821

which prescribes for the future endlessly patient work,loyalty to

"

our fathers, to our domicile, and to ourfatherland," without desire for retribution. If thenew rector has his way, the future of Heidelbergwill be guided by humane principles. He hopes thatthe former constitution and self-government of theuniversity will be restored ; and with them theclinical institutes, seminars, research, and (let it notbe overlooked) the means to live. So much, at theleast, will be expected by the world ; but it does not,as he rightly said, constitute the renewal of a uni-versity. That renewal, he suggested, can come onlythrough the individual efforts of scholars and studentsworking in the fellowship of their spiritual life, andthat fellowship must be guided by the idea of a

university. In present-day Germany this idea isnot yet a living force. The perversion of medicineby the Nazis, the compulsion of doctors to sterilise! .idividuals and to put to death mentally diseasedpeople, were, he said, products of National Socialism ;but they could come about, he added,

"

only becausethese possibilities were already present. Somewherein our antecedent tradition there lay hidden whathere found such disastrous expression." These

possibilities arose, he thinks, from the unscientifictrend which " runs through the greater part of ourscientific and medical literature " and he exemplified

- this by reference to the "swindle" of the Nazi

conception of race and the " murderous acts " whichattempted to get rid of races declared to be inferior.

Professor JASPERS believes that the two pillars ofmedicine are science and humanity. Science is, hesaid, knowledge accompanied by a consciousness ofthe limitations of knowledge and by unceasingcriticism and self-criticism ; humanity is respectfor human nature and an understanding that man isalways more than what is known about him. The

spirit of humanity makes a picture of man, and allthe faculties of a university are required to make thispicture : it is thus that medicine finds its place inuniversity life and activity ; for the picture madeprovides a setting for the physician, as for everyoneelse, in which he exercises his special knowledge andskill. In this recognition that science alone is not

enough for medicine JASPERS ranges himself with theauthors of the Goodenough report on Medical SchQols,with A. E. CLARK-KENNEDY in his recent essay onThe Art of Medicine in Relation to the Progress ofThought, and perhaps with the leaders of medicinethe world over. Although BILLROTH wrote in the’70s that theology does not properly belong to a

university, his heart, educated in the humanities,prevented him from actually supporting its expulsion.It was a disaster, said JASPERS, when, in the secondhalf of the 19th century, the universities lost thethreefold unity from which they sprang-the facultyof theology for the salvation of the soul, the facultyof law for the ordering of the earthly community, andthe faculty of medicine for health. As a consequence,the sciences were dispersed, the scientific spiritdecayed, individual sciences wished to be themselvesthe whole, and eventually the disintegration culmin-ated, in Germany, in the National Socialist period.This lost unity, he argued, must be regained. The

university must again be a whole, aiming at theeducation of the whole man. Only thus can it

educate its citizens to take a healthy attitude to the

State ; for a genuinely humane State self-limits itspower, because it aims at justice.

If we understand Professor JASPERS aright hewould restore the faculties of theology, law, andmedicine to their original supremacy, giving the

leading position to theology. " Apart from God andthe soul," he said, " there is nothing to prevent usfrom putting to death the mentally diseased." Thatstatement must give us pause ; but it is true at leastthat the doctor who takes part in all the activitiesof a university thus constituted would have an

opportunity to become " a doctor in the noble senseof HIPPOCRATES, who said that the physician who isat the same time a philosopher resembles the gods."

Annotations

THAT FLU VACCINE

SOME time ago the United States workers publisheda preliminary report of promising results obtained therein 1943 in trials of an anti-influenzal vaccine. A

description of these trials in detail occupies the entirenumber of the l -merica7c Journal of Hygiene for

July, 1945. An introductory paper and six othersrelate what happened at six different centres, spreadfrom New York to California. The vaccine differedfrom those previously tested here and in America bothin its source, being made from the embryonic fluids-ofinfected fertile eggs rather than from whole chickembryos or mouse lungs, and in being concentrated ten-fold. Three strains of virus were incorporated, two ofvirus A (a standard laboratory strain and one fairlyrecently isolated) and one of virus B. About 12,500persons participated in the trials, mostly students whowere taking part in an " Army specialised trainingprogramme." In its planning and control the testwas as nearly perfect as such trials can reasonably beexpected to be.The results in five of the six centres were unequi-

