Introduction:

In 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. 

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 middle of the room. The barber, Mr. Abdulla Al Hassan, came forward to me and said we will play a game. A man came from behind me and put his hand over my eyes. Then Al Hassan said to me to try to see stars in the sky through the man's fingers. So, I concentrated on seeing the stars while blindfolded and not paying attention to what else he was doing. I suddenly felt something touching between my legs. When the man behind me lifted his hand from my eyes I saw blood dripping over my leg. The sight of my blood made me cry. It was fast circumcision without anesthesia. It was done so fast that I did not feel any pain. It may not have been a sterile procedure, but it was much faster and more humane than the circumcisions I see in modern hospitals at the present time. 

I had many chances later to watch the traditional circumcision by our barber (Figure 1). He would insert a small glass ball in the foreskin sac to push the glans back. While grasping and stretching the foreskin a few millimeters distally, he would quickly cut the foreskin between his fingers and the glass ball with a sharp blade. The glass ball protected the glans from accidental injury. He dried the blood with cotton. He would then apply cotton soaked in iodine solution over the wound before wrapping it with a piece of cloth. The child was not given drink for 6-8 hours post circumcision to delay urination. After two to three days the child was taken to the sea. He would sit in the sea for 10 minutes to soak the wound in sea water. The sea water loosens the cotton which was firmly attached to the wound. Local Gulf people consider sea water as having antiseptic properties, may be because of the high salt content.



During the Gulf Heart Association meeting in Oman, which was held in January 13 -15, 2004, I visited the Oman Traditional Medicine Center in Muscat with my wife, Rachel. We saw the hajjam performing hijamah in modern clean environment using gloves and sterile glass cups. The traditional Arab hijamah was with bull horns (Figures 2 and 3) or metal cups (Figures 4, 5 and 6). I have seen glass cups for hijamah similar to the tea cups used by Gulf Arabs, with built-in sucking tube (Figure 7). At the Omani center, we interviewed a patient who came for hijamah treatment. I took his pictures during the procedure (Figures 8A-8D). The patient was a man about thirty years old with chronic seizure disorder. He had hijamah therapy one year earlier. He claimed that the frequency of his seizures decreased after the first treatment. He came again this time to have another course. He told me that he preferred hijamah because he does not like to take drugs daily. I did advice him however, that he should take the antiseizure tablets, even if he gets hijamah therapy.

    
    
Fig 2:
Horns used for hijama.
    

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

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.
     
   

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.
 
 

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

   
  


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

  

Fig. 8A: Applying vacuum to the cups using syringe to mark the 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 incised area.
  

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


Over the years, Oman is well known throughout the Gulf for its Arabic traditional medicine. Patients from all over the Gulf used to travel to Oman for both traditional medicine as well as witchcraft medicine. Some Omani men with experience in traditional medicine worked in other Gulf States as traditional doctors.

In Qatar, I remember a nice old Omani man practicing Hijamah and Keyy (cautery) for decades. He was well known in Qatar. His photos practicing his craft still appear in most Qatar publications on traditional medicine as seen in (Figure 4). 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. He went to the Islamic court to complain to the chief judge against my decision. The judge sympathized with the old man, especially since the prophet Mohammed (PBOH) had approved the use of Hijamah as a therapeutic measure. In fact the judge was disappointed with my decision. The judge ordered me to appear in court to hear the complaints and respond to them. I requested the judge to give me time to respond. The following day, I took the old man's file and blood screening test results and went to the judge. I showed the judge that the old man had Hepatitis B and explained to him how he was a risk to the society. I told the judge that I was not against hijamah but I can not allow persons with transmissible infections to practice it. He accepted my reasoning. He gave the poor old man a financial gift and ordered me to do the same. It was clearly a personal gift to help him, not a fine. I was happy to comply with the judge's instructions especially since the judge was my own father. The old man then left Doha and returned to Oman.

1.1. Hijamah tools:  the main tools are listed in table 1 and (Figure 9).


Fig. 9:
Hijama tools.



Table 1:  HIJAMAH Tools

1.2. The procedure: The skin site is shaved, 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. Then the horn is removed and superficial incisions are made within the marked area (Figures 4 and 8B). Then, the horn is reapplied and the horn's mouthpiece is vigorous sucked (Figure 3). Blood accumulates within the horn. When the horn is removed, 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. After that, the wound is cleaned with dry cloth and either left uncovered or herbal powder (Zaater) is applied. The patient is instructed to keep the wound dry for one day.

