Bimaristan

As hospitals developed during the Islamic civilization, specific characteristics were maintained. For instance, Bimaristans served all people regardless of their race, religion, citizenship, or gender.[9] The Waqf documents stated nobody was ever to be turned away.[10] This included those with mental illnesses or disorders–in Aleppo's Arghun Hospital, for example, care for mental illness included abundant light, fresh air, running water and music.[11] The ultimate goal of all physicians and hospital staff was to work together to help the well-being of their patients.[10]

There was no time limit a patient could spend as an inpatient.[12] Instead, waqf documents stated the hospital was required to keep all patients until they were fully recovered.[9] Men and women were admitted to separate but equally equipped wards.[9][10] The separate wards were further divided to address mental illnesses, contagious diseases, non-contagious diseases, surgery, medicine, and eye diseases.[10][12] Patients were attended to by nurses and staff of their same gender.[12] Each hospital contained a lecture hall, kitchen, pharmacy, library, mosque and occasionally a chapel for Christian patients.[12][13] Recreational materials and musicians were often employed to comfort and cheer patients up.[12]

The Qur'an provided the basis for the development of professional ethics where the rise of ritual washing also influenced the importance of hygiene in medical practice. The importance of hygiene promoted healthy lifestyles, and cut down on disease by enticing communities to create hygiene infrastructures. Bimaristans promoted hygiene through practices of regularly bathing patients and staff, providing clean bedding and medical materials, as well as through their architecture, which promoting air circulation and bright open lighting.[14] Pharmacies were periodically visited by government inspectors called muhtasib, who checked to see that the medicines were mixed properly, not diluted and kept in clean jars. Additionally, al-Razi, who was once asked to choose the site for a new hospital in Baghdad, suspended pieces of meat at various points around the city and recommended building the hospital at the location where the meat putrefied the slowest.[15]

The various Quranic injunctions and Hadith (or actions of Muhammad), which place values on education and emphasize the importance of acquiring knowledge, played a vital role in influencing the Muslims of this age in their search for knowledge and the development of the body of science.[16][17][18]

Bimaristans were not only used to provide care for individuals. They were also educational institutions meant to advance medical students’ knowledge in the medical field, especially in cities like Baghdad, Damascus, and Cairo.[19] Some madrasas were also closely linked with bimaristans so that students could learn in the institutions and put their theoretical knowledge directly into practice.[20] Basic science preparation was learned through private tutors, self-study and lectures. Many of these hospitals also contained a conjoined library typically filled with any possible writings that may be relevant to the medicine practiced in the hospitals.[21]

Physicians in these proto-medical schools were not exclusively Muslim; Jewish and Christian physicians also practiced and taught.[22] In the major hospitals at Cairo, Baghdad, and Damascus, students often visited patients while under the supervision of a practicing physician–a system comparable to a medical residency today. Like in today's medical training programs, working and learning in the bimaristans under the supervision of practicing physicians allowed medical students to gain hands-on experience treating various ailments and responding to a multitude of situations.[3]

During this era, physician licensure became mandatory in the Abbasid Caliphate.[12] In 931 AD, Caliph Al-Muqtadir learned of the death of one of his subjects as a result of a physician's error.[13] He immediately ordered his muhtasib Sinan ibn Thabit to examine and prevent doctors from practicing until they passed an examination.[12][13] From this time on, licensing exams were required and only qualified physicians were allowed to practice medicine.[12][13]

The early Islamicate empires, while on their quest for knowledge, translated the work of early pre-Islamic times from empires such as Rome, Greece, Pahlavi, and Sanskrit into Arabic, before this translation the work had been lost and perhaps it may have been lost forever.[23] The discovery of this new information exposed the Islamicate empires to large amounts of scientific research and discoveries. Arabs translated a variety of different topics throughout science including Greek and Roman research in medicine and pharmacology. Translated artifacts such as medical dictionaries and books containing information on hygiene and sexual intercourse are still preserved. Perhaps one of the most notable translated pieces is a human anatomy book translated from Greek to Arabic by Muslim physician, Avicenna, the book was used in schools in the West until the mid-17th century.[24]

The existence of hospitals in Baghdad has been documented since the 9th century CE, with the first having most likely been established in 805 by the caliph Harun al-Rashid and his vizier, Yahya ibn Khalid.[25] By the end of the 10th century CE, five more hospitals had been built in Baghdad.[1]

