The Canon of Medicine
The Canon of Medicine ( "al-Qānūn fī al-Ṭibb"; , "Qanun-e dâr Tâb") is an encyclopedia of medicine in five books compiled by Persian physician-philosopher Avicenna (, Ibn Sina) and completed in 1025. Perhaps one of the most famous and influential early books, that continued to influence later creations. It presents an overview of the contemporary medical knowledge of the Islamic world, which had been influenced by earlier traditions including Greco-Roman medicine (particularly Galen), Persian medicine, Chinese medicine and Indian medicine. "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. It is an important text in Unani medicine, a form of traditional medicine practiced in India. Title. The English title "The Canon of Medicine" is a translation of the Arabic title (), with "canon" (translated in English to "law") used in the sense of "law". Development. The medical traditions of Galen and thereby Hippocrates, had dominated Islamic medicine from its beginnings. Avicenna sought to fit these traditions into Aristotle's natural philosophy. He began writing the "Canon" in  Gorganj, continued in Rey and completed it in Hamadan in 1025. The result was a "clear and ordered "summa" of all the medical knowledge of Ibn Sīnā's time". It served as a more concise reference in contrast to Galen's twenty volumes of medical corpus. Overview. "The Canon of Medicine" is divided into five books: Books 1, 3, and 4 are each further divided into parts ("fanns)", chapters ("ta’līms)," subchapters ("jumlahs)", sections ("faṣls"), and subsections ("bābs"). Book 1. Book 1 is made up of six theses which give a general description of medicine in general, the cosmic elements  that make up the cosmos and the human body, the mutual interaction of elements (temperaments), fluids of the body (humours), human anatomy, and physiology. The book explains the causes of health and disease. Avicenna 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: Thesis I Definition and Scope of Medicine. Avicenna begins part one by dividing theoretical medicine and medical practice. He describes what he says are the "four causes" of illness, based on Aristotelian philosophy: The material cause, the efficient cause , the formal cause, and the final cause: Thesis II The Elements of Cosmology. Avicenna's thesis on the elements of the cosmos is described by Gruner as "the foundation of the whole "Canon"". Avicenna insists here that a physician must assume the four elements that are described by natural philosophy, although Avicenna makes it clear that he distinguishes between the "simple" element, not mixed with anything else, and what we actually experience as water or air, such as the sea or the atmosphere. The elements we experience are mixed with small amounts of other elements and are therefore not the  pure elemental substances. The "light" elements are fire and air, while the "heavy" are earth and water: Thesis III The Temperaments. The "Canon of Medicine" divides the thesis on temperaments into three subsections; a general overview, one based on members of the body, and temperaments based on age. I The Temperaments (General description). The temperaments are reported to be the interaction between the four different element's qualities, such as the conflict between dryness, wetness, cold, and hot. Avicenna suggests that these qualities battle between each other until an equilibrium state is reached and this state is known as the  temperaments. The "Canon" also adopted the ancient theory of Four Temperaments and extended it to encompass "emotional aspects, mental capacity, moral attitudes, self-awareness, movements and dreams". This expanded theory of four temperaments is given in the following table: Canon describes humans as having eight different "varieties of equipoise", or differing temperaments. The temperaments fall under two categories; In relation to beings other than men and in relation to the individual himself. i. "the equability of the temperament seen in man as compared with other creatures" ii. the temperament of other human beings iii. external factors "such as race, climate , atmosphere" iv. in relation to extreme climates v. "as compared to another person" vi. comparison of the individual himself vii. comparing one member of the body with another member of the body viii. comparison of a member to itself "The Canon" continues to explain the sun's position in relation to ideal temperament and the role that climate and human skin play. Organs are nowhere near ideal in temperament, but skin comes the closest. Avicenna says that the hand, especially the palm and the tip of the index finger, is the most sensitive of all and attuned to tactile contact . Medicine is described as "hot" or "cold", not based upon its actual temperature but with regard to how it relates to the temperament of the human body. "The Canon" then describes when temperaments are unequal, in other words, illness. Avicenna separates these into two categories, which are fairly self explainable within the context of what he had already defined as the temperaments. The compound intemperaments are where two things are wrong with the temperament, i.e. hotter and moister; hotter and drier; colder and moister; colder and drier. There are only four because something cannot be simultaneously hotter and colder  or drier and moister. The four simple temperaments and four compound intemperaments can each be divided into "Those apart from any material substance" and "Those in which some material substance is concerned", for a total of sixteen intemperaments. Examples of the sixteen intemperaments are provided in the "third and fourth volumes." II The Temperament of the Several Members. Each member of the body is described to be given each its individual temperament, each with its own degree of heat and moisture. Avicenna lists members of the body in "order of degree of Heat", from hottest to coldest. Then a list  is given of coldest members to hottest. Then a list is given in order of moisture. Avicenna credits Galen with this particular list. Finally, a list is given in order of dryness< III The Temperaments Belonging to Age. "The Canon" divides