NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Distribution of Leprosy.
59
TABLE V.
Relation between the Distribution of Leprosy and the Dryness of
the Climate.
Areas arranged according
to dryness of climate.
Bellary and districts
around
Sind
.
South-West Punjab .
Rajputana
North Western Prov-
inces and Oudh .
Behar .
Chota Nagpore
Bengal .
Cachar .
Assam (inclusive of
Cachar)
Ratio of
Lepers per
10, 000 ISt
Census).
2.9
1.4
3.0
...
4.2
3.9
2.5
7.8
4.7
6.8*
Ratio of
Lepers
per 10,000
(1st Census).
1.2
1.1
1.2 to 2
...
4.0
5.7
5.3
9.4
Ratio of Lepers
per 10,000
(3rd Census).
1 to 2
7
1.0
1.4
3.6
4.5
4.4
6.2
11.6
12.3
REMARKS.
* In 1872 less dis-
tricts were included
under Assam than in
1881, and 6.8 repre-
sents the ratio for 1872
of an area correspond-
ing to Assam in 1881.
This table shows that with increasing dampness the ratio
of lepers tends to increase, and the figures for 1881 and 1891
ascend in almost a perfect scale, while the figures under the
first census doubtlessly point to higher averages in the damp
than in the dry areas.
To enter more fully into this matter. The dryness of a
climate depends chiefly on the temperature, humidity, and
rainfall. No correspondence between the heat and the dis-
tribution of leprosy is traceable, as Table VI will show. For
all the meteorological information the Commissioners are
indebted to Mr. W. L. Dallas, Assistant Meteorological Re-
porter with the Government of India, who most obligingly
gave them all assistance, for which they here thank him :
60
REPORT OF THE LEPROSY COMMISSION :
TABLE VI.
Leprosy and Heat.
[Census 1881 and 1891.]
Area.
Orissa
Malabar
Madras (South-Central)
East Coast
.
.
Madras (South and Central)
Tenasserim
Burma
East Bengal
Deltaic Bengal
.
Central Bengal
Behar .
.
.
.
North-Western
Provinces
and Oudh
Berar
. . .
Kathiawar
Sind .
.
.
.
Cachar
....
Punjab (South and Central)
Khandesh
*
Central Provinces
Bombay
Assam Valley"
Chota Nagpore
Punjab (South and West) .
Punjab (North-West)
Amount of Heat.
Very hot, 80°a
nd above.
Hot, 78' and
70.°/
Medium, 76°a
nd 77°[
)
)
Cold, 74° and
Very cold, be-
low 74.°R
atio of
Lepers per
10,000
(1881).
12.4
6.3
2.8
5.0
2.8
4.2
6.9
5.5
57
4.0
14.0
2.2
II
7.8
2.5
14.1
3 to 9
6.1
6.4
5.3
2.0
3.6
Ratio of
Lepers per
10,000
(1891).
11.0
5.6
•8
4.0
•8
2.6
6.3
43
4.8
16.1
5.0
3.6
12.7
1.5
7
11.6
11.6
...
5.3
12 to 13
4.4
1.0
2.0
REMARKS.
Reg. No. 475, Lep. Com.—Oct. 91.—304.
Reg. No. 475 R. Leprosy Com.—Mar. 92.—1,004.
Litho., S. I. O., Calcutta.
Distribution of Leprosy.
61
A comparison of the appended map showing the annual
mean temperature (in degrees Fahrenheit) with the three leper
distribution maps demonstrates clearly that no relation between
leprosy and heat can be established, and it will thus be un-
necessary to delay any further over this subject.
A table will now be given to show the annual average of
rainfall and humidity respectively, and this is further illus-
trated by a map :—
TABLE VII.
Annual Average Rainfall and Humidity.
Area.
South-West Punjab
Sind
.
.
.
.
Rajputana
Central Madras
Khandesh
North-Western Provinces
Oudh
.
.
.
.
Central Punjab
South-Cenlral Madras
Mysore
Bombay
. . .
Berar
.
.
.
.
Central Provinces .
Kathiawar
East Coast (Central)
South Madras
Rainfall.
