NOTE ON THE VARIATIONS IN THE INCIDENCE OF CHOLERA ON THE POPULATION OF TOWNS AND VILLAGES, By Surgeon-General S. C.
Townsend, c.b. ( Concluded from page 62.) 34. We may now enquire how far these results of the analysis of the cholera statistics of six towns in the Punjab are confirmed by the statistics collected in the Central Provinces,
which
to
statistics
have
I
were
These
alluded.
previously
collected from 31 towns and in different districts of
over
the villages, in be found will and province, my report they on the epidemic of 1875-76. As they are very voluminous, I propose to reproduce here only 400
such of them
as
illustrate the variations
in
the
analysis of the already brought into view.
incidence of cholera which the
Punjab
statistics has
Table IX. shows the incidence of cholera on the populations of certain tow?is in the Central Provinces in 1875'
76:? Total
from cholera 1,471.
109,293.
Cases
pkr mille
OF POPULATION.
Deathsi millejIcent.
Deaths
PER
per of population.
of ca.VSES.
Towns. Both sexes.
Garakota Deori
Both
Both
M.
sexes.
81 "9
34'5
34'4
34-7
85-3
36-6
28"I
45*2
4? 4
34'7
67-9
i6'3
9*7
23*2
42-7
35'9
49'2
2I'S
i9'3
23-7
29*2
28*0
30 'o
13-6
15*9
Sindi
27'3
20*2
3? "4
6*9
6'i
7*7
23 "9
22*6
25 "4
9-8
9*5
io'o
Hinganghat..
16-5
14-2
i8"9
3*8
3'?
4*6
"5
i"o
2'0
Arvi
Mangel!
6*7
ii'i
1
those of the per cent, of of females.
liability
tics
we
Upper
27-5
21*3
Merwara
Sambalpur
..
29'5
30*2
9*8
II'I
8*5
Mangeli
41
43
40
35. On comparing the above table with Table VI., it will be observed that cholera was far more diffused among the population of the towns of the Central Provinces in 1875-76 than
extensively
towns in 1881.
The above table
also exhibits greater variation in the ratios of prevalence in the several towns as well as in the
fatality among those attacked. The excessive liability to cholera of females compared with males also comes out very prominently in the above table ; the ratios of cases for females are in excess of the ratios for males in nine of the towns
given,
very great.
and in many the excess was In the three lowest in the table,
however, the ratios for males those for females.
are
in
among Hindus while the lower
Cases of cholera per mille of each class.
Hindus.
Hindus.
22*7
Punjab
of women
Towns.
32*2
14-0
marked
more
liability
constant
LATION.
29'8
in the
more
OF TOTAL POPU-
22*0
*6
was
CLASS PER CENT.
37*2
12
found that the greater
Number of each
61'o
13*3
the
as
ed in Hindus.
42'S
34*4
well
than among Muhammadans, of cholera in women was also less mark-
75*8
28-9
as
of females to
fatality
39'9
31-7
This,
in favor
uniformly
not so
form a very small component of the population of the Central Provinces, for it will be remembered that in the analysis of the Punjab statis-
.,
..
of
cholera, may be partly ascribed to the circumstance that Muhammadans
Lodikhera
Mean
fatality
but the ratios of deaths
Punjab,
cases are
ii*4
Saugor
of the lower
point
Table X. shows the incidence of cholera on different classes of the population in certain towns of the Central Provinces.
sexes.
69'3 ..
..
F.
55'7
Wardha
Sehora
M.
On the
36.
cholera in women, the statistics of the Central Provinces are, on the whole, in accordance with
to cholera
Deaths
Cases of cholera 3,471.
population
Gadawara
87
TOWNSEND ON THE INCIDENCE OF CHOLERA.
1883.]
April,
excess of
12
7
Sehora Wardha Rehli Garakota Chanda Sindi Damoh Khandwa Gadawara
11
IS 11 10
8 11
14 23
Sambalpur Hoshangabad Raipur *
Chamars, Dhers,
draw
from the
water
37.
on
11
69 64 54 70
17-6
45'?
99 "4 21 *o
44'5 3?'5
204-3 171*1 137-2
62-4
69*6
1076
16 18 16
25
25 '2
36
27-8
22
IO'O
76
68
13 18
23^ 3 "4
63
14 12
78*2
20
31-2
71 82
21
33'6
23 19
59
58
18 23
63
10
Low*
40-4 147 3'9
29-S 32-5
i6-6 24 "4 2
"O
o*8 68-2 20 9 44-4
79'2
62-5 5?'3 47 "4 15-0 3"4
64*5 27'5 19-0
297
27-8
iro
7'9
14-1
2*0
Mehtars and other castes which are not sources with the general population.
allowed
to
same
manner
of cholera
77 77 7i
Upper
castes. castes.
73
The above
striking
castes
17 8 8
15
Saugor
Lodikhera
Low*
castes
table
illustrates in
the variations
a
very
in the incidence
the different sections of which the
of the towns and
populations villages are composed. In all of the towns cholera fell with unequal severity on Muhammadans and upperHindus, and in many the difference was great; but the most marked difference occurs in
caste
THE INDIAN MEDICAL GAZETTE.
;6'6 43*3
27 o
23*3
22-5
26-3 l6"5
1V9
i6-4
19-1 33'4
29-;
25'4
24*2
11
2-8
i'5
4*5
397
36-0
357
27-0
24'3
26'0
30-5
34-6 3*9 3*2 31'2
28-3
20'6 ...
197 villages in the district
villages in the districts of Jabalpur, Damoh, and Wardha
Belaspur
26*9
22*3
25-0
28-5
The
numbers
at
living
220
12 towns
1**33
2,418 1,285 district
197 villages in the Belaspur
...
villages in the districts of Jabalpur, Damoh,.and Wardha 220
15*4
19-6 3?'5
M. M.. F. Both
14
2,457
1.156
1,529 3.371 towns 12
28-8
37'o
30*8 36*3 23'2 25*9
M.
