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The Canon of Medicine

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A Latin copy of the Canon of Medicine, dated 1484, located at the P.I. Nixon Medical Historical Library of The University of Texas Health Science Center at San Antonio.

The Canon of Medicine (Arabic: القانون في الطب Al-Qanun fi al-Tibb "The Law of Medicine"; Persian: قانون Qanun "Law"; Latin: Canon Medicinae "Canon of Medicine"; Chinese: 回回藥方 回回药方 (Hui Hui Yao Fang) "Prescriptions of the Hui Nationality") is a 14-volume Arabic medical encyclopedia written by a Persian scientist and physician Ibn Sīnā (Avicenna) and completed in 1025.[1] Written in Arabic, the book was based on a combination of his own personal experience, medieval Islamic medicine, the writings of the Roman physician Galen,[2] the Indian physicians Sushruta and Charaka, and ancient Arabian and Persian medicine.[3] The Canon is considered one of the most famous books in the history of medicine.[4]

Also known as the Qanun, which means "law" in Arabic and Persian, the Canon of Medicine remained a medical authority up until the 18th century[5] and early 19th century.[6] It set the standards for medicine in Europe and the Islamic world, and is Avicenna's most renowned written work. Qanun was used at many medical schools—at University of Montpellier, France, as late as 1650.[7] Much of the book was also translated into Chinese as the Hui Hui Yao Fang (Prescriptions of the Hui Nationality) by the Hui people in Yuan China.[8] The Canon also formed the basis of Unani medicine, a form of traditional medicine practiced in India. The principles of medicine described by him ten centuries ago in this book, are still taught at UCLA and Yale University, among others, as part of the history of medicine.

The Canon is considered the first pharmacopoeia,[9][10] and among other things, the book is known for the introduction of systematic experimentation and quantification into the study of physiology,[11] the discovery of the contagious nature of infectious diseases,[12] the introduction of quarantine to limit the spread of contagious diseases, and the introduction of evidence-based medicine, experimental medicine,[13] clinical trials,[14] randomized controlled trials,[15][16] efficacy tests,[17][18] clinical pharmacology,[19] neuropsychiatry,[20] physiological psychology,[21] risk factor analysis, and the idea of a syndrome in the diagnosis of specific diseases.[22]

George Sarton, the father of the history of science, wrote in the Introduction to the History of Science:

"One of the most famous exponents of Muslim universalism and an eminent figure in Islamic learning was Ibn Sina, known in the West as Avicenna (981-1037). For a thousand years he has retained his original renown as one of the greatest thinkers and medical scholars in history. His most important medical works are the Qanun (Canon) and a treatise on Cardiac drugs. The 'Qanun fi-l-Tibb' is an immense encyclopedia of medicine. It contains some of the most illuminating thoughts pertaining to distinction of mediastinitis from pleurisy; contagious nature of phthisis; distribution of diseases by water and soil; careful description of skin troubles; of sexual diseases and perversions; of nervous ailments."[12]

Overview

File:Avicenna Persian Physician.jpg
Ibn Sīnā (Avicenna)

The book explains the causes of health and disease. Ibn Sina believed that the human body cannot be restored to health unless the causes of both health and disease are determined. He defined medicine (tibb) as follows:

"Medicine is the science by which we learn the various states of the body; in health, when not in health; the means by which health is likely to be lost; and, when lost, is likely to be restored. In other words, it is the art whereby health is concerned and the art by which it is restored after being lost."[23]

Avicenna regarded the causes of good health and diseases to be:

  1. The Material Causes
  2. The Elements
  3. The Humors
  4. The Variability of the Tumors
  5. The Temperaments
  6. The Psychic Faculties
  7. The Vital Force
  8. The Organs
  9. The Efficient Causes
  10. The Formal Causes
  11. The Vital Faculties
  12. The Final Causes

The Qanun distinguishes mediastinitis from pleurisy and recognises the contagious nature of phthisis (tuberculosis of the lung) and the spread of disease by water and soil. It gives a scientific diagnosis of ankylostomiasis and attributes the condition to an intestinal worm. The Qanun points out the importance of dietetics, the influence of climate and environment on health, and the surgical use of oral anaesthetics.[24] Ibn Sina advised surgeons to treat cancer in its earliest stages, ensuring the removal of all the diseased tissue.[25] The Qanun 's materia medica considers some 800 tested drugs, with comments on their application and effectiveness.[26] He recommended the testing of a new drug on animals and humans prior to general use.

