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Figure 9: Hakîm, Painting of a physician. Source: Topkapi Palace Library, Album no. III. A, 3690, Illustration 97.

Traditionally, Ottoman medical practitioners were unwilling to practice new and unknown methods in the treatment of patients. This unwillingness causing conservatism from time to time was caution, because of the fear of harming the patient. (The responsibility in using the current medical knowledge in treatment is nowadays an important norm of morality and law, too.) It is possible to trace in all kinds of documents the proofs of this expectation observed carefully in Ottoman medical practice; for example, in the trust deeds of hospitals and the Süleymaniye Medical Madrasa, in the law court records of the Muslim judges, in orders for appointments and in medical manuscripts. For example, the lecturer (müderris) to be appointed in accordance with the Süleymaniye Medical Madrasa's trust deed was required to have paid "high effort to learn former physicians' rules of medicine, behaving carefully to facilitate choosing proper rules of treatment and to attend his lessons regularly with the required equipment." According to the trust deed, the lecturer was expected to "transfer medical rules of the former medical authorities of the ancient Greek, Roman and Islamic period (such as Hippocrates, Galen and Ibn Sina), meanwhile simplifying the correct and important rules and methods of medical practice carefully." However, there is no definition of the criteria in choosing the proper medical rules and methods [108].

According to the trust deed, the primary criterion for a physician to be appointed to a hospital was "to be experienced"; however, the meaning of an experienced physician was, "to reinforce and strengthen the rules and the base of the medical art", and "to be informed of the rules of medicine and philosophy" [109]. That is, physicians should have strengthened the existing rules of medicine through their clinical experiences.

It was also important from the point of law to consider the rules of the medicine of the day . When the patient was injured as a result of medical practice, when the rules had been followed, the physician or surgeon was not regarded as responsible for the unexpected or undesired results of the treatment. The principle was that the physician "should not trespass the rules of medicine" [110]. In court records there are various examples of this rule. For example, according to a record of Gaziantep law court dated 1765, the surgeon being sued defended himself by this principle: "There was the illness called ‘ümmü's sibyan' - which is called düzümcü in our city- on the back of the boy. In treating this illness, it is incised with a lancet, then the fluid (ma-i cedit) in it is cleaned. Later, the wound is treated. This treatment has been practiced skilfully by surgeons for a long time" [111].

Nabi, a poet who related the attitudes and expectations of the time in his book Mebhas-i Lazime-i Hikmet-i Tib described the virtuous physician as one who treats his patients in accordance with the current principles of medicine, protecting the sacred lives of patients and being careful and avoiding experimentation on patients. Advising physicians poetically, "treat one observing law, do not sacrifice people for the sake of experience", Nabi complains of ignorant physicians who use their patients as a guinea pig and he also warns the patient addressing his son, "if not needed, don't trouble the body, don't use the body as if it were a guinea pig". It is easy to discern the difficulty in comprehending the differentiation between acquiring experience through treating patients and quackery, in this couplet of Nabi. The poet who relates the preferred Ottoman values, strictly opposes those who experiment on patients and the practice of those who had not been educated properly and those who ignore the principles of medicine. Patients should be treated by the well known methods in use and the patient must not be sacrificed to gain experience; the patient himself/herself must be conscious of his/her rights and should not allow the physician to use him/her as a guinea pig; moreover, the patient should look for and reach a successful (usta) physician who would treat in accordance with the principles of medicine. Nabi accentuates this with great insistence in his last couplet, advising his son to have a life long healthy body (bünye), as a result there would be no need for a physician [112]. In addition to treating the theme favouring conservative and preventive medicine, some of the existing realities are also reflected in this poem.

The Ottomans, in fact, had come across an important problem in medical practice. Some of the Europeans coming to the Ottoman territory, imagining to reach the country of fortunes, introduced themselves as if they were physicians. Some of these characters (so called travellers) who had come to Turkey, aimed to reach political favours; and others were ambitious to practice the new medicine. Especially from the 18th century on, we note an increase in the number of documents regarding quacks who presented themselves as if they were physicians, treated patients and harmed people. At the request of head physicians, decrees were issued from time to time, ordering medical practitioners to take an examination and the licences of those who were found to be incompetant were revoked and they were forbidden to practice while those found competent were permitted to practice. These decrees were not issued only for Ottoman subjects, but for those who had been coming from foreign countries and practicing medicine fraudulently, consequently harming people. However, it is interesting that in the examination conducted from May 20-29 1700, for instance, only 6 of the 25 physicians and 28 surgeons who were permitted to set up in practice, were Muslims; and among the non-Muslims, foreigners from France, Holland, Italy and Spain attract attention [113].

