Music Therapy in Medicine of Islamic Civilisation

Ibn Sina’s (Avicenna) denotes that one of the most effective methods in medical treatment is listening to music, which clearly illustrates the position of music therapy in medical treatment. This chapter discusses four matters: (i) the concept of music therapy as medical treatment, (ii) the function of music therapy as a method of complementary treatment aimed more towards calming and relieving pain, but not as a total cure for the patient, (iii) the hospitals that applied music therapy as treatment, and (iv) the process of applying music therapy in the medical tradition of the Islamic civilisation. Music here includes instrumental music, the sound of singing, adhan (call to prayer), Quranic recitation, as well as sounds of nature, such as of birds singing and of water from a fountain pool. Among the hospitals that applied such therapy was Bimarastan Fez in Morroco, Bimarastan al-Mansuri at Cairo, Egypt, Bimarastan al-Arghuni at Allepo, Syria, Bimarastan Nur al-Din at Damascus City, and Suleymaniye Sifahanesi.


Introduction
Using music as a therapy has been discussed and practised in various civilisations of the world. The act was thought to begin earlier than Islamic civilisation. A study by Mohd Jailani [1] showed that music therapy was applied in the ancient civilisations of Egypt, China, Greece, and Roman. The ancient Egyptians were described by al-Farabi [2] as pioneers in the field of music based on a picture depicting David treating Saul with al-ma'azif (a stringed musical instrument) for a melancholia caused by the disturbance of evil spirits (or deities). The influence of evil spirits gradually eroded the good spirit from Saul's body, and David applied music therapy to Saul until his health was restored. This picture was found on the wall of a tomb in Thebes (ancient Egyptian city east of the Nile River) [3]. The first ancient Egyptian physician who used music therapy in treatment was I-em hotep, a competent physician who lived around 3500 B. C, in the era of the third Dynasty of Ancient Egypt. I-em hotep also established a medical institution that applied music therapy as a line of treatment [4].
The history of ancient Chinese civilisation indicates that the Chinese had already recognised the benefits of music therapy since 4000 years ago [5]. The Chinese Emperor (Emperor Chung) himself was convinced that well-composed music could evoke the feelings of tolerance, compassion, pleasure, and courage, thus indicating that music could affect human emotions. Confucius, a well-known Chinese philosopher, also stated that music can improve eyesight, sharpen hearing, and improve blood circulation [6]. He considered the art of music as a symbol of civilization [7,8].
The Greek civilisation similarly believed that music therapy could play an important role in dealing with physical, mental, and spiritual health problems. Koc et al. [6] reported that the Greek poet Homer (who lived in the 9th Century BC) mentioned the ability of music therapy to stop bleeding. Music therapy was therefore said to be suitable for patients who underwent surgery. Pythagoras (who died in the year 495 BC) also recommended that music therapy be applied to a hot-tempered person and to those who suffer from disappointment. Pythagoras also believed that music therapy is very effective in treating diseases caused by hormonal disorders in the body [5]. According to Penelope & Burnett [9], Pythagoras had practically applied music therapy on an intoxicated young man from Taormina (located in Sicily) to restore his sanity and calm him down.
Music therapy was also applied as a line of treatment in the Roman civilisation [6]. The Roman society used it to assuage grief, overcome hysteria, alleviate pain from poisonous insect bites, treat microbial diseases, and treat dumb patients. Examples of music-based treatment in the Roman civilisation were their applications for individuals who suffered psychological disorders and for deaf people (using a trumpet). The therapy was also used in treating severe mental disorders, such as anxiety or restlessness. The Roman society believed that music therapy could alleviate pain, strengthen their spirit, and increase perseverance when they were unwell [10].

