TUBERCLE OF LUNGS IN BENGAL JAILS,

BY JOHN MUL\rANY, CAPTAIN, I.M.S.,

St(j/erin,te)ulent, Presidency Jail, Calcutta,

I. Is tuberculous disease of the lun^s mote prevalent in indiau jails than amon%st rhP general population ?

II. Does the disease progress more ranidh, in jails than outside ?

III. Has the disease become more prevalent in jails in recent years ? The solutions of the problems set forth above

appear at first sight to be unattended '

with difficulty. A cursory investigation soon reveals the numberless pitfalls which await the enquirer I have, therefore, considerable diffidence in sub- mitting this short paper as an attempt to throw some light 011 a very important subject

For the sake of convenience, I have con linn,] myself mostly to Bengal jails m general and the I residency jail in particular. Arguing d 'priori, the question, whether phthi

sis is more prevalent in jails than amongst tho general population, should receive a i.Lfi,,, reply From the moment of his admission!* he time of his discharge, the convict is under watch ful supervision, his labour i8 adapted to his physical and mental capabilities, ],is food selected and wholesome, his cluthino- i? and he is well housed. 0 ,s amPJe

It is true that the accommodation allowed bv regulation leaves much to be desired /i, 1

^

by^^erflcialan^rOcnhi^feS allowed for native roop.s-a fact tha(. ca be overlooked), but there can be no question

132 THE INDIAN MEDICAL GAZETTE. TAprIl 1903.

that the average convict is incomparably better off in jail than in his own house. At the outset we are met with what looks like

an insurmountable obstacle. Jail statistics stand alone. There is nothing with which we can compare them with any hope of getting useful results. The army consists of a body of selected men under special conditions: in the

general population the factors of age, sex, birth- rate, infant mortality and the incidence of

zymotic disease introduce complications which preclude any possibility of obtaining a practical basis for comparison.

If, however, this objection were non-existent* the reliability of general statistics is, I think,

open to question. In Iudia, more especially in the rural districts,

the vast majority of deaths is returned by the

village chowkidar, whose medical knowledge is for the most part limited to diarrhoea and fever.

By the kindness of Captain Leonard Rogers, I.M.S., I have been able to examine the records of 966 consecutive post-mortems made between August 1896 and June 1898 at the Medical College Hospital, Calcutta ; from these I find that in 13*4 per cent, death was due direct^ or in-

directly to tubercle of the lung, and further that 3'6 per cent, were due to other forms ot tubercle. These results were obtained in au institution where the admission of phthisis is discouraged. Captain Rogers also informs me that a large pro- portion of deaths from tubercular disease and about 10 per cent, of general cases, show signs of old tubercular disease of the lungs.

Turning to the Calcutta statistics, I find in the three years ending 1901 (the only figures at

my disposal) that the percentage mortality of phthisis to the general mortality averaged 3'98

showing a difference in favour of "post-mortem classification of 9*16 per cent,

and an excess of 1*5 per cent, in favour of Indian jails, and 0 32 per cent, in favour of Bengal jails, taking the figures quoted by Captain Waters in the November number (1902) of the Indian Medical Gazette.

As an ordinary rule the comparison of

percentage of deaths to general mortality is most misleading and should be avoided. Thus in 1875 there were 64 deaths from phthisis out of a general mortality of 986, or a percen- tage of 6-5, while in 1895 there were 38 out of 418, or a percentage of 9?an apparent increase of 2*5 per cent. Actually the ratios per mille of average population were 3 2 and 2 3 re- spectively, a real diminution of 0*9 per mille. 1 have, therefore, except in the above case, converted all my statistics into ratios per mille of average population. Here is a comparison between the death-rates

of Calcutta and the Presidency Jail:

Mortalities of Calcutta and the Presidency Jail contrasted.

RATIO PER MILLE OF AVERAGE POPULATION.

Tdbercle. Deaths from all causes.

1899 1930 1901

Presdy. Jail. Calcutta, j Presdy. Jail. Calcutta.

2-26 ! 10-71* .47-8 23-8 1-9 4*7 ; 53-8 21-7 1-25 3-02 38"2 17 39

Judging from statistics it would appear to be safer to live in the Presidency Jail than in Calcutta. From what I have said above, I think it is

evident that we in India have no statistics for comparison from which we can attain to results of any practical utility, and therefore at present we can give no definite reply to the first ques- tion, i.e., is phthisis more prevalent in jails than amongst the outside population ? If We

may accept Captain Rogers' post-mortems as an index of the true mortality, it is not. But further investigations are necessary. Turning to the question of the acuteness of

disease in jails, it is essential to discover what proportion of cases is infected before admissiou. In the Presidency Jail during the seven years ending 1901, there were 136 admissions to hos- pital for phthisis and 36 deaths. Of these deaths no fewer than 27 had been in jail less than three years, and of the 27, twelve had been in under six months, five under one year, and four under two years. Only two had been in over eight years. Below I append a table showing average

population according to period of incarceration together with the mortality liability for each

year.

