Chapter VIII: Afghan Surgeons and Physicians

Accidents from machinery in motion. The “dressers of wounds” in
Afghanistan. Their methods of treating dislocations, fractures, and
wounds, and the awful results of the same. The “Barber surgeons.”
Tooth drawing and bleeding. The Hindustani “Doctors.” “Eye Doctors”
and their work. The Hakims or Native Physicians. Treatment of
disease by the People. Aspect in which European Physicians are
viewed by the different Classes.

[Sidenote: Machinery Accidents.]

One morning soon after our arrival in Kabul, when I was at the Erg hospital, a messenger arrived in a great hurry to say a man had been injured at the Workshops. I jumped on my horse, which was waiting, and galloped off. Just outside the Workshop garden, on the road by the river bank, I saw the heavy portable engine with a crowd of people round it. Mr. Pyne was there in the middle of the crowd, and a man, one of the Afghan workmen, was lying on the ground. I examined the patient and found he was dead. Mr. Pyne was very upset and at first refused to believe it. He sent off a man to the shops for whisky, and begged me to send someone to the hospital for ammonia. I did so, though, of course, it was useless. They were moving the engine to the Salaam Khana or Durbar Hall to work the dynamo for the electric light there, but no one in the crowd seemed to have seen how the accident occurred, whether the man was crushed under the wheel or whether he had been struck on the head. There was no inquest, and post mortem examinations were not viewed with favour.

Later on, when the machinery was put together and some of it was in working order, accidents and deaths were, as might be expected, of frequent occurrence. In stepping over the shafting which ran across the entrance to one of the shops, about a foot above the ground, the long sheepskin postîn or coat would catch, and the wearer be whirled round and killed. Familiarity breeds contempt, and in spite of accidents it took a long time to educate the ordinary Afghan, after he had got over his first awe, up to the point of learning that machinery in motion should be approached with circumspection.

They had a way of putting their fingers under the punches of the cartridge machines, forgetting that the punch would inevitably come down at its appointed moment. It took one man in the palm, I remember, and I had to amputate his first and second finger and his thumb. Another got his hand between some steel rollers in motion, and but for the fact that Mr. Pyne was on the spot and at once threw the machine out of gear, the arm would have gone too. As it was, the skin was taken neatly and cleanly from the wrist and turned backwards like a glove over the finger tips. The bones of the hand were crushed, and I wished to amputate in the lower forearm; but the man, who was brought to the hospital, refused to have the hand taken off because he could move the fingers a little. I pointed out the danger he was running of further serious results, but he would not consent.

As he refused the only treatment that I felt was suitable, I could not undertake to treat him, and he was removed to his home in the city. I do not know who attended to his hurts, probably one of the native “dressers,” but four or five days afterwards he sent a friend to beg that I would come and remove the hand. Unfortunately, it was too late; “tetanus,” or lockjaw, had set in.

[Sidenote: Afghan Treatment of Dislocations.]

The “dressers” of wounds in Afghanistan are a body of men--natives--whose duty it is to dress wounds and ulcers, set broken limbs, and probe for bullets. They have no knowledge of even the groundwork of their profession. Never having dissected, nor studied anatomy, they are quite ignorant of the position and shape of the bones, to say nothing of the course and distribution of the larger arteries of the human body, so that the abscess knife and the scalpel put into the hands of one of these men work grievous harm. They carry about with them a flat tin box, with partitions inside, something like a paint box; and in it is a collection of most filthy looking ointments of different colours. These they plaster on indiscriminately; if one does not cure an ulcer perhaps another will. For dislocation of joints a mixture of flour and yolk of eggs smeared on is a certain specific; they have no idea of reducing the dislocation. For a broken bone, flour and yolk of eggs again comes in. Say the bone of one arm is broken between the shoulder and elbow, the following treatment is adopted. Some narrow strips of calico, smeared with the flour and egg mixture, are bound tightly round the limb at the seat of injury; thus breaking the first law of surgery, that no bandage be put on under a splint. Over this bandage are arranged longitudinally four or five narrow pieces of wood about five inches long, very like those you buy in a bundle for firewood, and utterly useless as splints, and another bandage is wound firmly over these; there is no padding with cotton wool. The patient is then left. The result is, of course, that the limb below the bandages becomes exceedingly swollen and painful.

