I was searching that how the allopathic medicine started in Kashmir & stumbled across a few references and papers on it which i would like to share with you people. I got references from the Indian Medical Gazette & Journal. Also i got a reference from a paper published online by the Royal College of Physicians in 2008.

Following is the Paper : 

mir-page-001

Paper J R Coll Physicians Edinb 2008;38:85–8© 2008 Royal College of Physicians of Edinburgh

Inspirational people and care for the deprived: medical missionaries in Kashmir

 NA Mir, V  Connell  Mir

Consultant Paediatrician, North Cheshire Hospitals NHS Trust,Warrington; Clinical Lecturer (Hon.), University of Liverpool; Clinical Nurse Specialist, Royal Liverpool Children’s Hospital, Alder Hey, Liverpool, UK

Published online March 2008

 In the European cemetery in Srinagar is the grave of Lieutenant Robert Thorpe, a British soldier who gave up his life for the people of Kashmir in the late nineteenth century. Like many other British officers, Thorpe came to Kashmir, in 1860, to escape from the heat of the plains and to shoot big game in the mountains. However, he was overwhelmed by the sorrows and the suffering of the people under the maharaja’s rule. He tried to bring the harsh conditions of the people to the attention of the maharaja as well as the British administration in New Delhi, and wrote to various newspapers in England. Thorpe was then ordered to leave the country and, when he refused, was bound to his bed and carried towards the border by other soldiers. He managed to escape and returned to Srinagar; however, the next morning he died of poisoning after taking his breakfast. There was no further investigation from the British authorities in New Delhi, and Thorpe was quietly buried in Srinagar. Other British officers who had been aware of Thorpe’s efforts raised 14,000 rupees for the CMS in London and requested them to send a medical missionary team to Kashmir.

   The picturesque valley of Kashmir is situated at an altitude of 1,730–7,077 metres above sea level and has a present-day population of more than 6·3 million people; it has two state-run medical schools, multiple tertiary healthcare centres including a supra-regional medical centre, and a large network of district and sub-district hospitals and dispensaries, offering free medical facilities to the people. At the beginning of nineteenth century, however, there was no hospital or dispensary in the state. Then, the country was very poor, and people died of malnutrition and in epidemics of cholera, plague and other illnesses.

EARLY MEDICAL MISSIONARIES

In 1864, the Reverend Robert Clark, the senior CMS missionary in the Punjab, went over the mountain passes into the Kashmir Valley. He was accompanied by his wife, who, without asking anybody’s leave, quietly opened a dispensary for women – now the site of the Government College For Women, Nowakadal – in Srinagar. Clark’s wife was not a qualified doctor, but knew more than the native hakims (herbalists) and very soon hundreds of women, who would have otherwise died of simple illnesses, came to her to receive treatment.

A young Scottish doctor of distinction, William Jackson Elmslie (born in Aberdeen in 1832), a graduate of the University of Edinburgh, responded to the Punjab Appeal initiated by the British officers after Thorpe’s campaign,and the following summer arrived and opened his dispensary on 9 May 1865. Elmslie (Figure 1) worked under extremely hard conditions; there was no hospital and he held his clinic in the open under a tree. During that first summer he saw more than 2,000 patients. There was opposition from the maharaja and his officials, who put firm conditions on the team: they were not allowed to stay in winter or purchase any land or buildings. Hence, Elmslie had to use a tent, adapting its inner part for inpatients. In the summer of 1866, more than 3,500 patients were seen by just two doctors. The work went on for seven summers,and overseas visitors helped Elmslie to carry out his work.The maharaja surrounded the dispensary with a cordon of soldiers to mark who attended, and opened a rival hospital himself, which was all to the good as there had not been anything of the kind before.

 Elmslie was a keen surgeon and performed many procedures under abysmal conditions but with successful results.This included the first lithotomy, for bladder stone, performed on 23 May 1866. He reported 30 cases of skin epithelioma and suggested its relationship with the use of Kangri, a clay fire-pot used close to the skin to keep warm in winter. Elmslie died while crossing the mountains in 1872.

Dr Theodore Maxwell, who succeeded Elmslie, was the nephew of General John Nicholson and exerted his New Delhi influence.Thus, the maharaja’s government became more favourable and gave land at the foothills of Solomon’s Temple in Srinagar for the construction of a hospital.

