PERIPHERAL NERVE DISORDERS AND TREATMENT …the Canon have revealed that Avicenna was the first author to discuss the surgical management of peripheral nerve injury. Although the Canon

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PERIPHERAL NERVE DISORDERS AND TREATMENTSTRATEGIES ACCORDING TO AVICENNA IN HISMEDICAL TREATISE, CANON OF MEDICINE

THE WRITTEN TRANSMISSION of knowledge has played a great part in the advance-ment of medicine, and historical documents hold the key to a full exploration of thehistory of medicine. Some fields, including disciplines that deal with peripheral nervedisorders, have received little benefit from such valuable material. In particular, periph-eral nerve surgery lacks perspectives from historical data. For many years, physicians haveobtained positive results in the surgical treatment of peripheral nerve diseases. Relevantdocuments reveal that the first author who described the surgical repair of damagedperipheral nerves was Avicenna, a leading figure of the medieval era who lived in theMiddle East. In his primary medical work, the Canon, he provides a description, albeitsketchy, of a suture procedure for peripheral nerve transection. This treatise influencedphysicians for several centuries. In this presentation, we analyze excerpts from theCanon that concern peripheral nerve disorders and strategies for their management.

KEY WORDS: Avicenna, Canon, History of medicine, Peripheral nerve, Surgery

Neurosurgery 64:172–178, 2009 DOI: 10.1227/01.NEU.0000335779.27115.D3 www.neurosurgery- online.com

LEGACY

Ahmet Aciduman, M.D., Ph.D.Department of Deontology,School of Medicine,Ankara University,Ankara, Turkey

Uygur Er, M.D.Neurosurgery Department,Yildirim Beyazit Diskapi Research andEducational Hospital,Ministry of Health,Ankara, Turkey

Deniz Belen, M.D.Neurosurgery Department,Numune Research andEducational Hospital,Ministry of Health,Ankara, Turkey

Reprint requests:Ahmet Aciduman, M.D., Ph.D.,Dögol Caddesi, No. 27-14,Mebusevleri,06580 Ankara, Turkey.Email: [email protected]

Received, March 27, 2008.

Accepted, August 15, 2008.

Peripheral nerve injuries and disorders andtheir management are, to some ex tent, aschallenging for physicians now as they

were in the past. The history of peripheralnerve disorders and strategies for their treat-ment have attracted little interest from physi-cians. One possible reason for this neglect maybe the paucity of literature that can be found inthe history of medicine, even though writingsabout peripheral nerves date back to the Hip -po cratic era. In reality, treatment methods,especially surgery for peripheral nerve dis-eases, have attracted the attention of physiciansand surgeons since ancient times. One source ofsystematic writings on this subject can be foundin the well- known medical book from the 11thcentury named Al- Qanun fi al- Tibb (the Canon ofMedicine; henceforth, the Canon), which means“the law of medicine,” written by the greatphysician Avicenna (Fig. 1).

Avicenna, known as Ibn Sina in the MiddleEast, was born in 980 in Afshana, Uzbekistan,and died in 1037 in Hamadan, Iran. Avicennais considered one of the principal mediatorsbetween the Western and Islamic worlds. Hisgreat work, the Canon, is an encyclopedic workabout medicine and comprises 5 books. Thiswork was a standard textbook in medical

schools until the 16th century in the West andthe 19th century in the Middle East. Gerard ofCremona translated the Canon into Latin forthe first time in the 12th century. This versionwas published in 1473 in Milan, 1476 in Padua,and 1482 in Venice (Figs. 2 and 3). The Hebrewversion was translated in 1279 in Rome andwas published in 1491 in Naples (12).

The first book concerns the description ofmedicine, anatomy, physiology, nosology, etio-

logy, symptomatol-ogy, health, diseasesand fatal conditions,and treatment prin -ciples. The secondbook deals with sim-ple drugs and theireffects. Internal andexternal diseases ofall the organs fromhead to foot (a capitead ca l c em ) are ex -plained systematicallyin the third book. Thefourth book considersthe disorders that donot occur in a specificorgan but affect the

FIGURE 1. Portrait ofAvicenna (drawn byAhmet Aciduman, M.D.,Ph.D.).

