Four Medieval Hospitals in Syria

The creation of hospitals as institutions for the care of sick people was developed during the early Islamic era. Over time, hospitals were found in all Islamic towns. This article describes four of these medieval hospitals in Syria, two in Aleppo and two in Damascus. The author, who visited these institutions, describes their history and functions and illustrates the article with photographs that he took himself.

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Dr. Nasim Hasan Naqvi*

Table of contents

1. Introduction

2. Aleppo

2.1. The Nūrī hospital

2.2. The hospital Arghun Al-Kāmilī

3. Damascus

3.1. The Nūrī Hospital

3.2. The Qaymārī Hospital

Note of the editor

This article was first published in Vesalius 2007; 8 (I), 10-15. We are grateful to the author for allowing publication in www.MuslimHeritage.com.

***

1. Introduction

There is enough historical evidence that hospitals existed during Byzantine period, these might be for the isolation of those suffering from leprosy, though convincing archaeological evidence has not yet been uncovered. The Muslim civilisation immediately followed after Byzantine and developed Arabic Medicine largely borrowing from the Greek traditions. The historians have recorded that in Damascus hospitals existed as early as 706 CE at the time of Umayyad Caliph Al-Walīd [1]. While during the zenith of Abbasid Caliphate, more than sixty hospitals served the city of Baghdad alone. We are also told that Bīmaristan which is a Persian word and literally means house of the sick was introduced into Arabic during the 9th century. The origin of this word goes back to middle of 5th century when persecuted Nestorians settled in Sasanid Persia where they were welcomed and over generations prospered as physicians. Although there is scepticism and controversy regarding founding of medical school and Bīmaristan at Jundi-Shapur but it is established that during the 8th century the decedents of Nestorians from Persia played an important role in translating Greek and Syriac medical texts into Arabic [2]. About this time the word Bīmaristan was introduced into Arabic vocabulary, for example Al-Rāzī wrote a book titled, Kitāb fī sifāt al-Bīmaristan, meaning a book on the merits of a hospital [3]. Later a shortened version of this word Māristan was also widely used in the Arabic literature [4].

Although hospitals were built during the Middle Ages in all major cities in Iraq, Persia, Syria and Egypt and Allen O Whipple has given a list of 63 hospitals in these countries [5]. But most do not exist today except in name or in history books. This paper describes four medieval hospitals in Syria, which were built during 12th and 14th centuries that have survived even today. Why these four have survived whilst others have not is not an easy question to answer. The historical significance of these four hospitals lies not only in the fact that they have continued to survive but they offer unique opportunity to study the social history of medical practice of the period when these were functioning medical units. They symbolise interesting and poignant medical history of Arabic Medicine written in stone. Two out of four of these hospitals are standing in perfect condition, one as a medical museum and the other was used as mental asylum until the 20th century, while the other two exist in rundown condition and are closed to public. The author visited all four in Aleppo and Damascus and in this paper offers a brief portrayal and few of the pictures, since images that can illustrate functional orientation of their medical past have rarely accompanied their descriptive accounts in the past medical writings [6]. Although the historians of Syrian architecture have taken great interest and studied the buildings of all four of these hospitals from the architectural point of view and have also published pictures of these buildings [7]. These architectural historical accounts also confirm that the buildings we see today have survived on the whole from the original [8].

2. Aleppo

Aleppo situated in north Syria is Syria's second largest city after Damascus and had celebrated the year 2006 as the capital of Islamic culture. It is a favourite destination for archaeologists since it is one of the few places continuously inhabited since Stone Age and it is surrounded with numerous archaeological sites from before Roman times attracting large number of tourists interested in history and archaeology. In the past, its prosperity was due to the strategic position on the trade route connecting Egypt and Roman Empire with the Silk Road. We may judge the prosperity of Aleppo during medieval times from the vast number of grand archaeological sites in its neighbourhood. With such past history it is expected that like many other contemporary cities Aleppo must had hospitals for the benefit of the community. An account of the two hospitals in Aleppo follows.

