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A PLEA FOR THE UNIFORMITY OF CONDITIONS IN VACCINATION.
1600 from a single centre, appearing at about the sixth week, there being an additional centra for the sternal end which ’does not form until the eighteenth or twentieth year. Although, however, ossification commences in this way from one centre, it afterwards, according to Quain’s "Anatomy" (tenth edition), progresses at both ends in cartilage as well as in fibrous substance. If this be so it seems possible that in such a case as this the membrane centre has not appeared, the two portions which are present being the inner and outer cartilaginous parts referred to. These portions are very imperfectly ossified, for when looked at with the x rays they did not compare in distinctnes with the ribp, and in a
and several other observers, including Schorstein’ and George Carpenter6 in this country, have recorded cases in which the clavicle was only represented by rudimentary inner or outer portions, or both, or was absent. Two cases in which the clavicular deformity was closely similar to that here described are reported by Preleitner6 occurring in a brother and sister, aged 12 and eight years respectively. In the case of the boy tense bands were felt passing from one fragment to the other; the joint was freely moveable and the shoulders could be met in front without pain. The sternal fragments in both these cases were about double the length of the acromial, the measurements being 6 and 3 centimetres in the one and 5 and 3 centimetres in the other. The deformity is clearly developmental. The possibility of fracture in utero or at birth is excluded by the symmetry of the lesion on each side. It is interesting to note that Preleitner regarded his first case as a double pseudo-arthritic united fracture, but changed his view on finding that the sister had the same deformity and that the labours were normal. Such a development or complete absence of the clavicles is usually associated with deficiencies of other membrane bones. I am indebted to Dr. F. J. Poynton for the reference to the paper of Marie and Sainton, These observers7 described cases in which absence or deformity of the clavicles was associated with a globular cranium with frontal or parietal bosses, imperfect ossification of the fontanelles, a high or deficient palate, and irregular teeth, the malformations being hereditary and present in one instance in a father and son and in another in a mother and daughter. To this condition they gave the name of sterno-cleido-dysostosis. It is now fairly well established that the majority of published cases of clavicular deformities show in addition one or other of this group of malformations. In one of Preleitner’s patients above referred to, that of the girl aged eight years, the photograph shows clearly enlargement of the cranium relatively to the face. Villaret and FrancozB have published an excellent summary of 28 recorded cases, with some good photographs. Abram has recently shown a case in this country9 of a more severe type than the one here described. Although we are indebted to Marie and Sainton for naming this group, it may be noted that Scheut. hauer noticed the association between the deformity of the clavicles and the cranium in 1871. The case here described should also, no doubt, be regarded as one of cleido-cranial dysostosis. The fontanelles were closed, but the clavicular deformity, the globular head, the arched palate, and the irregular teeth combine to form a clinical picture similar to that of the cases of Marie and Sainton. No hereditary connexion with a similar deformity in the mother is present in this case. I have not seen the father, but the mother says that his collar-bones are all right and that he is exceptionally strong and accustomed to lift heavy weights, and this is against the probability of there being a malformation of the shoulder-girdle. The presence of myxoedema in the mother is worthy of remark. She first noticed an affection of her health two years after this child was born-a boy, said to be normal, having been born in the interval. Other healthy children have been born since she has been under treatment with thyroid extract. This is the third case in which I have seen some developmental defect in the child of a myxoedematous mother. Mr. R. E. Humphry, late house surgeon at the Victoria Hospital for Children, kindly took the photograph of the
patient.
Bryanston-street, W.
could hardly be made out. According to Paterson1 it is probable that the clavicle contains more than one morphological unit, but this observer regards the outer part of the bone as ossified in membrane and the inner in
photrgraph
A PLEA FOR THE UNIFORMITY OF CONDITIONS IN VACCINATION. BY A. H. GERRARD, M.D.LOND., M.D. STATE MED., D.P.H. OXON.
AT the present time the source from which calf lymph is obtained, practically speaking, is under no control or superThat the shaft of the clavicle may form in two parts is vision except in the case of that used for public vaccination. shown by a number of recorded instances in which only one The lymph supplied in this instance is made under the most part has been present, either medially or laterally placed. rigid precautions by the Local Government Board, and each One such was recorded by Walsham,2 also by Grass,3 the 4 THE LANCET, Jan. 7th, 1899, p. 10. outer part being absent and the trapezius and deltoid getting 5 THE LANCET, Jan. 7th, 1899, p. 13. their attachment to the acromion process of the scapula ; 6 Wiener Klinische Wochenschrift, 1903, p. 70.
cartilage.
