|HISTORY OF MEDICINE
|Year : 2021 | Volume
| Issue : 1 | Page : 48-56
Cancer incidence in Madras Presidency in 1892–1901: William Niblock's commentary of 1902
Ramya Raman1, Anantanarayanan Raman2
1 University of Notre Dame (School of Medicine), Henry Street, Fremantle, WA 6130, Australia
2 Charles Sturt University, Orange, NSW 2800, Australia
|Date of Submission||08-Apr-2020|
|Date of Decision||12-Apr-2020|
|Date of Acceptance||16-Apr-2020|
|Date of Web Publication||20-Jul-2020|
Charles Sturt University, Orange, NSW 2800
Source of Support: None, Conflict of Interest: None
William J. Niblock (WJN), an Assistant Surgeon at the Madras General Hospital (MGH), published a paper 'Cancer in India' (2 pages of text and 3 pages of tables) in the Indian Medical Gazette in 1902. He appears to have been a popular surgeon in Madras who surgically treated mouth cancers, testicular filariasis, and calcareous stones in the liver, gall bladder, and kidney. His 'Cancer in India' article is a compilation of numerical data of different cancers recorded in MGH from 1892 to 1901 mostly, and from 1896 to 1901 occasionally. In this article, WJN refers to cancers of different internal organs and external parts. He attributes the mouth cancers to constant chewing of 'betel' (the betel quid), which he explains as giving rise to leukoplakia, forerunner of buccal carcinoma. He supplies many, easily comparable, paired tables. These tables are made of raw numbers about the diverse human populations living in Madras, such as the Indians (Hindus and Muslims), Europeans, and Eurasians (Anglo-Indians) extracted from the 10-year records of MGH. None of the tables has been analyzed statistically. Nevertheless, he supplies the total numbers of admissions into MGH, which serve usefully as denominators in this study; occasionally, he presents data as percentages. Despite the lack of parametric statistical analysis, WJN's article, written in 1902, impresses as a useful contribution, because it provides a cross-sectional view of cancer incidence in Madras, particularly in defiance of Saldanha's supposition that cancers do not manifest in dark-skinned people, such as Indians.
Keywords: 10-year records, carcinoma, Madras General Hospital, malignant growths, prevalence patterns, rodent ulcer, sarcoma
|How to cite this article:|
Raman R, Raman A. Cancer incidence in Madras Presidency in 1892–1901: William Niblock's commentary of 1902. Indian J Cancer 2021;58:48-56
| » Introduction|| |
In the ancient Indian-medical texts Çaraka and Suṣruŧa Samhita-s, cancer is alluded to as grãnŧi implying benign neoplasms and arbudã the malignant neoplasms. Under the chapter 'Medicine and botany of the Indians' in the book A Voyage to the East Indies, Containing an Account of the Manners and Customs, &c of the Natives …, Paulinus of Saint Bartholomew (Paolino da San Bartolomeo, an Austrian Carmelite priest and an Orientalist) — written, referring to his travels and stay mostly in the western parts of southern India in 1776–1789 — indicates that cancer was known in southern India and the local vaidyan-s diagnosed it. [2,pp.403–405] Paulinus lists 37 diseases prevalent among the southern Indians, i.e., people of Malabar, Canara, Mysore, Madurai, Tanjavur, Marava, and Parava (Note A) lands, in which arbuda features (p. 404).
