2
so far as is known, been established in the Punjab by any systematic investi-
gation conducted aver a large area. It may, however, be stated that a recent
inquiry in one area suggested that the total mortality figures were not appreci-
ably underestimated.
In regard to the " fever " mortality it is not possible to speak with the
same degree of confidence, for the determination of the cause of death is in
most cases made, by the village chaukidar, whose powers of diagnosis are neces-
sarily somewhat limited. A critical analysis of chaukidars' books -recently
carried out led to the conclusion that these returns are not so inaccurate as
might at first sight be expected.
Entries such as " tumours," "suppression of urine," "labour," " para-
lysis," " phthisis," "renal colic," as well as "measles," " cholera," " plague"
and " malaria " suggest that whilst the diagnosis is often vague, considerable
discrimination is used, and deaths are not wantonly attributed to " fever "
when another well defined cause of death is present, Whilst therefore a number
of deaths are no doubt incorrectly ascribed to this disease, there is at present
no reason to believe that these statistics are gravely inaccurate so far as
malaria is concerned. The extent of the inaccuracy has been variously esti-
mated by difierent observers, but in view of the fact that it probably varies
both from year to year and also in different parts of same district it is difficult
to gauge accurately the extent to which the provincial figures are vitiated by
errors of this nature.
A further complication is introduced by the fact that malaria so fre-
quently supervenes in the course of other diseases that it must often contribute
to a fatal termination in cases where it is not the primary disease ; again, the
occurrence of an acute disease, such as pneumonia, in an individual enfeebled
by long-standing malaria will be more likely to end fatally than in the case of
an healthy individual.
Whilst therefore necessity exists for " correcting " the provincial vital
statistics the. matter is one of considerable difficulty.
The error in the returns of '-fever" mortality is, however, one which,
must be more or less of a constant nature from year to year. It therefore
cannot be the cause of those marked oscillations in the fever deaths which form,
euch a prominent feature of Chart II. In regard to the latter it is possible to
speak with an unusual degree of confidence, for Major Christophers has been
able to show that the marked rises in the autumnal " fever " mortality are due
to malaria and malaria alore. For, in the case of the year 1908, he has con-
clusively shown that the abnormal fever mortality of that year occurred at a
time when malaria alone was prevalent, that it was accompanied every where
in an increase in dispensary admissions for what was clinically malaria, and that
it was followed by a noticable increase in the number of people attending
hospital for splenic enlargement. Finally, he was able to prove that in certain
areas the people exhibited at the conclusion of the epidemic an almost universal
infection with malaria parasites.
The conclusion therefore may be reached that, whilst endemic malaria
prevails to a varying extent throughout the province, giving rise to an annual
mortality, the exact extent of which can only be approximately estimated,
the disease periodically manifests itself in epidemic form, when it is attended
by a greatly enhanced mortality, the extent of which may be gauged with a,
considerable degree of accuracy by measuring the excess over normal of the
recorded fever mortality.
It is thus clear that malaria in the Punjab is a disease exercising a pre-
dominant influence over the well-being of its inhabitants. But the damage-
wrought by malaria cannot be measured from mortality bills alone, for even
in years, such as the one under review, when no autumnal epidemic occurred,
it. causes a serious amount of sickness and ill-health, and perhaps more subtle
of all, a Joss of energy and initiative in the apparently healthy, which though
incapable, of direct measurement is of incalculable importance.