INTRODUCTION
Traditional Medicine
Traditional medicine constitutes the knowledge, skills and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in health maintenance and in the prevention, diagnosis, improvement or treatment of physical and mental illness.1 It includes, for example, acupuncture and related techniques, chiropractic, osteopathy, manual therapies, qigong, tai chi, yoga, naturopathy, thermal medicine, and other physical, mental, spiritual and mind-body therapies.2
According to the WHO, which mentioned that approximately 70%–90% of the populations in Canada, France, Germany, and Italy have practiced complementary and/or traditional medicine in certain forms and that 110 of the 193 WHO member states reported having some type of policy in place regarding regulation and/or registration of traditional medications in 2007. Among children, cautery constitutes 76.1% of the traditional methods.3 The traditional medicine is also practiced by 80% of the population in the developing world.4
The source of traditional cautery is controversial but it was first reported in “Surgical Papyrus” written in 1550 BC by ancient Egyptians.5,6 Cautery causes pain relief followed by severe pain as reported from patients who underwent cautery and this may be explained by the fact that cautery stimulates the release of endogenous opioids and other neurotransmitters that prevent the perception of pain.7
Ancient Egyptian surgeons used cautery to stop severe bleeding from wounds.8 Agnikarma (thermal cautery) is practiced for a set of medical illnesses regarding liver, stomach, abdomen, joints, spine, the sciatic nerve, and the back.9,10 In Traditional Chinese Medicine, cautery (Moxa cautery [475–221 BC]) has been used in many diseases from ancient times.11 The Arabic traditional medicine is categorized into three types: herbal, Kaiy (Arabic for cauterization), and cupping.12 Abul Qasim Al Zahrawi (westernized as Albucasis, 936–1013 AD) recommended cauterization with hot metals or hot oils for stopping bleeding from vessels and treating many ailments like epilepsy, otalgia, headache, facial palsy, backache, eye diseases, oral fistula, toothache, depression, and hemorrhoids.13
Arabs use metal sticks or iron nails to perform cautery, the metal sticks or nails are placed over hot charcoal until it becomes red hot, and then the practitioner or healer places it over a certain site on the skin for a few seconds.14 The location of the cautery is based on the site of illness, for example, cautery scars was over the affected limbs in children with polio, in the midline of the spine or on the head in children with cerebral palsy whereas a round configuration around the umbilicus of the abdomen was found in many children in a study conducted in Saudi Arabia.15 In Eastern communities, patients resort to cauterization therapy for various medical ailments including backache, paralysis, facial palsy, ascites, migraine headaches, sore throat, splenomegaly, lymphadenopathy, jaundice, and glaucoma.16 It is mainly used to stop bleeding and to close blood vessels. The removal of growths such as viral warts and growth of cancerous tissues or chronic eczema are other uses.17 The newest endoscopic technique used a catheter-guided cauterization and this is similar to what is mentioned by AlRazi in his book (Al-Hawi) regarding the use of a catheter in the organs of the body that have a lumen, like the nose or anus.18
After cauterization, a wide variety of complications was reported including wound infection, delayed wound healing, abscess formation, septic shock, and deep skin burn. In the long term, branding procedures can cause disfigurement from contractures (especially over joint surfaces), scars, hair loss, keloids, orthokeratotic hyperkeratosis, acanthosis, and squamous cell carcinoma. Other medical complications include foreign body reactions, oral and tooth complications, aspiration and hypoxia, edema and swelling, infections and viral transmission including hepatitis and HIV.19 Tetanus was one of the adverse effects of cautery in another study.20
Aims of the study
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To acquire more knowledge regarding the practices of cautery in children in the Thi-Qar province.
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To highlight the reasons for practicing cautery in children together with other implications from adverse events resulting from the cautery.
SUBJECT AND METHODS
Study design and sitting
This descriptive cross-sectional study was performed in the Bint Al-Huda Maternity and Childhood Teaching Hospital in the Thi-Qar province, south of Iraq, and data were collected over an 8-month period (December 2019 to July 2020) from patients who are admitted to the Bint Alhuda Maternity and Childhood Teaching Hospital in Nasiriya city, and those who had recent cautery marks on their bodies (done for the treatment of the child illness). It included 133 children of different ages admitted to the hospital for various diseases.
