Random Musings of a Senile Physician-IV Alaf Khan

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.

Alaf Khan

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)