Traditional Medicine Among Gulf Arabs

Introduction

In the first part of my paper, Arab GulfTraditional Medicine, which was published ina previous issue of Heart Views1, I mentioned

that the major fields of Arab traditional medicineare Herbal, Cautery, and Blood-letting. Herbalmedicine is so diverse a topic that it is beyondmy ability to discuss it. In the previous issue I dis-cussed cautery and in this issue I will discussblood-letting: Hijamah and Fasd.

Fasd, which is phlebotomy or venesection, israrely practiced nowadays in the Arabian Gulf,but Hijamah, which is the sucking of blood bycupping, is still practiced in the Arabian Gulf orGulf Cooperation Council (GCC) states. Islamicbooks state that the prophet Mohammed(PBOH) had stated that there are three methodsto cure illness: “a drink of honey, a scratch ofhijamah and cautery.” But he was not too keenon the last one.

1. Hijamah

The Arabic word “hijamah” means “sucking.” Inthe Arabian Gulf, Hijamah was used not only fortreatment but also for prophylaxis against dis-eases. The pearl divers in the Arabian Gulf used

to undergo hijamah before the diving season inthe belief that the procedure will prevent dis-eases during the 3 months at sea. It was thoughtto be very effective against dizziness.

Barbers usually performed hijama. When Iwas a high school student I remember asking aBritish trained physician practicing in Doha:“Why do the British call their surgeons misterrather than doctors?” He replied: “Because theirprofession grew out of being barbers first, notmedical doctors.”

When I was a small child it was common tosee our village illiterate barber, Mr. Abdulla AlHassan, assume the role of a “doctor”. He per-formed circumcisions, cautery, and hijamah. Hewas a friend of my father and was a good neigh-bor. His wife and daughter used to help my moth-er take care of me. I also liked Al Hassanbecause he used to carry me as a child and heoften gave me candies and nabique (desertfruits). I used to watch him do hair cutting andperform hijamah and cautery in the open air inthe shade of his house. He used to shave myhead every two weeks then. He never lied to meexcept once. It was a white lie.

I was about six years old when I was broughtto my father who was sitting with friends in a liv-ing room. I was made to sit on a small stool in the

SPECIAL SECTION

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CHAIRMAN'S REFLECTIONSPart 17

TRADITIONAL MEDICINE AMONG GULF ARABSPart II

*Chief of Cardiology, Rumailah Hospital (1978 - 1982); Chairman, Department of Cardiology and Cardiovascular Surgery,Hamad Medical Corporation (HMC) (1982 to present); Managing Director, HMC (1979-1990); Undersecretary of Health (1981-1993); Chairman of the Board Hamad Medical Corporation (1998 - 2003); Minister of Health, Qatar (1999 - September 2004).Founder and President, Gulf Heart Association (GHA), Arabian Gulf (2002 to present).

Looking back at the first few years of workingas a cardiologist at home in Qatar, is likewatching an old movie. The scenes are clear,the events exciting, the struggles intense, andthe heroes real. Some characters are stillaround; some are no longer with us.

BLOOD-LETTING


Traditional Medicine Among Gulf Arabs: Part II

75

middle of the room. The barber, Mr. Abdulla AlHassan, came forward to me and said we willplay a game. A man came from behind me andput his hand over my eyes. Then Al Hassan saidto me to try to see stars in the sky through theman's fingers. So, I concentrated on seeing thestars while blindfolded and not paying attentionto what else he was doing. I suddenly felt some-thing touching between my legs. When the manbehind me lifted his hand from my eyes I sawblood dripping over my leg. The sight of myblood made me cry. It was fast circumcision with-out anesthesia. It was done so fast that I did notfeel any pain. It may not have been a sterile pro-cedure, but it was much faster and more humanethan the circumcisions I see in modern hospitalsat the present time.

I had many chances later to watch the tradi-tional circumcision by our barber (Figure 1). Hewould insert a small glass ball in the foreskin sacto push the glans back. While grasping andstretching the foreskin a few millimeters distally,he would quickly cut the foreskin between his fin-gers and the glass ball with a sharp blade. Theglass ball protected the glans from accidentalinjury. He dried the blood with cotton. He wouldthen apply cotton soaked in iodine solution overthe wound before wrapping it with a piece ofcloth. The child was not given drink for 6-8 hourspost circumcision to delay urination. After two tothree days the child was taken to the sea. Hewould sit in the sea for 10 minutes to soak thewound in sea water. The sea water loosens thecotton which was firmly attached to the wound.Local Gulf people consider sea water as having

antiseptic properties, may be because of thehigh salt content.

