SPECIAL SECTION CHAIRMAN'S REFLECTIONS Part 17

Looking back at the first few years of working as a cardiologist at home in Qatar, is like watching an old movie. The scenes are clear, the events exciting, the struggles intense, and the heroes real. Some characters are still around; some are no longer with us.

TRADITIONAL MEDICINE AMONG GULF ARABS Part II

BLOOD-LETTING
Introduction
n the first part of my paper, Arab Gulf Traditional Medicine, which was published in a previous issue of Heart Views1, I mentioned that the major fields of Arab traditional medicine are Herbal, Cautery, and Blood-letting. Herbal medicine is so diverse a topic that it is beyond my ability to discuss it. In the previous issue I discussed cautery and in this issue I will discuss blood-letting: Hijamah and Fasd. Fasd, which is phlebotomy or venesection, is rarely practiced nowadays in the Arabian Gulf, but Hijamah, which is the sucking of blood by cupping, is still practiced in the Arabian Gulf or Gulf Cooperation Council (GCC) states. Islamic books state that the prophet Mohammed (PBOH) had stated that there are three methods to cure illness: “a drink of honey, a scratch of hijamah and cautery.” But he was not too keen on the last one.

I

1. Hijamah
The Arabic word “hijamah” means “sucking.” In the Arabian Gulf, Hijamah was used not only for treatment but also for prophylaxis against diseases. The pearl divers in the Arabian Gulf used

to undergo hijamah before the diving season in the belief that the procedure will prevent diseases during the 3 months at sea. It was thought to be very effective against dizziness. Barbers usually performed hijama. When I was a high school student I remember asking a British trained physician practicing in Doha: “Why do the British call their surgeons mister rather than doctors?” He replied: “Because their profession grew out of being barbers first, not medical doctors.” When I was a small child it was common to see our village illiterate barber, Mr. Abdulla Al Hassan, assume the role of a “doctor”. He performed circumcisions, cautery, and hijamah. He was a friend of my father and was a good neighbor. His wife and daughter used to help my mother take care of me. I also liked Al Hassan because he used to carry me as a child and he often gave me candies and nabique (desert fruits). I used to watch him do hair cutting and perform hijamah and cautery in the open air in the shade of his house. He used to shave my head every two weeks then. He never lied to me except once. It was a white lie. I was about six years old when I was brought to my father who was sitting with friends in a living room. I was made to sit on a small stool in the

*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 (19811993); 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).

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HEART VIEWS VOLUME 5 NO. 2 JUNE - AUGUST 2004 : 74 - 85

I took his pictures during the procedure (Figures 8A-8D). I took the old man's file and blood screening test results and went to the judge. I had many chances later to watch the traditional circumcision by our barber (Figure 1). It was done so fast that I did not feel any pain. I told the judge that I was not against hijamah HEART VIEWS VOLUME 5 NO. So. antiseptic properties. 2 JUNE . His photos practicing his craft still appear in most Qatar publications on traditional medicine as seen in (Figure 4). When the man behind me lifted his hand from my eyes I saw blood dripping over my leg. He would then apply cotton soaked in iodine solution over the wound before wrapping it with a piece of cloth. 5 and 6). In Qatar. Rachel. Then Al Hassan said to me to try to see stars in the sky through the man's fingers. came forward to me and said we will play a game. Some Omani men with experience in traditional medicine worked in other Gulf States as traditional doctors. Oman is well known throughout the Gulf for its Arabic traditional medicine. He would insert a small glass ball in the foreskin sac to push the glans back. 2004.Traditional Medicine Among Gulf Arabs: Part II middle of the room. even if he gets hijamah therapy. but it was much faster and more humane than the circumcisions I see in modern hospitals at the present time. with built-in sucking tube (Figure 7).AUGUST 2004 : 74 . The patient was a man about thirty years old with chronic seizure disorder. Local Gulf people consider sea water as having Fig. I did advice him however. I visited the Oman Traditional Medicine Center in Muscat with my wife. We saw the hajjam performing hijamah in modern clean environment using gloves and sterile glass cups. He dried the blood with cotton. may be because of the high salt content. Over the years. He told me that he preferred hijamah because he does not like to take drugs daily. He would sit in the sea for 10 minutes to soak the wound in sea water. Mr. The sight of my blood made me cry. The judge sympathized with the old man. Patients from all over the Gulf used to travel to Oman for both traditional medicine as well as witchcraft medicine. He went to the Islamic court to complain to the chief judge against my decision. He had hijamah therapy one year earlier. The sea water loosens the cotton which was firmly attached to the wound. The barber. It may not have been a sterile procedure.1: Diagram of traditional Gulf Arab circumcision: 1=incision site. He was well known in Qatar. The child was not given drink for 6-8 hours post circumcision to delay urination. At the Omani center. While grasping and stretching the foreskin a few millimeters distally. After two to three days the child was taken to the sea.85 75 . he would quickly cut the foreskin between his fingers and the glass ball with a sharp blade. we interviewed a patient who came for hijamah treatment. The glass ball protected the glans from accidental injury. He came again this time to have another course. I concentrated on seeing the stars while blindfolded and not paying attention to what else he was doing. I remember a nice old Omani man practicing Hijamah and Keyy (cautery) for decades. I requested the judge to give me time to respond. In fact the judge was disappointed with my decision. Abdulla Al Hassan. The judge ordered me to appear in court to hear the complaints and respond to them. He claimed that the frequency of his seizures decreased after the first treatment. I showed the judge that the old man had Hepatitis B and explained to him how he was a risk to the society. It was fast circumcision without anesthesia. I have seen glass cups for hijamah similar to the tea cups used by Gulf Arabs. The traditional Arab hijamah was with bull horns (Figures 2 and 3) or metal cups (Figures 4. A man came from behind me and put his hand over my eyes. I had to prevent him from working in Qatar in 1981 when I was undersecretary of health after I made it mandatory to have blood screening test on such profession. 2=Glass ball 3-Glans. I suddenly felt something touching between my legs. During the Gulf Heart Association meeting in Oman. that he should take the antiseizure tablets. especially since the prophet Mohammed (PBOH) had approved the use of Hijamah as a therapeutic measure. which was held in January 13 -15. The following day.

