Mental Health Care and Bimaristans in the Medical History of Islamic Societies
One glaring lacuna in even the most recent studies on the histories of hospitals is the scarce number of pages dedicated to Islamic hospitals. A thorough study of Islamic hospitals as an integral part of a global hospital and health care history therefore merits long overdue attention. Even though hospitals went by a variety of names in Islamic times, this study will use the term bīmāristān to identify these institutions. I will especially focus on mental health and bīmāristāns, another field that still lacks scholarly attention.In recent studies, scholars have called for an integration of the study of medicine in Islamic societies into the field of science studies. They have urged their colleagues to go beyond the classical studies of medicine and leave the old paradigms of Islamic exceptionalism behind. In doing so, the academic community would gain a better understanding of the institutional contexts of medical practice. If we want to understand the history of Islamic hospitals, we have to turn to pre-Islamic times, such as pre-Islamic Arabia. It may even be more useful to study the Eastern part of what was to become the Islamic world. As a result, we will be able to analyze the institutional contexts of Islamic medicine—and especially all the aspects related to mental health.
On the History of bīmāristāns
A historical overview will have to assume the existence of pre-Islamic precursors to the bīmāristān and not consider these hospitals a genuine Islamic invention. The most important pre-Islamic hospital probably was the Gundishapur hospital of Iranian and Syriac origin.
Earlier scholarship and studies based on the older research literature have claimed that “[w]ithout doubt it is on Hārūn al-Rashīd (170/786-193/809) that the merit falls for having founded the first hospital to have functioned in the Islamic world.“ But there is another (hi)story to be told.
As Michael W. Dols and others wrote, the conventional history of bīmāristāns “bristles with difficulties.” This article does not allow for a detailed analysis of Dols’ argument on the pre-history of the bīmāristān and, especially, the Syriac influence. Dols sets the date for the foundation of the first Islamic hospital in the first decade of the ninth century CE.
Based on earlier research, one might also wonder whether a description of Gundishapur as a “provincial backwater” is fitting. Historical evidence suggests that Gundishapur may have indeed played a critical role in the history of medicine. Even if we accept that Gundishapur was not as important as some researchers suggest, we may interpret discussions about the historical importance of institutions as part of a dialogue among physicians about which tradition to prioritize: the Graeco-Arabic, Syro-Arabic, the Iranian, or even Indian school of thought. Thus, Gundishapur may be understood as a stake in a game for symbolic capital by Syriac physicians and not discussed in terms of its historical truth. al-Jāḥiẓ seems to support this argument:
“The kings of the Persians (ʿajam) used to divert the melancholic (maḥzūn) by listening to music (samāʿ), to distract the sick (marīḍ) and to keep him away from negative thoughts”.
If we therefore assume the existence of an ancient tradition of music therapy (see below) in Iran, we may consider Gundishapur as a prime symbol in the mythology of medical expertise. A passage from a literary work illustrates how much Gundishapur physicians were allegedly sought after and what kind of intercommunal tensions existed amongst practitioners:
“He [sc. Asad ibn Ǧānī] was a physician. Once business was slow, so someone said to him: ‘It is a plague year, disease rampant everywhere, and you are a knowledgeable man with steadfastness, experience, and clear understanding. How does it come about that you have this dearth [of patients]?’ To which he replied: ‘For one thing, people know me to be a Muslim, and have held the belief, even before I began to practice medicine, no indeed before I was born, that Muslims are not successful in medicine. Then, my name is Asad, when it ought to have been Ṣalīb, Ǧibrāʾīl, Yuḥannā, and Bīrā [i. e., Christian or Jewish names]. My surname is Abū l-Ḥāriṯ, but it ought to have been Abū ʿĪsā, Abū Zakarīya, and Abū Ibrāhīm [i. e., Christian or Jewish surnames]. I wear a shoulder mantle of white cotton, yet my shoulder mantle ought to be of black silk. My pronunciation is that of an Arab, when my dialect ought to be that of the people of Ǧundaisābūr [i.e., Christian physicians].’”
It is not clear why the death of the last eminent physician of the Gundishapur bīmāristān, Sābūr ibn Sahl (d. 869)—who moved from Gundishapur to Baghdad to join the circle of medical advisers to the Abbasid caliph—also meant the demise of the institution.
What is the origin of the name of the institution? It derives from the Persian for sick—bīmār—and the suffix, –stān, denoting place; the short form is māristān.
Savage-Smith describes the role of the bīmāristān:
“The Islamic hospital served several purposes: a centre for medical treatment, a convalescent home for those recovering from illness or accidents, an insane asylum and a retirement home giving basic maintenance needs for the aged and infirm who lacked a family to care for them. In the first two instances, admission would be for a limited period of time, with the view of curing a particular disorder. In the last category, it is unclear how many, if any, were of the truly indigent and uneducated classes. […] It is most unlikely that any true wealthy person would have gone to a hospital for any purpose, unless they were taken ill while travelling far from home. Except under very unusual circumstances all the medical needs of the wealthy and powerful would have been administered in the home or through outpatient clinics dispensing drugs. […] The care for the insane in hospitals was unprecedented and an important part of even the earliest Islamic hospitals.”