There was no end to the hardships of the people, with terrible famine following an exceptionally early winter in 1877. Another eminent physician, Dr Edmund Downes, and his team undertook much relief work, distributing food and helping to dig a canal.The plight of the mentally sick was distressing and, as these patients had no home or carers, they wandered through the streets and living as beggars.An asylum was built by the state in 1881–82 and handed over to the Mission Hospital team. Downes opened the asylum for the mentally sick; during its first year more than 250 patients were treated as inpatients. This was followed by the opening of a Leper Hospital, built in 1891–92, in Srinagar. On 15 August 1888, a dispensary that later became a hospital exclusively for women was opened by the Church of England Zenana (Ladies) Missionary Society. Among the notable female medical missionaries who worked hard to run this hospital were Dr Fanny J Butler and Dr Kate Knowles, with trained nurses Miss Irene Petrie and Miss Elizabeth Newman. During 1877–1880 Downes and the Reverend Mr Wade opened an orphanage where more than 150 children were cared for.

THE MISSION HOSPITAL

Two significant events changed conditions for the better in the Valley of Kashmir. The first was the arrival of Dr Arthur Neve in 1882 and the second was the Maharaja Rhanbir Singh’s death in 1885, leading to his son, Maharaja Pratap Singh,taking over the reigns of the state. Upon his arrival, Dr Neve  found the hospital to be a line of mud huts on the side of the hill. His vision was to develop a modern hospital. He and his brother, Ernest Neve, who joined him four years later, gradually gathered enough funds from donations to build and run the 80-bed Mission Hospital, which opened in 1888. In 1893, the then 135-bed Mission Hospital catered for 20,606 patient visits, including 853 inpatients and 2,589 operations. Other British staff who joined included Dr Cecil Vosper, Dr MR Roche and three English nurses, Nora Neve (Neve’s niece), Lucy McCormick and H Smith.A large number of visiting British physicians, surgeons and nurses helped them during the peak periods.

The new maharaja, Pratap Singh, was a reformist who took steps to eradicate poverty by abolishing harsh taxation laws and forced labour. He was very impressed with the Mission Hospital work and gave annual donations and free power supplies, and visited the hospital on several occasions. He also ceased the decree that demanded expulsion of foreigners each winter. However, the maharaja was unable to implement any real social and welfare plans for the improvement of people because of his weak and corrupt administration. Consequently, in 1889 the British government in New Delhi decided to hand over most of the maharaja’s administrative powers to the British Resident, Mr C Plowden, and his council in Srinagar. Kashmir Valley had an epidemic of cholera in 1896 and an outbreak of the plague in 1903–1904, which cost thousands of lives.The Mission Hospital team was at the forefront of relief work and helped the local administration in setting up medical facilities in various towns; including the opening of a new well-equipped hospital in Srinagar. In 1899, the now 150-bed Mission Hospital treated 16,158 outpatients with a total attendance of 38,954 patients, which included 4,143 operations.

 DR ARTHUR NEVE, FRCSE (1859–1919)

Dr Neve undertook his medical training at the University of Edinburgh in 1876. After working as a house physician in the Royal Infirmary of Edinburgh, he was appointed resident medical officer to the Livingstone Memorial Dispensary and Training Institution in Edinburgh, under the Medical Missionary Society. In 1881 he worked as a resident physician at 39 Cowgate, a dispensary and hostel for senior students in one of the poorest districts of Edinburgh. He later joined the CMS and went to Kashmir in 1882. Besides publishing several medical papers in The Lancet, he was the author of numerous books, including Kashmir, Ladakh and Tibet (1899), Picturesque Kashmir (1900), ThirtyYears in Kashmir (1913), and TheTourist’s Guide to Kashmir, Ladakh and Skardo (1923). He was a keen mountaineer and paid three visits to the 23,409-ft Nun Kun mountain peaks in 1902, 1904 and 1910. Romesh Thong Peak is also called Sunset Peak, a name given to it by Neve. He was awarded the Kaiser-i-Hind Gold Medal by the British government in India in 1901, served as the vice-president of the Indian Medical Congress in 1909 and was the president of the Medical Missionary Association of India from 1908–1910.

In 1915, Neve joined the British war effort, returning to Kashmir in the spring of 1919. At the end of August 1919, he was suddenly struck down by a fever and died in Kashmir, at the age of 59, on 5 September. He had spent 34 years of his life in the region, with the sole objective of helping the poor and the sick.The state had never before witnessed such a large gathering of local people to mourn the death of a hero.

DR ERNEST NEVE, FRCSE (1861–1946)

Ernest Neve was Arthur Neve’s younger brother by two years. He joined Arthur in medical training at the University of Edinburgh in 1878 and then followed him to Kashmir in 1886. Ernest was also the author of several books, including Beyond the Pir Panjal. Life Among the Mountains and Valleys of Kashmir (1912); A Crusader in Kashmir (1928), the story of his brother’s life and work;and Things Seen in Kashmir (1931). He pioneered work on Kangri cancers, which, as Elmslie had suggested the previous century, are epitheliomas induced on the abdominal wall or inner surface of the thigh of Kashmiri people, who warm themselves by braziers containing live coals held under their clothing and thus sustain recurrent burns. In 1923, Ernest Neve reported the results of his success with the surgical treatment of Kangri-burn cancer in a series of 2,491 cases in the British Medical Journal.

