Hajar Ahmed AlBinali, MD

Case History

A 30-year-old male poet, desert dweller called Qais, complained that intense love was driving him to madness.

At the age of ten, while taking his family goatherd to a grass area at the periphery of his town, he met a girl of his age, who also was taking her family’s goats to graze. The girl was a relative named Lila. She was from his town. After several such a daily meetings over several months, he fell in love with her. He recalled those early days in one of his poems:

I fell in love with her When she was small. Her breasts did not bud, As her playmates could recall.

That day was remote, But tears choked my throat When I remembered, How we tended a small goat.

Our love, like us, grew. It is old, it is new; I wish neither of us grew, Nor did the goats too.

As Lila grew older she was not allowed to graze the goats. Qais used to visit Lila while she was sitting with the other girls of the neighborhood.

One day Qais rode his camel and went to visit Lila and her girlfriends in an open area near the town. Qais was a poet but wrote only love poems. He recited his poem to the girls. When the girls got hungry, he butchered his camel and sat up a fire. Lila helped him cut the meat. While he was talking to Lila and cutting the meat, he cut his hand. She took the knife from his hand and tied his wound with a piece from her cloth. He was totally unaware of the cut and did not feel pain. Lila chose a piece of meat over the fire for herself. She asked Qais to see if the meat was cooked. He stretched his bare hand in the fire, turning and examining the piece of meat without feeling the heat. Lila had to pull his hand out of the fire.

Lila also loved Qais. Once, Qais’ father sent him to Lila’s house to ask for some oil for guests. Qais carried out his father’s request with pleasure. His uncle, Lila’s father, ordered Lila to pour oil for Qais. While she was pouring from their container to Qais’ container, they were talking and they forgot what they were doing. So, most of the oil spilled and soaked their feet over the sand.

Qais’ love poems for Lila spread all over their town. Lila’s father was unhappy with the exposure of his daughter as a love figure in Qais’ poems. Arab tradition does not view a girl praised in poems with respect. When Qais’ father asked Lila’s father the hand of Lila for Qais, he refused. He considered it shameful to allow his daughter to marry a man who had written poems about her. He forbade his daughter from seeing Qais. He obtained a proclamation that Qais may be killed if he met with Lila. Qais cried day and night. He said:

 

My life to Lila, I gave,

If from Lila I am deprived,

Bring my coffin and dig my grave,

Because my death has arrived.

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Qais became very disturbed. He cried with excessive tears. He could not eat or sleep. He became very thin and weak. Many traditional doctors saw him. He was treated with witchcraft, fire sticks and some elixirs. Nothing helped. Once, he forced himself to sleep in the hope that he and Lila will meet in the dream. He mentioned the incident in a poem dedicated to Lila:

 

I lay down under the moon’s beam,

While love thoughts flowed in a stream.

I forced myself to sleep,

Hoping to see you in my dream

 

Lila and her family migrated away from Qais town to prevent Qais from visiting Lila. She was forced to marry another man.

Qais became absent-minded. He could not concentrate on anything other than Lila. He was totally obsessed with his love for Lila. No one could draw his attention unless Lila’s name was mentioned. He became alert and talked normally only when he heard Lila’s name.

In his poems, he expressed his intense love, his feelings, and sensations such as palpitations, fainting, tears, sadness, anxiety, despair, sleeplessness, weight loss, and his death wish.

Qais father took him to Mecca to pray for him near the holy Ka’aba. He told Qais to touch the Ka’aba and say: O’ God, cure me of my love for Lila. Qais obeyed his father, touched the Kaaba, but said: “O’ God make me love Lila more and never let me forget her.”

Qais left his family and lived in the desert, away from people. He refused to talk to people or return to town. Some people would trick him to talk to him by mentioning Lila’s name or tell him that they saw Lila. His family sent food and water to him and left them at a place where he could see them.

Lila was not happy with her husband. Her love for Qais made her husband jealous. She missed Qais very much. She fell ill and became seriously sick. She was treated by a local physician but she did not get well. A man passing through the desert informed Qais that Lila was ill and sad. Qais fainted when he heard the news. When he regained his consciousness he cried and said:

 

Lila, they say, is ill And in a sad condition,

I wish I were, her treating physician.