Even if I cannot provide a comprehensive narrative of the history of the bīmāristān as an institution within the scope of this article, I would like to mention just one important type of bīmāristān, the bīmāristān for the care of mentally afflicted patients. This type of care may have been an important purpose of these hospitals. Big bīmāristāns frequently featured isolated spaces for physically aggressive patients. Other patients and visitors were protected from them by iron bars (see below). Knowing the etiology of the diseases from which these patients suffered, physicians must have inferred special care requirements.
Other types of bīmāristāns included leprosy, road-side, prison, and mobile bīmāristāns, the last two of which date back to the tenth century CE:
“According to some accounts, directions were given by a wazīr in the early fourth/tenth century to provide medical care to prisons on a daily basis and visits to doctors with a travelling dispensary to villages in lower Iraq.”
Treatment of sick people in bīmāristāns
Renowned author and traveler al-Ḥasan b. Muḥammad al-Wazzān al-Fāsī (d. around 1540) – known in Europe as Leo Africanus – gives a vivid description of a hospital in the city of Fez, today located in Morocco. After working there for a prolonged period of time, he writes:
“Howbeit there is another hospital for the releefe of sick & diseased strangers, who haue their diet onely allowed them, but no phisition or medicine: certaine women there are which attend vpon them, till they recouer their former health, or die. In this hospitall likewise there is a place for franticke or distraught persons, where they are bound in strong iron chaines ; whereof the part next vnto their walks is strengthened with mighty beames of wood and iron. The gouernour of these distraught persons, when he bringeth them any sustenance, hath a whip of purpose to chastise those that offer to bite, strike, or play any mad part. Sometimes it falleth out that these franticke people will call vnto them such as passe by; declaring how vniustly they are there detained, and how cruelly they are handled by the officers, when as notwithstanding they affirme themselues to bee restored vnto their right minde. And hauing thus perswaded the commers-by, approching neerer and neerer vnto them, at length they take hold with one hand on their garments, and (like villans) with the other hand they shamefully defile their faces and apparell with dung. And though all of them haue their priuies and close stooles, yet would they be poysoned in their owne filth, if the seruants did not often wash their lodgings : so that their abhominable and continuall stinke is the cause why citizens neuer visite them. Likewise this hospitall hath many roomes for the purueiors, notaries, cookes, and other officers belonging to the sicke persons; who each of them haue some small yeerely stipend. Being a yoong man I my selfe was in his notarie heere for two yeeres, which office is woorth three duckats a moneth.”
A miniature painting shows a caricature of the insane in the hospital showing insane inmates with chains around their necks and restrained.
This less idyllic presentation of life in bīmāristāns may give a more balanced view of the situation of – some – patients, preventing an apologetic view that portrays all of the bīmāristāns as a paradise on earth inhabited by – alas! – sick persons.
Dols also compares wards for the mentally ill in the Islamic world with insane asylums in Europe:
“Despite the unpleasantness of the hospital conditions described by Leo Africanus, the quarters for the insane were accessible to visitors, and the conditions of the insane appear to have been accepted matter-of-factly. These circumstances do not appear to reflect medieval bedlams offering public entertainment. The sources only mention the visits of men to male patients, and there is no evidence of a prurient interest. The Islamic hospital in general does not fit Michel Foucault’s popular interpretation of the function of the hospital movement in seventeenth- and eighteenth-century Europe as the ‘great confinement’ of the socially undesirable. The Islamic hospital was certainly not intended for the indiscriminate incarceration of the disadvantaged poor, as in pre-revolutionary France. Some patients were neither poor nor disreputable, and the supervision of admissions to a hospital by the local judge in the later Middle Ages would suggest discrimination in the provision of communal welfare. Nor was the confinement great. It is impossible to estimate precisely the numbers of insane patients in the hospitals, but even the greatest institutions, such as the Manṣuri Hospital in Cairo, probably contained only a few dozen insane patients at one time—a very small number in relation to the entire population of Cairo.”
Having avoided idealizing misinterpretations based on Dols’ precautionary judgment, I would now like to focus on the description of the treatment in bīmāristāns.
Staffed by physicians as well as male and female nurses, every bīmāristān pursued its mission of treating each and every patient, regardless of their origin. Bīmāristāns often included a garden, water fountains, and places of worship on their premises.
Waqf documents and eyewitness accounts point to the trail of paperwork produced in bīmāristāns.
“Physicians were expected to write down descriptions of patients’ conditions and to keep these records close to patients’ beds. They likewise had to write down the recipes of medication that they prescribed to patients confined in the bīmāristān.”
Outpatients were probably able to obtain written prescriptions.
There were separate wards for male and female patients who were cared for by persons of the same sex; there were wards for contagious and noncontagious diseases and ones dedicated to ophthalmology, general medicine, surgery, and mental illness. Physicians— including those who treated mental illness—had to pass examinations.
In order to determine the right diagnosis for mental conditions, physician needed to conduct “unbiased clinical observations.”