1.3. Time: The best season for Hijamah is in 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 traditional medicine are illiterate. They learned the profession from their fathers and mothers. They were not able to provide me with a rationale why a full moon is the best time for performing the procedure. I had to turn to the old Arabic medical scholar books to find some intellectual reasoning.

Ibn-Sina (Avicenna 980 - 1037) was an Islamic philosopher, physician, psychiatrist and a poet. He considered medicine as part of knowledge that must be learned by every scientist. His book THE CANON is well known and was used as a medical textbook for centuries.

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, because the humours are not yet on the move or not in a state of agitation; also against performing it at the end of the (lunar) month, because at that period (of the cycle) the humours are less plentiful. 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). During that period the brain is increasing in size within the skull, and the river-water is rising in tidal rivers. The best time of the day for hijamah is at second or third hours” i.e. 2-3 hours after sunrise2.

1.4. Site: For each complaint there is a specific site for hijamah. For headache, the location is behind the head. For chest pain, the location is on the shoulder, dorsally.

Abul Qasim Al-Zahrawi (936-1013 AD), an Arab Andalusian surgeon known to the west as Albucasis, was the greatest Arab surgeon of that time. He devoted his life to medicine and especially surgery. He described in his 30-volume medical encyclopedia, Al-Zahrawi's book Al-Tasrif li-man ‘ajaza ‘an al-ta’lif, i.e. “The Methods of Medicine”, his surgical techniques with about 200 illustrations of medical instruments that he made and drew. In his book, I found a description of the technique of hijamah, the timing and the tools.

Al-Zahrawi listed several points at which Hijamah (cupping) is performed: the occiput, the interscapular region, the two sides of the neck, the chin, the two shoulders, the coccyx, the antibrachium, the middle of the forearms, the two legs and the two heel-veins.

Al-Zahrawi said: 

“The application of cupping to the shoulders helps in palpitation of the heart arising from plethora and heat.” He also said: “What cupping does is to draw blood out of the fine vessels (capillaries) dispersed over the flesh; for this reason it does not cause the strength to decline as does venesection; nor may use cupping, in any disease due to plethora, until the whole body has been evacuated. If the disease or custom prescribe cupping, we may apply it at any hour, at the beginning or the end of the month, at wherever time it may be. For there are some people who, when there is an abundance of blood in them, so as to need cupping, feel heaviness and pain in the head. Some find they have fullness and redness of the face and also the head and neck. We therefore prescribe cupping after the second or the third hour of the day has passed”3.

Al-Zahrawi recommended the use of leeches to the part of the body to which application of cupping-vessels is impossible, either because of their smallness, such as the lips or because the part is bare of flesh, like the nose. 

There is no doubt that he got this idea from Greek medicine. He recommended fresh water leeches. He said: 

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

2. 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. 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. When we are bitten with insects, we scratch the site so hard that the skin may bleed. The scratching gives us satisfaction. 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. It was an old practice by the Gulf Arabs, as well as many other people, that when a snake bites a person, they make incision at the site of the bite to bleed it in order to expel the poison. 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. He had to cut the toes so fast that he did not have time to think to cut only the bitten toe.

We may have learned some ideas from observing animals. An animal licks its wound and man may well have done it also. He may have stopped a hemorrhage through compression just as he must have practiced bleeding at an early stage. Dr. Sigerist, a medical historian wrote: 

“Scratching become scarifications and sucking became cupping. Bleeding as a method of treatment was so universal that it also must be derived from instinctive actions, 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, bleeding from the nose, or when menstruation set in4.

In the Far East, Hijama or cupping was practiced over centuries. A jar was attached to the skin surface to cause local congestion through the negative pressure created by sucking. There are various types of cups - rubber, bamboo, glass and plastic, animal horns, etc. The technique varies from place to place or from country to country. This type of treatment has been practiced by the Chinese and the Arabs for thousand of years. The Chinese made negative pressure by introducing heat in the form of an ignited material. In ancient times, in China, cupping method was also called “horn method”. 

Bleeding through scarifications, venesection, or cupping is practiced by most primitive people in the treatment of pneumonia, pleurisy, and other diseases, particularly those that are combined with fever. It brings a certain relief by decongesting the system as the primitives found out empirically. The South American Indians practiced it in order to drain out a spirit4.

Among American Indians, sucking was a chief method of treatment. A special method of extraction was practiced by Arapaho and Choctaw Indians, where the medicine man did not suck the skin with his mouth directly but applied a horn cup, whereby the object was found in the blood that filled the cup4. (I wondered if the Indian “Arapaho” tribe is of Arab-aho origin that reached the New World, before Columbus, and introduced hijamah there!).