7
2
Brit. Med. Jour., 1902. vol. ii., p. 77. Proceedings of the Medical Society of London, vol. xii., 1889, 3 Münchener Medicinische Wochenschrift, 1903, p. 1151.
Marie et Sainton : Bulletin et Mémoire de la Société Médicale des 3 s., p. 706, 1897. 8 Nouvelle Iconographie de la Salpêtrière, 1906. 9 THE LANCET, August 17th, 1907, p. 429.
Hôpitaux des Paris, 14,
1
p. 277.
1601 Ibatch is
carefully registered. This, of course, is as it should On the other hand, the vaccination as carried out by the general practitioner is free from all restrictions or safeguards. He may obtain his vaccine from wherever he likes, he may .carry out the procedure in whatever way he may wish, and he may scarify in as many or as few places as his convictions He may also, if he cares to, return or his patients dictate. the slightest reaction as successful vaccination. He is under In such an important matter as no supervision whatever. vaccination where the benefit to the patient is not immediately apparent it is very serious if the operation is carried out by any means not ideal from a surgical point of view. All this might easily be obviated were vaccination completely under State control. This could easily be carried out without in any way disturbing the present public vaccinators, who undoubtedly carry out their work with great efficiency and with little friction. All that is required is to compel all vaccination to be done under present public vaccination conditions, both with regard to procedure and payment. Vaccination would then have a definite meaning. Undoubtedly those children who are vaccinated by the public vaccinator are protected more efficiently and with the least possible risk. From my observations on some hundreds of - cases I have never seen a public vaccination go wrong in any way. Strangely enough, in this matter the pauper is far better off than the prince. That is to say, the independent person who wishes to pay for his own vaccination cannot get as good conditions as the individual who accepts the gratuitous services of the State. Especially is this so in the matter of the quality and purity of the lymph used. Most of the lymph on the market to-day is sold as .glycinerated calf lymph, which, if manufactured in the manner originated by Dr. S. Monckton Copeman, should be free from extraneous organisms. It was with a view to looking into the matter of the relative purity of calf lymph that eight samples of glycinerated calf lymph were purchased in open market. All the specimens were examined microscopically and in none was there found anything but epithelial debris. For the purpose of bacteriological examination the following procedure was followed. Each tube of lymph was file-marked near the end and then washed in 1 in 20 carbolic followed by - sterile water and dried. The end of the tube was broken off, the cut edge flamed, and the sealed end containing a small ,portion of air was heated gently. This expelled the lymph which was caught in 10 cubic centimetres of sterile broth. This was then mixed and used as a standard dilution. Tubes of broth-glucose broth-and Loffier serum, agar, and gelatin plates were inoculated with one loopful of the above and the results of incubation are shown in the following table:be.
All the colonies in the various media were sub-cultured and investigated with regard to the presence of staphylococci and streptococci with the following result :Sample 1 contained staphylococcus albus and short chains of cocci
four long. contained staphylococcus albus and aureus, also a few suggestive of pseudo-diplitlieria bacilli. Sample 3 contained staphylococcus albus and aureus and motile bacteria. Sample 4 contained staphylococcus albus and aureus, short chains of cocci-large actively motile rods, and pseudo diphtheria-like bacilli. Sample 5 contained staphylococcus albus-a leptothrix-long chains of streptococci. Sample 6 contained no staphylococci but motile bacteria in chains. Sample 7 contained staphylococcus albus and aureus-short chains of cocci. Sample 8 contained streptococci in abundance and a staphylococcus not more than
Sample 2
bacilli
albus.
