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SPECIAL FEATURE

Avicenna (AD 980 to 1037) and the care of the newborn infant and breastfeeding
HD Modanlou
Division of Neonatology, Department of Pediatrics, University of California, Irvine, CA, USA Avicenna was born in 980 AD in Afshana, near Bukhara, Iran (now part of Uzbekistan) into a Persian family (his mother tongue was Farsi or Persian) and died in 1037 AD while traveling from central city of Esfahan to Hamadan, located in western Iran, where he is buried. He lived in the fourth century of the Islamic era, the ourishing Abbasid (Islamic caliphate-dynasty-rulers) period in regard to learning and knowledge. Islamic culture reached its peak around the time of Avicennas birth and in subsequent years.3,4 His earliest education was in Bukhara under the direction of his father, who was the governor of a village in one of Nuh ibn Mansurs estates. Since the house of his father was a meeting place for learned men, from his earliest childhood Avicenna was able to prot from the company of the outstanding masters of his day (Abu Bakr Ahmad b. Muhammad al-Barqi al-Khwarizmi: Arabic and Quran; Mahmud al-Massah: philosophy, geometry, mathematics, arithmetic, algebra and astrology; Ismail al-Zahid al-Bukhari: Islamic law and Susm; and Abu Abdallah al-Natli: philosophy). A precocious child, gifted with an exceptional memory that he retained throughout his life, he had memorized the Quran and much Arabic poetry by the age of 10 years.1 Regarding the learning of medicine, Avicenna says Then I desired to study medicine, and took to reading the books written on this subject. Medicine is not one of the difcult sciences, so naturally I became procient in it in the short time, until the excellent scholars of medicine began to study under me. I began to treat patients, and through my experience I acquired an amazing practical knowledge and ability in methods of treatment.3 His intellectual development was signicantly aided by his access to the rich royal library of the SamanidsFthe rst great native dynasty that arose in Iran after the seventh century AD Arab conquest of the Persian Empire. Before he was 16 years, he had mastered what was to be learned of Greek, Latin, physics, mathematics, logic and metaphysics; at the same age, he began the study and practice of medicine; and before he had completed his 21 years, he wrote the Canon of Medicine. The latter and part of his other writings were translated into Latin toward the end of twelfth century AD by Gerard of Cremona, Dominicus Gundissalinus and John Avendeath.5 The Canon of Medicine became a reference source and the principal authority for medical studies in the universities of Europe and Asia

A brief historical review of medicine during the fourth century Islamic civilization or eleventh century AD in Persia or Iran was undertaken with its focus on Avicenna. A physicianphilosopher, named Ibn Sina or Avicenna (980 to 1037), followed and further expanded the tradition of western philosophy and medicine by Aristotle, Hippocrates and Galen. Avicenna, a physician, philosopher, astrologist, anatomist, pharmacologist, ethicist and poet wrote, the Canon of Medicine, the most comprehensive medical textbook of its time. This important textbook was extensively used in European medical schools for centuries after Avicennas death. In the Canon of Medicine, a chapter is dedicated to the care of the newborn infant dealing with hygiene, breastfeeding and upbringing of the child. Journal of Perinatology (2008) 28, 36; doi:10.1038/sj.jp.7211832; published online 6 September 2007

Keywords: Avicenna; Canon of Medicine; Breastfeeding; Islamic medicine

Historical background Ibn Sina (Farsi), in full Abu Ali al-Husayn ibn Abd Allah ibn Sina (Arabic), a Persian/Iranian physician, known in Europe as Avicenna, is one of the most famous and inuential of the philosopherscientists of Islam. He was particularly noted for his contributions in the elds of Aristotelian philosophy and medicine. He composed the Kitab al-Shifa (Book of Healing), a vast philosophical and scientic encyclopedia, and the Canon of Medicine (both texts were written in Arabic), which is among the most famous books in the history of medicine.1 This massive general medical encyclopedia consists of ve books. It was composed, starting about 1012 AD, over a lengthy period of time as Avicenna moved westward from Gurgan in northern Iran, where the work was begun, to Ray near modern Teheran and then to Hamadan.2
Correspondence: Dr HD Modanlou, Division of Neonatology, Department of Pediatrics, University of California Irvine Medical Center, 101 City Drive South, Building 56, Suite 600, Orange, CA 92868, USA. E-mail: modanlou@uci.edu This work was presented at the 2007 Pediatric Academic SocietyFSociety for Pediatric Research meeting, Toronto, Canada.
Received 17 July 2007; revised 1 August 2007; accepted 7 August 2007; published online 6 September 2007

