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 A HANDBOOK 
 
 VACCINATION. 
 
 EDWARD C. ^SEATON, M.D., 
 
 MEDICAL INSPECTOR TO THE PRIVY CODKCIL. 
 
 PHILADELPHIA: 
 
 J. B. LIPPINCOTT & 00. 
 
 1868. 
 
 pfl 
 
 [\
 
 PREFACE. 
 
 In planning this book I had two purposes mainly in 
 view — intimately associated with each other. 
 
 The first of these was to provide a text-book on 
 the science and practice of Vaccination for the use of 
 my younger professional brethren, and of medical stu- 
 dents. 
 
 In the constant intercourse which, from the nature 
 of my office, I have for many years past had in refer- 
 ence to this subject with medical friends who are 
 interested in it, and of course especially with that 
 large part of the profession who are engaged as Pub- 
 lic Yaccinators, I have been repeatedly asked for advice 
 on various points connected with the practice and use 
 of Vaccination, and have many times heard the wish 
 expressed that there existed some book in which the 
 whole subject could be found fully treated. 
 
 It is a curious fact that since the publication, in 
 1809, of the enlarged edition of Bryce's "Practical 
 
 (Hi)
 
 iv PREFACE, 
 
 Observations on the Inoculation of the Cow-pox," 
 there has been no separate work published in the 
 United Kingdom which treats completely of Vaccina- 
 tion. To the different branches of the subject contri- 
 butions of the utmost value have been made — to the 
 natural history of Cow-pox, to its affinities with dis- 
 eases in other animals and with Small-pox in man, to 
 the practice of Vaccination, to the determination of the 
 hygienic value of that practice and the circumstances 
 by which this is affected : but no book giving a full but 
 concise view of the whole subject. And although, of 
 course, a general view of Vaccination has been pre- 
 sented in systematic works on medicine, in medical 
 dictionaries, cyclopaedias, etc., it was impossible that 
 so large a subject could be considered with the re- 
 quisite fullness in the necessarily limited space that 
 in such works could be allotted to it. 
 
 I was moreover particularly induced to attempt this 
 work from noticing that by many practitioners the 
 operation of Vaccination was not, as it appeared to 
 me, regarded at its real value. Seemingly so simple 
 in itself, many of the niceties and cautions which so 
 greatly influence success, and the value of which is so 
 well known to the practiced vaccinator, have been
 
 PREFACE. v 
 
 unheeded in general practice, and I could not but deem 
 it of very great importance that attention should be 
 called, or recalled, to them. I had this object espe- 
 cially in view in the practical section of an article on 
 Vaccination which I contributed to Reynolds's " Sys- 
 tem of Medicine:" and in the larger treatment of this 
 part of the subject in the present work, I have taken 
 great pains in the same direction. 
 
 My other purpose had reference to such assistance 
 as I thought I might be able to give to those engaged 
 in the administration of the system of Public Vaccina- 
 tion established in England. In this part of the book 
 I have had to treat of matters partly professional, and 
 partly administrative. The administrative sections of 
 the work might at first sight appear to concern only a 
 portion — itself, however, not an inconsiderable portion 
 — of the medical practitioners of the kingdom, yet it is 
 clear that the principles on which a public system of 
 Vaccination should be based are of interest and import- 
 ance to the whole profession. There are, besides, very 
 many others than professional men to whom a right 
 understanding of these principles is indispensable, and 
 notably to the Guardians of Unions on whom it de-
 
 vi PREFACE. 
 
 volves to make the local arrangements. It is always 
 a difficult matter to present a technical subject so as to 
 make it thoroughly intelligible to those who have had 
 no professional training; but the principles are broad 
 principles, and I trust I may have explained them 
 with sufficient clearness. 
 
 Each division of the United Kingdom has its own 
 Vaccination law. It is the system in use in England 
 to which this book refers : but England in legal phrase- 
 ology includes always the principality of Wales, and 
 throughout the book, whenever I have mentioned 
 "England," I must be taken to have said "England 
 and Wales."
 
 CONTENTS. 
 
 CHAPTEK I. 
 
 nun 
 
 Of the Natural Cow-pox 9 
 
 CHAPTER II. 
 Of the Horse-pox 33 
 
 CHAPTER III. 
 
 Of Pocks in other Animals which have been considered 
 analogous to Cow-pox and Horse-pox ... 44 
 
 CHAPTER IV. 
 
 Of the Relation of Cow-pox and Horse-pox to Human 
 Variola 56 
 
 CHAPTER V. 
 
 Of Vaccinia, or Cow-pox, in the Human Subject . . 80 
 
 CHAPTER VI. 
 Of Vaccinating 115 
 
 CHAPTER VII. 
 
 Of Arrangements for the Performance of Vaccination 
 and the Maintenance of Lymph-supply . . . 140 
 
 (vii)
 
 viii CONTENTS. 
 
 CHAPTEE VIII. 
 
 PAGE 
 
 Of the Conveyance and Storage of Lymph . . .158 
 
 CHAPTEE IX. 
 
 Of Skill and Success in Vaccinating, and of Insuscepti- 
 bility to Vaccination 179 
 
 CHAPTEE X. 
 
 Of alleged Degeneration of Lymph, and of Eecurrence 
 to the Cow 199 
 
 CHAPTEE XI. 
 
 Of the Protection which Vaccination affords against 
 Small-pox 211 
 
 CHAPTEE XII. 
 Of Eevaccination 299 
 
 CHAPTEE XIII. 
 
 Of Stamping-out Local Outbreaks of Small-pox . . 314 
 
 CHAPTEE XIV. 
 
 Of the Objections to Vaccination, and the alleged Dan- 
 gers of the Practice , . . 328
 
 Handbook of Vaccination. 
 
 CHAPTER I. 
 
 OF THE NATURAL COW-POX. 
 
 1. Cow-pox in the Cow. — Vaccinia, or the Cow- 
 pox — the Variolae Vaccinae of Jenner — is never met 
 with in the human subject but as the result of inocula- 
 tion. It is only in the cow and in the horse that we 
 have any certain or definite knowledge of it as a natural 
 disease, though it probably does occur as such in some 
 other animals. 
 
 2. General Description. — The natural history of 
 Vaccinia in the cow has been studied more or less by 
 various observers, but by none so accurately or so 
 comprehensively as by our distinguished countryman, 
 Robert Ceely; and it is his account of the disease 
 which I shall chiefly follow. It is a specific eruptive 
 disease, of the vesicular order, the eruption not being 
 general over the body, but limited (except as the result 
 of accidental or casual inoculation) to the udder and 
 teats. It is met with from time to time, either sporad- 
 ically, or (less commonly) as an epizootic. It particu- 
 larly attacks milch cows: indeed, as a spontaneous 
 
 2 (9)
 
 10 HANDBOOK OF VACCINATION. 
 
 disease, it occurs almost if not quite exclusively when 
 the animal is in that condition.* Young cows and 
 milch heifers appear to be more subject to it than 
 older cows. In its earliest stages it is attended with 
 so little general or obvious local disturbance that, in 
 the animals first attacked in a dairy, these stages sel- 
 dom come under skilled observation ; and as the fluid 
 of the vesicles is very infective, and the disease is thus 
 readily conveyed from animal to animal by the milkers, 
 it is difficult to distinguish, in animals subsequently 
 attacked, between those exhibiting the natural disease 
 and those who have been infected casually by inocula- 
 tion. The distinction, indeed, is not of any practical 
 moment : the course of the affection is in either case 
 essentially the same, and such difference as is believed 
 to exist has reference only to the duration, longer or 
 shorter by a day or so, of certain stages in the one 
 
 * " It is considered that the disease is peculiar to the milch 
 cow — that it occurs primarily while the animal is in that con- 
 dition — and that it is casually propagated to others hy the 
 hands of the milkers. But considering the general mildness 
 of the disease, the fact of its being at times in some individ- 
 uals entirely overlooked, and that its topical severity depends 
 almost wholly on the rude traetions of the milkers, it would 
 perhaps be going too far to assert its invariable and exclusive 
 origin under the circumstances just mentioned ; yet I have 
 frequently witnessed the fact that sturks, dry heifers, dry 
 cows, and milch cows milked by other hands, grazing in tRe 
 same pastures, feeding in the same sheds and in contiguous 
 stalls, remain exempt from the disease." (Ceely, in Trans. 
 Provincial Medical and Surgical Assoc, vol. viii. p. 299.) 
 Ceely subsequently saw what appeared to be a case of primary 
 infection in a sturk. (See Trans. Prov. Med. and Surg. 
 Assoc, vol. x. p. 223.)
 
 OF THE NATURAL COW-POX. \\ 
 
 case than in the other. These differences, so far as 
 they have been ascertained, will be pointed out in the 
 following description, which, otherwise, may be taken 
 to represent both the natural disease and the disease 
 as conveyed by casual inoculation. 
 
 3. Course of Local Phenomena. — There is first a 
 period of incubation ; but, from the extreme slightness 
 of the earliest symptoms, it is very difficult to say how 
 soon after infection has been received these may mani- 
 fest themselves. In the natural disease the incubative 
 period is probably three or four days, though Ceely 
 thinks there is reason to believe it may in some cases 
 be prolonged to from five to eight days. The earliest 
 symptoms noted are heat, swelling, and tenderness of 
 the udder, soon followed by irregularity of surface, and 
 development of hard papules about the size of a vetch 
 or pea, especially on that part of the udder which ad- 
 joins the bases of the teats, and on the bases of the 
 teats themselves. There is not generally, at this stage, 
 any loss of appetite, manifestation of fever, or other 
 sign of constitutional disturbance. In the casual dis- 
 ease, or that which arises from infection by the unin- 
 tentional inoculations of the milkers, it is very rare for 
 any indications of contagion to manifest themselves till 
 the sixth or seventh, sometimes they do not appear till 
 the eighth or ninth, day after undoubted exposure ; but 
 in thin-skinned animals, with cracks and chaps in the 
 teats, small red tender papules may often be found by 
 vigilant observation as early as the fifth day. The 
 papules increase in size as the disease goes on, and in 
 three or four days from their first appearance many of 
 them will be found to have acquired a distinct vesicular 
 character, with more or less of central depression.
 
 12 HANDBOOK OF VACCINATION. 
 
 The first change from papule to vesicle is indicated by 
 the appearance of a dull or dusky yellowish point at 
 the apex of the pimple ; the circumference then increases 
 in substance and extent, and the center becomes wider 
 and deeper, till at last the flattened vesicle with de- 
 pressed center is formed. As with the papules, so 
 with the vesicles, there is gradual increase of size, un- 
 til in three or four days more their full development is 
 attained. The number, size, shape, and color of the 
 vesicles differ much in different animals, as well as in 
 different parts of the same animal. There may be only 
 one or two of them, but much more frequently there 
 are ten, twenty, or more :* they are most common on 
 the base, neck, and body of the teats, often exist on the 
 udder, occasionally at the apex of the teats. Their size 
 varies from that of a large pin's headf to that of a six- 
 pence, or bigger, but is most ordinarily that of a vetch, 
 pea, or horse-bean ; in general, the more numerous the 
 vesicles are the smaller they are. Their shape is de- 
 termined chiefly by their position : around the base and 
 
 * The amount of eruption, and consequently the severity of 
 the disease, depends greatly on the state of the teats and 
 udder. With a short, compact, hairy udder, and thick, 
 smooth, tense, unchapped or scarcely cracked teats, the affec- 
 tion is often very mild, and sometimes there is only a single 
 vesicle. An animal with a voluminous, flabby, naked, pendu- 
 lous udder, and loose long teats, the skin of which is thin, fis- 
 sured, rough, and unequal, scarcely ever escapes a copious 
 eruption. (Ceely, Transact, etc., vol. viii. p. 303.) 
 
 f These very small vesicles are no doubt of later origin 
 than the others, the results of accidental auto-inoculation from 
 pressure when the animal lies down, or of inoculations by the 
 milkers.
 
 OF THE NATURAL COW-POX. 13 
 
 neck of the teats, they are almost invariably circular ; on 
 the body of the teats, generally oval; but oval vesicles 
 may be seen also on the udder, and the vesicles on the 
 teats are often interfluent. The color of the vesicles varies 
 according to the period of their progress, and according 
 to the color and texture of the animal's skin ; but they 
 have always a metallic glistening aspect. By the time 
 that the vesicle is completely formed, it is frequently 
 seven or eight lines wide ; has a solid, uniform, tense, 
 and shining margin, a glistening white, pinky, or sil- 
 very hue, and a bluish or slate-colored center ; it con- 
 tains a clear viscid lymph, which, however, is even at 
 this period generally in small quantity and often diffi- 
 cult to obtain ; and around its base there is a narrow, 
 pale rose, or light-damask areola, not more than a line 
 or two wide, and sometimes scarcely so much, though 
 subsequently extending, with circumscribed induration 
 of the adjacent skin and subjacent connective tissue. 
 The color of the areola, like that of the vesicles, is 
 greatly influenced by the hue and texture of the skin ; 
 and in some skins — as in dark, thick ones — the areola 
 is scarcely to be seen, or is entirely absent; but the 
 induration is always palpable. Between the tenth and 
 eleventh days the disease has generally reached its 
 acme ; the areola has extended, though seldom to more 
 than a width of from four to five lines, and there is 
 deep induration of the underlying integument. The 
 vesicles, such as have not been broken, are at their 
 fullest development; lymph, which two days before 
 was hard to get from them, is now so copious that it 
 raises the cuticle, destroying the central depression and 
 forming a globular or conoidal vesicle, or it bursts the 
 2*
 
 14 HANDBOOK OF VACCINATION. 
 
 cuticle and flows freely out;* it has already acquired, 
 or soon acquires, a pale straw-colored or light amber 
 hue, and speedily becomes more serous, turbid, and 
 opaque. While this is taking place in some vesicles, 
 in others the process of incrustation will already have 
 begun at the center, and in others it may even have 
 extended to the circumference. f On and after the 
 twelfth day, nearly all is passive ; the incrustation- 
 process continues steadily to advance, and by the thir- 
 teenth or fourteenth day the crusts have usually ac- 
 quired their greatest magnitude, are of a brownish- 
 black color, adhering more or less tenaciously to the 
 epidermis or skin beneath, the marginal induration and 
 intumescence at the same time subsiding. The crusts 
 
 * This acumination of the vesicle, however, is not uniform 
 either as to its presence or as to its time of appearance. It 
 may take place at an earlier or later period, or it may not 
 occur at all. 
 
 f Unequivocal cases of the natural disease — the first cases 
 in a dairy — seldom or never come under the notice of any one 
 competent to judge of the nature of the ailment, until it has 
 arrived at this stage, when almost invariably considerable 
 disturbance of the vesicles has taken place from traction in 
 milking. Many broken vesications will then be found, having 
 evidently a central depression with marginal induration ; if 
 any be found unbroken, they will be usually acuminated, and 
 full of amber-colored fluid more or less viscid, but on being 
 punctured will collapse, and at once indicate the same kind of 
 central and marginal character. With these there will be 
 mingled smaller vesicles, evidently of later date, either acumi- 
 nated or depressed, and crusts circular or ovoid on the udder, 
 circular, oval, or irregular on the teats; the appearance of the 
 disease at different stages, or at least the formation of a few 
 vesicles at different periods, being very evident. (Ceely, 
 Transact, etc., vol. viii.p. 306.)
 
 OF THE NATURAL COW-POX. 15 
 
 after this go on drying and shrinking, and they fall off 
 usually from the twentieth to the twenty-third day, by 
 which time the induration has nearly, but seldom 
 wholly, disappeared. The cicatrices left after the fall- 
 ing of the crusts are shallow, smooth, oval or circular, 
 and of pale-rose, white, or whitish color, according to 
 the contrast of the surrounding pigment. The vesicles 
 on the. teats are attended generally with less areola 
 and less induration of circumference than those on the 
 udders, but in other respects, in so far as they are un- 
 disturbed and out of the way of the milkers, they ex- 
 hibit exactly the same phenomena and undergo pre- 
 cisely similar changes. 
 
 4. The Local Affection as disturbed by handling. — 
 Such is the course of the undisturbed eruption ; but 
 from the tractions of the milkers it seldom happens 
 that the vesicles, where they are most numerous, viz., 
 on the base, neck, and bodies of the teats, escape dis- 
 turbance. By the eighth or ninth day, when the un- 
 injured vesicles are the most perfect, injured ones will 
 be found exuding lymph from their centers, the cuticle 
 being loose or partially detached. Haw surfaces and 
 brown or black crusts will be intermingled, and here 
 and there will be seen a conoidal vesicle, often with 
 slightly depressed apex, distended with pellucid lymph. 
 Two or three days later, the appearances on the teats 
 will exhibit crusts large, black, and solid, often more 
 than an inch or two long, some firmly adherent to a 
 raw and elevated base, others partially detached from 
 a raw, red, and bleeding surface ; many florid red ulctr- 
 ated surfaces secreting pus and exuding blood ; the 
 teats excessively tender, hot, and swollen, not unfiv- 
 quently one or more forming a tumid mass of black
 
 16 HANDBOOK OF VACCINATION. 
 
 crusts and naked red sores, the discharge from which 
 imparts to the finger an odor very closely resembling 
 that of the last stage of smallpox. In some animals 
 this state will continue for a week or two, but in others 
 the process of healing will go regularly on, crusts 
 being continually formed and renewed, till at last they 
 fall off, and leave cicatrices generally regular, smooth, 
 circular or oval, but occasionally deep and irregular.* 
 5. Duration of the various stages of Cow-pox. — 
 Thus the normal course of the disease occupies from 
 twenty to twenty-three days, which may be divided 
 into four stages, viz.: " a," about four days of early 
 symptoms, during which papulation takes place ; " b," 
 six or seven days to the full development and perfect 
 maturation of the vesicle; "c," five or six of decline 
 of the vesicle and formation of the crusts; and " d," 
 five or six more from the completion of incrustation to 
 the spontaneous separation of the crusts. Stages "a" 
 and "b" are often materially abridged in the natural 
 disease ; while in the casual disease " a" is sometimes 
 prolonged, "b" being proportionally abridged, or "a" 
 is prolonged, "b" and all subsequent stages occupying 
 the normal duration. These variations, however, in 
 the early stages of the disease are often more supposed 
 than real, the earliest symptoms being so extremely 
 slight in many cases that they are overlookd. Both 
 in the natural and casual cow-pox, "c" is sometimes 
 prolonged, often abridged. The whole of the cow-pox 
 eruption is not by any means always simultaneously 
 developed. Papules, depressed vesicles, acuminated 
 or globular vesicles, and vesicles more or less desic- 
 
 * See Ceely, Transact, etc., vol. viii. pp. 308-312.
 
 OF THE NATURAL COW-POX. n 
 
 cated, varying in size from a pin's head to a diameter 
 of eight or ten lines, may be seen on the same subject 
 at the same time ; but all, whatever their date of ap- 
 pearance, terminating together. No doubt these ap- 
 parent anomalies are due either to self-vaccination of 
 the cow from pressure, as in the act of lying down, 
 or, still more frequently, to the manipulations of the 
 milkers. 
 
 6. Structure of the Cow-pox Vesicle. — If we examine 
 the anatomical structure of the cow-pox vesicle, when 
 completely formed, we find it to consist of a number of 
 cells, which appear to be arranged in two concentric 
 rows, and are separated from each other by whitish 
 radiating partitions united at their converging extremi- 
 ties by a central membranous band. In these cells is 
 secreted and contained a clear viscid lymph. " The 
 dusky central spot — which marked the first change of 
 the pimple into the vesicle, and which has now become 
 darker and more distinct — seems to be caused by a 
 greater or less degree of separation of the epidermis, 
 stretched over a crypt-like recess, which contains a 
 small quantity of semi-concrete lymph-like matter, oc- 
 casionally a turbid opaque fluid." This cellular con- 
 formation of the vesicle is essential and diagnostic. It 
 is by the bursting and breaking up of the cells and 
 their connecting band, as the lymph becomes more 
 abundant and less viscid, and by separation of the 
 epidermis from its attachment to the subjacent adven- 
 titious membranae, that the vesicle in its further pro- 
 gress loses its distinctive central depression, and ac- 
 quires the acuminate or conoidal form which has been 
 described.* 
 
 * See Ceely, Transact, etc., vol. viii. p. 317.
 
 18 HANDBOOK OF VACCINATION. 
 
 7. Constitutional Symptoms. — The local symptoms 
 of cow-pox in the cow are seldom accompanied by any 
 material constitutional disturbance ; in the great major- 
 ity of animals, feeding and grazing go on apparently 
 as usual. The secretion of milk is sometimes dimin- 
 ished ; and, in most instances, the amount artificially 
 obtained is greatly lessened from the trouble and diffi- 
 culty of milking. In some cases, the cow exhibits in 
 the course of vaccinia a peculiar vesicular eruption 
 very like vesicular varicella. It occurs generally about 
 the ninth or tenth day, commencing with erythemato- 
 papular elevations, which in twenty-four hours have 
 become vesicles full of pellucid serous fluid. Next day 
 this fluid is straw-colored, and it becomes speedily 
 turbid, the cuticle collapses or bursts, turns yellowish- 
 brown, and before the fifth day from their origin the 
 vesicles desiccate with brown or black, thin, flimsy 
 crusts, which soon fall off.* 
 
 8. Spurious Pocks, etc. — The description of cow- 
 pox above given will, it is trusted, enable the practi- 
 tioner always to recognize the natural disease in the 
 cow, when it is presented to his observation ; but the 
 cow is liable to other diseases, which more or less 
 resemble cow-pox, and from which it is important to 
 distinguish it — a distinction all the more necessary that 
 some of these diseases may, and in fact not uncom- 
 monly do, either coexist with it or immediately pre- 
 cede or follow it. Besides certain cutaneous, sub- 
 cutaneous, and follicular inflammations and suppura- 
 tions on the udders and teats, which are liable to affect 
 occasionally the hands of the milkers, warty growths 
 
 * See Ceely, Transact, etc., p. 329.
 
 OF THE NATURAL COW-POX. \% 
 
 and even warty vesicles (that can scarcely, however, 
 be confounded with vaccinia), and eczema, or other 
 superficial vesicular eruptions, Ceely particularly no- 
 tices three kinds of spurious pock : " Tlie Yellow 
 Pock, a pustular eruption resembling ecthyma on the 
 teats and udders, succeeded by thin, dirty-brown, or 
 black irregular crusts ; the Bluish or Black Pock, 
 bluish or black or livid vesications on the teats and 
 udders, followed by thin dirty-brown, or black irregular 
 crusts, and some degree of impetigo on the interstices, 
 near the bases of the teats ; and the White Pock, a 
 highly contagious disease among milch cows and to 
 the milkers, quickly causing vesications and deep ulcer- 
 ations, often or almost always confounded by them 
 with the true vaccine, and certainly not readily distin- 
 guishable in all its stages by better-informed persons 
 than milkers."* In 1838-9, Ceely saw a number of 
 animals in a shed, which had scarcely recovered from 
 the vaccine disease, affected with white-pock, in conse- 
 quence of the introduction from another shed of a cow 
 who was suffering with it ; and several of these animals 
 continued under its influence for two or three weeks, f 
 9. Diagnosis of true Cow-pox. — Although the care- 
 ful observer will find broad and palpable grounds of 
 distinction between vaccinia and white-pock, in the 
 character of the genuine vaccine eruption, its cellular 
 structure, its hard and knotty feel, its glistening aspect, 
 its tardy and progressive changes to the vesicular form, 
 its central depression and its late acumination, the 
 necessity for caution and accuracy of diagnosis must 
 be borne in mind. Jenner himself pointed out that 
 
 * See Ceely, Transact, etc., vol. viii. p. 297 t Ibid., p. 329.
 
 20 HANDBOOK OF VACCINATION. 
 
 milkers were very liable to contract infection from 
 spurious pocks, and to acquire in consequence false 
 and delusive ideas as to their having immunity from 
 small-pox ; and Ceely informs us that he has also, in 
 several instances, known milkers who undoubtedly had 
 made this mistake suffer afterward from small-pox, 
 while in other instances he has discovered the mistake 
 they had made in time to save the subjects of it from 
 small-pox, by performing successful vaccination in the 
 ordinary way. The white or blister-pock in the human 
 subject exhibits sometimes, in fact, an appearance ex- 
 ceedingly like that of real cow-pox, so that, as is the 
 case with the two diseases in the cow, some care may 
 be necessary to distinguish them. It is communicable 
 by inoculation from one human subject to another,* 
 and may be communicated repeatedly to the same 
 subject, f 
 
 * Mr. Ceely has been kind enough to show me drawings of 
 three cases of casual blister-pock on the hands of milkers, in 
 one of which the appearance of the vesicles singularly resem- 
 bles that of true vaccine, and he tells me that some attention 
 was needed for a correct discrimination. He has also shown 
 me a drawing exhibiting the progress of blister-pock on a man 
 experimentally inoculated with it from a milker. Complete 
 vesicles were formed, with some areola, by the second day ; the 
 vesicles and areola were fully developed by the third day, and 
 had then very considerable resemblance to cow-pox at its full 
 or eighth-day development ; by the fifth day desiccation had 
 taken place, and the areola was declining. 
 
 f Mr. Ceely informs me that he has experimentally inocu- 
 lated himself successfully three or four times with the virus of 
 white or blister-pock. Other diseases of the cow besides 
 white-pock may be contracted by milkers and communicated 
 from them to other human subjects. A case is related by
 
 OF THE NATURAL COW-POX. 21 
 
 10. Supposed Origin of Cow-pox from "Grease." — 
 Singularly enough, the cow-pox was not considered 
 by Jenner to be a natural disease of the cow at all, 
 but was regarded by him as invariably induced from 
 an analogous disease on the heels of the horse (the 
 horse-pox, see Chap. II.), which, however, at first he 
 confounded with the grease. It so happened that all 
 the cases of cow-pox — all the first-infected cases in 
 dairies — which had presented themselves to his obser- 
 vation, or concerning which he had been able to inform 
 himself, had been in animals milked by men who had 
 sores on their hands contracted from dressing the heels 
 of horses affected with this so-called "grease;" and that, 
 so far as he could learn, the cow-pox never appeared 
 in dairies in which women were exclusively employed 
 in milking. He found, too, that the sores contracted 
 by these men from horses were in appearance like the 
 sores induced in milkers by cow-pox, and that, when 
 the matter of them was inoculated on the human sub- 
 ject, it produced effects exactly analogous to those re- 
 sulting from the inoculation of the cow-pox. And he 
 concluded that the source of infection in the cow was 
 always "a peculiar morbid matter arising in the horse," 
 expressing himself as well convinced "that it (the cow- 
 pox) never appears among cows (except it can be 
 traced to a cow introduced among the general herd 
 which had been previously infected, or to an infected 
 servant) unless they have been milked by some one 
 
 Ceely in which a whole family (a wife and five children) 
 labored under & pustular disease of the character of ecthyma, 
 from infection by the father, who had himself caught the 
 disease from a cow, described as being in a terrible condition. 
 (Trans. Prov. Med. and Surg. Assoc., vol. x. p. 235.) 
 
 3
 
 22 HANDBOOK OF VACCINATION. 
 
 who, at the same time, has the care of a horse affected 
 with diseased heels."* Undoubtedly he was so far 
 right, that the cow-pox and the horse-pox have a com- 
 mon specific infection ; and it is equally unquestionable 
 that the disease in the cow must, in very many of the 
 instances in which it has been met with, have had the 
 origin which Jeriner pointed out ; but the disease (for 
 whether we call it cow-pox or horse-pox it is the same 
 disease) has also been met with in each of these classes 
 of animals independently of the other on so many occa- 
 sions, that we cannot deny it to be as much a natural 
 or spontaneous disease in the one class as it is in the 
 other, f 
 
 11. Geographical Distribution of Cow-pox, and cir- 
 cumstances affecting its appearance and spread. — 
 The cow-pox has been met with in every climate — all 
 over Europe, in Asia, in North and in South America. 
 
 * An Inquiry into the Causes and Effects of the Variolas 
 Vaccinae, p. 46. 
 
 f Pearson, in 1798, pointed out that the cow-pox had been 
 met with in farms where the milkers had nothing to do with 
 horses, where no horses had grease, and even where there were 
 no horses on the farm at all. Sacco found it in cows quite 
 isolated, who had been in no communication at all with 
 horses, sound or ill. Hering says that in Wirtemberg (where 
 cow-pox has been so frequently seen) the cows are (except in 
 very large dairies) exclusively milked by women, as the horses 
 are exclusively tended by men ; and in most cases where cow- 
 pox was found, there were no horses on the cow-farms. (Ueber 
 Kuhpocken an Kiihen, p. 9.) And Ceelysays: "For many 
 years the spontaneous origin of the Variola? Vaccina? in the 
 cow has not been doubted here. In all the cases that I have 
 noticed, I never could discover the probability of any other 
 source." (Trans. Prov. Med. and Surg. Assoc, vol. viii. p. 
 300.)
 
 OF THE NATURAL COW-POX. 23 
 
 Jenner found that the oldest farmers in Gloucestershire 
 had been familiar with it in their earliest days, and the 
 disease had not passed unnoticed on the continent of 
 Europe, though previous to his great discovery no par- 
 ticular interest attached to it. But soon after this in- 
 terest had been awakened by his publications, cow-pox 
 was found either actually existing, or to have been of 
 recent occurrence, in the dairies of London, in various 
 counties of England, in different parts of Germany, in 
 the plains of Lombardy, in Massachusetts, in Connec- 
 ticut, and in Peru. After the first ardor of search had 
 relaxed, there were for many years but few recorded 
 instances of the disease being found, and it was be- 
 lieved to have become much rarer; in great measure, 
 no doubt, because it was less sought for. Since 1824, 
 interest in the search having in the mean while been 
 renewed, numerous outbreaks — sporadic or epizootic — 
 have been reported; and, without by any means in- 
 dorsing the statements of Sacco and Hering as to the 
 extent to which, wherever there are large herds of 
 cows, diligent search may be expected to discover cow- 
 pox, there can be no doubt that much more would be 
 found than really is found, if it were only looked for. 
 Still the balance of evidence seems to be that, in England 
 at all events, the disease is not so common now as it 
 at one time was ; and there is one obvious reason, I 
 think, why this should be so. Undoubtedly, infected 
 milkers were great agents in conveying the disease 
 from herd to herd, from dairy to dairy; but milkers 
 nowadays, from having been vaccinated, are not them- 
 selves susceptible of the infection of cow-pox to the 
 extent that their predecessors were, and only occa- 
 sionally, in fact, contract the disease. Another reason
 
 24 HANDBOOK OF VACCINATION. 
 
 also, as will presently appear, may be the much less 
 diffusion now than formerly of the variolous poison. 
 But under any circumstances we must allow that the 
 cow-pox of the cow, like small-pox and other epidemics 
 in man, has its periods of prevalence and of compara- 
 tive absence. 
 
 In some localities cow-pox is noticed to recur again 
 and again, while in others we have no account of it 
 except as being occasionally seen. This does not ap- 
 pear to depend on any conditions that can be traced. 
 Soil and elevation have apparently no influence. In 
 the Yale of Aylesbury, where the disease has been 
 long known and recurs at irregular intervals, it is met 
 with as much on the hills as in the valley. It is found 
 frequently recurring in the broad pastures of the Bridge- 
 water level, and in the very vale in which Jenner's own 
 observations of it were first made — the Yale of Glou- 
 cester.* The period of the year in which it has been 
 most frequently noticed to manifest itself is the spring, 
 especially in the months of May and June. Of sixty- 
 nine discoveries of the disease made in eleven years in 
 Wirtemberg, no fewer than thirty-one were made in 
 one or other of these two months. The practitioners 
 who have noticed it in the Yale of Gloucester, etc., 
 state that it usually appears in April, May, or June. 
 Ceely has met with it at all periods of the year from 
 August to June, but rarely in the height of summer. 
 It may occur under any condition of feeding, though 
 Hering attributes much to the change from dry to 
 moist food, from stall-feeding to pasturage, which takes 
 
 * Sixth Keport of Medical Officer of the Privy Council, 
 p. 10.
 
 OF THE NATURAL COW-POX. 25 
 
 place in the spring-time. It very much more often 
 occurs sporadically or in solitary instances, than as an 
 epizootic ; but when the disease has found its way into 
 a dairy, it will often, unless precautions be taken, 
 rapidly spread, so that in ten or twelve days many 
 animals will be found to have been affected in succes- 
 sion ; and in a dairy of, say, twenty-five cows, few will 
 have escaped the disease by the end of the third week. 
 Although the hands of the milkers are generally the 
 great agents of this extension, where it occurs, by con- 
 veying the disease from animal to animal, there is 
 every reason to believe that the natural form of the 
 disease exhibits itself on more than one animal in differ- 
 ent parts of the same dairy. Animals differ from one 
 another in their degree of susceptibility to cow-pox, 
 and Ceely states that he never remembers to have seen 
 a dairy in which two or three cows, equally exposed 
 with the others to casual infection, had not escaped. 
 One attack of the disease is believed to confer, as a 
 rule, immunity from further attacks. 
 
 12. Artificial production of Cow-pox in the Cow. — 
 The vaccine disease may be designedly induced in the 
 cow by inoculation in various ways : (a) with lymph 
 taken direct from other cows suffering from the natural, 
 casual, or inoculated form of the disease ; (b) with the 
 lymph of the horse-pox — by equination; (c) with 
 lymph which, derived originally from cow or horse, 
 has passed through the human system and become for 
 a longer or shorter time humanized — by retro-vaccina- 
 tion; (d) with the matter of human variola — by vario- 
 lation. In all these forms of inoculation, however, the 
 production of vesicles is limited entirely, or almost ex- 
 
 3*
 
 26 HANDBOOK OF VACCINATION. 
 
 clusively, to the points of inoculation. In other re- 
 spects the course of the disease is essentially the same 
 as that of the natural or casual disease ; but usually the 
 papular stage is not well marked, and the local phe- 
 nomena, especially in the case of inoculation with 
 humanized lymph, or with cow-lymph that (as stated) 
 has been passed through the bodies of several cows 
 successively,* are less active. Though in the ox tribe 
 the female alone exhibits the natural cow-pox, that 
 disease is producible in the male as readily as in the 
 female by inoculation. 
 
 (a) By Inoculation with Cow-lymph. — Our best 
 account of inoculation with lymph taken from the 
 natural or casual form of cow-pox is that given by 
 Ceely, who, with lymph taken from milch cows at a 
 time when the variola? vaccinae were prevailing in 
 many of the dairies, inoculated some young heifers 
 about ten months old. The parts selected for experi- 
 ment were the inside of the ear, the teats, and the soft 
 and vascular structure on and near the vulva. The 
 punctures inflamed early, as early as the second day, 
 but the papular stage was not well marked, and was 
 apparently retarded ; the vesicles were normal in char- 
 acter, but they declined by the eleventh day ; much 
 tumefaction, however, of the integuments on the teats 
 remained till the thirteenth day. When the crusts fell 
 spontaneously at the proper time, they left a moder- 
 ately deep smooth scar ; but if prematurely removed a 
 deep erosion of the skin ensued. There was slight ac- 
 celeration of the pulse, but no other sign of general in- 
 disposition. Lymph taken from the vesicles thus in- 
 
 * See note 2, p. 27.
 
 OF THE NATURAL COW-POX. 2*1 
 
 duced and inserted in the human subject produced the 
 effects ordinarily noticed from the use of primary cow- 
 lymph, except that the induration and inflammation of 
 the base of the vesicles were less considerable, and the 
 resulting scars less deep, though remarkably well de- 
 fined and extending through two-thirds of the substance 
 of the corium.* When primary cow-lymph has been 
 transmitted through several cows in succession, the 
 affection it produces in the animals appears, according 
 to the accounts given, to be much less active, and to 
 run a more rapid course. f There is, at the end of 
 
 * Ceely, in Trans. Prov. Med. and Surg. Assoc, vol. viii. 
 p. 352. 
 
 f "Rapport de l'Acade'mie Imperiale de Medecine sur les 
 Vaccinations pendant 1'AnnSe 1864." Notwithstanding the 
 positive and repeated assertions of M. de Paul, the reporter of 
 the Vaccine Commission of the Academie, that the lymph, 
 the effects of which are above described, was cow-lymph, 
 passed from animal, to animal without having ever gone through 
 the human system, I apprehend there can be no doubt that it 
 was, as repeatedly urged by numerous members of the Acade- 
 mie, lymph of retro-vaccine origin. It was lymph which had 
 been passed through animals since 1858, the original lymph, 
 it was said, being lymph direct from the cow obtained at that 
 time, by the then Neapolitan Ambassador in England, from 
 her Majesty Queen Victoria (!), and sent by him to M. Negri, 
 at Naples. What is meant is, I presume, that it was procured 
 from the National Vaccine Establishment. Anyhow, there 
 was no cow-pox among the royal herds in 1858, nor, as I 
 have ascertained, has that disease ever occurred among them 
 at any time since they have, been under their present manage- 
 ment, which dates back as far as 1852. Neither was any cow- 
 lymph whatever sent out from the establishment in 1858; nor 
 is there any record of the natural cow-pox having been seen 
 in tha^year in England at all. Still, with this explanation, 
 I have retained the description in the text, M it is at all
 
 28 HANDBOOK OF VACCINATION. 
 
 thirty hours, slight inflammatory action ; on the third 
 day, well-marked redness and inflammation ; on the 
 fourth day, the formation of an elevated papule, very 
 recognizable by the touch ; on the fifth day, develop- 
 ment of a vesicle with an inflammatory areola ; the 
 vesicle and areola extend on the sixth day, and by the 
 seventh day desiccation begins. The crust falls from 
 the fourteenth to the twentieth day. From these 
 vesicles, lymph, which is most intense on the fifth or 
 sixth day, and comparatively of little value afterward, 
 is more or less difficult of attainment. Some, in order 
 to get it, even resort to cutting away the whole of the 
 vesicle and then scraping its inner surface strongly, so 
 as to get a magma of lymph and dermal tissue ; others 
 content themselves with opening the vesicle superfi- 
 cially, and squeezing the base with forceps and collect- 
 ing the liquid which exudes. The effects produced by 
 this lymph, when transferred to the human subject, 
 will be subsequently stated (§ 45). 
 
 (b) By Equination. — The casual equination of cows 
 must have taken place hundreds of times, as already 
 
 events an account of the effects of lymph which (whatever its 
 origin) has made a great number of transits through animals. 
 In the spring of last year, the natural cow-pox having been 
 met with at Beaugency, in the department of Loiret, in 
 France, the lymph derived from that source has been con- 
 tinued through animals, and I was in great hopes that I might 
 have found somewhere a description of the effects which this 
 lymph produced on cows after a number of continuous inocu- 
 lations, but I have searched in vain for such account in all the 
 ordinary channels of information which were accessible to me. 
 Probably the effects after several transmissions are much the 
 same as those of humanized lymph, and no special description 
 has been thought necessary.
 
 OF THE NATURAL COW-POX. 29 
 
 stated, producing what was regarded as natural cow- 
 pox ; and several successful experimental inoculations 
 have also been made. The phenomena of one of these 
 inoculations with lymph taken directly from the pri- 
 mary equine vesicle, and inserted in a young heifer, 
 by M. Lafosse of Toulouse, in the spring of 1860, are 
 thus stated by him. Four punctures having been 
 made, one on each dug, there was, on the sixth day, 
 only slight redness on the punctured spots, and a fresh 
 puncture on each nipple was made ; on the ninth day 
 from the original inoculation, without any general 
 symptoms other than a slight cough and diminution of 
 appetite, there were noticed four vesicles each of the 
 size of a lentil, firm, circular, flattened, slightly umbili- 
 cated at the center, which was of a reddish color, the 
 circumference being silver-gray. Each vesicle had 
 round it a delicate red areola with distinct induration. 
 By the next day the vesicles had extended and were 
 more completely formed, and three of them being opened 
 yielded lymph, two in very minute quantity, but the 
 other in sufficient amount to serve for further experi- 
 ments. The day following, the eleventh, the appetite 
 had returned, the cough was gone, and the vesicles 
 were undergoing desiccation. In ten days more, by 
 the twenty-first day, all the scabs, of genuine mahogany 
 color, had fallen, either spontaneously or from" friction, 
 and had left red-colored depressed cicatrices. From 
 the vesicles that had been opened on the tenth day, 
 another heifer, a horse, and some children were inocu- 
 lated, and all of them with the result of producing the 
 genuine vaccine or equine disease.* 
 
 * Rapport do l'Academie Imperiale do Modecino sur les 
 Vaccinations pendant l'Annec 1861, p. 13, seq.
 
 30 HANDBOOK OF VACCINATION. 
 
 (c) By Retro-vaccination. — Retro-vaccination, or 
 inoculation of cows with vaccine lymph that has been 
 passed through the human body, or humanized, has 
 been performed times innumerable. Generally, when 
 the operation is successful, there are early local symp- 
 toms, and the vesicle begins to form by the third or 
 fourth day, and is distinctly formed so as to yield 
 lymph for use by the seventh ; occasionally very little 
 result of any kind is perceptible before the seventh day, 
 and no evidence of the presence of lymph can be got 
 before the ninth day; but, in either case, the vesicles 
 reach their acme by the tenth day, and then decline, the 
 detachment of the crusts taking place from the seven- 
 teenth or eighteenth to the twenty-third or twenty- 
 fourth day. Ceely made various discriminative ex- 
 periments, using (a) some very long humanized lymph ; 
 (/?) some lymph of a stock which had been derived 
 direct from the cow about two years before ; {y) some 
 variola-vaccine lymph, or humanized lymph, which had 
 been originally produced in the cow by the process of 
 variolation, and which was then at the nineteenth re- 
 move; (3) some retro-vaccine lymph, or humanized 
 lymph that had been passed through the cow, then re- 
 transferred to the human subject, and taken again from 
 the human subject at the fifth remove ; but whatever 
 the source of the lymph and whatever its age, he found 
 that, if it were only good lymph, it succeeded equally 
 often, and excited equally perfect and productive vesicles. 
 Only in the experiment with variola-vaccine lymph it 
 happened that there was, in the particular case de- 
 tailed, early rupture of the vesicles (by the eighth day), 
 and a much less perfect crust than in the other cases, 
 with absence of that marginal induration which is or-
 
 OF THE NATURAL COW-rOX. 31 
 
 dinarily met with from the period when the vesicle is 
 fully developed up to the fourteenth or sixteenth day.* 
 The most conflicting statements have been made as to 
 the facility with which cows may be infected with hu- 
 manized vaccine lymph. According to Heim, Ilering, 
 and Hausmann, it is an experiment only rarely suc- 
 cessful, perhaps once out often or a dozen trials; Fiard 
 met with only six or seven very doubtful successes in 
 seventy experiments ; Viborg and Ritter were quite 
 unable to succeed : on the other hand, Caque at Rheims, 
 Husson and Tenier at Paris and Versailles, Sacco at 
 Milan, and Hellwag at Eutin, in the early days of 
 vaccination, and more lately Neumann at Utrecht, 
 Billing at Stockholm (in 1832), Lentin in Weimar (in 
 1835), Prinz at Dresden (in 1838), and others, have 
 experienced no great difficulty. Carganico of Darkeh- 
 men succeeded every spring for several successive 
 years; Magleari of Naples professes to succeed "jour- 
 nellemcnt ;" while that excellent and justly distin- 
 guished authority, M. Bousquet, says that to him 
 "e'est un jeu que de transmettre," etc. Much, no 
 doubt, depends on the lymph employed, and much, as 
 Bousquet justly observes, on choosing the animals to 
 be experimented on. Young cows, and particularly 
 heifers, should be selected. No doubt, even then, it 
 has been generally found more difficult to infect the 
 cows with humanized than with cow-lymph ; but the 
 results of the extensive vaccinations of cattle carried 
 on in England in 1865-6, during the short time that a 
 hope was entertained that vaccination might prove a 
 prophylactic against cattle-plague, — a very large num- 
 
 * Ceely, in Trans. Prov. Med. and Surg. Assoc, vol. viii. 
 pp. 354-365. 
 
 \
 
 32 HANDBOOK OF VACCINATION. 
 
 ber of which vaccinations were done with lymph col- 
 lected from children, and others with retro-vaccine 
 lymph carried on from cow to cow, — showed that in 
 either way, with due care, successful results might be 
 very frequently attained. In Mr. Ceely's original ex- 
 periments it was distinctly made out that the age of 
 the lymph, the length of time that it had been human- 
 ized, made not the slightest difference as to its taking 
 power when retransferred to cows ; and the same has 
 been observed in some experiments recently made by 
 M. Chauveau and others at Lyons.* M. Chauveau 
 and his colleagues, in the course of these experiments, 
 took occasion also to compare the effect on cows of 
 long-humanized lymph directly transferred to them, 
 and of unhumanized cow-lymph (as they supposed it 
 to be) which had undergone a series of transmissions 
 through the bodies of animals,f and were unable to 
 detect any difference either as to the facility of taking 
 or as to the local effects induced. When lymph raised 
 in cows by retro-vaccination is vaccinated back to the 
 human subject, it produces, though with less infective- 
 ness during the first two or three removes, — that is, 
 until it has again become humanized, — the results of 
 ordinary vaccination (§ 46). 
 
 (d) By Variolation. — The variolation of the cow, 
 or production of vaccine by inoculation with the lymph 
 of human variola, will be considered in Chapter IV. 
 
 * Vaccine et Variole : Kapport par MM. Chauveau, etc., 
 Memoires et Comptes Eendus de la Societe des Sci. Med. de 
 Lyon, tome v. 
 
 f The lymph they used, however, was really lymph of retro- 
 vaccine origin, but which had undergone a large number of 
 transits through animals. It was the lymph referred to in 
 note 2, p. 27.
 
 OF THE IIORSE-rOX. 33 
 
 CHAPTER II 
 
 OF THE HORSE-POX. 
 
 13. Horse-pox ; its Relations to Cow-pox. — The 
 horse is subject, like the cow, to a specific eruptive 
 fever resulting in the development of a pock, the mate- 
 rial of which has the same property as the fluid of cow- 
 pox, of protecting the human system, when inoculated 
 with it, from small-pox. This pock has the outward 
 appearance and the anatomical structure which distin- 
 guish the vesicles of cow-pox. The chief points in 
 which the disease, as seen in the horse, differs from 
 that in the cow are — (1) the locality of the eruption, 
 which is chiefly on the heels, and on the na-o-labial 
 mucous membrane ; (2) the tendency of the eruption 
 in some cases to become generalized over the body; 
 and (3) its appearance in the male as well as in the 
 female, horses being subject to it as well as mares. 
 
 14. Its Relations to "Grease." — I have already 
 stated (§ 10) that this disease was at first confounded 
 by Jenner with that familiarly called "the Grease," 
 an affection with which it may and very frequently 
 does coexist, but with which it has nothing in common, 
 except that both diseases manifest themselves as dis- 
 charging sores on the same part of the animal, viz., the 
 heels. From the want of the necessary discrimination 
 between the two diseases, and the much greater fre- 
 quency with which the grease occurs than does the 
 
 4
 
 34 HANDBOOK OF VACCINATION. 
 
 horse-pox, it happened that most of the experimental 
 inoculations made with the view of infecting the cow 
 with grease, were unsuccessful. Several successes, 
 however, were met with in cases in which the true 
 equine matter had chanced to be got hold of. Mr. 
 Tanner, a veterinary surgeon at Rockhampton, so 
 early as 1800, raised a perfect vaccine vesicle on the 
 teat of a cow by first removing a scab from the sur- 
 face of an accidental sore, and then rubbing over the 
 sore the limpid matter taken from the heels of a horse 
 afflicted with what he regarded as grease ; lymph taken 
 from the vesicle thus raised was successfully transferred 
 to the human subject, and a stock of vaccine thus ob- 
 tained, some of which was sent to Jenner, and through 
 him to the Small-pox Hospital.* The year following, 
 Loy, among many futile attempts, succeeded in in- 
 fecting four cows, by inoculation with lymph from a 
 " greasy" horse which, with considerable indisposition, 
 had a generalized eruption, while the horses " that did 
 not communicate the disease had a local affection 
 only;" and he was led by the result of his experiments 
 to distinguish two forms of grease, the acute and the 
 chronic, the former of which alone he regarded as 
 capable of imparting the cow-pox to the cow or to man, 
 
 * This experiment of Tanner could not have been regarded 
 as conclusive if it had stood alone, for he had first applied to 
 the sore some cow-pox matter on a thread. This cow-pox 
 matter had been so long kept that it was not thought possible 
 by the surgeon who gave it him for it to be effective, and, in 
 fact, at the end. of five days not the smallest result was per- 
 ceptible. It was then that the matter of grease was used, with 
 the effects stated in the text. (See King, Treatise on the Cow- 
 pox, p. 336.)
 
 OF THE HORSE-POX. 35 
 
 and then only in case the matter were taken at the 
 proper period of the vesicle.* In 1803, Dr. La Font, 
 a French physician established a Salonica, though he 
 failed in infecting a cow, was successful in producing 
 the perfect vaccine vesicle in two young children, with 
 lymph taken direct from a horse suffering from a disease 
 which was known to the Macedonian farriers as 
 "grease," but which they distinguished from ordinary 
 grease by the epithet, "the variolous, "f Coleman, 
 whose early attempts had failed, at a subsequent 
 period succeeded in infecting a cow with matter taken 
 direct from the heels of a horse, and in propagating 
 vaccine from the vesicles thus induced. Further ex- 
 periments, with two or three exceptions only, J gave 
 
 * Loy, Experiments on the Origin of the Cow-pox, 8vo. 
 "Whitby, 1801. Before this distinction had been made by Loy, 
 Mr. Lupton, of Thame, in Oxfordshire, had in 1800 (see Med. 
 and Phys. Journal, vol. iv., Nov. 1800) more correctly pointed 
 out that the diseaso of the horse, which was analogous to cow- 
 pox and was communicable to the cow, was not " the grease'' 
 nor any form of grease, but a disease regarded by the farriers 
 of his neighborhood as widely different from it, and to which 
 they gave the name of the "scratchy heel." The distinction 
 also, according to Mr. Grose, of Winslow, was known in 
 Buckinghamshire, where the vaccigenous complaint in the 
 horse, from the singularity of making the fiair erect, was called 
 a "scratchy heel." (Ring, op. cit.,p. 237.) Compare this ob- 
 servation as to the distinctive character of the disease, with 
 the description of horse-pox subsequently given in the text 
 (3 15). 
 
 f De Carro in letter to Jenner, June 21, 1803. (See Baron's 
 Life of Jenner, vol. i. p. 432.) 
 
 X The direct inoculations from horses' heels, made by Viborg 
 and by Kiihlerton cows, and by Steinbeck both on cows and 
 children, though exception lias been taken to then, will be
 
 36 HANDBOOK OF VACCINATION. 
 
 negative results. But the experiments that had suc- 
 ceeded, and the almost familiar fact that lymph taken 
 directly from vesicles on the hands of farriers, which 
 had been contracted by them from the heels of horses, 
 was productive of effects exactly the same as those of 
 vaccine lymph — whether as regarded the phenomena 
 induced, or the protection against small-pox imparted 
 — left no sort of doubt in England as to the horse being 
 subject to a disease identical with cow-pox.* The 
 merely accidental relation of this disease to grease 
 was longer of being generally understood. Jenner 
 himself, though not at first, was fully aware of it, as 
 his description of the disease shows: "The skin of the 
 horse is subject to an eruptive disease of a vesicular 
 character, which vesicle contains a limpid fluid, show- 
 ing itself most commonly in the heels. The legs 
 first become edematous ; and then fissures are ob- 
 served. The skin contiguous to these fissures, when 
 
 admitted, I apprehend, now to have been genuine successes. 
 Sacco and several others succeeded in producing on human 
 subjects perfect vaccine vesicles with lymph taken from sores 
 (vesicles) on the hands of individuals, which sores they were 
 quite satisfied had been derived from the horse ; but the diffi- 
 culty here was to convince the skeptical that the origin as- 
 cribed by them to these sores was correct. Bousquet, review- 
 ing, in 1848, the whole of the experiments and observations up 
 to that time, declared himself unsatisfied as to whether cow- 
 pox had ever-been derived from the horse or not. (Nouveau 
 Traite de la Vaccine, p. 436.) 
 
 * Jenner largely employed and diffused equine lymph for 
 vaccinating. (See Baron's Life of Jenner, vol. i. pp. 254, 428, 
 and vol. ii. pp 220-7 and 388.) At first he had a notion that 
 this lymph needed to be passed through the cow before it be- 
 came protective against small-pox, but this idea he soon aban- 
 doned.
 
 OF THE HORSE -POX. 37 
 
 accurately examined, is seen studded with small 
 vesicles, surrounded by an areola. These vesicles 
 contain the specific fluid. It is the ill-management of 
 the horse in the stable that occasions the malady to 
 appear more frequently in the heel than in other parts; 
 I have detected it connected with a sore on the neck 
 of the horse, and on the thigh of a colt;"* and again, 
 "The matter which flows from the fissures in the heels 
 will do nothing. It is contained in vesicles on the 
 edges and the surrounding skin."f The distinct na- 
 ture of the two diseases was afterward generally re- 
 cognized;! and at least thirty years ago the horse- 
 pox was distinguished by the appropriate name 
 " Variolas Equinae,"§ but no minute description of it 
 was given by any English observer. In France, from 
 the general negative results of repeated inoculations 
 from horses' heels, doubts as to the existence of an 
 equine pox seem to have been largely entertained up 
 to a very recent period ; but within the last few years 
 these doubts have been completely set at rest. Two 
 outbreaks of the disease among horses — one near Tou- 
 
 * Baron's Life of Jenner, vol. i. p. 242. The date of this 
 description, apparently taken from Jenner's MS., is not given. 
 
 f Letter of Jenner to Moore, Oct. 1813 ; Baron's Life, etc., 
 vol. ii. p. 390. 
 
 % Kahlert of Prague, referred to in note 3, p. 35, describing 
 the horse-pox as he met with it in Bohemia, insists on the dis- 
 tinction between the febrile and constitutional equine disease 
 and the grease. A French translation of his paper will be 
 found in the Almanach de Karlsbad, 1833. It is entitled " Du 
 Javart Preservatif ; " and in it he suggests for the disease he 
 describes (the vaccigenous disease) the title of "Equin Pre- 
 servatif." 
 
 g Baron's Life, etc., vol. ii. p. 456. 
 4*
 
 38 HANDBOOK OF VACCINATION. 
 
 louse in I860, and one at Alfort in 1863 — gave rise to 
 inoculations the results of which were acknowledged 
 to be entirely unequivocal. These outbreaks were 
 carefully observed, and the phenomena of horse-pox 
 may be considered as now well made out. 
 
 15. Character and Course of the Disease. — The 
 disease differs so little in its course from the cow-pox 
 in the cow, that very minute description will scarcely 
 be called for. The chief distinction is as to the part of 
 the body affected, which in the horse is principally the 
 legs, particularly the hind-legs; the eruption being 
 generally more copious there than anywhere else, and 
 seldom extending beyond the hocks, except as the re- 
 sult of auto-inoculation.* It is, no doubt, from its 
 great exposure to this kind of inoculation that, after 
 the heels, the naso-labial mucous membrane is the 
 chief seat of eruption, f In some cases the vesicles 
 seen on this membrane may be primary ; and there are 
 
 * Of more than 100 mares affected in the epizootic at 
 llieumes, near Toulouse, there were only two in whom the 
 eruption extended to the thighs and vulva, and one in whom 
 it manifested itself (but probably from self-inoculation) on the 
 nostrils and lfps. But in the outbreak at Alfort, affection of 
 the buccal and nasal mucous membrane was much more fre- 
 quently noticed, and a general eruption observed in many 
 cases. 
 
 f As the first inoculations at Alfort were made from some 
 vesicles about the mouth, at a time when the real nature^of 
 the disease from which the horse was suffering was not made 
 out, and when, in fact, he was considered as having an 
 " aphthous stomatitis," this familiar disease of cattle was for 
 a short time put down as a new source of cow-pox ! But this 
 error received its correction far more speedily than the simi- 
 lar error with rearard to grease.
 
 OF THE HORSE-POX. 39 
 
 said to have been cases in which this membrane was 
 the sole seat of eruption. Occasionally, especially in 
 certain epizootics, the eruption has been seen extending 
 over the body, in greater or less abundance, from the 
 heels to the belly and from the head to the tail. This 
 general eruption, when it occurs, may come on in the 
 course of the disease, and after the usual local symp- 
 toms have manifested themselves; or the generaliza- 
 tion may be noticed from the very outset. The course 
 of the disease is this: there is a period of invasion, 
 sometimes accompanied with fever, which, if it occur 
 at all, is in the great majority of instances very trifling; 
 then, on the pasterns and other parts about to develop 
 the eruption, points are felt or seen, which soon acquire 
 prominence and take the form of pimples, becoming 
 rapidly flattened and umbilicated at the center. These 
 by the eighth or ninth day are fully developed, mostly 
 circular, and of the size of a big lentil, notably elevated 
 above the skin, resisting pressure, and having a well- 
 marked surrounding induration. They have absolutely 
 the same structure as the vaccine or variolous vesicle, 
 and yield, though generally in small quantity, a viscid 
 and slightly yellowish lymph. By the ninth, tenth, or 
 eleventh day, many of them burst, exuding, often co- 
 piously, a viscid serous or sero-purulent fluid ; incrus- 
 tation going on progressively and forming scabs or 
 crusts, which from the fifteenth to the twenty-fifth day 
 detach themselves, leaving whitish superficial cica- 
 trices. Varieties are observed, as in cow-pox, some of 
 the vesicles being smaller and later than others, some 
 less markedly umbilicated, some not umbilicated at all. 
 They are most developed in the parts that are naked or 
 have little hair, and where the skin is fine. If the hair
 
 40 HANDBOOK OF VACCINATION. 
 
 be long and close, they are smaller and less regular, 
 and attentive observation is often necessary to make 
 out their existence ; little pencils of hair will be seen 
 standing up here and there,* and if the finger be 
 lightly moved over these spots, slight indurations will 
 be felt, corresponding to pimples or vesicles, which may 
 be brought to light by cutting the hair away. Just as 
 the cow-pox among cows in dairies, the horse-pox is 
 communicated from animal to animal by casual inocu- 
 lations, immediate or mediate, and these inoculations 
 are the main cause of the spreading of the disease. 
 
 It is evident, from the observations already made, 
 that the disease has to be distinguished from Grease 
 on the one hand, and Aphtha epizootica on the other. 
 
 16. Artificial Production of Horse-pox by Inocula- 
 tion. — The horse-pox has been designedly induced in 
 the horse, and other animals of the horse tribe, by in- 
 oculation — (a) with equine lymph directly transferred 
 from horse to horse ; this was done on numerous occa- 
 sions and with great success, in 1863, by M. Bouley;f 
 (b) with equine lymph that had been passed success- 
 fully through a cow, producing in that animal all the 
 phenomena of the genuine inoculated cow-pox ; this 
 was done both in 1860 at Toulouse, by M. Lafosse,| 
 and in 1863 at Alfort, byM. Bouley, and at the Jardin 
 d'Acclimatisation at Paris ;§ (c) with lymph supposed 
 to be unhumanized cow-lymph, not primary, but the 
 product of a series of transmissions of primary lymph 
 
 * See the description of the " scratchy heel," note 1, p. 35. 
 f Bulletin de l'Academie, tome xxix. p. 236. 
 J Kapport de l'Academie Imperiale de Medecine sur les Vac- 
 cinations pendant l'Annee 1861. 
 
 § Bulletin de l'Academie, tome xxix. pp. 131-3 and 199.
 
 OF THE IIORSE-POX. 41 
 
 through animals of the ox tribe : this was done by M. 
 Chauveau and his colleagues ;* and (d) with ordinary 
 humanized vaccine lymph ; an experiment thus made 
 in 1862 by MM. Rayer and De Paul, at Alfort, re- 
 sulted in the production of eight well-characterized 
 vesicles, perfectly circular, with central depression and 
 induration of the whole surrounding thickness of the 
 dermis — a description which fully justifies us in regard- 
 ing the inoculation 'as successful, notwithstanding that 
 the fluid obtained from the vesicles, tried on a single 
 baby, produced no effect ;"}" and since then, M. Chau- 
 veau appears to have used this kind of lymph in several 
 successful inoculations. | 
 
 Although primary cow-lymph has not, so far as I 
 am aware, been used on any occasion for inoculating 
 horses, it may be taken as quite certain that such in- 
 oculation would be productive of the equine pox. And 
 there is every probability, I think, that if sufficient 
 trials were made, the same result might be obtained 
 from inoculating horses, under favorable conditions, 
 with the matter of human variola ; although the few 
 experiments that have hitherto been made with this 
 object have either given negative results, — as those 
 reported by Badcock,§ by Lalagade,|| by Bouley,^f and 
 
 * Vaccine et Variola, etc., op. cit. See, however, note 2, p. 
 27, where the origin of this lymph is referred to. 
 
 f Kapportde l'Academie Imperiale de Medecine sur les Vac- 
 cinations pendant l'Annec 18G1. 
 
 J Chauveau, Des Conditions qui president au developpement 
 de la Vaccine dite primitive: Bull, de l'Acad., tome xxxi. 
 
 § Badcock, Detail of Experiments confirming the Power of 
 Cow-pock, etc., p. 15. 
 
 || Rapport de l'Acad6mie Imperialo de Medecine sur les Vac- 
 cinations pendant l'Annee 1863, p. 102. 
 
 \ Bulletin de l'Acad6mie, tomo xxix. p. 286.
 
 42 HANDBOOK OF VACCINATION. 
 
 by Le Blanc and De Paul,* — or have afforded re- 
 sults such as those obtained by M. Chauveau and his 
 colleagues, which will be described hereafter, and 
 which lead, in their opinion, to an opposite conclusion. 
 This subject will be considered in Chapter IV. 
 
 In the horse-pox induced by the ordinary process of 
 inoculation, eruption is limited, with rare, if any, ex- 
 ceptions, to the points of inoculation. The local phe- 
 nomena are less active than in the natural disease, but 
 the course of the disease is essentially the same. 
 
 17. Artificial production of Horse-pox by Injection 
 of Lymph. — A variety of inoculation, viz., that of in- 
 jecting the liquid vaccine lymph into the blood-vessels 
 or lymphatics of horses, has recently been attempted 
 by M. Chauveau with the most interesting results. 
 It occurred to him that it might be possible by this 
 method of proceeding to produce the more extended 
 or generalized eruption, which in this tribe of animals 
 frequently attends the natural, or, as it is called, spon- 
 taneous disease. Accordingly, he inoculated four old 
 horses by injecting some vaccine lymph into a blood- 
 vessel, and four more by injection into a lymphatic 
 vessel just before its entrance into a ganglion. The 
 first series of experiments (those in which the injection 
 was into a blood-vessel) failed. But of the animals in 
 the second series (those inoculated through the lym- 
 phatics), the inoculation succeeded in three out of the 
 four, producing a fine eruption of vaccine, which had 
 all the characters of the spontaneous horse-pox. One, 
 a horse, had a full eruption, commencing at the end of 
 eleven days, and completely developed in three or four 
 
 * Bulletin de l'Aeademie, tome xxix. p. 370.
 
 OF THE 1I0RSE-P0X. 43 
 
 days more, on the nostrils and lips, as well as on the 
 hind heels; the second, a mare, injected from the pre- 
 ceding, had isolated vesicles disseminated over the body, 
 except the neck and pasterns, but chiefly to the mam- 
 mary region and on the lips — the eruption commencing 
 on the eighth day, and continuing to appear up to the 
 fourteenth ; and the third, a mare, had, on the twelfth 
 day, an eruption chiefly on the genital organs and the 
 inner surface of the thighs. And virus taken from the 
 eruption on each of these animals produced, it is said, 
 regular vaccine both on the cow and on children. M. 
 Chauveau, in a later course of experiments, succeeded 
 in inoculating a young colt by two injections of vaccine 
 lymph, at intervals of two days, direct into the san- 
 guineous system through the jugular vein ; vesicles 
 beginning to appear, principally in the naso-labial re- 
 gion, in twelve days, and continuing to appear for four 
 days more, the lymph of which was found to produce 
 regular vaccine both on a child and on animals of the 
 ox tribe. Following out still further the same idea, 
 M. Chauveau, by injecting vaccine into a pouch formed 
 in the subcutaneous cellular tissue on the left side of 
 the neck of a colt, but with great care that the lymph 
 should not touch the wounded skin, obtained no local 
 vesicle, but an eruption, commencing on the tenth day, 
 of a few vesicles on the naso-labial region. From these 
 results, in connection with the fact that, in nearly thirty 
 successful inoculations of horses with vaccine lymph in 
 the ordinary way, no general eruption followed, M. 
 Chauveau concludes the one essential condition of a 
 generalized eruption to be that the virus should not 
 pass through the membrane which is the anatomical 
 seat of the vaccine eruption. M. Le Blanc, however,
 
 44 HANDBOOK OF VACCINATION. 
 
 states that he has seen general eruption to occur in a 
 case in which inoculation had been done in the ordi- 
 nary way, and that he proved the vaccinal character of 
 the vesicles secondarily developed by equinating suc- 
 cessfully from them both horses and Tuminants. It is 
 exceedingly desirable that these interesting experi- 
 ments of M. Chauveau should be repeated. Young 
 colts appear more adapted for the purpose than old 
 horses.* 
 
 CHAPTER III. 
 
 OF POCKS IN OTHER ANIMALS WHICH HAVE BEEN CON- 
 SIDERED ANALOGOUS TO COW-POX AND HORSE-POX. 
 
 18. Sheep-pox By far the most interesting and 
 
 important of these is the sheep-pox, "le claveau," or 
 "la clavelee," of the French — the Yariola Ovina, as it 
 has been termed, — a disease frequently met with in 
 various parts of the Continent, but which has made 
 its appearance in England on three occasions only, viz., 
 in 1710-11, in 1847-50, and in 1862. It so far resem- 
 bles the diseases already treated of in the cow and 
 horse that it is an infectious febrile disease, character- 
 ized by a vesicular eruption. But the vesicles have 
 neither the appearance nor the structure of the vesicles 
 of cow-pox or horse-pox. Their surface is flat and not 
 
 * Chauveau, Des Conditions qui president au developpement 
 de la Vaccine dite primitive : Bulletin de l'Acad. Imp. de 
 Med., tome xxxi. Also, Comptes Rendus de l'Acad. des 
 Sciences, tome lxii. p. 1118, and tome lxiii. p. 573.
 
 OF POCKS IN OTHER ANIMALS. 45 
 
 umbilicated, and their structure is simple and unretie- 
 ulated, a single puncture with a lancet serving to empty 
 a whole vesicle. A further important difference to be 
 noted is in the severity of the general symptoms which 
 attend sheep-pox, and the very great fatality of that 
 disease; in these respects it more resembles natural 
 small-pox in the human subject. It has a period of in- 
 cubation not very different from that of human variola. 
 It is transferable from sheep to sheep by inoculation or 
 " clavelization." The disease produced by this claveli- 
 zation is very considerably milder than the natural dis- 
 ease, and imparts security to the animal against a nat- 
 ural attack of the sheep-pox. 
 
 19. Ovination of the Human Subject. — The question 
 of the relation, if any, which this disease holds to cow- 
 pox and horse-pox — whether its material inoculated on 
 the cow or horse, or on man, will produce the effects, 
 local and general, of the vaccine or equine affection — 
 and whether, conversely, the cow-pox or horse-pox can 
 be imparted to sheep — is one of considerable scientific 
 interest. Its practical importance is limited entirely 
 to the effect which inoculation of the latter kind might 
 have in protecting sheep from sheep-pox. Of the very 
 numerous attempts that have been made to communi- 
 cate the shcep-pox to man, the inoculations of one ex- 
 perimenter alone appear to have been successful ; but 
 the success with which he met was, according to ac- 
 counts, as constant as have been the failures of other 
 observers. Sacco, of Milan, when passing through 
 Capua, in 1804, saw accidentally some sheep affected 
 with sheep-pox, a disease which at that time he had 
 not before met with. He took virus from the finest 
 vesicles; and with this he, in conjunction with Dr. 
 