2.1. Fasd: Blood-Letting

Blood-letting, referred to as venesection, is called phlebotomy at the present time. It was a popular therapeutic practice from antiquity up to the late 19th century, involving the withdrawal of considerable quantities of blood from a patient in the belief that this would cure or prevent disease. 
Unlike hijama phlebotomy is rarely practiced in the Arabian Gulf nowadays. I have never seen the procedure practiced in the Gulf. It is reported by the GCC folklore center that it is still occasionally practiced in Bahrain for women only as treatment for dizziness5.

2.2. Greco-Roman domination of Blood-letting

Blood-letting was in use around the time of Hippocrates (460 - 377 BC) and was reinforced by the ideas of Galen (129- 210 AD). The Greeks thought that veins contained blood and arteries air - “pneuma”. There were two key concepts: The first is that blood was created and then used up. During the time of Galen, they did not know that the blood circulated. They thought it could “stagnate” and cause illness. The second is that humoral balance was the basis of illness or health. The four humours were blood, phlegm, black bile, and yellow bile (relating to the four Greek classical elements of earth, air, fire and water). Galen believed that blood was the dominant humour and the one in most need of control. In order to balance the humours, a physician would either remove “excess” blood (plethora) from the patient or give them emetic or diuretic. Galen created a complex system of how much blood should be removed based on the patient's age, constitution, the season, the weather and the place. Symptoms of excess blood were believed to include fever, stroke and headache. 

Galen in the third century regarded bleeding as the appropriate treatment for almost every disorder, including hemorrhage and fatigue. When the old Arab and Muslim physicians, in the tenth century and after, mentioned “the physician” they always meant Galen. He had great influence on their concept of medicine. Only Ibn Al-Nafis, the Arab Father of Circulation, dared to say that Galen was wrong about the flow of the blood in the heart. Therefore, Galen's teaching of blood-letting was accepted by the rest of the Arab physicians. For certain conditions, Galen recommended two brisk bleeding per day.The first should be stopped just before the patient fainted, because patients who survived the first operation would not be harmed by the second. Galen was so enthusiastic about the benefits of venesection that he wrote three books about it6.

Galen argued that women were spared many diseases that afflicted men because their superfluous blood was eliminated by menstruation6. The health benefit of menstruation was recently revived in cardiology as you will see below in this article.

Erasistratos was a contemporary of Galen, but belonged to the school of Alexandria in Egypt. He was a surgeon and a true scientist who was credited for naming the heart valves bicuspid and tricuspid. Even though Galen had also studied in Alexandria, he did not agree with Erasistratos' medical concepts. He wrote two books against him.

There was in Rome at that time a group of physicians who followed the conservative line of Erasistratos who opposed bleeding. They infuriated Galen to such a degree that he wrote the book “On Venesection Against Erasistratos”. Galen recommended blood letting for every disease. He even recommended bleeding to stop hemorrhage.

The Greeks believed that bleeding protected the wound from inflammation. Therefore, Corlius Celsus (born 25 BC) suggested that when there is a deep wound involving bone or muscle, it will not be desirable to suppress the bleeding early, but to let the blood flow as long as 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 recommended “rest and diet and plaster . . .” Then if the pain gets more severe the treatment becomes more energetic: bleeding, either by venesection or by application of leeches, cupping, and clipping of hair are added to the therapy9. Hair cutting as a form of treatment is an interesting new information for me. I never came across such therapy before.

Celsus advanced the practice of venesection to the point that it had indications in the very young and the very old, in pregnancy, and in other conditions. Phlebotomy thus became, and remained through Roman, Arab and medieval European medicine, the universal remedy10.

2.3. Blood-letting by the Arabs

Most of the pre-Islamic Arab surgery was based on Greco-Roman medicine. The very rare use of leeches for blood letting by the Arabs was Roman in origin. In fact the old Arabic word for clever physician is “Natasi”, a word the Arabic dictionary states that was Roman in origin. Greco-Roman medicine was transmitted to pre-islamic Arabs from Syria and and the Greek medical school in Jundishapur of Iran then.

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

Arab reasoning for removing blood was either the blood was more than what was needed or they removed bad or spoiled blood. The concept of “bad” blood has persisted until now in our society. This is the reason why hijamah is still practiced in the Arabian Gulf. 