CONCLUSION

Within the wider history of the British empire, the work of medical missionaries in India offers an interesting and important insight into the humanitarian role played by these physicians and nurses. It also reflects the level of their dedication in providing modern medical treatment to the sick and the needy. Scottish medical missionaries were the first to establish modern medical care in the valley of Kashmir in 1864. With their own distinct Scottish missionary zeal and healthcare traditions, they were able to initiate, guide and influence the development of medical treatment facilities in the state of Kashmir.They continue to inspire and remind us of the core values of caring for the sick in deprived areas.At the site of the old Mission Hospital in Srinagar now stands the largest Chest Disease Hospital in the valley, a monument to the great medical missionary pioneers who laid down their lives in the service of the Kashmiri people.

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From The Indian Medical Gazette published in January 1907, i also got some clinical conditions which were treated in Srinagar by the doctors of The Kashmir Medical Mission.

CASE OP PYONEPHROSIS WITH CALCULUS. KASHMIR MISSION HOSPITAL. Undbbthb care op A. Neve, F.R.C.8.B.

A WOMAN aged 30 was admitted on April 4th 1903, with a history of pain for some months. A large hard swelling was felt in the right hypochondriac region, extending downwards to near the crest of the ilium, and forwards to within three inches of the umbilicus. The dullness could be marked off above from the liver. The fever and anaemia of the patient indicated suppuration. Being sure that adequate adhesion must have formed, an incision was made over the most prominent part, and at no great depth pus was tapped. On exploring, a stone was felt, and withdrawn with narrow bladed forceps. It was not firmly embedded. It was a black irregular calculus, about the size of a water chestnut. The wound was drained with a rubber tube 3 inches long, and for the first fortnight the suppuration was free, and the temperature several times went over 102, but later on she made good progress. After a month the temperature remained normal, and there was very little discharge, although a sinus remained. She was dismissed on tlie 18ch of June.

CASE OF LARGE GOITRE; EXCISION THYROIDISM: RECOVERY. By B. F. NEVE, p.b.c.8. (Kdin.), Kashmir Mission Hospital.

Fatah, cbL 23, male, was admitted on September 8th, 1903, suffering from a large bronchocele. The tumour, which w?is the size of a small cocoanut, was on the right side. The isthmus was flattened out and pressing on the trachea. The left lobe was also somewhat enlarged. As a general rule, Kashmiris are well satisfied with the result of the action of the biniodide of mercury ointment, which has a great reputation, and for which they frequently ask. Consequently, unless the goitre is giving considerable discomfort, they decline operative interference. The following day, I removed the tumour with the kind assistance of Dr. H. T. Holland of Quetta. The operation presented no special difficulty, but was tedious and involved the h’gature of an enormous number of vessels, although we were working well beyond the limits of the capsule. And the isthmus was broad and very adherent. There was a good deal of unavoidable handling of the tumour mass. After excision I noticed that the cut surface of the isthmus was oozing freely and continued to do so, but the blood was thin and watery. The amount of blood lost was small. This was fortunate, for an hour afterwards, I was urgently summoned to the wards on account of haemorrhage. On removing the dressings, there was an appalling gush. I opened up the wound and, passing my thumb round immediately above the clavicle, commanded all the vessels and secured a branch of the internal jugular, which had been cut near the main trunk and had retracted. The ligature had apparently slipped off from the stra n of vomiting. The patient had lost 15 to 20 ounces of blood in the interval. He was fairly well till the following day, but began then to get restless, and a troublesome cough set in, and his condition soon became critical. He kept on trying to clear his throat and complained of severe headache. The pulse rate was found to be very high — 148, while the> temperature was 100 2**. The patient’s face was”” rather suffused. The dressings were soaked with a thin discharge. The combination of symptoms was unmistakable  and pointed to thyroid intoxication. The following treatment was adopted. The wound was opened and irrigated, and then carefully stuffed with iodoform gauze. As often as this got moist every few hours, it was removed, the wound again irrigated and fresh gauze inserted. Immediate improvement set in. The patient himself remarked upon the relief experienced every time the wound was dressed. On September 13th, the temperature was normal, the pulse had dropped to 90, and from that time recovery was uninterrupted. The points of interest about the case are that the symptoms did not at once follow the haemorrhage and slowly pass off, but that they gradually set in during the 24 hours following the operation, reaching their maximum intensity after 24 hours. The peculiar cough, restlessness, rapid pulse and suffused face, and the copious watery discharge were all, I think, characteristic of thyroidism. The actual poison was, no doubt, in the discharge and probably was derived from the isthmus. Possibly cases with a broad isthmus are more likely to suffer from this complication. In doing the operation the tumour should be very gently handled and not squeezed, and, if possible, the isthmus should be ligatured en bloc. If this is impossible, and oozing is occurring from the surface, it would be wise to sear it with the thermo- or electric cautery. It is important to recognise thyroid intoxication when it occurs and to treat it promptly, as otherwise it is likely to prove fatal.

