NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Distribution of Leprosy.
45
the other two censuses facilities are given to study any changes
in the relative leper proportion that may have occurred.
It will be found that, generally speaking, the ratios for the
present census are lowest, thus indicating a relative, if not an
absolute, decrease of leprosy, as far as it is possible to argue
from such figures.
" The foregoing numerical data regarding the distribution
of leprosy in British India can, as already stated, be accepted
as only approximately correct, so far as the actual enumer-
ation of the lepers is concerned, but what is probably of
considerably more importance in connexion with the study
of its aetiology is, that they convey fairly accurate information
regarding the particular parts of the country where the disease
is most prevalent. " 7
II.—It has been maintained that leprosy is most prevalent
on the sea coast or the borders of large rivers. 8 With regard to
India, Mr. Hutchinson asserts 9 that the chief prevalence of
the disease is on the seaboard or in the valleys. Leprosy, as
was mentioned above, is found all over India, and it remains to
examine whether it is more common along the sea coast
and large rivers. Looking at the map for 1872 it becomes
evident that the districts where the disease is most prevalent
are as a rule inland.
Taking the evidence afforded by the two previous censuses
first, amongst the facts conveyed by the maps this is brought
out most strikingly, that all along the Gangetic Valley, fifty to
one hundred miles north and south of the Ganges, the ratio of
lepers is lowest, with the exception of the Burdwan Division.
At the delta itself the proportion may be said to be about five to
ten thousand. The same applies to the area included between
( 7 ) Lewis and Cunningham. Op. cit., page 8. .
( 8 ) Journal of the Leprosy Investigation Committee, No. I, August 1890, page
78 ; Virchow, Krankhafte Geschwülste, page 507.
( 9 ) Journal of the Leprcsy Investigation Committee, No. I, August 1890,
page 82,
46
REPORT OF THE LEPROSY COMMISSION:
the five rivers of the Punjab. In fact, for the first and second
censuses the smallest proportions of lepers were found in the
four "doabs" between the Indus, the Jhelum, Chenab, Ravi,
and Sutlej—and thence down the whole course of the Indus
and along the coast from Kurrachee to Ahmedabad. So it is,
generally speaking, with the other rivers. Thus along the
banks of the Nerbadda the ratio was extremely low for 1871-72
and not excessive for 1881, while for the Koleroon river it
was under five per ten thousand for both censuses, with the
exception of Tanjore. Along the south banks of the Kistna and
Tungabadra the distribution of lepers amounted in the first
census to 3.5 per ten thousand and to less for 1881. On the
other hand, along the Tapti a high ratio is found. Now since
also along the seaboard and larger rivers the prevalence of
leprosy on an average is much below that of the inland
areas, it cannot be said that the earlier enumerations estab-
lish any proof in favour of the statement that in India the
disease has a preference for the former tracts.
These were, however, the only figures at the disposal of
writers previous to the recent census.
The records of the latter argue equally, if not more
strongly, against the prevalence of leprosy along the shores
of the sea or the banks of the large rivers. In the " doabs "
the ratios are again low, and the same applies to the north-west
coast and the seaboard in general. The map, however, gives
a more graphic demonstration than words possibly can do, and
reference should be made to the same.
III.—The maps convey the further information that some
hill tracts are especially attacked by leprosy. This fact can-
not be explained by immigration from adjoining native terri-
tories,—though this is responsible to a great degree for the
high ratios in some districts,—but is apparently due to certain
inherent conditions. The influence of immigration will be
discussed later on. In all the three census reports some
Himalayan districts show consistently a dense leper popula-
Distribution of Leprosy.
47
tion, varying from one to four per thousand. Some of these
will, for clearness' sake, also be given in a tabular form.
TABLE III.
Hill Districts of India with a dense Leper Population.
DISTRICT.
Bashahr
Chamba
Darjeeling
Dehra Dun .
Garhwal (British) .
Garhwal (Native) .
