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299 Pages
Preface
This is a book on sickness and health and how one dealt with it as a patient, a healer, and health administrator in the Ottoman Middle East in the early modern period. In some cases the story had a happy ending; in so many other instances, suffering, misery, and finally death were involved. This is of course not one the most cheerful topics one could choose as a focus to a scientific enquiry.
I have chosen it nevertheless, as health and sickness and finally death are an inherent part of life. This may be not terribly optimistic, but it has the merit of being realistic. Moreover, they are intimately connected to so many other aspects of life—intellectual debates, social interactions, religious beliefs, economic processes, and political order—and as a result they are very promising as a venue for delving into past societies.
The multifaceted of medicine turned this project into a double journey. It started as a foray into history, and I hope to bring to life in these pages a rich picture of the lives of people in the early modern Middle East. It was also a personal one. As I proceeded with this study I had to redefine my assumptions of what health and medicine were, not only for people of a distant time and place, but also for me and the society in which I live.
This book is about contemporary social consciousness and awareness, as the history of medicine is not of historical value only. In this case the past is very much relevant to our own modern society. It is also connected with the current public debate worldwide about the role that the medical establishment and the scientific community should play in a modern society, and how they should respond to the social and natural environment, especially when the cost of medical treatment is higher than ever. This debate is related also the current crisis within orthodox medicine.
More people choose alternative medicines rather than orthodox medicine and technology and question their moral basis. Academic studies add to the critical discourse of what is “good” or “modern” about contemporary health care institutions by going back to historical examples, Western and non-Western alike. This in turn should help society educate better medical personnel (whatever “better” is). By making the medical system better not only the lives of the sick and feeble are better, but the world becomes better, more just.
This work has two layers. The first layer is the story of Middle Eastern medicine(s) and medical institutions: what types of medicine(s) existed in the Middle East, who were its founders were, who worked in it, who the patients were, and where it was located. The second and more important layer deals with Middle Eastern society and culture from a medical point of view. The chapters in this book are devoted to subjects like prevention and curative therapeutics; holism, nature and ecology; charity, entitlement, and group identity; health and social hierarchy; dialogues between medicine and religious belief; and medicine, power and social order.
I accumulated quite a debt to so many people, and am glad Iam able to at least partially repay it by presenting them with this book; I would like to acknowledge their support here.
The project originated as a doctoral dissertation. Later on it went through a series of transformations, and (I hope)—improvements. However, I still owe a debt to my teachers at Tel Aviv University: my doctoral advisor, Professor Amy Singer; Professor Ehud Toledano, who did not carry any official roles but was and still is a constant source of support and inspiration; and Professor David J. Wasserstein, now of Vanderbilt University, who tutored a young research assistant. In London, I owe Professor Lawrence I. Conrad (now of Hamburg) much gratitude for hosting me for three months while carrying out my project at the wonderful facilities of the Wellcome Institute for the History of Medicine.
In Istanbul Professor Nil Sari of the Department of History of Medicine at the Cerrahpasa Faculty of Medicine in Istanbul was gracious enough to take real interest in the research of someone who at the time was still a novice in Ottoman medicine and Ottoman sources. In Cambridge it was Dr. Kate Fleet, the head of the Skilliter Centre for Ottoman Studies at Newnham College, who was a wonderful hostess. I was affiliated with the Centre for a term and benefited greatly from the vast Ottoman literature (primary and secondary) there. With Dr. Leigh N. B. Chipman of Ben Gurion University, a friend and colleague, I share interest in Muslim medicine. I thank her for all her help with editing the text.
The names of museums, libraries, and archives bring to mind faces and names of people I enjoyed working with and to whose help I am immensely grateful. In Istanbul I worked in the Basbakanlik Osmanli Arsivi (the Archives of the Ottoman Prime Ministry), the Topkapi Saray1 Miizesi Arsivi and Ktitiiphanesi (the Archives and Library of Topkapi Palace), and the Siileymaniye Library; in Ankara at the Vakiflar Genel Miidtirlugii Argivi (the Archives of the General Directorate for Charitable Institutions); in London at the British Library and the Wellcome Institute for the History of Medicine Library; in Cambridge at the Cambridge University Library; and in Princeton at the Firestone Library. The hospitality of librarians who supplied me with good advice with regard to the collections at their charge (and not to mention other types of help in the form of endless cups of hot tea and good conversation) helped me to move forward.
At the State University of New York Press, I would like to thank Dr. Michael Rinella, Diane Ganeles, and Wyatt Benner for their expert guidance in producing this book.
My thanks are also to the anonymous readers for the Press. Their endorsement and constructive criticism are very much appreciated. Finally, Tomer Miron, Liran Yadgar, Barak Rubinstein, and Ido BenAmi, my former and current research assistants, helped me in various ways in preparing this manuscript.
Iam happy to acknowledge the generous financial support from various institutions and grants that made the research and writing it up possible: the Israel Science Foundation (grant number 535/04), the Dan David Prize Scholarship in History, the Skilliter Centre for Ottoman Studies Research Grant, the Friends of the Library Fellowship at Princeton University Library, the Rothschild Fellowship, and a Research Scholarship from the Turkish Ministry of National Education (Milli Egitim Bakanhgi), and the Department of Middle Eastern and African History at Tel-Aviv University.
Finally, I would like to mention my family: my parents, brother, and in-laws, and especially my husband (to whom I dedicate this book) and two daughters, who were born into this project and grew with it. We all know how much I owe you. At this point I also remember my late grandfather, who would have been happy and proud to see his granddaughter writing a book.
As the book was copyedited, my father, Dr. Michael Shefer, passed away. I wish he could have seen the book.
Note on Transliteration
The problem of transliteration in Ottoman studies is complicated because of the very broad geographical, cultural, and lingual scope of the subject matter. Spreading over three continents for six hundred years, the Ottoman Empire was inhabited by members of many linguistic groups living alongside each other, including—in addition to users of Turkic dialects—users of Serbo-Croat, Berber, Hebrew, Arabic, Persian, Kurdish, and many more. Moreover, Ottoman society and culture enabled—indeed, encouraged—routine crossing of lingual and cultural boundaries.
