Theories of TB

In the early 1900s, Saint Nihal Singh, an Indian journalist, would make his way to Muthu's sanatorium. He eventually wrote a review of the sanatorium for the May, 1920 issue of "The Modern Review," an Indian based newspaper. His review was mostly positive, especially of Muthu, describing him as a makeup of "the best of the East, and the best of the West."3 But this review was not without its objections. Singh questioned why Muthu was in Britain instead of India. Reasoning that "India [cannot] afford to spare this son of hers to toil in a foreign land" and that Muthu should be "saving his own people from the dread scourge [of tuberculosis]," not the British.4

Tuberculosis was rampant in India, especially in cities where overcrowding and congestion was prevalent.6 Combining the deaths diagnosed as tuberculosis and a portion of fevers (which are miscategorized according to Muthu), Muthu found that the annual death rate is at least 900,000–1,000,000.7 That is around 317 deaths per 100,000, shockingly high. For comparison, around 1.25 million people died from TB worldwide in 2023, nearly as much as died just in India.8

A large portion of his book Pulmonary Tuberculosis outlines how to treat tuberculosis, usually consisting of a stay at a sanatorium, which provided the patient with fresh air, exercise, good nutrition, and psychological treatment.9 But it also outlines someting much more interesting: what he thinks causes tuberculosis

Muthu eventually settled on the latter, arguing throughout the book for a purely social cause of the disease—one not caused by a bacteria. But that cannot be said about where we have settled today.

From a purely biological perspective, we currently believe that tuberculosis is, indeed, caused solely by a bacteria (Mycobacterium tuberculosis to be specific). But as author and advocate John Green proclaimed in his book, Everything is Tuberculosis, "Ultimately, we are the cause [of tuberculosis]."12 To Green and many other advocates, tuberculosis is not just caused by the bacteria Mycobacterium tuberculosis but also the choices we as a society have made and continue to make.

Today we haven't chosen only one cause of tuberculosis (like Muthu was suggesting), but instead multiple. We have, in many ways, revived the debate of the past, looking in many of the same places Muthu and others looked, but also looking to new ones.

Before we dive into Muthu's ideas, we should first understand what he is refuting: a bacterial theory of tuberculosis.

To people who believed in germ theory, bacteria were little seeds floating in the air, ready to plant themselves wherever they could find the soil.15 They believed that bacteria infected human bodies, causing disease. An 1874 New York Times article put it perfectly:

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The thought itself is an impressive and natural one, that there may be a 'cholera seed' or 'scarlet-fever germ' or 'typhoid sporule' floating through the air, just as there are floating seeds of thistles or dandelion, or germs of tulip-trees or limes, or scores of the nameless plants which sow themselves wherever there is the slightest bit of soil or moisture favoring.16

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Muthu obviously had problems with this theory. One of the biggest being that it didn't bring anything new to the table curatively in the first couple decades, and he didn't believe it could. Aside from Koch's Lymph, which turned out to be fraudulent, the discovery of the tuberculosis bacteria yielded no new curative measures nor had preventative measures produced any results (at least in Muthu's eyes).17 He also saw multiple contradictions during his time studying tuberculosis, including "If pulmonary tuberculosis were a contagious disease, consumptive hospitals and sanatoria would be hotbeds of infection, and there would be evidence of the physicians, nurses, and others engaged in them being infected by the disease," going on to state "there is a remarkable history of immunity from consumption among the staff...."18 These factors, among many others, all contributed to Muthu looking elsewhere for the cause of tuberculosis.19 It wasn't in the seeds floating in the air, for him, instead it was something that was "in its infancy" at the time, yet was very promising in Muthu's eyes: biochemistry. In addition to his own ideas of how the body worked.