Below 25 inches,
very dry.
25—40 inches,
dry.
/
Humidity.
Very dry.
Dry.
< Dry.
Medium.
Dry.
Dry.
Medium.
Dry.
Medium.
Damp.
Medium.
. Dry.
Dry.
Very dry.
Dry.
/ Damp.
REMARKS.
62
REPORT OF THE LEPROSY COMMISSION:
Table VII—continued.
Annual Average Rainfall and Humidity.
Area.
Central Bengal
Chota Nagpore
Behar
East Coast (North and
South)
East Bengal
Assam Valley
Deltaic Bengal
North Bengal
Orissa
Tenasserim
Burma
Cachar
.
Malabar Coast
Rainfall.
40—60 inches,
medium.
\
60—100 inches,
wet.
Over 100 inches,
very wet.
Humidity.
' Very damp.
Medium.
Damp.
Damp.
Very damp.
Very damp.
REMARKS.
It will now be easy to select the driest areas and districts
of India and enquire into their leper ratios. This is done in
Table VIII.
TABLE VIII.
Areas with their Leper Ratios, arranged according to Dryness of
Climate,
Areas arranged according to
dryness.
South Punjab
Sind
Rajputana
Leper per
10,000
(Census 1881).
27
...
Leper per
10,000
(Census 1891).
7
1.4
REMARKS.
Distribution of Leprosy.
63
Table VIII—continued.
Areas with their Leper Ratios, arranged according to Dryness of
Climate.
Areas arranged according to
dryness.
Kathiawar
Central and Western Pun-
jab.
Khandesh .
North-Western Provinces
and Oudh.
Central Punjab
Berar
.
.
Central Provinces
Madras Central
South Madras
East Coast (Central)
Mysore
Bombay
Chota Nagpore
Behar
East Coast (North and
South)
Burma
East Bengal
Assam
Deltaic Bengal
Central Bengal
Orissa
Malabar
Lepeis per
10,000
(Census 1881).
2.2
2.0
14.1
4.0
2.4
14.0
2.8 to 9.0
2.0
4.1
3.6
2.6
6.1
5.3
57
5 to 6
6.9
5.6
7.0
} 7 to 19.5
12.4
6.3
Lepers per
10,000
(Census 1891).
1.5
75
11.6
3.6
.9
12.7
r8
2.1
2.7
3.4
5.3
4.4
5.0
4 to 5
6.3
4.3
12 to 13
5 to 16.1
11.0
5.6
REMARKS.
* The returns for Khan-
desh (1881) are pio-
bably too high (cf.
above.)
64
REPORT OF THE LEPROSY COMMISSION :
Speaking generally, at either end of this table the extreme
ratios are met with, while in the middle the intermediate
ones are found. The series is only disturbed by the high
proportions of Khandesh and Berar. In the appended map
red represents the driest areas, while blue indicates the
dampest, and yellow the intermediate ones. By comparing
this map with the leper distribution maps a graphic demonstra-
tion is given of what has been suggested above, that is, that
there is an apparent connexion between the dryness of the
climate and a small leper population ; for it will be seen that in
the four maps the red colours to a certain extent cover the
same areas, while blue in the climate map occupies those
spaces which in the other maps are darkly tinted, or at least
other than red, thus indicating a greater amount of leprosy.
Whether this is only accidental it is difficult to say, and
perhaps too much importance must not be attached to .it. It
is not intended to advance any theory on the strength of these
observations. Yet the fact seemed significant enough to de-
serve especial mention, all the more as all three censuses bring
out this general principle.
Leprosy and the Increase and Decrease of Population.
On' the climate of a country to a great extent depend the
health and wealth of the people. It is difficult to get a fair
estimate of the comparative healthiness of the various districts
of India, for it is impossible to do so by a study of the rates of
increase or decrease of the population as registered in the
Census Reports. This can in no way gauge with any amount
of accuracy the rate of mortality which may be considered
a pretty fair estimate of the healthiness of an area. Errors
cannot be excluded while arguing in this manner, as the
movement of the population depends not only on mortality,
but also on many other factors. The observation of Malthus
regarding the tendency of the population within a fixed area
Distribution of Leprosy.
