ORIGINAL COMMUNICATIONS. NOTE ON THE VARIATIONS IN
THE
CHOLERA ON THE
INCIDENCE OF
POPULATION OF
most
c.b.
distinctive characteristics and
of cholera, is the
uncertainty
of its incidence
different units of
irregularity population. In the most widely-spread epidemic the great majority of the villages escape altogether, and two
or
on
attacked, one will escape with three deaths, while another, at a little are
distance, and under similar conditions of soil and climate, will be more than decimated ; and, even
in
those
towns
and
collected in
villages that suffer epidemic falls with
it is found that the
severely, varying severity on different sections of the population. This irregularity of incidence indicates that the prevalence of cholera in a town or village is dependent on the presence of Whether cholera some local favoring condition. is to be regarded as primarily the product of influence pervading the atmossome climatic a or of specific contagium spread by huphere, man intercourse, the influence or the contagium,
in 1881 cholera to
this
was
prevalent
ascertain how far statistics would confirm the
province
results obtained elsewhere. The
4.
By Surgeon-General S. C. Townsend, One of the
desirable, when in the Punjab,
TOWNS
AND VILLAGES.
of those that
57
TOWNSEND ON THE INCIDENCE OF CHOLERA.
1883.]
March,
enough,
Commissioner
Sanitary
at my
request,
to
furnish
me
was
good
with state-
mortality from cholera in certain towns that were chiefly affected by the epidemic, and also the mortality from all causes in the same towns during the four months that the epidemic prevailed. 5. These statements showed the mortality at different periods of life and among different classes of the population, but they did not give showing
ments
the number of
the
cases
of cholera
or
the number
of persons attacked. This information, however, as will be seen in the sequel, was most essential to the proper treatment of the subject, and I was fortunately able to obtain it from the civil surgeons for six towns. The statistics of these six towns will be chiefly used in this paper, but the two first tables in which the rates of
whichever it may be, will not act upon the population unless this local condition or factor is
mortality from cholera are compared with the rates of mortality from all other causes, have been compiled from the statistics furnished by the Sanitary Commissioner. 6. These statistics were qollected during the season, extending from July lio October, in which malarial fever chiefly prevails ; and as the preva-
present.
lence of fever
It
2.
is
in the removal of this local factor
checking the ravages of must mainly rest, and the discovery of epidemics what this factor is should be the main object of cholera investigation. This discovery cannot be reached without minute investigation into the degree and manner in which the disease falls on the population of different towns and the different sections of the population ; and it is as a contribution to definite enquiry in this direction that I have undertaken the following note. In 1875 and 1876 I collected numerous 3. that
our
hope
of
statistics in the Central Provinces
on
the above
subject, which will be 154-156 of my report
found tabulated in pages on the cholera epidemics
of those years ; and those tables seemed
the results
ing
on
the
etiology
as
to
of
have
an
cholera,
brought important
out in
bear-
it seemed to
me
narily mortality
of
somewhat
was
the
severe in
autumn
from all
causes
more
than ordi-
of 1881, the ratios other than cholera
may be taken to represent resulting from malarial fever.
chiefly mortality
Table I. exhibits the ratios per inille of mortality from cholera andfrom all other causes in eight towns.
All causes except
Cholera.
CHOLERA.
Towns. Both
Male, j Female.
sexes.
Amritsar Batala Lahore Umballa Sialkot
...
...
...
...
Panipat Jullundur... Hoshiarpur
...
62'5
26 9 23-0 21*9 197 i6'2 132 i?'5
Both sexes.
Male. Female.
'
53'i 243
183 20'3
|i8'o 16-3 I
I
*2
9'0
73-6
29 6 277 23'5 21-4 i6-o 152 '9
11
4"i "'5
4'5 109
78
8-4
5i 77 5'9 8-o
5-2 7'5 7'4 8'o
5*4
5'?
3'5 119 7-2 5'? 8'0 4'4 8'o 5 6
THE INDIAN MEDICAL GAZETTE.
58
The ratios in the above table show
7.
relation between the
from
no
causes
and the amount of cholera in the several
towns.
In Amritsar, where the whole population was at the time prostrate from fever, the mortality from cholera towns
lower than in any other of the large attacked by the epidemic ; in the town of
less than half that of
was
were
causes
nearly equal,
in Lahore and
but the
from cholera in the latter town
was
mortality
very much
Lahore; the mortality from all other causes in Hoshiarpur was less than half that of Umballa, but the mortality from cholera was slightly greater. It is moreover worthy of note that, al8. though fever was unusually prevalent in the rural circles surrounding all these towns at the time to below that of
which the above statistics relate, cholera was in a remarkable degree limited to the central towns; the number of
attacked
villages
by
cholera
was
very small ; the fever mortality of the Sialkot rural circles, for instance, for the year 18S1, was equal to 20 per mille of the population, but the per mille. It will be observed in the above table that
cholera 9.
mortality
only
was
in all the towns, with
one
O'li
the morta-
exception,
much in of females, from all causes, excess of that of males. On the other hand, in
lity
was
four of the
of females from
the
mortality considerably below
towns
cholera
was
in
town the ratios
one
equal ; and in mortality from
the
that of males ;
of the two
remaining three,
sexes
were
in which the
cholera among females exceeded
that among males, the
excess was
very
slight,
causes
Cholera.
Both
5,114.
All other causes.
Male. Female.
sexes.
