International Journal of Cardiology 172 (2014) 36–39
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Review
How did Haly Abbas look at the cardiovascular system? Behnam Dalfardi a,b,⁎, Golnoush Sadat Mahmoudi Nezhad a,b, Alireza Mehdizadeh b,c a b c
Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. Research Office for the History of Persian Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Department of Medical Physics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
a r t i c l e
i n f o
Article history: Received 5 November 2013 Accepted 28 December 2013 Available online 8 January 2014 Keywords: Cardiovascular system Haly Abbas Medieval history Persia The Royal Book
a b s t r a c t Persian scholars, especially those who lived during the Golden Age of Islamic Medicine (9th–12th century AD), made significant contributions to the healing arts and secured a place of honor for themselves in the history of this science. Abū l- asan Alī ibn al-'Abbās al-Majūsī Ahvazi (? 930–994 AD), with the Latinized name of Haly Abbas, was a scientist from this part of the world who contributed to the advancement of medicine. He is the author of Kāmil al-Sinā'ah al-Tibbīyah (The Perfect Book of the Art of Medicine), also commonly known as al-Kitāb al-Malikī (The Royal Book), a medical encyclopedia renowned for its systematic and precise content. This textbook covers a wide variety of medical issues, among them topics related to the science of cardiology. This paper reviews the main points of Haly Abbas' knowledge of the cardiovascular system, of which little has been written until now. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Persia, originally founded by the Achaemenid Emperor Cyrus the Great (599–530 BC) and his successors, was a cradle of science and the homeland of several influential scholars [1]. Medical science in this part of the world flourished during the Golden Age of Islam (9th–12th century AD) [2]. It was an era boasting great figures such as Rhazes (865–925 AD), Haly Abbas (? 930–994 AD), al-Akhawayni Bukhari (?–983 AD), Avicenna (980–1037 AD), and Esmail Jorjani (1042– 1137 AD), who made original and significant contributions to the flowering of the healing arts, particularly cardiovascular medicine [2–6]. These Golden Age scientists compiled the knowledge of medical science from their era on the basis of observation and experimentation and added new information and theories to extant knowledge [4,7,8]. They wrote a number of major textbooks on medicine, including Rhazes' al-Hawi fil Tibb (Liber Continens), Haly Abbas' al-Kitāb al-Malikī (The Royal Book), al-Akhawayni's Hidayat al-Muta'allemin Fi al-Tibb (A Guidance to Medical Learners), Avicenna's al-Qanun-fi-al-Tibb (The Canon of Medicine), and Jorjani's Zakhīrah-i Khvārazm'Shāhī (Treasure of King Khwarazm) and greatly influenced the path of progress in medicine in both Eastern and Western countries [2,7–10]. Among the aforementioned works, Haly Abbas' The Royal Book is best remembered as a systematic and comprehensive book on the medical arts [11]. In spite of its qualities, this work, especially its sections on cardiology, has remained largely unnoticed until now. This paper discusses the expertise of Haly Abbas on the cardiovascular
⁎ Corresponding author at: Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. Tel.: +98 913 2483359; fax: +98 711 2122970. E-mail address: [email protected] (B. Dalfardi). 0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.171
system by analysis of his sole surviving textbook of medicine, The Royal Book. 2. Biography Abū l- asan Alī ibn al-'Abbās al-Majūsī Ahvazi (? 930–994 AD), also known as al-Majūsī or al-Ahvazi, and best known as Haly Abbas in the West, was an influential Persian physician and surgeon of the 10th century CE (Fig. 1) [12,13]. His precise birthday is unknown; although it estimated to be about 930 AD. Haly Abbas' lifetime coincided with the Golden Age of Islam. He lived during an era between Rhazes and Avicenna, and was a contemporary of al-Akhawayni Bukhari [2,14]. The city of Arrajan in Old Persia was his birthplace [12]. Although Haly Abbas himself was a Muslim by faith, he belonged to a family with Zoroastrian roots. In recognition of this, he was known as al-Majūsī (the Magian, a follower of the prophet Zoroaster) [12,15,16]. Unfortunately, little is known about the biography of Haly Abbas, but it is likely that he spent his entire life in Persia [14,15]. Haly Abbas attended primary school in his native city and afterward moved to Shiraz (now in Iran) to begin his medical education under the guidance of Shaikh Abu Maher Musa ibn Sayyār (died in 983 AD), a great physician of the era [12,16]. After training in the healing arts in Shiraz, Haly Abbas left that city to go to Baghdad (today's capital of the Republic of Iraq). His residence in Baghdad provided him new opportunities and time for new endeavors. For instance, Haly Abbas was appointed court physician for Adud al-Dawla Fana-Khusraw (936–983 AD), a king of the Buwayhid dynasty in Persia. He was also a physician at Azodi Hospital in Baghdad. It was in Baghdad that Haly Abbas compiled his encyclopedic work on surgery and medicine entitled Kāmil al-Sinā'ah al-Tibbīyah (The Perfect Book of the Art of Medicine) or al-Kitāb al-Malikī (The Royal Book) [13,16].