 5
 
 46 HANDBOOK OF VACCINATION. 
 
 Legni, of Cattolica, inoculated six children, vaccinating 
 two others at the same time with ordinary vaccine 
 lymph. lie did not stay to watch the results, but Dr. 
 Legni reported to him a month afterward that the 
 ovmation had been successful, and that no marked dif- 
 ferences had been observable between the vesicles 
 produced by the ovine and those produced by the vac- 
 cine lymph. Dr. Legni added, that he had continued 
 to propagate the ovine lymph on children. Sacco, on 
 his return to Milan, used what he had remaining of 
 the ovine virus (it had been collected in tubes), but 
 unsuccessfully. Two years afterward, however (in 
 1806), sheep-pox again prevailing in Italy, he inocu- 
 lated five children with virus taken from a lamb — in- 
 serting, in two out of these five children, the ovine 
 lymph on one arm and vaccine lymph on the other. 
 Two of the three children in whom the vaccine lymph 
 had not been inserted, and one of the two in whom it 
 had, had each one ovine vesicle ; the vaccine took effect 
 in both the children in whom it was employed, raising 
 in one of them a single vesicle, and in the other two 
 vesicles. When the three vesicles, the products of 
 each lymph, the three vaccine and the three ovine, 
 were compared together, Sacco says he was unable to 
 detect any difference of character between them. 
 Moreover, the two children who had ovine vesicles 
 only, were tested some days afterward by small-pox 
 inoculation, but no effect was produced. He inocu- 
 lated afterward, with ovine virus, some children at 
 Fotidinovo, and found the results in all to be the pro- 
 duction of vesicles exactly like vaccine ; and he inserted 
 ovine virus also in some children and a cow at Barba- 
 rasco. As he was unable to stay and watch the effects
 
 OF POCKS IN OTHER ANIMALS. 47 
 
 in this last series of inoculations, he left some of the 
 cases in care of a surgeon, Dr. Magnani, who reported 
 to him that out of four children the ovination had taken 
 in two, producing in one of them four vesicles, and in 
 the other a single vesicle only; that the vesicles were 
 like those of vaccine and surrounded by a red circle, 
 but containing a liquid which was not limpid, but 
 serous and yellowish; that this liquid, inoculated on 
 two children, produced vesicles which on the seventh 
 day were full of limpid fluid, with which three others 
 were inoculated ; and that in all the children of this 
 last inoculation vesicles arose, the contents of which on 
 the eighth day were limpid and crystalline, like the true 
 vaccine lymph. He further reported that on examina- 
 tion of the cow, he had found a single vesicle on the 
 udder, distended with yellow and turbid fluid, which 
 was inoculated on two children with the usual effects 
 of vaccination. Sacco says that ovine virus was in- 
 oculated afterward at Lucca, and that stocks of lymph 
 of this origin were employed like vaccine lymph for 
 vaccinating purposes, producing exactly the same 
 effects.* In other hands — in France as in England — 
 every attempt to produce the vaccine disease by ovina- 
 tion has (save in a single doubtful instance) failed ; and 
 this, though the number of experiments has been very 
 great, and though a large number of them have been 
 conducted by men singularly versed in experiments of 
 the kind. Mr. Marson and Mr. Ceely have, between 
 them, performed not less than 250 inoculations on 
 human subjects with the virus of sheep-pox, and with 
 the single equivocal exception, the particulars of which 
 
 * Sacco, Trattato di Vaccinazione, pp. 145-148.
 
 48 HANDBOOK OF VACCINATION. 
 
 will be afterward stated, they failed to induce any- 
 thing like a vaccine vesicle. The following is the ac- 
 count Ceely gives of the result of some of his en- 
 deavors: "I ovinated twenty-five subjects whose ages 
 ranged from three to fifteen years, some twice and 
 thrice over; in none were there fewer than six punc- 
 tures each time, making not less than 180 punctures; 
 no specific dfsease resulted ; but a prompt and devious 
 papular or diffuse inflammation, or, more rarely, a com- 
 mon local pustular. In the majority of these twenty- 
 five individuals the virus employed was liquid. When 
 very recently charged points were used, subsequent re- 
 inoculation with liquid virus was bad recourse to, but 
 with no other effect. Nearly all the above subjects 
 were shortly afterward vaccinated with current vaccine 
 lymph, which in each case exhibited the normal effects. 
 I may as well add, also, that the same kind of ovine 
 virus which did not succeed on children took promptly 
 on sheep."* Such uniformity of failure in the hands 
 of the best of experimenters, and when every pains 
 were certainly taken to produce success, suggests the 
 possibility of fallacy in Sacco's experiments, and sug- 
 gests it all the more for the very facility Avith which he 
 succeeded; for I agree with M. Bousquet, that where 
 one person succeeds so uniformly that his experiments 
 appear to be but an amusement to him where every- 
 body else's fail, there cannot but be some ground for 
 hesitation in accepting his conclusions, f A doubt 
 certainly suggests itself to the mind, whether, in 
 Sacco's experiments, done at the same time with two 
 
 * Simonds, Practical Treatise on Variola Ovina, p. 154. 
 f Bulletin de l'Academie, tome xxix. p. 585.
 
 OF POCKS IN OTHER ANIMALS. 49 
 
 viruses, — the ovine and the real vaccine, — some accident 
 might not have occurred by which the two may 1 ave 
 become inadvertently mixed, or inadvertently substi- 
 tuted for one another. Similar accidents, it is well 
 known, not unfrequently happened in England with 
 variolous and with vaccine lymph in the early days of 
 vaccination (when the variolous and the vaccine in )cu- 
 lations were carried on by the same practitioners, at 
 the same time and often on the same subjects), giving 
 rise to phenomena which, till the cause of them was 
 found out, greatly complicated and confused our un- 
 derstanding the real characters of the vaccine disease 
 in the human subject. The facility with which mis- 
 takes of this kind might occur when tubes and points 
 are used (and we know that Sacco was greatly in the 
 habit of using tubes to collect and convey his lymph 
 for experimental and other inoculations) is obvio.is.* 
 Still, among the constant failures that have attended 
 
 * It is impossible to mention the name of Sacco without an 
 expression of gratitude and respect for the vast services he 
 rendered in the diffusion of vaccination in Italy. The int rest 
 he took in the subject led him to the performance of innumer- 
 able experiments on all sorts of animals; but the very variety 
 and multiplicity of these experiments, and the evidently casual 
 way in which many of them were done, are suggestive of a 
 state of hurry which is not favorable to good experimentation. 
 His account of the experiments, and of his manner of con- 
 ducting them, is given in very general terms, and it is im- 
 possible to read it without feeling how many details arew ant- 
 ing to make it satisfactory and conclusive. And his conclu- 
 sions with regard to the constitutional effects of vaccination 
 on animals were certainly very hastily drawn, for he not '»nly 
 found vaccination to save sheep from sheep-pox, and dogs from 
 distemper and other diseases besides, but also horses from 
 glanders ! 
 
 5*
 
 50 HANDBOOK OF VACCINATION. 
 
 the attempts of all other experimenters to ovinate the 
 human subject, there has been one apparently success- 
 ful inoculation which was not Sacco's ; and as this case 
 occurred to so singularly cautious and able an experi- 
 menter as Mr. Marson, if he had been satisfied with 
 the result we might have been prepared to allow this 
 positive to outweigh the many negative observations 
 that have been accumulated. But Mr. Marson was 
 not satisfied, and his account of the circumstances 
 illustrates admirably, as it appears to me, the caution 
 which should be used in drawing deductions from ex- 
 periments made to determine doubtful issues: "When 
 small-pox appeared in this country in the sheep in 
 1847," he says, "we tried to communicate it, by inocu- 
 lation, to the human subject, and thought we had suc- 
 ceeded in doing so, and the virus was carried on from 
 one to another for several weeks in succession. The 
 pock produced was very like cow-pox, having only, as 
 we thought, a bluer tinge, and was protective against 
 small-pox, as we ascertained by inoculating the patient 
 afterward with the lymph of human variola; but we 
 had unfortunately used for the original ovination the 
 same lancet, instead of having a new one, as we ought 
 to have had, that we had previously used for vaccina- 
 ting ; and although it was, as we believe, perfectly clean, 
 and free from vaccine lymph, nevertheless, as the 
 disease could not be produced again in the human sub- 
 ject, either by Mr. Ceely, of Aylesbury, who made re- 
 peated trials with the lymph of sheep-pox, or by our- 
 selves, the experiment was never brought before the 
 medical profession."* 
 
 * Art. "Small-pox," in System of Medicine, ed. by J. B. 
 Keynolds, M.D., vol. i. p. 433.
 
 OF POCKS IN OTHER ANIMALS. 51 
 
 20. Ovination of Cows, etc. — The most careful en- 
 deavors made on various occasions by Professor Si- 
 monds, Mr. Ceely, and Mr. Marson to impart the 
 sheep-pox to the cow,* wholly failed ; and the French 
 veterinarians, whose acquaintance with sheep-pox is 
 extensive, are all of opinion that it cannot be commu- 
 nicated to the ox tribe either by inoculation or by in- 
 fection. M. Hurtrel d'Arboral also informs us that 
 attempts to inoculate it on other animals — deer, pigs, 
 dogs, monkeys, etc. — have been alike unsuccessful. f 
 Marson found the goat, though an animal in many re- 
 spects so like the sheep, equally unsusceptible. 
 
 21. Vaccination of Sheep. — But whatever uncer- 
 tainty may still be considered to exist as to the pro- 
 duction of the vaccine disease in the human subject by 
 ovination, there is none whatever that the phenomena 
 induced in sheep by inoculation with vaccine lymph are 
 very different indeed from those of the genuine vaccine 
 disease as exhibited on the cow or on man, or from 
 those of inoculated sheep-pox in the sheep. There is 
 generally some difficulty in getting vaccine lymph to 
 take any effect on sheep at all, and it is found that in 
 nearly two-thirds of the cases the inoculation requires 
 to be repeated once or oftener. " When effect is pro- 
 duced, the resulting affection," say Mr. Marson and 
 Professor Simonds, "even when developed to its fullest 
 extent, is very unlike the same disease in the human 
 subject. In the sheep it is but seldom anything more 
 
 * Simonds, Practical Treatise, etc., p. 155; also Report of 
 Experiments made under direction of the Lords of the Coun- 
 cil as to the Vaccination of Sheep, etc., by Mr. Marson and 
 Prof. Simonds (Pari. Paper, 1864), p. 5. 
 
 f Diction naire de Medecine Vete>inaire, art. "Clavelisa- 
 tion."
 
 52 HANDBOOK OF VACCINATION. 
 
 than the production of a small papule, which occasion- 
 ally results in the formation of a minute vesicle, or 
 more commonly a pustule, which is sometimes, although 
 very rarely, surrounded with a slight areola. Generally, 
 however, neither vesication nor pustulation follows, but 
 a small scab is produced, which soon falls from the site 
 of the puncture, leaving no trace behind. The disease 
 passes quickly and irregularly through its several 
 stages, so as to have ended by the eighth or ninth day, 
 or not unfrequently even before this time. Lymph is 
 but rarely obtainable, and never but in the smallest 
 quantity, and this on the fifth or sixth day succeeding 
 the vaccination. The effects are only local, and the 
 animal's health never impaired."* The entirely local 
 nature of this affection is shown by the fact that sheep 
 who have gone through it are, on the one hand, just as 
 susceptible of the action of the vaccine virus on imme- 
 diate repetition of the operation as if nothing had been 
 done to them, and are, on the other hand, not in the 
 least protected against sheep-pox. The description of 
 the results of vaccination on sheep, which is given by 
 other observers, agrees closely with that of JMarson 
 and Simonds, even of those observers who, like Sacco, 
 thought that the sheep was constitutionally affected 
 thereby, and was, in fact, really vaccinated. For Sacco 
 speaks of the vesicles being " mostly resolved before 
 coming to maturity; the cutis detaching itself in small 
 scales from their surfaces, as from the pustules of ovine 
 variola. It is very seldom that true vesicles are pro- 
 duced which are succeeded by scabs. "f Still, by this 
 
 * Keport of Experiments, etc., p. 6. 
 
 f Sacco, as quoted by Simonds, Pract. Treatise, etc., p. 142.
 
 OF POCKS IN OTHER ANIMALS. 53 
 
 affection, such as it was, Sacco hoped, and believed, 
 and taught that sbeep might be protected against sheep- 
 pox. Unfortunately, this has turned out not to be the 
 case. No fact is more conclusively established than 
 the utter worthlessness of vaccination for saving sheep 
 from sheep-pox.* The effects of vaccination in the 
 sheep, such as they are, are entirely local, not in the 
 least degree constitutional ; and this result is calcu- 
 lated, I think, to throw further doubt on those experi- 
 ments by which the converse — the production of con- 
 stitutional vaccinia in the human subject by inoculation 
 with the lymph of sheep-pox — has been supposed by 
 some to be established. 
 
 22. Variolation of Sheep. — It may be added that 
 attempts to inoculate sheep with human variola have 
 equally failed. Mr. Marson tried this on a hundred 
 sheep, six punctures being made on each sheep, but 
 the results were essentially the same, both locally and 
 constitutionally, as those obtained with vaccine lymph. 
 Sheep in whom the variolous virus had produced a local 
 
 * Keport of Experiments, etc.: also Simonds, Pract. Treatise, 
 etc., chap. vi. Hurtrel d Arboral, Huzard, and other French 
 veterinarians who have experimented on a large scale bear 
 unanimous testimony to the same effect. It is not a little 
 surprising, therefore, to find M. de Paul, the Director of the 
 Vaccinations of the Academie Imp. de Med. at Paris, stating 
 to the Academy that vaccination takes perfectly (prend a mer- 
 veille) on sheep, and gives them complete protection against 
 sheep-pox ; that sheep-pox matter inoculated on cows produces 
 perfect vaccine, etc. etc. (Bull, de l'Acad., tome xxix.) In 
 a former note (note 2, p. 27), I referred to very positive 
 statements made, and insisted on, by M. de Paul on very in- 
 sufficient evidence, but the present statements are in the teeth 
 of all evidence.
 
 54 HANDBOOK OF VACCINATION. 
 
 effect were found still susceptible of the sheep-pox, and 
 some of them being submitted to vaccination, became 
 affected in about the same proportion, and to the same 
 extent, as others not inoculated. 
 
 23. Analogous Pocks in other Animals. — In the 
 Camel. — Although various animals have at times been 
 stated to be liable to eruptive fevers which have been 
 considered to have some analogy to human variola on 
 the one hand, or to cow-pox on the other, we have no 
 accounts respecting any of these which are not vague 
 and wholly inconclusive. The most probable instance 
 of any animal being subject to an affection like the 
 cow-pox is the occurrence, it is said, among camels, in 
 the province of Lus, in Beloochistan, of a disease 
 which the natives call " Photoshootur," or the small- 
 pox of camels. This disease is affirmed to be commu- 
 nicable to the camel-milkers, and to protect them from 
 small-pox. No attempt is made by them to propagate 
 it by inoculation.* 
 
 24. Vaccination and Variolation of other Animals. 
 — The insertion of vaccine lymph on dogs produces 
 an effect much more resembling regular vaccine than 
 the like experiment on sheep ; but, according to Sacco, 
 the course is shorter than in the human subject, and 
 there is no areola. The lymph obtainable from the 
 vesicles produced in the dog may, it is said, be con- 
 tinued from animal to animal, and even reinoculated 
 in the human subject, with the result of reproducing 
 
 * Indian Journal of Medical Science, Oct. 1839.
 
 OF POCKS IN OTHER ANIMALS. 55 
 
 genuine vaccination.* Jenner at first believed that 
 dogs might be constitutionally affected by vaccinia, 
 and thereby protected against that infectious disease, 
 the distemper ; but he apparently did not remain long 
 in this belief, for, in his account of the dog distemper 
 in 1809, f he makes no allusion whatever to the em- 
 ployment of vaccination. Inoculation of dogs with 
 the matter of variola by MM. Reynal and Renault 
 produced no result; J and I do not in the least know 
 what value is to be attached to a statement that Vi- 
 borg performed a successful inoculation of this kind.§ 
 The goat is said, on the authority of M. Valentin, of 
 Nancy, || of M. Husson, and more recently of MM. 
 Mathieu and Auzias Turenne, to be susceptible of vac- 
 cination; and M. Chauveau and his colleagues pro- 
 duced on this animal, in two experiments, umbilicated 
 vesicles, but of a very modified kind.^[ The accounts 
 we have of inoculations performed with vaccine or 
 with variolous lymph on various other kinds of ani- 
 mals either record failure, or give results too vaguely 
 and inconclusively to render a detail of them of any 
 interest. 
 
 * Baron's Life of Jenner, vol. i. p. 243 ; and Sacco, as quoted 
 in King's Treatise, p. 941. 
 
 ■J - Medico-Chirurgical Transactions, vol. i. 
 
 I Bulletin de l'Academie, tome xxix. p. 334. 
 
 g Baron's Life of Jenner, vol. i. p. 216. 
 
 || Ibid., p. 243. 
 
 ^ Vaccine etVariole : Rapport, etc. (op. cit.). M. Chauveau 
 and his colleagues speak of the goat as being an animal to 
 which Jenner had communicated the vaccine, but this is a 
 mistake.
 
 56 n AND BOOK OF VACCINATION. 
 
 CHAPTER IV. 
 
 OF THE RELATION OP COW-POX AND HORSE-POX TO 
 HUMAN VARIOLA. 
 
 25. Jenner's views on this subject. — It was one of 
 Jenner's fundamental doctrines, that the cow-pox and 
 the horse-pox (or grease, as he at first regarded it) 
 were products of the same virus as produced the small- 
 pox in man. The disease in the horse was considered 
 by him to be the parent disease ; that in the cow and 
 in man as derived diseases. The malignancy and pe- 
 culiarly infectious character of human variola were 
 not, in his view, any essential part of the effects pro- 
 ducible by the variolous poison on the human consti- 
 tution, but were properties at first accidentally super- 
 added, and, when once acquired, capable of propagation. 
 " May it not be reasonably conjectured that the source 
 of the small-pox is morbid matter of a peculiar kind, 
 generated by a disease in the horse, and that accidental 
 circumstances may have again and again arisen, still 
 working new changes upon it, until it has acquired the 
 contagious and malignant form under which we now 
 commonly see it making its devastations among us?"* 
 If man would only go back to the horse or cow, and 
 take his small-pox direct from them, he might have it 
 apart from these unessential malignant characters. 
 
 * Inquiry into the Causes and Effects of the Variola) Vac- 
 cinae, p. 52.
 
 RELATION TO HUMAN VARIOLA. 57 
 
 And a person having, accidentally or designedly, con- 
 tracted cow-pox, was held by Jenner to be safe from 
 sn^all-pox, not because he had gone through some pecu- 
 liar disease which stood in mysterious antagonism to 
 small-pox, but simply because he had actually gone 
 through small-pox itself. So much of these specula- 
 tions as ascribes the origin of human and vaccine va- 
 riola to the horse has received less attention probably 
 than it deserved, and has certainly had little accept- 
 ance : but the truth of the more essential part of the 
 teaching — the common origin of the Variolar Vaccinae, 
 Variolas Equinae, and Variolae Humanae, from one spe- 
 cific infection — has been established by conclusive ex- 
 periments. 
 
 26. Inoculation of Cattle with Small-pox.— Jenner 
 himself did not perform any inoculations of cattle with 
 the lymph of human variola. But as early as 1801, 
 Gassner, of Gunsburg, by inoculating eleven cows with 
 small-pox matter, produced on one of them vesicles 
 from which he was able to inoculate four children : 
 these children developed the ordinary phenomena of 
 vaccination, and, with lymph from them, seventeen 
 other children were similarly infected.* Thus it hap- 
 pened that in the same year — the third after the pro- 
 mulgation of Jenner's discovery — Loy demonstrated 
 the production of the vaccine disease in the cow by 
 inoculation from Variolae Equinae (§ 14), and Gassner, 
 by inoculation from human small-pox. But the pro- 
 duction of vaccine in the cow by small-pox inoculation 
 is a matter of very considerable difficulty : for one case 
 in which the inoculation succeeds, it will fail in at least 
 
 * Henke's Zeitschrift Ergiinzungs, heft xxx. p. 67. 
 6
 
 58 HANDBOOK OF VACCINATION. 
 
 a dozen. And as Gassner's experiments, somehow or 
 other, were not very widely known, while other experi- 
 ments made about the same time in England and else- 
 where failed, Jenner's doctrine was far from being uni- 
 versally received. Beyond a mere general, though no 
 doubt well-founded, statement made by Dr. McMichael 
 to the Royal College of Physicians, in 1828, that in 
 Egypt it had been discovered by some medical men 
 that fine active vaccine virus might be produced by 
 inoculating the cow with small-pox from the human 
 body, and that several children had been vaccinated 
 with complete success with the lymph thus generated,* 
 there is no account of any further experiments till 
 1830. In that year Dr. Sonderland, of Barmen, man- 
 aged, he tells us, to infect cows with the contagion of 
 variola, by enveloping them in blankets taken from the 
 bed of a patient who had died of small-pox, and by 
 hanging such blankets up around the head of the ani- 
 mal, so that it must breathe the effluvia arising from 
 them. And the result was, that in a few days the cows 
 manifested the symptoms of cow-pox, and lymph taken 
 from them produced genuine vaccine vesicles in the 
 human subject, f Some remarkable circumstances will 
 presently be stated (§ 21), tending strongly to show 
 that vaccinia may be produced in cows by the action 
 of variolous effluvia. All the attempts, however, which 
 were made to infect cows directly by repetition of Son- 
 derland's experiments — as in England, by Mr. Ceely,| 
 
 * Keport of the Vaccination Section of Prov. Med. and Surg. 
 Assoc, 1839, p. 24. 
 
 f Hufeland's Journal, Jan. 1831. 
 
 % Trans. Prov. Med. and Surg. Assoc, vol. viii. p. 380.
 
 RELATION TO HUMAN VARIOLA. 59 
 
 in India, by Mr. Macpherson and by Mr. Lamb,* and 
 on the Continent at the Veterinary School at Alfort, at 
 Berlin, Weimar, Bergen, Dresden, Kasan, Utrecht, 
 and Stockholm — were unsuccessful; for although both 
 at Utrecht and Stockholm a pustular or vesicular erup- 
 tion manifested itself on those parts of the bodies of 
 the animals experimented on which were in immediate 
 contact with the infected coverings, this was evidently 
 of a local non-specific cbaracter.f 
 
 But, in 1836, Dr. Thiele, of Kasan, after several 
 fruitless attempts to infect the cow by inoculation of 
 the variolous virus, at length succeeded in so doing, 
 and in producing thereby the genuine vaccine disease ; 
 from this he raised a stock of lymph for human vaccina- 
 tions, which, at the time his account was published, 
 had gone through 75 transmissions, and been employed 
 in the vaccination of more than 3000 subjects, many 
 of whom had had their security against small-pox tested 
 by inoculation and by the closest exposure to the in- 
 fection of that disease. Dr. Thiele, on various occa- 
 sions afterward, succeeded in producing cow-pox in 
 cows by variolous inoculation, and he attributes much 
 of his later success, after so many early failures, to the 
 precautions he takes in the selection of the animals, and 
 in the mode of conducting the experiments. Cows 
 
 * Trans. Med. and Phys. Society of Calcutta, vol. vi. and 
 vol. viii. Both also tried variolous inoculation on cows, with- 
 out success. 
 
 f Hering, Ueber Kuhpocken an Kuhen, pp. 9-12. Hering 
 thinks that Ketzius, of Stockholm, told him that it had hap- 
 pened to Prof. Billing to produce regular vaccine by inocula- 
 ting cows on the udders with variolous matter, and that a 
 stock of lymph was thus obtained.
 
 60 HANDBOOK OF VACCINATION. 
 
 should be selected from four to six years old, which 
 have recently calved, and if possible which have white 
 or fair teats ; they should be kept at a uniform tempera- 
 ture (15° It.); the inoculation should be performed at 
 the base of the udder, out of the way of licking, the 
 udder being first shaven ; and the variolous lymph 
 should be in a clear limpid state.* Before Dr. Thiele's 
 experiments were known in this country, Mr. Ceely of 
 Aylesbury had succeeded (in February, 1839) in in- 
 ducing vaccine vesicles in two sturks by inoculation 
 with variolous lymph, and in thus establishing lymph- 
 stocks which passed at once into extensive use, so that, 
 in a few months, more than 2000 children had been 
 vaccinated from them.f In many of these subjects the 
 protective value of this variola-vaccine lymph was 
 tested by variolous inoculation by Mr. Ceely himself, at 
 various periods after the vaccination ; no constitutional 
 affection was produced thereby in any case, and the 
 local results resembled in every respect those recorded 
 by Willan as having attended the test inoculations 
 practiced in the early days of vaccination. | In De- 
 cember, 1840, Mr. Badcock, at that time residing at 
 Brighton, without any previous knowledge of Mr. 
 Ceely 's experiments, succeeded in variolating a cow, 
 
 * Henke's Zeitschrift, 1839, heft 1. 
 
 f Trans. Prov. Med. and Surg. Assoc., vol. viii. pp. 379- 
 402. The experiments were made on this occasion on three 
 animals, and succeeded on two ; but Ceely says he has many 
 times failed to variolate the cow, at different seasons and un- 
 der varying circumstances, by precisely or pretty nearly the 
 same modes of operating as were successful in these instances. 
 He gives most valuable hints to those disposed to repeat his 
 experiments. 
 
 X Ibid., vol. x. p. 262, etc.
 
 RELATION TO HUMAN VARIOLA. 61 
 
 and deriving therefrom a stock of genuine vaccine 
 lymph;* and he has from 1840 to the present time, by 
 inoculation of cows with the lymph of human variola, 
 raised stocks of vaccine lymph for use on no fewer than 
 thirty-seven separate occasions. •}■ The lymph thus ob- 
 tained by him is now largely employed ; it has been 
 supplied to many hundreds of practitioners, and very 
 many thousands of children have been vaccinated with 
 it. It is worthy of note, however, as illustrating the 
 difficulty attendant on the production of vaccinia in the 
 cow by variolous inoculation, that these thirty-seven 
 successes represent but 7 per cent, of the experiments 
 undertaken by Mr. Badcock; to obtain them, he had 
 to perform between five and six hundred variolous in- 
 oculations. In 1852, Mr. Ceely's experiments were 
 repeated in America .by Dr. Adams of Waltham, and 
 Dr. Putnam of Boston, who were able, it is said, in 
 consequence, to " furnish the city and neighborhood 
 (of Boston) with all the vaccine matter used there 
 since that period. "J 
 
 * A Detail of Experiments confirming the Power of Cow- 
 pox, etc. 
 
 •j- It must be distinctly understood that every one of these 
 thirty-seven successful experiments was the result of the direct 
 inoculation of the animal with lymph taken from a human 
 ■abject affected with variola; that no case is included in which 
 lymph taken from a cow that had been variolated was used to 
 inoculate other cows. But such transfer wa§ also on one oc- 
 casion made by Mr. Badcock, and a supply of vaccine lymph 
 thus obtained. 
 
 \ Boston (U. S.) Daily Advertise?-, April 14, 1852, as quoted 
 by Simon,— Papers relating to tho History and Practice of 
 Vaccination, p. xiv. 
 
 0*
 
 62 HANDBOOK OF VACCINATION. 
 
 27. Probable Case of Infection of Cattle by Vario- 
 lous Effluvia. — In 1840, Mr. Ceely met with a case of 
 exceeding interest, in which there was good ground 
 for believing that the vaccine disease was induced in 
 cows by variolous effluvia. Eight milch cows and 
 two sturks were turned to graze during the daytime 
 in a meadow at Oakley, in the Vale of Aylesbury, in 
 which the clothes and bedding of a person who had 
 died of malignant variola had previously been exposed 
 almost constantly night and day for a week, and in 
 which they were still always exposed at night, and not 
 always removed in the morning before the readmission 
 of the animals. On one occasion, at least, the cows 
 were observed in the midst of the bed-flock, licking it 
 up. Within twelve or fourteen days of their admission 
 to the meadow, five of the milch cows and one sturk 
 exhibited simultaneously, or almost simultaneously, 
 well-marked cow-pox. It was most clearly ascertained 
 that the animals, which were animals belonging to the 
 place, and had not been brought in from elsewhere, 
 were in good health at the time of their admission to 
 the meadow, and that there was no vaccine disease at 
 the time anywhere in the Vale. None of the milkers 
 had any .sores on their hands, except what they subse- 
 quently got from these cows ; besides, one of the in- 
 fected animals was a sturk. The simultaneousness of 
 the attack in all the animals showed a common cause; 
 and it is not in the least probable that this cause was 
 a sudden epizootic outbreak. For the disease, on the 
 most minute and diligent inquiry, was not met with 
 elsewhere ; and when cow-pox occurs as an epizootic, 
 its characteristic is, not an appearance all at once in 
 many animals in the same dairy, but an appearance of
 
 RELATION TO IIUMAN VARIOLA. 63 
 
 it at the same time, or about the same time, on one 
 or two animals in various different farms. When on 
 any farm several animals are attacked, this is found 
 always to proceed from infection from the one or two 
 primary cases; and Mr. Ceely states that, in the whole 
 course of his experience, he never saw so many primary 
 cases together in a dairy at one time, as on this occa- 
 sion. Lastly, the period of attack — ten or twelve days 
 from the first exposure — corresponds entirely with what 
 might be anticipated if the common cause of the out- 
 break were variolous effluvia.* 
 
 28. Phenomena of successful Variolation of Cows. 
 — The phenomena of successful variolation of the 
 cow, as described by M. Thiele, consist first in the 
 development of "tubercules" under the skin; these, 
 by the fifth day, resemble advancing vaccine vesicles ; 
 and from the seventh to the ninth day they have cen- 
 tral depression, and are found to contain limpid lymph. 
 From the ninth to the eleventh day desiccation sets in, 
 and a crust forms, which on falling leaves a smooth 
 cicatrix. If from three to six punctures have been 
 made, generally not more than one or two vesicles will 
 be found resulting. Ceely states, with great care, the 
 phenomena exhibited in his successful cases. In one 
 of these, though seven punctures were made, and four- 
 teen points, charged half their length with variolous 
 lymph, were introduced, as well as two setons inserted 
 which had been impregnated with small-pox virus, no 
 phenomena indicative of taking were noticed till the 
 tenth day, when some of the punctures were found 
 hard and elevated, and one had assumed the form and 
 
 * Trans. Prov. Med. and Surg. Assoc, vol. x. pp. 211-225.
 
 64 HANDBOOK OF VACCINATION. 
 
 appearance of the vaccine vesicle ; it was nearly circu- 
 lar, had an elevated margin, and a small crust in the 
 depressed center. From this vesicle it was possible, 
 by pains and care, scantily to charge thirty-eight 
 points in the course of an hour, which points were 
 afterward used to inoculate children, and produced in 
 them all the phenomena attending the use of primary 
 cow-lymph. Two other of the punctures in this cow 
 seemed to advance a little, but no lymph formed in 
 them, and the vesicle above described was the single 
 vesicle caused by variolation. In its progress and de- 
 cline this vesicle followed exactly the course of the 
 primary vaccine vesicle in the cow.* 
 
 In the other ultimately successful experiment, the 
 first attempt to inoculate the cow, made in the same 
 way, by seven punctures and two setons, failed ; and, 
 at the end of a fortnight, more small-pox virus, taken 
 at the seventh and eighth days of the disease, was 
 forced into eight punctures, " which were deluged with 
 it, the punctures being afterward irritated with points 
 deeply charged with the same, which were suffered to 
 remain in the punctures." By the fifth day there re- 
 sulted from this last inoculation eight distinct papules, 
 which by the day following had, each of them, all the 
 appearance of the vaccine vesicle. From one of them 
 clear lymph was obtained, with much difficulty, so as 
 scantily to charge thirty-nine points. On the eighth, 
 the ninth, and the tenth days, it was found that four 
 only of the papules had become decided vesicles, and 
 from one or other of these some more lymph was taken. 
 The vesicles were at their fullest development on the 
 
 * Trans. Prov. Med. and Surg. Assoc, vol. viii. p. 382, seq.
 
 RELATION TO HUMAN VARIOLA. 65 
 
 tenth day, and the commencement of the decline on 
 the eleventh was obvious; the crusts fell about the 
 twenty -fourth day.* When the lymph generated by 
 these experiments was employed on the human sub- 
 ject, it was found to produce exactly the same phenom- 
 ena as are developed by primary cow-lymph ;f and it 
 is most important to note, for reasons that will imme- 
 diately appear, that though on some of the subjects in 
 whom this lymph was used, eruptions of roseola and 
 lichen were seen, as is frequently the case when pri- 
 mary cow-lymph has been- used, no eruption with the 
 slightest approach to varioloid character was observed. 
 It is further very material to note that these experi- 
 ments were made with every care to guard against 
 any possible source of fallacy. The small-pox virus 
 used was collected by Ceely himself: every point and 
 tube used was perfectly new. The phenomena were 
 watched by himself and others day by day; and in 
 collecting the products of the inoculation, which was 
 also done by himself in the presence of others, every 
 precaution was employed so that no possible mistake 
 could arise. J 
 
 29. Change which the Variolus Virus undergoes in 
 passing through the Cow. — But though cow-pox in 
 the cow and human variola have been thus clearly 
 proved to arise from the same infection, this infection 
 
 * Trans. Prov. Med. and Surg. Assoc, vol. viii. p. 385. 
 
 f See description of the effects produced on the human sub- 
 ject by variola-vaccine lymph, in chap. v. \ 44. 
 
 J Trans. Prov. Med. and Surg. Assoc, vol. viii. p. 390. The 
 reader must himself consult this admirable memoir fully to 
 appreciate the care with which the whole investigation was 
 conducted.
 
 66 HANDBOOK OF VACCINATION. 
 
 in passing through the cow undergoes such alteration 
 as deprives it of all malignity and of all power of prop- 
 agating itself among the human species by effluvia. 
 The small- pox of man conveyed to the cow produces 
 cow-pox ; but the cow-pox thus induced, retransferred 
 to man, is as incapable as the natural cow-pox itself 
 of producing infectious small-pox. Many tens of thou- 
 sands of persons in England have been vaccinated by 
 various hands (see ante, § 2G) with lymph thus gener- 
 ated — variola-vaccine lymph, as it is called. Mr. Bad- 
 cock alone has performed upwards of 20,000 vaccina- 
 tions with it. So that the properties of the lymph are 
 established on a scale far too considerable for question. 
 30. Experiments of M. Chauveau, etc. — Probably 
 the experiments of Thiele and Ceely have been known 
 chiefly in France through the singularly inaccurate 
 and imperfect account of them given in the classical 
 work of Bousquet,* and probably also the confirmation 
 they have received from the repeated experiments of 
 
 * The fourteen pages devoted by M. Bousquet to the subject 
 of the renewal of vaccine <c en inoculant la varioleala vache" 
 (Nouveau Traite, pp. 437-451), besides many inaccuracies 
 with regard to Thiele's and Ceely's experiments, contain a 
 piece of intelligence which sounds strange and amusing to 
 English ears. M. Bousquet says that, in England, when 
 children were vaccinated with Ceely's variola-vaccine lymph, 
 "les premiers n'ont eu qu'une eruption locale; mais, en pour- 
 suivant les experiences, il s'en est trouve qui ont eu une variole 
 complete, tellement que l'autorite a fait defense de communi- 
 quer ce virus, et a puni une infraction de 300 fr. d'amende." 
 Perhaps this extraordinary statement, for which it need 
 scarcely be said there is not the slightest foundation, may 
 have helped to mislead M. Chauveau and his colleagues. 
 (Vide postea.)
 
 RELATION TO HUMAN VARIOLA. 6T 
 
 Mr. Badcock is there quite unknown ; but certain it is 
 that the variolous origin of cow-pox, which has been 
 completely accepted in this country for the last quar- 
 ter of a century and more, has^ remained in France 
 one of the open questions. And now, some recent ex- 
 periments which have been made at Lyons are said to 
 have shown that it is a delusion to suppose that the 
 inoculation of cows with variola has ever produced 
 cow-pox, for in fact it produces in that animal real 
 small-pox, and nothing else. This statement, how- 
 ever, is not quite new. Once before, at the Veterinary 
 School at Berlin, inoculation of the cow with variolous 
 lymph was performed, and "pustules," it is said, pro- 
 duced, which, when inoculated back on the human 
 subject, were found to reproduce small-pox. No de- 
 tails were given, and the value of the experiment can- 
 not, therefore, be determined.* A similar result is 
 said to have been obtained at Boston (U. S.) in 1860.f 
 But the more recent experiments leading to the same 
 conclusion, which were performed by M. Chauveau, of 
 Lyons, with the assistance of MM. Viennois and Mey- 
 net, are stated in full detail in a most interesting me- 
 moir published by them on this subject ;| and as these 
 experiments satisfied a committee of the AcadCmie des 
 
 * Verheyen, Momoire.sur la Vaccine primitive, in Mem. 
 de l'Acad. ltoyale de Medeeine de Belgique, tome i. But 
 Verheyen gives the statement at second-hand, and refers to 
 Viborg, Saviml. B. iii. S. 112. 
 
 f Boston Med. and Surg. Journ., Feb. 23, 1860, as quoted 
 in the "Year-Book of Medicine for 1860." (New. Syd. Soc.) 
 
 % Vaccine et Variolo : Rapport par MM. Chauveau, Vien- 
 nois, et Meynet, in Memoires et Comptes Rendus de la Soc. 
 des Sc. Med. de Lyon, tome v.
 
 68 HANDBOOK OF VACCINATION. 
 
 Sciences that a distinct small-pox disease may be in- 
 duced in the cow or horse by variolous inoculation, as 
 cow-pox is induced in them by vaccine inoculation, 
 the small-pox virus in its transit through these animals 
 being incapable of conversion into vaccine, they de- 
 mand our most attentive consideration. According to 
 the statements of M. Chauveau and his colleagues, in- 
 oculation of cows or of horses with the lymph of 
 human variola gives rise to no general symptoms of 
 any kind, but is invariably followed by a local erup- 
 tion of papules. These papules in the cow are described 
 as being from two to four millimetres only in diameter, 
 scarcely projecting above the surface, slightly conical, 
 and with the puncture of inoculation visible at the 
 center; they are at their fullest development by the 
 fifth day, and are quite gone by the twelfth, leaving an 
 extremely small blackish crust or scale at the point of 
 puncture ; at no period of their course do they exhibit 
 any tendency whatever to secretion. The authors 
 state that the greater number of persons, competent to 
 form a judgment, to whom these papules were shown, 
 regarded them as the simple result of inflammatory 
 action round an inoculated point, and as indicative of 
 no specific infection ; they themselves, however, con- 
 sider them to be a true variolous eruption, which, it is 
 admitted, is "si peu accuse dans un grand nombre de 
 cas, qu'il faut une certaine habitude pour en constater 
 la presence." There is, in fact, so little of definite 
 character about this eruption, that though the authors 
 can themselves detect it, they would find it difficult, 
 they say, to point out to others the exact characters 
 which should distinguish a successful inoculation from 
 a failure. In the horse, papulation was found, in the
 
 RELATION TO HUMAN VARIOLA. 69 
 
 three experimental inoculations that were made, to be 
 much more evident than in the cow; the papules were 
 conical, reddish, and tender; they ran a course exactly 
 like that of the papules in the cow, and disappeared 
 (" sans qu'on ait constate la moindre tendance a la se- 
 cretion") by gradual absorption and desquamation of 
 the epidermis over their surface. By removing a num- 
 ber of these papules from some cows, and scraping 
 well their inner surface, or by removing the central 
 scales from some of the papules of the horse, and 
 squeezing the little cavities then laid bare, excessively 
 minute quantities of a serous liquid were got, which, 
 when inoculated from cow to cow, or from horse to 
 horse, or from horse to cow, produced much slighter 
 local effects than the foregoing, so that (except in one 
 case, which unfortunately could not be followed out) it 
 was uncertain, even to the authors, whether the inocu- 
 lation had taken or not, but which when inoculated on 
 the human subject reproduced variola. With serosity 
 taken from one of the cows and one of the horses, local 
 vesicles, followed by general varioliform eruption, were 
 in fact produced on three children, and from these chil- 
 dren other variolous inoculations were performed.* 
 These results are regarded by the experimenters as 
 
 * "With regard to some of these cases, however, more par- 
 ticular information would have heen very desirable as to the 
 opportunities the children had of contracting variola by in- 
 fection in the usual way. It is clear there was small-pox at 
 Lyons at the time ; and I think it not improbable that in 
 some of the later inoculations, which were attended with 
 dangerous symptoms, the subjects of inoculation might already 
 have taken infection in the natural way. Refer to the con- 
 cluding note of this chapter. 
 
 7
 
 70 HANDBOOK OF VACCINATION. 
 
 showing that the inoculation of variola on horses and 
 cows produces a true variolous infection, and that the 
 organism of these animals is therefore incapable of 
 transforming variola into vaccine. But they do not 
 appear to me to lead at all necessarily to the conclusions 
 thus drawn. The local effects produced by these inoc- 
 ulations were not in any respect greater than those 
 produced by Ceely in cases which he regarded as fail- 
 ures,* nor than in cases which the authors themselves 
 at first put aside as failures, nor than the results which 
 followed some variolous inoculations of horses (two) 
 performed in 1863 by MM. Le Blanc and De Paul, 
 which were regarded by them as unsuccessful. \ And it 
 is not in the least improbable that if Mr. Ceely, or MM. 
 Le Blanc and De Paul, had, in the cases they describe, 
 dealt with the tumid papules that arose as M. Chauveau 
 and his colleagues did, J they might have got from them 
 the same stuff they had put in, stuff which had under- 
 gone no sort of transformation whatever, but which had 
 lain where it was put, as in a pouch, quite inert, giving 
 rise only to local irritation without inducing any sort 
 of general affection or disease. M. Chauveau and his 
 colleagues are indeed fully aware that, unless they can 
 
 * Ceely, Trans. Prov. Med. and Surg. Assoc., vol. viii. pp. 
 385, 387. 
 
 f Bulletin de l'Acad., tome xxix. p. 370. 
 
 \ No doubt, by removing the papules as they did, these ex- 
 perimenters may have missed a chance of a really successful 
 inoculation. In Mr. Ceely's first successful experiment (op. 
 cit. p. 382) the local phenomena on the fifth day were fully 
 as much developed as any described in the Lyons memoir, by 
 the ninth day he had begun to despair of the inoculation 
 taking, and it was not till the tenth that a vaccine vesicle was 
 developed. (See account in text, \ 28.)
 
 RELATION TO HUMAN VARIOLA. fl 
 
 prove that a disease, a constitutional affection, was im- 
 parted to the animals by variolous inoculation, their 
 experiments will remain inconclusive; and they en- 
 deavor to show that horses and cows that have under- 
 gone what they consider as successful variolous inocu- 
 lation (and all their inoculations of these animals with 
 the matter of natural human variola were successful),* 
 became insusceptible of vaccination. But their exper- 
 iments are far from establishing this : in ten cows and 
 one horse which had had the so-called variolous erup- 
 tion, vaccination took completely on one, imperfectly on 
 three, and on the remainder failed. It is quite true 
 that the same vaccine lymph with which these experi- 
 ments were made, used on three animals on which no 
 variolous lymph had been inserted, took effect in all, 
 and that, generally, the vaccination of cows was found 
 by the experimenters very surely to take effect; but it is 
 a well-known fact that the degree to which cows are sus- 
 ceptible of the vaccine inoculation, independently of any 
 variolous or other experiment having been tried upon 
 
 * Considering the difficulties always more or less attending 
 the transplantation of the exanthematous diseases of one 
 species of animal to animals of another species, the uniform 
 success of these attempts is very remarkable, and in itself sug- 
 gestive of error. Of twelve cows and three horses, in which 
 inoculation with variola was tried, there was not one failure ; 
 and although the results on five cows (they do not remember 
 the number exactly, but are sure it was at least five) inocu- 
 lated at an antecedent period had been regarded at the time 
 as unsuccessful, this judgment was afterward recalled by the 
 experimenters, and ascribed to their not having then made 
 out the real characters of the variolous eruption in the cow. 
 So that the inoculation, according to this account, took effect 
 on the whole twenty animals on which it was tried.
 
 72 HANDBOOK OF VACCINATION. 
 
 them, is very various (see § 12, c), and the test would 
 have to be applied to a much larger extent, and under 
 other conditions,* than has yet been done, to justify such 
 sweeping conclusions. When M. Bouley inoculated a 
 cow with variola with the same results as M. Chauveau 
 obtained, and vaccinated it afterward, he produced reg- 
 
 * Especially it would be desirable that the vaccination 
 should in some cases be tried some time after the variolous in- 
 oculation, and not, as in all these cases, immediately after it. 
 It has been said (I know not with what truth) that the vac- 
 cination of sheep, which only produces, as has been shown, a 
 local affection, and no disease which stands in the place of 
 sheep-pox, will yet for a few weeks render the animals insus- 
 ceptible of sheep-pox. In reference to this, Dr. W. Budd ob- 
 serves: "There is, indeed, evidence to render it probable 
 that, for some weeks after vaccination, sheep are somewhat 
 less prone to take clavelee — sheep-pox — in the natural way ; 
 but there is clearly nothing specific in the protecting influence. 
 Louis has remarked that typhoid fever hardly evej occurs in 
 persons who may at the time be the subject of any other mor- 
 bid disturbance. The two facts are probably of the same or- 
 der." I do not myself, however, lay much stress on this. I 
 simply think that a great deal too much is made of half a 
 dozen cows not taking cow-pox when inoculated with it, and 
 I confess I have not much doubt that, if the vaccination were 
 repeated on those animals, it would be found to take effect on 
 some of them — unless, indeed, they were animals which had 
 already had cow-pox naturally or otherwise. Four attempts 
 to produce the variolous eruption on animals of the ox and 
 horse tribe, which had previously had cow-pox or horse-pox, 
 are said to have failed, but the account is very unsatisfactory. 
 It is quite clear that some local effect was produced, and it is 
 with reference to these experiments on cows that M. Chauveau 
 and his colleagues make the observation, cited before in the 
 text, that they find it difficult to point out to others the differ- 
 ence between failure and success.
 
 RELATION TO IIUMAN VARIOLA. 73 
 
 ular cow-pox; and Ceely informs me that in his vario- 
 lous experiments on cattle he constantly produced the 
 phenomena described by M. Chauveau, and found subse 
 quent vaccination of these animals, in the great majority 
 of cases, successful. Lastly, the experimenters of Lyons, 
 who do not appear to have seen Ceely's original me- 
 moir,* do not in the least dispute his account of the 
 results he met with; only what he mistook for cow- 
 pox vesicles on the cow was the variolous eruption ; 
 and what he produced on children with lymph taken 
 from these vesicles — the effects he describes with such 
 singular care and minuteness — were not, as he imagined, 
 cow-pox at all, but simply inoculated small-pox ! The 
 hundreds of practitioners who in England have for 
 nearly thirty years been using Ceely's or Badcock's 
 lymph, must learn with extreme surprise that all this 
 time they have not been vaccinating, as they supposed, 
 but actually unconsciously variolating their patients 1 
 — that they have in fact been making their patients so 
 
 * They state that they have not seen "the plates," and the 
 memoir has not been published in English apart from them ; 
 they are also to be found in the only complete foreign trans- 
 lation with which I am acquainted, viz., that of Dr. Heim, of 
 Ludwigsburg, though, it must be confessed, sadly spoilt in 
 the coloring they underwent in Germany. There may, how- 
 ever, be some complete translation of the memoir with which 
 I am not acquainted. A sight of the plates would apparently 
 be of little consequence to the Lyonnese experimenters, be- 
 cause, if these should show any vaccine vesicle as the result 
 of the variolous inoculation, it would only, they say, prove 
 that the draughtsman did not know what he was about ! It 
 would at all events have shown them that their own local re- 
 sults on cattle were quite well known in this country twenty- 
 live years before. 
 
 7*
 
 74 HANDBOOK OF VACCINATION. 
 
 many foci of variolous infection!* It seems difficult 
 to treat as serious this hypothetical suggestion of M. 
 Chauveau. 
 
 31. Cattle not shown to be subject to any other 
 Variolous Affection than Cow-pox. — It has been ad- 
 vanced by some distinguished writers — the late Dr. 
 Baron, the friend and biographer of Jenner, held 
 strongly this opinion — that cattle are subject to an 
 epidemic small-pox of their own; probably, they 
 thought, a malignant variety of the disease known to 
 us as cow-pox, but differing from the cow-pox as we 
 see it, just as in the human subject a severe case of 
 natural small-pox might differ from an inoculated case 
 of the same disease. But the facts that have been ad- 
 vanced appear insufficient to sustain this opinion. 
 Great stress has been laid by those who have held it 
 on the resemblance which, in many of its features, the 
 "cattle plague" of last century bore to human small- 
 pox, a resemblance which had struck various distin- 
 guished observers of that period, and from which the 
 authors to whom I refer were led to consider that pes- 
 tilence as nothing else than bovine variola, f The 
 
 * "La variolation mediate" (by which is meant the inocu- 
 lation of human subjects with variolous virus that has passed 
 through the cow, but the statement particularly includes 
 Thiele's and Ceely's results) " comme l'inoculation variolique 
 directe, creerait, si elle se generalisait, un foyer permanent 
 d'infection, qui couvrirait presque toute la surface du globe." 
 (Vaccine et Variole, etc., op. cit.) 
 
 f Dr. Baron even regarded the cow-pox discovered by Jen- 
 ner in £he Gloucestershire dairies as the remains of the vio- 
 lent epizootics of cattle plague which invaded England during 
 last century. (Report of Vaccination Section of Prov. Med. 
 and Surg. Assoc, 1839, p. 12.) Cheshire was, of all the
 
 RELATION TO HUMAN VARIOLA. ?5 
 
 same opinion, it will be remembered, obtained consider- 
 able acceptance for a time respecting the cattle plague 
 which recently made such severe havoc among the 
 herds of Great Britain. Bift I believe I am right in 
 stating it to be now universally accepted that both 
 these plagues — the one of last century and the one 
 with which we have been lately visited — are one and 
 the same disease, that which has been long known 
 abroad as Rinderpest or Steppemurrain ; a disease 
 which, in its course and symptoms, has no doubt points 
 of analogy with small-pox, but which stands in no 
 causal relation to it. Each has its own distinct infec- 
 tion.* 
 
 In support of this opinion, reference has also been 
 made to a disease said to affect cattle in India, to 
 which the natives give the same name which they 
 apply to small-pox in human-kind, calling it Bussunt, 
 Mhata, or Gotee.f To this similarity of name no im- 
 portance whatever is to be attached, for the term, so 
 far as it is applied to cattle, is not limited to one disease 
 in particular, but includes a number of diseases, some 
 of which, so far from being analogous to small-pox, are 
 not attended with any sort of eruption. % Nor are 
 
 counties of England, the one that suffered most from cattle 
 plague during last century; but we have Dr. Percival's au- 
 thority that the covupox was unknown there, and yet it is not 
 less a dairy county than Gloucestershire, and the office of 
 milking is performed also by men and maid-servants indis- 
 criminately. (Letter from Dr. Percival to Dr. Jenner, Baron's 
 Life of Jenner, vol. i. p. 158.) 
 
 * See Third Report of the Commissioners appointed to in- 
 quire into the Origin, Nature, etc. of the Cattle Plague. 
 
 f Rep. of Vaccination Section, etc. (op. cit.), p. 17. 
 
 X Duncan Stewart's Report on Small-pox in Calcutta (1844), 
 pp. 84, 85.
 
 76 HANDBOOK OF VACCINATION. 
 
 those forms of Gotee which are attended with eruption 
 regarded by the natives as in any degree infectious to 
 mankind ; no fear of contracting sores from handling 
 affected animals being entertained by them. From some 
 kind of Gotee, cow-pox is said to have been propagated 
 to the human subject, in 1832, by Mr. Macpherson, 
 who was then the superintendent of vaccination at 
 Moorshedabad.* The disease which at that time pre- 
 vailed among the cattle in that district appears, by his 
 description of it, to have been very like rinderpest, the 
 analogy to small-pox consisting in its being attended 
 with what were called pustules all over the body, term- 
 inating in ulceration. All the cattle in the neighbor- 
 hood became affected, "and among others" (I now 
 quote Mr. Macpherson's words) "two belonging to 
 one of my own vaccinators. I had them covered with 
 blankets, leaving merely the udder and teats exposed 
 to the air; on the seventh day two small pustules made 
 their appearance on the teats of one, which dried up 
 on the tenth, and the crusts were removed on the 
 twelfth day." From these crusts eleven native chil- 
 dren were inoculated; one of them successfully, a 
 vesicle appearing on the fifth day which continued to 
 increase till the ninth day, when it had all the charac- 
 ters of true vaccine ; the child suffered much from fever 
 for four days. Two children were vaccinated from 
 this vesicle with complete success, the symptomatic 
 fever being very severe ; from these two children, five 
 others were successfully vaccinated, and the stock of 
 vaccine thus established was afterward regularly con- 
 tinued. Some of the children vaccinated with this 
 
 * Trans. Mod. and Phys. Society of Calcutta, vol. vi.
 
 RELATION TO IIUMAN VARIOLA. 77 
 
 lymph were tested by variolous inoculation and by ex- 
 posure to variolous infection, and found to be secure. 
 From these facts it is not to be doubted that a case of 
 cow-pox in the cow had been met with ; but what is to 
 be doubted is that the Gotee — the malignant disease 
 above referred to — was the source of this infection. 
 The description of the state of the animal from which 
 the lymph was taken (which I have fully quoted) is, 
 it will be remarked, exceedingly meager; there is not 
 any account whatever of the general symptoms it exhib- 
 ited,* and the eruption, so far from being like that said 
 to be prevalent, viz., one of pustules all over the body, 
 terminating in ulceration, was of a couple of pustules 
 (vesicles) only, having exactly the character of an or- 
 dinary case of casual small-pox. Other occurrences of 
 equal, and in some respects of more remarkable, inter- 
 est took place the year following (in 1833), in another 
 part of India, at Silhat, in Assam, j" A disease then 
 prevailing there among cattle, which the natives called 
 Gotee, and which, like the disease at Moorshedabad, 
 was attended with eruption, Mr. Furnell, a surgeon, 
 made an unsuccessful inoculation with some dry scabs 
 taken from the body of one of the animals, and, being 
 obliged then to leave for a short time, requested another 
 
 * All I think must participate in the "frequent regret" ex- 
 pressed by Dr. Duncan Stewart, in whose official report these 
 cases will be found, that " information was not given moro 
 fully regarding the appearances of the disease in the cows 
 from which he took the crusts, one of which succeeded." 
 (Stewart, op. cit. p. 146.) 
 
 f Trans. Med. and Phys. Soc. of Calcutta, vol. vii. p. 453 
 (Mr. Furnell's account) ; and vol. viii. Appendix, p. 97, seq. 
 (Mr. Brown's account).
 
 78 HANDBOOK OF VACCINATION. 
 
 surgeon, Mr. Brown, to continue the experiments. Mr. 
 Brown's inoculations of four children from similar scabs 
 were all successful. No account is given of the symp- 
 toms which the animals said to have Gotee manifested, 
 nor of the state of the particular cow from which the 
 scabs were taken, except that it was lean and ill con- 
 ditioned, and studded with scabs over the back and ab- 
 domen ; whence it is evident that, in this case, the 
 animal had a generalized eruption of some kind or other. 
 The four children inoculated from the scabs had genuine 
 vaccine vesicles, with the increased constitutional dis- 
 turbance usual when primary cow-lymph is used, and 
 for several weeks the lymph was continued, with the 
 production, as was believed, of only the ordinary effects 
 of vaccine, although afterward there was ground for 
 suspecting that, on some of the children vaccinated 
 during this period, an eruption of some kind (which 
 from subsequent events we need have no hesitation in 
 calling modified small-pox) had manifested itself after 
 the day on which the children had been inspected. At 
 length, however — at the end of about two months from 
 the introduction of this lymph — the vaccinations, as 
 they were believed to have been, of a particular day 
 resulted in unquestionable small-pox. Now as it is 
 quite out of the question that cow-pox on the human 
 subject should have been transformed into small-pox, 
 only one of two explanations of these occurrences is 
 possible : either the disease conveyed from the animal 
 to the children was, from the first, small-pox ; or some 
 of the native children who had been the subjects of the 
 vaccinations of Mr. Brown and the native assistants, 
 during the two months that elapsed before these oc- 
 currences took place, had before the day of their vac-
 
 RELATION TO HUMAN VARIOLA. ?9 
 
 cination been exposed to variolous infection, and con- 
 tracted variola; and from one of these cases variola 
 had been propagated. It is quite certain that the na- 
 tive child from whom the inoculations were performed 
 which resulted in undoubted variola bad had an erup- 
 tion, for it was sent for so soon as alarm was taken, 
 and there were found "a few scabs, about twenty, on 
 his entire body." There can be, I think, little hesita- 
 tion as to which of these explanations should be ac- 
 cepted.* I have not been able to find any particulars 
 of another case referred to by Dr. Baron as having 
 given rise to similar circumstances in the practice of 
 Mr. Wood, at Gowalpara. For the last thirty years 
 we have had no further accounts of Gotee in India, in 
 connection with small-pox. But it would be very in- 
 teresting that further inquiries should be made in that 
 
 * In trying new lymphs it is very essential to be on one's 
 guard against the fallacies that may arise if the subjects on 
 whom they are tried have been exposed, or are liable to ex- 
 posure, to small-pox infection. When, in 1799, Woodville 
 found the natural cow-pox in a London dairy and commenced 
 vaccinating with it at the Small-pox and Inoculation Hospi- 
 tal, he was astonished to find three-fifths of his patients have 
 eruptions not to be distinguished from variola ; and for some 
 time he held that the vaccine disease was an eruptive disease, 
 like inoculated small-pox, and, like it, infectious. Jenner at 
 once pointed out that a fallacy existed — that the effects ob- 
 served were not the effects of "uncontaminated" cow-pox, and 
 that variola itself must, in some way or other, have crept into 
 the constitution. When the same lymph was sent to Berke- 
 ley (whore there was at the time no small-pox), or when it was 
 used by Woodville himself in his large private practice, no 
 eruptions followed. Woodville afterward was quite satisfied 
 of, And admitted, his error.
 
 80 HANDBOOK OF VACCINATION. 
 
 country, not only in reference to this point, but for the 
 detection (and no doubt it will be discovered, if care- 
 fully looked for) of cow-pox in the form in which it is 
 known in Europe and in America, wherever it is met 
 with as a natural disease. 
 
 CHAPTER V. 
 
 OP VACCINIA OR COW-POX IN THE HUMAN SUBJECT. 
 
 32. Cow-pox in the Human Subject. — Cow-pox can 
 only be communicated to the human subject by inocu- 
 lation of the specific virus of the disease ; it is not 
 communicable by effluvia. The inoculation may be 
 made directly from the cow or horse, but is much more 
 surely and conveniently made in the way discovered 
 by Jenner, viz., from a human being who is at the 
 time the subject of the infection. The phenomena to 
 which cow-pox inoculation gives rise in those to whom 
 the infection is communicated for the first time, differ, 
 generally, considerably from those exhibited by per- 
 sons who have already passed through the disease. It 
 will be necessary, therefore, in description, to treat 
 separately of the course of primary and of secondary 
 vaccination. 
 
 (A) COURSE OF COW-POX IN PERSONS NOT PRE- 
 VIOUSLY INFECTED BY IT. 
 
 33. Phenomena and Course of Vaccination. — As 
 there are certain points of difference between the phe-
 
 COW-POX IN THE HUMAN SUBJECT. 81 
 
 nomena which ensue when the lymph used for vaccin- 
 ating is taken from human subjects, and when it is 
 taken direct from the cow, and as vaccination from the 
 human subject is the plan universally, or all but uni- 
 versally, adopted, I shall describe first the course of 
 vaccination thus performed, and then notice such dif- 
 ferences as are observed when lymph from the cow is 
 employed. 
 
 34. Usual Course. — When vaccine lymph taken on 
 the point of a lancet is inserted by puncture on the arm 
 of an infant who has not before been vaccinated, no 
 particular local effect is noticeable for the first two 
 days; but, if the vaccination be about to succeed, by 
 the end of the second, or by the third day, a slight 
 papular elevation is perceptible ; and this, by the fifth 
 or sixth day, has become a distinct vesicle, of a bluish- 
 white color, with a raised edge, and a peculiar, central 
 cup-like depression. This vesicle, the structure of 
 which, like that of the cow-pox vesicle in the cow (§ 6), 
 is cellular, gradually enlarges, and by the eighth day 
 (the day week from the insertion of the lymph) has 
 attained its highest perfection. It is then plump, 
 round, and more decidedly pearl-colored ; it is distended 
 with clear lymph ; the elevation of its margin and the 
 depression of its center are more marked. At this 
 date, or sometimes a few hours earlier, a ring of in- 
 flammation, termed the areola, begins to form about its 
 base, and the vesicle and areola together continue for 
 the next two days to spread. The areola is circular, 
 and, when fully developed, has a diameter of from one 
 to two inches ; it is often attended with considerable 
 hardness and swelling of the subjacent connective tis- 
 sue. The establishment of the areola demands always 
 
 8
 
 82 HANDBOOK OF VACCINATION. 
 
 the attention of the practitioner and student, as the 
 anatomical evidence that the cow-pox has produced its 
 specific effect on the constitution. Other proofs of the 
 constitutional influence of the vaccination are, at this 
 period of its course, generally afforded in the child's 
 restlessness and heat of skin, with (frequently) derange- 
 ment of the stomach and bowels, and with (sometimes) 
 swelling of the axillary glands. But these general 
 symptoms, though seldom altogether absent, are often 
 exceedingly slight; and their absence (provided always 
 that the proper areola is formed) constitutes no reason 
 for doubting the protective influence of the vaccination. 
 After the tenth day the areola begins to fade, the ves- 
 icle begins to dry in the center, the lymph remaining 
 in it becomes opaque and concretes, and, by the four- 
 teenth or fifteenth day, a hard brown scab is formed. 
 The scab gradually contracts, dries, and blackens, and 
 from the twentieth to the twenty-fifth day, falls off, 
 leaving a cicatrix which is commonly permanent, and 
 which in character is circular, somewhat depressed, 
 foveated or indented with minute pits, and sometimes 
 radiated. A well-foveated cicatrix is, next to having 
 watched the vaccination through its course, the best 
 test we have of the security of the system against 
 small-pox. On comparing the course of cow-pox as it 
 manifests itself in the human subject with its course in 
 the cow, we find that the phenomena are essentially 
 alike, but that there exist, at the same time, certain 
 points of difference. In the human subject the vesicles 
 are fresher, juicier, and more convex ; their appearance 
 is more exactly simultaneous ; they have more uni- 
 formly, and more essentially the central depression; 
 and the areola is much broader and much more marked.
 
 COW-POX IN THE HUMAN SUBJECT. 83 
 
 When the mode of inserting or applying the lymph 
 has not been by single puncture, nor by such abrasion 
 of the skin as would raise a single vesicle, but by two, 
 three, or more punctures close set together, or by scar- 
 ifications or abrasions over some extent of surface, in 
 a manner that will hereafter be described (§ 50, c. 3), 
 so that two, three, or more vesicles are developed in 
 close proximity, these usually coalesce, and a vesicle 
 results, the compound character of which is very ob- 
 vious ; or there may be a crop of coalescent vesicles, 
 each having its distinct head with characteristic depres- 
 sion. These compound vesicles and crops are round, 
 oval, or of irregular outline, according to the manner 
 in which they have been induced, and the shape of the 
 resulting cicatrices varies accordingly. 
 
 The clear, smooth, supple, delicate skin of the infant 
 is peculiarly adapted for manifesting in perfection the 
 local characters of the vaccine disease. In elder chil- 
 dren, and much more in adults, though the phenomena 
 of primary vaccination are essentially the same as in 
 the infant, the vesicle is often wanting in that plump- 
 ness, sharp definition of edge, and beautiful luster, 
 which the experienced vaccinator delights to see. 
 
 35. Constitutional Symptoms; Vaccine Roseola, 
 Vaccine Lichen, etc — In some instances constitutional 
 symptoms are noticed before the formation of the areola 
 — never, however, amounting to more than a little fe- 
 verishness and fretfulness, most observed in the even- 
 ing, and remitting in the morning, about the sixth or 
 seventh day;* but in elder children, and still more in 
 
 * From notes with which Mr. Squire, of Orchard Street, 
 has favored me, of a few observations made by him on the
 
 84 HANDBOOK OF VACCINATION. 
 
 adults, who arc the subjects of primary vaccination, 
 these early symptoms are usually more marked. The 
 amount of the constitutional affection which, two or 
 three days later, attends the development of the areola 
 (see previous section), varies in different subjects with 
 the texture and vascularity of the parts, with the ex- 
 tent of local inflammation, and with the temperament 
 and age of the individual ; infants suffer usually less 
 than elder children, and these less than adults. But, 
 even with the most perfect areola, the general symp- 
 toms are often very trifling. In adolescents and 
 adults the course of primary cow-pox is apt to be 
 somewhat more retarded than in infants, the areola is 
 frequently much more diffuse, and there is much oftener 
 swelling of the axillary glands. In young children of 
 full habit, especially in hot weather, about the ninth or 
 tenth day, when the areola is at its height, an eruption 
 of roseola will occasionally take place, especially on 
 the extremities ; sometimes the eruption takes a papu- 
 lar form, constituting what is termed vaccine lichen ; 
 sometimes it is vesicular.' In the latter case, however, 
 the vesicles have no resemblance to the cow-pox vesi- 
 cles, but are more like those of chicken-pox ; that dis- 
 ease, in fact, occurring in the course of a vaccination, 
 might easily, without due care and inquiry, be mis- 
 taken for the vesicular eruption which occasionally 
 attends the course of regular vaccine. But the occur- 
 
 temperature, as indicated by the thermometer, of children at 
 different stages of vaccination, it appears probable that a rise 
 will generally be found existing by the sixth day, or even per- 
 haps a day earlier. Mr. Squire is, I believe, continuing these 
 interesting observations.
 
 COW-POX IN THE HUMAN SUBJECT. 85 
 
 rence of any of these forms of eruption during vaccin- 
 ation is the exception and not the rule : when they do 
 occur, their duration is, for the most part, very transi- 
 tory, usually not extending beyond a week, and very 
 seldom indeed lasting beyond the falling of the scab. 
 Their appearance is almost limited to the* period of 
 childhood: they are very rarely seen on adolescents or 
 adults. 
 
 36. Abnormal course. — But vaccinia in the human 
 subject does not invariably follow the course above 
 described. Its progress may be (a) retarded, (b) ac- 
 celerated, or (c) altogether irregular and spurious. 
 
 (a) Retarded Cow-pox. — The most simple and fre- 
 quently seen form of retardation is a mere delay of a 
 day or two in the course of the vesicle ; by the eighth 
 day this has not more size and development than or- 
 dinarily it has on the sixth, and the areola does not 
 form till the tenth day, or even later. This amount of 
 retardation is held by many experienced vaccinators to 
 be more frequently met with in cold weather, especially 
 during the prevalence of a dry easterly wind, in persons 
 who are much exposed to the air. Sometimes a longer 
 delay occurs ; at the end of a week from the vaccination, 
 when the child is brought for inspection, there is so 
 little evidence of result, that it is a question whether the 
 vaccination has not altogether failed ; some fresh lymph 
 is inserted on other spots, and as the vesicles of the 
 new vaccination rise, those of the first vaccination are 
 seen also to develop themselves, the two vaccinations 
 running their course at the same time. Bousquet re- 
 fers to a case (not in his own practice) in which this 
 sort of revival of a dormant vaccination was said to 
 8*
 
 86 HANDBOOK OF VACCINATION. 
 
 have been brought about at the end of three weeks.* 
 But without any recourse to a second vaccination, it 
 will sometimes be found that vesicles will rise some 
 days, or a week, or more, after the usual period, and 
 when success had ceased to be looked for. A tardy 
 development of the vesicle occurs much more frequently 
 when the vaccination has been done with dry lymph 
 than when it has been performed direct from the arm. 
 In many of these cases, indeed, the vaccine process can 
 scarcely properly be said to have been retarded ; the 
 lymph, no doubt, at the time that it was deposited on 
 the cutis, was in a dry or undissolved state, and it 
 simply waited solution to be taken up by the system. 
 A mere retardation of cow-pox in a healthy individual 
 does not in the least impair its protective value, pro- 
 vided only the phenomena be regular in their char- 
 acter. 
 