life into four "periods" and then subdivides the first period into five separate categories. The following table is provided for the four periods of life: Avicenna says that the third period shows signs of decline in vigor and some decline in intellectual power. In the fourth period, both vigor and intelligence decline. Avicenna divides the beginning stage of  life in the following table, according to Oskar Cameron Gruner's edition of the "Canon of Medicine": Avicenna generalizes youth as having a "hot" temperament, but comments that there is controversy over which periods of youth are hotter. The general notion that youth are "hot" in temperament is due to youth's supposed relationship to members of the body that are hot. For example, blood was considered "hot" as was mentioned earlier, therefore youth is assumed to be hot partially due to blood being more "plentiful" and "thicker", according to Avicenna. Evidence for youth having an excess of blood is  suggested by Avicenna's observation that nose bleeds are more frequent within youth. Other contributing factors are the youth's association with sperm and the consistency of their bile. Further description of youth in regards to heat and moisture is given with respect to sex, geographical location, and occupation. "The Canon" says, for example, that females are colder and more moist. The Humours. "The Canon of Medicine" is based upon the Four Humours of Hippocratic medicine, but refined in various ways. In disease pathogenesis, for example, Avicenna "added his own view of different types of spirits (or vital life essences ) and souls, whose disturbances might lead to bodily diseases because of a close association between them and such master organs as the brain and heart". An element of such belief is apparent in the chapter of "al-Lawa", which relates "the manifestations to an interruption of vital life essence to the brain." He combined his own view with that of the Four Humours to establish a new doctrine to explain the mechanisms of various diseases in another work he wrote, "Treatise on Pulse": Definition of body fluid. "The Canon" defines a humour as "that fluid, moist 'body' into which our  aliment is transformed", and lists the four primary types of fluids as sanguineous, serous, bilious, and atrabilious. The secondary fluids are separated into "non-excrementitious" and "excrementitious". The sanguineous humour. Avicenna calls this humour "the most excellent of all" the humours. This section describes blood and compares its healthy states with its unhealthy states. Avicenna describes healthy blood as "red in colour, has no unpleasant odour, and has a very sweet taste." Abnormality of the blood stems from a change in temperament or an unhealthy humour has polluted it. The serous humour. The serous humour is described as a sweet  fluid that is cold and moist in relation to blood and bilious humours. Serous humour resembles blood and is necessary for body tissues for two reasons: to provide the tissue with nutrients as an auxiliary and to keep the bones and tissues moist. The bilious humour. The bilious humour is red and clear in colour, light and pungent, and its normal form is the foam of blood. It can pursue two routes, either into the blood or the gallbladder. When it passes into the blood, its function is to attenuate the blood in such a way, that it enables the  blood to transverse the very minutest channels of the body. The part which flows to the gallbladder is needed, since it cleanses the entire body of superfluity and nourishes the gallbladder. Anatomy or "The Members". In his thesis on "The Members", Avicenna explains that the humours help to make up the members of the body, gives a general description and how to repair them. Some are "simple members" or "elementary tissue" such as bone, cartilage and tendons. Some are "compound members" such as the heart, the liver, and the brain. He also categorizes these into vital organs and auxiliary organs . Avicenna continues to classify the organs by different systems. "According to actions" organizes members by what they do. "According to their origin" classifies members by assuming that each member originates from the blood or from male or "female sperm". General Physiology. In the thesis on General Physiology or "The Faculties of the Body", Avicenna separates life into three different categories: Vital, Natural, and Animal. He contrasts Galen's view that the brain is the "chief seat of sentient life" with Aristotle's view that the heart is the source of all the body's faculties, saying that if physicians considered  the matter carefully they would agree with Aristotle that the heart was the ultimate source of all the faculties, even if (for example) the brain is where the rational faculty manifests itself. Book 2 Materia Medica. Book 2 (the Materia Medica) of the "Canon" alphabetically lists about 800 "simple" medical substances that were used at the time. The substances are simple in the sense of not being compounded with other substances. The first part gives general rules about drugs and a treatise on what was called "the science of powers of medicines". The second part is a list of 800  simple floral, mineral, and animal substances. Each entry contains the substance's name, its criteria of goodness (which sometimes describes how the substance is found in nature), and its nature or primary qualities. Next are listed one or more of 22 possible general actions, followed by specific properties listed according to a grid of 11 disease types. Finally, potential substitutes for the substances are given. The "Canon" contains seven rules for experimenting with new drugs, taken partly from Galen. Book 3 Special Pathology. Book 3 is arranged by body part, progressing from the top of the body to the bottom  of the body and covering the function and diseases of each organ, as well as the etiology, symptoms, diagnosis, prognosis, and treatment for each disease discussed. The third book is also divided into several sections, including: 1.     Head, Eye, Ear, Nose, Mouth, Throat, Teeth 2.     Chest, Lung, Heart 3.     Alimentary tract: stomach, intestines; liver, gall-bladder, and spleen 4.     