Fig 5: The Traditional hajjam applied one metal cup by creating the vacuum with sucking and making incision for a second cup using his bare hands.7: Glass cup with build-in sucking tube used as mihjamah. Fig. 2 JUNE .Traditional Medicine Among Gulf Arabs: Part II Fig 2: Horns used for hijama. Fig. Fig 4: The Traditional hajjam applied one metal cup by creating the vacuum with sucking and making incision for a second cup using his bare hands.85 . 76 HEART VIEWS VOLUME 5 NO. Fig.AUGUST 2004 : 74 . 3: A traditional hajjam sucking on a horn applied near the shoulder. 6: The patient blood poured in a bowel for the patient to see before discarding.

Hijamah tools: the main tools are listed in table 1 and (Figure 9).2.1. 8D: Bleeding in progress into the cups. The patient is instructed to keep the wound dry for one day.Traditional Medicine Among Gulf Arabs: Part II Fig. Then the horn is removed and superficial incisions are made within the marked area (Figures 4 and 8B). The old man then left Doha and returned to Oman. 1. but I can not allow persons with transmissible infections to practice it. Time: The best season for Hijamah is in HEART VIEWS VOLUME 5 NO. 2 JUNE . 8B: Incising the skin in the marked (red and raised) area with a blade. I was happy to comply with the judge's instructions especially since the judge was my own father. 8C: Re-applying the cups and sectioning to the incised area.AUGUST 2004 : 74 . Blood accumulates within the horn. After that.3. It was clearly a personal gift to help him. 1. 8A: Applying vacuum to the cups using syringe to mark the area for incision. not a fine. cleaned and marked by placing the mihjamih such as a bull horn on the site and sucking the mouth-end of the horn to mark the site for extraction. dark clotted venous blood is shown to the patient as “bad blood” before being discarded (Figure 6). This gives the patient a psychological boost for getting rid of “bad” blood. Fig. 1. the horn is reapplied and the horn's mouthpiece is vigorous sucked (Figure 3). When the horn is removed. The procedure: The skin site is shaved. Fig. He gave the poor old man a financial gift and ordered me to do the same. He accepted my reasoning. Fig.85 77 . the wound is cleaned with dry cloth and either left uncovered or herbal powder (Zaater) is applied. Then.