65
to increase faster than the land yields food for it, is well
known, and its truth in the present day is fully accepted.
Physical and social influences greatly stimulate the multiplica-
tion of a people. There is for many parts of this country the
tropical climate, necessitating the barest requirements of food
and clothing, the extent of cultivable soil, and the religious
sanction or social influence that contains within itself all the
vitality of the popular belief of the masses : there is lastly the
retarding unprogressive form of Indian society which excludes
all advance of a standard of comfort from one generation
to another. As Mr. Baines writes in his excellent Report on
the Census for the Presidency of Bombay 13 : " Under different
circumstances the increase in material prosperity may have
the result of either increasing or decreasing the population,
and it is the same with a decrease in well-being. The differ-
ence depends upon whether the standard according to which
the people mould their life is that of subsistence or of mainte-
nance. As regards India the special features to be taken
into consideration are, first, the sharp and impassable social
distinctions,. in consequence of which the enterprising man
is conscious that, however he may increase his wealth, his
station is fixed for him by a barrier he cannot overstep ;
secondly, the fact that the religious obligation is imposed on
all who profess the Hindu religion ; thirdly, the place of the
standard of comfort is here taken by that of expenditure
on the half-social, half-religious ceremonies that are held to
mark the performer's place amongst his caste-fellows. The
motive of economy is not the desire of permanently ame-
liorating the position of the man himself or his posterity, but
of keeping up appearances for the occasion only."
There is thus in India a large class whose standard of
subsistence is of the lowest possible, and who are therefore
( 13 ) Imperial Census of 1881,—" Operations and Results in the Presidency of
Bombay, including Sind," page 29.
F
66
REPORT OF THE LEPROSY COMMISSION:
unusually sensitive to the effects of disease, scarcity, or want
of labour. There is an extraordinarily large proletariat living,
and such agencies as famine or drought must reduce their
numbers considerably. Again, the increased demand for labour
removes people from those districts which supply a large
portion of unskilled labour, and a large extent of unoccupied
fertile land available for cultivation will attract numbers of
people, as will also the increase of trade, by opening of rail-
ways and so forth.
All this must not be left out of sight in deducing from the
rate of increase or decrease of the population the amount
of mortality, and establishing from the latter the comparative
healthiness of an area. All the Census Reports bring out
this fact strongly that no connexion exists between the in-
crease or decrease of the population and the leper ratios.
The present enumeration, if an absolute value be attached
to the figures, indeed shows that, though the general popula-
tion has increased, the number of lepers has materially dimi-
nished during the last decade. In the Census Reports for the
Central Provinces 14 means are given to study the effect of
comparative healthiness of a district on the leper ratio. Mr.
T. Drysdale has arranged the districts of the Central Pro-
vinces in their order of annual rate of decrease, and it will
be seen that in some of the healthiest districts there is the
largest amount of leprosy, and the converse is also true. This
will now be given in a tabular form.
Distribution of Leprosy.
67
TABLE IX.
Relation between Leprosy and the Comparative Healthiness of the
Districts in the Central Provinces (1881).
Districts in the order of
comparative healthiness.
Nagpur
Wardha .
.
Saugor
Hoshangabad
Damoh
Balaghat .
Betul
Chanda
Bhandara
Chhindwara
Seoni
.
Sambalpur
Jubbulpore
Raipur
Bilaspur .
.
Mandla
Nimar
Narsinghpur
Rate of Increase
or Decrease in
population since
last census.
+ 10.5
+ 9.16
+ 7.05
+ 8.56
+ 16.06
+ 12.85
+ 11.32
+ 16.16
+ 21.06
+ 17.92
+ 11.37
+ 32.59
+ 29.95
+ 28.51
+ 42.2 ...
+ 41.66
+ 9.55
+ 7.59
Leper ratio
for 1881.
12.1
12.9
2.9
6.0
2.0
4.9
37
79
6.5
4'4
2.1
7.8
3.4
97
4.7
2.7
8.8
4.1
REMARKS.