 

Lila’s family took her to Iraq where the old traditional Babylonian physician practices mainly witchcraft medicine. She did not recover from her illness despite all types of traditional treatment. She died.

Shortly after Lila’s death, Qais was found dead in the desert. When he was bathed before burial, a piece of rug containing his last poem was found in his cloth. The poem read:

My heart is firmly seized By a bird’s claws. My heart is tightly squeezed When Lila’s name flows.

My body is tightly bound When the wide world I found Is like a finger ring around

Based on the above information, I had to issue a death certificate for Qais:

Love in the history of medicine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The above love story of Majnoon Lila is well known across all levels of society in the Arab world. The story is famous in Arabic literature as well as in Arab folk stories. The first time I heard the story was when I was seven years old. A lady was reading the story to a group of women including my mother. The sad parts of the story made me cry at that early age of my life. The women told my mother: “Your child will fall in love.”

I recently analyzed the poems of that poet, Qais, and made a diagnosis of organic heart disease from his complaints. I reviewed “Love” in the history of medicine and decided to summarize it for Heart views. However, I thought it appropriate to present an example of an Arab love story before discussing the topic. The Majnoon Lila story I described above is the best case for such a purpose.

I will summarize the story again as follows: A young man, a poet, named Qais fell in love with a girl called Lila in the 8th century A.D. The girl also loved him. Her father refused to allow Qais to marry her because Qais’ love poems about her had spread among the Arabs, which embarrassed and angered her father. It was not honorable for a traditional Arab, even today, to have his daughter described by a lover in public. Arab poetry at that time was the mass media of the Arabs. They had no newspapers or any other means to spread their news, glory, major events etc. A good poem is memorized and transmitted fast across the Arab lands.

Lila was forced to marry another man against her wish and moved away from Qais’ town. When Lila left, Qais lost his ability to concentrate and listen to people. He lost interest in family, friends, and society. He ran away in the desert, living among the animals, almost naked. He was considered sick with “love madness.” A mad man in Arabic is called “Majnoon” and therefore he became well-known in literature as the “Majnoon” or Majnoon Lila, which means “crazy about Lila.” He avoided people and fled to the desert. The only way to draw his attention was to mention the name, Lila. Then he would communicate appropriately hoping to hear more about Lila. He would recite his love poems about her.

In his poems, he described his tears, sleeplessness, lack of appetite, weight loss, fast respiration, racing heartbeats or palpitations, and fainting episodes. Those descriptions were made in very sad verses with musical rhythms. When he died, people found in his cloth his last poem to Lila, which he had written on a piece of cloth.

In the poem, he stated that he felt as if his “heart was gripped by a bird’s claws.” When the name “Lila” he hears, the claws’ grip “squeezes his heart tighter.” The whole wide world seemed like “a ring around him, it neither gets longer nor wider.”

The poem is an excellent description of an anginal attack before his death. I translate this poem, as well as a few others from his numerous poems, preserving some of its original rhymes as much as I can:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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My heart is firmly seized

By a bird’s claws;

My heart is tightly squeezed

When Lila’s name flows.

My body is tightly bound

When the wide world I found

Is like a finger ring around.

 

I concluded from the above and his other poems that the poet had coronary artery disease, episodes of arrhythmia, and most likely, he died of myocardial infarction.

Does love cause such sickness and destruction? It probably does.

 

Love in Greek Medicine

The Greek physicians considered falling in love with a disease that may lead to death. There are Arabic translations of the ancient Greek physician’s thoughts about falling in love. This is well illustrated by Hunayn Ishaq.

Hunayn ibn Ishaq was the most productive translator of Greek medical and scientific treatises into Arabic. He was a Nestorian Christian originally from southern Iraq who spent his working life in Baghdad, the center of the great 9th-century Greek-into-Arabic translation movement. Hunayn is known to Europeans as Johannitius.

