Bimaristan

Bimaristan is a Persian word (بیمارستان bīmārestān) meaning "hospital", with bimar- from Middle Persian (Pahlavi) of vīmār or vemār, meaning "sick" or "ill person" plus -stan as location and place suffix.[1] In addition, the term 'Bimaristan' is a word with Persian origin that originally meant 'location of disease.' [3]

In English literature, the term is often used to designate the historical or pre-modern institutions that existed in the Islamic world, but they are also still used sometimes in their native languages to refer to modern hospitals or to specific types of medical institutions.[4]

Islamic hospitals served many purposes. Bimaristans were some of Islamicate societies greatest achievements. Bimaristans served the purpose of being a designated place where medical treatment would be given to individuals in need. Along with being a central place for medical treatment to be given, Islamic hospitals also served the purpose of being a designated place where recovering individuals could go to help gain back their strength. They were hospitals, but were able to serve a wider purpose than just being a hospital. In Islamicate culture, there was not a limit on who would be seen; bimaristans were a place where people could be treated for any medical issues they were experiencing, where people could recover from illnesses or accidents that they were dealing with, where those that were suffering from mental problems could go, and where those that were suffering from illness and old age could go for assistance. [5]The individuals were typically recovering from accidents as well as sicknesses.[1]

Most Islamic hospitals did not discriminate on who could be a patient; even wealthy individuals used the bimaristans when they became ill when traveling instead of an outpatient facility or home care.[1] Islamic hospitals were able to care for many diverse people who all had unique accidents, illnesses, injuries, and needs due to the different sections within the bimaristans. Patients were divided into these different sections based on their needs.[6] Patients were also divided up to minimize the risk of spreading illnesses to other patients.[6] Not only were Islamic hospitals used to provide care for individuals, they were also used to advance medical students’ knowledge in the medical field, especially the most well-known bimaristans located in Baghdad, Damascus, and Cairo.[6] The earliest bimaristan that was established in Islamicate culture was built in Baghdad in the 9th century by Harun al-Rashid. [7]Islamic hospitals, books, and apprenticeships are the main three ways medical students learned different types of medical information to make tremendous advances in Islamic Medicine.[6]

Islamic hospitals can best be understood by being viewed as a philanthropy because they gave public assistance to individuals who needed care.[8] Bimaristans were able to provide these services at no costs due to waqfs, which were endowments that paid for the costs of creating bimaristans as well as maintaining them.[2]

Islamic hospitals were different from other hospitals because Muslims were led to form bimaristans by Muhammad, who taught that God would not create a disease without creating a cure.[9] Mobile hospitals were the first version of the bimaristans.[9] According to tradition, the first mobile hospital was located in a tent to treat war victims from the Battle of the Ditch (627 CE).[9] Mobile Hospitals consisted of medications, food and water, doctors, and pharmacists to aid the patients.[9] The use of the mobile bimaristan was not limited to the Battle of the Ditch. From that point on, Caliphs and rulers continuously developed mobile hospitals through the use of pharmacists, newly-created medical equipments and instruments, and the employment of qualified physicians.[10] One of the advantages to having mobile bimaristans was that it allowed the state to reach those in need who may not have previously been able to receive treatment due to their remote location.[10] These services from the mobile hospital transitioned into the other Islamic hospitals that were built as well. Bimaristans were generally located in urban areas.[1] Though the Islamic realm was very large, Baghdad, Damascus, and Cairo housed the most well-known Islamic hospitals.[1] The first six bimaristans show major changes within Islamic hospitals in a short period of time.[8] The first bimaristan, built in 706 in Damascus by the Umayyad Caliph named Al-Walid, focused on treating individuals with leprosy.[1][8] Around the same period the second bimaristan was built in Cairo.[8] The third and fourth Islamic hospitals were built in Baghdad.[8] The third bimaristan was built in 805 by Caliph Harun al-Rashid.[1] This Islamic hospital in Baghdad was the first documented general hospital.[1]