THE KASHMIR MEDICAL MISSION. Our pages for many years past have been enriched with the records of the good surgical and medical work done in the hospitals (of the Sept. 1904) NOTES ON CURRENT TOPICS. Kashmir Medical Mission, and to our readers the names of Mr. Arthur Neve, F.R.C.S., (Ed.) and Dr. E. F. Neve are very well known. We have received the annual report of the medical work of the mission for 1903. The introduction describes the floods of June 1903, which did so much damage in the neighbourhood of Srinagar. So with flood, scarcity and even plague, the ” Happy Valley ” was not so pleasant as is usual. The summary notes no less than 3,390 operations. The writer comments upon the rarity of tuberculous disease of glands and joints as compared with their frequency in British hospitals. ” Appendicitis is extremely rare. If we except the peculiar kangH-huvn cancer, of which we had 65 cases, malignant disease is not common in Kashmir. Our returns for the past year show only two cases of carcinoma of the breast, and 19 instances of sarcoma. Two more successful ovariotomies were performed. Both ovarian and fibroid tumours are relatively quite rare. On the other hand, as is usual in the East, eye diseases are common. For entropion alone,480 operations were required, and for pterygium 237. Altogether there were more than 1,000 operations for eye diseases,’* (including 80 for cataract).

The carcinoma statistics quoted in this paper hear out the general principle that cancer tends to occur at the sites of chronic irritation where there is constant need for cell repair. Fifty-eight cases of epithelioma and 36 of rodent ulcer occurred in the skin, which in India is almost constantly the seat of injury, owing to the scanty clothing worn by the Natives. Many of these are the scalp. It seems possible that they are set up by irritation caused by cuts with a blunt razor, for most Mahomedans shave the head as a whole, while many Hindus shave a portion. In patients from Kashmir an epithelioma of the skin of the exterior abdominal wall is common from bums produced by small charcoal fires in earthenware vessels, which they hold against the bare skin under the long, flowing skirt in winter to keep themselves warm. The freedom of Mahomedans from cancer of the penis, and their practice of circumcision, bears upon this point.

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From the Indian National Medical Journal Vol.23, No.1, 2010, the following pages i have extracted which are in relevance to Kashmir :

Classics in Indian Medicine

Capture

William Elmslie initially studied at the University of Aberdeen and graduated in 1864 from the University of Edinburgh. He went to Kashmir in 1865 when he heard of the plight of the people there because of the practically non-existent health services. Elmslie was the first person to practise western medicine in Kashmir. He was a dedicated surgeon who, because of resistance from the Maharaja and the local officials, was forced to hold his clinic under a tree and later in a tent! In fact, after some years, the Maharaja opened a rival hospital. Elmslie was perhaps the first person to describe what we now term as ‘kangri cancer’ and also correctly suggest its aetiology. He also did lithotomies for bladder stones and contributed greatly during the cholera outbreaks. He had planned to bring out a dictionary of the Kashmiri language, but died young of a liver disease in Gujarat on 18 November 1872.

Arthur Neve did his medical training at the University of Edinburgh in 1876. After working in Edinburgh for some years, he joined the Church Missionary Society and went to Kashmir in 1882. He was head of the Kashmir Mission Hospital for 37 years until his death in 1919. Besides being a skilful surgeon, he was a Himalayan mountaineer of repute and was the author of such books as Kashmir, Ladakh and Tibet, Picturesque Kashmir, and Thirty Years in Kashmir. During World WarI, he served as a Major in England, and later, in France. In 1919, he returned to Kashmir where he was given additional charge of the State Leper Asylum. He died of a fever suddenly on 5 September 1919 and was awarded a state funeral by the Maharaja of Kashmir. He was the subject of two biographies, Arthur Neve of Kashmir written by A. P.Shepherd and published by the Church Missionary Society, London in 1926 as well as A Crusader in Kashmir written by Ernest Neve.

