So wrote a western Virginia newspaper reporter, tongue firmly planted in cheek, describing a strange and unprecedented military phenomenon sweeping America in the months leading up to the Civil War in 1861. Americans were going nuts over a new kind of fighting force: Zouaves, Algerian-style fighters introduced to the Western world by the French during the Crimean War.
The Zouaves’ heritage was North African, running back to the indigenous Berber fighters who served the Arab dey, or ruler, of Algiers prior to the French occupation of 1830. Initially recruited into the French military, by the time of the Crimean conflict in the mid-1850s almost all of the Zouave troopers were French.
In 1855 us Army Captain George McClellan, who was stationed in Europe as an official observer of the Crimean War, had witnessed the Siege of Sevastopol and observed the French Zouaves in action against Russian troops. McClellan, who would later command the Union Army of the Potomac in the Civil War, praised the Zouaves “as the finest light infantry that Europe can produce; the beau-ideal of a soldier.” Other us officers and the American press shared his admiration for the unconventional troops.
Not long after that, Zouave units were springing up all over northern and southern states. As reporters put it, their drill performances were acrobatic, and their battle cries of “zoo-zoo-zoo!” had men cheering and women swooning.
By the early 1860s, when North and South took to the battlefield, about a hundred Zouave volunteer regiments entered the fray—more than 70 for the Union and about 25 smaller units, mostly companies, for the Confederacy. (A regiment was comprised of about 1,000 men, divided into 10 companies.)
“Zoo-zoos” fought throughout the war, from First Bull Run to Antietam, and from Gettysburg to Appomattox. The first Union officer to die in action was a Zouave. So was the first Union soldier to win the Medal of Honor. And the last Union trooper to die before the war ended in 1865 was a Zouave. Fans of the Zouaves thought of them as superheroes; critics dismissed them as showboaters.
Today some continue to make light of the Zouave units that served in that bloody and divisive conflict, suggesting they were little more than acrobats in Orientalist dress—a fashion fad that came and went in a few decades. The Zouave uniform was indeed colorful by American standards, with bright red baggy trousers, short braided jacket, vest and tasseled fez. The outfit was designed for warm climates and rugged terrain. (It occasionally proved to be a fatal drawback, too, as the vivid colors made Zouaves easy targets on a battlefield.)
But those who study the Zouaves’ role in the Civil War realize they were about much more than style. America’s interest in the French Zouaves was fundamentally military: us officers were impressed by the fast-moving, agile fighting style inspired by the Algerian Berbers who developed it. On July 20, 1860, The New York Times burbled:
If the Zouaves should be deprived by siege of their ammunition, they would fight with the butt end of their guns; if by stratagem they should lose their guns, they would throw stones; if there were no stones, they would indulge in fistiana, and if their hands and feet were cut off, they would “butt” with their heads and pummel with their stumps.
Zouaves won admiration also for their compassion for victims of war. The Atlantic Monthly in August 1859 described how French Zouaves escorted a large group of “prisoners, wounded, and helpless women, old men and children” across the Algerian desert to their home villages. The troopers “behaved like very Sisters of Charity, rather than rough bearded soldiers,” sharing their food and water, feeding orphaned babies with ewes’ milk and carrying the infants to their destination. Zouaves developed remarkable unit cohesion and morale, modeled on the close relationships of the French family. It was common for soldiers to refer to their commander as “Father.”
Newspaper coverage of the Crimean War and other European conflicts, backed up by engraved illustrations in magazines like Harper’s Weekly, had given Americans ample exposure to the Zouaves. As the North and South readied for war, it was only natural that each side would look to them for potential advantage in the field.
The first Zouave unit to capture the national imagination was a cadet drilling company formed in 1859 in Chicago by a bright young New York law clerk named Elmer Ephraim Ellsworth. While studying law in Illinois, Ellsworth spent much of his spare time on another pursuit: military drill teams. He was fascinated by military science but had failed to qualify for the United States Military Academy at West Point, New York. Undeterred and captivated by the Zouave craze like many of his generation, he threw himself into training drill teams and introducing them to Zouave methods.