Blood-letting was used to “treat” a wide range of diseases, becoming a standard treatment for almost every ailment. The Arabs used it to treat headache, eye disease, Sciatica, gout etc. A number of different methods were employed. The most common was phlebotomy or venesection, in which blood was drawn from one or more of the larger external veins, such as those in the foearm. 

Ibn-Sina (Avicenna) stated in his book, The Canon of Medicine, the general indications for blood-letting: 

1. When the blood is superabundant that a disease is about to develop. 
2. When disease is already present. 

He said that:

“The object in both cases is to remove the superabundant blood, to remove the unhealthy blood, or both. Examples of the first category are incipient sciatica, podagra (gout) and danger of hemoptysis from rupture of vessel in rarefield lung, for superabundance of blood then makes the vessel liable to give away”2.

Contra-indications: Blood-letting should not be peformed before age 14 or after 70 as well as in those patients who were very emaciated2.

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

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

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; therefore emesis should first be procured to guard against that, and may repeated at the time of bleeding.”2.
“Syncope rarely occurs during the flow of blood, unless a great amount is lost. Only bleed up to syncope in cases of synochal fever (continuous fever), in incipient apoplexy (stroke), extensive angina or inflammatory swelling, or in cases of severe pain”2.

So, Ibn-Sina recommended bleeding to induce syncope to relieve pain in cases such as angina. That is very odd to us now but at that time physicians did not have many options to relieve pain. 

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

The Arab Andalusian surgeon, Al-Zahrawi (Albucasis), mentioned about thirty blood-vessels as suitable for venesection. He mentioned sixteen vessels in the head, five in each arm and hand and three veins in each the leg and foot12. He devised and illustrated fine scalpels or lancets for veins, and he called one such lancet olivary scalpel (Figure 10).


Fig. 10:
Olivary Scalpel by Albucasis.

2.4. Non-therapeutic Phlebotomy

There were times when venesection was used by the Arabs as a non-therapeutic tool. There are some historical cases when pre-Islamic Arab kings killed opponents with venesection to distinguish them from common people. 

The most famous Arab Queen, Zenobia who revolted against Rome in the third-century and declared Palmyra (Tudmor) in Syria independent from Rome, expanded her role over all Syria and Egypt and named her son as emperor. She killed an Arab king, Jothima Al Abrash, with venesection.

The condemned King or very distinguished person of that period was given wine to drink until he gets intoxicated before the execution. The wine acted as a sedative or anesthetic for the victim to die a peaceful death.

The Arab king, Al Noman Ibn AL Monther, honored the famous Arab poet, Obaid ibn Al Abruss in his old age by killing the poet in 598 AD with venesection. He asked the poet how he wished to die. The poet said: “Let me drink wine until I get drunk, then do what you please.” The odd reason for that killing was that the king had felt guilty for the death of two of his friends. He pledged that one day in the year will be his ominous day and another day in the year will be his good day. He will sit next to the graves of his two friends at those days. He pledged to give the first person who appeared to him near the graves on his good day 200 camels. On his bad day, he executed the first person who appeared to him near the grave. 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).

Venesection was the preferred way for execution of kings because the king's blood must not be spilled on the ground. It must be collected in a container. They also believed that a king's blood had therapeutic value. It supposedly cured patients from rabies and insanity13.

Camel jugular venesection was performed by the Arabs pre-butchering. After the camel looses adequate blood and becomes so dizzy to fall, then it was butchered.

The Arabs did not use blood letting to drive evil spirits out of the body as the American Indians did. Sigerist stated that: “Throughout South America, the most popular method of driving out a spirit was bleeding through venesection or scarifications, and was believed that the demon escaped with the blood”4.

2.5. Origin of blood letting

It is assumed that blood letting as therapeutic and prophylactic measure originated with the Greeks. Some claim that the Babylonians started it, but I found no proof to support that claim. The Egyptian medicine was earlier than Greek medicine. They may have performed therapeutic bleeding before the Greeks. 

Prioreschi Plinio claimed that Bloodletting was common in antiquity and was practiced in Chinese and Hindu medicine, although not by Egyptian physicians14. Even though he claimed that bleeding was not practiced by the Egyptians, he cited a case of bleeding by the ancient Egyptians recorded in the Ebers Papyrus but consider that a drainage. He stated that “Sometimes the blood contaminated by whdw could be removed from an infected area as, for example, in the case of an infected ear: Thou shalt cut one side of it in order that its blood may come on one side.”15,16.