Body and Soul
Pauline Koetschet 2018 gives an excellent summary of the medical views on the relation of body and soul:
“According to Arabo-Islamic physicians, the overall functioning of the body demonstrated the reciprocity of the humours on one side and psychological events on the other. This is the reason that primary qualities […] were thought to have a strong influence on an individual’s moral character […] Conversely, the state of the soul was believed to have an impact on the bodily balance […] Soul-body reciprocity was the reason that physicians [were to] always pay particular attention to [their] patients’ emotional and spiritual state.”
This approach, which sounds like a “holistic” method to our modern ears, greatly impacted the concept of mental health at the time.
“The reciprocity between soul and body becomes crucial in the case of mental illness, where [it] is both crucial and problematic. To my knowledge, maladies of the soul do not correspond to any distinct category found in medieval medical encyclopedias written in Arabic. For most authors of these encyclopedias, the direct causes of all maladies were physical.”
In order to better understand the body and its mental aspects, we will therefore have to find a new epistemological approach to the mental-physical dichotomy inherited from historical and modern Western thought.
Mental Health and the View of Physicians
There is an Arab saying al-junūn funūn, which, for our purposes, can be translated as: “there are many forms of mental disease.” Medical literature indicates that depression and melancholy seem to have been wide-spread psychological problems in the non-modern Islamic world.
“Arab physicians’ accounts of the close correlation between melancholy and other psychosomatic diseases differ substantially from those given by Rufus and Galen.”
Abū Bakr al-Rāzī (d. 925) was a court physician in Baghdad, who practiced medicine in the new ʿAḍudī bīmāristān. He went down in history for placing experience at the center of his medical methodology and penning many case studies.
“Even though his understanding of the different kinds of mental patients relies on Greek sources such as Rufus and Galen, Abū Bakr al-Rāzī [established] further distinctions in the categories of mental illness and mental patients found in these sources. In his Comprehensive Book on Medicine, which gathers the lecture notes that al-Rāzī made on his Greek, Syriac and Arabic sources, he argues against the ‘common people’s (al-ʿāmma) tendency to characterise any person showing a confused state of mind or behaviour as ‘mad’.”
Contrary to Galen and Rufus, Al-Rāzī stressed the difference between melancholy and delirium, arguing for a
“more limited conception of melancholy that would not include other kinds of mental diseases such as φρενίτις or μανία. In the third chapter of the first book of The Comprehensive Book on Medicine, al-Rāzī denies that melancholy can be provoked by dark yellow bile, [which] can [induce] a form of delirium, but this should not be considered as a type of melancholy, as he explains in his Introduction to the Art of Medicine. In the thirteenth chapter of the same book, al-Rāzī deals with the affections of the faculties of the rational soul. In the part devoted to the affections of thought, he uses the term waswās in the general sense of ‘delirium,’ or ‘confusion of the mind.’ Different forms of delirium include melancholy, φρενίτις, or μανία. When the [affliction originates] in the brain (as opposed to the whole body) and is produced by yellow bile, this is a case of φρενίτις (sirsām). Black bile, on the other hand, causes ‘bestial madness’ (al-junūn al-sabuʿī).”
Al-Majūsī (d. 982-95 CE), a representative of Galenism before Ibn Sīnā, lists different types of melancholia. Black-bile melancholia, for example, is regarded as a confusion of reason (ikhtilāṭ al-ʿaql) without fever. According to al-Majūsī, melancholia originates in the stomach, the brain, or other parts of the body, with each kind of melancholia showing its own symptoms. Al-Majūsī talks about mental confusion, serious delirium, love-madness, anxiety, sadness, fear, terror, suspicion, hallucinations, etc. He mentions a very special type of melancholia:
“One kind of melancholia is said to be lycanthropy. Its victim behaves like a rooster and cries like a dog. He wanders among the tombs at night and stays there until morning. His complexion is yellow; his eyes are dark, brutish, and hollow; his tongue and mouth are dry and lack saliva; and his thirst increases. There are lesions or sores on his body. [Those afflicted] hardly ever recover, and the disease is hereditary.”
Isḥāq ibn ʿImrān’s (d. 932) interpretation
“produces roughly the same result, by extending the scope of melancholy to many mental plights. Isḥāq lived in Kairouan (in modern Tunisia) at the court of the Aghlabid sultan Ziyādat Allah III, and is the author of the only surviving monograph on melancholy produced in the Islamic medieval world, the Treatise on Melancholy. In this treatise, melancholy covers an extremely wide variety of symptoms, ranging from excessive sadness and fear—the two traditional symptoms attached to melancholy in the sixth book of the Hippocratic Aphorisms—to extreme forms of madness, including bestial madness.”
We should remember, however, that Isḥāq ibn ʿImrān was given the nickname “instant poison” because he often did not succeed with his treatments. A critical study of his theories may be in order.
Abū Zayd al-Balkhī (d. 934 CE) addressed mental problems in an early treatise in which he tried to present a comprehensive approach to preventive measures that created a new balance between body and soul.
Renowned physicians such as Ibn Sīnā (d. 1037 CE) also contributed to conceptions about mental conditions, yet a discussion of their ideas would go beyond the scope of this article. Distinctions were made between melancholy and madness, as becomes evident in diverse case histories.
