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Anesth Pain Med. 2014 August; 4(3): e15363. DOI: 10.5812/aapm.15363 Editorial Published online 2014 June 23.

History of Anesthesia and Pain in Old Iranian Texts

1,* 2 3 Ali Dabbagh ; Samira Rajaei ; Samad EJ Golzari

1Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, , 2Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran 3Department of Anesthesiology, University of Medical Sciences, Tabriz, Iran *Corresponding author : Ali Dabbagh, Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +98-9121972368, Fax: +98-2122074101, E-mail: [email protected]

Keywords: History; Anesthesia; Pain

There are many references in ancient Iranian litera- extended through (part of modern-day ) ture on anesthesia, analgesia and pain. Various cultural to modern-day Egypt. The most important interactions changes have occurred due to political, cultural and civil of Iranian culture in the pre-Islamic era were with the factors, one key example being the bilateral interactions ancient Greek empire, since they were the two main com- between Iranian culture and other cultures with regards peting cultures and empires of the time. On occasion, to many issues, involving medicine and medical sciences, these interactions even took the form of bloody wars. The a process that has been part of the dialogue between civi- main perspective of Iranian culture was concerning the lizations. Some aspects of ancient Iranian culture have key humanistic approaches, influencing all community been cited in Iranian literature, often involving Iranian life aspects. This is presented as the first human rights physicians. Iranian scientists of earlier times possessed a declaration on the Cyrus Cylinder, now preserved in the great wealth of knowledge in the fields of medicine, phi- of London. It contains ‘references to jus- losophy, literature, astrology, etc. and they recorded their tice and peaceful rules’ from around 550 BC. Therefore, experiences for posterity. Ancient Iranian culture cites Cyrus Cylinder is believed to be ‘an early charter of hu- the writings of many famous and great scientists and po- man rights’ (4). Large areas of Iranian science (including ets. Two main cultural eras are defined in Iranian culture: medical texts) came under the aegis of the ancient Greek pre-Islamic and Islamic. In this manuscript, the recorded Empire, following the Persepolis invasion by Alexander histories of anesthesia, analgesia and pain are followed (1-4) in 334 BC, which led to the end of the Achaemenid according to this historical classification. Throughout Empire. Ancient Greek culture had made an important the manuscript pain is frequently mentioned, because contribution to anesthesia and related issues. It has been pain is one of the key issues often mentioned in Iranian documented that in ancient times in the pre-Islamic era, literature, especially by the romantic poets, mainly as a Indian and Persian surgeons were very much respected sign of ‘’ from the ‘lover’ expressed towards the ‘be- and had operating skills regarding plastic nasal surgery loved one’. Lover in Farsi is A'ashegh and the beloved one and cataract couching (1-3). The anesthetic techniques is Ma'shough; two terms that will be mentioned through- used in this era are mentioned in texts written around out this manuscript. 1000 years later, mainly by ; a combination of cannabis and camphor used at the birth of 1. Anesthesia, Analgesia and Pain in The Pre- (which was prepared as a special wine, given to Rouda- Islamic Era of Iranian Culture beh, the birth giving mother, by a Zoroastrian), also re- corded as the first citation of an alternative method of The text of appears to be a proof of the fact childbirth, called Rostam-zad, described below. Although that general anesthesia had at least been described in an- Shahnameh is a narrative text, according to Ferdowsi its cient Farsi texts and possibly, that in ancient Iran general stories are based on the actual lives of the kings. However, anesthesia was used in surgical procedures for the first this section of Shâhnameh appears to be a proof of the time. This is described below. In 550-330 BC, under Cyrus idea that general anesthesia had at least been described and Darius, two kings of the , the in ancient Farsi texts. This issue is described further in Iranian Empire eventually became the largest and most the following pages, under Ferdowsi in the Islamic era powerful empire in human history to that point in time (4). Medicine has a very long and interesting history in (1-3). This empire stretched from the Indus and Oxus riv- ancient Iran. Some ancient academic centers like Jundi ers in the east, to the Mediterranean sea in the west, it also Shapur still exist in Iran (established in the third century

Copyright © 2014, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM); Published by Kowsar Corp. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Dabbagh A et al.

