26 VACCINATION teenth day, and often became an ulcer, either excavated under the crust or absolutely open. Estlin did not entirely get rid of ulceration until after the twenty-ninth remove from the cow. The constitutional disturbance was often severe in infants : axillary tenderness and swelling were somewhat constant, and eruptions were especially frequent about the second to the fourth week, including macular roseola, lichen, and pemphigoid bullae. At each successive remove from the cow the cycle of the process became more contracted, and the constitutional disturbance, cseteris pari- bus, became less. Bousquet gives a plate which shows by parallel series of figures the differences between the vesicles of the old lymph (Woodville s, nearly forty years old) and the lymph from the Passy cow. The new lymph induced a process more protracted at every stage : the vesicle con tinued to enlarge at the periphery for several days after the common vaccine vesicle of the period would have ceased to extend. It was not at its maximum until about the end of the second week, and it then became an eschar and a sore. Bousquet confesses that he first understood " les frayeurs de Jenner " when he saw the ulcerative and other effects of primary lymph. After a certain number of removes from the cow the cycle became so contracted that the vesicle was full at the eighth or ninth day ; the abbreviation of its life-history enabled it to heal without ulcerating. It thus becomes the ordinary vaccine vesicle a.s we know it, which heals under a scab, and leaves the peculiar punctated scar of subcrustaceous repair. The abbreviation or mitigation is effected by taking lymph from each successive vaccinifer at as early a period as it can be got, until the golden mean of safe vaccination, namely, maturity at the eighth day, is reached. That corresponds to Jenner s rule of taking the matter for vacci nation before the areola appears ; if the vesicle be emptied after that period, the lymph from it is apt to cause ulcera tion, or, as Ceely puts it, we have " all the inconveniences of primary lymph." It is thus clear that humanized cow- pox might be easily cultivated back to its original type ; and, as a matter of fact, it has sometimes been so culti vated back by misadventure, with serious consequences to the vaccinated. The risks of vaccination may be divided into the risks inherent in the cowpox infection and the risks contingent to the puncture of the skin. Of the latter nothing special requires to be said ; the former will be discussed under the five heads of (1) erysipelas, (2) jaundice, (3) skin eruptions, (4) vaccinal ulcers, and (5) so-called vaccinal syphilis. (1) A slight degree of erysipelas was recognized by Jenner him self, and even postulated by him, as part of the natural history of cowpox in man ; and it is so recognized by the more unbiased writers of recent date. 1 The usual time for it corresponds to the appearance of the areola (eighth or ninth day), that efflorescence round the pock being normally a slight erysipelas. It may start, however, from the puncture or scratch in the skin, after a day or two s interval ; but that form of it (the "early erysipelas" of German writers) is much rarer than the erysipelas of the areola, or "late erysipelas." Primary lymph, or lymph in the first removes, is most apt to excite an extensive and spreading areolar redness. In the ordinary course of vaccination remote from the cow the intensity of the superficial redness and deep infiltration would seem to de pend mostly on the child s constitution, or on whatever concurrence of circumstances serves to recall the "inconveniences of primary lymph." The registrar-general s tables of mortality for England and Wales have contained an entry of " erysipelas after vaccina tion" from 1855 down to 1881, when the entry was changed to "cowpox and other effects of vaccination," the numbers at the same time nearly doubling. The fatal cases of erysipelas in infants under one year referred to vaccination are but a small fraction of the whole mortality from erysipelas at that age, a mortality which is far greater than at any other period of life. It is quite certain that in foiindling hospitals, such as that of St Petersburg, the erysipelas of vaccination has been the starting-point of disastrous epidemics of erysipelas affecting the inmates generally. There is 1 Bolin, Handbiich der Vaccination, Leipsic, 1875, p. 174. no means of knowing whether the same has been the case among the population at large. In Table I. the column of deaths from erysipelas in general, among infants of the first year in England and Wales, is given side by side with the column of deaths from Erysipelas after Vacci nation. Erysipelas. Erysipelas after Vacci nation. Erysipelas. 1855
