NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
21
TABLE VIII.
I I . P A S T E U R I A N T R E A T M E N T .
Kasauli scheme.
One centimetre of cord is emulsified in 3 cc. sterile physiological salt
solution. Weight of rabbits about 1,500 grms.
Day of desiccation.
Dose.
Units.
I 14—13
.
.
.
.
.
3 cc.
.
. .
2 12—11
.
.
.
.
.
.
,,
. . .
3 10—9.
.
.
.
.
.
,,
.
. .
4 8 — 7 . .
. . . .
,,
. .
.
703.125
5
6
.
.
.
.
.
,,
.
.
.
700.00
6 5
.
. . .
.
.
.
,,
. .
.
937.50
7 5
. . . . .
,,
.
.
.
937.50
8 4.
.
.
.
.
.
.
,,
.
.
.
1,351.25
9 3
.
.
.
.
.
.
,,
.
.
.
1,875.00
10 7— 6 .
.
. . . .
,,
.
1,168.75
1 1 5
.
.
.
.
.
.
,,
.
937.50
12 4
.
. , . . .
,,
.
1,351.25
13 3
.
.
.
. . .
,,
. . .
1 , 8 7 5 . 0 0
14 6
.
. . . . .
,,
. . .
7 0 0 . 0 0
15 5
.
.
.
.
.
,,
.
.
9 3 7 . 5 0
6 4
.
.
.
.
.
.
,,
.
.
.
1,351.25
17 3
.
.
.
.
.
, ,
.
1,875.00
1 8 5
.
.
.
.
. .
,,
. . .
937.50
19 4
. . . . .
,,
. . .
1,351.25
20 3
. . . . .
, ,
. . .
1,875.00
2 1 5
. . . . . .
,,
. . .
937.50
2 2 4
. . . . . .
,,
.
.
.
1,351.25
23 3
.
.
.
.
.
.
,,
.
.
.
1,895.00
TOTAL
.
25,028.125
22
In Paris the rabbits used are 2 to 2½ kilos. weight, whereas those used at the
Kasauli Institute weigh on the average about 1½ kilos. In Paris, then, length for
length, cords would weigh more and dry less quickly than in Kasauli. The
result of this difference in weight probably is that the emulsions used in treat-
ment are of a higher concentration than those used in Kasauli and so a larger
dose is given. The doses used in Paris represent in all probability a greater
number of units than would be given by the assumption that the emulsions
used were exactly equivalent to those used in Kasauli. We have not therefore
attempted to estimate the Paris scheme. We have to note here that this
estimation of systems takes no account of dead vaccinal material separate from
living virus as we do not consider this to have any immunising value (vide
p. 27 ). Further, we take no account of the fact that a cord such as nine-day
cord although non-infective in a dose of 0.2 cc. of 1/5 dilution might be to a small
extent infective, and therefore immunising, in a dose of 3 cc. of this dilution.
However, we believe that no very great error is introduced by this last omission.
To return to our comparison of systems, we might lay down, supposing our
original assumptions to be somewhere near the truth, that 25,000 units given
in 14 to 20 days or very probably in a considerably shorter period of time would
be sufficiently protective for light anti-rabic treatment. This computation has, as
we have said, special reference to the Kasauli mode of procedure, taken in con-
junction with that of Höyges. In exactly the same way if we compared these
systems dose for dose instead of as a whole we should conclude that 3 cc. of a 5
per cent. emulsion (that ordinarily used in Kasauli) of three-day cord was as
nearly as possible intermediate in strength between 1 cc. (Höyges' dose) of
1/100 fresh rabies emulsion and 1 cc. of 1/200 fresh rabies emulsion. Similarly 3 cc.
of a five-day cord emulsion would hold the relation to 1 cc. of 1/200 fresh emulsion
of 1.5 : 2. The relations, therefore, of these different doses mentioned would be
4 : 3 : 2 : 1.5 .
4= 1 cc. 1/100 fresh in material.
3-= 3 cc. 5 per cent. three-day cord.
2-= 1 cc. 1/200 fresh.
1.5 = 3 cc. 5 per cent. five-day cord.
Other systems might be estimated after the same fashion.
IV.—Massive Doses of fresh Fixed Virus in Anti-rabic
Immunisation.
We have referred in our introduction to the possibility of immunisation against
rabies by giving large doses in 2, or at most 3, injections properly interspaced.