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PERIPHERAL NERVE TREATMENT IN AVICENNA’S CANON

whole body (e.g., epidemics, fever, dermatological disorders,injuries, fractures, luxation, and intoxication); the last section ofthe fourth book also includes cosmetics. Complex drugs are out-lined in the fifth book (19).

Studies of the history of medicine and the pertinent sections ofthe Canon have revealed that Avicenna was the first author todiscuss the surgical management of peripheral nerve injury.Although the Canon does not include detailed information aboutthe procedure, Avicenna emphasized the forced anatomic conti-nuity of the nerve for proper healing after a transection injury.

Each of the 5 large books of the Canon is divided into trea-tises (fen), each of which, in turn, is subdivided into chaptersand sections (6). Peripheral nerve disorders are considered inthe first 5 sections of the fourth chapter of the fourth fen of thefourth book (Fig. 4).

FOURTH FEN, FOURTH CHAPTER:NERVE AND BONE

Avicenna begins the introductory part of this section withgeneral information about nerve injury and some relevantsymptoms. He points out that nerve injury is a serious condi-tion and symptoms may sometimes be severe. The terminologyused in the Canon includes some inexact definitions for today’sreaders, such as spasm, confusion, or multiple swellings. Somedefinitions have dual meanings. We can deduce from otherchapters of the book that spasm may mean either tetanus- typemuscle contraction or flaccidity/spasticity in neurologicalterms. Avicenna indicated an infectious state when he referredto confusion (occurring with fever) and multiple swellings(abscess). At the same time, swelling may also indicate woundedema. Similarly, swelling may be an ominous sign, or at other

FIGURE 2. Frontispiece of Latin edition of the Canon,which was printed by Junta Press in 1544 in Venice.Before this publication, an influential Latin edition ofthe Canon was provided with a glossary of Arabicterms by Andrea Alpago; it was first published in 1527by Junta Press of Venice. In 1544, Paolo publishedanother edition with Junta; it included some furthertextual revisions, additions to Andrea’s glossary ofArabic terms, a life of Avicenna translated by NicolòMassa (in 1569), and a set of illustrations showing aphysician manipulating dislocations (from Tamani G:The Canon Medicinae of Avicenna in the HebraicTradition: The Miniatures in Manuscript 2197 of theUniversity Library of Bologna [in Italian]. Padova,Editoriale Programma, 1988 [18, p 14]).

FIGURE 3. Frontispiece of Latin edition of the Canonpublished in 1595 by Junta Press of Venice. Lookingback over the history of the publications of the Canonin 16th and 17th century Italy, one is struck by theprominent role played by Junta Press of Venice in theproduction of major new Latin editions of the Canon.Junta produced the most lavish and comprehensive edi-tions of the Canon (from Tamani G: The CanonMedicinae of Avicenna in the Hebraic Tradition:The Miniatures in Manuscript 2197 of the UniversityLibrary of Bologna [in Italian]. Padova, EditorialeProgramma, 1988 [18, p 21]).


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times it may refer to a more benign condition. In view of theseuncertain definitions and paradoxical statements, the textshould basically be considered in terms of historical humoraltheory. Causal relationships are not always logical in some sec-tions of the Canon:

Human nerves are exceedingly vulnerable tissues.Since they are in relation with the brain, pain and atormenting sense arising from their injuries areunbearable; thus, these injuries may lead to terribleconsequences like spasm and confusion. Usually,spasm precedes pain in nerve injury. Swelling appearsin any case even if the pain is not so terrible. The leasthazardous type of nerve injury is that which occurswith fever and multiple swellings outside the wound;the patient becomes thirsty, cannot sleep well, his/hermouth becomes dry, and these symptoms are moresevere if the swellings appear near the tongue.Comparable severe pain and terrible consequencesmay occur if the tendons are injured; in this situation,

the pain is more irresistible if the wounded segmentof tendon is located at a more distant site from themuscle. The pain is excruciating if the nerve swells, ashappens when the nerve is exposed to cold (10, p 518a;11, p 501).

