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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0011-HYGIENE

Lecture for 2nd year students on 25th November 2000 by Professor Omar Hasan Kasule, Sr.

A. FECAL HYGIENE

CONCEPT OF NAJASAT:

Najasat refers to: feces, al ghait/al buraaz (p 860 4:43, 5:6); human urine, bawl; arterial or venous blood, dam (p. 384 2:173, 5:3, 6:145, 16:115); menstrual discharge, dam al haidh (p. 383 2:222); pus/discharge of infected wounds, qaih; vomitus, qay'i; intoxicants, khamr (p. 405 5:90); saliva of some animals; suur al hayawaan (dog saliva, su ur al kalb, pig saliva, su ur al khanzir;  (p. 384 2:173, 5:3, 6:145, 16:115); prostatic fluid, wadi; and urethral fluid, madhi; animals not slaughtered according to Law; dead animals, maitat (p. 384 2:173, 5:3, 6:145, 16;115), or dead tissues and organs from living animals; milk of inedible animals, and hair of inedible animals. Smoke from burning of a najasat material is also najasat. Two types of blood are not najasat and are edible: the liver and the spleen (KS 235: Ibn Majah K26 B31; Ahmad 2:97). Prayer is allowed with a wound that has blood (KS 235 Bukhari K4 B34). In general solids are not najasat because when touched nothing is transferred, al jaf bi al jaaf tahirun bila khilaaf. When impurities are dry they can be touched without making the person impure, al yaabis la yanjis. The human, dead or alive, is not najasat but can be contaminated with najasat especially if he does not follow the Islamic hygienic code (MB#200). The following human emissions are not considered impurities, najasat: saliva, nasal discharge, throat clearings, sweat, 'irq; tears, dummu'u; fresh blood, fresh internal body fluids (cerebro-spinal, peritoneal, pericardial, pleural, and amniotic fluids) and the normal vaginal discharge (BG 121). Human sexual discharges, the male seminal fluid and the female sexual discharge are not najasat. Milk, human or non-human, is also not najasat. A distinction must be made between najasat which invalidates acts of ibadat and must always be cleaned and other causes of dirt such as sweat that have to be washed away anyway. Thus not everything that has to be washed is considered najasat. Non-najasat material that could encourage infection should not be left unwashed on the argument that it was nor specifically mentioned as najasat.  Both najasat and non-najasat material must be cleaned away; the difference is that the former nullifies wudhu but the latter does not. The term najasat, like taharat, has both a physical and moral dimension. The discussion above refers to the physical najasat, najasat hissiyat. The moral dimension, najasat ma'nawiyat, is discussed elsewhere.

 

HADATH

Excrement, hadath, abrogates/nullifies wudhu (MB#138). A Muslim must be in a state of ablution, wudhu, all the time. Hadath is of three types: flatus, riih al dubr, (MB#110), stool, ghait or buraaz (p 860 4:43, 5:6, BG#66), and urine, bawl. In cases of occurrence of hadath, ibadat is not possible before cleansing, taharat. The following acts of ibadat are specifically forbidden: prayer, salat; prostration during Qur'anic recitation, sajdat al tilawat; prostration for thanksgiving, sujuud al shukr; circumbulation of the ka'aba, tawaaf; and carrying the mushaf, haml al mushaf. It is however allowed to carry books that contain Qur'anic verses provided they are not more than 50% of the material. Exceptions are allowed for children who have to study the Qur'an and are not able to maintain ablution all the time. Sleep abrogates wudu because flatus may be passed during sleep and the person is not aware (BG #75). Flatus is always passing but in small quantities that should be ignored. The only amount of flatus that is taken seriously is when a clear sound is heard or when there is a smell (BG#76). Excreta of animals are treated as human excreta.