583 1870 20 685 1856 5 610 1871 22 710 1857
421 1872 16 617 1858
599 1873 19 675 1859 5 569 1874 27 807 1860 2 514 1875 36 796 1861 2 492 1876 21 700 1862 3 458 1877 20 667 1863 7 612 1878 35 582 1864 11 618 1879 31 561 1865 10 579 1880 32 618 1866 9 527 1881 562 644 1867 3 467 1882 652 696 1868 8 647 1883 512 641 1869 19 589 1884 492 618 erysipelas after vaccination. The post-vaccinal inflammation some times takes the form of phlegmon ; but there is no separate entry for that as a special sequel of vaccination. Many of the alleged deaths from erysipelas after vaccination have been the subject of coroner s inquests ; the verdict is often an open one, and even such cases as those near Gainsborough in 1876 and at Norwich in 1882 were found to have been returned (all but one) by the certifying medical practitioners as due to erysipelas merely. It may be assumed that "after vaccination" is not certified unless the case has left no doubt in the minds of the jury or of the certifying medical attendant. The increase in the first column from in 1855 to 32 in 1880 is probably in appearance only, and due to more correct diagnosis. (2) It is only within the last few years that jaundice has been Jaundice, recognized as a post-vaccinal effect ; and at present there is only one accepted instance of it on the large scale. This was the epi demic among re-vaccinated adults in a large shipyard at Bremen from October 1883 to April 1884. Owing to an alarm of smallpox, 1289 workmen were re-vaccinated between the 13th August and 1st September with the same humanized lymph preserved in glycerin ; of these 191 had jaundice at various intervals down to the month of April following. Circumstantial evidence (agreement and difference) clearly traced the epidemic to the vaccination. 3 In future an outlook will be kept for this effect of vaccination ; at present it has no intelligible theory. It may be noted that the lymph which caused the Bremen epidemic was mixed with glycerin. (3) The eruptions that follow vaccination are proper to cowpox Skin infection. Although little is said about them in the accidental erup- infection of milkers, they were very common in the practice oftious. Estlin, Ceely, and others with primary lymph. The eruption is a kind of exanthem, or " secondary " of the local infection, and does not ordinarily appear before the second week. One of its com monest forms is a patchy rose-rash, or macular roseola, not easily distinguishable from the macular roseola of syphilis. 4 Another form is lichen or dry papules, apt to scale ; it may also occur as a vesicular eruption, and in the form of pemphigoid bullse or blebs. In one of Ceely s cases the eruption extended to the whole mucous membrane of the mouth and throat. A peculiarity of the exanthem is that it may come and go several times before it finally disap pears ; and, like other skin eruptions, specific or non-specific, it may become inveterate. The widespread belief that much of the eczema of childhood dates from vaccination is not by any means to be dismissed as a mere fancy. The skin-disorders that followed vaccination in the first years of the practice were declared by Birch and others to be new in type. At present the vaccinal eruption, especially on the scalp, is sometimes distinguished by the size and form of the crusts, and by scars remaining for a time. (4) Ulceration of the vaccine vesicle, or of the site of it, is one Vaccinal of the commoner forms of "bad arm." It is a return to the native ulcers. or untamed characters of cowpox on the cow s teats, or on the milker s hands or face, or in the child s arm after experimental inoculation with primary lymph. It crops out not unfrequently in everyday practice, and is probably dependent for the most part on the lateness at which the lymph was taken for vaccination, or on retardation of the process in the vaccinifer, or on emptying the latter s vesicles too much ; however, it may result from picking the scab or otherwise dislodging it. The ulceration usually proceeds to some depth in the form of a crater under the crust, and is attended with induration and rounding of the edges and induration of the base. According to Bohn (op. cit., p. 166), it may alarm practitioners by its resemblance to syphilis. In other cases the crust is wanting and the ulceration has the distinct type of phagederia. The de- 2 Cowpox and other effects of vaccination. 3 See Ltirman, Berl. klin. Wochenschrift, 1885, p. 20.
4 Parrot, La Syphilis Hereditaire, 1886, p. 33.