In my reflection stories I started to narrate my personal experiences with patients, medicine, and colleagues. Occasionally, I incorporate stories from literary sources, mainly Arabic poetry and literature. I continue to follow the same format in any article I write here under “Reflections”. I may be influenced by the writing of my favorite Arab writer Al-Jahid (775-868 AD). I never get bored when I read his books. He deviates sometimes out of the main topic to entertain the reader with his humor. I do not possess his sense of humor but I try to avoid the rigid and dry style of medical writing for such reflections. I want both my professional colleagues and non-physician friends to enjoy reading my unusual experiences.

The main theme of this article is traditional medicine among the Gulf Arabs, but I may add a few other incidents here and there. The major fields of Arab traditional medicine are Herbal, Cautery, and Blood-letting (Hijamah). Herbal medicine is so diverse a topic that it is beyond my ability to discuss. The other two, cautery and blood-letting (hijamah), are easier to summarize. In this issue, I will discuss cautery. Hijamah will be discussed at a later date.

From the dawn of history, man admired fire and its power. Ancient cultures, especially the Persians, worshipped fire. Therefore, it is not surprising that ancient peoples used fire to cure diseases. The ancient Egyptians used cautery to stop bleeding and Hippocrates recommended it. Cautery is called Kaiy in Arabic. It is one of the most ancient forms of therapy used by the Arabs over centuries. The ancient Arabs had great faith in the therapeutic values of fire as cautery. The prophet Mohammed (PBUH) did not forbid cautery but discouraged the use of fire for treatment. One probable reasons given for that was his awareness of the Arab’s strong trust in cautery as curative and he wanted Muslims to keep their faith in God as the ultimate healer, not cautery. Another reason may be was that he did not want man to be subjected to the pain of fire, which will be used for the punishment of sinners in life after death.

Cautery was central to ancient Arabic surgery. Ibn Sina’s famous book Kitab al-Qanon (The Canon) and the surgical book, Al-Tasrif li-man ‘ajaza’ an al-ta’lif written by the Arab Andalusian surgeon, Abul Qasim Al Zahrawi (Albucasis d. 1013 AD), recommended cautery.

The Arab cautery is similar in concept to the Chinese old therapy of “moxabustion.” The Chinese moxabustion is the process whereby moxa - a dried herb - is burned, either directly on the skin, or just above the skin, over specific acupuncture points relative to a condition. A very common form of indirect moxabustion uses moxa sticks, which resemble large cigars or incense sticks. Ancient Chinese teachings advise that the formation of a blister is essential for healing to take place.

The Arab cautery utilizes metal sticks or iron nails as used by Gulf Arabs (Figure 1).



Figure 1a.
Primitive cautery tools rapped with cloth for heat insulation

Figure 1b
Modern cautery tools with handles

The sticks are heated over hot charcoal until they become as red as the hot charcoal (Figure 2).


Figure 2a
Heating the iron cautery tool on charcoal

Figure 2b
Hot iron ready for cauter application

Then, the practitioner places the hot metal over a specified location over the skin for a few seconds (Figure 3).


Figure 3a
Placing the hot metal over the back

Figure 3b
Placing the hot metal over the abdomen.
Multiple old cautery scars are visible over the abdomen

The number of cautery in one session varies between one to seven or more. Skin-deep burn followed by gross scar is the expected result. The choice of the location for the application of the cautery depends on the patient’s complaints. For jaundice for example, the cautery is applied to the left hand (Figure 4). If the patient complains of chest pain with shortness of breath, (which could be angina or myocardial infarction), it is applied to the 4th and 5th anterior or posterior ribs on the same side of the pain. The patient is usually instructed to avoid wetting the burnt area for a few days after the procedure as well as avoid the use of perfumes or eat food that produces gas. For sciatica, it could be as few as one or as much as 17 cautery buns at different locations (Figure 5).