Data collection
A data collection questionnaire was designated for the purpose of the study and was filled in the hospital by face-to-face interaction with the child caregiver. It involved the personal characteristics and variables related to cautery practices, the questionnaire included the following information: name, sex , patient age classified into 5 groups; <6 months, 6 months–1 year, 1–2 years, 2–5 years, and >5 years.
The residential address of the patients was obtained and classified as rural, urban, or semi-urban. Other variables in the questionnaire included parental education (illiterate; primary, intermediate, secondary school, or higher education), mother’s employment, and monthly income per capita (<250,000, 250,000–500,000, and >500,000 Iraqi Dinar (ID).
It also included information regarding the person who advised or performed cautery, together with the education of the advisor, whether the cautery was paid or free. During filling of the questionnaire, cautery site, size, shape, and total number of cautery marks was documented along with any complications.
Statistical analysis
Statistical Package for Social Sciences (SPSS) version (25) was used for data analysis. Descriptive statistical frequencies, percentages, associations, tests of significance (Chi-square test or Fisher exact test) were used for analysis of categorical variables. Means and standard deviations were used to present data of continuous variables t, ANOVA had been used. Correlation analyses were performed to identify independent factors.
Inclusion Criteria: The children admitted to the Bint Alhuda Maternity and Childhood Teaching Hospital who had recent cautery marks on their bodies (cautery done to them in a period <1 month before admission to the hospital and taking the information for the study).
Exclusion Criteria: Children with cautery marks >1 month from the day of obtaining the information from the child.
Ethical approval of the study: The clinical protocol was approved by the Institutional Review Board for each participating hospital, and the Department of Health and Education. This study was conducted in conformity with the guiding principles for research involving humans. Written informed consent and assent were obtained from all parents.
RESULTS
This study shows that the cautery was practiced on children in the Thi-Qar province for children even as early as the first month of their life.
Regarding the Sociodemographic characteristics of the study group, a total number of 133 cauterized children had been included in this descriptive cross-sectional study with a mean age of 9.25 ± 11.5 months with male to female ratio 1:0.72.
The number of cauterization points ranged from 2 to 25 with a mean of 8.8 cautery marks. The mean time before cauterization was 3.8 days, whereas the mean time of duration before seeking medical care was 2.1 days, and more than half of the patients were male (57.9%).
The mothers' employment was seen in only 10% of cauterized patients, whereas >91% of cauterized children were from the low per capita monthly income group.
Most of the cauterized children were below 1 year (80, 4%) and 1–2 years (14.3%).
More than two-thirds of the cauterized children’s parents were illiterate or had primary education.
Fever, excessive crying, and diarrhea were the main symptoms for which cautery were practiced.
The grandmother was the main advisor for cautery. Majority of the advisors for the cautery was illiterate or had primary education. The person performing the cautery was a traditional healer in 95.5% of the cases. In 73.7% of parents, they mentioned that they paid for the treatment.
Most of the cauterized patient were not improved or worsen their condition.
Complications seen in 9% of the cauterized patients had complication.
The main sites for cautery were the head followed by the abdomen and back.
The vast majority of the cautery was done by Lightened cotton tipped application (97%), and the circular shape of cautery was the commonest shape of cautery (63.9%).
DISCUSSION
This study shows that cautery was practiced on children in the Thi-Qar province as early as in their first month of their life.
TABLE 1. Selected variables of cauterized patients Descriptive Statistics for quantitative determinants of cautery.
| Variable | Median | Minimum | Maximum | Mean | S.D. |
|---|---|---|---|---|---|
| Age (months) | 107.5 | 0.5 | 108 | 9.25 | 11.509 |
| Duration of disease (days) before cautery | 5 | 1 | 6 | 3.8 | 1.980 |
| Duration of disease before seeking medical care (days) | 5 | 1 | 6 | 2.1 | 1.336 |
| Total number of cautery marks | 23 | 2 | 25 | 8.8 | 3.804 |
| Sex | Number | Percentage | |||
| Male | 77 | 57.9 | |||
| Female | 56 | 42.1 | |||
| Total | 133 | 100 | |||
TABLE 2. Socioeconomic characters of the sample.
| Variable | Number | Percent |
|---|---|---|
| Residence | ||
| Rural | 71 | 53.4 |
| Urban | 41 | 30.8 |
| Semi-urban | 21 | 15.8 |
| Economic state (per capita monthly income) Iraqi Dinar | ||
| <250,000 | 122 | 91.6 |
| 250,000-500,000 | 9 | 6.8 |
| >50,0000 | 2 | 1.6 |
| Mother’s employment | ||
| No | 123 | 92.5 |
| Yes | 10 | 7.5 |
| Total | 133 | 100% |
More than half of the cauterized children were of rural residency (53.4%).