Under 6 months 6 months to 1 year ...

Over 1 and under 2 years ? 2 ?

3 ?

>,3 ?, 4 ,,

>,4 ,, o ,,

? 5 ? *6 ?

i, 6 >i 7 ,,

? 7 ? 8 ?

j) 8 ,, 9

,,

? 9 ? 10 ?

Over 10 years

Average population per cent, convicts

only.

18-7 13-6 22*8

22-6

y i8-i I )

4-3

Phthisis

mortality for each

p riod.

12 5

5" 3Ul

ll2

Mortality liabi- lity by period

of incarceration.

1*70 1*01

s{ 60 ->

44

} 2-71

1*3 i -44 44

f "06 J-2-83 I -06

0-3-; -06 I -06 1-06 ?63 -63

The figures are instructive, 4?8*9 per cent, or

practically one-half the mortality occurred during the first year of incarceration, and the liability to death from phthisis diminishes year by year until ten years have passed.

* 1899 was an unfortunate year ;the deaths from phthisis equalled the total of the four preceding years.

April 1903.] ...CASES OP. TUBERCULOSIS:- 188;

In statistics for prisoners over ten years- in

prison being drawn-from one case must be accept- ed with reserve. The whole table is on too small a scale and

requires confirmation by other observers; but

taking it as it is, it would appear- probable that fully two-thirds of the whole were infected

prior to admission. Theodore Williams found that in 802 living patients the average duration of the disease was 8 years and 2

months, and of 198 fatal cases 7 yean? and 8 72 trionths. If we knock off 50 per cent, from their computation, on account of climate, mode of living, treatment, &c., we would still find two- thirds of the phthisis imported. The state of health of prisoners on their

admission to jail has undoubtedly an important bearing on sickness and mortality. The crimi- nal class is said to be short lived, at any rate it would be reasonable to suppose that the vicious lives led by a large proportion would pave the

way for disease in general. In Calcutta the abuse of opium and cocaine

is very common, and the population of the

Presidency Jail is largely composed of habitues of these drugs, many being admitted actually at death's door.

I find that from 1896 to 1901 only 55 per cent, of new admissions were received in good health, 33 per cent, in indifferent, and 12 per cent.- in bad health. Of the 36 fatal cases of phthisis 12 only were

admitted in good, 13 in indifferent, and 11 in bad health.

I give below an analysis of the 36 fatal cases at the Presidency Jail referred to above.

These notes are condensed for the sake of

brevity. Unfortunately the records of 8 cases have been destroyed Notes on fatal case of tuberculous disease at the Presi-

dency Jail from 1895 to 1901.

1. H. M , admitted in good health, in jail 11 years 1

month. age at death 36 ; n?.re^?I7'a- 2." N. R., admitted in indifferent health, in jail 2

months 13 days, age at death 26 ; no records. 3.* S. J., admitted in indiffarent health, in jail 1 month

5 days, age at death 38 ; no records. .4.* N. B., admitted in indifferent health, in jail 6

months 9 days, age at death 25 ; no records. 5. M B., admitted in good health, in jail U years, age

at death 28 ; no records. 6. S. N.', admitted in indifferent health, in jail 5|

years, age at death 34 ; no records. . 7. G. B., admitted in good health on 29th July 1892, pleurisy 22nd June 1894; chest Pain and cough 26tli June 1895; died 31st July 1896. lost ?mortem?Tubercular

meningitis, tubercle of lungs (extensive), liver, kidneys, age at death 34. ?

: 8.* U. M., admitted in indifferent health, in jail 9h months, age at death 28 ; no reco.?H-

9.* 13. B. G., admitted in indifferent health, in jail 2 months, age at death 35 ; no r?c?r^s

'10.* R. S: P., admitted in bad health on 30th October 1897, "an absolute skeleton,' died 4th December 1897. Post-mortem?Tubercle of lujig8- at death 30.

11.? K. K., admitted in bad health 11th May 1897 with

diarrhoea, died 9th December 1897> tubercle of. left lung and pleura and large intestine. Ageiat-deaf'h-28v

19 ST admitted in good health, 23rd August 1893, losing weight from admission ; spent

most of his time in

snecial and convalescent gangs, had dysentery in Feb-

nary 1895 and July 1896; died on 14th January 1898:.

