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History of Medicine

The Air of History (Part V)

Ibn Sina (Avicenna): The Great Physician and Philosopher
Rachel Hajar, M.D.
Non‑Invasive Cardiology, Department of Cardiology,
Heart Hospital, Hamad Medical Corporation,
Doha, Qatar

“Medicine is the science by which we learn the various states of the human body, in health,
when not in health, the mean by which health is likely to be lost, and when lost, is likely to be
restored to health.”
Ibn Sina, The Canon

U
ndoubtedly, Avicenna is one of the great
physicians in Islam and one of the greatest
thinkers and medical scholars in history.
Ibn Sina was born in 980 AD near Bukhara in
Central Asia (Uzbekhistan) and died in 1037 in Iran.
He was born at a time of change and uncertainty in the
Muslim world. He began his studies in medicine at the
age of thirteen. He became a distinguished physician
and his medical expertise brought him to the attention of
the Sultan of Bukhara and whom he treated successfully
for a serious infection. As reward, he asked only that
he be given permission to use the sultan’s library
Address for correspondence: Rachel Hajar, M.D., Director, Non‑Invasive
Cardiology, Department of Cardiology, Heart Hospital, P.O. Box 3050, Doha,
Qatar; E‑mail: rachelhajar@gmail.com
and its rare manuscripts, allowing him to continue his
research. He was associated with multiple short‑lived
sultanates, but relocated often, searching for a stable,
well‑paying position. At various times, he worked as
political administrator, court physician, soldier – and
occasional outcast and prisoner. During his hectic life,
he managed to write nearly 100 books, one of which was
al‑Qanun, fi al‑Tibb or The Canon of Medicine and which
was first translated to Latin in the 12th century, becoming
the standard textbook of medicine in European medical
schools and continued to be consulted in the Muslim
world well into the 20th 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.1

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Ibn Sina (Avicenna): The great physician and philosopher
From the autobiographical sketch that has come
down to us, we learn that Ibn Sina was precocious.
At the age of ten he knew the Qur ’an by heart.
Before he was sixteen, he had mastered physics,
mathematics, logic, and metaphysics and began
the study and practice of medicine. At the age of
twenty‑one, he wrote his famous “Qa’nun”, (Canon)
which remained the principal authority in medical
schools both in Europe and in Asia for several
centuries.
He served successively several Persian potentates
as physician and adviser, travelling with them from
place to place. Although he was known to be sociable,
The Canon of Medicine (Kitab al-Qanun fi al-tibb) by Ibn Sina (the
illuminated opening of the 4th book). A rare complete copy made in
Iran probably at the beginning of the 15th century.
(Source: http://www.nlm.nih.gov/exhibition/islamic_medical/
islamic_07.html)
197
he was studious and serious, devoting much of his
time to writing.
The Canon
Ibn Sina is known to the wet as Avicenna. His book,
The Canon surveyed the entire medical knowledge
available from ancient and Muslim sources at the time in
a clear and organized summary. It was originally written
in Arabic and later translated into several languages,
including Persian, Latin, Chinese, Hebrew, German,
French, and English. In addition to bringing together
then available knowledge, the book is rich with the
author’s original contributions.2
The Canon of Medicine set the standards for
medicine in Europe and the Islamic world. It is Ibn Sina’s
most renowned written work alongside The Book of
Healing.(2) Much of the book also formed the basis of
Unani (Greek) medicine, a form of traditional medicine
still taught in Islamic universities in India. The principles
of medicine described by the Canon ten centuries ago
are still taught at UCLA and Yale University, among
others, as part of the history of medicine.(2)
Avicenna’s important original contributions include
such advances as recognition of the contagious nature
of tuberculosis; spread of diseases by water and soil;
and interaction between psychology and health. In
addition to describing pharmacological methods,
the book described 760 drugs and became the most
authentic materia medica of the era. He wrote a book
on cardiac drugs, “al‑adwiyat al‑Qalbia”, which was
translated to English as “Avicenna’s Tract on Cardiac
Drugs and Essays on Arab Cardiotherapy.”3 He was
also the first to describe meningitis and made rich
contributions to anatomy, gynecology, and child
health.2
Avicenna as psychiatrist
Avicenna often used psychological methods to treat
his patients. One anecdote was when a malnourished
prince of Persia had melancholia, refused to eat and
suffered from the delusion that he was a cow. The
prince would moo like a cow crying, “Kill me so that a
good stew may be made of my flesh” and would not eat
anything. Ibn Sina 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 Ibn Sina approached the prince with a
knife in his hand, he asked “where is the cow so I may
kill it.” The patient then mooed like a cow to indicate
where he was. By order of the butcher, the patient was
also laid on the ground for slaughter. When Ibn Sina
approached the patient pretending to slaughter him, he
said, “The cow is too lean and not ready to be killed. It
must be fed properly and I will kill it when it becomes
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Ibn Sina (Avicenna): The great physician and philosopher
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.”4
The Pulse
Every beat of the pulse comprises two movements
and two pauses. Thus, expansion: pause: contraction:
pause.
Avicenna, The Canon
As a cardiologist, I was drawn to Avicenna’s
descriptions of the pulse. Taking the pulse is one
of the simplest, oldest, and most informative of all
clinical examinations. It is a key diagnostic method in
most medical traditions particularly ancient Egyptian
medicine, Chinese traditional medicine, Greco Islamic,
and Ayurveda medicine.
Throughout the history of medicine, the pulse
was an important parameter in assessing cardiac
dysfunction, and the tactile examination of the pulse
was referred to as “the messenger that never fails.”5 The
character of the pulse is still one of the most important
diagnostic clues in modern medicine. Feeling and
interpreting the pulse requires great skill. Pulse‑taking
A physician and his patient (Illustration from The Canon of Medicine
of Avicenna for the members of the Classics of Medicine Library)
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was a skillful bedside technique in Greco‑Islamic
medicine and the Middle Ages.
The Pulse and lovesickness
“The learned physician should read the happiness and
misery of the body by feeling the pulse at the root of the
thumb which stands as the witness of the soul.”
Sanscrit Law
One ailment in the history of medicine where
pulse‑taking is extremely useful was lovesickness.
Lovesickness is an illness that permeates the history
of medicine since the time of Hippocrates. Greek
physicians considered falling in love a disease that may
lead to death. Historically and traditionally, we have
metaphorically attributed feelings and emotions as if
they actually originated from the heart. The tradition
goes back thousands of years and has enriched our
language and literary heritage.
Descriptions of lovesickness have changed
extensively over hundreds of years but it may exist
today in the guise of psychiatric disorders. The ability
to diagnose it was the sign of a great physician. The
Egyptian medical tradition considered the pulse as
the sole “window” into heart for “the heart speaks out
of every limb” and hence, the diagnostic technique
employed involved pulse‑taking, which became central
to its diagnosis. Erasistratus, a Greek physician in
the fourth century B.C., and considered the father of
physiology, discovered that Antiochus, the son of King
Seleucus was lovesick for his stepmother by feeling his
pulse. One story tells how Ibn Sina diagnosed that a
Title page and spine of The Canon of Medicine of Avicenna in the
private library of Dr. H.A. Hajar Albinali.
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Ibn Sina (Avicenna): The great physician and philosopher