In his book “Nawader Al Falasifah”, Hunayn stated that Hippocrates said:

Love could occur between two smart persons and does not occur between the stupid or mentally deficient persons. The two wise persons could make an agreement to go on one certain way while the mentally deficient cannot make such an agreement together. In those afflicted with lovesickness, the heart is subjected to two emotional problems: Worry and sadness. Worry is the concern with the future, which may interfere with the ability to sleep. Sadness is caused by what happened in the past... the heart contains blood that is considered solid and the “worry”, will increase the heart and body heat. That heat will melt the blood.

The ancient Greek physicians considered the heart as the “oven of the body” and love increases the heat in the heart.

In Arabic poetry, there are plenty of descriptions of love causing “heat in the heart” that could “melt metals.” Al Majnoon wrote:

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When someone calls Lila’s name,

My chest will burn with fire’s flame.

 

He also said:

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I am mad with love and desire

And my heart burns with fire.

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The Arabs probably took the concept that love generates heat in the heart from the Greeks.

Hippocrates (470 - 410 BC) thought of the intense love as “greediness” created in the heart, and the stronger the intensity of love, the more a person becomes anxious and worried. The increased anxiety causes sleeplessness and the blood will “burn” and become dark. The “dark blood” spoils the person’s thoughts causing “mental deficiency”, which may lead to “insanity or madness.” This madness might cause a person in love or love addict to kill himself. Also, the person in love might get together with his loved one and they might die because of excitement and happiness. “You could observe”, he said, “that this love addict when he hears the name of the person he loves, his blood escapes and his color changes.”

Galen (129 - 210 A.D.) later said about those who are in love: “Concern or worry causes the death of the heart while their “sadness” is considered a “heart disease” in itself. He considered “falling in love” as a state of passionate liking combined with greediness or possessiveness. He stated that “falling in love” is created by the “Alnafs”, which is the Arabic word for what we now refer to as the psyche. “Alnafs” was thought by Galen to dwell inside the brain, the heart and the liver.

Galen stated that in the brain, there are three residing “powers in the head”: 1) Imagination in front; 2) Thoughts in the middle, and 3) Memory in the back. So, if the person in love leaves his loved one, then his brain will be “preoccupied” with thinking about him or her. The heart, as well as the liver, will be preoccupied with thoughts about the loved one. Therefore, the love addict might have less appetite because the liver is preoccupied with the loved one. He also suffers from sleeplessness because the brain is preoccupied with thoughts of the loved one. So, the “places” [organs] concerned with “Alnafs”, i.e. the heart, the liver, and the brain, will be preoccupied. If these are not preoccupied with the loved one, then the person is not really in love in Galen’s judgment. These places will be vacant when the lover meets his loved one (1).

All the ancient physicians agreed that love addiction is hard to cure with medication. The translator Hunayn Ishaq who was fond of Galen said that Galen had written on his ring, “those who hide their illness are difficult to cure.”

 

Love in Arab and Islamic Medicine

Greek thinking on love was actually based on theories from more ancient civilizations before them. The Greeks expanded and developed it further. The ancient Egyptians made the connection between love and the heart. The Babylonians made the connection between liver and love. I think the Arabs probably also have taken from the Babylonian directly the idea of linking the liver with love. The Arabs credited both the heart and the liver as the seat of love. An old Arabic poem states, “Our children are our livers walking on the ground.”

The theories explaining the physiology of falling in love with the Arab and Moslem physicians are influenced by Greek thinking.

Ibn Sina (Avicenna 980-1037) is one of the foremost physician and philosopher of the golden age of Islamic civilization. In his famous book, The Canon, he considered falling in love as a “disease of sadness” and he called it “melancholy.” The person inflicted that problem on himself by concentrating his thoughts on certain characteristics and appearance of a loved one. Sexual desire may or may not be involved in his opinion. He enumerated signs of falling in love as follows:

Deep-seated eyes, dryness of the eye, except when the person is crying, frequent movement of the eyelid, staring as if the person is looking at something very pleasant or hearing something pleasant, increased respiration, fluctuation in mood between happiness and sadness when hearing love poems. The body is thin, looks malnourished except the eyelid, which looks larger probably because of lack of sleep. His pulse is usually irregular, worse when he hears the name of the loved one, then the irregularity and the speed will increase. Feeling the pulse is a trick, which could be used to discover if the person is in love.