The earliest known copy of the Canon of Medicine dated 1052 is held in the collection of the Aga Khan and is to be housed in the Aga Khan Museum planned for Toronto, Ontario, Canada.

Influence in Europe

The Arabic text of the Qanun was translated into Latin as Canon medicinae by Gerard of Cremona in the 12th century and into Hebrew in 1279. Henceforth the Canon served as the chief guide to medical science in the West and is said to have influenced Leonardo da Vinci. Its encyclopaedic content, its systematic arrangement and philosophical plan soon worked its way into a position of pre-eminence in the medical literature of Europe, displacing the works of Galen and becoming the text book for medical education in the schools of Europe. The text was read in the medical schools at Montpellier and Leuven as late as 1650, and Arnold C. Klebs described it as "one of the most significant intellectual phenomena of all times." In the words of Dr. William Osler, the Qanun has remained "a medical bible for a longer time than any other work". The first three books of the Latin Canon were printed in 1472, and a complete edition appeared in 1473. The 1491 Hebrew edition is the first appearance of a medical treatise in Hebrew and the only one produced during the 15th century. In the last 30 years of the 15th century it passed through 15 Latin editions.

In recent years, a partial translation into English was made.

Experimental medicine

The Canon of Medicine was the first book dealing with evidence-based medicine, experimental medicine,[13] clinical trials, randomized controlled trials,[15][16] efficacy tests,[17][18] risk factor analysis, and the idea of a syndrome in the diagnosis of specific diseases.[22]

According to Toby Huff and A. C. Crombie, the Canon contained "a set of rules that laid down the conditions for the experimental use and testing of drugs" which were "a precise guide for practical experimentation" in the process of "discovering and proving the effectiveness of medical substances."[13]

Clinical pharmacology

The emphasis of the Canon on tested medicines laid the foundations for an experimental approach to pharmacology.[27] The Canon laid out the following rules and principles for testing the effectiveness of new drugs and medications, which still form the basis of clinical pharmacology[19] and modern clinical trials:[14]

  1. "The drug must be free from any extraneous accidental quality."
  2. "It must be used on a simple, not a composite, disease."
  3. "The drug must be tested with two contrary types of diseases, because sometimes a drug cures one disease by Its essential qualities and another by its accidental ones."
  4. "The quality of the drug must correspond to the strength of the disease. For example, there are some drugs whose heat is less than the coldness of certain diseases, so that they would have no effect on them."
  5. "The time of action must be observed, so that essence and accident are not confused."
  6. "The effect of the drug must be seen to occur constantly or in many cases, for if this did not happen, it was an accidental effect."
  7. "The experimentation must be done with the human body, for testing a drug on a lion or a horse might not prove anything about its effect on man."

The Canon lists 800 tested drugs, including plant and mineral substances, with comments on their application and effectiveness. For each one, he described their pharmaceutical actions from a range of 22 possibilities (including resolution, astringency and softening), and their specific properties according to a grid of 11 types of diseases.[26]

Inductive logic

While Ibn Sina often relied on deductive reasoning in The Book of Healing and other writings on logic in Islamic philosophy, he used a different approach in The Canon of Medicine. This text contributed to the development of inductive logic, which it used to develop the idea of a syndrome in the diagnosis of specific diseases. The Canon of Medicine was the first to describe the methods of agreement, difference and concomitant variation which are critical to inductive logic and the scientific method.[22][28]

Pharmaceutical sciences

The book's contribution to the pharmaceutical sciences include the introduction of systematic experimentation and quantification into pharmacology and the study of physiology,[29] the introduction of experimental medicine, evidence-based medicine, clinical trials,[14] randomized controlled trials,[15][16] efficacy tests[17][18] and clinical pharmacology;[19] the first careful descriptions of skin troubles, sexually transmitted diseases, perversions and nervous ailments;[30] and the discovery of the healing property of gaseous mercury besides its poisonous quality;[31] as well as the use of ice to treat fevers, and the separation of medicine from pharmacology, which was important to the development of the pharmaceutical sciences.[32]

