Thursday 2 February 1928 The WEEK REVIEWED BUNDABERG TRAGEDY. Fatal Injections. Terrible Blow to Parents. Agonising Scenes. THE campaign for the immunisation of children against, diptheria has led to a terrible tragedy at Bundaberg owing to a cause which as yet is inexplicable. On Friday last, 10 children received in- jections of the toxin-antitoxin, six receiv- ing their final treatment, and 13 their first injection. Hitherto no ill effects had fol- lowed these operations, but during Friday night some of the patients became ill, with violent attacks of vomiting and diarrhoea. On Saturday morning a num- ber of children were found to be serious- ly ill, and were hurried to hospital. Des- pite all that medical skill could do, many of the little patients failed to rally, and up to last night 12 deaths had occurred, while five others are dangerously ill. The victims, include the family—three boys—of Mr. and Mrs. Robinson, and also the family—two boys—of Ald. and Mrs. C. O. Baker. Mr. and Mrs. Sheppard have lost their two daughters, and their other children (two sons) are in a dangerous condition. This sad occurrence, which evokes the deepest sympathy for the bereaved parents, is utterly abnormal in the his- tory of this valuable method of preventive treatment, said Dr. J. S. Elkington, Director of Tropical Hygiene, Common- wealth Department of Health, in an in- terview yesterday. Whole Family Wiped Out BUNDABERG, January 20. BUNDABERG mourns the loss of 12 fine little children, whose bright young lives were nipped in the bud as the result of serum injected into their arms on Fri- daj for the purpose of assuring their safety against the dreaded diphtheria. The ■KJtims are :— Thomas Robinson, 5- 1/2 years. William Robinson, 4 years. Mervyn Robinson, 1 year 11 months. Edward Baker, 6 years. Keith Baker, 3 years. George Baker, 6 years. Marsden Coates 7 years. George Follitt, 2-1/2 years. Mary Sheppard, 5 years. Monica Sheppard, 2-1/2 years. Myrtle Brennan, 5-1/2 years. Joan Peterson, 5-1/2 years. First Ill Effects. SO sudden was the happening that the city was not aware of the dreadful con- sequences until late on Saturday after- noon. The victims disclosed no ill-effects until about 9 oclock on Friday evening, when they were seized with violent at tacks of vomiting and diarrhoea. Their parents rendered the usual attention, but they were not really concerned, feeling that the illness was merely an after- effect of the inoculation, so these at- tacks went on during the night. On Saturday morning Dr. Thomson was sum- mooed to one of the homes, and found the child dangerously ill. The child was immediately ordered to hospital, and the doctor, realising that something was amiss, rallied the other medical officers of the city, and sent them after the other chil- dren. Dr. Thomson, accompanied by a nurse, also hastened to the other homes, and found the children seriously ill. The parents themselves, up to this time, were not aware that their little ones were seriously ill. The Ambulance bearers were called out, and for the rest of the morning they were engaged rushing through the city picking up the victims and hurrying them off to the hospital, where everything had been got ready for their reception. In the collection of the children the medical officers did splendid work. Some of the children who had suffered no ill-effects were playing about the yards at their homes, and they were hurried to bed, the doctors leav- ing nothing to chance. At the .hospital there were heartrending scenes. Unforgettable Scenes. BY 11 oclock there were 23 children in the institution. The doctors and nurses worked perseveringly to save valuable lives, but in vain. The serum had done its deadly work, and the children writhed in agony. Oxygen was freely used to keep the little hearts going, but one by one they ceased to beat. At midday four had died, and as the afternoon wore on there were more deaths, with more to follow. It was a never-to-be-forgotten day for the hospital staff, what with children dying, others writhing in the throes of death, and the sobbing of heart-broken parents, sisters, and brothers. There were many touching incidents tn the ward. Mr. and Mrs. Sheppard saw two of their children die simultaneously. Despite this heavy blow, they bore up with fortitude, in the hope of their other two boys pulling through, and at their bedside the grief-stricken father and mother maintained a silent vigil through- out the night. Parents and relatives hung Danseroinly IN. Theme dangerously ill are:— Betty Peterson, 7 years. Jack Sheppard, 8 years. « William fifaeppard, 6 year*. Erne?t Docker, 7 years. Brenda Drews, 1 year. Doctors Story. T)R. E. G. THOMSON, the City Councils medical officer of health, discussed the matter frankly to-day. He pointed out that the object was to immunise chil dren now healthy against contracting diphtheria by injecting into their bodied what could be described as a serum, and which inoculation had been carried out successfully in Rockh&mpton and Ipswich, as well as in other parts of the Com* monwealth. The treatment consisted of three injections, each a week apart, the dose being increased at the second and thirjl stages. On the 17th instant six children were brought to the Council Cb.am.bei* in response to the public la* vitation of the Bundaberg City Council, for wbioh he was the medical officer of health, and they were inoculated with serum. There were no after effects of any kind. On the 20th instant another seven children were inoculated, without any after effects being apparent. On the 24th instant six children were pre sented to receive their second injection, and one child to receive its first. Again