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mise à jour du
12 avril 2009
Int J Cardio
Vasovagal syncope in the Canon of Avicenna:
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.