Concept of music therapy as medical treatment
We refer to several organisations to obtain a more precise definition of music therapy. The American Music Therapy Association (AMTA) defines music therapy as a clinical and evidence-based use of music interventions to accomplish individualised goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program [11]. Another organisation, the World Music Federation Therapy (WMFT), refers to music therapy as the professional use of music and its elements as an intervention in medical, educational, and everyday environments with individuals, groups, families, or communities who seek to optimise their quality of life and improve their physical, social, communicative, emotional, intellectual, and spiritual health and well-being. Research, practice, education, and clinical training in music therapy are based on professional standards according to social, cultural, and political contexts [12]. Music therapy is also defined as a therapy based on engagement in musical activities, namely the use of music as a therapeutic element to reduce anxiety, improve cognitive functioning, promote physical rehabilitation, and enhance interpersonal communication [13].
In the context of the Islamic civilisation, we use the definition of music therapy expressed by al-Faruqi [14]: the art and science of combining sounds or voice tones or instrumental sounds to form various expressions that satisfy emotions, aesthetics and structure of the basis for belief system held. This definition sums up the three main characteristics that form the basis of music: (i) sound, tone of voice, and instrument; (ii) capability of satisfying emotions and aesthetics, and (iii) fulfilling a particular purpose in a belief system. This definition is found to be relevant to the concept of music therapy in the Islamic medieval era as follows: DOI: http://dx.doi.org/10.5772/intechopen.98707 i. Sound, tone of voice, or instrument The method of music therapy is not limited to using only instrumental music and singing but also includes adhan (call to prayer), recitation of the Quran, and the sound of water as a medium of therapy, particularly with the elements in the sounds, such as tone, rhythm, and melody.
ii. Capability of satisfying emotions and aesthetics Treatment with music therapy functions to give tranquillity, alleviate pain, and reduce symptoms. The therapy is one of the methods applied with main treatment (medication or surgery) besides using other complementary treatments such as aromatherapy, bath therapy, storytelling, dance, and theatre presentation.
iii. Fulfilling particular purpose in a belief system Music therapy in the Islamic medieval era encompasses using music in al-sama' rituals by sufi dervishes at sufi activity centres, known as khaniqah, ribat, and zawiyah. The disciples of a sufi fraternity (tariqa), guided by their Sufi Sheikh or Master, used al-sama' as physical and mental therapy for the ennui (boredom and weariness) of the vagaries of life, and even as the remedy for the soul's longing to meet with the Divine. Hence, al-sama' is an essential ritual for sufis as it is considered a wasilah (means to get closer) to Allah SWT through the sense of hearing. It is also said to be the wasilah to gain peace of mind and purify the soul that has sinned. The reality of al-sama' is said to occur when a sufi experiences al-wajd (spiritual ecstasy in witnessing the grandeur of the Divine secret) and feels himself fana' (selfannihilation or extinction while still physically alive) from worldly affairs.
We can summarise here that music therapy is a treatment for increasing a person's health level emotionally, physically, and spiritually. It is not restricted to using particular musical instruments but includes the adhan (call to prayer), recitation of al-Quran, and sounds of nature (such as flowing water and singing of birds). However, music therapy is more of a complementary treatment applied adjunctly with main treatments, such as the use of medication or surgery.

Function of music therapy as a complementary treatment
As a medical treatment, music therapy has its functions. Among the functions, according to Ibn Sina and Ikhwan al-Safa, are (i) to entertain, soothe, relieve, or reduce pain; (ii) to strengthen body immunity (antibodies) to diseases; (iii) to help in healing, and (iv) to distract attention from pain and calm down, in order to facilitate the recovery process [15][16][17]. Clearly, the goal is more towards calming down and relieving pain, not to heal totally. On this basis, music therapy plays the role of complementary treatment. Another function of music therapy is to reduce stress as well as soothe and relieve symptoms. Cassileth and Deng [18] explained that a complementary treatment refers to the treatment administered adjunctly with the mainstream treatment. Music therapy is in the domain of body and mind intervention; it is categorised by the National Centre for Complementary and Alternative Medicine (NCCAM) (the Health Care Centre under the National Institute of Health of America) as a complementary treatment-similar to other treatments such as hypnosis, massage, and acupuncture [19]. The World Health Organisation (WHO) [20] refers to music therapy as a broad set of health care practices that are not part of that country's traditional medicine and are not fully integrated into the dominant health care system. However, if complementary treatment was to be integrated with conventional treatment, it would certainly improve its effectiveness and help to alleviate severe symptoms [21]. Complementary treatment is included in the category of mind and body therapeutic approach to assuage anxiety, emotional disorders, and chronic pain as well as increase the quality of life.
