_IMMUNIZING WITH POLLEN EXTRACT_
The idea of preventing disease and poisoning by preparing the body with
minute doses of that poison, gradually increasing until the body is
immune, is an ancient one. The practice is Ur-alt, as my favorite German
history books say; for it has been found among savages and primitive
peoples and is practised in a crude way by every boy who accustoms
himself to that noxious weed, tobacco. Then, there are the Psylli, whom
Lucan tells of, who were by heredity immune to snake poison and who
could make the favored stranger immune by inoculating him with small
doses (_Pharsalia_, Book ix); and old King Mithridates, of Pontus, who
believed in preparedness and kept himself prepared for the attentions of
his faithful subjects by taking small doses of poison every day, keeping
himself immune should by any accident some poison slip into his porridge
(_Pliny_, Book xxv). Old King Mithridates was a good immunologist. He
knew the transient nature of immunity and kept the treatment up. He
knew that, if he stopped taking the poison for a week or so, he would go
into a state of anaphylaxis and the next dose would kill him; so he kept
himself in a state of anti-anaphylaxis by not permitting too long a time
to elapse between doses, after the most approved rules of modern
immunology. That patient whom Goodale immunized against horse-asthma who
objected to a treatment that had to be taken for the rest of her life,
should learn of old King Mithridates the true practice of immunity.
This is still the weak point of artificial immunity; it does not last
very long. You can immunize a guinea-pig or a patient to almost anything
now-a-days by giving him minute doses gradually increased but the
immunity passes off quite rapidly when the treatment is stopped. We have
still something to learn from Nature in this respect. Nature can give us
one dose of yellow-fever or scarlet-fever or small-pox or measles and
make us immune for life but your artificially produced immunity may last
for a few weeks or months only. Our closest imitation of natural
immunity is vaccination against small-pox. Here we produce an actual
disease, cow-pox; yet, even here, we are not at all sure how long
immunity lasts. Even in Jenner's time, the original belief in protection
for life came down to seven years and our modern health boards would
vaccinate every two years or, in the presence of an epidemic, more
frequently.
However, Nature is a wasteful worker, wasteful of her material, and she
kills a great many of her children with measles and scarlet-fever and
small-pox and yellow-fever while immunizing the lucky ones. A Health
Board that would kill so many people while immunizing the rest would be
a public scandal. Yet it is probable that Nature's way is the most
effective and that the best immunizer is the disease itself, as Koch
found with tuberculosis among his guinea-pigs that the best protection
against tuberculosis was inoculation with living tubercle bacilli, not
with dead ones; and the autopsies show that the majority of the human
race that grow up at all have been successfully immunized against
tuberculosis by a mild local attack of the disease.
As yet, no one has had the boldness to inoculate human brings with
living bacteria and to imitate Nature in her manner of killing off all
the sensitive subjects in order to preserve the rest. This was formerly
done by inoculation with small-pox but the unfortunate results of the
practice compelled its abandonment among civilized people. Even Nature's
immunity is not perfect in all diseases, as many a patient with his
sixth attack of grippe or third pneumonia or fortieth year of hay fever
has learned most feelingly; and this irregularity of natural immunity
bears directly on the proposal to immunize patients against hay fever by
small and increasing doses of the offending pollen. If the natural
disease does not confer lasting immunity, you will have some difficulty
in conferring lasting immunity artificially, as the immunologist is just
now discovering. His immunity passes off so rapidly that he is now
searching for a method of immunizing that can be carried on for many
years without tying the patient to a laboratory for life. It is right
here that I believe that homoeopathy has valuable methods that can be
applied to the situation.
But we must not jump to conclusions. Because we can immunize
successfully against one disease, it does not follow that the same
methods will immunize against another disease. Each disease is a problem
in itself and may require its own methods. Nor because we can immunize
the guinea-pig in the laboratory, does it follow that the same methods
are applicable in the human patient. The only proof that we can immunize
against hay fever is to immunize against hay fever. So, to the subject!
