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Random Musings of a Senile Physician-III Dr. Alaf Khan

Thousands of men from Kurram Agency work in the Gulf States and Saudi Arabia. Their relatively high earnings and the global inflation have pushed bridal prices to a million Pakistani rupees or more. Mobile traders go about Charsadda, Peshawar, Nowshera, Swabi, and Mardan Districts looking for brides at good prices. These guys, like real estate agents, fleece both the buyer as well as the seller. One distraught greybeard from Kurram Agency brought to me for a medical checkup his newly purchased bride. His expensive and very coy wife was actually an intersex person raised as a woman. Doctor, I wanted sons and paid a lot of money for this thing. I will kill that bastard if I ever find him. 

Dr. Alaf Khan

F. Polygamy. Bigamy, though rare, does exist. Polygamy is rarer still. Occasional cases of bigamy by choice are not unknown. The majority of bigamous unions are due to sociocultural compulsions. A young married man may die of a natural cause or be killed in a feud or accident. Remarriage for his young widow out of the family circle is socially abhorred. The dead man’s brother or cousin, even if already married, shelters the widow and her kids for life through wedlock. Sometimes a teenage boy has to marry the widow of his much older brother. In a decade or two, the woman is past her wifely state while the husband still has his manly might. The issue is discussed in the family and the man marries a second woman closer to his own age —- and to his heart. Polygamy by choice, so common in the Arab world, is very rare in the tribal belt and in the rest of Pakistan.

G. Ghag (). This word, meaning a call, a shout, or a Public Announcement, is dead now. It was banned by legislation — The Ghag Act 2013 — enacted by the Khyber Pakhtunkhwa Assembly. It was made a criminal offense punishable by imprisonment for 3-7 years. Why such a broad band of imprisonment for a very specific offense is something perhaps only the lawmakers can explain.

 The Ghag was used when a man fancied some young woman in the clan, but there were some hurdles in making a proposal. He fired a few shots in the air and shouted publicly the words she is mine. He, so to speak, irrevocably booked her as his future wife. A marriage proposal by someone else could, and often did, lead to violence if not bloodshed. 
I have known cases of Honor Killing, Koshinda, Swara, and bigamy within my own clan and family circle. Hasti Khan, the husband of my elder sister, was killed by a man from the neighboring clan. It was to be a long-drawn feud or a Swara. The killer’s 20-year-old sister became the bride of the 22-year-old son of my widowed sister. The two households have bonded as one peaceful family all these years since the early 1990s.

My parents got married about a decade after the First World War. They and a few related families migrated to the northernmost plain of Charsadda district where they built a little hamlet of mud huts. The settlement, in keeping with the clan’s own tribal name, was christened Utmanzai Village. Incidentally, another much larger, and far more famous, village by that name lies about three kilometers north of Charsadda town. It owes its fame to being the hometown of the legendary politician Abdul Ghaffar Khan (alias Bacha Khan) and his clan.

Early childhood

No school, healthcare facility, or paved road existed in an area about 15 kilometers across the region where my parents had settled. A quack here and an herbalist there, rivaled by some faith healers and shrines, constituted the medical fraternity of the time. A few persons in a whole village could recite the Quranic words without knowing what they meant. Some Imams (prayer leaders) in larger villages could make sense of a few Persian classics like the Gulistan and Bostan of Saadi, a couple of primers of Arabic grammar, and an elementary text or two of Islamic jurisprudence. Some prayer leaders in larger towns were fairly well-versed in the translation of the Quran and the details of Islamic jurisprudence (). Most of these were Mulla sahibs (clerics) or Qazi sahibs (jurists) from the hilly gorges of Dir, Swat, and Afghanistan. They usually came to the plains of Peshawar in search of livelihood as prayer leaders (). Even a minimally literate person was addressed as Munshi sahib or Mirza sahib — i.e. a scribe — as a mark of honor. 

Some childhood memories. 