 

EXCRETA DISPOSAL, qadhau al haajat:

Relieving one-self of body wastes is a physiological necessity. It however must be done in such a way that infection and toxic material will not pollute the environment or cause harm to humans and other living things. Proper excreta disposal also has a social purpose of making sure there are no bad smells when the waste products putrefy. Proper excreta disposal also has an aesthetic dimension to make sure that the environment is pleasing to look at. Istinjah refers to cleansing oneself of all traces of the excreta. Cleansing is needed for stool and urine but not for flatus. In case of flatus, no physical cleaning is necessary in the anal area; only the wudhu is repeated.

 

MATERIALS FOR CLEANSING

Water and solid cleansers are used. The solids may be paper, stones, istijmar (MB124), or other plant material. Human bones and material known to be najasat are not allowed (MB#125, BG 84, BG#88, 89). It is preferred to use a solid followed by water (BG#93). Water is the universal and best cleanser or purifier. Water being a universal cleanser is preferred after defecation and urination (MB#117, 121, 122, 125, BG#1,2,3). Other liquids like milk or vinegar cannot be used for cleansing. In relation to purification water divided into three categories: pure water, tahuur; purifying water, mutahhir, and impure water, ghayr tahuur. Water may appear pure but cannot be used for purification because of pollutants like filth, microorganisms, and other hazardous solids and liquids. Seawater is generally taken to be purifying (BG 1). Water is purifying unless contamination is beyond a reasonable limit such as when the color, smell, or taste of the water changes (BG 3). A big amount of water is generally considered purifying because the concentration of pollutants is low. Ancient jurists had opined that 2 qullatain of water (216 liters) cannot be polluted (BG 4). With present-day sewage and industrial discharges into water, even amounts beyond 2 qullatain can be made impure. Polluted stagnant water is not purifying while running water may be (BG 5). There are limits of microbiological and hazardous material contamination beyond which water should not be used for purification. Water that has been used already in wudhu or cleaning najasat, mau musta'mal, is not usable in istinjah because it could transfer infection. Water that has any filth dumped into it cannot be used for cleansing if it is less than 216 liters. This is on the basis that a lot of water does not become najasat, al mau al kathiir la yanjis. It is not usable if there are easily visible signs of pollution such as change of colour, taste or smell even if it is more than 216 liters. We can extrapolate and say that water that appears normal and is more than 216 liters should not be used if bacterial assays indicate that it has more than the allowable coliform content.   

 

TOILETTE ETIQUETTE, adab qadhau al haajat:

Islam has emphasized toilet hygiene and treats it a religious duty. The Prophet took great care to teach his followers the main principles of hygiene. All books of fiqh start with the chapter on cleansing, taharat. Islam has taught toilet etiquette to protect both human dignity and also prevent infection. The following are forbidden: facing the qibla (MB#118, (BG 84, GB 85), facing Jerusalem, al quds, conversation in the toilet (BG#82), use of golden or silver utensils, or containers belonging to persons whose hygienic standards can not be ascertained. It is recommended to use the left hand (MB#123, BG #83) so that the right hand is used only for feeding thus preventing spread of infective and toxic material to human food, to enter the toilet with the left foot and to exit with the right foot, to expose the minimum of nakedness as necessary, even if no other human is in the vicinity. Persons defecating or urinating must hide where others do not see them, al khala (BG 82, 86). It is forbidden to defecate or urinate in water. Defecation must be in special places to avoid environmental contamination. Excretion is forbidden on the road, shades where people sit, and on the banks of rivers (BG#81). The toilet is an undesirable place (MB#116). Toilet stay must be as short as possible and the stay should never be prolonged beyond need. Shoes or sandals must be worn to prevent the feet from being soiled by filth. A dua must be recited on entering on entering (BG#78) and expression of gratitude to Allah must be recited on exiting (  ). Istinjah is the process of cleansing oneself of filth and its details have been given by Islam to make sure that there is personal hygiene that prevents infection. Ritual ablution for prayer cannot be valid before istinjah (MB # 138 p 119).