 Effects of incubation of Measles, Scarlatina, etc. on 
 course of Cow-pox. — Certain temporary conditions of 
 the system may operate to retard cow-pox. If vac- 
 cination has been successfully performed during the in- 
 cubation of measles, but the vesicles have not reached 
 their mature or areolar stage by the time that disease 
 manifests itself, it will very frequently, if not usually, 
 be found that they will not go through that stage until 
 such time as the measles have subsided. In such 
 cases the areola may not be formed till a fortnight or 
 more after vaccination, or it may not be formed at all. 
 The same has been observed with regard to scarlatina 
 and chicken-pox, and the early or febrile stage of hoop- 
 
 * Nouveau Traite de la Vaccine, p. 17G.
 
 COW-POX IN THE HUMAN SUBJECT. 87 
 
 ing-cough.* Jenncr gives a very interesting account 
 of two sisters in whom scarlatina manifested itself on 
 the eighth day from vaccination. In one, the vaccine 
 vesicle remained at its maturity, but " there was a 
 total suspension of areola till the scarlatina had retired 
 from the constitution ;" as soon as this occurred, the 
 areola advanced in the usual way. In the sister, the 
 symptoms indicative of scarlatina came on severely for 
 about twelve hours; then a rash showed itself faintly 
 upon the face and part of the neck, but in two or three 
 hours suddenly disappeared, and the patient was free 
 from every complaint ; it was then observed that the 
 vesicle had the usual areola, and this continued till the 
 fourth day, when it subsided, and scarlatina again ap- 
 peared, and went through its course with the common 
 symptoms, f It is not always, however, that scarla- 
 tina, or measles, or chicken-pox acts thus on the course 
 of cow-pox, or cow-pox on them ; vaccination has been 
 repeatedly seen running its course along with them and 
 uninfluenced by them. J The course of cow-pox when 
 accompanied by any of the specific febrile eruptive dis- 
 eases should be watched most carefully throughout, 
 
 * See interesting cases in point by Aikin, London Med. 
 Gazette, vol. xiii. p. 752, seq.; also Addington's eleventh and 
 twelfth cases, as cited by Ring, Treatise on Cow-pox, p. 524. 
 
 f A continuation of Facts and Observations, etc. 
 
 X Jenner (Further Observations, etc., p. 137) gives a case of 
 this kind. Various instances will be found recorded in Ring 
 (op. eit.). He also relates several cases of small-pox and measles, 
 running their course together, uninfluenced the one by the 
 other; and one case in which small-pox, measles, and hooping- 
 cough coexisted. (See, particularly on this subject, Marson's 
 Paper on the Coexistence of the Eruptive Fevers, Med.-Chir. 
 Trans., vol. xxx.)
 
 88 HANDBOOK OF VACCINATION. 
 
 and no warrant of protection against small-pox given 
 unless a regular areola has been developed. 
 
 Effects of incubation of Small-pox. — When vaccina- 
 tion has been performed on any one who is incubating 
 small-pox, if the incubation of that disease be so far 
 advanced that the small-pox manifests itself within two 
 or three days of the vaccination, no vaccine vesicles 
 will rise, but small-pox only will be developed.* But 
 if the incubation has been less advanced, and the cow- 
 pox has taken local effect before the small-pox symp- 
 toms s,et in, the further progress of the vaccination 
 may, or may not, be retarded. Very frequently the 
 two diseases will be seen going on together, so distinct, 
 the one from the other, that lymph from the cow-pox 
 vesicles will certainly produce cow-pox and cow-pox 
 only, and lymph from the small-pox vesicles will pro- 
 duce small-pox and small-pox only.f If, however, the 
 cow-pox vesicles had not reached the stage -of areola 
 before the small-pox set in, no influence will be pro- 
 duced on the course of the small-pox ; if, on the other 
 hand, the areola be fully formed round the cow-pox 
 vesicles before the small-pox symptoms appear, the 
 vaccination will, according to its date, either arrest 
 the small-pox at its premonitory stage, or alter and 
 
 * Under these circumstances variolous vesicles will often be 
 met with on the vaccinated spots. (See cases in point, King's 
 Treatise, etc., pp. 483 and 525. Also "Willan oil Vaccine In- 
 oculation, p. 8, note.) 
 
 f So distinct are they, that the variolous pustule may be 
 developed within the margin of the vaccine vesicle, and matter 
 taken from it produce small-pox, while fluid taken from the 
 opposite edge of the vesicle communicates cow-pox. (See 
 Willan on Vaccine Inoculation, p. 6, note.)
 
 COW-POX IN THE HUMAN SUBJECT. 89 
 
 modify the course of the eruption. This is a distinc- 
 tion of great practical importance, to which I shall 
 further advert hereafter (§ 50, a). In consequence of 
 the frequent delay of parents to have their children 
 vaccinated until epidemics of small-pox break out, it 
 is no uncommon thing to see variola and vaccinia con- 
 current. 
 
 (b) Accelerated Cow-pox. — A hastened course of 
 the cow-pox vesicle is to be regarded with much more 
 suspicion, in reference to its effect on the protection of 
 the individual, than a retarded course, for spurious 
 vaccination is generally accelerated. There may be, 
 however, simple acceleration — a course some twelve or 
 twenty -four hours in advance of the usual course ; the 
 vesicle on the eighth day being in the state in which it 
 is usually seen on the ninth, the areola nevertheless 
 being regular, and the crust being subsequently duly 
 formed. In such cases the protective value of the vac- 
 cination is not impaired. 
 
 (c) Spurious Cow-pox. — "Vaccination sometimes 
 runs an entirely irregular course. The varieties of 
 irregularity are considerable. In the form most fre- 
 quently seen, the course resembles very closely that of 
 a revaccination (§ 4?) : the vesicle begins with itching 
 
 / and irritation ; it is acuminated or conoidal, instead of 
 being flat and with central depression, and it contains 
 straw-colored or opaque fluid, instead of clear lymph ; 
 it has an early and irregular areola, which is at its 
 height by the fifth or sixth day, and when seen on 
 the day week is far on the decline; there is then a 
 small scab on the surface which usually drops off by 
 the tenth day. The local effect in some cases is 
 much less than this, and on the day week there is no-
 
 90 HANDBOOK OF VACCINATION. 
 
 thing to be seen but a very thin scab or scale just 
 about to detach itself, and which at the lightest touch 
 falls off. In other cases, the vesicles, when seen on 
 the eighth day, are found to have burst, and present an 
 irregular pustuloid or scabby appearance, or are so 
 many open sores. It would be difficult, and is quite 
 unnecessary, to give a minute verbal description of 
 each form of irregularity that may be observed ; the 
 real important practical point being, that a vaccination 
 presenting any deviation from the perfect character of 
 the vesicle, and the regular development of the areola, 
 is not to be relied on as protective against small-pox. 
 
 Causes of Spurious Cow-pox. — A spurious and ir- 
 regular course of the vaccine vesicle is sometimes seen 
 to occur where no cause can be assigned for it, as in a 
 child apparently perfectly healthy, and when the vac- 
 cination has been done by a careful and experienced 
 hand, with lymph which in other children has produced 
 only its normal effects. Occasionally the best vaccin- 
 ator may find that on a particular day some of his cases, 
 done probably from different sources, present more or 
 less of deviation from the normal results — whence it 
 has been assumed, for want of other explanation, that 
 there may be an occult and indefinable influence of 
 season or weather. But these are the exceptions — the 
 rare exceptions ; and far, far more commonly, spurious 
 vaccination may be traced directly to one of two causes 
 — either to the use of lymph which was not well chosen 
 by the vaccinator or which has been spoilt in the stor- 
 age or keeping, or to something amiss in the state of 
 the child vaccinated. The former of these causes is 
 illustrated by the occurrence of various forms of ir- 
 regularity in several children, vaccinated all from one
 
 COW-POX IN THE HUMAN SUBJECT. 91 
 
 and the same source ; the latter in children vaccinated 
 from unexceptionable sources, but in whom the pres- 
 ence, at the time of vaccination, of one or other of those 
 affections which, like herpes, intertrigo, etc., frequently 
 interfere materially with the regular progress of the 
 vaccine vesicle, had been overlooked or disregarded.* 
 
 * My experience supplies me with numerous instances of 
 cither kind. Some two or three years ago I saw nine chil- 
 dren who had been vaccinated the day-week previous, in each 
 of whom the vaccination was running an irregular course. I 
 found on inquiry that they had all been done from one source, 
 and that a source which, from the description given of it, 
 ought not to have been employed — a case in which the lymph 
 was thin and serous, running down the arm in profusion when 
 the vesicles were opened. On a subsequent occasion I saw, in 
 a large town in the south of England, spurious results in every 
 one of several children vaccinated the day-week previous, it 
 was believed all from one child ; and one of these irregular 
 cases was being used for the vaccination (?) of some more chil- 
 dren. The other kind of error is of more frequent occurrence ; 
 and seldom many weeks pass but that I see some irregular 
 case or another, and am able, by looking behind the ears of 
 the child, or in the folds of its neck, etc., to point out to the 
 vaccinator the cause of the irregularity. " If we see the vac- 
 cine pustule," says Jenner, "straying a few days after the 
 insertion of the vaccine fluid, we must not be content with a 
 superficial examination of the skin of our patient, but we shall 
 find it necessary to make a more minute inquiry. For after 
 a general examination without detecting conspicuous herpetic 
 blotches, we shall find perhaps that the child has an herpetic 
 eyelid, a speck behind the ears, or an excoriation in other 
 parts oozes out this fluid, which produces impediment. I find 
 that in many instances an abraded cuticle, not larger than the 
 surface of a split pea, is as capable as a blotch of fifty times 
 the extent, of producing this effect." (Letter to Dr. Labatt, 
 Jan. H, 1821, in Dub. Quar. Journal of Med. Sci., vol. xxvii. 
 p. 471.)
 
 92 HANDBOOK OF VACCINATION. 
 
 The best proof how much irregular and abnormal re- 
 sults of vaccination are dependent on the want of care 
 and skill of vaccinators, is the frequency with which 
 they are seen in the hands of some vaccinators, and 
 their great comparative rarity in the hands of others. 
 
 37. Effects of Mechanical Interference. — Mechani- 
 cal irritation of the vesicles of cow-pox, friction of the 
 clothes, scratching with the nails, etc., may cause the 
 vesicles to be prematurely ruptured, and may otherwise 
 materially affect the course of the disease; they should 
 always therefore carefully be guarded against. These 
 occurrences are more frequently met with in children 
 who are past babyhood when they are vaccinated, than 
 in young infants. But it is not at all an un frequent 
 thing to find a spoilt and broken appearance of the ves- 
 icles on the eighth day ascribed to rubbing, when in 
 fact it is really a form of spurious vaccination resulting 
 from one or other of the causes stated in the preceding 
 paragraph.* 
 
 * It is an interesting subject of inquiry how far a vaccina- 
 tion, the vesicles of which have been early broken, or are other- 
 wise spoilt or spurious, affects, or may affect, the constitution 
 as regards its liability to small-pox. In some cases of this 
 kind, vaccination duly performed soon afterward goes through 
 its regular course as if nothing had been done before ; and in 
 such cases we can have no doubt that the effect of the first 
 vaccination had been nil. But oftentimes, after spurious re- 
 sults, a repetition of the vaccination will only produce an ir- 
 regular and incomplete effect. Yet we have abundant evidence 
 that persons whose vaccination has been disturbed or imper- 
 fect are liable, if they do not take care to get revaccinated, 
 to contract small-pox and to have it badly. Ceely mentions 
 having met at different times with several cases in which vac- 
 cination took imperfectly, and in which subsequent vaccina-
 
 COW-POX IN THE HUMAN SUBJECT. 93 
 
 38. Degeneration of the Vaccine Vesicle ; Erysipe- 
 las, etc. — In a small proportion of cases vaccination, 
 especially if it has taken effect in a hastened or spurious 
 form, will in its course manifest inflammatory symp- 
 toms of considerable activity, and very sore arms will 
 result; the vesicle degenerating into a purulent ulcer, 
 or sometimes into a sloughing sore, leaving a cicatrix 
 which has none of the characteristic pittings, but is 
 simply a puckering, or a flat, smooth, shining scar. In 
 a still smaller proportion of cases true erysipelas may 
 occur. These events, it need scarcely be said, deprive 
 the cow-pox of its specific protective power. Small- 
 pox, and of a very severe kind, is frequently met with 
 in persons having the sort of cicatrix just described. 
 Lymph taken from revaccination cases, or from spu- 
 rious primary cases, or the lymph of normal primary 
 cases, if taken at too late a period of the vesicle, or if 
 kept so as to have become partially decomposed, may 
 give rise to these consequences ; but at other times 
 they are met with where no possible fault can be found 
 with the lymph, other children vaccinated with the 
 same lymph going through their vaccination in a per- 
 fectly normal way. The cause must then be looked 
 for either in the constitution and habit of body of the 
 child vaccinated, or (so far as erysipelas is concerned) 
 
 tion three or four months after took (not perfectly, hut) less 
 imperfectly. But one of these cases failing to appear, for re- 
 vaccination, as desired, sustained ahout ten years afterward a 
 severe attack of small-pox. (See an interesting note at p. 411 
 of his Memoir, op. cit.) Practically, revaccination should 
 always be carefully performed, whenever there has been any 
 irregularity, whether from mechanical disturbance or other- 
 wise, in the character of the tirst vaccination. 
 
 9
 
 94 HANDBOOK OF VACCINATION 
 
 in the " constitution of the air," to use Sydenham's 
 convenient form of expression. Accordingly, cases of 
 erysipelas following vaccination, when they do occur, 
 are not unfrequently met with two or three together in 
 one locality, and at times when erysipelas is noticed 
 as attending wounds from other surgical operations. 
 
 39. Effects of Climate on the course of Vaccination. 
 — In climates like our own, or in colder countries, the 
 utmost effect of season, of hotter or of colder weather, 
 is but to accelerate or to retard (and that only excep- 
 tionally, and seldom beyond a few hours) the course of 
 vaccination ; but the heat and moisture which at cer- 
 tain seasons of the year prevail within the tropics, and 
 in places with tropical climates, interfere considerably, 
 according to the best authorities, with the regular pro- 
 gress of the vaccine disease. In the northwest pro- 
 vinces of India, and to a less degree in Bengal, it has 
 been observed that, after the hot season has set in, 
 vaccination is less successful ; that in Calcutta, for in- 
 stance, it is only among the European and better-off 
 classes, who can afford to look after their children, and 
 protect them properly from the heat, that vaccination 
 can at this season be prudently performed.* But the 
 rainy season is even more inimical to successful vac- 
 cination in Bengal. At that period of the year, "in 
 some, if not all, the districts of Lower Bengal, the sim- 
 ple puncture for the insertion of vaccine virus fre- 
 quently produces violent inflammation, which either 
 degenerates into foul sloughing sores, or the same de- 
 generation succeeds to the maturation of the vesicle. 
 
 * See Keport of the Small-pox Commissioners appointed by 
 the (Indian) Government in 1850, pp. 50, 51.
 
 COW-POX IN THE HUMAN SUBJECT. % 
 
 In both cases vaccination must necessarily be suspended 
 for a time."* The Bengal Sanitary Commissioners 
 have recently also stated that the cool season of the 
 year is that in which alone vaccination can usually be 
 practiced with success in the plains of India, though 
 in the more temperate climate of the hills it can be 
 carried on almost throughout the year.f In most 
 parts of the Bombay Presidency, and in Sind, as would 
 appear from the annual official reports, vaccination is 
 carried out at all seasons of the year. None, or scarcely 
 any, of the surgeons officially employed in the perform- 
 ance and direction of vaccination in that Presidency, 
 find it necessary to omit vaccinating on account either 
 of the hot or the rainy season. But some of them 
 state that at these periods of the year difficulty is ex- 
 perienced in keeping lymph, so that they are obliged 
 to be then especially careful to maintain a series of 
 cases from arm to arm ; and some also note that the 
 operations are attended with a minor degree of success, 
 and with occasional deterioration of the vaccine vesicle. J 
 It would appear, on the whole, that in the cooler parts 
 of India vaccination may be performed at any period 
 of the year, but that in the hotter parts the best months 
 for vaccinating are from October till March. The ex- 
 perience of Dr. John Davy, in Ceylon and in the West 
 Indies, induced him to consider the cool season, the 
 winter months, as the best for vaccinating within the 
 tropics. 
 
 * See Report of the Small-pox Commissioners appointed by 
 the (Indian) Government in 1850, p. 51. 
 
 -}• First Annual Report, p. 60. 
 
 \ Reports (presented annually) on Vaccination, throughout 
 the Bombay Presidency and Sind.
 
 96 HANDBOOK OF VACCINATION. 
 
 40. Supernumerary Vesicles. — A very interesting, 
 but quite exceptional, phenomenon in the course of vac- 
 cination is the development of vaccine vesicles on parts 
 of the body where no vaccine lymph had been inserted ; 
 these are termed " supernumerary vesicles." They are 
 sometimes only two or three in number, at other times 
 eight, ten, twenty, or more, in various situations over 
 the body and limbs. Accidental supernumerary vesi- 
 cles — the result of a chance puncture with a lancet 
 charged with vaccine lymph, or of an accidental appli- 
 cation of lymph to an abraded surface — are by no 
 means rare ; but the phenomenon to which I refer is 
 the development of vesicles where, it is believed, none 
 of these accidental occurrences can have taken place — 
 vesicles which are really eruptive, and which neverthe- 
 less, as proved by the effect of vaccinating from them, 
 are of genuine vaccine character. The cares on record 
 seem to establish that real eruptive supernumerary 
 vesicles mmj occur in the course of an ordinary vaccin- 
 ation ; but so rare at all events is their occurrence, 
 that Bousquet, in his long career, has only seen two or 
 three instances of them (which, he says, at the time 
 satisfied his mind, but concerning which on subsequent 
 reflection he has been led to entertain doubts) ; and 
 Marson's vast experience, which amounts to about 
 60,000 vaccinations, does not, he informs me, enable 
 him to say more than that he has seen cases of addi- 
 tional vesicles which he thinks were eruptive.* In all 
 
 * Like many practitioners, I have seen cases of supernume- 
 rary vesicles, but never of any which I could regard as erup- 
 tive. M. de Paul stated, in a discussion at the Acad. Imp. de 
 Med., that he had seen five cases of eruptive vesicles, but gave 
 no particulars of them. (Bull, de l'Acad., tome xxix. p. 203.)
 
 COW-POX IN THE HUMAN SUBJECT. 97 
 
 cases of "supernumerary vesicles," we are not justi- 
 fied in regarding these as an eruption of vaccine until 
 we have satisfied ourselves, first, that the vesicles are 
 of real vaccine character, and not an ordinary vesicular 
 eruption attendant on cow-pox — this may be inferred 
 from their appearance, but proved by inoculating the 
 fluid from them ; secondly, that the vesicles, if genuine, 
 are not after all accidental, the result of an uninten- 
 tional inoculation of lymph by the vaccinator, by the 
 child, or by its nurse — for, as Ceely justly remarks, 
 " It is rare, indeed, for them to be found on spots to 
 which lymph might not have been directly applied," 
 and if the lymph be good and active, it is not indispens- 
 able that the skin should have been visibly abraded ;* 
 
 In the Annual Keports of the vaccinations in France for 
 twenty-four years (1841-64) I find but eight cases of super- 
 numerary vesicles reported by the different vaccinators, and 
 in four of these the accounts render it probable that the super- 
 numerary vesicles were accidental. Three of the remaining 
 four cases stand entirely on the accuracy and habits of obser- 
 vation of the individual reporters, and it can scarcely be said 
 of all of them that the accounts are quite conclusive. But in 
 one case (in 1841) the whole circumstances, the existence of 
 the supernumerary vesicles and the results of the vaccinations 
 performed from them, were watched by members of the Vac- 
 cine Commission of the Academic 
 
 * " Use active liquid lymph in great abundance to every 
 puncture, made so as to draw blood rather freely; wipe the 
 lancet over the puncture, leaving it covered all around with 
 lymph ; take care, by attention to position, etc., that the blood 
 shall dry over and around the wound, and thus cover the 
 _lymph. It will often happen, in young and favorable skins, 
 that one or two supernumerary vesicles will appear at a greater 
 or less distance from the punctures, which, in time, nearly or 
 completely coalesce. Sometimes they will appear even two or 
 
 9*
 
 98 HANDBOOK OF VACCINATION. 
 
 and, thirdly (and this applies particularly to those cases 
 in which the supernumerary vesicles are many in num- 
 ber, and have somewhat of the character of a general 
 eruption), that we have not mistaken for vaccine vesi- 
 cles an eruption of modified variola accompanying 
 vaccinia, such as happens in a person vaccinated during 
 the incubation of small-pox — the variolous eruption 
 under such circumstances being often very sparse, and 
 the vaccine vesicles and small-pox vesicles more or less 
 resembling one another. Each of these kinds of mis- 
 take has been made, and the second kind, viz., that of 
 mistaking accidental for eruptive, supernumerary vesi- 
 cles, very often made. 
 
 41. Reinsertion of Vaccine Lymph within five days 
 of a successful Insertion; Bryce's Test. — If, at any 
 period not later than the fifth day from the successful 
 insertion of vaccine lymph into the arm of a child, a 
 fresh insertion of lymph be made, this second vaccina- 
 tion will take effect as certainly as if no previous vac- 
 cination had been done ; but the vesicles arising, while 
 corresponding in size to the date of their origin, will 
 overtake in their course the vesicles first made, will ar- 
 rive at maturity and will fade at the same time with 
 them. Thus, if a child be vaccinated with effect on a 
 
 three inches distant from the puncture, when the blood, mixed 
 with lymph, has trickled down and dried there." (Ceely, in 
 Trans. Prov. Med. and Surg. Assoc, vol. viii. p. 326, note.) 
 In one case a vesicle, produced in this way at a distance of 
 four inches from the inoculated vesicles, attained on the twelfth 
 day the size of a small horse-bean, and having no firm, con- 
 nection with the skin at its center, like the casual vesicle on 
 the cow, it acuminated on the eleventh day, as perfectly as on 
 that animal. (Ibid., p. 400, note.)
 
 COW-POX IN THE nUMAN SUBJECT. 99 
 
 certain day, and some good active vaccine lymph be 
 inserted, say on the fourth or fifth day afterward, the 
 vesicles of this second insertion will by the tenth day 
 of the original vaccination not usually be larger than 
 ordinary vesicles of the sixth or fifth day, but they will 
 have an areola as advanced as the areola round the ves- 
 icles of the first insertion, and the incrustation and fur- 
 ther progress of the two inoculations will go on simul- 
 taneously. Had the second insertion been made a day 
 or two earlier, as by the second or third day of the 
 vaccination, the vesicles developed by it would have 
 got larger by the time the first insertion was at its 
 maturity than in the case just cited ; but, just as in it, 
 whatever was the day of maturity of the first inser- 
 tion would be the day of maturity of the second. 
 That this result, however, may follow a second inser- 
 tion of lymph, such insertion must be always made 
 within five days, i.e. within five times twenty-four 
 hours, from the primary insertion. If it be delayed 
 beyond this, it will fail ; there will either be no result 
 or a mere hard papule. No doubt there are apparent 
 exceptions to this rule, and cases are now and then 
 met with where lymph takes effect though not inserted 
 until the sixth or seventh day of a vaccination ; but 
 these, it will be found, are not real exceptions, they 
 are simply cases in which the course of the vaccina- 
 tion has been retarded, the areola, instead of appear- 
 ing on the eighth day of the first insertion, not coming 
 on till the ninth or tenth. 
 
 Its history. — The very first account, indeed, we have 
 of any experimental reinsertion of lymph during the 
 early stages of a vaccination, was in a retarded case 
 It was in a vaccination performed in 1T99, by .Tenner's
 
 100 HANDBOOK OF VACCINATION. 
 
 friend and correspondent, Henry Hicks. In two cases 
 of vaccination in which the arms on the sixth day ap- 
 peared to be not much more forward than they gener- 
 ally are on the third or fourth, and the appearances 
 were somewhat irregular, he two days afterward in- 
 serted some fresh lymph. "The second inoculation 
 seemed to make immense strides to overtake the first, 
 and, what is wonderful, the first pustules began to 
 change their character and to put on the true vaccine 
 character."* Jenner afterward (in 1801) made an ex- 
 perimental inoculation of this kind on a child with 
 lymph taken from the vesicle which was developing 
 itself on the child's own arm.f But it was Mr. Bryce, 
 of Edinburgh — one of the early and one of the best 
 writers on vaccination! — who first instituted any num- 
 ber of these experiments, or who suggested any prac- 
 tical application of the discovery. Starting with the 
 belief that there might be a. perfect local development 
 of the phenomena of vaccination without such affection 
 of the system as would impart security against small- 
 pox, he thought that, by inserting lymph always on 
 the fourth or fifth day of a vaccination, the existence 
 or absence of this constitutional affection might effect- 
 ually be tested. He argued that unless the system 
 were preoccupied by the vaccine influence, any inocu- 
 lation of vaccine lymph would of course produce effects 
 which would go through the ordinary periods of 
 action, and that an acceleration or cutting short of 
 these periods was to be taken as evidence of the con- 
 
 * Baron's Life of Jenner, vol. i. p. 331. 
 f Ibid., vol. i. p. 450. 
 
 \ Practical Observations on the Inoculation of Cow-pox, 
 Edinb: 1802; and 2d edition, 1809.
 
 COW-FOX IN THE HUMAN SUBJECT. 101 
 
 stitutional affection of the vaccine. Hence the practice 
 has become generally known as "Bryce's test." He 
 recommended that it should be systematically em- 
 ployed. The reasoning is ingenious, and the phenom- 
 ena are interesting, but the necessity of the practice 
 has never been generally admitted, and the practice it- 
 self is now wholly disused. Jenner recommended it 
 to the uninitiated, but, as he justly observed, the 
 course of the vaccination will be sufficient to enable 
 the experienced to determine. 
 
 Its analogy with some of the phenomena of natural 
 Cow-pox. — The analogy presented by the phenomena 
 resulting from Bryce's test, to some of the appear- 
 ances met with in the course of natural cow-pox in the 
 cow, in which vesicles are seen at the same time in 
 various stages of progress, but all terminating together 
 (§ 5), can scarcely have escaped the reader's notice. 
 Various apparent anomalies in the course of the disease 
 in the cow become thus readily explicable. " No sooner 
 is lymph produced in the cow," says Ceely, " than by 
 pressure in the recumbent posture, self-vaccination may 
 occur ; but a more frequent and more efficient cause are 
 the reiterated manipulations of the milkers. These 
 men, night and morning, in the performance of another 
 task, unconsciously but most effectually perform on an 
 extensive scale a very important process — a series of 
 revaccinations both from the infecting and infected 
 animals."* 
 
 42. Vaccination with Primary Cow -Lymph. — 
 When, instead of vaccination being performed, as it 
 usually is, with lymph that has been long humanized, 
 
 * Trans. Prov. Med. and Surg. Assoc, vol. viii. p. 325.
 
 102 HANDBOOK OF VACCINATION. 
 
 some lymph is employed which is derived directly or 
 very recently, say within three or four removes, from 
 the natural or casual disease in the cow, there is often 
 considerable difficulty in getting it to take effect. 
 While lymph transferred from one human being to 
 another will, if used under proper conditions, infect 
 with almost unerring certainty, cow-lymph will fail to 
 infect in a great number of instances. Ceely found that 
 more than half his attempts to vaccinate with primary 
 cow-lymph, taken from vesicles at a proper stage and 
 possessing all the characteristics of perfection, resulted 
 in entire failure, the same individuals being success- 
 fully vaccinated immediately afterward with the cur- 
 rent humanized vaccine lymph. Of the cases in which 
 the cow-lymph did not fail, it produced, in some, only 
 spurious results; in others, a still smaller number, it 
 succeeded perfectly; but, in nearly all the successful 
 cases, the number of vesicles seldom equaled one-half 
 of the number of punctures. Similar phenomena of 
 entire failure, imperfect vaccination, or complete vac- 
 cination, with all attendant circumstances, resulted from 
 the use of lymph from perfect casual vesicles on the 
 hands of milkers ; and the same was the case with the 
 early removes of primary cow-lymph until it became 
 humanized. 
 
 Local phenomena and general symptoms. — In all 
 cases, whether successful or not, the insertion of pri- 
 mary cow-lymph induces a remarkable and unusual 
 redness at the point of puncture, a vivid blush, which 
 gradually declines on the third or fourth day, and when 
 the vaccination fails soon entirely disappears, but when 
 it is successful becomes more and more concentrated, 
 and at length blends with the red elevation of the vac-
 
 COW-POX IN THE nUMAN SUBJECT. 103 
 
 cine pimple. But between the decline of the blush and 
 the commencement of papulation there is often an in- 
 terval, and papulation is sometimes postponed till the 
 sixth, seventh, eighth, or even tenth day, giving rise to 
 corresponding irregularity in the period of full develop- 
 ment of the vesicle, so that the areola is frequently not 
 complete till from the eleventh to the fourteenth, or 
 even the sixteenth day. At this period, especially in 
 children, small supernumerary vesicles in miniature 
 often appear within its limits ; sometimes they are seen 
 also on the shoulder, still more rarely on the face and 
 body. The papular and vesicular eruptions which 
 occasionally attend ordinary vaccination at this stage 
 of its course (§ 35) are more frequently seen when 
 primary cow-lymph is used.* The areola, when at its 
 height, is more indurated than is observed in vaccina- 
 tion with ordinary humanized lymph, and its color de- 
 clines and revives, continuing to exhibit a brick-red or 
 purplish hue while the hardness remains. The vesicles 
 themselves in most instances are not more developed 
 
 * Steinbrenner noticed the more frequent occurrence of the 
 papulo-vesicular eruptions attendant on vaccinia, when this 
 has been produced by primary cow-lymph and its early re- 
 moves, than when old lymph is used. In seven out of twenty 
 children vaccinated with lymph at the first, third, or twelfth 
 removes from the cow, there was a secondary papulo-vesicular 
 eruption from the twelfth to the sixteenth day ; but of thirty- 
 nine children vaccinated with the Passy lymph, then three or 
 four years old, or with lymph of the original stock, forty years 
 old or more, only one had a papular eruption. (Traite sur la 
 Vaccine, p. 552.) But this does not pertain to all stocks of 
 lymph. Jenner does not appear to have found these second- 
 ary eruptions more frequent in his earlier than in his subse- 
 quent vaccinations.
 
 104 HANDBOOK OF VACCINATION. 
 
 than those produced by ordinary lymph. Desiccation 
 is generally prolonged, being often for some clays 
 limited to the center. When the vesicle is neither 
 ruptured, nor spontaneously bursts, the crust is often 
 retained to the fourth or fifth week, bringing away with 
 it a circle of the corium, often the whole depth of it, and 
 some of the subjacent connective tissue. A deep fove- 
 ated red cicatrix is left, or there is a yellow foul ex- 
 cavation which ultimately furnishes the pink, shining, 
 puckered aspect of a small-pox scar. Often, however, 
 the vesicles burst or get broken at the time of the 
 height, or about the decline, of the areola; and when 
 this occurs in strumous or irritable subjects, secondary 
 inflammation may be set up, with sloughing, abscesses 
 in the cellular membrane and axillary glands, and pro- 
 portionate constitutional irritation — mischief which, 
 however, generally soon subsides. 
 
 Progress of humanization of lymph. — Transmission 
 of the lymph from subjects directly infected from the 
 cow, through two, three, or more children successively, 
 diminishes the severity of the local symptoms; and the 
 vesicles then acquire increased size and beauty. In 
 succeeding removes, varieties of appearance will, as in 
 ordinary vaccinations, depend much on variety of sub- 
 jects, vaccination with the same lymph producing in 
 some finer, in others smaller vesicles, the latter being 
 often accompanied with more intensity of constitutional 
 symptoms than the former. 
 
 Varieties in amount of constitutional disturbance. — 
 As regards, indeed, the general or constitutional dis- 
 turbance of subjects vaccinated by primary cow- 
 lymph, or its early removes, the greatest variety ex- 
 ists ; roseola or lichen, with vomiting, diarrhoea, deli-
 
 COW-POX IN THE HUMAN SUBJECT. 105 
 
 rittm, etc., arising in some subjects, while in others 
 mere acceleration of pulse is observed, without com- 
 plaint; a single vesicle in some being attended with 
 earlier, more severe, and longer protracted symptoms 
 than four or six will produce in others. " Although," 
 says Ceely, whose description of the effects of primary 
 cow-lymph I have closely followed, "the greater part 
 of my experiments with primary lymph and its early 
 removes have exhibited the above as its qualities and 
 accidents, I think it not improbable that primary lymph 
 may vary in these respects, and be modified by season 
 and other circumstances, both individual and local."* 
 Of the truth of this observation I apprehend there can 
 be no doubt The primary lymph, discovered at Passy 
 in 1836, which was the subject of M. Bousquet's ex- 
 periments, appears to have developed generally phe- 
 nomena closely corresponding to Ceely's description, 
 as (1) the reddish blush immediately succeeding the 
 operation, and passing gradually into papule ; (2) the 
 size, long duration, and hardness of the areola; (3) the 
 prolongation of the stage of desiccation; and (4) the 
 long retention of the crust, f The lymph-stock which 
 Mr. Estlin set on foot from the cow, in 1836, developed 
 for some time, during its early transmissions, very ac- 
 tive local and constitutional phenomena; much care was 
 required in its use, deep ulceration and glandular ab- 
 scesses otherwise sometimes resulting. But, in the 
 accounts we have of many other stocks, we are far from 
 finding that the same activity of symptoms has always 
 
 * See Ceely's admirable and oft-quoted Memoir, Trans. 
 Prov. Med. and Surg. Assoc., vol. viii. pp. 342-352. 
 f Nouveau Traite, etc., p. 403, seq. 
 10
 
 106 HANDBOOK OF VACCINATION. 
 
 been manifested, or that specialties have continued 
 through so many removes. The primary lymph of 
 some stocks, indeed, has been found to produce results 
 differing in no respect from those of an ordinary vac- 
 cination. More generally, there has been some retard- 
 ation of progress, and some manifestation of unusual 
 local or constitutional activity, at all events for a trans- 
 mission or two ; the phenomena, after two or three re- 
 moves, being the same as those observed where human- 
 ized lymph has been employed.* The difficulty in 
 getting the lymph to take until it has become human- 
 ized is always experienced. 
 
 43. Symptoms, etc. of the Casual Cow-pox of 
 Milkers. — In milkers who contract cow-pox casually 
 the severity of the local and general symptoms is often 
 much greater than in subjects in whom vaccination 
 with primary cow-lymph has been designedly per- 
 formed. This is due (1) to the constant movement to 
 which the vesicles, from their position on the hands, 
 etc., are generally subject, and (2) to their frequent 
 rupture, with consequent reiterated applications of 
 lymph. Hence there are not infrequently deep slough- 
 ing of the skin and connective tissue, and ulcerations 
 slow to heal. Ceely has met with instances in which, 
 probably either from an insufficient application of 
 lymph, or a local or constitutional indisposition to re- 
 ceive the disease in the usual way, the vesicles on 
 milkers have been imperfectly developed, with little or 
 no obvious constitutional disturbance, exhibiting a 
 
 * See Hering, Ueber Kuhpocken an Kvihen ; Kapport sur 
 les Vaccin. pratiquees en France pendant 1841 ; and Sixth 
 Keport of Medical Officer of the Privy Council, p. 10.
 
 COW-POX IN THE HUMAN SUBJECT. 10? 
 
 marked contrast to the local or general effects on other 
 individuals affected at the same time from the same 
 source ; and some such cases he has seen suffer after- 
 ward from unquestionable though mild small-pox. It 
 is not only, therefore, where milkers have mistaken 
 spurious for real cow-pox, that they are liable to be 
 deceived as to their protection against small-pox. They 
 may continue subject to that disease, according to 
 Ceely's observations, after infection from cows affected 
 with real cow-pox, if their infection has been "at a late 
 period of the disease with deteriorated and purulent 
 virus, or even with perfect lymph of which they had 
 not at the time been sufficiently susceptible."* The 
 casual cow-pox in man and its early removes are of 
 course liable to be attended occasionally with the same 
 papular and vesicular eruptions as have been described 
 as occurring sometimes in the course of vaccination 
 with primary cow-lymph (§ 42). 
 
 44. Vaccination with Variola-vaccine Lymph. — It 
 is impossible to read Ceely's careful and most interest- 
 ing accountf of the phenomena exhibited by human 
 subjects vaccinated by him with the lymph generated 
 by the variolation of the cow, without recognizing that 
 we are reading over again the whole story of the in- 
 oculation of the human subject with primary cow- 
 lymph. In the children and others inoculated with 
 the variola-vaccine lymph, either direct or in its ear- 
 liest removes, there was the same difficulty in making 
 the vaccination take, the same occasional occurrence of 
 imperfect results, the same retardation in successful 
 cases of the papular and subsequent stages, and the 
 
 * Ceely, op. cit, p. 336. f °P- cit -> PP- 412-420.
 
 108 HANDBOOK OF VACCINATION. 
 
 same activity of local symptoms as are noticed when 
 primary cow-lymph is used. The small supernumerary 
 vesicles round the vaccinated spots, within the sphere 
 of the areola, were also noticed in particular cases ; and 
 in four cases a supernumerary vesicle or two was de- 
 veloped elsewhere. The constitutional symptoms were 
 well marked and in some cases severe, but pertained 
 only to the secondary or developed state of the disease, 
 and were scarcely noticeable until the vesicles had at- 
 tained the stage of areola, — just as, with primary cow- 
 lymph, the vesicles improved in appearance by passing 
 through two or three subjects, and attained then, and 
 retained, a state of great beauty and perfection. 
 Roseola, strophulus, and lichen were seen in some of 
 the subjects ; the papules in a few instances became 
 vesicular. In one infant, six months old, vaccinated 
 at the sixth remove, an eruption of strophulus became 
 vesiculated at its summit to an extraordinary degree, 
 disappearing and reappearing for three weeks; in 
 another infant, aged fifteen months, six days after vac- 
 cination at the sixth remove, an eruption of vesicular 
 varicella (which disease was prevailing in the village 
 at the time) appeared, and retarded the progress of the 
 vaccination for a couple of days. But no eruption with 
 the slightest approach to varioloid was seen ; and the 
 only other sort of eruption noticed than those above 
 stated was, in a few instances, "a vesicular eruption of a 
 pemphigoid character, either in large bullae or closely 
 resembling lenticular varicella."* And, just as when 
 
 * This eruption is strictly one of the attendant vaccinal 
 eruptions. It may be seen on the cow, and often on young 
 dogs, during the progress of vaccination. In young children
 
 COW-POX IN THE HUMAN SUBJECT. 109 
 
 primary cow-lymph is used, the attendant vaccine 
 eruptions, when they did occur, were limited almost 
 exclusively to young children. 
 
 45. Vaccination with Secondary, or Inoculated 
 Cow-lymph; Animal Vaccination. — When primary 
 cow-lymph is first passed by inoculation through a 
 succession of animals and then transplanted to the 
 human subject, the effects it produces depend partly on 
 the properties of the parent stock, and partly on the 
 number of artificial transmissions it has undergone. 
 Lymph of a very active kind, which had been obtained 
 from the natural disease in a cow at Beaugency, in 
 1866, and which, after being passed through three 
 animals, was used for vaccinating children at the 
 Academie de Medecine at Paris (in the performance 
 of what has been termed "Animal Vaccination"), still 
 manifested the active and virulent symptoms which 
 attend, as we have seen, the use of some stocks of 
 primary cow-lymph. The vesicles it produced on chil- 
 dren were even said to be nearly double the size of 
 those resulting from the first removes of the Passy 
 lymph, and the inflammatory effects to be so exceed- 
 ingly severe that M. Bousquet, on seeing the cases, 
 judiciously recommended one of the members of the 
 Academie, who was about to take some of this lymph 
 for use in his own practice, to wait till it had under- 
 
 it may subside in a few days or may continue for some weeks. 
 Ceely (Trans. Prov. Med. and Surg. Assoc., vol. x. p. 231) 
 narrates a case in a child, eight months old, vaccinated with 
 lymph eighty removes from the cow, in which it appeared 
 and lasted five or six weeks; and Mr. Farish, of Cambridge, 
 also narrates a considerably protracted case. (See Willan on 
 Vaccine Inoculation.) 
 
 10*
 
 110 HANDBOOK OF VACCINATION. 
 
 gone further transmissions.* But with further tran- 
 sits through animals these peculiar effects appear to 
 have subsided; and when lymph of this stock, con- 
 tinued through animals and taken from an animal later 
 in the series, was sent to Brussels and there employed, 
 its effects resembled more those of an ordinary vaccina- 
 tion. Tried side by side, by a Commission of the Bel- 
 gian Academie, with some Jennerian lymph which 
 they had in use, the only difference noted was that 
 the vesicles it produced were a little bigger {tin peu 
 plus larges):f but, like Ceely's and some other pri- 
 mary lymphs, it was found to improve by a few tran- 
 sits through the human subject. When some of it 
 thus humanized, and some of it continued through 
 animals, were used in the vaccination of the same sub- 
 
 * Gazette Medicale, 1866, p. 319. 
 
 f Bulletin de l'Academie, tome xxxii. According to M. de 
 Paul, not only the vesicles produced by this lymph, but also 
 the vesicles produced by retro-vaccine lymph which had un- 
 dergone a number of transits through animals (p. 27, note), 
 when compared at the Academie with the vesicles produced 
 by the humanized lymph there in use, were found to be very 
 much finer and larger. But if so, the stock of the Academie 
 must have differed in its effects from the Jennerian stock in 
 use in Brussels. In these comparisons everything, in fact, 
 depends on the stocks with which the comparison is instituted 
 — whether they have or have not lost any of their essential 
 properties (see Chap. X., On the Alleged Degeneration of 
 Lymph, which should be read along with this Section). Let 
 it be well understood, however, that I am far from thinking 
 the size of the vesicle an essential quality ; any one has only 
 to look at Jenner's plates to see that it is nothing of the sort. 
 It is the character and course that must be looked to; and a 
 vesicle is not to be condemned on account of its size, unless it 
 is also puny and inactive.
 
 COW-POX IN THE HUMAN subject, m 
 
 jects, the vesicles of the humanized lymph were mani- 
 festly the finer and better developed. The course of 
 vaccination of the human subject with inoculated cow- 
 lymph (animal vaccination) is frequently retarded. 
 Vaccination thus performed is much less successful 
 than vaccination with humanized lymph.* 
 
 * Well aware of the difficulties frequently attending the 
 transplantation to the human subject of primary cow-lymph, 
 or of retro-vaccine lymph. I saw, certainly with surprise, the 
 statement of M. de Paul and others that the inoculated cow- 
 lymph (animal vaccination) was more successful in the per- 
 formance of human vaccinations than humanized lymph from 
 arm to arm ; and this surprise was greatly increased on ex- 
 amination of the facts on which the statement was based, viz., 
 the results of the animal vaccinations of M. Husson and at the 
 Academic A good vaccinator, it may be premised, vaccina- 
 ting from arm to arm with humanized lymph, does not fail to 
 infect above once in 150 operations (see \ 69). Now from the 
 largest series of observations which we have of animal vac- 
 cinations, that of M. Husson, it appears that of 4163 vaccina- 
 tions of children (I exclude, of course, all cases of revaccina- 
 tion) he was successful in 2614, or 62-79 per cent., was un- 
 successful in 949, or 22-80 per cent., 600 of the cases not having 
 been inspected. But this result, confessedly unsatisfactory, 
 is considered to be in some measure explained by M. Husson 
 having been obliged (from the limited number of animals at 
 his command) to perform many of the operations with lymph 
 taken from the animal after the sixth day of the vaccine in- 
 fection, and when it had become comparatively inert. The 
 vaccinations at the Academic were 681, but by eliminating 
 275 of these cases, or 40 per cent, of the whole, as being ea*es 
 in which it is said the vaccination had either also been done 
 with late lymph, or with lymph from heifers who were in ill- 
 health (genisses maladcs), [it is not explained why in this 
 large proportion of cases the vaccination had been done in 
 this objectionable way, or from these objectionable sources,]
 
 112 HANDBOOK OF VACCINATION. 
 
 46. Vaccination with Retro-vaccine Lymph. — 
 When active lymph, such as passes from arm to 
 arm with the greatest facility, is passed through the 
 cow (§ 12, c) and at once vaccinated back, it jetretains 
 so much of its humanization that it is not apt to fail 
 like primary cow-lympb, but will be found also to have 
 lost so much of its humanization that on its return to 
 the human subject it takes effect less kindly : papula- 
 tion is usually retarded, and though the vaccination 
 may attain maturity at the ordinary average period, 
 the completion of the maturation is often postponed. 
 The vesicles are often smaller and the disease not 
 really so well developed as by the stock from which the 
 lymph was derived. Two, three, four, or several re- 
 moves are necessary to give it the same activity as it 
 had before it was transferred. 
 
 it was found that, out of the remaining 406 cases, the opera- 
 tion had been successful on 278, or upwards of 68 per cent., 
 and unsuccessful on five only, or 1-2 per cent. But, as in no 
 fewer than 123 cases, or 30 per cent., the result was not ascer- 
 tained, the utter worthlessness of these observations to determ- 
 ine the real effects of a new mode of proceeding is obvious. If 
 any satisfactory conclusions at all are to be come to, it can 
 only be done by taking two or three hundred cases, and follow- 
 ing them completely out ; it is very singular that this course, 
 so properly recommended by M. Guerin, should not have been 
 pursued. Of 988 animal vaccinations, performed on babies at 
 La Pitie by M. Empis, the results were observed in all but 
 fifty-eight cases, and they gave 558 successes to 372 failures. 
 The vaccinations watched by the Commission in Brussels ap- 
 pear to have been made with great care and with unusual 
 success, but they were far too few in number for safe conclu- 
 sions. But, even in them, in the first series of twenty-four 
 (inspected) cases, there were but 104 vesicles for 144 inser- 
 tions — a number far short of that obtainable with good human- 
 ized lymph.
 
 COW-POX IN THE HUMAN SUBJECT. 113 
 
 (B) COUKSE OF COW-POJ IN PERSONS WHO HAVE 
 ALREADY BEEN INFECTED BY IT. 
 
 47. Phenomena and Course of Revaccination. — In 
 the majority of persons the regular phenomena of vac- 
 cination, such as have been above described, can only 
 be produced once in the lifetime ; any subsequent in- 
 troduction of vaccine lymph either failing to produce 
 any local effect whatever, or (much more- commonly) 
 producing a modified effect, resembling one of the forms 
 of spurious vaccination. The absence of effect is rela- 
 tively most common in the child, the spurious effect 
 most common in the adolescent and adult. This spu- 
 rious effect consists either in a papule, or (more often) 
 in an acuminated vesicle, with a hard and irregular 
 areola. The symptoms begin early, reach their height 
 by the fifth or sixth day, and then decline. The scab, 
 small and imperfect, forms generally on the eighth day, 
 and soon falls. There is usually much itching, and 
 often considerable constitutional irritation. Severe 
 constitutional symptoms are, out of all proportion, 
 more frecpaent in revaccination than in primary vac- 
 cination ; and in very exceptional cases the vaccine 
 lymph may act as an animal poison, giving rise to 
 phlegmonous erysipelas ; some still rarer cases have 
 occurred of pyaemia, terminating fatally. In a certain 
 proportion of cases, the results of revaccination are 
 the same as those of primary vaccination, the vesicle 
 in shape and character being in no degree distinguish- 
 able ; in such cases the areola is sometimes small and 
 transitory, and the scab on falling leaves a small and 
 poor cicatrix ; at other times the areola is perfect, and
 
 114 IIANDBOOK OF VACCINATION. 
 
 a good cicatrix is left. Normal vesicles resulting from 
 revaccination are much more frequent in adults than 
 in children, but I have seen them on the arms of chil- 
 dren a few years old, who had excellent marks of their 
 first vaccination. 
 
 (C) TKEATMENT OF VACCINATION. 
 
 48. Treatment of Vaccination. — The ordinary symp- 
 toms of cow-pox seldom call for any treatment, general 
 or local. If the child be feverish, a little castor oil, or 
 magnesia, or powder of jalap, or of calomel and jalap, 
 may be given with advantage : if the arm be more 
 than usually inflamed, a dressing of tepid water with 
 oil silk or tepid lead-lotion may be employed. A simple 
 cooling treatment is enough to meet any cases of vac- 
 cine lichen or roseola. If the vesicles should degene- 
 rate or ulcerate, the sores may be dressed with oxide 
 of zinc ointment, and the general health may require 
 to be looked to. If erythema or erysipelas should 
 occur, the treatment would be the same as that of ery- 
 thema or erysipelas arising from any other cause.
 
 OF VACCINATING. 115 
 
 CHAPTER VI. 
 
 OF VACCINATING. 
 
 49. Origin of the term Vaccination. — The terms 
 "Vaccination" and "to Vaccinate," to signify the in- 
 oculation of the cow-pox, were first introduced by 
 Dunning ;* and their convenience was at once recog- 
 nized. They are the terms now exclusively employed 
 for the purpose in medical writings, in the conversation 
 of the educated, and among the common people also 
 in the greater part of England ; but there are still parts 
 of the kingdom in which the lower orders seem never 
 to have heard of vaccination, though they are quite 
 familiar with the process of being "cut for the cow- 
 pock." 
 
 50. Things to be attended to in Vaccinating. — In 
 conducting vaccination special attention must be given 
 (a) to the state of the person to be vaccinated, (6) to 
 the selection of the lymph to be used in the vaccina- 
 tion, and (c) to the thorough insertion of the lymph. 
 
 (a) State of the Individual to be Vaccinated : (1) 
 Health. — Except for pressing reasons, persons should 
 only be vaccinated when they are in good health. By 
 this is not meant that they need always be robust at 
 the time of vaccination, but simply that they should be 
 free from any acute disease, or from any chronic disease 
 which is known to interfere with the regular course of 
 
 * Baron's Life of Jenner, vol. ii. p. 336.
 
 116 HANDBOOK OF VACCINATION. 
 
 the vaccine vesicle. There are many diseases which 
 do not interfere at all with the course of vaccination. 
 Cline's famous first vaccination was in a lad who had 
 disease of the hip-joint : it is well known that scrofula 
 and syphilis do not prevent the system receiving the 
 vaccine influence in the normal way : and one would 
 never hesitate to vaccinate a child, whose general con- 
 dition was fair, merely because it was going through 
 the chronic stage of hooping-cough. The diseases 
 which most decidedly contraindicate vaccination are 
 (besides acute febrile diseases) diarrhoea and cutaneous 
 diseases, especially cutaneous diseases of the vesicular 
 type, as herpes, eczema, and intertrigo. Jenner 
 throughout his writings insists strongly, and with 
 frequent iteration, on the extent to which herpes may 
 interfere with the regular course of the vaccine vesicle ;* 
 and that very simple disease, intertrigo, so often modi- 
 fies, or even completely spoils, the course of vaccina- 
 tion, that it is a precaution which should never be 
 neglected by a vaccinator, to look well whether there 
 be any chafing behind the ears, in the folds of the 
 neck, or in the groins, before he proceeds to vaccinate 
 a child (§ 36, c). But other cutaneous diseases of the 
 non-vesicular kind, such as strophulus and lichen, have 
 been observed to interfere with the full and correct 
 reception of the vaccine influence, and Jenner's own 
 
 * The same diseases were found to interfere with the regu- 
 lar progress of variolous inoculation. "The most ample tes- 
 timonies," says Jenner, M lie before me that the herpetic and 
 some other irritative eruptions are capable of rendering vario- 
 lous inoculation imperfect, as well as the vaccine." (See his 
 tract on the Varieties and Modifications of the Vaccine Pus- 
 tule.)
 
 OF VACCINATING. 117 
 
 rule, " to sweep away all eruptions from the skin pre- 
 vious to inserting the vaccine lymph," should never, 
 under ordinary circumstances, be departed from.* It 
 is nothing to the point that children suffering from 
 these and other forms of eruption have been frequently 
 vaccinated with perfect success and the utmost regu- 
 larity of vesicle. Undoubtedly this is so :f but fre- 
 quently also it is not the case, and the careful and 
 conscientious vaccinator looks always to the making 
 his success as certain as possible, and scrupulously 
 avoids anything of a hap-hazard kind. In laying down 
 these rules, however, so positively, as to the health of 
 a person in whom vaccination is to be performed, it is 
 always assumed that the patient is not in any imme- 
 diate risk of small-pox ; for, when this is the case, it 
 would be foolish in the extreme to hesitate or to wait. 
 However much, under other circumstances, we should 
 have preferred that the patient should be in a better 
 state of health, nothing but the actual presence of acute 
 febrile disease of a serious character would then be a 
 sufficient contraindication. 
 
 (2) Age. — Health permitting, vaccination should 
 always be performed in very early infancy. Young 
 children, unvaccinated, are the chief sufferers from 
 small-pox. About one-fourth of all the mortality which 
 arises from that fatal disease in England, takes place 
 in children under the age of one year. In Scotland, 
 where, until the passing of the recent excellent Yaccin- 
 
 * On the Influence of Artificial Eruptions in certain Dis- 
 eases. 4to. Lond. 1822. 
 
 ■f- As "Willan justly observes, " The effect of cutaneous erup- 
 tions on the vaccine vesicle in frequent, not universal." (On 
 Vaccine Inoculation, p. 40, note.) 
 
 11
 
 118 HANDBOOK OF VACCINATION. 
 
 ation Act, infantile vaccination was much more neg- 
 lected than in England, the proportion even amounted 
 to thirty per cent.; and of the deaths under one year, 
 nearly one-fourth were under the age of three months. 
 The great risk of delay is therefore obvious. This 
 risk is by far the greatest in large towns, because 
 from them small-pox is seldom absent at any time, 
 and never absent for any long period together. Plump 
 and healthy children living in such towns should be 
 vaccinated when a month or six weeks old;* in more 
 delicate children the vaccination might be postponed 
 till they are two or three months old, but all whose 
 health does not offer some positive contraindication 
 should be vaccinated by the age of three months. 
 This early period of life is also particularly suitable 
 for vaccination, as being usually free from the disturb- 
 ing influence of teething : it is therefore on every ac- 
 count to be preferred. Circumstances connected with 
 lymph-supply render a longer delay unavoidable, in 
 many instances, in small towns and rural districts; 
 and, when small-pox is not present in the localities, 
 such delay, if not .too long continued, is not of material 
 moment. But even children living in such districts 
 should always be vaccinated within a few months, six 
 or seven at the utmost, from birth. 
 
 * My opportunities of watching vaccination at this age have 
 been considerable, and enable me strongly to recommend it 
 when the children are well and plump. They take as surely, 
 have vesicles quite as fine, and go through the disease as regu- 
 larly, as do children vaccinated some weeks older. The early, 
 and all subsequent, Instructions of the National Vaccine Es- 
 tablishment recommend six weeks as the best age, except when 
 children are delicate, or suffering from disease.
 
 OF VACCINATING. 119 
 
 (3) Circumstances which call for the immediate 
 performance of Vaccination. — While the periods above 
 stated should not, except for special reasons in indi- 
 vidual cases, be exceeded, it may often be prudent, and 
 even indispensable, to perform vaccination at a much 
 earlier age. The danger of delay is always, of course, 
 in direct relation to the exposure, or liability to expo- 
 sure, to the infection of small-pox ; and when this dis- 
 ease is prevailing in a locality, every parent who has 
 an unvaccinated child, however young, should be anx- 
 ious and watchful until he has secured its protection. 
 When small-pox is in the family or house, no age must 
 be considered too early for vaccination ; repeatedly, 
 under such circumstances, have infants been vaccin- 
 ated immediately after birth, and saved thereby from 
 the disease ; repeatedly, for want of like precaution, 
 have their lives been sacrificed. Vaccination at this 
 early age is certainly as safe, and appears to be also 
 generally as successful, as in older infants.* 
 
 No question in medical practice may be regarded as 
 more completely settled than the course which a prac- 
 titioner should take when there are persons of any 
 age whatever, unvaccinated or not otherwise protected 
 against small-pox, in a house or family in which that 
 disease breaks out. At once, and without any delay, 
 the vaccination of all such persons should be performed : 
 
 * See "Bapport de l'Acad. Imp. de Med. sur les Vaccina- 
 tions," etc. 18G0, where a large number of facts are brought 
 together, from maternities and the practice of large vaccina- 
 tors, illustrative of this point. It is only, however, where 
 there is immediate exposure to small-pox infection that vac- 
 cination within the first few days from birth is necessary, or 
 is at all likely, I apprehend, to be practiced.
 
 120 HANDBOOK OF VACCINATION. 
 
 the loss of a clay may be the sacrifice of a life. It docs 
 not follow that because a person has been exposed to 
 the infection of small-pox, he has therefore received 
 the infection, and the vaccination may be in time to 
 prevent the disease altogether ; but, supposing that 
 before the vaccination is performed the variolous in- 
 fection has actually been taken up by the system (of 
 which, of course, during the stage of incubation we 
 can know nothing), unless that infection have so far 
 got the start that the small-pox symptoms appear 
 before the vaccination reaches the stage of developed 
 areola, the vaccine process will still either prevent or 
 modify the small-pox eruption ; if, on the other hand, 
 the variola manifest itself before the vaccination has 
 reached its protective stage, its stage of areola, the 
 vaccination, though it will have done no good, will 
 most certainly have done no harm — the small-pox will 
 simply go on as though it had never been performed. 
 Now, whether the vaccination shall reach the stage of 
 areola or not before the small-pox appears, depends 
 entirely on the length of time which had elapsed be- 
 tween the reception by the system of the variolous 
 poison and the performance of the vaccination. As 
 the incubative period of small-pox is twelve days, 
 while the time requisite to bring vaccination to the 
 stage of areola is only nine days, vaccination performed 
 any time within the first three days will reach areola 
 soon enough to produce its protective power ; after 
 this, whatever the local success of the vaccination, no 
 constitutional protection will be imparted.* 
 
 * " Suppose an un vaccinated person to inhale the germ of 
 variola on a Monday ; if he be vaccinated as late as the follow-
 
 OF VACCINATING. 121 
 
 If there were only any means of ascertaining whether 
 a person exposed to small-pox infection had actually 
 received it, and if so, at what moment this had taken 
 place, we should know exactly whether it were worth 
 while to vaccinate or not ; but as no such means exist, 
 the obvious rule of practice is to assume that the poison 
 has not been inhaled, or has only recently been inhaled, 
 and to give our patient the chance. But no prudent 
 practitioner, vaccinating under these circumstances, 
 will commit himself as to the protective value of his 
 vaccination until he sees the areola completely formed. 
 
 For want of knowledge or of consideration of these 
 simple facts, practitioners have repeatedly compromised 
 their credit, many lives have been lost that should have 
 been saved, and erroneous entries are daily made in 
 our death registers. Seeing perfect vaccine vesicles 
 on the eighth day, the practitioner who was not aware 
 of the necessity of waiting for areola has promised 
 safety, and been cruelly disappointed : his credit and 
 the credit of vaccination have equally suffered. The 
 occurrence of three or four cases together of unmodified, 
 and perhaps fatal, small-pox in persons having well- 
 formed and complete vaccine vesicles on their arms, 
 has at times led the practitioner, not to the true ex- 
 
 ing Wednesday, the vaccination will be in time to prevent 
 small-pox being developed ; if it be put off until Thursday, 
 tho small-pox will appear, but will be modified ; if the vac- 
 cination be delayed until Friday, it will be of no use, it will 
 not have had time to reach the stage of areola, the index of 
 safety, before the illness of small-pox begins ; this we have 
 seen over and over again, and know it to be the exact state of 
 the question." (Marson,art. " Small-pox," in System of Med- 
 icine, op. cit., vol. i. p. 477.) 
 
 11*
 
 122 HANDBOOK OF VACCINATION. 
 
 planation, viz , that his vaccination in these cases had 
 been too late, but to the notion that vaccination was 
 always useless when small-pox was incubating, and 
 even to the absurd and totally unfounded supposition 
 that it might increase the danger : so he has shut up 
 his vaccine lancet, and children have been allowed to 
 perish from non-performance of vaccination, whose 
 deaths were clearly chargeable to his error.* Our 
 death-registers contain innumerable entries of deaths 
 from " small-pox after vaccination," which were simply 
 cases of death from small-pox in children in whom vac- 
 cination was performed during the incubation of small- 
 pox: and heaps of published and other records are 
 quite unusable for any statistical purposes, because 
 cases of this kind are not distinguished from the cases 
 in which small-pox really did occur in persons who had 
 properly received the constitutional infection of vac- 
 cination.f 
 
 * "Pascal a dit qu'on ne fait jamais mieux le mal que 
 quand on le fait en surete de conscience. Telle etait la posi- 
 tion de ces medecins qui refusaient la vaccine a ceux qui la 
 demandaient, de peur d'attirer sur eux la maladie regnante." 
 (Kapport de l'Acad. Koy. de Med. sur les Vacc. etc. 1846, 
 p. 16.) 
 
 f In cases of small-pox in persons on whom vaccination ha3 
 only a short time before been performed, the most scrupulous 
 attention should be given to dates, whether in recording cases 
 for one's own information, or in certifying deaths. The date 
 of the successful vaccination, and the date of the first or pre- 
 monitory symptoms of the small-pox, should always be care- 
 fully noted. Might I venture to urge also on my professional 
 brethren a more careful use of the word "vaccinated"' in 
 death-certificates? I have known deaths from small-pox 
 medically certified as "vaccinated," when it was admitted on 
 inquiry that vaccination had only been attempted, and had 
 been without result.
 
 OF VACCINATING. 123 
 
 The practice, which I have known at times adopted, 
 of vaccinating a person after symptoms of small-pox 
 have actually manifested themselves, is utterly absurd : 
 so far as the patient is concerned, the effect, of course, 
 is nil ; but on account of the discredit it tends to bring 
 upon vaccination with the public, it is a practice which 
 should be strongly discountenanced. 
 
 (b) Selection of the Lymph to b 2 used in Vaccinating. 
 — This is a matter of the utmost consequence. The 
 lymph must be taken only from perfectly healthy sub- 
 jects, and from thoroughly characteristic vesicles. No 
 second-rate vesicles should ever be used to take lymph 
 from. Babies are in general much better lymph-givers 
 than elder children or adults. Children of dark com- 
 plexion, not too florid, with a thick, smooth, clear skin, 
 are those which yield the finest and most effective 
 lymph. Prime lymph is always perfectly limpid, and 
 has besides (and no less essentially) a certain degree 
 of viscidity. A thin serous lymph is always to be 
 avoided (see note, p. 91). With regard to the period 
 of the vesicle's course at which the lymph should be 
 taken from it, this may be done, and with perfect pro- 
 priety, as soon as ever the vesicle will yield any ; such 
 lymph, though it can only be got in small quantity, is 
 very effective. Usually, however, lymph is not taken, 
 nor for the purposes of good vaccination is there any 
 necessity whatever that it should be taken, until the 
 vesicle is fully formed, which, in regular cases, is the 
 day week from the vaccination. The vesicle then 
 yields lymph of the best quality, and in sufficient 
 abundance. It must be taken, however, according to 
 Jenner's "golden rule," before the appearance of the 
 areola, or at all events within a very few hours of its
 
 124 HANDBOOK OF VACCINATION. 
 
 commencement. No greater mistake can be made than 
 that of taking it later, and when the areola is fully com- 
 plete. The protest which Jenner felt it necessary to 
 make against this practice in the earlier days of vac- 
 cination has been repeated by every vaccinator of 
 authority since his time. No doubt the lymph flows 
 more freely at this late period, and may be got in 
 greater abundance, and no doubt also (as is alleged by 
 those who defend this practice) such lymph very often 
 takes ; but, in the first place, it does not take with any- 
 thing like the same certainty as earlier and more active 
 lymph, and, in the second place, it is more apt to be 
 followed by erysipelatous and spurious results. I 
 repeat, that judicious choice of lymph — the taking it 
 only from suitable subjects, from the primest vesicles, 
 at the proper time — is a cardinal point in good vaccina- 
 tion. And I will venture to say that just in propor- 
 tion as the rules here laid down — rules sanctioned by 
 all the best authorities — are adhered to, so will success 
 be attained, and irregularities in the course of the vac- 
 cinations performed be avoided. 
 
 (c) Performance of the Vaccination: (1) Collection 
 of the Lymph. — A child and a vesicle fit for the pur- 
 pose having been selected, the vaccinator, in order to 
 collect the lymph, proceeds to open the vesicle by a 
 number of minute punctures, which must be made on 
 its surface, and not round the base. The object of 
 many punctures is to open the various cells of the vesi- 
 cle in which the lymph is contained, and the reason for 
 making these on the surface and not round the base is 
 to obtain the lymph free from any admixture of blood. 
 If by accident any blood be drawn, this must be allowed 
 to coagulate, and then be carefully removed before tak-
 
 OF VACCINATING. 125 
 
 ing the lymph ; for it is a rule, never to be deviated 
 from, that the vaccination must be with vaccine lymph, 
 and with lymph only. When the cells of the vesicle 
 are freely opened, the lymph soon exudes and lies on 
 the surface ; and thus lying, it may be taken on the 
 point of a lancet, or in any other way that is desired, 
 for use. On no account must there be any pressure or 
 squeezing of the vesicle with the lancet, or otherwise, 
 to make the lymph exude ; and when lymph ceases to 
 stand spontaneously on the surface of a vesicle, that 
 vesicle must be considered no longer usable for lymph 
 supply. Very generally, however, when the lymph 
 which has first exuded has been taken, and the surface 
 of the vesicle left apparently dry, if the operator wait 
 a minute or two he will find there has been a fresh 
 exudation of good usable lymph ; and when he does 
 not find, he may often induce this in a way quite unob- 
 jectionable by wiping very gently the surface of the 
 vesicle with a soft wet linen cloth, thereby removing 
 or dissolving the inspissated lymph which clogs the 
 punctures. Vesicles of perfect character, and of the 
 same size and appearance, differ very much in their 
 yield of lymph ; ordinarily, from a vesicle of such size 
 as is produced by a single deep puncture, enough lymph 
 may be got for the direct vaccination of from four to 
 six children, or for charging (i.e. for well charging, 
 dipping once and again) six to eight ivory points. 
 Some vesicles yield much more, but the caution already 
 given against a thin, serous, too readily flowing lymph, 
 must be borne well in mind. When vesicles are com- 
 pound, their yield of lymph is of course proportionably 
 increased. 
 
 (2) Considerations respecting Vaccinating from the 
 Arm, or with stored Lymph. — Lymph should in every
 
 126 HANDBOOK OF VACCINATJON. 
 
 instance (where practicable) be inserted direct from 
 arm to arm. Vaccination with preserved and con- 
 veyed lymph — whatever the mode of preservation and 
 conveyance — is in the long run far less successful than 
 direct vaccination, and should only be adopted in case 
 of necessity. But a caution, which experience has 
 shown me to be much called for, must be interposed. 
 The superior relative advantages of arm-to-arm vaccin- 
 ation are so generally appreciated by vaccinators, that 
 practitioners whose vaccinations are few, and whose 
 opportunities of lymph selection are therefore limited, 
 are often induced to take lymph from second-rate vesi- 
 cles, rather than lose the opportunity of vaccinating 
 direct from an arm. This, which I know to be the 
 source of much current inferior vaccination, is a course 
 which should not be adopted. It is better to employ 
 preserved lymph of first-rate quality (and no lymph 
 which is not first-rate ought ever to be preserved), with 
 of course such extra care in the insertion of it as the use 
 of stored lymph always requires, than for the sake of a 
 direct vaccination to take lymph from an inferior vesicle. 
 Best of all is it, unless circumstances forbid, to put off 
 the vaccination till there is an opportunity of doing it 
 direct from the arm, from a thoroughly satisfactory 
 vesicle. 
 
