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Arthur Sladden - Medical Officer at Cyrene, 1910-1911

The Excavations at Cyrene, First Campaign, 1910-1911

Extract from the preliminary report of the Cyrene excavation, Archaeological Institute of America

Richard Norton, Joseph C Hoppin, C D Curtis, L Mott, A F S Sladden (Google Books)

Note by Richard Norton:  The Expedition was fortunate in having as its Medical Officer a man of broad and thorough standing. Dr Sladden has a degree in Arts as well as In Medicine from the University of Oxford ; he had worked also in St Bartholomew's Hospital, London.

Report of Dr A F S Sladden

As Medical Officer to the Expedition in charge of the excavations at Cyrene for the first campaign I have the honour to submit the following Report.

The health of the members of the party was generally excellent and gave very little cause for anxiety. Nevertheless, the accidents and other ailments which befell some of us, though fortunately not serious, showed that it will be a wise precaution to have the services of a doctor each season. In the fatal disaster which, to our deep and lasting sorrow, befell Mr De Cou, there was unfortunately no question of applying medical aid ; the murderers had done their work too thoroughly.

In addition to the care of the health of my colleagues my duties included rendering medical and surgical aid to our workmen, and it was thought desirable also to treat any other natives who applied for help. Such treatment had to be generally of a simple character, analogous to that of the Casualty Department of a general hospital, and subject to the same disadvantages often enhanced by the difficulty of language, the condition of the dwellings, and complete ignorance of the most elementary hygiene on the part of the natives, and indifference to it. Anything of the nature of in-patient work was out of the question ; the local officials deemed it wiser that so far as possible visits to sick persons in their native dwellings should be avoided, so that, with a few exceptions in urgent cases, all patients were seen at the Camp.

We planned at first to receive from natives asking for treatment a small gift in lieu of a fee, but soon found this impracticable owing to the poverty of the country. It was more politic to abandon such a scheme rather than refuse to see the patients, for their goodwill and friendliness were of chief importance to us.

There is little doubt that the local people appreciated the means of obtaining medical aid. They were a little slow to grasp the limitations of one's power to heal, but were never troublesome on that account; if disappointed, they kindly ascribed to the will of Allah any failure to cure. But the strongest faith was shown by one who on the death of his father came to ask for his resurrection. My regret at being unable to help him in his trouble was tinged with pardonable pride at receiving such a unique request. Throughout the season there was much that was interesting both from the professional and from the scientific and the anthropological points of view, though probably nothing entirely novel was seen.

The first "consulting-room" was the roadside, an arrangement admirably suited to the natives, who delighted in crowding around to see the fun, but not convenient from a surgeon's point of view. After a few weeks the Camp being put in order, a tent was set aside for use as a surgery, and did duty throughout the winter. In the spring this was abandoned in favour of a large and well-lit tomb which, despite its old associations, proved more convenient in every way, and should serve for the same purpose next season. It is a pleasure to mention here the useful help given frequently and with great willingness and intelligence in the surgery by George Morgan, one of the servants who accompanied the expedition. At one time when I was partially disabled this alone enabled me to carry on the daily work in the surgery without interruption.

Previous medical reports on the district are few in number, and those travellers who have made any such notes have dealt chiefly with the coast towns of Bengazi, Derna, and Bomba and their environs. Apparently no modern medical man has ever before had the opportunity of settling for several months at an inland point of the Cyrenaica, such as Cyrene. On the other hand, my opportunities of investigating the hygienic conditions of the coast towns were scanty; for literature dealing with these very complete references can be found in Hildebrand's voluminous book on the Cyrenaica. In the report of the Jewish Commission appointed in 1908 to travel through the Cyrenaica, a short medical topography by Dr Eder is included. I had no opportunities of observing the Jews of the coast towns, and inland there are but few Jews, but Dr Eder's notes on the Arabs and their prevalent diseases are substantially in agreement with my own experience. His military medical informants at Derna and Tripoli appear to have been singularly optimistic with regard to the health of their soldiers; at Derna there was said to have been no disease among the troops for a year. My experience with the men stationed at Cyrene was, that diarrhoea and dysentery were both prevalent among them, while quite the usual proportion of victims suffered from syphilis. The soldiers, however, were foreigners to the country and the conditions of their feeding and housing were very bad.