In the next paragraph, further clinical details regardingsymptoms are given, and the inflammation process after anerve injury is outlined. Owing to the delicate nature of thenerves, Avicenna warns the reader about the application ofvaporous or liquid thermal therapy after a nerve injury to pre-vent progressive inflammation within the nerve; these types ofprocedures were common in his time, according to humoraltheory, which had its roots in antiquity:

If the nerve is inflamed, it will swell; the swellingmay result in decay of the organs (10, p 518a; 11,p 501).

Subsequently, Avicenna gives some information about drugsthat can be used for the medical treatment of nerve injuries. Hemainly offers topical drugs with specifically anti- inflammatoryeffects:

The drugs used in nerve injury should remove themoisture from the nerve. Sometimes, swelling afternerve injury appears in a delayed fashion; in this situ-ation, the treatment period may be prolonged (10,p 518a; 11, pp 501–502).

In the next paragraph, Avicenna classifies the main woundtypes in nerve injuries:

Nerve injuries are encountered mainly in two forms:either a pinprick wound caused by a sharp object, or a cleft- type [splitting and fissuring] wound. The cleft- type injury can usually be diagnosed by the nakedeye, or, on rare occasions, the lesion is obscured due toits deep location in muscle, or the cleft can simply notbe spotted. The cleft- type injuries occur morphologi-cally either in longitudinal or transverse fashion. The longitudinal- type injury is more benign than the trans-verse one, because capillaries are commonly damagedin the latter type, which results in muscle spasm andmay induce a tormenting effect on the brain, and pos-sibly other systemic diseases which are difficult to treatwould follow this type of injury. If the splitting or per-forating injury to the nerve occurs in a transverse fash-ion, you shall most probably have to cut the nerve,and consequently the patient will calm down andsymptoms will disappear (10, p 518a; 11, p 502).

In the preceding paragraph, Avicenna emphasizes the betterprognosis of a longitudinal- type slash injury when comparedwith that of a transverse- type injury, because the longitudinalcut commonly occurs parallel to the “capillary” (the term waspossibly used for “nerve fascicle” in those times), so that themajority of the nerve fascicles remain undamaged.

In the following section, Avicenna describes the tissues thatmay be confused with injured nerves and clarifies the likely

FIGURE 4. Illustration from the Canon, Isphahan,1632, demonstrating the peripheral nervous system(from Doksat MK: Avicenna, Master and Ruler ofPhysicians [in Turkish]. P “Tip ve Sanat” 27:56–65,2002 [7]).



edges cannot be brought face to face and shall not fuse.If you realize that waiting will culminate in an inflam-mation process in transverse- fashioned fissure injury,then simply cut the nerve. Cut it carefully in orderto prevent further swelling and inflammation (10,p 518b; 11, p 504).

After these proposals, some medical methods and some top-ical drugs for care of the sutured nerves are discussed:

If a swollen nerve is exposed to cold, the conditionmay result in spasm and, consequently, inflammationmay develop, which would attack the entire extremity.Because of that, it is not sufficient to fuse only thewound edges; you should add medical therapy untilcomplete healing of the wound is achieved. If the inci-sion is not wide enough, lengthen the opening at first,and observe the wound carefully to differentiate anyclues that indicate inflammation, because some inflam-matory substances may accumulate inside the woundand cannot escape through this narrow opening. Besure that the wound is dry and there is no inflamma-tion and swelling. After confirming the preferablewound condition, close the wound ends (10, p 518b;11, p 504).