Muhammad ibn Zakariya al-Razi, Hunayn ibn Ishaq, Ibn Sina (Avicenna), Ali ibn Isa al-Kahhal, Ibn al-Nafis, and Mir Mu’min Husayni Tunikabuni were all students that trained at Islamic hospitals in order to advance their knowledge in the medical field.[6] These students were key players in the advancement of bimaristans because of contributions to Islamic Medicine from their observations and writings.[6] Muhammad ibn Zakariya al-Razi was an Islam philosopher, physician, and alchemist, who trained well in the Greek science and is known for his Comprehensive Book of Medicine.[6] Hunayn ibn Ishaq was viewed as a mediator between Greek sciences and Arabs due to his translations of multiple documents that were tremendously important.[2] Hunayn ibn Ishaq was also an optometrist.[6] Avicenna was a physician as well as a government official.[6] The Canon of Medicine constructed by Avicenna systemized medicine logically.[6] Like Hunayn ibn Ishaq, Ali ibn Isa al-Kahhal was also an optometrist, who classified more than one hundred diseases of the eyes.[6] Ibn al-Nafis was also a physician and an author,[2] most known for his commentary on pulmonary circulation.[6] Lastly, Mir Mu’min Husayni Tunikabuni focused on how yogic breath control can control the humours.[6] While all of these people did many different things, they all contributed to advancements in medicine.

There is evidence that the beginning of the human study of medicine was around 3500 B.C.E.[11] Religious priests and medicine men were the first medical practitioners. In ancient Mesopotamia, c. 3500 B.C.E., there were two kinds of medicine men–the "ashipu" who diagnosed the disease or injury, and the "asu" who practiced healing medicine and was practiced in herbal remedies.[11] Practices in this early period included bandaging and making plasters for wounds. Although many patients were treated in their home, the first houses of medicine were often placed near rivers, so the evil substances and spirits would be washed away.[11] This tradition continues into the Greek and Roman periods, both societies placing their centers of healing near the ocean, a river or spring. Temples to gods and goddesses of healing were often used as healing centers, with spiritual and scientific remedies practiced there.[11]

Ancient Indian medicine, or the Vedic tradition, encouraged the balance of body, mind and spirit between 3000 B.C.E. to about 800 B.C.E. They had knowledge of surgery and even the beginnings of plastic surgery were founded here.[11]

Ancient Egyptian medicine was quite advanced for c. 2500 B.C.E. They had a solid understanding of anatomy because human dissection did not have the taboo much later Christian societies experienced.[11] There are a few medical texts that have been preserved to the present that help us understand the medical practices of ancient Egypt. The Edwin-Smith papyrus, written c. 17th century B.C.E. and probably based on much older knowledge, is a text on trauma surgery.[11] It is suspected to be written based on military battles and battle wounds. Most medical practitioners were literate and often priests.[11] Once again, there is a connection between gods and medicine – the earliest recorded physician was Imhotep, who lived c. 2725 B.C.E., and who was later lauded as a deity and called the god of medicine and healing.[11] The practice of combining religious centers and medical centers was continued through the Greek and Roman periods, as well as into the medical practices of Muslims and Christians.

These ascelpia took the environment of their grounds into account as well as their healing rituals. Most of the ascelpia were centered on a spring or a fountain and were near a gymnasium or theater.[12] This was encouraged by the medicine at the time, which focused on balance of the whole person, both of body and mind. There were no official schools of medicine at the time, most practitioners learned their art through apprenticeships or assisting a practitioner.[12] Even after the Christian conversion of Constantine, the Askelpian cult continued their practices and rituals well into the fourth century CE. Towards the end of the century, Theodosius outlawed any pagan traditions and the cult finally died.[13]

After the Christening of Constantine, as well as the influx of refugees into cities as populations grew and land did not, the church became the center for healing. The term xendocheia began to be used, which came to mean a hostel for the poor.[13] Bishops became known as spiritual healers, or physicians of the soul.[13] One such bishop who was associated with an institution of healing was Saint Basil of Caesarea. Saint Basil built a hostel for the poor and the ill and placed it in the care of a monastery.[13] It is described by fifth century historian Sozomen as “a storehouse of piety where disease is regarded in a religious light and sympathy put to the test.”[13] Similar to the Askelpian cults, the idea of healing through incubation (sleeping in the temple) was also practiced under Christian empires. Patients would sleep in specific rooms that housed relics of a saint and hoped for the saint to appear in their dreams.[13]