I did find that the old Egyptians, before the Greeks, practiced bloodletting, at least for treating animals. The evidence is in a veterinary papyrus. 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 running, his forehead is wrinkled, the root of the teeth red, his neck swollen: I repeat incantation for him. Let him be laid on his side, let him be sprinkled with cold water . . . rubbed with gourds or melons, . . . Fumigated . . .
Thou shalt gash him (bleed him) from his nose and his tail, thou shalt say as to it, 'he that has a cut either dies with it or lives with it”, 

The above quote indicates that prognosis was uncertain when the illness has reached the point at which venesection must be practiced4.

I did not see that Egyptian veterinarian when he treated that bull thousands years ago, but I have seen a blood-letting treatment of an animal when I was a child in our house. During my childhood we had a section in our yard for animals. We had a dozen chickens, half a dozen goats, a few pigeons, a cow, a donkey, a guard dog and a cat. I also kept an aggressive large seagull free in the yard as my personal pet. 

Our cow became sick one day and could not eat or drink. I was sent to call Mr. Da'in, a local cow traditional therapist. He examined the cow's mouth and noted swelling of the tongue. He said that it was suffering from “irq”. Irq means blood vessel or root. He tied the cow's head with ropes attached to two wood posts so that the head was in a fixed position. He pulled the tongue out to the side of the mouth and massaged it vigorously with turmeric and salt for a few minutes. Then he pierced, probably, a vein in the tongue with a large needle. Blood started to drip. He removed the ropes and left the cow oozing blood from the mouth. Five hours later, I heard my mother saying that the cow had started to eat.

In ancient china, acupuncture was drainage, Chinese style. The Chinese conceived that the body contained a set of imaginary, or spiritual vessels or “meridian”, containing no blood but ch'i. This principle was something like the Greek pneuma or “energy.” It could be drawn out by needling the right ch'i vessel. Thus the needling could be called a form of drainage of “energy” rather than blood8.

2.6. Controversy on blood letting

Some have suggested that venesection might have suppressed the clinical manifestations of certain diseases, such as malaria, by lowering the availability of iron in the blood; the availability of iron may determine the ability of certain pathogens to grow and multiply. 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. Bleeding to the point of fainting would also force the patient to rest. 

William Harvey disapproved the practice of venesection in 1628 in the introduction of scientific medicine, La Méthode Numérique.

Jan Baptista van Helmont (1579-1644), 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. He also denied that plethora was the cause of disease. He suggested a clinical trial. He suggested taking 200-500 poor people and divide them into two groups by casting lots. He would cure his allotment of patients without phlebotomy, while his critics treat the other half with as much blood-letting as they thought appropriate.The number of funerals in each group would be the measure of success or failure. But that trial was never carried out6.

Pierre Charles Alexander Louis (1787-1872), a 19th century French physician performed statistical studies on the efficiency of venesection as a therapeutic measure in a large series of hospitalized patients. He concluded that blood-letting did not affect the course of pneumonia, a condition in which venesection was thought to be particularly beneficial. Most physicians did not accept the statistical data and believed the anecdotal evidence of patient survival with bleeding as a time-honored therapeutic method. 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 was generally believed in western countries that blood letting as treatment had become extinct by the end of the 19th century. But in reality, the end of the 19th century did not end therapeutic blood-letting practice. According to the 1923 edition of Sir william Osler’s Principles of Medicine, the “bible” of medicine for generations of American doctors, “bleeding was returning to favor in the treatment of cardiac insufficiency and pneumonia”6.

So, even after the humoral system fell out of favor, the practice was continued by barber-surgeons. It was used to “treat” a wide range of diseases, becoming a standard treatment for almost every ailment. It was especially popular in the young USA. George Washington was treated with blood-letting when he developed severe respiratory infection (acute bacterial epiglottitis). Almost four liters (3.75 liters or 124-126 ounces) of blood was withdrawn over a period of nine to ten hours and certainly contributed to his death.

3. Role of phlebotomy in modern cardiology care

Not too long ago, but during my internship and early residency in the USA (1973-1975) rotating tourniquets and phlebotomy was practiced for severe pulmonary edema. It was considered a life-saving procedure. I certainly participated in such therapy then. It may be useful to review briefly, the changing practice in the utilization of therapeutic phlebotomy during my lifetime until today in medical text books and current literature.