As we use here fresh living virus only it would be necessary to be sure that there
was no danger in the procedure of giving rise to the disease which it was intended
to ward off. We have at different times and for different purposes had occasion
to give considerable doses of fresh virus to animals by subcutaneous injection.
23
In no single case did rabies result from the procedure. The emulsion of virus
was always given in the loose abdominal subcutaneous tissue—after the fashion
of anti-rabic inoculation. In the case of some of the dogs thus treated which were
afterwards inoculated subdurally we found that immunity had been produced.
The following table gives in a succinct form the doses used and the results of sub-
sequent subdural inoculation when that was practised.
To show—
TABLE IX.
(1) That massive doses of fresh fixed rabies virus may be given to
certain animals subcutaneously without danger of infection.
(2) That a small number of inoculations or even a single, large inoculation
of such material can confer immunity to subdural infection.
Series.
Animal.
Weight.
No of
inocula-
tions of
fixed virus.
Total quantity
fixed virus
injected.
Duration
of inocula-
tions.
Subdural
inoculation.
Remarks.
Result.
1
Dog 1 . . 25 lbs. .
4
0495 grm.
. 4 days .
...
In Höyges'
method of
immunisa-
tion the
strongest
dose given
contains only
0.01 grm.
fixed virus.
Remained
well.
Dog 2 .
. 15 lbs. .
4
0.46 grm.
.
„
. 25th May 1906
—twenty-one
days after last
immunising
dose with
0.2 cc. of
2 per cent.
fixed virus
emulsion.
0.2 cc.
Ditto.
Small brown
monkey 1. ...
4
0.22 grm.
.
„
.
Ditto
Showed signs
of rabies nine
days later.
Monkey 2
.
Remained
well.
. . .
4
, , .
,,
.
. . .
...
Monkey 3
.
. . .
4
,,
.
,,
.
. . .
. . .
Ditto.
Goat 1 .
.
...
...
15th August 1906
to 19th August
1906, 0.845
grm. 15th
September 1906,
1/6 brain rabies
rabbit 8th
October 1906,
brain rabies
rabbit. 23rd
October 1906,
½ brain rabies
rabbit. 8th
November 1906
whole brain
rabies rabbit.
3rd December
1906, whole
brain. 3rd Ja nu-
ary 1906, whole
brain. 27th
January 1996,
whole brain,
and so on at
intervals of
about a month.
Still conti-
nuing.
...
. . .
Ditto.
Series.
Animal.
Weight.
No. of -
i n o c u l a t i o n s o f
fixed virus.
Total quantity
fixed virus
injected.
Duration
of inocula-
tions.
Subdural
inoculation.
Remarks.
Result.
III Dog 3 .
. 18½ lbs. .
1 ½ rabbit brain
fixed virus.
...
34 days after
last immun-
ising dose
0.3 cc. of 3
per cent. fixed
virus emul-
sion. 26th
February
1907.
. . .
Remained
well.
Dog 4 .
. 8 lbs. .
2
¾ brain rabbit
fixed virus.
(1) ¼ brain
24th Jan.
1907, (2)
½ b r a i n ,
3rd Feb.
1907.
23 days after
last immunis-
ing dose 0.3
cc. of 5 per
cent, fixed
virus. 26th
Feb. 1907.
...
Ditto.
Dog 5 (control) 16 lbs. .
...
...
. . .
26th February
1907, 0.3 cc. 5
per cent. fixed
virus.
. . .
Developed
rabies nine
days later.
From these experiments it will be seen that we were able to immunise a dog
(No. 2) with as small a quantity as 0.46 grm. given in four injections. Dogs
3 and 4 were immunised to subdural inoculations with one and two injections re-
spectively. In the first series of experiments it is evident that the amount given to
the small brown monkey (No. I) was insufficient to produce immunity, to subdural
injection. As this monkey was injected with the same amount and from the same
emulsion as dog 2 it serves to some extent as a control in the particular series
(Series I) of experiments in which it was used. The doses given subcutaneously
may be regarded as massive doses, and in no case was there any evidence of
harm resulting in either dogs, monkeys, or goat. We may infer therefore that
in this small number of cases massive subcutaneous injections of fixed rabies virus
did not produce infection but immunity to subdural inoculations and that this
immunity was achieved in one case by one single inoculation. There are also
numerous published instances in which massive doses have been given and no
harm resulted—often indeed they have been preliminary to the subsequent trial
of the immunity produced. Thus Krasmitski 1 r e l a t e s h a v i n g a d m i n i s t e r e d
5-8 cc. of thick emulsion of fresh fixed virus material intraperitoneally
and 8 and 20 cc. (two separate occasions) subcutaneously in rabbits without
harm resulting. Rabbits, however, are by no means immune to subcutaneous
injection of fixed virus and a considerable number will develop rabies after
such a procedure, owing, it is said, 2 to the impossibility of avoiding wounding
muscle. The dog and the sheep would seem less susceptible than the rabbit.