FIGURE 1. Distribution of patients according to age group.
FIGURE 2. Distribution of patients in relation to Parental education.
Regarding the sociodemographic characteristics of the study group, a total number of 133 cauterized children had been included in this descriptive cross sectional study with a mean age of 9.25 ± 11.5 months with male to female ratio 1:0.72. This result was similar to another study conducted on infants in the Southwestern Area of Saudi Arabia by al bilani et al.21 and shows no statistically significant differences between both control and cauterized groups regarding their age or sex as number of male children in both groups is higher than female children, as male to female ratio was 1:0.63 in both groups.
The number of cauterization points ranged from 2 to 25 with a mean of 8.8 cautery marks. The mean time before cauterization was 3.8 days, whereas the mean time of duration before seeking medical care was 2.1 days.
More than half of the cauterized children were of rural residency (53.4%), this may be explained partly by the low level of academic education in one hand and less accessibility to the health care systems in rural areas by other hand.
The mothers' employment was seen in only 10% of cauterized patients’ mothers in our study and this also supports the results of the Al-Binali et al study, which revealed that mothers’ employment was significantly associated with less practice of cautery for infants.21 More than 91% of cauterized children were from the low per capita monthly income group and this may attributed to the mother’s unemployment.
TABLE 3. The frequency of symptoms for which cautery was done.
| Variable | Single symptom | >1 symptom | Total percent | FE, P value | ||
|---|---|---|---|---|---|---|
| Number | Percent | Number | Percent | |||
| Fever | 7 | 5.26 | 21 | 15.79 | 21.1 | 126.53,0.026 |
| Excessive crying | 2 | 1.5 | 17 | 12.78 | 14.29 | |
| Diarrhea | 12 | 9 | 3 | 2.25 | 11.28 | |
| Abdominal pain | 0 | 0 | 8 | 6 | 6 | |
| Vomiting | 4 | 3.0 | 2 | 1.5 | 4.5 | |
| Lethargy | 1 | 0.75 | 3 | 2.26 | 3 | |
| Respiratory symptoms | 0 | 0 | 2 | 1.5 | 1.5 | |
| Jaundice | 1 | 0.75 | 0 | 0 | 0.75 | |
| F.T.T | 1 | 0.75 | 0 | 0 | 0.75 | |
| dehydration | 0 | 0 | 1 | 0.75 | 0.75 | |
| Poor feeding | 0 | 0 | 1 | 0.75 | 0.75 | |
| Abdominal distension | 0 | 1 | 0.75 | 0.75 | ||
| Multiple symptoms initially | 0 | 0 | 46 | 34.6 | 34.6 | |
| Total | 28 | 21.05 | 105 | 78.95 | 133 | 100 |
TABLE 4. Cautery adviser characters.
| Variable | Number | Percent |
|---|---|---|
| Cautery adviser | ||
| Grandmother | 60 | 51.9 |
| Grand father | 6 | 4.5 |
| Other family member | 40 | 30.1 |
| Other person | 18 | 13.5 |
| Education status of the adviser | ||
| Illiterate | 80 | 60.1 |
| Primary | 36 | 27.1 |
| Intermediate | 9 | 6.8 |
| Secondary | 5 | 3.8 |
| College and above | 3 | 2.2 |
| Person who did cautery | ||
| Traditional healer | 127 | 95.5 |
| Family member | 6 | 4.5 |
| Cautery payment | ||
| Yes | 98 | 73.7 |
| No | 35 | 26.3 |
| Total | 133 | 100 |
FIGURE 3. Distribution according to outcome of cautery.
FIGURE 4. Distribution according to presence of complication.