The streptococci in samples 5 and 8 were isolated in Drigalski’s plates and obtained in pure culture. They were then grown in milk. The culture was injected into a mouse which died on the second day, but the streptococcus was not recovered from the blood. Samples 5 and 8 were both
obtained from the same manufacturer. I was fortunate enough to be able to compare these results with those obtained by subjecting three tubes of Local Government Board lymph to a similar method of examination. Without going into details the lymph supplied by the Board was uniformly freer from organisms, gelatin plates only giving one or two colonies of staphylococcus albus and citreus and no other organisms. On the other hand, none of the tubes were sterile. These results then go to show that commercial glycerinated calf lymph is not so carefully prepared as that issued by the Local Government Board, that many of the samples contain the organisms of suppuration, and that at least one sample contains very definite streptococci. The Local Government Board lymph is practically as sterile as an article of that character which is subject to manipulation can be, the few organisms it contains being probably due to air contamination in filling the tubes, &c. Some of the purchased samples suggest the absence of glycerine. In such circumstances, then, it is too much for the practising physician to look to the Government to help him in a matter of this kind. Large sums of public money are spent yearly in supplying the public vaccinator with pure calf lymph, yet the same is denied to the practitioner. Surely he might be allowed to purchase his lymph from the Government and thus obtain with it a guarantee of its purity and source. There should be no difficulty about such an arrangement. Most firms that send out lymph send it out in numbered batches, so that in the case of untoward results the source can be traced and the results of other tubes from the same batch compared. This is also done by the Local Government Board. The machinery is already at work. it onlv reauires a little extension.
PULMONARY REGURGITATION DUE TO VEGETATIVE ENDOCARDITIS CONSEQUENT UPON RUPTURE OF ANEURYSM OF HEART. BY THOMAS
OLIVER, M.A. DURH , M.D. GLASG., F.R.C.P. LOND., LL. D.,
PROFESSOR OF PHYSIOLOGY AT THE COLLEGE OF MEDICINE, AND PHYSICIAN TO THE ROYAL VICTORIA INFIRMARY, NEWCASTLEUPON-TYNE.
APART from
congenital
malformation and intra-uterine
disease, pulmonary regurgitation is an event of such infrequency as to deserve notice, especially when in addition to being diagnosed during life its existence is confirmed by
examination after death. The cardiac lesion about to be described is so unusual that I offer no apology in craving for it a place in the pages of this journal. The patient, a labourer, was a married man, aged 37 years He was admitted into the Royal Victoria Infirmary, Newcastle-uponTyne, on Nov. 3rd, 1906, suffermg from dropsy of the feet and legs, pain in the cnest. and slight difficulty of breathing. In 1889 he tell from a 8caffold and injured his left chest. A few of his ribs were broken. Shortly after the accident he spat up blood. There was no history of rheumatism. The patient stated that be had had pain over the region of the heart for the last six years, accompanied by shortness of breath on exertion. Within the last few months he had had
and several other observers, including Schorstein’ and George Carpenter6 in this country, have recorded cases in which the clavicle was only represented by rudimentary inner or outer portions, or both, or was absent. Two cases in which the clavicular deformity was closely similar to that here described are reported by Preleitner6 occurring in a brother and sister, aged 12 and eight years respectively. In the case of the boy tense bands were felt passing from one fragment to the other; the joint was freely moveable and the shoulders could be met in front without pain. The sternal fragments in both these cases were about double the length of the acromial, the measurements being 6 and 3 centimetres in the one and 5 and 3 centimetres in the other. The deformity is clearly developmental. The possibility of fracture in utero or at birth is excluded by the symmetry of the lesion on each side. It is interesting to note that Preleitner regarded his first case as a double pseudo-arthritic united fracture, but changed his view on finding that the sister had the same deformity and that the labours were normal. Such a development or complete absence of the clavicles is usually associated with deficiencies of other membrane bones. I am indebted to Dr. F. J. Poynton for the reference to the paper of Marie and Sainton, These observers7 described cases in which absence or deformity of the clavicles was associated with a globular cranium with frontal or parietal bosses, imperfect ossification of the fontanelles, a high or deficient palate, and irregular teeth, the malformations being hereditary and present in one instance in a father and son and in another in a mother and daughter. To this condition they gave the name of sterno-cleido-dysostosis. It is now fairly well established that the majority of published cases of clavicular deformities show in addition one or other of this group of malformations. In one of Preleitner’s patients above referred to, that of the girl aged eight years, the photograph shows clearly enlargement of the cranium relatively to the face. Villaret and FrancozB have published an excellent summary of 28 recorded cases, with some good photographs. Abram has recently shown a case in this country9 of a more severe type than the one here described. Although we are indebted to Marie and Sainton for naming this group, it may be noted that Scheut. hauer noticed the association between the deformity of the clavicles and the cranium in 1871. The case here described should also, no doubt, be regarded as one of cleido-cranial dysostosis. The fontanelles were closed, but the clavicular deformity, the globular head, the arched palate, and the irregular teeth combine to form a clinical picture similar to that of the cases of Marie and Sainton. No hereditary connexion with a similar deformity in the mother is present in this case. I have not seen the father, but the mother says that his collar-bones are all right and that he is exceptionally strong and accustomed to lift heavy weights, and this is against the probability of there being a malformation of the shoulder-girdle. The presence of myxoedema in the mother is worthy of remark. She first noticed an affection of her health two years after this child was born-a boy, said to be normal, having been born in the interval. Other healthy children have been born since she has been under treatment with thyroid extract. This is the third case in which I have seen some developmental defect in the child of a myxoedematous mother. Mr. R. E. Humphry, late house surgeon at the Victoria Hospital for Children, kindly took the photograph of the
patient.