Various authors describe different bīmāristāns and their wards for the mentally ill until the 1700s. We have to bear in mind, however, that these institutions only housed patients with severe diseases; less severe cases were treated within the home. We also have be aware that some ways of behaving beyond what was perceived as “normal” were considered mere eccentricities that did not need to be treated by psychiatric invention. The renowned lexicographer and author of the Ṣiḥāḥ: Tāj al-lugha wa-ṣiḥāḥ al-ʿarabiyya, Ismāʿīl ibn Ḥammād al-Jawharī (d. 1002 or 1008 CE), describes the following scene:
“[al-Jawharī] stood atop the old Friday mosque in the Northeastern Iranian city of Nishāpūr and looked down [on] the astonished and bewildered faces of the crowd below him. A moment later, to the utter amazement and horror of his fellow townsmen, he leaped into the sky with artificial wings attached to his arms.”
After his failed attempt at flying, al-Jawharī fell to his death. A closer look at how his fall was interpreted renders interesting results. While some sources suggest that al-Jawharī acted in a fit of sudden madness, other sources wager that he unsuccessfully tried to fly. al-Jawharī’s condition was not understood as madness in and of itself.
There are many stories about eccentric behavior of Sufis, for example, who were regarded as “holy men or women,” not as mentally insane. Although the behavior of these people may nowadays be regarded as symptoms of schizophrenia, it was respected and tolerated because of its religious underpinnings.
“This acceptance was enforced by one of the most influential Sufis, Ibn al-Arabi (d. 1240 CE), who wrote, ‘the mystical experience assails a person suddenly and he loses his mind; God speaks through the lunatics. The mad people are God’s people, the madness is not caused by natural process, it is caused by divine revelation’.”
But there were women, too. In a biographical lexicon, we read about a “woman in Giza, Egypt, who stood for a long period in a field without any protection from the sun or the wind. She was fed from time to time, eating whatever was given to her.”
The Abbasid caliph al-Muʿtaḍid bi‘llāh (d. 902) we are told,
“was afflicted by a visual experience that manifested itself in several forms. He ordered the gates of the palace to be guarded and locked from all quarters to protect him from his visual experience. […] It seems also that the Caliph had persecutory delusions. […] Surprisingly, he even brought mentally ill patients from a nearby mental hospital, so that he could trace the source of his illness by calling upon the Jinn of one of the lunatics.”
Treating Mental Illness
Caliph al-Muʿtaḍid’s approach to curing his illness was not usual practice. A more adequate way of treating mental diseases will be described below.
The treatment of insanity and of what was regarded as “possession” in South West Asia dates back to Byzantine times. Mental illnesses were not always diagnosed as possessions, as some researchers claim. Rather, physicians were able to distinguish between insanity and illness. The bīmāristān tradition may claim to be a genuine heir of this tradition.
Creating an atmosphere and environment supportive of the successful cure of mental illnesses was a core element of treatment in bīmāristāns. Some
“therapies were water-based treatments. [The] [l]ife-giving strength of water [has] always attracted the attention of mankind and all its possible usage methods were developed with great inventiveness during different periods in history. [They] […] always received a vital consideration in Muslim countries. At an early stage, Muslim engineers were exploring new methods for increasing the effectiveness of water-wheels. The 13th century mechanical engineer Badi’ Al-Zaman Al-Jazari was responsible for the design of five of these machines. One such machine was located in Damascus in [the] Nahr Yazid [canal] and is thought to have supplied the needs of the nearby Al-Qaymari bimaristan. Praying five times a day is an important pillar of Islam. It is an Islamic obligation both for [sick] and for healthy [people]. [B]efore praying, where[ever] possible, one must wash face, head, hands, and feet. So generally, the bimaristan provided patients and employees with water reserves and bathing facilities.
Water treatment was used by Arabic physicians as a means in order to modify bodily equilibrium. [G]reat importance was [attached] to the temperature of the water as well as to the duration of the bath. Essential oils and aromatic and fragrant essences added to bathwater were also considered beneficial, […] to eliminate melancholy, [for example]. The sound of the water was considered therapeutic too […]. [The look and smell] of plants were considered treatments too and it was believed in particular that the scent of plants reached the brain and influenced it.
The medical treatments used in the bimaristans also included fomentations (especially to the head), baths, bloodletting, cupping, bandaging, and massages with different oils, compresses, particular personalized diets. It seems that ergotherapy was also largely utilized and that dancing, theatrical performances, as well as poems and Qu’ran recitations were part of the therapy.”
Following the evidence from medical texts, drugs were also used to treat mental illness. They were
“usually of vegetable origin [and] comprised purgatives, sedatives (especially opium), digestives, and emetics. They were used both [in their simple forms and as compounds] […] to stimulate the apathetic, soothe the violent […] and […] support depressed [patients].”
A topic of discussion in handbooks, flowers also played an important role in Islamic medical therapy. Fakhr al-Dīn al-Rāzī‘s (d. 1210 CE), for example, writes that violets (banafshe) are integral to curing several health problems and preserving bodily health:
“It opens warm growths, a sore breast is cured, cough and warm and dry headache are eased, conjunctivitis and stomach inflammation are cured. Drinking it eases pleurisy, pneumonia, nephritis or dysuria.
The waterlily is like the violet. Smelling and drinking it reduces the virility and the sperms, especially, used for the genitals.