Ernest F. Neve followed in his brother’s footsteps and trained at Edinburgh and joined him in Kashmir in 1886. He served as honorary/consulting surgeon at the same hospital until his death. His range of surgery and his contributions to the people of Kashmir are evident when one realizes that he published papers on cataract surgery, tubercular lymphadenitis, caesarean section in osteomalacia, besides kangri cancer. He was also one of the founders of the Kashmir State Leper Hospital in 1892 and was an honorary superintendent. Like his elder brother, he was a mountaineer and writer and wrote Beyond the Pir Panjal, Things Seen in Kashmir and A Crusader in Kashmir, a biography of Arthur’s life and work. He too served (as Captain) in the army during World War I. For over a decade after retirement, he continued to stay in Kashmir, where he eventually died in 1946.

ETIOLOGY OF EPITHELIOMA AMONG THE KASHMIRIS

BY  W. J. ELMSLIE.

In the beginning of the month of May, 1865, a Medical Mission Dispensary was opened in Sirinagar, the capital of Kashmir, under the auspices of the Punjab Medical Mission Society, and was kept open till the middle of October, when the season, as it is called, comes to an end, and all Europeans, whatever may be the nation to which they belong, are compelled to quit the valley, unless they be in the pay of His Highness the Maharaja of Kashmir and Jummoo. About the same time this year the dispensary was re-opened, and has been daily frequented by the sick, both men and women of the city and the adjoining country. The total number of patients belonging to the valley who have, up to the present date (18th September), applied at the dispensary for medicine and treatment is 5,080 and of this number no fewer than 30 have been cases of unmistakeable epithelioma, as was clearly and indubitably shown by the history, symptoms, and microscopical characters of the disease. These figures yield the most remarkable and unusually high proportion of one case of epithelioma in every 254 patients. The following table exhibits briefly, at a glance the names, sexes, ages, country, sites of disease, and treatment of these 20 cases of epithelioma.

 Epithelioma, as it occurs at home, is a disease which seldom makes its appearance before the age of 40; more frequently affects men than women ; as to situation, is partial to the lower lip, the penis, the scrotum, the vulva, the os uteri, the bladder, the larynx and the tongue, and is generally supposed to be produced by some sort of irritation. Now it will readily be observed, on inspecting the prefixed table, that there are certain remarkable differences existing between the disease as it is met with in England, and

Table of twenty cases of Epithelioma treated at the Medical Mission dispensary, Sirinagar, Kashmir.

Number Names Sex Age Country Site Treatment
1 Mukhti… Female 20 yrs Kashmiri Abdomen Excision
2 Rajbah… Male 38
3 Razakh… 30 Left thigh
4 Gafara… 24 Right thigh
5 Razakh… 50 Would not
submit to
treatment
6 Naki… 21 Abdomen Excision
7 Gulab… 60
8 Jamil… 70 Right thigh
9 Doni… Female 40 Abdomen
10 Adna… Male 50 Left thigh
11 Alam… 50 Abdomen
12 Hatim… 50 Left thigh
13 Fazli… Female 42 Abdomen
14 Sadik… Male 19
15 Gafara… 3
16 Jamah… 60
17 Mouli… Female 60 Caustics
18 Sadik… Male 50
19 Akldar… 60 Right thigh
20 Masihena… 50 Abdomen

the affection as it presents itself in Kashmir. While the disease is rarely met with before 40 in England, no fewer than 7 out of the 20 cases treated at the Medical Mission Dispensary, Sirinagar, occurred before that age, and one little patient was only three years old.

It must not be supposed that the table gives the true state of matters with respect to the comparative frequency of the disease as occurring amongst males and females ; for very many of the women, in common with the great majority of Asiatic women, entertain a strong and all but insuperable antipathy towards European skill and medicine, more especially when their ailments are situated in parts of the body where a spurious delicacy dictates to the pitiable and ignorant sufferers that it is preferable to allow them to remain uncared for and untreated, than expose them to the gaze of a foreigner and a white face. It seems probable that the apparent dislike of the European physician entertained by native women is mainly due, in very many instances at least, to the evil and bigoted influence of their male relatives and friends. But be this as it may, this antipathy of native women towards the Doctor of another continent is nevertheless true, and should be constantly remembered when statistics are brought forward to show the comparative frequency of particular diseases among native men and women, for if it is forgotten, the statistics are sure to lead to an erroneous conclusion. Although, therefore, it would appear from the mere inspection of the table that the frequency with which epithelioma affects men and women in Kashmir, is pretty similar to what it is at home, nevertheless, knowing and remembering this fact respecting the strong objections which native women have to European physicians, we have good reason for believing that a much larger proportion of women suffer from epithelioma than the prefixed table would lead us to conclude.

