The practice and study of medicine in Persia has a long and prolific history. Medical sciences including pharmacy has a long history in Middle and Near East and goes back to the ancient Mesopotamian period (Beginning with Sumer 3000 BC). There are many cuneiform tablets from cities as ancient as Uruk (2500 BC), the city of Prophet Abraham (PBUH). The bulk of the tablets that do mention medical practices have survived from the library of Asshurbanipal at Nineveh (668 BC) Assyria.

So far 660 medical tablets from this library and 420 tablets from the library of a medical practitioner from Neo-Assyrian period, as well as Middle Assyrian and Middle Babylonian texts have been published. The vast majority of these tablets are prescriptions, but there are a few series of tablets that have been labeled “treatises”.

One of the oldest (the oldest surviving copy of this treatise dates to around 1600 BC) and the largest collections is known as “Treatise of Medical Diagnosis and Prognoses”, which consists of 40 tablets.

The diagnostic treatise is organized in head to toe order with separate subsections covering convulsive disorders, gynecology and pediatrics.

Virtually all expected diseases exist, they are described and cover neurology, fevers, worms and flukes, venereal disease and skin lesions. The medical texts are essentially rational, and some of the treatments (such as excessive bleeding) are essentially the same as modern treatments for the same condition. The ancient Iranian medicine was combined by different medical traditions from Mesopotamia, Egypt, India, China and Greece for more than 4000 years and merged to form what became the nucleus and foundation of medical practice in the European countries in the 13th century. The Iranian academic centers like Jundishapur University (3rd century AD) were a breeding ground for the union among great scientists from different civilizations.

These centers successfully followed their predecessors’ theories and greatly extended their scientific research through history. Iranian physicians during the glorious Islamic civilization had a tremendous share in the progress of medical sciences. The excellent clinical observations and physical examinations and writings of Iranian scientists such as Rhazes (Al-Razi, 865-925 AD), Haly Abbas (Ali ibn-al Abbas-al Majusi, died 994 AD), Avicenna (Abou Ali Sina, 980-1037) and Jurjan (Osmail ibn al-Husayn al-Jurjani, 110 AD) influenced all fields of medicine The new era of medicine in Iran begins with establishment of Dar-ul-funoon in 1851, which was the only center for modern medical education before the establishment of Tehran University. Following the establishment of the Tehran university school of medicine in 1934 and the return of Iranian graduates from the medical schools in Europe, much progress was made in the development and availability of trained manpower and specialized faculties in medicine. After the Islamic revolution by the growing spirit of independence inspired by the Iranian government the number of medical schools and medical students increased more than 10 times. For the 1st time in recent modern history the Iranian medical universities started to offer post-graduate specialized degrees in basic, clinical and engineering sciences.

In recent years, some experimental studies have indeed evaluated medieval Iranian medical remedies using modern scientific methods. These studies raised the possibility of revival of traditional treatments on the basis of evidence-based medicine.

History and background

Pre-Islamic

The medical history of ancient Persia can be divided into three distinct periods. The sixth book of Zend-Avesta contains some of the earliest records of history of ancient Iranian medicine. The Vendidad in fact devotes most of the last chapters to medicine.

The Vendidad, one of the surviving texts of the Zend-Avesta, distinguishes three kinds of medicine: medicine by the knife (surgery), medicine by herbs, and medicine by divine words; and the best medicine was, according to the Vendidad, healing by divine words:

Of all the healers O Spitama Zarathustra, namely those who heal with the knife, with herbs, and with sacred incantations, the last one is the most potent as he heals from the very source of diseases.

— Ardibesht Yasht

Although the Avesta mentions several notable physicians, the most notable–Mani, Roozbeh, and Bozorgmehr—were to emerge later.

The second epoch covers the era of what is known as Pahlavi literature, where the entire subject of medicine was systematically treated in an interesting tractate incorporated in the encyclopedic work of Dinkart, which listed in altered form some 4333 diseases.

The third era begins with the Achaemenid dynasty, and covers the period of Darius I of Persia, whose interest in medicine was said to be so great that he re-established the school of medicine in Sais, Egypt, which previously had been destroyed, restoring its books and equipment.

The first teaching hospital was the Academy of Jundishapur in the Persian Empire. Some experts go so far as to claim that, “to a very large extent, the credit for the whole hospital system must be given to Persia”.