Kangra
Kumaun
Mandi
Nahan
Simla, etc.
Suket .
Proportion of
lepers per 10,000
of population
(1st Census).
10.0
19.0
24.0
...
18.0
19.0
...
...
347
...
Proportion of
) lepers per 10,000
of population
(2nd Census).
16.9
45.6
11.8
19.9
18.1
15.3
14.5
21.0
47.9
20 to 40
16.5
Proportion of
lepers per 10,000
of population
(3rd Census).
13.3
34.0
7.5
20.5
16.9
12.8
10.8
19.7
14.9
21.2
28.8
4.1
REMARKS.
Now in many of these hill tracts the people by no means
confine themselves to the valleys. It is true that in the
Himalayan districts of the Punjab the inhabitants do so more
or less, but it must be remembered that many of their most
densely populated places are at an height of from seven to
eight thousand feet, and villages may be even found at a height
of ten thousand feet. 10
On the other hand, it must not be thought that leprosy is
most frequent in the hills, for in the plains parts are found with
an exceedingly high ratio of leper population, as a glance at
the maps for 1881 and 1891 will show.
48
REPORT OF THE LEPROSY COMMISSION :
Hence, with regard to the geographical distribution of
leprosy in India, it cannot be said that the sea coast, riparian
areas or large valleys are affected more than other districts in
the country. The disease attacks all tracts impartially, and
so far as the surface relations are concerned no generalisations
whatever can be made. Similarly no connexion can be traced
between the geological formations and the density or dis-
tribution of the leper population.
These lines may suffice as mere outlines of the geographical
distribution of leprosy in India, which may be studied more
completely by careful reference to the maps and the appendix
than by a lengthy exposition and cumbersome statistics.
Increase of Leprosy.
In Table I the Feudatory States have been omitted, for
the reason stated above. For completeness' sake a table was
added to show the ratios of lepers for British as well as Feuda-
tory territory (Table I-a.)
In comparing the figures of the three censuses with a view
to studying the changes in the leper population from one
decade to another, it must be remembered that the later
censuses included districts and areas which were omitted in
the earlier ; again, that the first census was not taken on the
same day or at the same time all over India ; and that also as
time progresses the diagnostic powers of the people have
improved. To investigate the movement in the leper popula-
tion, Table I-b has been constructed, including under each
census only those districts which were enumerated on all three
occasions. But even then it must not be left out of sight that
changes in the divisions themselves have taken place from
time to time, one district having been given over from one
division to another. Selecting, however, as carefully as pos-
sible those districts for which returns were made at all three
censuses, the Table I-b permits of a comparison being made
Distribution of Leprosy.
49
of the three sets of figures available. Even making all due
allowances for errors, omissions, and changes in areas, it is plain
that the recent outcry about an alarming increase of leprosy in
British India is not based on fact, and that such increase has
not taken place. On the other hand, the figures suggest a
decrease rather than an increase, especially if it be remembered
that immigration of lepers into British territory takes place to
a great.extent.
TABLE I-b.
Increase of Leprosy in British India.
Total population at each census
on which the leper-ratios
have been calculated.
ist Census (1867—72).
182,000,000
2nd Census {188/).
191,000,000
• 3rd Census (1891).
210,000,000
Number of
Lepers.
100,000
115,000
J 3
105,000
Ratio per
10,000.
5-0
fro
REMARKS.
Only those districts and areas have
been selected which were enu-
meratpd in all censuses. To facil-
itate calculation round numbers
have been used, and the ratios are
approximate only. It has been
assumed that the number of lepers
in the Central Piovinces has re-
mained stationary.
% In arguing from this table great care must be employed.