Avicenna: care of the newborn HD Modanlou

from the twelfth century until the end of the seventeenth century.3,5 Between 1500 and 1674, some 60 editions of part or whole of the Canon of Medicine were published in Europe, mostly intended for use in university medical training.2 A Latin copy of the Canon of Medicine, dated 1484, is located at the PI Nixon Medical Historical Library of the University of Texas Health Science Center at San Antonio (TX, USA). In 1977, the Institute of the History of Medicine and Medical Research of New Delhi assembled a team of translators to do an English translation using the Istanbul manuscript of 1220 6 AD, the oldest extant manuscript of the Canon. Another English translation of Book 1 of the Canon of Medicine was published in 1999.7 Avicennas view of medicine was based on the synthesis of Aristotelian natural philosophy with Galenic humoral physiology. At the same time it draws on clinical experience in the Hippocatic tradition and comparative assessment of observational experiments.8 The Canon of Medicine was the nal codication of Greco-Islamic medicine. The rst four books were based on the principles of Galen and Hippocrates, with the addition of the teachings of Islamic physicians and Avicennas own observations. The fth book, a formulary of drugs, was a new Islamic contribution to medicine of inestimable importance.9 Like another Persian alchemistphysicianphilosopher Mohammad Zakariyya Razi or Rhazes (865 to 925 AD), Avicenna challenged the thoughts and writings of Socrates, Aristotle and Galen regarding the dichotomy of the mind and body and espoused the concept of mental health and self-esteem as being essential to a patients welfare. He noted the close relationship between emotions and the physical condition and felt that music had a denite physical and psychological effect on patients. Furthermore, he stated that the etiology of the disease must be understood; only then is it possible to begin treatment. Characterization of Avicenna The formative period of western intellectual tradition would be difcult to imagine without Avicennas inuence on specic individuals in addition to his many-layered complex legacy in diverse areas.8 Avicenna was one of the most brilliant gures in the history of medicine. He was described as having the mind of Goethe and the genius of Leonardo da Vinci.9 Dante acknowledged him in the Divina Comedia, and Chaucer in the Canterbury Tales. No Moslem or Oriental scholar has attained as high a reputation and as strong and lasting inuence in the west as Avicenna, who has been called the second teacher after Aristotle.1012 Avicenna was the most famous in a series of Muslim physicianphilosophers who preserved Greco-Roman knowledge and wisdom during the Dark Ages that followed the collapse of the Roman Empire. Having translated to Arabic and to Latin most of the writings of Greek philosophers and physicians, they enriched the writings with their own observations and interpretation. This information was again
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inuential on western civilization ve centuries later at the coming of the Renaissance.13 Avicenna was revered by his contemporaries who named him the Prince of Eastern Philosophers and Physicians.13 William Osler has described Avicenna as the author of the most famous medical textbook ever written. He noted that the Canon remained a medical bible for a longer time than any other work.14 Avicenna became to be known as the doctor of doctors.15 Darmani16 states Avicennas Canon of Medicine is thought to be the most famous medical textbook ever written. European medical historians consider him to be one of the most famous scientists of Islam. Perhaps, the best characterization of Avicenna can be found in a letter written by John Urquhart, professor of biopharmaceutical sciences, University of California at San Francisco, to the British Medical Journal in 200617 regarding how Islamic scholars changed medicine. Ibn Sina (Avicenna) saw medicine and surgery as one. The letter contrasted Ibn Sinas Canon of Medicine with Oslers Principles and Practice of Medicine. The author wrote:
I asked if the year were 1900 and you were marooned and in need of a guide for practical medicine, which book you would want by your side? My choice will be Ibn Sina. A leading reason is that Ibn Sina gives an integrated view of surgery and medicine, whereas Osler largely shunned surgical intervention. Ibn Sina, for example, tells how to judge the margin of healthy tissue to take with an amputation, a basic topic uncovered by Osler.