=Passive Immunity.= The first man to attempt to apply the methods of
modern immunity to hay fever was Dunbar, of Hamburg, in 1903, with this
_pollantin_. He attempted to duplicate in hay fever the triumph of
antitoxin in diphtheria by injecting a horse with increasing doses of
pollen until the horse became immune to large doses of pollen and his
blood full of antibodies. Dunbar expected to confer passive immunity on
the hay fever patient by transferring to him this horse serum with its
antibodies. There is no better example of the rule that each disease
requires its own methods of immunity. While diphtheria antitoxin is
harmless to the diphtheria patient, the serum of the pollen-immunized
horse nearly killed the first patient Dunbar tried it on, who happened
to be his assistant, a sufferer from hay fever. It is probable that
pollantin is based on the wrong principle, that hay fever is not, like
diphtheria, a poisoning by a toxin to be antidoted by an antitoxin.
However, to Dunbar belongs the credit of first attempting to put the
treatment of hay fever on a scientific basis and he introduced the
method of testing the patient that has been followed by all later
workers, dropping the pollen extract in the eye.
In the _Centralblatt für Bakteriologie, Referate_, xxxvi, s. 453, there
is an account of a most unseemly quarrel between Dunbar and Weichardt,
the latter claiming that before leaving Hamburg, he suggested the idea
of pollantin to Dunbar. Weichardt has since put on the market another
hay fever specific, called _graminol_, which is the blood-serum of
cattle that have fed on the offending grasses during the hay fever
season. The theory is that the blood of the cow contains antibodies to
those grasses and that passive immunity can be conferred on the hay
fever patient by transferring those antibodies to his blood.
This is the old, old experiment that has been tried so many times in
many diseases and has so often failed. It reminds us of the many
attempts to confer on the tuberculosis patient the natural immunity
possessed by the jackass by injecting the patient with the blood serum
of that friend of man. The result of these experiments left some doubt
as to who merited most the name of jackass, the doctor, the patient or
the patient beast. Both pollantin and graminol have been praised highly
in Germany but neither of them have succeeded so well in this country.
Perhaps a shrewd advertising campaign had something to do with it; for
the combination of a German scientist and his manufacturer can give
points to any Yankee in exploiting the public with sure cures for the
sick.
=Active Immunity.= In active immunization, the real pioneers, after
Mithridates, were the homoeopaths, who, for many years, have given
small doses of poison ivy to prevent ivy poisoning and small doses of
the poisons of infectious diseases to prevent and cure those diseases;
but the homoeopath did not realize the transient nature of immunity
and the necessity for continuing the treatment for many months or years,
nor did he adopt the principle of increasing the dose to the point of
toleration.
The first to attempt active immunization and cure of hay fever by
injecting extracts of the pollen that causes the disease appears to have
been Noon, working in Wright's laboratory in London. The work was
continued by Freeman, their work being reported in the _Lancet_, 1911,
i, page 1572 and ii, page 814. They found the English spring form of hay
fever due to the pollen of grasses. By dropping extracts of various
pollens into the patient's eye, after the manner of Dunbar, they
concluded that their patients were most sensitive to timothy grass and
they used timothy extract exclusively in the treatment. Freeman states
explicitly that a patient immunized against timothy grass is immune to
all other grasses of that season; that it is unnecessary to immunize
him to each particular grass, thus differing from some of our American
observers who use the skin reaction to determine the particular pollens
to which the patient is sensitive and inject every one of those pollens
in the treatment.
Independently of these British observers, Karl Koessler, of Chicago, in
1910, attempted to immunize patients against hay fever by injecting
pollen extracts. Like Noon and Freeman, he used the eye reaction to test
his patients and found them most sensitive to rag weed. Just as the
Englishmen had used only timothy grass in their cases, Koessler used rag
weed exclusively. His work is reported in his article on Hay Fever in
Forchheimer's _Therapeusis_, Volume V and also in the _Illinois Medical
Journal_, 1914, page 120.
