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I



C.L.NOORDIN
PPELIJKEBOEKHA
<MARKT *




THE LIBRARY

OF

THE UNIVERSITY

OF CALIFORNIA

PRESENTED BY

PROF. CHARLES A. KOFOID AND

MRS. PRUDENCE W. KOFOID

PUBLIC
HEALTH
LIBRARY




TUBERCULOSIS IN INDIA



PRINTED BY CALEDONIAN PRINTING COMPANY, LD
3, WELLESLEY PLACE, CALCUTTA



TUBERCULOSIS IN INDIA

Its Prevalence, Causation
and Prevention



BY
ARTHUR LANKESTER, m.d. (Lond.)

Formerly Medical Missionary, Church Missionary Society:

Officer for Tuberculosis, Government of India ; and

Director, Medical and Sanitation Department,

Dominions of H. E. H. The Nizam

of Hyderabad.



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CALCUTTA :

BUTTERWORTH & CO. (India), Ltd., 6, Hastings St.

Winnipeg : Sydney :

Butterworth & Co. (Canada), Ltd. Butterworth & Co. (Australia), Ltd.

LONDON :

BUTTERWORTH & CO., Beix Yard, Temple Bar

Mte6ical "publishers

1920



■RC3I7
I5L3



PUBLIC
HEALTH
LIBRARY



€o i¥lp Witt.



M376006



PREFACE.



Considering the wide prevalence of tuberculosis
throughout the East Indian Empire, and the recognition
of that prevalence both by the medical profession and
by the people themselves, it is somewhat surprising that
India has hitherto received so little attention from
writers on the disease. The literature regarding
tuberculosis in India is limited to isolated articles in
medical journals, together with a few small pamphlets
dealing with special aspects of the subject. No apology
is needed therefore, for an attempt to present in a
somewhat more comprehensive form information whicli
is now available, especially since in certain particulars
the results of Indian experience would appear to shed
valuable light upon the problem as it exists elsewhere.

As an instance of this may be mentioned the
important cjuestion of the causative connection between
surgical tuberculosis and the bovine disease. Some
authorities whose writings are widely read both in
England and in India, continue to express the opinion
that surgical tuberculosis is always of bovine origin.
In the following pages I have tried to shew that
surgical tuberculosis is prevalent over large areas in
India where the possibility of infection from bovine
sources may be practically or even absolutely excluded.
If this be true, the fact is at least worthy of consider-
ation by those in the United Kingdom or America who
would connect all surgical tuberculosis with the use of
tubercle-infected milk, while the recognition of the
same fact in India is of obvious importance in regard to
the question as to what may be the most fruitful lines
of preventive effort.

One criticism of the book which will almost certainly
be made, is that it is too popular for medical
readers, yet too technical for the laity. In reply, 1
have to confess that the attempt to reach both classes of



PREFACE. vii

readers simultaneously was made of set purpose. In
regard to such a disease as tuberculosis, it seems to be
of great importance that medical men should be fully
acquainted with the close connection which it has with
social problems, while on the other hand, in addressing
non-medical readers, I was anxious that it should be
clearly realized that statements made were not mere
theories propounded for popular consumption, but
actual matters of fact which could challenge contra-
diction by scientific observers.

A word of explanation may be offered with regard
to two obvious imperfections in the book. The first of
thes.e is its poverty in detailed statistical information ;
the second, the fact that many of the returns that have
been given are by no means recent, some of them dating
even from before the war. The first defect is due to
the unsatisfactory condition ,of the present machinery
for the reporting and registration of vital statistics ;
one purpose^ of the book indeed will be served in drawing
attention to what is lacking in this respect so far as the
one disease is concerned.

As regards the date of some of the returns given,
and of certain local reports quoted, it may be mentioned
that during the years 1912 — 14, there was- — owing largely
to the influence of that great Director-General of the
Indian Medical Service, the late Sir Pardey Lukis — a
very marked degree of interest taken in the subject of
tuberculosis throughout India. As a result of special
inquiries at various centres made during those years,
local returns and information were obtained which
have not again become available. In cases where there
was no reason to suppose that any marked change had
occurred, it seemed well to give figures dating from
this period, rather than to give no information at all.

I have heard quite recently of the establishment in
England of a " People's League of Health." No details
■of this organization have as yet reached me, but its
objects would seem to be somewhat similar to those
mentioned in connection with the suggested " League of
Health " for India. These two schemes have been
wholly independent of each other in their inception, both
as to title and aims, but it is somewhat significant that



viii PREFACE.

even in England, the need for an organisation for diffus-
ing health knowledge on a wide and popular scale, is
now at last being recognised.