we may apply it at any hour. because at that period (of the cycle) the humours are less plentiful. For there are some people who. at the beginning or the end of the month. If the disease or custom prescribe cupping. an Arab Andalusian surgeon known to the west as Albucasis. Scissors: Used for cutting hair at the site of hijamah. the coccyx. He considered medicine as part of knowledge that must be learned by every scientist. 9: Hijama tools. Bull horn was the instrument used in the old times. i. For headache. Nowadays metal or glass cups are made specifically for this purpose. the two shoulders. I had to turn to the old Arabic medical scholar books to find some intellectual reasoning. the antibrachium. Site: For each complaint there is a specific site for hijamah. i. Most of the local people working in traditional medicine are illiterate. either because of 78 HEART VIEWS VOLUME 5 NO. psychiatrist and a poet. The best day is in the middle of the lunar month. until the whole body has been evacuated.85 . the location is on the shoulder. I found a description of the technique of hijamah. During that period the brain is increasing in size within the skull..AUGUST 2004 : 74 . “The Methods of Medicine”. He devoted his life to medicine and especially surgery. Al-Zahrawi's book AlTasrif li-man ‘ajaza ‘an al-ta’lif. physician. Al-Zahrawi said: “The application of cupping to the shoulders helps in palpitation of the heart arising from plethora and heat. He described in his 30-volume medical encyclopedia. feel heaviness and pain in the head. nor may use cupping. 2-3 hours after sunrise2.1037) was an Islamic philosopher. the chin. 1.Traditional Medicine Among Gulf Arabs: Part II Table 1: HIJAMAH TOOLS: Mihjamih: The main tool for hijamah.” He also said: “What cupping does is to draw blood out of the fine vessels (capillaries) dispersed over the flesh. because the humours are not yet on the move or not in a state of agitation. for this reason it does not cause the strength to decline as does venesection. was the greatest Arab surgeon of that time.4. at wherever time it may be. the middle of the forearms. also against performing it at the end of the (lunar) month. The best time of the day for hijamah is at second or third hours” i.e. the two sides of the neck. Al-Zahrawi listed several points at which Hijamah (cupping) is performed: the occiput. Ibn-Sina (Avicenna 980 . in any disease due to plethora. so as to need cupping. when there is an abundance of blood in them. spring or fall to avoid too cold or too hot season. Blade: Used for incising the skin. In his book. The proper time according to them is the middle of the month (when the humours are in a state of agitation) and during the time when the moonlight is increasing (when the humours are on the increase also). Al-Zahrawi recommended the use of leeches to the part of the body to which application of cupping-vessels is impossible. his surgical techniques with about 200 illustrations of medical instruments that he made and drew. For chest pain. His book THE CANON is well known and was used as a medical textbook for centuries. a full moon. the timing and the tools. the two legs and the two heel-veins. They were not able to provide me with a rationale why a full moon is the best time for performing the procedure.e. It is the instrument for blood sucking. Ibn-Sina explained the prevailing thought at that time on the best timing to perform hijamah: “Some authorities advice against the procedure at the beginning of the lunar month. dorsally. Some find they have fullness and redness of the face and also the head and neck. and the river-water is rising in tidal rivers. Abul Qasim Al-Zahrawi (936-1013 AD).e. Fig. They learned the profession from their fathers and mothers. the location is behind the head. the interscapular region. We therefore prescribe cupping after the second or the third hour of the day has passed”3. at early morning. 2 JUNE .

although early observations probably contributed to a rapid development of the method: the fact that individuals suffering from fever diseases suddenly felt relieved when they had a spontaneous hemorrhage. they did not know that the blood circulated.“pneuma”. that when a snake bites a person. Greco-Roman domination of Blood-letting Blood-letting was in use around the time of Hippocrates (460 . and other diseases. Sigerist. He recommended fresh water leeches. In ancient times. He may have stopped a hemorrhage through compression just as he must have practiced bleeding at an early stage.Traditional Medicine Among Gulf Arabs: Part II their smallness. They thought In the Far East. When we are bitten with insects. Among American Indians. The oozing of the blood at the site of the insect bite may have given man the feeling that the offending substance or poison is washed out of the body. involving the withdrawal of considerable quantities of blood from a patient in the belief that this would cure or prevent disease. It is reported by the GCC folklore center that it is still occasionally practiced in Bahrain for women only as treatment for dizziness5.AUGUST 2004 : 74 . whereby the object was found in the blood that filled the cup4. This type of treatment has been practiced by the Chinese and the Arabs for thousand of years. etc. It brings a certain relief by decongesting the system as the primitives found out empirically. cupping method was also called “horn method”. Bleeding through scarifications. bleeding from the nose. a medical historian wrote: “Scratching become scarifications and sucking became cupping. Dr. venesection. 2. We may have learned some ideas from observing animals. in China. they make incision at the site of the bite to bleed it in order to expel the poison. where the medicine man did not suck the skin with his mouth directly but applied a horn cup. before Columbus. 2. The Chinese made negative pressure by introducing heat in the form of an ignited material. I have seen a man who was brave enough to cut off two of his toes with an ax after a snake had bitten one of his toes. such as the lips or because the part is bare of flesh. Bleeding as a method of treatment was so universal that it also must be derived from instinctive actions. glass and plastic. I have never seen the procedure practiced in the Gulf. A jar was attached to the skin surface to cause local congestion through the negative pressure created by sucking.210 AD). 2. A special method of extraction was practiced by Arapaho and Choctaw Indians. It was an old practice by the Gulf Arabs. When they are full they will fall off”3. sucking was a chief method of treatment. He said: “Leave them in fresh water for a day and a night until they are hungry and nothing is left in their bellies. and introduced hijamah there!). animal horns. or cupping is practiced by most primitive people in the treatment of pneumonia. bamboo. and then place the leeches on it. Unlike hijama phlebotomy is rarely practiced in the Arabian Gulf nowadays. like the nose. Hijama or cupping was practiced over centuries. is called phlebotomy at the present time. are various types of cups . An animal licks its wound and man may well have done it also. It is very likely that it was imperative that any primitive society would sooner or later evolve to practice it either by chance or by instinctive intuition. He had to cut the toes so fast that he did not have time to think to cut only the bitten toe. Bleeding: The Universal Therapy The therapeutic use of blood-letting was so universally common throughout history that it is hard to credit only one culture with it. The scratching gives us satisfaction. There HEART VIEWS VOLUME 5 NO.2. Scrub the afflicted part until it is flushed.377 BC) and was reinforced by the ideas of Galen (129. The South American Indians practiced it in order to drain out a spirit4. or when menstruation set in4. referred to as venesection. pleurisy. as well as many other people. particularly those that are combined with fever. During the time of Galen. There were two key concepts: The first is that blood was created and then used up. Fasd: Blood-Letting Blood-letting. 2 JUNE . The technique varies from place to place or from country to country. (I wondered if the Indian “Arapaho” tribe is of Arab-aho origin that reached the New World. we scratch the site so hard that the skin may bleed. There is no doubt that he got this idea from Greek medicine.rubber.1. It was a popular therapeutic practice from antiquity up to the late 19th century. The Greeks thought that veins contained blood and arteries air .85 79 .