The figures in the second
column show that it is im-
possible to judge as to the
comparative healthiness of
a district from the rate of
increase or decrease of the
population. •
The order of the districts was determined by the rate of
mortality, the only available estimate. Such tables could not
be obtained for other provinces, but for completeness' sake'
details will now be given for the province of Bengal and the
presidency of Bombay respectively as to the relation between
the leper population and the rate of increase of the inhabi-
tants from census to census.
68
REPORT OF THE LEPROSY COMMISSION :
TABLE X.
Relation between Leprosy and the Rate of Increase or Decrease of
Bengal [Census 1881).
Districts in the
order of rate
of increase.
Darjeeling
Jalpaiguri
Mymensingh
Dacca •
Nuddea .
Bankoora
Pubna
Tipperah
Jessore .
Furreedpore
Bogra
24-Pergunnahs .
Howrah
Khoolna .
Rajshahye
Chittagong
Moorshedabad.
Dinagepore
Backergunge .
Midnapore
Rungpore
Noakholly
Burdwan.
Beerbhoom
Hooghly.
Increase or
Decrease in
population
since last
census.
+
+
+
+
+
+
—
+
—
...
•••
+
+
—
+
—
—
—
+
—
+
—
. Leper
Ratios for
1881.
11.8
12.9
8.4
5 6
9.4
37.2
6.4
4.9
4.0
4.0
67
5.1
5.6
27
4.6
4.3
12.7
7.' 4
2.5
9.2
14.9
2.6
29.5
32.7
11.1
Increase or
Decrease in
Leper Ratios.
+
+
+
—
+
+
+
±
+
• •*
...
+
—
+
+
+
+
+
+
—
REMARKS.
+ – increase since last census.
— = decrease since last census.
± = No change since last census.
The increase or decrease has
been calculated from the Leper
Census Returns found in the ap-
pendix to this chapter. It will be
seen that in a few instances there
are discrepancies between the
second column of this table and
Table II of the various Census
Reports for 1881. However here
only the population on which the
leper ratios were calculated could
be considered, and this sufficiently
explains the differences, which in
any case are very slight.
Distribution of Leprosy.
69
TABLE XI.
Relation between Leprosy and the Rate of Increase or Decrease of
Bombay (Census 1881).
Districts in the order of
rate of increase.
Upper Sind Frontier
Khandesh
.
Thar and Parkar
Kurrachee
Shikarpur
Kolaba
Thana
Panch Mahals
Nasik
Kanara
.
.
Hyderabad .
Ahmedabad .
Kaira
Surat
Satara
Ratnagiri
Poona
Ahmednagar .
Broach
Belgaum
Dharwar
.
Sholapur
.
Kaladgi
Increase
or Decrease in
population since
last census.
+
+
+
+
+
+
+
+
+
+
+
—
—
—
—
—
—
—
—
Leper Ratios
for 1881.
1.3
.5
r8
•8
11.3
8.2
27
7.5
1.2
1.2
•8
2.4
6.2
11.0
9.3
12.0
10.1
2.5
3.3
r8
6.8
2.9
Increase or
Decrease in
Leper Ratios.
±
±
±
±
—
±
—
—
—
±
—
—
—
—
—
±
—
—
—
—
—
REMARKS.
Cf. Table X.
These three tables show clearly that from the census re-
ports, the only evidence at hand, no relativity can be estab-
lished between the amount of leprosy prevailing in a particular
district and the rate of increase on the one hand, or the com-
70 REPORT
OF
THE
LEPROSY
COMMISSION :
parative rate of mortality of the same on the other. How
little, however, the rate of increase of a district is a test of its
healthiness can be seen by comparing the approximate death
rate with the increase per cent. according to census figures.
They have been given for the Central Provinces in the second
column of Table IX. No tables have been constructed for
1891, as almost all leper ratios have decreased since the last
enumeration. In the Punjab, for instance, while the popula-
tion has increased by about 10 per cent. during the last ten
years, the number of lepers has decreased by about '35 per cent.