Comparing the first two censuses, there is an increase in the
absolute number of lepers of fifteen thousand. The present enu-
meration, on the other hand, shows a great decrease, both abso-
lute and relative, since the previous census, so that the recent
alarm is quite unnecessary. While comparing the first two
censuses, it must be remembered that on both occasions the
diagnosis was greatly at fault, and that the presidencies on
the first occasion were enumerated at different times. But
even allowing the figures to be genuine, the increase is so
small that it may easily be explained on the ground of faulty
counting. For one mistake in ten thousand, or if the ac-
tual figures be taken, one mistake in twenty thousand would
more than account for the increase of fifteen thousand.
After all this increase, when compared with the total
5 0
REPORT OF THE LEPROSY COMMISSION :
population, is but slight and too small to stamp leprosy as an
" Imperial Danger." For an increase of fifteen thousand
means that of the population, after an interval varying from nine
to fourteen years, less than .ooo1 became diseased. Such an
increase, if it actually existed, can hardly be considered in
the light of a danger. According to Table I the ratios of
lepers per ten thousand of the population for the two periods
were 5.5 and 6.o respectively, a sufficiently strong argument
against a rapid growth of leprosy. But the outcry about an
alarming development of the pest becomes unreasonable, when
the previous censuses are compared with the recent one,
which shows an actual decrease.
It has been said above, that on the recent occasion greater
care has been bestowed on the correctness of diagnosis and
though cases undoubtedly have been omitted by the enumera-
tors, fewer spurious ones have been admitted. This only
shows how difficult it is to come to a correct opinion by means
of a comparison of a few figures. But those who have raised
the alarm have had no other means of verifying their premises
than these census returns. It may be safer to suspend all
judgment, but if a verdict is given on so grave a matter, it
should be capable of the only proof existing at the present
time, viz., that afforded by the census figures. In the opinion
of this Commission, a comparison of the first two censuses
hardly points to an increase of leprosy, especially when it is
considered that the first enumeration on account of its novelty
was most likely more faulty, and not even taken at the same time
all over India, and that an increase of .5 per ten thousand may
be explained by the improved methods of enumeration. The
errors of diagnosis were more or less equal for the two censuses.
Again, while during the period from 1867 to 1881 the leper
population remained probably more or less stationary, in the
last decade there has been a decided decrease, according to
the figures available. But it would be equally unsafe to assume
that this represents an actual diminution of leprosy, for, as
Distribution of Leprosy.
51
was said above, great pains were taken in 1891 to exclude all
cases of white leprosy. Loath to give a decided opinion on
this subject, the Commission think, that the evidence of the
censuses excludes the idea of an increase of leprosy, and
points rather to a gradual decrease at the present time ; but
it may be safer to assume that the diffusion of this disease
has remained stationary. Anyhow an "Imperial Danger"
leprosy has not become as yet, for the previous increase is
more than counterbalanced by the present decrease, as far as
census figures go.
A comparative statement of the leper population arranged
according to divisions follows (Table IV), and a map is ap-
pended to show the changes in the ratios since the second
census (Map IV). Pink represents an increase, and light blue
a decrease, in the leper density since 1881, the darker shades
indicating that such increase or decrease has taken place
since the first enumeration. The map has been compiled ac-
cording to the ratios of the last two censuses, and should be
compared with a similar one in Chapter VI showing the increase
and decrease from the first to the second census on more
general lines. It will be seen from Map IV that, broadly
speaking, there has been a steady decrease of leprosy, as
estimated by the census returns, in Bombay and Madras Pre-
sidencies, in the Punjab, North-Western Provinces, Lower
Burma and Coorg, dark blue predominating over these areas.
Since the last enumeration a general decrease is noticed in
Bengal, while in Mysore and a few other tracts a slight increase
has taken place. There are but few districts (dark red) in
which the leper population has steadily increased during the
last thirty years. The increase from 1881 to 1891 nowhere
is great, and the ratios for 1891 are as a rule lower than
those for 1867 and 1871. In studying the map it should be
remembered that many districts were not enumerated on the
first occasion, and careful reference should be made to the
Appendix to this chapter. This, however, is evident from the
E 2
52
REPORT OF THE LEPROSY COMMISSION:
map, that as far as census figures go, the relative decrease of
leprosy since 1867 has been considerable.