During the Gulf Heart Association meeting inOman, which was held in January 13 -15, 2004,I visited the Oman Traditional Medicine Center inMuscat with my wife, Rachel. We saw the hajjamperforming hijamah in modern clean environ-ment using gloves and sterile glass cups. Thetraditional Arab hijamah was with bull horns(Figures 2 and 3) or metal cups (Figures 4, 5 and6). I have seen glass cups for hijamah similar tothe tea cups used by Gulf Arabs, with built-insucking tube (Figure 7). At the Omani center, weinterviewed a patient who came for hijamahtreatment. I took his pictures during the proce-dure (Figures 8A-8D). The patient was a manabout thirty years old with chronic seizure disor-der. He had hijamah therapy one year earlier. Heclaimed that the frequency of his seizuresdecreased after the first treatment. He cameagain this time to have another course. He toldme that he preferred hijamah because he doesnot like to take drugs daily. I did advice him how-ever, that he should take the antiseizure tablets,even if he gets hijamah therapy.

Over the years, Oman is well known through-out the Gulf for its Arabic traditional medicine.Patients from all over the Gulf used to travel toOman for both traditional medicine as well aswitchcraft medicine. Some Omani men withexperience in traditional medicine worked inother Gulf States as traditional doctors.

In Qatar, I remember a nice old Omani manpracticing Hijamah and Keyy (cautery) fordecades. He was well known in Qatar. His pho-tos practicing his craft still appear in most Qatarpublications on traditional medicine as seen in(Figure 4). I had to prevent him from working inQatar in 1981 when I was undersecretary ofhealth after I made it mandatory to have bloodscreening test on such profession. He went tothe Islamic court to complain to the chief judgeagainst my decision. The judge sympathizedwith the old man, especially since the prophetMohammed (PBOH) had approved the use ofHijamah as a therapeutic measure. In fact thejudge was disappointed with my decision. Thejudge ordered me to appear in court to hear thecomplaints and respond to them. I requested thejudge to give me time to respond. The followingday, I took the old man's file and blood screeningtest results and went to the judge. I showed thejudge that the old man had Hepatitis B andexplained to him how he was a risk to the socie-ty. I told the judge that I was not against hijamah

Fig.1: Diagram of traditional Gulf Arab circumcision: 1=inci-sion site. 2=Glass ball 3-Glans.



76

Fig.7: Glass cup with build-in sucking tube used asmihjamah.

Fig 5: The Traditional hajjam applied one metal cup by cre-ating the vacuum with sucking and making incision for a sec-ond cup using his bare hands.

Fig. 6: The patient blood poured in a bowel for the patient tosee before discarding.

Fig 2: Horns used for hijama.

Fig. 3: A traditional hajjam sucking on a horn applied nearthe shoulder.

Fig 4: The Traditional hajjam applied one metal cup by cre-ating the vacuum with sucking and making incision for a sec-ond cup using his bare hands.



77

but I can not allow persons with transmissibleinfections to practice it. He accepted my reason-ing. He gave the poor old man a financial gift andordered me to do the same. It was clearly a per-sonal gift to help him, not a fine. I was happy tocomply with the judge's instructions especiallysince the judge was my own father. The old manthen left Doha and returned to Oman.

1.1. Hijamah tools: the main tools are listedin table 1 and (Figure 9).1.2. The procedure: The skin site is shaved,

cleaned and marked by placing the mihjamihsuch as a bull horn on the site and sucking the

mouth-end of the horn to mark the site for extrac-tion. Then the horn is removed and superficialincisions are made within the marked area(Figures 4 and 8B). Then, the horn is reappliedand the horn's mouthpiece is vigorous sucked(Figure 3). Blood accumulates within the horn.When the horn is removed, dark clotted venousblood is shown to the patient as “bad blood”before being discarded (Figure 6). This gives thepatient a psychological boost for getting rid of“bad” blood. After that, the wound is cleaned withdry cloth and either left uncovered or herbal pow-der (Zaater) is applied. The patient is instructedto keep the wound dry for one day.

1.3. Time: The best season for Hijamah is in

Fig. 8D: Bleeding in progress into the cups.

Fig. 8A: Applying vacuum to the cups using syringe to markthe area for incision.

Fig. 8B: Incising the skin in the marked (red and raised)area with a blade.

Fig. 8C: Re-applying the cups and sectioning to the incisedarea.



spring or fall to avoid too cold or too hot season.The best day is in the middle of the lunar month,i.e., a full moon, at early morning.

Most of the local people working in traditionalmedicine are illiterate. They learned the profes-sion from their fathers and mothers. They werenot able to provide me with a rationale why a fullmoon is the best time for performing the proce-dure. I had to turn to the old Arabic medicalscholar books to find some intellectual reason-ing.

Ibn-Sina (Avicenna 980 - 1037) was anIslamic philosopher, physician, psychiatrist and apoet. He considered medicine as part of knowl-edge that must be learned by every scientist. Hisbook THE CANON is well known and was usedas a medical textbook for centuries.

Ibn-Sina explained the prevailing thought atthat time on the best timing to perform hijamah:

“Some authorities advice against the procedureat the beginning of the lunar month, becausethe humours are not yet on the move or not in astate of agitation; also against performing it atthe end of the (lunar) month, because at thatperiod (of the cycle) the humours are less plen-tiful. The proper time according to them is themiddle of the month (when the humours are ina state of agitation) and during the time whenthe moonlight is increasing (when the humoursare on the increase also). During that period thebrain is increasing in size within the skull, andthe river-water is rising in tidal rivers. The besttime of the day for hijamah is at second or thirdhours” i.e. 2-3 hours after sunrise2.