Avicenna’s Ten features in the Pulse

(1) The degree of expansion as estimated by its height, length, and breath. The pulse has thus nine simple and a large number of compound
varieties. The nine simple varieties of the pulse are the long, short, and medium; the broad narrow and medium. The various compound
varieties are worked out from combinations of the simple varieties. Thus a pulse which is large in length, breadth, and height is called a pulse
of large volume and one which is small in this dimensions is called the pulse of small volume. The average pulse between these two is known
as a bounding plse and that which is small in this respect is called a thin pulse. A pulse which is average of these two extremes is a medium
pulse.
(2) Quality of impact (lit. knocking at) imparted to the finger of the observer at each beat. It refers to the strength of the pulse beat as felt by the
fingers. The strength of the pulse may be strong, feeble or medium.
(3) Duration of the cycle, i.e., velocity of the pulse beat, i.e. speed. It maybe rapid or short or swift; where the movement is completed in a short
space of time; it may be slow or sluggish or long; and it maybe intermediate or moderately quick pulse.
(4) Consistence of the artery (resistance to the touch). This refers to the quality of the vessel. There are three variants: soft or easily compressible;
hard, firm or incompressible; and moderate compressibility.
(5) Emptiness of fullness of the vessel between the beats (compressibility). The pulse may be full, collapsing or medium.
(6) Temperature. The pulse may be hot, cold, or moderate in temperature.
(7) Duration of time occupied by the pauses. This refers to Rate, i.e., frequency. The pulse maybe rapid, slow, or medium
(8) Equality or inequality of force in successive beats. This is reckoned according as the successive pulses are similar or dissimilar, there being
a difference of size (large or small), strength (strong or weak), swiftness (rapid or slow; prompt or sluggish), hardness or softness, until it
happens that the second expansion of the first pulse is overtaken by the first of the next (due to excess of innate heat), or is weaker than the
next (excess of weakness).
(9) Regularity or irregularity; orderliness or disorderliness. Presence of intermissions.
(10) Rhythm; Metre; harmony; measure. Rhythm. Rhythm of the pulse is time relation between two periods of movements and the two periods of
rest. Marked deviations of rhythms indicate gross derangement in the body.
Gruner, Cameron. The Canon of Avicenna London: Leslie B. Adams Jr, 1930. Print