Ellsworth pursued two career tracks. On the one side, he studied legal practice by working as a law clerk. On the other, he worked during his free time as a drill instructor with cadets in Rockford, Illinois, and Madison, Wisconsin—and eventually in Chicago.
Ellsworth’s interest in the Zouaves intensified under the instruction of his fencing instructor, a former Zouave physician and expert swordsman named Charles DeVilliers, who had served in the Crimean War. From the Frenchman, Ellsworth learned the ins and outs of Zouave drill and tactics. He took command of a local military drill team called the Rockford City Greys, and in time his reputation as an effective drillmaster spread.
An eyewitness recalled the Greys’ performance:
They would fall to the ground, load their guns, fire, turn over on their backs, fire again, jump up, run a few steps, fall, then crawl on their hands and feet as silent and quick as cats, climb high stone walls by stepping on each other’s shoulders, making a human ladder.
Members of the National Guard Cadets of Chicago, a bankrupt and dispirited militia company, saw Ellsworth’s Greys perform this new system of drill that combined movements prescribed in the military manuals of American officers Winfield Scott and William Hardee with the athleticism and flamboyance of the French Zouaves.
It was not long before Ellsworth was offered command of the National Guard Cadets. At first he declined because he had just become engaged to marry the daughter of a Rockford businessman. When his putative father-in-law expressed concern that Ellsworth would not be able to provide for his daughter, Ellsworth assured him he would return to his law studies in Chicago. But then he told his fiancée in a letter that he had a plan:
I have changed my mind and have taken command of the Cadets for a limited time. I did not do so for the mere pleasure of commanding them, but I have an object in view which would justify me even in laying aside my studies entirely until after the Fourth of July. It was no idle move on my part I assure you and it throws a great additional labor upon me.
Ellsworth quickly transformed the moribund militia company into the United States Zouave Cadets. He began developing dramatic exercises, and under his training, in 1859 the Zouave Cadets won the national military drilling competition in Chicago.
Ellsworth advocated more than military discipline: He advocated also an unbending work ethic, the highest level of physical skills, and exemplary morality that renounced alcohol, pool halls, bawdy houses and any hint of scandal. This instilled a powerful sense of loyalty among his men, and Ellsworth booted out 12 cadets for failure to uphold his standards.
The 50 who followed his rules became a smash hit. They traveled throughout the country, visiting major cities of the Midwest and Northeast performing acrobatic drill demonstrations at fairs, parades and other events. They wore uniforms designed by Ellsworth: a dark blue jacket trimmed in orange and red, a red sash, loose red trousers and a bright red chasseur cap or a flat-topped, short-visored kepi with gold braid.
On July 4, 1859, the cadets staged a parade in Chicago before Tremont House for the mayor and city council. Ellsworth, in his personal journal, described their reception: “The Chicago Tribune and Press … after giving the company a long but flattering notice concluded by saying, ‘We express the opinion of all who saw the drill yesterday morning when we say the company cannot be surpassed this side of West Point.’”
One journalist commented: “Even their most sanguine friends were surprised at the wonderful precision, rapidity, and difficulty of their drill…. Major Ellsworth has done nobly and received well-merited applause.”
One of those who witnessed a drilling performance that summer in Springfield, Illinois, was a lawyer named Abraham Lincoln. He was greatly impressed by Ellsworth’s leadership and organizational skills, and when he discovered the young man was studying law as well, he acted. At this point, Ellsworth’s two career tracks converged. In 1860 Lincoln offered him a job as a clerk in his law office in Springfield.
And so Ellsworth joined the team of a man many believed was destined for the presidency. John Hay, Lincoln’s personal secretary, became close with Ellsworth and in July 1861 wrote in The Atlantic Monthly about this pre-election period:
Ellsworth found himself for his brief hour the most talked-of man in the country. His pictures sold like wildfire in every city of the land. School-girls dreamed over the graceful wave of curls, and shop-boys tried to reproduce the Grand Seigneur air of his attitude. Zouave corps, brilliant in crimson and gold, sprang up, phosphorescently, in his wake, making bright the track of his journey.