AD). These universities provided a creative environment and scientific heritage of the ancient Iran (8). The devel- for scientific research and cooperation between scientists opment of teaching hospitals, modeled with patterns from different cultures, extending throughout the - similar to modern medical schools and research activi- ic era. A key point is that ‘the credit for the whole hospital ties in the field of biomedicine, first originated from the system’ is principally due to the ancient Iran (1-4). Shahr- cooperation of scientists from different cultures at Jun- e Sukhte (Burnt City), known as the most important city di Shapur University Hospital, located in the modern- of prehistoric Iran, dating from the third millennium BC, day Iranian region of Khuzestan, during the Sasanian is located in the southeast of the country. Archaeologists Empire, in pre-Islamic Iran, eventually led to further there have found a skull that anthropologists believe to progress during the golden age of Islam, creating the be ‘the first evidence’ of brain surgeryperformance, a pro- foundations for modern academic medicine. According cedure impossible to carry out without anesthesia, from to the documents available from that period, it is pos- the prehistoric Iran (1-3); the skull of a 13year-old girl, di- sible that certain physicians in the Islamic era were able agnosed posthumously with chronic hydrocephalus (1). to perform some of the steps of inhalational anesthesia, much of this was performed at Jundi Shapur University 2. Anesthesia, Analgesia and Pain in the Hospital, which had the necessary facilities (1, 7, 8). In Islamic Era of Iranian Culture this part of the manuscript, texts related to anesthesia or pain, as recorded by some of the most famous Iranian The Islamic era is one with expanded cross-cultural in- poets and scientists are briefly presented. Ferdowsi, Avi- teractions. Islam was introduced to Iran by Arab people cenna, Rhazes, Jorjani, , Molavi, Sa'adi and Khayy- around 14 centuries ago. During the am may be regarded as being the cornerstones of the from the Arabian Peninsula throughout the other coun- Iranian culture, during the Islamic era. tries, like Egypt and Iran, encountered ‘long established civilizations and centers of learning’. 3. Ferdowsi Arabian scientists translated scientific texts from the Ferdowsi is one of the greatest Iranian poets, he wrote original languages, into (5). After acceptance of his masterpiece Shâhnameh (The History of the Kings) Islam, Iranians experienced many changes in the fields around 1000 AD. In this book, he talks about Iran’s past of language, culture and science. Many scientists flour- both mythically and historically, before and until the 7th ished, following the teachings of Islam that encouraged century, the period when Islam was introduced to Iran. science, serving others and saving lives, as valued crite- In the stories of Shahnameh the use of medicine, includ- ria (6). ‘Whoever resuscitates a human life (his work) is ing that of the poppy (used orally for pain relief and exactly the same as he has resuscitated the whole man- creating a sense of well-being), has been described. One kind’ is an instance from what the says, regard- of the heroes of Shahnamehis Rostam, who was the son ing the mentioned subjects. (Chapter 5, Verse 32). This of Zaal. , the grandfather of Zaal, was a special citation is clear about the invaluable role of resuscita- guardian of the country and an ancient Iranian hero: in tion.There is one very important point to be mentioned Shahnameh the country is named ‘Iran-zamin’ [the land here, before citing the key scientists and poets: the role of Iran) (1, 4). Zaal’s wife had a very difficult childbirth of the geographical map in relation to ancient Iran. As with Rostam, following which Zaal burned one of the we know, the current national and political geography three remaining feathers of Simorgh (the mythical bird of the countries, recognized by the nations and their in Shâhnameh, related to the Greek Sphinx), which then governments, differs from that in existence many cen- led to the appearance of Simorgh, who created a novel turies before. The ancient Iranian empire borders have method of delivering a baby via the abdomen, which been considerably extended, both eastwards and west- many decades later became known as a wards, from the time of the Achaemenid Empire and (‘Rostam-zad’ in Shahnameh). Zaal used a combination over many centuries throughout the Islamic era (7). The of cannabis and camphor to ameliorate the surgical pain Persian Empire was founded around 550 BC by Cyrus II (4). In another section of Shâhnameh, the adult Rostam and extended by Darius I, therefore, while the scientists becomes the chief guardian of the country. In one of the and poets from ancient times may be described as Ira- greatest and best-known passages in Shâhnameh, Rostam nian, the cities they inhabited may not be within the quarrels with his son, , failing to recognize each modern-day borders of Iran. This is also the case with other after long living apart. Following this lengthy quar- ancient Greek and Roman cities. A number of Mediter- rel, Rostam eventually kills Sohrab, but on realizing that ranean cities in various countries, according to modern his adversary is in fact his son, tries to treat and save him. geographical and political maps, were previously under He asks the king to send a pain relief and a life-saving an- Greek jurisdiction. However, for the purposes of this tidote (‘Noosh-Daru’), but the medications arrive too late manuscript we will not discriminate on such grounds. to save Sohrab and he dies. Rostam, although grief-strick- Fortunately, a number of other nations and countries en, saves his country (4). In ShahnamehFerdowsi tells us developed from the divided Persian territory and share more about real somatic pain and its treatments, rather the common bond of an association with the cultural than the pain love (4).