It is clear that Avicenna offers a secondary healing procedurefor these types of unclean injuries. He continues with sugges-tions that are not so unfamiliar to current medical knowledge:

Open the bandage two or three times a day, exam-ine the wound and wrap it again. Open the bandageon the night of the first day. If the bandage is appliedat night, open it on the following morning. If the painis not sharp in character, do not repeat examinationsso frequently. It is also enough to practice these dress-ings two times a day (10, p 518b; 11, p 504).

The second section on peripheral nerve disorders deals withthe treatment of acute and ulcerated nerve injuries. In this part,Avicenna considers medical treatment of nerve injuries. Thequantity and characteristics of recommended drugs are quiteastonishing. In the third section, Avicenna discusses swelling ofthe injured nerve. He gives highly detailed recommendationsfor nerve- related problems. The fourth section considers crush- type nerve injuries. Here, Avicenna recommends using only anti- inflammatory treatment. He emphasizes that if swelling isassociated with this type of injury, treatment should be differ-ent from that for a crush- only injury:

When swelling and pain occur simultaneously, treatthe more disturbing symptom first. . . . Treatment iseasier when there is only swelling. . . . If the nerve isdistorted by crushing, never expose it to hot or coldwater (10, p 519b; 11, pp 510–511).

In the fifth section, hardening and distortions of the nervesare considered. Although Avicenna’s descriptions are notdetailed, he discusses nerve entrapment syndromes and,notably, describes Tinel’s sign:

conditions of these tissues during surgical or medical interven-tions. At the end of the introductory section, he describes thedifferential diagnosis between nerves and those other tissues:

Fascia injury usually occurs in a mild form whencompared with tendon and nerve injuries. As youhave learned from anatomic dissections, fasciaevolves into one- layer tissue, and, because of the knit- like nature, its fibers cannot be differentiated by thenaked eye. On the other hand, the longitudinally posi-tioned fibers of the tendon can be observed. Contraryto fascia’s smooth nature, tendons are very firm tis-sues. Suturing of fascia is possible. Injury to the liga-ments that cross bones does not induce any disturbingcondition, and these tissues are tolerant to any treat-ment modality. Crushed or partial transverse- cutinjury of the nerve is more tormenting than completetransection injury, although the extremity can be par-alyzed in the latter condition (10, p 518a; 11, p 502).

The first section of the fourth chapter of the fourth fen of thefourth book of the Canon is written mainly about medical treat-ment of penetrating wounds to the nerves, such as piercing,splitting, and transection. In this section, the nature of topicaldrugs is described as cold, hot, dry, and moist. Avicenna givesdetailed information for each type of drug and recommendsinstructions for using them on specific occasions.

Do not attempt to fuse the injured nerve in the earlyphase; first try to relieve the pain. In order to achievethis, apply a heated fabric over the wound and letwarm oil soak into it…Whenever you eliminate thepain and swelling, and you are sure that inflamma-tory substances do not contact the wound, begin tofuse the nerve after proper cleaning has been done(venesection, etc.) (10, pp 518a–b; 11, pp 503–504).

In the following paragraph, Avicenna refers to incompletehealing after a nerve injury. He may be describing disintegratednerve tissue rather than neuroma formation and gives somehints on how to deal with it:

Incomplete healing of a nerve [after injury] is oftenseen. In particular, cold temperature and physicalstrikes may affect the healing process so that thewound may gain a shape like spun cotton and painmay worsen. In such a case, apply some heating oilfor relieving pain, and if the nerve is visible throughthe wound and has a firm structure [by palpation],and the injury happened in a longitudinal fissure- likefashion, try to cover it with flesh, put some drug on it,which I mentioned before, and wrap tightly with awide bandage (10, p 518b; 11, p 504).

In the next paragraph, Avicenna gives a proposal for repair-ing transection injuries to nerves; this recommendation hadgreat significance in the history of neurosurgery:

If the fissure or transection injury occurs trans-versely, you must suture the nerve ends; otherwise the

Twisting and hardening of a nerve more than usualfrequently occurs from falling down or receiving ablow on the nerve. The sign of twisting and hardeningof the nerve is numbness when compressing it with afinger (10, p 519b; 11, p 511).

