NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
322 THE INDIAN JOURNAL OF VETERINARY SCIENCE AND ANIMAL HUSBANDRY [ I, IV
Edwards, J. T (1927). The Acclimatization of Imported Stock. Agri. Jour. Ind., Vol. XXII,
Part VI, November 1927, pp. 411—421.
Gazeteer of the North Kanara District.
Hutyra and Marek (1926). Path, and Ther, of the Diseases of Domestic Animals, Vol. III, p. 782.
Hutyra and Marek (1926). Path, and Ther. of the Diseases of Domestic Animals, Vol. III, p. 85.
Hutyra and Marek (1926). Path, and Ther. of the Diseases of Domestic Animals, Vol. III,
p. 87.
Marillat, L. A (1916). Veterinary Surgery, Part III, p. 78.
Nuttal, G. H. F (1914). Tick Paralysis in Man and Animals. Parasitology, Vol. VII, pp. 95—104.
Sarif, M (1928). A Revision of the Indian Ixodidæ with special reference to the collection in the
Indian Museum. Records of the Indian Museum, Vol. XXX, pp. 217—344.
Smith (1912). Veterinary Physiology, p. 24.
Theiler, A (1910). The Veterinary Journal, p. 102.
The Statistical Atlas—Agricultural stock—Bombay Presidency, 1925.
Wardle and Buckle (1923). The Principle of Insect Control, p. 26.
SELECTED ARTICLES
ANTI-RABIES IMMUNIZATION.
VALUE OF KILLED CARBOLISED VIRUS IN CASES OF WOLF-BITE.
BY
G. STUART, O.B.E., M.A., M.D., D.P.H.,
AND
K. S. KRIKORIAN, M.D.
From the Central Laboratories, Department of Health, Government of Palestine.
(Reprinted from the Transactions of the Royal Society of Tropical Medicine and Hygiene, Volume XXV,
No. 1, 30th June 1931.)
In the evaluation of any method of anti-rabies immunization the influence on
statistical results of the nature of the biting animal cannot be disregarded, ranking
in importance as it does with virulence of local virus, severity of wounding, degree
of exposure to risk, duration and mode of treatment, lateness of arrival at an insti-
tute and the constitution of the attending population. The dog undoubtedly
plays the chief role in the infection of man with rabies, but transmission is fre-
quently effected by others of the Cynoidea, viz., wolf, fox, jackal and hyena; of
all animals, however, wolves are, in this connection, mostly to be feared, for, on
account of the greater severity of their wounding, they cause a proportionately
higher incidence of hydrophobia among the bitten and that too despite intensifica-
tion of treatment. It seems probable that in the case of dog-bites the benefit
derived from Pasteurian treatment is generally an overstatement and no agree-
ment here is ever likely to be reached ; with regard to wolf-bites and the value
of treatment, however, less misconception exists and the position is adequately
reviewed by BABES (1912). First it has to be noted that, while at least 50 per
cent. of dog-bites are inflicted by non-rabid animals, wounding of human beings
by healthy wolves is altogether exceptional; indeed any wolf which suddenly
appears in an inhabited area and makes an unprovoked attack on man and domes-
tic animals alike is to be regarded as definitely rabid. Secondly the percentage
mortality among persons bitten by mad wolves is generally accepted as being over
60 and as high as 90 when severe head injuries have been sustained. The effect of
( 323 )
F
324 THE INDIAN JOURNAL OF VETERINARY SCIENCE AND ANIMAL HUSBANDRY [ I, IV
anti-rabies treatment, however, on these high mortality figures has been consider-
able ; thus by Pasteur's classical method the death rate has been reduced to 15 to
20 per cent, and by the Roumanian method in which the use of a heat-weakened
virus permits the exhibition of a much larger immunising dosage, the rate has
fallen to 6.66. To illustrate the risks run by human being wounded by rabid dogs
and rabid wolves, BABES (1912) quotes the résumé given by REMLINGER, viz.,
(a) of persons bitten by rabid dogs and remaining without treatment 1 in 6 deve-
lops hydrophobia; treatment following dog-bite, however, reduces the risk to 1 in
200 ; (b) of persons bitten by rabid wolves and remaining without treatment 1 in
1.66 succumbs to rabies or in the case of head injuries, 1 in 1.11; here treatment
by Pasteur's classical method reduces the mortality to 1 in 5 or 6 and treatment
by the Roumanian method to 1 in 15.