All ages Under 1 year ,
1?2
Amritsar, the mortalithan double; the ratios
ty from cholera was more of mortality from all other Umballa
causes
Deaths from all other
2,037.
Period of Life.
was
Batala, where the mortality from all other
Deaths from cholera
population
270,911.
all
mortality
Total
[March, 1883.
2?3 3?4
...
...
4?5 1?5 5?10... ?.
???
xo?20
7-6
7'9
*o
21
7' 3 1-9
9"5
2
...
7'9
6-8
8-9
9'S
10-3 i4'3 105
9 4
8-4 6-4 6-9
12-9 10*4 8'2
73'3 6-9
677
5'6 7-8
3'6
5'6 7-0 5'9
40?50...
7'5
80
8-4
8-5
i3'5
151
upwards 10.
...
The first
131-i
IO'5 8-6
7'2
60 and
x3'4 1407
15-6
V 62
50?60...
'Female. 211
8-o
61
20?30...
17-3
1360
Male.
II'I
30?40...
...
Both sexes.
point
5 4
5
o
78-9 8-5 7-6
6*9 8'3
7-2 9'5 13-2
I0'2
107 9'4 8-8
r3'9
12-5
IT9
44 "2
34'5
53'9
49
for notice
which calls
in this table is the very small mortality from cholera among infants under one year of age
This, however, is in accordance with statistics which have been collected I believe, be
accepted
as
elsewhere, a
fact
and it may>
that infants at
almost
completely exempt from immunity does not liability extend to older children?the mortality is very high even in the second year of life, though not so great as in the three subsequent years. The highest mortality from cholera shown in the table occurs in the fifth year. In the period between 5 and 10 years, and again between the the breast
are
This
cholera.
to
ages of 10 and 20, there is considerable diminution in the mortality compared with that of the
period
1
to
5. The ratios for the three decades between 10 and 40 vary but little, with the exception of the ratio for females between 20 and 30, which is 11.
considerably
in
excess
of the ratios
immediately
After 40, the ratios preceding and following rise somewhat; and that for old people above it.
Table II. shows
the ratios of mortality per mille at different periods of life from cholera and front all other causes among the population of seven* towns of the Punjab, during the four months, fuly to October, 1881.
*
Note.?The statistics of the
city
of Amritsar have been
excluded from this table, for, while the mortality from cholera was
comparatively slight,
the
mortality
from fever
was so
excess
sive that its ratios dominated those of all the other towns, and to
have included them
They
have been
would have vitiated the
given in a separate
paper,
comparison.
of the series, with the exception of that for children between 4 and 5 years 60 is the
highest
of age. At every period after the age of 5 the ratios for females are below those for males, with the exception of the ratio for females at ages be12.
tween 20 and 30 ; but the difference is
between old
people
of the two
sexes
great only above 60.
March, 1883.]
TOWNSEND ON THE INCIDENCE OF CHOLERA.
13- Turning now to the ratios of from all causes (which, as I have
mortality explained above, represent, to a great extent, mortality Irom malarial causes), we find them in complete contrast with those of the mortality from cholera : instead of the very low mortality among
the effects of
infants which forms
returns
cholera ratios, the
so
marked
mortality
a
feature in the
from all other
hundred,
on
the
mortality from all causes fell proportion of more than
infants in the
in four of the deaths at all ages. 14. Among older children we find the from
We may now proceed to examine the statistics of the six towns from which complete 19.
were
furnished.
Table III. shows the population, and the number of cases
and deaths from cholera, in the six towns.
Number of deaths from Cholera.
Number 0/cases of Cholera.
Population, census of 1881.
mor-
Panipat Umballa Jullundur Hoshiarpur
25,020; 12,430
12,590
13,885 12,106 42.IOO' 22,502 19,658 20,614' 11,002 9,61 24,267! 12,243 12,024 33.8101 17,734 16,076
25,99r|
Batala
Sialkot Total
328
341 153
304
of population, and
61
155
110
21S 260
279
'.'77
';274
202
240
171,862 89,796 82,066
Table IV. shows the ratios of
56
149 l33 339
3=3 327
,669
264
'
67? 604
and deaths per mille
cases
the deaths per cent,
of
cases, in the six
towns.
from cholera is small in proporthe increase in the mortality from all
mortality
to
16.
of
increased, but the
cholera
After the age of 40 an increase is observable in both sets of ratios, but the increase
other
specific
up-
causes.
tion
the action of the
more
cause
cholera.
one
greatly tality mortality from all other causes diminished rapidly, so much so that the ratio for the ages 1 to 5 is just half that for infants under one year. 15. Among children under 5 the mortality from all other causes was greatly in excess of the mortality from cholera both among males and females, but at subsequent periods of life up to the age of 40 among males the mortality from cholera exceeded the mortality from all other
in the
to
develop-
thereby rendered
causes
among infants was enormous ; while in the case of cholera the deaths of infants in proportion to the deaths at all ages was barely one in a
unusual and excessive
an
ment of malaria is not
susceptible
59
causes.
At all
tion, the
Cases per mille
of
periods mortality from
life,
with
excepcholera of females was
slightly below that of males, but in the mortality from all other causes the reverse occurred ; at all periods above one year, with the exception of that from 40 to 60, the mortality among females was greatly in excess of the mortality among males. 17. The above
of population.
one
comparison
of the ratios of
mormortality tality from all other causes affords good reason for believing that cholera is the product of a specific cause distinct from the malaria, which is the primary cause of the greater part of the mortality among the population of this country.