Most of the cauterized children were of age below 1 year (80.4%) and the rest 1–2 years (14.3%). In comparison with another study conducted in Saudi Arabia by Watts HG,15 the mean age of the children who received cautery was 10.0 years and this may be explained by the fact that because the cause of cautery in our study is mostly due to fever, diarrhea, and vomiting, which is most common in the young age groups than in the others, the cautery appears to be more in infants than in other age groups, and this also explained that the higher percentage of cautery are in an age group where the symptoms or disease mostly occur.
More than two-thirds of parents of the cauterized children were mainly of illiterate or had primary education (this seen partly higher regarding mothers’ education), and this result supports what was reported by a study in the Aseer region of Saudi Arabia in infants with cautery whose parents also had lower levels of education,21 and also the same result in another study in Benghazi, Libya.22
The grandmother or other family members were the main advisors of cautery and this result supported what was obtained from a study in Libya where 90% of cauterized patients followed their parents’ or relatives’ advice for cautery.22
A vast majority of the advisors for the cautery was illiterate or had primary education. The person performing the cautery was a traditional healer in 95.5% of the cases, whereas the remaining 4.5% were family members and this was about the same result that appeared in another study in Saudi Arabia where cautery was performed by a professional traditional healer (89.3%).21
TABLE 5. The frequency and percent of sites of cautery.
| Site | Patients with single site | Patients with multiple sites | Total percent | FE, P | ||
|---|---|---|---|---|---|---|
| Number | Percent | Number | Percent | |||
| Head | 21 | 15.79% | 95 | 71.43% | 87.22% | |
| Abdomen | 10 | 7.52% | 98 | 73.68% | 81.1% | 5.367 0.368 |
| Back | 0 | 0 | 46 | 34.59% | 34.59% | |
| Upper limbs | 0 | 0 | 5 | 3.76% | 3.76% | |
| Chest | 0 | 0 | 2 | 1.5% | 1.5% | |
| Lower limbs | 0 | 0 | 1 | 0.75% | 0.75% | |
TABLE 6. Cautery characterization.
| Variable | Frequency | Percent |
|---|---|---|
| Method | ||
| Lightened cotton tipped application | 129 | 97% |
| Others | 4 | 3.0% |
| Shape | ||
| Circular | 85 | 63.9% |
| Linear | 2 | 1.5% |
| Other | 34 | 25.6% |
| More than one shape | 12 | 9% |
| Total | 133 | 100 |
TABLE 7. Outcome of cauterization in relation to selected criteria of cauterization.
| Improved | Outcome | Total P. value |
X2 or FE | ||||
|---|---|---|---|---|---|---|---|
| Partially improved | Not improved | Worsen | |||||
| Sex | Male | 5 | 23 | 31 | 18 | 77 | 5.763a 0.128b |
| 6.5% | 29.9% | 40.3% | 23.4% | 100.0% | |||
| Female | 10 | 17 | 22 | 7 | 56 | ||
| 17.9% | 30.4% | 39.3% | 12.5% | 100.0% | |||
| Residence | Rural | 7 | 24 | 28 | 12 | 71 | 2.719a 0.851 |
| 9.9% | 33.8% | 39.4% | 16.9% | 100.0% | |||
| Urban | 6 | 9 | 18 | 8 | 41 | ||
| 14.6% | 22.0% | 43.9% | 19.5% | 100.0% | |||
| Semi urban | 2 | 7 | 7 | 5 | 21 | ||
| 9.5% | 33.3% | 33.3% | 23.8% | 100.0% | |||
| Person performing the cauterization | Family member | 1 | 3 | 1 | 1 | 6 | 7.642 0.139 |
| 16.6% | 50% | 16.6% | 16.6% | 100% | |||
| Traditional practitioner | 14 | 36 | 53 | 24 | 127 | ||
| 11% | 28.3% | 41.7% | 18.9% | 100% | |||
| Indication | Diarrhea | 0 | 3 | 6 | 3 | 12 | 54.209 0.056 |
| 0.0% | 25.0% | 50.0% | 25.0% | 100.0% | |||
| vomiting | 0 | 1 | 1 | 2 | 4 | ||
| 25% | 25.0% | 25.0% | 100% | ||||
| Abdominal pain |
11 | 19 | 28 | 13 | 71 | ||
| (15.5) | (26.8) | (39.4) | (18.3) | (100) | |||
| Excessive crying | 1 | 3 | 5 | 0 | 9 | ||
| (11.1) | (33.3) | (55.6) | (0) | (100) | |||
| Mixed | 3 | 17 | 18 | 10 | 48 | ||
| (6.25) | (35.4) | (37.5) | (20.8) | (100) | |||
| Site | Head | 3 | 8 | 4 | 4 | 19 | 24.12 0.501 |
| (15.8) | (42.1) | (21.1) | (21.1) | (100) | |||
| abdomen | 0 | 0 | 1 | 0 | 1 | ||
| (0) | (0) | (100) | (0) | (100) | |||
| Upper limb | 1 | 2 | 6 | 0 | 9 | ||
| (11.1) | (22.2) | (66.7) | (0) | (100) | |||
| Multiple |
11 | 26 | 33 | 19 | 89 | ||
| (12.4) | (29.2) | (37.1) | (21.3) | (100) | |||
| Total | 15 | 40 | 53 | 25 | 133 | ||
| 11.3% | 30.1% | 39.8% | 18.8% | 100% | |||
TABLE 8. Correlation regression analysis of the determinants of the cauterization outcome.