Ellsworth and Lincoln, too, became good friends, and in the fall, the young clerk helped the lawyer with his presidential campaign. When President-elect Lincoln moved in February 1861 to Washington, D.C., Ellsworth accompanied the First Family and stayed at the White House, charming the Lincoln children and their parents alike. The President arranged several government job interviews for Ellsworth, but the young man dreamed of heading a military regiment and had little interest in office work.
Just before the outbreak of the war, Ellsworth traveled to New York, where he put together the 11th New York Infantry Regiment. Popularly known as the Fire Zouaves because most of its soldiers were recruited from the city’s volunteer fire departments, the 11th New York proudly wore red firefighter shirts as part of their Zouave uniforms. And like French Zouaves, the troopers shaved their heads.
Ellsworth brought the newly drilled regiment to Washington, D.C., where it was sworn into federal service on May 7 at the us Capitol, in a ceremony attended by President Lincoln and his son Tad. That same day, Ellsworth was promoted from the rank of second lieutenant to colonel. Two days later, the Willard Hotel, a local landmark, caught fire, and the regiment of New York firefighters rushed to the scene. Without ladders, and sometimes resorting to standing on each other’s shoulders to get to the fire, Ellsworth’s Fire Zouaves put out the blaze and won the hearts of the city.
On May 24 the Fire Zouaves became part of the first Union force to occupy Confederate territory when they captured the river port of Alexandria, Virginia, across the Potomac River from Washington. During the fighting, Ellsworth decided to cut down the Confederate flag that flew atop Marshall House inn. The flag was an enormous two and a half by four meters—so large President Lincoln had seen it from his office in the White House. It was a fatal mistake. As Ellsworth carried the captured flag down the staircase, the inn’s owner, James Jackson, met Ellsworth with a shotgun and killed him. Fire Zouave Corporal Francis Brownell in turn fatally shot Jackson, which earned Brownell the Medal of Honor—the first in the war.
When Lincoln heard the news, eyewitnesses said he wept openly and exclaimed, “My boy! My boy! Was it necessary this sacrifice should be made?” Ellsworth’s body was brought back to the White House, and his casket lay in state in the East Room.
From there the casket was taken to New York City Hall, where thousands came to pay respects to the first man to die for the Union cause. “Remember Ellsworth!” became a Yankee rallying cry, and the 44th New York Infantry Regiment was nicknamed Ellsworth’s Avengers.
However, the first Zouave regiment to officially enter the Civil War was Hawkins’ Zouaves, the 9th New York Infantry Regiment, which mustered on April 23, 1861. Other states in the North and South also saw a rapid creation of Zouave units. A French-language newspaper in New York commented with pride, “Il pleut des Zouaves” (“It’s raining Zouaves”), as unit after unit mustered up.
Each regiment dressed in the Oriental style, but uniforms varied widely depending on available fabrics and the whims of commanding officers. Some units featured the red balloon trousers, others dark blue or sky blue, and some wore the less baggy chasseur cut. Some regiments sported blue vests, others red. Sashes could be light or dark blue, turquoise or red. Some units were known for the tasseled fez of the original French Zouaves, with wrap-around white turbans for dress wear, and others wore a variation of the French kepi, which became popular also among conventional American military units of both the Union and the Confederacy.
The “Zouave craze” was so intense that tailors began creating Zouave-style uniforms for young children, and customers included President Lincoln’s son Tad and General Ulysses S. Grant’s son Jesse. Zouave paper cut-out dolls, coloring books and other toys began appearing in the marketplace. Women’s fashions also adopted the Zouave style with embroidered jackets, short vests and other Eastern flourishes.
