18 - 24 April 2002
Issue No.582
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Al-Ahram Weekly Online 18 - 24 April 2002 Issue No.582 |
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Al-Ahram:
A Diwan of contemporary life (438)
In 1929, scholar Ahmed Issa published a seven-part series in Al-Ahram on the bimaristans, institutions such as mosques and hospices, built by Muslim caliphs and by the benevolent as an act of charity. The commonly-held view which persists to this day was that bimaristans were an asylum for the insane after they fell into disrepair and were abandoned by all their patients with the exception of the mentally ill. But Issa's studies say they also served as a place for instruction in the sciences and medicine. Professor Yunan Labib Rizk* reports on misconceptions put right
Hospitals of yore
Al-Shefakhana and Al-Ospitalia were precursors to the Arabic term used today for hospital or Al-Mustashfa. The first, meaning "house of healing," was used during most of the 19th century and meant army hospitals in general although the term was sometimes used for ordinary hospitals. The second, obviously of European origin, gained currency in the latter half of the 19th century due to the influx of foreigners and the introduction of the practice and practitioners of modern European medicine into Egypt. Also to gain currency at this time was the term Al-Mustawsaf, meaning a place for the prescription of treatment. Perhaps the closest thing to Al-Mustawsaf would be an outpatients clinic.
Dr. Ahmed Bek Issa
However, prior to all these terms for hospital, there existed the term maristan, a later abbreviation of the original Persian, bimaristan, meaning "house of the ill." The bimaristan was "an institution built by Muslim caliphs, sultans and kings and by benevolent persons in general, as an act of charity, such as mosques and hospices. Its function was not restricted to the treatment of the ill; it also served as a place for instruction in the sciences and medicine from which students would graduate much as they do from our modern medical schools today."
This definition of bimaristan was offered by the "eminent scholar Ahmed Bek Issa," at the opening of a series of his articles published in Al-Ahram at the start of 1929. "The history of the Bimaristan in Islamic Nations," as Issa's lengthy study was called, is no less important today than it was 73 years ago.
One of the most prominent physicians of his age, Issa (1876- 1946), was one of that increasingly rare breed of individuals whose interests and activities led him well beyond the confines of his profession. After having established himself in his medical career, he enrolled in the Egyptian University to study Semitic languages, Greek and history. He was also active in the public domain: as a member of the Red Crescent Organisation, the Higher Council of the National Library, the Damascus- based Arab Academic Society and the International Academy of the History of Sciences in Paris. In addition, he served in the Senate in 1923. In view of his scholastic and professional background, Issa was clearly well-positioned to speak authoritatively on the bimaristan.
The commonly held view which prevails to this day was that the bimaristan was an asylum for the insane. Issa is quick to point out that this misconception derives from the abbreviation of one of the institution's functions. He explains, "Bimaristans were public hospitals for the treatment of all illnesses, whether those requiring surgery or medication, whether physical or mental. With the passage of time, however, these institutions fell into disrepair and were abandoned by all their patients with the exception of the mentally ill. As a result, in recent times the term, if used at all, refers only to a madhouse."
The usage of the term was all the more reason for Al-Ahram readers to be drawn to Issa's account of the history of the bimaristans in Islamic societies. They were first introduced into Islamic societies, Issa tells us, in the reign of the sixth Ummayid caliph, Al-Walid Bin Abdul-Malik.
Initially, there were two types of such hospitals: permanent and mobile. The latter was intended to cater to areas beyond the reach of ordinary medical services, to address sudden outbreaks of epidemics and to accompany Arab armies in their military campaigns. Permanent hospitals were housed in buildings of various sizes and degrees of grandeur depending on the country in which they were established, the location chosen and the services offered. The most famous of such health-care institutions were to be found in Baghdad, Damascus and Cairo. In Cairo, Issa specifically notes two hospitals -- in Al- Mansouri and Qalaoun. The Qalaoun hospital, he adds, "still exists and continues to dispense its humanitarian services, thus standing in lasting commemoration of the greatness and benevolence of its founder."
The hospitals in general were divided into two departments, one for women and the other for men. "Each was fully equipped with supplies and beds, and each department contained wards designated for internal medicine, surgery, ophthalmology and osteopathy." Each ward had several staff physicians, working in shifts, although the number of physicians in attendance depended on the size of the ward and the number of patients. Physicians from other wards could be called in for consultation.
Issa goes on to give an interesting account of how outpatients were handled. "A physician would sit on a large bench from where he would conduct his interview and dispense prescriptions which patients would take with them into the hospital to obtain the salves and other medications he prescribed."
In what he termed "clinical studies in the bimaristan," Issa turned to ancient manuscripts describing methods of instruction. According to these documents, the senior physician would examine patients as students gathered around to hear his diagnosis and his description of the methods of treating the illness. Parts of the hospital also served as lecture halls. In the large hospital of Sultan Al-Ghuri, for example, there was a hall where the Sultan Nureddin Bin Zinki had donated a large collection of medical books. Issa writes, "Physicians and medical scholars would come to this hall to hear the discourse of their professor, hold medical discussions and instruct students. Such sessions in which participants would investigate various subjects and consult the medical references on hand could last up to three hours."
