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Thursday, 14 June 1928

Mr SPEAKER - That does not justify the honorable . member in commenting on the report.

Dr MALONEY (MELBOURNE, VICTORIA) - I ask the Treasurer to take into consideration the health of the community, and-

Mr SPEAKER - The honorable member must not go into details.

Dr MALONEY (MELBOURNE, VICTORIA) - I shall not take ten minutes. On page 6 of the bill appears the item, " Department of Health - under control of Department of Works and Railways - Serum and Health Laboratories."

Mr SPEAKER - Yes, but that deals only with the provision of funds under the Department of Works and Railways. However, the honorable member may proceed .,!

Dr MALONEY (MELBOURNE, VICTORIA) - The danger, arises when the needle is inserted in the rubber cap of the bottle. This unfortunate accident would not have occurred if instructions had been more carefully followed. There is danger of infection if the plunger is not properly withdrawn. Every scientist knows that it is wicked and sinful to take so many doses from one bottle as were taken by that unfortunate doctor in Bundaberg. It was unfortunate for his son, but possibly lucky for him, that his own child was one of those injected with this filth. I was once travelling down from Thursday Island when a case of small pox developed on the ship. The last President of the Senate (Senator Givens), the former honorable member for Herbert (Mr. Bamford) and myself were together. The ship's company was inoculated against the disease, and some of us decided, as loyal Australians, to be inoculated with Australian lymph. We were inoculated with, under the guise of lymph, filth. For some time I doubted whether Senator Givens would escape with his life. His temperature was 104.5, that of Mr. Bamford 104, while mine was 103, and my friends assured me that I was never more bad tempered in my life than I was then. In contrast to the Australian lymph, that obtained from Japan was excellent, and produced no ill effects. The American lymph obtained at Manilla was also very good. Two officers of Parliament who accompanied us were inoculated with

Japanese lymph on one arm, and American lymph on the other, and the results were satisfactory. It was only those who chose Australian lymph who suffered. I informed Dr. Cumpston of the splendid results which had been achieved by the new kind of vaccine used in Japan, and I hope he will have time later to go into the matter. The report of the royal commission on the Bundaberg tragedy states that Dr. Thomson, on receipt of the toxin antitoxin mixture, stored the bottle until it was required in an instrument cupboard in his surgery, where it was also kept during the period of the inoculations which he made from it. I firmly believe that if the mixture had been used only once on that day, this terrible tragedy would not have occurred. Apparently the Minister, for Health (Sir Neville Howse) agrees with me. I do not care how much money is spent in protecting the public health, and particularly in the care of child life. That unfortunate medical man in Bundaberg is not to blame for what happened. He is no more guilty than would be a grocer who unwittingly sold sugar with which arsenic had been accidentally mixed. He was only less unfortunate than the children who were lost. The findings of the commission are as follow: -

1.   The injections of toxin-antitoxin mixture administered by Dr. Thomson at Bundaberg, on 27th January, 1928, were responsible for the deaths of twelve out of 21 children inoculated, and for the illness of several who survived.

2.   ' The toxin-antitoxin mixture as issued by the Commonwealth Serum Laboratories was properly prepared and sterile, but contained no antiseptic, and, therefore, did not prevent the growth of micro-organisms accidently introduced into it.

3.   The rubber-capped bottle of toxin antitoxin supplied to Dr. Thomson at Bundaberg was accompanied by no information as to the presence or absence of antiseptic.

I believe that the toxin anti-toxin would be better without an antiseptic, but it would have to be made up in containers holding only one dose. This would be more expensive, but would be justified on the ground of safety. The report continues -

The omission of antiseptic was intended to safeguard against the dangers attendant upon freezing, but the issue of this preparation without antiseptic in rubber-capped bottles suitable for repeated usage is an unsound procedure.

The toxin anti-toxin mixture- in the bottle', used by Dr. Thomson was contaminated by him with a pathogenic staphylococcus during a series of inoculations on the 17th, 20th, 21st, and 24th January; most probably on the' last occasion.

The consideration of all the available evidence concerning the deaths at Bundaberg points to the injection of living staphylococci as the cause of the fatalities.

The recommendations of the commission are as follows: -

That biological products in which the growth of pathogenic organisms is possible should not be issued in rubber-capped containers for repeated use unless there is present in the material a sufficient concentration of antiseptic to inhibit bacterial growth.

That will surely appeal to the Treasurer. He, being a surgeon and medical man, must realize that it woud be advisable to make up the serum in single doses. This may make him open his heart, and increase the vote for this class of work.

The recommendations proceed -

That all biological products not containing antiseptic, however issued, should bear a conspicuous printed notice, both on the container and on the package to the effect that no antiseptic is present; that they should be used immediately on opening, and any remaining product discarded.

That biological products should be distributed in bottles or ampoules of clear glass in which it is easier for the medical practitioner himself to detect turbidity or any other defect.

That the Commonwealth Department of Health should make full and careful inquiry as to whether it bc advisable to substitute ( anatoxin or some similarly modified immunizing agent for toxin-antitoxin.

To ensure the adoption of the most approved technique, facilities for special post-graduate training should be afforded to all medical officers entrusted with the conduct of public campaigns to diminish the incidence of disease by immunization.

No fewer than 45 separate injections were made from that bottle, and that was how the infection occurred. When it was proposed to appoint a royal commission I made a request that a member of the laity should be appointed to it, my reason being that this language, which is so technical-

Mr SPEAKER - The honorable member is now discussing the report, and going into questions of administration.

Dr MALONEY (MELBOURNE, VICTORIA) - A royal commission should not be permitted to make use of technical expressions that cannot be easily understood even by medical men.

Mr SPEAKER - The bill relates to the provision of loan funds in connexion with serum laboratories under the control of the Department of "Works and Railways, and, therefore, the honorable member may not further discuss the royal commission. I ask him to condense his remarks.

Dr MALONEY (MELBOURNE, VICTORIA) - "When a royal commission is appointed to investigate a mutter of a highly technical nature, its personnel should include a layman, to ensure that its report is couched in simple language. Even I, a retired medical practitioner, find great difficulty in following this report; how much more difficult would it be to the layman of ordinary intelligence? The Minister should spare no expense in protecting serum culture, particularly when human life is at stake. The tragedy at Bundaberg is an awful blot upon Australia, and I trust that the Government will be prepared to compensate the bereaved relatives for the serious losses that they have sustained.

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