The result was an extraordiary cultural mixture and diversity. To deal with it, any single system of transliteration is found lacking either grammatically, phonetically, or aesthetically. Hence I adopted a compromise that allowed me to achieve consistency as much as possible while emphasizing the theme of cultural diversity with regard to Ottoman medical realities of the early modern period and accurately reflecting the languages of the sources used here, which are mainly Ottoman Turkish and Arabic. In addition, I tried to simplify forms as much as possible to make the text accessible to medical historians who are nonspecialists in Middle Eastern studies.
Throughout the book I make the case of the high level of Ottomanness of medicine in the Middle East of the sixteenth and seventeenth centuries. With the Ottoman context in mind I find it appropriate to write most terms and names of places and individuals in OttomanTurkish forms. For the sake of simplicity, I rendered such terms and names in a modern Turkish form rather than following formal transliteration tables of Ottoman-Turkish. In modern Turkish, c is pronounced as j is in English, ¢ as ch, § is unvocalized and lengthens the preceding vowel; 1 (undotted i) sounds like u in the word turn; and s is pronounced like sh.
At the same time I give ample room to provincial-cultural variations, recognizing the Arab character of the Ottoman-Arab provinces.
Therefore, in cases where the context is Arabic-speaking I have used Arabic forms.
This dual system of transliterations allows me to make a distinction, for example, between a cerrah, a surgeon in a Turkish speaking site, and his colleague in an Arabic environment, who is a jarrah. I write about dariissifas and medreses, and refer to such physicians as Emir Celebi. Although he worked many years in a Cairo hospital, Emir Celebi owed his fame in the seventeenth-century Ottoman court to a medical treatise written in Ottoman-Turkish. However, I discuss also Ottoman physicians like the sixteenth-century physician, Da’tid al-Antaki, who operated from Antakya in an Arabic-speaking environment, and Salih b. Nasrallah Ibn Salltim, the seventeenth century physician from Aleppo who rose to be the imperial head physician but still wrote only in Arabic.
INTRODUCTION
The Marriage of Medicine and Society
Susan Sontag once wrote that we all hold dual citizenship, in the kingdom of the well and in the kingdom of the ill. Sooner or later we are obliged, at least for a spell, to be citizens of that other place.’ Although illness is so common, it is far from being taken in stride. Rather it was—and still is—regarded as a dramatic and surprising event. Yet there is hardly anything surprising about it. Human life was, and still is, riddled with illness and death. Illness is one of the more regular events in our lives, one that happens to all of us over and over again. Still, each time illness happens, it catches us by surprise.
Moreover, illness arouses passionate feelings. Some illnesses are regarded as horrid for the individual in question and his or her surrounding family. Some diseases are romanticized (like the case of TB). Other illnesses are used by some as metaphors for ill deeds and ill nature in the suffering individual or the community at large. The origins of disease are mysterious (like leprosy in the Middle Ages or HIV in our own society). Illness needed explanation. At the basis of everyday realities stand health and illness. These, among other factors (financial, etc.), determine the ability of a person to lead the life of his or her choice. Health and illness affect not just the length of life but its quality. Hence the importance of medicine that should—at least ideally—transfer people from the realm of disease to the realm of health.
This book is about health as much as it is about illness. Not only does each mirror the other, they exist only in relation to each other. Medicine in the early modern Middle East was not only for the ill; it concerned itself primarily with the healthy. Medicine defined what health and illness were, and suggested means to safeguard the former. Moreover, medicine and illness are not simply the backdrop to other historical processes. Illness is more than a minor nuisance that happens to people while they live their lives. Rather, it is a major factor in their lives and how they think of it. Illness is not a marginal and deviant occurrence.
The central theme of this book is that medicine is a human experience and as such is embedded in society and culture. Attitudes prevailing in the early modern Ottoman society concerning health and illness did not exist in isolation from the general social and cultural consensus. Hence, medicine discussed here comprises the realm of knowledge and social applications embedded in a specific historical setting, rather than discussed as a universal reality.
The historical setting here is the Ottoman Empire of the fifteenth to seventeenth centuries. The center of attention is the core area of the Ottoman world—that is, the Balkans and Anatolia as far as the Sivas-Kayseri area,’ with occasional reference to the Arab provinces. Although it is possible to see medicine as an ahistorical clinical reality and to focus on nosologies and treatments, here medicine is presented as the socially and culturally constructed and organized responses of individuals, social networks, and professional communities to health and illness.
It is society and culture that endow human medical experience with meaning and that shape various aspects of “reality.”° Here we shall see how Ottomans in the early modern period made sense of their medical realities; we shall see how medical realities and knowledge of medicine were reflected in the minds of Ottomans, who then articulated their perceptions and in so doing shaped the nature of that “reality.”
The study follows the many interactions between medicine (namely, theories and practices), and society (that is, the people who carry those theories and practices—the ill, the practitioners, the healthy). Illness and health do not “belong” to the patients or their doctors but are much wider phenomena embedded in very many layers of social and medical concepts, activities, arrangements, and relationships. There is a constant dialogue in these matters between society and individuals, and this dialogue eventually molds such concepts. Health and illness are social and public events, not only an individual experience and reality.
The basic argument of this book is that the ways in which we conceive health and illness, and organize medical care, reflect the society in which we live. Our understanding of medical concepts and institutions as cultural and social constructs enables us to understand the social organization and cultural values that mold them. Hence constructing the medical-health system of the early modern Middle East tells us who these individuals and their communities were, and what their goals and social values were.
To understand a human society one needs to decode the ways in which the society perceived health and illness. I suggest, therefore, that etiologies, therapeutic techniques, and institutions related to medicine, like hospitals and endowments, are a suitable framework for disentangling the complex and elusive life of men and women in the premodern Middle East. Medicine here is a prism through which we can reconstruct social and cultural realities, and we do not stay within the supposedly strict realm of medicine.