When the pain has reached such a pitch that it is no longer bearable, the patient releases his arm from the bandages, and the dresser is sent for to readjust them, so that the unfortunate limb is relieved for a time before it is tortured afresh. In spite of the dresser the bone sometimes unites, usually at a more or less obtuse angle; but not uncommonly, especially in compound or comminuted fractures, the pressure is taken off too late, and the whole limb mortifies. The patient, after months of suffering, may or may not recover. I have had them brought to me with the broken end of the bone protruding from a hanging mass of stringy and sloughing muscle and tendon, the rest of the limb being hidden from sight by unclean rags.

Such “dressers” as I could get hold of I put through an examination at the hospital, to try and find out what they knew, and endeavoured to teach them some elementary facts in anatomy and one or two common sense rules in surgery, but only one of them would even pretend to learn, and he was a humbug. They all knew better than I did how to treat wounds and ulcers, and set broken limbs, and they received any suggestions of mine in offended silence. I showed up one or two, pointing out the disastrous results of their treatment, but it did no good. I only had an extra enemy or two to consider, for they were very venomous.

[Sidenote: The Barber Surgeons.]

Besides the comparatively modern “dressers,” there is another body of men in Kabul who practise the noble art of surgery, namely, the “barbers.” The line they specially take up is that of bleeding and tooth drawing. They have very rough forceps for the latter operation, and when, as not infrequently happened, they snapped the crown of a tooth off instead of extracting it, they passed the patient on to me. It is annoying for a surgeon to have to extract broken but firmly-fixed fangs from an injured and bleeding jaw. It is not a pretty operation at all.

For fevers, dyspepsia, gout, headache, or any feeling of malaise, the barbers bled their patients--but besides these, which may be called the _irregular_ bleedings, there are regular bleedings every spring and autumn. These are generally done out of doors by the road side. The barber, squatting down by the side of his patient, makes his incision at the bend of the elbow: fortunately, not into the vein immediately over the great artery of the arm, the one usually bled from in England, but into one adjoining. The patient holds out his arm and allows the blood to drip on to the ground till he thinks enough has run away. There is not the slightest attempt made to measure the quantity of blood lost. The only precaution taken is to avoid drinking any water for twenty-four hours afterwards, lest it should mix with the rest of the blood in the vein and make it thin; or if they do drink any they hold the wounded arm above their heads to prevent the water running into it! Wet cupping, too, is performed by the barbers and dressers, and is a very popular means among the townsfolk of getting rid of their blood. It is a common thing to see an Afghan scarred all over the shoulders and loins. Cupping is employed generally as a remedy for muscular rheumatism. The custom was introduced some years ago by the Hindustani hospital assistants, who, after having had in India some slight training in the European system of medicine, found their way into Afghanistan under the guise of “doctors.” The majority of these were unqualified men, and were quite unfit to be anything but hospital assistants. Let loose upon the people they have worked as much havoc among the sick as a similar number of the hakims could have done.

[Sidenote: Eye Doctors and Hakims.]

There are also native “eye doctors!” These may do good sometimes by accident, though I never heard of a case, but they do an incredible amount of harm: for eye diseases, on account of the glare and the dust, the absence of proper treatment and ordinary care are very common in Afghanistan.[1]

[1] The commonest affections I met with were granular lids, chronic entropion, corneitis, nyctalopia, and cataract.

Finding out that I sometimes used sulphate of copper--an astringent and caustic--of which there was plenty to be had in the bazaars, they would put this powdered into any eye--say, of a child who had ulcer of the cornea! The Hindustani hospital assistants were not much wiser, for they sometimes used solutions of sulphate of zinc, a similar remedy, for the same purpose. The eye being irreparably damaged the patient is then handed on to me, and the Hindustani, like the dresser, smugly says that “If _he_ couldn’t cure the patient, neither could the Feringhi.”

However, the people and the Amîr judged, I found, according to general results. I remember in Turkestan a soldier getting leave of absence, travelling down to Kabul, and bringing his old mother on a donkey the two hundred odd miles over the mountains, for me to cure her eyes. They were past all hope.[2] The painful part of the affair was that they would not believe I _could_ not, but that I _would_ not restore her eyes; and the old woman went down on her knees to implore.

[2] Entropion, with nebulous and vascular cornea in an old woman of seventy.

There was one old fellow, an “eye doctor,” in Kabul, whom I used to notice on my way to the hospital. He sat in a hut of rushes and mud by the roadside, with his medicines in little packets before him. I often wished he would come and have a little elementary instruction in the “eye.” But he had such a sour expression when I went by, and he never would look at me, that I did not suggest it to him.