Figure 4. Cautery application sites for jaundice more common on the left hand at the base of the thumb and rarely at fifth finger
Figure 5. Cautery positions for sciatica

In rare situations, the Gulf Arabs used cloth, palm leaves (1) or oil instead of metal as a means of applying cautery. The boiled oil was also used to cauterize cut limbs to stop bleeding. The last procedure was not for a therapeutic purpose. When a thief was caught and condemned in court, the state governor orders the punishment. The punishment for a proven theft is amputation of the right hand of the thief with a sword. The bleeding arm stump was immediately immersed in hot oil. I have seen men whose hands had been amputated but I had never watched the procedure. Such a punishment is no longer carried out in almost all the Gulf States.

Another mode of punishment, which was carried out once in Ras Al Khaimah during my childhood, was very cruel. Mr. S. Al-Badi was appointed by the State governor as wali (Sheriff) of a town. He was supposed to act like the American sheriff in a cow-boy movie and guard the town. (Another word in Arabic for wali is al sharif. I do not know why the Americans use an Arabic word, al sharif, for sheriff). Mr. Al-Badi’s story was well known. He was accused of heading a group of thieves, an organized form of crime. The Governor ordered the extraction of both his eyes. A few years later, I was going to school in a passenger boat when Al Badi was guided to the boat and sat next to me. I saw his empty eye ball sockets under small sun glasses. His eye sockets were very red. I felt sorry for him, but the other kids with me in the boat did not sympathize with him. They said he deserved it.

The use of cautery in medicine is fading away with time. Even in the Arab countries it is rarely used nowadays. In the Arab Peninsula, including the Arabian Gulf, it is still practiced as traditional Gulf medicine, but its use is declining. In Oman, the government supports a traditional medicine center to preserve the Omani heritage.

During the Gulf Heart Association meeting in Oman, which was held in January 13 -15, 2004, my friend, His Excellency Dr. Ali Musa, the Minister of Health of Oman, arranged a visit to the Oman Traditional Medicine Center in Muscat for me and my wife, Rachel. We were welcomed by the center’s director. Patients were waiting for treatment. We interviewed two patients and took pictures with my digital camera while they underwent traditional treatment. The photographs in figures 1-3 were from Oman.

Even though the practice of traditional cautery is relatively rare now, it was a very common practice during my childhood days. When I was seven or eight years old, I used to watch our neighborhood barber, Abdulla Al Hassan, perform hijamah (blood letting). His house was adjacent to our house. I watched the procedure so frequently that I thought I could perform it. The sight of blood did not scare me. But I hated to watch the cautery. I was too young to realize why. Now I could make the link and understand the reason. At the age of six I was pale and sick. We had no medical doctor or modern medicine then. My mother arranged for a traditional medicine woman to treat me. That woman decided that I needed to have couple cautery sticks over my head as treatment for my paleness. I was terrified of the idea that my head will be burnt with fire. I cried and ran to my father for help. My tears worked well. He prevented my mother from carrying on the fire treatment. I was one of the very few lucky persons of my generation who had no cautery scars on their skin. That incident influenced my outlook at such practice. That was why I did not like to watch it.

It is very hard to assess the effectiveness of cautery but the “believers” in our society narrated amazing success stories. My father witnessed a dramatic incident. His friend, Sultan Al Mannai, was about sixty years old when he had severe chest pain while walking with my father. He had shortness of breath and sweating. My father sent for a local traditional doctor. The man came with his charcoal and metal sticks. He cauterized Sultan over the xiphoid area and left lower ribs. Sultan became calm and slept for one hour. When he woke up, he had no more chest pain. He did have recurrent pain a few weeks later and died.

My mother had several cauteries. One was very effective. She had dizziness, nausea and vomiting. She could not sleep because of the nausea. She was cauterized on the top of her head. She fell asleep immediately after the procedure. She improved and was cured in three days.

A patient stated: “The intense heat pain of cautery made the original pain seemed less . . . while the excitement about the impending cure made me forget the cautery pain fast.” (1). Another patient stated: “I was semi-crippled with sciatica. I could not stand to pray. Medical doctors treated me for months … but when my father cauterized me . . . as soon as I felt the cautery pain . . . I stood up and ran” (1).