B. Dalfardi et al. / International Journal of Cardiology 172 (2014) 36–39
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Fig. 1. Fabricated portrait of Haly Abbas (? 930–994 AD), by Mrs. Somayeh Tabatabaee (born in 1978). Reproduced with permission from the Museum of Shiraz University of Medical Sciences, Shiraz, Iran.
Haly Abbas was considered the most influential medical author and physician of his time [14,17]. He is credited with being the first scholar to reject ancient Aristotelian (384–322 BC) and Galenic (130–200 AD) principles of medicine. For apparently the first time in the Middle Ages (5th–15th century AD), Haly Abbas, on the basis of his own observations and experiences, put his efforts into introducing a new form of medicine [14,16]. Haly Abbas is remembered for his pioneering accounts in the fields of medicine and surgery. Among these are a description of uterine contractions during delivery, an explanation and method of surgical excision of goiter, advice on surgical management of the imperforate hymen and anus, and hydrocele repair [14].
3. Kāmil al-Sinā'ah al-Tibbīyah or al-Kitāb al-Malikī Kāmil al-Sinā'ah al-Tibbīyah (The Perfect Book of the Art of Medicine) was originally written in Arabic and is the only known extant work of Haly Abbas (Figs. 2 and 3). This medical encyclopedia is commonly known as al-Kitāb al-Malikī (The Royal Book) because he, in about 965 AD, dedicated it to the Buwayhid ruler Adud al-Dawla Fana-Khusraw to acknowledge the king's patronage of the arts and science. Examples of Adud al-Dawla's patronage of medicine is his founding of a number of hospitals in Baghdad and Shiraz [1,12,15,16]. The Royal Book can be divided into two sections (Juz') by content. The first section comprises 10 chapters (Maqala) and is devoted to theoretical elements of medicine. The second section consisted of the last 10 chapters and discusses practical medical issues [12,15,16]. It can be said that this work is composed of 20 chapters on a wide variety of medical subjects, including cardiovascular medicine. Each chapter begins with anatomical descriptions and proceeds to descriptions of different aspects of the disease under discussion. Topics such as preventive medicine, public health, dietetics, toxicology, clinical observations, disease managements, surgery, materia medica, and medico-ethical issues are discussed in detail in this book [12,14,16,18]. In the introduction to The Royal Book, Haly Abbas criticized the writings of prominent predecessors, including Hippocrates (460– 370 BC), Galen of Pergamon (130–200 AD), Oribasius (325–400 AD), Paul of Aegina (625–690 AD), Serapion the Elder (9th century AD), and Rhazes. In that same part of the book, Haly Abbas explains that his goal was the compilation of an encyclopedia containing the complete medical knowledge of his time [14].
Fig. 2. A page from a copy of the al-Kitāb al-Malikī (The Royal Book) (belonging to the 1726 version). This version was completed by a physician, Mu ammad 'Ā il al- abā Abā'ī. Courtesy of the US National Library of Medicine.
Constantinus Africanus of Monte Casino (1015–1087 AD) translated most of The Royal Book (particularly its discourses on surgery) into Latin in 11th century AD under the title Pantegni without attributing it to its original compiler, Haly Abbas. This event can be regarded as an early instance of plagiarism [16,19]. After this, in about 1127 AD, Stephen of Antioch (12th century AD) translated the entire text under the name of Liber Regalis Dispositionis or Liber Regius. This version was published in Venice in 1492 and again in Lyon in 1523 [13,19]. The Royal Book was reprinted over and over again in the West. In 1985, centuries after its first translation, a facsimile edition was published in two volumes [12]. This epic work served as a reference book of surgery in European medical schools for a period of time [1]. Although The Royal Book was written in a more systematic and concise way than the Liber Continens of Rhazes and a more practical style than Avicenna's Canon of Medicine, the glory of this work was overshadowed by the introduction of The Canon (completed in 1025 AD) to the medical community [1,16,20]. 4. Haly Abbas' knowledge of cardiovascular system Several pages of The Royal Book are devoted to cardiology. It includes an anatomical description of the heart and analyzed the role of the blood vessels. Haly Abbas distinguished between arteries and veins based on their wall thicknesses. The Royal Book includes anatomical illustrations of a large number of arteries and veins, some with general explanations and some in detail. One instance of Haly Abbas' precise anatomical descriptions is his explanation of the anatomy of the thoracic descending aorta: “… This vessel [aorta] moves downward; it is located on the surface of the vertebrae.