18. Further it would appear from the instance of Amritsar, that a population suffering from
population.
Deaths per cent,
of
cases.
Towns.
Panipat
Umballa
from cholera with the ratios of
Deaths per m ille of
Jullundur Hoshiarpur Bata.la
Sialkot
20.
tables cholera
157 5 "4 5i 5 "6, 18*1 11 "5 io-9 u-9 l6'2 77 7'5 8-o
*4*9
i5'6
!4'9|
Total
I2'S
12-9 I2"9 I2"6 12*2 I5'9 I5'I 147 13-8 i7'3 i6'5 13 "5
I
14 i| !
I;
167
As the six towns were
selected
5'9 5"i 8-o
7'4
7 '4 5'2 8-o
7 "4
given
"4 5"o 8-o
4
prevailed extensively
42
5?'
3s
47
the above
for illustration in all of
58
40
4.S
7'3
in
46
because
them,
thin
THE INDIAN MEDICAL GAZETTE.
6o
table does not in
degree
adequately represent
vail in the different towns and trict
variations in mille of
prevalence prevalence even
very marked?the
population ranged
la to 17 3 in Batala. Then
villages of a epidemic.
predisThe
we
find that females
nipat, the ratios of cases per females than for males.
attacked
very much below the ratios for males ;
35 against 58 for males. The next table illustrates the incidence
22.
of cholera the
on
only
the two
population
principal
of the
towns
aggregate number of the number of
them,
were
the dif-
greatest in Panipat, where the ratio was
cases
were as
14*6
Panipat
Umballa
is
two
composed.
The
classes, and the
:?
Cases per mille of population
tion
69
The
Cases of cholera.
107,175
1,60S
64,687
935
Hindus are,
on
the
whole,
j Deaths from cholera.
j
|
more
7S3 481
well-
to-do than the Muhammadans ; there is a larger proportion of wealthy and well-to-do people among them.
53
46
8"o
7'o
24. From this table it appears that cholera fell with varying severity on the two classes of which the population of the several towns is
composed. severity on
In
Panipat
the
it fell with much greater
Muhammadans than
on
the
Hindus ; in Umballa the proportion of the Hindu population attacked was just double what it
with the Muhammadans.
was
pur and in more
Jullundur proportion
in
In Hoshiar-
the Muhammadans suffered than the
Hindus.
ratios of the two classes in Batala and
nearly equal. 25. Taking both
The Sialkot
are
sexes
in all the towns, the
ratio for Muhammadans very slightly exceeded that for Hindus; but, on comparing the ratios of males
and females
males
females is in
11 indus
70
18-6
Deaths per mille of popula-
is
of the mean
females;
two
classes,
ratio for
considerably
ratio for Hindu males, the
Muhammadans
35 56 36
20"I
i4'6 13*0 i6"i
find that, while the
Population.
9 ? '7 4 17*0 I2'5
I5*2|
16-9 15-4 I7'? I7'4 15-0 14*9
madan
Section.
Mukammadans Hindus-
Hindus.
9*5 9*9 i6'2! 15*0 I3'5 T3*?i 13*4 I7"7 I5'3 14*7 109
7 "9 16*2
Jullundur Hoshirirpur
sections of which
and deaths from cholera among
follows
Muliammadans.
Towns.
OF CASES.
did the
find that not
other four towns the ratios for females
for females
Deaths per cen t.
per mille of
POPULATION.
Batala Sialkot
tala the ratios of deaths per cent, of cases in the two sexes were nearly equal, but in the
was
per mille of popula-
among Muhammadans and
are
only by cholera vary in the different towns, but the fatality of the disease in those attacked, as indicated by the deaths per cent, of cases, varied greatly; in Hoshiarpur it was 37 per mille, in Batala 67Lastly we find that, although females are more liable to be attacked by cholera, it is less fatal in them than in males ; in Hoshiarpur and Ba-
ference
cases
chole-
by exception of Pamille are higher for
Further, proportion of the population we
of
cases
Cases
ratios of cases per from 12'6 in Umbal-
; in all the towns, with the
21.
Table V. shows the ratios
2j.
tion and deaths per cent, of Hindus in the six towns.
in these towns are,
liable than males to be attacked
more ra
to
of an
the
during
however,
the variation
with which cholera is found
[March, 188;
mean
in
we
Muham-
excess
of the
ratio for Hindu
of that for Muhammadan we compare the male and
excess
and if
female ratios of the two classes, we find that while among Muhammadans the excess of cases among females, compared with males, was among Hindus it was very marked. These differences varied in the different towns, but it will be observed that in four of the towns the
slight,
greater liability
to
cholera of Hindu females
is
Hindu males is very great; in only one town the ratio for Muhammadan females much
in
excess
over
of the ratio for Muhammadan males.
March, 1883.} 26. find the
As
regards the fatality of cholera, that, taking the mean of the ratios for towns, the fatality among the males of
two classes
6r
TOWNSEND ON THE INCIDENCE OF CHOLERA.
was
females, although
all
among them was less than among males, the difference was considerably greater with Muham-
the
cases
and deaths from cholera at
fatality
madans than with Hindus.
the same, while, with respect to
Table VI. shows the
in both classes the
we
different ages among the population of the
six
towns.
COLUMN. Ages.
Under
Male.
Female.
60 & UPWARDS.
40?60.
year
i
Male.
Female.
Male.
Female,
Male.
Female.
