12
on any considerable scale till the middle of October, and in all districts the special-
staff did not really get to work until that time. The manner, however, in which
the operations started in spite of all difficulties, and the extent to which it was
possible in some districts to resume them in January, as well as the results of the
inoculations performed, afford clear evidence that, except for the fatal check
which the operations received from their suspension in the beginning of No-
vember, on account of doubts regarding the safety of the fluid then being supplied
by the Laboratory, and on account of a deplorable accident which followed a series
of inoculations in Gujrát, the operations would have been remarkable for their
success and would have achieved the objects for which they were under-
taken.
25. In the middle of September the Punjab Government was informed not
only that the Plague Research Laboratory was unable to supply the number of
doses which had been originally promised, but also that the fluid which it proposed
to supply would be prepared by a method different from that which had been fol-
lowed in the preparation of the fluid hitherto used in the Punjab. When the change
in the process of manufacture was notified to the Lieutenant-Governor, it was
practically impossible to do more than to take steps to assure himself that
it was safe to use the new fluid, and to allow the scheme to proceed, while a very
careful watch was kept on the operations It soon became apparent that the pro-
portion of the new fluid which was unfit for use was many times greater than had
been the case with the old. The unfitness was judged by the smell of the con-
tents of bottles and observation of their colour and general appearance. Reports
received from inoculating officers in all parts of the Province shewed that bottles
of bad smell or containing fluid of an abnormal appearance were not uncommon.
Abscesses occurred more frequently with the new fluid than they had with the old,
and though they might possibly have been due to careless inoculation, there was
good reason to believe that they were due to impurities in the fluid itself. More-
over, it was reported that the reaction of the new fluid was insufficient according to
the standard fixed for the old, and for this reason doubts as to its prophylactic value
were aroused. Finally a few deaths were reported to have closely followed inocu-
lation, and though subsequent investigation showed that they were not due to that
cause, the reports of these deaths added to the suspicion with which the new fluid
was regarded. In consideration of all the circumstances His Honour came to the
conclusion that it would not be justifiable to expose the people to the risk of inocu-
lation with a fluid in which he and his officers had not complete confidence. On
the 30th of October he felt compelled to ask the Plague Research Laboratory
to discontinue the supply of the fluid then being issued, which -enquiry later
showed to be different even from that which the Laboratory was supplying in
September. At the same time His Honour made arrangements for a resumption
of a supply of the old fluid as soon as possible. On the Ist of November
orders were issued with the object of withdrawing with as little suspicion as
possible all the new fluid which had been issued to districts, leaving the opera-
tions to be continued with the existing stock of old fluid as long as it held out.
At this very time, however, the use of the new fluid had resulted in a deplorable
calamity. On the 30th of October .9 persons were inoculated at Mulkowál in
the Gujrát District with the contents of one bottle of the fluid, and all of them
contracted tetanus and died. His Honour desires to state here that the people
of Mulkowál behaved admirably throughout, and the families of those who
suffered were compensated by Government. The Lieutenant-Governor is satis-
fied that the tetanus was not due to any carelessness or fault on the part of
the inoculating officer, Dr. Elliot, who later was granted a gratuity and
permitted to resign his appointment at his own request. The circumstances of
the case point to the conclusion that the fluid had been contaminated with
tetanus before it reached the Punjab. The Mulkowál disaster was reported
on the night of the 6th of November, and in order to guard against
the risk of any further calamity Sir Charles Rivaz felt it imperative to
issue orders for the immediate and entire cession of all inoculations. Such
orders reached the districts concerned on the 7th of November. Many local
officers, however, reported that the people were still anxious to be operated
upon, and after all the new fluid had been withdrawn, on the 19th of November