into all the conditions racial, climatic and social, local, existing in those localof a institution the and ities, comparison between of other places conditions the and those conditions, comparatively free from leprosy suggests itself as the only alternative procedure. Had this plan been followed, we cannot but think that some results less vague and more convincing would tematic
inquiry
Instead of this much valuable time seems to have been devoted to making a hurried general tour over the empire, and the examination of a comparatively small number of cases. In of this, it is to be noted that the have been attaiued.
Jutliau AUGUST 1893.
proof
report of the leprosy commission. Before of the
proceeding to
Commission,
we
review the
report
wish to record
be
of deep regret at the loss susonly by the Commission, but by the Indian Service, in the sad and untimely death of the late Surgeon-Major Arthur Barclay, who was justly held in the highest estimation botli in private and professional life by all who were privileged to kuow him.
mission
of the Cominto the truth of the
object
abstract
These figures
1881. 6*0
1891. 60
that any such plainly that above alluded to will not bear statement examination, and is manifestly a gross exaggeraIt is, however, probable, though not defition. in the report that there were other stated nitely
objects which induced the Commission to leave London, where they couldequally well have been furnished with the census reports, and to make a sojourn for one year in India. From this staudpoiut it is impossible to regard the method the
Commission
as
We can readily understand that, with the limited time at their disposal, and the large area of British India and Burma ?with the Native States, exhaustive investigation of the whole area was impracticable. The selection of notoriously bad localities with systhe most commendable.
no more
than two
days
Dehra Dun, Kumaon, Chamba and Jummoo. Indeed the time spent in all of these places, with possibly the exception of Almora, was useless for any serious purposes of investigation, while
pears
shew
investigation adopted by
spent
which is shown
by the last census to lepers per 10,000, apvisited at all; and, judg-
have between 20 and 30
as
of
and
on?Why should the Burdwan Divisiou consistently show almost the highest relative number of lepers ? The same remarks apply to
Chamba,
Proportion per 10,000 of population. 1871. 5*5
locality,
member of the Commission visited
there, in which time he examined 23 cases out of a leper population which, according to the census of 1881, was 4,118. So that in the worst district less than ^ per cent, were examined. And this in face of the question which the Commissioners
that
Lepers
one
ask later
that the main to
this
inquire leprosy was becoming "an imallegations perial danger," we consider that they have amply proved their case, as is shown by the census statistics, of which the following is a brief was
one
yet only
not
Assuming
by the census of 1871 and 1881 to of the worst localities in India for leprosy,
known
was
our
expressions
tained,
number of cases examined amounted to less than 2,500 out of a total of 105,000, that is to say, less than 3 per cent. Again, although Burdwau
not to have been
diary of the Commission and the asylums and localities visited, no part of Eastern Bengal, which is referred to by them as having leprosy so generally prevalent in it, was ing
from the
map of
Some of these localities would have been especially valuable sources of information in determining the incidence and prevalence of seen.
leprosy.
Inasmuch
as
in all three
censuses
the
highest ratios were found in Bankura, Burdwan, Birbhum, Simla, Dehra Dun, and Kumaon, some light might have been thrown upon the conditions influencing so constant a prevalence in these places. This is all the more important, because it is impossible to resist the conclusion that leprosy so far from diminishing in some of the particular areas where it was prevalent, has actually increased. Ellichpur, for example* increased from
Ado.
REPORT OF THE LEPROSY COMMISSION IN INDIA.
1893.]