Female.
Male.
Male.
Female.
Towns.
c3 !
c
Panipat Umballa
Jullundar Hoshiarpur Batala
29,
Sialkot
36
Total
218
24
38
164
29
abstract.
All
Cases per 1,000
living
...
Deaths per cent, of cases Deaths per 1,000
27.
living
...
14-1
Under I year.
a?es.
15-6
I'O
3'3
53"?
47 o
IOO'O
60'0
7*5
7'4
I'O:
I'9
In this table the almost
I ?12.
21'O
40 to 60 there is
cases
a
a
7*3
87
42 'O
64*0
59'o
76-0
IO'I
97
69
57
6-8
8-3
7'3
6-1
5"6
60
marked fall in
for both sexes, but
"'5
52*0
In the next
increase in the death-rate for males.
11*2
19 "5
38-0
period, 40, there is further slight decrease in the ratios, both of cases and deaths, for males, but a decided increase in the ratio for females. the ratio of
13-0
48*0
20 to
period
147
51-0
nity from cholera of infants under one year of age strikingly apparent. In the returns from Jullundur and Sialkot not a single case is shown. 28. The ratio of cases per mille among males, and the death-ratio of both sexes for the period of life 1 to 12, are higher than the ratios for any other period. In the ratios for 12 to 20 a con-
In the
14-3
upwards.
49'o
is very
siderable decrease is observable.
I7'4
60 &
40?60.
20?40.
68-o
immu-
complete
12?20.
slight
29- The ratios, both of cases and deaths, for old people above 60 are lower than the ratios for any other period, with the exception of those for infants, and in respect of this period there is a
decided
discrepancy
between the number of
deaths shown in the statements furnished
by
the
Sanitary Commissioner and the numbers returnby the civil surgeons ; in respect of all other ages the death ratios yielded by the two sets of statements agree very closely, but, as regards old people, while the death-ratios yielded by the Sanitary Commissioner's returns are high, the ed
death-ratios returns are
resulting from
comparatively
the civil surgeons'
low.
62
THE INDIAN MEDICAL GAZETTE.
30. The ratios of cases per mille for females at the period of life I to 12, is lower than the ratios for males
at
the
same
periods
ratio for males, but this in the ratios for the
fact,
excess
of the
is most marked
excess
of life
period
; at all other
period
the ratio for females is in
to 40 ; in
20
of the most remarkable features ap-
one
parent in this table is the far greater liability cholera of females between with males at the
20
and 40,
to
of life.
It will be observed in column 4 of the table, that in all the six towns the number of females attacked with cholera the number of males Sialkot it j/.
to 40
was
nearly
in
largely
was
attacked ; in double.
Taking all ages, Muhammadan males attacked in somewhat higher ratio than Hindu males, but Hindu females suffered more 32.
were
than Muhammadan females.
The ratio of cases mille for females of both classes at ages i to per 12, and for Muhammadan females at ages 12
to 20,
the
compared
corresponding period
of
excess
Batala and
Table VII. s,ives the ratios -per mille of cases at the ratios at others ages :?
20
compared with
Cases of cholera per i,coo living.
are
lower than the ratios for males
All other ages.
20?40
The
ages. ratios for
Hindu
Male.
Panipat
Umballa
11'2
17.S
IS'6
115
15*9
12*5
Jullundur Hoshiarpur
15-3
215
147
14-4 12-3 107
19-1
13-6
Rat;ila Sialkot
20-5
lS'2
20'0
I2'9
19-5
I,oooliving..
Female.
107 6
11
13-8 I3"s
6'S
at the corresponding ages. The is most marked in both classes at ages to 40, but it is much greater among Hindus
excess
20
than among Muhammadans. Females of both classes are more liable to be attacked by cholera than males, but this greater liability is evident at an earlier age, and is more marked 33.
women.
At ages 1 to 12 the fatality of cholera equal in the two sexes among Muham-
madans, somewhat less in males among Hindus. At all ages above 12, the fatality of cholera was much less in females of both classes, but this lower
fatality
in
females, compared
147
16 9 I4*3
was
madans.
Hindu
14-4
13'5
liable
be attacked
living
8-3
6-8
77
It will be observed that the ratios of
not
so
to
marked
in Hindus women
by
are
"
At "all other ages the ratios for females slightly below those for males.
ages. are
Table VIII. shows the ratios and deaths
of
cent, of cases, at Muhammadans and Hindus :?
per
Cases
Period of Life.
per
M uhammadans.
1,000
living.
// itidus.
cases
per 1,000 living,
different Deaths
ages among
per cent, of
Muhammadans.
All ages Under i year 12?20
..
20?40 and 40
..
upwards
i4'7 i*6
23*6
104
17*0
I4'7 12*7
13-8
13-8
io'8
"?3
iS'i
13'5
i6'i
53
4-6
100
I5'5
i6'5 21'8
50 45 52
i?'5
64
cases.
Hindus.
Male. I Female. Male. Female. Male. Female. Male.
(To
Female.
/
be
with males, in
as
not
Muham-
only
more
cholera than Muham-
them.
cases
per mille for females, at ages 20 to 40, are much in excess of the ratios for males at the same
at
for males
madan women, but it is somewhat Deaths per 1,000
females
all ages above 12, and for Muhammadan females at all ages above 20, are in excess of the ratios
was
Female.
Male.
at
corresponding
32 b.
in Hindu than in Muhammadan
Towns.