2.1. The Nūrī hospital

Nūr al-Dīn Zangī (1117-1173) in his early career was governor of Aleppo, later he occupied most of Syria and Mesopotamia. During his relatively short life, he controlled the most fertile lands and important trade routes accumulating fabulous wealth. His personality was of a benevolent autocrat, spending generously on social welfare for the poor. Nūr al-Dīn Zangī ordered to build the hospital in Aleppo under the supervision of his physician Ibn-Butlan [9]. The date of its construction in Whipple's book (1048) is a misprint but other sources have dated it to be 1148-1155. Its architectural merits have been recorded by T. Allen in his book on Ayyubid architecture, which also tells us something about its history and the following quote from this publication points to the cause of its present dilapidated condition [10]:

"Nūr al-Dīn Zangī built his hospital in Aleppo sometimes between 1148-55, near the route of an intramural water project he sponsored. Again only the portal and bit of masonry on the street façade survives from Nūr al-Dīn Zangī's building, which was seriously damaged by earthquakes and rebuilt several times."

What one can see above the door is an edifice of intricate stone carving, decorated with Arabic calligraphy in large letters engraved on stone. The writing starts from right wall and continued to the front (above the door) ending in a symmetrical fashion at the left lateral wall. This design of calligraphy above the portal is common to all four hospitals in Syria. It praises the charity and benevolence of Nūr al-Dīn Zangī who erected this hospital. The wooden door is covered with plated copper fixed with copper nails was described by the guide to be the original; there are large iron knockers on each door at about eye level. The place appears neglected and is not listed on the usual schedule where tourists are guided. When Allen O. Whipple visited this hospital in 1959 he found an Arab family was living in the rooms behind the outer wall otherwise the building was in ruins and neglected but he affirms that the inscription above the portal was intact and visible as it is today [11].

2.2. The hospital Arghun Al-Kāmilī

The other hospital in Aleppo is known as Bīmaristan Arghun Al-Kāmilī. Arghun Al-Kāmilī was Mamluk governor in Aleppo who built the hospital in 1354 on a site that was a residential palace [12]. The substantial stone building with quite complex plan is even today standing on sound footings, a short distance from the Bab Qinnesreen one of the many gates of the old city. The entrance protected by a modern wrought iron fence is facing west into the street also known as Qinnesreen. The front is highly decorated with intricate stone masonry work over and under the archway. On the left side in modern style its name and date is written in English and Arabic and below this fading writing is the original foundation stone in Arabic (Fig.1). The wooden door is covered with copper displaying typical geometric Arabesque design. Above the door we see four lines in Arabic writing starting from right wall ending on the left wall, the letters are large but difficult to read from ground level. Passing the metal covered door you enter in a small hall, a large room on left was described to be the hospital dispensary, and two other rooms on right were used as consulting rooms.

Figure 1: Entrance of Bīmaristan Arghun AI-Kāmilī, Aleppo, Syria.

The entrance hall leads to another set of wooden metal covered doors that open in to the main courtyard, which is sunny and airy having a large pool filled with water and a working fountain. On east and west of the courtyard there are ten cubicles five on each side, these were for inpatients. There are two arched halls (iwan in Arabic) on north and south sides, these halls were used for meetings, teaching and also for band of musicians and singers. In Arabic Medicine use of music as therapy is well documented. On all four sides there is a façade supported by delicately designed stone pillars to provide a shaded area to keep the rooms cool and protected (Fig.2).

Figure 2: The central courtyard and fountain.

There are further three purpose built courtyards on the eastern side accessible by a narrow passage from the south corner of the main courtyard. The first on the left is smallest, square in shape and with a square fountain in the middle, covered by a dome that also has a square opening into the sky matching with its squared design. There are small rooms on two sides with large windows overlooking the fountain; all these windows are well protected by strong iron bars (Fig.3). This confined area was obviously reserved for dangerous or violent mental patients. All these rooms can be reached by a narrow passage, which is dark and claustrophobic to a present day visitor. But if we see it in the context of middle of 14th century when this place provided shelter, free food medical treatment and other facilities to the most vulnerable mental patients, the charitable intensions of Prince Arghun Al-Kāmilī deserve our admiration.

Figure 3: The rooms for violent patients have large windows opening into the courtyard and protected with iron bars.

The second courtyard is designed around an oval central fountain; the dome above also has an oval opening into open sky. About ten slightly bigger rooms but all of different shapes and sizes are built on all four sides without any safety protection. This area was for the resident of non violent patients who were provided single accommodation. Some of the larger rooms might be used for other purposes such as consultation or treatment.