1949: A heart disease textbook by Charles Friedberg strongly recommended phlebotomy for congestive heart failure:

“Phlebotomy the removal of 350 to 1000 cc. of blood from the vein of a patient with congestive heart failure may rapidly and dramatically relieve dyspnea, orthopnea, cyanosis, systemic venous and hepatic engorgement. Phlebotomy is indicated chiefly when there is intense pulmonary engorgment (especially with pulmonary edema) due to left-sided heart failure. 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. Phlebotomy is often a life-saving measure when the patient suffers from acute pulmonary edema. The symptomatic improvement after phlebotomy usually occurs with incredible speed, often when the needle is still in the vein” 17.

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. It is seldom desirable to reduce the oxygen-carrying capacity of the circulation of patient with acute heart failure.”18
In the treatment of right heart failure phlebotomy is indicated when polycythemia is sufficiently severe (HCT >55 %).19

1988: Braunwald: Heart Disease 3rd edition discouraged its use for Pulmonary Edema:

“The combinations of morphine, rotating tourniquets, a diuretic, and sublingual nitroglycerin generally diminishes preload sufficiently to obviate phlebotomy. Although the removal of 500 ml of blood certainly diminishes preload, it is a time-consuming and often cumbersome procedure for an acutely ill patient, and it is therefore rarely, if ever, necessary to employ this technique”20.

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, mechanics, or hemodynamics has been found.”21. 

However, the book considered phlebotomy indicated for polycythemia vera or secondary polycythemia.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. 
“Adults with cyanotic congenital heart disease and erythrocytosis are frequently phlebotomized and occasionally anticoagulated. The rationale for phlebotomy assumes an inherent increase in the risk of cerebral arterial thrombotic stroke, 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.

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. There is no evidence that venesection alone (without myelosuppressive treatment) reduces the risk of thrombosis in polycythemia rubra vera; on the contrary, patients who undergo frequent venesection have a higher incidence of vascular occlusion. The risk of cerebral infarction in cyanotic children younger than four years relates to iron deficiency and a relative anemia, rather than to polycythemia. There is thus no evidence to support routine venesection to prevent stroke in adults with cyanotic heart disease. Some patients are stable without symptoms of hyperviscosity at a hematocrit of > 70; venesection is not indicated for these patients”25.

2001: Braunwald 6th edition stated that in the treatment of cyanotic congenital heart disease:

“An increased hematocrit, in the absence of symptoms, does not constitute an indication for phlebotomy”26.

Galen's concepts still haunt us in medicine. There was a revival of the concept that bleeding through menses protected women from heart disease. According to this hypothesis, the loss of iron with menstruation explains the lower risk of CHD in premenopausal women compared with men and postmenopausal women27. An article in Circulation in 1992 assured us that high stored iron levels are associated with excess risk of myocardial infarction28.

2001: Another Circulation article refuted the concept 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 iron stores are not a major coronary risk factor among US men without previous cardiovascular disease or diabetes. This conclusion is consistent with previous prospective investigations that found no association between serum ferritin and risk of CHD. So the study results do not support the hypothesis that reduced body iron stores lower CHD risk”29.

Finally, after all these useless concepts about blood-letting and negative and ill-effects associated with venesection or phlebotomy, is there still a place for this ancient therapy in modern medicine? Yes. I know for sure one undisputed indication for phlebotomy up to this year 2004. It is “hemochromatosis”. Hemochromatosis is a hereditary disease caused by excess deposits of iron in the tissue.

The treatment of hemochromatosis has not changed substantially since 1950. Therapeutic phlebotomy is safe, effective, and inexpensive. Each 450 to 500 ml of blood contains 200 to 250 mg of iron. Even if begun later, phlebotomy can improve constitutional symptoms, relieve hepatomegaly and liver tenderness, and protect joints from arthritis30. Therapeutic phlebotomy for hemochromatosis is usually effective in reducing stores of both plasma iron and tissue iron, and even aggressive phlebotomy generally poses no risk of anemia to the patient31. 

Phlebotomy for hemochromatosis is one of the few things I know that neither Galen nor Ibn-Sina knew. It did not matter for them anyway; they would have recommended phlebotomy for that or any other disease or even as prophylaxis against disease. Such patients with hemochromatosis would have done well under their care by 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, Marcell Dekker Inc. 1992.

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

8. Manjno, Guido: The Healing hand, Harvard University Press, 1975.

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

10. Editorial note in Albucassis: On Surgery and Instruments, 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 Publishing Co,1975 : 1172

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

20. Braunwald: Heart Disease 3rd edition, W. B. Saunders Co., 1988 : 555

21. 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. Heart 1998 ; 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 disease risk. Lancet. 1981,1:1293 - 1294. 

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

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

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

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

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