271
ratio of 16*5 iti 1891; all diseases especially of a zymotic and allied Goalpara from 7'3 to 19*3; Manbhura from 54 nature. It is necessary here also to take exto 12 3; Pooree from 3 3 to 155; Sylhet from ception to cholera being classified as a "fever," 10 to 13*5; Ward ha from 6-8 iu 1871 to 129 inasmuch as all available evidence is against in 1881. Moreover, taking into consideration such a view of the disease, and there is no new the fact thut. owinc to the conditions of life in evidence adduced in the report in support of O India very few women were seen, and that very such a hypothesis. Admitting, so far as Benfew are probably returned in the census as lepers, gal is concerned, that a general survey of the be even proviuce bears out the contention of the Comthe actual in all ratio of 5'6 in 1871
a
to :i
"
figures would,
probability,
higher thau these. Seeing also that the average mission that cholera and leprosy are coincident, duration of life iu lepers is, according to the still when we come to examine the districts in Commission, from 9 to 12 years, in the ten years' detail we find that of the entire endemic area
interval between the censuses, some 70 or 80 per of cholera, certain portions display a great precent, at least would have died. Consequently, valence of leprosy; while, on the other hantl, at least half this area is as free from leprosy as even a maintenance of the average points to fresh supplies of lepers to take the place of those re- other parts of Iudia outside the endemic area moved by death, while any increase iu the ratio of cholera; and, moreover, it has not been shown increase of that this large portiou in the endemic area of indicates a much
larger proportionate
lepers is cholera, where the leprosy ratio is not high, differs a factor of much an investigation in any essential details as regards poverty, overimportance of this nature, but curiously enough appears to crowding and insanitary conditions from that in have escaped notice in this connection. In ad- which the leprosy ratio is always high. Further,
the
disease.
The
high mortality
among
in
dition to this it is to be noted that the birth-
among lepers is abnormally low, the procreative powers being much diminished, so that by the end of ten years, which is the interval rate
between the censuses, these two causes, if not counterbalanced by other opposing forces, would lead of themselves to a very large reduction iu the number of lepers, but this reduction does
not occur.
shown that the increase or decrease population bears no constant relative proportion to the leper ratio, and having deduced from this that the general mortality is not the best index of the insauitary condition of a district, the Commission proceed to take cholera as a test of the climatic and local healthiness and sanitary state of an area, and in
Haviug
of the
this
we
only
be
are a
disposed
to coucur,
qualified approval,
though
for there
it
are
can
many
producing insanitary conditions, and of very few, and those of a very special kind,
factors
these are needed for cholera prevalence. The Commissioners do not show that the same insauitary
influences which are essential to the prevalence of cholera are those which are essential to the prevalence of leprosy, so that the test is incomplete, and finally resolves itself into a general statement that all insauitary conditions without elimination of any predispose to leprosy; but this general statement applies equally well to
when we come to Northern India, we find that the argument falls to the ground entirely, inas_ much as in the districts which admit of comparison, Kangra and the districts adjoining it, have much leprosy, and Jullundur, which is stated by
the Commission to have the densest leper population in the Punjab, are all withiu that area which is marked 011 their map as free from cholera endemicity. Again, in Southern India, the same contradiction is evident. And we are not dis-
posed
to admit that it has been showu that the
districts which suffer most from fever are those which have the greatest incidence of leprosy. The observation might possibly have applied to the Burdwan Division during the deceunium from 1871 to 1881, but in the last decennium other
districts, such
been
more
as
Nuddea and Jessore, have
fever-stricken without
a
correspond-
ing rise in leprosy. An important fact brought out by the Commission is that in times of famine the leper population suffers very severely and consequently decreases, but we think that sufficient importance is not given to this consideration when discussing the general increase or decrease of the leper population. They show that "most persons became
30; the
lepers between the frequent time
next most
ages of 26 and of onset was
from 21 to 25 years of age, then from 16 to 20." Well, between 1878 and 1891, there is an interval of 13 years, so that the people who would be be-
'
272
INDIAN MEDICAL GAZETTE.
tween 16 and 26 in
1890, would be between
2
and 12 in 1876, an age at which mortality from famine would be comparatively greater than among older people, consequently there would be fewer people in 1891 among the population
predisposed to leprosy at the age at which leprosy begins to appear. This may be held to be one of the factors which goes to explain the diminution of leprosy in 1891 in those districts affected In with famine during the period in question.
