Old patterns, new meaning : the 1845 hospital of Bezm-i Alem in Istanbul

DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. Old patterns, new meaning: The 1845 hospital of Bezm-i Alem in Istanbul MIRI SHEFER (*) BIBLID [0211-9536 (2005) 25; 329-350] Fecha de recepción: 18 de noviembre de 2004 Fecha de aceptación: 28 de febrero de 2005 SUMMARY 1.—Introduction. 2.— Bezmi-i Alem’s hospital: a new hospital following established Ottoman traditions. 3.—The Bezm-i Alem’s hospital: a new and european type of an institution. 4.—The context of the Bezm-i Alem’s hospital: the Tanzimat reforms. ABSTRACT This paper discusses the history of an 1845 Ottoman hospital founded by Bezm-i Alem, mother of the reigning sultan Abdülmecit I (reigned 1839-1856), embedded in the medical and political contexts of the Middle East in the nineteenth century. The main focus of this paper is the Ottoman discourse of modernization, which identified progress with modernization and westernization and included a belief in the positive character of progress, with a high degree of optimism regarding the success of the process. The Bezm-i Alem hospital illustrates the medical reality of the 19th century, reconstructed through Ottoman eyes rather than from the perspective of foreigners with their own agenda and biases. In many respects it continued previous medical traditions; other aspects reveal brand new developments in Ottoman medicine and hospital management. Ottoman medical reality was one of coexistence and rivalry: traditional conceptions of medicine and health were believed and practiced side-by- side with new western-like concepts and techniques. (*) Dept. of Middle Eastern & African History. Tel Aviv University. Israel. Email: [email protected] An early version of this paper was read in March 2003 at the Hadassah Convoy Memorial Conference of the Israeli Association for the History of Medicine and Science in Jerusalem. This research was supported by the Israel Science Foundation (grant #535/04). MIRI SHEFER 330 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. Palabras clave: hospitales, mujeres, modernización, Imperio Otomano, Oriente Medio, siglo XIX. Keywords: hospitals, women, modernization, Ottoman Empire, Middle East, 19th century. 1. INTRODUCTION The Istanbuli hospital, SSK Vakıf Gureba Hastanesi, one of the great medical compounds of today metropolis, has a very symbolic address. It stands on «Homeland Boulevard» (Vatan Caddesi), known also as «Adnan Menderes Boulevard», after Turkey’s Prime Minister in the 1950s, in Fatih Quarter, celebrating the Ottoman Sultan Mehmet II Fatih («The Conqueror») who conquered Constantinople from the Byzantines in 1453. Like the address of the hospital, which combines names from the present Turkish Republic with memories from an Ottoman imperial past, so does the history of the hospital. It brings us back to the Ottomans, and this past explains why a hospital is situated at this specific place. The Ottoman past is not an abstract memory, as to this day physical signs are still present: in front of this ultra-modern hospital stands a renovated mosque dating from the middle of the nineteenth century. The mosque still carries its original name: «The Mosque of the Queen Mother, Bezm-i Alem». The mosque is a remnant of a previous layer of this site when an Ottoman hospital, founded in 1845 by Bezm-i Alem, the sultan’s mother, was situated here. The site has been used for medical purposes ever since. The hospital was transformed into a university hospital for the first time in the 1920s but only for a few years. Following the University Reform (1933) it was utilized again as a training facility attached to Istanbul Medical Faculty, and various clinics were opened (dermatology, otorhinolaryngology, and several clinics for internal medicine) (1). Today it is one of the hospitals run by the Ministry for Health and Social Security and its name today bears its relation to welfare policy: the formal name of the hospital starts with «SSK» for Sosyal Sigortalar (1) EFE, Suat. Gureba Hastanesi’nde Faaliyet Göstermiş Olan İstanbul Tıp Fakültesi Klinikleri. Yeni Tıp Tarihi Araştırmaları, 1996-1997, 2-3, 176-188. Old patterns, new meaning: The 1845 hospital of Bezm-i Alem in Istanbul 331 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. Kurumu, or Social Securities Society. The hospital is obliged to treat sick people free of charge when they fulfill formal criteria of social and financial need, in addition to the regular paying patients. The statistics for the year 2000 reveal that on average, one thousand people were treated in the hospital per day and thirty four to fifty surgical procedures carried out daily (2). This paper discusses the history of this Ottoman hospital and the role of its female founder within the medical and political contexts of the Middle East in the nineteenth century. The main focus is the Ottoman discourse of modernization that identified progress with modernization and westernization, driven by a (naïve?) belief in the positive character of progress and a very optimistic view about the success of the process. The paper reconstructs Ottoman understanding of what was occurring and what decision makers wanted to achieve in the medical and political scenes. So far, such cases have usually been studies from a western perspective, in terms of objectives, speed and success. Here we shall see a Middle Eastern and Muslim example, reconstructed through Ottoman eyes, rather than how foreigners saw it with their own agenda and biases. I base myself on Ottoman sources inaccessible to many scholars of medicine due to the language barrier (3). I focus on the 1845 hospital which has attracted little scholarly attention so far. Bezm-i Alem was not the impressive figure of the sultan, «only» his mother. Middle (2) This state institution of SSK was founded in 1965 as a first step in the development of Turkey to a welfare state. It provided insurance for medical care, insurance against work accidents and life insurance. On contemporary criteria to free admittance into the hospital, see the details specified at the Directorate of Charitable Endowments website, <http://www.vgm.gov.tr/08diger03.html> (last visited on February 22, 2005). For the activities of the hospital in recent years, see Adem Yavuz ARSLAN, Herkesin Gözü Gureba’da. In: <http://www. aksiyon.com.tr/detay.php?id=13658> issue #313, December 2, 2000; Gureba Hastanesı Ortada Kaldı. In: <http://www.aksiyon.com.tr/detay.php?id=11848> issue #387 (May 6, 2002) (both visited last on February 22, 2005). Aksiyon is a weekly internet magazine run for ten years from Istanbul. MIRI SHEFER 332 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. Eastern women are less famous and less well documented, than their male counterparts, especially in European sources. This contrasts to Ottoman sources, as Bezm-i Alem was certainly well-known for Ottoman observers. Moreover, Bezm-i Alem’s hospital mirrors the transformations, which took place in the medical realm in the Middle East at that time. The nineteenth century was a period of major transitions in the Ottoman Empire. The Tanzimat reforms (literally «organizations») introduced institutional changes that affected state and social organs. Medicine and medical institutions were included, although the final aim was not necessarily to improve the well-being of the citizens (a new concept of its own in the Ottoman Empire), but rather to improve state management. Prior to the nineteenth century, Ottoman society knew three medical systems: Traditional Muslim medicine based on the Humouralistic system inherited from Greek Antiquity by way of translation and adaptation by Arab physicians during the Middle Ages ruled supreme in pre-modern Muslim hospitals. In addition, there was Religious Medicine, based on the sayings of the Prophet Muhammad, and Popular Medicine, sanctioned by customs and oral traditions, but they were practiced outside hospitals. Humouralistic medicine enjoyed the patronage of the Ottoman urban elite and thus served as the literate, learned (or «high») medicine in the Ottoman Empire. However, during the nineteenth century, this medicine had to give way to another type medicine sponsored by the same Ottoman elite, medicine influenced by Europe, emphasizing biology and pathology. More broadly, it was a period of change in Ottoman definitions of health and illness, which was part of a profound shift in Ottoman society and culture. Bezm-i Alem’s hospital was a new institution but it did not offer an unknown concept of medicine. It was founded in 1845, after the first and «heroic» wave of medical westernization took place in the (3) To make the article accessible for English readers who are not familiar with Ottoman Turkish, Arabic and Persian, I transliterated historical terms and names into modern Turkish which is based since 1928 on a modified Latin alphabet and eliminated under-dots on consonants and macrons on vowels. Old patterns, new meaning: The 1845 hospital of Bezm-i Alem in Istanbul 333 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. 