The barbers’ was a multi-faceted occupation in our rural community. They divided the villages into their well-demarcated territories, or bailiwicks as the British termed such domains. Every barber visited each village in his bailiwick once a week to shave the scalps and armpits, and trim the beards and mustaches, of his male clients. Young men got their beards shaved on these occasions. Safety razors such as Gillette, Bic, and 7 o’clock lay in the distant future. Electric shavers and clippers had to wait several decades to appear. A straight open razor, a whetstone, a leather strap for smoothing the cutting edge of the open razor, a pair of scissors, a small metal scoop for removing earwax, a pair of tweezers for plucking the nasal hair, a sharp scalpel for paring nails, and a wooden comb were a barber’s standard paraphernalia. Barbers apparently did not spread hepatitis B and C or other infections despite shaving several scalps and beards every day with the same open razor. These viruses probably had not yet invaded the human domain.

A pubertal lad would coyly whisper to the barber for the loan of a razor. Trying not to be noticed, he would coyly shuffle into the nearby cornfield or sugarcane field to shave the new manly hair growth in his groins, and scrotum. The barber would later quietly call on the boy’s mother to convey the tidings that her son was now a man. He received a pair of garments or a few kilograms of grain from her as a reward for the good news.

Barbers got no cash for individual items of service. They did, however, receive some cash, new garments, and other gifts after circumcising boys. More about circumcision later.
A barber was paid, as his wage, a fixed quantity of corn, wheat, and homemade cane sugar on a per capita basis for each male member of the family. Women did their own hairdo etcetera and were not on the barber’s list of clients. This harvest-time payment in kind was also the form of wages paid to the village carpenter and blacksmith for the maintenance of agricultural implements of the village peasants. Carpenters, blacksmiths, barbers, weavers, potters, and washer men were collectively referred to as kasabgar, i.e. craftsmen, as opposed to cast-iron Pashtuns who farmed their own or rented land.

The British had classified even their Muslim subjects into various Castes on the pattern of the Hindu Caste system despite Islam’s abhorrence for any such grouping of humanity. One had to enter one’s full name, date of birth, father’s name, home address, mother tongue, ethnicity, religion, and Caste while filling out any official form or a legal document. Government service, no matter how lowly, and farming were the two relatively respectable occupations for Indians under the British Raj. The word kasabgar (craftsman or artisan), by contrast, had a demeaning connotation.

Spinning wheels and weaving looms for making coarse cotton cloth were operated by professional weavers in most towns and sizable villages. The famous Pashtun leader, Abdul Ghaffar Khan, would often squat by his spinning wheel to make yarn. He was neither a weaver by occupation nor in need of some length of cloth. He was merely showing his devotion to, and admiration for, Gandhi. Weaving had been a respectable and rewarding occupation for ages. After all, one could do without food for a day or two, but not without clothes even for a minute — not in public anyway.

The world-famous Dhaka malmal from East Bengal was the finest, whitest, lightest, and smoothest fabric in the world. Its weavers demonstrated its legendary texture to the customers by swiftly pulling a full-size malmal shawl through a wedding ring. Its quality excelled even that of the famous Shetland shawl of Scotland. The BBC Urdu Service, in March 2021, posted a feature on this textile marvel. 

The wily Brits could not stomach the global popularity of this cottage industry. They needed the wool, jute, and cotton for their mills in the English Midlands. A ban on spinning and weaving in India would have sparked politically unacceptable repercussions. Success was feasible through a subtle social and psychological assault on weaving rather than using a coercive whip. Mythical tales about weavers were skillfully spawned and spread throughout the subcontinent. Weavers were portrayed as a semi-idiotic lot badly short on common sense. Being called a weaver’s son became as insulting as being called a bastard or catamite. Why did you look behind you like a weaver, was a remark that had a concocted background. When a loud fart escapes a weaver’s bottom, so went the fable, he looks behind him to see if there was someone who might have heard the taboo turrr. That mythical fart got the cunning colonists all the wool, cotton, and jute for their mills in Nottingham and Manchester. Who would want to be a weaver anymore, Gandhi and Ghaffar Khan excepted!