Founded in 981 by the then ruler of Baghdad, Adud al-Dawlah, this hospital was administered by al-Razi, who also chose its location along the Tigris River.[31] He determined where it should be located by "hanging a piece of meat in several places for a few days and deciding in favor of the place where meat was found to be least infected."[31] At its inception, the Al-Adudi Hospital had twenty-five staff members, specializing in fields ranging from optics to surgery. In addition to these specialists, the Al-Adudi Hospital also served as a teaching hospital for new doctors. The Al-Adudi Hospital remained operational into the 12th century CE when, in 1184, it was described as "...being like an enormous palace in size."[1] Ultimately, the Al-Adudi Hospital was destroyed in 1258 by Mongols led by Hulagu Khan in the siege of Baghdad.[31]

One of the first Egyptian hospitals was the Al-Fustat Hospital, which was founded in 872 CE. It was founded by Ahmed ibn Tulun and was located in Fustat, located in what is now modern Cairo. The Al-Fustat Hospital shared many common features with modern hospitals. Among these were bath houses separated by gender, separate wards and the safekeeping of personal items during a patient's convalescence.[31][8] In addition to these practices, the Al-Fustat Hospital is the first to have offered treatment for mental disorders.[1] Beyond the practice of medicine, the Al-Fustat Hospital was also a teaching hospital and housed approximately 100,000 books. Another key feature of the Al-Fustat Hospital was that it offered all treatment for free. This was made possible by waqf revenue, and the Al-Fustat Hospital was likely the first hospital endowed in this way.[8] Near the Al-Fustat Hospital, Ibn-Tulum also established a pharmacy to provide medical care in emergencies.[8] The Al-Fustat Hospital remained in operation for approximately 600 years.[31]

The Al-Mansuri Hospital was another hospital located in Cairo, and was completed in 1284 CE. Its founder, Al-Mansur Qalawun, was inspired to establish a hospital after his own experience being hospitalized in Damascus.[31] Because of Al-Mansur's vision for the hospital, treatment was free to make the hospital accessible to both the rich and the poor. Furthermore, "...upon discharge the patient was given food and money as a compensation for the wages he lost during his stay in the hospital."[31] The Al-Mansuri Hospital was so accessible, in fact, that it treated roughly 4,000 patients every day. The Al-Mansuri Hospital was a groundbreaking institution and acted as a model for future bimaristans to come.

The Al-Mansuri Hospital was substantial, both in size and endowments. This hospital had the capability of holding 8000 beds and was funded off of annual endowments totaling one million dirhams.[3] Like the Al-Fustat Hospital before it, the Al-Mansuri Hospital also treated mental patients and introduced music as a form of therapy. The Al-Mansuri also obtained the personal library of Ibn al-Nafis upon his death in 1258.[32] The Al-Mansuri Hospital remained operational through the 15th century CE and still stands in Cairo today, though it is now known as "Mustashfa Qalawun."[1][31]

Damascus is credited with being the home of the first ever Islamic hospital, which was established between 706 and 707 CE. Founded by Walid ibn 'Abdulmalik, this hospital was meant to serve as a treatment center for both those with chronic illnesses, like leprosy and blindness, as well as the poor or impoverished.[8] This began with ibn 'Abdulmalik gathering lepers and preventing them from spreading the illness by providing them money. This was done to prevent them from begging strangers for money, thereby curtailing the spread of leprosy.[33] To accomplish these objectives, separate wards existed for infectious diseases such as leprosy, and patients faced no cost to receive treatment. The Al-Walid Hospital has been compared to the Byzantine nosocomia, which was a charitable institution tasked with treating "...the sick, the lepers, the invalid, and the poor."[8]

The Bimaristan of Nur al-Din or Al-Nuri Hospital was founded in Damascus nearly four and a half centuries after the Al-Walid Hospital, in 1156 CE. It was named after Nur al-Din Zanji. The Al-Nuri Hospital, which operated for some 700 years, was the same hospital where Al-Mansur Qalawun was treated and inspired to establish his own hospital in Cairo. The Al-Nuri Hospital, in addition to bringing about the Al-Mansuri hospital, was innovative in its practices as it became the first hospital to begin maintaining medical records of its patients.[31] The Al-Nuri Hospital was also a prestigious medical school, with one of its most noteworthy students being Ibn al-Nafis, who would later pioneer the theory of pulmonary circulation.[31]

Exterior of the Sultan Bayezid II complex in Edirne, Turkey.