It is my earnest hope that this first attempt, however
imperfect it may be, to deal with the problem of tuber-
culosis in India, may serve to stimulate inquiry regard-
ing what is one of the great scourges of the country,
and may thus lead to that spread of knowledge which is
the essential preliminary to successful preventive effort.

I cannot conclude without expressing my grateful
appreciation of the unfailing courtesy and helpfulness
of my publishers, Messrs. Butterworth and Co. (India),
especially mentioning the lalte Mr. H. M. Rogers of that
firm, whose sudden death took place while the sheets
were passing through the press.



9, Waudby Road, A. L.

Boinbav.



TABLE OF CONTENTS.



INTRODUCTION.

PAGE
Connection of Tuberculosis with social reform —
Origin of the inquiry — Its objects, and methods
adopted — Lectures on consumption — Medical
discussions



PART I.
THE PREVALENCE OF TUBERCULOSIS IN INDIA.

CHAPTER I.
IS TUBERCULOSIS ON THE INCREASE IN INDIA ?

Alternative Theories — Is alleged increase real or
only apparent ? — Tuberculosis no new disease —
Probable increase in certain areas — Hyper-
susceptibility of virgin races — Evidence of
increase from Gilgit, Kashmir, North-West
Frontier Province, Kumaon, Chota-Nagpur —
Evidence from cities — Causes of increase —
Effect of removal of social barriers



CHAPTER II.
THE VALUE OF STATISTICS REGARDING TUBERCULOSIS IN INDIA

Paucity of statistics — Notification — Government
mortality returns — Vital statistics, defects in
present methods — Malarial fever — Investiga-
tions at Dinajpur and Cossipur-Chitpur —
Nomenclature of tuberculosis — Hospital returns,
outpatients and inpatients— Causes of inaccura-
cies 18



x CONTENTS.

CHAPTER III.

TUBERCULOSIS IN RELATION TO CLIMATIC CONDITIONS;

PREVALENCE IN RURAL AREAS.

PACE
Climatic and social elements in causation — Important
climatic factors — Various areas compared — Pre-
valence in Burma — In Bombay rural areas — In
Central Punjab— In Bengal — Indirect effects of
climate — Influence of natural features — Fertility
of soil — Abundance of water — Navigable rivers
— Meteorological factors — Humidity — Low tem-
perature — Rain-bearing winds 32



CHAPTER IV.

TUBERCULOSIS IN CITIES' AND TOWNS.

Urban statistics— Prevalence in Calcutta, Bombay.
Madras — Towns in Bombay Presidency —
Ahmedabad, Lucknow, Lahore. Amritsar, Nag-
pur, Delhi, Meerut, Cawnpur, Mysore, Karachi.
Benares. Salem, Patiala — Classification of Indian
cities according to prevalence — Extension from
cities to adjacent villages 44



CHAPTER V.
TUBERCULOSIS AND THE INDIAN CHRISTIAN COMMUNITY.

Reliable character of statistics — Cemetery returns,
Calcutta, Talicut, Lahore, Agra, Sikandra,
Amritsar — Causes of prevalence — Schools —
Imitation of Western customs — Prevalence
amongst missionaries — In Anglo-Indian com-
munity- 61



CHAPTER VI.

IMMUNITY AND SUSCEPTIBILITY.

•Question of heredity — Hyper-susceptibility of virgin
races — Hereditary predisposition — Protective
immunity — Natural preventive processes —
Instances in India of hyper-susceptibility — Of
acquired immunity — Practical bearing of facts
regarding immunity — Measures for protection
of children 7?>



CONTENTS.

CHAPTER VII.
BOVINE TUBERCULOSIS IN INDIA.



PAGE



Connection between bovine and human tuber-
culosis — Infection of children by bovine tuber-
culosis in the United Kingdom — Evidence as
to prevalence of bovine tuberculosis in
India — South India, Madras, Bombay, Calcutta,
Assam, Aligarh, Cawnpore, United Provinces,
Lahore — Cases found in Southern Punjab
— Prevalence in India contrasted with that in
Western countries — Resistance of Indian cattle
to tuberculosis — Custom of boiling milk before
use — Concluding remarks 87



CHAPTER VIII.
SURGICAL TUBERCULOSIS IN INDIA.