Narcissus is balanced. Its fragrance eases problems of the brain. Its oil strengthens the tendons. Its seeds close wounds and heal tendon injuries. Eating one or two of its bulbs helps vomiting. If the skin of alopecia is ground with it, hair will grow again.“
The list of flowers discussed by Fakhr al-al-Dīn al-Rāzī starts with roses and ends with cypress flowers.
One of the most important methods to cure mental problems was music therapy. Scholars have extensively discussed the philosophical preconditions of music therapy. Some examples may illustrate various positions in this discursive process:
“Both al-Kindi and the Brethren of Purity refer to music therapy as one aspect of the broad philosophical-metaphorical approach that considers harmony in the widest sense as a power involved in mastery of all arts. Originally conceived as such by the (Greek) philosophers, its proper manipulation for purposes of therapy implies a keen knowledge of the laws of universal harmony as well as their reflection in the music made by man. Therefore, this capacity belongs first and foremost to the musician-philosopher, because, as the Brethren say, the science of music is the principal wisdom leading to philosophical thought, and because harmony, wherever it is found in nature, cannot be described without being subordinated to the ideal laws of music.
It can be inferred from [the aforementioned quote] by al-Kindi that the musician should also have some knowledge of medicine. What about the physician?“ […]
In his encylopedic work Miftāḥ al-ṭibb wa-minhāj al-ṭullāb, Ibn al-Hindū (d. ca. 1019 CE) described the disciplines a physician should learn in order to perfect his trade—physics (ʿilm al-ṭabīʿiyyāt), mathematics (ʿilm al-riyāḍiyyāt) (including the subdisciplines of arithmetic and geometry), astronomy and music, metaphysics and theology (ʿilm al-ilāhiyyāt). Logic is excluded since he discussed it earlier on.
In regards to music, Ibn al-Hindū refers to a saying attributed to Hippocrates (buqrāṭ) that the “ancients” cured the ill (bīmārān) with music. Another author suggested that physicians be familiar with the theory and practice of music, especially with touching the strings of the musical instrument. This might aid them in their practice of pulse diagnosis.
In his seminal article on Arabic handbooks for music therapy, Eckard Neubauer determined lacunae in the selection of modi to be chosen by a musician for the treatment of certain diseases. Neubauer stated that an integrated concept of music therapy such as this one was unique in the history of music and medicine.
The oldest textual evidence of practical approaches to a music theory of affects dates back to the 9th century CE. It took several hundred years until a practical system was fully developed. In his Kitāb al-adwār (Book of Cycles), Ṣafiyy al-Dīn al-Urmawī (d. 1294 CE) presented an integrated tonal system and a series of twelve main modi (called šadd, pl. šudūd). These modi (also called anghām or maqām) were associated with the signs of the zodiac and formed an integrated therapeutic system based on astrological-medical considerations. To give an example from an anonymous manuscript:
“Iṣfahān stimulates the intellect (yuwarrith al-fiṭna), sharpens the thoughts (yuḥidd al-khawāṭir), makes [people focus on their] studying (yuʿayin ʿala ‘d-dirāsa) and cures diseases due to cold and dryness.”
The selections of the appropriate modi (Arab. maqām) was very important, since every maqām influenced the mood of the patients differently. One made patients laugh, others helped them fall asleep, soothed their senses, or drove fear away. The maqām Iṣfahān, for example, helped patients with memory problems. Equally important was the time of day the maqām was played, be it in the morning, at noon, or in the evening.
Solutions for specific mental diseases had to be aligned with a patient’s individual dispositions.
Music therapy developed throughout pre-modern Islamic history. The classification system of mental diseases in Ottoman manuscripts provides insights into theoretical considerations of music therapy in Ottoman times. According to Nil Sari, most of these diseases were classified as illnesses residing in the head. Others were regarded as physical illnesses, especially psychosomatic diseases such as hysteria, anxiety, or lack of appetite or sexual diseases resulting from mental disorders. Other mental illnesses, in turn, were attributed to alcohol or opium use. Additional mental or personal disorders were studied separately.
Based on this knowledge, we will now turn to Ottoman music therapy.
“It was during the Ottoman Empire that music as therapy reached its culmination (Terzioğlu 1985, 16). Evliya Chelebi mentions that in Edirne, Sultan Bayazid II built the state hospital (darüşşifa – the houses of healing) in 1488, where water sound and music therapy were regular prescriptions in the treatment of diseases, particularly in the treatment of mental illnesses. On different days of the week, the music therapy team of the hospital performed for the patients. Doctors who were also well trained in the effects of music on human health observed how different melodies (maqams) affected the heartbeat or which melody was suitable for various illnesses. It was generally accepted that the maqam Isfahan benefited patients who suffered from memory problems; the maqam Rehavi was [beneficial for] the treatment of anxiety; and the maqam Kuchi was good in the treatment of depressive thoughts and dysthymia. Chelebi also reports that another famous ruler of the Ottoman Empire, Bayezid Veli established his own charity hospital and appointed ten musicians who played the flute (ney) and string instruments such as santur, keman, çengi, and ud for patients at least three times a week. Chelebi claimed that patients benefited from various maqams, especially from the maqams Zengule and Buselik.“
Several Ottoman authors in the tradition of al-Fārābī, Abū Bakr al-Rāzī or Ibn Sīnā have studied the use of music for therapeutic means. All of them refer, however, to ancient Turkish ideas about the role of sound and melodies in day-to-day practice. As mentioned before, music therapy was used in Ottoman times in a framework informed by theoretical, practical, and empirical considerations.