20?40. Under 1 year
cases
of the 317 307 191 131 230 303 340
301
216 193 219 261 1,30j
146 154 338 525 183
465 7S6 252 308 179 243 271 303 347
1,842
276
F. Both
sexes.
M.
M.
F
M.
F.
M.
F
M.
F.
M. F. M.
40 and
6?12. 1?6. year.
Under 1
All ages.
Number of cases at each period.
Total Number of Cases
8,24.6.
20?40.
in the Central Provinces.
different periods of life at
of cholera Table XL shows the incidence
upwards.
males of these different classes.
F
I much regret that I am unable to show the incidence of cholera on the males and fe-
38.
M,
higher upper-caste Hindus, it is considerably below the ratio for Muhammadans; in Raipur, while the uppercaste Hindus suffered severely, the low castes almost escaped.
F,
the ratio for the low
ratio for
All ages.
though
than the
M.
for instance,
I
Saugor, castes is
Cases ter 1,000 living.
On
in Table XI.
entirely.
a
different ages given
almost
castes
hand, in
at
escaped
few of the towns, the low suffered less than the other classes ; in
the other
Table XII shows the ratios per mille
the other classes
of cholera
madans and upper-caste Hindus. In Khandwa and in Damoh the low castes were attacked, but
M.
severity
this class, and the ratios for it are from four to five times higher than the ratios for Muham-
on
M.
extreme
towns
sexes.
fell with
epidemic
of the
40 and
large majority
upwards.
the
a
6?12.
given,
In
1?6.
the low castes.
[April, 1883.
different ages
which the ratios in the above table have been
computed
from
the
census
1871, and the ratios may be taken very
fairly
cholera
on
the
incidence of the
the two
sexes
collected
to
on
based,
tables of represent
epidemic
of
at different ages in the
several groups of population. 39. We find from the above statistics
are
over
tables,
the wide
area
that the of the
Central Provinces coincide with those of the few towns in
under
the
Punjab,
one year
of age
in are
showing almost
that infants
exempt
from
April,
liability
The
to cholera.
tables of
census
1871
did not permit of my being able to show the ratios of liability in the several years of life between 1 and
6, but from the following figures it from cholera
would appear that the exemption extends in a considerable degree the second year of life
infants
to
as a
high
24 7 52
92
301
46
no
485
316
205
the
the above
1,224
mortality
con-
among children up to the fifth the number living diminishes
sixth year, rapidly, and consequently the ratio of or
438
61
full fourth of the children born as
figures though immensely
cases on
second year of life, in excess of the ratio for the for the
first year, would be small compared with the It ratio for the third and subsequent years. would
appear, therefore, under which infants under
that
condition
the
year of age are
one
rendered exempt from cholera, covers to a considerable extent children in the second year of life ; and as native women, as a rule, continue to
their infants
suckle
long
after
they
have
reached the age of one year, it may be inferred that the immunity of infants from cholera con-
only so long as they are fed from the breast. 41. The liability of children to cholera in the third year of life is high, but it is considerably higher among children between 3 and 6 ; and tinues
these statistics of the Central those of the
ing
Punjab given
that children from 3
Provinces confirm
II, in indicat-
in Table or
4 to 5
or
6
are
more
liable to cholera than persons at any other age. There is an increase in liability among old people
compared with persons of middle age. riod of least
liability is
between
12
The peand 20, but it is
much greater among males at ages 20 to 40. 42. It will be remembered that in the Punjab
not
statistics
(Table V)
children under
12, the
it
12 towns
appeared liability to
that among cholera was
on
of different
persons
ages in the Provinces and in the
of the Central
of
villages 114
...
die in their first year, and tinues very
especially pronounced in females in the period of life 20 to 40 ; we now find that these points are amply borne out by the statiswas
tics in the above table which show the incidence
3-6
2?3
year.
Cases of cholera in 12 towns Villages of Jabalpur and other districts Villages of Belaspur district
Now,
greater in boys than in girls, but that at subsequent periods of life it was greater in females than in males, and that this greater liability
of cholera 1
Total
in
:?
Under
40.
89
TOWNSEND ON THE INCIDENCE OF CHOLERA.
1883.]
and
Jabalpur
other
districts.
It
appears that, in these two groups of populations, the excess of male cases over female was limitthe ages between 1 the numbers of cases of the ed
to
to 6 ; at ages two sexes
ly equal,
but the female ratios
the male
in the
ratios;
period
are
in
12 to 20
6 to
are
12
near-
excess
there is
of a
decreast in the numbers of both male and female cases, but the female
in
are
excess
of the male
cases, and in the
period 20 to 40 this excess becomes very remarkable; it' is considerable also among old people. We find, however, that in the third group in the table (the villages in the Belaspur district) the relative number of cases in the
two sexes
are
in contrast with
their relation in the other two groups. 43. In Table IX. it appeared that, in the
greater number of the towns, females had suffered from cholera in far larger proportion than the males ; but examples were given in which the reverse obtained. The most notable of these
was
district; and
town in the
Belaspur
Mangeli,
a
we
find in Table XI. that
now
what occurred in the towns also occurred in the
villages
females
; instead of the
the
than the males, groups of populations, males as
was
two
in somewhat
higher proportion
The
of male
excess
in the other
period
1
more
in the other
were
attacked
than the females.
female cases, which
groups was limited to the to 6, extends in the third group to all the period 20 to 40 the numbers and
ages ; at ratios of the
great
over
suffering
case
excess
two
two sexes are
of female
nearly equal, but the compared with male
cases
cases at ages 12 to 20 and 20 to 40 which is so marked in the figures of the towns and Jabalpur
villages does not Beldspur villages.
occur
in the
figures
of the
THE INDIAN MEDICAL GAZETTE.