The Zouaves’ popularity was reinforced by the spread of Europe’s Romantic movement throughout the us in the early and mid-1800s, which exerted a strong influence on literature, the arts and popular culture. The dashing Zouaves, with their devil-may-care attitude toward combat, their moral enthusiasm, individualism and emotion, epitomized Romantic ideals. They also captured the essence of Orientalism with its vision of an exotic yet alluring East.
The best-known Union Zouave regiments organized out of New York, Pennsylvania, Ohio and Indiana. Among them were Duryée’s Zouaves (5th New York); Hawkins’ Zouaves (9th New York); McChesney’s Zouaves (10th New York); Ellsworth’s Fire Zouaves (11th New York); Collis’s Zouaves (114th Pennsylvania); Piatt’s Zouaves (34th Ohio) and Wallace’s Zouaves (11th Indiana). The most famous Confederate Zouave units, such as Wheat’s Tigers (1st Louisiana Special Battalion) and Coppens’ Zouaves (1st Louisiana Battalion), were set up, not surprisingly, in formerly French Louisiana. Though numerous—perhaps as many as 70,000 for the Union and 2,500 for the Confederacy—they served among vastly more numerous regular soldiers: some two million Union men and 750,000 Confederates.
Most of the Zouave units, particularly in the northern states, trained hastily in the early months of the war. Because time was short, they sometimes failed to meet European standards when it came to military training, tactical coordination and discipline—factors that had been so important to Ellsworth. Some regiments, however, excelled in drilling skills and unit discipline, such as Duryée’s Zouaves, the 5th New York, which General McClellan, who had seen French Zouaves in combat, in 1862 called the best-drilled regiment in the Army of the Potomac. The popular Louisiana units—Wheat’s Tigers and Coppens’ Zouaves—were reported to be first rate in drilling but otherwise somewhat undisciplined.
American Zouaves adopted the battlefield tactics of their French counterparts: speed, mobility and surprise. “Zouave tactics” meant that the men attacked in rapid advances of 100-200 meters, dropping to the ground between each advance and firing their rifled muskets. This was a distinct shift from the prevailing Napoleonic infantry tactics of tightly closed formations, often elbow-to-elbow in double-rank battle lines comprised of thousands of troops. However, in such formations, gun smoke drastically reduced visibility. Since gun smoke tended to rise, visibility was better for those lying on the ground. The Zouaves’ desired rate of fire was three rounds per minute, but in practice it was usually less, as soldiers struggled with their muzzle-loading muskets and sought to conserve limited supplies of ammunition.
The American Zouaves were not conventional soldiers, said Thomas Higginson, a white abolitionist who served as an officer in an all-black Union regiment: “Nobody knows anything about these men who has not seen them in battle. There is a fierce energy about them beyond anything of which I have ever read, unless it be the French Zouaves. It requires the strictest discipline to hold them in hand.” (The emphasis is in the original.)
Maj. Gen. Lew Wallace—later us minister to the Ottoman Empire and author of the 1880 historical novel Ben-Hur—described Zouave tactics used in the 1862 capture of Fort Donelson, Tennessee. Writing 22 years later in The Century magazine about the assault on the Confederate fort, Wallace explained the movements of two Zouave regiments he had led personally:
As the two regiments began the climb, the Eighth Missouri slightly in the lead, a line of fire ran along the brow of the height. The flank companies cheered while deploying as skirmishers. Their Zouave practice proved of excellent service to them. Now on the ground, creeping when the fire was hottest, running when it slackened, they gained ground with astonishing rapidity, and at the same time maintained a fire that was like a sparkling of the earth.
Zouave regiments distinguished themselves, earning high honors on the battlefield. No one ever doubted their courage in the face of enemy fire. Duryée’s Zouaves conducted a ferocious charge in 1863 at the siege of Port Hudson, Louisiana, losing 108 men, more than a third of their force, in one afternoon.