 (3) Various Methods of inserting Lymph. — Various 
 methods may be employed for inserting lymph, the 
 essential part of all of them being either to introduce 
 the lymph into the substance of the cutis, or to bring it 
 well in contact with its absorbing surface, (a) One of 
 the most familiar methods is that of puncture. When 
 it is intended to operate in this way, the arm of the 
 child to be vaccinated should be grasped by the left
 
 OF VACCINATING. 127 
 
 hand of the vaccinator, so as to put the skin on the 
 stretch, and a very sharp, perfectly clean lancet, well 
 charged with the lymph selected, should be introduced 
 by valvular puncture from above downward, so that 
 the lymph may gravitate into the wound. The lancet 
 should not be held level with the skin, but at an angle 
 of 45°, or thereabouts, and made to enter the cutis. If 
 the lymph be thus well put in, it is retained by the 
 valvular character of the puncture and the elasticity of 
 the skin; and any fear that the bleeding which ensues 
 will cause the vaccination to fail -is quite chimerical.* 
 Superficial puncture, on the other hand, unless the 
 lancet be thrust far under the cuticle, so as to bring the 
 lymph into contact with a considerable extent of ab- 
 sorbing surface, will oftener fail, or will result in much 
 smaller vesicles. In vaccinating by puncture not less 
 than five should be made, and they should be at a dis- 
 tance of half an inch from each other. Five or more 
 punctures at this distance from each other can very 
 well be made in one arm if the vaccinator prefer to vac- 
 cinate on one arm only, or three or four may be made 
 on each arm.f Six or seven vesicles, such as ordinarily 
 
 * Among high authorities, Gregory and Marson hoth insist 
 strongly on the advantages of making the punctures suffi- 
 ciently deep; and Bousquet ridicules the notion of the blood 
 that flows washing the lymph away, if this have only been 
 put in properly in the way recommended in the text, and re- 
 marks also on the finer vesicles which ensue from a deep, than 
 from a superficial, puncture. (Rapport de I'Acad. Imp. for 
 1850.) My own experience, as the text shows, entirely coin- 
 cides with that of these vaccinators. 
 
 •j- It is not a little surprising to those who are familiar with 
 the practice of the National Vaccine Establishment, and of 
 other first-class vaccinating stations in England, where nun-
 
 128 HANDBOOK OF VACCINATION. 
 
 result from puncture, are not at all too many for complete 
 protection, and are just as well borne by infants as one 
 or two would be. In the manipulations by which vac- 
 cination is effected by puncture, it is a very good plan 
 to make each puncture a double one, thus / /. A finer 
 and larger, often oval, compound vesicle is thereby 
 raised. For vaccination by puncture no instrument is 
 needed but a common lancet, very sharp : most of the 
 special instruments which have been devised for the 
 purpose are not nearly so good ; none certainly has any 
 advantage over it, and it is therefore not necessary to 
 enter into any description of them. (6) A modification 
 of the plan of vaccinating by puncture is that of mul- 
 tiple superficial puncture, or tattooing ; a number of 
 minute superficial punctures being made over one spot 
 with the point of the lancet, thus <4R8» and the lymph 
 then spread over with the flat part N&?" of the lancet. 
 The number of spots over which this tattooing should 
 take place will depend, of course, on the extent of sur- 
 face operated on at each spot. Tattooing over such a 
 surface as is above depicted, should be repeated on as 
 
 dreds of thousands of children have heen vaccinated in this 
 way without the least danger having been incurred, or with 
 the practice of various continental kingdoms, to hear this num- 
 ber of punctures excepted to as if it imported some " danger" 
 to a child. More than one practitioner has told me he would 
 not mind trying two punctures, but he should be quite afraid 
 to make three! Heim recommends six punctures, three on 
 each arm ; Marson always makes six ; Bousquet six, even on 
 children a day old ; and in tbe vaccinations to which refer- 
 ence was made in the former note, as performed in France 
 shortly after birth, the usual course of operating appears to 
 have been by six punctures. Steinbrenner makes ten punc- 
 tures, five on each arm. I am informed that it is usual in 
 Prussia to make sixteen punctures.
 
 OF VACCINATING. 129 
 
 many spots as one would operate on by the method of 
 puncture above described, — that is, on at least five 
 spots, and preferably on six or seven. But if the 
 tattooing at each spot be done over a larger surface, 
 as some practitioners prefer, raising compound vesi- 
 cles of larger extent, or sometimes crops of vesicles, at 
 each spot, the operation need of course be done over 
 fewer spots; thus, a tattooing such as this, ,.f> t 
 over two spots on each arm, or three spots yr'J'J' 
 on one arm, would be sufficient, (c) Another **** ' 
 modification of puncture, common in some of the north- 
 ern districts of England, is that of first spreading 
 the lymph on the arm of the child to be vaccinated, 
 and then ripping up the cuticle with the point of 
 the lancet (which for this purpose should not be too 
 
 /-/• 
 
 /• 
 
 sharp) over a surface equal to a sixpenny 
 piece or more, with, frequently, a second /* f^S f 
 plastering of lymph afterward : crops of f - /" /* 
 vesicles, close set together and nearly al- /•/•/* 
 ways confluent, are thus raised, often from f, 
 a dozen to twenty on one base, each vesicle having its 
 distinct depressed head, but prevented, of course, by the 
 pressure of surrounding vesicles from developing itself 
 in the way separate vesicles do. Two such crops 
 which may be made either one on each arm, or both on 
 one arm, may be regarded as sufficient for full protec- 
 tion, (d) Many practitioners prefer vaccinating by 
 scarification, to the plan of vaccinating by puncture. 
 Scratches, single or double, like . .. these, each 
 about half an inch or more long, but / / at distances 
 which should be from half to three- / / quarters of 
 an inch apart from each other on the' " arm, are 
 made with the point of a lancet, or with a thick needle, 
 12
 
 130 HANDBOOK OF VACCINATION. 
 
 and the lymph is then rubbed on.* In the course of 
 -p. /7\ each scratch two or three separate vesicles 
 jL/ / i W *^ ar i se > or more frequently one oblong 
 [ I compound vesicle will be produced. Two 
 P^ I / scratches of this kind should be made on 
 VJ/ each arm, or four on one arm. (e) An ex- 
 cellent modification of scarification, very generally 
 adopted, consists in abrading the cuticle by a 
 number of fine parallel scratches, thus: /k, 
 or by further cross-scratches, thus: A //W 
 
 Abrasion should only be carried Jmk 
 so far as to make it certain, by the / W > appear- 
 ance of blood oozing, that the cutis is reached ; it 
 is better, therefore, not to use for this purpose too 
 sharp a lancet: the oozing that occurs, or the 
 bleeding, if it should amount to that, is then rapid- 
 ly wiped away with the finger, and the lymph is 
 plastered on. Just as in tattooing, it depends on 
 the extent of surface abraded on each spot, how 
 many abrasions it is desirable to make. When 
 the abrasion is made over such surface as 
 this, /% o^, five or six should be employed; 
 but </// w when, as is the custom of many 
 practitioners, the abrasion is made over a consid- 
 erably larger surface, as above depicted, two on 
 each arm, or three on one arm, about three-quar- 
 ■WW ters of an inch or an inch from each other, will be 
 
 * In Denmark an instrument (invented by Professor Dryer, 
 of Copenhagen), which in appearance resembles the iron pen, 
 with two legs and screw for regulating their distance, com- 
 monly contained in cases of philosophical instruments, but 
 which has the extremities of the legs broad and sharp instead
 
 OF VACCINATING. 131 
 
 sufficient. Although for the performance of vaccina- 
 tion by scarification no instrument can be better than 
 a common lancet, many practitioners prefer a very good 
 little instrument invented by Dr. Gr. Weir, — a sort of 
 rake, consisting of four needle-points inserted in a 
 handle of ivory. (See preceding page.) The skin 
 being held very tense, this rake is drawn tightly across 
 in one direction, and then, if the operator pleases, 
 crossed in another ; a little spatula at the other end of 
 the instrument being employed for collecting the lymph 
 and plastering it on the abraded surface. 
 
 For the performance of the nice and delicate opera- 
 tion of vaccination, the most scrupulous care should 
 be taken to keep the instruments employed clean and 
 in good order. Lancets that are used for any other 
 purpose should never be employed for vaccinating ; 
 and vaccinating lancets should not only be cleaned 
 before being put away, but when several children are 
 to be vaccinated at a sitting, a cup of water and a 
 napkin should always be on the table, and the lancet 
 dipped and wiped after each operation. 
 
 (4) Particular steps necessary when the Lymph 
 used is dry-stored. — In the above descriptions it has 
 been assumed that the vaccinator was operating imme- 
 diately from child to child; and the same directions 
 are sufficient when he uses lymph that has been con- 
 veyed or preserved (Chap VIII.) in the liquid form, 
 as in the vaccine bottle, in capillary tube, sor in any 
 other way. But when he has to use lymph that has 
 
 of being pointed, is extensively employed for this form of lon- 
 gitudinal scarification. It answers its purpose very well, but 
 no better than a common lancet properly employed.
 
 132 HANDBOOK OF VACCINATION. 
 
 been preserved by drying, as on points or glasses, it 
 will be necessary this should be revived, or brought 
 back to the liquid state, in order that it may be taken 
 up by the system. This may be done by the use of 
 a very minute quantity of cold water ; if the lymph 
 to be revived has been preserved on glasses, a very 
 small drop of water should be taken on the point of 
 the lancet and well rubbed in with it, and the lymph 
 left for some minutes to soften ; if it has been kept on 
 points, these should be very lightly and for a moment 
 dipped in the water, the superfluous water shaken off, 
 and the moistened point left for a few minutes on the 
 edge of a book for the lymph to soften. Then, if the 
 vaccination is to be done by puncture, the revived 
 lymph should be taken on the lancet-point, and inserted 
 as in a vaccination direct from arm to arm ; or, better 
 still, supposing the lymph has been preserved on points, 
 punctures may be made with a clean uncharged lancet, 
 and the ivory points themselves then inserted into 
 these punctures, and kept in position by the thumb 
 for a short time — care being taken to press the thumb 
 well down as the points are being withdrawn, so that 
 the lymph may be thoroughly wiped off them and left 
 in the wound. If the vaccination is to be done by 
 scarification or abrasion, the revived lymph may either 
 be taken on the lancet and applied as in an ordinary 
 wet-lymph vaccination, or the flat of the glass or the 
 flat of the point may be itself rubbed over the scarified 
 or abraded surface. When the lymph on the point or 
 glass has not, by keeping or otherwise, become very 
 dry, the oozing of the abraded surface will generally 
 afford all the moisture that is needed for its revival. 
 When the scab is employed for vaccinating it must
 
 OF VACCINATING. 133 
 
 be well moistened, and worked up with a little cold 
 water on a slab or the back of a plate, by means of 
 a clean knife, and abundance of the ropy solution in- 
 serted. 
 
 (5) Is any one mode of insertion better than 
 another? — An important question arises, whether any 
 one of the different modes of inserting lymph above 
 described, or of numerous modifications of them that 
 are met with in practice, can be more relied on than 
 another for producing success. The only difference 
 that I am aware of, to a careful man who thoroughly 
 understands his work, is this, — that he will succeed 
 best in the way to which he is most accustomed. So 
 much depends on habit, and, if I may so say, on trick 
 of hand, that a practitioner who has learned properly 
 how to vaccinate, say by ordinary puncture, and can 
 rely on securing thus the results he aims at, is more 
 likely to be disappointed than gratified by attempting 
 to change his plan for any other, and vice versa. There 
 is not, in fact, one of these plans by which I have not 
 seen the best results of vaccination produced with sin- 
 gular uniformity and constancy by various practitioners, 
 and if a score of the best vaccinators in England were 
 picked out, there can be no doubt that each form of 
 working which I have described would have its repre- 
 sentative. Nothing certainly can be finer, or more 
 completely models of what vaccination should be, than 
 such results as Marson and some other vaccinators 
 produce by the process I first described, — that of sim- 
 ple puncture. Still, whether it be that this plan has 
 been often imperfectly taught (for few teach it and 
 practice it as Marson teaches and practices it), or 
 whether it be in itself more difficult than the other 
 12*
 
 134 HANDBOOK OF VACCINATION. 
 
 ways described, large opportunities of observing the 
 general practice of vaccination throughout England 
 have left no doubt on my mind, that in most hands it 
 has been much less successful than the others. This 
 is especially the case when, as in country practice, 
 conveyed lymph or dry lymph has frequently to be 
 employed. I have, in fact, found comparatively few 
 persons making dry lymph take well by simple punc- 
 ture ; and for vaccinations under these circumstances, 
 at all events, some of the forms of abrasion or scarifi- 
 cation are in most hands by far the most successful.* 
 Looking broadly at the results I have met with in the 
 practice of large numbers of vaccinators, and with no 
 personal prejudice in its favor (for it is not the mode in 
 which I have ever myself been in the habit of vaccina- 
 ting), it appears to me that no method is more highly to 
 be recommended than that of parallel scratches, crossed 
 or not crossed, dfc, and this whether regard 
 be had to the Mm infrequency of failure, 
 or to the size, ^W depth, and foveation of 
 the resulting cicatrices. And this conclusion in favor 
 of abrasion or scarification has, I believe, pressed itself 
 on the minds of all those who have taken part with 
 me in the inspection of public vaccination in England. 
 51. Watching the Course of Vaccination. Inspec- 
 tion of Results. — When the performance of vaccination 
 is completed, a particular charge should be given to 
 the parent to keep the arms from rubbing or other me- 
 chanical irritation, and means should be taken for seeing 
 
 * Ceely is of the same opinion. " With dry lymph on 
 points," says he, " there is no mode equal to that for certainty, 
 and I have tried many." (See Appendix to Badcock's Detail 
 of Experiments, etc., p. 7.)
 
 OF VACCINATING. 135 
 
 the child again on the same day of the following week, 
 that the success of the operation may be ascertained. 
 Such inspection is important to the practitioner, in 
 order that, in suitable cases, he may be able to obtain 
 lymph from the vesicles that have been produced, 
 whether for immediate use or for storage. It is indis- 
 pensable to the parent, who, without it, can never be 
 sure that the object of vaccination is gained, that the 
 child is really protected against small-pox. This is not 
 a point which an uninitiated person can determine for 
 himself; he can only know that an effect has been pro- 
 duced, not whether the specific effect which alone makes 
 the child safe has followed. On various occasions I 
 have known parents in perfect good faith, and without 
 the slightest intention of deceiving, affirm that a vac- 
 cination has taken beautifully, when inspection has 
 shown that the results were spurious. The law, there- 
 fore, requires that children should not only be vaccin- 
 ated, but that a vaccination should always be duly in- 
 spected ; nor, without actual inspection, can a medical 
 practitioner properly give a certificate of successful 
 vaccination. When, on this eighth-day inspection, 
 vesicles of a perfectly characteristic kind are found to 
 have risen, it is not very likely that anything in the 
 subsequent course of the vaccination will interfere with 
 its protective value, and the practitioner will seldom 
 find that he has made a mistake, who (besides giving 
 the parent the certificate of success to which he is then 
 legally entitled) should venture also to pronounce the 
 child safe; at the same time this assurance might be 
 given with more absolute certainty were the case seen 
 through the stage of areola, and I cannot but think it 
 is to be regretted that the old custom of inspecting the
 
 136 HANDBOOK OF VACCINATION. 
 
 vaccination on the eleventh or twelfth day, as well as 
 on the eighth, should have fallen into disuse. Without, 
 however, insisting on a second inspection in a perfectly 
 regular case, my experience compels me to urge strongly 
 the necessity of such further inspection in all cases 
 where the appearances on the day-week are retarded, 
 or in any degree dubious. Many times have I known 
 assurance given that the case was "all right," when, 
 from retardation, the vesicles were so little advanced 
 in their course that it was impossible for the practi- 
 tioner then properly to determine it; and I have also, 
 in non-retarded but dubious cases, seen results on the 
 day-week so far resembling the normal effects of vaccina- 
 tion that to an inexperienced person they might readily 
 have seemed such, and that an experienced person, if 
 compelled then to decide, would have been inclined to 
 pronounce them regular, and which yet, on further 
 watching, turned out irregular and spurious. The 
 only safe rule, therefore, with regard to doubtful or 
 retarded cases, is to inspect them again. Whenever a 
 case, whether on the day-week or on subsequent in- 
 spection, is found to be spurious, the parents should 
 be most carefully warned not to rely on that vaccina- 
 tion as protective against small-pox, but to have the 
 operation repeated either at once, if it be quite certain 
 that the cause of irregularity is not in the child's own 
 health or condition, or else after an interval of a few 
 weeks or months. 
 
 52. Performance of Vaccination from the Natural 
 or Casual Disease in the Cow. — Opportunities of seeing 
 the natural disease in the cow are not common, but for 
 the sake of those to whom they may chance to occur, 
 and who may conceive that some advantage may attend
 
 OF VACCINATING. 137 
 
 the raising a fresh stock of lymph from such cases, it 
 is desirable to offer a few hints, taken chiefly from 
 Ceely's admirable and oft-quoted memoir, both as to 
 the collection of the lymph and as to the insertion of 
 it. A practitioner in search of such lymph will often 
 have to take a great deal of trouble and be doomed to 
 much disappointment. He will frequently find himself 
 deceived by false reports, and, when he arrives, see 
 some spurious disease instead of the genuine cow-pock. 
 Even if the pock be genuine, the period for taking 
 lymph will most probably have gone by, and it is, in 
 fact, only when a number of animals are affected in 
 succession in a dairy that there is much chance of find- 
 ing any vesicles fit to yield lymph. Careful search, 
 especially on the lower and naked parts of the udder 
 and the adjoining bases of the teats, should, however, 
 be made, with the view of finding, if possible, some 
 entire unacuminated vesicles, or vesicles with central 
 crusts. The former, if found, should be punctured with 
 a sharp lancet as near the center of the vesicle as pos- 
 sible, ana" the epidermis gently raised to a moderate 
 extent round the discolored or most depressed part. 
 The greatest delicacy in manipulation throughout the 
 examination and subsequent puncture is necessary, for 
 the quantity of lymph is exceedingly small, and exu- 
 dation of blood will obscure it, or sensitiveness of the 
 animal under a rough manipulation prevent the opera- 
 tion altogether. With due care, slight gentle pressure 
 either with the blade of the instrument, or between the 
 thumb and finger, will enable the operator to charge a 
 few points. " Patience and a treble charging of the 
 points are always," says Ceely, " to be recommended." 
 Puncture at the elevated and indurated margin of the
 
 138 HANDBOOK OF VACCINATION. 
 
 vesicle will be useless, only yielding blood. Vesicles 
 with central crusts will be found perhaps more con- 
 venient than the entire unacuminated vesicles, and will 
 yield nearly as much lymph, if the crust be small and 
 the margin of the vesicle tender, hot, and tumid. The 
 crust may be removed or pressed on one side, the epi- 
 dermis then carefully raised, and a limpid fluid in small 
 quantities thus obtained.* Small superficial vesicles 
 will often yield more lymph than contiguous larger 
 vesicles more deeply seated. 
 
 When we are deprived of opportunities of getting 
 lymph in either of these ways, we may often succeed 
 by reviving (1) amorphous masses of concrete lymph 
 which have exuded from broken vesicles ; (2) the cen- 
 tral rough and irregular crusts, the more transparent 
 and nearer a dark brown the better ; (3) desiccated 
 vesicles, or formed crusts, if of primary formation, the 
 secondary and tertiary crusts being of scarcely any 
 value. 
 
 It is before acumination that we must always look 
 for lymph from the cow : after acumination, lymph is 
 comparatively of little value. The vesicle immediately 
 
 * In like way, when we desire to vaccinate from the casual 
 vesicle of a milker, and the case, as may often he, has not 
 come under our observation till the vesicle is well advanced, 
 the areola perhaps declining, as at the tenth day, effective 
 lymph may still be got from the center of the vesicle. Dis- 
 place the fragment of concrete lymph which occupies this 
 center; wipe away with repeated dossils of lint the turbid 
 serous fluid which issues. The lancet will then be able to take 
 up, though probably not without some intermixture with the 
 turbid opaque fluid, a tenacious limpid lymph from the deep 
 center of the vesicle. (Trans. Prov. Med. and Surg. Assoc, 
 vol. x. p. 245.)
 
 OF VACCINATING. 139 
 
 before acumination will yield it'in as active a state as 
 earlier ; while at an earlier period, as from the fifth to 
 the ninth day, it is scarcely possible to obtain it in any 
 quantity. In the early stages of some vesicles, espe- 
 cially those which are superficial or have been irritated, 
 lymph may be turbid and even bloody without impair- 
 ment of its efficacy. Even turbid lymph from an un- 
 acuminated vesicle will answer when limpid lymph 
 from an acuminated one will fail. Lymph will generally 
 be found more abundant on the cow than on the heifer, 
 more abundant and less viscid on the teats than on the 
 udder. 
 
 To establish and maintain a stock of lymph from the 
 cow, we must be careful to have at hand a sufficient 
 number of subjects to receive it, whether direct or 
 through its earliest removes. Young infants with a 
 thick, smooth, clear skin and a dark complexion, but 
 not too florid, are the best. Strumous, thin-skinned 
 children should be avoided. And this selection must 
 be adhered to with great care until (which, however, is 
 generally the case in a very few removes) the local in- 
 tensity of the symptoms is materially diminished. 
 With this very active lymph three or four punctures 
 will generally be amply sufficient, and unless we are 
 sure of our subjects it will be safer to use a less num- 
 ber : in all cases it is a matter of the greatest moment 
 to avoid rupture and disturbance of the vesicle. If we 
 desire for any reason to vaccinate with this acrid lymph 
 any subjects whom we deem unfavorable, we should 
 prepare them beforehand, as the old inoculators did the 
 subjects of variolous inoculation.* 
 
 * Trans. Prov. Med. and Surg. Assoc, vol. viii. pp. 338- 
 342, and 349.
 
 140 HANDBOOK OF VACCINATION. 
 
 CHAPTER VII. 
 
 OP ARRANGEMENTS FOR THE PERFORMANCE OF VACCINA- 
 TION AND THE MANTENANCE C? LYMPH-SUPPLY. 
 
 53. Great relative Advantages of Arm-to-arm Vac- 
 cination. — Vaccination performed direct from child to 
 child with well-selected lymph, in skilled hands, very 
 rarely fails. This is much more than can be said of 
 any other mode of proceeding. Lymph conveyed liquid 
 from patient to patient, however promptly, does not 
 infect with nearly the same certainty as the lymph 
 transferred immediately from arm to arm; and stored 
 or preserved lymph, whatever the mode of storage or 
 preservation, is greatly more unsuccessful. And if this 
 be the case with the best operators, the difference in 
 less practiced hands is still more remarkable. "De 
 quelque maniere qu'on s'y prenne," says Bousquet, "ja- 
 mais le vaccin conserve ne vaut le vaccin de bras a 
 bras."* The superiority, indeed, of arm-to-arm vac- 
 cination is not a point which admits of dispute, and, 
 by every practitioner who duly reflects on the im- 
 portance of making vaccination thoroughly success- 
 ful, the performance of it in this way is regarded as a 
 matter of the utmost consequence. 
 
 54. Method and suitable Arrangements are requi- 
 site for thus performing Vaccination. — : But for vac- 
 
 * Kapport de l'Academie sur les Vaccinations pratiquees en 
 France pendant l'Annee 1844. •
 
 ARRANGEMENTS FOR VACCINATION. 141 
 
 cinating from arm to arm, and especially for carrying 
 on a series of such vaccinations, method and suitable 
 arrangements are indispensable. " Our arrangements," 
 says Jenner, writing to a gentleman whose children he 
 had undertaken to vaccinate, "must be carefully made, 
 as the children must be met here by proper subjects for 
 transferring the lymph ; for on the accuracy of this part 
 of the process much depends." But how can we make 
 sure of having proper subjects for supplying lymph for 
 a day's vaccinations, unless we have several children 
 under vaccination at the same time? Every expe- 
 rienced vaccinator knows that a child who has been 
 successfully vaccinated so as to be well protected 
 against small-pox may yet not be a good, and often 
 will not be an eligible, child for transmitting lymph. 
 Let half a dozen successful cases of vaccination present 
 themselves for inspection on the same day, and you 
 may not have more than two or three, if so many, 
 really choice arms from which to carry on the day's 
 vaccinations; and a vaccinator who is dependent on 
 only one, two, or three vaccinations of the previous 
 week, is liable to be stopped in his proceedings, not 
 merely by the case or cases having failed, but by the 
 vesicles being such as experience dictates he had better 
 not employ for continuing his lymph. If, rather than 
 be stopped, he succumbs to the temptation of vaccina- 
 ting from such cases, more especially if (as such a vac- 
 cinator is sure to do) he succumbs again and again, he 
 will soon find his stock of lymph deteriorate. 
 
 55. Selection of Lymph is necessary to prevent its 
 
 degenerating. — Whatever opinion may be entertained 
 
 as to lymph losing any of its original power, necessarily 
 
 and inevitably, by the m^rc fact of its transmission 
 
 13
 
 142 HANDBOOK OF VACCINATION. 
 
 through a succession of human subjects (a matter which 
 will be discussed hereafter), no one can doubt that 
 such loss of activity may take place unless due care be 
 taken in the selection of the subjects through which 
 the lymph is continued: and the best vaccinators, 
 whether at home or abroad, lay great stress on this 
 point. Bousquet strongly insists upon it : "S'il y a un 
 moyen d'empecher ou du moins de ralentir la degene- 
 rescence du vaccin, c'est de le prendre toujours sur les 
 plus beaux enfants, et dans les plus belles pustules."* 
 Steinbrenner severely condemns the habit of taking 
 lymph almost indiscriminately from any vesicles which 
 are not abnormal, instead of choosing only the most 
 perfect and the most characteristic — unlike the wiser 
 husbandman, who*, he says, picks out the finest grain 
 for his seed-corn, f The case is admirably stated, and 
 the views of our own highest authorities in practical 
 vaccination are embodied, in the following extract from 
 Simon's preface to the " Papers relating to the History 
 and Practice of Vaccination :" " Whether slow pro- 
 gressive degeneration of the vaccine contagion in its 
 successive human transmissions be or be not proved, 
 whether its renewal at stated intervals from the cow 
 be or be not an unconditional necessity, the practical 
 conclusion evidently is, that its operation must in every 
 case be intelligently watched ; that no line of transmis- 
 sion is to be continued through a subject in whom im- 
 perfect infection is produced ; that at any such point 
 the vaccinator must stop; and that from all such 
 points, as they are arrived at, reapplication must be 
 
 * Nouveau Traite de la Vaccine, p. 228. 
 f Traite sur la Vaccuie, p. 570.
 
 ARRANGEMENTS FOR VACCINATION. 143 
 
 made to the parent stock — not necessarily at its source, 
 but at least at some stage of descent in which its in- 
 fective powers are unimpaired. Upon each individual 
 vaccinator must rest the responsibility of providing in 
 his own practice against those obvious chances of de- 
 terioration of supply. It becomes difficult or impossible 
 to fulfill this obligation, except when the vaccinator 
 carries on simultaneously a certain number of vaccina- 
 tions; so that he may be able at any time to choose 
 between several arms as sources for continuing his con- 
 tagion, and may never be tempted to take lymph other- 
 wise than from the typical Jennerian vesicle of a thor- 
 oughly healthy subject. It is on these grounds that 
 persons who have given most attention to the scientific 
 culture of vaccination (foremost among whom I am 
 permitted to name Mr. Ceely and Mr. Marson) look 
 with some alarm on our present minute subdivision of 
 the duty of public vaccination, as tending to reduce 
 many public vaccinators to an objectionable alternative ; 
 either that they must have frequent recourse to extrin- 
 sic assistance, or must incur the chance of the contagion 
 degenerating by its transmission through unselected 
 subjects."* 
 
 56. Continuous supplies of fresh Lymph depend on 
 the arrangements for Public Vaccination in Large 
 Towns. — Although a full consideration of the arrange- 
 ments for public vaccination in England involves de- 
 tails which must be reserved for a subsequent chapter, 
 it is impossible to treat properly of arm-to-arm vaccin- 
 ation, and of lymph-supply, without an examination 
 of the principles on which a public system of vaccina- 
 
 * Preface to Papers relating, etc., p. xxxvii., note
 
 144 HANDBOOK OF VACCINATION. 
 
 tion should be based. For, firstly, under the distribu- 
 tion of vaccination which now exists, a very large 
 majority — probably at the least two-thirds* — of the 
 children born are vaccinated by the public vaccina- 
 tors, and it depends therefore directly on the public 
 arrangements how far this large majority shall have 
 the advantages of well-performed arm-to-arm vaccina- 
 tion ; and, secondly, inasmuch as circumstances render 
 it impossible for any but the public vaccinators of large 
 towns to maintain continuously stocks of fresh lymph, 
 and as there is a constant demand for such lymph for 
 
 * More probably even tbree-fourtbs. It is impossible to 
 state exactly what proportion of each year's births are vac- 
 cinated by the public vaccinators in the kingdom, because, in 
 the annual returns of the public vaccinations performed, cases 
 of revaccination are included without being distinguished 
 from primary cases. The returns, however, give separately 
 the vaccinations performed under one year of age, which of 
 course are all primary ; and these alone have since 1854 aver- 
 aged annually more than half the registered births. Now, as 
 in the remaining, or minor half, are included (1) all that very 
 large number of children who, remaining unvaccinated till 
 they are more than a year old, are then vaccinated by the 
 public vaccinators, and constitute the bulk of the cases an- 
 nually returned as publicly vaccinated over one year of age, 
 
 (2) all children who die before vaccination has been done, and 
 
 (3) all living whose vaccination remains unperformed, the 
 remnant vaccinated by private practitioners cannot, I think, 
 exceed, and can scarcely amount to, one-fourth of the children 
 born. It must further be borne in mind that this small pro- 
 portion of cases is distributed among several times as many 
 operators as are employed in vaccinating the other and larger 
 portion, to understand the difficulties of private practitioners 
 with regard to maintaining their lymph-supply. The distri- 
 bution of vaccinations into private and public varies consider- 
 ably, it need scarcely be said, in different places and districts.
 
 ARRANGEMENTS FOR VACCINATION. 145 
 
 the use of other practitioners not so fortunately placed, 
 the public arrangements adopted in these towns must, 
 obviously, indirectly influence, more or less, the whole 
 vaccination of the kingdom. 
 
 A very little consideration of the subject is sufficient 
 to show that the conditions already stated — viz., that 
 for every arm-to-arm vaccination there should be a 
 choice of children for transferring the lymph, and that 
 properly to carry on a series of arm-to-arm vaccinations 
 there must be several cases assembled on each vaccin- 
 ating day — are conditions which only some out of the 
 many thousand medical practitioners who practice 
 vaccination in England can continuously fulfill. For 
 it has been found by experience that an average of ten 
 vaccinations at a time is as little as can be relied on 
 for the purpose ; and to supply this number of subjects 
 continuously once a week, a vaccinator would need to 
 have more than five hundred cases a year.* Now 
 such an amount of cases as this is not attainable in 
 
 * Of course with an average attendance of ten children a 
 week, there are many weeks when fifteen or twenty are 
 brought, and others when only four or five attend. In sum- 
 mer the attendance is always better than in winter, and par- 
 ticular causes, as bad weather, etc., often interfere with the 
 stational attendance on particular days. But, the law requir- 
 ing vaccination to be performed within a fixed period from 
 birth, it is found practically that there is so far steadiness of 
 attendance that, with the average stated, some children are 
 always brought, and that with a very little management a 
 vaccinator may make sure of having on any day at least three 
 or four. But an average of ten is quite the minimum that 
 should be allowed, and a larger average gives greater facili- 
 ties of working, and greater opportunities of choice. This 
 subject is farther considered in $ 57. 
 1,'}*
 
 146 HANDBOOK OF VACCINATION. 
 
 any rural district, nor, even if the amount were attain- 
 able, would considerations of distance admit of the 
 children in such districts being all brought together 
 to one place. It is not attainable in small towns, nor 
 in any town where the births are less than seven or 
 eight hundred a year, and frequently is not attainable 
 even where the births exceed this number, on account 
 of the vaccination of these children being distributed 
 among various practitioners. It is an amount which, 
 even in our largest towns, no private practitioner, or 
 scarcely any private practitioner, can command.* Con- 
 stant supplies of fresh lymph can only, I repeat, be 
 kept up by the public vaccinators of large towns ; nor 
 can they be maintained even by them, unless (1) the 
 authorities have taken care to supply the respective 
 vaccinators with the requisite number of cases, and (2) 
 the local arrangements have provided for these cases 
 being assembled in regular weekly succession. f 
 
 * In 1865 there were no fewer than 14,185, and in 1866 no 
 fewer than 13,718 separate applications for lymph made to the 
 Central Office of the National Vaccine Establishment alone, 
 by private practitioners practicing in England and "Wales ; 
 and this by no means represents all the assistance afforded by 
 the Establishment to this portion of the medical profession, 
 numerous applications being made and satisfied on the spot at 
 its various metropolitan and extra-metropolitan stations. And, 
 in each of these years, about 1500 applications were made to 
 the establishment from public vaccinators. Besides this, a 
 demand for lymph, the extent of which there are no means of 
 estimating, is constantly being made throughout the kingdom 
 to district vaccinators unconnected with the Establishment. 
 
 f Conditions which require attention to the following gene- 
 ral rules, which have for some time past been recommended 
 to local authorities for their guidance in this matter :
 
 ARRANGEMENTS FOR VACCINATION. 14? 
 
 Lymph-supply, then, is a matter primarily of public, 
 and only secondarily of individual professional arrange- 
 ment. And it is On the authorities charged with the 
 administration of the national system of public vaccin- 
 ation that it depends (1) to maintain continuously 
 and in abundance, wherever this can be done, constant 
 supplies of fresh lymph, and (2) to make the super- 
 fluous lymph of the public vaccinations of large towns 
 available for public use in other places, and for private 
 professional use throughout the kingdom. 
 
 57. Arrangements in Large Towns. — Wherever 
 large numbers of children can be brought together in 
 regular succession, stocks of fresh active lymph can be 
 maintained with the greatest ease, and the abundance 
 of supply is proportionate, of course, to the number of 
 children. Hence, while an average of ten cases on a 
 vaccinating day has been stated to be the minimum 
 below which no station ought to be expected to main- 
 tain a constant fresh supply, it is of great consequence 
 that, wherever practicable, a larger attendance of cases 
 
 (1) That, except at times when there is immediate danger 
 of small-pox, vaccination be not appointed to he performed at 
 any station oftener than once a week ; 
 
 (2) That, except at times when there is immediate danger 
 of small-pox, or for special reason in individual cases, vaccina- 
 tion in town districts (unless it be of private patients) be per- 
 formed only at the public station ; 
 
 (3) That, as opportunity offers, especially in urban unions 
 and parishes, all unnecessary subdivision of public vaccina- 
 tion among many districts or stations be discontinued ; and 
 that in populous towns, unless under special circumstances, 
 subdivision be not made beyond the point where each vaccina- 
 ting station will have annually at least 500 applicants for 
 vaccination.
 
 148 HANDBOOK OF. VACCINATION. 
 
 should be obtained. If the unfortunate, and in its 
 results mischievous, system of subdivision which has 
 heretofore existed in the arrangements for public vaccin- 
 ation in the towns of England (see Chap. XV.) were 
 abolished, it would be found that in the denser parts 
 of the metropolis, and of such towns as Liverpool, 
 Manchester, Birmingham, Leeds, Sheffield, Bristol, etc., 
 stations, at each of which the annual vaccinations should 
 range from 1000 to 1500, could readily be maintained 
 without any disregard of the public convenience as to 
 distance. London alone would supply a large number 
 of such stations within a quarter of a mile of nearly 
 every house, and within a third of a mile of every 
 house.* Many stations much more frequented than 
 this existed before the introduction of " Public Vaccin- 
 ation, "f but there are not now more than three or 
 four in the kingdom at which the average annual vac- 
 cinations amount to a thousand. In the official visits 
 which, in the course of the last seven years, I have 
 repeatedly made to the principal vaccinating stations 
 in England, I have had ample opportunities of noticing 
 
 * That is, in its central and most thickly-peopled parts ; this 
 was ascertained by Dr. Buchanan and myself in the in- 
 quiry we made into the public vaccination of London, by di- 
 rection of the Privy Council, in 1863. In parts in which 
 population was less dense, including the populous suburbs, 
 stations at the same distance apart would still have from 500 
 to 1000 cases a year. It was only in the outskirts that the 
 stations would have smaller attendances, or need to be placed 
 farther asunder. (See Sixth Rep. Med. Off. of Privy Coun- 
 cil, p. 118.) 
 
 f At the Small-pox Hospital the annual vaccinations were 
 above 3000, so also at Surrey Chapel ; at the Birmingham Dis- 
 pensary there were between 2000 and 3000, etc. etc.
 
 ARRANGEMENTS FOR VACCINATION. 149 
 
 the very great advantages these few larger stations 
 had over those at which the above-stated minimum 
 number of 500 annual cases was merely attained, or 
 only a little exceeded — whether in regard to their op- 
 portunities of selection, their assurance of a fair attend- 
 ance of- subjects in unfavorable weather, or their much 
 larger means of supplying lymph for the use of others. 
 Wherever they exist, the local population is greatly 
 the gainer by them. And their national importance 
 cannot be overrated. It is on them exclusively, if a 
 proper number of them were provided, that reliance 
 should be placed for obtaining that large fund of fresh- 
 stored lymph which needs to be constantly kept on 
 hand by the National Vaccine Establishment, for the 
 use of practitioners, public or private, in the small 
 towns and rural districts of the kingdom, as well as 
 for other public or professional needs. The stations 
 at which the annual vaccinations fall, on an average, 
 below a thousand, and especially those at which they 
 nearly fall down to the prescribed minimum — the sta- 
 tions, in fact, under a proper system, of the less dense 
 parts of towns of the first magnitude, and the stations 
 of moderate-sized towns — would not then be needed, 
 or would only exceptionally be needed, to contribute 
 to the national stores, and might be reserved for the 
 supply of local professional wants. It is only in the 
 very largest towns that these first-class stations (such 
 I call those the vaccinations at which amount to a 
 thousand a year) could be obtained ; but every town 
 in the kingdom, of 40,000 inhabitants, and many towns 
 of smaller population than this, yield annually a suffi- 
 cient number of subjects for public vaccination to main- 
 tain a station at which the performance of arm-to-arm
 
 150 HANDBOOK OF VACCINATION. 
 
 vaccination with selected lymph might be placed 
 weekly within the reach of the inhabitants, and at 
 which a continuous stock of lymph fresh from the arm 
 might be kept up. If at present, in such towns, a 
 large amount of the vaccination, and even of the public 
 vaccination, is done, as we know it is, with stored and 
 conveyed lymph, to the great detriment of the public, 
 it is because the advantages which number and aggre- 
 gation of population give have not been duly consid- 
 ered — have, in fact, been thrown away ; and the public 
 cases, instead of being kept together, have been so dis- 
 persed in various ways, that the maintenance of a local 
 fresh lymph supply became impossible. (See postea, 
 §61.) 
 
 I venture, then, to think that if the authorities will 
 do away with the present superfluous appointments 
 and the excessive subdivision in towns, and so divide 
 or distribute the public performance of vaccination in 
 England that the public stations in the denser parts of 
 towns of great magnitude shall be supplied with an 
 average of at least twenty cases on each vaccinating 
 day ; and in the less dense parts of such towns, and in 
 towns which, though smaller, can yet furnish cases 
 enough properly to maintain continuous arm-to-arm 
 vaccination with an average approaching that number 
 as far as population and other local circumstances ad- 
 mit — the following advantages would be derived: (1) 
 the necessity of any use whatever of preserved or con- 
 veyed lymph in the public vaccination of the town 
 (with rare exceptions for special reasons in some indi- 
 vidual cases) would be obviated altogether — and in 
 effect (inasmuch as public vaccination is a public right, 
 open to all) no necessity would exist in the town for
 
 " ARRANGEMENTS FOR VACCINATION. 151 
 
 the use of such lymph at all, except in so far as parents 
 preferred not to avail themselves of the public station; 
 (2) in the cases in which parents desired to have the 
 vaccination performed by their own medical attendants, 
 there would be furnished on the spot to the private 
 practitioners of the town (who, however methodical in 
 the arrangement of their own cases, must still, from 
 limited numbers, be more or less frequently obliged, 
 unless they had recourse to long-stored lymph, to seek 
 assistance from without) the aid they require, and in 
 the most effective manner, viz., with lymph perfectly 
 fresh ;* and (3) the lymph, which must necessarily be 
 
 * What an absurdity, what a gross absurdity, it is, that in 
 such towns as (say) Hull, or Bradford, or Nottingham, or 
 York (and I might name, indeed, nearly all the large towns 
 in the kingdom), a practitioner, instead of having in his own 
 town a station at which on the appointed week-day he might 
 always be supplied with lymph straight from the arm, should 
 either be obliged to send about, first to one place or neigh- 
 bor, and then to another, to beg some lymph — which often 
 cannot be got, and often if it be got is of some length of stor- 
 age — or be obliged to send up to London to the National Vac- 
 cine Establishment, whence the lymph sent out to him must 
 at the earliest be a day or two old, and frequently necessarily 
 older. From the towns Thave named, and others as large or 
 larger, applications to the National Vaccine Establishment 
 are of weekly occurrence. Contrast with these places a few 
 others where proper arrangements exist, and where a local 
 practitioner is not only sure of obtaining fresh from the arm 
 the lymph he wants, but where the public vaccinator (as I 
 have myself repeatedly seen) not unfrequently looks out for 
 him a suitable child, the parents of whom are willing for a 
 small douceur to accompany him to his patients' residences, so 
 that the -operations may he done direct from arm to arm. I 
 would take this opportunity of calling the attention of my
 
 152 HANDBOOK OF VACCINATION. 
 
 kept always in store {but which should always be as 
 fresh as possible) for the wants of small towns and of 
 rural districts, as well as for the use of the army and 
 navy, the colonies, and abroad, would be supplied of 
 the choicest kind, and in quantity practically unlimited. 
 Under such arrangements as have been here described, 
 any dearth of lymph of the best and freshest kind must, 
 I conceive (and I write with some practical knowledge 
 of the subject), be at any time utterly impossible. 
 
 58. Arrangements in Smaller Urban Populations. 
 — In urban populations in which the cases for public 
 vaccination fall short — but do not very largely fall 
 short — of the number assigned as the minimum for 
 properly carrying on continuous arm-to-arm vaccina- 
 tion, in which (say) there is but an average of seven 
 or eight cases a week instead of an average of ten, 
 weekly public vaccination may still with pains be 
 maintained, without the necessity for recourse to pre- 
 served lymph (except only occasionally), and with very 
 fair opportunities of selection. A good deal of con- 
 trivance, however, has often to be resorted to for the 
 purpose, the difficulties increasing as the number of 
 cases diminishes, but in a much greater ratio. Public 
 vaccinators, under such circumstances, require to be 
 watchful that their lymph does not deteriorate, and, 
 
 professional brethren to the great mutual advantages I have 
 always found attending a good understanding between the 
 public vaccinator and the private practitioners of a town, the. 
 latter sending to the public station such of their patients as 
 pay them no fee for vaccination, or doing what they can to 
 induce them to go there, and the former in return being 
 ready, and justly considering that under the circumstances 
 there is a claim on him, to give the assistance above stated.
 
 ARRANGEMENTS FOR VACCINATION. 153 
 
 though they may frequently be able to assist their 
 brethren in private practice, they are not to be counted 
 on for being able to do so at any and all times, as in 
 larger towns. What is the lowest annual number of 
 cases with which a practitioner may advantageously 
 attempt to carry on continuous weekly vaccination, 
 depends greatly on the pains he takes in methodical 
 arrangement, and on his judgment in his individual se- 
 lections. Hence, sometimes, vaccinators with limited 
 numbers are found maintaining better stations than 
 others who have larger opportunities. But, as a rule, 
 my experience would lead me to think it of disadvant- 
 age, if attempt were made to carry on a public station 
 weekly throughout the year where the annual number of 
 cases fell at all, or at all events if it fell much, below 300. 
 59. Arrangements in still Smaller Towns, and in Eu- 
 ral Districts. — Wherever the number and distribution 
 of cases for public vaccination is such, as it must be in 
 all small towns and rural districts, that a continuous 
 weekly succession of applicants in sufficient number at 
 a station cannot be maintained, the best mode of pro- 
 viding good arm-to-arm vaccination for the public con- 
 sists in the adoption of some form of periodical vaccin- 
 ation. Thus, public vaccination might be carried on 
 during the summer months only, and suspended during 
 the winter months. In a town which will give (say) 
 its 200 cases a year to a public vaccinator — a number 
 quite insufficient to keep a station always going — vac- 
 cinations may very well be kept up weekly throughout 
 the summer. Where population is smaller or more 
 scattered, the vaccination should be carried on for a 
 few successive weeks at two or three periods in the 
 year. The best provision for rural districts, including 
 
 14
 
 154 HANDBOOK OF VACCINATION. 
 
 the small towns of such districts, consists in the system- 
 atic sweeping of the district (if I may be allowed the 
 expression) every spring and autumn. In laying out 
 arrangements for periodical vaccination in districts of 
 this kind, with a view to the performance of the vaccin- 
 ation, as far as possible, from arm to arm, local authori- 
 ties should (1) appoint as few stations as is consistent 
 with due regard to the convenience of the population 
 as to distance, (2) consider in reference to each station 
 what is the number of cases to be annually provided 
 for thereat, and (3) so fix the attendances of the vaccin- 
 ator that, as a rule, there shall be several children as- 
 sembled for each attendance. In periodical vaccina- 
 tions, the vaccinator has only to provide himself from 
 without with lymph for the commencement of the peri- 
 odical proceedings. He gets lymph for the vaccination, 
 say, of three well-chosen children ; from them, or from 
 one or other of them, he is able to vaccinate his first 
 group, who yield him lymph not only wherewith to 
 continue his arm-to-arm work, but for use fresh-stored, 
 in those cases in which the use of preserved lymph may 
 be indispensable. No arrangements that can be devised 
 for rural, or for any little populated districts, will 
 obviate altogether the necessity for the occasional use 
 of lymph stored or conveyed: but what may and 
 should be done, is to reduce this necessity to a mini- 
 mum. And we know from experience that in rural 
 districts, by steady adhesion of the vaccinator to peri- 
 odical station al arrangements, the inhabitants may en- 
 joy, with few exceptions, the advantages of well-per- 
 formed arm-to-arm vaccination. Under the Vaccination 
 Laws recently in force, the establishment of a good 
 periodical system of public vaccination in districts
 
 ARRANGEMENTS FOR VACCINATION. 155 
 
 which required it was not practicable. It would have 
 liccii clearly inconsistent with a law which enacted, 
 under penalty, that all children (health permitting-) 
 should be vaccinated within three months of birth, that 
 public vaccination should in any district be suspended 
 for three> four, or six months together. But by the 
 "Vaccination Act, 186?," it is expressly provided that, 
 in those districts in which the paucity or diffusion of 
 population renders it expedient that public vaccination 
 should only be carried on at intervals exceeding three 
 months, parents shall be exempt from any penalty for 
 neglect arising during an interval, on condition that 
 the vaccination be performed during the next periodical 
 attendance of the public vaccinator. 
 
 60. Arrangements for Private Vaccination. — I 
 have but few hints to offer with regard to the conduct 
 of private vaccination, but some probably may be ac- 
 ceptable. The principles on which private vaccination 
 should be carried on are of course essentially the same 
 as those recommended for public vaccination. There 
 are scarcely any private practitioners whose cases are 
 numerous enough to enable them to maintain stocks of 
 lymph of their own for any long time together, and 
 most private vaccination has to be done periodically, 
 or in batches. Extraneous assistance must be given 
 for the commencement of each batch, but the practi- 
 tioner, having received this assistance to start with, 
 should endeavor so to arrange his cases as to keep up 
 his own supply until the batch requiring vaccination is 
 exhausted. I find many practitioners, in their desire 
 to maintain a stock of their own as long as possible, re- 
 ducing their weekly vaccinations to an inconveniently 
 low number — taking care, in fact, not to vaccinate above
 
 156 HANDBOOK OF VACCINATION. 
 
 a case or two a week. I venture to suggest that this 
 is an undesirable arrangement, and one that often de- 
 feats its own object. If a practitioner has twenty cases 
 on his list to vaccinate, he will do them more easily, 
 and more satisfactorily, if he vaccinate them all in two 
 or three successive weeks, than if he try to eke out his 
 vaccination for five, or six, or seven weeks, or more. 
 In the upper and upper-middle classes of society it is 
 usual to perform the vaccination at the patients' dwell- 
 ings ; but, where this has to be done, it is always de- 
 sirable that a child fit for transferring the lymph should 
 be taken to the house. Practitioners have not, gener- 
 ally, much trouble in getting most of their lower-mid- 
 dle class patients to attend at their surgery. Parents 
 are generally very ready to do this when they know 
 that it is for an object beneficial to the child : and the 
 surgery attendances of course should be regulated in 
 weekly succession. In all large towns where continu- 
 ous weekly public vaccination can be maintained (§ 51), 
 fresh lymph should be procurable by the private prac- 
 titioners at the station of the town, to enable them to 
 commence their proceedings when several cases have 
 accumulated for vaccination. Practitioners in other 
 places could always obtain it for the same purpose, as 
 at present, from the National Establishment. 
 
 61. Results of Disregard of the foregoing Consider- 
 ations. — I have felt the more anxious to make clearly 
 understood the sort of arrangements upon which reli- 
 ance may be placed for securing good lymph supply, 
 and, as far as possible, the performance of arm-to-arm 
 vaccination, because, in the discharge of my official 
 duties, I witness daily the unfortunate results which 
 have ensued from the adoption of quite other arrange-
 
 ARRANGEMENTS FOR VACCINATION. 157 
 
 merits for the performance of public vaccination — ar- 
 rangements in which these, the matters of first conse- 
 quence, have been overlooked or disregarded. It seems 
 scarcely credible, but it is nevertheless true, that in 
 this densely-peopled metropolis, where, if anywhere, 
 there should be every facility for affording to children 
 invariably the benefit of the best arm-to-arm vaccina- 
 tion, a large proportion even of the public vaccination 
 should be done with stored lymph, or done from the 
 arm under conditions that admit of no proper selection 
 of lymph being made ;* that in some districts of London 
 more than half the public vaccination, and in others 
 even a much larger proportion, should be so done ; that 
 in most of the large towns of England the same evils 
 should be found extensively to exist ; and that, in many 
 of them, not only is public vaccination with stored 
 lymph the rule, instead of being (what in such places 
 it should be) the very rare exception, but the perform- 
 ance of public vaccination at all is, in some of the dis- 
 tricts into which the towns have been divided, at times 
 suspended for months together."}" The Poor-Law 
 
 * It was only the other day that a public vaccinator of one 
 of the most densely-peopled parishes of London told me that, 
 from his small number of cases, he must sometimes vaccinate 
 from second-rate arms, or he could not do it from tbe arm at 
 all ; the public vaccinators of this parish were fivefold as 
 many as there should have been to keep up proper supplies. 
 
 f See fuller illustrations in the concluding section of Chap- 
 ter XV.; also, the successive Annual Keports of the Medical 
 Officer of the Privy Council (Appendices containing Results 
 of Local Inquiries as to Vaccination), iii.-vii. inclusive, and 
 particularly the Sixth Report, in which is included the results 
 of an inquiry, made by Dr. Buchanan and myself, into public 
 vaccination in the metropolis. 
 
 14*
 
 158 HANDBOOK OF VACCINATION. 
 
 Board will henceforth be able to put an end to that 
 multiplication of districts, and multiplication of appoint- 
 ments, which have been the main causes of these re- 
 sults. And the provisions which have been introduced 
 for that purpose into the New Yaccination Act — pro- 
 visions which give to the central authorities regulative 
 and controlling powers which they have not heretofore 
 had — will, there can be no doubt, soon lead to the sub- 
 stitution of arrangements more advantageous to the 
 public. 
 
 CHAPTER VIII. 
 
 OP THE CONVEYANCE AND STORAGE OP LYMPH. 
 
 62. Conveyance and Storage of Lymph. — After all 
 has been done that can possibly be done for giving the 
 population the benefits of arm-to-arm vaccination, there 
 will still be frequent occasions on which recourse must 
 be had to conveyed or stored lymph. Everywhere in- 
 dividual cases will be met with in which it may be re- 
 quired ; and it must be kept ready on a large scale, to 
 meet the wants of those who are unable to maintain 
 their own supplies — e.g. for starting periodical public 
 vaccinations, for starting series of private vaccinations, 
 for the use of the public services in the army, navy, 
 etc., and for transmission to the colonies and to other 
 foreign places, where, from paucity of subjects and 
 climatic or other causes, stocks of lymph cannot be 
 maintained, or require at times to be renewed. The
 
 STORAGE OF LYMPH. 159 
 
 best modes of conveying and storing lymph demand, 
 then, our most attentive consideration. 
 
 63. Modes of Conveyance for Immediate Use. — For 
 mere conveyance of lymph from one house to another, 
 some practitioners use their ordinary vaccinating lan- 
 cets, charging the points of them well, and keeping 
 the blades from contact with the handles by a strip of 
 paper folded as a shield round the base ; or they use 
 lancets specially constructed so as not to admit of the 
 blade coming into contact with the handles. For im- 
 mediate, or for very prompt use, this will do very well, 
 but the lymph on the lancet-points soon concretes, and 
 the drier it is allowed to get the greater are the chances 
 of failure ; besides which any attempt to keep lymph 
 on lancets beyond a day or two is at the risk of its 
 spoiling and decomposing. When lancets are em- 
 ployed for conveying lymph, the utmost care is requi- 
 site to prevent them from getting rusty, and usually 
 lancets so employed do not remain long fit for use. 
 The state of rust in which I have repeatedly seen lan- 
 cets sent by practitioners to vaccinating stations to be 
 charged, assures me that a caution in this respect is 
 much needed, and no doubt to this carelessness are 
 traceable not a few sore arms. To make sure of suc- 
 cess in using charged lancets, the practitioner should 
 allow for each insertion he makes, the charge collected 
 on one lancet. And if he is not able to perform his 
 vaccination on the day on which the lymph is taken, 
 he should not use the lancets at all, but wash off the 
 lymph and clean the instruments well. 
 
 A better way of conveying lymph in a fluid state for 
 prompt use, is the vaccine bottle — a small square bottle 
 with a well-ground glass stopper, so shaped that its
 
 160 HANDBOOK OF VACCINATION. 
 
 inner surface projects into the bottle, in the form of an 
 oblong blade of glass, on which the lymph is collected. 
 Or the lymph may be carried between two fiat, closely- 
 fitting bits of glass, each about three- 
 quarters of an inch square — one of 
 which bits may, if the practitioner 
 chooses, be furnished with a cup-like 
 depression at its centre. In either 
 case, the lymph must be used within 
 
 twenty-four hours, or, if the weather be cold and the 
 bottle or glasses have been kept in a cool place, within 
 thirty-six, or at the utmost forty-eight hours of being 
 taken. Lymph, like other moist animal matter that 
 has access to air, soon undergoes changes which ren- 
 der it unfit for use, and the prudent practitioner will 
 never attempt to keep it in a liquid state longer than 
 the time above specified, except in hermetically sealed 
 tubes. I think it scarcely necessary to advert, except 
 for the sake of deprecating it, to the proposal which 
 has been made of keeping lymph liquid for a longer 
 time by mixing it with glycerin. What effect, if any, 
 glycerin might have in retarding the decomposition of 
 lymph, I have not thought it worth while to inquire : 
 because it is with lymph — pure lymph, as pure, as con- 
 centrated, and as pungent as can be — that we should 
 vaccinate, not with mixtures and compounds. But I 
 happen to be acquainted with some results of using 
 the mixture, and they exhibited, as might be expected, 
 a large relative amount of failure. 
 
 64. Various Modes of Storage. — Lymph that is to 
 be kept beyond the times above stated before being 
 used should be dried and kept in a dry state on points
 
 STORAGE OF LYMPII. 101 
 
 or on glasses, or should be preserved liquid in capillary 
 tubes hermetically sealed. 
 
 (a) Points. — The points used for preserving lymph 
 are made of ivory. Old ivory should be used, as being 
 less absorbent. They are generally cut of this size and 
 
 shape, or scarcely so big, but 
 
 much larger points would be / ^> 
 
 far preferable, and best of all 
 
 are such points as Ceely, Marson, and others have 
 had made for their own use, which have the size and 
 shape of the ordinary lancet—rare, in fact, ivory lancets. 
 This size, no doubt, would be inconvenient for trans- 
 mitting lymph, but I know no reason why much larger 
 points than the present should not be used. For charg- 
 ing the points, the vesicles are opened according to the 
 directions given when lymph is to be taken from the 
 arm for a direct vaccination (§ 50, c, 1), and the points 
 well dipped in the exuded lymph till a good drop stands 
 on each of them ; they should then be laid on some flat 
 raised surface, as the edge of a book (but so that their 
 wet ends do not touch it), to dry; and if, when they 
 have undergone some drying, any should appear insuf- 
 ficiently coated, these should be redipped. Under any 
 circumstances, indeed, a second coating is most desir- 
 able; and a third coating will make them take all the 
 more surely. It is not only the ends of the points, but 
 some considerable part of their flat surface, which 
 should be coated. Under the disadvantages in which 
 a practitioner is placed who has to use preserved 
 lymph on points, care should be taken to give him as 
 abundant a supply of it on each point as possible. 
 When the points have dried they should be wrapped 
 up in oil silk, which must be tightly closed with gum ;
 
 162 HANDBOOK OF VACCINATION. 
 
 they should then be put away in a dry place, in a well- 
 corked bottle full of cotton-wool, or else they should 
 be sent off to their destination, if they are to be sent 
 away. Points charged from the arms of different 
 children should not be mixed together, and on each set 
 of points should be noted the source (the particular 
 child) from which the lymph was taken. 
 
 (b) Glasses. — The glasses which are used for storing 
 lymph are the same square closely-fitting bits of glass 
 already described as sometimes used for conveying 
 moist lymph. When the lymph, however, is to be dry- 
 stored, both of the plates must be flat and free from cup- 
 like depression. First one square, and then another, 
 is dipped and redipped in the lymph which stands on 
 the surface of an opened vesicle till they are found to 
 be well coated ; the lymph must then be allowed to 
 concrete, and the coated surfaces of the squares pressed 
 very close together. Successive pairs of glasses may 
 be treated, of course, in the same way : each pair should 
 be wrapped up in oil silk or tinfoil, and put by for use ; 
 the source of the lymph, as in the case of points, being 
 always noted upon it. Glasses should be so coated 
 that when they are held to the light the inspissated 
 lymph should be very visible. 
 
 (c) Tubes. — Capillary tubes, or tubes that were 
 called capillary, were of very early employment for 
 collecting and preserving lymph ; but, probably from 
 the nicety that attaches to the use of them, and the dif- 
 ficulty often experienced in filling them if the bore be 
 not really capillary, another form of tube, tapering in 
 shape and bulbed at the extremity, came into use, and 
 almost, if noj quite, superseded them for a time. The 
 bulb was warmed in the hand, in the mouth, or by a
 
 STORAGE OF LYMPH. 163 
 
 flame, so as to rarefy the air within the tube, the open 
 extremity of which was then plunged into the lymph 
 as it stood on the surface of a vesicle previously opened ; 
 when the lymph had risen in the tube as far as it would 
 rise, the open end was hermetically sealed. This kind 
 of tube was objectionable on account of the amount of 
 air which always remained in the bulb, and it is now 
 no longer employed. The only tubes now in use are 
 the plain straight tubes of capillary bore. The profes- 
 sion is much indebted to Dr. Husband, of Edinburgh, 
 for the pains he has taken to perfect this mode of col- 
 lecting and preserving lymph, and I cannot do better 
 than give an account of it in his own words : 
 
 "The tube employed is simple, straight, cylindrical, 
 open at both ends, and of such dimensions as to fulfill 
 the following conditions, upon which it will be found 
 that its peculiar value, as a means for preserving lymph 
 for future everyday use, essentially depends. It must 
 be, — 
 
 "1. In the first place, of such tenuity that it can be 
 sealed instantaneously at the flame of a candle. 
 
 " 2. In the second place, large enough to contain as 
 much lymph as is sufficient for one vaccination. 
 
 " 3. In the third place, long enough to admit of both 
 ends being sealed hermetically without subjecting the 
 charge to the heat of the flame. 
 
 "4. And, in the fourth place, of such strength as not 
 to break easily in the mere handling. 
 
 " There need be no difficulty in procuring tubes which 
 perfectly answer this description, only they must be 
 made according to a certain standard, which obviously, 
 from the very nature of the case, is not an arbitrary 
 one, admitting of being altered to suit the notions of
 
 164 HANDBOOK OF VACCINATION. 
 
 different individuals, but one concerning which, within 
 certain limits, there can be no dispute nor difference of 
 opinion.* 
 
 "The following is the mean of several measurements 
 which I have made of tubes, differing somewhat in size, 
 but all of them capable of containing a sufficient charge 
 of lymph, and of being sealed instantaneously, at the 
 flame of a candle, without subjecting the contained 
 charge to the heat, and also strong enough to bear all 
 necessary manipulations without breaking : 
 Average length, 2| to 3 inches. 
 Diameter, ^-th of an inch. 
 Thickness of wall, T |^th of an inch. 
 
 " If any one be disposed to find fault with these meas- 
 urements, and to prefer tubes differently proportioned, 
 I have no objection, provided he keep in view the neces- 
 sity of fulfilling the required conditions. The tubes 
 need not strictly and rigidly conform to the standard 
 laid down, but they must not vary from it except 
 within certain limits, otherwise they become unfit for 
 their purpose. 
 
 "Although their normal shape is cylindrical (fig.l, 
 c, T,) some of them are more or less fusiform toward 
 one extremity, and terminate there in a fine point (fig. 
 1, c', y'), or one of the extremities may taper to a 
 point without becoming fusiform (fig. 1, c", y"). In 
 
 * This standard is not always adhered to as it ought to he, 
 by the instrument-makers, partly owing to the conflicting or- 
 ders given them hy different persons, and hence large quan- 
 tities of tubes are at this moment in circulation which, being 
 much too large to be manageable, give a very erroneous idea 
 of the method.
 
 STORAGE OF LYMPH. Ifi5 
 
 either case this departure from the regular form is acci- 
 dental, and, as will appear presently, is no disadvant- 
 age, but rather the contrary. 
 
 Y- 
 Yl 
 
 =^C 
 
 Fia. 1. 
 
 " Having thus described the instrument itself, I come 
 now to the mode of using it. 
 
 " The vesicles having been opened with a lancet in 
 the usual way, the tube, held in a position more or less 
 inclined to the horizontal, is charged by applying one 
 end of it (the straight end, if they be not both straight) 
 to the exuding lymph, which enters immediately by the 
 force of capillary attraction. Allow as much to enter 
 as will occupy from about one-seventh to one-half the 
 length of the tube, according as its capacity is greater 
 or less. As a general rule, each tube should not be 
 charged with more than will suffice for one vaccina- 
 tion. 
 
 " It is now to be sealed in one or other of the follow- 
 ing ways: 
 
 " Either, 1st, make the lymph gravitate toward the 
 middle by holding the tube vertically and giving it 
 a few slight shocks by striking the wrist on the arm or 
 table ; then seal the end by which the lymph entered 
 by applying it to the surface of the flame of a candle, 
 or any similar flame. It melts over and is sealed im- 
 mediately. 
 
 15
 
 16G HANDBOOK OF VACCINATION. 
 
 " Proceed with the other end in the same way, but 
 first plunge it suddenly, say half an inch, into the flame, 
 and as quickly withdraw it till it touches the surface, 
 and hold it there till it too melts over. It is necessary 
 to plunge it first into the flame, for this reason, that if 
 it be once applied to the external surface of the flame 
 it melts over, no doubt, and is sealed ; but before you 
 have time to complete the process, and while the glass 
 is still soft, the contained air expands with the heat, 
 and forms a minute bulb, which either gives way on 
 the instant, rendering it necessary for you to break off 
 the end and Commence anew, or, what is still worse, 
 remains entire for the time, only to break afterward, 
 in consequence of its extreme tenuity of wall, by the 
 lightest touch. Mr. Ceely has suggested that while 
 this precaution is necessary for the reason stated, it 
 serves also to expel a portion of air, and so leaves less 
 air to be sealed up along with the fluid lymph. 
 
 " Or else, secondly, the charge having entered, hold 
 the tube with the finger and thumb, covering the inner 
 extremity (l) of the column of lymph (l, y, fig. 2), and 
 protecting it from the heat, and draw nearly the whole 
 of the empty portion (c, l) through the flame so as to 
 rarefy the contained air, and in withdrawing it seal the 
 
 YEip™ J " 
 
 Fig. 2. 
 
 further extremity (c). The column now passes quickly 
 along toward the middle of the tube as the contained 
 air cools, and you complete the process by sealing 
 lascly the orifice (y) by which it entered. 
 
 "This latter method answers especially well when
 
 STORAGE OF LYMPH. 167 
 
 the tube is below the average size, or has the form (c, 
 y) in which the opening at (c) is so minute that it 
 seals over in the merest fraction of a second. 
 
 "It should be observed, that in no case is a tube to 
 be laid down until the lymph has been made to pass 
 toward the middle of it, for the fluid concretes quickly 
 about the orifice, and you. cannot afterward detach it 
 without difficulty : but if it be at once made to pass 
 away from the orifice by holding the tube vertically, 
 you may lay the charge down and take half a dozen 
 or more in the same way before sealing them ; on'y if 
 you delay the sealing process too long, more than five 
 or ten minutes perhaps (a delay which need never hap- 
 pen), the lymph between the tube is apt, from evapo- 
 ration, to become adherent, especially if it be more than 
 ordinarily viscid, and it cannot afterward be blown out 
 when you come to use it. 
 
 " If the lymph do not exude freely, the tube may re- 
 quire to be drawn several times more or less obliqaely 
 across the surface of the vesicle, or cluster of vesicles, 
 until a sufficient charge has entered ; but generally if 
 the exudation be copious, and a drop of some size has 
 formed before you begin to take your supply, the orifice 
 of the tube need not, indeed ought not, to touch the 
 surface, but is merely to be dipped into the clear fluid ; 
 and one may commonly in this manner from one infant's 
 arm charge five or six tubes in almost as many seconds 
 with perfectly pure and limpid lymph, which shall con- 
 tain neither epithelian scales nor pus globules nor blood 
 disks, and therefore be, so far, in the best possible con- 
 dition for preservation. 
 
 "In order to obtain the lymph from a tube for the 
 purpose of vaccinating, the sealed ends are broken off,
 
 168 
 
 HANDBOOK OF VACCINATION. 
 
 and the contents blown out gently on the point of the 
 lancet."* 
 
 The source whence the lymph is taken may be con- 
 veniently indicated by attaching a piece of thin writing- 
 paper, as represented in fig. 3. 
 
 Fig. 3. 
 