One of the most curious and interesting points connected with epithelioma as it obtains amongst the degraded Kashmiris, is its remarkable preference for the abdomen and inner aspects of the thighs. It would be hasty and unwarrantable, with our present very limited observation and experience, to say that epithelioma occurs in no other situations among the pitiable inhabitants of the Fair Valley, but certainly, so far as the disease has been seen at the Medical Mission Dispensary, Sirinagar, these are the two sites it has invariably occupied. What can be the cause of this most note-worthy preference as to situation? That there must be something special and peculiar in the habits and customs of the Kashmiris to account for this exclusive choice of the abdomen and thighs on the part of epithelioma, seems pretty certain, and we believe that something to be what we shall now proceed to relate.

The clothing of the Kashmiris, both men and women, consists essentially of one long loose woollen garment, which extends from the neck to the ankles, and is not very unlike a woollen night-gown. So far as this article of clothing is concerned, men and women are dressed exactly alike. The men, however, frequently wear a kamarband round their waists when they have a journey to make, or some piece of work to perform which requires more or less of activity. The sleeves of the garment being wide and capacious, the wearer can with the greatest facility take his or her arms out of them, and place them alongside the body, in immediate contact with the bare skin. So much for the dress of the Kashmiris, in so far as it concerns our present subject; and now for a word or two respecting the climate of the valley.

Kashmir, a valley about forty miles long from north-west to south-east, and on an average fifteen miles broad, is situated in 34° 05′ 28″.69′” north latitude, 74° 58′ 00″ east longitude, and 5,350 feet above the level of the sea. The climate which this proverbially beautiful valley enjoys is in some respects similar to that which prevails in the most favoured spots in the south of England. The winter, however, is said some years to be extremely severe, as many as two feet of snow sometimes falling. We know for certain that many of the mornings and evenings of the months of April and May, and September and October are very cold indeed, although no snow falls in the plains during these months.

The houses of the Kashmiris are not at all calculated to afford efficient shelter to their occupants against the inclemency of the weather, being for the most part built of wood, and being besides generally in the most rickety and tumble-down condition imaginable. So far as the writer is aware, they are entirely destitute of fire-places, and when a fire is kindled inside one of them, the smoke must find a way of escape, either by the door or the window, which is never of glass, but as a rule, of trellis work, which is often very pretty, and for which Kashmir is justly famous.

Coal being unknown in the valley, wood is the material generally employed as fuel. The very poorest of the people, however, collect in the summer and autumn the ordure of cattle, which they mix with straw and then form into round cakes which they dry in the sun’s rays and carefully preserve against the coming winter. Having premised so much respecting the clothing and houses of the Kashmiris, and the climate and fuel of the valley, it only now remains briefly to describe a remarkable custom which the Kashmiris have, and which has an important bearing on the etiology of epithelioma, if we are not very much mistaken.

The Kashmiris being extremely poor and inactive, and the climate at different seasons of the year being unpleasantly and bitterly cold, the inhabitants of the Fair Valley are in the habit of carrying about with them, wherever they go, earthen-ware pots, which they have denominated kangris. These kangris or portable braziers are made of clay of varying fineness, and are usually covered with wicker-work, more or less ornamented according to the price of the article. Men and women, young and old, rich and poor, Hindu and Mussulman, all have their kangri, and all consider it indispensable in the cold season. The annexed rough pen-and-ink sketch will perhaps enable the fancy to form a dim conception of the shape and general appearance of the utensil as used by the Kashmiris.*

When the weather is extremely cold, it is customary for both men and women, while walking about out of doors, to carry the kangri under their loose woollen gowns, and in close proximity with the bare skin of the abdomen. When in doors, or in a sitting posture, the Kashmiris place the kangri between their thighs. The fuel consumed in the kangri is charcoal, and the heat evolved is often considerable. These then are the facts concerning epithelioma, and the use of the kangri or portable brazier used by the inhabitants of the valley of Kashmir ; and to say the very least, it seems highly probable that the disease is caused by the injurious effects of the heat of the kangri on the skin of the abdomen and thighs, the very part with which the utensil comes in contact when used. Do these facts respecting epithelioma among the Kashmiris throw any light on the disease as it occurs in the lower lip of smokers at home? It seems probable that they do, for the disease is said most frequently to affect those who use short-stalked pipes, as is generally done in Scotland. If the heat of the kangri acts injuriously on the skin, giving rise to epithelioma, it is just what we should have expected that those who use the shortest-stalked pipes would be the most liable to the disease at home, because then the heat of the stalk, coeteris paribus, will be greater.

With respect to the use of portable braziers for the purpose of warming, the custom is not altogether unknown in England, for in the straw plait districts the children employed in that work are said to carry earthen-ware or tin pots with them to warm themselves with in winter while engaged at their work. The writer saw with his own eyes, during a tour in the north of Italy, the inhabitants of Florence making use of a vessel not very much different from the Kashmirian kangri, and for exactly the same purpose. The use of portable braziers is not calculated to act injuriously in a similar manner in the case of the English and Italians, as the arrangement of the dress is considerably different to what obtains among the poverty-stricken inhabitants of the Fair Valley.

