The Early History of Tuberculosis in Central East Africa
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INT J TUBERC LUNG DIS 2(10):784–790 © 1998 IUATLD UNRESOLVED ISSUES The early history of tuberculosis in central East Africa: insights from the clinical records of the first twenty years of Mengo Hospital and review of relevant literature T. M. Daniel Case Western Reserve University School of Medicine, Cleveland, Ohio, USA SUMMARY SETTING: Mengo Hospital, in present day Kampala, of 93 cases of tuberculosis were included in 26 806 ad- Uganda, 100 years ago. missions to Mengo Hospital from 1897 through 1916. OBJECTIVE: To determine the presence of tuberculosis No secular trend in the prevalence of tuberculosis in the Bagandan population of central East Africa and among patients admitted was apparent. A review of the elsewhere in Africa at the time of early explorations by prior literature concerning tuberculosis in precolonial Europeans. Africa suggests that tuberculosis may have been present DESIGN: The case records kept by Albert Cook for two in several regions prior to European exploration, but decades beginning in 1897, 35 years after the first visit of was probably absent elsewhere. Speke to this region, were reviewed for evidence of CONCLUSIONS: The concept of all of Africa and all of tuberculosis among Bagandans. Writings of other con- the people of Africa as virgin soil for tuberculosis is temporary medical observers were reviewed for evidence rooted in an archaic Eurocentric view of Africa, and can- of tuberculosis in pre- and early-colonial Africa. not be supported today by available data. RESULTS: Well documented cases of tuberculosis were KEY WORDS: tuberculosis; history of tuberculosis; East observed by Cook beginning in 1897. A minimum total Africa; Uganda; Albert Cook; Mengo Hospital AS POINTED OUT eloquently by Stead and his col- sis in Buganda, East Africa, and elsewhere on the con- leagues,1–4 the early history of tuberculosis is impor- tinent. It is based on a review of the clinical records of tant today because it contributes to our knowledge of the first twenty years of Mengo Hospital and a review the epidemiology of this world-wide disease and may of literature relevant to the early history of tuberculo- give insight into genetic resistance to tuberculosis in sis in Africa. modern peoples of diverse origins. The early records of Albert Cook at Mengo Hospital give information CLINICAL RECORDS OF THE FIRST TWENTY about the early history of tuberculosis in central East YEARS OF MENGO HOSPITAL Africa. Albert Ruskin Cook (1870–1951) committed him- The clinical records of Mengo Hospital are currently self to missionary work while still a medical stu- stored at the Albert Cook Memorial Library of Ma- dent.5,6 He completed his medical training in London kerere University School of Medicine in Kampala, in 1895, and in 1896 he embarked for East Africa, Uganda. These records, hand-written in ink with clin- landing at Mombasa on 1 October. He reached the ical notes by Cook and vital signs charts and nursing kingdom of Buganda, populated by a people who notes by Katharine Timpson, who later married called themselves Baganda and situated on the north Cook, and other nurses, are bound in volumes by shore of Lake Victoria with its capital at Mengo, now year. Prior to 1904 no record numbering system was part of modern Kampala, Uganda. The kingdom was used; in that year a system of record numbers was be- ruled by Kabaka (chief, king, sovereign) Mutesa, and gun, with renumbering beginning each year. During the indigenous language was Luganda, a tongue the first seven years, an index alphabetized by patient which Cook had studied in England before his depar- name and listing diagnoses was kept by Cook and ture. In March 1897, Cook founded a hospital at bound with each volume. It is apparent that there are Mengo to serve the Bagandan people. a number of missing records, especially in the early This report explores the early history of tuberculo- years, and a rough estimate is that about 90% of the Correspondence to: Thomas M Daniel, MD, Center for International Health, Room T-505, School of Medicine, Case West- ern Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4978, USA. Tel: (ϩ216) 368-6321. Fax: (ϩ216) 368- 8664. e-mail: [email protected] Early history of tuberculosis in East Africa 785 patients hospitalized are documented in these ar- dence from Mengo. In the great majority, no indica- chives. A fire destroyed the hospital in 1902, and tion of the reason for admission was recorded. most of the records for that year were lost. RESULTS METHODS Table 1 summarizes the data obtained by reviewing With the assistance of the librarians and staff of the the early case records of Mengo