News agencies during the summer and autumn of 2016 have reported intentional airstrikes by Russian and Syrian government planes on numerous hospitals in the city of Aleppo, one of the most bitterly contested sites of the ongoing Syrian civil war. They have highlighted not only the tragic loss of life and the prevention of proper medical aid for the wounded, but also the political and strategic importance of hospitals in Aleppo and other Syrian cities. The importance of hospitals in Aleppo, or in any city for that matter, is obvious, but Islamic hospitals (bīmāristāns) have played a central role in the political and religious histories of cities of the Near East for over a millennium. This is the subject of Ahmed Ragab's 2015 monograph, in which he gives equal attention to the building and patronage of bīmāristāns in the shifting political landscape of the medieval Islamic Near East and to their varied roles as charitable, religious, and medical institutions. [1]
Even though the word "hospital" is used in the title of the book, apparently as a sop to Anglo-American readers, in the text itself Ragab challenges its use, arguing that bīmāristāns should be understood first as Islamic institutions of charity, and only second as medicalized institutions of bodily healing. Most bīmāristāns were located within complexes of Islamic religious buildings, which could include a madrasa (Islamic legal school), a mausoleum for the founder, waqfs (organizations or properties for managing and increasing the charitable endowment for the complex), and other explicitly Islamic buildings. Moreover, Ragab emphasizes that there was no single or coherent category of "Islamic hospital" (a failing of most histories of Islamic hospitals, he says) and that we should avoid the term "hospital" altogether when referring to Islamic bīmāristāns, a policy he follows with some rigor in the text.
This sort of care taken with terminology shows that Ragab situates himself within the revisionist school of Peter Pormann and Peregrine Horden, namely, those scholars who challenge the assumptions of Michael Dols concerning Islamic hospitals, which still often dominate discussions of the topic. One of his most pervasive criticisms of Dols' work on Islamic hospitals (always tempered by a certain reverence for the late scholar) is the tendency, shared by other historians since, to overly medicalize the Islamic hospital by separating charitable activities from the more strictly medical activities that nonetheless both occurred within the same bīmāristān.
Guided thus by a desire to describe bīmāristāns holistically and as complex products of their urban environments, Ragab states his purpose: "this book is a study of the material and embodied histories of bīmāristāns" (xiv). In this study he details the political contexts, charitable motivations, and waqfs of several bīmāristāns, not to mention their actual construction, layout, staff, patients, and relationship with surrounding buildings and streets. Specifically, he examines bīmāristāns built or rebuilt in Egypt and the Levant from the twelfth to the fourteenth centuries, since most research on medieval Islamic hospitals has concerned only the earliest examples of the ninth and tenth centuries, those founded in Iraq and Iran. The major bīmāristāns of Egypt and the Levant in this later period were all built or patronized by the leaders of caliphal dynasties, including two hospitals in Aleppo and Damascus built by Nūr al-Dīn Mahmud Zanki, both called al-Bīmāristān al-Nūri; al-Bīmāristān al-Nāṣirī in Cairo, built by Ṣalāḥ al-Dīn (known better to Western readers as Saladin); and al-Bīmāristān al-Manṣūrī, also in Cairo, begun by the Mamluk sultan Al-Manṣūr Qalāwūn in 1285. Of those high medieval Levantine hospitals, Ragab focuses most on al-Bīmāristān al-Manṣurī of Cairo, which was already the subject of his 2011 monograph Bīmāristān al-Manṣurī: Science and Religion in Medieval Egypt (Cairo-Paris: Centre d'Études et de Documentation Économiques, Juridiques et Sociales). [2]
Ragab begins the book with a rather dry, historiographical introduction and a more lyrical "Prologue: A Tale of Two Bīmāristāns," before beginning in earnest. The five chapters are divided into two parts, one on the bīmāristāns as institutions and buildings developed in the religious-political spaces of Jerusalem, Damascus, Aleppo, and Cairo (chapters 1-3), and the other on physicians and patients found within them (chapters 4-5). In an appendix ("Annex"), Ragab makes his own foray into the historiographical battle over "Who Built the First Islamic Hospital?", a subject touched briefly on in his introduction.