and yellow bile (relating to the four Greek classical elements of earth. Therefore. stroke and headache. Celsus advanced the practice of venesection to the point that it had indications in the very young and the very old. Arab and medieval European medicine. For certain conditions. Symptoms of excess blood were believed to include fever. eye disease. . mentioned “the physician” they always meant Galen. cupping. Blood-letting by the Arabs Most of the pre-Islamic Arab surgery was based on Greco-Roman medicine. fire and water). and in other conditions. it will not be desirable to suppress the bleeding early. Blood-letting was used to “treat” a wide range of diseases. gout etc. because patients who survived the first operation would not be harmed by the second. either by venesection or by application of leeches. Erasistratos was a contemporary of Galen. This is the reason why hijamah is still practiced in the Arabian Gulf. cautery and leeches were employed for bloodletting”11. The second is that humoral balance was the basis of illness or health. The Greeks believed that bleeding protected the wound from inflammation. The very rare use of leeches for blood letting by the Arabs was Roman in origin. in the tenth century and after. Galen in the third century regarded bleeding as the appropriate treatment for almost every disorder. Phlebotomy thus became. but belonged to the school of Alexandria in Egypt. Galen believed that blood was the dominant humour and the one in most need of control. The four humours were blood. Galen recommended two brisk bleeding per day. 2 JUNE . Only Ibn Al-Nafis. and clipping of hair are added to the therapy9. the universal remedy10. in pregnancy. . Sciatica. There was in Rome at that time a group of physicians who followed the conservative line of Erasistratos who opposed bleeding. The Arabs used it to treat headache. Galen created a complex system of how much blood should be removed based on the patient's age. constitution.3. The concept of “bad” blood has persisted until now in our society. He was a surgeon and a true scientist who was credited for naming the heart valves bicuspid and tricuspid. He wrote two books against him. He had great influence on their concept of medicine. The health benefit of menstruation was recently revived in cardiology as you will see below in this article. including hemorrhage and fatigue. dared to say that Galen was wrong about the flow of the blood in the heart. becoming a standard treatment for almost every ailment. he recommended “rest and diet and plaster . Corlius Celsus (born 25 BC) suggested that when there is a deep wound involving bone or muscle. I never came across such therapy before. 2. Galen was so enthusiastic about the benefits of venesection that he wrote three books about it6. A number of different methods were employed. a word the Arabic dictionary states that was Roman in origin. They infuriated Galen to such a degree that he wrote the book “On Venesection Against Erasistratos”. On the treatment of headache.85 . Galen argued that women were spared many diseases that afflicted men because their superfluous blood was eliminated by menstruation6.Traditional Medicine Among Gulf Arabs: Part II it could “stagnate” and cause illness. Arab reasoning for removing blood was either the blood was more than what was needed or they removed bad or spoiled blood. He even recommended bleeding to stop hemorrhage. . Even though Galen had also studied in Alexandria. a physician would either remove “excess” blood (plethora) from the patient or give them emetic or diuretic.AUGUST 2004 : 74 . the weather and the place.The first should be stopped just before the patient fainted. and remained through Roman. The 80 HEART VIEWS VOLUME 5 NO. but to let the blood flow as long as it is safe.” Then if the pain gets more severe the treatment becomes more energetic: bleeding. Historians claim that the “pre-islamic Near and Middle East possessed popular medicine akin to that of the Mediterranean . phlegm. he did not agree with Erasistratos' medical concepts. Greco-Roman medicine was transmitted to preislamic Arabs from Syria and and the Greek medical school in Jundishapur of Iran then. In fact the old Arabic word for clever physician is “Natasi”. In order to balance the humours. black bile. the Arab Father of Circulation. the season. If there seems too little bleeding. Galen's teaching of blood-letting was accepted by the rest of the Arab physicians. . air. Galen recommended blood letting for every disease. When the old Arab and Muslim physicians. Therefore. the blood should be let from the arm as well8. Cupping. Hair cutting as a form of treatment is an interesting new information for me.