1.4. Site: For each complaint there is a spe-cific site for hijamah. For headache, the locationis behind the head. For chest pain, the locationis on the shoulder, dorsally.

Abul Qasim Al-Zahrawi (936-1013 AD), anArab Andalusian surgeon known to the west asAlbucasis, was the greatest Arab surgeon of thattime. He devoted his life to medicine and espe-cially surgery. He described in his 30-volumemedical encyclopedia, Al-Zahrawi's book Al-Tasrif li-man ‘ajaza ‘an al-ta’lif, i.e. “The Methodsof Medicine”, his surgical techniques with about200 illustrations of medical instruments that hemade and drew. In his book, I found a descrip-tion of the technique of hijamah, the timing andthe tools.

Al-Zahrawi listed several points at whichHijamah (cupping) is performed: the occiput, theinterscapular region, the two sides of the neck,the chin, the two shoulders, the coccyx, theantibrachium, the middle of the forearms, the twolegs and the two heel-veins.

Al-Zahrawi said:

“The application of cupping to the shouldershelps in palpitation of the heart arising fromplethora and heat.” He also said: “What cuppingdoes is to draw blood out of the fine vessels(capillaries) dispersed over the flesh; for thisreason it does not cause the strength to declineas does venesection; nor may use cupping, inany disease due to plethora, until the wholebody has been evacuated. If the disease or cus-tom prescribe cupping, we may apply it at anyhour, at the beginning or the end of the month,at wherever time it may be. For there are somepeople who, when there is an abundance ofblood in them, so as to need cupping, feel heav-iness and pain in the head. Some find they havefullness and redness of the face and also thehead and neck. We therefore prescribe cuppingafter the second or the third hour of the day haspassed”3.

Al-Zahrawi recommended the use of leechesto the part of the body to which application ofcupping-vessels is impossible, either because of

Fig. 9: Hijama tools.

Mihjamih: The main tool for hijamah.It is the instrument for blood sucking.Bull horn was the instrument used inthe old times. Nowadays metal orglass cups are made specifically forthis purpose.Scissors: Used for cutting hair at thesite of hijamah.Blade: Used for incising the skin.

Table 1: HIJAMAH TOOLS:

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their smallness, such as the lips or because thepart is bare of flesh, like the nose.

There is no doubt that he got this idea fromGreek medicine. He recommended fresh waterleeches. He said:

“Leave them in fresh water for a day and a nightuntil they are hungry and nothing is left in theirbellies. Scrub the afflicted part until it is flushed;and then place the leeches on it. When they arefull they will fall off”3.

2. Bleeding: The Universal Therapy

The therapeutic use of blood-letting was so uni-versally common throughout history that it ishard to credit only one culture with it. It is verylikely that it was imperative that any primitivesociety would sooner or later evolve to practice iteither by chance or by instinctive intuition. Whenwe are bitten with insects, we scratch the site sohard that the skin may bleed. The scratchinggives us satisfaction. The oozing of the blood atthe site of the insect bite may have given manthe feeling that the offending substance or poi-son is washed out of the body. It was an old prac-tice by the Gulf Arabs, as well as many otherpeople, that when a snake bites a person, theymake incision at the site of the bite to bleed it inorder to expel the poison. I have seen a manwho was brave enough to cut off two of his toeswith an ax after a snake had bitten one of histoes. He had to cut the toes so fast that he didnot have time to think to cut only the bitten toe.

We may have learned some ideas fromobserving animals. An animal licks its wound andman may well have done it also. He may havestopped a hemorrhage through compression justas he must have practiced bleeding at an earlystage. Dr. Sigerist, a medical historian wrote:

“Scratching become scarifications and suckingbecame cupping. Bleeding as a method oftreatment was so universal that it also must bederived from instinctive actions, although earlyobservations probably contributed to a rapiddevelopment of the method: the fact that indi-viduals suffering from fever diseases suddenlyfelt relieved when they had a spontaneous hem-orrhage, bleeding from the nose, or when men-struation set in4.

In the Far East, Hijama or cupping was prac-ticed over centuries. A jar was attached to theskin surface to cause local congestion throughthe negative pressure created by sucking. There

are various types of cups - rubber, bamboo,glass and plastic, animal horns, etc. The tech-nique varies from place to place or from countryto country. This type of treatment has been prac-ticed by the Chinese and the Arabs for thousandof years. The Chinese made negative pressureby introducing heat in the form of an ignitedmaterial. In ancient times, in China, cuppingmethod was also called “horn method”.

Bleeding through scarifications, venesection,or cupping is practiced by most primitive peoplein the treatment of pneumonia, pleurisy, andother diseases, particularly those that are com-bined with fever. It brings a certain relief bydecongesting the system as the primitives foundout empirically. The South American Indianspracticed it in order to drain out a spirit4.