In his lengthy prologue (really a full chapter), Ragab provides significant historical and historiographical background for his study of how bīmāristāns changed over time and between regions, using two early bīmāristāns of Baghdad as the subject of his "Tale": al-Bīmāristān al-Ṭūlūnī (built 872 CE) and al-Bīmāristān al-Muqtadirī (919). He describes how these and all other medieval bīmāristāns were indebted to the invention of the first "hospitals" in the Christian Eastern Roman (or Byzantine) Empire. These Byzantine xenodocheia combined religious charity, poor relief, and a modicum of medical care, and were directly imitated by the founders of the earliest Islamic bīmāristāns in the eighth century CE. The more explicitly medical functions of the bīmāristāns are attributed to influence from the semi-mythical Bakhtīshū dynasty of physicians associated with the Persian city of Gundisapur, conquered by the Muslims in 638 CE. Ragab tells this "Tale" well, but it has been told several times before by Peregrine Horden, Timothy Miller, and Michael Dols, among others. Thus it is depressing to see many errors and inconsistencies in spelling in this Prologue. To name just a few examples, Ragab calls the Sassanid capital "Selecucia" multiple times (instead of Seleucia); he switches between xenodochia and xenodocheia several times, apparently without an understanding of Greek plurals; and he switches from Gundisapur to Gundeshapur without explanation.
The strongest elements of Ragab's book are those chapters and sections based on his own research on the bīmāristāns of Cairo, particularly Chapter 2, "Reclaiming the Past: The (New) Bīmāristāns of Egypt," in which he compares the bīmāristāns of Ṣalāḥ al-Dīn and Qalāwūn. Each ruler used the construction of bīmāristāns, among other examples of his "built patronage," to erase or literally overshadow the buildings of past dynasties and to emphasize the power and legitimacy of his own dynasty (namely, Sunni Ayyubids over Shiite Fatimids, then Qalawunid Mamluks over the Ayyubids). Chapter 3 is essentially a long footnote to the story of Qalāwūn in Chapter 2, in which Ragab performs a detailed analysis of the three surviving foundation documents from al-Bīmāristān al-Manṣūrī: the original waqf document and its appendices, and two of the sultan's decrees appointing a chief physician and director for his new bīmāristān.
Ragab's nuanced interpretations of the construction and layout of medieval bīmāristāns is most evident in the first half of his Chapter 1, "From Jerusalem to Damascus: The Monumental Bīmāristāns of the Levant." In that section, Ragab walks the reader through the major rooms (īwāns) of al-Bīmāristān al-Nūri in Damascus, exploring their functions, and unpacking the multivalent meanings of the pious inscriptions placed on their walls by Nūr al-Dīn. This sort of careful and novel treatment of the sources, evident in much of Part I, is painfully lacking in the second half of Chapter 1 (pages 59-75), on the relation of Crusader hospitals to Islamic bīmāristāns, and particularly on how Ṣalāḥ al-Dīn directly took over or imitated Hospitaller foundations in Jerusalem and the Crusader kingdoms. This section is highly derivative of other scholars, as Ragab quotes or paraphrases whole paragraphs from articles by crusade historians without understanding their context. This section is also more replete with errors in spelling, terminology, and historical details than any other in the book, demonstrating that Ragab did only minimal research on this topic. He is dependent primarily on the outdated interpretations and poor translations in Edgar Erskine Hume's excitable study Medical Work of the Knights Hospitallers of Saint John of Jerusalem (Baltimore, 1940). Using this work, apparently, Ragab tells us that Godfrey de Bouillon was king of Jerusalem (he was not); Richard I of England is called "Richard Coeur Lion" (a meaningless neologism); the author of the Hospitaller rule is called "Raymod" (not Raymond); all Hospitallers are inexplicably called by the French title "frere" without any indication of the differences between brothers of the Order and later friars; the Hospitaller castle of Krak de Chevaliers is incorrectly called "Le Crec" in two places; and the medieval Hospitallers are conflated with the modern Knights of Malta based on information provided on one of the latter order's websites (64, n. 51).
I will emphasize again the overall high quality of most of Chapters 1-3, but both the prologue and this section just described are so poorly proofread and researched as to throw the value of the entire book into doubt.
