Section: General contraindications and precautions
176. Introduction
As is discussed above, Hijamah is not without its risks, and it is not for everybody to undertake. The Hajjaam must see that the patient is fit for Hijamah and must know how to adapt the procedure based on the constitution of the patient and their current state of health. This is also borne out by the hadith:Jabir bin Abdullaah (RA) relates that he heard Rasulullaah (SAW) saying: "If there is any good in your treatments it is in the blade of the Hajjaam, a drink of honey or branding by fire (cauterisation/ moxibustion), whichever suits the ailment, and I do not like to be cauterized" (Bukhari & Muslim)This hadith infers that one must know if Hijamah is the best treatment for the patient, or another treatment would be more suitable. It is interesting to note that in this same hadith the 3 main principles of treatment are referred to, viz, supplementing (with honey), draining heat (by Hijamah) and treating cold and stasis (with fire).In order to know if Hijamah will suit the patient the Hajjaam must first know the contraindications and precautions for practicing Hijamah. Contraindications being those conditions if present, in which Hijamah should not be done and precautions being those in which it is not prohibited, but caution should be observed, especially in terms of how much blood is removed.
177. Excessive perspiration
“Do not bleed the one who is sweating, do not sweat the one who is bleeding”The first rule of preventing adverse effects of Hijamah is not to perform the procedure for a person who is suffering from excessive perspiration. In traditional medicine this is understood as a weakness of the body in its ability to hold the pores closed, which therefore results in excessive and easy perspiration. (This should not be confused with night sweats which are a different phenomenon mostly due to heat forcing the pores open at night.)A person who suffers from easy and excessive sweating is already suffering from a loss of body fluids and bleeding such a person will only aggravate this condition. They will also tend to bleed more easily and may exhibit excessive and uncontrolled blood loss should Hijamah be performed. Excessive sweating, or hyperhidrosis, can be a warning sign of thyroid problems, diabetes or infection. It is also more common in people who are overweight or out of shape. Such an individual is not normally suffering from an "excess heat" type of condition where Hijamah is indicated.The second part of this precaution, viz. do not sweat the one who is one bleeding, means that medication which is used to cause sweating (diaphoretics) should not be used in a person who is bleeding (as it will increase blood loss unnecessarily).
178. Hemophilia
Hemophilia is a genetic disorder that impairs the body's ability to control blood clotting or coagulation, which is used to stop bleeding when a blood vessel is broken, or to heal the incision that is created by the Hajjaam. It is more common in males than females and is characterized by lower blood plasma clotting factor levels of the coagulation factors needed for a normal clotting process.Thus when a blood vessel is injured, a temporary scab does form, but the missing coagulation factors prevent fibrin formation, which is necessary to maintain the blood clot. A hemophiliac does not bleed more intensely than a person without it, but can bleed for a much longer time. In severe hemophiliacs even a minor incision from Hijamah can result in blood loss lasting days or weeks, or even never healing completely. For this reason it is not recommended to perform Hijamah on a hemophiliac, unless it is in association with their medical practitioner who understands the severity and nature of the patients hemophilia and regards Hijamah as safe for the patient.The Hajjaam should take a proper history of the patient in order to determine if the patient is a hemophiliac.
179. Anticoagulant drugs
If a patient is on medication, the Hajjaam must determine whether it is safe to continue with Hijamah and that the medication will not cause excessive and potentially uncontrollable bleeding or other adverse effects.Amongst these medications the most dangerous are anticoagulant medicines. Anticoagulants are medicines that prevent the blood from clotting as quickly or as effectively as normal. Some people call anticoagulants blood thinners. However, the blood is not actually made any thinner - it just does not clot so easily whilst you take an anticoagulant.Anticoagulants are commonly used to treat and prevent blood clots that may occur in your blood vessels. Blood clots can block an artery or a vein. A blocked artery stops blood and oxygen from getting to a part of your body (for example, to a part of the heart, brain or lungs). The tissue supplied by a blocked artery becomes damaged, or dies, and this results in serious problems such as a stroke or heart attack. A blood clot in a large vein, such as a deep vein thrombosis (a clot in the leg vein), can lead to serious problems such as a pulmonary embolism (a clot that travels from the leg vein to the lungs).Patients on anticoagulant medication may exhibit excessive blood loss after Hijamah which in some cases can be fatal. The most common anticoagulants include warfarin and heparin, however these may go by different brand names and for this reason a Hajjaam should be familiar with basic pharmacology and be able to recognize anticoagulant use in prospective Hijamah patients. If you are using anticoagulants you should consult with your doctor before having Hijamah done.If you are not sure whether you are using anticoagulant medication you can check your medication against this list of common names for anticoagulant medication, the list is not exhaustive and ideally your Hajjaam should have the knowledge and training to identify if you are using an anticoagulant or not:Warfarin - Coumadin, Jantoven, Marevan, Lawarin, Waran, WarfantDabigatran - PradaxaAcenocoumarol - G 23350, Nicoumalone, NicumalonPhenindione - Dindevan, Fenindion, Phenylin-Zdorovye, SoluthrombineRivaroxaban - XareltoNote: Aspirin also has an effect of preventing clots by preventing platelets sticking together. However, it is classed as an antiplatelet agent rather than an anticoagulant.