Bryanston-street, W.
could hardly be made out. According to Paterson1 it is probable that the clavicle contains more than one morphological unit, but this observer regards the outer part of the bone as ossified in membrane and the inner in
photrgraph
A PLEA FOR THE UNIFORMITY OF CONDITIONS IN VACCINATION. BY A. H. GERRARD, M.D.LOND., M.D. STATE MED., D.P.H. OXON.
AT the present time the source from which calf lymph is obtained, practically speaking, is under no control or superThat the shaft of the clavicle may form in two parts is vision except in the case of that used for public vaccination. shown by a number of recorded instances in which only one The lymph supplied in this instance is made under the most part has been present, either medially or laterally placed. rigid precautions by the Local Government Board, and each One such was recorded by Walsham,2 also by Grass,3 the 4 THE LANCET, Jan. 7th, 1899, p. 10. outer part being absent and the trapezius and deltoid getting 5 THE LANCET, Jan. 7th, 1899, p. 13. their attachment to the acromion process of the scapula ; 6 Wiener Klinische Wochenschrift, 1903, p. 70.
cartilage.
7
2
Brit. Med. Jour., 1902. vol. ii., p. 77. Proceedings of the Medical Society of London, vol. xii., 1889, 3 Münchener Medicinische Wochenschrift, 1903, p. 1151.
Marie et Sainton : Bulletin et Mémoire de la Société Médicale des 3 s., p. 706, 1897. 8 Nouvelle Iconographie de la Salpêtrière, 1906. 9 THE LANCET, August 17th, 1907, p. 429.
Hôpitaux des Paris, 14,
1
p. 277.
1601 Ibatch is
carefully registered. This, of course, is as it should On the other hand, the vaccination as carried out by the general practitioner is free from all restrictions or safeguards. He may obtain his vaccine from wherever he likes, he may .carry out the procedure in whatever way he may wish, and he may scarify in as many or as few places as his convictions He may also, if he cares to, return or his patients dictate. the slightest reaction as successful vaccination. He is under In such an important matter as no supervision whatever. vaccination where the benefit to the patient is not immediately apparent it is very serious if the operation is carried out by any means not ideal from a surgical point of view. All this might easily be obviated were vaccination completely under State control. This could easily be carried out without in any way disturbing the present public vaccinators, who undoubtedly carry out their work with great efficiency and with little friction. All that is required is to compel all vaccination to be done under present public vaccination conditions, both with regard to procedure and payment. Vaccination would then have a definite meaning. Undoubtedly those children who are vaccinated by the public vaccinator are protected more efficiently and with the least possible risk. From my observations on some hundreds of - cases I have never seen a public vaccination go wrong in any way. Strangely enough, in this matter the pauper is far better off than the prince. That is to say, the independent person who wishes to pay for his own vaccination cannot get as good conditions as the individual who accepts the gratuitous services of the State. Especially is this so in the matter of the quality and purity of the lymph used. Most of the lymph on the market to-day is sold as .glycinerated calf lymph, which, if manufactured in the manner originated by Dr. S. Monckton Copeman, should be free from extraneous organisms. It was with a view to looking into the matter of the relative purity of calf lymph that eight samples of glycinerated calf lymph were purchased in open market. All the specimens were examined microscopically and in none was there found anything but epithelial debris. For the purpose of bacteriological examination the following procedure was followed. Each tube of lymph was file-marked near the end and then washed in 1 in 20 carbolic followed by - sterile water and dried. The end of the tube was broken off, the cut edge flamed, and the sealed end containing a small ,portion of air was heated gently. This expelled the lymph which was caught in 10 cubic centimetres of sterile broth. This was then mixed and used as a standard dilution. Tubes of broth-glucose broth-and Loffier serum, agar, and gelatin plates were inoculated with one loopful of the above and the results of incubation are shown in the following table:be.