“The aims of Ottoman music therapy by playing specific modes prescribed for certain physiognomies and nations can be classified as: treatment of mental diseases; treatment of organic diseases; maintaining/re-establishing the harmony of the person—a healthy balance between body, mind and emotions by pleasing him/her; leading the way to emotions, such as [making] people laugh or […] cry etc., preventing vicious feelings and attracting good ones, training the self and thus reaching perfection.“
A specific way of treating mental diseases similar to music therapy is the use of the recitation of the Qur‘an to ease tensions.
Some other aspects
One important way of curing diseases in bīmāristāns was based on the Arabic medico-culinary-dietetic tradition.
“In early Islamic times, inherited Greek dietetic theory was wedded to indigenous Middle Eastern culinary traditions, textual evidence for which may be traced to Babylonian times. A dialogue between medical professionals and laymen emerged, each group to some extent informing and being informed by the other. The culinary manuals provide a clue to the nature of this relationship. They point to the central place of the domestic household in the life of the leisured urban class in Islamic societies, where not only proper nourishment could be provided to its members but also remedies for minor ailments or disorders which did not initially, at least, require, the physician’s expert knowledge of drugs to combat more serious disorders. Healthy food habits were a primary concern of both physicians and household managers, yet the daily supervision of such management was possible with minimum intervention from the physician.“
The reference to the role of household managers in proper dietetics points to the importance of private healthcare—even in the case of mental illness. Sometimes vegetarian dishes are noted as an important part of the treatment.
Court physicians noted the importance of a personal relationship between patients and their physicians in bīmāristāns, even though it often was hampered by the bureaucratic apparatus of the hospital because every prescription and medical action had to be documented in written form.
An important section of the bīmāristān was dedicated to the dispensary—sometimes called sharābkhāna, which roughly translates as “room for medical potions.” Dispensaries also served as a storage room for drugs, precious instruments, and glass, metal, and porcelain vessels. Regarded as technicians, pharmacists administered drugs according to physicians’ prescriptions. The story described below shows that pharmacists’ duties went beyond merely handling drugs in the bīmāristān. It also illustrates that the hospital granted open access to visitors:
“The reason al-Rāzī began to study the medical art was that when he first came to the City of Peace—Baghdad—he visited the ʿAḍudī hospital so that he could see it for himself. There, he was fortunate enough to meet the hospital’s pharmacist, a venerable man, whom al-Rāzī questioned about drugs and who had first discovered them. […] When al-Rāzī heard this, he was impressed and visited the hospital another time, where he saw a child who had been born with two faces in a single head. Al-Rāzī asked the physicians about the cause of this, and when he was informed, he was impressed again with what he had heard and continued to enquire about one thing after another, remembering everything he was told until he decided to learn the medical art and eventually became the ‘Galen of the Arabs’.”
Referring among others to al-Rāzī again, a short remark about the relation between physicians and alternative practitioners is in order:
“Al-Rāzī complained that women were credited with successfully treating patients while he himself—at least if we are to believe his own account—was really responsible for effecting the cure. Al-Kaskarī displayed a patronizing attitude toward women, whom he perceived to be gullible and ignorant. It is a fair surmise to say that women—whether as midwives, healers, or carers—catered to the medical needs of a substantial part of the community, and were therefore in competition with male practitioners—which could account for al-Rāzī’s prejudices. However, it is difficult to make general assertions about women in medical and paramedical professions in the period and region discussed here, owing to the dearth of research on the topic; female practitioners in the classical period of Islam seem to be one of the blind spots of scholarly attention. In the absence of more sophisticated research, suffice it here to point out that gender was important when physicians demarcated themselves from alternative practitioners.“
This aspect of Islamic medical history therefore awaits further investigation. Another minor of the history of bīmāristāns: We encounter yet another narrative in the Fez bīmāristān, where storks were treated mostly for bone fractures. Traditionally, in pre-Islamic traditions storks were considered sacred animals. This narrative on storks and their veneration in the regions of the Western Mediterranean has to be contexualized in another setting. At the beginning of the 19th century, a traveler described charitable foundations for hospitals in Fez dedicated to the care, treatment and even burial of dead cranes and storks. Men from very distant islands were supposedly incarnated in the shape of storks (or cranes) so they could fly back to their homes and return to their human form. The regular migration of these birds made them an object of special veneration.
My overview of bīmāristāns will conclude another act with religious undertones.
Politics and Hospitals
A final remark may shed some light on the intersection of politico-military efforts and the founding of a bīmāristān. Under the rule of the Mamluk Qalāwūn (d. 1290), intense warfare against the Il-Khans of Iran took place. This group of people was suspected of having Shi’ite or pagan leanings. Mamluk Qalāwūn also attacked the crusader kingdoms in Palestine and Syria because he considered them potential allies of the Il-Khan enemy. These heightened tensions led to attempts to islamicize even the bīmāristāns. The construction of a bīmāristān could therefore be regarded as an act of jihād.