no after effects occurred. On Friday last seven children came, six to receive tho final inoculation, while there were 13. new children, making a total of 20. for the day. The Only Theory. rPHE serum injected on all four occasions was taken from the one bottle, in his care, supplied by the Commonwealth Serum Laboratory, Melbourne, where it was manufactured. The doctor stressed the point that the method of making all injections since the commencement had not been changed. A week previously he had inoculated his own son with the same serum, and in the same manner, without any ill-effect. The only theory as to the cause of the deaths was the assumption that some active properties had develop* ed in the serum, and turned it into a poison. However/ that was only supposi* tton, and post-mortem and pathological examinations might throw light on this aspect. Tfce Pint latftmtfoa. rnHE iiret intimation the doctors received ■*- that anything wu amiss altar Friday* inoeoUtions was a telephone message from Alderman C. 0. Baker, on his arrival home that night at midnight from a City Council meeting, stating that his two chil* dren were ill with vomiting and dysen tery. The significance was not realised at the time, but next morning Alderman Baker advised him that their condition was worse. Soon other messages came, and it .was obvious from the information coming in that the illnesses were asso* ciated with the previous days inocula tion*. In these circumstances «P«ciw efforts were made to locate all the dm* dren treated, and they were moved to the General Hospital for that purpose. Actually not a great deal could be done for them. By Saturday nights train Dr. Thomson posted communications to Dr. J. 8. Slkington (Director, Division of Tropical Hygiene. Brisbane), and Dr. J. I. Moore (Commissioner of Public Health for Qneensland),_«ivini; a resume of the circumstances. The foregoing was aU the • information he could ghw, said Dr. Thorn* son. Every care bad been exercised,! applying the treatment, and the fact that the same treatment and the same fetma at the outset had brought no fll-effects, arid on Friday and Saturday had result, ed fatally, were at present inexplicable circumstances responsible for what naa most unfortunately happened. Dm to Pttaon. T\R. E. G SCHMIDT (Government XJ^ Medical Officer of Health) con ducted eight post mortem examina tions to-day, and in each case certified that death waa due to acute toxaemia (poisoning), following an injec tion of toxin-antitoxin mixture. In an interview Dr. Schmidt said the tragedy was a niatter of surmise at this stage, and until something otherwise could be shown he agreed with Dr. Thomson that the only explanation Was that latent pro perties in the serum had suddenly become active and turned it into a virulent poison. Vomiting, dysentery, convulsions, and temperatures were features of the.ill nesses. Every possible thing had bfcen done to counteract the effects of the in oculations, some children having been gathered into hospital before they took ill, because of what had already occurred with other cases. It was a serious thing for the public and the medical fraternity alike, and a meeting of the public health committee of the British Medical Asso ciation would be held in Brisbane on Monday morning. . The. serum, or mix ture, he said, was tented each time any of it was sent out by the Commonwealth Laboratory* That was to say, each in dividual batch was thoroughl * tested* and it war quite certain that the serum sent to Bundaberg had been, no tested. Im munisation by the injection of -this serum was a world-wide practice. It was not n new discovery. It was used extensively in the F^ntf-n P^tes, and had been iwcd clm^-lipm in J-ucnsland with full success, so that the tragic happening, in Bundaberg was all the more mystifying. . Official statement. TNTERYIEWED with reference to the * deaths of children reported from Bunda berg, as having occurred after toxin antitoxin injection for the prevention of diphtheria, Dr. Elkington, Director of Tropical Hygiene, Commonwealth Depart* ment of HeaHh. said:— This sad occurrence, which evokes the deepest sympathy for the bereaved parents, is utterly abnormal in the history of this valuable method of preventive treat* ment. No similar instance, be con tinued, has. so far as I am aware, been recorded anywhere, despite the use of the method in many hundreds of thousand* of eases in all parts of the world. Two medical officers of the Commonwealth De partment of Health have been detailed to visit Bundaberg for inquiry, and all avail* able information is being collected.. The outstanding fact which has appeared so far, has been that a number of children were inoculated between January 17 and 24, without suffering any ill effect, and that only those who were inoculated on January 27, from the same, bateh of material, became ill. Some of these had already received one injection of it, but onlr became ill after the second; the others became ill very soon altar their first injection. Thu indicates dearly enough that the material, a* reeehred, did not contain any harmful agency; and tfcat it did not contain any for at least a week after its receipt at Bandaberg. The material, •as issued from the laboratories at Royal Park, in Metbowrae, is submitted to the most searching tests to ensure that it is sterile; —that ?. that it does not contain any tiring organisms, bat only the products of organisms, to which it owes its activity. Bad it con* tained, in the present case, any tiring organisms of disease, it is obvions that the children inoculated during the first week of its use would also hare been harmed. None of them suffered any untoward