All the colonies in the various media were sub-cultured and investigated with regard to the presence of staphylococci and streptococci with the following result :Sample 1 contained staphylococcus albus and short chains of cocci
four long. contained staphylococcus albus and aureus, also a few suggestive of pseudo-diplitlieria bacilli. Sample 3 contained staphylococcus albus and aureus and motile bacteria. Sample 4 contained staphylococcus albus and aureus, short chains of cocci-large actively motile rods, and pseudo diphtheria-like bacilli. Sample 5 contained staphylococcus albus-a leptothrix-long chains of streptococci. Sample 6 contained no staphylococci but motile bacteria in chains. Sample 7 contained staphylococcus albus and aureus-short chains of cocci. Sample 8 contained streptococci in abundance and a staphylococcus not more than
Sample 2
bacilli
albus.
The streptococci in samples 5 and 8 were isolated in Drigalski’s plates and obtained in pure culture. They were then grown in milk. The culture was injected into a mouse which died on the second day, but the streptococcus was not recovered from the blood. Samples 5 and 8 were both
obtained from the same manufacturer. I was fortunate enough to be able to compare these results with those obtained by subjecting three tubes of Local Government Board lymph to a similar method of examination. Without going into details the lymph supplied by the Board was uniformly freer from organisms, gelatin plates only giving one or two colonies of staphylococcus albus and citreus and no other organisms. On the other hand, none of the tubes were sterile. These results then go to show that commercial glycerinated calf lymph is not so carefully prepared as that issued by the Local Government Board, that many of the samples contain the organisms of suppuration, and that at least one sample contains very definite streptococci. The Local Government Board lymph is practically as sterile as an article of that character which is subject to manipulation can be, the few organisms it contains being probably due to air contamination in filling the tubes, &c. Some of the purchased samples suggest the absence of glycerine. In such circumstances, then, it is too much for the practising physician to look to the Government to help him in a matter of this kind. Large sums of public money are spent yearly in supplying the public vaccinator with pure calf lymph, yet the same is denied to the practitioner. Surely he might be allowed to purchase his lymph from the Government and thus obtain with it a guarantee of its purity and source. There should be no difficulty about such an arrangement. Most firms that send out lymph send it out in numbered batches, so that in the case of untoward results the source can be traced and the results of other tubes from the same batch compared. This is also done by the Local Government Board. The machinery is already at work. it onlv reauires a little extension.
PULMONARY REGURGITATION DUE TO VEGETATIVE ENDOCARDITIS CONSEQUENT UPON RUPTURE OF ANEURYSM OF HEART. BY THOMAS
OLIVER, M.A. DURH , M.D. GLASG., F.R.C.P. LOND., LL. D.,
PROFESSOR OF PHYSIOLOGY AT THE COLLEGE OF MEDICINE, AND PHYSICIAN TO THE ROYAL VICTORIA INFIRMARY, NEWCASTLEUPON-TYNE.
APART from
congenital
malformation and intra-uterine
disease, pulmonary regurgitation is an event of such infrequency as to deserve notice, especially when in addition to being diagnosed during life its existence is confirmed by
examination after death. The cardiac lesion about to be described is so unusual that I offer no apology in craving for it a place in the pages of this journal. The patient, a labourer, was a married man, aged 37 years He was admitted into the Royal Victoria Infirmary, Newcastle-uponTyne, on Nov. 3rd, 1906, suffermg from dropsy of the feet and legs, pain in the cnest. and slight difficulty of breathing. In 1889 he tell from a 8caffold and injured his left chest. A few of his ribs were broken. Shortly after the accident he spat up blood. There was no history of rheumatism. The patient stated that be had had pain over the region of the heart for the last six years, accompanied by shortness of breath on exertion. Within the last few months he had had