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B. Dalfardi et al. / International Journal of Cardiology 172 (2014) 36–39
Fig. 3. A page from a copy of the al-Kitāb al-Malikī (The Royal Book) (belonging to the 1208 version). This copy was provided by the Christian scribe Tawmā ibn Yūsuf ibn Sarkis al-Masī ī. Courtesy of the US National Library of Medicine.
In describing the anatomy of the heart, Haly Abbas first explains its gross features, its anatomical position within the chest cavity, and its relation to the adjacent organs. He then discusses the structure of the heart in detail. In his opinion, the heart consists of two main cavities, one on the left and one on the right. He introduces the left side of the heart as the origin of arteries (and liver as the origin of veins). Haly Abbas noted the existence of two atriums and two auricles (in current terminology). He points out the presence of the tricuspid, mitral and aortic valves, and their one-way action. In addition, he explains that the mitral valve consists of two leaflets while the tricuspid and aortic valves have three leaflets. Haly Abbas described the presence of pericardium (all recent terms in modern nomenclature) [21]. Despite his brilliance, some of Haly Abbas' opinions on the cardiovascular system appear to be incorrect. For example, it has been claimed that Haly Abbas was probably the first figure in medical history to reject the Galenic doctrine on the presence of small pores within the interventricular septum [1,14,25]. However, in fact, a review of the text of The Royal Book shows that Haly Abbas supposed the existence of a foramen within the inter-ventricular septum that acts as the route of blood moving from the right side of the heart to the left side [21]. With the statements of Haly Abbas on the presence of a connection between two ventricles of the heart and similar beliefs with regard to this subject from al-Akhawayni Bukhari (a Persian physician and contemporary of Haly Abbas), it can be concluded that Galen's theory on the movement of blood from the right ventricle to left was still dominant in the 10th century Persian medical community [6,21,26,27]. It is worthy of note that in Haly Abbas' opinion, the pulmonary artery (in today's nomenclature) is responsible for transferring blood to the lungs, nourishing these organs and receiving the air from them [21]. 5. Conclusion
When passing through in this section, adjacent to each vertebra, one vessel branches off from it [posterior inter-costal artery] …. One type of branch is a small vessel that branches off just in front of the lung and moves toward the confluence the trachea and lungs [bronchial artery]. … Two small vessels [superior phrenic arteries] branch off and move toward the ‘Hejab-e Hajez’ [diaphragm] …”. Coronary arteries are also described by Haly Abbas in a general form. He writes: “When this vessel [aorta] originates from the heart, two arteries divide off from it; one [right coronary artery] is smaller and moves toward the right ventricle and supplies [blood to] it; the other [left coronary artery] is larger and moves proportionally to the curvature of [the left side of] the heart wall and supplies [blood to] it”. The importance of the circle of Willis was not lost to Haly Abbas. He describes it as follows: “… Two of these arterial branches are large arteries [two internal carotid arteries] that move toward the deep ‘Vedajs’ [internal jugular veins] of the neck. … The pulsing of these two vessels is palpable on either side of the neck, and these vessels are now called ‘Sobat’. … Arterial branches [along the neck] are derived from them and the rest enter the skull. … These branches merge and form a net-like structure at the base of the brain … These branches disperse into the brain to supply [blood to] it…” [21]. It is interesting to note that the term “sobat” in Arabic (spelling: )ﺳـﺒـﺎﺕmeans lethargy or sleep. It is possible that Haly Abbas was familiar with what is known today as vasovagal syncope following carotid sinus massage. For what may be the first time in the history of medicine, Haly Abbas pinpointed the presence of a connection between the arterial and venous systems; he explains: “… There are some foramina within the non-pulsating vessels [veins] that open to the pulsating vessels [arteries] …” [21,22]. This statement was made long before the theories of Ibn al-Quff al-Karaki (1233–1286 AD) (a medieval Arab physician and surgeon) and William Harvey (1578–1657) (an English physician) on the existence of capillaries [23,24].