Pharmacotherapy

Avicenna wrote a separate supplement treatise dedicated to the pharmacotherapy of "Hindiba", a compound drug he suggested for the treatment of cancer and other tumors (see Cancer therapy below) and which could also be used for treating other neoplastic disorders. He gives details on the drug's properties and uses, and then gives instructions on its preparation as medication.[33]

Pharmacy

The Canon described no less than 700 preparations of medications, their properties, mode of action and their indications. He devoted in fact a whole volume to simple and compound drugs in The Canon of Medicine. It credits many of them to a variety of Arabic, Greek and Indian authors, and also includes some drugs imported from China, along with many of Ibn Sina's own original contributions. Using his own expertise, he was often critical of the descriptions given by previous authors and revised many of their descriptions.[34]

Anatomy and Physiology

The contributions of the Canon to physiology include the introduction of systematic experimentation and quantification into the study of physiology.[29]

Writings on anatomy in the Canon are scattered throughout the text in sections regarding to illnesses related to certain body parts. The Canon included numerous discussions on anatomy and diagrams on certain body parts, including the first diagrams of the cranial sutures.[35]

Blood pressure

Avicenna dedicated a chapter of the Canon to blood pressure. He was able to discover the causes of bleeding and haemorrhage, and discovered that haemorrhage could be induced by high blood pressure because of higher levels of cholesterol in the blood. This led him to investigate methods of controlling blood pressure.[31]

Dissection

The Canon distinguished anatomy "from other aspects of medicine by its need for a different methodology." It thus stated:[36]

"As for the parts of the body and their functions, it is necessary that they be approached through observation (hiss) and dissection (tashrih), while those things that must be conjectured and demonstrated by reason are diseases and their particular causes and their symptoms and how disease can be abated and health maintained."

Neuroanatomy and neurophysiology

Avicenna discovered the cerebellar vermis—which he named "vermis"—and the caudate nucleus, which he named "tailed nucleus" or "nucleus caudatus". These terms are still used in modern neuroanatomy and neurophysiology.[31]

The Canon was also the earliest text to note that intellectual dysfunctions were largely due to deficits in the brain's middle ventricle, and that the frontal lobe of the brain mediated common sense and reasoning.[37]

Ophthalmology

The contributions of the Canon to ophthalmology in medieval Islam include its descriptions and explanations on the physiology of eye movements, which still forms a basis of information for modern ophthalmology. He also provided useful information on the optic nerves, iris, and central and peripheral facial paralyses.[31]

Another contribution the Canon made to ophthalmology was the suggestion that "the optic nerves did cross."[1]

Pulsology and sphygmology

The Canon was a pioneering text in pulsology and sphygmology. In ancient times, Galen as well as Chinese physicians erroneously believed that there was a unique type of pulse for every organ of the body and for every disease.[38] Galen also erroneously believed that "every part of an artery pulsates simultaneously" and that the motion of the pulse was due to natural motions (the arteries expanding and contracting naturally) as opposed to foced motions (the heart causing the arteries to either expand or contract).[39]

The first correct explanation of pulsation was given by Avicenna, after he refined Galen's theory of the pulse and discovered the following in The Canon of Medicine:[38]

"Every beat of the pulse comprises two movements and two pauses. Thus, expansion : pause : contraction : pause. [...] The pulse is a movement in the heart and arteries ... which takes the form of alternate expansion and contraction."