Orissa, however, we find, in spite of a severe famine in 1866, that in the census of 1881 we have an actual increase, and in 1891, with no famine between the censuses, a continuous increase. Now,
seeing that a
large
the famine in 1866 must have removed
number of lepers, and that nevertheless in
15 years we find an actual increase of lepers, one of two things must have happened : either there must have been
a
large
must have
lepers
or
local increase of to this
immigrated
leprosy, province
from elsewhere, *If the latter circumstance was in operation then it would account for some of the diminution elsewhere, and in this case there would be
merely displacement
from
one
district
to another.
careful
perusal
of this first
the Commission's
report,
our
After
a
portion
of
conclusion differs
by the Commission, is that viz., leprosy kept up by insanitary conditions and poverty producing a special predisposition; while our contention is that pestilence and famine, and we might add floods, in virtue of the heavy mortality they cause are the principal agents which have kept down leprosy. toto ccelo from that arrived at
AVe agree with the Commission that "a disease only be endemic in an area where all the conditions leading to its acquisition exist." This
can
to all
applies
nearer to
zymotic diseases, and brings us no problem as to what
the solution of the
conditions favouring the prevaleprosy. To assume that the virus of is widely distributed throughout space, leprosy are
the
special
lence of
and hence the disease is
highly prevalent where insauitary conditions prevail, is a hypothesis without any support. lj the virus is widely distributed through space contagion may be practically neglected, since all measures directed "
against the latter could be ing out the disease." This statement, and
proviso they which
go
having on
f
no
is the
avail in
stampCommissioners'
laid down the necessary
to assume the very
priuciple
requires proof before their conclusion
cau
be
[Aug.
1893.
"
They say, Assuming that since the disease is highly prevalent, the virus is roidehj distributed through space." The premises are assumed consequently, and the whole arguaccepted.
ment is inadmissible.
Further,
with tetanus to
leprosy argument, forgetting
compare
the Commission
exemplify
their
that the tetanus microbe
be cultivated apart from the human body and is to be found in many localities, while that of leprosy cannot be cultivated outside the
can
any means at present known. We shall deal with the rest of the report in a further article.
human
body by
inquiry
Instead of this much valuable time seems to have been devoted to making a hurried general tour over the empire, and the examination of a comparatively small number of cases. In of this, it is to be noted that the have been attaiued.
Jutliau AUGUST 1893.
proof
report of the leprosy commission. Before of the
proceeding to
Commission,
we
review the
report
wish to record
be
of deep regret at the loss susonly by the Commission, but by the Indian Service, in the sad and untimely death of the late Surgeon-Major Arthur Barclay, who was justly held in the highest estimation botli in private and professional life by all who were privileged to kuow him.
mission
of the Cominto the truth of the
object
abstract
These figures
1881. 6*0
1891. 60
that any such plainly that above alluded to will not bear statement examination, and is manifestly a gross exaggeraIt is, however, probable, though not defition. in the report that there were other stated nitely
objects which induced the Commission to leave London, where they couldequally well have been furnished with the census reports, and to make a sojourn for one year in India. From this staudpoiut it is impossible to regard the method the
Commission
as
We can readily understand that, with the limited time at their disposal, and the large area of British India and Burma ?with the Native States, exhaustive investigation of the whole area was impracticable. The selection of notoriously bad localities with systhe most commendable.