In Qatar, Mr. Said Al-Badi was famous for his pearl diving and cautery skills. I invited him to my house once for dinner. I had written a poem about pearl diving and I needed his expertise on pearl diving. He approved of my description of pearl diving in the poem. I enjoyed his stories about his old days of pearl diving. He also told me about his experience with cautery. He told me that cautery does not work for every disease. He mentioned a case of a newly married young man who came to him requesting cautery because of impotence. He told the young man that cautery will not help him. He then gave him a bunch of herbs, mainly Ashrsge (Senna leaves, a purgative) to boil and to drink. The young man came back to him one week later to thank him for the “miraculous” cure.

In our region, the Gulf, cautery was not practiced by well-educated practitioners. Bedouins and laymen were the main practitioners. But the old Arab and Moslem physicians who practiced medicine centuries ago had scientific and anatomical knowledge that qualified them to use the technique with some degree of sophistication. I looked in my library at two well-known old medical books. One was written by Al Zahrawi and the other by Ibn Sina.

The Arab Andalusian surgeon Abul Qasim Al-Zahrawi (Albucasis d. 1013 AD) was called after the city of Al-Zahra which was built by Abd Al-Rahman III near Cordoba in 936 AD. Abul Qasim Al-Zahrawi was his physician and the physician of his son Al-Hakam II, who ruled after him. The city was beautiful and inspired those who saw it, but it did not last long. It was destroyed, ironically, at the same death year of Al-Zahrawi in 1013. In the first week of March 2004, Rachel and I toured the ruins of Medinat Al Zahra. The few walls left indicated a rich and magnificent city (Figure 6).


Figure 6
Madinat Al Zahra, Cordoba, Spain

Al-Zahrawi’s book Al-Tasrif li-man ‘ajaza ‘an al-ta’lif, recommended cautery as a form of treatment (2). The editor of the book stated that “The hot iron was one of the earliest and most popular means of treatment. Hippocrates speaks of it as a well-established way of opening a liver abscess; and every later writer gives plenty of room to the subject of the cautery.”

Abul Qasim Al Zahrawi said in his book:

“Cautery has universal application for every ill constitution, whether organic or functional, with the exception of two: the functional hot temperament and the functional dry temperament. About the organic dry temperament the ancients differed, some saying that cautery helps in a constitution of this kind, while others said the opposite: that cautery is of no use in a disease caused by heat or dryness; for fire is naturally hot and dry and it is obviously absurd to treat a hot dry sickness with a hot dry remedy. But he who holds the opposite view says that actual cautery may help in the case of such hot dry illnesses as arise in the human body; for when you compare the human body, humid as it is, with the nature of fire you find the human body cold. I myself from much experience agree with this last opinion. No one should attempt this operation unless he has had long training and practice in the use of the cautery, and is fully acquainted with the various human temperaments, and the character of the complaints in themselves; their causes, symptoms, and duration”

Al Zahrawi, in addressing the medical students and future physicians said:

“Now you should know, my sons, that the actual cautery and its superiority over cauterization with chemical caustics is one of the secrets of medicine. For fire is a simple substance having no action except upon the actual part cauterized; nor does it do more than slightly harm any adjacent part. But the effect of cauterization with caustic may spread to parts at a distance from that burnt; and also in the part cauterized it may give rise to a disease difficult to cure or even fatal. Whereas fire, on the other hand, on account of the nobility of its nature and its superiority has no such effect unless it is overdone. That has become clear to us by experience through length of service, devotion to the art, and acquaintance with the facts of the matter.”

Cautery is the last mode of therapy or cautery is the final remedy” is an ancient Arab saying or proverb. We still use that saying today to justify a drastic step when other methods do not work. In medicine, I tell my patients with coronary artery disease who did not benefit from medical therapy that surgery is the last option left. Then I may quote the proverb if the patient is an Arab: “Cautery is the final remedy.” The patient usually understands the analogy. The Arab Andalusian surgeon, Al Zahrawi, made an interesting comment on this proverb:

“Another common saying is that cautery is the final remedy; which is true, but not in the way which they mean. For they believe that after cauterization no treatment, either with or without medicine, will help. It means something precisely the opposite: after various treatments have been applied to a certain disorder without success, then last of all we apply cauterization and this proves effective; whence comes about the saying that the cautery is the final remedy, not in that sense in which it is popularly held by the laity and by many ignorant medical men.”