The first negative effect of European medicine on Ottoman society was brought about by the medicine of Paracelsus (1493-1541). The main reason for the Ottomans favoring the medicine of Paracelsus in the 17th and 18th centuries was the physicians' dependence on drug treatment. Drugs were believed to help reestablishing the imbalance caused by disease, even though by means of inorganic drugs. Well known Ottoman physicians such as Salih bin Nasrullah (d. 1669), Ömer bin Sinan of Iznik, Ömer Sifaî (d. 1742) and even Gevrekzâde Hafiz Hasan Efendi (d. 1801) devoted to Islamic medicine, quoted from Paracelsus's medical works. Yet, the Ottoman society paid painfully as the consequence of applying the medicine of Paracelsus known as "tibb-i cedid" (the new medicine), for treatment with inorganic drugs had caused poisoning. Finally, in 1704 the Sultan decreed: "Some so called European physicians, who putting aside the former physicians' directions, using drugs called new medicine, harmed the patients they treated… Those European physicians who managed to start an office must be forbidden to practice." While this decree tried to end the haphazard practice of the new medicine it also approved the Islamic medicine taught in the Süleymaniye Medical School and ensured its continuation [114].

Complaints against the poor practices of European physicians and their incompetence were not only recorded in official documents. For instance, head physician Gevrekâde Hafiz Hasan Efendi (1724-1801) especially complains of the European physicians in Istanbul and in the foreword of his eye treatise (1796) he notes: "Obviously, European physicians are incapable for treating illnesses. Everyone is aware that they lack information in the field (of medicine)." Gevrekzâde, who utilized his observations, experiences and explanations in his translations and compilations was eager for learning and inclined to think and from time to time noted works of European physicians too, though he highly favored Islamic medicine. I conclude that incorrect treatments by the European physicians who had come to the Ottoman territory, aiming to or pretending to have come to practice the new medicine (tibb-i cedid) that harmed the people of Istanbul enforced Gevrekzâde's bias towards Islamic medicine, because he used rather belittling terms against European physicians [115]. I would also like to quote another example from a foreigner.. Based on his observations during his visit to Gemlik in 1832, David Porter, an American diplomat noted: "We were disappointed when we learned that this place had been invaded by the European physicians, most of them immigrant physicians from Western Europe who were going to get us fly away from the place in future". He notes a Russian physician, an expert of smallpox vaccine, "who experimented his skill using children of the town and consequently all of them died" [116].

When I consider some of the archive documents I am studying, it appears that, by persuading the authorities some European physicians were granted permission to practice in the Ottoman territory and they were awarded comprehensive facilities. For instance, in the early 19th century the Italian physicians Eusebio Valli and Antonia Pezzoni were permitted to practice medical experimentation in Anatolia. This is an interesting example of the way the European physicians were protected and encouraged [117]. In the case of failure the European physicians were forbidden to practice by the authorities or sometimes they were driven out of the country; or from time to time physicians had to pass an examination. While the majority of the Turkish physicians were devoted to or forced to practice the medical principles based on the humoral theory, European physicians were permitted and even encouraged in the practice of the new medicine and even the new findings; however those who harmed people were prevented from practicing. The reasons underlying these different attitudes should be researched from various points of views.

The harm caused by the Europeans who had come to Istanbul to practice medicine was given as the reason for Greek citizens starting a School of Medicine in 1805 "Although the physicians who have come to Istanbul from Europe were educated in famous schools of medicine, many cases of malpractice have been noted during their treatment" [118]. According to this record, the great number of malpractice cases by European physicians in Istanbul was observed by experience. As it is mentioned in the decree above, being educated in Europe was not regarded as sufficient for being qualified as an competent physician.