Roux and Nocard 3 injected 5 cc. of rabies emulsion (? strength) intravenously
1
A n n
.
P a s t
. , 1 9 0 2 p . 4 0 3 .
2
H e l m a n
A n n
.
P a s t
., 1889, p. 1 9 .
3
A n n
.
P a s t
. , 1 8 8 8 , p . 3 4 7 .
25
in a sheep without effect. Helman and others have injected intraperitoneally
and subcutaneously large doses of rabies virus without producing any signs of
intoxication or of rabies.
More recently Nitsch1injected himself subcutaneously with the emulsion
made from a fresh piece of rabies cord (858th passage—fixed virus) of 4-5 mm.
length, without any harm.
V.—On the existence or non-existence of a rabies toxin together
with a consideration of the concurrent symptoms and
sequelæ of anti-rabic treatment.
The proofs of the existence of a rabies toxin as given by Babes2 are—
1. The premonitory fever in rabies is a specific fever.
2.The leucocytosis apparent in nerve ganglia and in the circulating
blood can be due only to the action of a toxin.
3.The hemorrhages observable in the central nervous system can result
only from injury to tissues acted on by a toxin.
4. Filtered rabies virus or killed rabies virus injected in large quantity
brings about death in test animals not by rabies but by marasmus.
From the argument which we develop in the following pages it will be seen
that we offer another explanation of the disturbance resulting from inoculation
of rabies virus. We do not consider that the reasons set forth above negative
our proposition.
A good deal of attention has been drawn of late years to some of the
symptoms which may accompany or follow anti-rabic treatment in their graver
manifestations, particularly by Remlinger. The symptoms following or accom-
panying anti-rabic treatment are, in our own experience, local reaction, local
irritability, headache, neuralgia, pains in the limbs, pains in the back or in joints,
fever, urticarias (local and generalised), dysphagia, giddiness, lassitude, anorexia,
nausea and, last and worst, paralysis of varying gravity. The former ideas with
regard to these were that the symptoms—at least the graver symptoms—might
be due (1) to a partial attack of rabies proceeding from the original infection
which was rendered more or less abortive and non-fatal (for these symptoms
rapidly disappear) by the anti-rabic treatment, or (2) to alcoholism in a person
undergoing anti-rabic treatment, or to (3) other conditions which need not here
be specified (vide article by Remlinger). 3
Remlinger has shown by an exhaustive analysis of a large number of
collected cases that these explanations will not answer. His belief, as far as we
can gather, is that here we have special evidence of a rabies toxin as distinguished
1 Quoted Art. "Lyssa." Handb. f. Path. Mikr.K o l l e & W a s s e r m a n n , 2 n d S u p p l e m e n t , p . 6 4 6 .
2 Quoted Art. "Lyssa" (Marx) Handb. f. Path. Mikroorg, 1904. Kolle & Wassermann, p. 1284.
3 Accidents Paraiytiques au cours du traitement antirabique. Ann. Past., No. 10, 1905, p. 639.
E
26
from the living virus. He directly incriminates, and we believe justly so, the
inoculation material as the active cause of these symptoms. Where we do
not follow him is in regard to his assumption that the symptoms must be
due to a rabies toxin. The sum and substance of his argument on this point
we conceive to be this (1) The existence of a rabies toxin is not to be doubted.
(2) In rabies we have an instance of a disease accompanied by paralysis.
(3) One of the gravest of the sequelæ of anti-rabic inoculation is a paralysis.