DISCUSSIONThe relevant sections of the Canon reveal that Avicenna was

the first to propose surgical repair for a transection nerveinjury. Scholars believe that Avicenna’s opinion concerningnerve repair, although rudimentary, remained the main proto-col until the 16th century (2). Throughout past centuries, thestudy of the history of peripheral nerves, peripheral nervepathology, and treatment of peripheral nerve disorders andinjuries has raised a number of questions. The surgical man-agement of the peripheral nerves has always been a challeng-ing and complex problem. Contemporary physicians haveachieved satisfactory results in the surgical management ofperipheral nerves thanks to technological advancements andpioneers who made great contributions in this area. In thewritten history of nerve repair, the first to consider the topicwas Paulus Aegineta (AD 625–690), who postulated restora-tion of severed nerves (1, 16). However, he did not describe theparticular technique for this procedure.

In the preceding historical period, Hippocrates (460–370 BC)had introduced early knowledge about the treatment of periph-eral nerve injuries in his Aphorisms. Section 5:18 of this book dic-tates that “Cold is inimical to the bones, the teeth, the nerves,the brain, and the spinal marrow, but heat is beneficial” (9,p 138). Avicenna also shared and defended this opinion.Hippocrates wrote in the same work (Section 6:19) that “Whena bone, cartilage, nerve, the slender part of a jaw, or prepuce iscut out, the part is neither restored nor does it unite” (9, p 140),and (Section 7:28) “Whatever piece of bone, cartilage, or nerveis cut off, it neither grows nor unites” (9, p 142). Hippocrates’works contain anatomic descriptions of peripheral nerves andtheir injuries; however, there is no mention of nerve repair.

Thus far, the relevant documents have revealed that most ofthe physicians of antiquity did not clearly distinguish betweennerves and tendons. In addition, the medical methods that theyused frequently had negative effects, which caused them toavoid attempting nerve repair procedures. Consequently, nervesurgery remained untouched for many centuries (16). Theprevalent notion was that a divided nerve could not be united.Fortunately, in the following era, Herophilus of Chalcedonfrom the Alexandrian School (ca. 300 BC) made a critical differ-entiation between nerves and tendons, and he also describedthe spinal cord as the anatomic origin of the nerves and dividedthem into motor and sensory tracts (8, 13). Half a millenniumlater, Galen of Pergamon (AD 129–200) reassessed these find-ings and accepted the brain as the center of the peripheralnerves (13). Galen found that spinal root injury may cause dis-tal paresis and suggested the application of topical drugs overthe region where the root was affected (4, 6). Although there isno clear description found in Galen’s books, some scholars


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have acknowledged that Galen may have implied surgicalrepair of nerve transection in his works on wound treatment(14). In the 7th century, Paulus Aegineta postulated restorationof severed nerves; however, he recommended only closureof the wound without including primary repair of nerves.Moreover, Paulus recommended that the nerve should not bepunctured by the needle (15).

There was another gap (of almost 400 years) in the historyof peripheral nerve repair until Avicenna’s account, whichstated that divided nerves can be sutured. Avicenna influ-enced his successors in an encouraging way. The “manual artof surgery,” before the introduction of the Canon to the LatinWest, formed one of the lesser and more neglected branches ofmedicine. Commencing with Avicenna, the medieval Arabicphysicians changed Galen’s dictum that surgery was an infe-rior branch of medicine. After Avicenna, there was a branch-ing out of surgery, and the issue of purely surgical worksexpanded. The earliest of these writers on surgery were Roger,Roland, and the so- called “Four Masters.” Guy de Chauliacmade extensive use of Avicenna’s writings (5). In Italy, thestudy of the Canon seems to have been first undertaken bysurgical writers associated with Bologna and Padua. Surgicalteaching in the Italian universities also drew upon practicallyoriented portions of the Canon; the use of parts of the Canonas a textbook of surgery is evidenced by the interest shown inAvicenna’s works by 13th century northern Italian surgicalwriters. The Canon was frequently copied in its entirety andoften studied as a reference work (17).