no more
than two
days
Dehra Dun, Kumaon, Chamba and Jummoo. Indeed the time spent in all of these places, with possibly the exception of Almora, was useless for any serious purposes of investigation, while
pears
shew
investigation adopted by
spent
which is shown
by the last census to lepers per 10,000, apvisited at all; and, judg-
have between 20 and 30
as
of
and
on?Why should the Burdwan Divisiou consistently show almost the highest relative number of lepers ? The same remarks apply to
Chamba,
Proportion per 10,000 of population. 1871. 5*5
locality,
member of the Commission visited
there, in which time he examined 23 cases out of a leper population which, according to the census of 1881, was 4,118. So that in the worst district less than ^ per cent, were examined. And this in face of the question which the Commissioners
that
Lepers
one
ask later
that the main to
this
inquire leprosy was becoming "an imallegations perial danger," we consider that they have amply proved their case, as is shown by the census statistics, of which the following is a brief was
one
yet only
not
Assuming
by the census of 1871 and 1881 to of the worst localities in India for leprosy,
known
was
our
expressions
tained,
number of cases examined amounted to less than 2,500 out of a total of 105,000, that is to say, less than 3 per cent. Again, although Burdwau
not to have been
diary of the Commission and the asylums and localities visited, no part of Eastern Bengal, which is referred to by them as having leprosy so generally prevalent in it, was ing
from the
map of
Some of these localities would have been especially valuable sources of information in determining the incidence and prevalence of seen.
leprosy.
Inasmuch
as
in all three
censuses
the
highest ratios were found in Bankura, Burdwan, Birbhum, Simla, Dehra Dun, and Kumaon, some light might have been thrown upon the conditions influencing so constant a prevalence in these places. This is all the more important, because it is impossible to resist the conclusion that leprosy so far from diminishing in some of the particular areas where it was prevalent, has actually increased. Ellichpur, for example* increased from
Ado.
REPORT OF THE LEPROSY COMMISSION IN INDIA.
1893.]
271
ratio of 16*5 iti 1891; all diseases especially of a zymotic and allied Goalpara from 7'3 to 19*3; Manbhura from 54 nature. It is necessary here also to take exto 12 3; Pooree from 3 3 to 155; Sylhet from ception to cholera being classified as a "fever," 10 to 13*5; Ward ha from 6-8 iu 1871 to 129 inasmuch as all available evidence is against in 1881. Moreover, taking into consideration such a view of the disease, and there is no new the fact thut. owinc to the conditions of life in evidence adduced in the report in support of O India very few women were seen, and that very such a hypothesis. Admitting, so far as Benfew are probably returned in the census as lepers, gal is concerned, that a general survey of the be even proviuce bears out the contention of the Comthe actual in all ratio of 5'6 in 1871
a
to :i
"
figures would,
probability,
higher thau these. Seeing also that the average mission that cholera and leprosy are coincident, duration of life iu lepers is, according to the still when we come to examine the districts in Commission, from 9 to 12 years, in the ten years' detail we find that of the entire endemic area
interval between the censuses, some 70 or 80 per of cholera, certain portions display a great precent, at least would have died. Consequently, valence of leprosy; while, on the other hantl, at least half this area is as free from leprosy as even a maintenance of the average points to fresh supplies of lepers to take the place of those re- other parts of Iudia outside the endemic area moved by death, while any increase iu the ratio of cholera; and, moreover, it has not been shown increase of that this large portiou in the endemic area of indicates a much
larger proportionate
lepers is cholera, where the leprosy ratio is not high, differs a factor of much an investigation in any essential details as regards poverty, overimportance of this nature, but curiously enough appears to crowding and insanitary conditions from that in have escaped notice in this connection. In ad- which the leprosy ratio is always high. Further,
the
disease.
The
high mortality
among
in
dition to this it is to be noted that the birth-
among lepers is abnormally low, the procreative powers being much diminished, so that by the end of ten years, which is the interval rate
between the censuses, these two causes, if not counterbalanced by other opposing forces, would lead of themselves to a very large reduction iu the number of lepers, but this reduction does
not occur.