The village barber not only shaved the scalps and trimmed the beards of his male clients, he also practiced leeching, bloodletting (), tooth extraction, and circumcision of boys. Additionally, he acted as a messenger for delivering invitations to wedding feasts, circumcision ceremonies, and funeral gatherings on behalf of his clients whose friends and relatives would be scattered far and wide. My services as a primary schoolboy were often utilized for listing on some soiled shred of paper the names of relatives and friends on such occasions. It was to ensure that the barber did not miss someone out. The barber, either on foot or on a squeaky bike, would round up the villages and verbally deliver the invitations. 
 Circumcision. All boys in the villages and towns were circumcised by the local barbers. I myself, my two elder brothers, and all my cousins and nephews have been the victims of the barber’s simple open razor. I was then too young to remember the ordeal. Luckily, none of us contracted tetanus that was so rampant in the rural environment and claimed the lives of so many of the newly-circumcised boys.

Tetanus, incidentally, is an eminently preventable infection, that is far from being tamed. I have had to manage dozens of patients during the twenty-five years of my hospital service in the Lady Reading Hospital in Peshawar. Newborn babies delivered at home died of tetanus during the first week of life as did many mothers after home deliveries. It was then popularly known as epilepsy of the first seven nights (). More about this so-called lockjaw later. 

Circumcision was always a festive occasion. Women sang, danced, and played drums and flutes every evening for a week or so preceding the amputation of the boy’s foreskin. Bursts of aerial gunfire one day meant that the foreskin was gone. Male guests were seated in a circle at the time of circumcision. The barber squatted on the ground in the center of that circle. His screaming little prey was seated on a crude stool or an earthenware pitcher turned upside down. An adult relative squatted behind the boy and brought forward the kid’s hands and forearms from behind his knees and clasped his wrists on the inside of his knees. This posture made the boy’s masculine assets readily accessible to the barber.

The kid would struggle and scream in vain to release himself. Hard as the barber tried to hide his razor from the boy, the hapless soul knew the fate of his foreskin. The man holding the boy would shout Look! Look up! See that bird? Look up there. See that crow? And, in an instant, the amputated foreskin would be tossed over to a waiting dog. The barber, additionally, carried a small aluminum bowl. Other boys, more or less the victim’s age, were asked to pass urine into that container just before the surgery.

The bleeding end of the penis was washed a few times with that freshly passed male urine. Close by his right side, the barber kept a small tin plate on which he burnt some old cotton rags to make fresh, warm ashes. The bleeding surface was generously covered with those warm ashes in several layers. A piece of clean-looking linen, torn off some old shirt or sheet, was wrapped around the organ’s bleeding end. This combination of fresh urine and warm ashes was, in fact, not as primitive a quackery as it sounds. These barbers used the only sterile things available to them, i.e. freshly passed male urine and freshly made warm cotton ashes.

I was struck by the wisdom of using fresh male urine when a young Afghan fighter consulted me during the Soviet occupation of Afghanistan in the 1980s. What’s the problem, I asked. Nothing, doctor saib. Please just test my urine for germs and anything poisonous, he demanded. Any reason? I asked. Well, doctor saib; we often clash with the Shuravis (Soviets) in remote gorges. When one of us is hit by a bullet or shrapnel the rest of us quickly pass urine directly over his wound to wash it clean. And I don’t know if my urine is safe for that kind of job. A striking example of purely empirical wisdom.

Circumcision ceremonies in the towns, especially in Peshawar city, were more like those of a wedding until recently. It was, in fact, called the little wedding (). The boy, riding atop a richly decorated horse, was himself adorned with floral wreaths, colorful attire, and garlands of currency notes. Taken out in a procession in the city streets on the day of his forthcoming amputation, the lad was accompanied by dancers, drummers, bagpipers, and singers. Coins were showered on him by relatives, friends, and neighbors. Scores of kids from the neighborhood walked along on both sides of the resplendent rider and his ornate steed. These children wrestled over the raining coins like two rugby teams in a ferocious tackle. These spectacular rituals, alas, are no more. The advent of surgeons and their crushing forceps have replaced these colorful scenes.