The church was often charged with the care of the sick, although students were not allowed to study theology and medicine at the same time. Statute 590 stated that students of theology could not even reside in the same area as medical students, because “books of the craft of the world should not be read with books of holiness in one light.”[13]

These centers of health in antiquity helped shape the many new advances Muslim scholars would pursue in medicine.

As for healing centers in the Islamic world, the first bimaristans were mobile centers that date back to the time of Muhammed. They were transported by beast of burden, primarily camels.[9] Before there were major towns and cities, the mobile bimaristans were able to travel to patients and the remote areas of the region.[9]

During the lifetime of the Prophet Muhammad, the first mobile Islamic center was a tent set up by female caretaker, Rufaydah al-Asalmiyah. In 627 AD during the 27 day Battle of Khandaq, also known as the Battle of Ditch, al-Asalmiyah treated wounded soldiers under a tent. Later on, these mobile care centers would evolve from one or two tents to enormous units of medical care equipped with medicinal herbs, food, physicians, and pharmacists. The idea was to be able to better extend medical care to rural communities that lived on the outskirts of major cities. Under the Seljuq Sultanate reign of Muhammad Saljuqi, a single mobile care center required 40 camels for transportation.[14]

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.[15] The Waqf documents stated nobody was ever to be turned away.[16] The ultimate goal of all physicians and hospital staff was to work together to help the well-being of their patients.[16] There was no time limit a patient could spend as an inpatient;[17] the Waqf documents stated the hospital was required to keep all patients until they were fully recovered.[15] Men and women were admitted to separate but equally equipped wards.[15][16] The separate wards were further divided into mental disease, contagious disease, non-contagious disease, surgery, medicine, and eye disease.[16][17] Patients were attended to by same sex nurses and staff.[17] Each hospital contained a lecture hall, kitchen, pharmacy, library, mosque and occasionally a chapel for Christian patients.[17][18] Recreational materials and musicians were often employed to comfort and cheer patients up.[17] the Medical Arts).

Because it was apparent to see how helpful bimaristans were, there were two types that were made in Islamicate culture: mobile and fixed bimaristans. Fixed bimaristans were like the initial ones that had been built in Baghdad and were large buildings that were fixed in their place. Mobile bimaristans were able to be moved around so that the doctors and physicians could help those that were in more remote areas or could not get to the fixed bimaristans. The same type of help could be offered in both bimaristans, but they were able to serve more people by having two kinds of hospitals.[19]

The hospital was not just a place to treat patients, it also served as a medical school to educate and train students.[16] Basic science preparation was learned through private tutors, self-study and lectures. Islamic hospitals were the first to keep written records of patients and their medical treatment.[16] Students were responsible in keeping these patient records, which were later edited by doctors and referenced in future treatments.[17]

During this era, physician licensure became mandatory in the Abbasid Caliphate.[17] In 931 AD, Caliph Al-Muqtadir learned of the death of one of his subjects as a result of a physician's error.[18] He immediately ordered his muhtasib Sinan ibn Thabit to examine and prevent doctors from practicing until they passed an examination.[17][18] From this time on, licensing exams were required and only qualified physicians were allowed to practice medicine.[17][18]

The first few Islamic hospitals that arose in Baghdad, in the early 9th century, were to quarantine those who suffered from leprosy. At first, it was considered by many as a "leprosorium" due to its limited purpose; nonetheless, these hospitals still salaried doctors whose specialties were not solely limited to leprosy.[20] The function of these hospitals soon became diversified over time as newly built hospitals in Baghdad began to incorporate the knowledge from Islamic physicians, scientists such as Al-Razi.[21] Al-Razi's hospital in Baghdad, had 24 physicians on staff; these physicians had diverse specialties, including, physiologists, occultists, surgeons, and bonesetters. In about one hundred years, there were five more bimaristans that had been built around Baghdad because the bimaristans had proved to be helpful, which was grounds for building more in order to serve more people. [1]