Urinary system 5.     Conception, Pregnancy, the Uterus, Diseases of women. 6.     The Muscles, The Joints, The Feet. 7.     Special subjects: The intemperaments of the Brain; Headache; diseases of the Brain, Epilepsy, Paralysis. The information presented in Book 3 of the "Canon  of Medicine" represents some of Avicenna's most important contributions to several fields of study, including atherosclerosis, pulsology, migraines, cataracts, vasovagal syncope, and neuroscience. Stroke. Strokes are described in extensive detail in Book 3 of the "Canon of Medicine". First, two causes of stroke are identified: blockage of vessels in the brain, and blockage of the affective spirit of the brain, a cause that can only be explained using theories on humoral medicine. The blockage of vessels is then further subdivided into two sub-types: collapse and ischemia. Following this description of the causes of stroke, Avicenna discusses how the  blocking agents are derived from the blood or phlegm humors, and how these are most abundant in people with wet and cold natures. Book 3 of the "Canon of Medicine" also lists several manifestations of stroke: asphyxia, hemiplegia, "headache with jugular vein engorgement, dizziness, vertigo, darkened vision, tremor, anxiety, weakness, grinding teeth during sleep, and dark urine with particles", and it distinguishes between the different causes and types of stroke: cold stroke, coma, subarachnoid hemorrhage, and trauma. Finally, Book 3 discusses several treatments for stroke including the use of herbal medicines and "non-pharmacological interventions such as venesection and dry  or wet cupping on the lower neck and upper back". While the accounts of the causes and treatments of stroke are based upon theories of humoral medicine, these descriptions are still similar to the modern understanding of strokes. Neuroscience. Book 3 also contains an extensive chapter about neuroscience, which "begins by explaining the structure and function of the nervous system, …parts of the brain, the spinal cord, the ventricles, meninges, nerves and roots, … [and] neurological and neuropsychological disorders, including signs and symptoms and treatment strategies". Furthermore, several specific neurological conditions are described, including: epilepsy, apoplexy and stroke, paralysis, vertigo, spasm , wry mouth, tremor, meningitis, amnesia and dementia, head injuries and traumas, hysteria and conversion disorder, fainting and stupor, nervous tic, sexual disorders, love sickness, delusion and hallucination, insomnia, sopor, nightmare, mania and psychosis, melancholia, paranoia, asthenia, hydrocephalus, and sciatica. Book 3 of the "Canon of Medicine" also describes fifteen kinds of headaches, as well as descriptions of treatments for each of these conditions that are divided into three steps: 1.     Change of lifestyle 2.     Simple medicines 3.     Compound medicines Surgical intervention and other non-pharmacological strategies were also recommended in some cases, such as electrical shocks to treat epilepsy. Book  4 Special Diseases Involving More Than One Member. Book 4 covers diseases that affect the whole body such as fevers or poisons, or conditions that could happen to any part of it such as wounds or bone fractures. The book "concludes with a treatise on personal hygiene, emphasizing care of the hair, skin, nails, body odor, and the treatment of overweight or underweight persons." In Book 4 – as with other ancient Islamic medical writings – large sections were devoted to covering fevers in great detail. Several types of fevers were distinguished, partly based on the location of the factors causing each  specific illness: 1.    Ephemeral (involving the pneuma) 2.    Putrid (putrefaction of humoral residues) 3.    Hectic (occurring in a major organ) Each of these classifications were further subdivided: for example, Avicenna also listed 23 different types of ephemeral fevers in Book 4 of the "Canon of Medicine." Book 5 Formulary. Book 5 (the Formulary) lists 650 compound drugs, attributing them to various Arabic, Indian and Greek sources. Avicenna added his own comments, highlighting differences between recipes from different sources, and sometimes giving his own recipe. He also gave his opinion of the effectiveness (or ineffectiveness) of some remedies, and gave details  of where particular ingredients came from and how they were prepared. He favoured proven remedies which had been tested through experience, cautioning that compounds could have unexpected or much stronger effects than might be expected from the effects of the individual components. Legacy and reception. The "Qanun" was translated into Latin as "Canon medicinae" by Gerard of Cremona. (Confusingly, there appear to have been two men called Gerard of Cremona, both translators of Arabic texts into Latin. Ostler states that it was the later of these, also known as Gerard de Sabloneta, who translated the "Qanun" (and other medical works ) into Latin in the 13th century.) The encyclopaedic content, systematic arrangement, and combination of Galen's medicine with Aristotle's science and philosophy helped the "Canon" enter European scholastic medicine. Medical scholars started to use the "Canon" in the 13th century, while university courses implemented the text from the 14th century onwards. The "Canon"s influence declined in the 16th century as a result of humanists' preference in medicine for ancient Greek and Roman authorities over Arabic authorities, although others defended Avicenna's innovations beyond the original classical texts. It fell out of favour in university syllabi, although it was still  being taught as background literature as late as 1715 in Padua. 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 housed in the Aga Khan Museum in 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. In addition to Latin, the "Canon of Medicine" was translated into Hebrew by Nathan ha-Meati during the 13th  century, and complete translations were also made into Turkish and Persian during the 18th century. William Osler 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 wrote in the "Introduction to the History of Science":