The hakims--the physicians of Afghanistan--practise purely as physicians; they do not use the knife surgically, rarely even for bleeding. When they find it necessary to treat an abscess, they apply an irritating ointment which causes ulceration of the skin. Since the introduction of European drugs into Afghanistan some of the hakims have made use of them; but as they do so in ignorance of their therapeutic properties, the results are rarely satisfactory, and, in some cases, are disastrous. They have great faith in the healing properties of a purge, but do not consider it has had any effect unless it acts at least twenty times. The way is prepared by administering every day for a week a large bowl of laxative mixture; afterwards, one or more bowls of a drastic purge are given. Some of the people seem to establish toleration of this class of medicine, and require a large dose before they are acted on; but with a vast number this mode of treatment, combined with the custom of eating largely of ripe and semi-ripe fruit, certainly predisposes them to the obstinate and often fatal bowel affections that are such a scourge in the spring and autumn.

These bowel troubles, according to a popular native idea, are caused by drinking tea immediately after having eaten fruit, particularly mulberries. There is no doubt, however, that some of the cases are due to the debilitated and enfeebled state of the digestive organs, produced by the malarial poison, the immediate exciting cause often being the sudden change in temperature experienced when climbing a mountain after a residence in the hot valleys. Other cases are due to the presence of minute intestinal parasites, the ova of these being ingested during the drinking of impure water, a common custom among the careless Afghans.

[Sidenote: Treatment of Disease by Hakims.]

The hakims practise, I was informed, according to the Yunani or ancient Greek system of medicine. The only books I could obtain on this system were written in Arabic, and this was an obstacle to my studying them; but, whatever the teaching of their books may be, the hakims I found knew nothing whatever about anatomy, physiology, or pathology. Their treatment of disease is entirely empirical. They act according to “authority.” Studying disease, not in the living subject, but in their books only, they have made no progress whatever upon the teaching of their ancestors. A sick man is brought to them, and some prominent symptom forces itself upon their notice. This is at once diagnosed as the disease. For instance, pain in the abdomen is to them “colic.” It is described in their books and a certain line of treatment is directed. They do not examine their patient, or attempt to find a cause for his pain; nor do they differentiate between different forms of colic, for they have not noticed that pain in the abdomen is sometimes unconnected with the bowel. As an example, Perwana Khan, the Deputy Commander-in-Chief in Kabul (“Dipti Supersala”), was for some weeks attended by the hakims, who, reporting him to be suffering from colic, administered purge after purge. As, however, he did not seem to be getting any better, the Amîr desired me to examine him. I found he had acute pain in the left loin, shooting downwards; the attacks of pain came on, he said, after he had been riding on horseback, and he had other symptoms, all pointing unmistakably to stone in the kidney. I administered suitable medicine for the relief of the pain, and he was overjoyed, imagining himself cured. I explained, however, to His Highness what was wrong.

To the hakims dropsy is a disease, and can be cured by the treatment set forth in their books. No attempt is made to discover the cause of the dropsy--whether it is due to kidney disease, heart, liver, lung or blood disease--it is simply an accumulation of gas (bâd) in the tissues! In diseases of the chest, they do not, of course, employ auscultation with a stethoscope, nor percussion; and bronchitis, pneumonia, and phthisis are classed together under the name of sûrfa, or cough. This, they say, is due to an accumulation of “slime” (balgham) in the body. In some cases the sûrfa is accompanied by dard i sîna, or pain in the chest, and occasionally blood as well as slime is coughed up: these are recognized as bad cases. I have related the case of the young brigadier in Turkestan, cousin of the Sultana, whom the hakims were treating for sûrfa, and who was dying of an improperly treated pneumonia, which had, eventually, become tubercular. As I did not want to have the credit of killing him, I sent in my report to the Amîr at once. The hakims did not in the least mind my being sent for to their cases, after they had become hopeless; for, like the dressers, they said, “Behold, the Feringhi doctor cannot cure them any more than we.”

Malarial fevers are diagnosed as “cold fever” or “hot fever” (tap i larza--tap i gurrum), according to whether there is a shivering stage or not. They are treated by copious bleedings and purgings, and by very low diet. Malarial fever, however, being due to the presence in the blood corpuscles of a microscopic animal, an amæba, the treatment that the hakims adopted was not likely to be very successful. Quinine in sufficient dose destroys this organism, but the hakims would rarely give it, or if, following my plan, they did so, they gave it in doses so small as to be useless, for they said, “Quinine is _hot_, and, therefore, bad for fever.”