 

WASHING HANDS:

Hands play a big role in the spread of feco-oral infection. Islam therefore emphasises their regular cleansing. After istinjah and before start of wudu the hands must be washed. Hands are also washed on waking up from sleep because they might have touched the anal or urethral openings (MB#131, BG #35).

 

B. URINARY HYGIENE

SAFEGUARDING FROM URINE:

It is a great sin not to protect the body and clothes from urine, istibrau min al bawl  (KS124: Ibn Majah K1 B19, Muwatta K2 H112, MB#164, BG#90). Care must be taken not to be contaminated by urine, al  tawaqqi min al bawl  (KS 124 Bukhari K4 B55, 56; Muslim K2 H111; AbuDaud K1 B11; Tirmidhi K1 B53; Ibn Majah K1 B26; Darimi K1 B61; Ahmad 4:396, 399, 414; Ahmad 5:35, 39, 266; Ahmad 5:382; Tayalisi H519. Care must be taken to avoid splashing urine. In cases of urinary incompetence, the person is exempted and can pray even if the clothes are contaminated.

 

ETIQUETTES OF URINATING:

The regulations about urine are logical measures to prevent urinary contamination and infection. Attempts must be made to empty the bladder fully to prevent spotting after urination (BG#92). Urethral massage for both the male and the female is recommended for this purpose. Urethral massage should be repeated three times to ensure complete emptying of the penis (BG 92). The following are prohibited: urination on hard ground, urination in a vessel, urinating in a bath, urinating in a hole, urinating in stagnant water (MB#177, KS 123 Bukhari K4 B68; Muslim K2 H94-96; Abu Daud K1 B36; Tirmidhi K1 B51; Nisai K1 B30, 45; Ibn Majah K1 B25; Ahmad 3:341, 356), urination on any edible material, and facing Makka or Jerusalem. It is prohibited to urinate while standing (KS 123 Tirmidhi K1 B8; Nisai K1 B24; Ibn Majah K1 B14, 26; Ahmad 6:136, 192, 213; Tayalisi H155, MB#168) if it is feared that it will cause splashing of urine. In some cases it is better to sit when urine splashing is less likely away. Urination is a vessel is forbidden (KS 123: Abudaud K1 B13; Abudaud K1 B14, 16; Nisai K1 B29; Nisai K1 B27).

 

CLEANSING URINE:

Urine of adults, male and female, is washed away (MB 165). Floors contaminated by urine are washed with water (MB #166).

 

INFANT URINE

The urine of babies still breast-feeding is treated differently because it has less content of impurities; for boys splashing of water is enough but for girls washing is necessary (KS 124: Bukhari K4 B59; Muslim K24 H101-104; Tirmidhi K1 B54; Nisai K1 B188, 189; Ibn Majah K1 B77; Darimi K1 B63; Muwatta K2 H109-110; Ahmad 1:86, 97, 137, 302; Ahmad 6:46, 52, 210, 212, 339, 355, 356, 422, 440, 464; Tayalisi H1636; MB#167, BG#26). There is a difference in the composition of the urine of male and female infants (KS 124 Ibn Majah K1 B77). Touching the penis requires repeat of wudhu (BG #68).

 

NON-HUMAN URINE:

Prophet ordered people to drink camel urine for medicinal reasons (MB#173). Dog's urine in the mosque was not washed away (MB#137) whereas human urine was. Human urine cannot be used as medicine (KS? Bukhari K74 B15). This may indicate higher infectivity of human urine and that animal urine may contain organisms generally not pathogenic to humans.

 

C. PHYSIOLOGICAL SECRETIONS

EXTERNAL SECRETIONS: SKIN & EYE

Skin secretions: Washing of the whole body, ghusl, is obligatory in connection with many acts to make sure that the body is regularly cleared of accumulated secretions. In wudhu, it is recommended to pass fingers between the bases of toes and fingers to clear away collected secretions that can be a substrate for infection. Rings and other coverings on the body must be removed before wudhu and washing to make sure that all parts of the body are washed.