such as those in the foearm. 2 JUNE . Camel jugular venesection was performed by the Arabs pre-butchering.” The odd reason for that killing was that the king had felt guilty for the death of two of his friends. and may repeated at the time of bleeding. in incipient apoplexy (stroke). The poet's bad luck was coming to praise the king in a poem and was the first one who appeared to the king on his bad day12). mentioned about thirty blood-vessels as suitable for venesection. five in each arm and hand and three veins in each the leg and foot12. He asked the poet how he wished to die. HEART VIEWS VOLUME 5 NO. then do what you please. The most famous Arab Queen. The Arab Andalusian surgeon. Phlebotomy could act as pain-killer when carried out aggressively enough to induce fainting. When it is urgent. Al-Zahrawi (Albucasis). “Syncope rarely occurs during the flow of blood. Ibn-Sina (Avicenna) stated in his book.AUGUST 2004 : 74 . in which blood was drawn from one or more of the larger external veins. honored the famous Arab poet. or both. He devised and illustrated fine scalpels or lancets for veins. There are some historical cases when pre-Islamic Arab kings killed opponents with venesection to distinguish them from common people. he executed the first person who appeared to him near the grave. Jothima Al Abrash. 2. Fig. 10: Olivary Scalpel by Albucasis.”2. Zenobia who revolted against Rome in the third-century and declared Palmyra (Tudmor) in Syria independent from Rome. She killed an Arab king. He mentioned sixteen vessels in the head. when digestion is completed and when the bowels are empty. olivary scalpel (Figure 10). It must be collected in a container. Obaid ibn Al Abruss in his old age by killing the poet in 598 AD with venesection. and he called one such lancet There were times when venesection was used by the Arabs as a non-therapeutic tool. reducing dislocation. or in cases of severe pain”2. They also believed that a king's blood had therapeutic value. The poet said: “Let me drink wine until I get drunk. When disease is already present. On his bad day. therefore emesis should first be procured to guard against that.4. the general indications for blood-letting: 1. Only bleed up to syncope in cases of synochal fever (continuous fever). and setting fractures6. So. The Arab king. After the camel looses adequate blood and becomes so dizzy to fall. The Canon of Medicine. He will sit next to the graves of his two friends at those days. 2. That is very odd to us now but at that time physicians did not have many options to relieve pain. He pledged that one day in the year will be his ominous day and another day in the year will be his good day. Venesection was the preferred way for execution of kings because the king's blood must not be spilled on the ground. Al Noman Ibn AL Monther.Traditional Medicine Among Gulf Arabs: Part II most common was phlebotomy or venesection. then it could be done any time”2. unless a great amount is lost. The proper time of the day for venesection according to IBN-SINA: “Before mid-day if the procedure is elective. It supposedly cured patients from rabies and insanity13. He said that: “The object in both cases is to remove the superabundant blood. expanded her role over all Syria and Egypt and named her son as emperor. Syncope: Ibn-Sina warned that: “The first blood-letting may be accompanied by syncope if it is carried out quickly on a person not accustomed to it. The wine acted as a sedative or anesthetic for the victim to die a peaceful death. The condemned King or very distinguished person of that period was given wine to drink until he gets intoxicated before the execution. Non-therapeutic Phlebotomy Contra-indications: Blood-letting should not be peformed before age 14 or after 70 as well as in those patients who were very emaciated2. Such bleeding were used in preparation for childbirth. for superabundance of blood then makes the vessel liable to give away”2. podagra (gout) and danger of hemoptysis from rupture of vessel in rarefield lung. with venesection. He pledged to give the first person who appeared to him near the graves on his good day 200 camels. Examples of the first category are incipient sciatica. When the blood is superabundant that a disease is about to develop.85 81 . extensive angina or inflammatory swelling. Ibn-Sina recommended bleeding to induce syncope to relieve pain in cases such as angina. to remove the unhealthy blood.