A bimaristan (the Darüşşifa or Bimarhane), Amasya, Turkey.

• Maristan of Sidi Frej in Fes, Morocco
• The Nasrid Bimaristan of Granada, Spain
• Maristan of al-Mu'ayyad, Cairo, Egypt
• Divriği Great Mosque's adjoining Turan Melek Sultan Darüşşifa in Divriği, Turkey
• Sultan Bayezid II complex in Edirne, Turkey
• Darüşşifa and Medrese (medical school) of Gevher Nesibe in Kayseri, Turkey
• Şifaiye Medrese (medical school) and Darüşşifa in Sivas, Turkey

Ammar al-Mawsili, a 10th-century physician and ophthalmologist, developed a revolutionary treatment for cataracts.[34] The practice included a hollow syringe (which he developed) and removing the cataract through suction. Although this procedure has further developed throughout the centuries, the basic treatment remains the same even today.[35]

Diseases of the eye were further explored during this era by ʻAli ibn ʻIsa al-Kahhal or Ibn Isa (died c. 1038), who practiced and taught in the Al-Adudi Hospital in Baghdad. He wrote and developed the Tadhkirat al-kaḥḥālīn (“The Notebook of the Oculist”), which detailed more than 130 eye diseases based on anatomical location.[36] The work was separated into three portions consisting of:

1. Anatomy of the eye
2. Causes, symptoms and treatments of diseases,
3. Less apparent diseases and their treatments.[34]

This work was translated into Latin in 1497, and then into several other languages which allowed it to benefit the medical community for centuries to come.[35]

Perhaps the largest contribution to Islamic surgical development came from Abū al-Qāsim Khalaf ibn al-‘Abbās al-Zahrāwī, also known as Abū al-Qāsim or Al-Zahrawi (936–1013). He contributed to advancements in surgery by inventing and developing over 200 medical instruments which constituted the first independent work on surgery.[37] Such instruments included tools like forceps, pincers, scalpels, catheters, cauteries, lancets, and specula, which were accompanied by detailed drawings of each tool.[35] Al-Zahrawi also wrote the At-Taṣrīf limanʿajazʿan at-Taʾālīf, or At-Taṣrīf (“The Method”), which was a 30-part text based on earlier authorities, such as the Epitomae from the 7th-century Byzantine physician Paul of Aegina. It was largely composed of medical observations, including what is considered the earliest known description of hemophilia.[37] The 30-volume encyclopedia also documented Zahrawi and his colleagues’ experiences with treatment of the ill or afflicted. Aside from the documentation of surgical instruments, the work included operating techniques, pharmacological methods to prepare tablets and drugs to protect the heart, surgical procedures used in midwifery, cauterizing and healing wounds, and the treatment of headaches.[35] Although Zahrawi was somewhat disregarded by hospitals and physicians in the eastern Caliphate[37] (no doubt due to his Spanish roots, being near Córdoba, Spain), his advancement and documentation of medical tools and observations contained in his work had a vast influence on the eventual medical development in Christian Europe, when it was translated into Latin during the 12th century.[35]

The Abbasid Caliphate in Baghdad underwent extreme intellectual and medical experimentation during the 10th and 11th centuries.[35] Among the many skilled physicians and intellectuals there was Abū Bakr Muḥammad ibn Zakariyyāʾ al-Rāzī, or in Latin, Rhazes (c. 865–925). Rhazes served as chief physician in a hospital in Rayy, Iran, before holding a similar position in the Baghdad hospital. He developed two significant works regarding advancements in medicine and philosophy. The Kitāb al-Manṣūrī and the Kitāb al-ḥāwī, (“Comprehensive Book”) which surveyed early Greek, Syrian, and Arabic medicine, and added his own judgement and commentary. He also wrote several minor treatises, perhaps the most famous being Treatise on Small Pox and Measles. This treatise was translated into several modern languages as well as Latin and Byzantine Greek for teaching purposes and medical treatment of such infectious diseases.[38]