Cases per
[March, 1883.
concluded.)
more
fatal in
THE
CHOLERA ON THE
INCIDENCE OF
POPULATION OF
most
c.b.
distinctive characteristics and
of cholera, is the
uncertainty
of its incidence
different units of
irregularity population. In the most widely-spread epidemic the great majority of the villages escape altogether, and two
or
on
attacked, one will escape with three deaths, while another, at a little are
distance, and under similar conditions of soil and climate, will be more than decimated ; and, even
in
those
towns
and
collected in
villages that suffer epidemic falls with
it is found that the
severely, varying severity on different sections of the population. This irregularity of incidence indicates that the prevalence of cholera in a town or village is dependent on the presence of Whether cholera some local favoring condition. is to be regarded as primarily the product of influence pervading the atmossome climatic a or of specific contagium spread by huphere, man intercourse, the influence or the contagium,
in 1881 cholera to
this
was
prevalent
ascertain how far statistics would confirm the
province
results obtained elsewhere. The
4.
By Surgeon-General S. C. Townsend, One of the
desirable, when in the Punjab,
TOWNS
AND VILLAGES.
of those that
57
TOWNSEND ON THE INCIDENCE OF CHOLERA.
1883.]
March,
enough,
Commissioner
Sanitary
at my
request,
to
furnish
me
was
good
with state-
mortality from cholera in certain towns that were chiefly affected by the epidemic, and also the mortality from all causes in the same towns during the four months that the epidemic prevailed. 5. These statements showed the mortality at different periods of life and among different classes of the population, but they did not give showing
ments
the number of
the
cases
of cholera
or
the number
of persons attacked. This information, however, as will be seen in the sequel, was most essential to the proper treatment of the subject, and I was fortunately able to obtain it from the civil surgeons for six towns. The statistics of these six towns will be chiefly used in this paper, but the two first tables in which the rates of
whichever it may be, will not act upon the population unless this local condition or factor is
mortality from cholera are compared with the rates of mortality from all other causes, have been compiled from the statistics furnished by the Sanitary Commissioner. 6. These statistics were qollected during the season, extending from July lio October, in which malarial fever chiefly prevails ; and as the preva-
present.
lence of fever
It
2.
is
in the removal of this local factor
checking the ravages of must mainly rest, and the discovery of epidemics what this factor is should be the main object of cholera investigation. This discovery cannot be reached without minute investigation into the degree and manner in which the disease falls on the population of different towns and the different sections of the population ; and it is as a contribution to definite enquiry in this direction that I have undertaken the following note. In 1875 and 1876 I collected numerous 3. that
our
hope
of
statistics in the Central Provinces
on
the above
subject, which will be 154-156 of my report
found tabulated in pages on the cholera epidemics
of those years ; and those tables seemed
the results
ing
on
the
etiology
as
to
of
have
an
cholera,
brought important
out in
bear-
it seemed to
me
narily mortality
of
somewhat
was
the
severe in
autumn
from all
causes
more
than ordi-
of 1881, the ratios other than cholera
may be taken to represent resulting from malarial fever.
chiefly mortality
Table I. exhibits the ratios per inille of mortality from cholera andfrom all other causes in eight towns.
All causes except
Cholera.
CHOLERA.
Towns. Both
Male, j Female.
sexes.
Amritsar Batala Lahore Umballa Sialkot
...
...
...
...
Panipat Jullundur... Hoshiarpur
...
62'5
26 9 23-0 21*9 197 i6'2 132 i?'5
Both sexes.
Male. Female.
'
53'i 243
183 20'3
|i8'o 16-3 I
I
*2
9'0
73-6
29 6 277 23'5 21-4 i6-o 152 '9
11
4"i "'5
4'5 109
78
8-4
5i 77 5'9 8-o
5-2 7'5 7'4 8'o
5*4
5'?
3'5 119 7-2 5'? 8'0 4'4 8'o 5 6
THE INDIAN MEDICAL GAZETTE.
58
The ratios in the above table show
7.
relation between the
from
no
causes
and the amount of cholera in the several
towns.
In Amritsar, where the whole population was at the time prostrate from fever, the mortality from cholera towns
lower than in any other of the large attacked by the epidemic ; in the town of
less than half that of
was
were
causes
nearly equal,
in Lahore and
but the
from cholera in the latter town
was
mortality
very much
Lahore; the mortality from all other causes in Hoshiarpur was less than half that of Umballa, but the mortality from cholera was slightly greater. It is moreover worthy of note that, al8. though fever was unusually prevalent in the rural circles surrounding all these towns at the time to below that of
which the above statistics relate, cholera was in a remarkable degree limited to the central towns; the number of
attacked
villages
by
cholera
was
very small ; the fever mortality of the Sialkot rural circles, for instance, for the year 18S1, was equal to 20 per mille of the population, but the per mille. It will be observed in the above table that
cholera 9.
mortality
only
was
in all the towns, with
one
O'li
the morta-
exception,
much in of females, from all causes, excess of that of males. On the other hand, in
lity
was
four of the
of females from
the
mortality considerably below
towns
cholera
was
in
town the ratios
one
equal ; and in mortality from
the
that of males ;
of the two
remaining three,
sexes
were
in which the
cholera among females exceeded
that among males, the
excess was
very
slight,
causes
Cholera.
Both
5,114.
All other causes.
Male. Female.
sexes.
All ages Under 1 year ,
1?2
Amritsar, the mortalithan double; the ratios
ty from cholera was more of mortality from all other Umballa
causes
Deaths from all other
2,037.