1820s and 1830s, organized by Mahmut II (reigned 1808-1839). It reveals therefore that western ideas were becoming something of a medical convention in mid-nineteenth century Istanbul. The process sketched here was one of gradual and complex transformation. The first Ottoman interest in new European medicine occurred toward the end of the seventeenth century with the translation of the German-speaking physician Paracelsus (Philippus Aureolus Theophrastus Bombastus von Hohenheim, d. 1541) on chemical medicine into Arabic and Ottoman-Turkish. Paracelsus offered a potent alternative to Galenic Humouralism. But it was more intellectual curiosity than something that had real lasting effect on Ottoman medicine and practice (4). Even when European medicine became more visible in Ottoman society during the nineteenth century it certainly did not replace the older medical traditions present in Ottoman society for centuries. Instead there was a reality of coexistence, traditional conceptions of medicine and health were believed and practiced sideby-side new western concepts and techniques. Coexistence brought about rivalry between the different types of medicines and health practitioners, until western medicine got the upper hand, towards the end of the nineteenth-century. Even then, although Popular Medicine and Religious Medicine became marginalized, they have remained a living tradition to this very day. Bezm-i Alem’s hospital illustrates the medical reality of its time. In many aspects it continued previous medical traditions; other aspects reveal brand new characteristics in Ottoman medicine and hospital management. The addition of these new features were intentional, not an afterthought or accidental. The hospital was a phase in a gradual and slow process, yet its founders used dichotomous discourse and (4) On the translator of Paracelsus into Arabic and then Ottoman Turkish, the Ottoman Court physician Salih b. Nasrallah Ibn Sallum (d. 1670) see AL-MUHIBBI, Muhammad Amin b. Fadlallah. Tarikh khulasat al-athar fi ayan al-mîa al-hadiya ashara, 4 vols, El Cairo, 1284H, vol. 2, pp. 240-242; RASHED, Muhammad bin Mustafa. Tarih-i rashed, 6 vols, Istanbul, 1282H, vol. 1, p. 96; ADİVAR, Adnan Abdülhak. Osmanlı türklerinde ilim, İstanbul, Remzi Kitabevi, 1991, pp. 122-123, 131-132; KÂHYA, Esin; ERDEMIR, Aysegül D. Bilimin ışığında osmanlıdan cumhuriyete tıp ve sağlık kurumları, Ankara, Türkiye Diyanet Vakfı, 2000, pp. 179-184. MIRI SHEFER 334 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. talked about a rupture in Ottoman medicine. They portrayed the hospital in terms of «new» (and meant modern, positive and therefore better) medicine and administration replacing the «old» (and thus bad and to be abandoned for good). The first part of the paper will be devoted therefore to discussing the hospital in the context of pre-ni- neteenth century Ottoman medical traditions. Then I shall portray the hospital as its founders wanted to present it to the Ottoman public: a new achievement in Ottoman medicine, indeed a glorious event in Ottoman great civilization. 2. BEZMI-I ALEM’S HOSPITAL: A NEW HOSPITAL FOLLOWING ESTABLISHED OTTOMAN TRADITIONS One of the characteristics of the hospital is evident in its name —the close association of the institution with its founder, Bezm-i Alem. Bezm-i Alem Sultan (died June 1853) was the wife of the Ottoman Sultan Mahmut II and mother of Abdülmecit (reigned 1839-1856). A thin and sensual lady who matured gracefully, according to her physician, she was a typical example of a high-ranking woman in the Ottoman imperial family. Like in the case of other females who joined the family (and in contrast to those born to it) her family, ethnic and religious background is obscure, but it is safe to assume she was from humble origin. Basic details, among them her date of birth and even her name, are left to speculation. According to one scholar she was a Russian Jewess who became a concubine in the Ottoman imperial Harem. Upon her entrance into the imperial Harem, she received a colorful name as was the custom with concubines in elite families in the Islamic world («Bezm-i Alem» means «A Feast of the World»), and abandoned her original name of Suzie. She knew enough reading and writing to correspond with her son and other members of the family, like other female members of the Ottoman elite (and unlike most of the Ottoman population, men and women alike), but never acquired basic formal education, as is obvious from her sloppy hand writing, many spelling mistakes and erroneous use of tenses. Bezm-i Alem was a very strong politician. Ottoman political tradition accepted women from the imperial family in positions of influence, as long as the Old patterns, new meaning: The 1845 hospital of Bezm-i Alem in Istanbul 335 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. source of their power was motherhood. Consequently, the mother of the reigning sultan was more important that his wives, who