International Journal of Cardiology 134 (2009) 297–301www.elsevier.com/locate/ijcard

Review

Vasovagal syncope in the Canon of Avicenna: The first mention of carotidartery hypersensitivity

Mohammadali M. Shoja a,⁎, R. Shane Tubbs b, Marios Loukas c, Majid Khalili d,Farid Alakbarli e, Aaron A. Cohen-Gadol a

a Clarian Neuroscience Institute, Indianapolis Neurosurgical Group and Indiana University Department of Neurosurgery, Indianapolis, IN, United Statesb Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, AL, United States

c Department of Anatomical Sciences, St. George's University, Grenadad Medical Ethics and History of Medicine Research Center, Tabriz University (Medical Sciences), Tabriz, Iran

e Institute of Manuscripts of the Azerbaijan National Academy of Sciences, Baku, Azerbaijan

Received 29 January 2009; accepted 27 February 2009Available online 29 March 2009

Abstract

Ibn Sina, known as Avicenna in the West, was a celebrated Persian thinker, philosopher, and physician who is remembered for hismasterpiece, The Canon of Medicine. The Canon that served as an essential medical encyclopedia for scholars in the Islamic territories andEurope for almost a millennium consisted of 5 books. In the third book, Avicenna described patients with symptoms of carotidhypersensitivity syndrome. These patients, who had excessive yawning, fatigue, and flushing, dropped following pressure on their carotids.Based on such history, it seems that Avicenna was the first to note the carotid sinus hypersensitivity, which presents with vasovagal syncopefollowing compression of the carotid artery. In this paper, we presented a brief account of Avicenna's life and works and discuss hisdescription of the so-called carotid hypersensitivity syncope. Notwithstanding his loyalty to the Greek theory of humoralism, Avicenna setforth his own version of “theory of spirits” to explain the mechanism of this disease. An account of the theory of spirits is also given.© 2009 Elsevier Ireland Ltd. All rights reserved.

Keywords: Avicenna; Carotid hypersensitivity; History; Syncope

1. Introduction

As early as the 10th century AD, in his famous book, theCanon of Medicine, Avicenna wrote of patients who hadbeen subjected to pressure on the carotid artery by hammam(traditional public bath) staffs or masseurs resulting inunconsciousness and falling [1,2]. Avicenna rebuked suchactions and wrote that these drop attacks revealed disturbancesof the ascending spirit of the brain. He called this condition “al-Lawa” in Arabic [2], translated as “Pichesh” in Persian [1] and“Torsion” in English [3]. He noted that such patients aregenerally fatigued, and have excessive yawning, muscle strainand flushing [1]. For the treatment of this condition, Avicenna

⁎ Corresponding author.E-mail address: shoja.m@gmail.com (M.M. Shoja).

0167-5273/$ - see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijcard.2009.02.035

recommended drinking cold water and consuming the herbSweet Flag (Calamus) or Coriander with sugar [1,2].

Based on his description, it is clear that Avicenna firstdescribed carotid sinus hypersensitivity, which presents withvasovagal syncope (falling) following compression of thecarotid artery. In this review, we presented a brief account ofAvicenna's life and works and discuss his description of al-Lawa or carotid sinus hypersensitivity.

2. Avicenna's life and his Cannon of Medicine

2.1. Avicenna and his youth in Bukhara

Abu Ali Husain ibn Abdullah ibn Sina (Fig. 1), whosename is Latinized as Avicenna [4], is one of the most

Fig. 1. Avicenna on a Tunisian post stamp from 1980 commemorating theone-thousandth anniversary of his birthday (with kind permission from thePost Office of the Republic of Tunisia).

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prominent figures in the history of medicine. Interestingly,Dante alluded Avicenna as with such greats as Hippocratesand Galen in his Divine Comedy, Inferno, Canto IV [5,6].

Fig. 2. Excerpts from amanuscript of Avicenna'sCanon, dated 1227AD, ascribed byIran; with permission).

Known as the Prince of Physicians [7], the Galen of Islam[8], the Aristotle of Arabians [9], and the Second Doctorafter Aristotle who was the First [10], Avicenna (Fig. 1) wasborn to a Persian family on the 23rd of August, 980 AD[11,12] (Fig. 2). In an autobiographical sketch, he referred toAfshaneh, a small village near Bukhara as his birth place; hisfather was from Balkh [13]. Avicenna's family moved toBukhara when he was a child [13]. Bukhara was a strategiccity in central Asia and in 874 AD was designated as thecapital city of the Samanid dynasty of Persia [14].

Avicenna mastered various sciences by his teens [13]. Ithas been said that “he spent a year and a half in his painfullabor [of studying], without ever sleeping all this time awhole night together” [15]. At the age of 21, he finished a 20-volume encyclopedia, Utility of Utilities (Al-Hasel va Al-Mahsoul), which included all the knowledge of the timeexcept mathematics [15,16].