Notwithstanding the few inaccurate opinions of Haly Abbas about the structure of the heart, possibly influenced by his predecessors' writings, it could be said that he contributed to the progress of the science of cardiology. Early on in the history of medicine, he theorized the existence of a connection between the arterial and venous systems. His knowledge of human anatomy allowed him to provide early descriptions of the circle of Willis and a large number of other arteries and veins. References [1] Shoja MM, Tubbs RS. The history of anatomy in Persia. J Anat 2007;210(4):359–78. [2] Yarmohammadi H, Dalfardi B, Ghanizadeh A, Bukhari Al-Akhawayni. Al-Akhawayni Bukhari (?–983 AD). J Neurol 2013. http://dx.doi.org/10.1007/s00415-013-7000-5. [3] Shoja MM, Agutter PS, Loukas M, et al. Leonardo da Vinci's studies of the heart. Int J Cardiol 2013;167(4):1126–33. [4] Khodadoust K, Ardalan M, Ghabili K, Golzari SE, Eknoyan G. Discourse on pulse in medieval Persia—the Hidayat of Al-Akhawayni (?–983 AD). Int J Cardiol 2013;166(2):289–93. [5] Khalili M, Shoja MM, Tubbs RS, Loukas M, Alakbarli F, Newman AJ. Illustration of the heart and blood vessels in medieval times. Int J Cardiol 2010;143(1):4–7. [6] Yarmohammadi H, Dalfardi B, Rezaian J, Ghanizadeh A. Al-Akhawayni's description of pulmonary circulation. Int J Cardiol 2013;168(3):1819–21. [7] Gorji A, Khaleghi Ghadiri M. History of headache in medieval Persian medicine. Lancet Neurol 2002;1(8):510–5. [8] Gorji A, Khaleghi Ghadiri M. History of epilepsy in Medieval Iranian medicine. Neurosci Biobehav Rev 2001;25(5):455–61. [9] Shoja MM, Tubbs RS, Loukas M, Khalili M, Alakbarli F, Cohen-Gadol AA. Vasovagal syncope in the Canon of Avicenna: the first mention of carotid artery hypersensitivity. Int J Cardiol 2009;134(3):297–301. [10] Hosseini SF, Alakbarli F, Ghabili K, Shoja MM. Hakim Esmail Jorjani (1042–1137 AD): Persian physician and jurist. Arch Gynecol Obstet 2011;284(3):647–50. [11] Frampton M. Embodiment theories of voluntary animal motion in the late Middle Ages. Embodiments of Will: Anatomical and Physiological Theories of Voluntary Animal Motion from Greek Antiquity to the Latin Middle Ages, 400 B.C.–A.D. 1300. Saarbrücken: VDM Verlag Dr. Müller/West-Germany; 2008. p. 333. [12] Hamarneh SK. Ibn al-Majūsī. Encyclopaedia of the history of science, technology, and medicine in non-Western cultures. New York: Springer-Verlag New York Inc./USA; 2008. p. 1093–4.
B. Dalfardi et al. / International Journal of Cardiology 172 (2014) 36–39 [13] Belen D, Aciduman A. A pioneer from the Islamic Golden Age: Haly Abbas and spinal traumas in his principal work, The Royal Book. J Neurosurg Spine 2006;5(4):381–3. [14] Aciduman A, Arda B, Kahya E, Belen D. The Royal Book by Haly Abbas from the 10th century: one of the earliest illustrations of the surgical approach to skull fractures. Neurosurgery 2010;67(6):1466–74. [15] Prioreschi P. Medicine. A History of Medicine: Byzantine and Islamic Medicine. Omaha: Horatius Press/USA; 2001. p. 251–8. [16] Zargaran A, Zarshenas MM, Ahmadi SA, Vessal K. Haly Abbas (949–982 AD). J Neurol 2013;260(8):2196–7. [17] Syed Akheel Ahmed A. Medicine. Islam and Scientific Enterprise. New Delhi: I. K. International Publishing House Pvt Ltd/North-India; 2008. p. 92. [18] Varma DR. The age of Islamic medicine. The Art and Science of Healing Since Antiquity. Bloomington: Xlibris Corporation/USA; 2011. p. 211. [19] Aciduman A, Arda B, Aşkit C, Belen D, Tuzcu K. Account of Haly Abbas regarding the management of hydrocephalus in children: a text from medieval times. World Neurosurg 2013;S1878-8750(13):00891–7.