 65. Is any one mode of Storage preferable to 
 another? — The question whether any one of these 
 modes of preserving lymph has a decided superiority 
 over the others, is difficult to determine. Probably, 
 under different circumstances and in different hands, 
 each has its advantages. At first sight it might appear 
 that the lymph in capillary tubes, existing apparently 
 in exactly the same condition as at the moment it was 
 taken from the vesicle, should not differ materially in 
 its efficacy from lymph transferred direct from arm to 
 arm; but this is far indeed from being the case. 
 Whether it be that the heat employed in the process 
 of sealing produces some action upon the lymph, or 
 whether by keeping in the liquid state it is liable to 
 undergo molecular changes,f quite certain it is that 
 
 * Second Ann. Kep. of Medical Officer of Privy Council, 
 p. 20. 
 
 f Whatever the changes may he that lymph undergoes by 
 storage in capillary tubes, they must take place either in the
 
 STORAGE OF LYMPH. 1G9 
 
 tube-vaccination does not even approach the success of 
 vaccination from arm to arm: the latter, properly per- 
 formed, will not fail above once in 150 times (§ <59) ; 
 but with tube-lymph, in Dr. Husband's own hands, 
 where we are quite sure that every proper precaution 
 will have been taken both in the collecting the lymph 
 and in sealing the tubes, the failures to infect are as 
 many as one in ten. MM. Bousquet and Bourdin, in 
 many comparative experiments, found that tube-lymph 
 produced, from an equal number of punctures, scarcely 
 more than half the number of vesicles resulting from 
 lymph taken direct from the arm.* Dr. Pearse has 
 been kind enough to furnish me with the comparative 
 results of 696 vaccinations performed from arm to arm 
 in the year 1865, at the Westminster station of the 
 National Vaccine Establishment, and 55 vaccinations 
 with lymph kept, but not long kept, in tubes. The 
 vaccination was performed by himself in every case, 
 
 act of storage or very soon after, for it seems quite established 
 (table, p. 173) that lymph stored in tubes is not affecttd by 
 length of keeping. Of the cases in that table, 70 were vac- 
 cinated with lymph that had been stored less than a week, 
 with as much relative failure as where the lymph was kept 
 three months. I cannot but strongly suspect that the heat 
 necessary for hermetically sealing does exercise an injurious 
 influence, even if Dr. Husband's caution to fill the tube only 
 from one-seventh to one-half of its length be observed, and d 
 fortiori if, as is sometimes the case, the tube be nearly filled. 
 * Bousquet, Nouveau Traite de la Vaccine, p. 240. It is 
 true that the tubes employed by MM. Bousquet and Bourdin 
 so far differed from Dr. Husband's that they were slightly 
 bulged at the center, but I cannot regard this difference as 
 material, and the results these observers obtained closely cor- 
 respond with those of Dr. Pearse, who used Husband's tubes. 
 15*
 
 no 
 
 HANDBOOK OF VACCINATION. 
 
 and by six punctures : the results, reduced to percentage 
 for the sake of comparison, are as follows : 
 
 Kind of 
 
 Vaccination. 
 
 Results pek 100 Cases. 
 
 Fail- 
 ure. 
 
 One 
 ves. 
 
 Two 
 ves. 
 
 Three 
 vee. 
 
 Four 
 ves. 
 
 Five 
 ves. 
 
 Six 
 ves. 
 
 Arm to arm.... 
 Tubes 
 
 0-72 
 5-45 
 
 0-43 
 
 12-78 
 
 105 
 9-1 
 
 1-87 
 7-25 
 
 3-3 
 14-5 
 
 5-0 
 14-5 
 
 87-6 
 36-3 
 
 
 These results represent not unfavorably, so far as 
 my^ own observations and inquiries (and they have 
 been very considerable) have extended, the results of 
 tube-vaccination ; as regards the proportion of total 
 failures, they are fewer than Dr. Husband's own ; as 
 regards the number of vesicles raised, they correspond 
 very closely with the results met with by MM. Bous- 
 quet and Bourdin. In the hands of many good vac- 
 cinators, tubes have certainly given a larger amount 
 of failure than they present; but even these results 
 show the vast difference between the two modes of 
 proceeding. 
 
 It is not, however, with arm-to-arm vaccination, but 
 with other modes of preserving lymph, that the com- 
 parison ought to be made. And if, in making this, I 
 were to take into account only what really skillful vac- 
 cinators can do, I should have little hesitation in saying 
 that vaccination with lymph that has been preserved 
 by drying, if only it be used within a few days or a 
 week or two of taking, and be carefully put on by 
 abrasion, is more successful than lymph in tubes. 
 From an account supplied by the late Mr. Vincent, of
 
 STORAGE OF LYMPH. HI 
 
 Oxford, an able and painstaking vaccinator, it appears 
 that with lymph kept dry, but used within periods 
 rarely exceeding three weeks from the time of taking 
 it, and inserted by abrasion, he had only three per cent, 
 of failures, and in 80 per cent, of his cases produced 
 vesicles corresponding to the number of insertions ; 
 that for 340 insertions made in 100 cases, he produced 
 altogether 311 vesicles, or upwards of 90 per cent, of 
 insertional success — no single case having less than 
 two vesicles.* These results, no doubt, are indicative 
 of great care both in the storage of the lymph and in 
 its use, but I have met with few really skilled vaccin- 
 ators whose failures with well-coated points, used 
 within the periods stated by Mr. Vincent, amounted 
 to more than five per cent., or half the proportion al- 
 lowed by Dr. Husband for failure with tubes, or who 
 did not get a much larger proportion of vesicles than 
 shown in the tube-returns of Bousquet and Dr. Pearse.f 
 On the other hand, practitioners who are not expert in 
 the use of dry lymph fail with it so frequently that 
 tubes have been to them a very welcome substitute. 
 The difficulties attaching to tube-lymph attach exclu- 
 sively to the collecting and storing, not to the use of 
 it : the difficulties attaching to dry lymph attach chiefly 
 to the using it. But if vaccinators were all properly 
 
 ♦Fifth Annual Keport of Medical Officer of the Privy 
 Council, p. 103. 
 
 f Marson's experience, he tells me, is very decidedly in 
 favor of points well charged (and he is not likely to use any 
 other), even though they should have been kept much longer 
 than the times mentioned above, as compared with tubes. 
 Especially, the latter disappoint him with regard to the num- 
 ber of resulting vesicles.
 
 172 HANDBOOK OF VACCINATION. 
 
 instructed, I believe the greatest amount of success 
 with stored lymph would be found to attend those 
 modes of storage where no heat was employed, pro- 
 vided the points or glasses were well charged, and the 
 lymph inserted by abrasion within a week or two of 
 its being taken. 
 
 But for long storage — for preserving lymph that 
 must be kept for some time before it can be used, as, 
 for example, for lymph which has to be sent abroad — 
 the balance of advantages seems to me altogether in 
 favor of tubes. It is quite true that lymph dried on 
 points or glasses has been used with the most complete 
 success after keeping three, four, six, .nine months or 
 more, and that it is seldom requisite, even with lymph 
 sent abroad, to keep it so long before it can be employed. 
 But great uncertainty attaches to the use of long-kept 
 dry lymph, and frequent disappointment attends it, 
 while to the length of time lymph may be kept in 
 tubes there seems practically no limit. Mr, Vincent 
 found that, in eleven operations with dry lymph kept 
 from eight to fifteen weeks, two failed, and thirty -four 
 insertions produced but twenty-three vesicles ; that, in 
 nine operations with dry lymph kept from fifteen to 
 twenty weeks, three failed, and twenty-five insertions 
 produced fifteen vesicles. Three operations with lymph, 
 kept eleven months, succeeded in raising a single vesi- 
 cle in one case only; and one vaccination with lymph, 
 kept eighteen months, failed. So that non-success was 
 much in proportion to the length of storage. On the 
 other hand, it appears to me well made out that length 
 of keeping does not, in the least, damage lymph stored 
 in tubes. Some years ago the late Professor Alison, 
 of Edinburgh, was so kind as to furnish me with the
 
 STORAGE OF LYMPH. 
 
 m 
 
 following results obtained from Dr. Husband, of com- 
 parative experiments made in 341 cases, with lymph 
 kept for different periods, varying from a day to two 
 and a half years ; the greater part of the lymph having, 
 also, for experiment's sake, been exposed for several 
 hours daily to a temperature of from 80° to 90° Fahr. 
 
 Length of time the lymph 
 was kept. 
 
 No. of cases 
 
 experimented 
 
 on. 
 
 Number of 
 these CHses 
 that were 
 successful. 
 
 Number of 
 these cases 
 that failed. 
 
 Under 1 month 
 
 126 
 
 122 
 
 93 
 
 107 
 
 107 
 
 86 
 
 19 
 
 15 
 
 7 
 
 From 6—30 months*... 
 
 Total 
 
 341 
 
 300 
 
 41 
 
 
 Mr. Ceely, who was requested by the Medical De- 
 partment of the Privy Council to make inquiry at 
 Edinburgh, in 1859, as to the results of this mode of 
 preserving lymph, states that he witnessed the suc- 
 cessful results of vaccinations from tubes that had been 
 kept 5£, 6£, *l\ years.f And lymph which has been 
 kept in this way for longer than the longest of these 
 periods has been used with perfect success. 
 
 When the transmission of lymph abroad is to trop- 
 
 * Dr. Hushand states that particular circumstances, not 
 necessary to enter into, would explain satisfactorily why in 
 these experiments the older lymph was apparently more active 
 than the more recent. 
 
 f Second Ann. Rep. Medical Officer of Privy Council, p 24.
 
 H4 HANDBOOK OF VACCINATION. 
 
 ical climates, there is another point to be taken into 
 consideration in balancing the advantages of dry lymph 
 and tube-lymph. The two conditions which most in- 
 terfere with the successful preservation of lymph in 
 hot climates are heat and moisture. When lymph sent 
 out on points to tropical countries, by the National 
 Vaccine Establishment, traveled in the ordinary mail- 
 bags, which were deposited in the hot and unventilated 
 holds of the ships, the result was, as Mr. Tomkins, 
 the experienced inspector of the Establishment, informs 
 me, that it very frequently spoilt. It is now the cus- 
 tom that the points should be carried in the writing- 
 desk of some officer of the ship, and they thus arrive 
 in a state fit for use. Tube-lymph has nothing to fear, 
 at all events, from moisture ; by heat, tropical heat, it 
 may be affected, and Mr. Tomkins tells me it certainly 
 is. He ^says, also (and any statement of his on this 
 point is worthy of the utmost attention), that the expe- 
 rience of the Establishment is still in favor of well- 
 charged points as the best mode of sending lymph 
 abroad, to whatever climate. It is certain, however, 
 that lymph sent in tubes to practitioners in various 
 tropical countries — the East and West Indies, China, 
 and the interior of Africa — has succeeded where former 
 transmissions on points or glasses had, possibly from 
 the circumstances pointed out by Mr. Tomkins, failed. 
 66. Use of the Vaccine Crusts. — A mode of storing 
 lymph, of which I have not hitherto spoken, consists 
 in preserving the crusts or scabs which detach them- 
 selves from genuine vaccine vesicles at the termination 
 of the vaccine affection. The perfect scab — the ma- 
 hogany-colored semi-transparent scab of a vesicle which 
 has not been damaged, either for taking lymph or in
 
 STORAGE OF LYMPH. IT 5 
 
 any other way — should alone be employed. It is used 
 by moistening it with water on the back of a plate, and 
 then working it up with a little water by means of a 
 clean knife, so as to get a ropy solution, abundance of 
 which should be inserted (p. 132). It seems at first 
 sight strange that this mode should succeed, when we 
 know that the lymph taken at a late period from a 
 vesicle is of very little value. Jenner illustrates and 
 explains the difference thus: "Several punctures were 
 made in the arms of a healthy child with vaccine mat- 
 ter taken from the edges of a vesicle when three-quar- 
 ters of the center were incrusted. Not one of them 
 took effect. Some weeks afterward, with a solution of 
 the same scab, I vaccinated effectually. This, I think, 
 may be accounted for — the scab is made up of the 
 early as well as the late-formed matter."* Still, vac- 
 cination from the scab is a very uncertain mode of pro- 
 ceeding, and no one would think of employing it now 
 in this country, where so much better means are at 
 hand. The scab has at times, however, been found 
 very useful as a means of transmitting lymph to hot 
 climates — crusts so sent having on various occasions 
 succeeded where points and glasses had failed; in parts 
 of India this mode of storage and transmission would 
 appear to be still employed to a considerable extent, 
 and in some places by preference. From the Hill 
 Station established by Dr. Pearson in Gurwahl, 7794 
 crusts were distributed in one year — the charges sent 
 out on points and glasses being only 1759. But one 
 chief reason of this is apparently to guard against the 
 frauds of the natives, who are necessarily much em- 
 
 * Baron's Life of Jcnncr, vol. ii. j>. 401.
 
 1?6 HANDBOOK OF VACCINATION. 
 
 ployed for the verification of the results of the vaccina- 
 tions performed and for the collection of lymph, and 
 who, while they might deceive in any other way, can- 
 not manufacture vaccine crusts.* 
 
 67. Early Attempts to Convey Vaccination Abroad. 
 — Some of the early attempts to convey vaccination to 
 tropical and distant countries are full of interest. After 
 various endeavors, successively made, to send lymph 
 dry to India had failed, Jenner urged that more effect- 
 ual means should be taken, and engaged that, if twenty 
 recruits who had not had small-pox were selected, and 
 he were allowed to appoint a surgeon to attend them, 
 the disease should be conveyed in the most perfect 
 state to any of our settlements. The proposition was 
 too startling to the official mind of that day for it to be 
 accepted, and the honor of establishing vaccination in 
 India was reserved for foreigners. It was the inde- 
 fatigable Dr. De Carro, of Vienna, who succeeded in 
 this way. Taking a pair of glasses, such as have been 
 described (§ 63), one of which had a concavity on its 
 surface, he carefully filled the cavity with charpie satu- 
 rated with lymph; a drop of oil was then put on the 
 internal surface of the glasses, and the flat glass was 
 made to slide upon the charpie so as to exclude the air 
 as much as possible ; the two bits were then tied to- 
 gether and the edges sealed. In order still more surely 
 to exclude the air, Dr. De Carro then took the glasses 
 to a wax-chandler's and there dipped them again and 
 again till a solid ball of wax was formed round them, 
 and this he inclosed in a box filled with shreds of 
 paper. In this state the packet was safely conveyed 
 
 * Special Keport of Bengal Sanitary Commission, 1864.
 
 STORAGE OF LYMPH. Iff 
 
 across European and Asiatic Turkey, and over the 
 whole line of deserts to Bagdad. When it arrived 
 there it was opened; its contents were still liquid, and 
 succeeded on the first trial. A vaccinated child was 
 then sent down to Bussorah, and from its arm various 
 vaccinations were there successfully performed. The 
 lymph thus raised was continued in weekly succession, 
 and toward the end of May, 1802, a few weeks after the 
 stock had first arrived at Bagdad, some of it was sent 
 on by the " Recovery" to Bombay.* The voyage to 
 Bombay lasted three weeks. With the lymph thus 
 conveyed, from twenty to thirty subjects were vaccin- 
 ated, but only one of them successfully. The anxiety 
 with which the progress of this case was watched may 
 be easily imagined. On the eighth day five .children 
 were vaccinated from it, all successfully, and hence 
 commenced the diffusion of vaccination over India. 
 The lymph thus sent was not from Jenner's stock, but 
 was Milanese lymph, with which De Carro had been 
 furnished by Sacco. And it was lymph, not of vaccine 
 but of equine origin, which, according to De Carro, had 
 never passed through the cow.j" 
 
 The year before (in 1801), Jenner had succeeded in 
 getting lymph out to Barbadoes through the kind 
 
 * The lymph being probably transferred from subject to 
 subject on the voyage, but this I cannot quite ascertain. 
 Baron's account (Life of Jenner, vol. i. p. 420, seq.), in many 
 respects very imperfect, is silent about this ; and I have not 
 been able to refer to Dr. Keir's "Account of the Introduction 
 of Cow-pox in India," a book which, De Carro says, is little 
 known, but contains an exact statement of the circumstance*. 
 
 f See De Carro's Letter to Dr. Monro, London Med. Gaz., 
 vol. xxix. p. 385. 
 
 16
 
 178 HANDBOOK OF VACCINATION. 
 
 offices of a gentleman who vaccinated several sailors 
 successively on the voyage * And the year after (in 
 1803), the Spanish government sent an expedition from 
 Corunna for the purpose of conveying vaccination to 
 all the Spanish colonies, and to the foreign possessions 
 of several other nations, with twenty-two children on 
 board, selected for the preservation of the vaccine fluid 
 by transmitting it from one to the other during the voy- 
 age. The Canary Islands and the American possessions 
 were first visited ; and the disease having been estab- 
 lished in America, was conveyed on to the possessions 
 in Asia, twenty-six more children being taken on board 
 at Acapulco in New Spain. This expedition was the 
 means of conveying cow-pox to some of the Portuguese 
 settlements in the East, and to the great empire of 
 China; and, on the way home, Dr. Balmis, who in 
 the execution of his mission had circumnavigated the 
 globe, touched at St. Helena, and (in 1806), "strange 
 to say, was the first to induce the English inhabitants 
 of that settlement to adopt the antidote, "f The Bra- 
 zilian government in like manner secured its introduc- 
 tion (in 1803 or 1804), by sending a number of boys 
 over to Lisbon, who were vaccinated in succession on 
 the home voyage. J 
 
 * Baron's Life of Jeuner, vol. i. p. 533. 
 f Ibid., vol. i. p. 606, and vol. ii. p. 78. 
 % Ibid., vol. ii. p. 10.
 
 OF SKILL IN VACCINATING. H9 
 
 CHAPTER IX. 
 
 OF SKILL AND SUCCESS IN VACCINATING, AND OP 
 INSUSCEPTIBILITY TO VACCINATION. 
 
 68. What is successful Vaccination? Necessity 
 for a Standard of Comparison. — Before a student of 
 vaccination can know whether he ought to consider 
 himself a successful vaccinator or not, he must have 
 before him a standard of comparison. We meet daily 
 with practitioners who call themselves "successful" 
 vaccinators, but who evidently, in thus speaking, mean 
 very different things; for while one would think it 
 anything but successful vaccination to fail once in 
 every hundred operations, another will interpret this 
 term to admit of two or three per cent, of failures, 
 another of five per cent., another even of ten per cent. 
 A failure, indeed, of one case only out of ten is very 
 commonly spoken of as being good vaccination ; and 
 there are not a few practitioners who think they do 
 well if they succeed in four cases out of five.* There 
 are, besides, degrees of success in vaccinating. If 
 
 * To an active and long-established vaccinator in London, 
 who did his vaccinations chiefly by carrying glasses always 
 about in his pockets, 1 said, " Do you find that children take 
 that way as well as if you got them together, and did them 
 from the arm ?" "I'll engage to make them take quite as 
 well as you will from the arm." "But how many miss?" 
 " Not more than one in five."
 
 180 HANDBOOK OF VACCINATION. 
 
 scarification or puncture be made on half a dozen sepa- 
 rate spots, and a vesicle arise on one spot only — a sin- 
 gle but genuine vaccine vesicle — this is no doubt, in 
 one sense, successful vaccination ; the system is in- 
 fected, and it will be impossible at the moment to in- 
 fect it any further; but, still, the result is so far un- 
 successful, and so far unsatisfactory, that it is much 
 short of that which was aimed at, and of that which 
 was necessary for fully accomplishing the object of 
 vaccination, viz., for protecting the patient as completely 
 as possible against small-pox. Here, again, we recog- 
 nize the want of a standard of comparison. While 
 one practitioner is disappointed if one case out of ten 
 exhibits a number of vesicles short of the number of 
 insertions of lymph which had been made, another is 
 very well content if he get the full number of vesicles 
 in only half his cases. 
 
 69. Marson's Standard. — Some years ago, Marson 
 gave it as the result of his experience, that " with good 
 lymph, and the observance of all proper precautions, 
 an expert vaccinator should not fail of success in his 
 attempts to vaccinate above once in 150 times."* 
 Marson's own habitual rate of success is, indeed, con- 
 siderably greater ;f but this was the conclusion to 
 
 * Medico-Chirurgical Transactions, vol. xxxvi. 
 
 f Of 1479 vaccinations performed by him at the Blackfriars' 
 station of the National Vaccine Establishment, in 1863, the 
 operation failed at the first attempt in three cases only ; and 
 on a recent visit to this station I found that, of the last thou- 
 sand operations in which the results had been inspected, there 
 had been only one failure. At the Birmingham station of the 
 Establishment, in 1864, out of considerably more than a thou- 
 sand inspected cases, there were three failures ; in 1865, out
 
 OF SKILL IN VACCINATING. 181 
 
 which his experience had led him as to what might be 
 reasonably expected of vaccinators. And that this is 
 not at all too high a standard is manifest from the re- 
 sults which, on examination of the records kept at 
 some of the stations of the National Vaccine Estab- 
 lishment, I find to have attended their practice. The 
 failures were, on the average of a large number of 
 cases, spread over a considerable time, but one in 170 
 operations. We may fairly, therefore, adopt Marson's 
 rate as the standard below which no vaccinator, vac- 
 cinating from arm to arm, has any right to be satisfied 
 with his performances. With regard to the degree of 
 success, it appeared from the records of the stations 
 above referred to, that, in their practice, vesicles had 
 risen at every point of insertion of lymph, in consider- 
 ably more than ninety per cent, of the children oper- 
 ated on, while the proportion of cases in which a sin- 
 gle vesicle only had resulted from the four, five, or more 
 insertions made, was about one in a hundred. 
 
 70. A Standard when Stored Lymph is used. — 
 But the operation in all these cases was done under 
 the circumstances most favorable for success — with se- 
 
 of 1068 inspected cases, there was no failure ; and on a recent 
 visit, I found that out of the last thousand inspected cases, 
 three only had failed. Mr. Sheppard, who has charge of the 
 Bristol station of the Establishment, performed and inspected 
 some years ago, when the cases there were far more numerous 
 than at present (the absurd division of public vaccination now 
 existing in that city not having then been adopted), abovo 
 2000 vaccinations without missing on one occasion ; and Mar- 
 son tells me the same thing happened to him once at the 
 Small-pox Hospital, at the time when the vaccinations at that 
 institution (before the introduction of the present miblic sys- 
 tem) amounted to some thousands a year. 
 10*
 
 182 HANDBOOK OF VACCINATION. 
 
 lected lymph, inserted direct from arm to arm. When 
 the operation has to be done with stored lymph, the 
 same amount of success cannot be looked for (§ 53), 
 and so many circumstances affect the successful use of 
 stored lymph (particularly, when the lymph is dry- 
 stored, the length of time it has been kept) that it is 
 much more difficult to fix a standard. But if a practi- 
 tioner be careful to use his points or glasses within a 
 week or ten days of the lymph being taken (and it is 
 presumed that, in this country, lymph need never be 
 older, and scarcely ever so old as this, before it can be 
 employed), and to put the lymph well on by abrasion, 
 he certainly ought not to fail in more than five per 
 cent, of his operations, or to obtain in less than three- 
 quarters of his cases the full results he aimed at.* 
 
 71. Skill of the Individual Vaccinator the most 
 important of all the conditions for success. Neces- 
 sity for special Instruction. — But whether the vac- 
 cination be done from arm to arm, or whether it be 
 done otherwise; whether it be performed under the 
 circumstances most favorable, or under circumstances 
 less conducive to success, surely the first of all things 
 necessary for its being well done is that those who 
 have to perform it shall have been duly instructed in 
 their work, and shall be possessed of a competent 
 knowledge of that which they have to do. Jenner 
 always strongly insisted — and it was a point equally 
 dwelt upon by all who obtained early distinction as 
 vaccinators, as Ring, Dunning, Bryce, etc. — that no 
 one ought ever to take upon himself to perform vac- 
 
 * Mr. Vincent's successes were greater than these, and the 
 lymph he used was in some of the cases three weeks old.
 
 OF SKILL IN VACCINATING. 183 
 
 cination who had not been specially instructed in it. 
 "Although," says Jenner, "vaccine inoculation does 
 not inflict a severe disease, but, on the contrary, pro- 
 duces a mild affection scarcely meriting the term dis- 
 ease, yet, nevertheless, the inoculator should be ex- 
 tremely careful to obtain a just and clear conception 
 
 of this important branch of medical science A 
 
 general knowledge of the subject is not sufficient to 
 enable or to warrant a person to practice vaccine inoc- 
 ulation ; he should possess a particular knowledge, 
 and that which I would wish strongly to inculcate, as 
 the great foundation of the whole, is an intimate ac- 
 quaintance with the character of the true and genuine 
 vaccine pustule "* And again : " I expect that cases of 
 this sort (failures of so-called vaccination to protect 
 against small-pox) will flow in upon me in no incon- 
 siderable numbers; and for this plain reason: a great 
 number, perhaps the majority of those who inoculate, 
 are not sufficiently acquainted with the nature of the 
 disease to enable them to discriminate with due ac- 
 curacy between the perfect and imperfect pustule. 
 This is a lesson not very difficult to learn, but unless 
 it is learnt, to inoculate the cow-pox is folly and pre- 
 sumption, "f And the Royal College of Physicians of 
 London, in their memorable Report on Vaccination in 
 
 * Varieties and Modifications of the Vaccine Pustule, p. 13. 
 
 f Jenner in Letter to Lord Berkeley, Baron's Life of Jen- 
 ner, vol. ii. p. 13. In various parts of his correspondence, 
 Jenner refers to mischief of different kinds that had arisen 
 from want of proper knowledge of the subject on the part of 
 vaccinators. In one letter (Baron's Life, vol. ii. p. 373) he 
 tells Moore, the Director of the National Vaccine Establish- 
 ment, that he ought to open a vaccine school.
 
 184 HANDBOOK OF VACCINATION. 
 
 180*7, remark that "those who perform vaccination 
 ought to be well instructed, and should have watched 
 with the greatest care the regular progress of the pus- 
 tule, and learnt the most proper time for taking the 
 matter."* With such injunctions, proceeding from 
 such authorities, it seems strange that a thorough ac- 
 quaintance with vaccination should never have been 
 required by any of the colleges and corporations who 
 are authorized to license for medical practice in this 
 country, as one of the conditions for receiving their 
 license, and that at this very day there is not any test 
 of medical proficiency in England which implies a 
 competent knowledge of vaccination. Till within the 
 last few years, students who were candidates for the 
 license — whether of the College of Surgeons or of any 
 other of the licensing boards — were not called on to 
 produce evidence of having received any instruction 
 whatever in vaccination. Accordingly, students have, 
 within my own knowledge, been admitted to practice, 
 and even been appointed public vaccinators, who, so 
 far from having learnt the niceties connected with the 
 proper performance of vaccination, had never even 
 seen the operation done. And although regulations 
 made by some of these boards within the last few 
 years (and since public attention has been prominently 
 called to their omission) now require that each student 
 presenting himself for examination should produce the 
 certificate of some member of the particular licensing 
 body, or of some "registered medical practitioner," as 
 to his proficiency in vaccination, a certificate that can 
 
 * Papers relating to the History and Practice of Vaccina- 
 tion, p. 8.
 
 OF SKILL IN VACCINATING. 185 
 
 be thus miscellaneously obtained conveys, assuredly, 
 no guarantee of the student's real competency. For, 
 apart from other obvious considerations, it must mani- 
 festly depend on whether the practitioner giving the 
 certificate were a good or a bad vaccinator, whether 
 his instruction and certificate of competency were worth 
 anything or not. But this is, so far as I am aware, 
 the only test attempted. Further, it was not till 1859 
 that any authorized places for the practical teaching of 
 vaccination existed. In that year, the Lords of the 
 Council, having been required by one of the provisions 
 of the Public Health Act, 1858, to take security "for 
 the due qualification" of persons to be thereafter ap- 
 pointed public vaccinators, certain of the stations of 
 the National Vaccine Establishment were selected as 
 places for instructing, or for testing by practical exam- 
 ination, the qualifications of all candidates for the office 
 of public vaccinator, and of any other professional per- 
 sons who desired to possess themselves beforehand of 
 evidence of their fitness for that office. These stations, 
 which combine the two essential requisites of a compe- 
 tent teacher and a sufficient number of cases for instruc- 
 tion, are now open to all medical students, and it is 
 greatly to be desired that all students, whether they 
 are likely or whether they are not likely to become 
 public vaccinators, should avail themselves of the op- 
 portunities of sound praetical instruction in vaccination 
 which they afford.* There are few students, what- 
 
 * The National Vaccine Board — at that time consisting of 
 the Presidents of the Colleges of Physicians and Surgeons, 
 the Senior Censor of the College of Physicians, and the Medi- 
 cal Officer of the Privy Council — had hoped and anticipated
 
 186 HANDBOOK OF VACCINATION. 
 
 ever their opportunities of seeing vaccination elsewhere 
 may have been, who will not derive advantage from 
 carefully following, for some weeks, the practice of 
 these stations, and there working under instruction, — 
 for it is only by practically working that the discrim- 
 ination and dexterity necessary to make a good vac- 
 cinator can properly be acquired. 
 
 72. Advantages which would attend the appoint- 
 ment of Professed "Vaccinators." — " The advantages 
 which would result from confining the practice of vac- 
 cination to such persons only, even among those of the 
 medical profession, as are duly qualified to undertake 
 it," along with other considerations, induced one of the 
 most distinguished of the early vaccinators, Mr. Bryce, 
 to propose that vaccination of rich and poor alike should 
 be carried on entirely by a special class of medical prac- 
 titioners, not otherwise occupied in medical practice, — 
 by " vaccinators" to be appointed for the purpose.* The 
 benefits which would have resulted to the public, had 
 such a course been adopted, are in my opinion incal- 
 culable ; nor must I withhold the expression of the 
 strong conviction, to which my experience has led me, 
 that the best of all things that could be done to protect 
 the population well against small-pox would be to 
 adopt this course now. At all events, it is indispensa- 
 ble that all who vaccinate should be trained to the work. 
 In the inquiry, already referred to, which was made 
 
 that attendance at the stations appointed by them would have 
 been required by the Medical Licensing Boards of all candi- 
 dates for their respective licenses. But this hope has not 
 hitherto been realized. 
 
 * Practical Observations on the Inoculation of Cow-pox, 2d 
 Edition, Appendix, p. 5.
 
 OF SKILL IN VACCINATING. 187 
 
 by myself and Dr. Buchanan into the state of vaccin- 
 ation in London in 1863, we compared the results ob- 
 tained by various vaccinators, as shown by the cica- 
 trices on the arms of large numbers of children, and 
 could not but express ourselves as " struck with the 
 great difference of results of diiferent operators, work- 
 ing under apparently the same conditions. This differ- 
 ence," we stated, "was quite irrespective of general 
 professional attainments, and depended altogether on 
 special knowledge and special practical skill ; for, 
 however trifling as a surgical operation vaccination may 
 be, there is nothing more certain than this, that careful 
 observation, practical experience, and painstaking ac- 
 curacy are indispensable for securing its proper results. 
 We do not hesitate for a moment to express our strong 
 conviction that the vaccination of London would be 
 best done by a few thoroughly trained vaccinators who 
 devoted themselves exclusively to the work."* 
 
 73. Consequences that have resulted from want of 
 proper Instruction and of an Authorized System of 
 Vaccination, (a) Marson's Statements. — Nearly fif- 
 teen years ago (1853), Mr. Marson called the attention 
 of the profession, in a paper read to the Medico-Chir- 
 urgical Society of London, f to the large amount of un- 
 skillful vaccination that was to be met with in England, 
 and to its consequences as shown in the experience of 
 the Small-pox Hospital. Persons were found to pre- 
 sent themselves frequently with small-pox at the hos- 
 pital who stated that they had been cut five, six, or 
 eight times or more for cow-pox without effect ; " an 
 
 * Sixth Keport of Medical Officer of Privy Council, p. 118. 
 f Medico-Chirurgical Transactions, vol. xxxvi.
 
 188 HANDBOOK OF VACCINATION. 
 
 evil," he said, "which could happen rarely in careful 
 hands. Such persons," he continues, "think it of no 
 use having the operation tried again, that it will not 
 take effect if they do, and ultimately they are attacked 
 by small-pox, and perhaps die ; whereas had they 
 fallen into the hands of a good vaccinator, their lives 
 would most likely have been saved." A large propor- 
 tion of the English admitted to the hospital, in whom 
 the vaccination had taken effect, were shown by their 
 cicatrices to have been very imperfectly done, and their 
 small-pox was severe and often fatal : while Swedes, 
 and Danes, and Norwegians, and Prussians, of whom 
 many had been brought to the hospital with small-pox, 
 had, from having been thoroughly vaccinated, the 
 small-pox in its light varicelloid form. Three years 
 afterward (in 1856), he again referred, in a petition to 
 the House of Commons, to the " large amount of very 
 insufficient, almost useless, vaccination performed in 
 England," traceable chiefly to no authorized system of 
 vaccination having been established, but to every one 
 having vaccinated in the manner he or she might think 
 proper.* 
 
 (b) Official Inquiry. — These allegations, proceeding 
 from such authority, and confirmed as they were by 
 many circumstances, were far too serious to be over- 
 looked ; and one of the most important objects of the 
 inquiry which the Lords of the Council, in 1859, directed 
 to be made by the Medical Department of the Privy 
 Council into the state of vaccination in England, was 
 to ascertain fully how far this unsatisfactory per for m- 
 
 * Papers relating to the History and Practice of Vaccina- 
 tion, p. 25.
 
 OF SKILL IN VACCINATING. 189 
 
 ance of vaccination was diffused over the kingdom, and 
 to trace more minutely its causes, with a view to their 
 remedy. In the course of that inquiry, which, under 
 the instructions of the Medical Officer, was made by 
 Drs. Stevens, Buchanan, Sanderson, and myself, per- 
 sonal observations, by one or other of us, were extended 
 to every vaccination district in England. The facts as- 
 certained by each of us, respectively, will be found in 
 the reports presented to Parliament.* In stating gen- 
 erally the results of that inquiry, so far as regards the 
 imperfect performance of vaccination in England — re- 
 sults which entirely bore out the statements of Mr. 
 Marson — it will be most convenient to trace these from 
 their causes upward. 
 
 In the first place, the rule which was laid down fifty 
 years ago by the National Vaccine Establishment, and 
 has never been departed from in the practice of the 
 Establishment^ viz., thoroughly to infect the system in 
 vaccinating by making at least four punctures, or by 
 production (if vaccination were not done by puncture) 
 of equivalent local results, as carried out by compara- 
 tively few only of the public vaccinators of the king- 
 
 * See, in the Annual Reports of the Medical Officer of the 
 Privy Council, iii.-vii. inclusive, the Appendices concerning 
 "Local Inquiries as to Vaccination." 
 
 f The National Vaccine Board, in their Report for 1820, 
 state that the principle of the practice they adopt and incul- 
 cate is " to affect the constitution of each individual very 
 completely with the vaccine disease ;" and, adverting to their 
 directions to their own operators to make four punctures, they 
 add, "from extensive experience and numerous reports the 
 Board have become most earnestly desirous that more rather 
 than fewer vesicles should he produced." 
 
 17
 
 190 HANDBOOK OF VACCINATION. 
 
 dom ; secondly, facts of the utmost practical importance 
 relative to vaccination, which had been brought to pro- 
 fessional notice, through the ordinary channels of publi- 
 cation, years and years before — such facts, for example, 
 as those noted by Marson with regard to the influence 
 exercised on the small-pox death-rate by the quality of 
 the vaccination performed (§ 92, a) — were found to be 
 absolutely unknown to a large majority of vaccinators; 
 thirdly, the rules about the proper period for lymph- 
 taking, about herpetic and other eruptions as affecting 
 the course of the vaccine vesicle, etc., were extensively 
 unknown or extensively disregarded, some thinking it 
 a matter of no moment whether Jenner's "golden rule" 
 were observed or not, and others taking the lymph by 
 'preference at the very periods at which he had specially 
 pointed out that it ought not to be taken ;* and lastly, 
 storage of lymph and the use of stored lymph were but 
 very imperfectly understood. There was, in fact, a state 
 of things which could never have existed, had only 
 Jenner's injunctions been regarded, and had there been 
 proper authorized teaching on the subject.f 
 
 It was found that, partly as the natural consequences 
 of the above defects, but also partly because of the im- 
 perfect arrangements about lymph-supply, on which I 
 have before commented, vaccination was carried on, in 
 a very large number of districts, extending all over the 
 kingdom, with an unwarrantable amount of failure, or 
 
 * Some important evidence on this point had heen commu- 
 nicated to the Epidemiological Society in 1851-2. 
 
 f The above statements, it must be remembered, represent 
 things as existing in 18G0-4. The inquiry itself produced im- 
 provement in many respects, and there is, on the whole, a 
 much better state of things now existing.
 
 OF SKILL IN VACCINATING. 191 
 
 with the production of results which, though in one 
 sense successful, still left the vaccinated persons but 
 very imperfectly protected against small-pox. It was, 
 indeed, a very common thing that children should have 
 been cut two, three, or four times before they took, or 
 without even taking then. Children on whom such 
 trials had been made, but who still had no marks of 
 vaccination, were met with repeatedly in attendance at 
 public schools ; frequently, children growing into man- 
 hood or womanhood told how many times they had 
 been done, and said it was no use their being done any 
 more, " for they wouldn't take. "* And many grown-up 
 men and women, under similar circumstances, had the 
 same belief. Vaccinators, generally, had a very low 
 standard of success ; and while some thought, as has 
 been already said, that for four operations to take out 
 of five was a satisfactory result, others thought two 
 successful cases out of three was as much as could rea- 
 sonably be expected, and others regarded success to be 
 very much a matter of chance. " Sometimes they'll take, 
 and sometimes they won't, you can't exactly tell which," 
 were the words of the vaccinator of a large metropoli- 
 
 * Many children are brought every year to some of the Es- 
 tablishment stations to be vaccinated who have been cut three, 
 four, five times, sometimes six or seven times, elsewhere, with- 
 out effect. But there is hardly an instance (I do not know one) 
 of failure to infect these children at the Establishment, and 
 almost always at the first operation. An excellent public vac- 
 cinator in the West of England, on his first appointment to a 
 district some years ago, found a large number of children in 
 the district whom his predecessor, having made various at- 
 tempts to vaccinate, had pronounced "insusceptible;" but 
 there was not one of them whom he found any difficulty in 
 infecting.
 
 192 HANDBOOK OF VACCINATION. 
 
 tan district ; and they describe, not unfairly, the exploits 
 of a certain class of vaccinators. Failure to raise a 
 number of vesicles corresponding to the number of 
 lymph-insertions was still more common,* and in a 
 
 * The failures were, of course, by far the most frequent with 
 stored and conveyed lymph, but even in vaccinating from arm 
 to arm the results of many vaccinators were far from what 
 they should be. The failures with dry lymph in some hands 
 were really surprising. One vaccinator had in one year 46 
 failures out of 155 vaccinations, and in another year 94 out of 
 171. In a district in South Wales, I found great complaints 
 of the people that they "got such a bad pock;" which did not 
 in the least mean that their children had suffered any ill 
 consequences from vaccination, but that they had to have 
 them done again and again before the operation would suc- 
 ceed. The following note of results met with in certain dis- 
 tricts in Yorkshire will give some idea of the failures of dry 
 lymph in unskilled hands. Taking eleven districts in which 
 the vaccination was performed almost exclusively with dry 
 lymph, and in none of which was it the custom to insert lymph 
 in less than two places, while in some it was inserted in three, 
 four, or more places, I found that upwards of 30 per cent, of 
 the children examined (446 out of 1465) had but one mark. 
 In a district in which it was the practice to make six inser- 
 tions, only 74 out of 147 children had more than two marks; 
 several children had been cut again and again ; and one four 
 times. In my notes are repeated entries of this kind: " Mr. 
 P. (vaccinator) says they take very badly, have often to be 
 done two or three times over." "Of 54 children 15 had but 
 one mark, three had been tried twice without effect, and one 
 three times." " Mr. R. (another vaccinator) says he has often 
 to do them a second time before they will take, and sometimes 
 three or four times." " Mr. W. (another vaccinator) says 
 they take very badly; the number of vesicles varies much; 
 he always inserts six points, but often only one or two take," 
 etc. etc. These entries have not reference to wild country
 
 OF SKILL IN VACCINATING. 193 
 
 large number of districts the imperfect character and 
 quality of the cicatrix attested the inferior quality of 
 the lymph that had been used.* In striking contrast, 
 indeed, with such results as the foregoing were those 
 met with in a large number of districts fortunately pos- 
 sessed of vaccinators who had been well trained to their 
 work. A group of children, of various ages, and vac- 
 cinated at various times by one vaccinator, would by 
 their scars show themselves, with rare exceptions, 
 thoroughly protected against small-pox ; while in an 
 adjacent district, similarly situated in all other respects, 
 or in an adjacent school — probably side by side with 
 the former children, in the same school or district — 
 would be found another group, whose vaccination had 
 been the work of another hand, few of whom were 
 really well protected against small-pox, and in many of 
 whom the vaccination had been little more than a sham. 
 The difference was so great that it was often difficult 
 to persuade a vaccinator of the latter kind that such 
 marks as he looked upon with surprise were but the 
 
 districts, in which it might he supposed the use of preserved 
 lymph was a necessity; the very first of them, for example, 
 was the statement of a public vaccinator of the City of York. 
 * In speaking of inferior lymph or bad lymph, I beg that 
 it may be most distinctly understood that I mean lymph of 
 inferior infective power, lymph that does not "take well," 
 and therefore leaves the persons vaccinated with it but poorly 
 protected against small-pox. Of bad lymph in any other sense 
 of the term, of lymph that has conveyed any disease or done 
 any other harm, I know nothing. I have never met with a 
 single instance of mischief arising in this way, nor do I think 
 has any one of my colleagues. I have investigated several 
 instances where there was allegation of it ; but in no one of 
 them was there a tittle of proof or even of probability. 
 17*
 
 194 HANDBOOK OF VACCINATION. 
 
 ordinary results of good vaccination.* Taken on the 
 whole, imperfect or incomplete vaccination was found 
 to have so far prevailed over England that, on examin- 
 ation of the arms of nearly half a million of vaccinated 
 children, it was found that about one in eight only had 
 been so vaccinated as to have the fullest protection 
 against small-pox that vaccination is capable of afford- 
 ing ; that not more than one in three could be considered 
 as even tolerably well protected ; and that at least one 
 in four had been so imperfectly done as to run no incon- 
 siderable risk of, at some time or other in their lives, con- 
 tracting small-pox, and having it badly, probably even 
 fatally, f In fact, in the words employed by Dr. Stevens 
 in one of his reports, "A very small proportion of the 
 supposed-to-be-vaccinated population had received such 
 protection from death by small-pox as efficient vaccina- 
 tion is known to give."! 
 
 * See Fourth Report of Medical Officer of Privy Council, p. 
 63 ; and Sixth Eeport, pp. 141-2. 
 
 f The children on whom these observations were made were 
 generally of the class that attends public schools. Most of them 
 had been vaccinated by public vaccinators, but a large num- 
 ber by private practitioners. Without affording statistical 
 evidence of the fact, a strong impression was left that, as a 
 rule, the latter were less well done than the former. Among 
 the upper and middle classes in England, I know, from my 
 own opportunities of observation, that the vaccination, in 
 many instances, has been very imperfectly done. If the vac- 
 cinated in these classes do not contract small-pox so frequently 
 as the vaccinated among the lower orders, it is not because of 
 their better vaccination, but because of their less exposure to 
 the infection. 
 
 % Fifth Report of Medical Officer of Privy Council, p. 66. 
 The imperfect way in which, frequently, vaccination had been
 
 OF SKILL IN VACCINATING. 195 
 
 Thus it is that we are able to read without surprise 
 that, of 150 cases of small-pox treated in the practice 
 of the Lincoln General Dispensary during a recent epi- 
 demic of the disease, no fewer than 18 were in persons 
 who said they had been vaccinated, but that the vac- 
 cination had not taken 1* In 20 years — -from 1836 to 
 1855 — there were 370 persons admitted to the Small- 
 pox Hospital, with small-pox, who said they had been 
 vaccinated, but who had no mark of it, and in 101 of 
 them the disease was fatal. In the same 20 years, 
 there were more than 4000 persons admitted with small- 
 pox who had a mark or marks of vaccination, and 298 
 of them died ;f but only 5 of these deaths took place 
 among that portion of these persons (544 in number) 
 whose marks showed them to have been vaccinated in 
 the best way. Though it belongs to a future section 
 (§ 92, a) to state in detail the important facts collected 
 at the Small-pox Hospital, it was necessary to advert 
 to them in this place, because, until the consequences 
 that may result, indeed are almost sure at some time 
 or other to result, from the bad and unskillful perform- 
 ance of vaccination have taken thorough possession of 
 the professional and public mind, we are not likely to 
 have the operation done so well as it ought to be. " If," 
 says Marson, "a little operation — little apparently in 
 
 performed, was noticed also by many of the Metropolitan 
 Medical Officers of Health in their examination of school- 
 children during the epidemic of small-pox in London in 
 1859-60 (Third Keport of Medical Officer of Privy Council, 
 p. 59). 
 
 * British Medical Journal, Jan. 14, 1865. 
 
 f Article M Small-pox," in System of Medicine, edited by J. 
 K. Reynolds, M.D., vol. i. p. 473.
 
 196 IIANDBOOK OF VACCINATION. 
 
 practice, but very important in its results — well per- 
 formed, can save many lives, as most certainly it can, 
 and prevent much suffering and sorrow, it should surely 
 always be done with the greatest care, and in the best 
 known way. The success of all operations depends on 
 nice care and management. Operations for hernia and 
 for stone, for instance, if roughly, carelessly, and badly 
 done, end badly: so it is with vaccination ; and, so far 
 as the public are concerned, it is quite as objectionable 
 to them, no doubt, to die of small-pox because they 
 have been carelessly and badly vaccinated, as it would be 
 to them to die of hernia or stone, because the operations 
 for these complaints, respectively, had been badly per- 
 formed. In the latter cases the day of retribution 
 would come immediately; in the former, unfortunately 
 for its correction, it is delayed for perhaps twenty years 
 or more; otherwise it would soon be set right."* 
 
 74. Insusceptibility to Vaccination. — Insuscepti- 
 bility to the infection of cow-pox, even for a very limited 
 period, is an occurrence of excessive rarity. For in the 
 few cases in which good operators fail to infect at the 
 first operation, they rarely fail at a second trial ;f but 
 now and then, however, a second attempt may not suc- 
 ceed, and even a third operation may not take. But 
 supposing vaccination to have been performed by a 
 practiced hand, and with lymph direct from the arm, 
 
 * Article " Small-pox," in System of Medicine, edited by J. 
 R. Reynolds, M.D., vol. i. p. 470. 
 
 f Of upwards of 9000 vaccinations performed at the Black- 
 friars' station of the National Vaccine Establishment since 
 1859, there has been but one case which on a second trial was 
 unsuccessful. In this case a third attempt was made, but the 
 child was not brought back for inspection, and the result is 
 unknown.
 
 • INSUSCEPTIBILITY. 19T 
 
 three successive weeks without result, it may be fairly 
 assumed that there is temporary insusceptibility. Cases 
 are recorded, and others have been stated to me on 
 authority on which I can rely, but I have never met 
 with any myself, in which persons have by skillful 
 hands been vaccinated again and again, at intervals of 
 months and years, without the vaccination taking effect. 
 We are not, however, to infer from this that the insus- 
 ceptibility was permanent, and still less that the per- 
 son was at all safe from small-pox. We do not know 
 even that, while the insusceptibility to vaccination 
 lasts, there is in all persons corresponding insuscepti- 
 bility to small-pox, though this may very probably be 
 the case.* But supposing this to be so, a change of 
 constitution may assuredly, at some quite indeterm- 
 inate and unknown period, render the hitherto insus- 
 ceptible person susceptible to one or the other, probably 
 to whichever he may be first exposed, of these infec- 
 tions, f 
 
 * The late Mr. Spurgin, of Northampton, forwarded some 
 years ago to the Epidemiological Society the particulars of a 
 case in which, in 1825, a hoy fourteen years old, whose family 
 were greatly opposed to vaccination, was inoculated with 
 variola six or seven times without any result, that disease 
 heing then prevalent. The father then allowed vaccination to 
 be tried, and the boy was vaccinated six or seven times, but 
 equally without effect. About a year after, when at a distance 
 from home, he contracted natural small-pox of the discrete 
 kind, and went through the disease favorably. And the late 
 Mr. Marshall, of Kinton, Herefordshire, in a communication 
 to the same Society, stated that in two cases which resisted 
 vaccination he tried small-pox inoculation and found it equally 
 resisted. 
 
 f See Marson's Article " Small-pox," in System of Medicine 
 (op. cit.); especially the very interesting case, related at p.
 
 198 HANDBOOK OF VACCINATION. 
 
 In the very interesting returns of the Registrar- Gen- 
 eral for Scotland, relating to the vaccination of children 
 under the law in force in that kingdom, I find that 
 rather more than one in 200 of the children vaccinated 
 (0-69 per cent, in 1864, and 0-41 per cent, in 1865) are 
 returned to the Registrars as constitutionally insus- 
 ceptible of vaccination. The term, of course, in these 
 cases is only to be taken as used in a legal sense, and 
 as merely implying that the children have undergone 
 the three successive vaccinations which the Act re- 
 quires to be performed before a parent is entitled, under 
 a certificate of insusceptibility, to exemption from the 
 penal provisions of the law. No doubt, the insecurity 
 of these children against future small-pox was well 
 explained by the medical practitioners to the respective 
 parents. Still, such a proportion of failures as this 
 return shows is a misfortune ; it indicates, even with 
 every allowance for the disadvantages under which, 
 from the scattered nature of the population, vaccina- 
 tion must be earned on in a great portion of Scotland, 
 a performance of vaccination which is not satisfactory. 
 The very considerable diminution, however, in the pro- 
 portion of these cases in the second of the two years, 
 is gratifying and encouraging. 
 
 450, of a woman, aged 83, dying of confluent small-pox, who 
 had nursed her own children and her grandchildren with the 
 disease, and had otherwise often been exposed to variolous in- 
 fection, but never before taken it. She had never been vac- 
 cinated nor inoculated.
 
 ALLEGED DEGENERATION OF LYMPH. 199 
 
 CHAPTER X. 
 
 OF ALLEGED DEGENERATION OP LYMPH, AND OF RE- 
 CURRENCE TO THE COW. 
 
 75. Will Lymph degenerate if due care be em- 
 ployed? Jenner's opinion on the subject. — It has 
 been held by many that vaccine lymph degenerates, 
 deteriorates, or loses something of its active power, 
 merely by passing through a succession of human 
 bodies. This hypothesis dates from a very early pe- 
 riod of the history of vaccination, and applications for 
 lymph " as recent from the cow as possible " were 
 made to Jenner within two or three years from the 
 promulgation of his discovery.* He thought it of no 
 importance whatever to comply with the exact terms 
 of such requests, for he was well satisfied from his ex- 
 perience at that time that no such deterioration had 
 then taken place. Nor did he think it likely that with 
 proper care it would occur at all ; though this, he said, 
 was a point which " time alone can determine. "f Fur- 
 ther experience — a careful watching of vaccination for 
 upwards of twenty years more, during which, lymph, 
 successively transferred from subject to subject, had 
 undergone no change whatever in its qualities — fully 
 satisfied him that the hypothesis was groundless. 
 
 But, in so deciding, he was most careful to draw the 
 
 * Ring, op. cit., p. 458. 
 
 f Continuation of Facts, etc., If 00, p. H>2.
 
 200 HANDBOOK OF VACCINATION. 
 
 essential distinction between deterioration of lymph by- 
 mere successive transmissions (the subjects for trans- 
 ferring it having been proper ones), by mere lapse of 
 time since it was taken from the cow, on the one 
 hand,* and deterioration by transmission through un- 
 selected subjects, through subjects not fit for transfer- 
 ring it, on the other. And while he regarded the 
 former as an utterly erroneous notion, a conjecture 
 which, as he said, " he could destroy by facts," he did 
 not fail to point out the danger of deterioration from 
 
 *" Lively aguments," says Simon, "for the necessary de- 
 generation of the vaccine contagion have proceeded on a belief 
 that the original cow-pox at each vaccination simply dilutes 
 itself vrith certain passive juices of the vaccinated body, that it 
 thus of course gets weaker and weaker at every stage, till at 
 its thirty-fifth succession it is reduced — according to Dr. 
 Nicolai — to at least the 8,809,458,688th fraction of its original 
 power." This argument founds itself on a radical misappre- 
 hension of the infective process in question. Wha't essentially 
 marks the infective action of cow-pox, small-pox, and similar 
 morbid poisons, is, that under their fermentative influence some 
 ingredient of the infected body converts itself into their like- 
 ness. The material contained within certain vaccine vesicles 
 is not a something which has been transfused into the body, 
 but a something which has been generated within it by a spe- 
 cific decomposition of its own proper substance ; and the origi- 
 nal lymph, which acted as a ferment to this process, has very 
 probably completed its decay and altogether passed from the 
 scene before those new vesicles begin to show themselves. 
 Successive dynamical infections do not imply a perpetuation 
 (with corresponding infinitesimal subdivision) of the original 
 efficient; or Nicolai's argument might equally have been used 
 to prove that the power of human procreation could not but 
 cease soon after the days of Adam." (Preface to Papers re- 
 lating to the History and Practice of Vaccination, p. xxix.)
 
 ALLEGED DEGENERATION OF LYMPH. 201 
 
 want of proper care in the choice of subjects. " The 
 matter," said he, writing in 1816, "may undergo a 
 change that may render it unfit for further use by pass- 
 ing even from one individual to another, and this was 
 as likely to happen in the first year of vaccination as 
 in the twentieth;" but that, with proper care and at- 
 tention, lymph underwent no change, was proved, he 
 held, by the fact that the vesicles he was then pro- 
 ducing were " in every respect as perfect and correct 
 in size, shape, color, state of the lymph, the period of 
 the appearance and disappearance of the areola, its 
 tint, and finally the compact texture of the scab, as 
 they were in the first year of vaccination ; and to the 
 best of my knowledge, the matter from which they are 
 derived was that taken from a cow about sixteen years 
 ago.*" 
 
 76. The Vesicles produced now by Jenner's Lymph 
 have the same character and course as he described. 
 — Now, if lymph could thus undergo from eight to 
 nine hundred transmissions without giving any evi- 
 dence of change, it seems difficult to understand why, 
 in equally careful hands, and with similar opportuni- 
 ties of choice, it should not remain equally unchanged 
 after an indefinite number of transmissions. Accord- 
 ingly, numerous trustworthy observers, who had 
 watched the vaccine disease at the introduction of 
 vaccination, on comparing what they had then seen 
 with the effects produced by lymph of the earliest 
 stocks after a lapse of thirty or forty years, were una- 
 ble to detect the slightest difference either in the 
 
 * Baron's Life of Jenner, vol. ii. p. 398. 
 18
 
 202 HANDBOOK OF VACCINATION. 
 
 course or character of the vesicles.* Exactly the 
 same is the case if we compare with Jenner's descrip- 
 tion the course of the vesicle induced at the present 
 day with lymph of Jenner's stock. Marson says he 
 has frequently produced lately, with lymph brought 
 into use by Jenner more than fifty years since, vaccine 
 vesicles which, on comparison, exactly correspond with 
 the vesicles sketched in Jenner's original work.f Mr. 
 Steele, the able and experienced teacher of vaccination 
 at Liverpool, states that the lymph he is now using 
 was supplied by Jenner himself, and is producing still 
 precisely the results it developed at first.| After it had 
 been more than fifty years in use there, it was com- 
 pared, side by side, with lymph which Ceely had taken 
 from a cow six years before, and which he guaranteed 
 to have lost none of its activity ; but no difference be- 
 tween the effects of the two lymphs was detectible.§ 
 The lymph now in use throughout the stations of the 
 National Vaccine Establishment is, if not exclusively, 
 nearly all of Jenner's original stock, and, from daily 
 opportunities of observation, I can affirm that it has 
 not lost anything of its infective power, || and that the 
 vesicles produced by it correspond accurately in their 
 character and course with Jenner's description. Other 
 
 * See Aikin, London Medical Gazette, vol. xiii.; also Rap- 
 port de l'Academie Royale de Medecine sur les Vaccinations 
 pendant l'annee 1841. 
 
 f Art. "Small-pox," in System of Medicine (op. cit), vol. 
 i. p. 476. 
 
 % Steele in Liverpool Medico-Chirurgical Journal, 1858. 
 
 \ British Medical Journal, 1862, vol. i. p. 275. 
 
 || I have hefore adverted (g 69) to its not failing on an aver- 
 age above once in 170 times.
 
 ALLEGED DEGENERATION OF LYMPH. 203 
 
 stocks have at times been introduced into use at the 
 Establishment, but they were found to present no ad- 
 vantages, and it was not, therefore, felt necessary to 
 take any particular pains to maintain them.* So far 
 as the correct character and course, and the energy (if 
 I may so say) of the vaccine vesicle are evidences of 
 its prophylactic power against small-poy, I cannot but 
 concur entirely, from personal observation, with the 
 statement which the National Vaccine Board made in 
 1854, "that the vaccine lymph does not lose any of its 
 prophylactic power by a continued transit through 
 successive subjects, and that it is a fallacy to predicate 
 the necessity of resorting to the original source of the 
 cow for a renewed supply, "f 
 
 77. And leave the same kind of Cicatrices — Mar- 
 son states, however, that he has found the cicatrices 
 left by some lymph which he has had many years in 
 
 * Strange notions appear to be entertained abroad, and I 
 have seen, I think, similar statements made even in this coun- 
 try, that lymph has only been kept alive and in a state of 
 energy, in England, by renewals from the cow, — that typical 
 vesicles are only seen in consequence of such renewal. But 
 this is a very erroneous notion. The lymph chiefly in use 
 throughout England is Establishment lymph, which is, mainly, 
 Jenner's lymph. Ceely, who has more knowledge of the cow- 
 pox in the cow, and the effects of cow-lymph on the human 
 subject, than any other man in England, was requested by the 
 Medical Department of the Privy Council, in 1862, to inspect 
 all the stations from which lymph was contributed to the Es- 
 tablishment. He "met with abundant evidence of the per- 
 fectly satisfactory character of the lymph in use." (Fifth 
 Annual Report of Medical Officer of the Privy Council, p. 9.) 
 
 f Annual Report of the National Vaccine Establishment 
 for 1854.
 
 204 HANDBOOK OF VACCINATION. 
 
 use, to be now not so good as the same lymph produced 
 formerly.* Whatever may have been the cause of this 
 change, its extent, I apprehend, is not such as to make 
 him doubtful of the essential qualities of the lymph re- 
 maining unaltered, or I am quite satisfied that he would 
 have discontinued the stock. The observation, coming 
 from such a quarter, is important: still I cannot think 
 it generally applicable. During the last eight years I 
 have examined the vaccine cicatrices on the arms of 
 more than a hundred thousand persons, of all ages, but 
 chiefly children in schools. Taking the results gener- 
 ally, I have not found them by any means indicative 
 of progressive deterioration in the character of the 
 vaccine scar. And taking particularly districts which 
 had good vaccinators, men who knew their work 
 thoroughly well, and who did it with lymph got origi- 
 nally from the Establishment, i.e. with lymph of Jen- 
 ner's stock, I have found the marks corresponding ex- 
 actly to Willan's delineatiou, and in no respect inferior 
 to cicatrices which I have seen on the arms of persons 
 vaccinated by Jenner himself, or by his well-known 
 contemporary, Dr. Walker. 
 
 78. Lymph accidentally degenerated should always 
 be at once changed. — As I have stated elsewhere, f I 
 have repeatedly, in the course of my official and other 
 inquiries into vaccination, met with lymph in use of 
 a comparatively feeble and inactive kind. It would 
 be strange indeed if this had not been so, considering 
 the very miscellaneous way in which practitioners have 
 
 * Art. "Small-pox," in System of Medicine (op. cit.),\o\. i. 
 f Art. "Vaccination," in System of Medicine (op. cit.), 
 vol. i.
 
 ALLEGED DEGENERATION OF LYMPH. 205 
 
 been frequently content to get their lymph from others, 
 and the unfavorable conditions under which they have 
 sometimes been content themselves to take lymph.* 
 But in recommending a change of stock, I have always 
 felt it enough to take care that the stock substituted 
 should be good active lymph, and have never troubled 
 myself as to the time which had elapsed since it had 
 come from the cow. Does the lymph produce the 
 effect which has been described (§ 34) as the normal 
 effect of the introduction of vaccine lymph into the sys- 
 tem ? That is really the only practical question. My 
 experience tells me that vaccinators who have to depend 
 on others for lymph should be very careful to whom 
 they apply : and it tells me still more, that when they 
 have got some good lymph they should be very careful 
 through what subjects they transfer it. 
 
 79. Particular Lymphs. The Passy Lymph. — In 
 1836, a stock of lymph was obtained at Passy, in the 
 environs of Paris, from the hand of a milker who had 
 contracted the cow-pox casually from the cow.f It 
 manifested, In the most marked manner, and through 
 many transmissions, the peculiarities already described 
 as attending the early transmissions of primary lymph 
 (§ 42). When compared with the old stock then in 
 use at the Academie de Medecine, it was found to be 
 more infective, to develop vesicles which were mani- 
 festly finer, to produce a more marked and more dura- 
 ble areola, and to leave better cicatrices. But the 
 lymph with which this comparison was made was 
 evidently lymph which, from some cause or other, had 
 
 * See, for illustrations, pp. 151, note, 157, note, etc. 
 
 f Bousquet, Nouveau Traite de la Vaccine, pp. 403-416. 
 
 18*
 
 206 HANDBOOK OF VACCINATION. 
 
 become deficient in those qualities which characterize 
 active lymph. When we are informed that the vesicles 
 produced by it had their complete development with 
 commencing areola by the seventh day,* were at this 
 date of softish consistence, so that the slightest touch of 
 the lancet would make them empty themselves, and 
 yield a virus which had already lost some of its trans- 
 parency (pour peu qu'on y touche avec la lancette, elle 
 se vide, et le virus qui en sort est deja un peu louche), 
 had commenced desiccation by the ninth day, completed 
 it by the twelfth, and somewhere from the fifteenth to 
 the eighteenth day threw off small crusts, leaving cica- 
 trices which at the end of some months were scarcely 
 to be discerned, we see at once that we are dealing 
 with a lymph very different from the ordinary lymph- 
 stocks of England, and one which could not too soon 
 be changed. And probably, some recent revelations 
 with regard to the mode of collecting lymph for the 
 service of the Academie may throw some light on the 
 cause of this degeneration. f 
 
 * I am doubtful, from M. Bousquet's description, whether 
 he means the seventh day, including the day of vaccination, 
 according to our mode of counting (or the day before the day- 
 week), or the seventh day after the vaccination (which, as 
 we count, would be the eighth day, or the day-week itself). 
 If the latter, the course would in this respect be quite normal. 
 
 f The following statement by M. Blot, publicly made at a 
 meeting of the Academie (January 15, 1865), has not been 
 challenged : " Je sais, en effet, comment les choses se passaient 
 a 1' Academie jusqu'a dans ces dernieres annees, et meme peut- 
 etre encore aujourd'hui. Nourri pres du serail, j'en connais 
 les habitudes. Comment croyez-vous qu'est recueillie une 
 grande partie du vaccin qui sert a 1' Academie? A quelles 
 sources pensez-vous qu'on aille le puiser? Par quelles mains
 
 ALLEGED DEGENERATION OF LYMPH. 207 
 
 When this Passy lymph of 1836 was compared with 
 some lymph which had been in use for twenty-nine 
 years at Tours, it exhibited during its first transmis- 
 sions considerably more local intensity of symptoms, 
 but in a very short time this peculiarity declined, and, 
 at the end of a year, there was scarcely the slightest 
 difference perceptible in the action of the two lymphs ; 
 when, in 1838, it was compared with a stock then 
 obtained new from the cow at Rouen, such difference 
 as was noted was in favor of the older (the Passy) 
 lymph ; when, in 1841, after from 200 to 250 transmis- 
 sions, it was compared with a stock from the cow near 
 Dijon, or with some lymph from Stuttgardt, at the 
 first, third, and twelfth removes from the cow, it was 
 
 cette recolte si importante est-elle faite? Je vais vous le dire. 
 Jusqu'cn ces derniers temps, voila comment les choses se pra- 
 tiquuient. On vaccinait ici deux, trois, quatre, ou cinq enfants 
 envoyes par la surveillante du service de la clinique d'ac- 
 couchement, puis ils retournaient a la clinique. Au bout de 
 huit jours on allait a l'hopital recueillir ce que chacun de ces 
 enfants avait pu produire de liquide vaccinal. Or, Messieurs, 
 qui croyez-vous qui allait faire cette recolte, dont le produit 
 devait servir a inoculer d'autres enfants, soit a l'Academie, 
 soit dans Paris, soit en province ? M. le directeur de la vac- 
 cine, peut-etre? Jamais. A son defaut, M. le sous-directeur ? 
 Pas davantage. Eh bien, alors, direz-vous, un des membres 
 de la commission permanente de vaccine ? Pas tu tout. Alors 
 quelque jeune medecin distingue, ou tout au moins un interne? 
 Vous n'y etes pas davantage. C'etait un simple em- 
 ploye des bureaux de l'Academie, un vieillard valetudinaire, 
 completement etrnnger a Part de guerir, et de plus atteint do 
 tremblement senile. Je n'ai pas besoin de dire si ce brave 
 homme tftait capable de choisir les sujets, d'examiner et d'in- 
 terroger les meres. En tout cas, en eut-il ete capable, il no 
 sen inquietait nullement."
 
 208 HANDBOOK OF VACCINATION. 
 
 as active as either of them ; and when, three years 
 later, and after some 400 transmissions, or more, it was 
 used, in 1844, side by side with some lymph just 
 obtained from a cow belonging to M. Majendie, there 
 was absolutely no difference in the action of the two 
 lymphs. On comparison, by various experimenters, of 
 the action of lymph from some of these more recent 
 stocks — the Rouen stock, and Majendie's — with lymph 
 of the original stocks which was in use in various 
 places, no difference was detectible.* 
 
 A lymph-stock, which was set in circulation by Mr. 
 Estlin, of Bristol, in 1838, f produced in its earliest 
 transmissions much of that extreme local irritative 
 effect which Jenner and others describe as attending 
 the use of unhumanized lymph, and which, so far from 
 regarding as an advantage, they were always anxious 
 to control. It was so exceedingly irritative, that I 
 know that life was endangered in some instances by 
 the use of it, and I rather think a fatal case or two 
 occurred-! When, after some transmissions, this viru- 
 
 * See Bousquet, Nouveau Traite, etc., pp. 415-6: also Rap- 
 port de l'Academie Royale de Medecine de Paris, sur les Vac- 
 cinations pratiquees en France pendent l'annee 1841 ; ibid., 
 1844; ibid., 1845. s 
 
 f It was obtained at the second remove from a little child 
 aged five years, who had been inoculated with a needle with 
 the discharge proceeding from the hands of a milker in a 
 dairy, in which there was cow-pox. (London Medical Gazette, 
 vol. xxii.) 
 
 \ The late Mr. Gilham, of the National Vaccine Establish- 
 ment, having vaccinated a number of children with Estlin's 
 lymph, during its early transmissions, when it was producing 
 severe local effects, tested tbem afterward by variolous inocu- 
 lation, and, for comparison's sake, inoculated with variola an
 
 ALLEGED DEGENERATION OF LYMPH. 209 
 
 lence abated, it was a fine and good stock, and was re- 
 garded by Mr. Estlin and others who employed it as 
 superior to the lymph they were then respectively 
 using. As the stock, however, which Mr. Estlin was 
 then using is described by him as producing small 
 vesicles, running a rapid course, and yielding little 
 lymph of diminished infective power, it is clear again 
 that the comparison was made with lymph very differ- 
 ent from that which now, thirty years later, may be 
 found in current use at our best public stations, pro- 
 ducing perfect results, and not failing once in a hun- 
 dred and seventy times.* When Mr. Aikin compared 
 Estlin's lymph with some he had in use from Jenner's 
 original stock, he could not detect any difference. - }" 
 
 In the dairy farms of the Bridgewater Level and of 
 the A' ale of Gloucester, the natural cow-pox is still not 
 
 equal number of children who had been vaccinated by him 
 with lymph of Jenner's old stock. Both series resisted equally 
 the action of the variolous inoculation. 
 