Education in medicine was not limited to instruction in the bimaristans. Many schools had been established specifically for that purpose, the most famous being the Dakhwariya Academy located near the Ummayad Mosque in Damascus and founded in 1225 by Abdel-Rahim Bin Ali Hamed. A religious and medical scholar, Hamed, who went by the nickname Dakhwar, "placed in the trust of this institute agricultural estates and various properties, the incomes from which funded its operations and the salaries of its staff. He was also the school's first instructor."
Dakhwar followed the classic method of instruction. After making the rounds of the hospital and tending to his more eminent patients, he would report to the school where he would consult his medical references, conduct any research necessary and copy works that had to be transcribed. "Once he finished these tasks, he would open his doors to physicians and scholars to each of whom he would deliver his lesson, elucidate on the substance to the best of his ability and, with the more advanced, deliberate on various problems that needed clarification if the situation required."
The hospitals also had pharmacies annexed to them, or what were called the "potion store." Issa writes: "These contained assorted tonics, valuable unguents, luxurious balms, diverse medications and superior aromas that could be found nowhere else. They also contained valuable equipment, porcelain and metal vessels that even kings could not afford. Each maristan had a complete 'potion store' which was overseen by a muhtar, meaning chief in Persian, who was of lofty status and had servants to assist him."
Readers today would be as surprised as Al-Ahram readers 70 years ago to learn that the staffing of these hospitals was no less complex than that of a modern hospital. At the top of the hierarchy was a superintendent, considered a high-ranking government position. In his book Bada'i' Al-Zuhur fi Waqa'i' Al-Duhur, Ibn Iyyas wrote that upon assuming office this official was escorted to his work premises in a grand procession with 20 chamberlains attached to him.
Below the superintendent were the chief physician, who "supervises the physicians (internists), licenses them to practice medicine and such like," the chief ophthalmologist, who "supervises the other ophthalmologists in the same capacity as that with which the chief physician supervises internists," and the chief surgeon who "similarly supervises the surgeons and the osteopaths."
The standing of these officials extended beyond the hospital into the community; they would be comparable to what we call public figures today. Issa informs us that the posts of physicians were among the highest-ranking offices in the Fatimid state. Chief among them was the personal physician of the caliph, who tended to the caliph daily and who "sat on the benches in the chamber in the palace known as the Golden Hall presiding over four other physicians. The servants and eunuchs would come to this chamber to summon one of the physicians to treat any ill individual in the palace. Following an examination, the physician would write out the prescription for the servants to procure from the pharmacy, from which the servants would obtain the quantity they required, retaining the prescription as testimony to this transaction. Each physician was accorded a salary and expenses befitting his station."
Remuneration, which included on top of the monthly salary allowances for attire and fodder for the animals they used as transport, were considerable by the standards of the age. The highest paid was the sultan's personal physician who received 50 dinars a month, compared with those immediately below him, who received 20 dinars a month. Doctors in the hospital were paid on a different scale entirely: anywhere from five dinars per month for the highest paid down to one dinar a month. But even these meagre salaries were sufficient to live quite comfortably. Citing an ancient manuscript, Issa noted that some physicians were able to lead a fabulous lifestyle. "The physician Bakhtishou, in the time of the Caliph Al-Mutawakil, had reached such a level of wealth, opulence and grandeur that he was able to vie with the caliph in dress, furnishings, hospitality, generosity and lavishness in spending that defy description."
Not all the incomes of physicians were derived from salaries; they also charged privately for their services, the fee more often than not determined by negotiations between the doctor and his prospective patient. In this regard, Issa writes about an amusing tale, also taken from an ancient manuscript. "There visited a certain eye doctor seven patients suffering from cataracts. Among them was a man from Khorasan. The doctor examined the patient's ailing eye and determined that the cataract should be pierced. They negotiated over the price and settled on 80 dirhams after the man from Khorasan vowed that that was all he had. To seal the bargain they embraced. However, in so doing, the doctor's hand brushed below the man's upper arm, where he felt a small purse which, as it turned out, was filled with dirhams. 'What is this?' the doctor asked. When the man tried to squirm out of his grip, the doctor exclaimed, 'You swore falsely before God in your appeal to have your vision restored. By God, I refuse to treat you as you deceived your Lord.' So saying, the doctor gave the man back his 80 dirhams and sent him away."
Issa went on to describe how physicians obtained their permits. After completing his studies, the student would present himself to the chief physician with a letter stating the field in which he hoped to be licensed to practice. The student was then referred to an eminent physician who "tested him in everything pertaining to the job. If the student answered the questions well, the physician granted him a licence to practice."
As Issa was both thorough and insatiably curious, his study on the bimaristan led him to numerous sources. In the Ahmed Zaki Library he came across two certificates issued in the 16th century, the first licensing its bearer for the practice of phlebotomy and the second licensing its bearer to practice surgery. Following a lengthy preamble, expressing praise and gratitude to God for the gift of medicine, the certificate attests that its bearer authored a "magnificent thesis" in the works of chief surgeon Shamseddin Mohamed Al-Shirbeeni. Having excelled in the examination, the candidate deserved to be "crowned with the laurel of a permit to practice surgery in which he will remedy internal ailments, extract teeth, let blood and mend arteries..."