Hospital. It is appar- Albert Cook Library, all records were reviewed and ent that tuberculosis was present in the indigenous each record with a diagnosis of phthisis, tuberculosis, Bagandan population from the time of Cook’s arrival bronchitis, pneumonia, pleurisy, empyema, or other in 1897, 35 years after the first European contact pulmonary condition was flagged. The author then with these people in 1862 by Speke, the British dis- personally reviewed all of the flagged records with coverer of the source of the White Nile. One patient diagnoses of phthisis or tuberculosis and approxi- with a chronic knee infection with a draining sinus mately 10% of the other flagged records. Whenever considered by Cook to be tuberculous (but not docu- repeated hospitalizations of the same patient were mented in the record to have had acid-fast bacilli in recognized in this review, the case was tabulated only the drainage) and seen in 1897 was said to have had once. A representative admission note by Cook is the disease for ten years. reproduced in the Figure. Cook had brought two microscopes equipped with No information about the criteria used for admis- oil immersion lenses with him to Mengo, and he used sion to the hospital could be obtained from this acid-fast stained sputum smears to confirm his diag- review. In some cases severity of illness appeared to noses. Thus, there is little doubt that his diagnoses of have dictated admission, in others distance of resi- pulmonary tuberculosis were correct. In fact, the Figure A representative admission note by Albert Cook describing a male patient with pulmo- nary tuberculosis. A history of cough, hemoptysis, and night sweats is recorded. As is typical of Cook’s notes, the physical findings over the left upper lobe are described in detail. A series of progress notes attest to the continuing hospitalization but provide little new information. A pos- itive sputum examination is recorded, apparently on 24 August 1899, 12 days after admission. 786 The International Journal of Tuberculosis and Lung Disease Table 1 Number of pulmonary and extra-pulmonary cases diagnosed at Mengo Hospital in Uganda, 1897–1916 Number of diagnoses of tuberculosis Number of Extra- Yearadmissions Pulmonary pulmonary Total 1897 250 3 3 6 1898 223 5 0 5 1899 255 5 1 6 1900 255 2 0 2 1901 623 1 1 1 1902 72* 1 2 3 1903 657 3 0 3 1904 843 2 0 2 1905 1 392 1 3 4 1906 1 690 3 1 4 1907 1 447 3 2 5 1908 1 354 5 1 6 1909 1 391 8 3 11 1910 1 696 4 2 6 1911 1 792 10 2 12 1912 1 764 2 1 3 1913 1 871 4 0 4 1914 1 786 3 4 7 1915 2 868† 80 8 1916 4 577† 20 1 21 Total 26 806 93 (0.35%) 27 (0.10%) 119 (0.44%) *Many records were lost in a fire that destroyed Mengo Hospital in November 1902. † Admissions in 1915 and 1916 include war casualties. number of cases of pulmonary tuberculosis reported Cook reported a survey of the diseases seen among in Table 1 is almost certainly a minimum figure, for it 1500 patients admitted to Mengo Hospital during its is apparent from review of the case records that Cook first four years, from March 1897 to March 1901.7 In rarely considered the diagnosis of pulmonary tuber- the table in his report he listed 58 cases of tuberculo- culosis in the absence of hemoptysis. Many chroni- sis (3.9%); in the text 71 (4.7%), the figure given for cally ill patients with diagnoses of bronchitis or pneu- nontuberculous pulmonary disease in the table and monia were described as having rales or ronchi over probably an error in the text. Our review documented the upper lobes and apices of the lungs, and it is likely 1606 admissions to the end of 1901, with a total of that a substantial number of them had tuberculosis. 21 diagnoses of tuberculosis (1.31%). We were un- On the other hand, Cook may have over-diagnosed able to find a reason for the discrepancy between our extra-pulmonary tuberculosis, for his clinical records review and Cook’s report from either the records or suggest that he considered a number of cases of chronic from Cook’s index. It is possible that Cook included osteomyelitis and chronic cutaneous fistulas to be out-patients in his review, although the text of his pa- tuberculous without microscopic confirmation. How- per specifically states that his review was based on pa- ever, progress notes and laboratory results were not tients admitted to the hospital. as conscientiously recorded by Cook as admission Cook’s diagnoses of pulmonary tuberculosis appear notes, and the absence of recorded results cannot be to have been accurate and his treatment modern by equated with negative findings. contemporary European standards. He used acid-fast No secular trend of increasing or decreasing tuber- staining to examine sputum smears from the time of culosis is demonstrated by the data in Table 1.