sultan’s wife was secretly lovesick over someone other
than her husband while feeling her pulse and asking
her questions.5
Pulses out of the Canon
Pulse‑taking has evolved in our time to a highly
sophisticated digital beat‑to‑beat display with blood
oxygen monitoring to aid us in making a diagnosis.
Hence, careful examination of the pulse is frequently
overlooked. Even though pulse‑taking is low‑tech and
inexpensive, a thorough examination of the pulse can
provide a lot of information and help form an accurate
diagnosis.
As students in medical school and during residency
training, we were taught that assessment of the
arterial pulse characteristics is an integral part of the
cardiovascular examination. Carotid, radial, brachial,
femoral, posterior tibial, and dorsalis pedis pulses
should be routinely examined – bilaterally – to ascertain
any differences in the pulse amplitude, contour,
or upstroke. Who can remember all the different
pulse findings in chronic severe aortic insufficiency?
The textbooks describe ten, yet I remember only
three (Corrigan’s pulse, bisferiens pulse, and water
hammer).
Imagine my shock and surprise on reading
Avicenna’s The Pulse in The Canon, a special edition
of The Classics of Medicine Library, from the collection
of Dr. H.A. Hajar Albinali, who kindly lent me his copy.
The title reads, A TREATISE ON THE CANON OF
MEDICINE OF AVICENNA Incorporating a Translation
of the First Book by Cameron Gruner, M.D. (Lond.)
and published in 1930. The section on The Pulse is
the most detailed and lucid discussion on the features
and characteristics of the pulse that I have ever read.
Of course, one can find numerous summaries and
commentaries on Avicenna’s pulse doctrine on the
internet and in articles published in medical journals
but you would not get the sense of erudition you get on
reading the original [translation]. It is a very impressive
piece of work. I was quite amazed. Did he personally
observe all that or he compiled various observations
from various sources? In the English translation that I
read, Dr. Cameron Gruner, the translator, has extensive
commentary and comparison to ancient Chinese
palpation and passages from Galen and other Greek
medical writers, so it is very likely that Avicenna compiled
them. Nevertheless, it is a remarkable piece of work.
The pulse section consists of thirty‑nine (39)
pages and covers the definition of the pulse; technique
in feeling the pulse; reasons for feeling the pulse at
the wrist; the emotional state of the patient and the
observer; characteristics of the pulse with detailed
explanation; discusses normal from abnormal pulse;
the varieties of irregularity; effect of age and gender on
the pulse; effect of emotion and personality; effect of
the seasons; effects of food and drink; effect of sleep;
the pulse during exercise; the pulse in pregnancy; the
pulse in pain; and the pulse in inflammation.
The most interesting is the description on the ten
features in the pulse:6 (see side bar).