 

Eye secretions: Tears are not najasat but should be wiped or washed away. Normal eye discharge seen in the morning is also not najasat but must be washed away quickly because it could be a focus of infection.

 

EAR, NOSE, THROAT, AND ALIMENTARY SECRETIONS

 

Ear secretions: The secretions of the external ear can accumulate and become earwax or could facilitate bacterial infection leading to otitis media. It is recommended in wudhu to clean the external meatus and the ear canal as deep as is safe. This regular cleaning prevents ear infection.

 

Nasal Secretions: Nasal secretions are not najasat (MB#179). The Prophet recommended blowing the nose three times on waking up, istinshaar (BG#34) to clear away secretions and accumulated infectious and toxic material. During wudhu washing the inside of the nostrils, istinshaaq, removes secretions and infections (BG#36). Care should be taken not to blow the nose in the open air because that spreads air-borne infections.

 

GIT secretions: Contents of the upper GIT are mostly recently ingested food. Upper GIT vomitus is not najasat and does not nullify wudhu. The lower GIT vomitus especially the lower intestine has fecal excretory material that is najasat. Vomitus that is severe may contain intestinal contents and should always be considered najasat.

 

Throat secretions: Throat clearings are not najasat but should be disposed of carefully because they transmit air-borne bacterial and viral infections.

 

Oral secretions: Saliva, su'ur, is the main oral secretion. It is not najasat (MB#179). It is useful for lubricating food, initiating the digestive process, keeping the oral mucosa well moistened, and being an anti-microbial. Spitting saliva should however be discouraged because it leads to spread of air-borne infection. Spitting in the mosque or the public highway is esthetically not acceptable.

 

Oral hygiene: Use of the toothpick, siwaak, is emphasized (MB 181-182). The prophet would have ordained it for every salaat were it not for fear of burdening people (BG 29). The prophet emphasized regular use of the toothpick to maintain oral hygiene and prevent infection.  It is recommended to use the toothpick in the following cases: when entering the mosque, reading Qur'an, after eating, before salat, and on waking up at night. The toothpick must be washed between uses. It is also recommended to rinse the inside of the mouth during wudhu, madhmadha, (BG #48).

 

URO-GENITAL SECRETIONS: VAGINAL AND PENILE DISCHARGES

Vaginal discharges:  The vaginal canal has no glands but there is moisture that is a transudate. The cervix secretes some fluids. Bartholin's glands near the introitus are also secretory. The moisture inside the vaginal canal is not najasat as long as it is inside the vaginal canal. Inter-menstrual vaginal discharges are not najasat (MB #219). Washing is needed when there is a vaginal discharge following a wet sexual dream (BG #96, 97) although the fluid itself is not najasat. All vaginal discharges and any other fluids in the perineal area should be washed away very quickly because of the high potential of infection. Chronic vaginal discharges or bleeding do not prevent a woman from praying. She should wash her vagina, pad it, make wudhu, and pray immediately. Any delay nullifies the wudhu. Touching the perineal area of one self or someone else nullifies wudhu. This also applies if the perineum is of a child or an animal. Menstrual blood is washed off the cloth. If dry it is scraped off the cloth. The cloth can then be used for prayer even if traces of the blood can be seen (BG 27, BG 28).

 

Penile discharges: There are three types of penile discharges: seminal fluid, mani, prostatic discharge, madhi, and urethral discharge, wadi. Semen is not najasat because it contains sperms that are living human hereditary material. Dry semen on a cloth is scraped away while the wet one is washed with water (MB #172, BG 25) and the cloth can be used for prayer. Wudhu has to be repeated when prostatic fluid, madhi, is passed (BG #69). Touching the penis or self or another person nullifies wudhu (BG68).