It must again be insisted upon that the Commissioners do
by no means regard such figures as absolutely correct, but
nevertheless as the best obtainable and of some value. To
reject them altogether and to substitute numbers derived from
general impressions of medical officers whose attention has
been suddenly attracted to the disease, and from the study of
dispensary returns is unreasonable. Again by others the
figures are objected to and considered worthless, since in an
enumeration the diagnosis is left in the hands of civil and police
authorities. No doubt this detracts greatly from their value,
but as may be seen from the general remarks at the com-
mencement of this report, the fault consists generally in the
inclusion of errors.
The Commissioners found, that where
cases had been collected for their inspection by non-medical
men as a rule, about 10 per cent, had to be rejected on
account of a mistaken diagnosis. It may thus be claimed,
with a fair amount of justness that whatever errors the census
returns contain, they do not under-estimate the true state of
affairs by much, if at all. But in any case, as has been said
at the beginning of this section, those who have spoken of an
alarming increase could not support their assertion except by
the figures of the first and second censuses. The highest
estimates of the actual leper population at the present time
have been two hundred and fifty thousand and five hundred
thousand ( 11 ) and this, if true, would point to an enormous in-
crease since 1881. But such calculations are based on impres-
sions only and are mere guesses of extremely questionable, if
any, value.
The lepers in India have been enumerated on three different
occasions, each time by different men and under altered condi-
tions, and yet we find that the figures of the three censuses agree
as much as can be expected. The total of the leper population
( 11 ) Journal of the Leprosy Investigation Committee, No. II, page 56.
Reg. No. 420, Lep. Com.—Nov. 92.-2,300.
Photo., S. I. O., Calcutta.
Distribution of Leprosy.
53
was somewhere about a hundred thousand in 1871 and this the
original estimate has already been confirmed at two separate
periods. This fact must clearly enhance whatever absolute
value the figures may possess, and allowing that such differ-
ences as there are from census to census cannot be consi-
dered sufficiently conclusive to establish an actual increase or
decrease, the only conclusion that can be supported by any-
thing like logical evidence is that from a hundred thousand to
one hundred and twenty thousand more or less accurately re-
presents the leper population, and also that though it may be
safer to assume that the latter has remained stationary, there is
at least a marked tendency towards a gradual relative decrease.
TABLE IV.
Comparative Statement showing the Changes in the Leper Ratios
since the first Census.
PROVINCE
OR PRESI-
DENCY.
Bengal.
\
DIVISION.
Burdwan
Presidency ".
Rajshahye
Cooch Behar
Dacca ,
Chittagong .
TOTAL FOR BENGAL
PROPER
Patna
Bhagalpur
TOTAL FOR BEHAR
Orissa
Chota Nagpore
TOTAL FOR BENGAL
Ratios per
10,000 (1st
Census).
16.5
5.6
69
57
5.5
2.6
7.8
4.3
3'°3
.9
3.4
2.5
6.0
Ratios per
10,000 (2nd
Census).
19.5
6.8
9.2
• • •
5.6
4.2
9.4
5.5
6.2
5.7
12.4
5.3
8.2
Ratios per
10,000 (3rd
Census).
16.6
4.6
5.3
• • •
4.6
28
6.9
4.0
5.4
4.5
11.0
4.4
6.2
REMARKS.
54
REPORT OF THE LEPROSY. COMMISSION:
Table IV—continued.
Comparative Statement showing the Changes in the Leper Ratios
since the first Census.
PROVINCE
OR PRESI-
DENCY.
Assam .
North-Western
Provinces and Oudh.
Punjab
DIVISION.
Assam
TOTAL FOR BENGAL
INCLUDING ASSAM
Meerut
Agra .
Rohilkhund .
