VACCINATION struction of tissue in cither case may be very extensive, going "down to the bone " and having as much as an inch or more of super ficial area. Healing is frequently an affair of weeks, and may be aided by mercurial treatment. There are no statistics of this sequel of vaccination ; but the frequency or infrequency of it may be learned in conversation with any intelligent chemist whose shop is resorted to by the poor, or with a medical practitioner of average experience. Vaccinal (5) It has been proved by many experiments, undesigned or syphilis, otherwise, in Paris (1831 and 1839), Vienna (1854), and elsewhere, that an infant with congenital syphilis develops correct vaccinal vesicles, provided its skin be clear of eruption and the lymph have been taken at the usual time ; also that the lymph taken from the correct vesicles of a syphilitic child produces correct vesicles in its turn, but does not produce syphilis in the vaccinated child. The congenital taint is, in fact, irrelevant to the course of cowpox in fection. So far as experiment and casual experience can prove anything, that has been proved ; the recent attempt to disprove it by an officer of the Local Government Board (Report for 1882, p. 46) is vitiated by fallacies, and has no value against the over whelming testimony collected thirty or forty years ago. What, then, is the meaning of the numerous outbreaks of syphilis in groups of children or adults vaccinated or re-vaccinated with lymph from one source ? A careful examination of these cases shows that syphilis at the source of the vaccine matter was in all cases an after-thought, that in most of the cases there was no evidence for it, and that in the remaining cases the evidence was so far-fetched as to be unlikely (apart from the known a priori improbability), or that the traces of constitutional infection found in the vaccinifer were subsequent to vaccination, and therefore capable of being explained as an effect concurrent with the more obvious symptoms in those vaccinated therefrom. The effects, however, were very much the same as in the venereal pox. The vaccine vesicle either became an indurated or phagedenic sore, as described in the foregoing section on vaccinal ulcers, or the scar opened into an indurated sore after the usual sub- crustaceous healing was complete, or became indurated without opening. The axillary and cervical glands were often indurated. In most of the epidemics there were a certain number of cases in which the effects were purely local, or confined to one only of the seats of puncture ; if these had not occurred along with others in a group, they would have been counted as ordinary vaccinal ulcers. But there were often secondary symptoms as well, including the roseolar, lichenous, or (rarely) pemphigoid eruption, and not unfrequently condylomata circa anum ct genitalia. In some epidemics (but not in all) there were, in a small minority of the cases, mucous patches on the tonsils, tongue, or lips, tending to ulcerate ; and in some of the Italian outbreaks the infection spread among the mothers and other members of the households in the form of specific sores of the nipples, with or without constitutional symptoms. Affections of the bones and viscera do not seem to have followed ; fatalities were not very common. It will be hard to persuade medical authorities that these second ary effects are not the result exclusively of the venereal pox. The evidence, however, does not allow ns to assume any other specific infection than that of cowpox, which, as we know, has its proper secondary exanthem in the form of macular roseola, lichen, or pemphigus ; the eruption has even been known to affect the mouth and throat. The evidence from epidemics of vaccinal sore arms teaches us that condylomata, mucous patches of the tonsils, tongue, and lips, and even iritis, are also possible, although far from in variable, among the "secondaries" of the primary vaccinal ulcer. The most general fact that comes out in these epidemics is that the lymph was taken late from the vaccinifer, or that the vesicles of the vaccinifer were drained dry to vaccinate a large number, or that the same vaccinifer was used for arm-to-arm inoculation on two successive days. It is not difficult to see how, in those cir cumstances, the abbreviated cycle of humanized cowpox may be departed from and the native or untamed characters of cowpox infection reverted to. Cowpox, indeed, is parallel with the venereal pox, both in the circumstances of its becoming an infective ulcera- tion (indurated or suppurating) and in its secondary or constitu tional manifestations as an infection in man. But the "bad" lymph has hardly ever been used beyond the second remove ; and there the parallel fails. The following is a list of the so-called syphilitic epidemics after vaccination, including those that have been considered spurious, because they were either anomalous in type from the point of view of syphilitic infection or had no obvious causal connexion with that disease. Depaul, loc. cit.). Dispon near Pesth, 1855-57 (Oester. Zeitschr. fiir praM, Heilk., 