180. Anemia
Anemia is a common condition in which the blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's tissues. Iron deficiency anemia is due to insufficient iron. Without enough iron, the body cannot produce enough hemoglobin, a substance in red blood cells that enables them to carry oxygen. As a result, iron deficiency anemia may leave an individual tired and short of breath.A number of recent studies are showing a link between excessive and unnecessary bloodletting and iron deficiency anemia, some even as severe as resulting in cardiomyopathy which is only seen in chronic severe iron deficiency anaemia.For this reason care should be taken not to cause this type of anemia through Hijamah. This will most often occur when women who are menstruating normally receive Hijamah without a serious reason, or when Hijamah is practiced too often and/or too much blood is removed.For the healthy person not living in a very hot climate, to have Hijamah once a year in the hot season is sufficient, provided the person exhibits signs of a healthy constitution and does not already suffer from anemia. If so, then it should be administered in a "low dose" only once every few years so as to encourage haematopoiesis. (For a women who is menstruating general Hijamah is not needed except where the woman is suffering from an abundance of blood as sometimes happens in the arab regions.)
181. Pregnancy
During pregnancy there is a tremendous demand by the baby for nourishment which is provided by means of the mothers blood. For this reason the woman's appetite grows tremendously due to the increased production of blood in her body. This is the system that Allaah has created to provide for the child in the womb of the mother. The heat of the body is also concentrated internally during the pregnancy period which leaves the outer parts relatively cold and lacking in blood. The normal menstrual cycle also ceases, which in traditional medicine is seen as a sign that there is no need for the woman to lose blood in this period. As a result, if Hijamah is applied in such a stage then great harm is done to the body and to the developing baby, this can easily result in miscarriage.It is shocking to me when I hear that women who are pregnant are having Hijamah done, and on more than one occasion I have come to know that this has resulted in miscarriage. The irresponsible Hajjaam then hides behind the claim of "taqdeer" when in fact this is medical malpractice and they will be held responsible in the court of Allaah for not adhering to basic medical guidelines in respect of care during pregnancy.Pregnancy is a clear contraindication for Hijamah, it should not be done or even considered during pregnancy and should a Hajjaam either due to ignorance or pursuit of money cause a miscarriage then the Hajjaam is to blame and in my opinion should be charged with a crime by the legal system prevailing in that country.
182. Wound healing disorders
When performing Hijamah incisions are made in the skin to release blood. Normally these heal within a short period and leave minimal scarring (especially when a post Hijamah blood and healing herbal formula and/or low level laser therapy is applied afterward).In some conditions however, the body's ability to heal and repair the incision is impaired, and results in either a longer healing time, no healing at all or excessive scarring and keloid formation.Keloids are thickened scars due to excessive synthesis of collagen after an acute injury, which can include the incision, required for Hijamah. Hypertrophic scarring and keloids most frequently arise in young adults and are particularly prevalent in dark-skinned individuals. They are equally common in males and females. These scars may also itch and/or be painful to touch. They are firm or hard, skin-coloured to bright red, smooth, elevated nodules and may have claw-like extensions far beyond the original wound. They are particularly frequently seen on earlobes, shoulders, upper back and anterior chest. Hijamah should be avoided in individuals who have a history of easily developing keloids and hypertrophic scarring. (This is not a contraindication but rather a precaution as we have experienced less occurrence of keloids if the patient is exposed to low level laser therapy after the procedure)Healing of the incisions can also be impaired by other factors that slow down or prevent complete healing and include issues such as the lack of growth factors, the presence of edema, poor blood flow, infection, hypoxia, arterial or venous insufficiency and neuropathy.Other systemic causes of impaired wound healing include metabolic disease, diabetes mellitus, the patients nutritional state, a history of smoking or drug use, exposure to radiation, aging, immune disorders, and abnormal collagen syndromes. A thorough history will reveal if the patient may have wound healing problems.Diabetes deserves special mention as it is a common disorder and when present gives rise to a high risk of major complications in the Hijamah incision, including infection and cellulitis and can even lead to amputation when performed on the extremities. Vascular, neuropathic, immune function, and biochemical abnormalities in diabetes each contribute to delayed healing. Even careful wound care in a patient with excellent glucose control may fail and result in these adverse effects. Special care should therefore be taken in diabetic patients in order to determine whether Hijamah is appropriate for the patient and if so, it should be done only in those areas and in a way that will not risk poor wound healing, subsequent infection and other adverse effects.
183. Who should have Hijamah done
In the hadith related by Jabir ibn Abdullaah (RA), the Nabi (SAW), said: توافق الداء meaning "whichever fits the ailment", in these 2 words the entire field of differential diagnosis and differential treatment was proven and emphasised. In this particular hadith the Nabi of Allaah (SAW) said this in respect of the 3 treatments of honey, hijamah and cauterisation. This indicates that albeit established that the contraindications are not present and the precautions are observed, Hijamah may not be the appropriate treatment for the patient.In order to determine if Hijamah fits the patient and their ailment the Hajjaam should possess some basic skills of differential diagnosis. This includes both western and traditional medicine diagnostic skills in order to determine two essential aspects, viz:1. The constitution or body type of the patient2. The pattern of the illnessBeing able to determine these two aspects will guide the Hajjaam as to whether Hijamah fits the ailment or not.