in turn enjoyed greater power if they bore a child to the sultan. Bezm-i Alem did. Her public career took its rise only when her son Abdülmecit came to the throne in 1839, immediately after his father and her husband, Mahmut II, passed away. Her special position was acknowledged with the traditional and formal title «Queen- Mother»(valide-i sultan), in addition to others with symbolic character, like «The Great Cradle» (mehd-i ulya). From a woman who could not make her presence felt in the crowded harem of her husband, she became a famous public figure involved in her son’s rule. Mahmut was a very dominant figure, and something of a tyrant, which prevented many —including women— to enjoy a central place in Ottoman politics. Abdülmecit was only sixteen and inexperienced when he ascended to the throne, and therefore may have been prone to outside influence. This could explain why Bezm-i Alem could assert her power. She represented her son in Istanbul when he was away on excursions, and sent him letters informing him about news (or gossip) surrounding the palace. The correspondence between mother and son reveals that they were genuinely attached to each other, in addition to being political allies. Bezm-i Alem’s involvement in her son’s reign was not extraordinary for mothers of the sultans, and apparently was not excessive, especially in comparison to her predecessor and mother-in-law, Mahmut II’s mother. The Ottoman elite expected to see mothers of the sultans as informal political advisors to their sons, while the laity expected to see the mothers involved in philanthropy on a large scale. Despite rumors that her great wealth was not necessarily of legal origin (some members of the elite accused her of nepotism and of accepting many gifts and bribes) she was highly esteemed and loved by Istanbulis for her many charities in the capital. She had several fountains erected throughout the city, in addition to a lavish complex composed of a splendid mosque, hospital and schools (5). (5) ULUÇAY, M. Çağatay. Padişahların kadınları ve kızları, 3. baskı, Ankara, Türk Tarih Kurumu, 1992, pp. 120-121; ULUÇAY, M. Çağatay. Harem II, 3. baskı, Ankara, Türk Tarih MIRI SHEFER 336 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. What is unique about Bezm-i Alem, if her career is rather typical to a mother of the sultan? True, a woman who establishes a hospital was not very common in the history of the area. It is also true that Bezm-i Alem’s hospital is impressing in its grandeur and longevity. But in Istanbul one can find at least one more impressive example of a hospital founded by a female member of the imperial family and in use for hundreds of years. The Haseki Hospital stands today on the ruins of an Ottoman hospital erected by Hürrem Sultan, and bears today her title of «Haseki» («The Favorite»), as she was first the favorite concubine and then the only wife of Sultan Süleyman the Magnificent (reigned 1520-1566) (6). In many ways Bezm-i Alem’s hospital was a standard, traditional Ottoman hospital. The foundation deed of Bezm-i Alem’s hospital makes it clear that the institution was neither for the chronically ill nor for healthy bachelors who lacked permanent dwellings in the city and tried to take refuge in the institution. The wardens of the hospital were warned to not fill the institution with them, since they would take the beds needed for the sick who must receive treatment in the hospital. This warning was certainly in tune with the Ottoman hospital tradition. The Ottoman hospital was not a convalescence home or a hospice. In Ottoman society (like other pre-modern Muslim societies and differently from its Christian counterpart), the term «hospital» (timarhane, bimarhane or darüşşifa) was dedicated to an institution which employed professional medical staff and treated patients suffering from physical as well as mental illnesses. In this respect, Bezm-i Alem’s hospital was not more «modern» than its predecessors. Besides, Ottoman sources relaying the foundation of the institution use the familiar language from previous centuries. The founda- Kurumu, 1992, pp. 62, 65, 154; SAKAOĞLU, Necdet. Bezmiâlem Valide Sultan. In: Dünden bugüne istanbul ansiklopedisi, İstanbul, Tarih Vakfı, 1993-1994, vol. 2, pp. 224-225; PEIRCE, Leslie. The imperial harem, New York, Cambridge University Press, 1993. (6) For the foundation deed, see the Archives of the Directorate of Charitable Endowments (Vakıflar Genel Müdürlüğü Arşivi [VGMA]), Ankara, defter 608/23, p. 226. Old patterns, new meaning: The 1845 hospital of Bezm-i Alem in Istanbul 337 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. tion deed of the hospital is especially revealing