 * Mr. Estlin considered it important testimony that at the 
 Vaccine Institution at Glasgow his lymph had not failed once 
 in 43 trials, while in the preceding 43 vaccinations there had 
 been 10 failures and 9 spurious or imperfect results ; and at the 
 time the new supply reached them " all the children vaccinated 
 on the day-week preceding presented, instead of true vesicles, 
 raw surfaces resembling spots that had been vesicated and then 
 denuded of their cuticle." Surely there is nothing here proved, 
 but the worthlessness of the stock of lymph (?) they bad in 
 use. I do not know what is the Institution referred to as the 
 Vaccine Institution at Glasgow, but I do happen to know that 
 at the Royal Infirmary of that city in bygone days an occa- 
 sional, if not a frequent, performer of the vaccination was the 
 hospital porter. 
 
 f London Medical Gazette, vol. xxvi. p. 189.
 
 210 HANDBOOK OF VACCINATION. 
 
 infrequent, and inoculations direct from the cow have 
 been practiced in several districts with success. "All 
 who have employed such lymph agree in stating that, 
 after the first or second transmission, the results ob- 
 tained do not differ from those of ordinary vaccination, 
 either in respect of the progress or character of the 
 vesicle."* 
 
 The comparison of the Passy lymph with other 
 lymphs direct from the cow, tends, indeed, to show 
 that all primary stocks are not identical in their local 
 action on the human subject; but there is nothing 
 whatever to show, or to lead even to a probable infer- 
 ence, that the points in which they differ are in the 
 least essential. Mr. Ceely, writing in 1841, tells us, 
 that during the preceding three years he had observed 
 and noted the effects on a variety of subjects, of more 
 than fifteen different stocks of vaccine lymph, of which 
 six had been from the natural disease, either taken 
 direct from cows or from vesicles on the hands of 
 milkers, and seven artificially produced in the cow. 
 These stocks had all varied in their effects, both locally 
 and constitutionally, but none had lacked the essential 
 qualities and properties, nor had any possessed them 
 in a superior degree to those indicated in the descrip- 
 tion and illustrations of Jenner. This is the "stand- 
 ard," he says, "to which we may at all times confidently 
 appeal. "f " My own repeated applications to the cow" 
 (for lymph), he tells us elsewhere, " have been chiefly 
 for the purpose of experiment, for the satisfaction of 
 
 * Sanderson, quoted in Sixth Report of Medical Officer of 
 Privy Council, p. 10. 
 
 f Trans. Provincial Medical and Surgical Association, vol. 
 x. p. 261.
 
 PROTECTION AGAINST SMALL-POX. 211 
 
 patients or the accommodation of friends, not from any 
 belief in its superior efficacy over active humanized 
 lymph."* 
 
 CHAPTER XI. 
 
 OP THE PROTECTION WHICH VACCINATION AFFORDS 
 AGAINST SMALL-POX. 
 
 80. What Small-pox was before the Discovery of 
 Vaccination. — Until the close of the last century, 
 small-pox was by far the most formidable and fatal 
 of all the diseases that afflicted mankind. The great 
 and eloquent modern historian of England, comparing 
 the ravages it made in this country toward the close 
 of the seventeenth century — when, among others, 
 JVIary, the wife of William III., fell a victim to it — 
 with the ravages of the plague, justly assigned to 
 small-pox the foremost place, as "the most terrible of 
 all the ministers of death." " The havoc of the plague," 
 says Macaulay, " had been far more rapid, but the plague 
 had visited our shores only once or twice within living 
 memory, but the small-pox was always present, filling 
 the churchyards with corpses, leaving on those whose 
 lives it spared the hideous traces of its power, turning 
 the babe into a changeling at which the mother shud- 
 dered, and making the eyes and cheeks of the betrothed 
 
 * Trans. Provincial Medical and Surgical Association, vol. 
 viii. p. 376.
 
 212 HANDBOOK OF VACCINATION. 
 
 maiden objects of horror to the lover."* This descrip- 
 tion applied with at least equal force a hundred years 
 later. Few indeed, then, were those who were not 
 at some time or other of their lives attacked by this 
 fell disease ; and happy was it for any one so attacked 
 that he should escape with life, or with unimpaired 
 health, or without serious disfigurement. I must refer 
 to others for a description of the ravages small-pox 
 made in other countries :f in England, according to 
 the calculation of Dr. Lettsom, the average annual 
 deaths from it were about 3000 out of every million of 
 the population ; \ a death-rate which, with the present 
 population of the kingdom, would give an average of 
 considerably more than sixty thousand deaths from 
 small-pox a year. Nearly one-tenth part of all the 
 persons who died in London, within the bills of mor- 
 tality, during the last half of last century, died of this 
 one cause. § The younger part of the population were 
 peculiarly its victims; in some of our great cities it 
 was found that, on an average of long series of years, 
 
 * Macaulay, Hist, of England, vof. iv. p. 530 (8vo. edit. 
 1855). 
 
 •j- See particularly the most interesting account given by 
 Simon, Preface to Papers relating to the History and Prac- 
 tice of Vaccination, pp. ii.-vii.; see also Baron's Life of Jen- 
 ner, vol. i. pp. 256-272 ; and Moore's History of Small-pox. 
 
 J A calculation, separately made, by Sir Gr. Blane, corre- 
 sponded very closely with Lettsom's. (See " The Evidence at 
 Large, as laid before the House of Commons," etc., by the Kev. 
 G. C. Jenner.) 
 
 \ 90 per 1000; see Report on Small -pox and Vaccination, 
 presented to the President and Council of the Epidemiological 
 Society, by the Small-pox and Vaccination Committee, 1853 
 (8vo. edit.), p. 42.
 
 PROTECTION AGAINST SMALL-POX. 213 
 
 nearly or more than one-third of all the deaths which 
 took place in children, under ten years of age, arose 
 from small-pox.* The mutilations which it caused, 
 when it did not slay, were so frequent and so consid- 
 erable, that we have it on record that at the period of 
 which we are speaking, two-thirds of the applicants for 
 relief at the Hospital for the Indigent Blind owed their 
 loss of sight to small-pox -f and we need but refer to 
 the writings of physicians of that time, to see how 
 frequently it was followed by deafness, and, in consti- 
 tutions disposed to scrofula, by glandular swellings, 
 obstinate ulcerations, and other evidences of the devel- 
 opment of that disease. 
 
 81. The Characters of Small-pox, when uncontrolled 
 by Vaccination, are still the same. — It is quite neces- 
 sary to recall these facts, because, as has been well 
 remarked, since by the introduction of vaccination, 
 small-pox has almost ceased to be a fatal disease 
 among the civilized classes of society, there is to them 
 " a temptation to forget how their fathers and grand- 
 fathers regarded it. "J If we could only, for a moment, 
 suppose that the protection against small-pox, which 
 our population now enjoys from vaccination, were all 
 at once removed, it is beyond a doubt that we should 
 find ourselves thrown back into all the horrors of last 
 century. For the small-pox itself appears to have lost 
 
 * In Glasgow, from 1783-1792, 36 per cent., and from 1793- 
 1802, 32 per cent., of all the deaths under ten years of age 
 were deaths from small-pox. (See Cowan's Vital Statistics of 
 Glasgow.) 
 
 f Sir G. Blane in Medico-Chirurg. Trans., vol. x. p. 326. 
 
 X Simon, op. cit, p. ii. 
 
 19
 
 214 HANDBOOK OF VACCINATION. 
 
 nothing of its malignancy and fatality, either by lapse 
 of time, or (since Sydenham's day) by any improve- 
 ment in medical treatment. We find from the records 
 of the Small-pox Hospital that, during the last 25 
 years of last century, the death-rate in the hospital 
 (the patients, of course, being all unvaccinated) was 
 32i per cent, of the admissions.* In the same hos- 
 pital, during the years 1836-51, the deaths, excluding 
 the vaccinated, were 35 per cent.f Dr. Jurin, writing 
 early in last century, laid it down as the result of his 
 investigations, "that of persons of all ages, taken ill of 
 natural small-pox, there will die of that distemper one 
 in five or six."! From returns made to the Epidemio- 
 logical Society in 1852, by 156 medical practitioners 
 in various parts of England, who had kept numerical 
 records of their small-pox experience, it appeared that 
 the proportion of deaths to cases which they had met 
 with in the natural form of the disease, was 19 7 per 
 cent., or, as nearly as possible, one to five — a result 
 which closely corresponds with, and is certainly in no 
 
 * As given in Appendix to the Annual Keport of the Na- 
 tional Vaccine Board, printed by order of the House of Com- 
 mons, March 2, 1826. 
 
 f See table I. in Marson's Papers on Small-pox and Vacc. 
 in .Medico-Chir. Trans., vol. xxxvi. I apprehend it is hardly 
 necessary to say that it would not be at all a fair inference, 
 from the somewhat higher death-rate of the later period, that 
 the small-pox had become worse; probably, in the earlier 
 period, some cases of the inoculated small-pox (a comparatively 
 little fatal disease) are included. But these would have con- 
 stitated but a small proportion of the whole, and it is a fair 
 inference from the figures, as they stand, that the fatality of 
 the natural disease has undergone no essential change. 
 
 | Moore's History of Small-pox, p. 243.
 
 PROTECTION AGAINST SMALL-POX. 215 
 
 degree more favorable than that of Dr. Jurin.* And 
 the same sequelae which Willan describes as attending 
 the natural suiall-pox in his time, attend the natural 
 small-pox now. If, further, we look to see what has 
 happened when, in recent times, small-pox has invaded 
 or invades populations among whom vaccination has 
 been but little practiced, we find its ravages to be ex- 
 actly like those met in Europe during last century. 
 This was the case in 1846-8, in an epidemic which 
 occurred in the Argentine Confederation, and which is 
 described by Dr. Makenna — a British physician, then 
 practicing at Montevideo — as sweeping with the 
 wings of death over that enormous tract of country, 
 which extends from the seaboard of the Atlantic on 
 the east to the Corderilla of the Andes on the west. 
 "Throughout this whole space," he observes, "it may 
 be said that hardly a single house or rancho escaped 
 its fearful visitation, wherever the current of human 
 intercourse reached ; and such was its fatality, that I 
 have known thirty children taken in one morning from 
 the houses of one quadra of a street 150 yards long, 
 and I have seen two men above seventy years of age, 
 and deeply pitted with a former attack, carried off by 
 it. Whole families were swept away, and, in short, 
 
 * Seaton, Protective Power of Vaccination, San. Kev., vol. 
 ii. p. 354. These returns must be looked upon as very favor- 
 able, because they did not include any severe epidemics in 
 large towns. In such epidemics the proportion of fatal cases 
 is frequently one in four, or greater. (See p. 238, note.) In 
 the Small-pox Hospital the mortality is still higher — partly, 
 no doubt, because it is for the severer cases of disease that 
 hospital accommodation is peculiarly sought, and partly also 
 on account of hospital influence.
 
 216 HANDBOOK OF VACCINATION. 
 
 the terrors of the plagues of former times were, if not 
 surpassed, fully equaled by this horrible scourge. . . . 
 But that which struck me as most truly remarkable 
 was, that not one of those English people who had 
 been vaccinated at home, and who had the large, deep, 
 oval thimble-mark on one or both arms, ever took the 
 disease."* In Japan, at the present time, where, 
 though vaccination is known, it is practiced to a very 
 limited extent only, "small-pox is endemic and ex- 
 tremely prevalent. It is very rare, indeed," says Mr. 
 Dickins, "to meet a man on whose face there are not 
 some marks of the disease left. A very large propor- 
 tion die, and a much larger proportion are horribly 
 marked, as a very short walk through the town or 
 country will convince the inquirer It very fre- 
 quently attacks the eyes, and when it does, blindness 
 is almost an inevitable result. Almost every 'Amma,' 
 or blind beggar, of whom I made inquiry as to the 
 cause of his blindness, told me that it was the result 
 of sm all-pox. "f 
 
 82. Introduction of Variolous Inoculation : its Re- 
 sults. — An attempt made early in the last century to 
 mitigate the ravages of this disease was found but to 
 extend its deadly influence. The practice of inocu- 
 lating into the skin the matter of small-pox, which had 
 been long known in Eastern countries, was introduced 
 into England in 1121, through the advocacy and exam- 
 ple of Lady Mary Wortley Montague. J It purposed, 
 
 * Australian Medical Journal, January, 1858. 
 
 f Statistical Keport of the Health of the Navy for 1864, pp. 
 242, 243. 
 
 % Inoculation by rubbing the matter of small-pox on the 
 skin of the arm, or pricking the skin with pins or other pointed
 
 uoi-pu joqijnj uav< 
 sji put? 'uojirqnoc 
 -3i %i 9jiqAv 'mAiqj 
 -sa"s irouinq q\\% 03 
 qoiqAV oSui?qo ra i A' 
 -aopun ■juauuaj si 
 eiquoildxoui pun ; 
 
 2ups9J9}UI A\l9A p 
 
 punoi 'qduiX[ sruq 
 jfq paopoujd uggq 
 jo sptnqqSiH 9t W 
 'Xauora jo 9D9td u 
 nosaad aqj ssgpan 
 Suioq uoppsaodns 
 suav ^i -qoBoj pp 
 uaaq 9At?q o% pui? 'i 
 9ABqo^ piBssi'jg^ 
 
 aAniqtiaom aq^ 
 jo abound 13 qS 
 -t;j« si }i uaqAV 9 
 joj saraooaq 'aja 
 
 XbAI XxBOipjO 91] 
 
 s}i m 9iq-Bnoj;uo; 
 -uoooyiaads aq; % 
 pu-c Sni^soaa^ui %\ 
 3qi o%„ 'sjfjmuo. 
 s;i ngitij o; aona 
 -I1DOUI sjBnpiAipt 
 -%v aari^nj ^suibSi 
 ui asuasip aq^ j( 
 'J[SIJ %i\S\\s %■$ p 
 -uup aiwjj puB p 
 
 US 
 
 X0c/-771
 
 218 HANDBOOK OF VACCINATION. 
 
 process was, indeed, far from being absolutely void of 
 danger;* but, relatively to the natural disease, the dan- 
 ger was so slight, and the obvious advantages of inocula- 
 tion to the individual were consequently so great, that 
 the practice, having been at first hesitatingly accepted, 
 afterward made considerable progress. But just in pro- 
 portion to this progress did the one great and fatal 
 drawback to the use of variolous inoculation become ap- 
 parent. It was found that it multiplied the foci of con- 
 tagion: the small-pox produced by inoculation was as 
 capable of conveying infection as the natural small- 
 pox-itself; and as it was not in most instances severe 
 enough to confine the patient either to his bed or to his 
 house, while free exposure to the air was justly re- 
 garded as the best mode of treatment, it is obvious 
 how, especially in large towns, the chances of infection 
 must have been multiplied. Besides, as small-pox 
 could thus be set agoing anywhere by merely sending 
 a bit of cotton-thread dipped in variolous lymph for the 
 purpose of inoculation, it was constantly being intro- 
 duced into places from which otherwise it might have 
 been long absent. Hence the general mortality from 
 small-pox after the practice of inoculation had become 
 diffused was considerably greater than it had been be- 
 fore that practice was known. "However beneficial," 
 says the Royal College of Physicians of London, in 
 
 * In the early experiments with inoculation in England, 
 the deaths resulting from the process were two per cent, of the 
 operations performed ; hut this death-rate was subsequently 
 greatly diminished when the management of inoculation he- 
 came better understood, and Dr. Gregory gives three in a 
 thousand as the average of deaths from inoculation at the 
 Small-pox and Inoculation Hospital.
 
 PROTECTION AGAINST SMALL-POX. 219 
 
 'their Report on Vaccination (1807), "the inoculation 
 of small-pox may have been to individuals, it appears 
 to have kept up a constant source of contagion, which 
 has been the means of increasing the number of deaths 
 by what is called the natural disease. It cannot be 
 doubted that this mischief has been extended by the 
 inconsiderate manner in which great numbers of per- 
 sons, even since the introduction of vaccination, are 
 still every year inoculated with the small-pox, and af- 
 terward required to attend two or three times a week 
 at the places of inoculation, through every stage of 
 their illness."* It is stated by Dr. Heberden that 
 while, out of every thousand deaths from all causes 
 within the bills of mortality, the small-pox deaths 
 during the first thirty years of the eighteenth century, 
 before inoculation could yet have had any effect upon 
 them, amounted to seventy-four ; they amounted during 
 an equal number of years, at the end of the century, 
 to ninety-five, showing an increase in the proportion of 
 about five to four. It was becoming evident, there- 
 fore, that unless inoculation could be made by compul- 
 sion universal, it would be better for the community 
 that it should be abandoned altogether. 
 
 83. Discovery of Vaccination. — Such was the appa- 
 rently hopeless condition of things when, toward the 
 close of the century (in 1798), .Tenner made known to 
 the world that he had discovered and matured a pro- 
 
 * Papers relating to the History and Practice of Vaccina- 
 tion, p. 7. In France, in consequence of the multiplication of 
 foci of infection through inoculation, a royal decree prohib- 
 ited, in 17G3, the practice altogether, "dans 1 'enceinte des 
 villes et des faubourgs." (Kapport de l'Acad. Imp. etc., sur 
 les Vaccinations en 1858-9.)
 
 220 HANDBOOK OF VACCINATION. 
 
 cess by which persons might be protected against' 
 small-pox without any danger to themselves and with- 
 out any risk of infecting others. 
 
 Thirty years before, when he was apprentice to a 
 surgeon at Sodbury, in the County of Gloucester, a 
 young countrywoman had said in his hearing that she 
 could not take small-pox, "for she had had cow-pox." 
 These words riveted his attention, and the impression 
 they made was never effaced. He found that in that 
 county, where cow-pox was frequently met with among 
 the dairies, and where the milkers were continually 
 getting accidentally infected from the sores on the cows' 
 teats, the notion was widely diffused, though appa- 
 rently of no very long standing, that such of them 
 as had been thus infected were insusceptible of small- 
 pox.* A careful investigation of the grounds of this 
 belief enabled him both to establish its general truth, 
 and satisfactorily to explain and account for the appa- 
 rent exceptions; and it was during these inquiries, 
 continued for many years, that his genius conceived 
 the idea that not only might the cow-pox be given at 
 will to man by the process of inoculation from the cow 
 
 * "At what period the cow-pox was first noticed here is not 
 upon record. Our oldest farmers were not unacquainted with 
 it in their earliest days, when it appeared among their farms 
 without any deviation from the phenomena which it now ex- 
 hibits. Its connection with the small-pox seems to have been 
 unknown to them. Probably the general introduction of in- 
 oculation first occasioned the discovery." (Jenner, Inquiry 
 into the Causes and Effects, etc., p 64.) The belief among 
 dairy-folk of the antivariolous powers of cow-pox existed in 
 other parts of England, as well as in Ireland, parts of Ger- 
 many, etc. (See Ring, Treatise on the Cow-pox; and see 
 also Simon, op. cit., p. xii.)
 
 PROTECTION AGAINST SMALL-POX. 221 
 
 whenever opportunity offered, but that it might be 
 transferred and continued by that process from one 
 human subject to another, and that in this way protec- 
 tion against small-pox might be imparted to mankind 
 in perpetuity. 
 
 As early as 1780, he communicated to his friend Ed- 
 ward Gardner the views he had been led to entertain 
 on this subject, but it was not till sixteen years later 
 that (in 1796) he was able to put these views to ex- 
 perimental proof. With what trembling anxiety must 
 Jenner have watched these first experiments ! What de- 
 light must he have felt when he saw that the great an- 
 ticipations he had expressed to Gardner were about to 
 be realized ! Circumstances, however, obliged him to 
 suspend his experiments for awhile, but early in 1798 
 he was able to resume them ; and by the summer of 
 that year he had established his great discovery on so 
 ample a basis of observation and experiment that he felt 
 the time was come for making it known to the world. 
 
 84. Its Protective Power against Small-Pox dem- 
 onstrated.— The " Inquiry into the Causes and Effects 
 of the Variola? Vaccinae" — for so the first tract he pub- 
 lished on the subject was entitled — has been justly 
 called by one well qualified to judge a "masterpiece 
 of medical induction "* In this treatise Jenner proved 
 that the natural cow-pox, casually communicated to man, 
 rendered him insusceptible of taking small-pox, whether 
 by inoculation or by infection; that this protective 
 power was not lost by lapse of time, but manifested 
 itself at the end of twenty, thirty, or even fifty years ; 
 that it was possessed by the genuine cow-pox alone, 
 and not by other eruptions to which the cow was sub- 
 
 * Simon, op. cit., p. xii.
 
 222 HANDBOOK OF VACCINATION. 
 
 ject, and which might be confounded with it ; that the 
 cow-pox might be communicated at will, to man, by 
 the hand of the surgeon, whenever the requisite oppor- 
 tunity offered ; that, once engrafted on the human sub- 
 ject, it might be continued from individual to individual 
 by successive transmissions ; and that so transmitted 
 it conferred on each individual the same immunity from 
 small-pox as was enjoyed by the one first infected direct 
 from the cow. The disease had then, indeed, only 
 been conveyed from human subject to human subject, 
 through five successive transmissions; but as the child 
 last vaccinated had been submitted to the variolous in- 
 fection, and resisted it, equally with the one who had 
 been vaccinated direct from the cow, reason and analogy 
 rendered it difficult to doubt that this transmission 
 might be perpetually maintained. In two years more 
 Jenner was able to report that upwards of 6000 persons 
 had been inoculated with the virus of cow-pox, con- 
 veyed through a succession of human subjects, " and 
 the far greater part of them have since been inoculated 
 with that of small-pox, and exposed to its infection in 
 every rational way that could be devised, without 
 effect."* It is in the successive transmission of cow- 
 pox through human subjects that the practical useful- 
 ness of Jenner's great discovery lies ; and since the 
 process was first made known by him, all ordinary 
 vaccinations have been thus carried on. 
 
 85. Jenner's opinion as to the Degree of Protection 
 it afforded. — The protection which vaccination would 
 afford against small-pox was held by Jenner to be ex- 
 
 * A Continuation of Facts and Observations, etc., by E. 
 Jenner, M.D. Lond. 1800.
 
 PROTECTION AGAINST SMALL-POX. 223 
 
 actly that — neither more nor less — which an attack of 
 small-pox, either taken naturally or induced by a com- 
 pletely successful inoculation, would confer against a 
 subsequent attack of the same disease. Whatever 
 phrase may be picked out of his writings here and 
 there to show that he looked on the security which 
 cow-pox would impart against small-pox as absolute, that 
 he believed that the human system which had once felt 
 genuine cow-pox was "never afterward, at any period 
 of its existence, assailable by small-pox,"* must be 
 read with this limitation. Any other reading would 
 be quite inconsistent with the doctrine he invariably 
 held of the identity of cow-pox and human small-pox. 
 The system of a person who had been vaccinated was 
 regarded by him as having already passed through 
 small-pox. and as being, quoad future small-pox, ex- 
 actly in the condition of a person who had had small- 
 pox in the ordinary way (§ 25). And as he was well 
 aware, and indeed constantly urged, that the small-pox 
 itself did, in some individuals, recur, and that the hav- 
 ing passed through one attack, was not, in every in- 
 stance, a security against a future attack, so he looked 
 for similar occurrences after vaccination. What, in 
 short, he really claimed for vaccination is thus stated 
 by him : " Duly and efficiently performed" (for this, 
 of course, was indispensable), " it will protect the con- 
 stitution from subsequent attacks of small-pox as much 
 as that disease itself will. I never expected it would . 
 do more ; and it will not, I believe, do less."f 
 
 *A Continuation of Facts and Observations, etc., by E. 
 Jenner, M.D. Lond. 1800. 
 
 f Baron's Life of Jenner, vol. ii. p. 135.
 
 224 HANDBOOK OF VACCINATION. 
 
 86. Small-pox after Natural Small-pox. — That small- 
 pox may occur twice in the same individual is a fact 
 now so well known, and so universally admitted, that 
 it is a matter of some astonishment that any physicians 
 should have ever been found to express a doubt on the 
 subject. There have been those, indeed, who denied 
 altogether the possibility of it ; but generally the pos- 
 sibility was fully allowed, the difference of opinion 
 being as to the frequency with which the occurrence 
 took place. On this point medical authorities have 
 been most divided. While Mead and others looked on 
 a recurrence of small-pox as of the utmost rarity, many 
 physicians regarded it as by no means extremely in- 
 frequent. Perhaps the discrepancy is not wholly inex- 
 plicable. Those, probably, who held a second attack 
 of small-pox to be so extremely rare, did not consider 
 any attack to be small-pox which had not the full 
 course and character of a primary attack. Certain it is 
 that when, soon after the discovery of vaccination, the 
 modified form in which small-pox occasionally pre- 
 sented itself among the vaccinated began to attract at- 
 tention, it was found that the same modifications were 
 also sometimes seen in persons who had been vario- 
 lated. Further, before the diagnostic marks of variola- 
 and varicella were well made out and generally recog- 
 nized, there was, no doubt, much mutual confusion ; 
 and as, in the present day, wherever the distinction 
 between these two diseases is not acknowledged or not 
 well attended to, cases of varicella are frequently re- 
 corded as modifications of small-pox, so, conversely, no 
 doubt, when the modifications of small-pox were little 
 thought of, many modified secondary cases of this dis- 
 ease might be ascribed to chicken-pox. Except on
 
 PROTECTION AGAINST SMALL-POX. 225 
 
 some such grounds as these, I cannot understand how 
 it is that the variolous fever without eruption — the 
 " febris variolosa" — seen at this day, so far as I know 
 only in protected persons', should nevertheless be so 
 well described by Sydenham, who appears to have met 
 with many cases of it,* though I cannot find that he 
 refers to the circumstance whether those attacked by 
 it had had small-pox before or not. 
 
 87. Small-pox after Inoculated Small-pox. — Al- 
 though the occurrence of secondary small-pox is es- 
 tablished by numerous writers before the period when 
 inoculation of small-pox was first introduced, it is much 
 more frequently referred to by those who have written 
 since that date. And this, indeed, is what might have 
 been anticipated, for it seems to me scarcely to be 
 doubted that cases of small-pox must have occurred 
 with greater relative frequency among individuals to 
 whom small-pox had been given, or was believed to 
 have been given, by inoculation, than among those who 
 had had the disease in the natural way. The process 
 of variolous inoculation is liable, like the vaccine pro- 
 cess, to accidental disturbances and interferences in its 
 course, and to irregularities, arising cither from the 
 state of the matter used, or from the state of the child 
 in whom it was inserted, that must have rendered in- 
 evitable, as it seems to me, the occasional occurrence 
 of such cases as the following, described by Mr. Earle : 
 In a general inoculation he had made in the village 
 of Arlingham, in 1784, he had inoculated five children 
 with variolous matter which was undoubtedly genuine, 
 
 * Sydenham's Works, trans, by K. G. Latham, vol. i. p. 
 152, seq. 
 
 20
 
 226 HANDBOOK OF VACCINATION. 
 
 though it had been taken at a late period of the disease ; 
 infection was produced, but peculiarities arose in the 
 progress of the cases which led Mr. Earle to consult an 
 elder practitioner, who, however, pronounced the chil- 
 dren safe; nevertheless, four out of the five children 
 took small-pox afterward, and one of them died ; the 
 only one who escaped an attack had not, at the time 
 the account was published, been exposed to infection. 
 And it was only the lesson which Mr. Earle had learnt 
 from this occurrence that made him, on a subsequent 
 occasion, test, and by this testing inoculation, save 
 three children whose inoculation had been followed by 
 results which, to most, would have been considered 
 satisfactory.* Other writers record instances in which 
 the results following inoculation, though peculiar, were 
 yet such as, according to the highest authorities in 
 inoculation, justified the practitioner in pronouncing 
 the patients safe, and yet small-pox was subsequently 
 taken, f nor were cases wanting in which the progress 
 of the inoculation so closely indeed resembled that 
 which was normal and regular, that the most experi- 
 enced could not distinguish it, but in which the process 
 was yet unprotective, true natural small-pox manifest- 
 ing itself in the children within a few weeks after the 
 phenomena had subsided. J 
 
 * Jenner, Further Observations, etc., 4to. 1799. 
 
 f Kite, Memoirs of Med. Soc. of London, iv. 114. The in- 
 oculation took local effect early, and ran a hastened course, the 
 case being exactly analogous to one of spurious vaccination. 
 But Dimsdale, who was familiar with cases of this kind, used 
 to regard them as safe. 
 
 % Kite's cases showed conclusively that this might occur 
 where the inoculated small-pox had gone through such a
 
 PROTECTION AGAINST SMALL-POX. 227 
 
 88. Frequency or Infrequency of Recurrent Small- 
 pox. — Ploucquet gives a list of seventy-four writers 
 who record cases of second, and some of them even of 
 third, or of several, attacks of small-pox in the same 
 individual:* Dr. Hennen gives a still more copious 
 list f Half a century and more ago, when small-pox 
 was much more common than now, cases were cer- 
 tainly Dot rare. Jenner refers to the very large num- 
 ber of which there were authentic accounts, no fewer 
 than seventeen of them in the families of the nobility. J 
 But even with the diminished prevalence of small-pox 
 since that period, innumerable cases have been put on 
 record. The Provincial Medical and Surgical Asso- 
 ciation collected, in 1839, from various correspondents, 
 
 course as the most careful and experienced practitioner could 
 not distinguish from the regular course — the local phenomena 
 heing the same, the fever commencing at the regular period, 
 and continuing the normal length of time, and the eruption 
 duly following ; the only possible point of distinction being 
 that most of the pustules did not completely maturate — which, 
 as he remarked, is repeatedly the case in the real small-pox 
 when the eruption has been moderate. The matter used in 
 some of these inoculations had been taken at a late period of 
 the pustule : there was no record of that used in the others. 
 But Mr. Kite speculates whether variolous matter, if not prop- 
 erly taken, or if not properly kept, may not have undergone, 
 or may not undergo, changes which enable it to produce a 
 certain degree of variolous infection, but not enough to pro- 
 duce the disease fully and completely. A similar, most inter- 
 esting, question arises with regard to the effects of vaccination 
 under the like circumstances. (See p. 92, note.) 
 
 * Literatura Medica Digesta, tome iv. and Supplement. 
 
 f Edin. Med. and S. Journal, vol. xiv. p. 460. 
 
 % Baron's Life of Jenner", vol. ii. p. 159. See also pp. 29 
 and 303.
 
 228 HANDBOOK OF VACCINATION. 
 
 239 such cases; and in the inquiry made by the Epi- 
 demiological Society of London, in 1851, which has 
 been already referred to, numerous practitioners re- 
 ported cases of second small-pox, and some even of 
 third attacks, with a circumstantiality of detail which 
 left no ground for doubting the accuracy of the state- 
 ments. More than 200 cases of second small-pox were 
 thus communicated, the evidence of the primary .attack 
 being generally the full and characteristic marking of 
 the patient, and the second attack being watched 
 through its course by observers whose competence to 
 discriminate accurately could in most instances be 
 relied on. In the official inquiries relative to small- 
 pox which I have been called on to make since 1859, 
 and notably during the recent epidemic (1863-6), the 
 occurrence of cases of second small-pox has been 
 brought to my notice on numerous occasions; not only 
 in most of the large towns which I have had occasion 
 to visit, but also in small towns and rural districts. 
 As regards many of these cases the sufficiency of the 
 evidence was quite beyond question : one or two of them 
 I had the opportunity of seeing in progress, and in sev- 
 eral instances, though the attack was over, I was able 
 to examine and interrogate those who had suffered. 
 Experience abroad coincides with experience in this 
 country. . Haeser states, on the authority of Regoni- 
 Stern, that at Verona in the ten years 1829-38, twenty- 
 four cases of second small-pox had been noted, eight 
 of which were fatal ;* and Heim reports in the epi- 
 demics in Wirtemberg, 1831-5, fifty-seven cases of re- 
 current small-pox, of which sixteen died, and, in sub- 
 
 * Haoser, Die Vaccination und ihre neuesten Gegner, p. 52.
 
 PROTECTION AGAINST SMALL-POX. 229 
 
 sequent epidemics, eighty-six cases, twelve of which 
 were fatal.* 
 
 Data do not exist for determining in what propor- 
 tion variolated persons may afterward take small-pox. 
 The proportion will no doubt be affected by the same 
 circumstances as will hereafter be referred to (§ 92) as 
 influencing the extent to which small-pox may be taken 
 after vaccination, especially by the presence of epidemic 
 influence The calculation which was made by the 
 Societe de Medecine of Marseilles, that one per cent, 
 of the variolated portion of the population of that town 
 suffered from second small-pox during the epidemic 
 that prevailed there in 1828,f can only be taken as a 
 very rough approximation. All that is certain is, that 
 twenty cases of second small-pox, or what was held to 
 be second small-pox, were noted during a part only of 
 that outbreak. Other observations which have more 
 numerical precision have been made on special classes 
 of the community. Thus, of the 1950 boys admitted 
 into the Royal Military Asylum, Chelsea, between the 
 years 1803 and 1831, who, at the time of their admis- 
 sion, were recorded as having marks of small-pox, 
 twelve (or 615 per thousand) contracted small-pox 
 during the period of their residence at the Asylum. J 
 
 * Heim, as quoted by Simon, Papers relating, etc. (op. cit.), 
 pp. xxvii. and xxxv. 
 
 f Bousquet, Nouveau Traite", etc., p. 269. 
 
 % It is just possible that in some of these cases the marks 
 which the children exhibited on their admission might be 
 marks of chicken-pox. The distinction between such marks 
 and the marks left by small-pox, when these are few and scat- 
 tered, as they would generally be in cases of the inoculated 
 disease, is not always easy, nor even always possible : and a 
 20*
 
 230 HANDBOOK OF VACCINATION. 
 
 In answer to some inquiries which were made by the 
 Epidemiological Society of London, in 1851, of various 
 medical practitioners in the United Kingdom, as to 
 their personal protection against small-pox, thirty-two 
 who had had natural small-pox when young had none 
 of them suffered from any second attack, but of ninety- 
 five who had been inoculated, and were considered to 
 be safe, three had since contracted small-pox: and in 
 reply to a further set of inquiries on this subject, after- 
 ward more extensively distributed by the society, fifty- 
 four practitioners stated that they had had natural 
 small-pox in childhood, of whom one had suffered from 
 a second attack; two, who had been vaccinated in 
 childhood, had since had small-pox more than once; of 
 five who had had small-pox in childhood, either natu- 
 rally or by inoculation, but did not state which, none 
 had since had small-p6x; and of 219 who had been in- 
 oculated successfully, seven answered distinctly that 
 they had had small-pox at a subsequent period of their 
 lives, and six more stated that they had had small-pox, 
 but the wording of the answer was so ambiguous that 
 it was not certain whether the attack referred to was 
 that which resulted from the inoculation or was of sub- 
 sequent and independent occurrence.* These facts, so 
 far as they go, tend to the conclusion that natural 
 small-pox is more protective against a second attack 
 than the inoculated form of the disease. And it is 
 quite possible that, now that the practice of inoculation 
 
 knowledge of the history and circumstances of the first attack 
 is often necessary to make the diagnosis sure. 
 
 * Further inquiries were made on this point, but the neces- 
 sary information not elicited.
 
 PROTECTION AGAINST SMALL-POX. 231 
 
 has been so long forbidden by law, and so long discon- 
 tinued, cases of second small-pox will be less common 
 than they were during the latter part of the last and 
 the earlier part of the present century. Marson regards 
 second small-pox as very rare — more rare than my own 
 observations, or my own inquiries among my profes- 
 sional brethren, or the facts above cited would lead me 
 to consider it. Still, one per cent, of all the admissions 
 into the Small-pox Hospital are cases of second attacks 
 of the disease. In the Annual Medical Reports of the 
 Army and Navy many indisputable cases of second 
 small-pox will be found : among the small proportion 
 of the troops serving in the United Kingdom whose 
 protection against small-pox was the having already 
 had that disease, three such cases occurred in the six 
 years, 1859-64.* 
 
 89. Small-pox after Vaccination. — The lapse of a few 
 years from the promulgation of Jenner's discovery was 
 enough to bring to light cases in which vaccination 
 failed to give complete immunity from small-pox. As 
 early as 1806, the Medical Council of the Royal Jenne- 
 rian Institution stated that a few cases had been brought 
 to their notice of persons having the small-pox, though 
 generally of a mild description, who had apparently 
 passed through the cow-pox in a regular way ;f and in 
 
 * The proportion of recruits who are protected hy variola 
 is now about one-eleventh ; but some years ago, from 1846-55, 
 it exceeded one-fifth. I apprehend that scarcely any of the 
 troops now serving can have had the inoculated form of variola. 
 
 f Papers relating to the History and Practice of Vaccina- 
 tion, p. 5. The Council states also " that cases, supported by 
 evidence equally strong, have also been brought before them, 
 of persons who after having once regularly passed through the
 
 232 HANDBOOK OF VACCINATION. 
 
 the same year Willan recorded, in his most interesting 
 and useful treatise "On Vaccine Inoculation," various 
 cases in which a very trivial eruption, but of true 
 variolous character, appeared, in children who had been 
 vaccinated, at intervals which had varied from five 
 months to seven years after the performance of the 
 vaccination. The singular modification which the 
 small-pox underwent, and the harmless and insignifi- 
 cant character it usually assumed, in those protected 
 by vaccination — thus early noted — attracted much more 
 attention when, in the great epidemic of small-pox 
 which prevailed in 18 17 and the years immediately fol- 
 lowing, cases of post-vaccinal small-pox became more 
 common. It was then remarked, and the observation 
 has been confirmed by the experience of all subsequent 
 epidemics, that though some vaccinated persons may 
 contract small-pox at an early period after vaccination 
 — even, as Willan showed, within a few weeks or 
 months — post-vaccinal small-pox was met with in much 
 larger proportion among those who are grown up ; and 
 that it was exclusively among these latter that it as- 
 sumed (and even among them in only a relatively small 
 proportion of cases) a serious, and especially a fatal, 
 character. Many cases of the small-pox which mani- 
 fested itself in those who had been vaccinated were 
 clearly assignable to imperfect vaccination, but in 
 others the vaccination appeared to have been regular 
 and complete. The difference in its symptoms and 
 
 small-pox, either by inoculation or natural infection, have 
 had that disease a second time." This interesting report 
 (signed, among others, by Lettsom, Bahington, Denman, 
 and Baillie) is well worth perusal.
 
 PROTECTION AGAINST SMALL-POX. 233 
 
 course which the small-pox assumed in those who had 
 been vaccinated was so striking, that the late Dr. John 
 Thomson of Edinburgh was induced to propose for this 
 form of the disease a distinguishing name, calling it 
 "varioloid." The name, as Marson justly observes, 
 though it has been very extensively adopted, is ill 
 chosen : " The disease is not simply 'like' small-pox, as 
 the name implies; it is small-pox; it will give the dis- 
 ease in the most severe form, in the natural way, by 
 infection, to the unvaccinated, and will produce small- 
 pox by inoculation just as a case of small-pox unin- 
 fluenced by vaccination will do."* The term "modi- 
 fied small-pox," which Marson proposes to apply to all 
 the post-vaccinal cases which exhibit the characteristic 
 modification, is very much better, and will, I trust, 
 wholly supersede it. 
 
 90. Modes in which the Power of Vaccination over 
 Small-pox is manifested. — It is not solely then in the 
 way that Jenner appears to have first anticipated, 
 that the benefits of his immortal discovery are felt by 
 mankind. Nearly seventy years' use of vaccination 
 has proved beyond doubt that, "duly and efficiently 
 performed," its power of influencing small-pox is indeed 
 almost absolute, — but that it acts, not invariably by 
 preventing, but sometimes only by controlling that 
 disease. The vast majority of those who have gone 
 regularly through the vaccine process are saved thereby 
 from any future attack, however modified or slight, of 
 small-pox. In the minority, who have not been ren- 
 dered by it completely proof against the influence of 
 
 *Art. "Small-pox," System of Medicine (op. cit), vol. i. 
 p. 472.
 
 234 HANDBOOK OF VACCINATION. 
 
 the small-pox poison, the action of that virus on the 
 economy is yet so modified by it that the small-pox, as 
 a rule, is deprived of all danger to life, and does not 
 leave behind it those disfiguring traces which are not 
 the least of the terrors of unmodified variola. 
 
 (a) By conferring on the large majority of the Vac- 
 cinated complete immunity from that disease. — There 
 is certainly no subject on which medical testimony is 
 more unanimous than on the very large immunity from 
 attacks of small-pox which successful vaccination will 
 confer. While there are exceedingly few unvaccinated 
 persons who reach the average duration of human life 
 without having sustained an attack of variola, and 
 while the very great majority of such persons are at- 
 tacked by it in childhood, the vaccinated are, as a rule, 
 entirely exempt from that disease. The first question, 
 says that distinguished medical philosopher Dr. Ali- 
 son, which we have to consider, is "whether or not we 
 have at this time, in the matter of cow-pox, a power at 
 our command capable, if duly employed, of depriving 
 the poison of small-pox of all fatal influence over an 
 immense majority of mankind. And on this subject 
 there has been quite sufficient information collected, 
 since the date of the papers which were held decisive 
 of the question fifty years ago, to show that the same 
 inference is still inevitable, and that he who disputes 
 it is equally unreasonable as he who opposes, in like 
 manner, any proposition in Euclid. Of course, when 
 I say that there has been ample evidence to decide this 
 question statistically, I mean to refer to cases where 
 we have not only the negative evidence of large num- 
 bers of persons duly vaccinated not having subsequently 
 been affected with small-pox, but the positive evidence
 
 PROTECTION AGAINST SMALL-rOX. 235 
 
 of such duly vaccinated persons having been subse- 
 quently, most of them repeatedly, or for a long time 
 together, exposed to the contagion of small-pox, i.e. 
 placed in the same circumstances in which unvac- 
 cinated people have been very generally affected, and 
 many of them died of the small-pox; these vaccinated 
 persons have nevertheless escaped, most of them with- 
 out any indication of disease. To show that this is 
 the light in which I have always regarded such col- 
 lections of facts, I quote one sentence from my own 
 lectures, written as long ago as 1820-21, and repeated 
 almost every winter since then: 'You will remember 
 that the question is, not how many vaccinated persons 
 never take small-pox, but how many vaccinated persons 
 are fully exposed to the contagion of small-pox and 
 escape without any disease; and our assertion is, that, 
 so far as is yet known, absolute protection of the human 
 constitution is the rule, and the occurrence of any dis- 
 ease is the exception.'"* A vast body of evidence 
 which was collected by the Epidemiological Society, in 
 1851-2, from all parts of the kingdom and from abroad, 
 fulfilled exactly the conditions which Dr. Alison has so 
 justly pointed out as essential for proof, — evidence of 
 vaccinated persons (children or grown up) living in 
 crowded and ill-ventilated dwellings in which the small- 
 pox infection was, occupying the same rooms, and sleep- 
 ing in the same beds with small-pox cases, mothers 
 nursing their babies who were suffering from the dis- 
 ease, — all placed in circumstances in which no un vac- 
 cinated or otherwise unprotected person, or scarcely 
 any such, escaped, and yet themselves remaining en- 
 
 * Papers relating to the History, etc., p. 119.
 
 23 fi HANDBOOK OF VACCINATION. 
 
 tirely unscathed. One of the most striking proofs of 
 the protective power of vaccination is that which has 
 been repeatedly afforded by cases in which pregnant 
 vaccinated women were the means of passively con- 
 veying the variolous infection to the foetus in utoro, 
 themselves remaining entirely unaffected by it.* But 
 this general immunity of the vaccinated from small- 
 pox is such an established and admitted fact, that in a 
 professional work it would be idle to dwell upon it any 
 longer. 
 
 (b) By modifying the course of Small-pox, or other- 
 wise diminishing its danger, in those in whom the 
 protection has not been absolute. — The modifying 
 power of vaccination — its power of so altering the 
 course and character of small-pox as to concert it from 
 a disease usually severe, confluent, and in a large pro- 
 portion of cases fatal, into a disease for the most part 
 slight, unimportant, and void of danger — is equally 
 well established. The degrees in which small-pox may 
 be modified by vaccination are various, depending on 
 various circumstances, but chiefly, as we shall see pres- 
 ently, on the way in which the vaccination has been 
 done. There may be absolutely no eruption at all, the 
 disease being cut short in the stage of primary fever — 
 "febris variolosa;" or there maybe a mere efflorescence, 
 without papulation or vesiculation; or there may be a 
 few scattered vesicles ; or a full discrete eruption which 
 is semi-confluent or confluent, but yet which is modified 
 
 * See a Paper by Jenner in Medico-Chir. Trans., vol. i.; 
 Rapport de l'Acad. Roy. de Medecine, 1842; ibid. 1846. Some 
 cases of this kind were communicated to the Small-pox Com- 
 mittee of the Epidemiological Society. The same occurrence 
 has been noted in women protected by having had small-pox.
 
 PROTECTION AGAINST SMALL-POX. 
 
 23 1 
 
 in its course. Modification, indeed, does not occur in 
 all cases of post-vaccinal small-pox: in some, particu- 
 larly where the vaccination has been imperfect, the 
 small-pox is observed to run its usual course. The 
 following table will show in what proportion cases of 
 post-vaccinal small-pox were found to be modified or 
 unmodified, in the practice of the Small-pox Hospital 
 of London from 1836 to 1851 inclusive, as compared 
 with the disease when it occurred in unprotected per- 
 sons: 
 
 Per 100 Patients of 
 
 each class 
 
 respectively. 
 
 Eruption of Small-pox 
 unmodified. 
 
 Eruption of Small-pox 
 modified. 
 
 a 
 
 ■ 
 
 9 
 
 <a 
 
 a 
 
 a 
 
 = . 
 o *> 
 
 at 
 
 a 
 
 5 
 
 6-3 
 3-2 
 
 "3 
 o 
 H 
 
 a 
 
 m 
 a 
 
 a 
 
 a . 
 o - 
 o a 
 J- - 
 
 h 
 
 J 
 
 .5.2 
 .s = 
 
 "3 
 1 
 
 
 68-6 
 15-3 
 
 22-5 
 8-3 
 
 97-4 
 26-8 
 
 0-635 
 17-5 
 
 0-635 
 15-0 
 
 1-32 
 40-5 
 
 2-6 
 730 
 
 Vaccinated with 
 
 But even in a large proportion of the cases in which 
 the course of the eruption was apparently unmodified 
 by the vaccination, the controlling power of that pro- 
 cess (imperfect as the vaccination had in most instances 
 been) still manifested itself in the death-rate, which in 
 the unmodified natural cases was very nearly the dou- 
 ble of what it was in the unmodified post-vaccinal 
 cases (38 per cent, of attacks, as compared with 21 
 per cent.). In the modified cases, the death-rate 
 scarcely exceeded 1$ per cent. Hence, when the total 
 mortality arising from small-pox in the hospital in the 
 patients who were unprotected was compared with the 
 total mortality of the disease in those patients who 
 
 21
 
 238 HANDBOOK OF VACCINATION. 
 
 had any mark of vaccination (all cases of superadded 
 disease being deducted from either of the two classes), 
 it was found that in the former it was nearly seven 
 times as great as in the latter, that the death-rate of 
 natural small-pox was in fact 3555 per cent, of the 
 cases, while the death-rate of post-vaccinal small-pox. 
 was but 525 per cent.* A similar difference is met 
 wi h whenever and wherever small-pox prevails. 
 While, as has been before stated (§ 81) the mortality 
 of natural small-pox is seldom below 20 per cent, and 
 often greatly exceeds that rate,f post-vaccinal small- 
 pox, as recorded by observers who have been careful 
 no to include cases of varicella, is fatal in proportions 
 varying from 3 to 5 and 6 per cent. only.J Not to 
 dwell on a point which really does not admit of dis- 
 pute, and which will besides be abundantly illustrated 
 in the course of this chapter, it will be sufficient here 
 to state that, of 658 cases of post-vaccinal small-pox 
 
 * Marson in Medico-Chir. Trans., vol. xxxvi. 
 
 | E.g. in the Edinburgh epidemic (1818-19), 24-3 per cent.; 
 in an epidemic at Chelsea (1838-9), 27-9 per cent.; in one at 
 "Wandsworth (1844-5), 27-5 per cent.; in five epidemics at 
 Copenhagen (1824-35), 25-7 per cent.; in the practice of the 
 Gh.sgow Infirmary, 31-7 per cent. (Seaton, Protective Power 
 of Yaccin., etc., Sanitary Review, vol. ii. p. 354.) 
 
 \ The returns to the Epidemiological Society, when summed 
 up. gave the death-rate of post-vaccinal small-pox as about 3 
 (2-'J) per cent., and many of the deaths on which this rate was 
 calculated were not really from small-pox, but from super- 
 added disease. But these returns included a number of cases 
 of she post-vaccinal small-pox of childhood (almost always a 
 trivial affection). In comparing the records of different ob- 
 ser/ers with regard to the fatality of post-vaccinal small-pox, 
 this is a point that must not be overlooked.
 
 PROTECTION AGAINST SMALL-POX. 239 
 
 which occurred during the six years 1859-65, among 
 the troops stationed in the United Kingdom, thirty- 
 eight only, or 5 - 8 per cent., were fatal ; and that, in 
 observations which have particular value on account 
 of the large scale on which they were made — viz. those 
 made for twenty-one years in Bohemia, on four mil- 
 lions of people — the death-rate among vaccinated per- 
 sons who happened to contract small-pox was found to 
 be but 5 T ' g per cent., wh : le the death-rate from the 
 same disease in persons who were unprotected was 
 29 1 per cent. 
 
 91. Testimony of the Medical Profession as to the 
 Protective Power of Vaccination. — The Epidemio- 
 logical Society, in the course of the inquiry it instituted, 
 in 1851-2, into the state of small-pox and vaccination 
 in England, elicited from nearly 2000 medical practi- 
 tioners the results of their experience as to the protec- 
 tive value of vaccination. Various differences of 0] tin- 
 ion were expressed by these correspondents with regard 
 to the exact extent to which, and the time during 
 which, the successful vaccination of a person was pro- 
 tective against small-pox, some holding this protection 
 to be much more absolute and durable than others did ; 
 but there was the utmost unanimity of expression re- 
 specting the existence of the protective power, and 
 there was not a single practitioner who did not look 
 on vaccination as a practice which ought to be univer- 
 sally adopted. And when, some years later, the Medi- 
 cal Officer of the then Board of Health (now the Medical 
 Officer of the Privy Council) addressed to distinguished 
 members of the medical profession, at home and abrcad, 
 the question, " Have you any doubt that successful 
 vaccination confers on persons subject to its influence
 
 240 HANDBOOK OF VACCINATION. 
 
 a very large exemption from attacks of small-pox, and 
 almost absolute security against death by that dis- 
 ease ?" — of 542 respondents, only two expressed any 
 doubt whatever.* 
 
 92. Circumstances which influence the Protective 
 Power of Vaccination. — Various circumstances exer- 
 cise more or less of influence on the protective power 
 of vaccination. The principal of these are (a) the 
 quality of the vaccination, (b) the age of the individual, 
 (c) personal, hereditary, or family susceptibility, (d) 
 change of climate, (e) frequency and extent of expo- 
 sure to infection, (/) intensity of epidemic influence. 
 Each of these demands separate consideration. 
 
 (a) Quality of the Vaccination. — It need, one would 
 suppose, scarcely be said that no case of small-pox 
 should ever be recorded as post-vaccinal, until-the prac- 
 titioner has taken care to ascertain that the vaccination 
 has been an effectual one. My experience, however, 
 shows me that this care is by no means always taken. 
 I have repeatedly known cases of small-pox put down 
 as post-vaccinal on the mere statement of the parents 
 or the patients that " they had been vaccinated," with- 
 out any inquiry being made as to the results of the 
 operation — cases in which a few questions, subse- 
 
 * One of these gentlemen distrusted vaccination, and 
 "would gladly inoculate his own children with small-pox;" 
 according to the other, the eccentric Dr. Hamernik, of Prague, 
 neither cow-pox nor small-pox, when once passed away, has 
 any influence on future events ; and a person who has had 
 small-pox itself is no more protected thereby against future 
 attacks than he would have been by, say, an attack of measles ! 
 (Preface to Papers relating to the History, etc., p. lxxx., and 
 Papers, p. 127, seq.)
 
 PROTECTION AGAWST SMALL-POX. 241 
 
 quently put, elicited at once that the vaccination had 
 not taken effect at all. The terms "vaccination " and 
 " vaccinated," as popularly used, so frequently refer to 
 the mere performance of the operation irrespective of 
 its results,* that, in any case of small-pox in a child or 
 other person said to have been vaccinated, the practi- 
 tioner should never omit (1) to get the best information 
 he can as to what the immediate results of the opera- 
 tion were, and (2) to examine for himself the character 
 and the number of the cicatrices. The typical char- 
 acter of the cicatrix is our best available test, and it is 
 a most reliable one, of the vaccination having been 
 genuine and perfect. f 
 
 In order that persons should have from vaccination 
 the fullest protection against small-pox which it is ca- 
 pable of imparting, it is necessary that the vaccination 
 
 * This is one of the reasons of the erroneous entries respect- 
 ing vaccination frequently occurring in the Death-Registers ; 
 see postea (p. 251, note); see also ante (p. 122, and note) as 
 to another source of error, and the points for inquiry when 
 the alleged vaccination has been of recent occurrence. 
 
 f Foveated cicatrices, closely or exactly resembling the vac- 
 cine, may occasionally arise from other causes than vaccina- 
 tion ; but it is rare indeed for them to be seen on the spots on 
 which vaccination would have been performed, unless as the 
 result of that process; and though, in above 100,000 ob- 
 servations, I have met with here and there a case in which, 
 on superficial examination, I might have hesitated, I do not 
 remember one in which, by a little attention, I was not able 
 to discriminate. On the other hand, cases are more frequent 
 in which, though the vaccination has gone through a com- 
 plete and satisfactory course, the cicatrices left are, after a 
 time, indistinct or imperfect. But these cases are still quite 
 the exception, and do not affect the validity of the rule laid 
 down in the text. 
 
 21*
 
 242 HANDBOOK OF VACCINATION. 
 
 should not only be perfect in character, but that it 
 should be sufficient in amount — that the system should 
 not only be infected, but that it should be well infected. 
 By observations, of unsurpassable interest and value, 
 made for upwards of thirty years at the Small-pox 
 Hospital, it has been demonstrated that the extent to 
 which small-pox, if it should be contracted at all after 
 vaccination, is modified by the vaccination, is determ- 
 ined by the character and number of the cicatrices ; 
 that it is in the exact ratio of the excellence and com- 
 pleteness of the vaccination, as determined by these 
 tests. Persons whose vaccination has resulted in their 
 having one genuine vaccine vesicle, and one only, are, 
 as a class, much less protected than those who have 
 had two, those who have had two than those who have 
 had three, etc.; and the protection against fatal small- 
 pox which is afforded by four or more genuine vesicles 
 is almost absolute. The subjoined table, giving the 
 results of Marson's observations on nearly 5000 post- 
 vaccinal cases which occurred in the twenty years from 
 1836 to 1855 inclusive, will show, at a glance, the in- 
 fluence exercised on the course of small-pox by the 
 character and number of the vaccine marks :* 
 
 Classification of Patients Number of Deaths 
 
 affected with Small-pox. per cent, in each 
 
 class respectively. 
 
 1. Unvaccinated 35 
 
 2. Stated to have been vaccinated, but having 
 
 no cicatrix 23-57 
 
 * Art. "Small-pox," in System of Medicine, ed. by J. R. 
 Reynolds, M.D., vol. i. pp. 448 and 473. The death-rate 
 among those having previously had small-pox is not given in 
 this Article, but is taken from Marson's Paper in Medico- 
 Chir. Trans., vol. xxxvi.
 
 PROTECTION AGAINST SMALL-POJT. 243 
 
 3. Vaccinated — 
 
 a. Having one vaccine cicatrix 7-73 
 
 b. Having two vaccine cicatrices 4-70 
 
 c. Having three vaccine cicatrices 1*95 
 
 d. Having four or more vaccine cicatrices 055 
 
 a. Having well-marked cicatrices 2-52 
 
 /3. Having badly-marked cicatrices 8-82 
 
 4. Having previously had small-pox 19 
 
 It is in the classes which had only one or two cica- 
 trices that the influence of character of the cicatrix 
 was most remarkably seen. In those who had one 
 cicatrix only, if this cicatrix were thoroughly well 
 marked, the death-rate per cent, was 3 83; but among 
 cases in which the single cicatrix was badly marked, 
 the death-rate was 11*91 per cent. And while among 
 cases which had two well-marked cicatrices the death- 
 rate per cent, was 2 32, among cases which had two 
 badly-marked cicatrices the rate was 8 34. 
 
 It is probable that a modification of Marson's observ- 
 ations which should have taken into account the area, 
 as well as the number of the cicatrices, would have 
 told still more for character as distinguished from mere 
 number of marks. No size of cicatrix will convert a 
 bad one into a good one, nor is any kind of mark to be 
 more distrusted than a large one, if it be smooth and 
 irregular : but, on the other hand, it is impossible that 
 two cicatrices of typical character 
 like these should represent the /*^Tt\ /*»*» / *>\ 
 same amount of local effect, or \^f¥) [#Y/*j>'*l 
 that it can make any difference \5/ V^VV 
 whether the two or three vesicles ^■""^ 
 
 which must have combined to produce the larger of 
 these marks, should have been produced together on 
 one spot of the skin, or singly on two spots.
 
 244 HANDBOOK OF VACCINATION. 
 
 Recurring, however, to Marson's observations as 
 they stand, we see at once that the statement pre- 
 viously made, that in the Small-pox Hospital post- 
 vaccinal small-pox was fatal in from five to six per 
 cent, of the cases that occurred, requires a great deal 
 of qualification. It is true in the gross, if we take 
 good and bad vaccination together, but in the gross 
 only. It represents much too favorably the results of 
 bad vaccination, and much too unfavorably the results 
 of good vaccination. Let an unvaccinated person con- 
 tract small-pox, and the chances are more than one in 
 three that he dies ; let a very badly vaccinated person 
 (a person with one imperfect cicatrix) contract small- 
 pox, and the chances are not quite one in eight that he 
 dies ; let a person with two good vaccine cicatrices 
 have small-pox, and his chances of dying are less than 
 one in forty ; but persons who have been vaccinated 
 in the best and most complete way will, if they ever 
 get small-pox afterward, not die of it at the rate of 
 much more than one in two hundred. The small-pox 
 death-risks of no-vaccination are to the death-risks 
 of the very worst vaccination as three to one, to the 
 death-risks of the best vaccination as seventy to one ; 
 and a well-vaccinated person has not one-twentieth 
 part the risk of dying of small-pox that a badly vac- 
 cinated person has. Nor is the death-risk the only 
 thing to be taken into account in estimating the differ- 
 ence between good and bad vaccination ; there is also 
 to be considered the difference in the amount of suffer- 
 ing and in the risk of disfigurement. 
 
 "Small-pox after vaccination," says Marson, "has, 
 in fact, various degrees of severity and modification: 
 from the slightest form, in which there is none, or
 
 PROTECTION AGAINST SMALL-POX. 245 
 
 hardly any eruption at all, to the most severe conflu- 
 ent cases, closely, almost exactly, resembling the dis- 
 ease in the unvaccinated ; and it also assumes the pe- 
 techial and malignant types after vaccination, just as 
 in the unvaccinated state. All this depends in a great 
 measure on the way in which patients have been vac- 
 cinated. Those who have been fortunate enough to 
 have been vaccinated in four or more places with 
 lymph that leaves good, easily perceptible cicatrices, 
 have almost invariably a slight form of small-pox when 
 it occurs; but those who have only one or two marks 
 from vaccination, such as are hardly visible, will prob- 
 ably have a severe form of the disease ; and those who 
 have no marks at all are in still worse circumstances. 
 Now, although this rule holds good generally, almost 
 invariably, still it is not an invariable rule; and per- 
 haps more exceptions will be found — we may say, will 
 certainly be found — in those who have been indiffer- 
 ently vaccinated, than in those who have been well 
 vaccinated. Persons seemingly indifferently vaccinated 
 will oftener afterward have a light form of small-pox 
 than well-vaccinated persons will have a severe form 
 of the disease. So far it is fortunate. But what we 
 contend for, and always have contended for, is that, if 
 possible, all should be vaccinated in the best way ; at 
 least the attempt should be made to vaccinate all in 
 the best way, that there should be as little as possible 
 of haphazard vaccination, done with a view that if the 
 operation takes effect badly it can be done again. By 
 such a proceeding persons often take vaccination badly, 
 and cannot be made to take it properly afterward ; the 
 imperfect success prevents its taking fully again, and 
 yet some day they may take small-pox severely, and
 
 246 HANDBOOK OF VACCINATION. 
 
 perhaps die of it. Every effort should, therefore, be 
 made that there may be as few imperfect vaccinations 
 as possible."* 
 
 The necessity of thoroughly infecting the system in 
 vaccinating had been inculcated by many before Marsort. 
 But it is to him that we owe the complete demonstra- 
 tion of this necessity ; and the importance of his labors 
 it is impossible to exaggerate. It is a thing to be 
 thankful for, that the resources of the Small-pox 
 Hospital — the only field of observation, I think, in 
 which any inquiry of this kind could ever have been 
 carried to such a complete demonstration — should have 
 fallen to hands so competent to turn them to account. 
 And, now that the fact is established, it is not too much 
 to affirm, that no practitioner will have done his duty 
 in any case in which he is called upon to vaccinate, 
 unless, besides taking all requisite precautions with re- 
 gard to the genuineness of the lymph he employs, and 
 the means of insuring success, he has also taken care 
 to vaccinate sufficiently, i.e. to produce, so far as in 
 him lies, four or five genuine good-sized vesicles, such 
 as result from separate punctures ; or if vaccinating 
 otherwise than by separate puncture, to produce equiva- 
 lent local results. 
 
 Whether the amount of local effect produced in vac- 
 cinating has the same relative influence in altogether 
 preventing the occurrence of small-pox afterward, that 
 it has been proved to have in modifying the character 
 of the small-pox if it should be contracted — whether 
 persons with four good cicatrices are more able to re- 
 sist any action of the variolous infection, than persons 
 
 * Art. "Small-pox" (op. cit.), p. 472.
 
 PROTECTION AGAINST SMALL-POX. 247 
 
 with only one good cicatrix — there are not facts suffi- 
 ciently numerous and precise to determine. Analogy 
 would lead us to believe that it must be so: and facts, 
 so far as they go, tend to confirm the belief. An 
 attempt was made in 1851-2, by the Epidemiological 
 Society, to throw some light on this question by in- 
 quiring of medical practitioners as to the marks they 
 personally had of vaccination, and as to their having 
 suffered or not from any form of variola subsequently. 
 But the replies given were too few in number, and, in 
 some instances, too vague in their information, to justify 
 any positive conclusion being drawn. Out of 347 
 practitioners who stated that they had been vaccinated 
 in childhood, 44, or 126 per cent., said that they had 
 subsequently contracted some, generally the most- 
 modilied form of variola ; but these included some cases 
 in which the variola, as it was called, had been a mere 
 local affection taken by inoculation from small-pox 
 corpses in the dissecting-room. Some of the 347 prac- 
 titioners had no cicatrix of their vaccination ; in others 
 the cicatrices were imperfect, or were only one or two 
 in number : but 57 of them had three or more good 
 vaccine marks ; and of these 57, only two, or 35 per 
 cent., had had subsequently any form of variola.* In 
 1863, during the epidemic of small-pox then raging in 
 London, Dr. Buchanan and I, in the course of an ex- 
 amination of upwards of 50,000 children in national 
 and infant schools, workhouses, etc., with the view of 
 ascertaining what proportion were unvaccinated, what 
 
 * Seaton on the Protective Powers ofVaccination (op. cit.), 
 p. 351. It deserves note that this proportion very closely cor- 
 responds with the proportion in which those who were pro- 
 tected by variolous inoculation had small-pox afterward.
 
 248 
 
 HANDBOOK OF VACCINATION. 
 
 proportion had been vaccinated, and how, among these 
 latter, the vaccination had been done, took occasion 
 also to note how far the children, in each of these classes 
 respectively, had marks of small-pox. Forms of variola 
 which any of the children might have had, which left 
 no traces whatever behind, we were obliged to leave 
 out of account, because, unless we had carried our in- 
 quiries to the homes of the children, it would have 
 been impossible to ascertain precisely the number of 
 such cases. They had been comparatively very few : 
 but among the vaccinated children there had been 
 some. Hence the investigation did not give us exactly 
 the information we had been desirous to obtain as to 
 the relative effect of different kinds of vaccination in 
 absolutely preventing any manifestation of the action 
 of the variolous poison — the totally preventive, as dis- 
 tinguished from the modifying power. But it brought 
 out very strongly the different degrees in which differ- 
 ent kinds of vaccination control small-pox. The 
 following: were the results of our observations : 
 
 Classification of Children. 
 
 Number 
 examined of 
 each class. 
 
 Number in 
 each class 
 that had 
 traces of 
 Small-pox. 
 
 Proportion 
 having traces 
 of Small-pox, 
 
 per 1000 
 
 children, in 
 
 each class 
 
 respectively. 
 
 1. Without any mark of 
 vaccination 
 
 2,837 
 
 508 
 
 49,570 
 
 1,010 
 30 
 
 88 
 
 360 
 59 
 
 1-78 
 
 2. With doubtful mark 
 
 of vaccination. 
 %3. With mark or marks 
 
 And, on further classification of the vaccinated chil-
 
 PROTECTION AGAINST SMALL-POX. 249 
 
 dren with reference to the kind of vaccination, the re- 
 sults were these: 
 
 Proportion having 
 Marks of Smnll- 
 Classification of Vaccinated Children. pox. p r KKH) 
 
 children, in each 
 class respectively. 
 
 a. Having one vaccine cicatrix 680 
 
 b. Having two vaccine cicatrices 2-49 
 
 c. Having three vaccine cicatrices 1-42 
 
 d. Having four or more vaccine cicatrices 0-67 
 
 a. Having cicatrix or cicatrices of bad quality... 7 -60 
 /3. Having cicatrix or cicatrices of tolerable 
 
 quality 235 
 
 y. Having cicatrix or cicatrices of excellent 
 
 quality 122 
 
 The extremes were represented by children having 
 four or more vaccine marks of perfect character, of 
 whom only 062 per 1000 had a trace of small-pox, 
 and children having a single vaccine mark of bad 
 quality, of whom we found 19 per 1000 with marks of 
 small-pox. But these numerical statements by no 
 means bring out the whole difference that existed be- 
 tween the vaccinated and the unvaccinated, or between 
 the well vaccinated and the ill vaccinated. For the 
 marks which small-pox had left on most of the vaccin- 
 ated children, and particularly on the well vaccinated, 
 were very slight — such as without some care might 
 have passed undetected — and in only exceptional cases 
 were in the least disfiguring : while of the unvaccinated, 
 a very large proportion were seriously marked and 
 disfigured, some being really hideous to look at, and 
 several suffering from permanent blindness and deaf- 
 ness, the consequences of the small-pox. 
 
 It has often occurred to me that probably the re- 
 turns of the army, in which service, no doubt, both 
 22
 
 250 HANDBOOK OF VACCINATION. 
 
 the character and number of the vaccine marks pre- 
 sented by each recruit on entering are exactly re- 
 corded, may eventually give us data for determining 
 precisely to what extent the amount of vaccination 
 imparted to individuals determines their relative sub- 
 sequent immunity from any degree of action of the 
 variolous poison. 
 