2 Anesth Pain Med. 2014;4(3):e15363 Dabbagh A et al.

4. (Aka Pouresina or IbnSina) are considered to be among his discoveries or are attrib- uted to his writings, including smallpox, measles, alco- Avicenna, who lived in the 10th and 11th centuries, is well hol and many discoveries in the field of chemistry (11, 12). known as the father of modern medicine. He was not only His writings are recorded in over 200 books and articles. a physician, also an Islamic scholar, psychologist and theo- He is considered the first physician to have used opium logian, an astronomer, a chemist, a geologist, a physicist, a for anesthesia and was also a great neurosurgeon, having teacher, a paleontologist, a logician, a mathematician and described his methods for the diagnosis and treatment of a poet. Avicenna is known to be the most influential and hydrocephalus (13). He was not only the first to discover famous scientist from the golden age of the Islamic era. alcohol, he also used it for the first time in the field of Avicenna’s tomb is located in Hamadan, a city in north- medicine. His writings were frequently cited later in Eu- western Iran. Many citations state that both Avicenna and ropean texts (5, 11-14, 20-22, 24,25). Rhazes were Iranians (9-14). A number of Western research- ers also believe that Avicenna was born in Persia and that 6. Jorjani his most famous text, translated as Canons of Medicine, was the main medical textbook in Persia and Europe for Esmail Jorjani was a Persian physician and anatomist over 500 years (15-18). Avicenna adopted the theory of epi- who lived in the 11th and 12th centuries. He wrote a com- demics from the Greeks. The Canon of Medicine was the prehensive textbook of medicine, Zakhire-ye Kharazm- first text to describe experimental medicine, including shahi (The Treasure of King Kharazm), considered being evidence-based medicine, randomized controlled trials the oldest Persian medical textbook (11). Among the many and related issues. In addition, he established seven basic topics in this book, one might mention his comprehen- rules for testing the effectiveness of new drugs and medi- sive description of the cranial nerves, in which he gave cations, leading to a modern basis for clinical pharma- a comprehensive explanation of trigeminal neuralgia, cology and medical trials (19-21). The scientific citations hemifacial spasm and Bell's palsy (5, 12, 13). Some believe attributed to Avicenna include the following techniques: he was the first to recognize ‘artery-nerve conflict’, as tracheotomy, pharyngeal intubation and a method for one of the causal factors of trigeminal neuralgia, docu- clearing the secretions of the upper airway in stridor and mented in Zakhire-ye Kharazmshahi. Additionally, some respiratory distress. He also discovered and described a believe that this theory was later adopted by Dandy and number of plants having pharmacological effects, like Jannetta, as a part of their theory for the modern surgi- opium; and introduced a number of methods for anes- cal approach used in trigeminal neuralgia. Among the thesia induction and surgical analgesia implementation other interesting topics covered by Jorjani in this book, (22, 23). His recommended analgesic techniques included regarding pain, are his writings on obstetrical pain and drug-impregnated sponges and compresses, ointments, the complications of childbirth (5, 11-14,20-22, 24,25). oils, aroma therapeutic salts and drinks, smoke, pills and 7. Molavi many more. These methods of analgesia demonstrate not only the depth of knowledge of Avicenna, but also his abil- Molavi (Jalal-ad-Din Mohammad Balkhi, aka Mowlana or ity to put that knowledge into practice. Analgesia-related ) was a Persian Muslim poet and an Islamic theolo- references to Avicenna are numerous. He wrote of three gian, living in the 13th century. The location of his birth pain-alleviating groups of drugs: 1) those that counter- and the native language used throughout his various act and nullify pain, like fennel or linseed, used directly texts, indicate that he was of Persian heritage. He was born as a poultice on the painful region; 2) those that induce in either Wakhsh or (then both located in Khorasan, sleep and decrease activity levels, like inebriants, milk and a province of Iran, but now in modern-day Tajikestan and sweet water; and 3) those that decrease the perception of , respectively). He was buried at (in pain, like narcotics and somniferous agents (24). Avicen- modern-day Turkey). The majority of his books and nearly na also described a method for rendering a person uncon- all of his poems have been published in modern Farsi. He scious and hence oblivious to pain, using opium, henbane is cited many times with regard to pain and its alleviation and mandrake. Avicenna listed 15 different types of pain: through the use of opium and wine, especially in his po- boring, compressing, corrosive, dull, fatigue, heavy, inci- ems on . His writings are too numerous, extensive sive, irritant, itching, pricking, relaxing, stabbing, tearing, and broad-ranging to be summarized in this article (14). tension and throbbing (9, 10). 8. Sadi 5. Rhazes The following well-known verse written by the poet Rhazes, who lived in the 9th and 10th centuries, was a Sa'adi can be found as a general humane concept among Persian physician, chemist and scholar and also a great all the human being: The sons of Adam are organs of the medical teacher. He was born and died in Rey, near Teh- same body; for they are created from the same essence. ran, the modern-day capital of Iran (11, 12). Some believe Should an organ be afflicted by pain of the era, the other he was possibly ‘the greatest clinician of all time’ (21-22). organs would not be calm and silent if you disregard oth- Many ‘firsts’ in chemistry, medicine and medical research er people's sorrowfulness you are not eligible to be called