Roger of Salerno (12th century) is widely accepted as thepioneer of the management of peripheral nerve injuries; herecommended anastomosis of the interrupted nerves, withparticular emphasis on anatomic continuity (8). It is obviousthat because Avicenna wrote his work approximately a centuryearlier than Roger, he must be considered as the pioneer ofsurgical nerve repair. A little later, Guglielmo da Saliceto(1210–1280) offered nerve fusion methods. Although his tech-nique is unknown, one of his pupils, Guido Lanfranchi, prac-ticed direct nerve suture by sewing the ends of the nervetogether with the skin. The modern concept of the surgery ofperipheral nerves started essentially with Gabriele Ferrara’swork (1543–1627) in Italy. He was the first to provide a precisedescription of suturing of the stumps of a transected nerve,which we are still practicing today (2).

Although there is currently no consensus among scholars asto whether Avicenna made a clear anatomic differentiationbetween the nerves and tendons/fasciae, the relevant text pre-sented here suggests that he did. In the section of his book con-cerning peripheral nerve disorders, he clearly describes such adivision in the principles for the treatment of nerve injury.

The medical comprehension of Avicenna was based on theHippocratic and Galenic principles (6). His methods of treat-ment and drug use may be understood through considering hismedical comprehension. Avicenna classified the organs accord-ing to their characteristics such as hot, cold, wet, and dry.According to this classification, Avicenna included the nervesin both the cold and dry groups:



Motor nerves, as against the normal balance, aremore cold and dry in temperament while sensorynerves are colder but not drier. Sensory nerves are, per-haps, in regard to dryness nearer to the general tem-perament but are also too far from coldness (3, p 31).

Avicenna also classified organs as simple and compound,and he placed nerves in the “simple” category:

Nerves. These arise from the brain and the spinalcord. They are white and elastic and are easily bentbut do not break. They serve sensation and move-ment (3, p 48).

In the treatment of nerve injury, Avicenna gives priority tocessation of pain and suggests treating the injured nerve subse-quently. The most important aspect is the proposal of suturingthe nerve ends after transverse cutting. Another significantissue Avicenna touches on is inflammation, which, he recom-mends, can be prevented by appropriate drugs. These propos-als are somewhat parallel to modern neurosurgical compre-hension. Drainage of inflammatory substances that havecollected inside the wound, cleaning of the contaminatedwound, and treating the nerve after the management of inflam-mation are among his principles to cure the injured nerve.

Avicenna imparts some important knowledge about emer-gencies, and he quotes a prescription from Galen in the secondsection of the fourth chapter of the fourth fen. He also quotessome prescriptions from Galen in the third section.

In conclusion, Avicenna dedicated a large part of his princi-pal medical book, the Canon, to peripheral nerve disorders,including trauma and inflammatory diseases of the nerves. Onthe basis of the theory of the four humors, Avicenna recom-mended a great number of prescriptions for all kinds of periph-eral nerve disorders. Although, he did not give a detaileddescription, he also recommended, for the first time, a sutureprocedure for transection nerve injury. As Avicenna’s Canonbecame influential in the West through Latin and Hebrewtranslations in the centuries that followed, it is likely that hisopinions regarding peripheral nerve repair may well haveencouraged succeeding generations of physicians.

REFERENCES1. Anderson RG: Facial nerve disorders and surgery. Selected Readings in

Plastic Surgery 9:1–39, 2001.2. Artico M, Cervoni L, Nucci F, Giuffré R: Birthday of peripheral nervous sys-

tem surgery: The contribution of Gabriele Ferrara (1543–1627). Neurosurgery39:380–383, 1996.