 (b) Age. — It is a mistake to suppose that post- vac- 
 cinal small-pox may not take place in early childhood, 
 or within a comparatively short period from vaccina- 
 tion. In those in whom that process has not com- 
 pletely exhausted the susceptibility to variola, the 
 modified effects of the variolous infection may manifest 
 themselves at any period — even, as Willan showed, 
 within a few weeks or months of the vaccination.* In 
 the returns made to the Epidemiological Society, in 
 1852, many cases of post- vaccinal small-pox in chil- 
 dren under ten years of age, were included — occurring 
 at various intervals after the vaccination. But the 
 modified small-pox of young children is generally a 
 very trivial affection, . and of the light varicelloid form. 
 In some cases it is not indeed the disease, small-pox, 
 at all, but a mere local affection, without the usual pre- 
 monitory symptoms of small-pox, resulting from inocu- 
 lation by sleeping with, or playing with children infected 
 with the disease. In others, when it arises from infec- 
 tion, there may, probably, with severe premonitory 
 symptoms, be half a dozen, or a dozen, or two or three 
 dozen pustules only, running a modified course : or the 
 eruption may, in some cases, be more copious but still 
 modified. And severe cases at this early period of life 
 
 * Willan on Vaccine Inoculation.
 
 PROTECTION AGAINST SMALL-POX. 251 
 
 are very rare. " We have satisfactory evidence," says 
 Dr. Gregory, "that under fifteen years of age, the 
 deaths by small-pox, after vaccination, are scarcely no- 
 ticeable;"* and Marson, also, speaking from his une- 
 qualed experience, tells us that among children under 
 14 years of age, who have been vaccinated, small-pox 
 hardly ever proves fatal. f After the change of sys- 
 tem which takes place at puberty, not only is post-vac- 
 cinal small-pox of more frequent occurrence, but the 
 disease, though still in the immense majority of cases 
 
 * As quoted by Simon, op. cit., p. lxix. 
 
 f Petition to the House of Commons in Papers relating to 
 the History, etc. (op. cit.), p. 25. Exceptions to this rule are 
 often more apparent than real — death, when it does occur, 
 being due, not to small-pox, but to some concurrent or super- 
 added disease. I may notice that the not infrequent entries in 
 our death-registers of death from " small-pox after vaccina- 
 tion," in young children of all ages, often when only one, two, 
 three, four years old, are almost invariably incorrect and mis- 
 leading. Some years ago, on personal investigation of a num- 
 ber of these entries, with a view to ascertain their real value, 
 I found that in every case included in my inquiry, except one, 
 either (1) there had been no attempt at vaccination, the parent 
 having given a false answer to the Registrar's question, under 
 fear that he should be subjected to penalty if he gave the true 
 one; or (2) that vaccination had been indeed attempted, but 
 had never taken effect ; or (3) that the vaccination had been 
 performed while the patient was incubating small-pox. One 
 child only, between 11 and 12 years of age, whom the mother 
 stated to have been successfully vaccinated when an infant, 
 and to have retained a mark on the arm, appeared to have 
 died of the hemorrhagic form of small-pox. As the child 
 was buried I had no opportunity of seeing the mark, and the 
 doctor who attended the case had never thought of looking 
 at it.
 
 252 HANDBOOK OF VACCINATION. 
 
 light and modified, runs in some cases a severer 
 modified, and in some an unmodified, course — de- 
 pending chiefly, as has been seen in the preceding 
 subsection, on the quality of the vaccination. The 
 table given at page 237, showing the different forms in 
 which post-vaccinal small-pox manifested itself at the 
 Small-pox Hospital, may bo taken as referring substan- 
 tially to cases after puberty, the post-vaccinal cases 
 received for treatment in the hospital before that 
 period of life being comparatively very few.* This 
 much more frequent occurrence of severe post-vaccinal 
 small-pox in persons who are grown up than in chil- 
 dren, has been held by some to give countenance to the 
 hypothesis that the influence of vaccination in the in- 
 dividual is but temporary, that it diminishes by lapse 
 of time, and tends gradually to wear out:f and there 
 have been all sorts of arbitrary assumptions that vac- 
 cination holds good for seven years, or for ten years, 
 or for fourteen years, etc. Dr. Gregory pointed out, 
 upwards of thirty years ago, that no real grounds had 
 ever been shown for the doctrine thus propounded, and 
 
 * There are obvious reasons why young children affected 
 with small-pox, especially if the disease be not severe, would 
 be treated at home rather than sent to a hospital ; still, in the 
 years which the return includes (1836-51), a great number of 
 unprotected young children were admitted. 
 
 f The hypothesis itself dates from the earliest days of vac- 
 cination, before there could be facts to establish it. The same 
 hypothesis had been advanced with regard to variolous inocu- 
 lation, by the opponents of that practice. Jenner had an- 
 swered it, as regards cow-pox, by anticipation in his "In- 
 quiry," showing that milkers who had contracted the cow-»pox 
 thirty or forty years before were as safe as those recently 
 infected.
 
 PROTECTION AGAINST SMALL-POX. 253 
 
 the facts that have since accumulated satisfactorily 
 prove that it is not in this way that the greater fre- 
 quency and severity of small-pox in vaccinated per- 
 sons after puberty than in childhood is to be explained. 
 For, if the influence leading to this result consisted in 
 a mere wearing out of the protection by lapse of time, 
 it would be steadily progressive, and in observations 
 on large masses of vaccinated populations at different 
 ages, we should find the liability to small-pox becoming 
 greater, the greater the age, or the longer the time that 
 had elapsed since the performance of the vaccination. 
 But that this is not the case is shown by observations 
 made for a long series of years on the troops of the 
 British army serving in the United Kingdom ; for 
 while the deaths from small-pox among every 10,000 
 soldiers serving under twenty years of age, were 3 4, 
 and among every 10,000 soldiers, from twenty to 
 twenty-five years old, were 31, the deaths from this 
 cause among soldiers above twenty-five years of age 
 were but 1 per 10,000.* In like manner, the great 
 bulk of admissions of cases of post-vaccinal small-pox 
 into the London Small-pox Hospital is found to take 
 place between the ages of fifteen and twenty-five : after 
 the age of twenty-five there is a remarkable diminu- 
 tion, j - And, correspondingly, observations which were 
 collected by Heim of 1055 cases of small-pox in vac- 
 cinated persons, with special reference, not so much to 
 the age of the individuals, as to the number of years 
 that had elapsed since the vaccination, showed that 
 
 * T. G. Balfour, on the Protection against Small-pox afforded 
 by Vaccination, in Medico-Chir. Trans., vol. xxxv. 
 f Marson in Medico-Chir. Trans., vol. xxxvi. table v. 
 22*
 
 254 HANDBOOK OF VACCINATION. 
 
 while the average annual number of cases in the first 
 twelve years after vaccination was twelve, and in the 
 next thirteen years was over fifty-one, the average for 
 the following ten years was under twenty-five. The 
 facts find their best explanation, as Dr. Gregory sug- 
 gested, in the disturbing influence of puberty, and they 
 point to the importance of renewing the vaccine pro- 
 cess after that change has taken place. 
 
 (c) Personal, Hereditary, or Family tendency. — 
 Some persons appear to be peculiarly susceptible of the 
 action of the variolous poison. I have alluded before 
 to recorded cases of persons having small-pox three 
 times and oftener. A friend of my own, one of the 
 most careful and observant of practitioners, saw a case 
 of small-pox in a vaccinated person, and saw this 
 attack succeeded after an interval of years by another 
 attack : and I have been furnished with notes of a case 
 of a naval officer who was vaccinated in infancy, got 
 confluent small-pox in South America, and had another 
 confluent attack afterward at Bath. One vaccinated 
 medical practitioner of my acquaintance gave, on each 
 epidemic of variola to which he had been exposed, some 
 manifestation of the action on his system of the vario- 
 lous poison, though once it amounted only to an efflo- 
 rescence following on the premonitory symptoms, and 
 once was altogether limited to the premonitory symp- 
 toms. But the misfortune is, that we have no outward 
 signs whereby to recognize beforehand these particu- 
 larly disposed individuals. If a dozen children be 
 vaccinated, and the vaccination go through its course 
 regularly in all, we know for certain that nine, ten, or 
 eleven of them will be safe for life against any assault 
 of small-pox, while possibly in one, two, or three the
 
 PROTECTION AGAINST SMALL-POX. 255 
 
 susceptibility to some degree of future action of the 
 variolous infection may remain : but there is nothing to 
 tell us beforehand which are the permanently and com- 
 pletely, and which the less completely, protected. One 
 thing, however, which would lead us to anticipate a 
 special liability to post-vaccinal small-pox, would be 
 the previous occurrence of such an event in more than 
 one member of the family. There can be no doubt 
 that the variolous diathesis exists more in some fami- 
 lies than in others. Dr. Kendrick of Warrington, in an 
 account of 434 cases of post-vaccinal small-pox with 
 which he favored the Epidemiological Society, noted 
 that 276 of these were single cases, no other members 
 of the family being attacked, but that there were 37 
 families which had 2 cases, 13 which had 3, 7 which 
 had 4, 2 which had 5, and 1 which had 7 cases ; and in 
 a similar communication of 125 cases of post-vaccinal 
 small-pox, Mr. Grove, of Wandsworth, related that 28 
 only were single cases, there being 14 families which 
 had 2, 10 which had 3, 7 which had 4, 1 which had 5, 
 and 1 which had 6 cases.* Mr. Marshall has recorded 
 the circumstance of twelve brothers and sisters, of ages 
 varying from five to twenty-four years, all of whom had 
 been vaccinated when infants, being all attacked to- 
 gether, during an epidemic of small pox, with the 
 mildest and most modified form of that disease ; the 
 father and mother also sustaining a mild attack, though 
 the former had been twice vaccinated with effect, and 
 
 * Of course, in the different families inquired into, whether 
 by Dr. Kendrick or Mr. Grove, there were differences in the 
 degrees of exposure to infection, some persons being much 
 more careful as to isolation, etc. than others, but this did not 
 explain the whole difference.
 
 256 HANDBOOK OF VACCINATION. 
 
 the latter had had small-pox when she was five years 
 old ; the only person in the family who escaped was 
 the grandfather, who was seventy-eight years old, and 
 who had been vaccinated at the age of forty-eight. He 
 also states that during the same epidemic in which he 
 witnessed this occurrence, he attended no fewer than 
 five cases of second small-pox, four of which were in 
 two branches of the same family.* Simon relates a 
 case, communicated to him, of three brothers, vaccin- 
 ated in infancy, who all contracted small-pox subse- 
 quently, one by infection from without and the other 
 two by infection from him, when their ages were re- 
 spectively thirteen, eleven, and seven years, and who 
 all had a further attack some years afterward. He 
 gives, on the authority of Dr. Arnott, a case of post- 
 vaccinal confluent small-pox, in a patient whose father 
 had had small-pox twice, and an uncle three times, 
 another uncle having died from a first attack of the 
 disease ; and he refers to an instance of three brothers 
 and sisters having post-vaccinal small pox, one of 
 them once, another twice, and the other three times, 
 the third attack in the last proving fatal. f 
 
 Medical friends have, on various occasions, informed 
 me of cases — especially during the severe epidemic of 
 small-pox which has prevailed since 1863 — in which, 
 while some members of families were suffering from 
 post-vaccinal small-pox, some other member of the 
 family, who had had small-pox before, by inoculation 
 
 * Mr. Marshall in Lancet, vol. xxxvi. 
 
 f Simon, Preface to Papers relating, etc. (op. cit.), p. xxx. 
 The last case is reported by Dr. Webster in the Lancet, vol. i. 
 for 1861, p. 271.
 
 PROTECTION AGAINST SMALL-POX. 257 
 
 or otherwise, had been again affected with that disease. 
 And several instances have come to my knowledge in 
 which brothers vaccinated in infancy have each soon 
 after puberty had post-vaccinal small-pox. 
 
 (d) Change of Climate. — The protection which vac- 
 cination gives against small-pox is seen in all races of 
 mankind, and in all climates (§ 94) ; but change from 
 one climate to another, when that change involves 
 considerable variation of temperature, would seem to 
 render vaccinated persons in many instances more 
 susceptible of small-pox. It is certainly often noted 
 that persons get that disease soon after passing from 
 a temperate to a tropical or a very hot region — as from 
 England to India — or vice versa, especially when the 
 cicatrices are not very well marked. The influence of 
 climatic change is evident, I think — though it is impos- 
 sible to separate it from the influence of other, and no 
 doubt more powerful, causes (especially those to be 
 noticed in the next subsection) — in the much more 
 frequent occurrence of small-pox among our soldiers 
 employed in China, and among our sailors serving in 
 China and Japan, than in any other section of the 
 British army and navy. While the small-pox cases in 
 the entire British navy, during the six years 1859-64, 
 were but 4 2 per 1000 of the mean force ; and on the 
 whole force, if we except the East India and China 
 squadron* were but 31 per 1000, the cases in that 
 
 * By an alteration which took place early in 1864, the East 
 Indies were detached from the China station and added to the 
 Cape of Good Hope command. But " the force employed in 
 the East Indies had always been so very small that, practi- 
 cally, its withdrawal from one station and its addition to the
 
 258 HANDBOOK OF VACCINATION. 
 
 squadron exceeded 13 per 1000.* And during the same 
 six years, while the cases of small-pox among the 
 troops serving in the United Kingdom were less than 
 one and a half per 1000, they amounted among the 
 white troops in China to nearly 6 per 1000.f The 
 black troops in China suffered very little from small- 
 pox, the ratio of small-pox cases among them having 
 during the six years been considerably less than one 
 per 1000 of the force. This arose mainly from differ- 
 ence of stationing, exposing them much less than the 
 whites to the infection of that disease, especially dur- 
 ing the epidemic year of 1862, which year alone sup- 
 plied about half the total number of the cases that 
 
 other has had little or no effect, in a statistical point of view, 
 on the returns of either." (Statistical Report of Health of 
 Navy for 1864.) 
 
 * The difference is probahly not so great as these numbers 
 would show, because some of the cases of small-pox, both at 
 home and abroad, occurred in individuals not vaccinated, and 
 it is fairly presumable that, in the event of men joining who 
 were unprotected, there would be more difficulty in getting 
 vaccination done on the China station than on the Home or 
 many other stations. The navy is not, as regards small-pox, 
 an entirely protected force. The admirable statistical returns, 
 yearly published, frequently mention, in cases of small-pox, 
 that the persons had not been vaccinated. But unfortunately 
 the surgeons of a very large number of ships, in their returns 
 of small-pox cases, omit to give any definite and reliable in- 
 formation with regard to vaccination. 
 
 f The soldiers both in the United Kingdom and in China 
 were an entirely protected force. The cases of small-pox in 
 China in the six years were 135 ; all the. individuals attacked 
 had marks of vaccination except two, and these had marks of 
 former small-pox. One of these two died.
 
 PROTECTION AGAINST SMALL-POX. 259 
 
 occurred in the entire force during the whole period. 
 But climatic change had probably, too, its influence : 
 for the general health of the black troops was much 
 less affected by the change of climate than that of the 
 whites. 
 
 But change of climate has probably a much greater 
 and more decided effect in influencing the course 
 and character of post-vaccinal small-pox, if con- 
 tracted, than in disposing the system to contract it. 
 Of 658 cases of post-vaccinal small-pox among the 
 troops in the United Kingdom, from 1859 to 1864, 38 
 were fatal, of 5 8 per cent ; but of 614 cases of small- 
 pox among the troops in India, from 1860 to 1864, 90 
 were fatal, or 14*6 per cent.; and of the 133 post-vac- 
 cinal cases in the China force, from 1859 to 1864, 20 
 were fatal, or 15 per cent.* 
 
 The influence of change of climate in disposing to 
 small-pox is noticeable in persons protected by variolous 
 inoculation, or by previous natural small-pox, as well 
 as in the vaccinated. In them, also, Marson tells us, 
 the disposition to contract the disease a second time is 
 promoted by any great climatic change, whether from 
 a hotter to a colder, or from a colder to a hotter 
 region, f 
 
 (e) Frequency and Extent of Exposure to the Vari- 
 olous Infection. — The influence which these must ex- 
 ercise is obvious. Whatever the protection or non- 
 protection of individuals, they cannot contract variola, 
 
 * Specific information on the quality and amount of the vac- 
 cination in these cases would have been most important : but 
 the facts in the text point to the extreme necessity of renew- 
 ing the vaccine protection after great climatic change. 
 
 f Art "Small-pox" (op. cit.), p. 452.
 
 200 HANDBOOK OF VACCINATION. 
 
 unless they come in contact with its specific cause. 
 Hence, our soldiers and sailors employed on various 
 foreign stations, from which small-pox is sometimes 
 absent for long periods together, suffer much less 
 from that disease than those who are employed at 
 home, who are mostly quartered in, or stationed near, 
 large towns, where the infection of small-pox is often 
 prevailing. In Australia and New Zealand, no case 
 of small-pox has occurred, either in the army or navy, 
 for a long series of years. Again, also, where small- 
 pox is present, the degrees of exposure may vary infi- 
 nitely. , 
 
 The Registrar-General for Scotland, in his annual 
 reports, classifies the small-pox mortality of that king- 
 dom in a way which gives a good general illustration 
 of the effect of frequency of exposure to the variolous 
 contagion. He compares each year the small-pox 
 deaths occurring among the population dwelling in 
 the islands of Scotland, in the rural districts of the 
 mainland of Scotland, including small towns and vil- 
 lages, and in the towns of 10,000 inhabitants or more. 
 The following table, which I have compiled from these 
 reports, shows the results for ten years, per 100,000 
 of the population, in each class of the district:
 
 PROTECTION AGAINST SMALL-POX. 
 
 261 
 
 Year. 
 
 1855... 
 1856... 
 1857... 
 1858... 
 1859... 
 1860... 
 1861... 
 1862... 
 1863... 
 1864... 
 
 Totals 
 
 Small-pox Deaths per 100,000, living 
 
 In Insular 
 Districts. 
 
 In Rnral 
 Districts and 
 Small Towns. 
 
 In Towns of 
 10,000 In- 
 habitants 
 or more. 
 
 17 
 
 34 
 
 75 
 
 11 
 
 26 
 
 84 
 
 16 
 
 11 
 
 61 
 
 6 
 
 8 
 
 17 
 
 5 
 
 10 
 
 46 
 
 21 
 
 33 
 
 83 
 
 4 
 
 16 
 
 44 
 
 1 
 
 6 
 
 27 
 
 10 
 
 37 
 
 87 
 
 19 
 
 48 
 
 78 
 
 110 
 
 229 
 
 602 
 
 There is no reason whatever for supposing that the 
 insular and rural districts are better vaccinated than 
 the large towns : the probability is that it is just the 
 reverse. Their small relative mortality from small-pox 
 is due to their being much less exposed to the infection. 
 In the large towns of England, it is a matter of daily 
 observation that much of the small-pox met with occurs 
 in unvaccinated persons who have immigrated from 
 rural districts. 
 
 Extent of exposure to the small-pox infection is of 
 no less consequence than frequency of exposure. The 
 degree may vary from the merest chance contact with 
 an infected person or thing, to the occupying the same 
 house, room, or bed, with a variolous patient. Inter- 
 esting inquiries have at times been made, as to the 
 23
 
 262 
 
 HANDBOOK OF VACCINATION. 
 
 protection which vaccination afforded to persons ex- 
 posed to the small-pox infection in the utmost degree. 
 Mr. Cross, of Norwich, during a severe epidemic of 
 small-pox which prevailed in that city in 1819, noted 
 what took place in 112 families, in which he had, be- 
 tween the months of March and August, attended 
 above 200 cases of small-pox, there being at least one 
 case in each family. The following are the results of 
 his observations, reduced to a tabular form : 
 
 Protection or non-protection of 
 Individuals. 
 
 Number of 
 Persons. 
 
 Cases of 
 Small-pox. 
 
 Death s from 
 Small-pox. 
 
 1. Protected by former 
 
 297 
 
 91 
 215 
 
 
 
 2. Protected by Vac- 
 
 2 
 200 
 
 
 3. Unprotected 
 
 46 
 
 
 Totals in the 112 in- 
 fected households 
 
 603 
 
 202 
 
 46 
 
 The 91 vaccinated persons were continually in the 
 same rooms, and many of them occupied the same beds, 
 with variolous patients, and the only two individuals 
 among them who took the small-pox had it in its 
 most modified form. At the time the epidemic was at 
 its height, Mr. Cross extended his inquiries to families 
 in parts of the town with which he was little ac- 
 quainted, and found that, "in 31 families, those who 
 had had cow-pox were living in the same room, or lying 
 in the same bed, with others suffering or dying from 
 natural small-pox, yet remained perfectly safe, with 
 the exception "only of one child, whose mother reported 
 that it had ten pustules." In the whole inquiry It
 
 PR TECTION A GAINST SMA LIs-POX. 263 
 
 families were met with in which the vaccinated lived 
 in the same room with small-pox : and not one indi- 
 vidual among them had any serious disease, and not 
 above one in thirty had any eruptive disease at all.* 
 In 1838-9, Mr. Marshall, of Chelsea, made inquiries 
 respecting 757 persons, who during an epidemic of 
 small-pox which then prevailed in that parish had been 
 exposed in an excessive degree to the contagion, inas- 
 much as they were all members of infected families, 
 and a large proportion of them had occupied the same 
 rooms with the small-pox cases. Of the 757 persons, 
 231 were stated to have been vaccinated, and, of these, 
 27 had suffered from small-pox in some form during 
 the epidemic. Of the remaining 526, Mr. Marshall 
 does not state how many were protected by previous 
 small-pox, or were without protection : but he tells us 
 that of those who were unprotected only 7 escaped 
 attack during this outbreak. There were among the 
 526 individuals fourteen alleged cases of second small- 
 pox, the character of the attack in these, as compared 
 with the post-vaccinal cases, being as follows : 
 
 * Cross, A History of the Variolous Epidemic which pre- 
 vailed in Norwich, etc. 8vo. Lond. 1820. A very interesting 
 and valuable work. In all the cases in which vaccination had 
 been performed, Mr. Cross examined the cicatrices. During 
 the epidemic, several hundreds of persons vaccinated, at times 
 varying from the earliest period of the practice to within a 
 few weeks, were tested by variolous inoculation, without the 
 production in any instance of the regular small-pox.
 
 264 HANDBOOK OF VACCINATION. 
 
 Second Small-pox. Post-vaccinal Small-pox. 
 
 Mild cases 7 Mild cases, unattended 
 
 Severe cases, but recov- with fever, with a few 
 
 erod 4 isolated pustules, vary- 
 
 Severe cases, fatal 3 ing in number from 2 
 
 — to 70 22 
 
 14 Modified, attended with 
 constitutional disturb- 
 ance, but recovered... 4 
 Fatal 1 
 
 27 
 
 The number of alleged cases of second small-pox is 
 so extraordinary, that we can hardly suppose but that 
 there must have been some error of statement to Mr. 
 Marshall with regard to some of them. Five, how- 
 ever, passed under his own observation, four of these 
 being, as already stated (p. 255), in two branches of 
 the same family.* Dr. Paine, of Cardiff, during a 
 most severe epidemic of small-pox which prevailed in 
 that town in 1857, made inquiry respecting 1722 per- 
 sons living in four streets in which the disease partic- 
 ularly prevailed. Of these persons 1011 were adults, 
 of whom only 8 contracted small-pox, and 711 were 
 children, of whom 88 contracted small-pox. And re- 
 specting the children, the following further particulars 
 were made out : 
 
 * Lancet, vol. xxxvi.
 
 PROTECTION AGAINST SMALL-POX. 
 
 265 
 
 Protection or non-protection 
 of Individuals. 
 
 Nnmber of 
 Children. 
 
 Case* of 
 Small-pox. 
 
 Proportion 
 per cent, 
 infected. 
 
 1. Protected by former 
 
 small-pox 
 
 2. Protected by Vaccin- 
 
 33 
 608 
 
 70 
 
 
 
 18 
 70 
 
 2-96 
 100 
 
 
 
 The vaccinated children, in many instances, occupied 
 the same rooms, and frequently the same beds, with 
 small-pox cases; and in every one of the 18 among 
 them, who were in any degree infected, the disease 
 was exceedingly modified.* 
 
 Probably the extreme of closeness and constancy of 
 exposure is to be found on board an infected ship ; for 
 (1) the cubic sleeping space that can be allowed to 
 each person on board ship is necessarily very limited ; 
 and (2) whatever endeavors may be made to isolate 
 infected individuals, when once the atmosphere of a 
 ship has become variolated, there is no escape from it, 
 it must always be breathed. Persons on shore, living 
 in infected houses or rooms, can generally, at all events, 
 for some hours in the day, get away from the specially 
 infected air of the house or room ; but there is no run- 
 ning away from the infected air of aboard ship. Where 
 such an atmosphere has to be constantly breathed by 
 adults, whose systems may probably, at the same time, 
 be particularly predisposed to infection from the action 
 of climatic change and of epidemic influence, the value 
 of a single vaccination in infancy or early childhood is 
 
 * Fifth Annual Report on Sanitary Condition of Cardiff. 
 8vo. Cardiff, 1858. 
 
 23*
 
 266 HANDBOOK OF VACCINATION. 
 
 perhaps put to the severest test that can be applied to 
 it. On Dec. 4, 1860, small-pox made its appearance 
 on board H.M.S. the Imperieuse, then at anchor off 
 the Peiho, but which sailed that very day for Japan. 
 A fortnight afterward (Dec. 18), when the ship was 
 at anchor off Nagasaki, two other cases broke out, and 
 these were followed by others in rapid succession till 
 the 25th of January, 1861, after which date no case 
 occurred. Of the 505 men and officers who constituted 
 the force of the vessel, who were nearly all, but not 
 all, vaccinated, 148 gave some evidence or other of 
 having been affected by the variolous poison. In 15, 
 all of them vaccinated, there was simply the variolous 
 fever, without any eruption. The remainder exhibited 
 every form of the variolous eruption, from the mildest 
 modified to the confluent and malignant form. A hun- 
 dred and eleven cases, with five deaths, occurred in 
 men with fair vaccine marks (unfortunately the num- 
 ber of marks in the respective cases is not stated), 13 
 cases with three deaths in men with imperfect vaccine 
 marks, and 9 cases with two deaths in men who had 
 no mark of vaccination whatever.* On Feb. 3, 1864, 
 small-pox made its appearance on board H.M.S. Eury- 
 alus, then stationed off the coast of Japan, and it con- 
 tinued until the 19th of April. During this period 
 there occurred, among the 510 officers and men who 
 constituted the complement of the vessel, and who 
 were with few exceptions protected, 40 cases of a sim- 
 ple fever (which the surgeon considered to be, and 
 which from the description evidently was, variolous 
 
 * Statistical Report of the Health of the Navy for the Tear 
 1860.
 
 PROTECTION AGAINST SMALL-POX. 267 
 
 fever), with or without an attendant rash, but without 
 any development of vesicles; and 72 cases of some 
 kind or other of variolous eruption. In 20 cases, this 
 eruption amounted to one or two, or a few, umbilicated 
 vesicles only;* in 35 there was a discrete and generally 
 modified eruption of variola; and in 17 a confluent 
 eruption. The different forms of attack among the 
 vaccinated are reported to have been chiefly influenced 
 by the kind of vaccine cicatrices. When these were 
 well marked and foveated, the susceptibility, according 
 to the report of Mr. Morgan, the surgeon of the vessel, 
 was comparatively small: the greater number of per- 
 sons with such marks having the variolous fever only, 
 with or without rash, or having but a few vesicles. 
 Among the 35 cases of discrete eruption, two occurred 
 in persons who had previously had small-pox, one of 
 them being well pitted from his former attack, and the 
 rest in persons with vaccine marks which were good, 
 but not so good or so numerous as in the class of pa- 
 tients just referred to : those, says Mr. Morgan, who 
 had the variolous fever, or very slight eruption only, 
 "were all of them well marked on both arms, whereas, 
 the majority of these were marked on one arm only." 
 In all the confluent cases, vaccination marks could 
 either not be seen, or were ill defined and not good. 
 Six of the confluent cases died, and one was invalided. 
 Of these seven cases, one was ascertained not to have 
 
 * "In two officers who were covered with patches of the 
 peculiar scarlet rash on the trunk and the upper extremities, 
 only one solitary vesicle, which was depressed in the center 
 and surrounded by a red areola, appeared, in one case on the 
 face and in the other on the back." (Stat. Rep. of the Health 
 of the Navy for 1864, p. 245.)
 
 268 HANDBOOK OF VACCINATION. 
 
 been vaccinated ; three had no vaccination marks what- 
 ever; in two the vaccination marks were indistinct, 
 and one had cicatrices on both arms, which though 
 distinct, were not foveated.* An outbreak of small- 
 pox occurred on board H.M.S. Octavia, in 1866, which 
 was very remarkable for the rapidity with which the 
 infection spread. The disease was introduced into the 
 ship at the end of February; it began to spread on the 
 17th of March, and between that date and the 27th 
 of March inclusive — that is to say, in the space of 
 eleven days — no fewer than 164 officers and men mani- 
 fested some degree of affection from the variolous poison. 
 No case occurred after the 27th of March. The follow- 
 ing particulars, with regard to the protection of the 
 officers and crew, are given in the journal of the sur- 
 geon of the ship:f "On the 1st of March, when the 
 Octavia left Bombay for the Persian Gulf, there were 
 on board 610 officers and men; of these, 589 were 
 'protected' by vaccination, and twenty-one (fourteen 
 of whom were Kroomen, shipped at Sierra Leone when 
 the Octavia was on her way out from England in 
 October of last year) were 'unprotected.' Of those 
 protected, 437 escaped altogether, while 147, or 249 
 per cent., were only attacked with symptoms of pri- 
 mary fever, or with the disease in a distinct and com- 
 paratively mild form,| all of whom recovered; and 
 
 * Statistical Report of the Health of the Navy for the Year 
 1864. 
 
 f For this extract I have to express my best thanks to 
 Deputy Inspector-General Mackay, of the Admiralty. 
 
 J Of these persons 85, or 14-4 per cent., had merely the 
 variolous fever, and only 62, or 10-5 per cent., had any form, 
 however modified, of variolous eruption. See return relating
 
 PROTECTION AGAINST SMALL-POX. 269 
 
 only five, or 08 per cent., were attacked with the con- 
 fluent form, and those also all recovered. While of 
 the 'unprotected' all were attacked, 18 or 85 - T per 
 cent, with the disease in its confluent form, of whom 
 six died; and three; or 142 per cent., with severe 
 attacks of the distinct form, all of whom, however, 
 recovered."* 
 
 (f ) Intensity of Epidemic Influence. — Like scarlet 
 fever, measles, etc., small-pox not only has its periods 
 of peculiar prevalence, conveniently called epidemic 
 periods, but at some of these it manifests a much 
 greater activity and virulence, and is attended with 
 greater fatality than at others. This occasional differ- 
 ence in the severity of different small-pox epidemics 
 was remarked on by Jenner, who in his first treatise 
 refers to a singularly mild epidemic which he had wit- 
 nessed some years before in the County of Gloucester. f 
 The epidemic which prevailed in the greater part of 
 England in 1858, and which invaded London in 1859- 
 60, was a severe epidemic; but its intensity was much 
 less than that of the epidemic which, beginning toward 
 the end of 1 862, has continued more or less to the pres- 
 ent time. The mortality in London from small-pox in 
 1863 was greater than had been known for upwards of 
 twenty years. It occurred, as at all other times, chiefly 
 among the unvacCinated, but a large number of vac- 
 
 to H.M.S. Octavia, Pari. Papers, House of Commons, Sess. 
 1866, No. 278. 
 
 * In former epidemic periods, instances of the disease spread- 
 ing extensively aboard ship had been noticed — in 1825, on 
 board the Phaeton, and in 1836, on board the Hastings. (See 
 Rep. of Vacc. Sec. of Prov. Med. Assoc, p. 81.) 
 
 j- Inquiry into the Causes and Effects, etc., p. 64.
 
 2 TO HANDBOOK OF VACCINATION. 
 
 cinated persons also contracted the disease ; and the 
 mortality of post-vaccinal small-pox, as treated in the 
 Small-pox Hospital, was 99 per cent, of the cases, in- 
 stead of the usual average of 6'76 per cent* But the 
 proportion of deaths also from natural small-pox in 
 the hospital in the same year, instead of being 35 per 
 cent, of the cases, mounted to 47 per cent. So that 
 the difference was due, not to falling off in the prophy- 
 lactic power of vaccination, but to the greater intensity 
 of the variolous influence. This varying intensity of 
 epidemic influence must be well kept in mind. From 
 overlooking it, the most erroneous conclusions are some- 
 times drawn as to the decadence of the protection of 
 vaccination. Any time the last fifty years that an un- 
 usually severe epidemic has occurred, there have been 
 those who have asserted that vaccination was wearing 
 out. It was said as much fifty years ago (in the epi- 
 demic of 1818-19) as now. Yet the records of the 
 Small-pox Hospital for 1825 teach the same lesson as 
 the records for 1863: in 1825, the epidemic being, as 
 Dr. Gregory stated, unusually malignant, the mortality 
 in the hospital of post-vaccinal cases amounted to 8 
 
 * Of the cases, that is, taken in the gross, and irrespective 
 of the existence of marks of vaccination or of the quality of 
 the vaccination. By deducting cases in which there were no 
 cicatrices of vaccination, the death-rate would be considerably 
 reduced both on the average of years (see page 238) and in 
 1863. Among the thoroughly vaccinated patients in 1863, the 
 death-rate was under 1 per cent.; only three, in fact, out of 
 123 deaths that took place from small-pox in the hospital in 
 that year in persons who had undergone some sort of vaccina- 
 tion, being in persons who had been thoroughly vaccinated. 
 (See Trans. Epidem. Soc, vol. ii. part 1, App. containing Ke- 
 port of Small-pox and Vaccination Committee, 1864.)
 
 PROTECTION AGAINST SMALL-POX. 2U 
 
 per cent., and the mortality of the natural disease cor- 
 respondingly rose to 41 per cent.* 
 
 93 . The power of Vaccination as exhibited by ' ' pro- 
 tected" classes of the general population. — The an- 
 nual Medical Reports of the British Army and Navy, 
 to which I have already so frequently referred, afford 
 striking proofs of the protective power of vaccination 
 in adult populations, exposed to the ordinary chances 
 of infection of the countries in which they may be sta- 
 tioned. The troops serving in the United Kingdom may 
 be looked on as, virtually, a wholly "protected" force, 
 — for since 1858 every recruit, whether or not he have 
 marks of small-pox or of previous vaccination, is re- 
 quired to be vaccinated on entering the service, and 
 the soldiers who had previously enlisted, who were 
 without proper marks of vaccination, have also been 
 ordered to be revaccinated. The protection of the men 
 employed in the navy is less complete than that of the 
 army; partly, apparently, because the strict rule of 
 the service that all who have not marks of protection 
 should at once be vaccinated does sometimes get evaded 
 (page 258, note), and partly from the absence, if I 
 am not misinformed, of a rule requiring the vaccination 
 of all who enter, whether previously protected or not ;f 
 
 * Paper from Hospital for Casual Small-pox and Vaccina- 
 tion in Annual Keport of the Nat. Vaccine Board, printed 
 March 2, 1826. 
 
 f By making the rule absolute to vaccinate every person, 
 whatever his marks of protection, not only a great security is 
 obtained against errors of individual judgment, and an assur- 
 ance provided that could not otherwise have been had that 
 every one has been vaccinated, but a large majority of those 
 subjected to the rule are put in the still more advantageous
 
 272 HANDBOOK OF VACCINATION. 
 
 and though, relatively to the number of men employed, 
 the number who are unprotected is exceedingly small, 
 the presence of unprotected persons at all cannot but 
 affect the returns whenever small-pox prevails, and will 
 probably account in chief measure for the different 
 small-pox liabilities, particularly as regards mortality, 
 which, as we shall immediately see, the two services 
 have. In upwards of nine-tenths of the men employed 
 in either service, the protection against small-pox is 
 that which is afforded by vaccination.* Now, if we 
 examine the records of these services to see what havoc 
 is made among them at the present day by small-pox — 
 the disease which, according to Sir G. Blane, was, be- 
 fore the discovery of vaccination, "one of the greatest 
 embarrassments to the operations of armies," and 
 obliged ships of war occasionally to quit the seasf — 
 we shall find that on the average of the six years 1859 
 -64, notwithstanding that that period includes two se- 
 vere epidemics, the annual deaths from it were some- 
 what less than 1 per 10,000 among the soldiers, and 
 somewhat more than 2 per 10,000 among the sailors; 
 that the cases of variolous affection of any kind did not 
 exceed annually 14 out of every 10,000 soldiers, nor 
 33 out of every 10,000 sailors; the disease being in 
 
 position of having been revaccinated. Even this simple rule 
 requires, however, I believe, a good deal of vigilance to see 
 that it is not disregarded ; and, as will be seen by the note to 
 the table on next page, individual cases may now and then 
 escape. 
 
 * See note, p. 231, with regard to the proportion of the 
 recruits in the army who have marks of previous variola. 
 As the navy is recruited from the same class of the popula- 
 tion, the proportion may fairly be assumed to be the same. 
 
 •f- Med.-Chir. Trans., vol. x.
 
 PROTECTION AGAINST SMALL-POX. 
 
 273 
 
 the great majority of the cases exceedingly modified. 
 In the tables which I subjoin, showing the results for 
 each force and for each year, the reader will not fail to 
 note the effect of presence or absence of epidemic in- 
 fluence; and as it happened that during this particular 
 period this influence was present in the unusual pro- 
 portion of four years out of the six, the average of 
 cases and deaths is unquestionably largely in excess of 
 what an average for a longer period would give.* 
 
 Table — showing the Cases and Deaths from Small-pox among 
 the Troops se7 % vlng in the United Kingdom for Six Years. 
 
 Year. 
 
 Number of 
 Troops. 
 
 Cases of 
 Small-pox. 
 
 Deaths. 
 
 Ratio per 10,000 of 
 strength. 
 
 Cases. 
 
 Deaths. 
 
 1859 
 
 71,715 
 85,443 
 88,955 
 78,173 
 75,945 
 73,252 
 
 175 
 140 
 51 
 64 
 123 
 111 
 
 7 
 9 
 4 
 4 
 6 
 10 
 
 24-3 
 
 16-8 
 
 5-9 
 
 8-1 
 
 16-2 
 
 151 
 
 0-97 
 105 
 0-45 
 0-51 
 0-79 
 1-36 
 
 I860 
 
 1801 
 
 1862 
 
 1863 
 
 1864 
 
 
 Totals .. 
 
 473,483 
 
 664f 
 
 40 
 
 14 
 
 0-84 
 
 * The publication of annual returns for the army began 
 only with 1859: those for the navy began three years earlier. 
 The tables are for corresponding periods, but if I had included 
 in the table for the navy the years 1856-8, the ratio of cases 
 would have fallen slightly below 30 per 10,000 ; and of deaths 
 to 215. 
 
 f All these cases were in men who had vaccine cicatrices, 
 except three cases (one severe and two mild), in 1860, in men 
 who had marks of previous small-pox, and three cases (of 
 24
 
 274 
 
 HANDBOOK OF VACCINATION. 
 
 In the navy, if we except the remarkable return for 
 1864, to the circumstances of which I shall have occa- 
 sion by and by to revert, the annual average number 
 of cases would only be 20 per 10,000 as compared with 
 14 per 10,000 in the army; but the mortality would 
 still (partly, as already explained, from there being in 
 the force some who were not vaccinated, and partly 
 probably from the less extent to which the deficiencies 
 of primary vaccination had been supplemented by re- 
 vaccination) be more than double. 
 
 Table — showing the Cases and Deaths from Small-pox in the 
 British Navy employed on the u Home Force" for Six Years. 
 
 Yeab. 
 
 Mean 
 
 Strength. 
 
 Cases of 
 Small-pox. 
 
 Deaths. 
 
 Ratio per 10,000 of 
 strength. 
 
 Cases. 
 
 Deaths. 
 
 1859 
 
 19,300 
 23,500 
 22,900 
 20,760 
 21,570 
 19,630 
 
 51 
 84 
 35 
 8 
 39 
 199 
 
 4 
 
 12 
 1 
 1 
 
 2 
 9 
 
 26-4 
 35-7 
 153 
 3-8 
 18-0 
 101-0 
 
 2-1 
 
 51 
 
 0-43 
 
 0-48 
 
 0-97 
 
 4-0 
 
 1860 
 
 1861 
 
 1862 :..... 
 
 1863 
 
 1864 
 
 
 Totals 
 
 127,660 
 
 416 
 
 29 
 
 33 
 
 2.3 
 
 These returns, satisfactory as in many respects they 
 are, are much less so than we may hope to receive a 
 few years hence, when the general population of the 
 kingdom shall have received, in place of the slipshod 
 vaccination heretofore too frequently practiced, the kind 
 
 which two were fatal), in the same year, in men who had no 
 satisfactory marks either of small-pox or of vaccination.
 
 PROTECTION AGAINST SMALL-POX. 275 
 
 of vaccination necessary for full protection ;* and when 
 the revaccination of the services shall have been com- 
 pletely carried out. 
 
 In younger classes of the population the evidence of 
 protection is still more striking. In the Royal Military 
 Asylum there has been no fatal case of small-pox among 
 the many thousand vaccinated children admitted since 
 its institution in 1803 : four deaths from small-pox there 
 have been in the asylum, but they were all in children 
 who, being believed to have already had small-pox, had 
 not been vaccinated, f Among an annual average of 
 550 boys in Christ's Hospital there occurred, during 
 the last half of last century, thirty-one deaths from 
 small-pox ; among an annual average of 800 boys there 
 was, during the first half of this century, but one death 
 from this cause — a death which occurred in the year 
 I880.| 
 
 94. The Protective Power of Vaccination extends 
 to all Climates. — The protective power of vaccination 
 against small-pox extends to every race of mankind, 
 and is exhibited in every climate and in every part of 
 the habitable globe. Natural small-pox, severe and 
 fatal as it is in Europe, is.frecmently a much more 
 
 * The vaccination that men entering the army, navy, etc. 
 have previously received is, of course, the current vaccination 
 of the country, and we do not know how many of the fatal 
 small-pox cases were in men who had only the one, two, or 
 three marks insufficient for full protection. It would be very 
 desirable if in all cases of post-vaecinal small-pox, in both 
 services, the number and the quality of the vaccine marks 
 were noted. 
 
 f T. G. Balfour, Medico-Chir. Trans., vol. xxxv. 
 
 % Communication from Mr. Stone: Papers relating, etc. 
 (op. cit.), p. 153.
 
 276 BANDBOOK OF VACCINATION. 
 
 severe and fatal disease in tropical climates and among 
 dark races. But, relatively to this greater severity, 
 vaccination appears to be in them fully as protective. 
 A person vaccinated in a temperate climate may some- 
 times, there is reason to believe, by change to a trop- 
 ical climate, become somewhat more liable to small-pox 
 (§ 92, d) ; but a person vaccinated in India, and remain- 
 ing in India, if the course of his vaccination have been 
 regular, is probably just as safe relatively as a person 
 vaccinated in England. " It is the opinion of every 
 medical man we have consulted," say the Small-pox 
 Commissioners appointed by the Indian Government in 
 1850, " and we believe it is that of every educated man 
 in India, that when properly and successfully con- 
 ducted, vaccination is just as efficient a safeguard here 
 as it is in England."* Sixteen medical correspondents 
 of the Epidemiological Society in India, dependent all 
 of them on vaccination for their protection against 
 small-pox, had been, with two exceptions, greatly ex- 
 posed to its infection, some of them almost living for a 
 length of time in variolated atmospheres, but none of 
 them had ever taken it. As in the East Indies, so also 
 in Ceylon, in the Mauritius, in the West Indies, on the 
 West Coast of Africa, in Brazil, and other similar cli- 
 mates, whenever small-pox has prevailed, exemption 
 from attack has been the rule among the vaccinated, 
 the rare exception among the unvaccinated, population; 
 and the disease, if contracted by the vaccinated, has 
 put on precisely the same kind of modifications that 
 have been noticed in Europe. But in tropical climates 
 there are sometimes difficulties in keeping up supplies 
 
 * Report of the Small-pox Commissioners [op. eit.), p. 41.
 
 PROTECTION AGAINST SMALL-POX. 
 
 277 
 
 of active vaccine lymph (§ 39) at certain seasons of the 
 year, which render attention even more necessary there 
 than here to ascertain that the vaccinations performed 
 have been really genuine and effective. Whenever an 
 apparently high rate of post-vaccinal small-pox mor- 
 tality has obtained, investigation has never failed to 
 show that there has been defect in the quality of the 
 vaccination. This was well ascertained by Dr. Kinnis 
 in the very interesting and instructive inquiries he 
 made into the circumstances of two epidemics in Cey- 
 lon (the two first of the epidemics included in the fol- 
 lowing table), in both of which epidemic influence must, 
 judging from the high death-rate of the cases of the 
 natural disease, have been very intense. 
 
 Epidemic. 
 
 Natural Small-pox. 
 
 Second Small-pox. 
 
 Post- vaccinal 
 Small-pox. 
 
 I 
 
 a 
 ft 
 
 * J: m 
 
 u SS * 
 C.QO 
 
 So** 
 
 ss 
 
 
 08 
 
 ■ 
 ft 
 
 c m 
 
 Z -Z as 
 a.ftO 
 
 3° 
 
 
 I 
 
 §5 8 
 SIS 
 
 CftO 
 
 M 
 
 Ceylon (1830) 
 
 Ceylon (18*3-4).... 
 Mauritius (1840-1) 
 Jamaica (1851-2).. 
 
 123 
 
 228 
 281 
 477 
 
 58 
 88 
 120 
 75 
 
 47 
 38-5 
 42-7 
 16 
 
 4 
 
 2 
 
 2 
 
 
 1«9 
 197- 
 421 
 120 
 
 34 
 
 21 
 
 30 
 
 4 
 
 18 
 10-6 
 
 7 
 
 3-33 
 
 
 
 
 11 
 
 2 
 
 
 
 In reference to the first of the Ceylon epidemics, it 
 was found, on inquiry, that out of the 189 cases of al- 
 leged post-vaccinal small-pox, there was in 56, including 
 18 of the fatal cases, not the slightest evidence what- 
 ever that vaccination had at anytime been successfully 
 performed ; and that, of the lb3 remaining cases, 57, 
 with. 15 deaths, were among persons whose marks of 
 vaccination were unsatisfactory, " not such as are left 
 24*
 
 278 HANDBOOK OF VACCINATION. 
 
 by vaccination when undisturbed in its course : while 
 in those (76) who had good marks of vaccination, the 
 disease was rendered so mild that only one died." In 
 the other Ceylon epidemic, of the 197 professedly vac- 
 cinated persons who contracted small-pox, 86, includ- 
 ing 19 of the 21 fatal cases, had either no marks at 
 all of vaccination, or marks which were not satisfactory, 
 and only 2 deaths took place among the 111 cases in 
 which there were genuine vaccine marks * And in 
 the interesting account which Mr. Gardner has given 
 of the Mauritius epidemic, it is stated that in 13 only 
 of the 30 deaths alleged to have occurred from post- 
 vaccinal small-pox, were the evidences of vaccination 
 satisfactory, f 
 
 Among the native soldiers in India, whose wives 
 and families are frequently the subjects of virulent and 
 fatal small-pox, the protection resulting from the vac- 
 cination to which the regulations of the service have 
 obliged the soldiers themselves to submit, is most 
 strikingly seen. The ratio, also, of small-pox cases 
 occurring in the European troops stationed in India, 
 from 1860 to 1864 inclusive, as exhibited in the fol- 
 lowing table, though somewhat higher than that no- 
 ticed among the troops stationed in the United King- 
 dom (p. 273), is not more so than is explicable by the 
 greater and more frequent exposure to which they are 
 liable in some of the stations in India to the specific 
 cause of the disease ; the greater relative mortality is 
 due, probably, partly to vaccination having in a few 
 
 * Kinnis, Keport on Small-pox as it appeared in Ceylon, etc. 
 8vo. Columbo, 1835. 
 •j- Seaton, op. cit., p. 355.
 
 PROTECTION AGAINST SMALL-POX. 
 
 279 
 
 cases been omitted, or not repeated in cases in which 
 the marks were imperfect, and partly to the influence 
 of climatic change. 
 
 Province. 
 
 Aggregate 
 strength 
 (5 years). 
 
 Cases of 
 Small- 
 pox. 
 
 Deaths 
 from 
 
 Small- 
 pox. 
 
 Annual ratio per 
 10,000 of strength. 
 
 Cases. 
 
 Deaths 
 
 
 201,677 
 59,580 
 56,620 
 
 482 
 31 
 101 
 
 71 
 4 
 15 
 
 24 
 5-2 
 
 17-8 
 
 3-55 
 0-67 
 2-65 
 
 
 
 
 Total 
 
 317,877 
 
 614 
 
 90 
 
 19-2 
 
 2-83 
 
 
 The valuable statistics which Mr. Leith has pub- 
 lished respecting the Island of Bombay, show that for 
 the five years 1848-53, the small-pox deaths among the 
 general population, the majority of which is unpro- 
 tected, were 5 - 8 per cent, of the mortality from all 
 causes — about two-thirds the rate which used to pre- 
 vail in England before the discovery of vaccination : 
 but among the European community on the island, 
 which is, with comparatively few exceptions, protected 
 by vaccination, the small-pox deaths were for the same 
 period only 1 per cent, of the deaths from all causes.* 
 
 95. The Protective Power of Vaccination shown 
 in National Statistics of Small-pox. — In consequence 
 of the remarkable power of vaccination in protecting 
 against small-pox, and the adoption of the practice 
 universally by educated people and in annually in- 
 creasing proportion by the population at large, the 
 present average death-rate from small-pox is scarcely 
 
 * Morehcad's Researches on Disease in Tndia, vol. i. chap. v.
 
 280 HANDBOOK OF VACCINATION. 
 
 in any European country one-tenth part, and in those 
 countries in which vaccination has been most carefully 
 carried out, it is much less than one-tenth part, what 
 it was at the end of the last century. Thus in Sweden, 
 where, before vaccination was discovered, the average 
 annual death-rate from small-pox was 2050 out of 
 every million of population, during the forty years, 
 1810-50, it was but 158; in Westphalia, where the 
 small-pox death-rate used to be 2643 per million, it 
 was from 1816-50 only 114; in Bohemia, Moravia, 
 and Austrian Silesia, it has been reduced, in like man- 
 ner, from 4000 to 200; in Copenhagen, from 3128 to 
 286 ; and in Berlin, from 3422 to 176. Especially in- 
 teresting is it to review what has been done in our 
 own country, and to contrast with the 3000 annual 
 deaths from small-pox per million of population in 
 England — the estimated death-rate at the end of the 
 last century — the present death-rate from the same 
 cause, amounting only to two hundred per million; 
 or with the 1780 average annual deaths which took 
 place from small-pox, in London, within the bills of 
 mortality, between the years 1790 and 1800, on a 
 population little exceeding a quarter of a million, the 
 759 deaths which have been the annual average of the 
 last thirteen years, in our present London, containing 
 more than ten times the population.* If the reader 
 
 * And this, notwithstanding the intensity of epidemic in- 
 fluence manifested in some of these years [vide ante, p. 270). 
 It will he seen that small -pox prevailed epidemically in 
 London in five, if not in six, out of these thirteen years. In 
 this vast metropolis, with its two thousand hirths a week, 
 the law w T ith regard to early infantile vaccination requires 
 to be administered in its utmost strictness to give any-
 
 PROTECTION AGAINST SMALL-POX. 281 
 
 will examine these tables, first year by year, and 
 then for series of years, he will see that, when the 
 disturbing influence of epidemic prevalence in special 
 years is got rid of, by taking the years not one by 
 one, but in groups, each group comprising epidemic 
 and non-epidemic years, the decline of small-pox mor- 
 tality exhibits a regular progression, in correspond- 
 ence with the progress that has been made in the 
 adoption of vaccination. This is seen at a glance from 
 the following summary : 
 
 thing like reasonable security against frequently recurrent 
 epidemics of small-pox. A3 it has been heretofore adminis- 
 tered, scarcely ever more than two years together have passed 
 without an epidemic visitation. "Whatever may be the various 
 circumstances, some of them unknown to us, which determine 
 why diseases like small-pox, scarlatina, measles, etc. should 
 be epidemic at one time and not at another, the aggregation of 
 susceptible individuals is assuredly one of the most influential 
 circumstances in determining the frequency of recurrence. In 
 this we have the most rational explanation why, the observ- 
 ance of infantile vaccination being about the same, London 
 should have epidemics of small-pox every two years or there- 
 abouts, while Liverpool or Birmingham may remain five, six, 
 or seven years without an epidemic visitation, and other 
 smaller towns a much longer time. But take smaller towns 
 in which infantile vaccination is much more neglected than 
 in the foregoing — such towns, for instance, as Northampton — 
 and we find epidemics recurring more frequently than in 
 Liverpool or Birmingham. In Northampton (the like of 
 which for scandalous neglect of vaccination it would be diffi- 
 cult to find in England), though its population little exceeds 
 40,000, there were very fatal and wide epidemics of small-pox 
 in 1856, in 1860, and in 1865.
 
 282 
 
 HANDBOOK OF VACCINATION. 
 
 Periods compared. 
 
 Annual 
 Deaths by 
 Small-pox 
 inKnirhind 
 and Wales. 
 
 Annual 
 rate per 
 million of 
 the Popu- 
 lation. 
 
 1. Average of thirty years previous to introduction of 
 Vaccination, estimated by Dr. Lettsom and Sir 
 Gilbert Blane 
 
 
 3000 
 
 770 
 304 
 202 
 
 2. Average of three years (1838—10),* when Vaccination 
 had become to a great extent diffused, but before 
 any public provision was made for its gratuitous 
 
 11,944 
 5,221 
 3,967 
 
 3. Average of ninef of the years (1841-53) when pub- 
 lic Vaccination was gratuitously provided, but 
 
 4. Average of the twelve years (1854-65) during which 
 Vaccination has been to a certain extent obliga- 
 
 
 The Registrar-General of England, in his most re- 
 cent report, | states some facts which put in a very 
 strong light the beneficial results which have been ob- 
 tained from the increased ohservance of vaccination in 
 England, consequent on the compulsory Vaccination 
 Act of 1853, imperfect as that act was, and imper- 
 fectly as it has been administered. His figures show 
 that, on comparing the mortality of the kingdom from 
 all causes during the last of the periods in the above 
 table with the period immediately preceding, there had 
 been an annual gain of life of 31 per 100 000 of popu- 
 lation, and that one-third of this gain had been from 
 small-pox alone. Comparing also the mortality from 
 all causes in London for thirteen years immediately 
 preceding, and thirteen years immediately following 
 that act, it appeared that during the latter period six- 
 
 * Eegistration of the deaths in England began only in 1837. 
 f During the years 1843-46 the causes of death were not 
 analyzed in the Keports of the Kegistrar-General. 
 % Twenty-eighth Annual Keport, for the year 1865.
 
 PROTECTION AGAINST SMALL-POX. 283 
 
 teen lives had been saved every year out of every 
 100,000 of the population, and that ten of the lives so 
 saved, or nearly two-thirds of the total gain, had been 
 from small-pox. The annual mortality from all causes 
 in London was, in the two periods, 2447 and 2431 
 per 100,000 living, respectively; the annual mortality 
 from small-pox, 38 and 28 per 100,000 living, respect- 
 ively. Small-pox — which in England thirty years ago 
 was, in one of its years of epidemic prevalence, the 
 fifth most fatal disease — has, in the worst epidemic 
 that has occurred in the last twelve years, occupied no 
 higher than the eighteenth place among the causes of 
 death, as arranged by the Registrar-General. 
 
 The time which has elapsed since compulsory vac- 
 cination was extended to Scotland has been far too 
 short to enable us to form any complete judgment of 
 its results in that portion of the kingdom. It was not 
 till the middle of 1864 that it began to take effect ; and 
 though there has been since then an extraordinary 
 diminution in the small-pox mortality, the connection 
 of which with the increased observance of vaccination 
 cannot be doubted, an average of many years must be 
 awaited before the full extent of the benefits to be de- 
 rived from it can be ascertained. The average annual 
 small-pox mortality of the ten years, 1855-64, was 
 1054, or 366 deaths per million of population.* The 
 total deaths from small-pox in 1865 were 123, and in 
 1866, 280; or 39 and 88 per million of population, 
 respectively. In no two previous years is there any 
 record of the small-pox mortality being so low. 
 
 * Tenth Detailed Annual Report of Registrar-General for 
 Seotland.
 
 284 
 
 HANDBOOK OF VACCINATION. 
 
 96. Theory of Decadence of Vaccine Power. — This 
 
 progressive decline of small-pox as vaccination has ad- 
 vanced, affords but little countenance to the theory 
 that has at times been propounded, that the protective 
 power of vaccination over populations is wearing out.* 
 The very precise statistics of the army are equally at 
 variance with it. If we compare the number of cases 
 of, and the mortality from, small-pox now, with what 
 these were from thirty to twenty years ago, we find 
 there has been a very remarkable diminution : 
 
 Troops serving in the 
 
 Uuited Kingdom 
 
 during the 
 
 undermentioned years. 
 
 Aggregate 
 Strength. 
 
 Cases of 
 Small- 
 pox. 
 
 Deaths by 
 Small- 
 pox. 
 
 Annual Ratio per 
 10,000 of strength. 
 
 Cases. 
 
 Deaths. 
 
 2-20 
 0-84 
 
 1837-1846f 
 
 254,597 
 473,483 
 
 557 
 664 
 
 56 
 40 
 
 21-88 
 14-0 
 
 1859 1864J 
 
 
 The small-pox mortality, in fact, of the worst epidemic 
 year of the latter period (1 36 per 10,000 troops — see 
 table, page 273) is far short of the average of the pe- 
 riod 1837-46. Yet the army is far more dependent 
 on vaccination for its protection now, than it was thirty 
 or twenty years ago (see note, p. 231). The gain, 
 in fact, is wholly due to the means which have been 
 taken in these latter years to make the protection by 
 
 * The facts on which principally- this hypothesis has heen 
 hased have (as already stated) quite another explanation 
 (2 92, f). 
 
 •}• T. G. Balfour on the Protection against Small-pox, etc., 
 in Medico-Chir. Trans., vol. xxx'v. 
 
 J Annual Statistical, Medical, and Sanitary Eeports of the 
 Army, commenced in 1859.
 
 PROTECTION AGAINST SMALL- POX. 285 
 
 vaccination more perfect (§ 93). It has been already 
 seen (Chapter X ) that, with due care, vaccine lymph 
 loses nothing of its essential properties, so far as its 
 immediate effects on the human system are concerned, 
 by successive transmissions through the human sub- 
 ject ; and, from this fact alone, it would be a fair in- 
 ference that it loses nothing of its prophylactic power. 
 But the matter has been repeatedly put to experiment. 
 Sacco, in 1825 (for the theory of decadence had its ad- 
 vocates then as it has now), performed variolous inoc- 
 ulation on a number of subjects who had been vaccin- 
 ated two years before, with the then current lymph, 
 i.e. with lymph that had been upwards of twenty-three 
 years in use, and at the same time on a number of 
 other subjects who had been vaccinated twenty, twenty- 
 two, and twenty-four years before, or with lymph only 
 a very few removes from the cow : in each class of 
 subjects the results were the same, and were local only.* 
 Similar variolous testings in England, previous to the 
 time when the variolous inoculation of human subjects 
 was made illegal, gave precisely similar results, f But, 
 in truth, we have experiments on a much larger scale 
 made to hand in every epidemic of small-pox that oc- 
 curs. In each such epidemic — no matter at what 
 epoch since the introduction of the practice of vaccina- 
 tion — it has not been the persons vaccinated with the 
 then current lymph, the lymph farthest from the cow, 
 but those vaccinated some sixteen, twenty, or twenty- 
 five years before, with lymph so much the nearer to 
 
 * Sacco, Do Vaccinat. Necessitate, Mediol. 1832. 
 f See for examples pages 208, note, and 2G3, note. 
 25
 
 286 HANDBOOK OF VACCINATION. 
 
 the parent source, who have been found to be the chief 
 sufferers from postvaccinal small-pox. 
 
 97. Evidence that the present Small-pox mortality 
 in England is due to Neglect of Vaccination and to 
 its Inefficient Performance. — But, if vaccination can 
 so control small-pox, how comes it that there should 
 be still, as on the average of the last ten years there 
 have been, above 4000 deaths a year from this cause 
 in England ? First and chiefly, because vaccination is 
 still largely neglected ; and secondly, because in many 
 cases it has been inefficiently performed. That these 
 are the real causes, is provable in two ways : (a) from 
 analysis of the death returns, and (b) from the results 
 of special inquiries. 
 
 (a) From Analysis of the Death-returns. — If the 
 reader will refer to the deaths from small-pox Avhich 
 take place in England, he will see at a glance that 
 seven-tenths of this mortality is in children under 
 puberty, at a time of life when the power of vaccina- 
 tion, even of such vaccination as results only in a sin- 
 gle characteristic vesicle, to save from death by small- 
 pox is quite indisputable. In the whole, therefore, of 
 the mortality, or about 3000 out of the annual 4227 
 deaths, the non-performance of successful vaccination 
 may, with rare exceptions in individual cases, be prop- 
 erly assumed. Of the .remaining 1200 annual deaths 
 or thereabouts — the deaths after puberty — there are no 
 means of knowing in how many of the subjects vac- 
 cination had been performed, or in how many not ; we 
 should probably little err if we stated that not nearly 
 the half of them had been vaccinated, but for our pres- 
 ent purpose we may; if we like, assume that the whole 
 had been, as it is called, vaccinated — and the question
 
 PROTECTION AGAINST SMALLPOX. 287 
 
 would then arise, in ivhat manner had the vaccination 
 been done ? This point, as regards the individuals, 
 cannot of course be ascertained. But we may fairly 
 apply to the group the observations made for twenty 
 years in the Small-pox Hospital on fatal cases of small- 
 pox in individuals believed to have been successfully 
 vaccinated. Of the total number of 402 such fatal 
 cases, 101 exhibited on their arms no evidence what- 
 ever of having ever had effective vaccination ; 2*7*7 had 
 but one or two vaccine marks, and these in 191 of them 
 were of imperfect character ; 16 were in persons who 
 had three cicatrices ; and only 5 in persons who had 
 been vaccinated in the way that has been shown to be 
 the most protective, — of which 5 two did not die of the 
 small-pox, but of concurrent or superadded disease.* 
 Only one, then, in 80 of these fatal cases among the 
 vaccinated, occurred in patients who had been vaccin- 
 ated in the best way. Such facts can leave no doubt 
 on the mind of any reasonable being, that the 1200 
 adults who die on an average every year in England 
 from small-pox can either not have had vaccination 
 performed at all, or must, with few exceptions, have 
 had it very imperfectly done, and must have taken no 
 after-steps to remedy the imperfection. 
 
 (b) From the Results of Special Inquiries. — From 
 the official inquiry into the state of vaccination in 
 England made from 1860 to 1864, under the direction 
 of the Privy Council, it appears that the districts into 
 which the kingdom is divided for the purpose of public 
 
 * Marson, art. "Small-pox, etc. (op. cit.), p. 473. These 
 five deaths occurred among 544 patients, who, having been 
 properly vaccinated, had most of them the small-pox in its 
 light or varicelloid form only.
 
 238 HANDBOOK OF VACCINATION. 
 
 vaccination exhibit every shade of variety as to the 
 extent to which vaccination is carried out, — from com- 
 plete observance of the law, to the most culpable and 
 reckless disregard of it. In numerous districts infan- 
 tile vaccination was found to be carried out either com- 
 pletely, or with such trivial delay as could readily be 
 overtaken at the slightest alarm ; and in all these dis- 
 tricts not only did the death-registers show absence 
 of small-pox mortality of the native population, but the 
 disease itself had never made any serious lodgment, 
 had never to any extent spread. With scores of such 
 districts I am myself acquainted, districts in which, 
 although the population has been exposed again and 
 again to the infection of small-pox, the disease prevail- 
 ing all around them, and being frequently imported 
 into them, the utmost suffering of the native population 
 has yet been the occurrence of a few modified cases of 
 it, here and there, without any extension. The type 
 of such a district is that of Mold, in the Holywell 
 Union, Flintshire. It is a district comprising a popula- 
 tion of nearly 16,000 persons, partly mining and partly 
 agricultural, which, since the passing of the Compul- 
 sory "Vaccination Act of 1853, has been kept completely 
 vaccinated. It is a district greatly exposed to small- 
 pox, not only from adjacent districts, but from its con- 
 stant communication with Liverpool. In the fourteen 
 years which have passed since 1853, small-pox has pre- 
 vailed on various occasions all round it. At such times 
 the disease has been imported into it again and again. 
 During the epidemic of small-pox that pervaded Eng- 
 land in 1858-9, there were repeated importations ; in 
 1864, there were at least thirty distinct importations, 
 chiefly from Liverpool, and there were several fatal
 
 PROTECTION AGAINST SMALL-POX. 
 
 289 
 
 cases within the district in persons who were strangers 
 But the utmost suffering of the native population or 
 among the regular inhabitants of the district, in the 
 whole fourteen years, was four cases of natural small- 
 pox in children who had not passed the period lawfully 
 allowed for the performance of vaccination; a fifth 
 (fatal) case in a child born with the disease, its mother 
 having modified small-pox at the time of her confine- 
 ment; and a few modified cases in persons who came 
 directly in contact with the imported cases. Beyond 
 the points of importation the disease has never spread.* 
 
 * Dr. Hughes, of Mold, who was the Public Vaccinator of 
 the district during the whole of this period, and to whose 
 exertions these great results are due, has been kind enough to 
 furnish me with the complete statistics of vaccination in the 
 district from the date of the Compulsory Act to September 
 30, 1867, as under : 
 
 Period. 
 
 id 
 
 Hi o 
 
 ^ c 
 
 || 
 
 si 
 
 I* 5 
 
 Certified as 
 successfully 
 
 Vaccinated. 
 
 s 
 c 
 '> , 
 
 S-.2 
 1.1 
 
 •5 -5 
 
 V 
 
 n3 
 
 o 
 
 il 
 '> * 
 
 .- ~ 
 
 5 
 
 3 
 
 _o 
 '? . 
 
 ELg 
 
 H 
 - * 
 
 IS 
 
 I 
 
 Not 
 Vaccinated. 
 
 — - 
 
 Si 
 
 ■ 
 
 -* o 
 
 o to 
 
 IS 
 
 lit 
 
 - = i- 
 
 ^ Oto 
 
 13 years ending Sept. 30, 
 1S66 
 
 6925 
 729 
 
 5784 
 454 
 
 324 
 63 
 
 202 
 22 
 
 600 
 54 
 
 4 
 
 11 
 61 
 
 
 Year ending Sept. 30, 
 1867 
 
 85 
 
 
 Total 14 years.... 
 
 7654 
 
 6238 
 
 377 
 
 224 
 
 654 
 
 4 
 
 72 
 
 85 
 
 It will be seen that there were at the time of this return only- 
 eleven postponed vaccinations of children whose births were 
 registered before September 30, 1866 : ten of these eleven 
 were children registered in the year ending September 30, 
 25*
 
 290 HANDBOOK OF VACCINATION. 
 
 In some districts of this kind, in which the younger 
 population were all duly vaccinated, but in which the 
 elder children, who had been born before the enact- 
 ment of the compulsory law, and who were therefore 
 exempt from its provisions, had remained, many of 
 them, unvaccinated, the first epidemic of small-pox 
 which swept over the districts after the passing of that 
 law had laid hold of the latter; and very singular it 
 was to note how, under these circumstances, the 
 usual distribution of small-pox deaths, with regard to 
 the age of the patients, had been reversed ; instead of 
 more than half the mortality being in children under 
 five years old, there were under that age no deatks at 
 all, or but an occasional death recorded, the mortality 
 being altogether of elder children, adolescents, and 
 adults. Such were the districts at one end of the 
 scale — districts which kept small-pox at bay — not actu- 
 ally few in number, but still in small proportion to the 
 total districts of England ; for, taking the kingdom 
 throughout, neglect of early vaccination, of more or 
 less serious amount, was found to be the rule and not 
 the exception.* To such neglect anything beyond 
 
 1866. Dr. Hughes adds, " No child born in the Mold district, 
 and alive at the date of the registration of its birth, has died 
 of small-pox during the fourteen years. One infant, whose 
 mother was ill of varioloid disease at its birth, died of small- 
 pox when four or five days old." (See further interesting par- 
 ticulars on this district in Brit. Med. Journ., May 11, 1867.) 
 
