'Madras trials' in tuberculosis management
Published: 28th June 2010 02:10 AM |
Historically tuberculosis was known by different names: 'Consumption', 'phthisis', 'scrofula', 'Pott's disease', and 'White Plague'. Although established to have been in existence for more than 15,000 years, tuberculosis peaked in impact, as measured by the affected human population, in the 19th century. In India, it was known as yaksma (Rg Veda, 1500 BC) and ksya. Yajr Veda recommended that the patients of tuberculosis be moved to higher altitudes (cooler places). The Susruta Samhita (1500 BC) includes treatment suggestions. Until 1882 tuberculosis was thought of unknown etiology.
A funguslike bacterium (Mycobacterium tuberculosis; tubercle bacillus, hence TB), discovered by Robert Koch (pronounced as Kosh) (1843-1910) in 1882, induces tuberculosis. This bacterium is biologically related to the leprosy agent (Mycobacterium leprae). With the discovery of xray by Wilhelm Konrad Röntgen in 1895 and discovery of new drugs (e.g., streptomycin, isonicotinicacid hydrazide, p-amino salicylate) tuberculosis today, across the world, is under control. Tuberculosis was a major death factor in the temperate world in the 17th and 18th centuries because of poor socioeconomic conditions. Koch isolated 'tuberculin' (a protein derivative) from the inducing bacterium. Tuberculin application was ineffective in immunization, but Charles Mantoux (1877-1947) (pronounced as Sharl Maantoo) in 1908 found that it could be used in the diagnosis of tuberculosis, a test used even today.
In colonial Madras (and in India) tuberculosis was dreaded because of high fatality rates. For a detailed historical account of the incidence and management of tuberculosis in Madras, read B Easwara Rao in the Indian Economic Social History Review (2006, 43: 457487).
With a better understanding of the etiology and its contagious nature, a need to house patients in isolation became imperative. George Boddington (1799-1882) in Britain proposed the idea of 'sanatoria' in 1840. In 1842, John Croghan (1790-1849) in USA tried 'caves' explaining that consistent temperature and clean air would help. Hermann Brehmer (1826-1889) in Germany suggested that hill stations with lower atmospheric pressure would help the heart function in patients of tuberculosis because the understanding was that the disease manifested from the difficulty of heart to irrigate lungs well (refer to the remark pertaining to Yajr Veda made earlier). The first sanatorium was established at Görbersdorf (650 m asl) in 1854. Brehmer and one of his patients Peter Dettweiler canvassed for sanatoria.
In the 19th and early 20th century India, the disproportion between the numbers of sufferers and hospital beds was so wide that alternatives were necessary. The World Health Organization coordinating with the British Medical Research Council (BMRC), Indian Council for Medical Research, and the Government of Madras funded a study to explore alternatives in Madras. A Tuberculosis Chemotherapy Centre (TCC) in SpurTank Road was set up with a fiveyear dictate in 1956. TCC launched, under the leadership of Wallace Fox (BMRC), welldesigned clinical trials, which principally tested the efficacy of the patient being treated in their respective homes rather than in sanatoria. TCC findings showed that a drugbased treatment (chemotherapy) with the patients continuing to live at their homes bore identical results of patients treated in the sanatoria and did not lead to any increase in the infection in family members.
These studies, known as the 'Madras trials', were published in professional medical journals and were accepted in tuberculosis management throughout the world, although in later years minor modifications have been made. Madras blazed new trails in tuberculosis management.
(The author is a senior lecturer in Ecological Agriculture at Charles Sturt University, Orange, New South Wales, Australia)