Details of various types of cancers diagnosed and the attempted treatments in Bengal in the mid-19th century are available in A Practical Essay on Some of the Principal Surgical Diseases of India by Frederick Harrington Brett (1803–1859), Surgeon, Governor-General's Bodyguard, Calcutta. Under the caption 'On parasitic growths' (pp. 89–160) [Figure 1], Brett explains benign tumors and malignant growths in great detail. Highly likely, Brett's volume is the earliest documentary evidence of benign and malignant tumors occurring in India, written based on western-medical practice. Under benign tumors, he speaks of sarcomatous, adipose, fibrous, and encysted tumors and polypus ('polyps', today). Under malignant growths, he speaks of carcinoma, medullary sarcoma, fungus hœmatodes (Note B), melanoid tumors, and malignant polypus. Charles Morehead (1807–1882), Professor of Clinical Medicine and the first Principal, Grant Medical College and Physician, Jamsetjee Jejeebhoy Hospital, Bombay, mentions of a rare incidence of liver cancer in his Clinical Researches on Disease in India, which he had diagnosed in a fisherman living near Bombay. [4, p.429]
|Figure 1: Page 89 of Chapter II in A Practical Essay on Some of the Principal Surgical Diseases of India by Frederick Harrington Brett (1840) Public Domain|
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Then came William James Elmslie (1832–1872), a Scottish medical missionary, who worked in Punjab and Kashmir representing the Church Mission Society (earlier, the Church Missionary Society) of London. Elmslie was the first to link the occurrence of epithelioma to the use of kangri pot in Kashmir, through a note published in the inaugural issue of the Indian Medical Gazette in 1866. Out of the 5000-odd patients he had examined and treated for different illnesses, he diagnosed the kangri-pot related epithelioma in 30 of them, which he established based on medical history, symptoms, and microscopic features. Elmslie says, [5,p.324] 'these figures yield the most remarkable and unusually high proportion of one case of epithelioma in every 254 patients'. In the table supplied in this article accounting for 20 patients suffering epithelioma, he treated 15 of them by excising the cancerous tissue and four via caustics. One of them declined any form of treatment. Among the treated 19, one was a 3-year old child.
By this time, cancer came to be recognized as a serious issue to reckon with in India. This becomes apparent from the reports of Arthur Tomes (Note C) attached to the Purulia Dispensary, West Bengal (23°34'N, 86°36'E) and Ernest Neve (Note C) published during his professional trips to Srinagar (Jammu and Kashmir, 34°5'N, 74°47'E) from Punjab. Neve established the epithelioma induced by kangri-pot use among the Kashmiris with clear histological evidences., At this time, a widely prevailing belief among the medical personnel in India and elsewhere was that cancers were rare in dark-skinned human races, e.g., Indians. That this belief was proved incorrect by Leonard Rogers (1868–1962) of the Bengal Medical Service in 1925, is a different story. In synchrony with such developments in the understanding of cancer problems in India, Niblock, while serving as an Assistant Surgeon at the Madras General Hospital (MGH), published a short paper 'Cancer in India' in the Indian Medical Gazette (IMG) in 1902. This article aims to sketch the details supplied by William J. Niblock (WJN) in his paper and situate it in the cancer scenario of India of the early 20th century. Little of WJN's life is known. Therefore, we have strung details of his life, whatever possible, in the following section.
| » William James Niblock|| |
Throughout his professional life in India (1896–1923), WJN worked as a surgeon in the Madras General Hospital (MGH) and taught different medical disciplines at the Madras Medical College (MMC). He was a contemporary of Charles Donovan of leishmaniasis fame. Compared with the popularity Donovan commanded in the medical circles in India and overseas, WJN was less known. An anonymous colleague of WJN at MGH [13,p.825] says,
'Niblock was a modest and an unassuming person and did not make friends easily. He was direct in his methods and scorned at subterfuge. Under a somewhat brusque exterior, he possessed a keen sense of humour, a fund of common sense, and a wealth of kindness.'
The British Medical Journal [BMJ] mourned WJN, when he died in England in 1935. This was followed by the short eulogy by his anonymous colleague at MGH in a later issue of the same volume of BMJ.
WJN was born in Clontibret (Ireland) in 1871. He qualified for M.B.B. Ch. and earned a unique-to-Ireland medical diploma Baccalaureus in Arte Obstetricia (B.A.O.) in 1894. On entering the Indian Medical Service in January 1896, he was posted to the Madras Government's Army Medical Service as a Surgeon–Lieutenant (Assistant Surgeon) in MGH. He was promoted as Surgeon–Captain (Assistant Surgeon) and in 1899 was made a Surgeon-Major (full surgeon) in 1901. He was the Surgeon of the Third District in MGH and held the conjoint professorship of Biology at MMC, Second Surgeon and Professor of Anatomy, and theFirst Surgeon and Professor of Surgery in 1901, 1909, and 1912, respectively. He was admitted to the Fellowship of the Royal College of Surgery in Ireland in 1906 [Figure 2]. He retired from MGH in 1923 at the rank of 'Surgeon–Lieutenant-Colonel'. Margaret, his only child, born in India, later turned out to be an avid breeder of the majestic Afghan hounds.