At Cyrene during the period of our stay, from October to May, the temperature was never tropical and at times was cold; in February on two days there was a slight fall of snow, and cold heavy rains were frequent in December and January. The coolness of the climate during our stay came rather as a surprise to many of us ; it is probably determined by the height of Cyrene above sea level (1800-2000 feet), by the formation of the country in wide plateaus and terraced bills, facing due north, by the proximity of the Mediterranean and the consequent trend of the winds.

The prevailing winds are from the north and northwest and certainly tend to make the climate cool. By contrast, when the "Gibli" or south wind blows, a type of sirocco intensely hot and suffocating, charged with fine dust from the desert, one realizes the benefit of the prevailing north wind.

Except at the height of the rainy season (December and January) there is no standing water to be seen in the district, and by the end of April most of the wadis are dry. But a few springs, and notably the fountain of Apollo at Cyrene, flow constantly throughout the year; and bearing in mind the heavy rainfall of the winter months, we can see that with a comprehensive scheme of conservation the country could be made to supply water in quantity sufficient for a far larger population than is at present found there. Under present conditions the water supply, after irrigating a few acres of garden, is allowed to trickle down the hills to waste.

I saw no mosquitoes at Cyrene, but would not undertake, on seven mouths' experience, to say there are none. Likewise I found no evidence of malaria, and this agrees with the observations of others, who have found malaria only on the coast, at Derna and Bomba.

The inhabitants are mainly Bedouin Arabs; there are a few Cretans near Cyrene at Marsa Sousa, the nearest coast settlement, and a sprinkling of negroes from the Sudan. All are Moslems, of varying degrees of strictness.

They are not a clean people, partly no doubt owing to local circumstances, but partly from their Oriental acquiescence in things as they are. The local soap is poor in quality and often hard to obtain; a great boon to the people, if they would use it, would be a cheap and readily available supply of good soap.

There are no doctors and no drugs. A few of the old men, generally in their dotage, acquire a reputation as healer, and practise principally the use of cautery and the seton on patients, who seem to realize the futility of these methods, but who bow to tradition and public opinion.

The cauterization is performed by means of a piece of metal heated in a brazier and applied to the skin for a couple of seconds. No special form of instrument is used and the area cauterized varies. No dressing or cover is applied subsequently, I have seen patients with scars following this treatment for cough and bronchitis, for abdominal pain, and for joint pains, and one notable case of sciatica where the leg had been lightly cauterized with a metal disc about half an inch in diameter, at intervals of two inches from the buttock down the posterior aspect of the leg to the ankle. The operation had been skilfully done, but apparently without any benefit to the patient.

The seton is a very common mode of treatment. A coarse linen or cotton thread, generally dyed blue, is passed under the skin surface within the subcutaneous tissue for about an inch, then out again, and the two free ends loosely tied. A large sewing needle is used for the purpose, and no attempt to clean or prepare the skin first is made. Consequently some suppuration invariably occurs, but is rarely very serious in its extent.

The site of application of the seton is generally at the seat of pain, such as the epigastrium in dyspepsia. Frequently ophthalmia of all kinds is treated by insertion of a seton to the outer side of the orbit of the affected eye; corneal ulcers and opacities, and cataract, are also treated thus, or by an alternative method of passing the setons through the auricle of the corresponding ear. Amongst other cases seen where the seton had been applied were : a boy with curvature of the spine, with setona applied over the curve; a woman with ventral hernia, another with chronic tympanitic abdomen, and a man with a tapeworm, all liberally stitched as to their abdominal walls. A phthisical patient had similar stitches at each apex in front, whilst one with acute rheumatism carried them in each wrist.

Occasionally open wounds are dressed with leaves ; more often a dirty rag, or nothing, suffices, and the condition of large chronic ulcerating surfaces or wounds under such treatment defies description. Nevertheless in many cases healing does ultimately occur.