in this regard (7). It follows the formal structure and contents of similar legal documents. It opens with salutations to the benevolent founder, and exalts her philanthropies. Than it moves to lay out in great detail the medical and administrative structure and activities of the hospital. The medical staff to be employed follows the standard of previous hospitals: two physicians, two surgeons and two pharmacists. The salaries assigned to each staff member in Bezm-i Alem’s hospital reflected a subtle yet clear hierarchy within the hospital. Like in previous Ottoman hospitals, the medical and administrative personnel in Bezm-i Alem’s institution were to be paid higher salaries than the «blue collar» employees (although their duties too carried medical meaning), like the cooks, the cleaners (in- and outside the hospital building), the barber and the launderers. The «para-medi- cal personnel», like the male «nurses» and the blood-letter, were also at the bottom of the salary ladder. The administrative body of the hospital was well compensated financially, paid more than some physicians. The manager of the hospital was the highest ranking official, immediately followed by the head-physician; the first clerk was paid more than the two surgeons and two pharmacists, whose salary was similar to that of the steward. The salary for the employees was also in foodstuffs. The endowment deed stipulates that in addition to their daily cash salaries, the personnel should receive daily meals from the hospital kitchen, the amount of which reflected their hierarchy within the hospital. The manager, for example, was to be given daily meals suitable for eight people and fodder for one animal in addition to 1,200 silver coins (kurush) cash, whereas the two servants were paid each only 150 silver (7) The original copy is kept at the VGMA, note 6, which I was not allowed to examine when I carried out my research there in 1997-1998. I rely therefore on a publication of the original document, a lingual adaptation from Ottoman Turkish to modern Turkish. I suspect the publication omits several parts from the original document (like a section on the endowed properties which financed the hospital) and includes only the part dealing with the administration of the hospital. BAYRAM, Sadi. Sağlık Hizmetlerimiz ve Vakıf Gureba Hastanesi. Vakıflar Dergisi, 1982, 14, 104-118. MIRI SHEFER 344 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. inheritors, and if such did not exist, the estate went to the endowment. To the extent that similar closes were included in previous endowment deeds, they were not that detailed. This lacuna in the regulations of older hospitals could explain two identical sultanic decrees (ferman) sent to the Ottoman judge in Mecca at an interval of two weeks in March 1568. The sultan ordered the judge to inform him in detail about who had taken charge of the personal effects of dead patients in the hospital there. The judge was to explain what had been done with them, how and to whom they were sold, how much was received for them and how that amount was spent (20). Prior to the nineteenth century, the type of medicine applied in Ottoman-Muslim hospitals was an Arabic-Muslim adaptation of Greek Humouralism as laid down by Galen. In Bezm-i Alem’s hospital, this holistic approach that had characterized Muslim hospitals for centuries gave way to a newer medicine. The medical doctors employed at the hospital were educated in European medicine, which emphasized biology and pathology, not the traditional Hospital medicine based on Humours. Thus, the posts of head-physician and junior physician (but not that of the surgeons!) were filled by graduates of the Imperial Medical School in Istanbul. The school was first opened on March 14, 1827 by Mahmut II (though reorganized and renamed in 1938). This day was later adopted by the medical community of the Turkish Republic as Medicine Day (Tıp Bayramı), to celebrate modern medicine. In this school, European doctors taught medicine, while Ottoman teachers taught the general non-medical subjects. Dr. Karl Ambros Bernard, a medical doctor and surgeon and a graduate of the Vienna medical faculty, was brought from Vienna in 1838 to establish the school. He acted as its manager until his death in 1844. The curriculum at the school was decidedly western, combining general and medical subjects. The general syllabus included arithmetic and geometry, drawing, geography, history, zoology and languages, Muslim ones, like Arabic and Turkish, but also western: Latin and French, the language of instruction. The general curriculum was taught by Otto- (20) Prime Ministry Ottoman Archive (Başbakanlık Osmanlı