3. Avicenna: The Canon of Medicine, in Shah MH: The General Principles ofAvicenna’s Canon of Medicine. Karachi, Naveed Clinic, 1966, pp 31, 48.

4. Awad IA: Galen’s anecdote of the fallen sophist: On the certainty of sciencethrough anatomy. J Neurosurg 83:929–932, 1995.

5. Campbell DE: Arabian Medicine and Its Influence on the Middle Ages. New York,AMS Press, 1973, vol 1, pp 129–132.

6. Castiglioni A: A History of Medicine. New York, Alfred A. Knopf, 1958, ed 2,pp 224, 272.

7. Doksat MK: Avicenna, Master and Ruler of Physicians [in Turkish]. P “Tip veSanat” 27:56–65, 2002.

8. Goodrich JT: History of spine surgery in the ancient and medieval worlds.Neurosurg Focus 16:E2, 2004.

9. Hippocrates: Hippocratic writings (translated by Adams F), in Hutchins RM(ed): Great Books of the Western World. Chicago, Encyclopedia Britannica, Inc.,1952, vol 10, pp 138, 140, 142.

10. Ibn Sina: The Canon of Medicine (translated by Mustafa Ibn Ahmed Ibn Hasan et- Tokati) [in Ottoman Turkish]. Istanbul, Suleymaniye Library of Hand -written Works, Manuscript no. Hamidiye 1015, folio 518a–519b.

11. Ibn Sina: The Canon of Medicine (translated by Sharafkandi A) [in Persian].Tehran, Soroush Press, 1997, vol 4, pp 501–512.

12. Kahya E: Introduction, in Ibn Sina: The Canon of Medicine (translated by KahyaE) [in Turkish]. Ankara, Atatürk Kültür Merkezi Press, 1995, vol 1, ppXIX–XLIII.

13. May MT: Introduction, in Galen: On the Usefulness of the Parts of the Body(translated by May MT). Ithaca, Cornell University Press, 1968, pp 25, 61.

14. Ochs S: A History of Nerve Functions: From Animal Spirits to MolecularMechanisms. Cambridge, Cambridge University Press, 2004, pp 187–190.

15. Paulus Aegineta: The Seven Books of Paulus Aegineta (translated by Adams F).London, The Sydenham Society, 1846, vol II, pp 132–137.

16. Shah SB, Jackler RK: Facial nerve surgery in the 19th and early 20th cen-turies: The evolution from crossover anastomosis to direct nerve repair. AmJ Otol 19:236–245, 1998.

17. Siraisi NG: Avicenna in Renaissance Italy: The Canon and Medical Teaching inItalian Universities after 1500. Princeton, Princeton University Press, 1987, pp52–53, 133–134, 145.

18. Tamani G: The Canon Medicinae of Avicenna in the Hebraic Tradition: TheMiniatures in Manuscript 2197 of the University Library of Bologna [in Italian].Padova, Editoriale Programma, 1988, pp 14, 21.

19. Terzioglu A: Avicenna’s Art of Medicine and Its Effects on Europe [in Turkish].Ankara, Türk Tarih Kurumu, 1984.

AcknowledgmentsWe thank Sehriyar Sems, D.M.D., for his invaluable contribution in translat-

ing the Persian text and Philip Glover, Ph.D., for his kind support for the Englishlanguage revision of the manuscript.

COMMENTS

ciduman et al. from Ankara, Turkey, have provided a well-writtenarticle that illuminates the history of peripheral nerve surgery, the

Canon of Medicine, by the 11th century physician, Avicenna. I particu-larly enjoyed learning about the significant contribution made by thisgreat physician to the description and management of peripheral nerveinjuries. Indeed, it appears that Avicenna was an early, if not the first,authority to discuss the surgical management of the peripheral nerve.He clearly identified and described the gross pathoanatomic features ofnerve injuries in continuity, including the swelling (neuroma) thatoccurs in this situation. Importantly, he recognized the differentialprognosis of longitudinal versus transverse nerve injuries in that thenerve may be in continuity more often in the former than in the lattercase. He emphasized that nerves that were transected should berepaired. I think that all readers of the Journal who are interested in thehistory of neurosurgery as well as enthusiasts of peripheral nerve sur-gery will enjoy reading this article immensely.