According to the Vendidad, physicians, to prove proficiency, had to cure three patients from the followers of Divyasnan; if they failed, they could not practice medicine. At first glance, this recommendation may appear discriminant and based on human experimentation. But some authors have construed this to mean that, from the beginning, physicians were taught to remove the mental barrier and to treat adversaries as well as friends. Interestingly, physician’s fee for service was based on the patient’s income.

The Iranian science was interrupted by the Arab invasion (630 A.D.). Many schools, universities, and libraries were destroyed, books burned, and scholars killed. Nevertheless, the science of Persia resurfaced during the Islamic period. To save the books from Arab carnage, many Pahlavi scripts were translated into the Arabic, and Iran produced physicians and scientists such as Abū ʿAlī al-Ḥusayn ibn ʿAbd Allāh ibn Sīnā and Muhammad ibn Zakariya al-Razi as well as mathematicians such as Kharazmi and Omar Khayyám. They collected and systematically expanded the Greek, Indian, and Persian ancient medical heritage and made further discoveries.

Medieval Islamic Period

One of the main roles played by medieval Iranian scholars in the scientific field was the conservation, consolidation, coordination and development of ideas and knowledge in ancient civilizations. Some Iranian Hakim (practitioners) such as Muhammad ibn Zakariya ar-Razi, known to the West as Rhazes, and Ibn Sina, better known as Avicenna, were not only responsible for accumulating all the existing information on medicine of the time, but adding to this knowledge by their own astute observations, experimentation and skills.

“Qanoon fel teb of Avicenna” (“The Canon”) and “Kitab al-hawi of Razi” (“Continens”) were among the central texts in Western medical education from the 13th to the 18th centuries.

In the 14th century, the Persian language medical work Tashrih al-badan (Anatomy of the body), by Mansur ibn Ilyas (c. 1390), contained comprehensive diagrams of the body’s structural, nervous and circulatory systems.

Cranial surgery and mental health

Evidence of surgery dates to the 3rd century BC, when the first cranial surgery was performed in the Shahr-e-Sukhteh (Burnt City) in south-eastern Iran. The archaeological studies on the skull of a 13-year-old girl suffering from hydrocephaly indicated that she had undergone cranial surgery to take a part of her skull bone and the girl lived for at least about 6 months after the surgery.

Several documents still exist from which the definitions and treatments of the headache in medieval Persia can be ascertained. These documents give detailed and precise clinical information on the different types of headaches. The medieval physicians listed various signs and symptoms, apparent causes, and hygienic and dietary rules for prevention of headaches. The medieval writings are both accurate and vivid, and they provide long lists of substances used in the treatment of headaches. Many of the approaches of physicians in medieval Persia are accepted today; however, still more of them could be of use to modern medicine.

An antiepileptic drug-therapy plan in medieval Iranian medicine is individualized, given different single and combined drug-therapy with a dosing schedule for each of those. Physicians stress the importance of dose, and route of administration and define a schedule for drug administration. Recent animal experiments confirm the anticonvulsant potency of some of the compounds which are recommended by Medieval Iranian practitioners in epilepsy treatment.

In The Canon of Medicine (c. 1025), Avicenna described numerous mental conditions, including hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor.

Obstetrics and Gynecology

In the 10th century work of Shahnama, Ferdowsi describes a Caesarean section performed on Rudaba, during which a special wine agent was prepared by a Zoroastrian priest and used as an anesthetic to produce unconsciousness for the operation. Although largely mythical in content, the passage illustrates working knowledge of anesthesia in ancient Persia.

Some Famous Persian (Iranian) Physicians

Avicenna, the Persian Galen[1] (by Robert A. Thom, 1953)

 

 

Avicenna (Ibn Sina) (980—1037)

Avicenna (Ibn Sina)

Abu ‘Ali al-Husayn ibn Sina is better known in Europe by the Latinized name “Avicenna.” He is probably the most significant philosopher in the Islamic tradition and arguably the most influential philosopher of the pre-modern era.

He was a Persian polymath who is regarded as one of the most significant thinkers and writers of the Islamic Golden Age. Of the 450 works he is known to have written, around 240 have survived, including 150 on philosophy and 40 on medicine.

His most famous works are The Book of Healing, a philosophical and scientific encyclopedia, and The Canon of Medicine (al-Qanun fi’l-Tibb), a medical encyclopedia which became a standard medical text at many medieval universities and remained in use until the early modern period.