Arşivi, İstanbul), Mühimme, 7, 365/item 1057, 402/item 1154. Old patterns, new meaning: The 1845 hospital of Bezm-i Alem in Istanbul 345 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. man Muslim teachers. Medical studies, taught mainly by non-Muslim and non-Ottoman teachers, comprised anatomy, dissection, pathology, chemistry, botany and pharmacology, diagnostics, ophthalmology and medical devices (21). The dedication inscription on the portal of the hospital in Istanbul echoes this shift. After salutations to the mother of the sultan as benevolent, it moves to exalting her hospital. It is depicted first as a life-giving institution. The inscription explains that although Galen’s medicine is excellent, the excellence of the hospital makes Galen redundant (the poetic wording is that hospital increases the delicious water of life of the patients). What the author had in mind here was apparently praising the hospital, rather than claiming that Galen’s medicine was no longer relevant yet it is clear that Galen’s skills were downgraded. Galen is used in pre-modern Ottoman sources as a metaphor of the ideal doctor and Humouralism of excellent medicine. This inscription reveals therefore a shift of Ottoman medicine away from Humouralism —increasingly influenced by western science. However, Galenic medicine was still accepted as a concept in this period, even if the process of abandoning it was already in play. 4. THE CONTEXT OF THE BEZM-I ALEM’S HOSPITAL: THE TANZIMAT REFORMS The changes in medicine in the Ottoman Empire during the nineteenth century were part of a wide range of reforming measures. Under Mahmut II’s rule, government responsibilities proliferated well beyond the traditional realms of administering justice, collecting taxes and maintaining armed forces. Matters that had traditionally been left to private hands were forcibly brought under government administration. This was the period of the Tanzimat which saw the re-organization of state bureaucracy. (21) SHEFER, Miri. Tibbiyye-i ‘Adliyye-i Shāhāne. In: Encyclopaedia of Islam, new edition (hereafter EI2) Leiden, Brill, vol. 12, supplement, 2004, pp. 810b-811b. MIRI SHEFER 346 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. Here we should note that although the sultan was celebrated in the foundation deed for issuing the formal decision to establish this hospital, his role is restricted to ceremonial procedure. The real power of influencing, managing and supervising this institution rested with the central administration, at the offices of the Imperial Head-Physi- cian and Endowed Charities. This reality went hand-in-hand with the change in the balance of power in the Ottoman political system during the Tanzimat era. Between the reigns of Mahmut II (reigned 1876- 1909) and Abdülhamit II (reigned 1876-1909) the centre of power lay to a large extent in the Vizierate, rather than in the Imperial Palace, the seat of the sultans. The growing state went through a process of centralization and bureaucratization, and the new ministries gained power over the governmental system. Scholars have traditionally emphasized several means by which Ottomans strove to reach these intertwined aims. First there was a translation drive: many European texts were translated into Muslim languages (Arabic, Ottoman Turkish and Persian). Ata Allah Muhammad Shanizade (died 1826), «the father of modern Turkish medical terminology», was especially important in this regard the. His translations forced him to invent new medical vocabulary in Ottoman-Turkish to suit the new medical concepts and terms. This vocabulary was passed on to modern Turkish and was used until another lingual reform in the mid-twentieth century (22). (22) He was appointed official court historiographer in 1819 due to his erudite learning (his history book is an important source for Ottoman realities in the nineteenth century). Shanizade was removed in 1826 because of his supposed reactionary religious tendencies. He came from a Muslim religious background yet mastered several European languages and studied western medicine and other branches of science. The most important of his treatises was a translation into Ottoman-Turkish of an Austrian medical textbook, apparently from the Italian version. He added to it his own study of physiology and anatomy and a translation of yet another Austrian medical book —this one on vaccination. ADİVAR, note 4, osmanlı türklerinde ilim, pp. 214-217; KÂHYA/ERDEMIR, note 5, bilimin ışığnda Osmanlıdan cumhuriyete tıp ve sağlık kurumları; BABINGER, Franz. Osmanlı tarih yazarlalı ve eserleri, Ankara, Kültür ve Turizm Bakanlığı, 1982, pp. 375-372; DAVISON, R.H. Shānī-zāde Mehmed ‘Atā’ Allāh