9?
From the above
44-
analysis Punjab and
cholera in the
of
Provinces,
find that both
we
coincide in
of the statistics
Punjab
in the Central
above tables, and also in the villages of Jabalpur, the number of women attacked was very largely
of statistics
sets
evidence of the
affording
following
facts :?Cholera exhibits incidence
on
great variation in its different units of population, and
varies in
of diffusion among the inhabitants of different towns in which it may
it not
only
become
epidemic,
extent
shown
as
the number of
by
persons attacked, but it also varies in virulence and intensity of action as shown by its fatality, or
the deaths in
to
follow from this,
proportion to cases. It appears that, though an outbreak of cholera, in a unit of population, may be due primarily to some malefic influence pervading the atmosphere, or to a specific contaghim commu-
in
and of the Central Provinces
for females and the
was
villages
the
that
in this local condition
or
Cholera varies
45. different units of
on
its incidence
unit.
Taking
on
on some
varying quality
factor.
only population, not
in
its incidence
all the
same
Punjab towns the statisgiven above, the mean
tics of which have been
ratios of cases per mille of Muhammadans and Hindus, for both sexes, were nearly equal, yet in individual towns the incidence
on
the
two
classes
very unequal ; from this it is apparent that, while, as regards class, Muhammadans and Hin-
more
subject
equally liable to cholera, the local may operate unequally on the two classes same locality. are
two
may be due
much
47. In
a
very
This lower fata-
constitutional but it is
peculiarity probably
more
difference in mode of life.
marked
in Muhammadan
Hindu
Punjab
From the tables
in
constant
those of the
striking
relating to
It is
than
more
than in
statistics
Central Provinces, but several of it occur in Table IX.
instances
the incidence
of cholera persons of different ages, the points that come most prominently into view are ; that on
infants to
almost
are
females
entirely exempt
and that the
cholera,
at
occurs
The
50.
20
to 40.
of infants
it is limited
to
occurs
the
period
in all when
the breast, we infer that it is due this condition. Older children are, more than are
fed
as
liability liability of
all ages above the age of 6,
exemption
localities, and,
from
excessive
but is most marked at ages
to
unequally on the two sexes. large majority of the towns of the
to a
in the
49.
less
generally considerably
to the sex, to
more
any other
at
class, liable
to
cholera.
The excessive
liability of females, above 51. the age of six years, to cholera is found to vary in different localities, and, while occurring both in Muhammadan to
be
more
and Hindu
marked and
to
women, is found
commence at an ear-
lier age among Hindu women ; we therefore infer that it is due to some occupation by which women are
the local
Cholera falls
women.
women, and is therefore
in the
classes.
as-
of cholera
prevalence
fatal in females than in males.
they
ing the excessive severity with which cholera commonly falls on certain castes. Muhammadans may become more subject to the local factor in one locality, the upper-caste Hindus in but the low castes more another; commonly come under its operation than either of the other
is
Cholera
48.
factor
46. The statistics of the Central Provinces furnish additional evidence on this point in show-
may therefore be
the action of this local factor
to
than Muhammadan
was
dus
It
among females, where it occurs, is due to the operation of the local factor. Hindu women are
it also varies in
different sections of the
in contrast with those of
this greater
attributable
dependent
lower than the ratio for males, Belaspur district are, in
district.
Jabalpur
sumed
In
cases
of the
respect of this point,
operation the presence of a local adjuvant or factor, and it may be assumed that the varying intensity of the operation of the primary or essenis
in the
of the number of males attacked.
excess
lity appertaining
cause
given
several of the towns, however, the ratio of
nicated by human intercourse, the influence or contagium, whichever it may be, requires for its
tial
[April, 188.3.
women
that in
commonly brought
into contact with
factor
men,
more some
more
than
than Muhammadan localities this
and
Hindu
women,
occupation
does
but not
the
place tion
in
women
unfavourable
a more
cholera than
regards
as
would
but
posi-
In fact it
men.
for this
occupation, appear that, would be less liable to cholera than
women men.
The
52.
problem, then, is,
find the local
to
condition which meets these variations in the incidence of cholera tion and
are
operation
exempt, but
to the
same
operation
of
specially Hindu women, are subject in a greater degree
which women, and in many localities men.
I believe this condition
53. in the
of the
water-supply
circumstances
the
unit ; of which infants
different sections of the
on
at the breast
than
different units of popula-
011
condition from the
a
is to be found In
people.
conditions
or
none
of
of life under
people live is there so great variation quality of the water which they use for
which the as
in the
drinking, and in the which they draw it. river
or
stream
in another
ply, ply may
nature
In
of the
sources
town
one
an
open
be drawn from
may be
foul
or
from
village
a
source of supthird the supbut the wells will
will form the chief
tank, wells,
in
a
differ in construction and state of some
mere
holes sunk
at
repair, edge
the
and of a
pool.
54. In the towns and larger villages the sources of supply will be numerous, and each section will have its
own
wells
or
tank ; and it is
to
this
that the variation in the incidence of cholera the different sections is
attributable;
on
on
the
other hand, the inhabitants of many of the smaller villages are dependent on a single source of
supply,
and to this is due
a
circumstance that
all
wide-spread epidemics, vis.y that although the epidemic may reach comparatively few of the small and remote villages, the proportion of the population attacked, when it does reach them, is often far greater than in the large villages and towns in which the sources of supply are numerous ; in proof of this assertion I need only refer to the Annual Report for ] 881 of the Sanitary Commissioner for the Punjab. In the epidemic of that year, the mortality in the towns that suffered most severely from cholera occurs
in
no
in
case
9*
TOWNSEND ON THE INCIDENCE OF CHOLERA.
1883.]