Re-reading the history of hospitals as a history including bīmāristāns will enable medical history to draw a rich picture of the human endeavour to maintain health including one of the most important traditions of health care and medicine: Islamic medicine. A specific dimension of this tradition is mental health care and, esp., music therapy. Integrating the preventive and holistic dimensions of Islamic medical history in a new global idea of health care will enrich the human idea of health and medicine.
 Risse includes a mere four pages, therefore excluding Islamic institutions from a general history of hospitals (Risse 1999).
 I am indebted to Margareta Wetchy for her invaluable comments. I am also grateful to the organizers of the 2019 Maimonides Lectures at the Austrian Academy of Sciences, which took place in the Austrian city of Krems at the Karl Landsteiner University of Health Sciences. My hosts afforded me the opportunity to present a first version of the ideas described in this article, the Karl Landsteiner University afforded their generous hospitality to the Maimonides Lectures. Many thanks to Salim al-Hassani for helping me refine my argument.
 Brömer 2010 and Northrup 2013. cf. Gran 1998, pp. 165ff. for a—seldom referred to—first attempt at an advanced analysis of medical literature.
 At present, we still lack a reconstruction of patient perspectives.
 For a recent conceptualization of this period, cf. Al-Azmeh 2014a and Al-Azmeh 2014b.
 Female physicians and healers in pre-Islamic times in Arabia have been well documented (Shehata 2007-2008: 10-11). A comprehensive history of female physicians in Islamic healthcare still needs to be written. For male physicians in pre-Islamic times we would have to turn to the chapter on the Classes of Physicians in the time of the rise of Islam in Ibn Abī Uṣaybiʿa’s famous history of physicians. However, it includes some seminal material (Ibn Abī Uṣaybiʿa 1965 and Ibn Abi Usaibia 2020).
 For an overview cf. Savage-Smith 2007. For older works including additional aspects, cf. Ullmann 1997. For one treatise from Egypt, cf. Dols/Gamal 1984. Pormann 2011 is a highly valuable volume with many interesting chapters.
 Mental health may be contextualized within recent discussions on “embodied experience” (körperliche Erkenntnis) to inscribe into broader philosophical discussions; cf. the contributions in Bockrath/Boschert/Franke 2008. For a recent overview of research on mental health and religion, cf. Classen 2014.
 For later hospitals in Iran often called dār al-shifāʾ, cf. Tadjbakhsh 2012 and Floor 2012.
 Micheau 1996: 991.
 Dols 1987: 369.
 Dols 1987: 382.
 Vivian Nutton quoted in Nayernouri 2017.
 Following Nayernouri 2017, cf. especially, Shahbazi/Richter-Bernburg 2012.
 Some of them even misquote other research literature. Cf. Miller 2006 quoting Dols 1987 (leaving aside some other mistakes including numbers, etc.).
 Speziale 2018 analyzed the Indian influence on Persian medicine in Islamic times.
 It may therefore be interesting to follow the idea of Tabaa reading the Abbasid support for hospitals as an attempt to “outshine the glory of the Sassanian kings” (Tabaa: 98) and to claim the heritage of the previous dynasty by tracing a genealogy back to Gundishapur.
 al-Jāḥiẓ 1965: 286.
 Evidently, I am referring to Ragab’s excellent chapter (Ragab 2018: 140). Cf. Pormann/Savage-Smith 2007: 20.
 For the distinction between professional physicians, cf. Pormann 2005.
 Pormann 2005: 221. The translation from Jahiz‘ Kitab al-Bukhala‘ by Serjeant was slightly adapted by Pormann; cf. Taylor 2010: 1 and Dols 1987: 381ff for the context of the story in Jahiz‘ book.
 For him, cf. Kahl 2009 and Lev/Chipman 2007.
 Shabazi/Richter-Bernburg 2012.
 Savage-Smith, Medicine, 933ff.
 Important insights may be gained from Ragab 2015.
 Al-Ghazal 2007: 6ff.; cf. Weisser 1991: 6.
 Savage-Smith 1996: 934
 Cf. Davies 2008.
 Quote in older English; I have refrained from translating it into standard English because I did not want to distort the atmospheric quality of this description.
 Leo Africanus 2010: 425-426.
 Dols 1995: 130. Similar representations can be found in plays for puppet theatres (cf. Dols 1995: 131).
 Dols 1995: 128-129.
 Some early reports indicate that 24 physicians worked at the important ʿAḍudī hospital in Baghdad in ca. 981 CE (Ibn al-Qifṭī 1908: 438, biography of Ibn Mandawayh).
 For the importance of horticultural therapy, cf. Bascands 2015.
 Ragab 2015: 176.
 Cf. Weisser 1991 for examinations and other training for physicians.
 Meyerhof 1935: 322 with several clinical observations by Abū Bakr al-Rāzī.
 I intentionally inverted the title of the chapter of Koetschet 2018— as mental diseases were explained by physical ailments, we will “treat” the body before the soul in this paragraph.
 This new field of research has been opened by the contributions in Annales Islamologiques 48 (2014).