Post-mortem?Tubercle of both lungs and large intestine,

AglV*tHaLh's3?admitted in bad health, 17th April 1896

881/* \ C G admitted in indifferent health, 23rd Sep- * wYrqr ? had dysentery 10th October 18J8, died 3rd

both lu,|8s and

large iSi?r.it he.altli, 7th December 1S96- no symptoms till 22nd April 1898, influenza

follow-

5 w rliJnmatism ; phthisis diagnosed October 1898? ^ , L, January 1899. Post-mortem?Tubercle of both died 1-1 th Janua y inteBti?e. Age at death> 52

il"* PT^P K admitted in bad health, 1st November Min'cin died 24th March 1889. Post-mortem?

KX E l lS IS* "*?? Age at death, 30 d in indifferent health, 16th Feb-

17< .qqt' VniTes 22nd February 1897 diarrhoea ; ruary 1897, wi I

jn apecjai gaugj died 30th

bm? ̂?-":/dtu1:137otbothl",,e',,,r84 and small ̂ nt?8t,"fm:tted in bad health, 22nd January

18 * L H. J-,

:c large spleen with phthisis, died 1899; emaciatec, A? ^m'orteni?Tubercle of both lungs, 7th April 1899 _

ton* Agfl at(leath) 22

large *nd small in ted in g00(1 health, 23rd August 19. K. C. H , pt0ruber 1897 ; htemoptysis, 26th

1897 ; diarrhoea, ?> ^ ^lay 1899. Post-mortem?

September 1897, d iarge intestine. Age Tubercle of both lung9

at death, 25. . ?ood health, 21st September go. G. A . admitted in ^ ̂ _ dyflentery) 2nd Mfty

189G ; bronchitis, tjm0 jn special gang, died 2nd 1899 ; spent most o Tubercle of both lungs. Age July 1899. Postmortem A * fe

at death, 27. . ood health, 17tli June 1895 ; 21. P- B-i admi ^95 . 8pent mo8t of Iub time

dysentery, 12th Sep ^ 1899. Post-mortem? in special gang, die 9jgnioid flexure and rectum. Tubercle of both lung8)

Age at death, 45. . ?ood health, 8th February

22* B. D ? a(lmi March 1899, died 29th 1898 ; hospital for Ph Tubercle of both lungs; August 1899 2?e destroyed

? Age at death, 31. right lung absolut y

jjfferent health, 7th December 23.* B., admitte i

weight, 10th January 1897; 1896 ; commenci6(1 in special gang, died 2nd Sep- 9pent most of his wl?Tubercle of both lungs and tember 1899 Age at death, 50. lar?e and small

in e . d jn g0od health, 25th June 24. K. 0. S., a

December 1897 ; ague, 5th May 1894;?diarrhoea, ?wt 1899 ; died 16th October 1899; phthisic Tubercle of left lung, empyema. 1899. Post mortem xuu

Age at death, 26. . od health, 24th December 25. B. S-. admi jUIie 1897 ; ague twice, 1897 and

1891 ; ana abscess, / _ ig99. died 19fch 0ctober ,899

1898 ; phthisis, 1 ^ ̂oth iUng8. Age at death, 29. Post-mortem-?lu ... d jn good health, 28th Novem-

26. S. G. M., ,ttejune 1899 ; then began to lose ber 1898;

October 1899. Post-mortem^-Phthisis weight, died 29th 0ct?blath) 27. of both lungs. Ago a ^ad health on transfer 3rd

27.* I. ?*?qadi ct to hospital with dysentery, died February 1899, post mortem?Tubercle of small 26th January 'ipftth 29. (This case was returned intestine. Age at deatn,

as phthisis.) ? -ttcd in good health, 5th February 28. H.

jroveniber 1898 and 27th Dflcenibef

HIS; phthiai8, 20tb JEi'luriry W00-; died

m THE INDIAN MEDICAL GAZETTE. [April 1903.

Post-mortem?Tubercle of both lungs and large and small intestines. Age at death, 31.

29.* M. P., admitted in bad health with phthisis on 6th March 1900, died 2Sth May 1900. Poit-mortem? Tubercle of both lungs. Age at death, 22.

30 * M. S., admitted in bad health, 22nd September

1899, with phthisis, died 29th May 1900. Post-mortem? Tubercle of both lungs and small intestine. Age at death, 36.