The Canon also pioneered the modern approach of examining the pulse through the examination of the wrist, which is still practiced in modern times. His reasons for choosing the wrist as the ideal location is due to it being easily available and the patient not needing to be distressed at the exposure of his/her body. The Latin translation of his Canon also laid the foundations for the later invention of the sphygmograph.[40]

Avicenna also wrote a supplemental treatise on diagnosing diseases using only the methods of feeling the pulse and observing inhalation. He was often capable of finding the symptoms of certain diseases only by feeling a patient's pulse.[31]

Etiology and Pathology

In etiology and pathology, the Canon described the contagious nature of infectious diseases such as phthisis and tuberculosis, the distribution of disease by water and soil, and the existence of sexually transmitted disease.[30] The Canon provides a full understanding of the pathology of contagious disease.[41]

The Canon also distinguished between mediastinitis and pleurisy, provided careful descriptions of skin troubles, perversions, and nervous ailments."[12] Meningitis was also first described in The Canon of Medicine, which also described the first known treatments for cancer.[25] The book also recognized the parasitic diseases of Ascaris, Enterobius, tapeworms, and Guinea worms.[42]

Since the Canon, Bimaristan hospitals were created with separate wards for specific illnesses, so that people with contagious diseases could be kept away from other patients who do not have any contagious diseases.[43]

Bacteriology and microbiology

The Canon stated that bodily secretions are contaminated by "foul foreign earthly bodies" before a person becomes infected, but he did not view these bodies as primary causes of disease.[44]

Cancer therapy

In cancer therapy, the Canon recognized cancer as a tumor. He noted that a "cancerous tumour progressively increases in size, is destructive and spreads roots which insinuate themselves amongst the tissue elements." He also attempted the earliest known treatments for cancer. One method he discovered was the "Hindiba", a herbal compound drug which Ibn al-Baitar later identified as having "anticancer" properties and which could also treat other tumors and neoplastic disorders.[33] After recognizing its usefulness in treating neoplastic disorders, Hindiba was patented in 1997 by Nil Sari, Hanzade Dogan, and John K. Snyder.[45]

Another method for treating cancer first described in the Canon was a surgical treatment. It stated that the excision should be radical and that all diseased tissue should be removed, which included the use of amputation or the removal of veins running in the direction of the tumor. He also recommended the use of cauterization for the area being treated if necessary.[25]

The Canon was also the first to describe the symptoms of esophageal cancer and the first to refer to it as "cancer of the esophagus."[46]

Hepatology

The advances of the Canon in hepatology includes its introduction of new methods of hepatitis treatment.[31]

Quarantine

The Canon introduced quarantine as a means of limiting the spread of contagious diseases.[14]

Neurosciences and Psychology

In Islamic psychology and neurosciences, the Canon noted the close relationship between emotions and the physical condition, and the author felt that music had a definite physical and psychological effect on patients.

Clinical psychology and psychotherapy

In clinical psychology and psychotherapy, Avicenna often used psychological methods to treat his patients.[47] One such case study is when a prince of Persia had melancholia and suffered from the delusion that he is a cow, and who would low like a cow crying "Kill me so that a good stew may be made of my flesh" and would never eat anything. Avicenna was persuaded to the case and sent a message to the patient, asking him to be happy as the butcher was coming to slaughter him, and the sick man rejoiced. When Avicenna approached the prince with a knife in his hand, he asked "where is the cow so I may kill it." The patient then lowed like a cow to indicate where he was. "By order of the butcher, the patient was also laid on the ground for slaughter." When Avicenna approached the patient pretending to slaughter him, he said, "the cow is too lean and not ready to be killed. He must be fed properly and I will kill it when it becomes healthy and fat." The patient was then offered food which he ate eagerly and gradually "gained strength, got rid of his delusion, and was completely cured."[48]

Among the many other psychological disorders described in the Qanun, one is of unusual interest: love sickness. Ibn Sina is reputed to have diagnosed this condition in a Prince in Jurjan who lay sick and whose malady had baffled local doctors. He noted a fluttering in the Prince's pulse when the address and name of his beloved were mentioned. The great doctor had a simple remedy: unite the sufferer with the beloved.