For tuberculosis, Muthu cited malnutrition as the main factor that causes tuberculosis. In his book, after refuting bacteria as a cause of tuberculosis, he looks to biochemistry for an explanation. Specifically he looked at the body's metabolism—which he defined as the pathways between food intake and the nutrients getting into the blood. A working metabolism was crucial to the health of the body: if there is "a break in any part of [the metabolism], any deficiency in the quantity and quality of food material...", he claims, "will bring about abnormal changes in the chemical processes and reactions which, if continued, would ultimately lead to pathological and diseased conditions."24 A breakdown of the metabolism would also cause a lack of nutrition, which likely causes such "abnormal changes." This lack of nutrition is what Muthu cites as being fundamental to the cause of tuberculosis, stating "Tuberculosis is fundamentally a disease of lowered nutrition...."25 The lowered nutrition, in the context of his theory about change, causes tuberculosis through the body's reaction and attempts to adjust back to equilibrium.

There can be multiple causes of malnutrition, aside from simply not eating enough, according to Muthu. He first cites stale and cooked foods as being a source of malnutrition, stating that "in stale, cooked food there is a deficiency and destruction of enzymes."26 It isn't just the destruction of enzymes that makes stale food cause malnutrition, but also the destruction of chemicals and vitamins and the introduction of "purion and other toxins," which cause malnutrition according to Muthu.27

He also claims that civilization can cause malnutrition, and subsequently tuberculosis. Specifically, parts of civilization cause the body's metabolism to become impaired, which then causes tuberculosis. These disrupters were mainly dirty, "insanitary" environments, mental strain and the aforementioned food, which Muthu claims are synonymous with civilization.28 These disrupters "induce chemical changes which impair normal metabolism," causing malnutrition and tuberculosis.29 This "excessive physical strain" is caused by "poverty and insanitation" and likely the overworking of people in civilized society, which he talks about earlier in the book.30

But what were these insanitary conditions? In a paper published a year after his book, he outlines what he considers insanitary conditions as when there is "drainage, disposal of sewage, clean water supply, good housing is very low" going further to say that ventilation is also very important.31 These conditions, specifically poor ventilation, were often synonymous with a space being enclosed, causing people to be deprived of light and fresh air, and new Western cities.

These factors alone wouldn't cause death because, according to Muthu, disease is the body's adjustment to change; disease is healing. But, at the time, 1 million people died of tuberculosis in India each year. To explain this, Muthu proposed a different stage of disease, one where it becomes deadly. This stage appears when someone stays in insanitary and malnourished conditions.32 Staying in these conditions long enough causes the body to fail "to adjust itself to the abnormal conditions," causing the "functional adaptive [changes]" that the body made to pass onto "structural changes, and structural to more or less permanent organic changes," which cause the disease to turn truly pathogenic (in the sense that it can cause death).33

The seed doesn't infect the soil, it comes from the soil.

With this view of disease, a cure using drugs would not be feasible, it would "be like administering a pill to cure an earthquake" in Muthu's words.38 Instead, Muthu believed in curing through open air sanatoriums—removing the person from the conditions that cause their disease in the first place.39

In July 1928, Muthu's wife passed away, forcing Muthu to abandon the Tambaram project. After some convincing, he got the Madras government to take over the Tambaram.42 After leaving India, he would continue to question everything from spirituality to biology, but as Venkat pointed out, "his influence in the mainstream of medicine faded away."43 He would die in 1940, being buried in the cemetery of St. Andrew's in Bangalore.44

Even though his ideas didn't catch on at the time, they are representative of similar ideas of etiology reliant on a social understanding of disease. There are also parallels between our new social understanding of the disease and Muthu’s understanding. Unsanitary conditions and malnutrition, while not directly causing tuberculosis, can aggravate it and cause a case of latent tuberculosis to develop into active tuberculosis. We also see social causes elsewhere where Muthu didn’t (and in many ways couldn’t): we see it in a lack of access to tuberculosis drugs (which requires an understanding of the disease as a symptom of our social world and biological world, something Muthu wouldn’t accept), we see it in a lack of research and funding, preventing people from being able to treat some forms of tuberculosis. In many ways, the debate never ended.