Abu-Bakr al-Razi was instrumental in improving the medical education within hospitals and was credited with the creation of 'ward rounds,' which served as a teaching method for the medical students within the hospital.[39] The ward rounds consisted of several rounds of questions designated for students with different levels of medical expertise to answer.[39] In the first round, students were expected to answer medical questions having to do with the current cases.[39] The second round was designated for students with more experience to answer the remaining, more complex questions.[39] Finally, if questions still remained after round two, al-Razi would provide answers and often document his findings.[39] Abu-Bakr al-Razi has been credited with writing more than 200 books and treatises throughout his life.[39]

Although surgical developments and advancements made in the medieval Islamic period are of extreme importance, the largest and most wholesome contribution to the medical world stemming from Islamic medicine and hospitals came from the Baghdad firmament from Ibn Sina, or “Avicenna” in the West.[35] Ibn Sina, who had already become a doctor by the age of 18, developed the Al-Qanun fi al-Tibb (Canon of Medicine).[35] This work is largely known as one of the most famous medical works of all time. The ways in which Ibn Sina's Canon of Medicine worked to bring together various disciplines and cultures, essentially revived Greek authors and philosophers and fostered new thought patterns to develop much of the future medical practices we see today. Ibn Sina did this by combining the medical developments of Greek physician and philosopher Galen, with the philosophy of Aristotle.[35] Furthermore, as Islamic medicine recognized that many diseases are contagious, such as leprosy, smallpox, and sexually transmitted diseases, Ibn Sina recognized tuberculosis as a contagious disease, among others which can be spread through soil and water.[40] The Canon of Medicine continued to be studied by European medical professionals and institutions even into the 18th century. This combination and rationalization of practical science, religion, and thought highlighted the pinnacle of Muslim medical scholarship, and the nature of the true developments which were made in the medical world.[35]

In addition to his work with Canon of Medicine, Ibn Sina served as a trailblazer for 'holistic medicine,' making an emphasis on the patient as a whole, not just focusing on one certain aspect when diagnosing.[41] While Ibn Sina looked at a patients medical symptoms, there was also focus on the patient's nutrition, emotional health, and environmental surroundings when coming up with a diagnosis.[41] Ibn Sina also had the belief that anatomy served as the cornerstone of medicine.[41] Ibn Sina was the first known physician to use a flexible catheter with the purpose of irrigating the bladder and combatting urinary retention in the human body.[41] Ibn Sina was groundbreaking in his recognition of esophageal cancer, ligation of bleeding arteries, the anatomy of nerves and tendons, compartment syndrome following injury to human appendages, and the idea that arterial repair would one day be possible.[41]

• Hunayn ibn Ishaq, an Arab Nestorian Christian translator, scholar, physician, and scientist, was viewed as a mediator between Greek sciences and Arabs due to his translations of multiple documents that were tremendously important.[2]
• Ibn al-Nafis, an Arab polymath whose areas of work included medicine, surgery, physiology, anatomy, biology, Islamic studies, jurisprudence, and philosophy was also a physician and an author,[2] was most known for his commentary on pulmonary circulation.[19]
• Mir Mu’min Husayni Tunikabuni, a 17th-century Persian schfolar, focused on how yogic breath control can control the humors.[19]

Islamic hospitals also brought about the idea of separate wards or segments of the hospital that were separated by patient diagnostic. When Islamic hospitals first brought this about, not only were the wards separated by diagnostic but by sex as well.[44] While hospitals today are not as strict and do not separate by sex anymore, they still separate people by disease or problem. By doing so, different wings could specialize in certain treatments specific to their patient. This practice not only still exists today in modern hospitals but also lead to the advancement of treatments back then that now comprise the “Canon of Medicine.” This separation of diseases not only helped the timely treatment of patients but also helped the patients and physicians from getting sick with other diseases that surrounded them because they only had to worry about the prevention of one disease. By separating patients, the specialization of certain wings and treatments really advanced the medicine and improved the efficiency of hospitals ultimately leading to how modern day hospitals are designed.

With Islamic hospitals advancing medicine so quickly, they needed a way to catalogue all of their findings which in the end lead to the first medical records. This made hospitals more efficient as they were able to check records of other patients for people that had similar symptoms and, hopefully, treat them the same way they were able to with the other patients. Not only did physicians keep medical records but they kept notes on patients and provided them for peer review as a way to not be held responsible for malpractice.[45] This information also enabled physicians to start to notice patterns in patients more making the medicinal practices more accurate as everything is with more trials. The efficiency gained from keeping records allowed hospitals to run more smoothly and treat patients faster. This information also enabled physicians to start to notice patterns in patients more making the medicinal practices more accurate as everything is with more trials. This keeping of records ultimately lead to the accumulation of the “Canon of Medicine,” which is a book of medicine compiled by the Persian philosopher Avicenna (Ibn Sina) that was completed in 1025.

