Al-Akhawayni's views on stroke

Abstract

From the dawn of medicine physicians were familiar with the manifestations caused by a cerebrovascular accident (stroke) [1]. Throughout the centuries, the continued practices of the scholars, their observations, experimentation, and theories on variousmedical subjects suchas strokes, resulted in today's knowledgeon them.Muslimscientists were among the first to play a role in this progressive path [1–3]. Stroke was among thosewhich they investigated and contributed to its concept [1]. In this respect, we present the views of the medieval physician, Al-Akhawayni Bukhari (?–983 AD), concerning the issues of a stroke. Abubakr Rabi-ibn Ahmad Akhawayni Bukhari, nicknamed Abu Hakim (Father of Wisdom), was an influential Islamic Golden Age (9th–12th centuries AD) Persian physician [4]. Al-Akhawayni authored the Hidayat al-Muta'allemin fi al-Tibb (A Guide for Medical Students), the first medical text written in Persian [5]. In theHidayat (Guide), Al-Akhawayni presents his knowledge on the different aspects of the healing arts, particularly cardiovascular medicine. He was to some good degree, familiar with the anatomy and function of the heart and blood vessels, in addition to a number of their related diseases [6]. Stroke is a subject specifically discussed in the Sakteh (Stroke) chapter of the Hidayat, as will be examined below [7]. In the aforementioned chapter, Al-Akhawayni first quotes Rhazes' (865–925 AD) description of stroke who classified it into two following categories: (1) Damavi (related to dam, meaning blood), a type of stroke resulting from a hemorrhage within the intracranial space (comparable to the hemorrhagic stroke in the current nomenclature); and (2) Balghami (related to balgham, meaning phlegm), a disease causedbyanobstruction in the arteries responsible for theblood supply to the brain (alike the ischemic stroke in modern medicine). AlAkhawayni declares his disagreement to the first of Rhazes' theory and explains the balgham as the only etiology of stroke [7]. In Al-Akhawayni's opinion, blood carries the Ruh-e Nafsani (Affective Spirit) from the heart to different areas of the body and keeps them viable; therefore, when an artery is being obstructed by balgham, Ruh-e Nafsani fails to reach the affected organ. This phenomenon finally causes the loss of viability of the involved body part [7]. According to the traditional Persian medicine, abnormal balgham plays an important role in creating the chain reaction of those processes which will eventually lead to the arterial obstruction, an event that could be diagnosed as an early description for the present-day concept of thrombus formation in the vessels [8]. Al-Akhawayni's theory on the role of balgham in the obstruction of blood vessels together with his knowledge of arteries supply the brain allowed him to explain stroke as an event resulting from the blockage of brain's arterial blood supply. As a result, when an obstruction occurs in a main artery, it involves a significant portion of the brain and causing Sakteh (Stroke) [6,7]. In contrast, the blockage of a minor artery will lead to Falej (Paralysis), a condition in which a smaller portion of the brain is being affected [7]. In addition,Al-Akhawayni explains: “Itwas said that the brain has twoparts [cerebral hemispheres]... .... if the nature dominates the substance caused the sakteh [stroke], and that substance do not be so solid, the nature can move the substance being stuck in the vessels of the brain..., and the nerves which are located in this part [and being supplied by the reopened artery] regain their sensory and motor function and the [affected] body part regains its function once again...” [7]. These statements could be compared to the modern concept of reperfusion in cases with stroke [9]. Al-Akhawayni introduces headache, flushed face, suffocating feelings, and decreased level of consciousness as the common clinical manifestations of a stroke. He describes the patient's respiratory condition as a prognostic indicator [7]. In sum, although Al-Akhawayni did not agree with Rhazes' notion of hemorrhagic stroke, a weak point of his work, he provided an early detailed description of an ischemic stroke and its related reperfusion phenomenon, and tried to justify it using the Four Humors Theory. He differentiated between the consequences of obstruction in both the small and large arteries. In reviewing his succeeding physician's opinions about stroke (such as those of Avicenna), they show significant similarity to Al-Akhawayni's descriptions of this disease [1,7]. It could be ascertained, that Al-Akhawayni contributed to filling the gap between the two great scientists, Rhazes and Avicenna, and passed down the medical knowledge to the next generations [10].