Efendi. In: EI2, note 21, vol. 9, pp. 303a-303b. Old patterns, new meaning: The 1845 hospital of Bezm-i Alem in Istanbul 347 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. Secondly, Ottoman students were sent to universities in Europe to acquire a profession in selected valued fields, like medicine or, engineering. Thirdly, new schools were established and given precedence over the traditional Muslim madrasas. Madrasas focused on religious fields of knowledge, like law and theology. They reproduced Arab- Muslim knowledge still based to a large extent on interpretations of, and additions to, medieval Muslim texts, which now seemed irrelevant to modern life and statesmanship. But hospitals too mediated new medical ideas and practices throughout the Middle East. Here many scholars refer to foreign hospitals founded with European funds and knowledge throughout the Middle East, especially in Ottoman Palestine being the Holy Land and therefore a traditional focus of religious and political attention. These hospitals and European physicians are usually described as a means to bring progress and well-being to the backward Muslim east. The emphasis on European activities is based on the assumption of nineteenth century western observers (23), which some Orienetalist scholars (in Edward Said’s terminology (24)) share, that without these European stimuli, medicine in the Middle East would not have modernized on its own initiative. According to this logic, Europe indeed forced its own medical standards on the Middle East along with foreign social and cultural world-views, but allowed local medicine to break its shackles. However, European involvement was not altruistic. Hospital foundation served European powers as a political declaration, helped strengthen their interests in their competition for influence in Europe and the Middle East, and benefited the local Ottoman-Christian communities under their respective patronage. The general public —that is Muslims (and also Jews)— could not necessarily enjoy these new medical institutions. We should award greater importance to Ottoman (23) For a recently published example see LEV, Efraim; AMAR, Zohar. The turning point from an archaic Arab medical system to an Early Modern European system in Jerusalem according to the Swiss physician Titus Tobler (1806-1877). Canadian Bulletin of Medical History, 2004, 21, 159-182. (24) SAID, Edward. Orientalism, New York, Vintage Books, 1978. MIRI SHEFER 348 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. activities in the realm of medicine, for example as an initiator of new hospitals for the local population. Bezm-i Alem’s hospital was intended first and foremost to serve the Muslim population of Istanbul. The military, the patients of the first new hospitals, was supposed to be one of the cornerstones of the new and strong modern bureaucratic state. Bezm-i Alem’s hospital, in contrast, was a civil institution which was supposed to treat those at the bottom of the social ladder, the desolate, the poor, i.e. the hoi polloi. It should be noted here that the use of the terms «desolate» and «poor» does not mean that the hospital was only for the poor, and the institution was more of an alms-house than a «real» hospital (in our own modern understanding), far from it. First, let us remember that even pre-modern Ottoman hospitals, whose example Bezm-i Alem’s hospital followed to some extent, were institutions that offered medical treatment practiced by professional healers to physically and mentally ill patients. Secondly, in the Ottoman charity discourse, the adjectives «poor» and «desolate» were very common and actually meant «deserve» or «entitled» rather than financial neediness. Hence we find this type of language repeated in various documents pertaining to hospital management throughout the Ottoman centuries without referring to specific difficult context (25). These points of difference from other contemporary local and foreign hospitals meant that Bezm-i Alem’s hospital could have a wider impact on Ottoman society. Indeed, it was established to influence Istanbulis. In addition to expanding existing medical facilities, it dispensed intentionally a new type of medicine in the capital and served the political agenda of the Tanzimat. The use of charity work to promote politics is not a new phenomenon in Ottoman society and politics. When a figure like a sultan or a member of his immediate family was involved, a personal philanthropy always carried an aura of a political statement. Female appearance in (25) The foundation deed of Nurbanu Sultan’s hospital in late sixteenth century uses the same terms, note 14. Old patterns, new meaning: The 1845 