Another legacy that vastly changed the way through which medical practices were developed, was the method of education and perpetuation of medical knowledge. Islamic hospitals modernized the qualification of physicians and education leading to a license to practice medicine in hospitals. In 931 CE, Caliph Al –Muqtadir started the movement of licensing physicians by telling Siban Ibn- Thabit to only give physician licenses to qualified people. The origin of Caliph Al-Muqtadir's order to Siban Ibn-Thabit was due to the fact that a patient had previously died in Baghdad as a consequence of a physician's error.[3] Siban Ibn-Thabit was tasked with examining each of the 860 practicing physicians at the time, resulting in the failure of 160 and setting a new precedent within the medical world.[3] From this point on, physicians were required to pass licensing examinations prior to being able to practice medicine.[3] In an effort to properly enforce licensing examination, the position of 'Muhtasib' was established.[3] The Muhtasib was a government official who administered oral and practical licensing examinations to young physicians.[3] If the young physician was successful in proving his professional competence through the examinations, the Muhtasib would administer the Hippocratic Oath and a license allowing the physician to legally practice medicine.[3] Seeing as how one of the chief objectives of Islamic hospitals was the training of new physicians or students, senior physicians, and other medical officers would often hold instructive seminars in large lecture halls detailing diseases, cures, treatments, and techniques from class manuscripts. Islamic hospitals were also the first to adopt practices involving medical students, accompanied by experienced physicians, into the wards for rounds to participate in patient care.[43] Hospitals doubling as schools not only provided hospitals with more fresh working hands but also helped in the advancement of medicine. Education in hospitals during the Islamic period modernized hospitals today in that now before people can become doctors they must complete a period of residency in which students study at a hospital and job shadow licensed physicians for a number of years before they are fully able to become licensed physicians.[43] This came at a time when much of Europe's medical practices were much less advanced, and with the compilation and creation of Avicenna's (Ibn Sina) medical textbook, the “Canon of Medicine,” these groundbreaking Islamic discoveries were able to influence Europe and the rest of the world for centuries to come.

During the Islamic Golden Age, there was a translation movement to convert Greek medical texts into Arabic. Some of the books that impacted the field were Tarkib-Al-Advieh about mixtures of drugs, Al-Advieh Al-Mofradeh which was written about single drugs, Ghova-Al-Aghzieh which concerned the potency of food for medicine, Al-Advieh Ao Al-dava, Al-Oram which concerned swellings of the body, and Al-Teriagh or The Book of Theriac.[46] Through readings, Islamic doctors were able to find drugs that they could use to help treat patients.[47]

One of the most notable contributors to pharmacology was Galen, a physician in the Roman Empire, wrote on theories of drug action. Galen's theories were later recorded, simplified, and translated by Arabic scholars, notably Hunayn ibn Ishak. Because of the need for the works to be translated from Greek to Arabic, there is a lot of documentation available regarding the naming of drugs. Authors such as Abulcasis and Maimonides, went into detail on this aspect and discussed the naming of drugs including the linguistics, as well as the synonyms and explanations behind the name given to the drug.[47] Avicenna also contributed to the naming and categorization of drugs. In his Cannon of Medicine, he explained medicine types such as antiseptics and narcotics as well as explained the forms such as tablets, powders, and syrups.[46]

After learning from the different books and coming to their own conclusions, Arabic physicians made numerous contributions when it came to determining dosage for patients depending on their condition. Multiple scholars, including the Arabic scholar and physician al-Kindi, determined the geometric progression of dosage. They found there was an arithmetic increase in the drug's sensation as the dosage was increased.[47]

Some of the main areas of study when it came to pharmacology involved Toxicology and the science behind sedative and analgesic drugs. Many physicians, Arabic and not alike, were fascinated with poisons. They sought out knowledge on how to make them and remediate them. Similarly, the science of sedative and analgesic drugs also fascinated Arabic physicians. Substances such as Cannabis sativa (Hashish), Hyoscyamus Niger (narcotic), and Papaver somniferum (opium) were well studied and used in their medicine.[46]