What they meant I do not know.

The hakims divide not only malarial fevers into “hot and cold,” but they arrange all diseases into these two classes, and I was asked of almost every disease that came under my notice whether it were hot or cold; for instance, whether dyspepsia were hot or cold. The reason for the classification in the case of malarial fevers is obvious enough, but for the other diseases I never was able to find out upon what they founded their conclusions. It certainly was not simply whether the patient had fever or not.

It was particularly embarrassing when the Amîr asked the question, and I once told His Highness that in Europe we did not speak of diseases as being either hot or cold, that it was often impossible to consider them as either one or the other. His Highness was quite indignant at my denying what apparently seemed to him such a self-evident fact, so much so that he doubted if my interpreter had translated what I had said correctly. After that, when I was asked, I told the interpreter to class the disease as hot or cold, according to the custom of the country.

[Sidenote: Treatment of Disease by the People.]

In the distant villages, where there is no hakim, and the priest’s amulet has failed to cure, the people either go untreated or treat themselves. A popular mode of treatment for diseases of bones and joints, and also for almost any pain in the chest, abdomen, or back, is the employment of the “actual cautery.” A piece of live charcoal is placed against the skin until a deep burn is produced; this is done in two or three places, the scars, of course, remaining till the end of the patient’s life.

Another custom, mostly for diseases accompanied by fever, is to kill a sheep, skin it rapidly, and at once wrap the patient in the hot skin. I do not know that it does any harm. The Amîr himself, when suffering from gout, and when the hakims had failed to relieve him, employed this essentially Afghan mode of treatment for his leg and foot. Afterwards he sent for me.

For wounds, ulcers, or abscesses the villagers bind on either a piece of fresh sheepskin, which they leave on till it stinks, or a piece of an old water bag (mussack), which they soften afresh by soaking. Sometimes they plaster on mud or clay. In the case of ulcers, the fact that they _never_ heal under these circumstances does not seem to strike the Afghans, and they continue in the old custom. If the discharge oozes from under the clay they plaster on a little more. Cover a sore, get it out of sight, is the golden rule of hakims, dressers, and people. The condition of the ulcer when the clay is removed is indescribable. In some cases the only possible treatment is the removal of the limb.

[Sidenote: The Feringhi as a Healer.]

I noticed that the richer and more educated Afghans did not seem so ready to avail themselves of European medical aid as the poorer people, and it struck me there were two reasons for this. First, that the hakims took the trouble to explain to the richer people, from whom they expected to receive fees, that Europeans use deadly poisons in their medicines, which are just as likely to kill as to cure. A certain amount of weight attaches to this by the often unfortunate results of medical treatment by the Hindustani hospital assistants. The other reason seems to be due, not to the hakims, but to the influence of the priests. The more religious of the Afghans apparently look upon a European as one who, by the help of the Powers of Evil, has in this world the gifts of knowledge, skill, and wealth, but who in the next life must inevitably be consigned to eternal torment. Doubtless with his deadly poisons he can cure diseases if he wish, but it is not wise, and, indeed, is scarcely lawful, for a sick man to make use of him.

They feel it will offend God less if, before they traffic with the evil one by employing a Feringhi doctor, they use all lawful and right means to become well, such as trying the efficacy of prayer, or the wearing of amulets and charms: should these fail, by placing themselves under the care of their hereditary physicians, the hakims, who attended their fathers and their fathers’ fathers. They can always call in the Feringhi as a last resource.

The peasants and the hillmen, the soldiers and the poorer townsfolk--in fact, all those who are but occasionally under the influence of the priests, and from whom the hakims can expect a small, if any fee--these are ready enough to trust themselves, when sick, to European medical skill. They take advantage of that which seems to them good, as an animal might, without entering upon the deeper question whether it is religiously right or wrong--in fact, they even look upon a doctor as one to be classed with Dewanas or madmen, and prophets, who are all more or less sacred.

It must be a powerful reason, such as the fear of being poisoned or damned, that prevents the richer Afghans from employing European medical aid, for they have to pay the hakims, whereas at the hospital no fees or presents were received, and it is not the nature of an Afghan to pay for a thing if he can get it for nothing.