The death rate is dependent to a great extent on climate
epidemic fevers, endemic diseases, and similar conditions, and
it might a priori be expected that the diffusion of leprosy
could not depend on such causes per se, though the condi-
tions leading to the constant presence of a specific disease in
any particular area may possibly cause a special predisposition
towards leprosy. The factors to be considered are the per-
sonal health and wealth of the individual, and the degree to
which he is liable to suffer from such diseases as are caused
by bad nourishment, poverty, overcrowding, and other speci-
ally endemic conditions. To obtain such details is exceed-
ingly difficult in a vast empire like India.
Leprosy and Cholera.
It was shown that from the healthiness of a district, de-
duced from its rate of mortality, nothing could be argued as
to the density of the leper population. Taking now cholera
as a test of the climatic and local healthiness and sanitary
state of an area, an enquiry will be made into the diffusion of
leprosy over the regions stricken by this fever.
It must not be thought that a direct connexion between
these two diseases is suspected, or that it is intended to imply
that the causes which lead to cholera bring about a totally
different morbid condition. While searching for a possible
explanation of the high leper ratios for certain parts of Bengal,
Distribution of Leprosy.
71
the following enquiry suggested itself,—Why should the Burd-
wan Division consistently show almost the " highest relative
number of lepers ? Again, why should leprosy be so generally
prevalent over Lower and Eastern Bengal and Burma ? One
striking feature which these districts have in common is the
perennial existence of cholera and fever. Areas where such
diseases rage at all times and seasons cannot be considered
healthy, and must present certain permanent specific condi-
tions, whatever view may be held regarding the aetiology of
these fevers. Regions where cholera is endemic must be in the
possession of certain definite, though at present perhaps un-
known factors ; and if it be found that in these regions leprosy
is also common, may it not be possible that the deleterious
conditions which cause the fever to be endemic, exercise a
specific influence on the general health of the population ?. In
the present state of medical knowledge it is not decided how
far bad health and hygiene, poverty and overcrowding predis-
pose towards such diseases as leprosy and tuberculosis, but
sufficient evidence exists to make it appear quite possible
that such like agents play at least some, if not an important,
part in the development of these affections. On this hypothe-
sis it is not quite so irrelevant as it may appear at first sight
to enquire into the correlation between leprosy and endemic
cholera.
" Certain regions and tracts of country in India which bear
a striking general similarity in respect to the main features of
their physical aspects and climatic characteristics are much
more favourable to the development of the epidemic activity
of cholera than other regions and tracts of country in India
which differ from them very essentially in the characteristic
features of their physiography and meteorology, as well also
as in point of density of population and the condition of the
material prosperity of that population. In the former class of
regions or tracts of country cholera is found to be more or
less always active at all times and seasons, and is conse-
72
REPORT OF THE LEPROSY COMMISSION :
quently, although subject to regularly recurring periods of
epidemic intensity, considered an endemic disease in such
regions or tracts of country. In the other class of regions or
tracts of country cholera is not found to be always active at
all times and seasons. On the contrary, in these areas it
prevails only in seasons of periodically recurring general epi-
demic diffusion of the disease, and consequently cholera in
these regions and tracts of country is considered only an occa-
sional visitor and an epidemic disease." 15
Now, as explained above, the areas in which cholera is en-
demic may be considered unhealthy in a general way, and this
unhealthiness will depend to a certain extent on the climatic,
geological, and meteorological conditions of such area, the
density, prosperity, and general life and habits of the popula-
tion. In this respect cholera may be assumed to be a better
test of the health and wealth of a region than the decennial
rate of mortality, which at best must always be an uncertain
quantity for a vast country like India, and therefore quite
inadequate as a standard of healthiness.
Cholera is endemic in the whole of Bengal, especially in
its low-lying districts, with alluvial soil, subject to periodical
inundations or water-logging by seasonal floods of the great
rivers, with moist and hot tropical and sub-tropical climate.