April,
exceeded
12 per
mille, but in many of
the small
it
villages
from 25 to
ranged
100
per
mille.* The excessive
55lera
falls
severity
with which cho-
the low castes, also
commonly points to the water-supply on
as
the local factor
to
which the variation in the incidence of cholera different
on
These castes food and
population is due. necessarily, in respect of
sections of are
not
living,
a
off than many other higher place in the religi-
worse
castes which take
a
scale of castes ; they fulfil necessary functions in the communities in which they live, and
ous
are
perhaps
less
subject
than other castes
;
to
but in
vicissitudes of life
respect of
water-
the distinctly separated rest of the community ; they are not allowed even to approach the well or tank from which the other castes draw their supply, and they are thus commonly driven to inferior sources of supply. 56. That the exemption of infants from liability to cholera may be taken as evidence of a relation between cholera and water-supply, will scarcely be denied, and, with regard to the excessive liability of adult women, there is little
supply they
room
are
from
for doubt that it is connected with their
daily occupations which bring them so much in contact with impure water. 57. One of the chief occupations of Hindu women of all but the highest classes, and of Muhammadan women also, but to a less extent, is drawing water and washing clothes. Muhammadan women are kept more in seclusion, and none but those of the poorest class are permitted to engage in any outdoor occupation ; but any one entering a Hindu village in the early morning will find the female population, from girls to old women, drawing water from the various sources, and during the day large numbers will be employed in washing clothes or cooking-utensils. The water they take home for domestic use is commonly drawn from a well 01* some other source comparatively safe from pollution, but the washing they will do in a *
See also
Report vinces.
on
a
remarkable table at page 29 of the synopsis of the epidemic of 1875-76 in the Central Pro-
the cholera
THE INDIAN MEDICAL GAZETTE.
92
neighbouring and
stream
or
tank
or
stagnant nullah,
often drink of the water in
doubt
they working. Not unfrequently cholera will be confin58. ed almost entirely to women so employed, or they will be the first attacked. In the epidemic of 1866, at Nag pur, out of 40 cases reported during the first week, 8 only were males and 32 females ; and in the epidemic of 1868, of 52 persons attacked during the first week, 43 were females and only 9 males. Of 18 adults attacked in the town of Bhundara in 1875, 14 were women and only 4 men ; and in the following no
which
they
year, in the
arc
and
2i were women
59. stream
town, of 26
same
Where, forms
as
adults attacked,
the
sole
source
of
this great
liability to cholera and the nature of the water-supply, has long been recognised by the administration,* and effect
improvement
have been made
to
; the
construct
the of
tanks that for
same
supply of
excess
water-supply
it will
even
ages)
It is
to
In the above pages I have shown that certain peculiarities in the incidence of
pulation
Belaspur district, exhibited in so greatly from what occurs in other localities. The water-supply of the Chattisgarh plain, of which the Balaspur district forms a part, is drawn entirely from exposed sources ; where villages are situated on the bank of a river, the water-supply may be drawn from it, but far more commonly tanks form the At the larger villages there sources of supply. be several tanks may belonging to different castes, but very commonly one tank forms the sole source of supply, and different corners or parts of this tank will be assigned to different castes, in the
Table XL. differs
but all will bathe and tank from which 61.
a
particular
unit of po-
unit is determined
by
a
the circumstance that the water-
it
cattle
or
on a
section of
I might pursue the subject evidence to show that it is of the
even
occur.
cholera, and that these peculiarities result from operation of a local factor?that, in fact, tlu;
population is of this nature, that supply the relative incidence of cholera on the two
and
not
the medium
of the
sexes
districts, does
(taking proportion than
suffer in greater
the females. 60.
source
local factor ; and I have given reason for believing that this local factor is the water-supply.
be reversed, and the males
will
common
are
incidence of cholera
all
the
drinking ; consequently the liability to cholera of women over
is drawn, this difference between the
;
villages
wells, and efforts
and
the
occur
m
for
for all purposes, and the washing is carried on in the source from which the supply for drinking not
of
people to reserve drinking-water. But caste is a change in such matters, and in is very slow; the improvement progress wells that have been provided are little used, and the people still bathe and wash clothes in
62.
proportion
proprietors
separate tanks for great obstacle to
there
tank
a
have been taken to
have been made to induce the
or
of males and females attacked docs
measures
men, observed in other
only
5 men. is often the case,
[April, 1883.
they
are
Under this
wash clothes in the draw
water
watered in the condition of
for
same
drinking,
same
tank.
water-supply cholera prevails with great severity in Chattisgarh, and it is greatly aggravated in seasons of unusual drought. The connection between
water-supply
that
further and
through epidemic
the
lence of cholera is influenced and
undoubtedly
conditions, rainfall
;
but this
preva-
controlled,
is in this
more
adduce
as
climatic
country, by especially by drought and would be beyond the scope of
this paper.
Moreover, my object in working out the tables has been, not so much to prove the above
63.
connection as
to
between cholera and
indicate
a
definite line of
impure water, enquiry ; to show
peculiarities in the incidence of cholera point to its dependence on some local condition, and that the discovery of this local condition would probably give the key to the solution of many of the problems which the epidemic prethat the
valence of cholera presents. 64. If it should be conceded water is this local factor,
for
measures
definitely
a
that
basis will be
directed
impure gained
towards
the
* Mote ?See letter from Secretary to Chief Commissioner, Central Provinces, to Commissions, Chattisgarh Division, in Appendix I., to report oil the cholera epidemic of 1875-76.
April,
SAUNDERS ON ENTERIC FEVER.
1883.]
of cholera ; but there would still remain for further enquiry the nature of the re-
prevention
lation between or
essential
impure
cause
of
water and
cholera.
the Does
primary impure
merely act by disturbing the balance of health, and thereby rendering individuals more susceptible to the action of a malefic influence pervading the atmosphere ; or does it serve as a suitable cultivating fluid and medium of dissemination to a specific contagium communicated from without; or, lastly, can the specific virus of cholera be generated de novo in water charged with organic impurities by the action of a tropiwater
cal /
sun or
other climatic force ?