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[20] Dallal A. Science, medicine, and technology. The Oxford History of Islam. New York: Oxford University Press/USA; 1999. p. 203. [21] Ghafari MK. Kāmil al-Sinā'ah al-Tibbīyah (The Perfect Book of the Art of Medicine) by Alī ibn al-'Abbās al-Majūsī Ahvazi. [in Persian] Tehran University / McGill University, Institute of Islamic Studies; 2009 151–65, 243-245, 321. [22] Wakim KG. Arabic medicine in literature. Bull Med Libr Assoc 1944;32:96–104. [23] Yarmohammadi H, Dalfardi B, Kalantari Meibodi M, Ghanizadeh A. Ibn al-Quff (1233–1286 AD), genius theorist of the existence of capillaries. Int J Cardiol 2013; 168(6):e165. [24] Khan IA, Daya SK, Gowda RM. Evolution of the theory of circulation. Int J Cardiol 2005;98(3):519–21. [25] Batirel HF. Early Islamic physicians and thorax. Ann Thorac Surg 1999;67(2):578–80. [26] French RK. The thorax in history. 5. Discovery of the pulmonary transit. Thorax 1978;33(5):555–64. [27] Meyerhof M. Ibn An-Nafîs (XIIIth Cent.) and his theory of the lesser circulation. Isis 1935;23(1):100–20.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Review
How did Haly Abbas look at the cardiovascular system? Behnam Dalfardi a,b,⁎, Golnoush Sadat Mahmoudi Nezhad a,b, Alireza Mehdizadeh b,c a b c
Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. Research Office for the History of Persian Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Department of Medical Physics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
a r t i c l e
i n f o
Article history: Received 5 November 2013 Accepted 28 December 2013 Available online 8 January 2014 Keywords: Cardiovascular system Haly Abbas Medieval history Persia The Royal Book
a b s t r a c t Persian scholars, especially those who lived during the Golden Age of Islamic Medicine (9th–12th century AD), made significant contributions to the healing arts and secured a place of honor for themselves in the history of this science. Abū l- asan Alī ibn al-'Abbās al-Majūsī Ahvazi (? 930–994 AD), with the Latinized name of Haly Abbas, was a scientist from this part of the world who contributed to the advancement of medicine. He is the author of Kāmil al-Sinā'ah al-Tibbīyah (The Perfect Book of the Art of Medicine), also commonly known as al-Kitāb al-Malikī (The Royal Book), a medical encyclopedia renowned for its systematic and precise content. This textbook covers a wide variety of medical issues, among them topics related to the science of cardiology. This paper reviews the main points of Haly Abbas' knowledge of the cardiovascular system, of which little has been written until now. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Persia, originally founded by the Achaemenid Emperor Cyrus the Great (599–530 BC) and his successors, was a cradle of science and the homeland of several influential scholars [1]. Medical science in this part of the world flourished during the Golden Age of Islam (9th–12th century AD) [2]. It was an era boasting great figures such as Rhazes (865–925 AD), Haly Abbas (? 930–994 AD), al-Akhawayni Bukhari (?–983 AD), Avicenna (980–1037 AD), and Esmail Jorjani (1042– 1137 AD), who made original and significant contributions to the flowering of the healing arts, particularly cardiovascular medicine [2–6]. These Golden Age scientists compiled the knowledge of medical science from their era on the basis of observation and experimentation and added new information and theories to extant knowledge [4,7,8]. They wrote a number of major textbooks on medicine, including Rhazes' al-Hawi fil Tibb (Liber Continens), Haly Abbas' al-Kitāb al-Malikī (The Royal Book), al-Akhawayni's Hidayat al-Muta'allemin Fi al-Tibb (A Guidance to Medical Learners), Avicenna's al-Qanun-fi-al-Tibb (The Canon of Medicine), and Jorjani's Zakhīrah-i Khvārazm'Shāhī (Treasure of King Khwarazm) and greatly influenced the path of progress in medicine in both Eastern and Western countries [2,7–10]. Among the aforementioned works, Haly Abbas' The Royal Book is best remembered as a systematic and comprehensive book on the medical arts [11]. In spite of its qualities, this work, especially its sections on cardiology, has remained largely unnoticed until now. This paper discusses the expertise of Haly Abbas on the cardiovascular
⁎ Corresponding author at: Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. Tel.: +98 913 2483359; fax: +98 711 2122970. E-mail address: [email protected] (B. Dalfardi). 0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.171