3 Anesth Pain Med. 2014;4(3):e15363 Dabbagh A et al. a human being. Sa'adi was a very famous Iranian poet who technical and material support and study supervision. lived in the 12th and 13th centuries in , one of the Samira Rajaei took part in study concept and design, main cities of ancient and modern Iran. In Iranian culture acquisition of data, analysis and interpretation of data, and literature, the writings of Sa’adi are among the best drafting of the manuscript, critical revision of the manu- known. Much of his writing was in the form of or of script for important intellectual content, administrative, prose, containing poetry. His fictional work embraced the technical and material support and study supervision. topics of pain, anesthesia and medical ethics (25). Samad EJ Golzari: took part in drafting of the manuscript, critical revision of the manuscript for important intellec- 9. Hafez tual content and technical support. Hafez, one of the greatest Farsi-speaking poets, lived in References Shiraz in the 14th century. In his romantic poems, he fre- Middle East J Anaesthe- 1. Dehesh S. Pre-Islamic medicine in Persia. siol. 4 quently documented the pain which the lover (A'ashegh) 1975; (5):377–82. experiences on account of the distance, separating him 2. Astyrakaki E, Papaioannou A, Askitopoulou H. References to anesthesia, pain, and analgesia in the Hippocratic Collection. from his beloved (Ma'shough). Since the lover wishes and Anesth Analg. 110 hopes to be reunited with his beloved, he believes that 2010; (1):188–94. 3. Askitopoulou H, Ramoutsaki IA, Konsolaki E. Analgesia and an- his suffering (pain) is not intolerable and does not wish esthesia: etymology and literary history of related Greek words. Anesth Analg. 91 it to be treated, in order that she will never be out of his 2000; (2):486–91. Anesth 4. Dabbagh A, Elyasi H, Rajaei S. Anesthesia in ancient Iran. thoughts. Hafez wrote: Analg. 111 2010; (2):584. BMJ. 331 It is better for me to have my pain hidden from interfer- 5. Majeed A. How Islam changed medicine. 2005; (7531):1486–7. ing physicians,would it be that I get treated by the hid- 6. Wujastyk D. A Persian anatomical image in a non-muslim manu- Med Hist. 51 den treasures (of ). He has many other poems regard- script from Gujarat. 2007; (2):237–42. 7. Afshar A. Honoring Avicenna, the great Persian physician on the ing pain and anesthesia (5). Arch Iran Med. 13 world's postage stamps. 2010; (5):447–53. 8. Modanlou HD. Historical evidence for the origin of teaching hos- J Perina- 10. Khayyam pital, medical school and the rise of academic medicine. tol. 31 2011; (4):236–9. Khayyam was a poet, mathematician, philosopher, mu- 9. Sajadi MM, Mansouri D, Sajadi MR. Ibn Sina and the clinical trial. Ann Intern Med. 150 sician, astrologist and Islamic scholar, living in the 11th 2009; (9):640–3. 10. Nasser M, Tibi A, Savage-Smith E. Ibn Sina's Canon of Medicine: and 12th centuries. He wrote a number of scientific and J R Soc Med. 11th century rules for assessing the effects of drugs. 102 literary texts on many subjects, including mathematics, 2009; (2):78–80. algebra and calculations. He also prepared a revised ver- 11. Aciduman A, Belen D. Hydrocephalus and its treatment accord- J Neurosurg Pediatr. 