=Selecting the Pollen. The Skin Reaction.= The next step in the
development of the pollen treatment was to substitute the skin reaction
for the eye reaction in testing the patient's sensitiveness to various
pollens. The advantage of the skin reaction over the eye reaction is
that it permits testing many pollens at the same time and does not
distress the patient as does a sharp eye reaction.
While Noon and Freeman selected the one typical pollen of spring, the
timothy grass pollen, and Koessler selected the typical fall pollen of
the American hay fever, rag weed, for all cases of that season, later
workers, using the skin reaction, go to the extreme of injecting the
patient with each and every pollen to which his skin reacts. Oppenheimer
and Gottlieb carry this individualization to the point of attempting to
discriminate by the skin test the patient's varying resistance to his
different pollens at each treatment. This resistance may rise for some
and fall for other pollens so that six or eight different pollens in
different doses must be injected separately at each treatment. This is
individualizing the case with a vengeance and requires an expenditure of
time and skill (I almost said _skin_) that must be rather expensive for
the patient.
A series of light scratches are made on the skin of the forearm or the
inner side of the arm where the skin is delicate. The scratch must be
only superficial and not draw blood. Really the best method is to make
a round denuded spot by twirling a small brad-awl. A drop of extract of
different pollens or a speck of the pure pollen protein is rubbed into
each scratch and the result awaited for fifteen minutes. Within that
time, a redness and swelling, like a hive or a bite, will appear at some
of the scratches.
This swelling is the skin reaction to that pollen. Its appearance
indicates the presence in the skin of reaction bodies to that pollen. It
is argued, and partially proved by practice, that the pollens to which
the skin reacts are the pollens to which that patient has been
sensitized and these pollens are selected for administration.
=The Dose.= The first dose of pollen extract is the danger dose and
differs for each patient according to his susceptibility for a given
pollen. It is determined by dropping the pollen extract into the eye or
rubbing it on the skin. To avoid anaphylactic shock, this dose must be
incredibly small. Noon and Freeman's first dose was one-third c. c. of
the weakest dilution of which one drop in the eye would cause
hyperaemia. This was usually four drops of a millionfold dilution in
water. Later doses were never more than 1 c. c. of a 1 to 100,000
dilution "to avoid unpleasant reactions."
Goodale begins with five drops of that dilution that just fails to cause
a skin reaction. Later, to avoid the risk of shock, he advises one-tenth
of this dose.
Koessler's theoretical initial dose of rag weed extract is one drop of
the weakest dilution that will just redden the conjunctiva. As he finds
rag weed more toxic than the English timothy, his actual first dose is
one-half of this theoretical dose. The actual first dose will vary from
one drop of a 1 to 1,000,000 to one drop of a 1 to 20,000 dilution, the
smaller of which he estimates to contain of pollen protein one
one-hundredth part of a millionth of a gramme or .000,000,01 gramme.
Shade of Samuel Hahnemann, the first and greatest homoeopath! And they
drove you out of Leipzig into poverty and exile for teaching that in
using drugs that are similar to the disease there is serious danger of
aggravating the disease; that the dose must be extremely small; and that
disease so sensitized the patient that a dose so small as to be
inappreciable in health becomes active in disease!
The smaller doses of pollen extract are given every three or four days
and increased as rapidly as possible, judging the increasing tolerance
or resistance by a diminishing eye or skin reaction. With larger doses,
the interval is longer, a week or ten days. The pioneer, Noon, and all
workers since, warn against increasing the dose too fast, for the
reactive power of the patient is easily exhausted, his resistance
lowered and he may be left more sensitive than before.