The efforts to control the physicians coming from Europe was regulated in the second half of the 19th century by means of the regulation about the municipal medical practice (Tababet-i Belediye Icrasina Dair Nizamnâme) dated 1861. To be allowed to practice medicine or midwifery in the Ottoman Empire foreigners had to get their diplomas registered in the Royal School of Medicine (Mekteb-i Tibbiyye-i Sahane) and successfully take the examination required [119].

In the decree and the supreme parliament (Meclis-i Vâlâ) registry dated 1866, the reason for starting the Civilian School of Medicine (Mülki Tibbiye) was noted: "As the Military Medical School Mekteb-i Tibbiyye-i Sahane educates military physicians, people had to apply to European physicians, however, their ability and skill is usually insufficient for protecting public health." So, incompetence of the European physicians was once more accentuated [120].

Quackery in medicine is not limited in geography. It is obvious that the ignorant and incompetent foreign physicians from Europe resulted in a high level of mistrust in the new medicine amongst Ottoman people and this is also one of the causes for the delay of the Ottoman physicians, who favoured the old Islamic medical principles, in adopting the new medicine.

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Figure 10: Mansur bin Muhammed bin Ahmed: Kitab Tashrihi al-Bedenî. Source: Cerrahpasa Medical School Medical History Museum Library, no.17, fol. 32a.

Ottoman medical practice stressed the importance of allowing nature's healing power as much as possible, abstaining from complicated treatments and practicing medicine appropriate to the temperament of the patient. As a consequence of this opinion, nonmaleficence ("doing no harm") was regarded as more important than the other moral principles. The current medical rules were to be applied properly in order to protect the patient from being harmed. Practicing unknown methods was not considered to be right, because it would not be fair for the patient. This attitude which might hinder the way to new approaches attracts attention as a factor blocking attempts to develop medicine [122].

The interaction between man and nature determines the main direction of culture. Which value should the physician prefer in his relation with nature? Should the physician behave as one making use of technical tools invented by mankind's intellect to master nature in order to help his patient get rid of his suffering; or should act as a servant of nature through observing the process of nature? If one of these contradictory values is preferred, the other will be endangered. For example, preferring one method of treatment to another or even having one meal instead of another reflects value inclination. Veatch, a known theorist of medical ethics, demonstrates through certain examples the importance of these two main value orientations for describing and solving ethical dilemmas in the clinics. According to the attitude of the physician comprehending himself as one who is serving nature, "The organism has a natural tendency to protect its health. The concept of equilibrium in medicine, today known as homeostasis, in other words the body's natural tendency to protect its healthy status- the body's having an inner mind- and the protective approach toward the human being is not just a reality of biology but it is also a philosophy of medicine. According to the people believing in this approach, the intervention of mankind to the created/nature can be dangerous. Whenever we attempt to use a chemical substance that is man-made or a technology, it means that we interfere in nature. We have to intervene in the human body as little as possible, because it usually does what is needed. Physician's duty is to help patient's nature determine its own path" [123].

Man's concept of life is one of the most important factors that describes what he believes to be valuable. People act in accordance with their own values, as individuals do. Traditional justice that determines man's interaction with nature, in accordance with his/her concept of life influenced Ottoman medical practice, as it did in other fields. As it has often been emphasized in medical manuscripts, the medical doctor expected to progress as a philosopher physician, even a sage, was to serve the Creator, the healer. The Ottoman physician, who followed Hippocratic and Islamic medicine, laid great stress on the healing power of nature; based his practice on the equilibrium of the four humours and trusted in the idea of treatment by re-establishing the balance of the humours, contributing to the natural healing power of the body. Man, the most honourable of all created beings (esref-i mahlûk) should be treated with due care [124].