Hence, we can conclude that music therapy is a complementary treatment. In support of this, the treatment procedure is presented for some types of mental disorders for which music therapy was one of the treatments recommended to alleviate and distract attention from the pain, as stated in some authoritative medical works such as al-Kamil fi Sina'at al-Tibbiyyah by al-Majusi, Maqalah fi al-Malikhuliya by Ibn 'Imran and al-Qanun fi al-Tibb by Ibn Sina. Based on al-Kamil fi Sina'at al-Tibbiyyah, al-Majusi explained the treatment using music therapy for hypochondriac melancholia (al-maraqiya) and lovesickness (al-'ishq). According to al-Majusi [22], a melancholia patient was also treated with music therapy besides treatment using evacuation (istifragh); pricking the calf and arm veins; and giving a bath, massage, oral medication, and nutritious diet. The patient was taken for a walk in the garden while listening to melodious strains of music. For the lovesick (al-'ishq) patient, music therapy was used adjunctly with bath treatment, horse riding, and massage. Music therapy was usually applied by playing the oud instrument.
Based on Maqalah fi al-Malikhuliya, Ibn 'Imran [23] suggested music therapy for treating melancholia besides nutritious diet, evacuation, mother's milk, warm water mixed with chamomile flowers, poppy peel, hibiscus seeds, violet leaves, liqourice and cloves, immersion therapy, bath therapy, and massage. In al-Qanun fi al-Tibb, Ibn Sina [24] explains that music therapy is for mental disorders, including insomnia, melancholia, and lovesickness. For insomnia, the treatment was to use music therapy through gentle and melodious singing with rhythms like al-hazaj and al-thaqil, besides other treatments, such as eating cold foods, bath therapy, smearing oil on the head, forehead and both sides of the area between the eye and jaw, rubbing milk on the head, dropping oil into the nose and ears, opium, and recreation. For treating melancholia, Ibn Sina recommended listening to music and singing, besides ventilation, selected foods, bath therapy, massage with poultice, medication, evacuation, cupping, wrapping, and distracting patient with something pleasurable and soothing, such as bringing someone he/she likes. For lovesickness, Ibn Sina recommended treatment by listening to singing or music, besides evacuation, nutritious diet, bath therapy, and counselling.
The treatment methods recommended by al-Majusi, Ibn 'Imran, and Ibn Sina for melancholia, insomnia, and lovesickness clearly illustrate that music therapy was not the main (conventional) treatment. Music therapy was more of an adjunct treatment to complement the main treatment methods suggested, with the role of overcoming symptoms so that the patient is distracted, calmed down, and entertained.

Hospitals that applied music therapy
Many Islamic civilisation medieval hospitals applied music therapy as a treatment. Bimarastan Fez (Sidi Frej) in Morroco was built in the year 1286 AD by Sultan Yusuf ibn Ya'qub (Banu Marin). Here, patients suffering from depression were treated with music therapy, herbs, and spices [25]. This hospital was also a shelter for insane patients [26]. The writer's personal experience in a visit to the hospital site in Morocco in the year 2019 witnessed that it became a bazaar selling souvenirs to tourists. Interestingly, written on the notice board at the location was a statement that this hospital later became the prototype for building a psychiatric hospital in Valencia, Spain, in the year 1410 AD (Figures 1 and 2).
Bimarastan al-Mansuri in Cairo, Egypt (Mamluk era) was the hospital built in the year 1284 AD by Malik al-Mansur Sayf al-Din Qalawun. It was the most famous and prestigious in the history of Islamic medieval era hospitals and was acclaimed by many scholars. Al-Balawi [27] described the hospital as a marvellous large palace with the most perfect building structure. al-Qalqashandi [28] and Ibn al-'Umari [29] were very impressed with the hospital architecture and described the facility as highly reputable beyond compare. Ibn Batutah [30], who managed to visit this hospital on vacation in Egypt, also commented on its indescribable beauty. Hunke [31] denoted this hospital to be the biggest and richest health institute ever built on this planet. This hospital was operated fully using endowment (waqf) funds from the following sources ( Table 1).