Various forms of surgical tuberculosis — Prevalence
of surgical tuberculosis in India — Tuberculous
inflammation of lymphatic glands — Relation be-
tween glandular and pulmonary tuberculosis-
Surgical tuberculosis in Indian hospitals — Dis-
tribution of various forms of surgical tuber-
culosis — Suggested explanation — Medium of in-
fection in surgical tuberculosis in India — Route
of infection in systemic disease — Influence of
removal of focus of infection 99



PART II.
THE CAUSATION OF TUBERCULOSIS IN INDIA.

CHAPTER IX.

INTRODUCTORY— THE TUBERCLE BACILLUS.

The tubercle bacillus described — Its connection with
human tuberculosis — Methods of detection
— Conditions of vitality of the bacillus— Methods
of destruction — Characteristics of the bovine
type . . 117



CONTENTS.
CHAPTER X.

POVERTY AND OVERCROWDING.



PAGE



Overcrowding in Indian cities — Possibilities of
improvement — Duties of health officers and
municipal councils — Importance of expert
health committees — Economy of site areas —
Organized efforts to lessen overcrowding —
City improvement schemes — Housing problems —
Calcutta "bastis" — Labourers' settlement at
Karachi 123



CHAPTER XI.

SOCIAL CUSTOMS REGARDING WOMEN.

Decline in female tuberculosis-rate in England —
Present sex-incidence in England compared with
that in India — Sex-distribution in Indian cities —
The seclusion of women — Evidence of its effect
re tuberculosis — Explanation of this effect —
Possibilities of gradual relaxation — Importance
of ventilation in homes 136



CHAPTER XII.

SOCIAL CUSTOMS REGARDING WOMEN-(Continued).

Child marriage — Evidence of its influence as regards
tuberculosis — Explanation of such influence —
The strain of maternity — Management of child-
birth in India — Description of conditions —
Effect in relation to tuberculosis — Suggestions
for remedial measures — Improved maternity
nursing — The barrier of caste — Responsibility
of men 145



CHAPTER XIII.
HABITS TENDING TOWARDS THE SPREAD OF CONSUMPTION.

Spitting — "Open" and "Closed" cases — Disposal
of tuberculous sputum — The " foul air habit "
— Sleeping with covered face — Carelessness
regarding food — Use of common food vessels
— of common " huqqa " — Tuberculous dust
the chief medium of infection— Alcohol and the
drug habit — Unwise fashions in clothing 161



CONTENTS. xiii

CHAPTER XIV.

OTHER ECONOMIC AND SOCIAL FACTORS.

PAGE

Rise in price of food — Scarcity of milk— Close
inter-marriage — Early marriage of youths —
Trades and occupations predisposing to tuber-
culosis — " Derzis ", weavers — Indian factories —
Railways and railway offices — Factors special
to Burma — Supposed prejudicial effect of cook-
ing smells 174

CHAPTER XV.

EDUCATIONAL INSTITUTIONS AND THE SPREAD OF TUBERCULOSIS.

Prevalence of tuberculosis in certain institutions —
Influence of change of environment — School
buildings and overcrowding — Instances — Sug-
gested remedies — Open-air schools — School at
Sakhi Gopal ; at Bolpur — Styles of construction
of open-air schools — Day schools for girls .... 188

CHAPTER XVI.
EDUCATIONAL INSTITUTIONS AND THE SPREAD OF
TUBERCULOSIS— (Continued).

Necessity for segregation — Medical inspection of
schools — Signs of commencing phthisis — Need
of sanatorium accommodation for segregation
of students — Errors as regards diet — Errors in
curriculum — Miscellaneous suggestions — Making
change of environment gradual — Sleeping with
uncovered face — Errors in clothing — Physical
exercises — School desks and mode of sitting —
Concluding observations — Calcutta students . . 204



PART III.

THE PREVENTION OF TUBERCULOSIS IN INDIA.

CHAPTER XVII.
EXISTING ANTI-TUBERCULOSIS EFFORTS.
Institutions — Sanatoria — King Edward VII Sana-
torium, Bhowali — Almora — Dharmpur— Arogia-
varum- Tilaunia — Tuberculosis wards in hos-
pitals — Tuberculosis dispensaries — Educational
efforts— In Bombay— In other centres— Mater-
nity and Infant Welfare Association— Society
for promotion of Scientific Knowledge— St.
John Ambulance Association— Other educational
efforts 224



xiv CONTENTS.

CHAPTER XVIII.
MEASURES FOR THE PREVENTION OF TUBERCULOSIS IN INDIA.

General observations — Magnitude of the problem PAGE

— Compulsory notification — Research — Facilities
for special training — Legislative measures —
Protection of local areas from infection — Safe-
guarding of cattle-breeding — Improvement of
industrial conditions 238

CHAPTER XIX.
EDUCATIONAL MEASURES.