While the Ottoman law and moral rules protected patients against being harmed by new medical treatments and operations, did the rule of not going against the current medical principles cause medical practitioners to be cautious and careful against innovations? Practices not aiming at treatment were regarded as against the professional ethics of the Ottoman medical practitioner. Physicians were expected to prescribe only those drugs in use; they should not prescribe unknown new drugs or those advised by the unqualified in the field [125]. The drug compositions called mücerreb (meaning experimented, as a word, in fact meaning a current drug) that we come across in medical manuscripts; and the slight modifications of known surgical methods, techniques and tools were not carried out as experiments and these innovations can not be evaluated as a result arrived at through research. New information obtained over many years through experience by empirical methods were contributions achieved in case better results were reached in treating patients, as a result of modifications of the known treatments and operations. Yet, successful drug compositions and treatment methods provided a privilege and superiority for requesting service and treatment, so they were kept a secret. These secrets in development were mostly transferred from father to son or from master to apprentice and some were gradually forgotten [126]. These kinds of experiences for use in treatment was a means of obtaining knowledge, yet not being controlled experiments, they were not scientific data. The aim was not to try an innovation out of curiosity as Europeans had done. The main aim of the Ottoman physicians was healing the patient; and they had a life ideology for becoming a wise man. It is difficult to assume that Ottoman physicians, with a few exceptions, were eager to attain scientific knowledge. In fact, according to Abbas Vesim, "it was very strange that acquiring scientific knowledge was not paid importance in Anatolia, especially in Bursa and Istanbul" [127].

A physician simply aiming at treatment would not be sufficient to contribute to science. Many well-known European physicians continued their researches while practicing their profession [128]. Besides, from start of the Renaissance onwards, the renewal of various branches of knowledge was carried on alongside new ideas in philosophy and the reinterpretation of religion [129]. According to Veatch, European people preferred a basically different medical approach as "Homo faber", that is "Man the Maker" controlling nature through tools. According to the philosophy reflecting an interpretation of the Holy Bible, "The human being will dominate the world and the nature and have it submit to man" [130]. In the late 16th century, Bacon (1561-1626) viewed science as a most profitable tool for understanding and overruling nature [131]. Through this philosophy creating miracles in medicine, the suffering of man was treated, life expectation was doubled, illness formerly believed to be the inevitable effect of an evil spirit is now being cured by means of an antibiotic. Yet, medical technology not only has the power of healing patients, but also the power of destroying, too. In fact, illnesses and infirmities, even deaths caused by physicians, that is iatrogenic illnesses have continued to increase [132].

[108] For the qualifications expected to be employed as a lecturer (müderris) according to the trust deed of Süleymaniye Medical Madrasa, see K. Kürkçüoglu: Süleymaniye Vakfiyesi, Vakiflar Umum Müdürlügü, Ankara 1962, p. 86.

[109] N. Sari: "Osmanli Darüssifalarina Tayin Edilecek Görevlilerde Aranan Nitelikler", op.cit., pp. 17, 18.

[110] A. Bardakoglu: Islam Hukukunda Doktor ve Diger Saglik Personelinin Hukuki Mesuliyeti. Kayseri Üniversitesi Gevher Nesibe Bilim Haftasi ve Tip Günleri, 11-13 Mart 1982, pp. 527-530
- A. Udeh (trans. R. Özcan-A. Safak): "Et-Tesriü'I-Cinâiyyü'l-Islâmî Mukarinen Bi'l Kanuni'l-Vaz'i. Mukayeseli Islâm Hukuku ve Beseri Hukuk (Notlar Ilaveli ve Türk Ceza Kanunu ile Karsilastirmali), vol. 2, "Rehber, no. 11, Temel Eserler, seri 1", Ankara 1990, p. 124.

[111] C. Güzel, H. Yetkin: Gaziantep Ser' i Mahkeme Sicillerinden Örnekler (vol. 81-141/Milâdî 1729-1825). Gaziantep, "Gaziantep Kültür Dernegi, no. 55", 1970, p. 80 (Gaziantep defteri, vol. 122, pp. 72, 15 Saban 1178/8.02.1765).

[112] Treat observing prudence and findings
Do not spoil the temperament by lack of knowledge
Behave as a guide of health
Do not be a cause of illness
Treat in accordance with medical rules
Do not sacrifice people for the sake of experiment
Do not shed blood ignorantly with a lancet
Do not be a robber of dear life
If his/her syrup relieves the humours
It balances the contrariness of nature
So do all the physicians of the time
Most are ignorant and don't know qualities
If not necessary do not trouble the body
Do not make use of the body as if it was a guinea pig.
For the advice to physicians not to use drugs he/she does not know, see foot note 35; also see: N. Akdeniz (Sari): Osmanlilarda Hekim ve Deontolojisi, op.cit., pp. 113-114.