|Figure 2: WJN's signature in the registry of candidates admitted to the Fellowship of the Royal College of Surgery in Ireland, 1906, RCSI/ LIC/03, page 124 (Courtesy: Leanne Harrington, archivist, Royal College of Surgery in Ireland, Dublin)|
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WJN was such a passionate surgeon that he saw surgery as the solution for many human illnesses. A few examples of his surgical work are illustrated here. He conducted the first successful gastrojejunostomy in India to rectify gastric-outlet obstruction arising because of acute peptic ulcer. He did this procedure by connecting the stomach and the proximal end of the jejunum in MGH on 2 March 1905. This is considered a pioneering effort by professional gastroenterologists. Well-known gastroenteric surgeon of Madras of recent years, the late Natesan Rangabashyam  appreciates WJN's gastrojejunostomy procedure as novel. WJN made efforts to save the limbs of people affected by potter's gangrene  (Note D).
The Indian Medical Gazette carries a case report  on an intracranial surgery done by WJN as an attempt to rectify trigeminal neuralgia (TN). He did this procedure in MGH over two days: 19 and 23 July 1903. A 35-year old male, diagnosed with TN, was admitted into the MGH on 2 June 1903. Before deciding on surgery, WJN tried various medications, such as butyl-chloral hydrate, gelsemium, sodium salicylate, quinine, strychnine, potassium iodide, potassium bromide, morphia, exalgin, and paraldehyde, then recommended to help patients to feel better from the stabbing pain of TN, which did not help in this particular instance. WJN operated on the patient. The patient recovered, although modest ulceration of the right cornea occurred at the time of discharge from MGH on 18 September 1903. WJN reviewed this patient after six months and reported that the patient had fully recovered.
In an article entitled 'Notes on operations for abscess of the liver, ascites, and gall-stones' published in 1903, WJN describes various procedures he had conducted at MGH on multiple patients between 1900 and 1903. In p. 401, he remarks:
'Nowadays I never use sutures whether the operation be trans-thoracic or not, and have had no bad results through not doing so. The gauze, if carefully inserted all round the opening will effectually prevent any extravasation into either the pleural or peritoneal cavity, which is more than can be said of stitches in many cases.', which reads, somewhat oddly.
A couple of vague Internet sites indicate that WJN operated on patients suffering glaucoma. But during his time in Madras, the Government Ophthalmic Hospital, Egmore, Madras was fully functional and popular.
Nicholas Senn (1844–1908), Professor of Surgery, College of Physicians and Surgeons in Chicago until 1890 and later Professor of Clinical Surgery at the Rush Medical College, Chicago, traveled through Madras in the early years of the 1900s. Senn stopped at MGH and witnessed some of the procedures carried out by different surgeons of MGH, and has described them in his travelogue Around the World via India: Medical Tour. Senn refers to surgical procedures — especially to the surgical management of cancer [Figure 3] — by WJN, then an assistant surgeon at MGH. Senn mentions that WJN surgically treated mouth cancers, testicular filariasis, and calcareous stones in the liver, gall bladder, and kidney.
|Figure 3: Chondrosarcoma of humerus and scapula, amputated by WJN in MGH (Source: Senn 1905, fig. 39, p. 203)|
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| » 'Cancer in India' Article|| |
This is a 5-page article, two pages of written text, and three pages of extensive tables. At the start (p. 161) WJN clarifies,
'As the subject of Cancer in India is exciting some interest at the present time, I have carefully gone through the registers of the Madras General Hospital, and noted down all cases of carcinoma, sarcoma, and rodent ulcer which have been admitted into the hospital during the past ten years. I have also made out a separate list of cases shown as suffering from “malignant disease” which term I take to be synonymous with that of Cancer in its broader sense. It will be noted, on looking at the tables, that no females or children are shown in the list of admissions prior to 1895. Up to that year there was a separate women and children's hospital (see Note E) in Madras, which was amalgamated with the General Hospital on 27th September 1895, the latter having been enlarged.'