Among American Indians, sucking was a chiefmethod of treatment. A special method of extrac-tion was practiced by Arapaho and ChoctawIndians, where the medicine man did not suckthe skin with his mouth directly but applied ahorn cup, whereby the object was found in theblood that filled the cup4. (I wondered if theIndian “Arapaho” tribe is of Arab-aho origin thatreached the New World, before Columbus, andintroduced hijamah there!).

2.1. Fasd: Blood-Letting

Blood-letting, referred to as venesection, iscalled phlebotomy at the present time. It was apopular therapeutic practice from antiquity up tothe late 19th century, involving the withdrawal ofconsiderable quantities of blood from a patient inthe belief that this would cure or prevent disease.

Unlike hijama phlebotomy is rarely practicedin the Arabian Gulf nowadays. I have never seenthe procedure practiced in the Gulf. It is reportedby the GCC folklore center that it is still occa-sionally practiced in Bahrain for women only astreatment for dizziness5.

2.2. Greco-Roman domination ofBlood-letting

Blood-letting was in use around the time ofHippocrates (460 - 377 BC) and was reinforcedby the ideas of Galen (129- 210 AD). TheGreeks thought that veins contained blood andarteries air - “pneuma”. There were two key con-cepts: The first is that blood was created andthen used up. During the time of Galen, they didnot know that the blood circulated. They thought



it could “stagnate” and cause illness. The secondis that humoral balance was the basis of illnessor health. The four humours were blood,phlegm, black bile, and yellow bile (relating tothe four Greek classical elements of earth, air,fire and water). Galen believed that blood wasthe dominant humour and the one in most needof control. In order to balance the humours, aphysician would either remove “excess” blood(plethora) from the patient or give them emetic ordiuretic. Galen created a complex system of howmuch blood should be removed based on thepatient's age, constitution, the season, theweather and the place. Symptoms of excessblood were believed to include fever, stroke andheadache.

Galen in the third century regarded bleedingas the appropriate treatment for almost everydisorder, including hemorrhage and fatigue.When the old Arab and Muslim physicians, inthe tenth century and after, mentioned “thephysician” they always meant Galen. He hadgreat influence on their concept of medicine.Only Ibn Al-Nafis, the Arab Father ofCirculation, dared to say that Galen was wrongabout the flow of the blood in the heart.Therefore, Galen's teaching of blood-lettingwas accepted by the rest of the Arab physi-cians. For certain conditions, Galen recom-mended two brisk bleeding per day.The firstshould be stopped just before the patient faint-ed, because patients who survived the firstoperation would not be harmed by the second.Galen was so enthusiastic about the benefits ofvenesection that he wrote three books about it6.

Galen argued that women were spared manydiseases that afflicted men because their super-fluous blood was eliminated by menstruation6.The health benefit of menstruation was recentlyrevived in cardiology as you will see below in thisarticle.

Erasistratos was a contemporary of Galen,but belonged to the school of Alexandria inEgypt. He was a surgeon and a true scientistwho was credited for naming the heart valvesbicuspid and tricuspid. Even though Galen hadalso studied in Alexandria, he did not agree withErasistratos' medical concepts. He wrote twobooks against him.

There was in Rome at that time a group ofphysicians who followed the conservative line ofErasistratos who opposed bleeding. They infuri-ated Galen to such a degree that he wrote thebook “On Venesection Against Erasistratos”.

Galen recommended blood letting for every dis-ease. He even recommended bleeding to stophemorrhage.

The Greeks believed that bleeding protectedthe wound from inflammation. Therefore,Corlius Celsus (born 25 BC) suggested thatwhen there is a deep wound involving bone ormuscle, it will not be desirable to suppress thebleeding early, but to let the blood flow as longas it is safe. If there seems too little bleeding,the blood should be let from the arm as well8.On the treatment of headache, he recommend-ed “rest and diet and plaster . . .” Then if thepain gets more severe the treatment becomesmore energetic: bleeding, either by venesectionor by application of leeches, cupping, and clip-ping of hair are added to the therapy9. Hair cut-ting as a form of treatment is an interesting newinformation for me. I never came across suchtherapy before.

Celsus advanced the practice of venesectionto the point that it had indications in the veryyoung and the very old, in pregnancy, and inother conditions. Phlebotomy thus became, andremained through Roman, Arab and medievalEuropean medicine, the universal remedy10.

2.3. Blood-letting by the Arabs

Most of the pre-Islamic Arab surgery was basedon Greco-Roman medicine. The very rare use ofleeches for blood letting by the Arabs wasRoman in origin. In fact the old Arabic word forclever physician is “Natasi”, a word the Arabicdictionary states that was Roman in origin.Greco-Roman medicine was transmitted to pre-islamic Arabs from Syria and and the Greekmedical school in Jundishapur of Iran then.

Historians claim that the “pre-islamic Nearand Middle East possessed popular medicineakin to that of the Mediterranean . . . Cupping,cautery and leeches were employed for blood-letting”11.