2.2. Avicenna traveling in Persia

Avicenna's life is highlighted by his dangerous travels todifferent Persian cities. Although most of these travels werebecause of political pursuits, they also provided him with anopportunity to access libraries, such as the Khwarizmi libraryof Gorganji, the Buwayhid libraries of Ray and Hamadanand the Kakuyid library of Isfahan [17].

By the fall of the Samanid dynasty, Avicenna fledBukhara for Gorganji of the Khwarizmi Kingdom where hemet Abu Reyhan Biruni, a great pharmacist and encyclope-dist of the day, and Abu Sahl Masihi, a knowledgeable

a physician, Abi al-Fakhr ibnWahshi al-Motabeb (from Tabriz Central Library

,

Fig. 3. UNESCO's medal of Avicenna fashioned by Victor Douek(© UNESCO/Niamh Burke; reproduced with permission).

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physician [18]. In 1017 AD, the Khawarizmi dynasty wasoverthrown by the Ghazan ruler, Sultan Mahmood [16].Although Sultan Mahmood had called for him, Avicennawas unwilling to join his court and fled to Jurjan; from there,he went to Ray, Qazvin, Hamadan, and Isfahan [14,16,19].Avicenna was given a home by Prince Abu MohammadShirazi in Jurjan, a city located in the southeast part of theCaspian Sea, where he began to write his masterpiece theCanon [7,20]. While residing in Ray, near the moderncity of Tehran, Avicenna treated the Buwayhid ruler SultanMajd al-Douleh, the son of Fakhr al-Douleh, for depression[20–22] and reportedly served the court as a businessmanager [23]. Here, Avicenna was appointed a minister bythe young Sultan [24]. Displeased with this appointment,Sayyida, a very influential and powerful figure of the periodand the mother of the Sultan, rejected Avicenna [24].Following this, Avicenna arrived in Hamadan, anotherBuwayhid state, where he treated Sultan Shams al-Douleh,the older son of Sayyida, for severe colic [25]. It has beensaid that he spent 40 days and nights beside Sultan Shams al-Douleh in order to cure him [16]. Sultan Shams al-Doulehsoon appointed him minister [25]. In 1021 and following theSultan's death, Avicenna refused to continue his court dutiesunder the Sultan's son, Taj al-Mulk [26]. Charged of bet-raying Buwayhids and secretly corresponding with Kakuyidruler of Isfahan, Sultan Aala al-Douleh, Avicenna was sent toprison [27]. However, he escaped from the prison andtraveled to Isfahan in 1024 where he prospered under SultanAala al-Douleh [20,25,28]. Later when Sultan Aala al-Douleh moved to Hamadan, Avicenna accompanied him[25].

Ultimately, at the age of 58, Avicenna died of colic a fewdays after arriving in Hamadan in 1037 [25,29]. His studentand biographer, Juzjani, illustrated his master's illness whosuffered with protracted and recurrent attacks of colic,seizures and intestinal bleeding [16]. Avicenna treatedhimself with enemas and used celery seeds to eliminate hisbloating [16]. Elgood cited Ducastel as attributing Avicen-na's death to gastric cancer based on his course of illness[25].

Avicenna was described as very intelligent, so much sothat a popular Persian legend described his arguing againstSatan and outwitting him [16]. A story also tells thatAvicenna fell in love with the daughter of a king who exiledhim from the city once the romance was discovered [16].Such legends are proof of Avicenna's influence over thepublic as a brilliant, ingenious, and extraordinary person-ality. In his will and in a letter to Abu Said Abu Al-Khayr, aPersian poet and Gnostic, Avicenna reflected his philosophyof life: to bear adversities and difficulties, help mankind, andseek a proper and genteel science in order to satisfy God[30]. Avicenna's contributions to medicine are honored in hishomeland by celebrating his birthday (23rd of August) as theDay of the Physician [12]. For his leading role in the sciencesand in politics, Avicenna received the title Sheikh al-Rais orMaster the Elder [31]. Avicenna authored more than 400

treatises and books on various subjects including medicine,philosophy, theology, logic, etc. [16,32].

2.3. The Canon of Medicine (Qanoon fi al-Tibb)

The Canon of Medicine (Fig. 3) is regarded as “the mostfamous single book in the history of medicine both East andWest” (from The Encyclopedia Britannica, as cited in Ref.[33]). The Latin translation of the Canon was made availableby Gerard of Cremona in the 12th century [34] and remainedan essential teaching book in European universities up untilthe 17th century [35]. The Canon, which also was translatedinto Hebrew, German, French, and English [36], consisted of5 books: Book I was dedicated to general anatomy andprinciples of medicine; Book II, matrica medica; Book III,diseases of the special organs; Book IV, general medicalconditions and Book V, formulary [3,36]. In Book III, eachchapter began with a brief account of anatomy followed by alist of signs and symptoms related to diseases of the specificorgan. The Canon was such an influential treasure in thehistory of medicine that Sir William Osler credited it as a“medical bible” and “the most famous medical textbook everwritten” [36,37].

