Islamic Civilization

Hospitals [1]

Whilst travelling in the Near East in the years 1183-5, Ibn Jubayr  noted one or more hospitals in every city in the majority of the places he passed through, which prompted him to say that hospitals were one of ‘the finest proofs of the glory of Islam,' (and the madrasas another).[2]

Some twenty or so years before, in 1160, another traveller, Benjamin of Tudela, found no fewer than sixty well organized medical institutions in Baghdad .[3] Earlier, in the Muslim West, it was said that there were 50 hospitals in Cordoba .[4]

Possibly the earliest hospital in Islam was a mobile dispensary following the Islamic armies, dating from the time of the Prophet, a tradition which remained throughout the centuries of Islamic glory.[5] The first known hospital in Islam was built in Damascus  in 706 by the Umayyad Caliph, al-Walid Ibn Abd al-Malik. It was to cater for all sorts of patients including the blind, but also the lepers.[6] The hospital, its equipment, its staffing and organisation, was to serve as model for other hospitals to follow throughout the Islamic world. Hence, in Baghdad , Caliph Harun al-Rashid (r. 796-809) ordered the court physician to build the Baghdad hospital, a vast endeavour he financed generously, whilst Caliph Al-Mansur (r. 754-775) instructed his court physician, Ibn-Bakhtishu to set up hospitals to ‘reflect the true glory and prosperity of Baghdad.'[7] In Cairo , the first hospital was established at al-Fustat by Ibn Tulun, governor of the city in 872. It included a library of 100,000 books,[8] and had halls divided according to genders, illness, or the required surgical operation, and two separate baths for men and women.[9] After admission, each patient was required to wear special apparel provided by hospital authorities, while personal possessions were safely kept until the day of discharge.[10] In Tunisia , the Aghlabid ruler, Ziyadat Allah I (r. 817-838) built a hospital in Al-Qayrawan  in 830, where for the first time in history, female nurses were used. It also had a mosque, spacious wards, its services well indicated for visitors, and waiting rooms for both visitors and patients.[11]

More hospitals were erected, and by the 12^th century, the institution of the hospital in Islam had reached very advanced standards as seen in these instances. In Damascus , the largest hospital, built in 1156 by Nur Eddin Zangi, the Al-Nuri Hospital, was placed under the direction of the physician al-Bahili. It was well supplied with food and medication, and had a well stocked library for teaching.[12]  Ibn Jubayr  admired most particularly the way in which the administrator of the hospital kept a register of patients,[13] probably the earliest of its kind.[14]

In Morocco , in 1190, the Almohad ruler, Al-Mansur Ya'qub Ibn Yusuf built a hospital in Marrakech  in a spacious area surrounded by fruit trees, flowers, herbs, and vegetables.[15] In this hospital, the historian al-Marrakuchi says, ‘water was brought in aqueducts to all its sections, besides four pools in the centre thereof, of which one was built of white marble.'[16] The daily endowment was thirty golden dinars for the purchase of food supplies, un-stocked medication, and unpredicted expenses.[17] Physicians cared for the sick and prescribed diet and medications, while appointed pharmacists specialised in the compounding and preparing of drugs. Here, too, patients were provided with special apparel for the summer and winter seasons.[18]

In Cairo , the Mamluk sultan Qalawun (d. 1290) began the construction of al-Mansuri Hospital, the largest of all.[19] Masons and carpenters were brought from all parts of Egypt ; loiterers in the street, and passers by, whatever their rank were obliged to assist in the holy work.[20] When completed, in 1284, this hospital attended 4000 patients daily, had different wards for diverse diseases, and even applied music therapy on mentally ill patients.[21]  Al-Mansuri is described by Durant:

‘Within a spacious quadrangular enclosure four buildings rose around a courtyard adorned with arcades and cooled with fountains and brooks. There were separate wards for diverse diseases and for convalescents; laboratories, a dispensary, out-patient clinics, diet kitchens, baths, a library, a chapel, a lecture hall, and particularly pleasant accommodations for the insane. Treatment was given gratis to men and women, rich and poor, slave and free; and a sum of money was disbursed to each convalescent on his departure, so that he need not at once return to work. The sleepless were provided with soft music, professional story-tellers, and perhaps books of history.’[22]

Major adds that the income devoted to this hospital by the Mamluk rulers was the equivalent of $100,000 a year, and that each patient received the equivalent of $12 (1954 value) on their dismissal from the hospital.[23]

Pushmann acknowledges how the Muslims developed the hospital institution on efficient lines.[24] Muslim hospitals, indeed, were managed according to standards that compare favourably with those of today. Nearly all hospitals had separate wards for male and female patients, with different wards for the different therapeutic branches, such as medicine, surgery, orthopedics and eye diseases.[25] A separate ward or pavilion, with barred windows, was used for the care of the mentally ill, whilst a pharmacy, in the charge of a competent and licensed pharmacist, was used for both the Out-Patient and In-Patient services.[26]  Care for the patients was not just during stay at hospital, but also after. At Al-Mansuri of Cairo , for instance, patients on discharge, were given food and money to help them compensate for lost income during illness.[27] The position of the director of the hospital was considered one of the highest in the government, and as a rule was assigned to one of the princes, or an officer of the highest rank, and as a rule these were men of ability and culture, greatly respected, and ranking with the vizier or minister.[28] Al-Razi , Ibn Sina  and Ibn Zuhr, amongst others, worked both as hospital directors and deans of medical schools.[29] The hospitals also housed staff and students, whilst physicians were paid with regular salaries, and governmental budgets covered expenses.[30] Islamic chroniclers kept accurate accounts concerning the administration of the hospitals in Baghdad , which allows us to have records of their budgets, including salaries of the physicians, oculists and attendants.[31]