Ibn Sina claimed that he had tried that “trick” to diagnose love sickness several times. He also said there was no successful treatment except getting the two loved ones together. Ibn Sina warned: “this intense love will decrease the power” (I understand that to mean decrease the power of fighting disease). He had seen people who got cured of this disease and their “meat” returned back after getting together with the loved one.

Ibn Sina’s description of the signs and symptoms of love may have been influenced by reading the life story of Majnoon Lila. That was the classical case example of a love sufferer.

Ibn Al Nafis (1213 - 1288 A.D; the first physician in history who described the pulmonary circulation) did not really add much more to Ibn Sina’s descriptions and thoughts. He followed the same thoughts, but he considered falling in love as a disease that is peculiar to the single, idle, and to a common person. He also described the way to diagnose it by holding the hand of the victim, put the finger on the pulse, and mentioning the names and characters of the people in the area. When there is a change in the pulse and it speeds up accompanied by a change in the color of the face, then, that person mentioned is the loved one. He also stated that there is no treatment except getting the two together. That is the only successful therapy (1).

 

Love in modern medicine

When reviewing a modern Textbook of Psychiatry (2), the above-mentioned love addiction sounds like Anxiety Neurosis, which is characterized by anxious over- concern extended to panic and frequently associated with somatic symptoms. The clinical characteristics are feelings of tension and nervous discomfort associated with cardiac symptoms as follows: awareness of changes in the heartbeats, which become more rapid and forceful; sharp and sticking chest pain that lasts for a few seconds only, unrelated to exertion, not relieved by cessation of activity and may come on while the patient is in bed, resting. Even the respiration symptoms are dominated with discomfort, a sense of not being able to get enough air into the lungs, a feeling of fullness in the chest, and inadequate respiration. The patient often breathes more rapidly and more deeply and may feel compelled to run out of doors to get more air. Hyperventilation may cause respiratory alkalosis. The CNS symptoms are as follows: dizziness is described as an awareness of irregular blurring and swimming motion of the surroundings. There is usually a sense of light-headedness and faintness (2).

A modern psychiatrist, Richard B. Rosse, who seemed to have studied the phenomenon of love problem, calls it “Love Trauma Syndrome.” He wrote:

Love Trauma Syndrome is a form of traumatic grief that does not have to involve the death of a desired and loved person. Like its diagnostic cousins Post-traumatic Stress Disorder and traumatic grief, many patients with “Love Trauma Syndrome” present “on the surface” with more conventional diagnoses such as depression, anxiety, and substance use disorder. It can be a serious condition with considerable psychosocial impairments. Sometimes, Love Trauma Syndrome is associated with suicidal or homicidal ideation. It can also be associated with considerable dissociation and symptoms of hyperarousal (e.g., insomnia). Love Trauma Syndrome can be associated with anger, irritability, and revenge fantasies (3).

The same author has written a book titled, Love Trauma Syndrome (4). He wrote:

Love is one of the most exhilarating emotions we experience, unfortunately, it is also one of the most painful and sometimes traumatic. The unresolved emotional scars from a broken heart can manifest as a “love trauma syndrome”. At times, the syndrome can seriously diminish the sufferer’s quality of life, and dramatically impair social, academic, and occupational activities. Patients may end up committing suicide. A few become so obsessed by their lost loves that they are driven to stalk, attack . . . and ultimately commit suicide. Most patients, however, suffer alone and in silence without ever resorting to an act of physical violence.

Love Trauma Syndrome is a clinical disorder of “too much memory” in which the past intrudes upon the present to influence thoughts, feelings, and behaviors to a much greater extent than is expected. It can also be associated with a variety of other behavioral problems: the avoidance of future loving relationships, nervousness, feeling “unreal” or out of place, anger, and sleep disturbances (4).

