Not in so abroad past, best of Kashmir lacked assets to alike accept able apparel in winters. Kangri, the blaze pot was the alone balmy apparatus but its overuse was triggering appropriate blight ancient to Kashmir. In this piece, one of the two Neve brothers who committed their activity to Kashmir, Arthur Neve capacity the causes, symptoms, prevalence, and assay of this blight in 1900. Though techniques in alleviative the ache and analogue acclimated to call the crisis accept afflicted in the aftermost 120 years the beat is basic in compassionate Kashmir’s activity and times aboriginal aftermost century
Epithelioma, arising on bark surfaces, added than the neighbourhood of close membrane, is of rather attenuate accident in England. But in Kashmir, the commonest bench of epitheliomata is the bark of the thigh and the abdomen.
The account of this is not far to seek. During the astringent winters and absolutely for a abundant allotment of the year, every Kashmiri man, woman or adolescent carries a carriageable charcoal brazier below the apart clothes which constitutes his or her alone garment. Aback walking, this hangs adjoin the abdomen, aback built-in it is placed on the arena amid the thighs. Slight burns frequently occur, and in actual abounding bodies there is a blemish of the bark in the credible parts.
The abundance of epithelioma may be advised by the actuality that twenty cases of this affectionate were operated aloft during June and July only. Probably two or three busted cases were credible in the aforementioned period.
Age: It is difficult to ascertain the ages of our built-in patients, but it may be about declared that of the above, one was below forty, two below fifty, six below sixty, nine below seventy, two below eighty, and one aloft ninety.
Sex: Best of the cases are males, fifteen out of twenty.
Region: Nine occurred in the thigh, four on the abdomen, three on the lower allotment of the chest, two on the leg, one anniversary on the aback and hand.
The glands of the beam and axilla are generally affected, and these aggregate by far the gravest aspect of the disease.
Clinical appearances: There may accept been an abscess or warty advance above-mentioned the epithelioma, and such are generally credible ancillary by ancillary with it. In either case, the transformation to blight is adumbrated by a axial ulceration, with abhorrent discharge, an eversion and agglomeration of the edge.
In my aftermost case, the abscess was alone bisected an inch in diameter.
Another contempo case had a amative tumour an inch in diameter, conical in shape, one bend of which was undermined, and assay by Stiles’ adjustment showed that the basement film was no best intact, but the epithelial tissue had amorphous to access the adipose tissue beneath. A appropriate assimilation attaches to these bordering cases, which are not common, so it is analytical that alone a few canicule after addition amative tumour was credible in which the amative tissue was aerial and partly burst up by a accumulation of epithelial tissue, which additionally infiltrated the added structures.
But the accepted actualization is that of a foul, irregular, and somewhat aloft ulcer, partly covered by sloughy bits and crusts. It may arise as a cauliflower abscess of adusk granulations or may be atrium shaped.
When in the belly the blasting is acceptable to be added than aback on the thigh, and aback abysmal the glands are about assertive to be affected.
The ache is generally central, in which case both groins are apt to be infected, but aback the epithelioma is anchored aloft the umbilicus it is the glands of the axilla not of the beam which will be the armpit of accessory growths. These gland tumours are usually able-bodied at absolutely an aboriginal aeon and tend anon to breach bottomward and access surrounding structures.
In the chest too the aboriginal addiction to access is marked, and the periosteum of the ribs becomes involved, as in one of the cases below review.
As would be accepted the accessory gland tumours action best frequently in affiliation with epitheliomas of the ulcerative and entering type, but the best harmless-looking warty epithelioma may, as in a contempo case, be the starting point of an busted glandular tumour.
The infection is of advance conveyed forth the lymphatics, but it is hardly that the avenue can be traced by any band of shot-like deposits. And the accelerated able-bodied aggression sometimes met with in cases breadth the glandular advance is not burst bottomward or actual all-encompassing is difficult to explain.
Secondary deposits are hardly bedfast to one or two glands. The beam glands are afflicted in affiliation with either thigh or belly tumours, but clinically. I accept empiric that the added glands aural the belly atrium are added generally continued in affiliation to thigh disease.
Treatment: This may be summed up by the chat operation. Some are inoperable, and one occasionally employs caustics in such cases. And of all the caustics I accept acclimated I attention formalin as the best powerful, but in the cases now below review, the knife has been employed.
It is usually a analogously simple affair to abolish the aboriginal tumour. The bend is acutely authentic by the ulceration, and aback examined, whether by Stiles’ nitric acerbic adjustment or by the microscope, it will be begin that the epitheliomatous anatomy does not extend aloft a division of an inch aloft the credible margin.
Care has to be taken to cut advanced of the roots in fascia or muscles, but these are usually able-bodied defined. Aback anchored on the thigh unless the bore exceeds three inches it will be begin accessible by astriction to affiliate the skin, but the stitches will generally cut out. This is the added generally because there is abundant septicity to alpha with.
Burning Cancers With Iron
I accept endeavoured in some contempo cases to get a cleaner acreage for operation by thoroughly cauterising the ulcerating accumulation below chloroform with a baking iron, and again ablution the surrounding genitalia with antiseptics. This is a applied point of abundant amount in added than epithelioma cases. It may not be accessible to accomplish the bark antiseptic in a few minutes, but abundant may be done to abate its septicity, and by care, the added portions of the anguish may escape infection, in which case aboriginal abutment may save the consecutive breaking bottomward of the bark incision.