A licence, however, did not exempt the practitioner from regulatory controls. These were institutionalised in the muhtasib, a type of professional ethics inspector. In the course of his research, Issa discovered that the duty of the muhtasib was to make sure that doctors adhered to the Hippocratic oath and to have them pledge not to administer harmful medicine, concoct poison for a patient, allow poisonous substances to pass into the hands of commoners, prescribe or administer medication to women that would cause an abortion or to men that would impede propagation.
The muhtasib was also responsible for ensuring that doctors did not commit wrongdoings in the course of their duties or betray the confidentiality of their patients. Physicians and surgeons were also required to possess all the tools of their craft, "and the same applied to ophthalmologists and osteopaths. The latter were not permitted to practice bone-setting until they knew all the parts of the human body and the shape, size and place of every bone."
Evidently, corruption is a constant throughout all ages and all professions had their own irregularities. Issa writes about a story he came across in the course of his studies: One day a man called upon the chief physician. The man was of such elegant dress and dignified countenance that Sheikh Sinan, the physician's name, did not hesitate to invite him to speak. The man said, "I would like the venerable sheikh to grant me a licence in this profession." The man then reached up his sleeve, pulled out a purse full of dinars, placed it in the hands of the physician and said, "I neither write nor read well, and I have never read anything at all. I have children to support and my pension has run out, so I ask you not to cut off my means of livelihood." Sinan laughed and said, "On the condition that you do not assault patients with knowledge you do not possess and that you do not advise bloodletting or laxatives unless the patient shows signs of illness." The man responded, "That has always been my creed and I have never departed from it." So saying, the man took his leave.
Like other trades, medicine was sometimes a profession passed down by the family. In the course of listing some of the most famous physicians in the Islamic empire, Issa gives prominence to the Bakhtishau family. Bakhtishau is Syriac for the Christian name Abdel-Messih. One physician from this family served in the court of Haroun Al-Rashid. Gabrael Bin Bakhtishau, he writes, was a skilful physician who bequeathed to medicine many books, among which was a letter to the Caliph Al-Ma'moun on food and drink, an introduction to the practice of medicine, a work on sexual potency, the fundamental principles of medicine and a manual on the manufacture of incense.
Another famous Syriac Christian physician was Yohanna Bin Masawiya, who according to Issa, wrote about 40 medical works, covering such subjects as fevers, medical rarities, food and drink, phlebotomy, the benefits of the bathroom, the treatment of poisons, headaches and their types, causes and remedies, voice hoarseness and the administration of laxatives.
From this survey of famous physicians and their contributions, Issa returns to the bimaristan, specifically the most famous of such institutions in Egypt. Perhaps the earliest was the Zuqaq Al-Qanadil in the ancient quarter of Fustat. Issa informs us that the hospital was so named because it bore the image of an oil lamp (qandil) that hung on the door of the residence of Fustat's founder, Amr Ibn Al-'As.
The hospital of Ahmed Bin Tulun, also known as Al-'Atiq (the ancient) and as Al-'A'la (the supreme), was founded by Ahmed Ibn Tulun in 872. The sultan is said to have allocated an exorbitant 60,000 dinars for its construction and dedicated to it the earnings of the slave market. Ibn Tulun further decreed that neither soldiers nor slaves were to be treated in the hospital "which he personally supervised and inspected once a week."
The Egyptian historian Al-Qalqashandi attests that the Tulunid hospital still existed in his time (1418), that a private room could be had for 12 dirhams a day. Al-Qalqashandi adds that upon admission to the hospital, patients removed their clothes, to be kept with the custodian who then gave them clean gowns and bedding. He continues, "Patients were given food and medicine until they recovered. When they could eat a chicken and a loaf of bread, they were ordered to leave and given back their money and clothes."
Ibn Jubeir, the Moroccan explorer, also wrote about this hospital. Apparently, it had undergone major renovation work under Salaheddin for he remarks that it was one of the triumphs of that famous sultan. Ibn Jubeir also paid tribute to a physician who acquired widespread fame from his work in that hospital.
Dating approximately a century after the Tulunid hospital was Al-Bimaristan Al-Asfal, otherwise known as the hospital of Kafour Al-Ikhshid, who dedicated to it the income from all the storehouses and inns he built and donated to it two ablution fountains, two water fountains and the shrouds for the dead. Issa adds, "Egyptian historians mention that this hospital contained porcelain urns, copper pots, mortars, basins and other such vessels, valued at 30,000 dinars, and equipment many times this value, which was transferred from Al-Bimaristan Al-A'la."
Al-Bimaristan Al-Asfal was not destined to live as long as its Tulunid counterpart. The historian Al-Maqrizi wrote that in his day the hospital ran out of potions and medication for the poor.
On this sad note in the last chapter of his seven-episode series, Ahmed Issa marked the end of the age of the bimaristan and the beginning of the age of the Western-style hospital.
* The author is a professor of history and head of Al-Ahram History Studies Centre.
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