Political Life, IQ Kültür Sanat Yayıncılık, İstanbul 2010, pp. 153–154.

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Hamilton Caroline

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32.

Upon examining the data, it is noted that while the total patient count is 258, an analysis of ethnic distribution reveals information for only 244 patients. This suggests that there are 14 patients whose ethnic identity is not specified. The gender distribution, recorded as 150 men and 108 women, corresponds to the overall patient count of 258. These findings indicate a discrepancy in the data regarding ethnic identity information. “Central Turkey Mission”, Annual Report of the American Board of Commissioners for Foreign Missions, Home Department, 1905-1906, Boston: Congregational House, 1906, p. 78.

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Bewer Alice

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37.

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38.

Greene Joseph

. Leavening the Levant. Boston, New York: The Pilgrim Press, 1916. p. 151.

39.

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40.

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. Shepard of Aintab. New York: Interchurch Press, 1920. p. 71.

41.

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. A Briefer History of Aintab, A Concise History of the Cultural, Religious, Educational, Political, industrial and Commercial Life of the Armenians of Aintab, Union of the Armenians of Aintab, Printed in the USA, 1957, p. 68.

44.