Arab reasoning for removing blood was eitherthe blood was more than what was needed orthey removed bad or spoiled blood. The conceptof “bad” blood has persisted until now in our soci-ety. This is the reason why hijamah is still prac-ticed in the Arabian Gulf.

Blood-letting was used to “treat” a wide rangeof diseases, becoming a standard treatment foralmost every ailment. The Arabs used it to treatheadache, eye disease, Sciatica, gout etc. A num-ber of different methods were employed. The



most common was phlebotomy or venesection, inwhich blood was drawn from one or more of thelarger external veins, such as those in the foearm.

Ibn-Sina (Avicenna) stated in his book, TheCanon of Medicine, the general indications forblood-letting:

1. When the blood is superabundant that adisease is about to develop.

2. When disease is already present. He said that:

“The object in both cases is to remove thesuperabundant blood, to remove the unhealthyblood, or both. Examples of the first categoryare incipient sciatica, podagra (gout) and dan-ger of hemoptysis from rupture of vessel in rar-efield lung, for superabundance of blood thenmakes the vessel liable to give away”2.

Contra-indications: Blood-letting should notbe peformed before age 14 or after 70 as well asin those patients who were very emaciated2.

The proper time of the day for venesectionaccording to IBN-SINA:

“Before mid-day if the procedure is elective,when digestion is completed and when thebowels are empty. When it is urgent, then itcould be done any time”2.

Syncope: Ibn-Sina warned that:

“The first blood-letting may be accompanied bysyncope if it is carried out quickly on a personnot accustomed to it; therefore emesis shouldfirst be procured to guard against that, and mayrepeated at the time of bleeding.”2.“Syncope rarely occurs during the flow of blood,unless a great amount is lost. Only bleed up tosyncope in cases of synochal fever (continuousfever), in incipient apoplexy (stroke), extensiveangina or inflammatory swelling, or in cases ofsevere pain”2.

So, Ibn-Sina recommended bleeding toinduce syncope to relieve pain in cases suchas angina. That is very odd to us now but atthat time physicians did not have manyoptions to relieve pain.

Phlebotomy could act as pain-killer when car-ried out aggressively enough to induce fainting.Such bleeding were used in preparation for child-birth, reducing dislocation, and setting fractures6.

The Arab Andalusian surgeon, Al-Zahrawi(Albucasis), mentioned about thirty blood-ves-sels as suitable for venesection. He mentionedsixteen vessels in the head, five in each arm andhand and three veins in each the leg and foot12.He devised and illustrated fine scalpels orlancets for veins, and he called one such lancet

olivary scalpel (Figure 10).2.4. Non-therapeutic Phlebotomy

There were times when venesection was usedby the Arabs as a non-therapeutic tool. There aresome historical cases when pre-Islamic Arabkings killed opponents with venesection to distin-guish them from common people.

The most famous Arab Queen, Zenobia whorevolted against Rome in the third-century anddeclared Palmyra (Tudmor) in Syria independentfrom Rome, expanded her role over all Syria andEgypt and named her son as emperor. She killedan Arab king, Jothima Al Abrash, with venesec-tion.

The condemned King or very distinguishedperson of that period was given wine to drinkuntil he gets intoxicated before the execution.The wine acted as a sedative or anesthetic forthe victim to die a peaceful death.

The Arab king, Al Noman Ibn AL Monther,honored the famous Arab poet, Obaid ibn AlAbruss in his old age by killing the poet in 598AD with venesection. He asked the poet how hewished to die. The poet said: “Let me drink wineuntil I get drunk, then do what you please.” Theodd reason for that killing was that the king hadfelt guilty for the death of two of his friends. Hepledged that one day in the year will be his omi-nous day and another day in the year will be hisgood day. He will sit next to the graves of his twofriends at those days. He pledged to give the firstperson who appeared to him near the graves onhis good day 200 camels. On his bad day, heexecuted the first person who appeared to himnear the grave. The poet's bad luck was comingto praise the king in a poem and was the first onewho appeared to the king on his bad day12).

Venesection was the preferred way for execu-tion of kings because the king's blood must notbe spilled on the ground. It must be collected ina container. They also believed that a king'sblood had therapeutic value. It supposedly curedpatients from rabies and insanity13.

Camel jugular venesection was performed bythe Arabs pre-butchering. After the camel loosesadequate blood and becomes so dizzy to fall,

Fig. 10: Olivary Scalpel by Albucasis.



then it was butchered.The Arabs did not use blood letting to drive

evil spirits out of the body as the AmericanIndians did. Sigerist stated that: “ThroughoutSouth America, the most popular method of driv-ing out a spirit was bleeding through venesectionor scarifications, and was believed that thedemon escaped with the blood”4.

2.5. Origin of blood letting

It is assumed that blood letting as therapeuticand prophylactic measure originated with theGreeks. Some claim that the Babylonians startedit, but I found no proof to support that claim. TheEgyptian medicine was earlier than Greek medi-cine. They may have performed therapeuticbleeding before the Greeks.