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3. Discussion

The brief discussion of al-Lawa appeared in the secondchapter of Article 5, Book III of the Canon, which wasdedicated to “brain diseases effecting intentional movements”.Avicenna was a meticulous clinical observer. He examined hispatients carefully and wrote of their signs and symptoms indetail: aside from carotid hypersensitivity and drop attacks, al-Lawa was associated with flushing, yawning and fatigue.Flushing is a common finding in neurogenic syncope.Yawning can be one of the first manifestations of thevasovagal reflex [38]. In a recent study, fatigue was alsofound to be a prominent feature in patients with vasovagalsyncope [39].

Avicenna believed in the Greek theory of the 4 humors ascontributing to disease pathogenesis. However, he furtheradded his own view of different types of spirits (or vital lifeessences) and souls, whose disturbances might lead to bodilydiseases because of a close association between them and suchmaster organs as the brain and heart. An element of such beliefis apparent in the chapter of al-Lawa in which Avicennarelated themanifestations to an interruption of vital life essenceto the brain. The following passages from Avicenna's Treatiseon Pulse clearly show how he combined the 2 theories, basedon his own thoughts, in order to establish a new doctrine usedto explain the mechanisms of various diseases:

“From mixture of the four [humors] in different weights,[God themost high] created different organs; onewithmoreblood like muscle, one with more black bile like bone, onewithmore phlegm like brain, and onewithmore yellow bilelike lung.

[God the most high] created the souls from the softness ofhumors; each soul has it own weight and amalgamation.The generation and nourishment of proper soul takes placein the heart; it resides in the heart and arteries, and istransmitted from the heart to the organs through the arteries.At first, it [proper soul] enters the master organs such as thebrain, liver or reproductive organs; from there it goes toother organs while the nature of the soul is being modifiedin each [of them]. As long as [the soul] is in the heart, it isquite warm,with the nature of fire, and the softness of bile isdominant. Then, that part which goes to the brain to keep itvital and functioning, becomes colder and wetter, and in itscomposition the serous softness and phlegm vapordominate. That part, which enters the liver to keep itsvitality and functions, becomes softer, warmer and sensiblywet, and in its composition the softness of air and vapor ofblood dominate.

In general, there are four types of proper spirit: One isbrutal spirit residing in the heart and it is the origin of allspirits. Another – as physicians refer to it – is sensualspirit residing in the brain. The third – as physicians referto it – is natural spirit residing in the liver. The fourth is

generative – i.e. procreative – spirits residing in thegonads. These four spirits go-between the soul ofabsolute purity and the body of absolute impurity.”(Translated from Persian) [40].

Avicenna had a vision of blood circulation, but heerroneously accepted the Greek notion regarding theexistence of a hole in the ventricular septum by which theblood traveled between the ventricles. He ignored thepulmonary circulation, which was later described by anArab physician, Ibn Nafis, in the 13th century AD [41].Interestingly, in describing cardiac morphology, he essen-tially followed the teachings of Aristotle, rather than Galen,on the 3-chambered nature of the heart [42]. Beginning in the16th century, the anatomy of the Canon became increasinglycriticized by some western scholars such as da Vinci andParacelsus [43]. At about the same time, Lorenz Fries ofColmar, himself a physician, wrote a treatise on defense ofAvicenna highlighting the important influence that he had onthe progression and preservation of medicine [44,45].Andreas Vesalius and William Harvey both read the Canon[43,46] and Harvey mentioned Avicenna in his treatise, AnAnatomical Disquisition on the Motion of the Heart andBlood in Animals [47]. Although some of Avicenna'sanatomical descriptions were erroneous, he correctly wroteon the cardiac cycles and valvular function [48]. It may beworth mentioning a quotation from Michelangelo, an Italiansculptor who also studied anatomy [49]: “It is better to bemistaken following Avicenna than to be true followingothers” [50].

4. Conclusions

Notwithstanding the shortcomings in his anatomicalteachings, Avicenna was skillful in physical examinationand history taking. He pulled together his own experiencesand compiled the teachings of his predecessors, Aristotle,Hippocrates and Galen, in order to write his masterpiecebook of medicine, the Canon. Article 5 from Book III of thisencyclopedia described drop attacks following compressionof the carotid artery, yawning, fatigue and flushing, whichtogether resemble neurogenic syncope. Such a description ismost likely the first mention of carotid sinus hypersensitivityand vasovagal syncope.

Acknowledgments

The authors of this manuscript have certified that theycomply with the Principles of Ethical Publications in theInternational Journal of Cardiology [51].

The authors are grateful to the Tunisian Post Office,Tabriz Central Library and UNESCO's Photolibrary for theirpermissions to include Figs. 1, 2 and 3, respectively, in thispaper.

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