The third area or ward is much bigger than the previous two, quadrangle shaped, with similar central fountain and opening in its dome. There are two large cubicles on two opposite sides and two much bigger rooms on one side while on the fourth side is located an arched hall, its design and purpose was teaching and meeting place, similar to the arched halls in the main courtyard area. It is possible that this area and its much larger rooms were used for the occupancy of more than one patient.

The rest of the building includes storage rooms, kitchen and a number of recesses for various uses. A passage between kitchen and storage area leads to outside into the street that must have been used as back access for supplies etc.

The Arghun in Aleppo is considered to be a specialised hospital that was built to treat patients suffering from insanity. Insanity and its treatment during Islamic Middle Ages have been extensively discussed by a number of historians [13]. A close look at the architecture of this hospital validates the reliability of historical data as regard to treating mentally disturbed patients and a rational compassionate approach towards mental illness. The patients were provided free accommodation, medicines, medical care, food and even entertainment. The building of this hospital constructed during the Middle Ages remained in use till 20th century. When Whipple visited this building in 1959, he was not able to inspect the inside completely as it was occupied by three Arab families [14]. It has survived with many original features and even today stands in sound condition; considered to be the best preserved example of a hospital from late medieval period. The building appears to be reasonably maintained and presently used occasionally for cultural events such as dancing dervishes or special musical programmes.

Its historical importance has been highlighted recently by a delightful poem penned by Chris Ellery, professor of English at Angelo State University in Texas. Professor Ellery spent some time at Aleppo University teaching English as Fulbright scholar. His visit to Bīmaristan Arghun inspired a long and moving poem that was published in March 2006 in a collection titled All the Light We Live In, the poem is quite long only first six lines are reproduced below [15]:

Bīmaristan Arghun
The wealth and benevolence of Arghun al Kāmilī
Provided here for the dangerous insane
An asylum of darkness, water, bread, and stone.
The walls have absorbed their wails, their stench,
Their outrageous laughter in a honeycomb of cells
Like the chambered heart of Aleppo [16].

3. Damascus

Damascus is an ancient city that was mentioned in the earliest Egyptian documents. In its past history due to its strategic position, surrounded by fertile land that has been endowed by ample water and other natural resources, it has always attracted great many conquerors. During Roman and then Byzantine period it became an important centre of Hellenic traditions where scholars of Greek and Syriac languages transformed her into a depository of knowledge. In 635 CE, the city was taken over by the Muslims for good and has seen great heights as well as degradation. During the 12th century Damascus enjoyed reputation of centre for medical teaching producing a number of outstanding names of Arabic Medicine. The list of physicians in a relatively short period during the reign of Saladin (1171-1193) contains twenty-one names of exceptional ability. The list has been derived from the well known biographer Ibn Abi Usaybia (1203-1270) [17]. Now the remaining two Syrian hospitals in Damascus and their pictures are presented in the following pages.

3.1. The Nūrī Hospital

Nūr al-Dīn Zangī mentioned before, after becoming master of all Syria made Damascus a centre of trade and industry. A site to build a hospital was selected after great care southwest of the famous Umayyad Mosque and building was started in 1154. Nūr al-Dīn Zangī not only endowed large amounts for its maintenance he also donated his huge personal library to this hospital. The building was further extended and enlarged a century later in 1242 to its present appearance. The entrance or main gate is a grand structure in typical Seljuk style (Fig.4). Passing through the wooden door which is covered with copper and decorated in geometrical designs you enter a huge squared entrance hall. A large room on the left is presently used as reception for the museum of Arab technology and medicine that is now housed in the building. The visitors can see few leaflets and purchase a booklet on history of the hospital, which is only available in Arabic and unfortunately not translated in any other language [18]. The hall is ornamented with high arches, one spanning the width of the hall when viewed from inside shows colourfully painted figures of peacocks, flower motifs and calligraphy (Fig. 5). Passing the hallway you enter a large courtyard with central fountain, a feature common in every historical building of Arab design in Syria. The courtyard is surrounded by a number of rooms and much larger arched halls on east and south sides. One room was labelled as library but was not open; other rooms contained various exhibits belonging to Arabic science, chiefly of medical interest displayed in glass cabinets. Almost all medical exhibits were perceptibly modern copies.

Figure 4: Arch of the hallway viewed from inside.