Prioreschi Plinio claimed that Bloodletting wascommon in antiquity and was practiced inChinese and Hindu medicine, although not byEgyptian physicians14. Even though he claimedthat bleeding was not practiced by theEgyptians, he cited a case of bleeding by theancient Egyptians recorded in the Ebers Papyrusbut consider that a drainage. He stated that“Sometimes the blood contaminated by whdwcould be removed from an infected area as, forexample, in the case of an infected ear: Thoushalt cut one side of it in order that its blood maycome on one side.”15,16.

I did find that the old Egyptians, before theGreeks, practiced bloodletting, at least for treat-ing animals. The evidence is in a veterinarypapyrus. In the Veterinary Papyrus of Kahun,there is a description of treating a “bull with wind”:

“If I see a bull with wind, he is with his eyes run-ning, his forehead is wrinkled, the root of theteeth red, his neck swollen: I repeat incantationfor him. Let him be laid on his side, let him besprinkled with cold water . . . rubbed with gourdsor melons, . . . Fumigated . . .Thou shalt gash him (bleed him) from his noseand his tail, thou shalt say as to it, 'he that hasa cut either dies with it or lives with it”,

The above quote indicates that prognosis wasuncertain when the illness has reached the pointat which venesection must be practiced4.

I did not see that Egyptian veterinarian whenhe treated that bull thousands years ago, but Ihave seen a blood-letting treatment of an animalwhen I was a child in our house. During my child-hood we had a section in our yard for animals.

We had a dozen chickens, half a dozen goats, afew pigeons, a cow, a donkey, a guard dog anda cat. I also kept an aggressive large seagull freein the yard as my personal pet.

Our cow became sick one day and could noteat or drink. I was sent to call Mr. Da'in, a localcow traditional therapist. He examined the cow'smouth and noted swelling of the tongue. He saidthat it was suffering from “irq”. Irq means bloodvessel or root. He tied the cow's head with ropesattached to two wood posts so that the head wasin a fixed position. He pulled the tongue out tothe side of the mouth and massaged it vigorous-ly with turmeric and salt for a few minutes. Thenhe pierced, probably, a vein in the tongue with alarge needle. Blood started to drip. He removedthe ropes and left the cow oozing blood from themouth. Five hours later, I heard my mother say-ing that the cow had started to eat.

In ancient china, acupuncture was drainage,Chinese style. The Chinese conceived that thebody contained a set of imaginary, or spiritualvessels or “meridian”, containing no blood butch'i. This principle was something like the Greekpneuma or “energy.” It could be drawn out byneedling the right ch'i vessel. Thus the needlingcould be called a form of drainage of “energy”rather than blood8.

2.6. Controversy on blood letting

Some have suggested that venesection mighthave suppressed the clinical manifestations ofcertain diseases, such as malaria, by loweringthe availability of iron in the blood; the availabili-ty of iron may determine the ability of certainpathogens to grow and multiply. Bleeding wouldalso affect the body's response to disease bylowering the viscosity of the blood and increasingits ability to flow through the capillary bed.Bleeding to the point of fainting would also forcethe patient to rest.

William Harvey disapproved the practice ofvenesection in 1628 in the introduction of scien-tific medicine, La Méthode Numérique.

Jan Baptista van Helmont (1579-1644), aphysician and chemical philosopher was proba-bly the first individual to strongly protest againstblood-letting as a dangerous waste of thepatient's vital strength. He also denied thatplethora was the cause of disease. He suggest-ed a clinical trial. He suggested taking 200-500poor people and divide them into two groups bycasting lots. He would cure his allotment of



patients without phlebotomy, while his criticstreat the other half with as much blood-letting asthey thought appropriate.The number of funeralsin each group would be the measure of successor failure. But that trial was never carried out6.

Pierre Charles Alexander Louis (1787-1872), a 19th century French physician per-formed statistical studies on the efficiency ofvenesection as a therapeutic measure in a largeseries of hospitalized patients. He concludedthat blood-letting did not affect the course ofpneumonia, a condition in which venesectionwas thought to be particularly beneficial. Mostphysicians did not accept the statistical data andbelieved the anecdotal evidence of patient sur-vival with bleeding as a time-honored therapeu-tic method. But Pierre Louis’ demonstration thatphlebotomy was entirely ineffective in the treat-ment of pneumonia was convincing to somephysicians and the controversy tilted against theprocedure in the 19th century.

It was generally believed in western countriesthat blood letting as treatment had becomeextinct by the end of the 19th century. But in real-ity, the end of the 19th century did not end ther-apeutic blood-letting practice. According to the1923 edition of Sir william Osler’s Principles ofMedicine, the “bible” of medicine for generationsof American doctors, “bleeding was returning tofavor in the treatment of cardiac insufficiency andpneumonia”6.

