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THE STUDENT AND THE ALMONER
34 If Dr. Edsall can suggest an alternative to the term " insusceptible " in such cases, or suggest some international agreement whereby after, say, three unsuccessful THE STUDENT AND THE ALMONER revaccinations the vaccinee will be exempt from further SIR,—If students are to gain any insight into the social vaccination and from all quarantine measures, he will rendering us a good service. Even then the vaccinee problems uncovered by regarding the patient as a human be have to wait 24 days before embarking, by sea being with family, living, and income-earning problems," would or air, for say the U.S.A. You will appreciate, Sir, the some way must be found of introducing them under effect on travel and commerce of such serious a of into number homes. large expert guidance Hospital almoners are already overworked ; but impedances. The fact is that we are a non-immune population, at physicians on hospital teaching staffs can stimulate considerable risk of invasion by smallpox, and we their interest through the questions they put, and comments ; and midwifery on the district often makes the have only ourselves to blame for it. While we can do what we like with our people, we must not more imaginative aware for the first time of aspects whine if other countries dislike our practices and take untouched by the writers of textbooks. I am, however, precautions. convinced that a month spent with a general practitioner It is up to the authorities to decide how to protect us, who took the students into such homes as he could, and if not from smallpox, at least from serious interference who discussed other cases as he went round, would be with our liberty to travel and to trade. the most valuable method. I should like this training M. T. MORGAN
Letters
to
the Editor
inserted between the final examination and qualification. Those of us who teach must be aware of a certain impatience among students towards knowledge that does not help in examinations ; but when these are passed there is a swing-over towards practical knowledge. Both practitioner and student would find the experience entertaining and illuminating. There are difficulties, as Dr. Harding (June 21) says ; but the plan is feasible. S. R. EASTWOOD. SUCCESSFUL REVACCINATION
SIR,—Dr. Geoffrey Edsall’s letter of June 21 will be of great interest to many of your readers, and his theses as to the interpretation of the reactions to vaccination seem to be sound. They do not, however, provide a solution to the problems that concern the quarantine officer in practice, and Dr. Edsall’s contention that a nil " reaction should not be accepted (no matter how many failures to take the patient has already experienced) is not a practical proposition for those who wish to travel-particularly if they wish to travel in some "
haste. The United States authorities have recently laid down’ that no person shall be admitted to the States from this. country unless he can produce a certificate of successful vaccination performed within the last three years. This, following Dr. Edsall’s contentions, has the effect of excluding certain people, including myself, from any possibility of going to the United States. I was vaccinated in infancy with four criss-cross insertions, the scars of which are still clearly visible. I was revaccinated on the opposite arm by exactly the same method at the age of twelve and took successfully. Since then, though I have been revaccinated on many occasions, I have never had the slightest suggestion of a take, and the so-called immunity reactions have been barely perceptible. On the last occasion that I came into contact with a suspected case of smallpox, only a few weeks ago, I decided to be vaccinated as brutally as possiblethat is, by four large insertions (two on one leg by the criss-cross method, two on the other leg by multiple puncture) using fresh lymph obtained from the Government laboratory. A few hours afterwards I had a slight trauma reaction, which rapidly cleared up, but no sign whatsoever of any take or immune reaction. Dr. Broom would certify me as " insusceptible to vaccination," which seems a reasonably good description of the state of affairs, but which I take it does not necessarily mean that I am immune to an attack of smallpox, though the fact remains that I have seen and handled a number of cases of smallpox in recent years and have not been attacked. What is to be done from the point of view of travel and immunity from quarantine measures for people who, like me, fail to take ? We do not object to a reasonable amount of revaccination, though it is a bit of a nuisance to have to be revaccinated every eight days for an indefinite period. What is more serious is the risk that we run, in leaving the country, of having to submit to " surveillance," or possibly to revaccination with a doubtful lymph applied by methods that may not be above criticism, or even of being refused permission to embark, or to land, because we have not a certificate of successful vaccination.
Port M.O.H., London.