Now in the treatment of persons bitten by dogs, cats, jackals, foxes, solipeds
and ruminants, the efficacy of killed carbolised virus has been placed beyond
dispute by the results obtained at Kasauli and at Lisbon—to mention but two
important anti-rabies institutes. At Kasauli, India, during the years 1900 to
1926, three methods of treatment were in force at different periods, viz., 1900 to
1907 by dried cords, 1907 to 1912 by HOEGYES' method, 1912 to 1926 by killed
carbolised virus.
The results may thus be tabulated :—
TABLE I.
Period.
1900 to 1907
1907 to 1912
1912 to 1926
Method.
Pasteur's dried cord
....
Hoegyes' dilution
Killed carbolised virus (0.28 to 0.7 gramme
dosage).
No. Treated.
5,141
8,435
84,844
Total Mortality
Rate
per cent.
1.81
1.61
1.16
Again, at the Camara Pestana Institute, Lisbon, PEREIRA DA SILVA (1930)
has found that of 1,158 persons treated by etherised fixed virus the percentage
mortality was 0.08 while among 6,529 treated with carbolised virus the death rate
was 0.06. Further, apart from these figures which adduce sufficient statistical
evidence in favour of the use of killed carbolised virus in the treatment of man,
we (1929) have shown that' immunity produced in experimental animals by such
virus approximates in practice to that produced in the survivors of animal groups
treated with living virus in normal saline solution', when tests of resistance are
ANTI-RABIES IMMUNIZATION
325
made by the injection, deep into the neck muscles, of 2 c. cm. of a 1 per cent.
emulsion of street virus recovered from a dog.
No records, however, are available of cases of wolf-bite treated with carbolised
vaccine and in Palestine the wolf is so very rarely encountered that up till now
the opportunity has not arisen of testing in this respect the value of the carbolised
preparation of fixed virus sent out under the scheme of complete decentralisation
of treatment in force here. It is to be understood that the anti-rabics vaccine
manufactured at the Central Laboratories consists of a 2 per cent. suspension of
the brain of a rabbit killed with fixed virus, in a dilution of 1 per cent. phenol in
distilled water. After the emulsion has been in the incubator for 24 hours and
the virus destroyed as a result of the combined action of heat and phenol, it is
then taken out and mixed with an equal volume of normal saline solution so that
the vaccine finally consists of a 1 per cent. brain suspension in 0.5 per cent. car-
bolic solution. The complete course of treatment consists of the daily injection
of 5 c. cm. intracutaneously on 14 consecutive days. The dosage is universal, re-
maining constant for all bitten persons, irrespective of age, sex, severity of bite,
location and multiplicity of wounding, interposition of clothing and the several
different conditions requiring consideration when most other methods of treat-
ment are employed.
It is true that during the past eight years twelve Arab peasants attending
for treatment, other than those affected by the incident about to be described,
have, at different times, incriminated wolves as their attackers, but until Febru-
ary, 1930, no authentic case of wolf-bite had been brought to our notice and no
biting animal identified as a true wolf by a competent zoologist.
On February 15, 1930, early in the morning, a male wolf, Canis lupus, one
of a pair which had been recently observed in the district, made its appearance; at
El Auja, a small Arab settlement near Jericho and caused much excitement by
its indiscriminate attack on villagers, dogs, and goats alike. On quitting the
settlement the animal made for a flock of sheep grazing some distance away but
by chance it was observed by the herdsman Suleiman el Hussein (Case 1) who,
after a sharp tussle during which he was badly wounded, succeeded in dispatching
it with a dagger. In all, six persons received injuries of a sufficiently serious
nature to necessitate their removal to the Government Hospital, Jerusalem, for
general and specific treatment. The five dogs and twenty goats bitten were de-
stroyed.
Three weeks after this occurrence, on 8th March, the female wolf visited the
same settlement El Auja, and savagely attacked the inhabitants; among the three
persons bitten was Suleiman el Hussein, who killed this second wolf also with his
F 2
326 THE INDIAN JOURNAL OF VETERINARY SCIENCE AND ANIMAL HUSBANDRY [ I, IV
dagger. All three wounded were brought immediately to Jerusalem for treatment
but on this occasion no anti-rabies vaccine was administered to the herdsman.
Including then Suleiman el Hussein (Case 1), who was bitten by both animals,
eight persons were injured by this pair of wolves. The nature of the wounding
is shown in Table II.
Anti-rabies vaccination proved successful in each case, all eight bitten persons
treated in the ordinary way with a total dosage of 0.7 grammes carbolised rabid
nerve substance being alive and well one year after completion of the 14 days'
course.