 For a critical view of the assumption of the dominance of humoral theory for medical practice, cf. Savage-Smith 2013 (footnote RL).
 Koetschet 2018: 60-61; cf. ibid. 2008.
 Although it may be true in terms of quantity, the literature in Persian and Hebrew is an important element of non-modern medical discourses (footnote RL).
 Koutschet 2018: 63.
 Koutschet 2015: 227; cf. Koutschet 2019 for an overview of the position of Abū Bakr al-Rāzī towards Galen.
 Koutschet 2015: 228.
 Koutschet 2015: 229.
 Dols 1995: 64-65.
 Dols 1995: 65.
 Koutschet 2015: 230-231.
 Ibn Abi Usaibia 2020 13.1.1.
 al-Balkhī 2005; for partial translation and some introductory chapters cf. Badri 2013. I have to thank Salim al-Hassani for reminding me to include the approach of al-Balkh.
 Cf. Koutschet 2015: 238ff.
 al-Jawharī 1979.
 Leiser 1988: 173; Youssef/Youssef 1996 list a wrong name (Hamad instead of Hammad).
 Leiser 1988: 173-174
 See interesting stories in Gramlich 1987.
 For the spiritual dimensions of health following Sufi views, cf. Cecere 2014.
 Chronology adopted by the author (RL).
 Youssef/Youssef 1996: 60; the references to the Futuḥāt in this article are inaccurate.
 Youssef/Youssef 1996: 60.
 Youssef/Youssef 1996: 61.
 See Horden 1993 challenging conventional views.
 For a study of the thermal and ventilation systems of a hospital in Damascus, cf. Maraqa/Van Moeseke/De Herde 2014.
 Gorini 2007-2008: 17. In Fakhr al-Dīn al-Rāzī‘s handbook for the preservation of bodily health, we find a similar holistic approach (al-Rāzī 1390h).
 Gorini 2002: 41.
 For the role of scents and fragrances in the Islamic world, cf. Bonnéric 2016.
 For an overview of the positive and negative effects of scents, cf. the fifth chapter in al-Rāzī 1390h, pp. 49ff.
 Referring to the categories accorded to humoral pathology used by Fakhr al-Dīn al-Rāzī we cannot discuss here.
 al-Rāzī 1390h, pp. 53-54.
 Cf. Quintern 2017: 55-56; being aware of the problems of a distinction between psyche and soma.
 Cf. Neubauer 2012-2014, Farmer 1930.
 For a general, cross-cultural overview, cf. Horden 2000; Bates/Bleakley/Goodman 2014; Ka‘bān/Qatāya s. d. for an Arabic language overview.
 For links to Islamic mysticism/Sufism, cf. Shiloah 2000: 244.
 We cannot follow this line of thought here.
 Shiloah 2000: 81.
 For a short overview, cf. Nasser/Tibi 2007.
 Ibn Hindū 1422/2002, pp. 81-86; I am following Bürgel/Käs 2016, pp. 134-137.
 Following Moḥaqqeqī 1988, pp. 239-240, cf. Bürgel/Käs 2016, p. 136.
 Bürgel/Käs 2016, p. 134. For the special case of the new discipline of Islamic music theory on musical meters (īqāʿ), cf. Neubauer 2008-2009.
 Neubauer 2009: 233-234. Cf. Wright 2004/2005 and Neubauer 2004/2005.
 Neubauer 1990: 233.
 For the modern practice of music therapy spreading from Turkey to Austria and other European countries, cf. Güvenç/Güvenç 2009. For some empirical data on the effects of this therapy, cf. Gutjahr et al. 1994.
 Al-Urmawī 1986; on him, also cf. Arslan 2007.
 Neubauer 1990: 235.
 Neubauer 1990: 257 (translation by the author).
 For a general overview, cf. Isgandarova 2015.
 Sufie/Sidik 2017.
 Sari 2005.
 The role of women in health care and medical therapy in Ottoman times was aptly described by Sari 2009a.
 Isgandarova 2015: 110-111.
 For a better understanding of a global history of medicine, possible links to East Asian (and South Asian) ideas on health care or music should also be investigated. Sari 2009b addresses this lacuna.
 For Ottoman music therapy, cf. the excellent article by Sari 2009b.
 Sari 2009b.
 Nelson 2001 and for a more recent study Babamohamadi et al. 2015; in contemporary Iran, especially, there are many studies on the effect of Qur‘an recitation.
 Waines 1999: 240.
 Cf. Pitchon 2016.
 Ibn Abi Usaibia 2020 15.42.
 Ragab 2015: 221ff.
 For the drugs used, cf. Kahl 2009 and Kahl 2007; cf. Saad/Said 2011.
 For an excellent overview of pharmacology, cf. Chipman 2018. For the role of pharmacies in Mamluk and Mongol times, cf. Chipman 2007 and for examples of prescriptions, cf. Chipman/Lev 2010-11 and Lev/Chipman 2012; how to read prescriptions, cf. Chipman 2019a and 2019b.
 Ibn Abi Usaibia 2020 11.5.2.
 Pormann 2005: 226.
 Roque n. d.: 104.
 I am aware that “politics” may not be the appropriate term for this period.
 Northrup 2013: 14-15.
 Northrup 2013: 14.