The village barber’s leather bag always contained a few additional implements of his trade. A leather strap (tourniquet) and a scalpel () were used for bloodletting (venesection) as a treatment for a wide range of maladies. Even those already anemic due to hookworm infestations or women having heavy menses were thought to have foul blood and were subjected to venesection ( ). The clients, mercifully, survived these additional blood losses. This may sound like witchcraft, but it has a respectable ancestry in European medicine. King Charles II of England suffered a stroke in 1685. A team of Royal Physicians drained two cupfuls of his blood through venesection. His Majesty then had an enema, sneezing powder, and one further venesection. His shaven scalp and bare feet were then branded with hot iron pokers. The king had fits. A mixture of powdered pearls and a good amount of pigeon dung were made into a paste and rubbed on the royal feet. Finally, an extract of human skull bones was made into a potion and 40 drops of it poured into His Majesty’s mouth. His Majesty died that afternoon. 

The healing art of my childhood in the villages differed little from the 17th-century British medicine. Some of these practices persist even today in the remote hilly areas and in the tribal belt of Pakistan. Inflamed knee joints and bellies with enlarged spleens are branded with red hot iron pokers. Blacksmiths replace barbers in this branding art. I have known dozens of patients with ghastly-looking burn scars on their knees, spines, and tummies. 
The barber’s shoulder bag also contained a small tin box containing fine sand and a few shriveled and ravenously hungry leeches. When allowed to suck the patient’s blood, the leeches would swell to many times their hungry size. 

Leeches are unique in having a mouth at each end and a row of stomachs along each side of the body. They release an anti-clotting chemical once their mouths puncture the patient’s skin. This ensures a steady flow of blood into their stomachs by preventing clot formation at the puncture site.

There are about 650 species of leeches in the world. Only one, Hirudo medicinal is, has been — and still is — in medical use. After a long period of disrepute, the leeches, like the maggots, are back in business. Stalin was leeched in 1953 in his terminal illness, but the harbinger of death proved smarter than the Russian leeches. The medicinal leech has been the physician’s ally since the year 900 CE. Therapeutic leeching and bloodletting were common in Britain and Europe till not that long ago. London imported 7.2 million leeches from Bordeaux and Lisbon at a cost of 900,000 British pounds. The import had dropped to 2,000 leeches per year by 1940 at 20% of the previous price. France exported 10 million leeches in 1825 and retained three million for domestic need. It, however, re-imported 41.5 million of them to meet the soaring domestic demand. Our village barbers were, after all, not all that silly in utilizing the services of hungry leeches. Incidentally, people sometimes refer to our medical fraternity as leeches. Some of us admittedly do suck our patients’ wallets dry. But, like the medicinal leeches, we might also be doing some occasional good to our patiens, even if inadvertently.

There were only a couple of dentists in the whole of Peshawar city till the late 1940s. They were probably dental technicians practicing a few basic procedures. Dental extraction in the villages was one of the barber’s many jobs. I had three of my milk teeth pulled out with crude pliers with long handles made for the barbers by the local blacksmith. It was more than pain when uncle barber pulled the decaying roots out.

The advent of penicillin, chloramphenicol (Chloromycetin), and the Sulfa group of drugs was considered a medical revolution during the last few years of the Second World War. M. A. Hakim was the only store in Peshawar that sold these antibacterials in very small amounts to one customer at a time. You had hit the jackpot if you got a dozen Chloromycetin capsules, thanks to a strong word from some influential friend. Hoarding, black-marketing, and the sale of fake products had not then infected the trading community so badly. Penicillin treatment requires a syringe and needle and a person who could inject it. These requirements made penicillin use impracticable in the villages during most of the1940s.

Malaria spared virtually no one under about 12-14 years of age. Its onset was at precisely the same time of the day every 48 hours. Violent shivering, bursting headache, and stressful vomiting were typical features of this so-called Tertian Malaria. Profuse sweating and a very warm feeling all over the body heralded the recovery phase of each bout. I suffered from this every autumn until I was about twelve years old. The word Tertian may wrongly suggest that the fever recurs every third day. It is, in fact, based on the Roman numerals “I – II – III”. You are fevered on days I and day III with a fever-free day II in between. Malaria occurred mostly in the autumnal months of September and October that followed the monsoon rains. Monsoon rains during July and August filled all the pits and ditches in the rural terrain with stagnant water. These stagnant pools were ideal places for the mosquitoes to breed their infective larvae.