At Gettysburg Ellsworth’s Avengers took part in the heroic defense of Little Round Top during a major Confederate assault, taking heavy casualties. Collis’s Zouaves lost over half their riflemen at Gettysburg’s Peach Orchard. The 2nd Fire Zouaves, fighting alongside Collis’s force, also suffered grave losses. Elsewhere on the battlefield, a single Confederate enfilade volley dropped over 80 men of the 72nd Pennsylvania Zouaves, part of the famous Philadelphia Brigade.
Two Zouave regiments, the 140th and 146th New York (the latter Garrard’s Tigers), fought at Sanders Field at the 1864 Battle of the Wilderness in Virginia, losing more than a third of their forces in the battle. That same year, the 33rd and 35th New Jersey Zouaves lost more than half their men during the Atlanta Campaign.
Zouave units saw combat in every major battle of the war. Difficulties in maintaining their ornate uniforms meant that later in the war Zouave soldiers sometimes had to settle for articles of clothing in conventional blue or gray. They did their best to keep the Oriental flavor of their uniforms.
In the North, the government tried to standardize the Zouave uniform, with limited success. Some conventional units that performed well on the battlefield were rewarded with Zouave garb. In the South, the Zouave uniform gradually disappeared; it was difficult enough for the Confederacy to secure the gray cloth for regular uniforms, much less expensive Eastern-style fabric.
On April 9, 1865, as General Robert E. Lee formally surrendered the Confederate Army to the Union commander, General Grant, at the courthouse in Appomattox, Virginia, the Zouaves suffered the war’s last Union fatality. Seventeen-year-old William Montgomery of the 155th Pennsylvania (part of the 5th Corps’ Zouave Brigade) was mortally wounded by a Confederate artillery shell just one hour before the truce took effect.
With the end of the war, the remaining Zouave volunteer units quickly disbanded. On the Union side, where Zouave dress had persisted, thousands of uniforms were sold as surplus and later continued to appear in ceremonies and parades across America. The last Zouave regiment, a militia unit from Wisconsin, retired its garb in 1879.
Many of Ellsworth’s Chicago Zouave Cadets had gone on to important posts in the Union Army during the war, and they continued to advocate their fallen commander’s Zouave traditions and high standards of leadership. For their last reunion, held in November 1910 at Chicago’s Wellington Hotel, eight former cadets showed up; five others were still living but unable to attend.
The spark ignited by the Zouaves more than a century and a half ago is kept alive today by the Civil War reenactor movement, made up of hobbyists and researchers across the country who represent numerous military units on both sides (Ellsworth’s Avengers are represented by a group in Bakersfield, California). These units commemorate the major events of the conflict and celebrate national holidays by staging encampments and mock battles throughout the area of the conflict—and even appearing in television and motion-picture productions. The recreated Duryée’s Zouaves, for example, organized in 1971, is one of the oldest and most respected “living history” units in the country.
The rapid disappearance of the Zouave units signaled their limited long-term impact on tactical theory and organization in the us military. They were widely viewed as “elite” units, modeled on the best France had to offer. At the same time, they were transitional, a “missing link” between the armies of the 18th and 20th centuries. There were doubts over the value of their fluid, Berber-influenced guerrilla-style tactics, particularly when coupled with flashy, colorful uniforms and the emphasis on formal drilling. Clearly, however, the Zouave units generally brought out the best in their soldiers. In this sense, the Zouaves influenced the course of the Civil War, and they will long be remembered for that.
The modern West’s approach to health and medicine owes countless debts to the ancient past: Babylon, Egypt, Greece, Rome and India, to name a few. The hospital is an invention that was both medical and social, and today it is an institution we take for granted, hoping rarely to need it but grateful for it when we do. Almost anywhere in the world now, we expect a hospital to be a place where we can receive ease from pain and help for healing in times of illness or accidents.
We can do that because of the systematic approach—both scientifically and socially—to health care that developed in medieval Islamic societies. A long line of caliphs, sultans, scholars and medical practitioners took ancient knowledge and time-honored practices from diverse traditions and melded them with their original research to feed centuries of intellectual achievement and drive a continual quest for improvement. Their bimaristan, or asylum of the sick, was not only the true forerunner of the modern hospital, but also virtually indistinguishable from the modern multi-service healthcare and medical education center.