vocally good. The outbreak which followed was pure Aand there was an all-over 3- to 4-fold reduction inincidence of influenza in the vaccinated as comparedwith control groups (x 2,3, x 2.3, x 3.5, x 4.3, x 4.9in the several centres). In all of these an influenzaoutbreak began within a fortnight of the inoculations-in one actually 3 days before the inoculations. It maybe argued that this fortunate coincidence alone explainsthe apparently great success which this vaccine achievedwhen compared with earlier trials ; for the influenzacame when, for most subjects, immunity would beexpected to be maximal. Such a view would be sup-ported by the evidence from the sixth trial centre, inCalifornia, where the epidemic did not hit the communityuntil 6-8 weeks after inoculation and the incidence ofthe disease was unaffected by the injections. If onetakes the result at its face value as indicating thatbenefit from vaccination has passed away after 6 weeks,it is clear that the five good results were in a way "flukes "and that any future success would depend on very skilfultiming of inoculations in relation to accurately forecastoutbreaks. There are, however, reasons for lookinginto the matter more deeply. Serological studies,particularly those of the Michigan group, point to adefinite relationship between susceptibility to attackand antibody titre against the locally prevalent straiit.Vaccination raised the antibody level of most of thecommunity out of the zone of high liability to a zoneof relative resistance. Further, antibody titres remainedup for several months after inoculation in a way not atall suggesting the likelihood that immunity would bevery transient. The key to the failure in Californiamay rather be that the virus in that state was antigenic-

822

ally more remote from those incorporated in the vaccinethan‘ were the viruses in the rest of the Continent ;evidence in favour of this possibility is presented. Quiteapart from what it tells us of the value of vaccination,this series of papers is full of points of interest, par-ticularly in emphasising that serological variety amonginfluenza viruses may be epidemiologically all-important.Were it not for that variety it is not improbable that wecould forecast influenza by "Gallup polls " of our

community antibody levels, but until we know muchmore of the antigenic repertoire of the influenza virusesthey will be able to keep us guessing.

ALARUMS OF AN ALLERGIST

DEALING as he does with a hypersensitive section ofthe community, the physician who specialises in allergicdiseases must be prepared to meet with startlingreactions to apparently trivial stiinltli. Waldbott 1 hassummed up some of the alarms he has encountered ina wide experience. In the first place it is essential todifferentiate the non-allergic reactions which may resultfrom any hypodermic injection. These include syncope,and febrile, focal, or toxic reactions. Reactions specificto the allergic individual may arise as a result of diag-nostic skin-tests or from treatment with allergenicextracts. Severe reactions from skin-tests are due eitherto an extreme sensitivity or to accidental introduction ofsome of the testing material into a vein. To avoid suchrisks Waldbott proposes four rules. Intradermal testsshould never be carried out in children under the age ofsix years, since it is in them that the severest reactionsoccur. If a patient says he is sensitive to any particularsubstance, then this substance should not be used fortesting purposes except in very great dilution-e.g.,1 in 1,000,000. Pollens are least likely to cause reac-tions, so they should be used first in diagnostic testsand the strength and scope of further tests should be

’ decided by the response. The arm or leg are preferableto the back for the tests, because a tourniquet can beapplied in these sites if necessary. Superficial veinsshould be carefully avoided. A fifth rule might be moreeffective than any of these-to use the prick methodadvocated by Harley.2 Three types of reaction must bedifferentiated if the correct treatment is to be applied-the overdose reaction, the intravenous reaction, andthe back-seepage reaction. The intravenous reaction, themost dangerous of all, occurs within 10-20 seconds of theinjection, and there is no oedema at the site of injection.The back-seepage reaction takes several minutes to

develop and is accompanied by intense localised oedemawhich spreads quickly. The treatment of both these isthe immediate injection’ of 1-2 c.cm. of adrenaline,followed by aminophylline, 0.2-0.5 g., intravenously.Overdose reactions are always accompanied by oedemaat the site of injection, and the generalised oedema thatfollows may take an hour to develop ; the application ofa tourniquet is often beneficial in treatmtnt, or smalldoses (0-1-0-2 c.cm.) of adrenaline may be given ;careful inspection of the site of injection 10-15 minutesafter it has been given may reveal signs of an

impending reaction.Other emergencies may be equally dramatic but are

fortunately rare. Asthma maybe so severe that it doesnot respond to adrenaline or arniuophylline ; here theintroduction of a bronchoscope for the aspiration ofaccumulated mucus may be a life-saying measure.