In the whole of Assam, Behar, and Burma cholera is always
found. According to Dr. Bellew the disease is endemic in the
following districts : the great river deltas of the Ganges and
Brahmaputra in Bengal and Assam ; of the Mahanadi in
Orissa ; the interfluvial tracts of Behar ; the deltas of the
Irrawaddy and Salween in Burma, which means practically the
whole of Lower Burma ; to a less degree the deltas of the
Godavari, Kistna, and Kaveri ; the coast districts of Malabar
and Konkan ; Oudh and the Southern Gangetic districts of the
North-Western Provinces as far up as Allahabad, and still less
( 15 ) H. W. Bellew : History of Cholera in India, page 773.
Reg. No. 486, Leprosy Com.—Sept. 91.—310.
Reg. No. 488 R., Leprosy Com.—Mar. 92.—1,004. Oct. 92.-1,000.
Litho., S. I. O., Calcutta.
Distribution of Leprosy.
73
so in some districts of the Punjab and the Central Provinces.
Of all these districts, Bengal, especially Lower Bengal, Assam,
Lower Burma, Behar, and the specified parts of the North-
Western Provinces and Oudh may be singled out, the last-
mentioned being the least visited by cholera.
In the appended Cholera Map of India the endemic areas
are tinted dark blue. It will be seen that here the tracts where
cholera is always found, and at all seasons, cover a smaller area
than those enumerated by Dr. Bellew. The map has been
constructed according to a similar one in the Sanitary Com-
missioner's Reports, and may be taken to express the views
generally accepted by Indian medical officers. However, it is
only fair to state both opinions, so as to avoid all exclusiveness
or prejudice.
A tabular survey will facilitate the study of the leper density
in these areas.
TABLE XII.
Cholera and Leprosy.
Districts and provinces
in which cholera is en-
demic, according to
Bellew.
Bengal Proper* .
Behar*
Orissa*
Assam*
Burma*
Southern
North
Western Prov-
inces
Delhi
Amritsar
Jullundur
Peshawar
Leper Ratios
per 10,000
(1 st Census).
7.8
3.9
2.4
6.8
11.6
3.3
6.6
6.4
11.1
1.9
Leper Ratios
per 10,000
(2nd Census).
9.4
5.7
12 4
7.0
6.9
4.0
3.4
3.9
7.6
2.2
Leper Ratios
per 10,000
(3rd Census).
6.9
4.5
11.0
12.3
6.3
3.4
1.7
1.5
5.1
1.6
REMARKS.
* The districts marked
with an asterisk are
those in which accord-
ing to the map of the
Sanitary Commission-
er's Report cholera is
endemic.
For Assam
cf. Table V.
74
REPORT OF THE LEPROSY COMMISSION :
TABLE XII.—continued.
Cholera and Leprosy.
Districts and provinces
in which cholera is en-
demic, according to
Bellew.
Konkan
Malabar
Godavari
Kistna
Tanjore
Trichinopoly
South Arcot
Leper Ratios
per 10,000
(1st Census).
8.4
6.0
4.l
3.5
7.2
2.8
4.3
Leper Ratios
per 10,000
(2nd Census).
9.2
5.8
4.0
5.0
4.0
6.6
Leper Ratios
per 10,000
(3rd Census).
8.3
4.4
4.6
2.6
3.1
2.3
47
REMARKS.
It will be seen from this table that from a consideration of
the three censuses the highest leper ratios are obtained in
Bengal, Orissa, Assam, Burma, and Konkan, and of these the
first four are the most choleraic districts in India. Consider-
ing Bengal alone, the highest ratios are found in Burdwan,
Bankoora, Beerbhoom, Hooghly, Moorshedabad, Rungpore,
in all of which the health, as estimated by the prevalence of
cholera, is exceedingly bad, the Burdwan District being perhaps
the worst in this respect. The leper ratios of Bengal, Burma,
Assam, and Orissa are among the highest in the empire, and
in Madras those of the choleraic districts are higher than those
of cholera-free areas, with the exception of Kistna and Tri-
chinopoly. Cholera, however, is not exceptionally virulent in
this presidency. The ratios for Konkan are very much above
the averages for Bombay, and Jullundur has the densest leper
population in the Punjab.
It is only possible to argue on broad lines, and all ex-
clusiveness must be carefully avoided. Here, as in the rest of
this chapter, the great difficulties which necessarily exist in a
survey of so large a continent are keenly felt, and all that