. Controversy on blood letting Some have suggested that venesection might have suppressed the clinical manifestations of certain diseases. Fumigated . a local cow traditional therapist. The Chinese conceived that the body contained a set of imaginary. in the case of an infected ear: Thou shalt cut one side of it in order that its blood may come on one side. a donkey. La Méthode Numérique. before the Greeks. he cited a case of bleeding by the ancient Egyptians recorded in the Ebers Papyrus but consider that a drainage. William Harvey disapproved the practice of venesection in 1628 in the introduction of scientific medicine. or spiritual vessels or “meridian”. half a dozen goats. Chinese style. . his neck swollen: I repeat incantation for him. the availability of iron may determine the ability of certain pathogens to grow and multiply. by lowering the availability of iron in the blood. Our cow became sick one day and could not eat or drink. Then he pierced. 2 JUNE .85 . practiced bloodletting. Bleeding would also affect the body's response to disease by lowering the viscosity of the blood and increasing its ability to flow through the capillary bed. for example. In ancient china. at least for treating animals. and was believed that the demon escaped with the blood”4. Some claim that the Babylonians started it.AUGUST 2004 : 74 . . there is a description of treating a “bull with wind”: “If I see a bull with wind. 2. He removed the ropes and left the cow oozing blood from the mouth. although not by Egyptian physicians14. He tied the cow's head with ropes attached to two wood posts so that the head was in a fixed position. his forehead is wrinkled. Da'in. such as malaria. He also denied that plethora was the cause of disease. The Arabs did not use blood letting to drive evil spirits out of the body as the American Indians did. . He pulled the tongue out to the side of the mouth and massaged it vigorously with turmeric and salt for a few minutes. the root of the teeth red. He examined the cow's mouth and noted swelling of the tongue. The evidence is in a veterinary papyrus. containing no blood but ch'i. a physician and chemical philosopher was probably the first individual to strongly protest against blood-letting as a dangerous waste of the patient's vital strength. a cow. Even though he claimed that bleeding was not practiced by the Egyptians. In the Veterinary Papyrus of Kahun. Thus the needling could be called a form of drainage of “energy” rather than blood8. Let him be laid on his side. Bleeding to the point of fainting would also force the patient to rest. he is with his eyes running. . 'he that has a cut either dies with it or lives with it”. Prioreschi Plinio claimed that Bloodletting was common in antiquity and was practiced in Chinese and Hindu medicine. He would cure his allotment of The above quote indicates that prognosis was uncertain when the illness has reached the point at which venesection must be practiced4. I heard my mother saying that the cow had started to eat. The Egyptian medicine was earlier than Greek medicine.Traditional Medicine Among Gulf Arabs: Part II then it was butchered. Jan Baptista van Helmont (1579-1644). but I have seen a blood-letting treatment of an animal when I was a child in our house. rubbed with gourds or melons. Origin of blood letting It is assumed that blood letting as therapeutic and prophylactic measure originated with the Greeks. During my childhood we had a section in our yard for animals. Thou shalt gash him (bleed him) from his nose and his tail. They may have performed therapeutic bleeding before the Greeks. the most popular method of driving out a spirit was bleeding through venesection or scarifications. We had a dozen chickens.16. let him be sprinkled with cold water . Irq means blood vessel or root. I did find that the old Egyptians. 82 HEART VIEWS VOLUME 5 NO. He suggested taking 200-500 poor people and divide them into two groups by casting lots. I also kept an aggressive large seagull free in the yard as my personal pet. He said that it was suffering from “irq”. Five hours later. I did not see that Egyptian veterinarian when he treated that bull thousands years ago. . a guard dog and a cat. Sigerist stated that: “Throughout South America.6. Blood started to drip.5.”15. thou shalt say as to it. He suggested a clinical trial. acupuncture was drainage. This principle was something like the Greek pneuma or “energy. I was sent to call Mr. 2. a vein in the tongue with a large needle.” It could be drawn out by needling the right ch'i vessel. He stated that “Sometimes the blood contaminated by whdw could be removed from an infected area as. a few pigeons. probably. . but I found no proof to support that claim.