February, 1883.
93
Townsend, c.b. ( Concluded from page 62.) 34. We may now enquire how far these results of the analysis of the cholera statistics of six towns in the Punjab are confirmed by the statistics collected in the Central Provinces,
which
to
statistics
have
I
were
These
alluded.
previously
collected from 31 towns and in different districts of
over
the villages, in be found will and province, my report they on the epidemic of 1875-76. As they are very voluminous, I propose to reproduce here only 400
such of them
as
illustrate the variations
in
the
analysis of the already brought into view.
incidence of cholera which the
Punjab
statistics has
Table IX. shows the incidence of cholera on the populations of certain tow?is in the Central Provinces in 1875'
76:? Total
from cholera 1,471.
109,293.
Cases
pkr mille
OF POPULATION.
Deathsi millejIcent.
Deaths
PER
per of population.
of ca.VSES.
Towns. Both sexes.
Garakota Deori
Both
Both
M.
sexes.
81 "9
34'5
34'4
34-7
85-3
36-6
28"I
45*2
4? 4
34'7
67-9
i6'3
9*7
23*2
42-7
35'9
49'2
2I'S
i9'3
23-7
29*2
28*0
30 'o
13-6
15*9
Sindi
27'3
20*2
3? "4
6*9
6'i
7*7
23 "9
22*6
25 "4
9-8
9*5
io'o
Hinganghat..
16-5
14-2
i8"9
3*8
3'?
4*6
"5
i"o
2'0
Arvi
Mangel!
6*7
ii'i
1
those of the per cent, of of females.
liability
tics
we
Upper
27-5
21*3
Merwara
Sambalpur
..
29'5
30*2
9*8
II'I
8*5
Mangeli
41
43
40
35. On comparing the above table with Table VI., it will be observed that cholera was far more diffused among the population of the towns of the Central Provinces in 1875-76 than
extensively
towns in 1881.
The above table
also exhibits greater variation in the ratios of prevalence in the several towns as well as in the
fatality among those attacked. The excessive liability to cholera of females compared with males also comes out very prominently in the above table ; the ratios of cases for females are in excess of the ratios for males in nine of the towns
given,
very great.
and in many the excess was In the three lowest in the table,
however, the ratios for males those for females.
are
in
among Hindus while the lower
Cases of cholera per mille of each class.
Hindus.
Hindus.
22*7
Punjab
of women
Towns.
32*2
14-0
marked
more
liability
constant
LATION.
29'8
in the
more
OF TOTAL POPU-
22*0
*6
was
CLASS PER CENT.
37*2
12
found that the greater
Number of each
61'o
13*3
the
as
ed in Hindus.
42'S
34*4
well
than among Muhammadans, of cholera in women was also less mark-
75*8
28-9
as
of females to
fatality
39'9
31-7
This,
in favor
uniformly
not so
form a very small component of the population of the Central Provinces, for it will be remembered that in the analysis of the Punjab statis-
.,
..
of
cholera, may be partly ascribed to the circumstance that Muhammadans
Lodikhera
Mean
fatality
but the ratios of deaths
Punjab,
cases are
ii*4
Saugor
of the lower
point
Table X. shows the incidence of cholera on different classes of the population in certain towns of the Central Provinces.
sexes.
69'3 ..
..
F.
55'7
Wardha
Sehora
M.
On the
36.
cholera in women, the statistics of the Central Provinces are, on the whole, in accordance with
to cholera
Deaths
Cases of cholera 3,471.
population
Gadawara
87
TOWNSEND ON THE INCIDENCE OF CHOLERA.
1883.]
April,
excess of
12
7
Sehora Wardha Rehli Garakota Chanda Sindi Damoh Khandwa Gadawara
11
IS 11 10
8 11
14 23
Sambalpur Hoshangabad Raipur *
Chamars, Dhers,
draw
from the
water
37.
on
11
69 64 54 70
17-6
45'?
99 "4 21 *o
44'5 3?'5
204-3 171*1 137-2
62-4
69*6
1076
16 18 16
25
25 '2
36
27-8
22
IO'O
76
68
13 18
23^ 3 "4
63
14 12
78*2
20
31-2
71 82
21
33'6
23 19
59
58
18 23
63
10
Low*
40-4 147 3'9
29-S 32-5
i6-6 24 "4 2
"O
o*8 68-2 20 9 44-4
79'2
62-5 5?'3 47 "4 15-0 3"4
64*5 27'5 19-0
297
27-8
iro
7'9
14-1
2*0
Mehtars and other castes which are not sources with the general population.
allowed
to
same
manner
of cholera
77 77 7i
Upper
castes. castes.
73
The above
striking
castes
17 8 8
15
Saugor
Lodikhera
Low*
castes
table
illustrates in
the variations
a
very
in the incidence
the different sections of which the
of the towns and
populations villages are composed. In all of the towns cholera fell with unequal severity on Muhammadans and upperHindus, and in many the difference was great; but the most marked difference occurs in
caste
THE INDIAN MEDICAL GAZETTE.
;6'6 43*3
27 o
23*3
22-5
26-3 l6"5
1V9
i6-4
19-1 33'4
29-;
25'4
24*2
11
2-8
i'5
4*5
397
36-0
357
27-0
24'3
26'0
30-5
34-6 3*9 3*2 31'2
28-3
20'6 ...
197 villages in the district
villages in the districts of Jabalpur, Damoh, and Wardha
Belaspur
26*9
22*3
25-0
28-5
The
numbers
at
living
220
12 towns
1**33
2,418 1,285 district
197 villages in the Belaspur
...
villages in the districts of Jabalpur, Damoh,.and Wardha 220
15*4
19-6 3?'5
M. M.. F. Both
14
2,457
1.156
1,529 3.371 towns 12
28-8
37'o
30*8 36*3 23'2 25*9
M.