SQUAMOUS CELLED EPITHELIOMA DUE TO KANGRI BURN

BY  ERNEST F. NEVE, M.D., C.M., F.R.C.S.E., Senior Surgeon, Kashmir Mission Hospital.

AT the present time the causation of cancer is being so vigorously investigated that at any time a flood of light may be thrown upon the whole subject. Meanwhile, although the origin of many forms of malignant disease is involved in profound obscurity, there are certain types of cancer, which have a sharply defined causation. The kangri cancer is a case in point.

The affection is considerably commoner in men. This is perhaps due to women not using the kangri so continuously as men, owing to domestic occupations, cooking, etc. The essential cause of the disease is constant irritation by intense heat from the kangri (Fig. 1) being held against the body and producing first dermatitis, then proliferation of epithelium, followed by escape of the overgrown cell elements from trophic control. Heat is the prime factor. Wood charcoal is consumed in the kangri. Products of combustion, wood ash, and volatile substances may play a secondary part. There is a series of epitheliomata. At one end of the scale we have tar, paraffin and soot cancers. Intermediate are clay-pipe lip cancer and tongue and lip cancer probably caused by smoking cigarettes. At the other end of the scale are the cancers due to heat irritation. I have not met with cases due to the sun’s heat or to light rays, but further down the spectrum the minute x-ray waves and radium are dangerous. Then there is a group due to chemical irritants, caustics, the betel chewers’ cancer, and the mysterious action of arsenic which ought to be a help in elucidating the problem underlying cancerous cell proliferation.

The epithelioma of workers in comb factories, due to contact of hot water pipes with the skin, is important because it appears to be an instance of simple heat action apart from chemical agencies euxetics, etc.

The kangri burn cancer is I think also due to simple heat. The temperature to which the skin is exposed is, I have found by experiment, between 150° and 200° F. Thus, year by year we have going on under observation the experimental production of cancer by the action of one particular cause. The average age of the patients affected is 55. I have seen a few cases in patients under 40 but they are rare. About 6 or 7 per cent. are over 70 years of age. There may be some pre-disposing factor. Many elderly Kashmiris exhibit small localized papules or macules. These are dry, slightly scaly and usually pigmented. Curiously enough they are found not only on areas exposed to heat irritation but also on extensor surfaces and on the back, although they are more abundant on sites liable to intermittent kangri burn. Does heat irritation in one area stimulate epithelial growth elsewhere?

Where there is actual exposure to heat rays, every stage of chronic dermatitis may be seen, from redness with or without desquamation to thickened patches, warty induration, or even horny outgrowth projecting from the surface. The skin of the thighs and abdomen, owing to the constant application of heat, often appears dry and horny. Pigmentation is increased over the distribution of the superficial veins, the course of which is marked by brown discolouration. Such patients are especially prone to epithelioma. The frequency of actual scars from previous burns is noteworthy. And it is these which usually form the starting point of the malignant growth.

Thus we have under observation, in different patients, every stage, from the earliest signs of epithelial proliferation to the most advanced cancerous growths with secondary deposits.

The evidence of the kangri burn cancer is indeed strongly against the parasitic theory of cancer. It is a local disease from a local cause, arising on a site which is in a protected position. The hands, face and feet, which are exposed without clothing are never attacked. Parasitic diseases are more apt to attack young people than the elderly. The local infectivity of cancer is no proof of parasitic origin. Skin grafts by Thiersch’s method not only adhere but grow, and the more sterile they are the better they grow. The peculiar vital stimulating influence of such a graft has probably some bearing on the problem. The essential factor in epithelioma is the outlawing of a mass of tissue, over which the nerve influence controlling growth has

ceased to act. What is the mechanism of regulation of epithelial growth? What part does trophic nerve influence play? What share have endocrines? The skin changes in Addison’s disease are suggestive. So are the influence of the ovarian internal secretion on mammary cancer and the action of arsenic in the occasional production of epithelioma. All these considerations are adverse to the parasitic theory of origin of epithelial cancer. The incidence in elderly people emphasises the probable relation to impaired functions of growth and repair and unstable equilibrium of endocrines.