Period of Life.
was
Batala, where the mortality from all other
Deaths from cholera
population
270,911.
all
mortality
Total
[March, 1883.
2?3 3?4
...
...
4?5 1?5 5?10... ?.
???
xo?20
7-6
7'9
*o
21
7' 3 1-9
9"5
2
...
7'9
6-8
8-9
9'S
10-3 i4'3 105
9 4
8-4 6-4 6-9
12-9 10*4 8'2
73'3 6-9
677
5'6 7-8
3'6
5'6 7-0 5'9
40?50...
7'5
80
8-4
8-5
i3'5
151
upwards 10.
...
The first
131-i
IO'5 8-6
7'2
60 and
x3'4 1407
15-6
V 62
50?60...
'Female. 211
8-o
61
20?30...
17-3
1360
Male.
II'I
30?40...
...
Both sexes.
point
5 4
5
o
78-9 8-5 7-6
6*9 8'3
7-2 9'5 13-2
I0'2
107 9'4 8-8
r3'9
12-5
IT9
44 "2
34'5
53'9
49
for notice
which calls
in this table is the very small mortality from cholera among infants under one year of age
This, however, is in accordance with statistics which have been collected I believe, be
accepted
as
elsewhere, a
fact
and it may>
that infants at
almost
completely exempt from immunity does not liability extend to older children?the mortality is very high even in the second year of life, though not so great as in the three subsequent years. The highest mortality from cholera shown in the table occurs in the fifth year. In the period between 5 and 10 years, and again between the the breast
are
This
cholera.
to
ages of 10 and 20, there is considerable diminution in the mortality compared with that of the
period
1
to
5. The ratios for the three decades between 10 and 40 vary but little, with the exception of the ratio for females between 20 and 30, which is 11.
considerably
in
excess
of the ratios
immediately
After 40, the ratios preceding and following rise somewhat; and that for old people above it.
Table II. shows
the ratios of mortality per mille at different periods of life from cholera and front all other causes among the population of seven* towns of the Punjab, during the four months, fuly to October, 1881.
*
Note.?The statistics of the
city
of Amritsar have been
excluded from this table, for, while the mortality from cholera was
comparatively slight,
the
mortality
from fever
was so
excess
sive that its ratios dominated those of all the other towns, and to
have included them
They
have been
would have vitiated the
given in a separate
paper,
comparison.
of the series, with the exception of that for children between 4 and 5 years 60 is the
highest
of age. At every period after the age of 5 the ratios for females are below those for males, with the exception of the ratio for females at ages be12.
tween 20 and 30 ; but the difference is
between old
people
of the two
sexes
great only above 60.
March, 1883.]
TOWNSEND ON THE INCIDENCE OF CHOLERA.
13- Turning now to the ratios of from all causes (which, as I have
mortality explained above, represent, to a great extent, mortality Irom malarial causes), we find them in complete contrast with those of the mortality from cholera : instead of the very low mortality among
the effects of
infants which forms
returns
cholera ratios, the
so
marked
mortality
a
feature in the
from all other
hundred,
on
the
mortality from all causes fell proportion of more than
infants in the
in four of the deaths at all ages. 14. Among older children we find the from
We may now proceed to examine the statistics of the six towns from which complete 19.
were
furnished.
Table III. shows the population, and the number of cases
and deaths from cholera, in the six towns.
Number of deaths from Cholera.
Number 0/cases of Cholera.
Population, census of 1881.
mor-
Panipat Umballa Jullundur Hoshiarpur
25,020; 12,430
12,590
13,885 12,106 42.IOO' 22,502 19,658 20,614' 11,002 9,61 24,267! 12,243 12,024 33.8101 17,734 16,076
25,99r|
Batala
Sialkot Total
328
341 153
304
of population, and
61
155
110
21S 260
279
'.'77
';274
202
240
171,862 89,796 82,066
Table IV. shows the ratios of
56
149 l33 339
3=3 327
,669
264
'
67? 604
and deaths per mille
cases
the deaths per cent,
of
cases, in the six
towns.
from cholera is small in proporthe increase in the mortality from all
mortality
to
16.
of
increased, but the
cholera
After the age of 40 an increase is observable in both sets of ratios, but the increase
other
specific
up-
causes.
tion
the action of the
more
cause
cholera.
one
greatly tality mortality from all other causes diminished rapidly, so much so that the ratio for the ages 1 to 5 is just half that for infants under one year. 15. Among children under 5 the mortality from all other causes was greatly in excess of the mortality from cholera both among males and females, but at subsequent periods of life up to the age of 40 among males the mortality from cholera exceeded the mortality from all other
in the
to
develop-
thereby rendered
causes
among infants was enormous ; while in the case of cholera the deaths of infants in proportion to the deaths at all ages was barely one in a
unusual and excessive
an
ment of malaria is not
susceptible
59
causes.
At all
tion, the
Cases per mille
of
periods mortality from
life,
with
excepcholera of females was
slightly below that of males, but in the mortality from all other causes the reverse occurred ; at all periods above one year, with the exception of that from 40 to 60, the mortality among females was greatly in excess of the mortality among males. 17. The above
of population.
one
comparison
of the ratios of
mormortality tality from all other causes affords good reason for believing that cholera is the product of a specific cause distinct from the malaria, which is the primary cause of the greater part of the mortality among the population of this country.