 

INTERNAL SECRETIONS: INTRAVASCULAR FLUIDS, MEMBRANOUS CAVITY SECRETIONS

Intravascular fluids: There are 2 types of intra-vascular fluids: blood (haemorrhage, epistaxis, menstruation) and lymph. Blood is cleaned away with water (MB#171). The liver and spleen are not considered blood and can be eaten (BG#11). Menstrual blood on a cloth is washed away if wet and scraped away if dry (BG#27, 28) and the cloth can be used for prayer. Blood of epistaxis is not najasat (BG #69) but must be washed away immediately. Normal blood is washed away (MB 170)

 

Membranous cavity secretions: Pleural, peritoneal, pericardial, and synovial fluids are not najasat and must be washed away if they are outside their cavities.

 

NON-HUMAN SECRETIONS

Non-human secretions: The saliva of a dog is considered dirty and has to be washed with water 7 times one of them with soil (MB #136, BG8). On the other hand cat saliva (BG #9) and camel saliva (BG#24) are not considered najasat. The same ruling applies to domestic animals whose meat is edible.

 

D. THE SKIN

HAIR

Scalp hair: Scalp hair can trap and accumulate infectious and toxic material from the atmosphere because of its continuous exposure. Rubbing the hair with wet hands in wudhu, mash al ra'as, helps remove accumulation of possible air-borne pathogens. Scalp hair must be washed and combed regularly to prevent any accumulation of filth. Dyeing, plaiting, hair locking of hair are permissible provided they do not prevent proper cleaning. Proper cleaning of hair requires that water reach the root of the hair. Hair of both men and women can only be dyed with colours other than black. Black dyeing or plucking away white hair is considered deception about the age of a person. The only exception is in situations of jihad when enemies are made to believe that Muslim soldiers are young and therefore strong. Shaving scalp hair is needed when lice and other ecto-parasites are feared to grow in it. It is however offensive, makruh, to shave only part of the head unless there is a medical indication. Shaving of scalp hair for women is discouraged without the consent of the husband.

 

Beard: The male beard must be kept to maintain gender identity. It is recommended to cut the moustache and grow the beard. The beard should be trimmed and not left to grow wild. The beard should not be allowed to grow beyond the size that can be maintained hygienically. Grey hair can be dyed with any colour but black.  The beard should be washed during wudhu. Regular combing of the beard is necessary to prevent accumulation of dirt.

 

Armpit hair: Cut axillary hair, natf al ibt, is sunnat and is necessary for hygiene

 

Pubic hair: Cutting and regular cleaning

 

Trunk hair: Skin hair can be shaved as needed for cleanliness. Regular washing and shaving of abdominal, chest hair, pubic hair, and axillary hair is recommended for hygiene.

 

BODY HYGIENE

Hand washing: On waking up from sleep, the hands cannot put into any utensil until they are washed three times.

 

Hygiene of nostrils: Blowing the nostrils, istinshaar, is required on waking up from sleep (BG 34)

 

NAILS

Nails, adhfar, It is sunnat to trim fingernails and toenails. If left to grow, nails accumulate dirt and pathogens. Some of the excreta may lodge under the nails during istinjah and be a nidus for infection.

 

EXPOSED SKIN

Ablution, wudhu: Regular ablution involves washing the parts of the body that are most likely exposed to environmental pollution. The exposed organs that are washed are the face, the forearm, hands, the feet, and the head. It is recommended to wash or pass the wet hand over parts of the body that are normally exposed to the atmosphere such as the nostrils, the ear, and the back of the neck.

 

THE TRUNK

Bathing, ghusl: Washing of the whole body is obligatory after menstruation, haidh;  post-natal bleeding, nifaas; and coitus, janaba. Bathing is also undertaken before for hajj, umrah, and on Fridays. Bathing should not be in the open. Nudity must not be exposed at any cost.

 

PERINEUM

Circumcision, khitaan: circumcision is obligatory for males and is recommended for females. In men only the prepuce is removed. Circumcision is a hygienic measure to prevent accumulation of urethral discharges and urine under the prepuce that can lead to infection. In females circumcision should not involve clitoridectomy and should not cause any disfigurement of the perineal area.