Allahabad
Benares
Jhansi
Kumaun
TOTAL
FOR THE
NORTH-WESTERN
PROVINCES .
Lucknow
.
Sitapur
Fyzabad
Rae Bareli .
TOTAL FOR OUDH .
TOTAL
FOR THE
NORTH-WESTERN
PROVINCES
AND
OUDH
Delhi .
Hissar
Umballa
Jullundur
Amritsar
Lahore
Rawal Pindi .
Ratios per
10,000 (1st
Census).
6.8*
5.9
2.9
2.2
4.2
33
1.9
2.2
21.1
3.2
6.8
7.1
6.9
6.9
6.9
4.2
6.6
4.9
9.2
11.1
6.4
3.3
7.3
Ratios per
10,000 (2nd
Census).
7.0
8.0
3.2
1.7
5.8
3.8
3.6
4.1
16.1
4.1
5.4
3.9
3.1
3.2
3.9
4.0
3.4
2.5
47
3.9
1.5
4.5
Ratios per
10,000 (3rd
Census).
12.3
6.6
2.4
r6
3.9
3.3
2.8
4.0
3.4
5.3
3.6
3.8
4.0
4.1
3.6
1.7
1.4
3.4
1.5
.8
2.5
REMARKS.
*cf. Remarks in
Table V.
Distribution of Leprosy.
5.5
Table IV—continued.
Comparative Statement showing the Changes in the Leper Ratios
since the first Census.
PROVINCE
OR PRESI-
DENCY.
Punjab
Central
Prov-
inces.
Berar
Madras
DIVISION.
Mooltan.
Derajat
Peshawar
TOTAL
FOR THE
PUNJAB
Nagpur
Jubbulpore
Narbada
Chhattisgarh
Upper Godavari
TOTAL FOR THE
CENTRAL
PROV-
INCES
Berar
Grand Total for
Bengal Presi-
dency
Ganjam
Vizagapatam
Godavari
Kistna
Nellore
Cuddapah
Kurnool
Bellary
Chingleptit
North Arcot
South Arcot
Ratio per
10,000 (1st
Census).
3.0
1.9
6.2
3.9
.7
3.4
2.6
1.9
27
6.4
5.2
5.0
3.1
4.1
3.5
3.9
2 9
3.6
37
6.1
6.2
4.8
Ratio per
10,000 (2nd
Census).
1.2
1.3
2.2
3.6
9-0
2.8
77
...
6.5
14.0
6.2
4.0
47
5.8
4.0
3.2
r8
3.4
2.6
10.0
6.3
6 6
Ratio per
0,000 (3rd
Census.)
•6
•6
r6
2.0
*
†
12.7
5.1
5.1
4.9
4.6
2.6
2.8
1.4
2.0
2.8
6.0
5.2
47
REMARKS.
* Not received.
† Not received.
56
REPORT OF THE LEPROSY COMMISSION :
Table IV—concluded.
Comparative Statement showing the Changes in the Leper Ratios
since the first Census.
PROVINCE
OR PRESI-
DENCY.
/
Madras
\
\
(
Lower
Burma.
\
Bombay
V
DIVISION.
Tanjore
Trichinopoly
Madura
,
Tinnevelly
Salem .
Coimbatore .
Nilgiris
Malabar
South Canara
Madras City
TOTAL FOR MADRAS
PRESIDENCY
Arakan
Pegu .
Irrawaddy
Tenasserim .
.
TOTAL FOR LOWER
BURMA
Gujarat
.
Konkan
Deccan
Western Karnatic .
Sind .
City and Island of
Bombay
TOTAL FOR BOMBAY
PRESIDENCY
Ratios per
10,000 (1st
Census).
7.2
2.8
29
47
28
2.2
8.2
6.0
8.1
10.5
4.4
3.8
12.4
...
15.7
11.6
5.4
8.4
11.6
...
1.4
...
8.5
Ratios per
l0,000 (2nd
Census).