Laboratory diagnosis of rabies was, unfortunately, impossible in respect of the
male wolf, for, according to a local superstition, immunity against hydrophobia can
only be secured by removal and destruction of the biting animal's head and these
customs had been duly observed before the arrival of the investigating Veterinary
Officer. From this it will be seen that in the more unenlightened parts of the
country confidence still continues to be reposed in ancient beliefs and that a sturdy
conservatism is antagonistic to the introduction of newfangled methods of
treatment. The Veterinary Officer's visit, however, prevented a repetition of the
customary rites in the case of the female wolf, with the result that the head arrived
for laboratory investigation on the same day as that on which the second attack
on the settlement had been made. Histological examination of the hippocampus
major showed, with Mann's stain, negri bodies measuring 2 to 8 Μ in diameter
to be present in large number in the pyramidal cells. Further subdural inocula
tion of rabbits with emulsions of the brain first produced typical symptoms in
10 days and caused death in 12. That both wolves, however, were rabid at the
time of biting, is abundantly proved by their association and behaviour.
TABLE II.
No. of
case.
1
2
3
4
Sex.
M
M
M
F
Age.
18
24
13
25
Biting
wolf.
M
F
M
M
M
No.
18
7
15
3
2
Nature of Wounds.
Location.
2 on face involving loft eye; 9 on Upper
arm and 5 on forearm through clothing;
2 on left hand.
All on upper extremity through naked
skin.
On upper extremity; 12 through naked
skin ; several very deep involving muscle.
On face ; 1 over left parotid; 1 extending
4 cm. from corner of mouth; 1 through
lower lip.
On right hand ; 1 on dorsal, 1 on palmar
aspect, both very deep involving bone.
Gravity.
Severe.
Moderate.
Severe.
Severe.
Severe.
ANTI-RABIES IMMUNIZATION
327
TABAL II—coutd.
No. of
case.
5
6
7
8
Sex.
M
M
F
M
Age.
60
25
20
9
Biting
wolf.
M
M
F
F
No.
7
11
2
5
Nature of Wounds.*
Location.
1 on right cheek 4 cm. long down to
muscle; 2 on thumb penetrating all
structures ; 4 on left arm deep and 3 cm.
long through naked skin. Compound
fracture of left radius.
7 on face; 2 involving lip and right cyclid ;
4 on right hand down to muscle.
Both on face through superficial structures
of cheek.
1 on face through check; 4 on lower
extremity through naked skin.
Gravity.
Severe.
Severe.
Moderate.
Severe.
* None cauterised within two hours of the biting.
An interesting point is raised by a consideration of the foregoing : the same
individual was bitten by two rabid wolves within a period of three weeks ; should
anti-rabies treatment have been administered a second time or should it have
been withheld on grounds that the first course was sufficient to confer full protec-
tion : Obviously no opinion of value can be advanced unless and until a satisfac-
tory answer to the following question is forthcoming : how soon after completion
of protective vaccination is anti-rabies immunity established and how long does
it persist ? According to Babes (1912), experiments on animals conducted by
PASTEUR and HOEOGES proved that in dogs treated by the dried cord method
immunity was not properly acquired until some 15 days after the last inoculation
at the time when in the sera of human beings similarly treated, rabicidal antibodies
were first shown by KRAUS and KREISSL (1902) to make their appearance. Duration
of immunity, however, among the dogs thus protected was found to vary within
wide limits; thus in 21 per cent. it had disappeared within one year and in
33 per cent. within two years, while in the rest it lasted up to five years. In this
connection we (1931) have shown that in rabbits of 1,400 g. vaccinated according
to different methods but in an equal dosage administered over the same period of
time, i.e., with a 2 per cent. suspension of variously prepared fixed virus in a
dosage of 5 c. cm. daily on 14 consecutive days (1.4 grammes), immunity was lost
160 days, 250 days and 260 days after completion of treatment with carbolised
killed virus, with fresh living virus in normal saline, and with etherised killed
virus respectively. It has to be observed that loss of immunity in the case of
these rabbits coincided with the disappearance of rabicidal antibodies from their
sera. But in man the estimation of how long immunity lasts is much more
difficult and is, moreover, largely conjectural. Here information can be derived
solely from a record of patients, who, bitten again after the termination of treat-
328 THE INDIAN JOURNAL OF VETERINARY SCIENCE AND ANIMAL HUSBANDRY [ I, IV
ment and not having undergone a further course of injections, have died of
hydrophobia. Such cases are very rare; indeed, only two have come within our
notice, viz., the case of de Blasi and Russo Travali reported by BABES and that
of Park referred to by ROSENAU (1927), but these only indicate that in one patient
immunity lasted less than four years and in the other not longer than fourteen
months. From the above mentioned experiments on animals, however, BABES
(1912) concluded that it is not necessary to repeat the protective inoculations if a
second infection takes place within 18 months after completion of treatment.