| Outcome | ||
|---|---|---|
| Age | Pearson Correlation | -.081- |
| Sig. (2-tailed) | .353 | |
| Duration Of Disease | Pearson Correlation | -.131- |
| Sig. (2-tailed) | .134 | |
| Total number of cautery | Pearson Correlation | -.128- |
| Sig. (2-tailed) | .148 | |
| Duration of disease before seeking medical care | Pearson Correlation | -.296-** |
| Sig. (2-tailed) | .001 | |
In all, 73.7% of parents mentioned that they paid for the treatment, whereas the remaining were for free. In addition, some of the parents mentioned that the payment was not fixed and they paid what they wanted to or what they could afford. This result does not coincide with the results from another study in Saudi Arabia where 64% were for free.15. This difference may be explained by the time and place where the study was conducted.
Most of the cauterized patients were not improved or their condition worsened (58.6%), whereas only 11% showed improvement, and this result coincides with the results from other studies like those done in Oman in which improvement was seen in only a small percentage, and also supported what has been found in studies from Libya and Sudan.3,22-4 This small percentage of improvement after cautery may be attributed to the self-limited course of some diseases or the effect of the treatment, which was taken before the cautery.
Complications were seen in 9% of the cauterized patients (ulcerations 8.3% or infections 0.7% at the sites of cautery). The same complications were reported in different percentages in other studies like the one conducted in Saudi Arabia and Sudan. The difference in percentage of patients developing complications may be attributed to the method of cautery and also because the majority of the patients in our study were seeking medical care before cautery and within a 6-day period after cautery.25
The main sites for cautery were the head followed by the abdomen and back, whereas the upper and lower limbs and chest constitute a lower percentage. This differs from a result of a study from Saudi Arabia where the main percentage was the chest and abdomen.26,27 This may be explained by the fact that the cautery site was usually on the site of symptoms, which were mostly diarrhea and vomiting in our study, whereas abdominal distension and prolonged cough in another study.
The vast majority of the cautery was done by a lighted cotton-tipped application (97%), and the circular shape of cautery was the commonest shape of cautery (63.9%). This is in contrast to a study done in Saudi Arabia where most parents described the cautery as being done with a hot metal or an iron rod, which had been placed in the fire.28
Limitation of the study
1-This study was performed during the COVID-19 pandemic and therefore includes pediatric patients admitted to the Bint Alhuda Maternity and Childhood Teaching Hospital only, and does not include patients who visited the hospital outpatient clinic or the patients who practice cautery and visit other primary health care centers or other hospitals.
CONCLUSION
Low level of education in parents, low socioeconomic status, residence in rural areas, and cultural familiarity of traditional cautery are the main reasons behind the continued resort to traditional medical healers with subsequent impact on the health of the population partly from the delay in medical consultation and the delay in treatment of the disease on the one hand and cautery adverse events on the other hand.
ETHICAL APPROVAL
The manuscript is written in original and all the data, results pertaining to this manuscript are original according to the research performed. The authors followed academic integrity and have not copied any content/results from another source.