Galen’s theory that the loved one “preoccupied” a place in the brain of the lover seems to be substantiated nowadays with fast MRI. The activity in the brains of 17 subjects who were deeply in love was scanned using fMRI, while they viewed pictures of their partners, and compared with the activity produced by viewing pictures of three friends of similar age, sex and duration of friendship as their partners. The activity was restricted to foci in the medial insula and the anterior cingulate cortex and, subcortically, in the caudate nucleus and the putamen, all bilaterally. Deactivations were observed in the posterior cingulate gyrus and in the amygdala and were right-lateralized in the prefrontal, parietal and middle temporal cortices. The combination of these sites differs from those in previous studies of emotion, suggesting that a unique network of areas is responsible for evoking this affective state. This leads us to postulate that the principle of functional specialization in the cortex applies to affective states as well (5).

The cardiology literature (6) states that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. Acute stress also causes coronary vasoconstriction. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals (6).

Recently, chemical transmitters have been found to be associated with romantic love. Platelet serotonin 5-HT transporter in the early romantic phase of a love relationship was found to be significantly lower than in the normal controls (7).

Endocrinological investigations of the neurobiology of attraction have found involvement of several chemical processes. Several observations have highlighted the role of monoamines and of neuropeptides, in particular, oxytocin, vasopressin, and opioids; but this is only the beginning of the story. Love, the most typical human feeling, can be viewed as a dynamic process that represents the result of different components probably sub-served by distinct neural substrates at different times. As such, some steps can be identified, in particular, it's beginning, which is the process of attraction, followed by the attachment process that, in some cases, can last forever (8).

 

 

 

 

 

 

 

 

 

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Love and digoxin

Finally, the most fascinating finding of this year is the involvement of digoxin in love and affection (9). The researchers found that the hypothalamus produces digoxin. You fall in love because your hypothalamus produces less digoxin. The human hypothalamus produces an endogenous membrane Na+-K+ ATPase inhibitor, digoxin, which can regulate neuronal transmission. The digoxin status and neurotransmitter patterns were studied in individuals with a predilection to fall in love. It was also studied in individuals with differing hemispheric dominance to find out the role of cerebral dominance in this respect. In individuals with a predilection to fall in love, there was decreased digoxin synthesis, increased membrane Na+-K+ ATPase activity, decreased tryptophan catabolites (serotonin, quinolinic acid, and nicotine), and increased tyrosine catabolites (dopamine, noradrenaline, and morphine). This pattern correlated with that obtained in left hemispheric chemical dominance. Hemispheric dominance and hypothalamic digoxin could regulate the predisposition to fall in love (9).

I wonder how much love and affections of our patients with heart failure we ruined with digoxin! I also wonder if the passionate love or lovesickness that afflicted Majnoon Lila could have been cured with our once miraculous drug digoxin. In the history of medicine, we have seen wonder drugs become popular, fade, and then “rediscovered” as wonder drugs years later. Aspirin was such a drug. Who knows, the historical drug, digoxin, might evolve again to the wonder drug it once was. ¨

 

References

1. Ibn Sabia’: Oyoon Al Anba’ Fitabaqat al Atiba’. (Arabic text) ​

2. Freedman AM. Modern synopsis of comprehensive textbook of psychiatry. Lippincott, Williams & Wilkins, 1976: 610 ​

3. Rosse, Richard (2000). An Argument for Love Trauma Syndrome: An Important and Often Underrecognized Form of Traumatic Grief. [Online]. Perspectives. [2000, February 1].

4. Rosse RB. Love trauma syndrome. Perseus Publishing, 2001.

5. Bartels A, Zeki S. The neural basis of romantic love: Neuroreport. 2000;11 (17):3829 - 34.

6. Rozanski A, Blumental JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for Therapy Circulation. 1999;99:2192 - 2217

7. Marazziti D, Akiskal HS, Rossi A, Cassano GB: Alteration of the platelet serotonin transporter in romantic love. Psychol Med. 1999; 29(3):741 - 745.

8. Marazziti D, Cassano GB: The neurobiology of attraction. Endocrinol Invest. 2003; 26 (3 Suppl):58 - 60.

9. Kurup RK, Kurup PA. Hypothalamic digoxin, hemispheric dominance, and neurobiology of love and affection. Inter. J. Neuroscience. 2003;11:721 - 729.