The science of healing dates back several millennia to the Greeks, Persians and Indians. However, the institution of a hospital as we understand it today, and the practices found within it, have a peculiar history not commonly known. What the Persians and Arabs called bimaristan, or darüşşifa in Turkish, was the birth of an institution and an idea that revolutionized medicine and healthcare. While Christian Europe had facilities to host the sick in monasteries, modern scholars credit Islam with the birth of hospitals.
Background
The earliest example of a bimaristan dates back to the time of the Prophet Muhammad
ﷺ when a woman named Rufaidah al-Asalmia, in 627 AD, set up a treatment facility in a tent during the Battle of Khandaq (Trench). Later, this concept of a mobile bimaristan (some used camels to transport medicines and facilities) expanded into large, dedicated units found in city centres around the Islamic world, equipped with medicinal herbs, pharmacies and full-time physicians. The first major bimaristan was established in the city of Damascus in 706 AD, followed by several more in the cities of Cairo (where the first true general hospital was built in 805 AD by Harun al-Rashid), Granada and Baghdad. By the end of the 15th century, Muslim Granada alone had 50 major hospitals.
What makes these establishments so important and unique is that at a time when public hospitals did not exist (the first true hospital in Europe was to be founded 500 years later), the bimaristans in the Arab and Muslim world offered world-class healthcare, all for free. No patient was to be turned away, regardless of their race, religion, gender or type of illness, including mental illnesses and contagious diseases. Alongside having separate wards for different illnesses, patients suffering from anxiety or showing signs of psychological distress were treated in the same way as patients with physical illnesses–a remarkable fact given mental health has only recently been taken seriously in Western medicine. The patients, as well as practitioners in bimaristans, would have been Muslim, Jewish or Christian, with up to twenty eight physicians doing rounds in each institution.1 Most hospitals would also include pharmacies that carried medicine or remedies imported from as far as India.
Patronage
The majority of hospitals attained their endowments through charitable donations or waqfs (bequests). When a waqf was set up, a legal contract would be drawn up that stipulated conditions for the operation of the bimaristan. It was through these documents that a bimaristan kept its doors and services open for all those that needed care.
In large cosmopolitan cultural capitals, such as Baghdad, Damascus or Fes, the ruling and noble class would feel a sense of obligation to create institutions for the benefit of the common folk. A bimaristan, madrassa (school) or hamam (bathhouse) would not only raise the standard of living for all, but be seen as a charitable act that would inevitably make rulers more popular. The hospital of Nur al-Din in Damascus, created by the Zangid Sultan Nur-al Din Zangi, is a fine example of a 12th century bimaristan that demonstrates the vast efforts that this sultan underwent to please his subjects.
Farther west, in the old medina of Fes, Morocco, signs of another unique and important bimaristan can be found. The Maristan of Sidi Frej, founded in 1286 AD by the Marinid king Youssef Ibn Yakoub, functioned as a hospice for the destitute and mentally ill up until 1944, making it one of the longest continuing institutions of its type in history. It served not only human patients, but also had the curious function of operating as a stork hospital as well, nursing sick and injured storks back to health. Such charity towards humans and animals could not have been possible without donations from wealthy and powerful donors. So advanced and popular were bimaristans in North Africa and the Middle-East, that patients and scholars would travel from across the world for treatment and teaching. The Andalusian scholar, Ibn Rushd, left Cordoba to teach in a bimaristan in Marrakech.
Types of Treatment
Bimaristans were at the forefront of providing groundbreaking medical advancements. Amongst them were developments in surgery, anatomical and disease studies, as well as focus on less visible conditions, such as psychological disorders. Eye surgery (especially cataract) was one of Islamic medicine’s greatest success stories with the Andalusian polymath, al-Zahrawi (Albucasis), considered the father of modern surgery, writing a 30-volume encyclopedia on medical practices that was used in Europe up until the 18th century.
Patients who suffered from mental illnesses were treated in new and ingenious ways. Separated from the general patient population, the environment was used, as opposed to medicine, as a remedial technique. Treatment included the use of abundant light, beautiful sounds (musical instruments and the sound of running water), plenty of fresh air and conversations. The rule of bimaristans was that no patient would leave until cured. The design and location of bimaristans was key. The Seljuk darüşşifa, for example, would be found inside or near gardens, using the serenity found in nature to aid treatment. A well-known darüsiffa found in the north-west Turkish city of Edirne, constructed by Sultan Bayezid II, is evidence of architectural and locational considerations. Whilst this house of healing is longer operational, its large size and complex layout indicate just how serious psychiatry was taken. Founded just outside the city limits, it relied heavily on sound and fragrance for treatments, so it needed to be away from the hustle and bustle of the once Ottoman capital. Needless to say, beautification was an essential element of the design language for darüsiffas and bimaristans.