The bimaristan served variously as a center of treatment, a convalescent home for those recovering from illness or accident, a psychological asylum and a retirement home that gave basic maintenance to the aged and infirm who lacked a family to care for them.
The bimaristan was but one important result of the great deal of energy and thought medieval Islamic civilizations put into developing the medical arts. Attached to the larger hospitals—then as now—were medical schools and libraries where senior physicians taught students how to apply their growing knowledge directly with patients. Hospitals set examinations for the students and issued diplomas. The institutional bimaristans were devoted to the promotion of health, the curing of diseases and the expansion and dissemination of medical knowledge.
Although places for ill persons have existed since antiquity, most were simple, without more than a rudimentary organization and care structure. Incremental improvements continued through the Hellenistic period, but these facilities would barely be recognizable as little more than holding locations for the sick. In early medieval Europe, the dominant philosophical belief held that the origin of illness was supernatural and thus uncontrollable by human intervention: As a result, hospitals were little more than hospices where patients were tended by monks who strove to assure the salvation of the soul without much effort to cure the body.
Muslim physicians took a completely different approach. Guided by sayings of the Prophet Muhammad (hadith) like “God never inflicts a disease unless He makes a cure for it,” collected by Bukhari, and “God has sent down the disease and the cure, and He has appointed a cure for every disease, so treat yourselves medically,” collected by Abu al-Darda, they took as their goal the restoration of health by rational, empirical means.
Hospital design reflected this difference in approach. In the West, beds and spaces for the sick were laid out so that the patients could view the daily sacrament of the Mass. Plainly (if at all) decorated, they were often dim and, owing to both climate and architecture, often damp as well. In the Islamic cities, which largely benefited from drier, warmer climates, hospitals were set up to encourage the movement of light and air. This supported treatment according to humoralism, a system of medicine concerned with corporal rather than spiritual balance.
The first known Islamic care center was set up in a tent by Rufaydah al-Aslamiyah during the lifetime of the Prophet Muhammad. Famously, during the Ghazwah Khandaq (Battle of the Ditch), she treated the wounded in a separate tent erected for them.
Later rulers developed these forerunners of “mash” units into true traveling dispensaries, complete with medicines, food, drink, clothes, doctor and pharmacists. Their mission was to meet the needs of outlying communities that were far from the major cities and permanent medical facilities.
They also provided the rulers themselves with mobile care. By the early 12th-century reign of Seljuq Sultan Muhammad Saljuqi, the mobile hospital had become so extensive that it needed 40 camels to transport it.
The first Muslim hospital was only a leprosarium—an asylum for lepers—constructed in the early eighth century in Damascus under Umayyad Caliph Walid ibn ‘Abd al-Malik. Physicians appointed to it were compensated with large properties and munificent salaries. Patients were confined (leprosy was well known to be contagious), but like the blind, they were granted stipends that helped care for their families.
The earliest documented general hospital was built about a century later, in 805, in Baghdad, by the vizier to the caliph Harun al-Rashid. Few details are known, but the prominence as court physicians of members of the Bakhtishu’ family, former heads of the Persian medical academy at Jundishapur, suggests they played important roles in its development.
Over the following decades, 34 more hospitals sprang up throughout the Islamic world, and the number continued to grow each year. In Kairouan, in present-day Tunisia, a hospital was built in the ninth century, and others were established at Makkah and Madinah. Persia had several: One in the city of Rayy was headed for a time by its Baghdad-educated native son, Muhammad ibn Zakariya al-Razi.
In the 10th century five more hospitals were built in Baghdad. The earliest was established in the late ninth century by ‘Al-Mu’tadid, who asked Al-Razi to oversee its construction and operations. To start, Al-Razi wanted to determine the most salubrious place in the city: He had pieces of fresh meat placed in various neighborhoods, and some time later, he checked to determine which had rotted the least and sited the hospital there. When it opened, it had 25 doctors, including oculists, surgeons and bonesetters. The numbers and specialties grew until 1258, when the Mongols destroyed Baghdad.