WJN cataloged the incidence, mostly, of carcinoma among Indians, both males and females, and the incidence of carcinoma, sarcoma, and rodent ulcer (a persisting ulcer that arises in the exposed skin and especially in the face, which is destructive locally and spreads slowly. Also referred as Jacob's ulcer; presently 'basal-cell carcinoma') among the resident Europeans and Eurasians (males and females; 'Eurasians — Anglo-Indians). WJN's Tables numbered I and II are summarized in [Table 1] in this article.
|Table 1: Raw numbers of patients suffering different cancers extracted from the records of the Madras General Hospital, 1892-1901* |
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Under carcinoma (WJN's Table I — Indians, Table II — Europeans and Eurasians), WJN  categorizes them as (i) head and face, (ii) mouth, (iii) throat and neck, (iv) alimentary canal, (v) urinary organs, (vi) male genital organs, (vii) female genital organs, (viii) skin, (ix) peritoneum, (x) lymphatic glands (groin). For each category, he further subclassifies them: for example, under '(iii) throat and neck', he provides details under (a) larynx, (b) pharynx, and (c) neck.
WJN specifically refers to the 'enormity' in the number of patients admitted for carcinoma of the cheek and jaws. According to him, carcinoma of the cheek alone, among the cancer patients admitted into MGH, accounted for nearly a third, and the carcinoma of the cheek, jaws, and tongue taken together accounted for more than half of the total admissions for cancer in 1892–1901. Cheek was the most affected part in a majority of the admitted Hindu and Muslim men and women, as against the Europeans and Eurasians admitted for cancer. The disease, according to WJN [23.p.161]:
'… affected the buccal surface of the cheek, generally commencing opposite the teeth of the lower jaw and spreading with varying rapidity.'
He attributes this to constant chewing of betel quids (See Note F), a common practice in both Indian (Hindu and Muslim) males and females, prevalent in India for several centuries. Carcinoma of the cheek, he says, was more common in populations from the West Coast, viz., Malabar; the proportion being three in five admitted in MGH. He attributes the development of carcinoma to high quantities of caustic lime used in betel quids by the people of Malabar. He clarifies this p.161:
'The irritation caused by the chewing of 'betel' can be seen in many cases to give rise to well-marked leukoplakia, which is the forerunner of the carcinoma which ultimately develops.'
A sentence referring to a more-intense use of tobacco along with betel quid in Malabar occurs in passing.
He speaks, rather briefly, of the epithelioma of the lip, carcinoma of the alimentary canal except rectum, and of the male and female reproductive organs, sarcoma of feet, by comparing their incidence patterns in Hindu vis-à-vis Muslim patients. He compares his data between Indian men and women on the one hand and European and Eurasian men and women patients on the other. Referring to the rodent ulcer, WJN remarks that few suffered this problem, the proportion being four recorded in MGH in 10 years.
In this article, WJN has compiled the data about cancer incidence as available in the records of MGH, which, in high likelihood, provides a cross-sectional view of cancer incidence in southern India. Notable that the Madras Presidency was spread over most of southern India in 1901 (total land area — 151,695 mile 2 = 392,888 km2 and population — 42,397,522, https://en.wikisource.org/wiki/1911Ency- cvlop%C3%A6dia_ Britannica/Madras_[presidency], accessed 31 March 2020). Moreover, the MGH was the largest and best-equipped public hospital in the whole of the Madras presidency in the 1900s.
To convey his intents better, he presents three pairs of tables. These paired tables presented independently, include comparable data, except for the nature of the population, such as either 'natives' (= Indians) or the 'Europeans and Eurasians' treated as the variables. For instance, in p. 613, under tables captioned 'Admissions for 10 years', he supplies data for 'Natives' in Table A and 'Europeans and Eurasians' in Table B. In these paired tables he lists the timeperiod from 1892 to 1901 in the first column, followed by six columns each captioned, 'total admissions', 'admitted for cancer', 'admitted for sarcoma', 'for malignant disease', 'for rodent ulcer', 'carcinoma' — expressed as % of total admissions, and 'for sarcoma' — also expressed as % of total admissions. The above pair is followed by a set of four independent tables captioned as 'A — Hindus', 'B — Mohammedans', 'C — Europeans', and 'D — Eurasians'. These four refer to a six-year period from 1896 to 1901, unlike the others. These tables consist of columns captioned as 'year', 'total admissions, 'cancer, sarcoma, 'cancer' — expressed as % of total admissions, and 'sarcoma' — expressed as % of total admissions. The final set of tables consists of 'A — Hindus' and 'B — Europeans and Eurasians'. This set is further divided into 'men' and 'women' first, followed by 'year', 'total admissions, 'cases' (number of cancer cases), and 'percent'. Unfortunately, these tables are neither independently nor sequentially numbered.