The letter concluded that, the gap between medicine and surgery is now closing, with the advent of interventional cardiology, gastroenterology, radiology and other procedural specialties, a synthesis that Ibn Sina correctly foretold in seeing medicine and surgery as a one therapeutic whole. Avicennas portrait hangs in the hall of the Faculty of Medicine in the University of Paris. Care of the newborn infant The Canon of Medicine, Book 1, contains four chapters on the hygiene of newborn infants, including the disease of infancy, and the care of the newborn infant, the period from birth to the commencement of weaning. What follows is an abbreviated version of what appears in the Canon of Medicine.
Care of the umbilical cord: Immediately after birth the umbilical cord should be cut at a point four ngers breadth from the umbilicus tying it with a clean woolen thread so soft and lightly twined that it does not produce any injury. Avicenna does not specify what instrument should be used to cut the umbilical cord (It is known that he performed surgery. His surgical instruments are conserved in a museum in Bukhara, Uzbekistan). The end of the cord is dressed with a clean piece of cloth soaked in olive oil. To assist healing, the cut surface should be dusted with a ne powder made of equal parts of tumaric, dragons blood (a resin from dark-red plant product), cumin seed and lichen. When the cord is separatedFand it generally happens in three to four

Avicenna: care of the newborn HD Modanlou

daysFthe navel is dusted with the ashes of oyster shell, burnt tendon of a calfs heel, or burnt zinc dissolved in alcohol. (Although Avicenna has described transmission of diseases by dirty water and soil, he did not mention about infection related to the umbilicus. He also described puerperal tetanus as a complication of difcult labor). Swaddling: The nurse should handle the limbs gently and mold the various parts according to their shape, spreading out those which should be at and thinning the ones which are to remain slender. The head should be covered with a light turban or a properly tting cap. Eyes: The eyes should be carefully wiped with a soft silken cloth. A few drops of olive oil should be dropped in the eyes. Bathing: The face and body of the newborn should be bathed in salt water to harden the skin and set the features. Care should be taken to protect the nose and mouth while washing the face. Bath is best given after a spell of sound sleep and there is no harm if it is repeated 2 or 3 times a day. In summer, the water should be tepid and in the winter lukewarm. Sleeping Quarters: The nursery should be warm and airy, but dark and shady rather than bright and glary. During sleep, the head should be kept slightly elevated and care taken to avoid twisting the body. Breastfeeding: The baby should be nourished as far as possible, from the mothers breast. Having received its nourishment in the womb from her menstrual blood, the mothers milk, which is really another form of the same, is naturally the most suitable for the further growth and development of the baby. It is generally observed that the baby gets readily quiet after receiving the mothers breast. If the milk is inclined to be sour, breast feeding should be avoided. Gentle rocking and the customary lullabies help to induce sleep and strengthen the constitution. This should, however, be within the limits of tolerance of the baby as observed from his physical and musical responses. The former (breast milk) relates to the development of the body and the latter (music) to that of the mind. A small quantity of milk should be squeezed out before each feed and especially before the morning feed. This helps the ow of milk and saves the baby from unnecessary strain and exertion. Massage of the breasts enhances the production of milk. The nursing mother should take moderate exercise and eat wholesome food. A little crying before the feeds is generally benecial to the baby. Vegetable such as watercress, mustard, wild basil, and to some extend, even mint are best avoided, as they are not good for lactation. The nursing mother should take plenty of rest and avoid work and excessive exercise. If there is no contra indication, she should drink sweet wines and grape juice and have plenty of sleep. Weaning: When the incisor teeth begin to erupt, milk feeds should be gradually supplemented with things which are not too hard and difcult to masticate. A normal period of nursing should be two years. Wet-Nurse: When for the reason of health or because of some abnormality in the milk, or for the sake of her own comfort the mother herself is unable to nurse the baby, a wet-nurse should be

