A study of the evidence as to the source of the infection which caused the cases of tetanus at Mulkowal, Punjab, India, during inoculation against plague in October, 1902 / by James Cantlie.

  • Cantlie, James, Sir, 1851-1926.
Date:
1907
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Licence: In copyright

Credit: A study of the evidence as to the source of the infection which caused the cases of tetanus at Mulkowal, Punjab, India, during inoculation against plague in October, 1902 / by James Cantlie. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    amount of toxin which they elaborate. , Regarding the Mulkowal microbe, it has already been mentioned that a bottle of prophylactic in which it had been growing only for seven days appeared to contain a virus many hundreds of times more deadly than that found by Lieutenant-Colonel Semple in an ordinary tetanus cul- ture. Its action was also several times quicker than that of the latter (Appendix to this letter, under (4) (p. 54)). Had, therefore, the Mulkowal bottle been contaminated in Bombay, the patients would have received into their tissue 1^ cc. of such a potent and rapidly acting toxin ready prepared, instead of, as is the case in accidental tetanus, benefiting by an interval required for the elaboration of toxin in their own tissues.1 The large amount of germs that would have been present in a dose of 1-^ cc. of a Bombay contaminated prophylactic as compared with the doses in accidental cases; the introduction of that dose right into the tissues ; the predisposing inflammation created by the prophlactie ; and the presence of 1-| cc. of ready-made and rapidly acting toxin, should have caused the disease to manifest itself with a rapidity and gravity far above those observed in average cases; but, where- as in ordinary Indian practice cases may be met with of an incubation period of less than twenty-four hours, ending fatally within another twenty-four hours, the patients infected at Mulkowal took five and six days to develop the first symptoms, and the length of their illness—which in tetanus is usually fatal—varied from two to five days, and in one case was of one day. (Some remarks on this matter are made in the Appendix, under (6) (p. 55).) The Commission had before them an important .term of comparison in the isolated case of tetanus which they investigated together with the Mulkowal Case, and which had occurred at Ferozepore, Punjab, eleven days before the accident at Mulkowal. On this case the Commission reports as follows : “ We are satisfied that the isolated case of tetanus cannot be ascribed to contaminated fluid.” The con- tamination -was therefore conveyed through that natural dose of a tetanus impurity, unmultiplied by growth in a culture, as causes ordinary tetanus cases. The patient died two and a half days after the time when she was inoculated, the first symptoms appearing sixteen or eighteen hours after that time, and the illness lasting forty-six hours. The details of the case are reproduced in the Appendix of this letter under (7) (p. 55). The Mulkowal cases were less affected by the con- tamination which fell to their lot. The character of their disease, when compared to that of the Feroze- pore case, was such as to induce one almost to say that the amount of tetanus impurity which, in Feroze- pore, affected a single person, was, in Mulkowal, divided by an accident of procedure into nineteen shares, and weakened in its effect. D. Lastly, the following fact refers to the condition of the fluid at the time of using it at Mulkowal. 1 Vide Lister Institute Experiments, 2 and 6, Appendix F (B), p. 77 ; Indian Commission’s Experiment 1, Appendix B., p. 43. w The syringe with which contents of bottle 53 N. ere injected was dealt with afterwards as follows ': It was filled with carbolic lotion 1 in 20, left so for a few (three or four) minutes ; then the lotion was squirted out, and the instrument used for inoculating other people. None of the latter suffered. In a culture of four to seven weeks, as it would have been had the bottle been contaminated in Bombay, and even in one of a much shorter duration, tetanus germs develop spores or special forms of resistance, made to with- stand heat, desiccation, adverse chemical action, &c. For destroying such spores by carbolic lotion an action of some fifteen hours is required. The procedure applied to the contaminated syringe thus amounted practically to an imperfect cleaning. If spores of such an abundant culture as would have developed in a bottle of prophylactic had been drawn into the syringe, the above cleaning would have left the instrument very grossly contaminated (vide the Lister Institute’s Report, Appendix G, Experiment 1 ; and the Indian Commissioner’s Report, Appendix B, Experiment 2 (pp. 48 and 43)). The fact that the passage through that instrument of one syringeful of lotion was sufficient to render it harmless, points to its having been in contact with only a small amount of impurity, such, for instance, as was experimented with by the Lister Institute in Appendix G, Experiment 2 (p. 48). The force of this argument is the greater that, as has been mentioned already, man is so sensitive to tetanus that an imperceptible trace of virus left on a surgical instrument exposes him to the disease; and in the Mulkowal circumstances the sub- jects were made particularly susceptible by the inflam- mation from the prophylactic injection. Summary of the Above. The following facts indicate that the germs of tetanus had not effected an entrance into the Mulkowal bottle even only a few days prior to its opening. The bottle was odourless at the time of using it, whereas in less than three days a tetanus odour be- comes unmistakable in a contaminated bottle. Tetanus germs generally, and the Mulkowal speci- men in particular, when growing in a full bottle of prophylactic, give in a few days a rich and extremely active culture; whereas in the sample left in the Mulkowal bottle a poor culture was found of a much lesser activity, such as would develop in the rem- nants of prophylactic fluid, in a bottle emptied of its contents. The character of the disease exhibited by the nine- teen patients was that observed in average clinical cases in India, of a not very severe description, i.e., in cases due to minute accidental doses of virus, not multiplied by culture ; and that character is incom- patible with the supposition that the Mulkowal cases were injected with 1-| cc. of a virus of such potency as was found in infected, full, bottles of prophylactic, after even only a few days accumulation of virus in them. And, lastly, the fact that contamination could be easily removed from the infected syringe and the latter rendered harmless, indicates that it had been in contact with only a small amount of virus ; whereas when