18. Further it would appear from the instance of Amritsar, that a population suffering from
population.
Deaths per cent,
of
cases.
Towns.
Panipat
Umballa
from cholera with the ratios of
Deaths per m ille of
Jullundur Hoshiarpur Bata.la
Sialkot
20.
tables cholera
157 5 "4 5i 5 "6, 18*1 11 "5 io-9 u-9 l6'2 77 7'5 8-o
*4*9
i5'6
!4'9|
Total
I2'S
12-9 I2"9 I2"6 12*2 I5'9 I5'I 147 13-8 i7'3 i6'5 13 "5
I
14 i| !
I;
167
As the six towns were
selected
5'9 5"i 8-o
7'4
7 '4 5'2 8-o
7 "4
given
"4 5"o 8-o
4
prevailed extensively
42
5?'
3s
47
the above
for illustration in all of
58
40
4.S
7'3
in
46
because
them,
thin
THE INDIAN MEDICAL GAZETTE.
6o
table does not in
degree
adequately represent
vail in the different towns and trict
variations in mille of
prevalence prevalence even
very marked?the
population ranged
la to 17 3 in Batala. Then
villages of a epidemic.
predisThe
we
find that females
nipat, the ratios of cases per females than for males.
attacked
very much below the ratios for males ;
35 against 58 for males. The next table illustrates the incidence
22.
of cholera the
on
only
the two
population
principal
of the
towns
aggregate number of the number of
them,
were
the dif-
greatest in Panipat, where the ratio was
cases
were as
14*6
Panipat
Umballa
is
two
composed.
The
classes, and the
:?
Cases per mille of population
tion
69
The
Cases of cholera.
107,175
1,60S
64,687
935
Hindus are,
on
the
whole,
j Deaths from cholera.
j
|
more
7S3 481
well-
to-do than the Muhammadans ; there is a larger proportion of wealthy and well-to-do people among them.
53
46
8"o
7'o
24. From this table it appears that cholera fell with varying severity on the two classes of which the population of the several towns is
composed. severity on
In
Panipat
the
it fell with much greater
Muhammadans than
on
the
Hindus ; in Umballa the proportion of the Hindu population attacked was just double what it
with the Muhammadans.
was
pur and in more
Jullundur proportion
in
In Hoshiar-
the Muhammadans suffered than the
Hindus.
ratios of the two classes in Batala and
nearly equal. 25. Taking both
The Sialkot
are
sexes
in all the towns, the
ratio for Muhammadans very slightly exceeded that for Hindus; but, on comparing the ratios of males
and females
males
females is in
11 indus
70
18-6
Deaths per mille of popula-
is
of the mean
females;
two
classes,
ratio for
considerably
ratio for Hindu males, the
Muhammadans
35 56 36
20"I
i4'6 13*0 i6"i
find that, while the
Population.
9 ? '7 4 17*0 I2'5
I5*2|
16-9 15-4 I7'? I7'4 15-0 14*9
madan
Section.
Mukammadans Hindus-
Hindus.
9*5 9*9 i6'2! 15*0 I3'5 T3*?i 13*4 I7"7 I5'3 14*7 109
7 "9 16*2
Jullundur Hoshirirpur
sections of which
and deaths from cholera among
follows
Muliammadans.
Towns.
OF CASES.
did the
find that not
other four towns the ratios for females
for females
Deaths per cen t.
per mille of
POPULATION.
Batala Sialkot
tala the ratios of deaths per cent, of cases in the two sexes were nearly equal, but in the
was
per mille of popula-
among Muhammadans and
are
only by cholera vary in the different towns, but the fatality of the disease in those attacked, as indicated by the deaths per cent, of cases, varied greatly; in Hoshiarpur it was 37 per mille, in Batala 67Lastly we find that, although females are more liable to be attacked by cholera, it is less fatal in them than in males ; in Hoshiarpur and Ba-
ference
cases
chole-
by exception of Pamille are higher for
Further, proportion of the population we
of
cases
Cases
ratios of cases per from 12'6 in Umbal-
; in all the towns, with the
21.
Table V. shows the ratios
2j.
tion and deaths per cent, of Hindus in the six towns.
in these towns are,
liable than males to be attacked
more ra
to
of an
the
during
however,
the variation
with which cholera is found
[March, 188;
mean
in
we
Muham-
excess
of the
ratio for Hindu
of that for Muhammadan we compare the male and
excess
and if
female ratios of the two classes, we find that while among Muhammadans the excess of cases among females, compared with males, was among Hindus it was very marked. These differences varied in the different towns, but it will be observed that in four of the towns the
slight,
greater liability
to
cholera of Hindu females
is
Hindu males is very great; in only one town the ratio for Muhammadan females much
in
excess
over
of the ratio for Muhammadan males.
March, 1883.} 26. find the
As
regards the fatality of cholera, that, taking the mean of the ratios for towns, the fatality among the males of
two classes
6r
TOWNSEND ON THE INCIDENCE OF CHOLERA.
was
females, although
all
among them was less than among males, the difference was considerably greater with Muham-
the
cases
and deaths from cholera at
fatality
madans than with Hindus.
the same, while, with respect to
Table VI. shows the
in both classes the
we
different ages among the population of the
six
towns.
COLUMN. Ages.
Under
Male.
Female.
60 & UPWARDS.
40?60.
year
i
Male.
Female.
Male.
Female,
Male.
Female.
Female.
Male.
Male.
Female.