The vizier ‘Ali ibn Isa ibn Jarah ibn Thabit wrote in the early 10th century to the chief medical officer of Baghdad about another group:
I am very much worried about the prisoners. Their large numbers and the condition of prisons make it certain that there must be many ailing persons among them. Therefore, I am of the opinion that they must have their own doctors who should examine them every day and give them, where necessary, medicines and decoctions. Such doctors should visit all prisons and treat the sick prisoners there.
Shortly afterward a separate hospital was built for convicts, fully staffed and supplied.
In Egypt, the first hospital was built in 872 in the southwestern quarter of Fustat, now part of Old Cairo, by the ‘Abbasid governor of Egypt, Ahmad ibn Tulun. It is the first documented facility that provided care also for mental as well as general illnesses. In the 12th century, Saladin founded in Cairo the Nasiri hospital, which later was surpassed in size and importance by the Mansuri, completed in 1284. It remained the primary medical center in Cairo through the 15th century, and today, renamed Qalawun Hospital, it is used for ophthalmology.
In Damascus the Nuri hospital was the leading one from the time of its foundation in the mid-12th century well into the 15th century, by which time the city contained five additional hospitals.
In the Iberian Peninsula, Cordóba alone had 50 major hospitals. Some were exclusively for the military, and the doctors there supplemented the specialists who attended to the caliphs, military commanders and nobles.
In a fashion that would still be recognizable today, the typical Islamic hospital was subdivided into departments such as systemic diseases, surgery, ophthalmology, orthopedics and mental diseases. The department of systemic diseases was roughly equivalent to today’s department of internal medicine, and it was usually further subdivided into sections dealing with fevers, digestive troubles, infections and more. Larger hospitals had more departments and diverse subspecialties, and every department had an officer-in-charge and a presiding officer in addition to a supervising specialist.
Hospitals were staffed also with a sanitary inspector who was responsible for assuring cleanliness and hygienic practices. In addition, there were accountants and other administrative staff to assure that hospital conditions—financial and otherwise—met standards. There was a superintendent, called a sa’ur, who was responsible for overseeing the management of the entire institution.
Physicians worked fixed hours, during which they saw the patients who came to their departments. Every hospital had its own staff of licensed pharmacists (saydalani) and nurses. Medical staff salaries were fixed by law, and compensation was distributed at a rate generous enough to attract the talented.
Funding for the Islamic hospitals came from the revenues of pious bequests called waqfs. Wealthy men and rulers donated property to existing or newly built bimaristans as endowments, and the revenues from the bequests paid for building and maintenance. To help make it pay, such revenues could come from any mix on the property of shops, mills, caravanserais or even entire villages. The income from an endowment would sometimes also cover a small stipend to the patient upon dismissal. Part of the state budget also went toward the maintenance of hospitals. To patients, the services of the hospital were free, though individual physicians occasionally charged fees.
Bimaristans were open to everyone on a 24-hour basis. Some only saw men while others, staffed by women physicians, saw only women; still others cared for both in separate wings with duplicate facilities and resources. To treat less serious cases, physicians staffed outpatient clinics and prescribed medicines to be taken at home.
Special measures were taken to prevent infection. Inpatients were issued hospital wear from a central supply area while their own clothes were kept in the hospital store. When taken to the hospital ward, patients would find beds with clean sheets and special stuffed mattresses ready. The hospital rooms and wards were neat and tidy with abundant running water and sunlight.
Inspectors evaluated the cleanliness of the hospital and the rooms on a daily basis. It was not unusual for local rulers to make personal visits to make sure patients were getting the best care.
The course of treatment prescribed by doctors began immediately upon arrival. Patients were placed on a fixed diet, depending on condition and disease. The food was of high quality and included chicken and other poultry, beef and lamb, and fresh fruits and vegetables.