He was also a distinguished philosopher whose major summa the Cure (al-Shifa’) had a decisive impact upon European scholasticism and especially upon Thomas Aquinas (d. 1274).

Avicenna began his prodigious writing career at age 21. As mentioned, some 240 extant titles bear his name which cross numerous fields, including mathematics, geometry, astronomy, physics, alchemy, metaphysics, psychology, Islamic theology, logic, philology, music, and poetry.

According to his autobiography, Avicenna had memorized the entire Quran by the age of 10. He turned to medicine at 16, and not only learned medical theory, but also by gratuitous attendance of the sick had, according to his own account, discovered new methods of treatment. The teenager achieved full status as a qualified physician at age 18. The youthful physician’s fame spread quickly, and he treated many patients without asking for payment.

He lived a hectic life, he declined the offers by many emirs (kings) and wandered from city to city, seeking for a place to settle down in order to find an opening for his talents.

In the last ten or twelve years of his life he began to study literary matters and philology. In the last year of his life a severe colic seized him, so violent that he could scarcely stand. The disease kept returning, and with difficulty he reached Hamadan, where, finding the disease gaining ground, he refused to keep up the regimen imposed, and resigned himself to his fate. His friends advised him to slow down and take life moderately. He refused, however, stating that: “I prefer a short life with width to a narrow one with length”.

He died in June 1037, in his fifty-eighth year, and was buried in Hamadan, Iran.

Avicenna’s tomb, Hamadan, Iran.

 

The Canon of Medicine

Persian version of The Canon of Medicine at Avicenna’s mausoleum in Hamadan, Iran.

The Canon of Medicine (al-Qānūn fī al-Ṭibb) is an encyclopedia of medicine in five books compiled by Avicenna (Ibn Sina) and completed in 1025. It presents an overview of the contemporary medical knowledge.

The Canon of Medicine remained a medical authority for centuries. It set the standards for medicine in Medieval Europe and the Islamic world and was used as a standard medical textbook through the 18th century in Europe.

The Canon of Medicine is divided into five books:

1. Essays on basic medical and physiological principles, anatomy, regimen and general therapeutic procedures.
2. List of medical substances, arranged alphabetically, following an essay on their general properties.
3. Diagnosis and treatment of diseases specific to one part of the body.
4. Diagnosis and treatment of conditions covering multiple body parts or the entire body.
5. Formulary of compound remedies.

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 earliest known copy of volume 5 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. The earliest printed edition of the Latin Canon appeared in 1472, but only covering book 3. Soon after, eleven complete incunables were published, followed by fourteen more Latin editions in the 16th century until 1608.

William Osler[2] described the Canon as “the most famous medical textbook ever written”, noting that it remained “a medical bible for a longer time than any other work.”

George Sarton[3] wrote in the Introduction to the History of Science:

“The Qanun 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.”

Reduction techniques for spinal deformities, 1556 edition, “The Canon of Medicine”. Reduction involved the use of pressure and traction to correct bone and joint deformities. The Reynolds Historical Library, Lister Hill Library, University of Alabama at Birmingham

Statue of Avicenna, United Nations Office, Vienna, Austria.

Rhazes

(born in 854 CE, Reu Iran, died in 925 CE Rey, Iran)

Abū Bakr Muhammad ibn Zakariyyā al-Rāzī (also known by his Latinized name Rhazes or Rasis), was a Persian polymath, physician, alchemist, philosopher, and important figure in the history of medicine.

A comprehensive thinker, Razi made fundamental and enduring contributions to various fields, which he recorded in over 200 manuscripts, and is particularly remembered for numerous advances in medicine through his observations and discoveries.

He was among the first to use humorism to distinguish one contagious disease from another, and wrote a pioneering book about smallpox and measles providing clinical characterization of the diseases. He also discovered numerous compounds and chemicals including Alcohol, kerosene, among others.

Through translation, his medical works and ideas became known among medieval European practitioners and profoundly influenced medical education in the Latin West. Some volumes of his work Al-Mansuri, namely “On Surgery” and “A General Book on Therapy”, became part of the medical curriculum in Western universities.

Edward Granville Browne considers him as “probably the greatest and most original of all the Muslim physicians, and one of the most prolific as an author”. He has been described as a doctor’s doctor, the father of pediatrics, and a pioneer of ophthalmology. Al-Hawi (Kitab al-Hawi fi tebb, Comprehensive book on medicine) is the title of a major medical book on medicine in twenty-five volumes by Rhazes. He spent 15 years on this book.