Madrasas, in Islamic civilizations, were teaching institutions, some of which focussed on medicine. These madrasas were often closely linked with hospitals so that students could learn in the institutions and put their theoretical knowledge into practice in the hospitals.[21] Physicians were not exclusively Muslim; practicing physicians included Jews, and Christians.[22] In the major hospitals at Cairo, Baghdad, and Damascus, students could visit patients often with the supervision of a practicing physician, in a system that is comparable to that of medical residents today.

Besides being a place for people that were sick or needed some kind of healing, bimaristans also served as a medical school for students in medical school and those that had completed medical school to learn at. They were able to receive clinical instruction and learn what it was like to work in a hospital setting and help the people that needed it the most. Working in hospitals that served as medical schools allowed people to get the experience that they needed in order to learn how to react in a multitude of different situations in bimaristans [3]

The greatest contribution of the Islamic hospitals was the structure itself and how it functioned in Islamic culture. The first documented general hospital (hospitals that treated a multitude of pathologies, including mental illness) arose in Baghdad, in 805, built by vizier to the caliph, Harun al-Rashid.[21] Although not much is known about this hospital due to poor documentation, the system of the general hospital itself set forth an example for the many other hospitals to come. Soon after, 34 new hospitals were built throughout the Islamic world with the number increasing annually. Islamic hospitals were even the first to specialize in treating convicts as the prison population was continually increasing.[23]

Newly founded hospitals strived to be better than their preceding counterparts in the Islamic world. The purpose was to compete with European hospitals as well in order to attract more physicians and scholars. 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.[24]

In order to meet the demands of these specialties, Islamic hospitals were subdivided into departments for surgery, ophthalmology, orthopedics, mental illness, and systemic diseases. The systemic disease department was designated for general illnesses that did not fall into categories of other departments.[24] In some hospitals, they were further divided into subsections to address the needs of the patient depending on the symptoms. Examples include, but are not limited to, infections, fevers, and digestive issues. Hospital staff was not limited to physicians. Much like today's hospitals, they also relied on pharmacists, nurses, sanitary inspectors, supervising specialists, secretaries, and superintendents. The superintendents, or in Arabic, sa'ur, ensured that hospitals met certain standards in addition to managing the entire hospital institution.[24] Pharmacists produced drugs as means for treatment of the hospitals' patients; they relied on a knowledge of chemistry, or Alchemia.[24]

Before the 10th century, hospitals operated throughout the day and closed at night. Later hospitals operated on a 24-hour basis. Nonetheless, the practicing physicians worked a set number of hours with their salaries prescribed by law; the physicians were paid generously enough so as to retain their talent. Chief of staff physician, Jabril ibn Bukhtishu, was salaried 4.9 million Dirham; for comparison, a medical resident worked significantly longer hours salaried at 300 Dirham per month.[24]

Islamic hospitals attained their endowment through charitable donations or bequests, called waqfs. The legal documents establishing a waqf also set forth rules for how the hospital should be organized and operate in relation to the patient, stating that anyone can be admitted irrespective of race, gender, or citizenship.[23] Patients of all socioeconomic statuses would have had access to full treatment, that is, costs were borne by the hospital itself. An example was the Al-Mansuri Hospital, in Cairo, built under the orders of the Mameluke ruler of Egypt, Al-Mansur Qalawun. Its maximum capacity was around 8000, and the annual endowment alone was said to be one-million Dirhams. The design was intended to accommodate various pathologies, for both men and women; as well as a pharmacy, a library, and lecture halls. The lecture halls were used for regular meetings on the status of the hospital, lecturing residents, and staff as well

With the development and existence of early Islamic hospitals, came the need for new ways in which to treat patients. While the institution of a complex hospital was still comparatively new, Islamic hospitals brought forth many groundbreaking medical advancements in Islamic culture during this time, which eventually spread to the entire world. These revolutionary medical practices came not only from Islamic hospitals, but also distinguished physicians of this era, in the form of surgeries, techniques, discoveries and cures for ailments, and the invention of countless medical instruments.