As recorded by Ibn Iyas [33], the endowment (waqf) documents required the hospital to comply with two stipulations. The first precondition was that an ensemble of musicians would play musical instruments, such as oud, every evening to strengthen the spirit of patients. The musicians were paid a fixed monthly income. The second stipulation was that Qurra' were required to recite the holy verses of al-Qur'an in al-Qubbah (domed hall). They were also paid monthly with four aradib (600 kilogrammes) of wheat and birds such as pigeons.
As a hospital that applied music therapy as a treatment, it was designed with a suitable structure and landscape to support the implementation of music therapy. According to Dols [34], its landscape featured a pool, a water fountain, and a garden that had a therapeutic effect on patients. The sound of flowing water could be heard in every space in the hospital [35,36]. The sound of adhan that reverberated from the nearby mosque minaret also became therapy for insomnia patients. This hospital also used the services of a specific ensemble of musicians to make a concert presentation so that the patients were always cheerful and restful [37]. These musicians were paid from a special provision for their daily performance [38]. After having served for seven centuries, the hospital is now called Mustashfa Qalawun for treating eyes or ophthalmology.

Figure 2.
Picture displaying information that the hospital was a prototype for building a psychiatric hospital in Valencia, Spain.  Bimarastan al-Arghuni in Allepo, Syria, was another hospital that applied music therapy. The building was originally a palace which was later modified to become a hospital by the Allepo governor Arghun al-Saghir al-Kamili (Mamluk Emir) in the year 1344 AD. The building continued to function as a hospital until the 16th Century AD. Music therapy applied in this hospital was not restricted to using instruments and singing, but also included the strains of Qur'an recitation every morning and evening. Interestingly, the hospital provided a stage specifically for the music ensemble to entertain patients, especially mental patients, so they would be calmer and always cheerful. The salaries for musicians were paid from a special allocation from the hospital expenditure [39].

No. Types of premises Location
Hospital al-Arghuni was also listed as a hospital that applied music therapy. In the same way, music therapy was applied to mental patients using instrumental music and the sound of water. Instrumental music used in therapy was played in a big iwan (vaulted hall with an arched opening to the courtyard) at the southern side of the hospital. There, musicians presented musical concerts with singing to entertain mental patients. For therapy using the sound of water, this hospital utilised the sound of flowing water from a fountain in a small pool in the middle of the hospital garden. The mental patients were also treated with the fragrance of flowers of potted plants placed in every corner of the pool and the entire hospital garden. In addition, the aroma of basil also had a therapeutic effect as an anti-depressant, as it helped to calm the mind. The mental patients were also entertained by dance and theatre presentations, storytelling, and the strains of Qur'an recitation [39].
Bimarastan Nur al-Din in Damascus had the design and landscape which supported applying music therapy for mental patients [40]. The hospital design and beautiful landscape featured a water fountain in a pool and garden, which had a therapeutic effect on mental patients. Even the sound of adhan reverberating from the mosque minaret nearby became therapeutic for insomnia patients [34]. However, this building no longer functions as a hospital as it was converted into a museum for the history of Arabic medical science [25].
Next, Kayseri Gevher Nesibeh Darussifas was also listed in the list of hospitals that applied music therapy [41]. Usually, this therapy was applied to mental patients whereby the hospital's own musicians performed three times daily in the middle section of the hospital, which extended directly to the patients' rooms through the balconies. The hospital musicians played several types of musical instruments such as flute, violin, tanboor, and dulcimer [42]. However, the hospital no longer functions as it was converted into a museum of the history of medicine of the Kayseri Gevher Nesibeh's Faculty of Medicine.
Divrigi Ulu Mosque and Darussifas was a hospital built by Turan Malik in the year 1228 AD. In this hospital, music therapy was intensively applied together with herbal treatment [41]. The application of music therapy was facilitated by the hospital building structure, which featured facilities conducive for a health institution. The amenities included a pool and a water fountain system, which made natural music. Currently, the hospital building is a gazetted UNESCO World Heritage Site [43].