Figure 5: Arch of the hallway viewed from inside.

One wooden cabinet seemed to be a genuine antique and contained among other objects a green glass condenser that looked like a genuine piece (Fig.6). Only scant historical notes were displayed but regrettably none of the exhibits were identified and the visitors were not able to make any sense about the nature or period of the exhibits. Few other items such as weights, mortar and pastels were also displayed and may also belong to an unknown early period. One room was dedicated only to medical and surgical items in various glass cabinets. One of these contained few surgical metal instruments, which were replicas of surgical instruments from the book of Albucasis (Fig.7). Next to this was displayed an anaesthesia sponge in an earthen ware pot. One more cabinet had some glass jars and bottles (Fig.8) and another contained pharmaceutical implements (Fig. 9).

Figure 6: A green glass condenser seen on the far left, on the middle shelf.

Figure 7: Surgical instruments replicas from Albucassis manuscript.

Figure 8: A display of glass jars and similar other objects.

Figure 9: The Pharmaceutical equipments.

One remarkable aspect of this hospital that must be mentioned is that during its acme it was a centre of excellence for medical education and training. Sami Hamarneh has pointed out to a reference indicating that in this hospital patient records were also kept by the chief of the hospital [19]. The Nūrī hospital has been mentioned by Ibn abi Usaybi‘a in his famous biographies of the physicians who himself was a student at Nūrī Hospital [20]. Even today a study of its architecture alludes to the testimony that for many years despite repeated political upheavals it played a crucial role in providing health care and medical learning. The larger arched hall (iwan) opposite to the entrance was originally used for teaching and as a meeting place for discussion and debates. When you imagine that men like Ibn al-Nafis (1210-1288) who described pulmonary circulation in the middle of 13th century sat here as a student and then as teacher, the place will appear to exude true scholastic aura [21]. But this romantic imaginary is wholly spoiled by the ill conceived tableau representing a teacher surrounded by students and the fake books placed where once valuable manuscripts were resting. This ugly symbolic presentation regrettably cuts a true sorry figure.

The other arched hall on south side exhibits only a replica of a water wheel; this machine known as norias has been used in Syria for centuries to scoop water from a lower point and supply it to a higher level. It utilises the energy of water current directed into a narrow channel where the lower end of the wheel comes into motion by the energy from water flow lifting the water at the same time. Many working waterwheels are still in operation around the city of Hama; one of these more than twenty meters in diameter can be seen out side the town next to a popular restaurant.

It is recorded that Nūrī hospital in Damascus functioned as hospital till 1899 when a new hospital was built and services from here were transferred. The vacated building then accommodated a girl's school and then a school for boys [22]. Allen O. Whipple visited this hospital and has described that at the time of his visit the building was still used as school for boys and school was in session at the time of his visit. He also published a photograph of the hospital entrance which matches with the picture in this paper taken in 2006. Its conversion into a museum is fairly recent though it was not possible to ascertain the date. The significance of this hospital in Damascus is indicated by the fact that it has been mentioned by almost all historians of hospitals and those who have written history of Arabic Medicine. Although the past literature that exists lacks any detailed architectural features and pictures to make comparison with the present building that might have brought reality closer to the readers.

3.2. The Qaymārī Hospital

Bīmaristan al Qaymārī is almost an unknown old hospital, which is not mentioned by any of the medical historians who have written and enumerated more than 60 hospitals from Islamic period. Its location in the middle of vegetable market, surrounded by unsightly rubbish from the local traders and general neglect might be the reason of its obscurity. It is situated in the Salihiyya district on the hill that overlooks the old Damascus. The area was first inhabited by the refugees from the time of Crusaders and migrants uprooted by the Mongol invasion. There is a tomb of a 12th century Sufi saint nearby and charitable intension to construct a free hospital in the area where the poor lived is understandable. A brief historical note in Arabic on a relatively modern marble on the right side describe that it was built in 1248 by the member of a Kurdish family Sayf al-Din Yusef Al Qaymārī. The entrance facing north is monumental stonework with interlocking black and light coloured stone in typical Mamluk architecture. A single weight bearing stone above the door more than two feet in width contains three lines of inscription in large letters in Arabic. It is the original dedication or foundation stone paying tributes to Al Qaymārī for his great charity and glorifying the king of the time, this follows some verses from the holy book.