I saw one of these native healers treating an abscess by murmuring prayers and then spitting on it ; later the same patient came to sample modern methods which in a few days gave more satisfactory results. The use of written charms carried on the person is quite common, and several of these were shown to me, generally consisting of passages from the Koran.

The people are ignorant of nearly all Western medical lore, though rumours of it have reached them, and any traveller passing through the country is soon besieged by patients. They know of Jennerian vaccination, and I had several requests for this preventive measure from Arabs going to a neighbouring district where smallpox was prevalent.

The natives have a systematic method of treating fractured limbs which has quite a rational basis. They apply splints made from bark and softened in water, shaping them to the limb. The splints are left on for as many days as the patient has years to his credit, so that on a boy of fourteen the splint remains for a fortnight, while on an old man of seventy, presumably it would be kept on for ten weeks. Their skill in applying splints was impressed upon me by the case of a man suffering from a compound fracture of the upper arm, the result of a bullet wound. Inflicted a month before, the wounds had never been dressed, but the whole upper arm, wrapped in rags, had been very neatly cased in with strong bark, and windows cut in the splints to relieve the pressure on the wounds. Owing to suppuration no attempt at union of the broken fragments had occurred, but had the fracture not been compound there is little doubt that the excellent setting would have insured good union.

A practical and quite up-to-date remedy for headache, which I witnessed on one occasion, was a form of massage of the scalp. This was carried on briskly for about ten minutes, and then the masseur concluded operations by giving a vigorous twitch to the root of the patient's nose. The local cure for jaundice consists of three shallow incisions made vertically in the forehead.

Besides the setona and the cautery, very commonly used as a remedy for localized pain, there is a favourite practice of pigmenting the painful area by a tattooing process. Although I did not see the actual method of application, nor the material used, I was informed that the skin was pricked with a needle and the pigment, producing a deep blue colour, firmly rubbed in. The favourite patterns were circles, and short lines in series crossed by longer ones, and many variations of these designs. Several cases of pain in the knee had been marked thus, and I saw also a case of mitral disease where the left breast had been tattooed. Tattooing for purposes of ornamentation and tribal distinction is, of course, quite common, as also is the custom of slitting the nostrils of infants.

As an instance of local superstition in matters of health, an old Arab consulted me for abdominal pain which he said had been laid upon him some months previously by the curse of some infidel unknown. He believed that the effect of the curse could only be removed by an infidel doctor of the same faith as the offender, who, he thought, was either a Jew or a Christian; so, hearing of the presence of a "Nazrani" doctor in the district, he came to try his luck. He went away with his faith cure supplemented by a strong dose of castor oil, and no more was heard of him.

In the course of seven months 721 patients applied for treatment, making in all 1229 visits. The cost of drugs and dressings, together with a margin for depreciation of instruments, works out at fivepence (ten cents) per patient, or threepence per visit. It goes without saying that treatment was necessarily simple in character, and that a good proportion of the cases were trivial only.

A detailed analysis of the cases seen is not of special value, but an outline of the trend of disease among the Arabs of Cyrene may be of interest. Their commonest diseases are ophthalmia and its sequelae ; syphilis in many forms and all its stages ; and tuberculosis, also in many forms. One must also record a large number of cases of impetigo, many very chronic, and of skin complaints arising from the attacks of parasites conveniently classed as macroscopic.

The commonest conjunctivitis seen was the contagious form trachoma, but slight mucopurulent conjunctivitis was by no means uncommon, and all forms were much aggravated by lack of cleanliness. The purulent eyelids of an infant might often be seen covered with flies, while neither child nor mother made the slightest attempt to brush them away. As one might expect, many cases of long-continued and severe conjunctivitis lead on to such sequelae as corneal ulcer, nebulae, general opacity of the cornea, anterior staphyloma, anterior polar cataract, general shrinking of the eyeball, or complete loss of vision; and examples of all these were seen. Squint was also very common, especially inwards and upwards. Several examples of pterygium were seen, and also senile cataracts. Very few cases of iritis, and none of glaucoma, appeared, and myopia was very rare.