Amasya Darussifas was a hospital built in the year 1308 AD. In this hospital, music therapy was applied to mental patients through a combination of instrumental music and the sound of water [5].
Fatih Darussifas Istanbul was built in the year 1470 AD and was the first hospital built in the Ottoman era. It had 70 rooms and 80 domes. Music therapy was applied to treat mental patients and this continued until the year 1824 AD [44].
Edirne Sultan Bayezid II Darussifas also offered music therapy specifically for mental patients [45]. This treatment used not only instrumental music but also the burbling sound of water flowing from the pool fountain in the middle of the facility [40]. Music therapy applied in this hospital was considered the peak in the history of medieval music therapy for its systematic implementation, namely through musical concerts three times daily by the hospital's ensemble of musicians. The ensemble comprised ten musicians, three of whom were singers, and the rest were musicians who played various types of instruments. This hospital was also equipped with a stage for a musical concert. The instruments frequently used the reed-flute, dulcimer, harp, kemence (similar to a small violin), pan flute or pan-pipe, and oud. With these instruments, various melodic modes (maqam) were played, such as neva/nawa, rast, dugah/dukah, segah/sikah, cargah/jaharkah, suzinak, zankulah, and busalik [42]. The combination of the sounds produced by the musical instruments and flowing water added to the therapeutic effect not only to the patients but also to the visitors.
Suleymaniye Sifahanesi was a hospital built by the famous architect, Mimar Sinan, in the year 1550 AD, as commissioned by Sultan Suleyman. In contrast to other hospitals, Suleymaniye Sifahanesi provided music therapy through a specific unit, namely the Neurology Unit. Music therapy as a treatment was availed until mid-19th Century AD [45], using the services of about 30 staff [46].
Another hospital that applied music therapy was established by Ayse Hafsa Sultan, the mother of Sultan Suleyman and wife to Sultan Selim 1. The facility was established in Manisa in the year 1522 AD. Despite its relatively small size, it provided music therapy as a treatment to mental patients until the 19th Century AD. As for now, the hospital building is currently a museum [45].
The existence of these hospitals showed that music therapy was widely applied in the Islamic medieval centuries, specifically in the Seljuq and Ottoman eras. The application involved not only instrumental music but singing, the recitation of al-Qur'an, and the sound of water. The use of instrumental music was supported by the use of a domed hall or stage for presentation. For enhanced therapeutic effect, some of the hospitals were equipped with an acoustic system; a dome was built to reflect sound off its concave walls, which focused it in the centre, thus amplifying the sound. This acoustic system helped in disseminating the sound of music to reach all corners of the hospital. The hospital landscape with its fountain pool in the garden was conducive for therapy using the natural sound of flowing water; such created a tranquil ambiance not only for the patients but for the hospital staff and visitors as well. Those treated with music therapy were frequently mental patients as well as individuals with psychological disorders, such as depression, insomnia, and melancholia. The function of this treatment was to entertain, calm down the patients, and relieve pain. However, music therapy was no longer available in these Islamic medieval hospitals by the 19th Century AD.

Process of applying music therapy in Islamic civilisation medicine
We use the example of music therapy applied in Bimarastan al-Mansuri in Cairo. This hospital was selected based on four considerations. First, the important document relating to the hospital's affairs, specifically the endowment (waqf) document, is extant and kept in good condition for reference. Second, this hospital has a long lifespan of almost six centuries, from the end of the 13th Century until the beginning of the 19th Century AD. According to Ibn al-'Umari [29], the hospital building itself still stands until now. However, its status as a general hospital was changed to an ophthalmology hospital by the 20th Century AD. Third, this hospital is based on two unique principles: welfare (free treatment) and equality. Thus, its treatment services were available regardless of rank and position. Leaders, military, social elite, or common people -all were entitled to equal treatment. Fourth, this DOI: http://dx.doi.org/10.5772/intechopen.98707 hospital provides formal and intensive music therapy treatment as stipulated in the waqf document.