effect, however. Risk of CoatMimtien. AN ordinary method of using this . ■*> material in a series of guaa such as school children, is to hare a rubber cap for the bottle, through which the needle is thrust to withdraw the content* as re* quired. A special warning is issued by the Commonwealth Serum Laboratories with all material so packed that the whole contents should be need as promptly as possible, in order to aroid any risk of contamination, and that ampoules, with sealed glass necks are safer. The rubber* capped containers are. howerer, mere eon* venient, and hare been largely used. The tiniest particle of dust entering with the needle—a particle far too smaH to eee with the naked eye—wouP be sufficient to contaminate the contents if it intro duced eren a single serin. This would multiply as yeast multiplies in deugh set for bread, and after a sufficient time cotrtd produce sufficient germs and their product* to render the product dangerous. The presence of such contamination, would not necessarily be accompanied by any obnous change in the appearance of the product. Arrangements have, however, been made to recall the particular batch from which the Bundefoerff sufferers were inoculated, nod to discontinue issue of toxin-antitoxin material for the present, pending full in vestigation. For the reasons stated, how ever, it appears unlikely that results will reveal anything pointing to original con tamination in the material as issued from the Commonwealth Serum Laboratories. Analysts Startlina Statement BUNDABERG. January 30. IITB. JACOB CHRISTEXsIBN, B.Sc., who is puolic analyst by apyiolntinont of the Bundaberg City Council- and the Queensland CommuanoDec for Public Health, and has occupied that position for the past 20 yean, when interviewed, said that the serum as supplied by the Com* monweaitu Laboratory in Melbourne was perfectly safe, as demonstrated by the tact that inoculation from the 17th to the 24th inst. produced no harmful effects. For some reason or other it was decided to practise economy, for which furpose the serum was obtained in bulk. netead it should have been obtained in individual doses. Anti-tetanus and all serums were available, and were sup* plied in individual doses* Who advised economy by buying in bulk he did not -know, but it was a very wrong pro* eedure. If he had been consulted, as the public analyst, he would not have permitted the serum to be bought id -bulk- The makers of the serum knew that each time the container was opened, and the air admitted, sterilisation wan interfered with. In this case, to avoid opening the bottle containing the serum in bulk, the rubber cover over the month of the bottle was pierced with a syringe, ■and the serum was drawn up into it. The contracting of the rubber was relied on to close up the hole made by the syringe. One, two, three, or six punctures could be made perhaps, and the holes might dose up again. If the rubber were tightly stretched it would tend to open instead of close the holes. If it were loose the tendency naturally would be to close. The serum was a serum of the blood, and was a most tempting medium for bacterial growth, as also was milk. The air going through the minute holes in the rubber covering could carry enormous quantities of foreign bacteria, the action of which on the serum they did not know. From the sad experience of the week-end they saw it produced a deadly toxin. A serum under such circimv stances of use could not be regarded sate for more -than 98 hours; then it should be thrown away. To blame the serum and science which had produced it was wrong. If he had been consulted as the public analyst he would have in sisted on individual doses, and then absolutely no harmful results eoald have occurred, unless the syringe was dirty. Events showed that the serum bad kept safely for a week, which «m greatly in exeess of what was to be ex pected. Instructions accompanying the serums were to use them quiekly, and not to keep them, as was the cast in Btmdaberg. We have economised by buying serum in bulk, said Mr. Chris* tensen, but we have spent dearly in precious lives/ He quite agreed with the instructions of the Commonwealth Laboratory, as mentioned by Dr. Siting ton, that the senna should be used aa promptly as possible to avoid the risk of contamination, and that sealed glass con tainers were safer than rubber-covered neck bottles. He further agreed with Dr. Slkington.as to the possible contamina tion from dust in the air. The tragic occurrence at Btmdabmr. will, undoubtedly, have the effect of causing a State-wide cessation of this pre ventive measure, until the whole matter is cleared «p. In any ease, the Commonwealth aataori ties, it m understood, have ordered that all the serum held in Queensland should be, at once, completely withdrawn from use. Furthermore, arrangements which had been mads for immunisation at State and other institutions have been cancelled until the fullest investigation has been made into the cause of the deaths at Bundaberg. F■ntraJi af VMtiffli. fTCdS entire city of Bundaberg; was in deep mourning on Monday, when the last tribute of respect was paid to the child victims of the fatal injections of anti-diphtheria serum. DandsJberg has) never passed through such a grief-stricken period. Women and children wept in the streets, and strong men were moved to tears as the tiny coffins passed by. Hie scenes at the gmveside were unforgetable. Rtal Estate AfMt: Whtfs W Maar • htttMrin with aa sU rim Ilk* that t Iva sot a fin* mw htm jast ■■ tfct strati. —Country Gentleman. Close Like · · Share · about a minute ago John Pollard Write a comment...
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