The
first mention of carotid artery hypersensitivity
Avicenne 980 - 1037
Mohammadali M. Shoja, R. Shane
Tubbs, Marios Loukas, Majid Khalili, Farid
Alakbarl, Aaron A. Cohen-Gadol
Ibn Sina, known as Avicenna in the West, was
a celebrated Persian thinker, philosopher, and
physician who is remembered for his masterpiece,
The Canon of Medicine. The Canon that served as
an essential medical encyclopedia for scholars
in the Islamic territories and Europe for almost
a millennium consisted of 5 books. In the third
book, Avicenna described patients with symptoms
of carotid hypersensitivity 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 syncope following
compression of the carotid artery. In this
paper, we presented a brief account of
Avicenna's life and works and discuss his
description of the so-called carotid
hypersensitivity syncope. Notwithstanding his
loyalty to the Greek theory of humoralism,
Avicenna set forth his own version of
‚"theory of spirits" to explain the
mechanism of this disease. An account of the
theory of spirits is also given.
1. Introduction
As early as the 10th century AD, in his
famous book, the Canon of Medicine, Avicenna
wrote of patients who had been subjected to
pressure on the carotid artery by hammam
(traditional public bath) staffs or masseurs
resulting in unconsciousness and falling.
Avicenna rebuked such actions and wrote that
these drop attacks revealed disturbances of the
ascending spirit of the brain. He called this
condition "al- Lawa" in Arabic, translated as
‚"Pichesh" in Persian and "Torsion" in
English. He noted that such patients are
generally fatigued, and have excessive yawning,
muscle strain and flushing. For the treatment of
this condition, Avicenna recommended drinking
cold water and consuming the herb Sweet Flag
(Calamus) or Coriander with sugar. Based on his
description, it is clear that Avicenna first
described carotid sinus hypersensitivity, which
presents with vasovagal syncope (falling)
following compression of the carotid artery. In
this review, we presented a brief account of
Avicenna's life and works and discuss his
description of al- Lawa or carotid sinus
hypersensitivity.
2.3. The Canon of Medicine (Qanoon fi
al-Tibb)
The Canon of Medicine is regarded as "the
most famous single book in the history of
medicine both East and West". The Latin
translation of the Canon was made available by
Gerard of Cremona in the 12th century and
remained an essential teaching book in European
universities up until the 17th century. The
Canon, which also was translated into Hebrew,
German, French, and English, consisted of 5
books: Book I was dedicated to general anatomy
and principles of medicine; Book II, matrica
medica; Book III, diseases of the special
organs; Book IV, general medical conditions and
Book V, formulary. In Book III, each chapter
began with a brief account of anatomy followed
by a list of signs and symptoms related to
diseases of the specific organ. The Canon was
such an influential treasure in the history of
medicine that Sir William Osler credited it as a
"medical bible" and "the most famous medical
textbook ever written".
3. Discussion
The brief discussion of al-Lawa appeared in
the second chapter of Article 5, Book III of the
Canon, which was dedicated to ‚"brain
diseases effecting intentional movements".
Avicenna was a meticulous clinical observer. He
examined his patients carefully and wrote of
their signs and symptoms in detail: 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 the vasovagal reflex. In a
recent study, fatigue was also found to be a
prominent feature in patients with vasovagal
syncope.
Avicenna believed in the Greek theory of the
4 humors as contributing to disease
pathogenesis. However, he further added his own
view of different types of spirits (or vital
life essences) and souls, whose disturbances
might lead to bodily diseases because of a close
association between them and such master organs
as the brain and heart. An element of such
belief is apparent in the chapter of al-Lawa in
which Avicenna related the manifestations to an
interruption of vital life essence to the brain.
The following passages from Avicenna's Treatise
on Pulse clearly show how he combined the 2
theories, based on his own thoughts, in order to
establish a new doctrine used to explain the
mechanisms of various diseases: "From mixture of
the four [humors] in different weights,
[God the most high] created different
organs; one with more blood like muscle, one
with more black bile like bone, one with more
phlegm like brain, and one with more yellow bile
like lung. [God the most high] created
the souls from the softness of humors; each soul
has it own weight and amalgamation.
The generation and nourishment of proper
soul takes place in the heart; it resides in the
heart and arteries, and is transmitted from the
heart to the organs through the arteries. At
first, it [proper soul] enters the
master organs such as the brain, liver or
reproductive organs; from there it goes to other
organs while the nature of the soul is being
modified in each [of them]. As long as
[the soul] is in the heart, it is quite
warm, with the nature of fire, and the softness
of bile is dominant. Then, that part which goes
to the brain to keep it vital and functioning,
becomes colder and wetter, and in its
composition the serous softness and phlegm vapor
dominate.
That part, which enters the liver to keep
its vitality and functions, becomes softer,
warmer and sensibly wet, and in its composition
the softness of air and vapor of blood dominate.
In general, there are four types of proper
spirit: One is brutal spirit residing in the
heart and it is the origin of all spirits.
Another as physicians refer to it is sensual
spirit residing in the brain. The third
– as physicians refer to it
is natural spirit residing in the liver. The
fourth is generative i.e. procreative spirits
residing in the gonads. These four spirits
go-between the soul of absolute purity and the
body of absolute impurity." (Translated from
Persian) [40]. Avicenna had a vision of
blood circulation, but he erroneously accepted
the Greek notion regarding the existence of a
hole in the ventricular septum by which the
blood traveled between the ventricles. He
ignored the pulmonary circulation, which was
later described by an Arab physician, Ibn Nafis,
in the 13th century AD. Interestingly, in
describing cardiac morphology, he essen- tially
followed the teachings of Aristotle, rather than
Galen, on the 3-chambered nature of the heart .
Beginning in the 16th century, the anatomy
of the Canon became increasingly criticized by
some western scholars such as da Vinci and
Paracelsus. At about the same time, Lorenz Fries
of Colmar, himself a physician, wrote a treatise
on defense of Avicenna highlighting the
important influence that he had on the
progression and preservation of medicine.
Andreas Vesalius and William Harvey both read
the Canon and Harvey mentioned Avicenna in his
treatise, An Anatomical Disquisition on the
Motion of the Heart and Blood in Animals.
Although some of Avicenna's anatomical
descriptions were erroneous, he correctly wrote
on the cardiac cycles and valvular function
[48]. It may be worth mentioning a
quotation from Michelangelo, an Italian sculptor
who also studied anatomy: "It is better to be
mistaken following Avicenna than to be true
following others".
4. Conclusions
Notwithstanding the shortcomings in his
anatomical teachings, Avicenna was skillful in
physical examination and history taking. He
pulled together his own experiences and compiled
the teachings of his predecessors, Aristotle,
Hippocrates and Galen, in order to write his
masterpiece book of medicine, the Canon. Article
5 from Book III of this encyclopedia described
drop attacks following compression of the
carotid artery, yawning, fatigue and
flushing, which together resemble neurogenic
syncope. Such a description is most likely the
first mention of carotid sinus hypersensitivity
and vasovagal syncope.