These contexts of medicine result in the presentation of an alternative picture of medicine in the Middle East, one that is less heroic or dramatic but perhaps more real. The binary image so far existing in the literature, either heroic (scientific discoveries, progress) or abysmal (redundant, declining medicine) is replaced by a more nuanced one. Here medicine is linked to other fields of knowledge and social activity shared by medical men, men of letters, men of religious scholarship, and laymen and laywomen.
The links between medicine and the rest of early modern Ottoman intellectual and social life were many and close. Medicine was a subject of high intellectual status and at the same time also a popular, oral, and empiric activity. Such medicine is largely terra incognita, both for historians of the Middle East and for historians of medicine.
The (In)Visible Middle Eastern Ill in the Scholarship
The history of medicine was centered for a long period on physicians, their interests, and their worldview of what medicine and health constituted. This was a medicine “from the inside” as many historians of medicine used to come from various medical fields, like physicians, nurses, public health officers, or medical administrators. It was an “internalist” intellectual history of medicine that focused on recorded achievements.
It was the story of exceptional individuals and their triumphs. The first signs of change were seen in the middle of the twentieth century with George Rosen and some others and gained acceptance later in the 1970s and 1980s.* The changes originated in the expropriation of history of medicine by a new generation of historians with new research interests (like social, financial, political, and cultural factors affecting medicine).
These new historians wrote the history of medicine “from the outside,” introducing new research methodologies borrowed from the social sciences. The result is an interdisciplinary field inviting scholars to consider medicine as a social category. This “social history of medicine” includes such topics as the sociology of the medical profession, medicine and popular culture, and public health.
Two primary goals of most work in the social history of medicine appear to be first the delineation of the profiles of complete local or regional medical communities—that is, of all those who practiced healing of any kind, however varied their level of academic preparation, wealth, status, or full-time commitment to the healing arts—and second, the exploration of the experience of ill health and its treatment across the broadest possible social spectrum.°
One of the outcomes of this new discipline is the positioning of the patient as the focus of study. In a seminal article on the methodology of medical history, the late Roy Porter called the physician-centered account a major distortion of history. He urged the scholarly community to replace it with one that considers how ordinary people have actually regarded health and illness, and managed their encounter with medical personnel.® Porter’s plea to map the experiences of the ill has been heard, and in the last twenty years our body of knowledge of lay perceptions of medicine has grown considerably.
While Roy Porter advocated history of medicine from below, another research path highlighted societal power over the ill individuals via the power of medical knowledge. This theory is associated, of course, with Michel Foucault. He outlined “the great confinement” from the Middle Ages onward. This process of segregation of anyone who was perceived as not able to or as not wanting to conform to everyday routines reached its height in the eighteenth century. It was rationalized by contemporaries as a means to protect the interests of two social groups that conspired together: the aristocratic elite and the rising bourgeoisie.’
This is mentalités history, on the borders between history (here: of medicine), psychology, and social science, at the juncture of the individual and the collective. This elusive French term refers to mind-sets, social attitudes, and the forms through which they are conveyed. These may include language (oral and body) and rituals, among other things. This type of history focuses on decoding the manner in which historical circumstances were portrayed and presented in contemporary sources. Its interest is in image and representation rather than in compiling data.®
There is a fly, however, in this intellectual ointment. The Middle Eastern ill and illness are (still) missing from the pages of history, as work on social history of medicine is clearly Western-oriented. Many historians of medicine did not include Muslim aspects in their discussion and thus produced Eurocentric narratives. An example is Guenter Risse’s masterful exposition of the history of hospitals. Risse traces the evolution from antiquity to contemporary hospitals by favoring the Christian and Anglo-Saxon worlds. It starts with Asclepius, moves on to Byzantium, and focuses on European history, mainly Western (with one subsection dedicated to Vienna), and culminates in the United States.’
We can find a similar situation in the wider field of history for science, where studies influenced by Thomas Kuhn are charting how sciences (in the plural) and their cultures coevolve. Yet even the post-Kuhnian stream of studies that brought in skepticism about the separability of science from society seems parochial if one asks questions outside the European-American medical systems.’ Indeed, for this very reason some historians have criticized the “tyranny” of Anglo-Saxon models forced upon the history of medical systems in non-Western societies. It was mainly Western medicines that were revisited and reconsidered as multifaceted phenomena.
Likewise, scholars of Muslim medicines too have not concerned themselves with the social practice of Middle Eastern physicians, and their interactions with patients did not interest the scholars. The experience of illness and how medicine was viewed from the angle of the ill were also not commented on. Those few studies which did mention illness and ill people described neglect, stoic attitudes, and even fatalism as characterizing the Muslim Middle East.
Medicine in the Muslim Middle East has indeed received considerable attention, yet few have considered it in its social and cultural contexts. Although social history of medicine is a well-established field, for historians of the Middle East it still remains at the periphery of the discipline. While a great deal has been written, very creatively from a methodological point of view, about medicine as a social phenomenon in European and U.S. history, this is a new area of interest for historians of Muslim societies in general and Ottoman society in particular.
History of medicine is a field with a history of its own within Middle Eastern history. The discourse has focused on famous physicians and their great medical discoveries, or, alternatively, the intellectual decline thereof. As Emilie Savage-Smith has observed in a state-ofthe-art article, the questions that have customarily been asked of early Islamic science have concerned the reception, transformation, and transmission of earlier scientific ideas. This was the rather traditional text-bound approach to the history of Islamic medicine.”
Manfred Ullmann’s Islamic Medicine, published more than thirty years ago, is symptomatic of the scholarship that reigned supreme for a long time.’ Under this title Ullmann focused exclusively on only one type of Muslim medicine, presenting it as the only medicine there was, or the only type that counted as “medicine,” the others being mere folklore or superstitions. For him, medicine was an intellectual activity, rather than a social phenomenon embedded in a specific culture. And Muslim medicine was presented as an Arabic medicine in the sense it existed (that is, was written) in Arabic. Ullmann studied Arabic manuscripts minutely, since he, like other scholars of his period, among them Max Meyerhof and Joseph Schacht, came from an academic background in Arabic philology.’ Moreover, Ullmann was very much influenced by the “decline theory.” This paradigm maintained that after a golden period under the Abbasid caliphate, continuous decline started in the Muslim world as a whole.