20?40. Under 1 year
cases
of the 317 307 191 131 230 303 340
301
216 193 219 261 1,30j
146 154 338 525 183
465 7S6 252 308 179 243 271 303 347
1,842
276
F. Both
sexes.
M.
M.
F
M.
F.
M.
F
M.
F.
M. F. M.
40 and
6?12. 1?6. year.
Under 1
All ages.
Number of cases at each period.
Total Number of Cases
8,24.6.
20?40.
in the Central Provinces.
different periods of life at
of cholera Table XL shows the incidence
upwards.
males of these different classes.
F
I much regret that I am unable to show the incidence of cholera on the males and fe-
38.
M,
higher upper-caste Hindus, it is considerably below the ratio for Muhammadans; in Raipur, while the uppercaste Hindus suffered severely, the low castes almost escaped.
F,
the ratio for the low
ratio for
All ages.
though
than the
M.
for instance,
I
Saugor, castes is
Cases ter 1,000 living.
On
in Table XI.
entirely.
a
different ages given
almost
castes
hand, in
at
escaped
few of the towns, the low suffered less than the other classes ; in
the other
Table XII shows the ratios per mille
the other classes
of cholera
madans and upper-caste Hindus. In Khandwa and in Damoh the low castes were attacked, but
M.
severity
this class, and the ratios for it are from four to five times higher than the ratios for Muham-
on
M.
extreme
towns
sexes.
fell with
epidemic
of the
40 and
large majority
upwards.
the
a
6?12.
given,
In
1?6.
the low castes.
[April, 1883.
different ages
which the ratios in the above table have been
computed
from
the
census
1871, and the ratios may be taken very
fairly
cholera
on
the
incidence of the
the two
sexes
collected
to
on
based,
tables of represent
epidemic
of
at different ages in the
several groups of population. 39. We find from the above statistics
are
over
tables,
the wide
area
that the of the
Central Provinces coincide with those of the few towns in
under
the
Punjab,
one year
of age
in are
showing almost
that infants
exempt
from
April,
liability
The
to cholera.
tables of
census
1871
did not permit of my being able to show the ratios of liability in the several years of life between 1 and
6, but from the following figures it from cholera
would appear that the exemption extends in a considerable degree the second year of life
infants
to
as a
high
24 7 52
92
301
46
no
485
316
205
the
the above
1,224
mortality
con-
among children up to the fifth the number living diminishes
sixth year, rapidly, and consequently the ratio of or
438
61
full fourth of the children born as
figures though immensely
cases on
second year of life, in excess of the ratio for the for the
first year, would be small compared with the It ratio for the third and subsequent years. would
appear, therefore, under which infants under
that
condition
the
year of age are
one
rendered exempt from cholera, covers to a considerable extent children in the second year of life ; and as native women, as a rule, continue to
their infants
suckle
long
after
they
have
reached the age of one year, it may be inferred that the immunity of infants from cholera con-
only so long as they are fed from the breast. 41. The liability of children to cholera in the third year of life is high, but it is considerably higher among children between 3 and 6 ; and tinues
these statistics of the Central those of the
ing
Punjab given
that children from 3
Provinces confirm
II, in indicat-
in Table or
4 to 5
or
6
are
more
liable to cholera than persons at any other age. There is an increase in liability among old people
compared with persons of middle age. riod of least
liability is
between
12
The peand 20, but it is
much greater among males at ages 20 to 40. 42. It will be remembered that in the Punjab
not
statistics
(Table V)
children under
12, the
it
12 towns
appeared liability to
that among cholera was
on
of different
persons
ages in the Provinces and in the
of the Central
of
villages 114
...
die in their first year, and tinues very
especially pronounced in females in the period of life 20 to 40 ; we now find that these points are amply borne out by the statiswas
tics in the above table which show the incidence
3-6
2?3
year.
Cases of cholera in 12 towns Villages of Jabalpur and other districts Villages of Belaspur district
Now,
greater in boys than in girls, but that at subsequent periods of life it was greater in females than in males, and that this greater liability
of cholera 1
Total
in
:?
Under
40.
89
TOWNSEND ON THE INCIDENCE OF CHOLERA.
1883.]
and
Jabalpur
other
districts.
It
appears that, in these two groups of populations, the excess of male cases over female was limitthe ages between 1 the numbers of cases of the ed
to
to 6 ; at ages two sexes
ly equal,
but the female ratios
the male
in the
ratios;
period
are
in
12 to 20
6 to
are
12
near-
excess
there is
of a
decreast in the numbers of both male and female cases, but the female
in
are
excess
of the male
cases, and in the
period 20 to 40 this excess becomes very remarkable; it' is considerable also among old people. We find, however, that in the third group in the table (the villages in the Belaspur district) the relative number of cases in the
two sexes
are
in contrast with
their relation in the other two groups. 43. In Table IX. it appeared that, in the
greater number of the towns, females had suffered from cholera in far larger proportion than the males ; but examples were given in which the reverse obtained. The most notable of these
was
district; and
town in the
Belaspur
Mangeli,
a
we
find in Table XI. that
now
what occurred in the towns also occurred in the
villages
females
; instead of the
the
than the males, groups of populations, males as
was
two
in somewhat
higher proportion
The
of male
excess
in the other
period
1
more
in the other
were
attacked
than the females.
female cases, which
groups was limited to the to 6, extends in the third group to all the period 20 to 40 the numbers and
ages ; at ratios of the
great
over
suffering
case
excess
two
two sexes are
of female
nearly equal, but the compared with male
cases
cases at ages 12 to 20 and 20 to 40 which is so marked in the figures of the towns and Jabalpur
villages does not Beldspur villages.
occur
in the
figures
of the
THE INDIAN MEDICAL GAZETTE.
9?