system by analysis of his sole surviving textbook of medicine, The Royal Book. 2. Biography Abū l- asan Alī ibn al-'Abbās al-Majūsī Ahvazi (? 930–994 AD), also known as al-Majūsī or al-Ahvazi, and best known as Haly Abbas in the West, was an influential Persian physician and surgeon of the 10th century CE (Fig. 1) [12,13]. His precise birthday is unknown; although it estimated to be about 930 AD. Haly Abbas' lifetime coincided with the Golden Age of Islam. He lived during an era between Rhazes and Avicenna, and was a contemporary of al-Akhawayni Bukhari [2,14]. The city of Arrajan in Old Persia was his birthplace [12]. Although Haly Abbas himself was a Muslim by faith, he belonged to a family with Zoroastrian roots. In recognition of this, he was known as al-Majūsī (the Magian, a follower of the prophet Zoroaster) [12,15,16]. Unfortunately, little is known about the biography of Haly Abbas, but it is likely that he spent his entire life in Persia [14,15]. Haly Abbas attended primary school in his native city and afterward moved to Shiraz (now in Iran) to begin his medical education under the guidance of Shaikh Abu Maher Musa ibn Sayyār (died in 983 AD), a great physician of the era [12,16]. After training in the healing arts in Shiraz, Haly Abbas left that city to go to Baghdad (today's capital of the Republic of Iraq). His residence in Baghdad provided him new opportunities and time for new endeavors. For instance, Haly Abbas was appointed court physician for Adud al-Dawla Fana-Khusraw (936–983 AD), a king of the Buwayhid dynasty in Persia. He was also a physician at Azodi Hospital in Baghdad. It was in Baghdad that Haly Abbas compiled his encyclopedic work on surgery and medicine entitled Kāmil al-Sinā'ah al-Tibbīyah (The Perfect Book of the Art of Medicine) or al-Kitāb al-Malikī (The Royal Book) [13,16].
B. Dalfardi et al. / International Journal of Cardiology 172 (2014) 36–39
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Fig. 1. Fabricated portrait of Haly Abbas (? 930–994 AD), by Mrs. Somayeh Tabatabaee (born in 1978). Reproduced with permission from the Museum of Shiraz University of Medical Sciences, Shiraz, Iran.
Haly Abbas was considered the most influential medical author and physician of his time [14,17]. He is credited with being the first scholar to reject ancient Aristotelian (384–322 BC) and Galenic (130–200 AD) principles of medicine. For apparently the first time in the Middle Ages (5th–15th century AD), Haly Abbas, on the basis of his own observations and experiences, put his efforts into introducing a new form of medicine [14,16]. Haly Abbas is remembered for his pioneering accounts in the fields of medicine and surgery. Among these are a description of uterine contractions during delivery, an explanation and method of surgical excision of goiter, advice on surgical management of the imperforate hymen and anus, and hydrocele repair [14].
3. Kāmil al-Sinā'ah al-Tibbīyah or al-Kitāb al-Malikī Kāmil al-Sinā'ah al-Tibbīyah (The Perfect Book of the Art of Medicine) was originally written in Arabic and is the only known extant work of Haly Abbas (Figs. 2 and 3). This medical encyclopedia is commonly known as al-Kitāb al-Malikī (The Royal Book) because he, in about 965 AD, dedicated it to the Buwayhid ruler Adud al-Dawla Fana-Khusraw to acknowledge the king's patronage of the arts and science. Examples of Adud al-Dawla's patronage of medicine is his founding of a number of hospitals in Baghdad and Shiraz [1,12,15,16]. The Royal Book can be divided into two sections (Juz') by content. The first section comprises 10 chapters (Maqala) and is devoted to theoretical elements of medicine. The second section consisted of the last 10 chapters and discusses practical medical issues [12,15,16]. It can be said that this work is composed of 20 chapters on a wide variety of medical subjects, including cardiovascular medicine. Each chapter begins with anatomical descriptions and proceeds to descriptions of different aspects of the disease under discussion. Topics such as preventive medicine, public health, dietetics, toxicology, clinical observations, disease managements, surgery, materia medica, and medico-ethical issues are discussed in detail in this book [12,14,16,18]. In the introduction to The Royal Book, Haly Abbas criticized the writings of prominent predecessors, including Hippocrates (460– 370 BC), Galen of Pergamon (130–200 AD), Oribasius (325–400 AD), Paul of Aegina (625–690 AD), Serapion the Elder (9th century AD), and Rhazes. In that same part of the book, Haly Abbas explains that his goal was the compilation of an encyclopedia containing the complete medical knowledge of his time [14].