The disposition of the material in al-Ḥāwi generally follows the traditional order: localized diseases and their therapy from the crown of the head to the sole of the feet; worms, gout, etc; external lesions and their treatment; fevers; acute diseases; crises; uroscopy, animal bites, etc., poisons; materia medica, pharmacy; diabetes, dermatology etc.

Kitab al-Hawi fi al-tibb (The comprehensive book on medicine), which was translated into Latin in 1279 under the title Continens Rasis. This book is also known in Latin as Continens Liber and in English as The Virtuous Life. Shown here is the rare 1529 edition of Continens Rasis, which was printed in Venice by Johannes Hamman.

Statue of Rhazes, United Nations Office, Vienna, Austria.

 

 

 

Diagnosis and treatment of cancer in medical textbooks of ancient Iran[4]

Prominent Iranian physicians have mentioned the term “cancer” in their textbooks since about twelve centuries ago, and have associated certain conditions with it. Among these are headaches, ailments of the ear, eyes, pharynx, larynx, nervous system, musculoskeletal system, gastrointestinal tract, and urologic diseases. They have also provided descriptions of some types of cancer, methods of diagnosis and treatment, prognosis, and other interesting issues.

According to ancient Iranian textbooks, cancer is a hard lump with a dark color, abnormal appearance and uneven margins with peripheral outgrowths that give it the appearance of a crab, and hence it is called “cancer”.

Cancer may occur in the skin, external or internal organs, especially in intestines or the uterus. It can also occur in some major organs of the body, such as the brain and heart, which will make surgery impossible. If cancer spreads to internal organs and surgery is not an option, it must not be manipulated because any form of stimulation may lead to side effects such as severe and intolerable pain.

One of the most significant works on the description, diagnosis, differential diagnosis, prognosis and therapeutic approaches towards cancer is Alhawi by Rhazes. In this article, first a brief summary of Rhazes’ views on cancer is presented, and subsequently it is recommended to review the medical heritage of Iran and evaluate the proposed treatments in order to help resolve complicated and problematic cases.

Some causes of cancer

1. Liver dysfunction and production of abnormal or harmful chemicals by this organ.
2. Spleen dysfunction and inability of this organ to remove abnormal or harmful substances from the blood.
3. Eating food that can cause cancer.

Prevalence

As mentioned in medical textbooks of ancient Iran and confirmed by modern studies, the prevalence of cancer is higher in women than men with uterine and breast cancer being the most common. Breast cancer is the most prevalent type of cancer among women. Cancer is more common in soft tissues than in hard tissues and also in organs with more blood vessels. It also occurs more frequently in organs closer to the neck area and those organs with abundant blood vessels and nerve fiber.

Diagnosis of cancer

According to Rhazes and Avicenna it is difficult to diagnose cancer at its onset stage and most physicians cannot successfully detect it at first. If diagnosed early on, however, medication may be administered, although definitive treatment is rarely achieved.

At the onset stage, a cancer mass or tumor is the size of a fava bean, lacks adhesion and moves when touched, but after growth it becomes adhesive and immovable. The outer tissue turns red and becomes very painful, and the patient may feel a burning and agonizing sensation. After the tumor grows, there are sometimes unclean and foul smelling secretions, and in some cases the vessels surrounding the cancer afflicted organ become congested, warm and dark.

Symptoms of some types of cancer

Rhazes, Avicenna, Ali ibn Abbas al-Ahwazi and other physicians have written about cancer of the eye, nose, pharynx and larynx, breast, uterus, gastrointestinal tract and other organs in their textbooks; they have described diagnostic signs and symptoms, differential diagnosis, treatment and prevention, and have discussed other interesting details that can be subject of research and study. In the following section we will investigate some instances of their works.

Eye cancer

If cancer occurs in any of the eye layers, they become red and varicose-like protuberances develop in ophthalmic vessels. The patient will feel a severe pain from cornea to the temporal bone, and the pain will be more severe while walking or moving around. Other symptoms are headaches, diluted and burning secretions and loss of appetite. Potent drugs are not effective and may even intensify the patient’s pain.

Uterine and Breast cancer

One symptom of uterine cancer is a prolonged, diluted bloody discharge. Ali ibn Abbas al-Ahwazi wrote that a hard and thick mass detected between the navel and pubic area in a woman may indicate uterine cancer. According to Rhazes, there is a correlation between breast cancer and the quality and quantity of menstrual bleeding, that is, the more regular and normal the menstrual bleeding is, the less the possibility of breast cancer will be. There is also a correlation between breast cancer and liver and spleen dysfunction.