hospital of Bezm-i Alem in Istanbul 349 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. the public sphere was restricted, especially for elite women. They had the financial means to support the lifestyle that goes along with the separation of the genders, and therefore they were expected to adhere to female restriction to the private sphere. However, they had other means of public declarations of power that were easily understood by the various audiences (other elite members, the general public, the religious institution, etc). One of these means was charity work and patronage of monuments built for social functions (26). Muslim philanthropies are supposed to stem from altruistic motivation or self-improvement (27), but Ottoman imperial benevolence is best understood in the framework of gift relationships, or the «Gift exchange» to use Marcel Mauss’s term (28). On the elite side, it was a duty to God and men, an egoistic pleasure, a fashion, and political and social prudence. Benevolent donors were not averse to possible religious gains coming from good deeds in general and alleviating the misery of the poor, as they thought about their fate in the Hereafter. They did not shy away from materialistic profits in this world, and certainly did not conduct their philanthropic endeavors at random. It was always a very practical means to an end. Through specifically chosen charity acts Ottoman elite member immortalized their name for posterity, enhanced their public image, legitimized their social and political standing, established patronage relationships, strengthened their position in the ever-changing power relations among the elite, influenced economic and urban activities, etc. Meanwhile, it was the receivers’ duty to acknowledge the benevolence with gratitude and accept the subtle strings attached to the gift, like political loyalty, (26) BATES, Ülkü Ü. Women as patrons of architecture in Turkey. In: Lois Beck; Nikki Keddie (eds.), Women in the Muslim world, Cambridge, Harvard University Press, 1978, pp. 245-260. (27) WEIR T.H.; ZYSOV, A. Sadaka. In: EI2, note 21, vol. 8, pp. 708b-716a; ZYSOV, A. Zakāt. In: EI2, note 21, vol. 9, pp. 406b-422a. (28) MAUSS, Marcel. The gift: forms and functions of exchange in archaic societies, London, Routledge, 1970. See also PORTER, Roy. The gift relation: Philanthropy and provincial hospitals in eighteenth-century England. In: Lindsay Granshaw; Roy Porter (eds.), The hospital in history, London, Routledge, 1989, pp. 149-178. MIRI SHEFER 350 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 329-350. social obedience, and adherence to the new political agenda the elite presents (29). Bezm-i Alem’s hospital is a case in point. Legally, Bezm-i Alem’s hospital was a private initiative of one woman, as in all Muslim endowed charities, but its real executioner was the emerging ministerial agencies. It was part of the new centralized bureaucracy and was created to serve it. The public face of the institution was that of a grand woman as it was customary in such charities, not the growing apparatus that was invading people’s life and could be regarded as menacing. Yet, the hospital was exactly that: it was an initiative from above which suited government needs and medico-political concepts. The founder of the hospital seemed to be removed from the seat of political power: although the mother of the sultan was not just anybody in political terms, she was neither the sultan (the sovereign) nor the bureaucracy (the emerging political power at the expense of the imperial palace). Yet, the new state machinery had the real power over the hospital and had the final say about its management, although for the public this charity work was associated with one woman, Bezm-i Alem, who had no official political position. The central administration used here a «benign» form of action to promote a subtle yet far-reaching medico-political agenda to educate and control the public. This is exactly the importance of the hospital. It reflects a period of transition in the Ottoman Empire between the old and the new, when both were still very much present in the medical scene. For the public eye it seems quite similar to familiar medical traditions, where in fact it was also very new in its administration and medical practice. (29) On the use of imperial charities for political aims in the Ottoman Empire a slightly later period see utilizing the «gift» concept, see ÖZBEK, Nadir. Imperial gifts and sultanic legitimation during the late Ottoman Empire, 1876-1909. In: Michael Bonner; Mine Ener; Amy Singer (eds.), Poverty and charity in middle eastern contexts, Albany, State University New York Press, 2003, pp. 203-220.