Fig. 2. A page from a copy of the al-Kitāb al-Malikī (The Royal Book) (belonging to the 1726 version). This version was completed by a physician, Mu ammad 'Ā il al- abā Abā'ī. Courtesy of the US National Library of Medicine.
Constantinus Africanus of Monte Casino (1015–1087 AD) translated most of The Royal Book (particularly its discourses on surgery) into Latin in 11th century AD under the title Pantegni without attributing it to its original compiler, Haly Abbas. This event can be regarded as an early instance of plagiarism [16,19]. After this, in about 1127 AD, Stephen of Antioch (12th century AD) translated the entire text under the name of Liber Regalis Dispositionis or Liber Regius. This version was published in Venice in 1492 and again in Lyon in 1523 [13,19]. The Royal Book was reprinted over and over again in the West. In 1985, centuries after its first translation, a facsimile edition was published in two volumes [12]. This epic work served as a reference book of surgery in European medical schools for a period of time [1]. Although The Royal Book was written in a more systematic and concise way than the Liber Continens of Rhazes and a more practical style than Avicenna's Canon of Medicine, the glory of this work was overshadowed by the introduction of The Canon (completed in 1025 AD) to the medical community [1,16,20]. 4. Haly Abbas' knowledge of cardiovascular system Several pages of The Royal Book are devoted to cardiology. It includes an anatomical description of the heart and analyzed the role of the blood vessels. Haly Abbas distinguished between arteries and veins based on their wall thicknesses. The Royal Book includes anatomical illustrations of a large number of arteries and veins, some with general explanations and some in detail. One instance of Haly Abbas' precise anatomical descriptions is his explanation of the anatomy of the thoracic descending aorta: “… This vessel [aorta] moves downward; it is located on the surface of the vertebrae.
38
B. Dalfardi et al. / International Journal of Cardiology 172 (2014) 36–39
Fig. 3. A page from a copy of the al-Kitāb al-Malikī (The Royal Book) (belonging to the 1208 version). This copy was provided by the Christian scribe Tawmā ibn Yūsuf ibn Sarkis al-Masī ī. Courtesy of the US National Library of Medicine.
In describing the anatomy of the heart, Haly Abbas first explains its gross features, its anatomical position within the chest cavity, and its relation to the adjacent organs. He then discusses the structure of the heart in detail. In his opinion, the heart consists of two main cavities, one on the left and one on the right. He introduces the left side of the heart as the origin of arteries (and liver as the origin of veins). Haly Abbas noted the existence of two atriums and two auricles (in current terminology). He points out the presence of the tricuspid, mitral and aortic valves, and their one-way action. In addition, he explains that the mitral valve consists of two leaflets while the tricuspid and aortic valves have three leaflets. Haly Abbas described the presence of pericardium (all recent terms in modern nomenclature) [21]. Despite his brilliance, some of Haly Abbas' opinions on the cardiovascular system appear to be incorrect. For example, it has been claimed that Haly Abbas was probably the first figure in medical history to reject the Galenic doctrine on the presence of small pores within the interventricular septum [1,14,25]. However, in fact, a review of the text of The Royal Book shows that Haly Abbas supposed the existence of a foramen within the inter-ventricular septum that acts as the route of blood moving from the right side of the heart to the left side [21]. With the statements of Haly Abbas on the presence of a connection between two ventricles of the heart and similar beliefs with regard to this subject from al-Akhawayni Bukhari (a Persian physician and contemporary of Haly Abbas), it can be concluded that Galen's theory on the movement of blood from the right ventricle to left was still dominant in the 10th century Persian medical community [6,21,26,27]. It is worthy of note that in Haly Abbas' opinion, the pulmonary artery (in today's nomenclature) is responsible for transferring blood to the lungs, nourishing these organs and receiving the air from them [21]. 5. Conclusion