Towns.
c3 !
c
Panipat Umballa
Jullundar Hoshiarpur Batala
29,
Sialkot
36
Total
218
24
38
164
29
abstract.
All
Cases per 1,000
living
...
Deaths per cent, of cases Deaths per 1,000
27.
living
...
14-1
Under I year.
a?es.
15-6
I'O
3'3
53"?
47 o
IOO'O
60'0
7*5
7'4
I'O:
I'9
In this table the almost
I ?12.
21'O
40 to 60 there is
cases
a
a
7*3
87
42 'O
64*0
59'o
76-0
IO'I
97
69
57
6-8
8-3
7'3
6-1
5"6
60
marked fall in
for both sexes, but
"'5
52*0
In the next
increase in the death-rate for males.
11*2
19 "5
38-0
period, 40, there is further slight decrease in the ratios, both of cases and deaths, for males, but a decided increase in the ratio for females. the ratio of
13-0
48*0
20 to
period
147
51-0
nity from cholera of infants under one year of age strikingly apparent. In the returns from Jullundur and Sialkot not a single case is shown. 28. The ratio of cases per mille among males, and the death-ratio of both sexes for the period of life 1 to 12, are higher than the ratios for any other period. In the ratios for 12 to 20 a con-
In the
14-3
upwards.
49'o
is very
siderable decrease is observable.
I7'4
60 &
40?60.
20?40.
68-o
immu-
complete
12?20.
slight
29- The ratios, both of cases and deaths, for old people above 60 are lower than the ratios for any other period, with the exception of those for infants, and in respect of this period there is a
decided
discrepancy
between the number of
deaths shown in the statements furnished
by
the
Sanitary Commissioner and the numbers returnby the civil surgeons ; in respect of all other ages the death ratios yielded by the two sets of statements agree very closely, but, as regards old people, while the death-ratios yielded by the Sanitary Commissioner's returns are high, the ed
death-ratios returns are
resulting from
comparatively
the civil surgeons'
low.
62
THE INDIAN MEDICAL GAZETTE.
30. The ratios of cases per mille for females at the period of life I to 12, is lower than the ratios for males
at
the
same
periods
ratio for males, but this in the ratios for the
fact,
excess
of the
is most marked
excess
of life
period
; at all other
period
the ratio for females is in
to 40 ; in
20
of the most remarkable features ap-
one
parent in this table is the far greater liability cholera of females between with males at the
20
and 40,
to
of life.
It will be observed in column 4 of the table, that in all the six towns the number of females attacked with cholera the number of males Sialkot it j/.
to 40
was
nearly
in
largely
was
attacked ; in double.
Taking all ages, Muhammadan males attacked in somewhat higher ratio than Hindu males, but Hindu females suffered more 32.
were
than Muhammadan females.
The ratio of cases mille for females of both classes at ages i to per 12, and for Muhammadan females at ages 12
to 20,
the
compared
corresponding period
of
excess
Batala and
Table VII. s,ives the ratios -per mille of cases at the ratios at others ages :?
20
compared with
Cases of cholera per i,coo living.
are
lower than the ratios for males
All other ages.
20?40
The
ages. ratios for
Hindu
Male.
Panipat
Umballa
11'2
17.S
IS'6
115
15*9
12*5
Jullundur Hoshiarpur
15-3
215
147
14-4 12-3 107
19-1
13-6
Rat;ila Sialkot
20-5
lS'2
20'0
I2'9
19-5
I,oooliving..
Female.
107 6
11
13-8 I3"s
6'S
at the corresponding ages. The is most marked in both classes at ages to 40, but it is much greater among Hindus
excess
20
than among Muhammadans. Females of both classes are more liable to be attacked by cholera than males, but this greater liability is evident at an earlier age, and is more marked 33.
women.
At ages 1 to 12 the fatality of cholera equal in the two sexes among Muham-
madans, somewhat less in males among Hindus. At all ages above 12, the fatality of cholera was much less in females of both classes, but this lower
fatality
in
females, compared
147
16 9 I4*3
was
madans.
Hindu
14-4
13'5
liable
be attacked
living
8-3
6-8
77
It will be observed that the ratios of
not
so
to
marked
in Hindus women
by
are
"
At "all other ages the ratios for females slightly below those for males.
ages. are
Table VIII. shows the ratios and deaths
of
cent, of cases, at Muhammadans and Hindus :?
per
Cases
Period of Life.
per
M uhammadans.
1,000
living.
// itidus.
cases
per 1,000 living,
different Deaths
ages among
per cent, of
Muhammadans.
All ages Under i year 12?20
..
20?40 and 40
..
upwards
i4'7 i*6
23*6
104
17*0
I4'7 12*7
13-8
13-8
io'8
"?3
iS'i
13'5
i6'i
53
4-6
100
I5'5
i6'5 21'8
50 45 52
i?'5
64
cases.
Hindus.
Male. I Female. Male. Female. Male. Female. Male.
(To
Female.
/
be
with males, in
as
not
Muham-
only
more
cholera than Muham-
them.
cases
per mille for females, at ages 20 to 40, are much in excess of the ratios for males at the same
at
for males
madan women, but it is somewhat Deaths per 1,000
females
all ages above 12, and for Muhammadan females at all ages above 20, are in excess of the ratios
was
Female.
Male.
at
corresponding
32 b.
in Hindu than in Muhammadan
Towns.
Cases per
[March, 1883.
concluded.)
more
fatal in