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Ibn Sina (Avicenna): The great physician and philosopher
In Ibn Sina’s classification we recognize certain
types of arrhythmias such as atrial fibrillation,
premature and dropped beats. He also described
different pulses similar to pulses being observed in
arterial and ventricular arrhythmias. He described
more than fifty identifiable pulses. He distinguished
two kinds of irregular pulses: regularly irregular or
irregularly irregular, and that the difference might be
difficult to appreciate. He compared the rhythm of an
irregular pulse to the flight of the gazelle, the “pulsus
ghazalans”. The rat‑tail pulse described by Ibn Sina
is similar to what is known as “pulsus alternans”
secondary to a weakened myocardium. “You may
feel a strong pulse followed by a faint pulse. as if you
pass your hand on a rat, you feel the body, then the
tail feels small compared to the body.” Undulating
pulse, dicrotic pulse, and ventricular pulse are a
few examples of different types of pulse that were
described by him.
Ibn Sina also compared pulse rhythms to musical
rhythms. The musical character of the pulse did not
escape his attention for he was an accomplished
poet. Some of his pulse descriptions are written in
the form of Arabic poetry [the Canon was written in
Arabic].
It has been over 1000 years since Ibn Sina
described the characteristics of a normal and abnormal
pulses and how environmental and various conditions
and stimuli affect the pulse. His thesis on the pulse is
remarkable and many of his remarks on the pulse are
still true today but pathological correlation was absent.
This is because at that point in time, postmortem
examinations were not done or forbidden. Our
knowledge and understanding of the pulse in health
and disease have evolved by leaps and bounds since
then. We know so much more about the pulse now
because of the widespread availability of the ECG,
sophisticated digital beat‑to‑beat monitor display, and
electrophysiological studies. Unlike the time of Ibn
Sina, we have specific therapies for different types of
arrhythmias.
Ibn Sina and Galen
It is well‑known that the Arabs preserved most of the
wisdom and knowledge of antiquity in their writings
when Europe was plunged into the Dark Ages. The
knowledge and scholarship were re‑translated back
into Latin during the Renaissance by monk scholars,
and medicine was no exception. It is therefore
not surprising to find that Ibn Sina’s descriptions
of the pulse have been described by the Greeks
before, most notably by Galen who controlled
medical thinking for centuries. Galen’s teaching
on the pulse dominated clinical practice for about
sixteen centuries. Some of his books on the pulse
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have been lost but eighteen books are known to be
extant and are regarded as authentic.7 Many journal
articles have reproduced Galen’s descriptions. I find
the similarity in the doctrines and descriptions of
the pulse by Galen and Ibn Sina quite striking and
startling. Clearly, Ibn Sina subscribed to Galen’s
pulse doctrines.
What is felt by the fingers must be described to give
shades of meaning to a purely subjective perception.
Ancient scholars often resorted to comparing pulse
rhythms to the motion of animals and Ibn Sina was
no exception. As already mentioned, he compares
the rhythm of an irregular pulse to the “flight of a
gazelle” or pulsus ghazalans, and this was described
earlier by Galen as the “leap of a goat”, or pulsus
caprizans. Reading such pulse metaphors is rather
charming but no longer helpful in our technical‑oriented
world. Nevertheless, against a background of modern
knowledge, I still find Ibn Sina’s pulse descriptions
extraordinary.
CONCLUSIONS
Avicenna was a product of the rich intellectual,
cultural, and scientific ferment that swept the Islamic
world. He created a complete philosophical system
in the Arabic language. Among the great sages of
Islamic medicine, Ibn Sina is the best known in the
West. Considered as the successor to Galen, his
great medical treatise, the Canon was the standard
textbook on medicine in the Arab world and Europe
in the 17th century.
He was a philosopher, physician, psychiatrist and
poet. Like Galen, he devoted a large portion of his
work to the study of the pulse and his contributions to
the field of sphygmology were significant. Avicenna
comprehensively covers the subject of the pulse,
describes the technique of pulse‑taking and records
the effects of a variety of conditions on the pulse such
as environment, physical condition of patient and
emotional states such as anger, pleasure, joy, greaf and
fear. Like Galen, he describes ten features in the pulse
and more than fifty identifiable pulses. He described
different pulses similar to the pulses being observed
in arterial and ventricular arrhythmias. According to
Avicenna, vital power, resistance, and elasticity, were
important in the quality, size, and volume of the pulse.
He defined concepts such as resistance and elasticity
in a physiological manner.
Feeling the pulse is simple, fast, and inexpensive
and is still a very useful diagnostic technique. Ibn
Sina’s descriptions and concepts on the pulse are the
foundation for our current state‑of‑the‑art knowledge on
the pulse, arrhythmia, and electrophysiology. It is of course
impossible for physicians to note all the characteristics
of the pulse on palpation as described by Ibn Sina one
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Ibn Sina (Avicenna): The great physician and philosopher

thousand years ago, but still, many of his observations on REFERENCES

the pulse in health and disease are valid today.
Although many Western historians choose to
believe that the Arabs were merely transmitters of
Greek achievements, it cannot be denied that Islamic
philosophers, scientists, and physicians added their own
observations and wisdom to the knowledge that they
acquired from more ancient civilizations. They made many
original contributions to mathematics, astronomy, physics,
alchemy, optics, pharmacology, and medicine. Ibn Sina
may have been a follower of Galen but he made many
pioneering contributions. Historians agree that he is one
of the greatest thinkers and medical scholars in history.
He is rightly called the “Prince of Physicians” of his era.
1. http://en.wikipedia.org/wiki/Avicenna.
2. http://www.princeton.edu/~achaney/tmve/wiki100k/docs/
The_Canon_of_Medicine.html.
3. Hakeem Abdul Hameed, ed. Avicenna’s Tract on Cardiac Drugs
and Essays on Arab Cardiotherapy, New Delhi, India: Hamdard
Foundation Press, 1983. Print.
4. http://www.ucalgary.ca/applied_history/tutor/islam/learning/
ibnsina.html.
5. http://www.sciencemuseum.org.uk/broughttolife/themes/
diagnosis/pulseindifferenttraditions.aspx.
6. Gruner, Cameron. The Canon of medicine of Avicenna. London:
Leslie B. Adams Jr, 1930. Print.
7. http://heart.bmj.com/content/13/4/423.citation#related‑urls.

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