LUBINISKI and PRAUSNITZ (1926), on the other hand, quite apart from the fact that
21 per cent., of the animals in the experiments referred to were proved to be no
longer immune in one year's time, " do not believe that such important conclusions,
reached after animal-experimentation, should be applied to man. It might easily
lead to disastrous results ". They consider that " in the case of a further bite
occurring later than three months after completion of treatment, the treatment
should be repeated, but in case of particularly unfavourable prognosis (head and
face injuries, etc.), the inoculations should in every case be repeated". These
authors, however, do not state on what clinical or experimental evidence they
have based their opinion. Now if the development and duration of anti-rabies
immunity could on all occasions be ascertained by the appearance and persistence
of rabicidal substances in the serum of treated cases, a reliable guide would be
furnished as to the need for further courses of treatment. But experience has
shown this not to be the case; thus BIGLIERI and VILLEGAS (1926) counted that
anti-rabies immunity is not necessarily a blood immunity and few will deny that
occasionally a solid immunity is encountered when no antibodies can be found in
the sera of the immunised. Further MARIE (1927), while accepting the view that
specific changes in the blood serum characteristic of all active immunisation follows
treatment with anti-rabies vaccine, maintains that the rabicidal antibodies so
produced gradually disappear without there being any correlation with the dura-
tion of immunity. That ordinarily there exists a definite relationship between
immunity and the antibody content of immune serum, however, is the belief of
many workers including FERMI, PEREIRA DA SILVA and ourselves. FERMI (1929),
for example, was able to prove that a highly virulent strain of rabies virus used as
an immunising agent confers a much higher degree of immunity and evokes a
correspondingly greater rabicidal antibody response than an avirulent. Again,
PEREIRA DA SILVA (1927) asserts the superiority of his etherised vaccine over all
other protective methods on the ground that in the serum of patients treated at
his Institute anti-rabies substances appear most quickly, attain the highest value
and persist the longest. We (1929), also have stated that normally " immunity
and rabicidal action of the serum are produced concomitantly; they appear
ANTI-RABIES IMMUNIZATION
329
together, are present in greatest degree together and disappear at or about the
same time " and that " it may be concluded with reasonable certainty that the
rabicidal properties of the serum of an animal are an indication of the immunity
against rabies possessed by that animal ". Further it is of importance to note that
among the resolution adopted by the second and third Commissions of the
International Rabies Conference held in Paris during 1927, was one to the effect
that " This Conference, having considered the results obtained by the various
methods of anti-rabic treatment now employed in the different Institutes and the
advantages and disadvantages of each, have arrived at the following conclusion :—
(6) The Conference recommends that enquiries be made
into the
rabicidal action of the serum of man and animals during and after immunisation ".
Under the circumstances, therefore, it seems to us to be of interest to record
what actually was the rabicidal antibody content possessed by the serum of a case
definitely proved by the inoculation test to have been immune to rabies infection
three weeks after commencement of treatment with carbolised killed virus.
The serum-neutralisation experiments were carried out as under : Case 1 was
bled 7, 14, 23, 37, 70, 88, 100 days after commencement of treatment. One unit
volume of undiluted serum was mixed with a varying number of unit volumes of 1
in 100 suspension of fresh fixed virus in normal saline solution, and of these
mixtures, after their exposure for two hours to a temperature of 37° C., 0.2 c. cm.
was introduced subdurally into rabbits, two rabbits for each mixture.
The following table shows the results obtained :—
TABLE III.
Experiments to show the rabicidal properties possessing at different times after anti-
rabies injection by the serum of a human case treated with carbolised killed fixed
virus.
Time of Bleeding
after injection.
7 days .
.
. {
14 days
.
. {
Serum and varying
amounts of living
fixed virus mixed
and tested after
2 hours' incuba-
tion at 37° C.
Amount of
Serum in
c. cm.
0.5
0.5
0.5
0.5
0.5
0.5
Amount of
1:100 F. V.
in c. cm.
0.125
0.250
0.500
0.125
0.250
0.500
Result of Rabbit inocula-
tion with 0.2 c. cm. of
serum fixed virus
mixtures.
Died
.
.
Died
....
Died
....
Died
....
Died
....
Died
....
Rabicidal properties
of serum.
}Nil.
} Nil.
330 THE INDIAN JOURNAL OF VETERINARY SCIENCE AND ANIMAL HUSBANDRY [ I, IV
TABLE III—conld.
Time of Bleeding
after Injection.