He concludes saying (p. 162), 'The figures given above show that in Madras, at any rate, cancer is by no means uncommonly met with.'
| » Remarks|| |
The 'Cancer in India' article by WJN is a compilation of numerical data of different cancers noted in the MGH records from 1892 to 1901 mostly, and from 1896 to 1901 occasionally. He refers to cancers of different internal organs and external parts. He was attempting to see patterns in the incidence of various cancers among the Indian (Hindu, Muslim), European, and Eurasian populations of both sexes, approaching MGH for medical help. His end statement impresses as a strong rebuttal, particularly of Saldanha  (see Note G), who suggested two years earlier, that cancers were rare in dark-skinned human races, such as Indians [10, pp.1246–1247]:
'It will be familiar to those who have practised in the East that cancer is practically unknown among the Brahmins and almost so among the Hindoos and Mahomedans.'
WJN does not categorically implicate tobacco (Nicotiana tabacum, Solanaceae), which was, and is, used as a component of the betel quid in southern India, although he does mention it in passing when referring to a greater incidence of mouth cancers among the people of Malabar. The link of tobacco smoking and chewing to cancer was widely recognized in Victorian England in the 1850s, although it was being aggressively debated. Sadly this practice of chewing the betel quid in India has not reduced, despite vigorous campaigns against tobacco use in post-1947 India. According to GATS–2 (2016–2017), 29.6% of men, 12.8% of women, and 21.4% (199.4 million) of all adults in India currently use betel quids with tobacco and gutkha, a commercially marketed product. Buccal cancer accounts for 30–40% of cancers known in India, and the presently established cause is the uncontrolled use of the above masticatories.[e.g.27,28] One key cultural belief for the widespread use of the betel quid for centuries — either with or without tobacco — was that it is a potent aphrodisiac, presently established as incorrect. Nevertheless, WJN, as a medical scientist, makes the cut by suggesting that the continued chewing of the betel quid, with or without tobacco shreds, is a pre-empting factor for buccal cancer. Today we know that tobacco, in whatever form used, established by Sanghvi et al. in 1955, is a high-risk factor for cancers of the abdomen, lung, and prostate. However, we need to know more about the association of human papilloma virus (HPV) in buccal cancer, although a well-laid out recent study in India negates any relationship between HPV and buccal cancer.
WJN's paper  snugly fits as an early form of an epidemiological study, wherein he refers to types of cancers occurring in men and women (divided as Hindus and Muslims, based on cultural practices), Eurasians, and resident Europeans in Madras. He presents lengthy tables comprising raw numbers extracted from the records of MGH for a decade (1892–1901). He describes them as statistics. However, his effort in seeking an answer to the question 'why so?' is the highlight of this paper. Epidemiological studies are trialed to design and launch strategies to restrict illnesses in the present and prevent them in the future. They are also helpful in designing suitable management practices.
James Mouat  (see Note I) in the medical annual report of the 13th Dragoons (also known as 13th Cavalry, 13th Light Dragoons, later named 13th Hussars, mostly stationed in Bangalore, active 1755–1915) refers to the importance of using statistics in medical science in the first half of the 19th century. He says [34, pp.178–179]:
'The benefit or otherwise of every remedial measure should be based on statistical numbers or that rigorous exactness, which mathematical calculation alone is susceptible. This important science has been reserved for our own age and promises hereafter to place our profession on a scale with the more exact sciences, and so far to remove one of its greatest approbia, by giving its problems a certainty not hitherto possessed, and as it has been justly observed elucidating much that is now obscure, and reducing to precision much that is now doubtful in medical science. Like all other questions it is liable to be abused, since individuals are too prone to reason from their own limited observations, and which must be influenced by a thousand causes to vitiate their accuracy. In fact in the statistics of medicine, it is only in large numbers that we can place confidence, where the observations and experience of one must come into correct those of another, and hence the importance of each individual adding his mite to the general stock.'