=Dangers of Pollen Injections.= Treatment by pollen injection is beset
with dangers for the unlucky patient. It has been noted how Dunbar
nearly killed his first patient by injecting the serum of the horse that
had been immunized to pollen. All experimenters, without exception, say
that the injection of pollen extract is attended with danger to the
patient, danger of anaphylactic shock, and warn against the use of any
but the most infinitesimal doses. The hay fever patient is a human being
who, in some way, has been sensitized to pollen. He is in a state of
exquisite anaphylaxis and a dose of pollen injected into his blood may
kill him in twenty minutes. Goodale reports shock (faintness, nausea,
vomiting) in two patients following the mere rubbing of a drop of pollen
extract into a scratch on the skin. Evidently the scratch was too deep
and the pollen poison was absorbed rapidly into the blood instead of
being stopped by the deep epithelia. I have seen a similar absorption
and general reaction in children after a skin test with tuberculin, when
the tuberculin entered the blood through too deep a scratch.
Another danger lies in the instability of the pollen extracts. Koessler
expressly warns against commercial preparations of pollen protein
because of the danger of decomposition. His extracts do not keep more
than three weeks and are dangerous to use after that time. On the other
hand, Goodale, making his extracts with 15% alcohol, reports them as
active and fit for use after more than one year. Oppenheimer and
Gottlieb object to commercial preparations on different grounds. The
commercial preparations contain many different pollens so as to be sure
to include those to which the patient is sensitive. They point out that
in these mixtures, the dose of the individual pollens cannot be adjusted
to the changing conditions of the patient and, in addition, injecting
into the blood of the patient pollens to which he is not already
sensitive may sensitize him to these pollens also and leave him worse
than before.
There is the lesser danger that the patient will not be immunized by the
injections but become more sensitive to his old pollens than he was
before, as Noon pointed out in his first paper; for artificial immunity
is a difficult thing to control and is by no means as easy as it looks
in the book. Nor is it as easy to immunize a human being over many years
of life, subject to so many conflicting influences, as it is to immunize
a guinea-pig living in a cage.
To lessen the dangers and enable the patient to keep up his immunization
for many months and years, Goodale borrowed an idea from Schloss, who
fed his egg-oat-meal-almond anaphylaxis patient minute doses of these
foods until he so raised his resistance that he was able to eat them in
ordinary quantities without harm. Such artificial resistance must be
kept up by eating a small quantity of the food each day or it will be
lost (old King Mithridates again). As most of the pollens are not edible
and as patients react to botanically allied plants, Goodale tried
feeding the patient over long periods of time with vegetables and edible
plants that were allied to the offending pollens, expecting that, as in
Schloss's patient, some minute part of the protein would pass unto the
blood unchanged and maintain the protection. So far, these feeding
experiments have failed. Trial with homoeopathically potentized
pollens over long periods of time has not been made.
=Conclusions on Pollen Extracts.= My conclusions on the pollen treatment
are that it is in line with our best practice of immunity but that it is
still in an experimental stage, the pollens are possibly dangerous even
in the hands of a skilled immunologist. In a disease that is usually so
easily controlled by rosin-weed, faradism and ichthyol, I would not
expose a hay fever patient to the very real danger of anaphylactic
shock. The conditions governing immunity stated in the beginning of this
chapter still hold good. It is transient. Already some of the early
workers have discontinued the practice. The despair of Goodale has been
quoted. Scheppegrell, probably the first in this country to use the
pollens, has given them up and advises the patient to keep away from his
irritant and to have the weeds cut in all cities as the best treatment
obtainable (_Journal of the A. M. A._, March 4, 1916, page 710). The
most hopeful aspect of the pollen extracts seems to me to be their
administration all around the year in high dilutions, _more
homoeopathico_, and to this practice I believe the immunologist will
eventually come.
=Pollen Extracts not Vaccines.= Some manufacturers and all British writers
speak of pollen extracts as _vaccines_ and of immunizing the patient as
_vaccination_. This seems an unnecessary confusion. We have two kinds of
vaccines already, the cow-pox vaccine and the killed cultures of
bacteria introduced by Wright. For an account of the use of these
vaccines in hay fever, we will pass to the next chapter.