It is most interesting that this hospital building is unknown to medical historians but Terry Allen has dedicated nearly eight pages describing its architectural merits and recorded far more historical details than he has written about the other three hospitals in Syria [23]. He has also given details of the building from inside having a quadrangular water tank in the courtyard which is surrounded by four arched halls or iwans on all sides. It is further mentioned that one side of this hospital was reserved for female patients. The hospital originally was supplied with water by a water wheel specially installed on the neighbouring river known as Nahr Yazid.

The locked up entrance was surrounded with unsightly discarded material and the wooden door does not match the original grand stonework and appears to be rather modern (Fig. 10). A book on history of Damascus depicts a picture of a large stucco medallion from inside of this hospital but gives no textual historical details [24]. The building was closed to public and in disuse state at the time of visit in April 2006 (Fig. 11).

Figure 10: The stonework and Arabic calligraphy above the door of Bīmaristan al Qaymārī, Damascus.

Figure 11: The locked door of Bīmaristan al Qaymārī, Damascus.

Footnotes

[1] Dols MW. "The origin of the Islamic Hospital: myth and reality." Bulletin of the History of Medicine 1987; 61: pp. 367-390.

[2] Johna S. The Mesopotamian schools of Edessa and Jundi-Shapur: The roots of modern medical schools. Am. Surg. 2003; 69: pp. 627-630.

[3] Gibb HAR, Kramers JH, Lévi-Provencal E, Schacht, (eds). Encyclopaedia of Islam, New Edition. Leiden: EJ Brill, 1960, pp. 1221-1226.

[4] Al-Maqrizi. Kitab Al-Khitat, Cairo: Al-Azhar University, 1946 reprint. pp. 252.

[5] Whipple AO. The role of the Nestorians and Muslims in the history of medicine. New York: Allen O. Whipple Surgical Society, 1967. pp. 111-113.

[6] Hamarneh S., "Development of hospitals in Islam". Journal of the History of Medicine and Allied Sciences 1962; 27: pp. 366-386.

[7] Allen T. Ayyubid Architecture, Occidental, CA: Solipsist Press. 2003.

[8] Rihawi A. Arabic Islamic architecture in Syria. Damascus: Ministry of Culture and National Heritage, 1979.

[9] Whipple, Op, cit., note 5 above. p. 90-91.

[10] Allen, Op, cit., note 7 above.

[11] Whipple, Op, cit., note 5 above. p. 90.

[12] Isa Bay Ahmed, Histoire du Bimaristan à l'Epoque Islamique, Cairo: Imprimerie Paul Barbey, 1928. Quoted by Whipple AO, The role of the Nestorians and Muslims in history of medicine. New York: Allen O. Whipple Surgical Society, 1967. Pp. 88-89.

[13] Dolls MW. Insanity and its treatment in Islamic society. Medical History 1987; 31: pp.1-4.

[14] Whipple, Op, cit., note 5, p. 92.

[15] Ellery C. All This Light We Live In, Panther Creek Press. 2006.

[16] With the kind permission of Professor Chris Ellery.

[17] Jadon S. The physicians of Syria during the reign of Salah Al-Din 570-589 A.H. 1174-1193. Journal of history of the History of medicine and allied sciences 1970; 25: pp. 323-340.

[18] Sukhanani Z. Muthaf at-tib wa- al- ulum indal Arab. Bimaristan Nur-Uddin. (Arabic) Damascus: Ministry of Culture, Syria. 1997.

[19] Hamarneh, Op, cit., note 6 above, p. 371.

[20] Usaybia, Ibn Abi. Uyun al anba fi tabqat al atibba, Farnborough: Greg International Publishers, 1972.

[21] Bittar E. A study of Ibn Nafis, Bull. Hist. Med 1955; 29: pp. 352-447.

[22] Isa Bay Ahmed, Histoire du Bimaristan à l'Epoque Islamique, op.cit.,; quoted by Whipple AO. The role of the Nestorians and Muslims in history of medicine, New York: Allen O. Whipple Surgical Society, 1967. pp. 88-89.

[23] Allen, Op cit., note 7 above

[24] Rihawi A, tr. Cheveden PE. Damascus. Damascus: 1977. p.106.

* FRCA Consultant Anaesthetist, Bolton General Hospital, Bolton.

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