Talismans (taweez), incantations (dam darood), herbs, and visiting shrines were popular remedies for many illnesses, including malaria. The only miracle drug was quinine which came on the market in scant supply towards the end of WW II. One Dr Thakardas of Mardan had probably been a nursing assistant rather than a physician. He ran a flourishing medical practice in Mardan town. He had acquired access to some source of quinine in fairly large amounts. He sold it in syrup form in one standard-sized bottle that contained about 100 ml of the syrup. Quinine, incidentally, is one drug that has retained its antimalarial efficacy for over 75 years.

The decades from 1950 to 1980 witnessed an unimaginable expansion in the antibiotic world. Disease-causing germs soon learned the art of developing resistance to one antibiotic after another. Antibiotics kept multiplying, and so did the bugs. Viruses have joined bacteria in the battle against humans. Human history is replete with cyclical epidemics and pandemics caused by viruses and bacteria. It is a numbing reality that an unconscious and invisible particle can paralyze all the scientific and technological achievements that man is so proud of. The 1918-22 Spanish Flu killed more people than the preceding First World War had done. And now, since 2019, the coronavirus (COVID-19) has greatly restricted human activity, stagnated the world economy, and shortened many lives. This new enemy makes no distinction between the developed, the developing, and the backward nations.

Tricks of the Trade

Many of us are unaware of certain misnomers that we proudly display on our letterheads and sign boards. These patient-grabbing tactics are interesting. The abbreviation MBBS, like the British MBChB, is a Bachelor’s Degree and not a Doctorate. The title Dr. for a medical graduate is technically incorrect but is now firmly rooted worldwide. A person is correctly called ‘Doctor’ only if he holds the postgraduate Degree of PhD, MD, DSc, DD, DLit, or the graduate MD in countries like the USA and Canada. A person holding a Bachelor’s in basic sciences or humanities is never called Doctor. I had used the word Dr. on my letterhead for some years before I became conscious of this anomaly in 1980. Thereafter it was reduced to my name followed by my Registered qualifications only. The change harmed neither me nor my patients. 

MRCP, FRCP, FRCS, MRCS, FCPS, MRCOG, DGO, DCH, FRCOG, and FACS are diplomas awarded by Colleges, Boards, or Institutions. Treating them as.

Degrees is Incorrect

Double-barreling oneself, though very common, is rsather silly. You don’t need to write Dr. Sher Shah MBBS, or Dr. Akbar Hussain Ph.D. One flag is enough. It ought to be Dr. Sher Shah, or Sher Shah MBBS. Likewise, Ph.D. itself makes Akbar Husain a Doctor. Calling himself Dr. Akbar Husain, Ph.D. is shouting needlessly twice. A pretty girl with a pretty face can’t be twice as pretty. Drop the MRCP, MRCS, and MRCOG the day you are elected FRCP, FRCS, and FRCOG. You can’t be a Fellow without having been a Member just as you can’t be an M.A. without having been a B.A.

The law requires a practicing physician or surgeon to write on his letterhead and nameplate his name, Registered qualifications, and current professional appointment so that patients know the identity and specialty of the person they wish to consult. Boastful strings like Prof. Dr. Surgeon Jansher Khan, Orthopedic Specialist, are unlawful, unethical, and ostentatious. Ex-this or ex-that, Principal or CEO of, Tamgha-i-Imtiaz, Pride of Performance, etc. are decoration pieces that may fatten one’s ego but do not enhance one’s professional competence.

It is doubtful if any Honorary Physician to the President has ever put his palm on the Presidential tummy. RMP (Registered Medical Practitioner) is another ornamental product manufactured in abundance only in Pakistan, especially in the Khyber Pakhtunkhwa province. Some RMPs are incredibly ingenious. One such soul practiced in Shabqadar about sixteen miles north of Peshawar. Fixed above the entrance to his clinic was an impressive signboard that read: 

Dr. Jnepl Nexaz MBBS (KMC)RMP
Physician and Surgeon 
ex-House Physician to
PROF. S I R A J, L R H

From half a mile you could read PROF. SIRAJ, LRH, but few would notice the guy’s own particulars. You needed a microscope to read the ex-House Physician to. That was obviously the purpose.