AUGUST 2004 : 74 . practice in the utilization of therapeutic phlebotomy during my lifetime until today in medical text books and current literature. the changing The book did not support its use even for Cor pulmonale: “In the case of phlebotomy most older studies have demonstrated an improvement in the subjective complaints related to vascular engorgment but no evidence of improvement in pulmonary gas exchange. But it is also useful in cases of right-sided heart failure in which there is an extreme elevation of the venous pressure and associated manifestations of systemic engorgment. often when the needle is still in the vein” 17. However. Phlebotomy is often a life-saving measure when the patient suffers from acute pulmonary edema. rotating tourniquets. It was considered a life-saving procedure. the “bible” of medicine for generations of American doctors. 1949: A heart disease textbook by Charles Friedberg strongly recommended phlebotomy for congestive heart failure: “Phlebotomy the removal of 350 to 1000 cc. a condition in which venesection was thought to be particularly beneficial. or hemodynamics has been found. 3. systemic venous and hepatic engorgement. But Pierre Louis’ demonstration that phlebotomy was entirely ineffective in the treatment of pneumonia was convincing to some physicians and the controversy tilted against the procedure in the 19th century. it is a timeconsuming and often cumbersome procedure for an acutely ill patient. the practice was continued by barber-surgeons. It is seldom desirable to reduce the oxygen-carrying capacity of the circulation of patient with acute heart failure. mechanics. Phlebotomy is indicated chiefly when there is intense pulmonary engorgment (especially with pulmonary edema) due to left-sided heart failure. It was used to “treat” a wide range of diseases. a diuretic. Role of phlebotomy in modern cardiology care Not too long ago.”18 In the treatment of right heart failure phlebotomy is indicated when polycythemia is sufficiently severe (HCT >55 %). The symptomatic improvement after phlebotomy usually occurs with incredible speed. 1975: Phlebotomy was still recommended in a heart disease text book but with less enthusiasm: “Venesection is reserved for severe acute pulmonary edema in whom all else had failed. But that trial was never carried out6. “bleeding was returning to favor in the treatment of cardiac insufficiency and pneumonia”6. Most physicians did not accept the statistical data and believed the anecdotal evidence of patient survival with bleeding as a time-honored therapeutic method.Traditional Medicine Among Gulf Arabs: Part II patients without phlebotomy.The number of funerals in each group would be the measure of success or failure. I certainly participated in such therapy then. orthopnea.19 1988: Braunwald: Heart Disease 3rd edition discouraged its use for Pulmonary Edema: “The combinations of morphine. necessary to employ this technique”20. So. Pierre Charles Alexander Louis (17871872). 2 JUNE . becoming a standard treatment for almost every ailment. the end of the 19th century did not end therapeutic blood-letting practice. a 19th century French physician performed statistical studies on the efficiency of venesection as a therapeutic measure in a large series of hospitalized patients. and sublingual nitroglycerin generally diminishes preload sufficiently to obviate phlebotomy. It was generally believed in western countries that blood letting as treatment had become extinct by the end of the 19th century. It may be useful to review briefly. the book considered phlebotomy indicated for polycythemia vera or secondary poly- HEART VIEWS VOLUME 5 NO. cyanosis. George Washington was treated with blood-letting when he developed severe respiratory infection (acute bacterial epiglottitis). even after the humoral system fell out of favor.”21. It was especially popular in the young USA. He concluded that blood-letting did not affect the course of pneumonia.75 liters or 124126 ounces) of blood was withdrawn over a period of nine to ten hours and certainly contributed to his death. Almost four liters (3. of blood from the vein of a patient with congestive heart failure may rapidly and dramatically relieve dyspnea. Although the removal of 500 ml of blood certainly diminishes preload. if ever. According to the 1923 edition of Sir william Osler’s Principles of Medicine.85 83 . But in reality. but during my internship and early residency in the USA (1973-1975) rotating tourniquets and phlebotomy was practiced for severe pulmonary edema. while his critics treat the other half with as much blood-letting as they thought appropriate. and it is therefore rarely.

donation reduces the risk of myocardial infarction. 1992. Therapeutic phlebotomy is safe.1967.AUGUST 2004 : 74 .85 . The Classic of Medicine Library 1984. 4. The results of our study suggest that body iron stores are not a major coronary risk factor among US men without previous cardiovascular disease or diabetes. 2. Hemochromatosis is a hereditary disease caused by excess deposits of iron in the tissue. III). venesection is not indicated for these patients”25. Nanil Sobhi Hana: Al tib alsgabi fil Khaleege 1998. the loss of iron with menstruation explains the lower risk of CHD in premenopausal women compared with men and postmenopausal women27. Lois N. I) New York: Oxford Univ. So the study results do not support the hypothesis that reduced body iron stores lower CHD risk”29. Such patients with hemochromatosis would have done well under their care by pure chance. effective. 3.22 1997: Braunwald 5th edition withdrew its support for its use in polycythemia: “Whether phlebotomy is efficacious in polycythemic patients with cor pulmonale is controversial”23. relieve hepatomegaly and liver tenderness.Traditional Medicine Among Gulf Arabs: Part II cythemia. Albinali Hajar HA. It did not matter for them anyway. Some patients are stable without symptoms of hyperviscosity at a hematocrit of > 70. Prioreschi Plinio: A History of Medicine (vol. in the absence of symptoms. and inexpensive. Marcell Dekker Inc. There is no evidence that venesection alone (without myelosuppressive treatment) reduces the risk of thrombosis in polycythemia rubra vera. 2001: Braunwald 6th edition stated that in the treatment of cyanotic congenital heart disease: “An increased hematocrit. Albucassis: On Surgery and Instruments. Heart views 2004. Horatius Press. Avicenna: The Canon Of Medicine. 2001: Another Circulation article refuted the concept that iron was a risk factor for CAD: “Our primary hypothesis was that regular blood 84 HEART VIEWS VOLUME 5 NO. and protect joints from arthritis30. 1995 : 89 Galen's concepts still haunt us in medicine. Magner: A History of Medicine. There was a revival of the concept that bleeding through menses protected women from heart disease. 5. 1973. There is thus no evidence to support routine venesection to prevent stroke in adults with cyanotic heart disease. is there still a place for this ancient therapy in modern medicine? Yes. phlebotomy can improve constitutional symptoms. “Adults with cyanotic congenital heart disease and erythrocytosis are frequently phlebotomized and occasionally anticoagulated. a risk that has not withstood scrutiny in a study of 112 adults with cyanotic congenital heart disease observed for a total of 748 patients years”24. Press. after all these useless concepts about blood-letting and negative and ill-effects associated with venesection or phlebotomy. 2 JUNE . An article in Circulation in 1992 assured us that high stored iron levels are associated with excess risk of myocardial infarction28. rather than to polycythemia. Sigerist Henry: A History of Medicine: Primitive and Archaic Medicine (vol. It is “hemochromatosis”. This conclusion is consistent with previous prospective investigations that found no association between serum ferritin and risk of CHD. 5(4):178-183. does not constitute an indication for phlebotomy”26. they would have recommended phlebotomy for that or any other disease or even as prophylaxis against disease. I know for sure one undisputed indication for phlebotomy up to this year 2004. According to this hypothesis. The risk of cerebral infarction in cyanotic children younger than four years relates to iron deficiency and a relative anemia. Even if begun later. on the contrary.? References: 1. 7. Each 450 to 500 ml of blood contains 200 to 250 mg of iron. Finally. patients who undergo frequent venesection have a higher incidence of vascular occlusion. and even aggressive phlebotomy generally poses no risk of anemia to the patient31. Arab Gulf traditional medicine: cautery. London: Welcome Library of Medicine. 1998: An article in Heart Journal stated that: “Polycythemic cyanotic patients experience symptoms caused by the detrimental effects of hyperviscosity on tissue oxygen delivery rather than by a high hematocrit itself. The treatment of hemochromatosis has not changed substantially since 1950. The rationale for phlebotomy assumes an inherent increase in the risk of cerebral arterial thrombotic stroke. (Arabic text) 6. Phlebotomy for hemochromatosis is one of the few things I know that neither Galen nor IbnSina knew. Therapeutic phlebotomy for hemochromatosis is usually effective in reducing stores of both plasma iron and tissue iron.