From the above
44-
analysis Punjab and
cholera in the
of
Provinces,
find that both
we
coincide in
of the statistics
Punjab
in the Central
above tables, and also in the villages of Jabalpur, the number of women attacked was very largely
of statistics
sets
evidence of the
affording
following
facts :?Cholera exhibits incidence
on
great variation in its different units of population, and
varies in
of diffusion among the inhabitants of different towns in which it may
it not
only
become
epidemic,
extent
shown
as
the number of
by
persons attacked, but it also varies in virulence and intensity of action as shown by its fatality, or
the deaths in
to
follow from this,
proportion to cases. It appears that, though an outbreak of cholera, in a unit of population, may be due primarily to some malefic influence pervading the atmosphere, or to a specific contaghim commu-
in
and of the Central Provinces
for females and the
was
villages
the
that
in this local condition
or
Cholera varies
45. different units of
on
its incidence
unit.
Taking
on
on some
varying quality
factor.
only population, not
in
its incidence
all the
same
Punjab towns the statisgiven above, the mean
tics of which have been
ratios of cases per mille of Muhammadans and Hindus, for both sexes, were nearly equal, yet in individual towns the incidence
on
the
two
classes
very unequal ; from this it is apparent that, while, as regards class, Muhammadans and Hin-
more
subject
equally liable to cholera, the local may operate unequally on the two classes same locality. are
two
may be due
much
47. In
a
very
This lower fata-
constitutional but it is
peculiarity probably
more
difference in mode of life.
marked
in Muhammadan
Hindu
Punjab
From the tables
in
constant
those of the
striking
relating to
It is
than
more
than in
statistics
Central Provinces, but several of it occur in Table IX.
instances
the incidence
of cholera persons of different ages, the points that come most prominently into view are ; that on
infants to
almost
are
females
entirely exempt
and that the
cholera,
at
occurs
The
50.
20
to 40.
of infants
it is limited
to
occurs
the
period
in all when
the breast, we infer that it is due this condition. Older children are, more than are
fed
as
liability liability of
all ages above the age of 6,
exemption
localities, and,
from
excessive
but is most marked at ages
to
unequally on the two sexes. large majority of the towns of the
to a
in the
49.
less
generally considerably
to the sex, to
more
any other
at
class, liable
to
cholera.
The excessive
liability of females, above 51. the age of six years, to cholera is found to vary in different localities, and, while occurring both in Muhammadan to
be
more
and Hindu
marked and
to
women, is found
commence at an ear-
lier age among Hindu women ; we therefore infer that it is due to some occupation by which women are
the local
Cholera falls
women.
women, and is therefore
in the
classes.
as-
of cholera
prevalence
fatal in females than in males.
they
ing the excessive severity with which cholera commonly falls on certain castes. Muhammadans may become more subject to the local factor in one locality, the upper-caste Hindus in but the low castes more another; commonly come under its operation than either of the other
is
Cholera
48.
factor
46. The statistics of the Central Provinces furnish additional evidence on this point in show-
may therefore be
the action of this local factor
to
than Muhammadan
was
dus
It
among females, where it occurs, is due to the operation of the local factor. Hindu women are
it also varies in
different sections of the
in contrast with those of
this greater
attributable
dependent
lower than the ratio for males, Belaspur district are, in
district.
Jabalpur
sumed
In
cases
of the
respect of this point,
operation the presence of a local adjuvant or factor, and it may be assumed that the varying intensity of the operation of the primary or essenis
in the
of the number of males attacked.
excess
lity appertaining
cause
given
several of the towns, however, the ratio of
nicated by human intercourse, the influence or contagium, whichever it may be, requires for its
tial
[April, 188.3.
women
that in
commonly brought
into contact with
factor
men,
more some
more
than
than Muhammadan localities this
and
Hindu
women,
occupation
does
but not
the
place tion
in
women
unfavourable
a more
cholera than
regards
as
would
but
posi-
In fact it
men.
for this
occupation, appear that, would be less liable to cholera than
women men.
The
52.
problem, then, is,
find the local
to
condition which meets these variations in the incidence of cholera tion and
are
operation
exempt, but
to the
same
operation
of
specially Hindu women, are subject in a greater degree
which women, and in many localities men.
I believe this condition
53. in the
of the
water-supply
circumstances
the
unit ; of which infants
different sections of the
on
at the breast
than
different units of popula-
011
condition from the
a
is to be found In
people.
conditions
or
none
of
of life under
people live is there so great variation quality of the water which they use for
which the as
in the
drinking, and in the which they draw it. river
or
stream
in another
ply, ply may
nature
In
of the
sources
town
one
an
open
be drawn from
may be
foul
or
from
village
a
source of supthird the supbut the wells will
will form the chief
tank, wells,
in
a
differ in construction and state of some
mere
holes sunk
at
repair, edge
the
and of a
pool.
54. In the towns and larger villages the sources of supply will be numerous, and each section will have its
own
wells
or
tank ; and it is
to
this
that the variation in the incidence of cholera the different sections is
attributable;
on
on
the
other hand, the inhabitants of many of the smaller villages are dependent on a single source of
supply,
and to this is due
a
circumstance that
all
wide-spread epidemics, vis.y that although the epidemic may reach comparatively few of the small and remote villages, the proportion of the population attacked, when it does reach them, is often far greater than in the large villages and towns in which the sources of supply are numerous ; in proof of this assertion I need only refer to the Annual Report for ] 881 of the Sanitary Commissioner for the Punjab. In the epidemic of that year, the mortality in the towns that suffered most severely from cholera occurs
in
no
in
case
9*
TOWNSEND ON THE INCIDENCE OF CHOLERA.
1883.]