Waldbott mentions three cases of severe cyanosis duringan asthmatic attack when the patient has suddenlyfallen unconscious on the floor ; recovery was spon-taneous, and the loss of consciousness may have been dueto cerebral anoxia. Even adrenaline is not without itsrisks ; in one patient intravenous adrenaline given for therelief of allergic shock resulted in aphasia, athetotic

1 Waldbott, G. L. J. Amer. med. Ass. 1945, 128, 1205.2. Harley, D. Studies in Hay Fever and Asthma, London, 1942.

movements, and facial palsy for two days. Amongdrugs which give rise to trouble ill hypersensitive persons,Waldbott gives pride of place to aspirin, with opiatesa close second. Sclerosing agents for varicose veins

may also be responsible for violent reactions. If such

drugs are to be administered regularly to allergic sub-jects they should be given daily or weekly ; if given atlonger intervals-e.g., every 10 days or once a month-they are more likely to result in sensitisation. Wald-bott thinks that nitrous oxide is the safest anaestheticfor the allergic patient ; if spinal anaesthesia is used, theuse of a drug to which the patient is sensitive may provedisastrous. For minor procedures, such as broncho-

scopy, intravenous anaesthetics may provoke a trouble-some spasm of the glottis, and Waldbott prefers a

barbiturate given by mouth.

DIPHYLLOBOTHRIID TAPEWORMS OF BIRDSAND MAN

LAST year Duguid and Sheppard demonstrated thata highly fatal outbreak of peritonitis in trout andsticklebacks in a South Wales reservoir in 1942-43 wascaused by plerocercoid larvae of a diphyllobothriid tape-worm. Duguid and Sheppard fed the plerocercoids to dogsand rats and obtained from these hosts adult tapewormswhich resembled, but were not identical with, D. uctumof man. They also fed eggs from these experimentally-reared tapeworms to the crustaceans Diaptomus gracilisand Cyclops strenuus, which are intermediate hosts ofD. latum of man, and -obtained procercoid larval in thecrustacea. They failed, however, to infest fish with theexperimentally-reared procercoids. Later, Hickey andHarris 2 found plerocercoids of diphyllobothriid tape-worms in trout in Poulaphouca reservoir near Dublin andreared these to maturity in a kitten. In cormorants and

gulls in the same area they also obtained all the stages ofthe life-cycle from the plerocercoids found in the trout tothe adult tapeworm. Unsworth,3 who received materialfrom both South Wales and Dublin, successfully rearedthe whole life-cycle of the tapeworms in the crustaceansDiaptomus gracilis and (especially well) Cyclops strenuusas the first intermediate hosts, in sticklebacks and pikeas the second, and in dogs as the definitive host. Theadult tapeworms thus obtained by all these workers weresubmitted to Baylis,4 who concluded that none were D.latum of man, but that they all belonged to the speciesD. dendriticurn, which is normally parasitic in gulls,except that the tapeworms obtained from the Dublincormorants may have been D. ditremum-if they were,the cormorant is a new host for this species.

There was therefore no reason to suppose that any ofthe plerocercoids found in trout in South Wales and theDublin area were those of D. latum of man, and the sug-gestion made in our annotation that D. latum mighthave been brought to this country by refugees fromNorway or Poland seemed to have little support. Nordid it seem likely that either the plerocercoids found introut from a Northamptonshire reservoir by Gibson 5or those which, according to Dr. Peterson of Yell (seeDuguid and Sheppard), are endemic in trout in some ofthe Shetland Islands were other than those of diphyllo-bothriid tapeworms of birds.The possibility that D. l!ttUfn may be found in these

islands has now been raised again by the announcementby Harris and Hickey 6 that they have received fromDr. T. V. McLoughlin a specimen of D. lnturn from a boywho had eaten perch from Gardice Lake, co. Leitrim.Harris and Hickey examined 79 perch from this lakeand found plerocercoids in 38 of them. When, more-

1. Duguid, J. B., Sheppard, E. M. J. Path. Bact. 1944, 56, 73 ;see Annotation, Lancet, 1944, i, 475.

2. Hickey, M. D., Harris, J. It. Brit. med. J. 1944. ii, 310.3. Unsworth, K. Ann. trop. Med. Parasit. 1944, 38, 213.4. Baylis, H. A. Ibid, 1945, 39, 11.5. Gibson, T. E. Brit. med. J. 1945, i, 199.6. Harris, J. R., Hickey, M. D. Nature, Lond. 1945, 156. 447.