While people used to learn medicine by travelling, working in their homes, in madrasas, or in hospitals, people learned that bimaristans were one of the most helpful institutions for people to learn in. They had all the resources and teachers available at all times, which made it a very convenient place to learn and teach in. Bimaristans paved the way for many medical institutions.[35]

Much of the legacy surrounding the Islamic influence on modern hospitals and science can be found in the discoveries, techniques, and practices introduced by scholars and physicians working in these hospitals between the tenth and nineteenth century. This time period was extremely important to the advancement of modern medicinal practices, and is known as one the greatest periods of development. Many of these discoveries laid the foundation for medical development in Europe, and are still common practice in modern medicine. Among these discoveries in astronomy, chemistry, and metallurgy, scholars developed techniques for medicine such as the distillation and use of alcohol as an antiseptic, which is still being used in hospitals today. Not only did these discoveries lead to lasting improvements in medicine in the Muslim world, but through the influence of early Islamic and Arabian hospitals, medical institutions around the world were introduced to various new concepts and structures, increasing the efficiency and cleanliness which can still be found in modern-day institutions.

Some of these influential concepts include the implementation of separate wards based on disease and gender, pharmacies, housing of medical records, and the education associated with practicing medicine. Prior to the Islamic era, most European medical care was offered by priests in sanatoriums and annexes to temples. Islamic hospitals revolutionized this by being operated secularly and through a government entity, rather than being solely operated by the church.[36] This introduction of government operated hospitals lead to not having any discrimination against people for any reason allowing the hospital to solely focus on their main goal of serving all people and working together to help everyone out.

Bimaristans were some of the first known hospitals to have been built and truly served a purpose to the people around them. They became established centers for patient care, a main source of medical education for students, and a form of practical training for all doctors and physicians that were working within the bimaristans.[3] They documented how the centers ran: how medical records were kept safe, how doctors and physicians became properly licensed, and how upkeep was maintained so that the hospitals could continue to serve the patients that needed many different forms of help. Later hospitals were modelled from the original bimaristans, which shows that they were well-run centers that served a great purpose to the people in surrounding areas. Western hospitals may not be what they are today without the history of early medical practices in bimaristans [3]

Separate wards

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.[37] 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.

Medical records

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.[38] 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.[39] 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.

Education and qualification

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.[36] 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.[36] 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.

Pharmacies

During the ninth century the concept of pharmacies was born. Advancements in chemistry and medicine during this time period created a need for a separate place to distribute medicine. Hence, the modern pharmacy was created. After some time, pharmaceuticals became its own field of study. People were able to pursue careers in pharmacy after the field became more established. The Golden Age of Arabic Medicine was key for the creation and advancement of this field.

During the Golden Age of Arabic Medicine and the translation movement, many advancements were made in regard to medicine and pharmacy. These developments stemmed from the mindset that for every ailment that is inflicted on man, God creates a cure in nature. This thought process was termed pharmacognosy. Books were one of the main ways people studied different drugs. Most books on pharmacology were not originally Arabic, but were Greek. 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.[40] Through readings, Islamic doctors were able to find drugs that they could use to help treat patients.[41]

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.[41] 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, powers, and syrups.[40]

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.[41]

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.[40]

• Academy of Gondishapur
• Medicine in the medieval Islamic world

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• Morelon, Régis; Rashed, Roshdi (1996), Encyclopedia of the History of Arabic Science, 3, Routledge, ISBN 978-0-415-12410-2
• Noshwrawy, A.R., The Islamic Biarmistans in the Middle Ages, Arabic Translation by M. Kh. Badra, The Arab Legacy Bul. No. 21, P 202
• Sajjādī, Ṣādeq (1989). "BĪMĀRESTĀN". Encyclopaedia Iranica, Vol. IV, Fasc. 3. pp. 257–261.