23 days
37 days . . {
70 days . . {
88 days . . {
100 days . . {
Serum and varying
amounts of living
fixed virus mixed
and tested after
2 hours' incuba-
tion at 37° C.
Amount of
Serum in
c. cm.
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Amount of
1 : 100 F. V.
in c. cm.
0.125
0.250
0.500
1.000
0.125
0.250
0.500
1.000
0.125
0.250
0.500
1.000
0.125
0.250
0.500
0.125
0.250
Result of Rabbit inocula-
tion with 0.2 c. cm. of
scrum fixed virus
mixtures.
Lived
....
Died ....
Died ....
Died ....
Lived ....
Lived
....
Died ....
Died ....
Lived
....
Lived ....
Lived ....
Died ....
Lived ....
Died ....
Died ....
Died ....
Died ....
Rabicidal properties
of serum.
}Present
in
low
degree (4:1).
} Present+
(2:1).
} Present.+
(1:1).
} Disappearing.
} Nil.
From the above Table the results following upon the intracutaneous inocula-
tion of a human case with a 1 per cent. suspension of killed carbolised fixed virus
in a dosage of 5 c. cm. daily on 14 consecutive days (0.7 grammes) may briefly be
summarised:—
(1) Rabicidal properties were absent from the serum 7 and 14 days after the
commencement of treatment (and this was true for the sera of all the eight cases
of wolf.bite treated).
(2) Rabicidal properties were demonstrable in the serum 23 days after the
commencement of treatment, one unit volume of serum neutralising 0.25 volume
of a 1:100 fixed virus suspension in normal saline solution.
(3) Rabicidal antibody content reached a maximum (1:1) some 50 to 60 days
after completion of treatment and thereafter subsided fairly rapidly.
(4) The immune serum retained rabicidal properties for a period of three
months.
It seems, therefore, that although anti-rabies immunity may be fully
developed comparatively little rabicidal antibody production follows the exhibition
ANTI-RABIES IMMUNIZATION
331
of carbolised virus vaccine in ordinary dosage. If, however, the presence of such
detectable rabicidal substances is actually an index of immunity acquired, then
in the present case immunity was already established three weeks after the
commencement of treatment and at the time of second biting by a rabid wolf.
A logical reason for the non-treatment would thus be advanced. Further, accord-
ing to this conception, anti-rabies immunity would actually be highest some two
months after commencement of treatment, and would last in all three months.
Arguing on these lines one might feel justified in advising with LUBINISKI and
PRAUSNITZ that" in the case of a further bite occurring later than three months
after completion of the treatment the inoculation should be repeated, with the
exception of cases which are particularly unfavourable prognostically (head and
face injuries, etc.), in which cases the inoculation should in every case be
repeated ".
CONCLUSIONS.
1. Carbolised killed fixed virus in a total dosage of 0.7 gramme administered
intracutaneously over 14 consecutive days proved wholly successful in protecting
eight human beings bitten by rabid wolves.
2. Anti-rabies immunity was established at the time when rabicidal antibodies
first became demonstrable in the patient's serum.
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Babes, V. (1912). Traite de la rage. Paris, Bailliere of File.
Biglieri, R., and Villegas, C. (1926). Immunite locale dans la rage. C. R. Soc. Biol., xcv, 1176.
Fermi, C. (1929). Beeinflusst die virulenz des fixen Virus die immunisierende Wirkung des anti-
rabischen Impfstoffes und die Produktion des Antikorpers ? Ztschr. Immun-Forsch, lix, 276.
Kraus, R., and Kreissl, B. (1902). Ueber den Nachweis von Schutzstoffen gegen Hundswut, beim
Monschen. Zentble. Bakt., xxxii, 810.
Lubinske, H., and Prausnitz, C. (1926). Lyssa. Ergeb. Hyg. Bakd., viii, 1.
Maric, A. C. (1927). Report to the International Rubies Conference, Paris. Geneva, League of Nations.
Pereira Da Silva, E. (1927). Substances rabicides dans le sang des individus traites par le virus rabi-
quo fixe etherise Arquiros. Inst. Bact. Cam. Pest, vi, 42.
Pereira Da Silva, E. (1930). Substances rabicides dans le sang des individus vaccines au virus fixe
pheniquo mort. Ibid, vi, 138.
Rosenau, M. J. (1927). Article on Rabies Preventive Medicine and Hygiene. Now York, Appleton
and Co.
Stuart, G., and Krikorian, K. S. (1929). Studies in anti-rabies immunisation. Jour. Hyg., xxix, 1.
Stuart, G., and Krikorian, K. S. (1931). Appearance and persistence in rabbits' blood of rabicidal
antibodies produced by various methods of anti-rabies immunisation.