5.0
4.0
37
4.7
2.2
1.4
6.3
5.1
9.4
10.7
47
2.8
7.3
9.5
5.5
6.9
2.8
9.2
10.8
2.4
1.1
5.5
6.1
Ratios per
10,000 (3rd
Census).
3.1
2.3
2.1
2.1
1.2
.5
4.0
4.4
8.6
7.6
3.4
3.0
7.1
87
37
6.3
1.9
8.3
9.6
27
7
4.4
5.3
REMARKS.
Distribution of Leprosy.
57
Climate and Leprosy.
The climate, or more correctly speaking the climates, of
India vary considerably in passing from east to west, or in
comparing the extreme north with the most southerly pro-
vinces. Meaning by the term " climate " the average of the
weather as hot or cold, dry or moist, at different seasons
of the year, a brief enquiry will be made as to its possible influ-
ence on the distribution of leprosy.
Climate cannot be
considered the cause of the disease, for leprosy exists in all
latitudes. By comparing the various districts of India, how-
ever, the atmospheric influences upon the malady may be
more efficiently studied. It must not be forgotten that while
discussing the relation between climate and leprosy in so vast
a country, it is impossible to exclude all such factors as food,
race, soil, and habits of the people.
Leprosy is undoubtedly more common between the tropics
than in the temperate zones. India, lying half within the
tropics, is nowhere free from this disease. Still the distribu-
tion of leprosy is very unequal, and it may be asked whether
any law can be established between the dryness and heat of
the climate and the number of the leper population.
To take dryness first. " The west coast of the Peninsula
is very damp, whereas most of the Madras districts on the
east coast, and still more those in the interior, have a compa-
ratively dry climate. But the driest part of the Peninsula is the
tableland around Bellary, the northern district of Mysore, and
that part of the Bombay Presidency that lies between the West-
ern ghâts and the Hyderabad State. In Northern India the
contrast of dryness and dampness is even greater than in the
Peninsula. Sind, with the South-Western Punjab and Western
Rajputana ; is exceedingly dry, so much so that large tracts
are desert and devoid' of vegetation, and agriculture is very
58
REPORT OF THE LEPROSY COMMISSION :
precarious, except where the land can be irrigated from the
rivers. On the other hand, Cachar and Assam are the dampest
provinces in India ; they have no dry hot season like most other
parts of India, and vegetation is green and luxuriant all through
the year. Between these extremes the dampness of the climate
increases gradually from west to east. Thus Eastern Raj-
putana, Central India, and the North-Western Provinces are
less dry than Sind and the Punjab, and their eastern districts
less so than their western ; Behar and Chota Nagpore, which
lie to the east of these, are still damper, and Bengal much
more so, especially its eastern districts and those bordering
on the sea. The dampness of the climate increases also every-
where on approaching the Himalaya, and lofty hills are always
damper than the plains." 12
Looking at the three leprosy distribution maps, it seems
that actually the smallest proportions of lepers are found in
the driest areas. Thus undoubtedly there is less leprosy in
the Madras districts of the east coast than on the west coast,
and in Sind and the South-West Punjab the ratio of lepers to
the healthy population is lower than in any other part of India.
Again, in Bengal a great amount of leprosy prevails, and it may
be said that, in general, passing from west to east an increase
in the relative leper population can be easily traced. Of course,
it is not maintained that the dryness of the climate is the
sole, or even a chief, factor in the numerical distribution of
the disease, yet it must always remain a significant and
suggestive fact that the leper ratios vary inversely with the
dryness of the climate. This is especially well demonstrated
by the censuses of 1881 and 1891. Table V is arranged
according to the above extract from Blandford's " Geography
of India."
( 12 ) H. E. Blandford : op. cit., page 23.
Reg. No. 475, Lep. Com.—Oct. 91.-304.
Reg. No. 475 R Leprosy Com.—Mar 92.—1,004.
Litho., S. I. O., Calcutta.