CONSENT TO DEATH
SIR,—In your annotation of June 7 you quote from Dr. Harry Roberts’s book, Euthanasia and other Aspects of Life and Death, published in 1936. In the passage quoted, Dr. Roberts criticises as being unduly complicated
the procedure given in the first draft of a Bill which followed suggestions made in my presidential address to the Society of Medical Officers of Health. May I point out that the provisions of the Bill sponsored by the society which I represent, and introduced into the House of Lords by the late Lord Ponsonby, are much less complicated. There is no reference to a magistrate, the nearest relative does not have to be informed, and there is no delay of seven days. Practically all of Dr. Roberts’s criticisms have therefore been met. C. KILLICK MILLARD Hon. Secretary, Voluntary Euthanasia
Legalisation Society. COLD AGGLUTININS IN ATYPICAL PNEUMONIA SIR,—I was associated with Dr. G. E. 0. Williams in part of the work on cold agglutinins in atypical pneumonia, which he reported in your issue of June 21 (p. 865), and would like to make a few comments. Dr. Williams’s views on the aetiology of cases with high titres are strongly supported by the work of Eaton and others.’ They have isolated a virus from cases of atypical pneumonia, grown it in the chick embryo, and transmitted it to cotton rats in which it produces a pneumonic illness. Serum from cases in convalescence, but not in the acute stages, protected the rats from infection (the basis now of a diagnostic test 2). They found high coldagglutinin titres in 12 out of 16 cases from which the virus had been isolated.3 Such titres have been described in several outbreaks of atypical pneumonia 45 whereas apart from trypanosomiasis they are uncommon in other infections (note especially Finland’s5 series of over 800 controls). It is difficult to resist the conclusion that most cases of atypical pneumonia with high coldagglutinin titres are due to a specific virus. The common radiological findings of mottling and patchy consolidation in Dr. Williams’s cases with high cold-agglutinin titres might have been predicted from the findings at post mortem in a case from whom Eaton and others3 isolated the virus. The lung contained nodules, discrete in some areas, corlfluent in others. The pleura over superficial nodules was inflamed. Stimulated by Dr. Williams, Iset out to determine the clinical picture presented by infection with the supposed virus, taking 1 : 128 as a. diagnostic cold-agglutinin titre. I was able to collect only 12 cases. Nevertheless the case-records are similar to one another and to 16 cases from which the virus had been isolated described by Eaton and others.3 I would therefore like to sketch tentatively what I suspect to be the picture of the J. exp. Med. 1. Eaton, M. D., Meiklejohn, G., van Herick, W. 1944, 79, 649. 2. Eaton, M. D., van Herick, W., Meiklejohn, G. Ibid, 1945, 82, 329. 3. Meiklejohn, G., Eaton, M. D., van Herick, W. J. clin. Invest. 1945, 24, 241. 4. Meiklejohn, G. Proc. Soc. exp. Biol., N.Y. 1943, 54, 181. 5. Finland, W. et al. J. clin. Invest. 1945, 24, 451 (see also Dr. Williams’s references).
Letters
to
the Editor
inserted between the final examination and qualification. Those of us who teach must be aware of a certain impatience among students towards knowledge that does not help in examinations ; but when these are passed there is a swing-over towards practical knowledge. Both practitioner and student would find the experience entertaining and illuminating. There are difficulties, as Dr. Harding (June 21) says ; but the plan is feasible. S. R. EASTWOOD. SUCCESSFUL REVACCINATION
SIR,—Dr. Geoffrey Edsall’s letter of June 21 will be of great interest to many of your readers, and his theses as to the interpretation of the reactions to vaccination seem to be sound. They do not, however, provide a solution to the problems that concern the quarantine officer in practice, and Dr. Edsall’s contention that a nil " reaction should not be accepted (no matter how many failures to take the patient has already experienced) is not a practical proposition for those who wish to travel-particularly if they wish to travel in some "
haste. The United States authorities have recently laid down’ that no person shall be admitted to the States from this. country unless he can produce a certificate of successful vaccination performed within the last three years. This, following Dr. Edsall’s contentions, has the effect of excluding certain people, including myself, from any possibility of going to the United States. I was vaccinated in infancy with four criss-cross insertions, the scars of which are still clearly visible. I was revaccinated on the opposite arm by exactly the same method at the age of twelve and took successfully. Since then, though I have been revaccinated on many occasions, I have never had the slightest suggestion of a take, and the so-called immunity reactions have been barely perceptible. On the last occasion that I came into contact with a suspected case of smallpox, only a few weeks ago, I decided to be vaccinated as brutally as possiblethat is, by four large insertions (two on one leg by the criss-cross method, two on the other leg by multiple puncture) using fresh lymph obtained from the Government laboratory. A few hours afterwards I had a slight trauma reaction, which rapidly cleared up, but no sign whatsoever of any take or immune reaction. Dr. Broom would certify me as " insusceptible to vaccination," which seems a reasonably good description of the state of affairs, but which I take it does not necessarily mean that I am immune to an attack of smallpox, though the fact remains that I have seen and handled a number of cases of smallpox in recent years and have not been attacked. What is to be done from the point of view of travel and immunity from quarantine measures for people who, like me, fail to take ? We do not object to a reasonable amount of revaccination, though it is a bit of a nuisance to have to be revaccinated every eight days for an indefinite period. What is more serious is the risk that we run, in leaving the country, of having to submit to " surveillance," or possibly to revaccination with a doubtful lymph applied by methods that may not be above criticism, or even of being refused permission to embark, or to land, because we have not a certificate of successful vaccination.