shown that the increase or decrease population bears no constant relative proportion to the leper ratio, and having deduced from this that the general mortality is not the best index of the insauitary condition of a district, the Commission proceed to take cholera as a test of the climatic and local healthiness and sanitary state of an area, and in
Haviug
of the
this
we
only
be
are a
disposed
to coucur,
qualified approval,
though
for there
it
are
can
many
producing insanitary conditions, and of very few, and those of a very special kind,
factors
these are needed for cholera prevalence. The Commissioners do not show that the same insauitary
influences which are essential to the prevalence of cholera are those which are essential to the prevalence of leprosy, so that the test is incomplete, and finally resolves itself into a general statement that all insauitary conditions without elimination of any predispose to leprosy; but this general statement applies equally well to
when we come to Northern India, we find that the argument falls to the ground entirely, inas_ much as in the districts which admit of comparison, Kangra and the districts adjoining it, have much leprosy, and Jullundur, which is stated by
the Commission to have the densest leper population in the Punjab, are all withiu that area which is marked 011 their map as free from cholera endemicity. Again, in Southern India, the same contradiction is evident. And we are not dis-
posed
to admit that it has been showu that the
districts which suffer most from fever are those which have the greatest incidence of leprosy. The observation might possibly have applied to the Burdwan Division during the deceunium from 1871 to 1881, but in the last decennium other
districts, such
been
more
as
Nuddea and Jessore, have
fever-stricken without
a
correspond-
ing rise in leprosy. An important fact brought out by the Commission is that in times of famine the leper population suffers very severely and consequently decreases, but we think that sufficient importance is not given to this consideration when discussing the general increase or decrease of the leper population. They show that "most persons became
30; the
lepers between the frequent time
next most
ages of 26 and of onset was
from 21 to 25 years of age, then from 16 to 20." Well, between 1878 and 1891, there is an interval of 13 years, so that the people who would be be-
'
272
INDIAN MEDICAL GAZETTE.
tween 16 and 26 in
1890, would be between
2
and 12 in 1876, an age at which mortality from famine would be comparatively greater than among older people, consequently there would be fewer people in 1891 among the population
predisposed to leprosy at the age at which leprosy begins to appear. This may be held to be one of the factors which goes to explain the diminution of leprosy in 1891 in those districts affected In with famine during the period in question.
Orissa, however, we find, in spite of a severe famine in 1866, that in the census of 1881 we have an actual increase, and in 1891, with no famine between the censuses, a continuous increase. Now,
seeing that a
large
the famine in 1866 must have removed
number of lepers, and that nevertheless in
15 years we find an actual increase of lepers, one of two things must have happened : either there must have been
a
large
must have
lepers
or
local increase of to this
immigrated
leprosy, province
from elsewhere, *If the latter circumstance was in operation then it would account for some of the diminution elsewhere, and in this case there would be
merely displacement
from
one
district
to another.
careful
perusal
of this first
the Commission's
report,
our
After
a
portion
of
conclusion differs
by the Commission, is that viz., leprosy kept up by insanitary conditions and poverty producing a special predisposition; while our contention is that pestilence and famine, and we might add floods, in virtue of the heavy mortality they cause are the principal agents which have kept down leprosy. toto ccelo from that arrived at
AVe agree with the Commission that "a disease only be endemic in an area where all the conditions leading to its acquisition exist." This
can
to all
applies
nearer to
zymotic diseases, and brings us no problem as to what
the solution of the
conditions favouring the prevaleprosy. To assume that the virus of is widely distributed throughout space, leprosy are
the
special
lence of
and hence the disease is
highly prevalent where insauitary conditions prevail, is a hypothesis without any support. lj the virus is widely distributed through space contagion may be practically neglected, since all measures directed "
against the latter could be ing out the disease." This statement, and
proviso they which
go
having on
f
no
is the
avail in
stampCommissioners'
laid down the necessary
to assume the very
priuciple
requires proof before their conclusion
cau
be
[Aug.
1893.
"
They say, Assuming that since the disease is highly prevalent, the virus is roidehj distributed through space." The premises are assumed consequently, and the whole arguaccepted.
ment is inadmissible.
Further,
with tetanus to
leprosy argument, forgetting
compare
the Commission
exemplify
their
that the tetanus microbe
be cultivated apart from the human body and is to be found in many localities, while that of leprosy cannot be cultivated outside the
can
any means at present known. We shall deal with the rest of the report in a further article.
human
body by