It encompassed all aspects of Muslim life, including intellectual and scientific thought. These two factors explain Ullmann’s almost total silence on Turkish and Persian medicines. According to Ullmann, after the end of the Islamic (Arabic) golden age in the thirteenth century nothing good or innovative happened in Muslim medicine till the westernization of the nineteenth century. Hence, Ullmann devoted only a small portion of his book to the Ottoman period, and the few Ottoman physicians who are mentioned are only those who wrote in Arabic and were accessible to him.
Only in the beginning of 2007, almost thirty years later, were we presented with an updated replacement to Ullmann’s monograph in the form of Medieval Islamic Medicine, which was included in the New Edinburgh Islamic Surveys." The different title is telling. Peter E. Pormann and Emilie Savage-Smith declare the mandate they took upon themselves: they surveyed medicine in a specific historical reality, that of medieval Muslim societies. Intentionally they left out later Muslim medical systems, like the Ottoman. However, they end their excellent survey with a chapter entitled “Afterlife” where they discuss in brief various trends in Muslim medicine in the Middle East, Persia, and India from the early modern period till today.
A rare example of scholarly work focused on Persian medicine is the that of Cyril Elgood, who published several monographs on premodern Persian medicine using Persian sources.’? However, other than the choice of a different geographical scope, Elgood’s work represents the same scholarly fashion as Ullman’s. In terms of methodology, both were text-bound and interested only in learned (that is, written) medical traditions. They belonged to the same historiographical generation.
Meanwhile, from the 1930s onward, many studies on Turkish medicine have been published, but in Turkish (the authors were Turks), which made them inaccessible to most Western and Middle Eastern readers. These scholars, such as Osman Sevki Uludag, Mehmet Cevdet, Adnan Abdtilhak Adivar, Ahmet Stiheyl Unver, and Bedi N. Sehsuvaroglu did focus on medicine in later periods in the premodern Muslim world, including the Ottoman period.’®
Despite these noted differences, the two groups of scholars were partners in a similar discourse on the history of medicine in a Muslim society. First, both groups wrote a “Whiggish” history, looking for heroes, success stories, and scientific progress. They were fascinated by what Charles E. Rosenberg described as “a past that could be constructed as progressing toward an enlightened and ethical present. The intellectual significance of individuals and events was seen in terms of their relationship to the development of a contemporary understanding of the human body and not to the particular historical context in which those individuals worked and thought.”’” Second, if one group focused on medicine in Arabic to the exclusion of other types of medical activity, the other’s focus was mainly Turkish. Furthermore, both groups concentrated on “learned medicine.”
They downplayed the importance of other types of medicine, so-called popular medicine, and thus not “scientific” and important. Their studies too were text-based and tried to discern “what happened” rather than why history unfolded in certain ways or medicine’s relation to other processes in society (economic, social, cultural, or intellectual). They did not pay attention to medical clinical reality and those who shared in its practice, healers and patients alike.
All was not static, however. There were intellectual changes in the 1970s, when historians of the Middle East started to write about medical education and professionalism, hospitals, plagues, and westernization and modernization. Some of these studies were prepared by scholars like Franz Rosenthal, an Arabist. Rosenthal previously had worked on the concept of knowledge in medieval Arabic Muslim society and the classical heritage in Islam. Now his work included studies on gambling, hashish, and other narcotics, and on the medical profession, although still within the context of “high” and learned medicine."
It is especially in the past quarter of a century that there has been a new wave of studies on medicine in the field of Islamic studies. In part these studies were inspired by the new trends in history of medicine in general, within which social aspects have gained momentum in the last thirty years. These studies showed that a body of evidence pertaining to the experience of illness in the historical Middle East still exists. If the ill and disabled were left in history’s shadow, it was because they were hidden from scholars’ sight, rather than due to contemporaries’ lack of interest. Let me select three names to illustrate the considerable distance the field has gone, and that there is still a long way to go. The attention of most historians of Islamic science was and still is directed toward Arabic sources. The vast quantity of Turkish and Persian manuscript and archival sources still interest only a few scholars."
One of the first “encouraging trends,” as Savage-Smith termed them in the late 1980s, is the research of Michael W. Dols, who wrote several pioneering works on various aspects of plagues, leprosy, hospitals, and madness in the medieval Muslim Middle East. He lays the groundwork for understanding the physical realities as well as the social and cultural aspects of illness and disability.” Lawrence I. Conrad has been carrying the torch since Dols’s untimely death with regard to studying plagues in the early Muslim Middle East (as well as other topics related to the history of medicine).”!
A second name is Khaled Fahmy. Fahmy considered modernization and state building in late nineteenth-century Egypt, mainly under British rule, through the prism of medicine and medical institutions. His main interest lay with medicine and power, whether between the state and its organs and the population, or between genders.” It is interesting to note that the geographical area of North Africa and Egypt has been privileged more than other regions of the Middle East to be the focus of studies on the history of medical professionalism and public health in the late eighteenth and early nineteenth centuries.”
While illness in either the medieval or modern periods has started to be addressed, the examples above demonstrate there is still a lacuna in the scholarship with regard to the early modern period. In most of the publications the ill do not occupy a central spot. Instead, the studies focus on demography and internal and international politics rather than on the realities of individual ill people.“ Certain remnants from previous trends in scholarship still linger.