Port M.O.H., London.
CONSENT TO DEATH
SIR,—In your annotation of June 7 you quote from Dr. Harry Roberts’s book, Euthanasia and other Aspects of Life and Death, published in 1936. In the passage quoted, Dr. Roberts criticises as being unduly complicated
the procedure given in the first draft of a Bill which followed suggestions made in my presidential address to the Society of Medical Officers of Health. May I point out that the provisions of the Bill sponsored by the society which I represent, and introduced into the House of Lords by the late Lord Ponsonby, are much less complicated. There is no reference to a magistrate, the nearest relative does not have to be informed, and there is no delay of seven days. Practically all of Dr. Roberts’s criticisms have therefore been met. C. KILLICK MILLARD Hon. Secretary, Voluntary Euthanasia
Legalisation Society. COLD AGGLUTININS IN ATYPICAL PNEUMONIA SIR,—I was associated with Dr. G. E. 0. Williams in part of the work on cold agglutinins in atypical pneumonia, which he reported in your issue of June 21 (p. 865), and would like to make a few comments. Dr. Williams’s views on the aetiology of cases with high titres are strongly supported by the work of Eaton and others.’ They have isolated a virus from cases of atypical pneumonia, grown it in the chick embryo, and transmitted it to cotton rats in which it produces a pneumonic illness. Serum from cases in convalescence, but not in the acute stages, protected the rats from infection (the basis now of a diagnostic test 2). They found high coldagglutinin titres in 12 out of 16 cases from which the virus had been isolated.3 Such titres have been described in several outbreaks of atypical pneumonia 45 whereas apart from trypanosomiasis they are uncommon in other infections (note especially Finland’s5 series of over 800 controls). It is difficult to resist the conclusion that most cases of atypical pneumonia with high coldagglutinin titres are due to a specific virus. The common radiological findings of mottling and patchy consolidation in Dr. Williams’s cases with high cold-agglutinin titres might have been predicted from the findings at post mortem in a case from whom Eaton and others3 isolated the virus. The lung contained nodules, discrete in some areas, corlfluent in others. The pleura over superficial nodules was inflamed. Stimulated by Dr. Williams, Iset out to determine the clinical picture presented by infection with the supposed virus, taking 1 : 128 as a. diagnostic cold-agglutinin titre. I was able to collect only 12 cases. Nevertheless the case-records are similar to one another and to 16 cases from which the virus had been isolated described by Eaton and others.3 I would therefore like to sketch tentatively what I suspect to be the picture of the J. exp. Med. 1. Eaton, M. D., Meiklejohn, G., van Herick, W. 1944, 79, 649. 2. Eaton, M. D., van Herick, W., Meiklejohn, G. Ibid, 1945, 82, 329. 3. Meiklejohn, G., Eaton, M. D., van Herick, W. J. clin. Invest. 1945, 24, 241. 4. Meiklejohn, G. Proc. Soc. exp. Biol., N.Y. 1943, 54, 181. 5. Finland, W. et al. J. clin. Invest. 1945, 24, 451 (see also Dr. Williams’s references).