The above commentary runs onto two successive pages, reinforcing the importance and relevance of statistics in medical science. Mouat's report includes many tables composed of raw-numbers for 1838–1839. Another example from nearly the same period in Madras would be the medical reports made by Edward Green Balfour, which consist of lengthy tables of raw numbers when Balfour was an assistant surgeon attached to Madras Army.
WJN has not explored the data he had mined from MGH records by analyzing them statistically, given that methods of statistical inference based on direct probability were known since 1812, thanks to Pierre-Simon Laplace (1747–1827) of Paris, who created a theory for testing and estimation via relative frequencies, arithmetic mean, and linear model. Before Laplace, Daniel Bernoulli (1700–1782), a Basel- based mathematician–physicist, had developed the normal approximation to the binomial distribution and had applied it successfully in arriving at patterns in human sex ratios. Importantly Bernoulli applied calculus to evaluate mortality rates by treating them as continuous functions, which enabled him to obtain a solution to a serious public-health question of his day, 'estimating life expectancy on eliminating smallpox through mandatory variolation' (see Note H).
Despite using only raw numbers, WJN's article written from Madras in 1902 is a useful contribution. It provides a cross-sectional view of cancer incidence as available in the records of MGH. A vague sense of validity exists in this presentation because he has faithfully recorded the total number of admissions into MGH he looked for different cancers for a decade. This recording vitally serves as a useful denominator from which the prevalence pattern of the disease could be inferred. In epidemiological studies, denominators are helpful because those numbers relate to the population that had developed the condition of interest — 'cancer' in the present instance — referred to as the numerator. The denominator population numbers are helpful in referring to the numbers of the population at risk. Also because the denominators refer to the numbers of disease-free people, WJN has done extremely well by including them in his datasets. WJN uses the term 'frequency' interpreting it loosely as a measure of the existing number of patients suffering from the type of cancer. This could have been better said as 'prevalence' because presently we define and explain frequency — rather absolute frequency — as a measure of the number of times an event occurs in a study. In one or two instances, WJN includes percentages of the incidence patterns of certain cancers that are useful in inferring the prevalence proportion.
| » Conclusions|| |
One serious belief that prevailed in the 1900s was that cancers, in general, were far fewer in dark-skinned people than in light-skinned people, which has been a matter of deep interest to Western medical scientists for long. This belief was proved wrong by Leopold Rogers. However, Saldanha's  commentary provoked a considerable number of follow-up investigations in Asia, and WJN's report, discussed in the present article, was one of them. This is substantiated by WJN's concluding remark that his figures — the numbers derived from the records of MGH between 1892 and 1901 — show that in Madras, at any rate, cancer was common.
Nonetheless, Saldanha's  supposition appears a grand possibility in the context of skin cancers. In dark-skinned people, cancers of the skin are of low incidence because of the greater intensity of melanin that defends skin from bright sunlight than what normally occurs in the light-skinned Caucasians. We know too well that the larger melanosomes of greater melanin intensity in dark-skinned people absorb and scatter more of light energy than the smaller melanosome endowment in the skins of Caucasians do.
One striking inference made by WJN in this study  was the positive relationship among betel-quid chewing, leukoplakia, and oral cancer, which unfortunately has been overlooked by most of the later investigators in this field. Several recent studies confirm the point made by WJN. For example, Shiu and Chen  examined the effects of betel quid chewing, smoking, and drinking on the incidence of oral leukoplakia and malignant transformation to oral cancer. They found that the humans who chewed betel quid were at greater risk of leukoplakia. They concluded that tobacco use and betel-quid chewing were two high-risk predisposing factors for leukoplakia. A more recent analysis by Song et al. has determined a positive association between betel-quid chewing and oral cancer, which goes to reaffirm what WJN proposed more than a century ago.
| » Notes|| |
- Marava people live in southernmost parts of the Tamil country, e.g., the districts of Tirunelveli, Sivaganga. The Parava people live in coastal Tamil country, usually implying the fisherfolk
- An early description of 'fungus hœmatodes' is available.