So, even after the humoral system fell out offavor, the practice was continued by barber-sur-geons. It was used to “treat” a wide range ofdiseases, becoming a standard treatment foralmost every ailment. It was especially popularin the young USA. George Washington wastreated with blood-letting when he developedsevere respiratory infection (acute bacterialepiglottitis). Almost four liters (3.75 liters or 124-126 ounces) of blood was withdrawn over a peri-od of nine to ten hours and certainly contributedto his death.

3. Role of phlebotomy in moderncardiology care

Not too long ago, but during my internshipand early residency in the USA (1973-1975)rotating tourniquets and phlebotomy waspracticed for severe pulmonary edema. Itwas considered a life-saving procedure. Icertainly participated in such therapy then. Itmay be useful to review briefly, the changing

practice in the utilization of therapeutic phle-botomy during my lifetime until today in med-ical text books and current literature.1949: A heart disease textbook by CharlesFriedberg strongly recommended phlebotomyfor congestive heart failure:

“Phlebotomy the removal of 350 to 1000 cc. ofblood from the vein of a patient with congestiveheart failure may rapidly and dramatically relievedyspnea, orthopnea, cyanosis, systemic venousand hepatic engorgement. Phlebotomy is indicat-ed chiefly when there is intense pulmonaryengorgment (especially with pulmonary edema)due to left-sided heart failure. But it is also usefulin cases of right-sided heart failure in which thereis an extreme elevation of the venous pressureand associated manifestations of systemicengorgment. Phlebotomy is often a life-savingmeasure when the patient suffers from acute pul-monary edema. The symptomatic improvementafter phlebotomy usually occurs with incrediblespeed, often when the needle is still in the vein” 17.

1975: Phlebotomy was still recommended in aheart disease text book but with less enthusi-asm:

“Venesection is reserved for severe acute pul-monary edema in whom all else had failed. It isseldom desirable to reduce the oxygen-carryingcapacity of the circulation of patient with acuteheart failure.”18

In the treatment of right heart failure phlebotomyis indicated when polycythemia is sufficientlysevere (HCT >55 %).19

1988: Braunwald: Heart Disease 3rd edition dis-couraged its use for Pulmonary Edema:

“The combinations of morphine, rotating tourni-quets, a diuretic, and sublingual nitroglyceringenerally diminishes preload sufficiently to obvi-ate phlebotomy. Although the removal of 500 mlof blood certainly diminishes preload, it is a time-consuming and often cumbersome procedure foran acutely ill patient, and it is therefore rarely, ifever, necessary to employ this technique”20.

The book did not support its use even for Corpulmonale:

“In the case of phlebotomy most older studieshave demonstrated an improvement in the sub-jective complaints related to vascular engorg-ment but no evidence of improvement in pul-monary gas exchange, mechanics, or hemody-namics has been found.”21.

However, the book considered phlebotomy indi-cated for polycythemia vera or secondary poly-



cythemia.22

1997: Braunwald 5th edition withdrew its supportfor its use in polycythemia:

“Whether phlebotomy is efficacious in poly-cythemic patients with cor pulmonale is contro-versial”23. “Adults with cyanotic congenital heart diseaseand erythrocytosis are frequently phle-botomized and occasionally anticoagulated.The rationale for phlebotomy assumes an inher-ent increase in the risk of cerebral arterialthrombotic stroke, a risk that has not withstoodscrutiny in a study of 112 adults with cyanoticcongenital heart disease observed for a total of748 patients years”24.

1998: An article in Heart Journal stated that:

“Polycythemic cyanotic patients experiencesymptoms caused by the detrimental effects ofhyperviscosity on tissue oxygen delivery ratherthan by a high hematocrit itself. There is no evi-dence that venesection alone (without myelo-suppressive treatment) reduces the risk ofthrombosis in polycythemia rubra vera; on thecontrary, patients who undergo frequent vene-section have a higher incidence of vascularocclusion. The risk of cerebral infarction in cyan-otic children younger than four years relates toiron deficiency and a relative anemia, rather thanto polycythemia. There is thus no evidence tosupport routine venesection to prevent stroke inadults with cyanotic heart disease. Somepatients are stable without symptoms of hyper-viscosity at a hematocrit of > 70; venesection isnot indicated for these patients”25.

2001: Braunwald 6th edition stated that in the treat-ment of cyanotic congenital heart disease:

“An increased hematocrit, in the absence of symp-toms, does not constitute an indication for phle-botomy”26.

Galen's concepts still haunt us in medicine.There was a revival of the concept that bleedingthrough menses protected women from heartdisease. According to this hypothesis, the loss ofiron with menstruation explains the lower risk ofCHD in premenopausal women compared withmen and postmenopausal women27. An article inCirculation in 1992 assured us that high storediron levels are associated with excess risk ofmyocardial infarction28.

2001: Another Circulation article refuted the con-cept that iron was a risk factor for CAD:

“Our primary hypothesis was that regular blood

donation reduces the risk of myocardial infarction.The results of our study suggest that body ironstores are not a major coronary risk factor amongUS men without previous cardiovascular disease ordiabetes. This conclusion is consistent with previ-ous prospective investigations that found no asso-ciation between serum ferritin and risk of CHD. Sothe study results do not support the hypothesis thatreduced body iron stores lower CHD risk”29.