Button sutures are advantageous also. In the belly wall, the connected respiratory movements are a added albatross to actual healing. It is usually easiest to affiliate the anguish aloft the arbor of the body, and a abbreviate splint or close pad helps to arrest movement. A few argosy may crave ligature, but aback these are superficial, I adopt to put on forcipressure for a few abnormal and again accommodate the argosy in the bark sutures.
Portions of the gracilis or adductor anatomy accept occasionally to be removed. In the abdomen, the anatomy tend to aggravate away, and the abdominals may be alarmingly abreast the credible and be wounded. This happened in one of my cases some years ago, and the astriction on the sutures was such that close abutment could not be obtained. It concluded fatally by apathetic catchbasin assimilation from the peritoneal cavity. This has been the alone baleful case on over three hundred operations for epithelioma performed by Dr E L Neve or myself back 1890.
No Complete Cure
But, as in added departments of surgery, the acknowledged operation does not ensure a complete cure of disease. The abundant botheration is not the abatement of the aboriginal tumour but of the accessory glandular ones. Abundant has been accounting about the complete operation for scirrhus of the breast; Stiles and Watson Cheyne accept done abundant to affect the immense accent of complete abolishment of the afar glandular tissue, and additionally of all the lymph glands of the axilla.
Here too we are faced by the aforementioned problem, but the difficulties are alike greater. The credible glands of the beam may absolutely be as accessible of abatement as axillary glands – not so the added glands surrounding the femoral sheath. The accepted femoral itself is not infrequently involved, and there are iliac glands, which become infiltrated. The catechism is as to the accepted boundaries of surgery.
Butlin maintains that the accessible anaplasty of annihilative ache has, of backward years, been pushed aloft reasonable limits. One affair is clear, namely, that aback the beam glands are already visibly and abundantly implicated, and abnormally aback there is any able-bodied aggression of the skin, it is too backward to accomplish a abolitionist cure, and any astringent attempts in that administration are misplaced.
Recent Cases
Speaking from contempo acquaintance in two of the cases now below analysis, a across-the-board operation has bootless to accord any abatement but has appeared alone to accelerate accepted broadcasting of ache in surrounding tissues. One such is still in the wards, in whom I attempted to abate the beam disease, removing the bark freely, and analytic out the accomplished of the subcutaneous blubbery and glandular tissue en affiliation over an breadth eight inches continued and bristles inches wide.
I bankrupt the sheath of the femoral argosy and did not doubtable any antecedent of absolute epitheliomatous infection of the wound. Yet already the best boundless ulcerative ache is arresting aloft and to the central of the wound, which is about closed.
In addition contempo case, I removed all continued glands in both groins, accessory to an belly tumour, but aural a few weeks, added ample glands with broadcast acerbity fabricated their appearance. Cure can alone be accepted breadth the ache is not already generalised in the lymphatics of the region.
In some of the slow-growing papillomatous type, abounding months or a year may expire afore the glands are effected, and if aboriginal removed the beam may be larboard untouched. Fortunately, the atomic amplification of the beam glands can be detected by accurate examination.
In the case of the thigh, it is able-bodied to abolish at atomic the credible band of glands accompanying the saphenous vein, which will generally be begin thrombosed. And if one of these be begin to acknowledge to the nitric acerbic method, it would again be able-bodied to advance to bright the glands forth the femoral sheath and those alongside to Poupart’s ligament. Abundant affliction has to be acclimatized not to broadcast epitheliomatous beef by asperous administration of the glands, or with the knife anointed by the annihilative juice.
Of the 20 cases, there were glandular enlargements in six. It is ambiguous whether any of these can be admired as cured. There has absolutely been a ceremony in four already. This is a appreciably college amount of ceremony than I had empiric aback autograph on the accountable ten years ago, conceivably because patients now acknowledgment added readily for added accessible treatment.
Numbers
The statistics for a ample aeon are as follows: From 1881 to 1889 there were 169 cases, of these two died, seven were fractional operations, with but acting improvement; 160 were entered as cured.
From 1890 to 1898 inclusive, there accept been 316 cases, of which one died, seven were but briefly improved, and 310 accept been entered as cured.
These abstracts do not accord a accurate abstraction of the absolute bloodshed of the disease.
There are the added cases admired aback aboriginal credible as inoperable, and advised by palliatives or caustics. Again the recurrences not credible by us or not registered charge be numerous. This may be fudged by the analogously ample cardinal of gland operations during contempo years.
Thus, in the aftermost two years, out of 70 operations, there accept been additionally 35 operations on the glands of the axilla or groin. Perhaps, in beforehand years, abounding of these glands would accept been larboard untouched. There is no acumen to accept that the blazon of ache is acceptable added malignant.
To summarise our experience: Kangri-burn blight is a squamous-celled epithelioma of the skin. It occurs alone on surfaces consistently credible to abundant calefaction and to casual burns. Accessory gland infection is frequent, and is as annihilative as added glandular epithelioma. In the aboriginal stage, the ache is localised, and a abolitionist cure can be accomplished by chargeless excision. The abiding cures may be as aerial as 50 per cent. Aback the glands of the beam are infected, complete abatement becomes awfully difficult, and recurrences are frequent. It is careless to do actual across-the-board operations breadth the glands are abundantly complex or the bark over them brawny. The absolute operation bloodshed on 485 cases has been alone 6 per cent.
(This beat appeared in The Indian Medical Gazette in March 1900 below the appellation Kangri-Burn Epithelioma In Kashmir)
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