Health education in schools and colleges — Recent
progress — Compulsory health teaching in
schools — Confirmatory views — of the Director-
General, Indian Medical Service — of Dr. C. A,
Bentley — Benefits of health teaching — Possibi-
lities of a comprehensive scheme — Literature
on hygiene and domestic science — Bearing of
hygiene education upon problem of tuberculosis . . 249

LIST OF BOOKS ON HYGIENE AND DOMESTIC ECONOMY.

Manuals for training classes and college use — For
use in secondary schools — For use in primary
schools — For popular use (including home
hygiene, nursing and midwifery) 260-

CHAPTER XX.
HEALTH PROPAGANDA BY MEANS OF VOLUNTARY AGENCIES.

Creation of a " Sanitary Conscience " — Arguments
for general health campaign as against special-
ized anti-tuberculosis movement — Existing
organizations insufficient — The League of
Health — Objects— Proposed constitution and
conditions of membership — Relations, to other
educative organizations — Health bureau — Rural
sanitary reform — Co-operation with Government
in sanitary matters 263-

CHAPTER XXI.
TUBERCULOSIS INSTITUTIONS— I.

Preliminary considerations — Sanatorium treatment
for the poor — For members of public services
— Hospitals for advanced cases of consumption
— Tuberculosis wards in General Hospitals —
Types of construction — Tuberculosis wards in
village mission hospitals — Tuberculosis dis-
pensaries — Their relation to municipal author-
ities and to civil hospitals 277



CONTENTS.

CHAPTER XXII.
TUBERCULOSIS INSTITUTIONS— II.



TAGB



Open-air sanatoria for adults — Climatic and other
features determining location — Open-air in-
stitutions for the young — Schools or "Homes"
for tuberculous children — Convalescent homes
and sanatoria for Christian children and stu-
dents — Tuberculosis settlements or " Colonies " . . 289



CHAPTER XXIII.
CONCLUSION.

Comparative importance of tuberculosis problem
— Its relation to social reform — Its urgency —
Voluntary effort available — Assistance from
Christian missions — United social effort, a
remedy for political discord — Dangers of ill-
balanced activity — Paramount need of spread
of knowledge 299



APPENDIX A.

Not 2 on construction of huts 305



Index . 309



TUBERCULOSIS IN INDIA.



INTRODUCTION.



The subject of tuberculosis is one which has attracted
a considerable and increasing amount of attention
in India during- recent years. The interest which
has been taken in the disease in Europe and America,
the immense volume of literature which has been
produced regarding it, and the extensive efforts
made for limiting its spread, have naturally had their
effect in this country, while its actual prevalence in the
large cities, now that its causes and dangers are better
understood, has aroused a deep interest in the minds of
thinking men. There are many facts in the distribution
and causation of tuberculosis in India which are of great
importance when taken in conjunction with parallel facts
observed in other countries ; and on the other hand much
of the experience gained elsewhere has been lacking in
practical value for India, because it has not been brought
into relation with Indian conditions of climate and social
life.

There is one reason why this particular disease calls
for the earnest consideration of all educated men and
leaders of public opinion. The incidence of tuberculosis
is one of the surest indications which nature gives, to
those who have eyes to see, of widespread outrage
against her laws of health. When a race or a community/
in its progress towards what is regarded as a higher
civilisation, or in its quest after comfort or luxury or
wealth, advances with too great rapidity in any special
direction, or makes changes in habits of life without
balancing those changes with the necessary safeguards.



2 INTRODUCTION.

there will inevitably be a price to pay, and there is no
more accurate measure of this price than is afforded. by
the death-rate from consumption in its various forms. In
the following pages I shall attempt to give illustrations of
the truth of this thesis as applied to India, and at the
same time, to show how the indication may be utilised
not only to lessen what is now regarded with alarm as
one of the severest scourges of the country, but also to
correct some of the social errors of which it would seem
to be the outcome. Opinions will differ widely as to the
possibility or advisability of attempting to modify long-
established social observances or habits, but it is surely
well that thinking men should provide themselves with
all the possible data which may enable them to estimate
the cost in life and suffering which the continuance of
such habits involves.

The material here presented represents the results of
an inquiry into the causes, prevalence, and possible
measures for prevention of tuberculosis in India, under-
taken under the auspices of the Research Fund Associa-
tion of the Indian Government. The Association, how-
ever, is in no sense responsible for the opinions advanced
in this book, which represent throughout my own in-
dividual conclusions.