 

E. PATIENT HYGIENE, nadhafat al mariidh

INTRA-VASCULAR FLUIDS:

Phlebotomy is one of the commonest procedures in medicine. Venepuncture for diagnostic or therapeutic purposes is more common that operations on arteries. Lymphatic channels are rarely operated on. Surgery and catheterisation also involve dealing with blood. Fresh blood is not  najasat when in the body. At the time of the prophet the therapeutic procedure of cupping, hijaamah, was common and the blood was not treated as najasat (BG #74).

 

INTERSTITIAL SPACE FLUIDS

Diagnostic and therapeutic procedures are carried out involving pleural, peritoneal, pericardial, cerebro-spinal, and synovial cavities and spaces. The fluids and effusions are generally not considered najasat. Amniotic fluid in amniocentesis is treated in the same way.

 

INTUBATION

Esophageal, gastric, and naso-gastric tubes are inserted for diagnostic or therapeutic purposes. The fluids involved are not najasat but must be washed away to prevent their becoming nidi of infection. A tracheostomy tube may be inserted in cases of respiratory distress and respiratory secretions may accumulate in it. These secretions are not najasat.

 

CATHETERISATION

Catheters can be introduced into the heart and the bladder for diagnostic or therapeutic purposes.

 

STOMA:

A Stoma is an opening of the GIT onto the surface of the abdomen. It may be temporary as in esophagostomy, gastrostomy, jejunosotomy, and cecostomy. It may be permanent as in ileostomy and colostomy. Ileostomies are usually constructed following proctocolectomy. They discharge small amounts of liquids continuously. They do not need irrigation but an appliance must be worn all the time. Colostomies may be sigmoid or transverse. The sigmoid colostomy discharges solid stool on an average once a day and a pattern similar to normal defecation may develop. An appliance is not needed but a pouch must be worn for reassurance. Irrigation is achieved by use of a catheter. A transverse colostomy discharges liquid foul-smelling stool and is best avoided.  The fluids from an ileostomy are not najasat but those from the colostomy are definitely najasat and must be dealt with accordingly. Enterostomy therapy is a specialised area of nursing that involves, inter alia, post-operative education and counseling of patients and their families (b) care of the stoma (c) dealing with long-term emotional and physical problems.

 

FISTULAE:

Bladder fistulae may join the vagina (vesico-vaginal fistula) or the colon (vesico-intestinal fistula). They usually follow trauma, infection, or irradiation.  Rarely intestinal fistulae may discharge to the outside. Urethral fistulae may open into the vagina (urethro-vaginal), the rectum (urethro-rectal) or the skin (urethro-cutaneous). The contents of the fistula must be washed away. Those that contain stool or urine are treated as najasat and they can nullify wudhu.

 

4.2.7 DISCUSSION ON HYGIENE

Ruling on flatus and wudhu: flatus is released continuously in normal situations

Microbiological basis for stool being najasat

Microbiological basis for urine being najasat

Physiological basis for considering vomitus from upper GIT non-najasta and that from lower GIT najasat

Microbiological basis for wadhi and madhi being najasat

Basis for why semen is not considered najasat

Rulings on blood transfusion

Microbiological basis for dead animals being najasat

Properties of water that make it a universal cleanser

Microbiological and toxicological standards for water purity

Microbiological basis for prohibition of conversation in the toilet

Scientific basis for prohinition of excreta disposal in public places

Basis for prohibition of using the right hand in the toilet

Rulings on wudhu and salat for patients with urinary incontinence

Urethral massage

Basis for prohibition of urinating on hard ground, in vessels, in the bath, in a hole, in stagnant water

Microbiological basis for different treatment of urine of breast-feeding boys and girls

Rulings on spitting

Rulings on the use of the tooth-pick

Wudhu with open wounds

Wudhu with bandaged wounds

Wudhu and ghusl in patients with stoma

Wudhu and ghusl for patients with fistulae

Professor Omar Hasan Kasule, Sr. November 2000