The first matter is that Bimarastan al-Mansuri used two out of three main characteristics that form the basis of music therapy: (i) sound, tone of voice or instrument; and (ii) satisfying emotions and aesthetics. The second matter is that the hospital structure was designed to suit such treatment. The interior was spacious, measuring 150 feet in length and width. In the center of the building was a large pool with a fountain from which water is shot up as high as a combined height of two male adults. Next to the pool was the prayer hall (musalla). Some nearly healed patients in the process of rehabilitation usually rested by the pool while enjoying the sound of water from the fountain wall and being served by hospital staff. Chronic mental patients were placed in spacious rooms equipped with a pool and wall fountain to enable enjoying the engrossing sound of flowing water. This hospital also had a psychiatric unit that warded mental patients. They were treated with full concern through the burbling sound of fountain water in the porch area of the hospital.
The third matter is that musicians and Qurra' formed part of the hospital staff, apart from physicians and nurses. Musicians were given the responsibility to soothe and entertain the patients with singing and the melodious strains of musical instruments, at once distracting their attention from the pain they endured. This hospital even provided payment to musicians who came daily to entertain patients, including those who were going through rehabilitation sessions, with singing and music. Qurra' were also paid to recite al-Qur'an at neighbouring mosques to create spiritual peace. This hospital paid fixed salaries to 50 Qurra'. The fourth matter is that music therapy was given as a complementary treatment. Thus, it was applied adjunctly with other treatment, including listening to stories told by professional storytellers, watching dance presentations and comedy sketches, and using medication.
Bimarastan al-Mansuri had a specific process relating to music therapy. The usual procedure for a patient before admission to a ward was to undergo a preliminary examination by an assistant or trainee physician at a polyclinic in the southern part of the hospital. If further treatment was required, the patient would be advised to be warded so that his/her level of condition could be monitored constantly. The main procedure required registration before admission to a ward. In this process, the registration record must first be verified by the chief physician and only then, can a patient be placed in a ward based on gender as wards for men and women were separate with attending male and female nurses, respectively. Nurses always gave their best service throughout the patient's stay in the ward; they administered medication, gave food and drink, managed the bedding, and bathed and clothed the patients.
In the context of treating with music therapy, a musical band or ensemble was assigned the task of entertaining patients every evening by playing the oud. Insomnia (primary or secondary) patients and rehabilitation patients were frequently treated with instrumental music. Although treated in a special room provided by the hospital for the music therapy, other patients could hear the music in their respective wards. Thus, music therapy was indirectly applied to all patients, mental or physical, through nature's music (sound of water), and human vocals (chanting of adhan and recitation of the holy verses of al-Qur'an).

Conclusion
Even though music therapy of the Islamic civilisation medieval era had ended by the 19th century AD, it is still relevant to the approach of modern medicine. This is due to the awareness of its most encouraging effectiveness as complementary medicine. Data from the World Health Organisation (WHO) [20] showed that the use of complementary medicine among populations is strongly acknowledged in many regions, including the African Region (87%), the Region of the Americas (80%), and the Eastern Mediterranean Region (90%). Based on the categorisation of medical subfields by the National Center for Complementary and Alternative Medicine (NCCAM), music therapy is placed under the subfield of mind and body interventions in the art therapy grouping. Mind and body interventions refer to the techniques of enhancing the level of mental ability so that it can influence the body functions and overcome symptoms. Besides music therapy, meditation and prayer (supplication) are also included under this subfield.
Positive development in the use of complementary treatments in hospitals will certainly ensure the continuity of using music therapy as the complementary treatment in today's hospitals. The basic matters that need to be developed first are the training of music therapists and selection of music genre-appropriate to a country's moral values, customs, and socioculture. To gain expert advisory services, strategic cooperation needs to be forged with music therapy organisations such as the American Music Therapy Association (AMTA), World Federation of Music Therapy (WFMT), and Traditional Turkish Music and Movement Therapy (TUMATA). These organisations have vast experience in music therapy, particularly in training programmes and facilities.