Finally, after all these useless concepts aboutblood-letting and negative and ill-effects associ-ated with venesection or phlebotomy, is there stilla place for this ancient therapy in modern medi-cine? Yes. I know for sure one undisputed indi-cation for phlebotomy up to this year 2004. It is“hemochromatosis”. Hemochromatosis is ahereditary disease caused by excess deposits ofiron in the tissue.

The treatment of hemochromatosis has notchanged substantially since 1950. Therapeuticphlebotomy is safe, effective, and inexpensive.Each 450 to 500 ml of blood contains 200 to 250mg of iron. Even if begun later, phlebotomy canimprove constitutional symptoms, relievehepatomegaly and liver tenderness, and protectjoints from arthritis30. Therapeutic phlebotomy forhemochromatosis is usually effective in reducingstores of both plasma iron and tissue iron, andeven aggressive phlebotomy generally poses norisk of anemia to the patient31.

Phlebotomy for hemochromatosis is one ofthe few things I know that neither Galen nor Ibn-Sina knew. It did not matter for them anyway;they would have recommended phlebotomy forthat or any other disease or even as prophylaxisagainst disease. Such patients with hemochro-matosis would have done well under their careby pure chance.?

References:1. Albinali Hajar HA. Arab Gulf traditional medicine:

cautery. Heart views 2004; 5(4):178-183. 2. Avicenna: The Canon Of Medicine, The Classic of

Medicine Library 1984.3. Albucassis: On Surgery and Instruments, London:

Welcome Library of Medicine, 1973.4. Sigerist Henry: A History of Medicine: Primitive and

Archaic Medicine (vol. I) New York: Oxford Univ.Press,1967.

5. Nanil Sobhi Hana: Al tib alsgabi fil Khaleege 1998.(Arabic text)

6. Lois N. Magner: A History of Medicine, MarcellDekker Inc. 1992.

7. Prioreschi Plinio: A History of Medicine (vol. III),Horatius Press, 1995 : 89



8. Manjno, Guido: The Healing hand, HarvardUniversity Press, 1975.

9. Prioreschi Plinio: A History of Medicine (vol. III)Horatius Press, 1995 : 89, 119

10. Editorial note in Albucassis: On Surgery andInstruments, London: Welcome Library of Medicine,1973 : 624

11. Roy Porter: The Greatest Benefit to Mankind ,Harper Collins Publishers 1997 : 93.

12. Diwan Abid bin al Abras, Dar Sader, Beirut, 1964.(Arabic text)

13. Jawad Ali: Pre-Islamic history of the Arabs vol. 8.Dar Al Malayeen, Beirut, 1971 (Arabic text)

14. Prioreschi Plinio: A History of Medicine (vol. II),Horatius Press, 1995.

15. The papyrus Ebers, translated by B. Ebbell,Copenhaen, Levin & Munksgaard, 1937 : 106.

16. Prioreschi Plinio: A History of Medicine (vol. I)Primitive and Ancient Medicine, Horatius Press,1995.

17. Friedberg Charles: Diseases of the Heart, W. B.Saunders Co, 1949 : 205.

18. Silber & Katz: Heart Disease, Macmillan PublishingCo,1975 : 1172

19. Silber & Katz: Heart Disease, Macmillan PublishingCo,1975 : 1292

20. Braunwald: Heart Disease 3rd edition, W. B.

Saunders Co., 1988 : 55521. Braunwald: Heart Disease 3rd edition, W. B.

Saunders Co.,1988 : 1608.22. Braunwald: Heart Disease 3rd edition, W. B.

Saunders Co., 1988 : 1742-1743.23. Braunwald: Heart Disease 5th edition, W. B.

Saunders Co., 1997 : 1620.24. Braunwald: Heart Disease 5th edition, W. B.

Saunders Co., 1997 : 972.25. Thorne S A. Management of polycythaemia in

adults with cyanotic congenital heart disease. Heart1998 ; 79: 315 - 316.

26. Braunwald: Heart Disease 6th edition, W. B.Saunders Co., 2001 : 972.

27. Sullivan JL. Iron and the sex difference in heart dis-ease risk. Lancet. 1981,1:1293 - 1294.

28. Salonen JT, Nyyssonen K, Korpela H, et al. Highstored iron levels are associated with excess risk ofmyocardial infarction in eastern Finnish men.Circulation. 1992; 86 : 803-811.

29. Ascherio A, Rimm EB, Giovannucci E, et al. BloodDonations and Risk of Coronary Heart Disease inMen. Circulation 2001; 103: 52 - 57.

30. Andrews N. C. Disorders of Iron Metabolism. N EnglJ Med 1999; 341:1986-1995.

31. Pietrangelo A. Hereditary hemochromatosis - a newlook at an old disease. N Engl J Med 2004; 350:

The mountains of Ras Al-Khaima.

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