Rajiv MidhaCalgary, Canada

In this remarkable article, the authors have presented a thorough andcomprehensive view of an outstanding figure of medieval medical

history and his contributions in the advancement of medicine of thatera. Avicenna provided the greatest contribution in Western medicine;his fame was equal to that of Galen, both in Islam and in Christendom.Although he was already practicing medicine at the age of 16 years (hewas a child prodigy able to recite the Koran from memory at the age of10 years), he was especially famous as a compiler and commentator.

A


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His primary medical book, Al-Qanun (the Canon), a textbook used byall European universities, influenced physicians in the ensuing period.In this treatise, Avicenna first described a suture procedure for periph-eral nerve transection. Over the years, his management strategies werepracticed for a long time by physicians who obtained encouragingresults in the surgical treatment of peripheral nerve disease. The detailsof his technique are most remarkable and awesome, especially consid-ering the period and the few resources available at the time. Theauthors have provided a distinct service by reporting on Avicenna’sheritage through the description of his life and his treatise. Articleslike this one, appearing in the Legacy section of NEUROSURGERY, areremarkable additions to the history of medicine.

Enrico de DivitiisNaples, Italy

The authors have put together a most interesting article on Avicennaand his early techniques and concepts dealing with peripheral

nerve injury. Until reading this article, I was unaware of Avicenna’scontribution to this subject, and I am particularly impressed that thiswork was done by one whom Westerners do not think of as an “oper-ating” surgeon. The authors have also done an excellent job in ferret-ing out the important passages in the Canon, and they seem to havedone the translations well. Also intriguing was reading of Avicenna’sunderstanding of the different types of nerve injuries and which wouldrecover well and which would not. Avicenna appeared to be able to dif-ferentiate between the tendons and nerves, something not commonly

done then. In reviewing the techniques for repair and treatment ofperipheral nerve injury, his methods were clearly innovative andinsightful for this period, i.e., the 11th century. However, as the authorspoint out so clearly, medical treatment and medications unfortunatelyremained a bit primitive. This presentation is clearly innovative andprovides us with a new insight into the pioneering work of this greatIslamic physician (and surgeon!).

James T. GoodrichBronx, New York

Avicenna was a pivotal figure in the development of clinical medi-cine. A millenium ago, he attempted to codify all medical knowl-

edge. Eminent bibliographers, Fielding Garrison and Leslie Morton,stated that “His ‘Canon’ is one of the most famous texts ever written.”Its influence extended into the 20th century in the Near East. WilliamOsler mentions a physician in Tehran who cited Avicenna in a consul-tation on a febrile patient in 1915. Avicenna’s importance can also begauged by the number of his manuscripts in Latin and Arabic and bythe incunabula found in the libraries of well-known bibliophiles suchas the Biblioteca Osleriana housed at McGill University in Montreal,the Harvey Cushing collection at Yale, and the Erik Waller collectionbequeathed to the library of the Royal University in Uppsala, Sweden.The authors of this article are to be commended for bringing Avicenna’sviews on peripheral nerve injuries to our attention.

Norman H. HorwitzWashington, District of Columbia

Human embryonic stem cells stained with two stem cell markers, Oct4 (red) and SSEA4 (green). Credit: Rick Cohen, Ph.D., W.M.Keck Center for Collaborative Neuroscience, Rutgers, the State University of New Jersey. See Apuzzo, p 1, and Farin et al., pp 15–39.

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PERIPHERAL NERVE DISORDERS AND TREATMENT …the Canon have revealed that Avicenna was the first author to discuss the surgical management of peripheral nerve injury. Although the Canon