The majority of the work on this period is still conducted in Turkey, by Turkish scholars, in the Turkish language. A minority (although a growing one) publishes also in English or German,” but with few exceptions they too do not seek audiences outside Turkish academic journals. More importantly, to a large extent work on Ottoman medicine is still a “history of heroes.” Ekmeleddin fhsanoglu, without whose publications any survey of studies of Ottoman science cannot be complete, and the third name to be mentioned here, referred to this point. In the preface of his collection of articles published by Ashgate in the Variorum Collected Studies Series Ihsanoglu presented his research program. He explained that while studying the history of Ottoman science it is imperative to consider nonscientific activities, like political, economic, and social factors, as well.” Despite this declaration in Ihsanoglu’s own work, descriptive narratives of physicians and the contents of their manuscripts are the usual context. The few ill people who do appear are discussed under the heading of “famous illnesses of famous people,” which is yet another version of the history of “big names.”
The present book tries to contribute to filling up some of the gaps in our knowledge and understanding of Muslim medicines in past Muslim societies by focusing on two major areas so far neglected in Middle Eastern history: Ottoman medicines and the experiences of illness. It is done by offering a work of fusion. In addition to social history of medicine brought into a Middle Eastern context, there are other fields of research from history and social sciences pertaining to medicine and illness that are absorbed into this book. They help to ask and attempt to answer basic questions about what illness was as a human experience. The result, it is hoped, is a thick description of this phenomenon in the early modern Middle East. In focusing on the early modern Middle East, this study adds to the growing literature on medicine and society in non-Western societies. Moreover, in this way cross-fertilization is achieved: This work considers research issues raised by historians and anthropologists of Western societies, adjusts these topics to the Ottoman case, and tries to discuss them in a context that can enrich works on Western medicine as well.
Recent evolutions within history, for example, have had an influence on this study. The first is “disability history,” which in its present form was launched in the middle of the 1980s. Disability was added to historical inquiries as an analytical category of society on a par with key terms like “gender,” “race,” and “class.” It thus adds another theoretical tool to exploring the “Other.” As in the case of social history of medicine, physical impairment is considered here as (only) a part of a multifaceted reality of abnormality that also includes social and cultural power relations that may yield oppression and inequality.” Disability studies focus on the interaction between individuals and their society.
The second evolution within recent history unfolds a story of interaction with the organic world. This is “environmental history” — that is, the story of humanity as a participant in local, regional, and worldwide ecosystems. In the words of Emmanuel Le Roy Ladurie, the field embraces climate, epidemics, natural calamities, population explosion, urbanization, industrial overconsumption, and pollution.”
The present work does not make nature and the environment its focus, but reflects on the fact that early modern Middle Easterners were aware of the environmental consequences of their behavior. Moreover, the category of “nature” adds an important dimension to medicine and health; the context of ecology with its physical and moral dimensions. It highlights the fact these are also, to a degree, ecologically circumscribed.
The dynamics in the realm of history did not occur in isolation from changes within anthropology, including its exciting and promising subdisciplines of medical anthropology.” The goal of medical anthropology is the comprehensive description and interpretation of the interrelationships between human behavior, past and present, and health and disease. Another aim is the improvement of human health levels through greater understanding of health behavior in directions believed to promote better health. The field has a wide range of interests, some of which are close to biology (human development, genetics, etc.). Other of its interests are closer to sociology and culture. These involve “ethnomedicine,” medical personnel and their professional preparation, illness behavior, the doctor-patient relationship, and the dynamics of the introduction of Western medical services into traditional societies. The field bears a Geertzian influence in considering medicine as a public cultural phenomenon rich with symbols and values.
It is, however, the understanding of medicine as a composite system, made of subsystems and multiple institutions, beliefs, and practices, that most influenced the present book. At the same time, beneath the surface of luxuriant variety, several unifying principles and mechanisms operated to bring systematic organization to the seemingly random action (here Claude Lévi-Strauss and structuralism contributed to medical anthropology). We shall see that the Ottoman Empire produced a variety of medical systems rather than one, universal and uniform. Yet they interacted in a way that proved that there was one “medical space” in which they all participated.
Medical anthropology formulates several universals, some of which echo findings from social history of medicine. These are that medical systems are integral parts of cultures; that illness is culturally defined; that all medical systems have both preventive and curative sides; and that medical systems have multiple functions, in addition to caring for a patient, among them enacting social roles and norms or offering devices to control behavior. Although the infrastructures that make up a medical system are accepted as very powerful and can shape human action, medical anthropology leaves room also for the doer, presenting the actor’s point of view. IIIness is also what people make within the constraints of the system they operate in; they are active persons who shape their reality and are not mere passive recipients.”
The Aims and Scope of the Book
The ill and their illness in the Muslim Middle East were missing from historical narratives but certainly not from historical realities. A society never stops being interested in medicine and health, and never neglects trying to improve them. This is after all a very basic human need, both mentally and physically. It was certainly so in the early modern Middle East, where life was riddled with health hazards and death lurked at every corner, with life expectancy at around the age of forty. Such is the hunger for preserving health and curing illness as commodities that there has nearly always been a buyers’ market for them. However, buyers, suppliers, and, indeed, markets have varied enormously, not only over time but also within a country in any one period, with different groups and classes of patients patronizing different types of medical practitioners.*! The present book shows that the Ottoman understanding of health and usage of medicine were much more complex than previously envisioned.
This volume does not claim to deal with every aspect of health, disease, and medicine in the early modern Ottoman Middle East. Although readers will find here a wide-ranging study of some aspects of medicine in the Ottoman Middle East, the book in no way pretends to present the definitive history of Ottoman health care. This has yet to be written. Such an attempt at comprehensive coverage would have led to too much diffuseness in a volume of the present length or to an unacceptably long monograph. Consequently, I have preferred to include detailed studies of certain important issues pertaining to health and disease and agencies of health care and leave other important but so far neglected questions to future investigations.
Thus, one task this book takes on is to chart the gaps in our knowledge and understanding with regard to Ottoman medicine and health. Many aspects have not been written about because this cannot yet be done. Sources are still to be located, studied, and deciphered. Methodological problems are to be solved, mainly the tangled and not always obvious relationship between the sources pertaining to health care (medical, legal, financial and literary) and historical medical reality.