3 sion of a calendar, still very accurate today. His poems are ing to Rhazes. 2009; (3):161–5. 12. Hosseini SF, Alakbarli F, Ghabili K, Shoja MM. Hakim Esmail Jor- Arch Gynecol in the form of quatrains (originally called Rubaeiyat), jani (1042-1137 AD: ): Persian physician and jurist. Obstet. 284 in which he frequently makes reference to pain and its 2011; (3):647–50. alleviation by opium and wine. One of the best known 13. Shoja MM, Tubbs RS, Khalili M, Khodadoost K, Loukas M, Cohen- Gadol AA. Esmail Jorjani (1042-1137) and his descriptions of tri- translations of his book of poems into English was done Neurosur- geminal neuralgia, hemifacial spasm, and bell's palsy. gery. 67 byEdward Fitzgerald, in the 19th century (26). 2010; (2):431–4. Rumi: Past and Present, East and West. 14. Lewis FD. : Oneworld Publi- 11. Others cations; 2000. 15. Aziz E, Nathan B, McKeever J. Anesthetic and analgesic practices Am J Chin Med. 28 in Avicenna's Canon of Medicine. 2000; (1):147–51. There many other remarkable texts by ancient Persian J Invest Surg. 16. Qayumi AK. Avicenna: a bright star from the east. physicians and writers, citing the Iranian physicians quo- 11 1998; (4):243–4. Clin Pediatr (Phila). tations, among which are so many poets, making it hard 17. Smith FR, Jr. More on Avicenna and Shiraz. 3 to mention all, individually. They have written in Farsi 1964; :508. Clin Pediatr (Phila). 3 on anesthesia, pain and analgesia, in the ancient Persian 18. Ziai M. Avicenna. 1964; :120–4. 19. Hamidi S, Sajjadi H, Boroujerdi A, Golshahi B, Djalilian HR. Otol Neurotol. texts, under the umbrella of Islamic medicine, Islamic Avicenna's treatise on otology in Medieval Persia. 29 Science and Islamic knowledge (5, 20-22,24). 2008; (8):1198–203. 20. Golzari SE, Khan ZH, Ghabili K, Hosseinzadeh H, Soleimanpour H, Azarfarin R, et al. Contributions of Medieval Islamic physicians Acknowledgements Anesth Analg. 116 to the history of tracheostomy. 2013; (5):1123–32. 21. Broumand V, Keyhani S, Broumand B. The importance of origins? The authors would like to thank the kind efforts and Science. 309 2005; (5741):1673–5. help given by Professor Steven Shafer, in the preparation 22. Broumand B. The contribution of Iranian scientists to world civi- Arch Iran Med. 9 of this manuscript. lization. 2006; (3):288–90. 23. Aciduman A, Belen D, Simsek S. Management of spinal disor- Neurosurgery. Authors’ Contributions ders and trauma in Avicenna's Canon of medicine. 59 2006; (2):397–403. 24. Rangappa P. History of analgesia and regional anaesthesia Ali Dabbagh took part in study concept and design, Anaesth Intensive Care. 36 Suppl 1 through philately. 2008; :12–8. acquisition of data, analysis and interpretation of data, Sa'di, the Poet of Life, Love and Compassion (A com- 25. Katouzian H. prehensive study of Sa'di and his works). 2006. drafting of the manuscript, critical revision of the manu- : ISBN 1-85168-473-5. The Columbia Encyclopedia. script for important intellectual content, administrative, 26. Khayyám O. 6 ed; 2001.

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