31. P. Efc., admitted in good health on 13th April 1898 ; ague, 9th August 1899, then began to lose weight, died 9th August 1900. Post-mortem?- L'ubercle of both lungs and mesenteric glands. Age at death, 30.

32.* S. A., admitted in bad health with " cirrhosis of liver" on 16th June 1900, died on I9tb December 1900. Post-mortem?Liver small and fibrous, tubercular. Tubercle of both lungs and mesenteric glands. Age at death, 38.

33.* S. T., admitted in bad health with diarrhoea on 28t,h February 1900, died 10th March 1902. Post-mortem ?Tubercle of both lungs, mesenteric glands and large intestine. Age at death, 30.

34.* H. M., admitted 19th February 1901 in bad health with phthisis, died 15th July 19'2. Post-mortem? Tubercle of both lungs and large and small intestine. Age at death, 23

35. E. K. D., admitted 9th December 1897, in in- different health, commenced to lo->e weight in January 1899, died 1st October 1901. Post-mortem?Tubercle of both lungs and large and small intestines. Age at death, 63.

38 R. D. L., admitted, 31st October 1900, in indifferent health ; phthisis, 30th August 1901, died 5th October 1901. Post-mortem?Miliary tubercle of both lungs. Age at death, 40.

I am of opinion that the *20 cases marked with an asterisk had become infected with tubercle

prior to their admission to the Presidency Jail. Of the other 16 cases it is by no means certain that the disease was contracted in jail in all cases. The fact which struck me most in looking up

these records was that very extensive disease of the intestinal tract may exist with practically no symptoms except an occasional attack of

diarrhoea. Admissions to hospital in jail for phthisis are

not criteria of an3T value in estimating the dura- tion of the disease. The jail hospital is reserved for serious cases,

and a large number is treated in the special convalescent and phthisis gangs. I find that the actual stay in hospital has no relation to the duration of the disease.

Cases N >s. 7, 15, 20, 21, 24, 25, 26, 28 and 31 seem to have contracted the disease in jail. Calculating the duration of the disease from the first reliable symptom the average works out at

something under two years for each case. Several out of the 36 were only diagnosed

after death.

Special interest attaches to these statistics from the fact that the Presidency Jail is the

only jail in Bengal where a po^t-mortem must be made on every case and where an inquest is

held on every death. Of the 36 ca es, 23 were Hindoos and 13

Mali nnedans. Taking into consideration the

relative populations the mortality is roughly ?peeing equal in each class.

The ages of the 36 cases are? Age 20?25 ... ... 2 deaths. ? 25?30 ... ... 13

?

? 30-35 ... ... 9 ?

i, 35 40 ... .?? 7 ,,

? 40?50 ... ... 2

?

Over 50 ... ... 3 ,,

Total ... 36

Has the disease become more prevalent ? Below I give Bengal statistics ranging over 27 years, from these it appears that the mortality rate has remained fairly constant, while the admission rate has increased. This may mean that the number of cases has increased, or it may mean that there have been more re-admissions of individual cases.

BENGAL JAILS.

1875 1880 1885

*1889 1895

Average of j 7 years ending 1901 ...

Ratio per millb of average strength.

Tubercular Disease.

Other Respira- tory Diseases.

Admissions. Deaths.

8'1 9-9 7-7 6-7 6-7

11-2

3*2 3-9 2-6 2-9 2-3

3-9

Admissions. Deaths d ?; ??

42-3 55-0 43'0 46-0 5fi-0

54-7

4-2 6-3 4-0 4-8 6-5

4-8

50-4 65-0 76-1 52-6 26-9

29-2

In the Presidency Jail only males over the age of 22 are admitted. This fact must

be taken into account when considering the statistics of that jail. I have, moreover, dealt exclusively with the disease as affecting native

prisoners. Since writing the above I have compiled the

statistics of death from tubercle of the lungs at the Presidency Jail during the year 1902. Ten cases in all (including <>'ie under-trial prisoner and one discharged from considerations of

humanity) died during the year. Of these six were admitted suffering from the disease, and one at least of the remaining four was probably in- fected prior to conviction.

If the scanty details that I have been able to collect are of any value, it would appear probable that there is no reason to believe that tubercle of the lungs is moie prevalent in Bengal jails than amongst the general population, nor

that it has become more prevalent in recent

years. Personally I am of opinion that the disease

is far commoner outside. If the medical officers of other Central jails

would publish their experiences, we would have very valuable data for comparison.

* The report for 1890 is not at present forthcoming. I have thtr*for? giv?n th? figures for 1889.