The kangri burn epithelioma is usually met with as a single or multiple growth resting on a scarred skin surface. It is confined to the flexor aspects of the body. In the earliest stages warty or keratinous thickening may be present without erosion. But more commonly there is an ulcer. There may be excavation with little increase of tissue. But there is also a type with fungation. The eroded type is more characteristic of the aged. It consists of ulceration with irregular steep edges, undermined in places, and a ragged floor with necrotic areas and deep recesses, the whole bathed in thin, intensely foul discharge which has overflowed at some dependent angle and dried on the skin around. In many cases, however, overgrowth is more evident and there is a projection of two or three inches diameter approximately circular or oval with a crater like ulcer (Fig. 2). Sometimes the overgrowth is the most striking feature and there is a fungating excrescence projecting one or two inches from the surface and measuring three or four inches across. In advanced cases muscles, peritoneum, costal cartilages or even bone may be encroached upon by the infiltrating base of such tumours. More than fifty per cent. of the cases, when first seen show secondary infection of lymph glands. If the growth is above the umbilicus, the anterior axillary glands may be attacked. As, however, the tumour is usually on the thigh or lower abdomen it is the glands of Scarpa’s triangle and along Poupart’s ligament which require examination and especially those close to the pubic spine. In advanced cases the deep femoral and even the external iliac glands are involved. Infected glands soften early. They may attain the size of a pigeon’s egg. When they break down, rapid diffuse infiltration occurs, the overlying skin becomes red and brawny, and suppuration follows. Such a secondary growth in the groin or axilla then presents a similar appearance to the primary cancerous ulcer except that it is deeper and undefined in extent (Fig. 2). From its ragged cavities and deep recesses there is copious foul discharge until, after months of suffering the patient dies of exhaustion, septic intoxication, or haemorrhage. The external iliac, femoral or axillary arteries may be opened up by ulceration with rapidly fatal result.

The appearance of the kangri burn cancer on section are characteristic. Stiles’ method is useful in demonstrating the epithelial neoplastic infiltration. The substance of the tumour consists of a framework of fibrous tissue with numerous blood vessels and masses of friable tissue, mottled red and grey.

Sometimes woolly looking patches are found, composed of cholesterin crystals. The surface of the tumour shows thickened and heaped up edges. The floor is thinner and grey or cream coloured with translucent opaque patches. Microscopically, the growths present all the characters of typical squamous–celled epithelioma with abundant cell nests (Figs. 3 and 4). The lymph glands are often mere bags of soft septic epithelial debris. In the early stages they show on section grey spots or patches and later on granular pultaceous areas. These are found to consist of large

epithelial cells of the same type as the primary tumour. Microscopically, nucleated cells are found in the sinuses, arranged concentrically, the inner layers being flattened and keratinous (Fig. 5).

During the past thirty-five years, on an average, we have performed 45 operations annually for kangri burn cancer as compared with 10 per annum for other forms of cancer.

The first procedure is to remove the lymph glands through a separate incision. The “Scylla” of imperfect removal or damage with wound implantation and the “Charybdis” of excessive dissection in subcutaneous tissue, imperilling the vitality of the thin skin of the groin or axilla, must be equally avoided. The glands, if softened, may have septic contents. Rough handling must be avoided or they may rupture. Small glands of the external pubic group are apt to elude observation. In epigastric tumours both axillae should be carefully examined.

There is a knack in excising the primary growth in such a manner as to avoid infection of the fresh wound. It may previously be cauterized with pure carbolic acid or chloride of zinc. Too much care cannot be taken in striving to render the surrounding foul and sodden skin aseptic. With the aid of two or three volsellae fixed in the skin well beyond the tumour above and below and perhaps at the sides and held by an assistant, the growth is raised as far as possible and then excised with a rapid clean incision. Frequently underlying muscle requires removal and small areas of peritoneum may require excision. Even where the edges cannot be brought together and omentum is

exposed, I have obtained healing under a dressing of ambrine wax. In advanced cases very extensive operation may be required. An incision more than a foot in length may be required to clear tumour, intervening area and axilla or groin. Ill defined induration and redness in a lymphatic area almost invariably preclude operation. Such cases if dealt with are largely responsible for mortality from rapid recurrence, or early haemorrhage due to ulceration into a large vessel. Occasionally it may be worth while to excise the primary growth, even if the glands are inoperable.

A large number of cases when first seen are, however, too advanced for surgical treatment. Many patients after discharge continue to use the kangri and sometimes get a recurrent local growth. Recurrence in lymph glands is doubtless due to an incomplete operation. Most patients in whom a return of the disease occurs probably come back to us. Such cases form certainly less than 20 per cent. of the total.

Summary.—The cause of the kangri burn epitheliomais definite irritation, viz., the continued application of intense heat. In this respect it is similar to the cancers arising from electrical, chemical, thermal and mechanical stimulation. The nature of this causation is against a parasitic theory of origin and favours the view that direct irritation is sufficient to start epithelial proliferation, uncontrolled by trophic nerve influence. In early stages the malignancy is mild and glandular infection supervenes slowly. Distant metastases do not occur. The disease is very amenable to operative treatment. It is a typical squamous celled epithelioma.

 

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