[113] O. S. Uludag: Osmanli Sarayinin Yabanci Hekimleri, op.cit., pp. 189-194.
- F. N. Uzluk: Fatih Sultan Mehmed Zehirlendi mi Eceli ile mi Öldü?"Ankara Üniversitesi Tip Fakültesi, no. 150." Specially see pp. 22, 23, 25, 32, 38, 44, 46, 48, 52.
- N. Akdeniz (Sari): Osmanlilarda Hekim ve Deontolojisi, op.cit., pp. 154-164.
- G. A. Russell: Physicians At The Ottoman Court, op.cit., p. 248.
- E. Kâhya: On Dokuzuncu Yüzyilda Osmanli Imparatorlugu'nda Tip Egitimi ve Türk Hekimleri. "Kültür Merkezi Baskanligi, Türk Kültüründen Görüntüler," Ankara 2 1997, p. 2.
- A. Adivar: op.cit., p. 178.
- E. Kâhya: On Dokuzuncu Yüzyilin Ilk Yarisinda Osmanli Imparatorlugunda Tip Egitimi ve Kalburüstü Hekimlerimiz, op.cit., see p. 688.
- H. Sahillioglu: 1700 Yilinda Istanbul'da Muayenehane Açma Izni Olan Tabib ve Cerrahlar, op.cit., p.12.

[114] N. Sari - M.B. Zülfikar: "The Paracelsusian Paracelsian?? Influence on Ottoman Medicine in the Seventeenth and Eighteenth Centuries". Transfer of Modern Science and Technology to the Muslim World; Proceedings of the International Symposium on Modern Science and the Muslim World (Istanbul, 2-4 September 1987) Istanbul 1992, pp. 157-179.
- N. Sari-B. Zülfikar: Gevrekzâde Hafiz Hasan ve Zübdetü'l Kuhliyye fi Tesrihi'l-Basariyye, op.cit.
- A. Adivar, p. 101: "According to Paracelsus, as diseases are the result of the increase or decrease of chemicals that provide the chemical composition of the body, patients could be treated either by supplementing or by releasing elements of the chemical composition."
- E. Atabek: op.cit., pp. 28-30.
- E. Kâhya: "Tanzimatta Eski ve Yeni Tip", op.cit., p. 292.

[115] Gevrekzâde Hafiz Hasan Efendi: Risale-i Zübdetü' i Kuhliyye fi Tesrihi' l Basariyye. Topkapi Palace Library/ Hazine, no. 571. See foreword.

[116] R. Murphey: pp. 265-267. (David Porter: "Constantinople and Its Environs in a Series of Letters (1831-1834)" I, Harper and Brothers, New York 1835, p. 271.)

[117] The Italian physicians Valli and Pezzoni and their assistants were officially authorized to practise safely and freely in Bolu, Bursa, Iznik, Izmir, Ankara, Nigde, Konya, Kayseri and other provinces. See B.O.A., Cevdet Sihhiye 484 (Though undated it is probably an early 19th century document).

[118] B. O. A.: Cevdet Sihhiye, no. 304.
- N. Sari: "Osmanlilarda Tiphanenin Kurulusuna Kadar Tip Egitimi", op.cit., p. 162.
- O. Ergin: Istanbul Tip Mektepleri Enstitüleri ve Cemiyetleri. "Istanbul Üniversitesi Tib Tarihi Enstitüsü, no. 17", Istanbul 1940, p. 2.

[119] Düstur Tertip I. vol. 2, pp. 814-6.
- N.Akdeniz (Sari): Osmanlilarda Hekim ve Deontolojisi, op.cit., pp. 149-150.

[120] O. Ergin: Türkiye Maarif Tarihi. vol. 2, Istanbul 1940, pp. 364-5.
- E. K. Unat-M. Samasti: Mekteb-i Tibbiye-i Mülkiye. "Istanbul Universitesi, Cerrahpasa Tip Fakültesi Yay.", Istanbul 1990, pp. 8-9.