Neurology and neuropathology

The book's contributions in neurology and neuropathology include its diagnosis of facial nerve paralysis, its distinction between brain paralysis and hyperaemia, and most importantly the discovery of meningitis. It diagnosed meningitis as a disease induced by the brain itself and differentiated it from infectious brain disease, and its author was also able to diagnose and describe the type of meningitis induced by an infection in other parts of the body.[31]

Neuropsychiatry and neuropsychology

The Canon was a pioneering text in neuropsychiatry and neuropsychology. It first described the neuropsychiatric conditions of hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor.[20] Three chapters of The Canon of Medicine were dedicated to neuropsychiatry.[49]

The book defined madness (Junun) as a mental condition in which reality is replaced by fantasy, and discovered that it is a disorder of reason with its origin in the middle part of the brain.[50] It also described a condition resembling schizophrenia which it referred to as Junun Mufrit (severe madness), which was clearly distinguished from other forms of madness such as mania, rabies, and manic depressive psychosis. The author observed that patients suffering from schizophrenia-like severe madness show agitation, behavioural and sleep disturbance, give inappropriate answers to questions, and in some cases are incapable of speaking at times. The book states that such patients need to be restrained, in order to avoid any harm they may cause to themselves or to others.[51]

A chapter of the Canon was also dedicated to mania and rabies. It described mania as bestial madness characterized by rapid onset and remission, with agitation and irritability, and described rabies as a type of mania.[51]

Psychoanalysis

The Canon of Medicine extended the theory of temperaments to encompass "emotional aspects, mental capacity, moral attitudes, self-awareness, movements and dreams." This work may thus be considered a "forerunner of twentieth century psychoanalysis."[52]

Psychophysiology and psychosomatic medicine

The Canon was an early text in psychophysiology and psychosomatic medicine, and the first to recognize 'physiological psychology' in the treatment of illnesses involving emotions, and developed a system for associating changes in the pulse rate with inner feelings, which is seen as an anticipation of the word association test attributed to Carl Jung. Avicenna identified love sickness (Ishq) ... illnesses together. It described melancholia (depression) as a type of mood disorder in which the person may become suspicious and develop certain types of phobias. It stated that anger heralded the transition of melancholia to mania, and explained that humidity inside the head can contribute to mood disorders. It recognized that this occurs when the amount of breath changes: happiness increases the breath, which leads to increased moisture inside the brain, but if this moisture goes beyond its limits, the brain would lose control over its rationality and lead to mental disorders. It also described symptoms and treatments for nightmare, epilepsy, and weak memory.[47]

Sleep psychiatry

An early psychological perspective on bedwetting was given in The Canon of Medicine:[53]

"Urinating in bed is frequently predisposed by deep sleep: when urine begins to flow, its inner nature and hidden will (resembling the will to breathe) drives urine out before the child awakes. When children become stronger and more robust, their sleep is lighter and they stop urinating."

Surgery

In surgery, the Canon was the first to describe the surgical procedure of intubation in order to facilitate breathing.[25]

Anesthesia

The Canon described the "soporific sponge", an anasthetic imbued with aromatics and narcotics, which was to be placed under a patient's nose during surgical operations.[25]

Cancer therapy

See Etiology and Pathology above

Hirudotherapy

Hirudotherapy, the use of medicinal leech for medical purposes, was introduced by The Canon of Medicine. It considered the application of leech to be more useful than cupping in "letting off the blood from deeper parts of the body." He also introduced the use of leech as treatment for skin disease. Leech therapy became a popular method in medieval Europe due to the influence of his Canon.[54]

Other contributions

Chromotherapy

The Canon, which described colour to be of vital importance in diagnosis and treatment, made significant contributions to chromotherapy. It stated that "Color is an observable symptom of disease" and also developed a chart that related colour to the temperature and physical condition of the body. His view was that red moved the blood, blue or white cooled it, and yellow reduced muscular pain and inflammation. The author further discussed the properties of colours for healing and was "the first to establish that the wrong colour suggested for therapy would elicit no response in specific diseases." As an example, "he observed that a person with a nosebleed should not gaze at things of a brilliant red color and should not be exposed to red light because this would stimulate the sanguineous humor, whereas blue would soothe it and reduce blood flow."[55]

