The Islamic Roots of the Modern Hospital by Mostafa Ghandar

In Egypt, the first hospital was built in 872 in the southwestern quarter of Fustat, now part of Old Cairo, by the ‘Abbasid governor of Egypt, Ahmad ibn Tulun. It is the first documented facility that provided care also for mental as well as general illnesses. In the 12th century, Saladin founded in Cairo the Nasiri hospital, which later was surpassed in size and importance by the Mansuri, completed in 1284. It remained the primary medical center in Cairo through the 15th century, and today, renamed Qalawun Hospital, it is used for ophthalmology.

In Damascus the Nuri hospital was the leading one from the time of its foundation in the mid-12th century well into the 15th century, by which time the city contained five additional hospitals.

In the Iberian Peninsula, Cordóba alone had 50 major hospitals. Some were exclusively for the military, and the doctors there supplemented the specialists who attended to the caliphs, military commanders and nobles.

Organization

In a fashion that would still be recognizable today, the typical Islamic hospital was subdivided into departments such as systemic diseases, surgery, ophthalmology, orthopedics and mental diseases. The department of systemic diseases was roughly equivalent to today’s department of internal medicine, and it was usually further subdivided into sections dealing with fevers, digestive troubles, infections and more. Larger hospitals had more departments and diverse subspecialties, and every department had an officer-in-charge and a presiding officer in addition to a supervising specialist.

Hospitals were staffed also with a sanitary inspector who was responsible for assuring cleanliness and hygienic practices. In addition, there were accountants and other administrative staff to assure that hospital conditions—financial and otherwise—met standards. There was a superintendent, called a sa’ur, who was responsible for overseeing the management of the entire institution.

Physicians worked fixed hours, during which they saw the patients who came to their departments. Every hospital had its own staff of licensed pharmacists (saydalani) and nurses. Medical staff salaries were fixed by law, and compensation was distributed at a rate generous enough to attract the talented.

Funding for the Islamic hospitals came from the revenues of pious bequests called waqfs. Wealthy men and rulers donated property to existing or newly built bimaristans as endowments, and the revenues from the bequests paid for building and maintenance. To help make it pay, such revenues could come from any mix on the property of shops, mills, caravanserais or even entire villages. The income from an endowment would sometimes also cover a small stipend to the patient upon dismissal. Part of the state budget also went toward the maintenance of hospitals. To patients, the services of the hospital were free, though individual physicians occasionally charged fees.

Patient Care

Bimaristans were open to everyone on a 24-hour basis. Some only saw men while others, staffed by women physicians, saw only women; still others cared for both in separate wings with duplicate facilities and resources. To treat less serious cases, physicians staffed outpatient clinics and prescribed medicines to be taken at home.

Special measures were taken to prevent infection. Inpatients were issued hospital wear from a central supply area while their own clothes were kept in the hospital store. When taken to the hospital ward, patients would find beds with clean sheets and special stuffed mattresses ready. The hospital rooms and wards were neat and tidy with abundant running water and sunlight.

Inspectors evaluated the cleanliness of the hospital and the rooms on a daily basis. It was not unusual for local rulers to make personal visits to make sure patients were getting the best care.

The course of treatment prescribed by doctors began immediately upon arrival. Patients were placed on a fixed diet, depending on condition and disease. The food was of high quality and included chicken and other poultry, beef and lamb, and fresh fruits and vegetables.

The major criterion of recovery was that patients be able to ingest, at one time, an amount of bread normal to a healthy person, along with the roasted meat of a whole bird. If patients could easily digest it, they were considered recovered and subsequently released. Patients who were cured but too weak to discharge were transferred to the convalescent ward until they were strong enough to leave. Needy patients were given new clothes, along with a small sum to aid them in re-establishing their livelihood.

The 13th-century doctor and traveler ‘Abd al-Latif al-Baghdadi, who also taught at Damascus, narrated an amusing story of a clever Persian youth who was so tempted by the excellent food and service of the Nuri hospital that he feigned illness. The doctor who examined him figured out what the young man was up to and admitted him nevertheless, providing the youth with fine food for three days. On the fourth day, the doctor went to his patient and said with a rueful smile, “Traditional Arab hospitality lasts for three days: Please go home now!”

The quality of care was subject to review and even arbitration, as related by Ibn al-Okhowa in his book ‘Ma’alem al-Qurba fi Talab al-Hisba’ (The Features of Relations in al-Hisba ):

If the patient is cured, the physician is paid. If the patient dies, his parents go to the chief doctor; they present the prescriptions written by the physician. If the chief doctor judges that the physician has performed his job perfectly without negligence, he tells the parents that death was natural; if he judges otherwise, he tells them: Take the blood money of your relative from the physician; he killed him by his bad performance and negligence. In this honorable way, they were sure that medicine is practiced by experienced, well-trained persons.

In addition to the permanent hospitals, cities and major towns also had first aid and acute care centers. These were typically located at busy public places such as large mosques. Maqrizi described one in Cairo:

Ibn Tulun, when he built his world-famous mosque in Egypt, at one end of it there was a place for ablutions and a dispensary also as annexes. The dispensary was well equipped with medicines and attendants. On Fridays there used to be a doctor on duty there so that he might attend immediately to any casualties on the occasion of this mammoth gathering.

Medical Schools & Libraries

Because one of the major roles of the hospitals was the training of physicians, each hospital had a large lecture theater where students, along with senior physicians and medical officers, would meet and discuss medical problems in seminar style. As training progressed, medical students would accompany senior physicians to the wards and participate in patient care—much like a modern residency program.

Surviving texts, such as those in Ibn Abi Usaybi’ah’s ‘Uyun al-anba’ fi tabaqat al-atibb’ (Sources of Information on Classes of Physicians), as well as student notes, reveal details of these early clinical rounds. There are instructions on diets and recipes for common treatments, including skin diseases, tumors and fevers. During rounds, students were told to examine the patients’ actions, excreta, and the nature and location of swelling and pain. Students were also instructed to note the color and feel of the skin, whether hot, cool, moist, dry or loose.

Training culminated in an examination for a license to practice medicine. Candidates had to appear before the region’s government-appointed chief medical officer. The first step required was to write a treatise on the subject in which the candidate wanted to obtain a certificate. The treatise could be an original piece of research or a commentary on existing texts, such as those of Hippocrates, Galen and, after the 11th century, Ibn Sina, and more.

Candidates were encouraged not only to study these earlier works, but also to scrutinize them for possible errors. This emphasis on empiricism and observation rather than slavish adherence to authorities was one of the key engines of the medieval Islamic intellectual ferment. Upon completion of the treatise, candidates were interviewed at length by the chief medical officer, who asked them questions relevant to problems of the prospective specialties. Satisfactory answers led to licensed practices.

Another key aspect to the hospital, and of critical importance to both students and teachers, was the presence of extensive medical libraries. By the 14th century, Egypt’s Ibn Tulun Hospital had a library comprising 100,000 books on various branches of medical science. This was at a time when Europe’s largest library, at the University of Paris, held 400 volumes.

Cradle of Islamic medicine and prototype for today’s hospitals, bimaristans count among numerous scientific and intellectual achievements of the medieval Islamic world. But of them all, when ill health or injury strikes, there is no legacy more meaningful.

( Reprinted from AramcoWorld )