In Chapter 4, "Theory and Practice: The Reign of the Bīmāristān Physicians," which starts Ragab's Part II, "Physicians and Patients," he explores the intellectual background and careers of professional physicians in the twelfth- and thirteenth-century Levant. Particularly important for Ragab are those physicians active at al-Bīmāristān al-Nūri in Damascus, beginning with al-Naqqāsh (d. 1178) and culminating with the influential medical teaching and service of al-Dakhwār (d. 1231) and Ibn al-Nāfis (d. 1288). All of these medical scholars used as a basis for their theoretical medicine al-Qānūn of Ibn Sina (the Canon of Avicenna in the West), al-Rāzī's al-Ḥāwī (the Liber continens of Rhazes in the West), and commentaries on Hippocrates' Aphorisms. In this chapter Ragab approaches the difficult question of the relation between Muslim and non-Muslim physicians in the Islamicate Levant. He is dependent for this subject on the work of Paulina Lewicka, author of the 2012 monograph Medicine for Muslims?, who argued that medicine was intentionally Islamicized in the thirteenth-century Levant, thereby driving out Christian and Jewish practitioners, and leading to the end of an era of vigorous, and mostly secular, creativity in medicine. [3] Ragab places the Damascene phsyicians al-Dakhwār and his circle in this context of a more religiously motivated, less universal, and less theoretical medical practice.
Only Chapter 5, "'A House for King and Slave': Patients and Medical Practice in the Bīmāristān," will satisfy those readers looking for actual Islamic medicine. This chapter is well illustrated with photographs and floorplans of al-Bīmāristān al-Manṣūrī, and similar complexes. Since almost no documents survive from this bīmāristān, Ragab must rely on the physical remains, as well as on contemporary and later medieval Arab chroniclers, to understand the actual functioning of the bīmāristān. The bīmāristān did, of course, house sick patients, who were treated with an elaborate pharmacology, but as a charitable institution it also maintained travelers, the poor and other urban seekers of charity, the mad and disturbed, and those simply visiting to pick up medications. This is a fascinating and readable chapter, but it tells us little about any specific bīmāristān, or anything new about Islamic medicine. Ragab relies on much older, and well known, works of Islamic medicine to paint a picture of patient-physician interactions in the bīmāristāns, especially the clinical observations of al-Rāzī, as translated into English by Max Meyerhof some eighty years ago. [4] Perhaps this tendency is necessary, without sources directly from al-Bīmāristān al-Manṣūrī, but the reader is led to believe that this one bīmāristān in particular is being described.
The core of Ragab's book is a careful and challenging study of al-Bīmāristān al-Manṣūrī built in Cairo, beginning 1285, under the patronage of Sultan Qalāwūn, which was the subject of his doctoral dissertation and first book. Wherever Ragab remains on this subject, his book is masterful. But in his attempt to turn those earlier studies into a book on medieval Islamic hospitals in general, Ragab has gone far out of his comfort zone, and produced a book that is at times misguided, poorly researched, and embarassingly full of errors. It adds an important perspective to our understanding of medieval bīmāristāns, but it must be used with great care.
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Notes:
1. The subject of medicine and religion in Mamluk Egypt is a new and vibrant field in the English-speaking world, also represented by recent monographs like Nahyan Fancy's Science and Religion in Mamluk Egypt: Ibn al-Nafīs, Pulmonary Transit and Bodily Resurrection (London: Routledge, 2013) and Kristina Richardson's Difference and Disability in the Medieval Islamic World: Blighted Bodies (Edinburgh: Edinburgh University Press, 2012), both of which Ragab cites.
2. I have not been able to find a copy of this first book to compare the two, nor does Ragab cite this earlier book in the bibliography of his new book. Both are based on his 2010 doctoral dissertation "Bīmāristān al-Manṣurī: une métaphore de santé", defended in the École Pratiques des Hautes Études, Paris.
3. Paulina Lewicka, Medicine for Muslims? Islamic Theologians, Non-Muslim Physicians and the Medical Culture of the Islamic Near East (Bonn: Annemarie Schimmel Kolleg Working Papers, 2012).
4. Max Meyerhof, "Thirty-Three Clinical Observations by Rhazes," Isis 23:2 (1935), 321-372.