Of thirty cases diagnosed as syphilitic the greater number were either late secondary or tertiary. Gummatous ulcers were common, while five perforated ulcerated palates were seen. In a remarkable case of advanced syphilitic rhinitis, the whole of the nose and central part of the face had sloughed away, so that one looked directly on to the posterior wall of the pharynx. Very few eases of primary syphilis came up for treatment, illustrating the marked dislike in the Arab mind to exposing a part of whose function he is ready to talk in the freest language to his friends. For similar reasons one had no opportunity of gynaecological or obstetric practice, though probably in cases of urgency the local Arabs would not hesitate to call a physician to the aid of their women.

Tuberculosis appeared in many forms. Thirty-six certain cases were seen and many other probable ones. Ten cases of phthisis were seen, eight of which were in male adults. Six tuberculous joints, four of these being in children, were seen, but these included no case of hip disease, nor were any cases of old hip trouble seen. Tuberculous lesions of bones were found in eight patients of various ages. Tubercle in the cervical glands was only found in a few instances, a much commoner cause of enlargement of these and neighbouring glands being found in head-lice. I saw six children whom I considered to have tuberculosis in the abdominal cavity, and one young adult. The causes of the distribution of tubercle in the body are still a matter for discussion, and generalizations should only be made on the basis of many hundreds of cases. At Cyrene the housing is extremely bad, and nourishment scanty in many families. Milk of both cows and goats is a staple of diet; meat is only an occasional luxury in most households. In this connection it should be noticed that as the result of a more liberal diet following several months' receipt of good wages from the Expedition, our natives seemed decidedly to improve in condition and to have greater vitality and energy.

Amongst other ailments which came to my notice there were, on the medical side, two cases of acute rheumatic fever, two diabetics, rheumatoid arthritis, rickets, and a ease of puerperal septicaemia first seen when in extremis and showing a well-marked purpura. A few cases with old mitral lesions presented themselves, but on the whole there seemed very little cardiac disease. Intestinal parasites are said to be common. I can vouch for several tapeworms (Taenia solium), which the natives seem to regard almost as necessarily associated with their lives. Since there is a certain amount of intercourse with Egypt, one would expect to see the bilharzia parasite occasionally, but no examples of haematuria came to my notice. The tropical diseases of the text-books were conspicuous by their absence.

On the surgical side a few notes of other diseases seen or not seen may be interesting. Six undoubted malignant growths were met with, and others probably carcinomatous. A large lymphadecoma of the cervical glands was seen in a man at Derna. One patient had a thyrogloasal cyst with which he refused to part, while in my last few days at Cyrene another patient with a large lipoma at the back of the neck was equally anxious to be rid of it.

An interesting case of wrist-drop following a bullet wound at the shoulder was shown to me; the wound had healed, the bullet having entered above the right clavicle in its outer half, and emerged above the spine of the scapula. Except for the musculo-spiral nerve paralysis no other lesion was present. Other bullet wounds served to remind one of the character of the country we were in.

Hernias were infrequent, I saw only one case of inguinal hernia, in an infant. Two umbilical hernias and one ventral in an old woman, situated two inches above the umbilicus, completed my total of four. It would be interesting to determine whether the congenital liability to rupture is less in the Arab, or whether his mode of living and working render him less liable to this weakness. No "acute abdomens" were seen, and only one case suggesting appendicitis.

Varicose veins and varicocele were rarely met with, but possibly the latter would be found if one had more opportunities of examining for it. In a man seen at Marsa Sousa there was extreme talipes equino-varus, while in the hands there was a symmetrical deformity, all the fingers and both thumbs having only half of the first phalanx present, the remainder of each digit having apparently been removed at some time. The condition was stated to have existed from birth and was possibly an example of amputation in utero by amniotic adhesions.

It is a pleasure to record these experiences shared with companions so congenial as my American friends, and did other considerations permit it I would gladly accompany them for another season's work. That not being possible, I take this opportunity of acknowledging the invariable kindness and good fellowship which I received from all and expressing my heartfelt hopes for continued and increasing success to the Expedition during the coming years.

Arthur F S Sladden