employed. This wet-nurse should be suitable in respect to her age, physique, shape of breasts, quality of her milk, and the time elapsed since her connement. The nurses own baby should neither be quite grown up, nor less than one or two months old. It would be the best if her own baby, is also of the same age as her charge. Her age should be between 25 to 35 years, when women are at the height of their youth and vigor. Her milk should be moderate in quantity and consistency. It should be white rather than dark and never greenish, yellowish or reddish in color. The odor should be agreeable and not acrid or pungent. The taste should be sweet and not bitter, salty or sour. It should be homogeneous and plentiful and not too watery nor too thick, cheesy or frothy. The nurse should be cheerful and of good moral character and not liable to emotional outbursts of anger, grief or fear which tend to undermine character and affect the baby adversely in other ways. It is for the same reason that the Holy Prophet prohibited the employment of mentally deranged women as wet-nurses. A nurse of bad character cannot be trusted to give conscientious care of the baby. The nurse should take moderate exercise and eat wholesome food which gives good chime like wheat, frumenty, and lamb, kid of goats which are not putrescent or have hard esh, lettuce, almonds, lbert-nuts, and mint. She should abstain from sexual intercourse during the nursing period, as this activates the menstrual blood and makes the milk foul and reduces its quantity. It may also lead to new pregnancy which would be injurious both to the baby at the breast and the fetus in the womb. The baby suffers because the mothers blood gets diverted towards the fetus and the fetus suffers from inadequate nutrition as it has to be shared with the baby.7

Conclusion Islamic civilization originating in the Arabian Peninsula in the seventh century AD, rapidly expanded its domain northward to the vast Persian Empire and westward to Syria, Palestine, North Africa and eventually to Spain, all with preexisting rich historical and cultural traditions. From the beginning of Islamic civilization, the acquisition of new knowledge in medicine, philosophy, mathematics, astronomy, metaphysics and literature was encouraged and became part of societal culture. The rst dynastic rulers or caliphate moved the center of power to Damascus, Syria. A second caliphate subsequently moved to Baghdad, in Mesopotamia. The Islamic civilization reached its zenith during the second caliphate during the reign of Haroun al-Rashid. During this period, every Greek text was translated to Arabic and then to Latin. Hospitals and medical schools were established in the cities of Baghdad and Rey. Every major province of the Islamic domain had libraries and center of learning. The learned men or masters had high social status and privileges. It was in that cultural milieu that a child prodigy like Avicenna could express his genial talent. Some 240 to 450 texts, in variety of subject matters were written by Avicenna, some voluminous as the Book of Healing and the Canon
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Avicenna: care of the newborn HD Modanlou

of Medicine. For the early eleventh century, Avicennas knowledge and practice of medicine was vast and very advanced. His knowledge of human physiology and anatomy with precise description of the optic and recurrent laryngeal nerves, and surgical interventions such as removal of diseased gallbladder are examples of his prowess. Avicenna advocated the use of music for some psychiatric illnesses. His recommendations for the care of the newborn infant and the importance of neonatal and maternal hygiene and proper nutrition for both are being applied, encouraged and supported today. From the foregoing, it is evident that Avicenna emphasized the importance of breastfeeding. His description of the wet-nurse and the age of her own child implies that she should also breastfeed her own baby. There is no mention of an alternative feeding regimen such as animal-derived milk. During the past few decades, the American Academy of Pediatrics and the American College of Obstetrics and Gynecology as well as many other organizations have developed recommendations and educational services in support of breastfeeding.1820 It is remarkable to note that a millennium before, Avicenna recognized the nutritional and psychological benets of breastfeeding and suggested that as far as possible, the newborn infant should be nourished from the mothers breast. Furthermore, he also emphasized the importance of music during breastfeeding for the proper development of the mind. References
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