Ibn Sina who was then in Baghdad stated an old idea in his book “Al Qanon”: “A cautery is best made of gold” (3). Al Zahrawi, the Andalusian, who lived in the same era of Ibn Sina, but died three decades earlier than Ibn Sina’s death, had another opinion. He said:

“The Ancients have stated that cauterization by gold is more effective than by iron. Now they said that on account of the temperateness of gold and its noble character. They also stated that the site of cauterization does not become purulent, but that is not absolutely so; for I myself have experience of that and have found that it happens in some cases and not in other cases. Cauterization by gold is indeed better and more successful than with iron, as they have stated; except that when you are heating the gold cautery in the fire you are uncertain, by reason of the redness of the gold, when it reaches the desired temperature. In addition to this it cools very quickly; and if you overheat it, it melts in the fire, melts and runs, and the practitioner finds himself in difficulties. Therefore, in our own opinion cauterization is swifter and more successful with iron” (2).

“Know also, my sons”, Alzahrawi added, “that the Ancients disagreed also as to the fit time for cautery, affirming that spring was the best. Myself, I say that the cautery is suitable at all times. Nor let enter your minds, my sons, the groundless notion of the laity and of ignorant doctors, that the complaint cured by the cautery never comes back later; do not cleave to this opinion. The fact is not as they think” (2).

Al Zahrawi invented or devised several instruments for cauterizing each disease. He illustrated the instruments in his book. Some seemed very interesting. For cauterization of relaxation of the eyelid (ptosis) he devised crescent or semicircular shaped instruments (Figure 7). Such shaped cauterization of the eyelid no doubt will produce scar and contraction of the eyelid which may result in improvement. He also described a technique to cauterize the eyelid when the eyelashes are turned inwards, irritating the eye. He illustrated the shape of the instrument for the last procedure (Figure 8). This kind of problem was very common in the Gulf during my childhood due to complication of trachoma. Local people did not know how to treat it. Twenty years ago, I had one inward eyelash. I asked an old-fashioned ophthalmologist in our hospital to take care of it. He asked me to wait in his office. He went to his car and returned with a small dusty electric machine. I asked him why should such a hospital equipment be stored in his car trunk? He said that he had used it on a patient outside the hospital. He then plugged it in the wall and stretched a needle-like instrument towards my eye. I jumped out of the chair before he touched me. I complained that he was using a dirty instrument and I insisted to have it cleaned first. He said, “Never mind. The heat will kill any germ on the tip.” I disagreed with such unhygienic practice. After he cleaned the instrument, he electrically cauterized the eyelash site. Al Zahrawi probably would have done a better job before the discovery of electricity.



Figure 7
Instruments for cauterization of relaxation of the eyelid

Figure 8
Instrument for cauterization of the eyelid when the eyelashes are turned inwards

Al Zahrawi also illustrated in his book an instrument to treat non-chronic migraine (Figure 9) and instrument for lung disease cauterization (Figure10).


Figure 9
Cauterization instrument for treatment of non-chronic migraine

Figure 10
Cauterization instrument for treatment of lung disease

Ibn Sina in The Canon of Medicine (3) said:

“Cauterization is a very useful method of treatment, for (a) it prevents the spread of destructive lesion; (b) has an invigorating effect on a member whose cold temperament we wish to rectify; (c) it brakes up putrefactive matters imprisoned in a tissue; (d) it restrains the flow of blood. If the cautery is being applied to remove dead flesh (tissue), pain will show you when you have reached the healthy tissue. The person applying the cautery must take care not to expose nerves, or fascia or ligaments to the brunt of the burning. For arresting hemorrhage, great heat is required, with vigorous cauterization, so that a firm thick eschar is produced which will not readily come off.”

Ibn Sina wrote in a poem:

Stop a bleeding artery
In the body with cautery . . .

Refrences:

1. Hana NS. Al Tib Al Shabi fil Khaleeg, GCC Folklore Center, 1998.

2. Albucassis: On Surgery and Instruments, London: Welcome Library of Medicine, 1973.

3. The Canon of Medicine of Avicenna: The Classics of Medicine Library. London: Luzac & Co., 1984

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