Intentionally I chose to follow a topical framework rather than a geographical or chronological one. The benefit of this approach is that it scans a wide spectrum of discussion on medical topics. The four chapters and conclusion portray Ottoman health care in a way that weaves together social, cultural, and political dimensions into a coherent picture of a complex, multifaceted system. As an aid to facilitate orientation with the main Ottoman medical institutions, I include a list of the main hospitals discussed here as an appendix.
Each of the four numbered chapters of this book deals with different aspects of health beliefs and health maintenance and preventive practices that existed in the early modern Middle East. The chapters discuss various sectors in society that were involved in medicine, among them are professional healers, patients, health administrators, and philanthropists. They explore issues of power, knowledge, personal and social norms, and social structures and networks related to medicine and health. The chapters explain how both the personal and the communal affect the perception, experience, and expression of health and illness and how care is delivered. They illustrate how elite and nonelite Ottomans talked about medicine and health and how they lived it. Two realities unfold here: a discursive one that exists in the realm of language and thought, alongside a social reality of how people experienced medicine and health in concrete life experiences.
The first two chapters discuss treatment as intervention, whether symbolic or instrumental, and show etiquette, treatment style, and therapeutic objectives. The chapters show that practitioner and patient shared in the responsibility for the treatment: decisions about its nature and course and its ultimate success are determined by both. The medical reality of the early modern Ottoman world was that of medical ideas and skills widely disseminated in the community and not segregated in the profession. Laymen could understand as well as manipulate many medical ideas, and the result was a shared medical language for both healers and patients.
The first chapter, “Medical Pluralism, Prevention, and Cure,” presents the medical settings: what types of medicine existed in the early modern Ottoman Empire and the Middle East. The Ottoman medical system was based on several traditions—Galenic humoralism, folkloristic medicine, and religious medicine. Like in our modern medical system (which features the existence of “alternative” medicine), various traditions complemented one another and competed with one another for hegemony (and finances) within the medical system. The discussion revolves around medical theories and actual therapeutics, and tries to get as close as possible to the patient’s bed: how were patients really treated at home and in the hospitals? Clinical reality can be elusive, as medical practice was not necessarily identical to the medical theory discussed in learned treatises. The chapter highlights two characteristics of Ottoman medicine. The first: in contrast to our modern medicine, Ottoman medicines emphasized preventive measures rather than curative, “heroic,” and invasive procedures. The second characteristic is that medical options were tied to social and economic realities. Medicine was a means for social demarcation and in turn helped to reinforce those status distinctions.
Chapter 2, “ ‘In health and in sickness’: The Integrative Body,” continues to discuss the interaction between medical theory and clinical reality, but here the emphasis is on the integrative dimensions of Ottoman medicines. The chapter argues that all the traditions that make up the Middle Eastern medical system shared an integralistic approach to healing. All recognized that the emotional, spiritual, physical, and ecological elements of each person comprise a system, although the exact definition of each component and the relative balance between them varied from one medical tradition to another. This was on the theoretical level. On the practical level, the chapter demonstrates how all medical traditions attempted to treat the whole person, concentrating on the cause of the illness as well as symptoms.
The chapter stresses four examples where such philosophical, psychological, and theological attitudes were most apparent: the use of all the human senses in the healing process; the intentional use of belief in various forms (belief in oneself, in one’s healer, or in God) to promote health; the importance of water for the constant upkeep of hygiene and for therapy; and finally, Ottoman perceptions of health and illness as much more than physical conditions. This chapter helps us to understand the distinction between health and well-being, as the latter was not the medical absence of illness but also the ability to live a full social life. This last section in the second chapter serves as a summation to the first two chapters. It explains why although Ottomans ascribed much importance to preventive medicine, as explained in the first chapter, there were nevertheless many curative measures. Indeed, there were multiple means to treat all kinds of aches and ailments. This feature of Ottoman medicine goes hand in hand with the great significance Ottomans attached to health and the major political, social, cultural, financial, and religious consequences of ill health in that society.
This book is also about how that society organized health care and its institutions. This is the subject of the third chapter, “ ‘Feed the hungry, visit the sick, and set those who suffer free’: Medical Benevolence and Social Order,” which discusses how charity was a basic financial and legal mechanism for medical aid in general and for hospital management in particular. The chapter considers the two sides of charity, the partners to the “gift exchange”: those who offer it (e.g., the founders of hospitals) and the consumers (e.g., the patients in the hospitals). The discussion reveals that benevolent donors had concrete materialistic and political aims in this world, in addition to gaining merit for pious deeds in the world to come. More importantly, by discussing medical philanthropy we can discern two related social process. One was the means by which medical charity expressed and controlled Ottomans’ conceptions of belonging to their society during the early modern period. Those who were entitled to medical services were so entitled because they were members of Ottoman society. An interrelated aspect of this issue was the means by which medical aid reveals the identity of marginal groups in Ottoman-Muslim society. While clearly there was a process of marginalization in action in pre-modern Ottoman society, this was not a society that was quick to exclude minority groups from within the larger community. The second process was using medical charity for social order by controlling people’s behavior, through moral and professional codes, financial resources, and a sense of obligation. In other words, medical charity is presented here as a means to bring about social cohesiveness.
Chapter 4, “Spaces of Disease, Disease in Space,” examines the physical setting of hospitals in the Ottoman Empire in the early modern period. I present this physical setting by investigating the location and structure of hospitals in the Ottoman realm as a whole and within the urban space in particular. My aim is not to focus on the architectural aspects of these buildings as such. Following Charles E. Rosenberg’s The Care of Strangers on the rise of the American hospital system,” I use hospitals as a means to learn about social and cultural assumptions that are otherwise not easily visible; since they govern hospital life, they are revealed. I discuss the perceptions of these buildings by contemporary Ottomans as a reflection of the competing etiologic theories (miasma, celestial causes, contagion, and jinns) that were at work in the Ottoman society. Their existence explains the diverse (and sometimes opposing) Muslim medical and religious attitudes toward diseases, like the plague, as some stayed put and some ran away. Ottoman hospitals were an epitome of one medical tradition, humoralism, and thus an epitome of the ecological concepts embodied in this medical tradition.