Intestinal cancer

Ali ibn Abbas al-Ahwazi believed that continued, bloody stools, diarrhea, and painful, frequent and foul smelling defecation may be symptoms of advanced intestinal cancer, which usually leads to the patient’s death.

Differential Diagnosis

In the differential diagnosis of cancer, detection is of great importance as some non-cancerous cases may be very similar to cancer in the examination and evaluation stage. For example, if the areas around the neck or axillary lymph nodes are suspected to be cancerous, the physician will examine those areas carefully, and if they are warm to the touch, he may conclude that they are

afflicted by cancer. On the other hand, some tumors like Scrofula are colder than body temperature or have the same temperature as the body.

Metastasis

In some cases of breast cancer, despite mastectomy of the cancerous breast, the cancer will spread to the other breast due to the causative factor

Disease transmission

Ali ibn Abbas al-Ahwazi argued that some malignant diseases may affect the male semen and thus be transmitted to the next generation. It is interesting that he differentiated between this kind of transmission and the transmission of diseases such as smallpox, as the hereditary transmission of cancer is an ongoing topic of discussion in modern medical texts.

General principles in cancer treatment

1. If cancer is detected at the onset stage, in some rare cases it can be treated definitively.
2. If cancer is advanced, the physician must try to prevent its progress by medication or surgery. In surgery, all cancerous cells must be removed and the whole afflicted organ may need to be extracted.
3. If cancer is confirmed to be resistant and permanent, its progress must be prevented in order to prolong the patients’ life. In such cases, however, inappropriate attempts may cause side effects that can lead to the patients’ death. Sometimes the patient may live longer and suffer less without undue intervention.
4. In cases where surgery is impossible, the cancerous mass must not be incised or pierced, and if ulcerated, prevention from infection must be provided and the ulcerated area must be treated carefully.
5. The important side effects of surgical therapy such as damage to the nerve fibers, vessels and/or muscles should not be overlooked.

Generally speaking, ancient physicians would have three objectives in treating patients with cancer:

1. Preventing progress of the disease.
2. Preventing the cancer mass from being incised or pierced in order to avoid complications.
3. Reducing the side effects and trying to calm the patient and treat secondary infections.

Prognosis

The majority of great ancient Iranian physicians have categorized cancer and leprosy among major malignant diseases, and have pointed out that pessimism, continuous anxiety and depression can cause malignant diseases. In modern literatures on psycho-oncology, it is stressed that cancer patients are afflicted by depression and anxiety and similar disorders are important factors in the prognosis of the disease.

Ancient Iranian physicians believed that cancer is a malignant disease which is particularly challenging for the physician, and that the physician must not expect a definitive treatment as there is not much hope for one.

They also thought that the darker and more concentrated the patient’s blood is, the more malignant the disease will be. This may be true of certain types of cancer that are associated with abnormal changes in the blood.

They also believed that in cancers of the throat, palate and female genital organs, surgery might result in the patient’s death.

Discussion

Ancient Iran experienced a golden age of medicine between the 10th and the 18th centuries A.D., when great physicians such as Rhazes, al-Ahwazi, Avicenna and others lived and practiced. These physicians revised the medical textbooks written in the centuries before Christ that were adopted and translated from civilizations such as Greece and India, and attempted to advance this very important and vital science. Each of these prominent physicians revised and criticized the opinions of others before themselves, eliminated incorrect ideas such as superstitious beliefs, added their innovations to the pre-existing knowledge and passed their achievements to the next generations. It can be claimed that Iranians made great contributions to the medical science during these years and provided the grounds for the development of modern medical knowledge, a fact that most people nowadays are hardly aware of.

Among the abovementioned contributions are valuable textbooks such as Alhawi by Rhazes, Cannon by Avicenna and Kamil al-Sina’ah by al-Ahwazi, all of which contain a wealth of medical knowledge. This article presents a brief, selective investigation of the phenomenon of cancer as discussed in these works.

It is clear that despite their limited resources and lack of advanced equipment, ancient Iranian physicians had succeeded in gaining valuable information that may even be beneficial to modern science. The details in these works on the diagnostic symptoms, differential diagnosis, predisposing factors, treatment, and prognosis of cancer are strong evidence for this claim.