16. 12.1294. 27. Prioreschi Plinio: A History of Medicine (vol. Saunders Co. 31. Horatius Press. B. 1995 : 89... 25. Saunders Co.1975 : 1292 20.316. 1988 : 555 21. Dar Sader.. 23. Copenhaen. 30. Saunders Co. 103: 52 . Heart 1998 . Silber & Katz: Heart Disease. Braunwald: Heart Disease 5th edition. 29. Braunwald: Heart Disease 3rd edition. Macmillan Publishing Co. Iron and the sex difference in heart disease risk. Sullivan JL. HEART VIEWS VOLUME 5 NO. Saunders Co. Harper Collins Publishers 1997 : 93. 86 : 803-811. 17. et al. 79: 315 .. 2 JUNE . Saunders Co. W.1:1293 .AUGUST 2004 : 74 . High stored iron levels are associated with excess risk of myocardial infarction in eastern Finnish men.a new look at an old disease.1988 : 1608. 1997 : 972. 1937 : 106. 28. Guido: The Healing hand. I) Primitive and Ancient Medicine. Rimm EB. Thorne S A. Prioreschi Plinio: A History of Medicine (vol. 1995. Nyyssonen K. N Engl J Med 2004. W. Manjno. Jawad Ali: Pre-Islamic history of the Arabs vol. 1971 (Arabic text) 14. II). B. translated by B.1975 : 1172 19. 350: The mountains of Ras Al-Khaima. Pietrangelo A. Braunwald: Heart Disease 6th edition. Horatius Press. Silber & Katz: Heart Disease. 1975. 15. N Engl J Med 1999. 1988 : 1742-1743. 341:1986-1995. Saunders Co. Disorders of Iron Metabolism. 1997 : 1620. 1949 : 205. B. 2001 : 972. 1995. Roy Porter: The Greatest Benefit to Mankind . Korpela H. 18.. Hereditary hemochromatosis . Braunwald: Heart Disease 5th edition. Saunders Co. B. Andrews N. The papyrus Ebers. 26. Diwan Abid bin al Abras. Blood Donations and Risk of Coronary Heart Disease in Men. Dar Al Malayeen. 9. Ascherio A. Circulation 2001. Harvard University Press. Editorial note in Albucassis: On Surgery and Instruments.57. Giovannucci E. C.85 85 . Macmillan Publishing Co. 1973 : 624 11. 1964. Ebbell. Lancet. W. 1981. et al. Levin & Munksgaard. Beirut. Friedberg Charles: Diseases of the Heart. Braunwald: Heart Disease 3rd edition. Braunwald: Heart Disease 3rd edition. B. 1992.Traditional Medicine Among Gulf Arabs: Part II 8. Beirut. W. Salonen JT. 8. B. (Arabic text) 13.. W. W. Prioreschi Plinio: A History of Medicine (vol. 119 10. Management of polycythaemia in adults with cyanotic congenital heart disease. W. III) Horatius Press. 24. Circulation. 22. London: Welcome Library of Medicine. B.