The final pages of the book are dedicated to two questions that are hinted at in previous chapters. First, how far and in what ways was the Ottoman medical system indeed “Ottoman”? Second, was this medical system at all successful in Ottoman eyes? By reconsidering issues analyzed in the previous chapters, the discussion here confronts the question of the extent to which medicine is a universal and cosmopolitan entity, or else is embedded in specific social and cultural contexts.
Several themes weave the chapters together. One is the discussion of multiple and contradictory /conflicting morals and worldviews. Ottoman medicine was a blend of customs, ideas, and realities aiming to solve a constant human problem—illness and death. Individuals and communities decided for themselves issues like right and wrong, true or false. Ottomans selected their own medical paths to follow as occasion arose (and it always did). The story throughout the book is one of constant interpretations and contested ideas and ideals. Society juggled different medical beliefs and customs, and different medical professionals competed among themselves and with the widespread tradition of self-treatment. We learn of the harmonious but sometimes tense or ambiguous and overlapping relationship between traditional and customary medical and health practices and innovations, between public and private considerations, between the individual and his worlds, between individual needs and societal ones. The narrative explores the process of the failed attempts to establish one medical system as canonic and defuses dichotomies like high/learned/elite versus low/oral/popular in the medical realm. It is a story of the dynamics of dissemination and transmission of medical knowledge. The relationship between producers, transmitters, and consumers of that knowledge changed, yet all played active roles in the realm of medicine, albeit different ones.
Balance (Arabic, mizén), too, serves as a theme throughout the book. The chapters bring forth various balances pertaining to the human being; some are “real,” physical, while others are symbolic. The opening two chapters present balances within the human being. The first chapter discusses various working explanations existing in Ottoman medicine concerning the physical balance in the body. These explanations were different interpretations of what Greek Galenic medicine termed “humors,” the four basic “fluids” of the body (blood, phlegm, black bile, and yellow bile), corresponding to the four elements in nature (air, water, earth, and fire). The second chapter tackles the balance Ottomans sought to establish within the body between body and soul, between the material and the spiritual. There is a pattern of the integrative, or holistic, in Ottoman medicine. The following two chapters leave the body and seek to position man in balance with his social and physical surroundings. The third chapter discusses the balance between the individual and society via the obligation to give and the need to receive. The chapter explores various needs of society and how the elite controlled it by balancing the offerings of medical charity between as many groups as possible. The fourth chapter picks up the ecological balance: the fact that man had to be one with his surrounding nonhuman world. This theoretical moral concept had physical implications in the situating of hospitals within the urban space and in the organization of their inner space, such as the inclusion of walls and gardens as an integral part of the hospital.
The last two numbered chapters are connected in discussing the community and its borders, in the social context (chapter 3) and in the physical meaning of quarantines and hospitals’ walls (chapter 4). Medical charity, with its choice of entitled beneficiaries and the implementation of etiological theories in the realm of public health, reveals what Muslim Ottomans understood to be their community, who was part of it, who was regarded as being on the fringes, and who belonged at all. IIIness was one of the indicators of the “other” in early modern society; yet it was not a final marker. Even while ill and admitted into hospitals, people were not cut off from society. Hospitals were situated in most cases in very central places in the urban space. Once illness (including lunacy) was removed, the ad hoc marginalization stopped and people were reintegrated into society.
The book discusses inter alia various aspects of medical professionalism. It is brought up in the first chapter while discussing surgery. The Ottoman period saw growing professionalism within medicine. The institutionalization of surgery as a discipline of its own, for example, was one aspect of this process. Medicine is discovered to be a body of knowledge and a profession that arouses opposing emotions. As discussed in the third chapter in the context of physicians working pro bono as a form of medical charity, there was a debate about the nature of occupation: was it indeed a noble calling, a field of knowledge (ilm), or a craft (sina‘a)? The conclusion sums up by saying that medicine as a body of knowledge was respected, even admired; but the profession elicited some disparagement. Medical healers were idolized in some sources as having special knowledge and capabilities for the good of people, but in many others they were the target of jests and were accused of charlatanism, miserliness, and foolishness. Physicians were feared because of their ability to harm people, whether intentionally (they were able to do so with their gifts of special knowledge and capabilities) or unintentionally, as a result of an error. Yet physicians were sued for their failures. This shows that they did not induce that much fear in their patients.
The treatment of this subject here only scratches the surface and will be scrutinized in another study, but we can safely say that whatever the precise reaction medicine and medical professionals caused, one thing did not happen: they were not ignored, nor taken for granted, nor met with indifference.
In preparing this work, several problems had to be solved. One was the need to place limits on a topic that entices its students to deviate to other relevant subjects. As Mary Lindemann observed,* the history of medicine and society is especially notorious for presenting such a challenge. There are numerous routes through which one may trace the concepts and organization of health and illness in a given society. The solution was a combination of selections followed rigorously, yet within these selections I allowed myself to be tempted to broaden the discussion.
A choice was made of (only) one route to follow, and this is the interplay between knowledge and practice. Knowledge and practice shape each other; moreover, much of what we know about an object can be attained through the practices surrounding it. Each chapter deals with these two aspects of medicine, their complex relationship with each other, and their relationships with society. Yet this theme was a springboard to discussions of several basic principles that govern human lives and how abstract concepts about life and death, health and illness, entitlement and obligation, nature and the environment, are put into social praxis. Hence the various chapters deal with medical, legal, and literary discussions and clinical realities and their social meanings (chapter 1), holistic therapeutics and concepts of health (chapter 2), medical welfare and philanthropy as connected to social discipline (chapter 3), and, lastly, medical institutions and urban space and nature (chapter 4).
Another means of focusing the discussion was to prefer the urban segment of society. The geographical scope of the book is the central urban centers in the Ottoman Empire, and it does not comment on the medical realities of the rural parts of the empire. This is not to say that the peasants lacked medical attention. Rather, medical aid in the countryside was organized in a different way, and as a result is excluded from this work. As the rural area encompassed the majority of the empire in terms of geography and population, this book should be followed by a sequel.