Endocrinology

In endocrinology, the Canon provided a detailed account on diabetes mellitus in The Canon of Medicine, "describing the abnormal appetite and the collapse of sexual functions and he documented the sweet taste of diabetic urine." Like Aretaeus of Cappadocia before him, the Canon recognized a primary and secondary diabetes. It also described diabetic gangrene, and treated diabetes using a mixture of lupine, trigonella (fenugreek), and zedoary seed, which produces a considerable reduction in the excretion of sugar, a treatment which is still prescribed in modern times. It also "described diabetes insipidus very precisely for the first time", though it was later Johann Peter Frank (1745-1821) who first differentiated between diabetes mellitus and diabetes insipidus.[56]

Gerontology and Geriatrics

The Canon of Medicine was the first book to offer instruction for the care of the aged, foreshadowing modern gerontology and geriatrics. A chapter entitled "Regimen of Old Age" stated that "old folk need plenty of sleep. Time spent on the couch should be liberal—more than is legitimate for adults." It further stated that after waking up, the body should be anointed with oil "to stimulate the sensitive faculties". Regarding exercise, it recommended walking or horse-riding. It stated:[57]

"The factors to consider in regard to exercise in old people are the various bodily states of different persons; the sequels likely to arise from their ailments; and their previous habits as regards exercise."

The book said that if the body is healthy, it can perform attempered exercises, but if one part of the body is infirm, "then that part should not be exercised until after the rest", and that exercises are not to be strictly graduated "as if the body were to be strengthened". The Canon recognized four periods of life: the period of growth, prime of life, period of elderly decline (from forty to sixty), and decrepit age. He states that during the last period, "there is hardness of their bones, roughness of the skin, and the long time since they produced semen, blood and vaporal breath". However, he agreed with Galen that the earth element is more prominent in the aged and decrepit than in other periods. Avicenna did not agree with the concept of infirmity, however, stating:[57]

"There is no need to assert that there are three states of the human body—sickness, health and a state which is neither health nor disease. The first two cover everything."

Thesis III of the Canon discussed the diet suitable for old people. Avicenna wrote that they should be given food in small amounts at a time and that they can have two to three meals a day, divided up according to the digestive powers and general condition of the old person in question. He also recommended fruits, such as figs and prunes. He also stated:[58]

"Some laudable nutrition may be allowed at bedtime, [but] robust old folk may have a more liberal supper, as long as they avoid any gross aliment... all hot, sharp or dessicative foods, such as dishes made with vinegar, salt, hot aromatics, seasonings and pickles. [Milk is good for the aged, being] nutritious and humectant in nature. [Yet] articles of food with a laxative action are most appropriate for the elderly."

The book also dedicated several sections of its Thesis III to elderly patients who become constipated, and wrote:[58]

"Strong clysters (enemata) must be avoided because they dry up the gut. An unctuous enema is beneficial in cases where the bowels have been constipated for several days. ... Evacuations must be procured with as little stress as possible in the aged and decrepit, for it is to their advantage to get bowels opened gently."

Phytotherapy

In phytotherapy, the Canon introduced the medicinal use of Taxus baccata L. He named this herbal drug as "Zarnab" and used it as a cardiac remedy. This was the first known use of a calcium channel blocker drug, which were not used in the Western world until the 1960s.[59]

Temperaments

The Canon of Medicine adopted the ancient theory of Four Humours and Four Temperaments and extended it to encompass "emotional aspects, mental capacity, moral attitudes, self-awareness, movements and dreams." Avicenna summarized his own theory of four temperaments in a table presented as follows:[52]

Avicenna's four primary temperaments
Evidence Hot Cold Moist Dry
Morbid states inflammations become febrile fevers related to serious humour, rheumatism lassitude loss of vigour
Functional power deficient energy deficient digestive power difficult digestion
Subjective sensations bitter taste, excessive thirst, burning at cardia Lack of desire for fluids mucoid salivation, sleepiness insomnia, wakefulness
Physical signs high pulse rate, lassitude flaccid joints diarrhea, swollen eyelids, rough skin, acquired habit rough skin, acquired habit
Foods & medicines calefacients harmful, infrigidants beneficial infrigidants harmful, calefacients beneficial moist articles harmful dry regimen harmful, humectants beneficial
Relation to weather worse in summer worse in winter bad in autumn

See also

References

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