A masterpiece of self-projection, garbed as Public Announcement, was published in the Daily Mashriq of Peshawar some days after the deadly crane crash in the Holy Mosque in Makkah that killed many pilgrims. The advertisement, in large color print, also carried an impressive photograph of the doctor concerned. It read: 

ANNOUNCEMENT

The famous physician, Dr. M.K-u-R of Mez Road, Ignat (Medical Specialist & Gastroenterologist) is, by the grace of God, safe and well. A baseless rumor was spread some days ago that he had died in a crane accident in the Holy Mosque in Makkah. This rumor is totally unfounded. Dr. M.K-u-R has not in fact gone for Hajj at all this year. He is available as usual in his clinic to serve patients. Dr. M.K-u-R says that no one should heed this false rumor. He is, by the grace of God, safe and sound and is running his clinic regularly. The man obviously pretended that someone else wrote and published this announcement on his behalf. This Famous Physician, incidentally, was once my student at Khyber Medical College.

Many of us make no distinction between our Register able professional qualifications and our job description or employment designation. Assistant Professor, Associate Professor, Professor, Consultant, Director, Principal, CEO, Chairperson, Ambassador, President, Prime Minister, Vice-Chancellor, etc. are all career designations rather than qualifications. You may add such titles to your name in personal as well as formal correspondence as long as you hold such an office. The title ends with your retirement, resignation, expiry of contract, or getting kicked out anytime. It is unethical and unlawful to continue to call oneself Professor after retirement.

Tony Blair no longer refers to himself as Prime Minister or Ex-Prime Minister, nor does Barack Obama call himself President or Ex-President of the USA. A university or other recognized institution may grant you the special privilege to continue using for life the title Professor Emeritus if you are a male or Professor Emerita if you are a female. Emeritus Professor is lopsided and should not be used. Incidentally, in Pakistan one also loses the status of being a Gazetted Officer (i.e. a Notary Public) for the purpose of Attesting any legal document the day one retires. Speaking of the late Professor Thomas Harrison is in order if the gentleman had died while holding that post. Arbitrary convention in many countries allows retired army officers to continue writing their ranks with the letters Retd in brackets, e.g. Gen. (Retd) Javed Qamar Bajwa. My own letterhead, while I was in service until 4 March 1996, read as follows:

Alaf Khan, MBChB DCH FRCP
Professor of Medicine
Postgraduate Medical Institute,
Lady Reading Hospital, Peshawar – Pakistan.

During the few years of private practice after retirement, it was changed to:

Alaf Khan, MBChB DCH FRCP

The signboard above the entrance to my private office showed only my name and occupation (i.e. Alaf Khan — Physician) in Urdu only as below:

The change did not affect the number of those who wished to consult me.
One of our senior medical teachers continues to use his usual letterhead in its customary bold font for about three decades after his retirement. Here it is:

Prof. Nrxlfatgyn Amba Nmhk
F.R.C.P. (LONDON) F.R.C.P. (EDIN) F.A.C.C. (USA) F.C.P.S. (PAK)
President’s Award For Pride Of Performance
President’s Award For Lifetime Achievement
Governor’s Award For Lifetime Achievement
Honorary Physician To The President 
Honorary Brigadier Army Medical Corps
Former Health Minister Nvg Province 
Principal Brehyk Medical College
Dean Faculty Of Medicine, University Of Sawahntp
Vice President, Pakistan Medical and Dental Council

Little space is left for recording the patient’s history, clinical findings, lab results, or the diagnosis. The patient’s own name, his/her history, the date of consultation, and clinical findings are not recorded. Every male patient is Khan and every female one is Bibi. Then follows a list of the prescribed drugs. This is perhaps a shrewd ploy for dodging the Income Tax Officer as well as any troublesome patient who might be tempted to sue the gentleman for some reason. A nameless and dateless prescription sheet has little weight in a court of law or in the Income Tax Appeal Tribunal. Allah posed a blunt question to us more than 1400 years ago: Believers! Why do you say that which you do it not? Greatly abhorred by Allah is that which you utter but do it not (Quran 61: 3).

(To be continued)

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