Therefore it would seem justifiable that, as undoubtedly the same virus is
present in both instances, the symptoms must in both cases be due to the
same cause. But as in the second of the two instances it may practically
be said that cure is the invariable rule, therefore in this case we can only be
dealing with the rabies toxin and not directly with the living rabies virus as cause
of the condition. The argument is based on this, that in the case of two
occurrences where similar effects are produced and where in both of them the
same antecedent condition exists, that condition is probably the cause of the
effect. But this argument may be pushed too far, and the conclusion can only
be accepted as amounting to a probability, not a certainty. The possibility
remains open of there being more than one invariable antecedent, and in that
case we have to consider the different claims of each to be regarded as the
cause of the condition.
Now we believe, in opposition to the opinions hitherto set forth, that there
is evidence for the view that the nerve material derived from the rabbit either
per se or through its decomposition products (? neurin, cholin, etc.) may be
the cause of the symptoms which we are discussing. Sir A. E. Wright has
made us familiar with the idea of poisoning effects due to a too rapid succession
of inoculations of material, in itself comparatively little toxic, but capable of
producing cumulative effects unless recovery and reaction are allowed to take
place between successive injections. The condition known as "serum disease"
is also very interesting in this connection. Here "the phenomena of the disease
are to be interpreted as events in a process of immunisation by which the
organism purges itself from the foreign serum." 1 What the exact relationship
may be between the state illustrated by the serum disease which is termed
anaphylaxia and that "negative phase" condition so much emphasized by Wright,
it is difficult to say. It is very probable that they are both manifestations of
one and the same cell state. However this may be, we are able to state that
some of the symptoms of the "serum disease" are identical with those which
we have seen to follow anti-rabic inoculations. In this method of treatment we
are compelled to inject large quantities of foreign albuminoids (nerve substance)
day after day. May we not be dealing from start to finish here, both as regards
1 W r i g h t , C l i n . J o u r n a l ,
M a y 1 6 t h , 1 9 0 6 , p . 7 2 .
27
trivial effects and grave, with a condition of anaphylaxia due to this foreign
material and not to a rabies toxin ? We believe this to be so. But what proof
is there for the suggestion which we now put forward ? That proof is of an
indirect rather than a direct nature, but then so also is the proof of the existence
of a rabies toxin. We take up the subject under the following heads :—
A.—The probable non-existence of a rabies toxin—extracellular or in-
tracellular.
B.—Toxicity of non-rabic foreign nerve-material.
C.—Comparison of effects of treatment by the methods of Pasteur, Höyges,
and others and conclusions to be drawn therefrom.
D.—Existence of blood changes concurrent with or subsequent to anti-
rabic inoculations which are explainable on the theory of inoculation
of foreign albumins.
A.—The probable non-existence of a rabies toxin.
(1) Extracellular toxin.
If such did exist we should expect to have the symptoms of rabies in
animals rapidly induced by the injection of fresh rabies virus in massive doses
—an intoxication as distinguished from an infection. But no such phenomenon
can be definitely said to occur. The injection of 1 cc. of a thick emulsion of fresh
rabies virus (fixed)—an emulsion of about 10 per cent.—will not produce any
immediate symptoms of specific intoxication in a rabbit or other animal even
when inoculated subdurally. Nor will it even produce rabies any quicker than
the inoculation of 0.2 cc. of a 0.2 per cent. emulsion—a very much smaller
quantity. In a similar way relatively enormous doses of fixed virus may be
inoculated subcutaneously or intraperitoneally (vide detailed description and
references, pp. 23, 24) without producing any symptom of intoxication.
Further, we found (p. 17) that a prolonged attempt at immunisation with
nine-day cord alone failed to produce any immunity, a fact which would seem to
indicate that if the function of the rabies toxin was to produce a degree of
immunity to the rabies virus then the former was not present in this case. As
far as we understand the arguments brought forward, the existence of such a toxin
is largely based upon the necessity of explaining the rapid immunising power of
inoculations of fixed rabies virus. One view which is current with regard to this
point is that the toxin introduced with the material inoculated is rapidly absorbed
and produces its effect upon the central nervous system, whereby the latter is
rendered unassailable by the rabies organism, whether that of the original in-
fection or of the subsequent injected material. Once this is accomplished, anti-
body production to the organism results in the ordinary way. But if we have no
E 2
28
sufficient evidence of the existence of a toxin we have no right to invoke its aid
in explanation of the immunity brought about.
(2) Intracellular Toxin.
The non-existence of an endotoxin in fixed virus is more difficult to prove.
In the case of a dead bacterial emulsion, say of B. typhosus, inoculated
subcutaneously we obtain, if the dose is sufficient, evidence of distinct toxic effects.