The need of an investigation into some of the
problems connected with tuberculosis in India had been
felt at the discussion on the subject at the second All-
India Sanitary Conference, held in Madras in 1912, and
was expressed in one of the resolutions : —

" That statistics appear to show that this disease is
) rapidly increasing in India, especially in urban areas, but
that it is doubtful whether the increase is real or
apparent only and due to such causes as more accurate
diagnosis and registration. In view of the importance of
this question a full and thorough inquiry seems
desirable "

Nothing however was done to give effect to this reso-
lution, and at the fuller discussion which took place at
the Lucknow Sanitary Conference in 1914, it was apparent
that there were many matters, apart from the mere ques-
tion as to whether tuberculosis was or was not on the
increase in India, upon wdiich further information was
desirable, before preventive efforts on any wide scale



INTRODUCTION. 3

could be wisely initiated. The resolution on the subject
passed at Lucknow commenced as follows: —

" (7) That the present prevalence of tuberculosis is
such as to demand serious attention and special methods
for dealing with it. That officers should be placed on
special duty to study in detail the different problems
affecting tuberculosis in India; to investigate the causes
underlying it, and to organise efforts towards the
diffusion of information on the subject, and measures for
the prevention of infection."

The above mentioned inquiry, which occupied two
years (July 1914 to June 1916), was a direct outcome of
this resolution. The objects aimed at were, in the first
place, to obtain more exact knowledge than had hitherto
been available as to the actual prevalence of consump-
tion in India ; secondly, to investigate the causation of the
disease with special reference to any points of difference
or contrast as compared with what has been observed
in other countries ; and, thirdly, to arrive at some definite
conclusion as to what measures of prevention appear to
give most promise of ultimate success. The problem
of the spread of tuberculosis is so closely bound up with
some of the most widespread of India's social customs
and habits of life, that any practical measures would be-
doomed to disaster which were founded merely upon
Western experience, and not corrected, with the most
sympathetic caution, by reference to Eastern prejudices
and feeling.

Furthermore, it had been boldly asserted that the only
chance of success in dealing with a question of such
magnitude lay in calling out a far closer co-operation
between Government enterprise and voluntary effort than
dad hitherto been contemplated ; and that at the present
time such co-operation was possible ; that in fact India
was ready and willing to help and was only waiting for a
" lead." Here again was a question of undeniable
importance, and one that could only be settled, short of
actually putting it to the test in practice, by intimate
and careful personal inquiry from those amongst the
Indian community whose opinions would command most
respect.

The above prepares the way for a word of explanation
regarding the limited scope of the present volume. India



4 INTRODUCTION.

presents to the tuberculosis expert an almost in-
exhaustible field for useful inquiry into the pathology of
the disease, its special clinical manifestations in this
country, its therapeutics, and the like. It will be found
that in my suggestions for preventive measures, pro-
minence is given to the necessity for such expert investi-
gation. But in making a survey which was to embrace
the whole of India, to have attempted to include such
aspects of the subject, would have inevitably led to the
thrusting into the background of matters which, for the
immediate present, were more pressing. I have, there-
fore, confined myself almost exclusively to the consi-
deration of the disease in its more general aspects, its
prevalence in various parts of the country, its dependence
upon various social conditions and customs, with special
reference always to the question of possible practical
measures of prevention.

A short account of the inquiry itself may be of in-
terest ; the methods employed in obtaining information
will be seen to be in keeping with the nature of the prob-
lems in question. During the eleven months of actual
travelling in India and Burma, covering a distance of
nearly 35,000 miles, 85 cities were visited, including 29
out of the 30 which contain a population of over 100,000
inhabitants. The following Native States were included
in the tour : — Hyderabad, Mysore, Gwalior, Indore,
Bhopal, Udaipur, Jaipur, Jodhpur, and Bharatpur. At
the presidency cities and provincial capitals from one to
two weeks were spent, while at other cities the visits
lasted as a rule only two or three days. The time was
occupied largely with personal interviews and visits to
institutions. Information and advice were sought from,
and freely given by, heads of Governments, rajahs and
administrators of native states, inspectors-general of civil
hospitals, directors of public instruction, members of the
staffs of the larger hospitals, civil surgeons, district
magistrates, health officers and municipal secretaries.
Missionaries of experience, both men and women, were
everywhere consulted, as well as any other residents
who were known to have taken an interest in matters



Online LibraryArthur LankesterTuberculosis in India; its prevalence, causation and prevention → online text (page 1 of 28)