In my case, I believe the focus here has several merits. First, the urban centers were the seats of Ottoman power. The state was more salient in the cities. The empire maintained a system of several urban centers. The Ottoman capital moved from Bursa, the first capital in the fourteenth century, to Edirne in the 1360s and finally to Istanbul after the conquest of Constantinople in 1453. Even after the official move, the previous capitals retained some power and imperial symbolism. Sultans invested in magnificent complexes of buildings in Bursa and Edirne many years after they officially sat in another capital. Several seventeenth-century sultans moved their royal court to Edirne for several months each year. The Ottoman ideology was further disseminated through a network of provincial centers in western and central Anatolia that hosted princes’ courts. Until the days of Siileyman I in the sixteenth century, teenage Ottoman princes were sent off to such towns to mature and acquire hands-on experience in administration and politics (another object was to distance a potential heir to the sultanate from the center and reduce his political threat to the reigning sultan, till his death). In these urban centers the Ottoman state and Ottoman elite were visible and active, and so it was also in the medical realm.
Another reason to choose this specific geographical area is related to the first one. As these centers were the seats of power, they were better documented. The central administration was naturally interested in regulating these places politically, socially, and financially. The Ottoman elite lived here, and here it patronized cultural and intellectual activity. It was in the centers that manuscripts on every subject imaginable were produced, works related to medicine included. The same scholars also documented the activities of an elite that was involved in medicine as patients and as patrons of medical charity. The centers drew many travelers, both locals and Europeans. They were diplomats, merchants, and adventurers. Some of them were interested in medicine, botany, and nature. They all wrote later about their experiences and impressions of medicine and health in the Ottoman Empire.
The subject of the book and its focuses determined the sources, and this was the second problem that had to be solved in preparing this work. Because this is the first foray into the social history of Ottoman medicine, the sources for this kind of research had first to be found and evaluated. As the point of departure is the center of the empire, I located the sources representing the viewpoints of the three capitals. In addition to the geographical aspect of this selection, these sources are the product of a certain social group—namely, the political, social, and military elite of the Ottoman Empire. The sources range from the foundation deeds of the hospitals, the annual reports of the pious foundations (muhasebe defterleri), decrees of the sultans (sing. ferman), to medical treatises, travel literature, and biographical dictionaries. There is a variety of written sources—archival, literary, and medical—as well as pictorial miniatures in manuscripts depicting medical scenes. The more diverse the sources, the more complex the picture we can construct out of them, and therefore gain closer access to the realities of the premodern era.
Our understanding of what constitutes “health” and “illness” is ever changing. Here we focus on the early modern period. Focusing on the early modern period is not an arbitrary choice. I borrow this periodization from European history, although it is not a natural outgrowth of Middle Eastern realities. Moreover, it is an artificial term in the European context, too. However, “early modern” recognizes the beginning of a new period and world in the fifteenth century, a period and world different from the previous one, that of the Middle Ages.
In Europe “early modern” is the period of the humanists and Renaissance, a profound intellectual change intertwined with deep changes in society and economy, including religious ideas and institutions, politics, the state, and warfare. This was the age of technological and scientific discoveries and advances like the printing press or sea voyages. The modern experience of Europe and the end of the old ways Starts in the late eighteenth century with the fall of the ancien régime and industrial society replacing an agrarian one. Medicine was linked to all these changes and was thus affected too.
For the Middle East with regard to medicine I define “early modern” as the fifteenth through the seventeenth centuries. I argue that Middle Eastern medicine changed profoundly during this period. Intellectually, professionally, and administratively it is a period that should be studied on its own merit. Moreover, the fifteenth century through the seventeenth century was a period that became a formative link between medieval medicine and the modern medical system in the Middle East. It was a period when Ottoman medicines went through systemization, organization, and professionalization on a scale not experienced before. Throughout the book various aspects of this process will be discussed. The conclusion will argue that these changes in the realm of medicine are not separable from the wider process of Ottomanization that various institutions went through during the fifteenth to seventeenth centuries, changes that set the stage for the modern medical systems of the future.
I have in mind hospitals, a prominent medical institution, and the Ottoman Empire, the important political entity in the region in that period, as a dual yardstick. After a period of an almost complete halt in the foundation of large-scale hospitals in the later Middle Ages (from the Zangids onward only a few new big hospitals were erected), the Ottomans renewed with gusto the tradition of imperially patronized hospitals and were associated with hospital foundation from the late fourteenth century. Whereas hospitals were founded in major cities all over the Ottoman Empire in the fifteenth and seventeenth centuries, this activity came to a halt in the eighteenth century. When it was resumed at the end of the end of the eighteenth century, again the hospitals were founded with elite and even imperial backing, but they were of a different type. New hospitals in the eighteenth and nineteenth centuries were established against the background of reforms based on Western models of modern society, culture, and state. These reforms touched upon medicine and hospital management as well as upon so much else. The medicine practiced in the new westernized hospitals was not humoralism, the medical theory studied and practiced for hundreds of years by Muslim and Ottoman doctors within and outside hospitals as learned medicine. Instead, patients were now treated according to a new conceptualization of medicine, illness, and health that emphasized biology and pathology over the holistic and human approach of previous centuries. The conceptual changes affected the location of new hospitals, too. New hospitals were no longer part of the charitable complexes system—that is, imperial complexes composed of mosques, soup kitchens, and several other dependent charitable institutions.* The post-1700 medical realities and changes lie therefore outside the scope of this work.
The early modern period was a period of change in Ottoman medicine. At the same time, there was also continuation. Hospitals serve again an example. On the one hand, they were physically bigger than the pre-Ottoman Muslim hospitals. They employed a larger staff that displayed wider medical capabilities and a higher level of medical professionalism. Yet the medical, administrative, and architectural basis for this new hospital was clearly that of previous centuries. The Ottomans, as in other aspects of their culture, drew on previous traditions and made them their own.
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