The symptoms of typhoid fever cannot be explained except upon the basis of a
certain amount of intoxication ; and as we are unable to obtain a typhoid toxin
apart from the bodies of the organism itself, we speak of a typhoid endotoxin as
distinguished from an extracellular and separable toxin. Again, we have evidence
of the production of a definite immunity to typhoid fever by the inoculation of
dead emulsions of the organism.
Now how does the case stand with the rabies virus ?
(1) We have no convincing evidence to bring forward in favour of the produc-
tion of toxic effects by the subcutaneous inoculation of fixed virus.
(2) The symptoms of the actual disease together with the fatal issue might
quite easily be ascribed to purely mechanical interference with the functions of
the cells of the central nervous system—such for instance as might be produced
by the rapid sporulation of a protozoon or sudden increase in numbers
of an organism which found itself in a situation suitable for multiplication. More-
over the undoubted relation between distance of the infected wound from the
central nervous system and the length of the incubation period would seem to
militate against the idea of any toxic action and favour the mechanical view. In
fact we have here a purely physical relation between length of course and time
of development of symptoms.
(3) There remains still the argument from a consideration of the immunity
produced by the use of dead emulsions. In the case of rabies there is little or
no evidence for the production of any immunity from the use of dead virus. The
evidence in fact is entirely in the other direction, namely, that dead virus has no
immunising power. This would point to the existence of some material difference
between living and dead virus in the case of the rabies organism which does not
exist in the case of the Bacillus typhosus. Immunity by means of dead typhoid
emulsion is explained partly as immunity to endotoxin—the endotoxin having
been unaffected by the mode of preparation of the vaccine—partly as due to the
production of anti-microbic stuffs. But apparently we get no such immunity
in the case of dead rabies emulsion. Have we then any right under these
circumstances to conclude in the case of rabies that there exists an endotoxin
like that present in the Bacillus typhosus ? We think not.
How then are we to explain the immunity obtained by inoculation of a
29
rabies virus against rabies infection? We venture to put forward the
following tentative explanation as a possible one. We conceive that the
explanation may lie in a difference between street virus and fixed virus. Many
authors, amongst whom are Marx1 and Nitsch, 2 are now inclined to support the
view that fixed virus is comparatively innocuous for man. May it not be the
case then that by continued subpassage through the rabbit the original street
virus has been rendered practically harmless for man although more virulent for
the rabbit? Man may be "atreptic" 3 towards fixed virus. We have a certain
analogy too in the case of the small-pox virus which by continued subpassage
through the calf is rendered more and more virulent for this animal but much
less so for man. No one has suggested, so far as we know, that the immunity
obtained to small-pox by the use of a small-pox vaccine is due in any special way
to a preliminary immunisation by small-pox toxin.
We imagine then that anti-bodies may be produced to living harmless fixed
virus just as they would to any non-infective foreign albuminoid and that these
anti-bodies have at the same time the power of counteracting the infective action
of street virus. The effectiveness of the method might depend essentially on
the innocuousness of living fixed virus, whereby comparatively large quantities
can be safely introduced subcutaneously in the human being, with the result that
large quantities of rabies anti-bodies are rapidly produced locally, pass into the
circulation, and so counteract the infection by street virus.
To sum up, then, we see no sufficient grounds for the acceptance of the
view of the existence of a rabies toxin, and therefore we reject that theory of
immunity which builds upon its presence. We have also incidentally commented
upon the fact that there is no case for immunising power in dead rabies virus.
We can therefore now more confidently state the corollary already given in a
tentative way to the proposition on page 16, viz., that :— Slow desiccation kills
the rabies virus and the immunising power of a given portion of rabies cord is a
function of the unkilled remnant of rabies virus contained in it.
B.—Toxicity of non=rabic foreign nerve material.
In the examples we have cited where massive doses of rabies virus were
used without producing any toxic effect we are in almost all cases compelled to
1 Thus Marx (Art. "Lyssa," Handb. f. Path. Mikroorg. Kolle & Wassermann, p. 1284) says Fixed
virus is, in purely subcutaneous injection, quite harmless for man and apparently much less infective for
animals than street virus.
2 Nitsch, vide Extr. Bull de l' Inst. Past., 1905, p. 300.
3 Ehrlich, Second Harben lecture "On the Atreptic Function," Fourn . of the Roy. Inst. Pub. Health,
July 1907.