For mental illnesses to be treated correctly, a clear diagnosis was needed. The tenth-century Persian scientist, physician and philosopher, Ibn Sina (Avicenna) attempted to deal with unseen illnesses that were previously ignored, notably the pain associated with love. He went as far as defining psychosis as independent from other mental health conditions. His most famous encyclopedic work, The Canon of Medicine, remained unparalleled for over a millennia and was taught to medical students around the world until the 18th century.
Another notable Persian scholar, al-Balkhi, whose most famous surviving treatise, Sustenance of the Soul, from the 9th century dedicates half its pages to psychological illnesses, where he argues that they are just as, if not more, important to treat as physical illnesses. Balkhi dealt with depression, anxiety and even obsessive-compulsive disorder (recognised as a real ailment as late as the 20th century in the West). He pioneered splitting depression into two types: environmental and biological, suggesting different treatments for each. Mental health was taken seriously and was separated from a believer’s practice of faith, removing the idea that a disease or ailment was a result of a patient’s sins.2
Music Therapy
Music has been understood as divine in many circles of Islamic thought, especially Sufism. Ibn Farabi, a philosopher and music theorist, wrote an early treatise on music in the 9th century AD, presenting its cosmic qualities and discussing its therapeutic effects on the soul and body. He explained how music could revive or accentuate emotions depending on the melodic modes used, which would correct an imbalance, reestablishing a patient’s equilibrium in body (based on the principles of humorism from Greco-Roman medicine), mind and spirit. Each mode could elicit different feelings such as contentment, sadness, fear, sleepiness and more. A sophisticated set of mathematical principles were then organized by al-Farabi in his book Kitab al-Musiqi al-Kabir (Grand Book of Music) which formed the basis for Arab and Ottoman music therapy practices as well as the music-related medicinal practices of early Europe. The Ottomans further classified and organized music modes to the treatment of particular illnesses. Some modes were useful for individuals suffering from paralysis, others for diseases of the urinary tract, and others for insomnia and foot pain – an illustrative example of how music and sound therapy could be used to remedy both psychological and physical illness.
The Sick and the Sacred
Bimaristans also served as places of learning and devotion alongside healing. Many would be built adjacent to or as part of larger complexes that would include a madrassa (school), library and a mosque. This bonding highlights the intertwined nature of healing as seen in the Islamic tradition: it was through the seeking of knowledge and reason that physical ailments could be diagnosed and cured in schools and hospitals, but it was through the submission and remembrance of God that one would seek spiritual betterment.
The design and architectural techniques employed in bimaristans for providing relief and remedy for the sick, were also used in wider urban designs. For example, the inner courtyards of noble Arab, Persian and Indian homes were filled with gardens that included carefully selected types of plants known for their soothing properties. These houses, as in the case of those found in Damascus, would include at least one central fountain and be oriented to control the quantity of light in each part of the house.
Concluding Remarks
The legacy of the bimaristan lives on. While the contribution of Muslim scholars to the field of Western medicine is increasingly acknowledged, the design language, operating philosophy and holistic approach to healthcare developed within bimaristans remain mostly hidden, including the beautiful art of sound therapy. In recent decades the use of sound and music as a therapeutic tool has gained a foothold in Western medicine, and a school of thought is developing that promotes a natural approach to remedy over drugs and medicine. It is a shame that modern hospitals have adopted so few of the beautiful characteristics of one of Islam’s most valuable contributions to the world: bimaristan, the house of healing.
Edited by Leila Khansa
Footnotes
1 Zarshenas, M.M., Mehdizadeh, A., Zargaran, A. et al. Rhazes (865–925 AD). J Neurol 259, 1001–1002 (2012). https://doi.org/10.1007/s00415-011-6398-x
2 Badri, Malik, Abu Zayd al-Balkhi’s Sustenance of the Soul: The Cognitive Behaviour Therapy of A Ninth Century Physician, IIIT, 2014.
Further Reading
- Malik Badri, Abu Zayd al-Balkhi’s Sustenance of the Soul: The Cognitive Behaviour Therapy of A Ninth Century Physician, IIIT, 2014.
- Denise Gill, Melancholic Modalities: Affect, Islam, and Turkish Classical Musicians, Oxford University Press, 2017.