April,
exceeded
12 per
mille, but in many of
the small
it
villages
from 25 to
ranged
100
per
mille.* The excessive
55lera
falls
severity
with which cho-
the low castes, also
commonly points to the water-supply on
as
the local factor
to
which the variation in the incidence of cholera different
on
These castes food and
population is due. necessarily, in respect of
sections of are
not
living,
a
off than many other higher place in the religi-
worse
castes which take
a
scale of castes ; they fulfil necessary functions in the communities in which they live, and
ous
are
perhaps
less
subject
than other castes
;
to
but in
vicissitudes of life
respect of
water-
the distinctly separated rest of the community ; they are not allowed even to approach the well or tank from which the other castes draw their supply, and they are thus commonly driven to inferior sources of supply. 56. That the exemption of infants from liability to cholera may be taken as evidence of a relation between cholera and water-supply, will scarcely be denied, and, with regard to the excessive liability of adult women, there is little
supply they
room
are
from
for doubt that it is connected with their
daily occupations which bring them so much in contact with impure water. 57. One of the chief occupations of Hindu women of all but the highest classes, and of Muhammadan women also, but to a less extent, is drawing water and washing clothes. Muhammadan women are kept more in seclusion, and none but those of the poorest class are permitted to engage in any outdoor occupation ; but any one entering a Hindu village in the early morning will find the female population, from girls to old women, drawing water from the various sources, and during the day large numbers will be employed in washing clothes or cooking-utensils. The water they take home for domestic use is commonly drawn from a well 01* some other source comparatively safe from pollution, but the washing they will do in a *
See also
Report vinces.
on
a
remarkable table at page 29 of the synopsis of the epidemic of 1875-76 in the Central Pro-
the cholera
THE INDIAN MEDICAL GAZETTE.
92
neighbouring and
stream
or
tank
or
stagnant nullah,
often drink of the water in
doubt
they working. Not unfrequently cholera will be confin58. ed almost entirely to women so employed, or they will be the first attacked. In the epidemic of 1866, at Nag pur, out of 40 cases reported during the first week, 8 only were males and 32 females ; and in the epidemic of 1868, of 52 persons attacked during the first week, 43 were females and only 9 males. Of 18 adults attacked in the town of Bhundara in 1875, 14 were women and only 4 men ; and in the following no
which
they
year, in the
arc
and
2i were women
59. stream
town, of 26
same
Where, forms
as
adults attacked,
the
sole
source
of
this great
liability to cholera and the nature of the water-supply, has long been recognised by the administration,* and effect
improvement
have been made
to
; the
construct
the of
tanks that for
same
supply of
excess
water-supply
it will
even
ages)
It is
to
In the above pages I have shown that certain peculiarities in the incidence of
pulation
Belaspur district, exhibited in so greatly from what occurs in other localities. The water-supply of the Chattisgarh plain, of which the Balaspur district forms a part, is drawn entirely from exposed sources ; where villages are situated on the bank of a river, the water-supply may be drawn from it, but far more commonly tanks form the At the larger villages there sources of supply. be several tanks may belonging to different castes, but very commonly one tank forms the sole source of supply, and different corners or parts of this tank will be assigned to different castes, in the
Table XL. differs
but all will bathe and tank from which 61.
a
particular
unit of po-
unit is determined
by
a
the circumstance that the water-
it
cattle
or
on a
section of
I might pursue the subject evidence to show that it is of the
even
occur.
cholera, and that these peculiarities result from operation of a local factor?that, in fact, tlu;
population is of this nature, that supply the relative incidence of cholera on the two
and
not
the medium
of the
sexes
districts, does
(taking proportion than
suffer in greater
the females. 60.
source
local factor ; and I have given reason for believing that this local factor is the water-supply.
be reversed, and the males
will
common
are
incidence of cholera
all
the
drinking ; consequently the liability to cholera of women over
is drawn, this difference between the
;
villages
wells, and efforts
and
the
occur
m
for
for all purposes, and the washing is carried on in the source from which the supply for drinking not
of
people to reserve drinking-water. But caste is a change in such matters, and in is very slow; the improvement progress wells that have been provided are little used, and the people still bathe and wash clothes in
62.
proportion
proprietors
separate tanks for great obstacle to
there
tank
a
have been taken to
have been made to induce the
or
of males and females attacked docs
measures
men, observed in other
only
5 men. is often the case,
[April, 1883.
they
are
Under this
wash clothes in the draw
water
watered in the condition of
for
same
drinking,
same
tank.
water-supply cholera prevails with great severity in Chattisgarh, and it is greatly aggravated in seasons of unusual drought. The connection between
water-supply
that
further and
through epidemic
the
lence of cholera is influenced and
undoubtedly
conditions, rainfall
;
but this
preva-
controlled,
is in this
more
adduce
as
climatic
country, by especially by drought and would be beyond the scope of
this paper.
Moreover, my object in working out the tables has been, not so much to prove the above
63.
connection as
to
between cholera and
indicate
a
definite line of
impure water, enquiry ; to show
peculiarities in the incidence of cholera point to its dependence on some local condition, and that the discovery of this local condition would probably give the key to the solution of many of the problems which the epidemic prethat the
valence of cholera presents. 64. If it should be conceded water is this local factor,
for
measures
definitely
a
that
basis will be
directed
impure gained
towards
the
* Mote ?See letter from Secretary to Chief Commissioner, Central Provinces, to Commissions, Chattisgarh Division, in Appendix I., to report oil the cholera epidemic of 1875-76.
April,
SAUNDERS ON ENTERIC FEVER.
1883.]
of cholera ; but there would still remain for further enquiry the nature of the re-
prevention
lation between or
essential
impure
cause
of
water and
cholera.
the Does
primary impure
merely act by disturbing the balance of health, and thereby rendering individuals more susceptible to the action of a malefic influence pervading the atmosphere ; or does it serve as a suitable cultivating fluid and medium of dissemination to a specific contagium communicated from without; or, lastly, can the specific virus of cholera be generated de novo in water charged with organic impurities by the action of a tropiwater
cal /
sun or
other climatic force ?
February, 1883.
93