When passing through in this section, adjacent to each vertebra, one vessel branches off from it [posterior inter-costal artery] …. One type of branch is a small vessel that branches off just in front of the lung and moves toward the confluence the trachea and lungs [bronchial artery]. … Two small vessels [superior phrenic arteries] branch off and move toward the ‘Hejab-e Hajez’ [diaphragm] …”. Coronary arteries are also described by Haly Abbas in a general form. He writes: “When this vessel [aorta] originates from the heart, two arteries divide off from it; one [right coronary artery] is smaller and moves toward the right ventricle and supplies [blood to] it; the other [left coronary artery] is larger and moves proportionally to the curvature of [the left side of] the heart wall and supplies [blood to] it”. The importance of the circle of Willis was not lost to Haly Abbas. He describes it as follows: “… Two of these arterial branches are large arteries [two internal carotid arteries] that move toward the deep ‘Vedajs’ [internal jugular veins] of the neck. … The pulsing of these two vessels is palpable on either side of the neck, and these vessels are now called ‘Sobat’. … Arterial branches [along the neck] are derived from them and the rest enter the skull. … These branches merge and form a net-like structure at the base of the brain … These branches disperse into the brain to supply [blood to] it…” [21]. It is interesting to note that the term “sobat” in Arabic (spelling: )ﺳـﺒـﺎﺕmeans lethargy or sleep. It is possible that Haly Abbas was familiar with what is known today as vasovagal syncope following carotid sinus massage. For what may be the first time in the history of medicine, Haly Abbas pinpointed the presence of a connection between the arterial and venous systems; he explains: “… There are some foramina within the non-pulsating vessels [veins] that open to the pulsating vessels [arteries] …” [21,22]. This statement was made long before the theories of Ibn al-Quff al-Karaki (1233–1286 AD) (a medieval Arab physician and surgeon) and William Harvey (1578–1657) (an English physician) on the existence of capillaries [23,24].
Notwithstanding the few inaccurate opinions of Haly Abbas about the structure of the heart, possibly influenced by his predecessors' writings, it could be said that he contributed to the progress of the science of cardiology. Early on in the history of medicine, he theorized the existence of a connection between the arterial and venous systems. His knowledge of human anatomy allowed him to provide early descriptions of the circle of Willis and a large number of other arteries and veins. References [1] Shoja MM, Tubbs RS. The history of anatomy in Persia. J Anat 2007;210(4):359–78. [2] Yarmohammadi H, Dalfardi B, Ghanizadeh A, Bukhari Al-Akhawayni. Al-Akhawayni Bukhari (?–983 AD). J Neurol 2013. http://dx.doi.org/10.1007/s00415-013-7000-5. [3] Shoja MM, Agutter PS, Loukas M, et al. Leonardo da Vinci's studies of the heart. Int J Cardiol 2013;167(4):1126–33. [4] Khodadoust K, Ardalan M, Ghabili K, Golzari SE, Eknoyan G. Discourse on pulse in medieval Persia—the Hidayat of Al-Akhawayni (?–983 AD). Int J Cardiol 2013;166(2):289–93. [5] Khalili M, Shoja MM, Tubbs RS, Loukas M, Alakbarli F, Newman AJ. Illustration of the heart and blood vessels in medieval times. Int J Cardiol 2010;143(1):4–7. [6] Yarmohammadi H, Dalfardi B, Rezaian J, Ghanizadeh A. Al-Akhawayni's description of pulmonary circulation. Int J Cardiol 2013;168(3):1819–21. [7] Gorji A, Khaleghi Ghadiri M. History of headache in medieval Persian medicine. Lancet Neurol 2002;1(8):510–5. [8] Gorji A, Khaleghi Ghadiri M. History of epilepsy in Medieval Iranian medicine. Neurosci Biobehav Rev 2001;25(5):455–61. [9] Shoja MM, Tubbs RS, Loukas M, Khalili M, Alakbarli F, Cohen-Gadol AA. Vasovagal syncope in the Canon of Avicenna: the first mention of carotid artery hypersensitivity. Int J Cardiol 2009;134(3):297–301. [10] Hosseini SF, Alakbarli F, Ghabili K, Shoja MM. Hakim Esmail Jorjani (1042–1137 AD): Persian physician and jurist. Arch Gynecol Obstet 2011;284(3):647–50. [11] Frampton M. Embodiment theories of voluntary animal motion in the late Middle Ages. Embodiments of Will: Anatomical and Physiological Theories of Voluntary Animal Motion from Greek Antiquity to the Latin Middle Ages, 400 B.C.–A.D. 1300. Saarbrücken: VDM Verlag Dr. Müller/West-Germany; 2008. p. 333. [12] Hamarneh SK. Ibn al-Majūsī. Encyclopaedia of the history of science, technology, and medicine in non-Western cultures. New York: Springer-Verlag New York Inc./USA; 2008. p. 1093–4.
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