The major criterion of recovery was that patients be able to ingest, at one time, an amount of bread normal to a healthy person, along with the roasted meat of a whole bird. If patients could easily digest it, they were considered recovered and subsequently released. Patients who were cured but too weak to discharge were transferred to the convalescent ward until they were strong enough to leave. Needy patients were given new clothes, along with a small sum to aid them in re-establishing their livelihood.
The 13th-century doctor and traveler ‘Abd al-Latif al-Baghdadi, who also taught at Damascus, narrated an amusing story of a clever Persian youth who was so tempted by the excellent food and service of the Nuri hospital that he feigned illness. The doctor who examined him figured out what the young man was up to and admitted him nevertheless, providing the youth with fine food for three days. On the fourth day, the doctor went to his patient and said with a rueful smile, “Traditional Arab hospitality lasts for three days: Please go home now!”
The quality of care was subject to review and even arbitration, as related by Ibn al-Okhowa in his book ‘Ma’alem al-Qurba fi Talab al-Hisba’ (The Features of Relations in al-Hisba):
If the patient is cured, the physician is paid. If the patient dies, his parents go to the chief doctor; they present the prescriptions written by the physician. If the chief doctor judges that the physician has performed his job perfectly without negligence, he tells the parents that death was natural; if he judges otherwise, he tells them: Take the blood money of your relative from the physician; he killed him by his bad performance and negligence. In this honorable way, they were sure that medicine is practiced by experienced, well-trained persons.
In addition to the permanent hospitals, cities and major towns also had first aid and acute care centers. These were typically located at busy public places such as large mosques. Maqrizi described one in Cairo:
Ibn Tulun, when he built his world-famous mosque in Egypt, at one end of it there was a place for ablutions and a dispensary also as annexes. The dispensary was well equipped with medicines and attendants. On Fridays there used to be a doctor on duty there so that he might attend immediately to any casualties on the occasion of this mammoth gathering.
Because one of the major roles of the hospitals was the training of physicians, each hospital had a large lecture theater where students, along with senior physicians and medical officers, would meet and discuss medical problems in seminar style. As training progressed, medical students would accompany senior physicians to the wards and participate in patient care—much like a modern residency program.
Surviving texts, such as those in Ibn Abi Usaybi’ah’s ‘Uyun al-anba’ fi tabaqat al-atibb’ (Sources of Information on Classes of Physicians), as well as student notes, reveal details of these early clinical rounds. There are instructions on diets and recipes for common treatments, including skin diseases, tumors and fevers. During rounds, students were told to examine the patients’ actions, excreta, and the nature and location of swelling and pain. Students were also instructed to note the color and feel of the skin, whether hot, cool, moist, dry or loose.
Training culminated in an examination for a license to practice medicine. Candidates had to appear before the region’s government-appointed chief medical officer. The first step required was to write a treatise on the subject in which the candidate wanted to obtain a certificate. The treatise could be an original piece of research or a commentary on existing texts, such as those of Hippocrates, Galen and, after the 11th century, Ibn Sina, and more.
Candidates were encouraged not only to study these earlier works, but also to scrutinize them for possible errors. This emphasis on empiricism and observation rather than slavish adherence to authorities was one of the key engines of the medieval Islamic intellectual ferment. Upon completion of the treatise, candidates were interviewed at length by the chief medical officer, who asked them questions relevant to problems of the prospective specialties. Satisfactory answers led to licensed practices.
Another key aspect to the hospital, and of critical importance to both students and teachers, was the presence of extensive medical libraries. By the 14th century, Egypt’s Ibn Tulun Hospital had a library comprising 100,000 books on various branches of medical science. This was at a time when Europe’s largest library, at the University of Paris, held 400 volumes.
Cradle of Islamic medicine and prototype for today’s hospitals, bimaristans count among numerous scientific and intellectual achievements of the medieval Islamic world. But of them all, when ill health or injury strikes, there is no legacy more meaningful.