- Arthur Tomes (1851–1926) after qualifying for M.R.C.S. and the Licence of the Society of Apothecaries (L.S.A.) in 1873 joined the Bengal Medical Service in 1876. He was promoted as Lieutenant Colonel in 1896 and retired to England in 1897. The Neve brothers — Arthur and Ernest — medical graduates of the University of Edinburgh, came to India to serve as medical missionaries at the Church-Mission-Society Hospital in Srinagar. Ernest Neve (1861–1946) established the Kashmir Leper Asylum in 1892 and was its honorary superintendent for many years.
- Potter's gangrene was a common problem in southern India [46, pp.500–503] until the early decades of the 20th century. This problem has been amply recorded by Theodor Ludvig Frederich Folly, a Regimental Surgeon of the Danish East-India Company (Ostindisk Kompagni) in Tranquebar (Ŧarangampãdi, 11°1'N, 79°51'E) in the 1790s. Between the 17th and the early decades of the 20th century, southern-Indian potters dealt with fractures in arms and legs, similar to barbers dealing with 'surgeries' of abscesses and tumours. The potters — officiating as bone-setters — mud-packed broken arms or legs and 'bandaged' them with cloth supported by bamboo splints. Usually, trouble arose because of tight bandaging constricting blood circulation. Invariably, in 19 out of 20, such unscientific bandaging resulted in acute gangrene in patients over time and frequently ended in spontaneous detachment (auto-amputation) from bodies in a short time.
- This remark by WJN is messy. The Egmore Maternity Hospital has been operating from 1797, first as a ward in the 'Native Hospital' in Purasawalkam and later as an expanded facility at a new, dedicated precinct in Egmore, when it was re-named 'the Maternity Hospital (MH)' in 1881. Arthur Branfoot, Professor of Midwifery and one-time Principal of MMC was superintending the MH between 1878 and 1897. Likewise, Gerald Giffard worked at MMC and MH holding concurrent academic and administrative positions in the 1890s. Whether WJN means the Royal Victoria Hospital for the Caste and Gosha Women, which was first established in Egmore in 1884 and later shifted to its own precinct in Triplicane in 1890, is not clear.
- WJN  explains the 'betel quid' as made of the betel leaf (leaves of Piper betle, Piperaceae) used as the material to roll thin shavings of areca nut (fruits of Areca catechu, Areaceae) with a generous spread of semi-viscous caustic lime (CaO, CaOH). Pieces of clove (dry flower buds of Syzygium aromaticum, Myrtaceae), nutmeg mace (Myristica fragrens, Myristicaceae), cardamom seeds (Elettaria cardamomum, Zingiberaceae), and cubebs (tailed pepper, fruits of Piper cubeba, Piperaceae) were also added to this betel-quid as embellishing agents. WJN comments p.161: 'The above components are mixed in varying proportions, rolled up in a betel leaf, and placed in the mouth. They are then chewed and rolled about by the tongue and cheek for a period varying from 10 to 30 minutes and then spat out.' Indians have known of the above plant products and have been using them as masticants for ages. But tobacco was introduced into India by the Portuguese c. 1600 AD, during the reign of Jalal-ud-din Akbar (1542–1605), which soon became a widespread item of cultivation in India. Nur-ud-din Jehangir (1569–1627), Akbar's successor, decreed forbidding the cultivation and use of tobacco in India. In spite of it, tobacco cultivation struck roots almost throughout India. Today India is the second largest producer of tobacco in the world (Tobacco Institute of India, https://www.tiionline.org/facts-sheets/tobacco-production/, accessed 30 March 2020).
- In spite of best effort, we could not trace any detail of C. N. Saldanha (CNS). His article on the aetiology of beri-beri published in the British Medical Journal 1908 [2 (2500): 1609–1610] identifies him as: 'Formerly medical examiner of Indian emigrants'. From the sort of details CNS speaks in this paper, we suspect that he was a medical examiner of Indian emigrants in South Africa.
- The indicated advantages of variolation were shortly thereafter proved superfluous, because Edward Jenner in England demonstrated the safety of cowpox vaccine against smallpox in 1796.
- James Mouat (1815–1899), Medical Officer, 13th Dragoons, Bangalore. India service: 1838–1848.
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