1802; Bohn, loc. cit., p. 322). Rivalta (Piedmont), 1861 (Pacchiotti, Sifilide Trasmessa per Mezzo delta Vaccinazione in Rivalta presso Acqui, Turin, 1802). Torre cle Bus: near Bergamo, 1862 (see Depaul, loc. cit.). United States (troops on both sides in the Civil War), 1861-65 (Jones, Circular II., Louisiana Board Of Health, Baton Rouge, 1884). Argenta near Ferrara, 1S66 (Gamberini in <;a* dee Hi ipitaux, 1870, p. 505). Morbihan (neighbourhood of Vannes and Aurav) 1866 (Degaul, Bull, de I Acad. de Med., xxxii., 1806-67, p. 201- Bodt-lio ibid p. 1033). Cardaillac (Lot), 1866 (Bull, de I Acad, de Med., 28th February 1807)! Schleinitz (Styria), 1870 (Kochevar, Allgem. Wiener Med. Ztg., 1870, Xos 21 and 24 ; abstract in Arch, fur Dermatologie imd Syph., 1870). London (two series) 1871 (Hutchinson, Med. Chir. Trams., liv., 1871). Switzerland, 1878 (Bull de la Soc. de la Suisse Romande). Algiers, 1880-81 (Journ. d Hygiene, 25th August 1881) Lyck (East Prussia), June 1878 (Pincus, Viertdjhschr. f. gericht Med 187!> p 193). Asprieres (Aveyron), March 1885 (P. Brouardel, Rapport, Paris, 1880). Attention was drawn to these cases because they occurred in groups varying in number from 10 to 100 or more, which made considerable stir, especially in country districts. It is unlikely that all cases have been reported. In the third Report of the clinical hospital of Manchester, Whitehead states the results of his inquiries on post-vaccinal illness in children. Setting aside most of the cases of illness vaguely alleged by the mothers to have been the con sequence of vaccination, he admits as truly post-vaccinal 34 cases of syphilis or pseudo-syphilis ; of tl ese he enumerates only 14 in his table of 63 cases of children s syphilis of all kinds, the other 20 cases being omitted, it would appear, not because there was any doubt of their being post-vaccinal, but because they were not of the perfect type of infantine syphilis. Such was the experience of a competent observer at a single hospital during a period of 20 months. White- head s Report was published in 1859 ; but, when Hutchinson pub lished his first series of London cases in 1871, the subject was con sidered to be quite new. Here again it was the concurrence of some ten cases in a group that helped the reluctant assent of the profession. The first group of London cases had hardly begun to be talked of when one of Hutchinson s colleagues was led by two cases of skin disease at a hospital to follow up the traces of another group, the very existence of which was unsuspected by the public vaccinator or general practitioners in whose district the eleven patients with vaccinal ulcers and occasional secondaries resided. In the registrar-general s tables of mortality for England and Wales about one-half of the deaths from "cowpox and other effects of vaccination," or nearly thirty per annum, may be put down to effects of vaccination other than erysipelas ; but there is nothing to show that these were fatal cases of vaccinal ulcers with constitu tional symptoms or marasmus. On the other hand, the table of deaths from syphilis shows an enormous and steady increase in the number of deaths of infants under the age of one. In the first year of compulsory vaccination (1854) the deaths suddenly increased by one-half, and the increase has gone on steadily since then (see Table II.) The interpretation of the fact is by no means easy or free Infantine Death- Rate from Syphilis (England and Wales). Infants under One Year. All Other Ages. Infants under One Year. All Other Ages. 1847 255 310 1808 1364 522 1 1852 380 243 1869 1361 498 11853 380 242 1870 1422 436 11854 591 373 1871 1317 425 1855 579 368 1872 1410 421 1856 579 300 1873 1376 467 1857 656 301 1874 1484 513 1858 684 322 1875 1554 580 1859 778 311 1876 1580 554 1800 707 300 1877 1550 524 1861 798 379 1878 1647 535 1862 867 378 1879 1493 536 1863 983 403 1880 1588 571 1864 10S9 401 1881 1540 557 1865 1155 492 1882 1666 561 1806 1180 482 1883 1813 500 1867 1241 457 1884 1733 547 from fallacies. There are doubtless other- and better reasons for the increase besides vaccination ; and it is significant that the tables for Scotland show the mortality to be chiefly in the first three months of life, whereas the statutory limit for vaccination in that country is six months. In the polemical writings of anti-vaccinists, such diseases Other as scrofula, tubercle, hooping-cough, diarrhoea, and other alleged common causes of infantine mortality are alleged to have increased owing to vaccination. There is little or no ti on _ reason, in theory or in experience, to suspect that tuber culous or scrofulous infection is ever communicated by vaccine lymph. As regards the above and other infantine maladies, vaccination may predispose the child to fall into them, in so far as it produces, or ought in theory to pro duce, a considerable constitutional disturbance and pre sumably a loss, for a brief period, of the natural power to 1 The proportion assigned to the first year of life is calculated from the specimen table for 1852 (females only) and from the tables of
London mortality.