[121] S. Ural argues in many aspects the philosophy - science relation in its historical course by means of examples from different nations. See: Bilim Tarihi, op.cit.

[122] For the necessity of treatment appropriate to the temperament of the patient, not disturbing his/her nature, see N. Akdeniz (Sari): Osmanlilarda Hekim ve Deontolojisi, pp. 112-113, 114, 159.

[123] R. M. Veatch: Case Studies In Medical Ethics. Harvard University Press, 1976, pp. 20-21.

[124] For the importance paid to man created as the most glorious being and the essence of the universe, see N. Akdeniz (Sari): Osmanlilarda Hekim ve Deontolojisi, pp. 20, 22, 27-32.
Nabi expresses his anxiety and advices for operating on the human body carefully:
"Drugs must be used carefully and after research
Should not spoil the temperament because of ignorance
Shall be a guide of hygiene for the sick
Should not spoil the temperament because of ignorance."
See foot note 35.

[125] N. Akdeniz (Sari): Osmanlilarda Hekim ve Deontolojisi, op.cit., pp. 113-114. See Ibn-i Serif (15th century): Yadigâr, f. 59 b.; Hayrullah Efendi (1820-1869): Makâlat-i Tibbiye, pp. 145 etc.
- For the Islamic rules related to the legal responsibility of the physician, see:
- A. Udeh (trans. R. Özcan - A. Safak): op.cit., sp.123.
- Ö. N. Bilmen: Hukuki Islamiyye ve Istilahati Fikhiyye Kamusu. Bilmen Yay., vol. 3, p. 113; vol. 7, Istanbul, p. 272.
- H. Günenç: Günümüz Meselelerinde Fetvalar, vol. 1, "Ilim Yay., vol. 138", Istanbul 1983.

[126] It was not unusual that health practitioners recorded their secret knowledge and experiences as a keepsake for their son or apprentice, so as not to be forgotten. As an example of such work written down not to be copied, see Dervis Mehmed's (1764/5-1840) treatise on ointment prescriptions. There are phrases in this manuscript about keeping drug prescriptions as secret. See f. 8a-8b, 10b-11a, 19a. See N. Sari-R. Tug: "Enderun-i Hümayun Kilâr-i Hassa Baskullukçusu Dervis Mehmed'in (1764/5-1840) Dühn Terkiplerine Ait Risalesi". IV. Türk Eczacilik Tarihi Toplantisi (4-5 Haziran l998) Bildirileri (Ed. E. Dölen), "Marmara Universitesi Yay., no. 657, Eczacilik Fakültesi Yay., no.15", Istanbul 2000, pp. 238-297. In the anonymous book "Kitabü'l Mecmuatü'l Mücerrebat" (probably of the 18th century) on chemistry and alchemy, it is noted that some specially secret knowledge was intended to be hidden from "incompetent people". See N. Sari-Y. Okutan: "Kimya Ilmine Ait Kitâbü'l Mecmuatü'l Mücerrebât'a Kisa Bir Bakis". IV. Türk Eczacilik Tarihi Toplantisi Bildirileri (4-5 Haziran l998, Istanbul). "Marmara Universitesi Yay., no. 657, Eczacilik Fakültesi Yay. no.1 5", Istanbul 2000, pp. 261-276).

[127] N.Akdeniz (Sari): Osmanlilarda Hekim ve Deontolojisi, op.cit., p. 153; See: Abbas Vesim: Düstûrü' l Vesim, f. 507 b.

[128] There are many examples in F. H. Garrison: op.cit.; for instance, John Hunter was a famous surgeon, as well as a biologist and a researcher, see p. 347.

[129] Making use of various examples, S. Ural approaches from different aspects through a historical perspective the relation between acquiring knowledge and philosophy and argues the factors that direct this relation. Bilim Tarihi, op.cit., pp. 150-155, 159, 168, 220 etc.

[132] N. Sari: "19.Yüzyil: Tip Büyük Adimlarla Ilerliyor", Cerrahpasa Medical School, Medical History and Ethics Department, 1990 lecture notes, p. 8.
- R. M. Veatch: op.cit, p. 20.

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