Hospitals  were the perfect symbol of universality of health care in Islam, and unlike their successors elsewhere, they catered for the needs of all, rich and poor alike, in urban and in rural areas, and freely. This attitude derives directly from the Qura’nic text which imposes upon the believer to give care and cure to every human regardless of their rank in society, including slaves.[32] For instance, Ibn Abi Usaybi'a speaks of an eminent Syrian doctor of the 12^th century, who, after examining the sick in the hospital, went to court to treat the important people.[33] The constitution establishing the Al-Mansuri hospital in Cairo , also talks of its duty is to give care to the ill, poor, men and women until they recover, without demand for any form of payment, but only for the sake of God, the Provider.[34] There was no distinction for faith or race either, whether in the provision of care or in the staffing of the hospitals. Staff came from every background, Christians, Jews, and others, often holding the highest authority in the institution. Sarton’s Introduction is an excellent window on such multi-faith diversity in Muslim hospitals.[35]

Hospitals  were places of care and also of learning and training. Hence, the leading figures of Islamic medical science who worked as directors of hospitals also took the lead in generalising the practice of studying patients and preparing them for student presentation.[36] At al-Nuri hospital of Damascus , teaching and discussions on topics related to medicine were conducted by people of great renown.[37] Some of the physicians at al-Adudi in Baghdad  took on the task of teaching ‘interns' and students of medicine.[38] In some of the famous hospitals there was a large hall, containing manuscripts, where the professors met undergraduate and graduate medical students for lectures and conferences.[39] At Al-Mansuri, in Cairo , there was a place where the head doctor gave lectures on medicine.[40] The hospital itself was manned by interns, residents and twenty four hour consultants, some of whom were specialists in ophthalmology, surgery and orthopaedics. They called on the patients and prescribed for each his daily requirements of diet and medication.[41] In that hospital, there was on average one professor of medicine for every eighteen students in its early stages.[42] The chief surgeons and physicians also gave demonstrations to students, examined them and issued diplomas.[43] Al-Madjusi (d. 994) may be called the father of the medical 'intern' system, for he required that the student be present at the professor's examinations.[44] He also insists:

‘And one of those things which are more incumbent on the student of this art, are that he should constantly attend the hospitals and sick houses; pay unremitting attention to the conditions and circumstances of their inmates, in company with the acute professors of medicine; and enquire frequently as to the state of the patients and symptoms apparent in them, bearing in mind what he has read about these variations, and what they indicate of good and evil.’[45]

As places of learning, the hospitals were also richly endowed with libraries. Nur Eddin Zangi (r. 1146-1174) constituted into waqf a large number of books on medicine for the Al-Nuri Hospital, which he had founded in Damascus .[46] This collection was located in two specified spots at the entrance of the Iwan, and a group of physicians and hospital employees sat in front of al-Bahili Ibn Ubayd Allah, who then distributed books out from these two spots for reading.[47] Exchange between students took place following the reading of such works for as long as three hours.[48] Sultan Qalawun (Qala’un) (r. 1277-1290), after having the hospital constructed, had a madrasa built near it, and fitted it with a library.[49] He had a librarian appointed for 40 dirhems a month.[50] Many scholars also dedicated works to such libraries. Ibn Al-Nafis, for instance, made his house into a waqf, and gave his books to the al-Mansuri Hospital,[51] which includes his major work al-Shamil fi’l Tibb in 300 volumes.[52]

Having looked briefly at the Islamic hospital, which in its main features and operations, reflects the modern day hospital, we can safely assert, that this institution was born under Islam, and not under some previous civilisations,[53] which at no instance shows one single advanced form of management or operation, or state involvement, as was the case with the Islamic hospital. Watts insists that we should remind ourselves that in earlier times, in the world of Greece and Rome, there had been no such a thing as hospitals for ordinary people.[54] Houses for refugees and the afflicted certainly existed, but hospitals run, organised and providing care in the modern sense, as in the Islamic world, certainly did not.

The best Islamic hospitals, Whitty says, were several centuries in advance of European ones, although to what extent they directly influenced European practice is difficult to quantify.[55] Meyerhof, however, makes an outline of the Islamic impact upon the Christian West in this field, stressing the role of the crusades.[56] Western hospitals, he notes, may well have been imitations of such splendidly installed ‘Bimaristans’ as that of the contemporary Seljuk ruler Nur Eddin in Damascus .[57] The Mansuri hospital of Cairo  was much admired by European travellers of later centuries.[58] The asylum and hospital ‘Les Quinze Vingt' was founded in Paris by Louis IX (St Louis) after his return from his unhappy crusade in 1254-60. Originally intended for three hundred poor blind men, it had added to it later a hospital for eye diseases which is now one of the most important in the French capital.[59] In teaching methods, Muslim hospitals exerted a strong influence, and Muslim methods with teaching ward rounds in clinical medical schools have been re-discovered many times, from the School at Salerno to Sir William Osler (a great admirer of Ibn Sina ) at the end of the 19^th century in Canada, the USA and Britain.[60] They remain the standard method of teaching Western medicine to this day.[61]

The hospital institution in its rise reflects the glory of Islamic civilisation. In its collapse it also reflects the collapse of the same civilisation. In 1258 the Mongol Hulagu conquered Baghdad  and made the illustrious Addudi hospital the centre of his attack.[62] When the traveller, Ibn-Battuta, visited Baghdad in 1330 he found the place in complete ruin, only traces of the walls were left.[63] That was also the fate of the city, from once being the glory of Islamic civilisation, now there was barely a trace of it.