 * In the Keport of the Vaccination Section of the Provin- 
 cial Medical and Surgical Association, 1839, and in the Report 
 of the Small-pox and Vaccination Committee of the Epidemi- 
 ological Society, 1853, the reader will find interesting ac- 
 counts of the state of vaccination in England at those periods 
 respectively. Great progress bad been made since then.
 
 PROTECTION AGAINST SMALL-POX. 291 
 
 mere casual small-pox mortality was always traceable. 
 In very many districts this neglect had been allowed to 
 go on accumulating till it assumed considerable, and in 
 some really enormous proportions ; and these specially 
 neglected districts not only themselves contribute most 
 unduly to the large small-pox mortality of the kingdom, 
 but are the means of spreading the disease broadcast. 
 This was strikingly illustrated in the great epidemic of 
 small-pox that set in while the inquiry was in progress. 
 The places in which, in 1864-5, there was a very high 
 rate of small-pox mortality, were all of them places in 
 which there had been the most scandalous neglect of 
 vaccination ; and except in the very few of them which 
 the inquiry had not reached till the epidemic was already 
 prevailing, the local authorities of each place had been 
 warned beforehand of that neglect and of its inevitable 
 consequences, but had not thought fit to take proper 
 steps to remedy it. Of the 7684 deaths from small- 
 pox in England in 1864, 648, or a twelfth part of the 
 whole, occurred in 2 out of the 641 Registration Unions 
 into which England is divided : two unions, in which 
 the unvaccinated children literally amounted to thou- 
 sands. They were the Union of Dudley, with a popu- 
 lation of 130,267, in which 420 deaths from small-pox 
 were registered ; and the Union of Portsea Island 
 (Portsmouth and its suburbs), with a population of 
 94,828, in which there were 228 deaths from small-pox. 
 And each of these places was an enormous center of 
 infection. If the reader will turn back to the table 
 showing the extent of small-pox in the " Home Force " 
 of the British Navy (p. 274), he will notice the very 
 remarkable entry for 1864, of no fewer than 199 cases 
 of small-pox and 9 deaths. Now more than three-
 
 292 HANDBOOK OF VACCINATION. 
 
 quarters of these cases (151), and two-thirds of the 
 deaths (6), were from infection at Portsmouth. Nor 
 was this all : from infection traced to Portsmouth the 
 disease manifested itself on board the Duncan, when on 
 its voyage from the North American station ; 38 men 
 were temporarily disabled by it, and 1 died. In like 
 manner, in the year following, of the 6411 deaths from 
 small-pox which occurred in England, 1419, or more 
 than one-fifth, were among the 664,161 inhabitants of 
 14 unions, which not only themselves suffered the con- 
 sequences of their neglect of infantile vaccination, but 
 became so many centers of pestilence.* Surely the 
 
 t>„ ..!„*• _ Deatha from 
 
 ,n 1851 - In 1SU5. 
 
 Northampton 41,152 151 
 
 Whitehaven 39,950 126 
 
 Bath 68,336 106 
 
 Dover 31,575 73 
 
 Burton-on-Trent 41,065 72 
 
 Brighton 77,693 70 
 
 Shrewsbury 25,784 59 
 
 Canterbury 1 16,643 55 
 
 Merthyr 93,008 185 
 
 Neath 58,583 153 
 
 Newport (Mon.) 51,412 104 
 
 Pontypool 30,288 92 
 
 Pontypridd 30,387 91 
 
 Cardiff 58,285 82 
 
 In many of these places this mortality was but part of the 
 mortality of the town or union from the epidemic, many 
 deaths having occurred toward the end of the preceding year, 
 as at Brighton, .Bath, Shrewsbury, and Burton, or still more 
 especially in the six Welsh unions, in which there had been,
 
 PROTECTION AGAINST SMALLPOX. 293 
 
 continuance of a state of things like this is not to be 
 regarded as a matter of mere local concern : surely it 
 was time for the legislature not to leave it optional 
 any longer to local authorities whether to enforce or 
 not the vaccination of the young population ; but to im- 
 pose this enforcement upon them as a positive duty. 
 
 There still exists in the minds of many people a mis- 
 apprehension on the subject of neglect of vaccination. 
 If in a number of families, or say in a whole district, 
 all the children two years old and upward are found 
 vaccinated — the parents, in fact, being well disposed 
 to vaccination — and only the children under two years 
 of age are unvaccinated, it might be said (indeed it 
 has, under some such circumstances, been repeatedly 
 said to me) that there is no neglect of vaccination. 
 Even in official documents it used to be argued that 
 the number of vaccinations annually performed in the 
 
 in 1864, 244 small-pox deaths: most of these places, besides, 
 had had similar visitations of fatal small-pox but a few years 
 before, which might in themselves have been a sufficient warn- 
 ing. Three of the places in this list — Merthyr, Northampton, 
 and Shrewsbury — are among the four unions which (from 
 their gross neglect of vaccination) had exhibited the highest 
 mortality from small-pox among the children living under 
 five years of age in the decennial period 1851-60. (See Table 
 in Sixth Report of M. O. of P. C, p. 8.) I had reported of 
 Northampton in 1860 that it exhibited greater neglect of vac- 
 cination than any other place I had up to that time visited : 
 and five years afterward (at the time of the epidemic here 
 referred to), Dr. Stevens stated it to be the least vaccinated 
 town of the least vaccinated county he had that year in- 
 spected ; " that it has been, and still is, a center in which 
 smalUpox is constantly present, and from which that disease 
 is largely distributed to the neighboring towns and villages."
 
 294 HANDBOOK OF VACCINATION. 
 
 kingdom was, irrespective of the age at which the vac- 
 cinations were done, the test of the efficiency with 
 which vaccination was carried out. To the Epidemi- 
 ological Society belongs the merit of having pointed 
 out the fallacy and the danger involved in this mode 
 of regarding the subject.* The period of infancy be- 
 ing particularly obnoxious to the ravages of small- 
 pox, any delay in the performance of vaccination, 
 beyond the earliest period at which it can properly 
 be done, is neglect. Previous to the Report of the 
 Society, and the legislative action taken upon it, 
 more than half the public vaccinations of the king- 
 dom were not performed till children were above a 
 year old : but if half the children born were left to 
 be a year old before being vaccinated, there would on 
 any given day be in England some 300,000 children, 
 or thereabouts, under one year of age alone (at a time 
 of life when small-pox is so peculiarly fatal),, unpro- 
 tected against the pestilence. It is by overlooking this 
 important consideration, that in countries on the con- 
 tinent of Europe, conspicuous for the care with which 
 vaccination is carried out and the good general results 
 derived therefrom, an epidemic of small pox is found 
 every now and then to carry off many victims. This 
 has been the case in Sweden, where vaccination is 
 strictly compulsory ; but the compulsion not taking 
 effect till two years of age, and the vaccination being 
 frequently deferred by parents till then, a number of 
 unprotected and susceptible subjects is kept up. The 
 most conspicuous result in England of the Act of 1853 
 
 * Keport of Small-pox and Vaccination Committee (op. cit.), 
 p. 19.
 
 PROTECTION AGAINST SMALL-POX. 295 
 
 has been the change that has taken place with regard 
 to the age at which vaccination is now performed, and 
 to this is due in great measure the diminution in the 
 mortality from small-pox. 
 
 But the neglect of vaccination, which on the recent 
 official inquiries was found to obtain in a very large 
 proportion of the districts into which England is di- 
 vided, was a neglect which far exceeded the period 
 of infancy. Frequently children who were of age to 
 be in attendance at infant schools were found unvac- 
 cinated in the proportion of 15, 20, and 25 percent, 
 of the school attendance : in some districts the pro- 
 portion had exceeded a third, and had even mounted 
 up to a half.* 
 
 The small relative proportion of cases in which, on 
 these inquiries, it was found that vaccination, in its 
 mode of performance, had been carried to the extent 
 necessary for the full development of its protective 
 powers, has already been stated (§ 73, b). 
 
 98. Summary. — The evidence then is conclusive 
 that the vast majority of mankind may, by a single 
 properly performed vaccination, be rendered wholly 
 unsusceptible of any subsequent action of the variolous 
 poison ; and that in the minority, whose susceptibility 
 to that infection has not been entirely exhausted by 
 the vaccine process, the small-pox will, with rare ex- 
 ceptions, be so modified, that if all the population were 
 completely vaccinated, i.e. vaccinated in the best way, 
 serious and spreading small-pox would be but little 
 
 * Even in National Schools, attended by much older chil- 
 dren, it was not unusual to find 8 or 10 per cent, unvaccin- 
 ated. Many of these children had already suffered the con- 
 sequences of neglect, and were marked by small-pox.
 
 296 'HANDBOOK OF VACCINATION. 
 
 known among us, and entries of fatal small-pox would 
 be all but banished from our death-registers. What is 
 to be done for those in whom vaccination has not been 
 properly performed, or has not properly taken effect — 
 in what way a larger measure of protection may be 
 extended to those who, though properly vaccinated, 
 are still in some degree amenable to the small-pox in- 
 fection, are points next to be considered. 
 
 It will be well, however, first briefly to recapitulate 
 the more important conclusions established by the facts 
 stated in this chapter. 
 
 1. Natural small-pox, though with rare exceptions 
 it protects the human constitution against any further 
 attack of the same disease, does not invariably do so. 
 Persons have had small-pox twice, thrice, and oftener. 
 Absolute protection against an attack of small-pox does 
 not exist. 
 
 2. Small-pox induced by successful inoculation pro- 
 tects generally like an attack of the natural disease, 
 but — to a certain degree from the imperfections insepa- 
 rable from an artificial process, and to a much more 
 considerable extent from errors or carelessness in the 
 performance of the inoculation or from disturbance in 
 its course — a larger proportion of those who have had 
 small-pox by inoculation than of those who have had 
 the natural disease, are liable to a second attack of 
 variola. 
 
 3. Second small-pox, whether after the natural or 
 the inoculated disease, is very often modified in its 
 course, and is much less fatal than small-pox in unpro- 
 tected persons.* 
 
 * Marson gives 19 per cent, as the proportion of deaths to 
 cases of second small-pox in the Small-pox Hospital (Table,
 
 PROTECTION AGAINST SMALL-POX. 29T 
 
 4. Though the practice of variolous inoculation is 
 not wholly void of risk, that risk is so slight as com- 
 pared with the dangers of natural small-pox, that, were 
 there no other way of protecting the system against 
 that disease, it is a practice of which every prudent 
 person would be glad to avail himself. But inocula- 
 tion, though thus on the whole beneficial to the indi- 
 vidual, has the effect of keeping alive and diffusing the 
 variolous poison ; whence the effects of it, as noted on 
 the population generally, were not to diminish, but 
 considerably to increase, the small-pox mortality. For 
 the last twenty-seven years the practice has, in Eng- 
 land and Ireland, been very properly made illegal. 
 
 5. Vaccination, without endangering the life of the 
 individual submitted to it, and without diffusing any 
 infection, entirely and permanently exhausts the sus- 
 ceptibility to small-pox in the vast majority of those 
 in whom it has been properly performed ; but leaves 
 an undetermined proportion still subject in a greater or 
 less degree to the action of the variolous poison. 
 
 6. In those whose susceptibility has been only par- 
 tially destroyed, the action of the variolous infection 
 may be manifested at any period, from a few weeks or 
 months to any number of years, after the performance 
 of the vaccination: but it is most frequently not mani- 
 fested till after puberty, and when manifested before 
 puberty is generally inconsiderable in degree and only 
 quite exceptionally fatal. 
 
 7. The degree of severity which post-vaccinal small- 
 
 p. 242). The returns to the Epidemiological Society gave a 
 much smaller proportion of mortality than this — 8-3 per cent. 
 (Seaton, op. cit., p. 354.) 
 
 26
 
 298 HANDBOOK OF VACCINATION. 
 
 pox may manifest after puberty is chiefly determined 
 by the perfection of character and the sufficiency of 
 amount of the vaccination that' has been performed. 
 Even when the vaccination has been the most imper- 
 fect, leaving but a single mark of indifferent character, 
 the disease is still in most instances modified in its 
 course, and is not fatal in one third the proportion of 
 cases in which natural small-pox is fatal ; but when the 
 vaccination has been done in the best known manner, 
 the modification is so general and so great that the 
 proportion of deaths to attacks is scarcely more than 
 one-seventieth part of that which occurs in the natural 
 disease. 
 
 8. It is therefore a matter of vital importance with 
 regard to the controlling small-pox through the agency 
 of vaccination that the vaccination should be always 
 done in the best known manner. 
 
 9. The protective influence of vaccination extends to 
 all climates and all races ; and in countries where the 
 practice is general, the small-pox mortality has declined 
 under its influence to a fraction of that which formerly 
 prevailed. In England, notwithstanding a very serious 
 amount of neglect, and an average performance of the 
 operation susceptible of very great improvement, it has 
 reduced the death-rate by small-pox to one-fifteenth 
 part of what it was at the close of last century. 
 
 10. A strict enforcement of vaccination in early in- 
 fancy, and the most scrupulous care as to the complete 
 and perfect performance of vaccination, would further 
 reduce to a small fraction of its present amount the 
 still considerable small-pox mortality of this kingdom.
 
 OF REVACCINATWN. 299 
 
 CHAPTER XII. 
 
 OP REVACCINATION. 
 
 99. Purposes for which Revaccination is necessary. 
 — It was a cardinal rule with Jenner, and has ever 
 been the practice of those who have been careful to fol- 
 low his precepts, whenever any irregularity had oc- 
 curred in a vaccination, to warn the parent or other 
 person concerned that such vaccination could not be 
 relied on as securing against small-pox, and that the 
 process must either immediately, or at some suitable 
 time, be renewed: and it would have saved many a dis- 
 appointment, and added greatly to the confidence of 
 the public, if Jenner's practice of watching vaccinations 
 throughout their course with a view to the application, 
 in all necessary cases, of this essential rule, had been 
 uniformly adopted. Many of the cases of post-vaccinal 
 small-pox which are met with in practice are in persons 
 whose vaccination had been irregular or imperfect. 
 When, also, after a lapse of years, it became evident 
 that some individuals, whose vaccination had been 
 normal in its course, might yet afterward be suscepti- 
 ble of small-pox infection, and that these cases occurred 
 chiefly to persons who were grown up, the idea of re- 
 newing the vaccine process, once or oftener, in the life- 
 time of each individual, naturally suggested itself. 
 When, further, the necessity of a certain amount of 
 local infection in vaccinating was recognized, revaccina-
 
 300 HANDBOOK OF VACCINATION. 
 
 tion was looked to for supplying this amount in cases 
 in which in the original vaccination it had been deficient. 
 Hence the present practice of revaccination aims at 
 much more than Jenner thought of: it aims not only 
 (1) at repairing whatever was irregular in the course 
 of a primary vaccination, but also (2) at supplying 
 what was imperfect in the amount of infection in cases 
 in which the course of the disease was regular, and 
 further (3) at extinguishing the susceptibility to small- 
 pox which may remain, or may rearise, in an inde- 
 terminate number of persons whose primary vaccina- 
 tion may have been complete as well as regular. 
 
 100. Carelessness in Primary Vaccination not to he 
 excused on the ground that Revaccination will make 
 good its defects. — But before proceeding to consider 
 the rules under which revaccination should be practiced, 
 one important preliminary observation must be made. 
 No practitioner should ever allow himself to neglect or 
 overlook any means in his power of making a primary 
 vaccination perfect, under the notion that imperfection 
 may easily be made right by revaccination. This 
 caution is not offered without ample experience that it 
 is called for; cases having come to my knowledge not 
 unfrequently in which lymph had been used of the effi- 
 ciency of which the practitioner had himself doubts, in 
 the belief that it might take, and that if it did not take, 
 no harm was done, as it was easy to repeat the opera- 
 tion. And what has happened again and again under 
 such circumstances has been this : the vaccination has 
 taken, but it has taken badly ; either at once, or at some 
 no distant period, the vaccination has been repeated, 
 and perhaps done a third time, but ineffectually (for it 
 will constantly happen that spurious vaccination will
 
 OF REVACCINATION. 301 
 
 prevent subsequent vaccination from taking effect prop- 
 erly) ; then no more is thought about it, or the child is 
 perhaps declared "insusceptible;" it grows up, gets 
 small-pox, and very likely dies. Or, probably, the 
 parents were directed to bring the child again at some 
 specified time, and failed to do so, and the same fate 
 as in the other case befalls it. Take it at the best, an 
 originally imperfect or incomplete vaccination is a very 
 great misfortune. 
 
 101. Age, etc. at which Revaccination should be 
 performed. — But, supposing it to have occurred, how 
 is the practitioner to act? Is he to revaccinate at 
 once, or is he to wait till after puberty, when, as we 
 have seen, the danger of insufficient vaccination chiefly 
 manifests itself? He must be guided in determining 
 partly by the degree of imperfection, and partly by the 
 liability to exposure to small-pox. 
 
 (a) Circumstances under which it is called for in 
 Childhood. — If a vaccination is found on inspection 
 imperfect in character, if it is spurious, irregular, or 
 disturbed and spoilt in its course, the first thing would 
 be to ascertain whether there might not be something 
 in the child's then state of health which had been over- 
 looked, but which might account for these irregularities 
 or imperfections. If such should turn out to be the 
 case, this must be corrected before any attempt is made 
 to revaccinate the child ; but if there should be nothing 
 of this kind, the vaccination may be repeated at the 
 earliest opportunity. Probably the revaccination will 
 not take, at all events will not take properly; but it 
 may take perfectly. Anyhow the chance must be 
 given, and given with the utmost care to produce 
 effect. When local result follows, even though it be 
 86*
 
 302 HANDBOOK OF VACCINATION. 
 
 only the spurious or modified effect generally following 
 the revaccination of a properly vaccinated person, the 
 practitioner will have done all he can at the time, and 
 need recommend no further proceedings till puberty— 
 at all events unless there should arise some immediate 
 danger of small-pox. But if there be no local evidence 
 that the lymph applied on the revaccination had been 
 absorbed, the operation should be repeated at intervals 
 until he is satisfied that the child is, for the time at all 
 events, insusceptible. Supposing, however, the defect 
 of the primary vaccination to have consisted, not in im- 
 perfection of character of the vesicle induced, but in an 
 insufficient amount, or dose, if I may so say, of vac- 
 cination — that is, supposing one vesicle only to have 
 risen instead of the four or five the operator had de- 
 sired to produce, but that vesicle a good one — revac- 
 cination may, except under circumstances of immediate 
 danger, be left with propriety until the child grows up. 
 
 We should be guided by similar rules in determining 
 from the cicatrices left on the arms of young children 
 whether revaccination is called for. If these be de- 
 cidedly imperfect in character, revaccination should 
 be performed with as little delay as possible : but if 
 the cicatrices be deficient in number only, or if the 
 character, though less strikingly good than it might be, 
 is yet genuine, the child may be considered safe up to 
 the age of puberty, but its revaccination at, or soon 
 after, that period of life, should be strictly enjoined. 
 
 But when there is immediate exposure, or much risk 
 of exposure, to small-pox infection, — when children 
 are in a house, or in a crowded court, in which there, 
 is a case of small-pox, — revaccination may with pro- 
 priety be carried further : those children who have
 
 OF REVACCINATION. 303 
 
 marks at all imperfect, or who have not at least two 
 decidedly characteristic marks, should, unless revac- 
 ciuation have already been tried upon them with local 
 result, be revaccinated. 
 
 (b) It should be performed on all persons after 
 Puberty. — Revaccination about or after puberty is of 
 extreme importance when the primary vaccination has 
 been anything short of Marson's highest class, and is 
 necessary in proportion as it falls short of it : but it 
 seems also certain that a revaccination at or after 
 this period of life, may give additional security to 
 many whose original vaccination has been complete. 
 In some of these, as we have already seen, the suscep- 
 tibility to variola is not wholly exhausted, and such 
 may contract the disease, though no doubt with slight 
 comparative danger, after growing up. But even in 
 its most modified form, small-pox is a disease which 
 all would desire to escape, and well conducted revac- 
 cination appears to afford a very sure and reliable 
 means of such escape. After successful revaccination, 
 small-pox, even of the most slight or modified kind, is 
 rarely met with. Thus, Heim found that in five years 
 there occurred among 14,384 revaccinated soldiers in 
 Wirtemberg, only one instance of varioloid, and among 
 30,000 revaccinated persons in civil practice, only two 
 cases of varioloid (one of which was, probably, really 
 a case of chicken-pox), though during these years 
 small-pox bad prevailed in 344 localities, producing 
 1674 cases of modified or unmodified small-pox among 
 the not revaccinated, and in part not vaccinated, popu- 
 lation of 363,298 persons in those places in which it 
 had prevailed. In the Prussian army, since the intro- 
 duction of systematic revaccination in 1834, the cases
 
 304 HANDBOOK OF VACCINATION. 
 
 reported as "varioloid," and still more those called 
 " variola," have been nearly all of them among that 
 portion of recruits whose turn for revaccination had 
 not come, or whose revaccinations had not been suc- 
 cessful, or who were incubating small-pox when they 
 were revaccinated ; in the twenty years which imme- 
 diately succeeded the adoption of this system there oc- 
 curred altogether but forty deaths from small-pox in 
 this large army — or an average of two deaths per an- 
 num — only four of the entire forty being in persons 
 who (it was said) had been successfully revaccinated. 
 So, in the Bavarian army, in which there has been 
 compulsory revaccination since 1843, there had not, 
 from that date up to the time of a report made by the 
 Minister of War in 1855, been a single case of unmodi- 
 fied small-pox, and only a very few cases of modified 
 small-pox without any deaths. And other national 
 experiences might be cited to the like effect.* Nothing 
 can put in a stronger light the value of revaccination 
 than Marson's statement of his experience at the 
 Small-pox Hospital. He tells us, firstly, that during 
 the period of his connection with the hospital, not one 
 of the nurses or servants had taken small-pox during 
 her residence there, each one of them who had not al- 
 ready had small-pox having been carefully revaccin- 
 ated before being allowed to enter on her duties ; 
 and, secondly, that when the new hospital was built 
 (some thirteen or fourteen years ago), and a large 
 number of workmen were there employed for several 
 months after the arrival of the patients, most of the 
 workmen consenting to be revaccinated, not a single 
 
 * See Sirnon, Papers relating, etc., pp. xxxv. xxxvi.
 
 OF REVACCIXATION. 305 
 
 case of small-pox occurred among those so consenting, 
 while twocases of the disease did occur among the few 
 who were not revaccinatcd.* In places where small- 
 pox has been epidemic, the total, or all but total, ex- 
 emption of revaccinated persons, when others who had 
 been vaccinated in childhood, but not revaccinated 
 since, were in some proportion attacked, has been 
 matter of quite familiar observation among medical 
 practitioners. The reports of the Academie Imperiale 
 de Medecine abound with such cases ;f and from them, 
 and other sources, many instances might be cited pre- 
 cisely parallel to Marson's observations on the work- 
 men at the Small-pox Hospital — instances in which 
 the revaccinated members of an infected family es- 
 caped any form of infection, while those who had 
 declined revaccination, had to sustain an attack of 
 small-pox. Nor, wherever smalJ-pox has broken out 
 in public institutions, and means have been at once 
 taken to revaccinate those adolescents or adults who 
 had not before been revaccinated, and those children who 
 properly required it, am I aware of a single instance 
 in which the disease has not been summarily brought 
 to an end. 
 
 From these considerations we draw the important 
 practical rule, that every person should take care to be 
 
 * Marson in Medico-Chir. Trans., vol. xxxvi. (op. cit.). 
 He had then been connected with the hospital above seven- 
 teen years : but the statement with regard to the nurses holds 
 equally good now, after a connection of more than thirty-two 
 years. 
 
 f Rapport de l'Academie Imp. de Med. sur les Vaccinations, 
 etc., 1847, p. 16; 1848, p. 21; 1849, p. 19; 1852, p. 50; 1853, 
 p. 14 seq.; 1854, p. 14 seq., etc. etc.
 
 306 HANDBOOK OF VACCINATION. 
 
 revaccinated about, or soon after, the period of puberty. 
 Under ordinary circumstances, about fifteen years of 
 age is the best time for it to be done; and it should not 
 be left much beyond this, for the age of most danger 
 from post-vaccinal small-pox is from fifteen to twenty- 
 five. On the other hand, where there is any unusual 
 risk of small-pox, as in localities in which the disease 
 is prevailing, it would be imprudent to wait so long, 
 and the re vaccination may be done at any period after 
 twelve years of age, or, in individual cases, even earlier 
 than this. In girls, especially, in whom the changes 
 connected with puberty manifest themselves early, re- 
 vaccination may be performed correspondingly early. 
 The degree, however, in which vaccinated persons, 
 when they are grown up, stand in need of revaccina- 
 tion, is, I repeat, very different. Those who have im- 
 perfect marks need it much more than those whose 
 marks are characteristic; those who have but one or 
 two good marks much more than those with three or 
 four. Small, indeed, as the risk of contracting the 
 variolous infection in any form is to those who have 
 been thoroughly vaccinated, who have four good marks 
 of their vaccination, and infinitely small as is to them 
 the risk of having it severely, it is a risk not worth the 
 running ; and as no individual can tell whether he is 
 one of the wholly protected majority, or one of the 
 but partially protected minority, it is the part of wis- 
 dom, even for the best vaccinated, to seek the addi- 
 tional security of a revaccination. 
 
 102. Kevaccination requires the same care and 
 pains in its performance as Primary Vaccination. — 
 In revaccinating — if revaccination is to be anything 
 more than a deception and a sham — the same care must
 
 OF REVACCINATION. 307 
 
 be used, and as much pains taken to insure succeess, 
 as in performing a primary vaccination. Revaccina- 
 tion should be done, as far as possible, from the arm, 
 and the lymph must be always of the very best. No 
 doubtful lymph must ever be used. " L'essentiel,"says 
 Bousquet, " est de n'employer a la revaccination qu'un 
 vaccin dont on soit parfaitement sur, sinon l'epreuve ne 
 meriterait aucune confiance . . . Cependant nous avons 
 connu des medecins qui se servaient de vaccin sec, con- 
 serve sur verre ; ils echouaient le plus souvent, et de 
 leurmauvais succes ils concluaient hardimental'inutilite" 
 de la revaccination. C'est aussi pour eux que nous 
 disons qu'elle est sans valeur 1 'experience >dont on peut 
 rejeter le mauvis succes sur le vice des procedes ou sur 
 la maladresse de l'artiste."* But much worse than the 
 negative mischief arising from the use of dry lymph 
 has been the positive, as well as negative, mischief 
 which I have known result from using the lymph of 
 revaccinations. Several instances of this have fallen 
 under my observation. The practice cannot be too 
 strongly reprehended. Even with the best lymph, and 
 with every care, we shall meet with failure in a very 
 large proportion of cases, probably from a third to a 
 half of those operated upon ; and in many or most of 
 these an immediate repetition of the operation may not 
 be attended with success. Such cases should be noted 
 for a further trial at some future time. But persons in 
 whom the revaccination has so far taken as to give 
 clear evidence that the lymph was absorbed (§ 47 — for 
 it is only in a minority of the operations that the same 
 degree of success as attends a primary vaccination is 
 
 * Rapport de l'Acad. Imp. de Med. 1854, p. 21.
 
 308 HANDBOOK OF VACCINATION. 
 
 attained) may feel themselves perfectly safe — that is to 
 say, as safe as any human proceeding- can make them — 
 against future small-pox. The experience of the Small- 
 pox Hospital with regard to their servants and nurses 
 may be appealed to confidently in proof of this. The 
 repetition of revaccination every five or seven years, 
 or at whatever other intervals people may choose ar- 
 bitrarily to fix, or whenever they get frightened because 
 an epidemic of small-pox is about, is mere trifling, — a 
 practice unsupported by reason or by observation. In 
 so far as it may be thought well in particular cases to 
 use it to meet the caprices of a timid patient, I have 
 nothing more to say against it than that I think it be- 
 hooves us, as members of the medical profession, to be 
 the leaders rather than the followers of the public in 
 these matters. But the practice is wholly uncalled for. 
 One thoroughly good primary vaccination to start with 
 (for that is, as Marson says, the sheet-anchor), and one 
 careful revaccination after puberty, so conducted as to 
 give evidence that the lymph was absorbed, are all 
 that is necessary for complete protection — protection 
 as complete as any known proceedings can give — 
 against small-pox. If the primary vaccination have 
 not been thorough, it must be reserved for medical 
 judgment to determine whether, and when, in that par- 
 ticular case, revaccination before puberty might be de- 
 sirable : and in the preceding subsection I have en- 
 deavored to state what, as it appears to me, should 
 determine that judgment. 
 
 103. The performance of Revaccination should not 
 be left to periods when Small-pox is epidemic— As 
 revaccination is, like primary vaccination, a strictly 
 precautionary measure, it is needless to say that we
 
 OF RE VACCINATION. 309 
 
 ought not to wait till small-pox is at hand to have it 
 performed. The revaccination of persons as they reach 
 about fifteen years of age should be as systematically 
 done as is the vaccination of young infants. My expe- 
 rience of revaccination, as it is at present conducted 
 in England, has shown me that, except by an intelli- 
 gent few, it is only practiced at times when small-pox 
 is epidemic, and people under the influence of panic. 
 It is then generally done with very little selection, and 
 more 1 according to the fears of individuals than accord- 
 ing to the judgment of the practitioner. It is squan- 
 dered accordingly where it is not wanted at all, or is 
 of very little moment, and is frequently omitted in the 
 very cases in which it is most urgently necessary. Be- 
 sides which, a pressure for lymph is in this way often 
 put upon the practitioner which it is very difficult for 
 him to meet. If careful arrangements be necessary to 
 carry on a series of primary vaccinations, most of which 
 will be reproductive of lymph fit for use, how much 
 more to carry on a large series of revaccinations, which 
 exhaust, but do nothing to replenish the operator's 
 lymph-supply. Under these circumstances there is a 
 temptation — a temptation, I regret to say, not always 
 resisted — to use any sort of lymph, and even to em- 
 ploy the lymph of revaccinations. If the public can 
 only be made to understand how much worse an arti- 
 cle they run a risk of getting by putting off their pre- 
 cautionary measures to a period of panic, they will be 
 more careful, I apprehend, than heretofore to get their 
 revaccination done beforehand. 
 
 Under the regulations which are now in force for 
 public vaccination, the vaccinators are authorized to 
 revaccinate at the public expense all applicants above 
 
 27
 
 310 HANDBOOK OF VACCINATION. 
 
 fifteen years of age who have not before (so far as can 
 be ascertained) been successfully revaccinated, or, if 
 there be immediate danger of small-pox, all who have 
 attained the age of twelve years. 
 
 104. Local results of Revaccination : no indication 
 is derivable therefrom as to the person's liability to 
 contract Small-pox. — The immediate results of the 
 performance of revaccination may be either the com- 
 plete umbilicated vaccine vesicle (§ 34), or the modi- 
 fied vesicle or papule (§ 47), or entire failure. The 
 following table, exhibiting the results of revaccination 
 on each 1000 individuals revaccinated in the Wirtem- 
 berg army in 1831-5, and in our own army in 1861, 
 appears to me to represent a larger ratio of complete 
 results (perfect vaccine vesicles) than we ordinarily 
 meet with in civil practice,* but there is no statistical 
 record of re vaccinations in civil practice made on so 
 large a scale as would justify me in presenting it. It 
 shows, at all events approximately, what may be 
 looked for in the revaccination of adults generally. 
 
 * The proportion of complete successes in revaccination 
 reported in the annual returns of the British army, varies 
 greatly in different years, and in the same year in different 
 corps. It has sometimes been such as to lead to the belief 
 that proper judgment was not exercised in discriminating the 
 perfect and the modified vesicle, and toward the end of 1865 
 a circular was addressed to the medical officers on this subject 
 by the Director-General.
 
 OF REVACCINATION. 
 
 311 
 
 
 
 L. X 
 
 * 2 
 
 1 
 
 • 2 
 
 
 a 
 
 Cur 
 
 
 
 if 
 
 £"3 
 
 lid 
 
 o o-3 
 
 III 
 
 o*5 
 
 
 Persons in whom the 
 
 . Degree of 
 
 ■2 1 
 
 la § 
 
 3£S 
 
 Oca 
 
 Ro vaccinations were 
 performed. 
 
 Success of 
 Revaccination. 
 
 
 ■S'SJ 
 
 * | a 
 
 J feu 
 
 1° § 
 
 
 
 HO 
 
 "1 
 
 o-— £ 
 
 So* 
 
 aj3 = 
 
 
 
 *H 
 
 
 a 
 
 H 
 
 s 
 
 Wirtembprg Army, 
 1831-5 
 
 (13,861 cases). 
 
 
 319-5 
 
 310-4 
 
 280-7 
 
 337-3 
 
 
 2481 
 432-3 
 
 1000 
 
 280-5 
 409-2 
 
 259-0 
 460-4 
 
 1911 
 471-6 
 
 1000 
 
 
 
 1000 
 
 1000 
 
 Soldiers in Brit. Army, 
 not recruits, in 1861 
 
 
 451-4 
 
 484-6 
 
 236-8 
 
 3260 
 
 
 159-6 
 
 157-4 
 
 505-3 
 
 277-5 
 
 (2053 ciiaes). 
 
 None - 
 
 389-0 
 
 3580 
 
 257-9 
 
 396-5 
 
 
 
 1000 
 
 1000 
 
 1000 
 
 1000 
 
 Recruits in Brit. Army, 
 in 1861 
 
 
 345-5 
 
 407-3 
 
 461-3 
 
 527-3 
 
 
 266-8 
 
 240-8 
 
 301-3 
 
 202-6 
 
 (4395 cases). 
 
 
 387-7 
 
 loot) 
 
 351-9 
 
 "iooo 
 
 237-4 
 
 270-1 
 1000 
 
 
 1000 
 
 One important practical conclusion we clearly derive 
 from this table, and from the large experience which is 
 now accumulated on the subject of revaccination. 
 The local results obtained by the revaccination of any 
 individual give us absolutely no information whatever 
 as to the constitutional condition in which the re-vac- 
 cinated person was with regard to liability to contract 
 small-pox. It has frequently been argued, and is in- 
 deed often to be heard said now, that if a revaccination 
 cannot be made to take, or if it take only in a modified 
 way, it is evidence that the constitution would not at 
 the time take small-pox ; whereas, if a complete local 
 result follow, it may be assumed that the protection of 
 the primary vaccination had worn out, and that the 
 person was in danger, or at all events in more danger
 
 312 HANDBOOK OF VACCINATION. • 
 
 than in the former case, of taking the variolous infec- 
 tion. Now, if this were so, the Wirtemberg results 
 would prove that 319 out of every thousand persons 
 who had had small-pox, 310 out of every thousand who 
 had been well vaccinated, but only 281 out of every 
 thousand who had been ill vaccinated, were in present 
 danger of taking small-pox ; and of the soldiers (not 
 recruits) in our own army, 451, 485, and 237 would rep- 
 resent the ratio in the three classes respectively, which 
 is clearly a reductio ad absurdum. M. Yleminkx, find- 
 ing the results of his revaccinations of the prisoners 
 in Belgium more successful in those who had marks of 
 small-pox than in those who had good marks of vac- 
 cination, in the proportion of 30 per cent, of the former 
 to 19 per cent, of the latter, argued that it was more 
 important to vaccinate persons who had had small-pox 
 than to revaccinate persons who had good marks of 
 vaccination: with perfect logical consistency, if only 
 the premises were sound that the " taking" of vaccine 
 in a protected person shows anything whatever with 
 regard to the liability to receive variola. Jenner 
 himself distinctly pointed out that this was not the 
 case. "Although," he says in his first Tract, "the 
 cow-pox shields the constitution from the small-pox, 
 and the small-pox proves a protection against its own 
 future poison, yet it appears that the human body is 
 again and again susceptible of the infectious matter of 
 the cow-pox :"* and he gives instances in which the 
 cow-pox was thus taken twice or thrice by persons who 
 could not be variolated either by inoculation or by 
 exposure. Further, in one of his subsequent essays, 
 
 * Obs. on the Variolae Vaccinae, p. 21.
 
 OF REVACCINATION. 313 
 
 speaking- of the vaccination of those who had already 
 had small-pox, he observes that " although the suscep- 
 tibility of the virus of the cow-pox is for the most part 
 lost in those who have had the small-pox yet in some 
 constitutions it is only partially destroyed, and in 
 others it does not appear to be in the least diminished. 
 By far the greater number on whom trials were made 
 resisted it entirely ; yet I found some on whose arms 
 the pustule from inoculation (vaccination) was formed 
 completely, but without producing the common efflores- 
 cent blush around it, or any constitutional illness, while 
 others have had the disease in the most perfect man- 
 ner."* Exactly in the same way, as he pointed out, 
 the perfect variolous pustule, a pustule capable of com- 
 municating variola to others, may be raised in the skin 
 of a person who has had variola without in the least 
 degree giving him a second time the disease variola.f 
 The utility and necessity of revaccination do not 
 stand on any speculative reasoning from the local phe- 
 nomena it develops, but upon broad grounds of observ- 
 ation and experience. 
 
 * Continuation of Facts, etc. 
 
 f " Upon the skin of every human being that possesses a 
 more than ordinary share of irritability, the insertion of the 
 variolous virus ( whether the person has previously had the cow- 
 pox or small-pox) will produce either a pustule or a vesicle 
 capable of communicating the small-pox, and frequently at- 
 tended with extensive inflammation." (Letter to Mr. Bod- 
 dington in Baron's Life, vol. i. p. 445.) 
 
 27*
 
 314 HANDBOOK OF VACCINATION. 
 
 CHAPTER XIII. 
 
 OF STAMPING-OUT LOCAL OUTBREAKS OF SMALL-POX. 
 
 105. Universal Vaccination would render the dan- 
 gers of Small-pox quite inconsiderable. — If all the 
 children throughout the kingdom were properly vac- 
 cinated in early infancy, as the law requires, with due 
 care to watch the process in each instance, and to 
 remedy in any spurious, doubtful, or imperfect case 
 what had been amiss — still more surely if, as each child 
 attained puberty, the vaccination were repeated — we 
 should soon, I apprehend, have little or no small-pox 
 current among us. At all events, the risks of importa- 
 tion of the disease into any locality would be as no- 
 thing to what they now are, and there would be little 
 or no danger of its ever spreading : for when an impor- 
 tation did take place, our anxieties being limited to 
 that small and manageable part of the population, on 
 whom, on account of their tender age or indifferent 
 health, vaccination had not yet been done, the easy 
 task of vaccinating immediately such of those as ran 
 any risk of exposure to the infection would soon be 
 accomplished. 
 
 106. Dangers to which now the Careful are sub- 
 jected by the Careless. — But, as things now are, with 
 whatever care the local authority or the local officers of 
 particular districts or places may keep their native 
 populations protected, they cannot avoid the risks
 
 OF STAMPING-OUT SMALL-POX. 3J5 
 
 arising both from the immigration into their districts of 
 unprotected families, and from the frequent importation 
 of small-pox from other and neglected places. Thirty 
 times in one year, as we have seen, was small-pox im- 
 ported into the district of Mold, chiefly from neglected 
 Liverpool ; and though the precautions taken and the 
 vigilance exercised in that district were quite sufficient 
 to prevent the disease from spreading from any one of 
 these centers of infection, — for nowhere, where due 
 vigilance is used, need small-pox spread, — still the 
 strain at present imposed upon those who are careful 
 by those who "are careless is very great. 
 
 107. Steps that should be taken immediately on 
 Importation of Small-pox to prevent its spreading. — 
 When a case of small-pox is imported anywhere, the 
 first thing must be to isolate it as far as possible. When- 
 ever an airy room can be given up to it, there will be 
 no necessity whatever to move the case to a hospital, 
 even where the opportunity for such removal exists; 
 but where, as among most of the laboring classes, etc., 
 there are no such means of isolation, but the case would 
 have to remain in a room to which many must have 
 access, and in which perchance some part of the family, 
 or perhaps the whole family, might be sleeping, if not 
 altogether living, removal to a hospital, or place of 
 proper isolation, is of the utmost consequence, and 
 wherever it is practicable should never be omitted. It is 
 greatly to be lamented that there are not provided, as 
 there ought to be, within the bounds of every sanitary 
 jurisdiction in the kingdom, and especially in every 
 town, places for the reception of cases of small-pox, 
 and of the other infectious fevers, with a view to their 
 isolation and treatment ; and it is to be hoped that the
 
 316 HANDBOOK OF VACCINATION. 
 
 powers which the Sanitary Act has conferred on local 
 authorities for this object will not be suffered to remain 
 dormant * 
 
 The next thing- is to take care that those who have 
 to deal with the case, or are likely in any way to come 
 in contact with it, are thoroughly protected. The arms 
 of all in the house must at once be examined; the un- 
 vaccinated must be vaccinated without any delay ; the 
 inmates above twelve years of age who have not already 
 been successfully vaccinated since attaining that age, 
 should be revaccinated, and if all cannot be done at the 
 same time those should be done first whose marks are 
 the most imperfect, or the fewest; and (though this 
 can well afford to be left till the other things have been 
 looked to) the vaccinated children who have not at least 
 two marks of good quality should also be revaccinated. 
 When the house is situated in a crowded court, it is 
 well to extend these precautionary measures at once to 
 the other houses in the court. 
 
 And the last thing — never to be omitted — is care- 
 fully to disinfect every article of clothes, bedding, etc. 
 which have been used for the sick person, and after the 
 
 * This is really a matter of the most urgent necessity. It 
 is often now a very difficult thing to know how to dispose of 
 a case of small-pox when it occurs ; and in the anxiety of one 
 parish to get rid of it, and the determination of another not 
 to receive it, I have known the most cruel things done. But 
 hesides the means of isolation, so immediately called for, an 
 eventual want is the power of compelling it (not necessarily, 
 of course, in a hospital, but in some way that should be ap- 
 proved by a competent authority) ; and there should certainly 
 be some severe penalty on concealment of the existence of 
 small-pox.
 
 OF STAMPTNG-OUT SMALL-POX. 31? 
 
 disease is over to disinfect the room and the furniture 
 of the room in which the case has been. 
 
 These measures, thoroughly and promptly carried 
 out, are pretty certain to limit the attack to the im- 
 ported case or cases, when the surrounding population 
 generally is in a good state of protection, and I have 
 again and again known them successful when the sur- 
 rounding population generally was but very imper- 
 fectly protected. A community imperfectly protected 
 is subject, however, to two great risks of the infection 
 spreading, which all the injunctions of the practitioner 
 with regard to isolation may not suffice to guard 
 against: (1) whether from mistaken kindness or from 
 love of gossip, a case of small-pox really appears fre- 
 quently to be an attraction to the neighbors, and the 
 infected house a favorite place of rendezvous ; and if 
 it be a mild case in a child, it is pretty certain that 
 some of the neighbors' children will be sent in to play 
 with the patient; and (2) from the great modification 
 small-pox generally undergoes in the vaccinated, there 
 is often so little illness that it is very difficult to 
 keep the patient even in doors, and much less in a par- 
 ticular room or part of a house ; and as the disease 
 has, by its modification, lost nothing of its power of 
 infecting others, it is constantly becoming diffused in 
 this way, in spite of all warnings, and in spite of the 
 prohibitions of the law.* Hence whenever there is 
 
 * Under the thirty-eighth clause of the Sanitary Act, 1866, 
 persons exposing themselves, or their children, or others af- 
 fected with small-pox, in the streets, or in any public places, 
 or public conveyances, may be proceeded against summarily; 
 before that enactment, they could only be punished by the 
 tedious and expensive process of indictment. See on this, and
 
 318 HANDBOOK OF VACCINATION. 
 
 importation of small-pox into a badly protected district, 
 it is a very urgent matter, as soon as the immediate 
 surroundings of the imported case or cases have been 
 looked to, to work up, if I may so say, the general 
 vaccination of the district. 
 
 108. Steps necessary to arrest it when it has begun 
 to spread. Necessity for Prompt Action. — When to 
 the earliest cases of small-pox no such barriers as I 
 have described have been opposed, or when these bar- 
 riers have been overleapt, and the disease has begun 
 to spread, this spread is at first generally slow, and 
 many weeks elapse before there is anything like epi- 
 demic diffusion. And it depends entirely on whether 
 advantage is taken of this interval or not, whether 
 there ensue, even in places in which vaccination had 
 been much neglected, an inconsiderable or a formidable 
 mortality. If we take, for example, the outbreaks of 
 small-pox which occurred in Cardiff and in Sheffield, 
 in 1857, both atttended with enormous mortality in 
 unvaccinated young children, and the progress of which 
 was as follows — 
 
 on the powers of local authorities with regard to disinfection, 
 "The Sanitary Act, with Introduction, etc., hy J. B. Hutchins: 
 Knight & Co."
 
 OF STAMPING-OUT SMALL-POX. 
 
 319 
 
 1857. 
 
 January.... 
 February., 
 
 March 
 
 April 
 
 May 
 
 June 
 
 July 
 
 August.... 
 September 
 October.... 
 November 
 December 
 
 Total. 
 
 Deaths from Small-pox. 
 
 Cardiff (town). Sheffield 
 
 1 
 
 1 
 
 5 
 
 8 
 
 42 
 
 35 
 
 19 
 
 14 
 
 14 
 
 13 
 
 7 
 
 2 
 
 161 
 
 3 
 
 3 
 
 10 
 
 14 
 
 16 
 
 132 
 
 178* 
 
 — we see at once what opportunity there had been in 
 the earlier weeks for repairing the gross neglect of vac- 
 cination that had existed in these places, and for thus 
 arresting the further spread of the disease. And what- 
 ever town, or whatever epidemic period, might be se- 
 lected, the same thing would be shown : Slow progress 
 of the epidemic at first, affording yet a period for re- 
 pairing neglect, and subsequent progress dependent 
 entirely on the activity or inactivity with which the 
 outbreak had been met. 
 
 In 1858, when there were 111 deaths from small-pox 
 
 * And these were but the prelude to a still more formidable 
 amount of mortality next year, when the deaths from this 
 cause were 290. There has certainly existed heretofore a very 
 scandalous neglect of vaccination in Sheffield ; but active 
 measures, I am informed, are being taken under the powers 
 of the new law to remedy this lamentable state of things.
 
 320 HANDBOOK OF VACCINATION. 
 
 in the union, and chiefly in the town, of Carmarthen, 
 there had, as in the foregoing instances, been plenty of 
 warning of the approach of the disease from adjacent 
 rural districts ; and even after it had reached the town 
 there had been plenty of time to prevent the catas- 
 trophe which occurred, for it was not till after a four 
 months' sojourn that extensive spread occurred : some 
 forty or fifty cases and eight deaths represented the 
 extent of the mischief done during the first sixteen 
 weeks. In the town and district of Carnarvon, where 
 in 1859 there were sixty deaths from small-pox, and in 
 the City of York, where in 1862 there were above a 
 hundred deaths from this cause, there had been the 
 same warning of approach, the same gradual progress 
 of the disease at first, the same supineness and indif- 
 ference in dealing with it. But in the official reports* 
 in which these and other similar cases are recorded, 
 instances will be found, on the other hand, in which 
 under the like circumstances of antecedent neglect, the 
 activity of the local authorities, or of the local officers, 
 either arrested the outbreak altogether, or limited its 
 spread, and rendered the mortality comparatively 
 trifling. One illustration here must suffice, not se- 
 lected by any means because it was the most complete 
 in its results, but rather because the local difficulties 
 that had to be met were considerable. When small- 
 pox broke out in Gravesend in 1860, there were great 
 arrears of vaccination. The first step taken was the 
 issuing by the local authority, on the representation of 
 the public vaccinators, of cautionary notices; as soon 
 
 * Annual Reports of the Medical. Officer of the Privy Coun- 
 cil, iii.-vii. inclusive.
 
 OF STAMPING-OUT SMALL-POX. 321 
 
 as the disease began to spread, the managers of all the 
 public schools insisted on the immediate vaccination of 
 any unvaccinated children in attendance ; and the In- 
 spector of Police made personal inquiry, founded on 
 the birth-registers and on his local knowledge, respect- 
 ing unvaccinated children. When these were found, 
 they were not lost sight of till they were vaccinated. 
 The population being thus put in a comparatively well- 
 protected condition, the consequence was that, though 
 the epidemic lasted altogether more than a year, there 
 were but four deaths from small-pox in children ille- 
 gally unvaccinated : there were eleven other deaths 
 from this cause, but five of these were in adults, and 
 two in young babies born at the time their mothers 
 were suffering from the disease.* 
 
 Directly, then, that in any district small-pox has 
 begun to spread beyond its points of importation, the 
 utmost vigilance and promptitude of action of the local 
 authority are called for. Whatever arrears of primary 
 vaccination may exist must be immediately dealt with ; 
 and all the means with which the law has armed local 
 authorities for finding out the unvaccinated population, 
 and obtaining their protection, at once exercised f 
 
 * The remaining four were in children not subject to the 
 provisions of the compulsory law. 
 
 f Systematic inquiries respecting young children (under two 
 years of age) whose successful vaccination has not been regis- 
 tered, is one important means. Hereafter, this is directed to 
 take place regularly every six months, irrespective of whether 
 small-pox be present or not. Another important rrieans is the 
 examining the children attending various charitable schools, 
 especially infant schools. If all the managers of such schools 
 would make it an absolute rule not to admit any child without 
 28
 
 322 HANDBOOK OF VACCINATION. 
 
 And those adults or adolescents who have not already, 
 since growing up, been successfully revaccinated, 
 should be urged to avail themselves at once of the re- 
 vaccination which is everywhere freely provided for 
 them (page 308). But the essence of the complete 
 success of these measures lies in their being taken 
 without delay. So long as local authorities will make 
 light of " a few" cases of small-pox, and hesitate to 
 take efficient steps " for fear of creating alarm," so long 
 will epidemic outbreaks flourish. 
 
 109. Steps necessary for its Arrest when it has be- 
 come extensively diffused. — But suppose these import- 
 ant steps have been thus improperly delayed, and that 
 the place has become thoroughly infected before any 
 active measures of suppression have been adopted. 
 Even under these adverse circumstances, it is quite 
 possible to arrest within a very short time the fatality 
 of the disease, and, in a little while further, to extin- 
 guish it altogether. But the measures which almost 
 certainly would have sufficed before, will not now be 
 enough, and others must be taken adequate to the 
 emergency. The infected localities must be mapped out 
 and systematically visited from house to house, from 
 room to room, and from child to child. Though it is 
 not in the least necessary that this visitation should be 
 made by a public vaccinator, or by a medical practi- 
 tioner, and though often, indeed, it would be a mere 
 waste of force to employ medical agency for the pur- 
 
 a medical certificate of its successful vaccination, or without 
 having its arms examined by the public vaccinator of the 
 district, it would be a very useful check upon neglect. But it 
 is not enough to make a rule : they must see that it is carried 
 out.
 
 OF STAMPING-OUT SMALI^-POX. 323 
 
 pose, yet, when other circumstances admit of such 
 employment, there are obvious advantages derivable 
 from the knowledge which medical men generally have 
 of the population, and from their influence over them. 
 Much, no doubt, will depend on the kind of population 
 which has to be dealt with. But the person employed, 
 if not a medical man, must at all events know the proper 
 characters of the vaccine cicatrix, in order that he may 
 be able to examine for himself the arms of the children 
 in the houses that he has to visit. His first and most 
 important duty in this visitation will be to see that the 
 cases found illegally unvaccinated are taken, according 
 to previous arrangement, to a vaccinator ; and he should 
 at the same time endeavor to procure the immediate 
 vaccination of unvaccinated children, who are below 
 the age at which non-vaccination becomes illegal, 
 pointing out to parents the extreme danger of delay. 
 If he meet with vaccinated children whose vaccine 
 marks are doubtful or imperfect, he should induce the 
 parents to send them for revaccination. Further, he 
 must not neglect to urge upon adults, who have not 
 already been successfully revaccinated, the necessity 
 for being revaccinated forthwith. By a judicious exer- 
 cise of firmness and kindness all this may be readily 
 done. The families visited, however, must not be lost 
 sight of: having received their directions, they must 
 be visited again, to see that these have been complied 
 with ; and they must be kept in view until their full 
 protection is obtained. If these measures be thoroughly 
 carried out, and if, as their indispensable complement, 
 measures of thorough disinfection be also steadily pur- 
 sued, the eradication of the small-pox from the locality 
 will certainly follow. But that they may "fee completely
 
 324 HANDBOOK OF VACCINATION. 
 
 effectual, they must be systematically undertaken and 
 intelligently supervised. The services of a good medi- 
 cal officer of health are here invaluable. Assuredly no 
 circumstances could have been more difficult or un- 
 promising than those under which, in 18fi0, the small- 
 pox was routed out of the crowded population of South 
 St. Giles's, London, at the height of the very severe 
 epidemic then prevalent in the metropolis. The dis- 
 ease had extended to that district in September, 1859, 
 and at first made therein its usual gradual progress : 
 but, also, as usual, after a three months' sojourn, or 
 thereabouts, the mortality from it leapt up all at once 
 from thirteen deaths, spread over a quarter of a year, 
 to nine deaths, in two weeks. Local inquiries also 
 showing the disease to be then rapidly spreading, im- 
 mediate authoritative interference was determined on. 
 The representations which, in conjunction with the 
 medical officer of health of the district, I made to the 
 Board of Guardians, led to its directing a most com- 
 plete visitation, for the purpose of which it offered to 
 put on any amount of force that might be required. 
 The public vaccinator of the district, however, under- 
 took himself to get the work done ; and so completely 
 and with such energy was it set about that, in a few 
 days, all the infected localities had been thoroughly 
 visited by himself or his deputy ; 169 children, totally 
 unprotected against small-pox, many of them in tJw 
 very houses, and some in the very rooms, with small- 
 pox cases, having been discovered and vaccinated, 
 and a number of imperfectly vaccinated children 
 having been revaccinated. The impression thus made 
 on the mortality of the small-pox was such that, ex- 
 cepting some cases which were incubating the disease,
 
 OF STAMPING-OUT SMALL-POX. 325 
 
 when they were visited, there were but three more 
 deaths from it in South St. Giles's up to the termination 
 of the epidemic in London, eight months afterward, 
 only one of these deaths being in parochial practice, 
 and that one being an accidental case four months after 
 the date of the visitation. Now that this immediate 
 arrest of the mortality was really due to the measures 
 employed, and did not arise from the epidemic having 
 happened to come to a natural termination in St. Giles's 
 just at the period these measures were taken, was not 
 only to be inferred from the large number of unpro- 
 tected persons discovered to be living within the im- 
 mediate influence of the infection, who, had they not 
 been thereupon vaccinated, would, we may be quite 
 sure, have had to sustain an attack, but was actually 
 proved by the fact, that for the first three or four weeks 
 following their adoption, the cases of small-pox in the 
 vaccinated continued to be as numerous as before,* 
 after which lapse of time this class of cases also grad- 
 ually diminished, till the disease died out altogether. 
 The cases of post-vaccinal small-pox which were ad- 
 mitted during the month preceding the visitation were 
 twenty eight, and those admitted during the month 
 
 * In correspondence, in short, with the progress of epidemic 
 force, which, according to the natural history of the disease, 
 would have manifested its continuance among the unvac- 
 cinated also at this period but for the interference which had 
 taken place; it should also be explained, in reference to these 
 post-vaccinal cases, that the primary vaccination of the locali- 
 ties visited was made complete; the revaccination, especially 
 of adults, from their being away from home at the times of 
 the visits, or in some instances from their being unwilling to 
 be revaccinated, was not so complete as was desirable. 
 28*
 
 326 
 
 HANDBOOK OF VACCINATION. 
 
 immediately succeeding it were twenty-nine. The fol- 
 lowing abstract of the small-pox register of the district 
 medical officer, for the half year during which the epi- 
 demic lasted in South St. Giles's, from October 1, 1859, 
 to March 31, 1860, — arranged in two periods, the one 
 before and the other after the house-to-house visitation 
 had time to take effect, — shows what that visitation ac- 
 comp' : shed: 
 
 
 Cases of Small-pox admitted. 
 
 IN VACCINATED 
 
 IN UNVACCINATED 
 
 
 PLRSONS. 
 
 PERSONS. 
 
 Date. 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 a 
 
 E 
 
 £ 
 
 3 
 
 5 
 
 a 
 5 
 
 3 
 
 3 
 
 1 
 
 s 
 
 £ 
 
 
 <a 
 
 
 
 
 <n 
 
 B 
 
 
 
 
 a 
 
 6 
 
 3 
 
 49 
 41 
 
 51 
 41 
 
 A 
 
 13 
 
 a 
 
 s 
 
 H 
 
 p 
 
 Oct. 1 to Jan. 21 
 
 2 
 
 1 
 
 29 
 4 
 
 12 
 
 2 
 
 41 
 
 6* 
 
 14 
 
 Jan. 21 to Mar. 31.. 
 
 
 
 In reference, however, to the measures of house-to- 
 house visitation which are necessary for thoroughly 
 eradicating small-pox when it has been allowed to get 
 epidemically diffused, it is very important to remember 
 that house-to-house visitation is not house-to-house 
 vaccination. In the visitation in South St. Giles's, 
 though it was made by medical men, they did not 
 dream, except under particular circumstances, of stop- 
 ping in each room to do the vaccinations required, but 
 had the cases brought to an appointed place by a pre- 
 organized arrangement, so that the vaccinations were 
 done direct from the arms of children. Under no cir- 
 
 * Of which three occurred in a part of the district distant 
 from that which had been visited from house to house.
 
 OF STAMPING-OUT SMALL-POX. 327 
 
 cumstances is it more important that the operation 
 should be done in a way almost sure not to fail than 
 when it is done under immediate or proximate danger 
 of small-pox. 
 
 110. Responsibility of Local Authorities for pre- 
 venting the Spread of Fatal Small-pox. — Whatever, 
 then, be the circumstances under which we have to 
 encounter small-pox — whatever its stage of diffusion — 
 we have in vaccination (including, of course, revac- 
 cination wherever this is necessary) the means of as- 
 suredly controlling and subduing it, and in vaccination, 
 along with disinfection, the means of eradicating it. 
 But these means will invariably be found to be easy or 
 difficult of application, to be of very trifling cost or 
 a source of heavier expenditure, according as vaccina- 
 tion has been previously cared for or neglected in the 
 population to whom the infection has come, and ac- 
 cording to the promptitude with which the disease has 
 been met on its arrival: it is in keeping a population 
 vaccinated pari passu with the births that the real 
 economy of life, and health, and money lies. Under 
 the powers which the present vaccination law confers 
 on local authorities, the spread of fatal small-pox, let it 
 occur when it may, must be taken as in itself a sufficient 
 indication of the apathy, indifference, or incompetence 
 of the local authority within whose jurisdiction it takes 
 place."* 
 
 * No doubt the law has hitherto been very imperfect and 
 unsatisfactory, hut not so imperfect as to leave any excuse 
 for the extreme neglect which has frequently been allowed 
 to prevail. I have lately been inspecting the Eastern Dis- 
 tricts of London, in which small-pox may be almost said 
 to be endemic, and in which, last year, it made great rav-
 
 328 HANDBOOK OF VACCINATION. 
 
 CHAPTER XIY. 
 
 OF THE OBJECTIONS TO VACCINATION, AND THE ALLEGED 
 DANGERS OF THE PRACTICE. 
 
 111. Allegation that it has produced. New Diseases. 
 — I should deem it a waste of the reader's time to en- 
 ter on any particular consideration of some of the ob- 
 jections that have been advanced against vaccination. 
 That it has produced new, strange, and unheard of 
 diseases — that it has caused degeneration, mental and 
 physical, of the human species, diminishing men's 
 stature, incapacitating them for the fatigues of mili- 
 tary service, or even for the exercise of dancing, and 
 driving them for consolation to tobacco — are assertions 
 that have been very seriously and very vehemently 
 made, but against which it is surely not necessary se- 
 riously to argue.* The nonsense about degeneration 
 has not, so far as I am aware, found any echo in this 
 
 ages. For any special steps that had been taken to arrest 
 it by the local authorities, it could not be supposed that 
 there had even existed authorities having any responsibility 
 whatever in a matter so seriously affecting the lives and health 
 of more than half a million of our population, and possessing 
 powers for the enforcement of vaccination which, if duly exer- 
 cised, might assuredly have prevented a very large proportion 
 of the terrible suffering and mortality from small-pox that 
 had there prevailed. 
 
 * Verde de Lisle, De la Degenerescence Physique et Morale 
 de l'Espece Humaine determine par le Vaccin. Paris, 1855.
 
 OBJECTIONS TO VACCINATION. 329 
 
 country ; and here certainly, since the days of Row- 
 ley, and Squirrel, and Birch, the diseases "produced 
 by vaccination" have occupied, "in medical teaching 
 and medical conversation, about the same space as 
 diseases produced by witchcraft and the evil eye."* 
 
 112. Allegation that it has led to Increase in the 
 Mortality of other Diseases. — Another objection that 
 has been urged, equally destitute of medical support, 
 is that though vaccination may save from small-pox, 
 there has been no real gain of life after all, but a mere 
 " displacement of mortality," the persons who should 
 have figured in the death-register as dead of small-pox 
 appearing at some time or other, but without living to 
 grow old, in some other column, as having died from 
 some other disease. Of course, in a certain sense and 
 to a certain degree, this statement is quite true. Vac- 
 cination does not profess to make mankind immortal — 
 it saves from small-pox and its sequelae, and from 
 nothing else ; and everybody whom it saves therefrom 
 lives to die of some other cause at some future period. 
 One might as well argue on such grounds against 
 saving a man from drowning. To make the objection 
 of any value it would need to be shown that vaccina- 
 tion, either by some positive action of its own, or by 
 depriving the constitution of some advantages conse- 
 quent on having small-pox, leaves it more prone than 
 
 * Simon, Preface to Papers relating to the History and 
 Practice, etc. [op. tit.), p. xliii. To the interesting and ad- 
 mirable chapter " On the alleged Drawbacks from the Ad- 
 vantages of Vaccination," in this Preface, I would refer the 
 reader for an exhaustive discussion of the subject ; it is well 
 worthy of the most careful study, and I desire to express my 
 own great indebtedness to it.
 
 330 HANDBOOK OF VACCINATION. 
 
 it would otherwise be to take on other diseases, and 
 more prone to such a degree as to counterpoise the 
 saving of life and health from small-pox. Fever and 
 scrofulous diseases are the diseases especially pointed 
 out as having taken the place of small-pox. 
 
 In support of this notion, some statistics,* imperfect 
 in themselves and utterly misunderstood, have been 
 advanced to show that, so far is vaccination from hav- 
 ing saved life, the general death-rate of populations 
 has increased since its introduction, that this increase is 
 very notable at particular ages, and that there has been 
 especial rise in the death-rates from fever and scrofulous 
 diseases. Now, supposing all this had been true, there 
 would yet have been wanting a great deal more to 
 show that post had not merely been mistaken for prop- 
 ter, and that these results had in any way depended on 
 the practice of vaccination; but it so happens that, as 
 soon as the statements were scrutinized (and they were 
 immediately subjected to competent scrutiny, both here 
 and abroad), each one of them was found to be the very 
 reverse of the truth. Thus, on comparison of the 
 present general death-rate with the death-rate of the 
 
 * "Collected with more zeal than judgment by a former ar- 
 tillery officer, M. Carnot." (Simon, op. cit., p. xlvii.) Car- 
 not's statistics related only to France, and their fallacies were 
 at once exposed to the Academie des Sciences by Baron Ch. 
 Dupin. The reader who is interested in this part of the sub- 
 ject, and who has leisure, will find it treated ably and with 
 much detail in a little work by Dr. Bertillon, " Conclusions 
 Statistiques contre les Detracteurs de la Vaccine." The reader 
 who has not leisure may be very grateful to Simon for the 
 pains he has taken to examine and expose, in his own com- 
 pact and exhaustive way, Carnot's crudities. He has left, in 
 fact, nothing more to be learnt or said on the matter.
 
 OBJECTIONS TO VACCINATION. 33 1 
 
 middle of last century, in any population for which the 
 materials for the comparison exist, it appears that(a//er 
 deducting the small-pox gain) the present rate is greatly 
 below that which obtained before the date of vaccina- 
 tion. In London, for example, the annual death-rate 
 from all causes, at the middle of the last century, was 
 355 per 10,000 of population, and from all causes, ex- 
 cept small-pox, 325 ; but in the middle of the present 
 century it was, including small-pox, but 249. In Swe- 
 den, in the period from 1755 to 1115, the general death- 
 rate was 289 per 10,000 of population; from 1841 to 
 1850 it was but 205. And similar results are obtained 
 from the statistics of other countries. Again, analysis 
 of the death-rates at particular ages, wherever the data 
 for such analysis exist, show that this gain pertains to 
 all periods of life. Between the ages of twenty and 
 forty years — the very time of life when, it was said, the 
 particular liability of those whom vaccination had saved 
 from small-pox to be carried off by other diseases mani- 
 fested itself — the gain is very obvious. The mortality 
 of early life, and at all ages short of old age, has 
 steadily diminished, and the number of persons who 
 attain a good old age has as regularly increased. 
 Lastly, so far as fe*vers and scrofulous diseases — the 
 forms of disease specially alleged to have taken the 
 place of small-pox — from having increased in frequency 
 and fatality, that (as has been clearly shown by Dr. 
 Greenhow, in a very able and elaborate investigation 
 of the death-rates of London, at different ages and 
 from different diseases) there has been a most remarka- 
 ble diminution. The present death-rate of "fever" (if 
 we include with the deaths now registered under that 
 title all those deaths of the present day which might
 
 332 HANDBOOK OF VACCINATION. 
 
 have been included in days gone by under the term, as 
 scarlet fever, and inflammation of the brain, and inflam- 
 mation of the lungs) amounts only to 385 per 100,000 
 of population, whereas a century ago its death-rate was 
 close on 539.* This diminution in the mortality from 
 fever has been also fully established by the researches 
 of that eminent statistician Dr. Farr, who tells us that 
 this cause of death has progressively subsided since 
 1771, and further that the combined mortality of small- 
 pox, measles, and scarlatina now is "only half as great 
 as the mortality formerly occasioned by small-pox 
 alone, "f The smaller mortality occurring nowadays 
 from scrofula and consumption has been likewise satis- 
 factorily shown by both these able inquirers, working 
 from separate data. And to the gain of life in diseases 
 of this class there cannot, I apprehend, be any doubt 
 that vaccination has largely contributed. It is one of 
 the terrors of natural small-pox that, by its depressing 
 influences on the constitution, it frequently develops, 
 in those disposed, the seeds of tubercular and other 
 scrofulous diseases. This is repeatedly noticed by 
 writers on scrofula. Guersant and Blache, in their 
 experience at the Hopital des Enfants Malades at Paris, 
 were struck with the effect which they noticed small-pox 
 to have in developing scrofula and pulmonary phthisis. J 
 " Having often," says Dr. Alison, " seen scrofulous, espe- 
 cially tubercular, diseases, originating during the feeble 
 
 * Simon, Preface, etc. [op. cit.), p. lv. Dr. Greenhow's ex- 
 cellent paper, which is well worthy of study, will he found in 
 extenso in these Papers at p. 26. 
 
 f McCulloch's Descriptive and Statistical Account of the 
 British Empire, 4th edit. vol. ii. 
 
 X Diet, de Med., art. " Variole."
 
 OBJECTIONS TO VACCINATION. 333 
 
 state of convalescence from bad small-pox, and being 
 aware that small-pox, before vaccination was introduced, 
 was always stated to be a mutilating, when not a fatal 
 disease, I have no doubt that whatever prevents small- 
 pox in a population will save many of that population 
 from scrofulous and tubercular disease, otherwise to be 
 fatal to them."* This indirect prevention of scrofu- 
 lous affections was, indeed, among Jenner's hopes 
 when he announced the discovery of vaccination. In 
 various passages of his writings he refers to the noto- 
 rious frequency with which such affections were excited 
 by small-pox ; and he appeals to general consent as to 
 inoculated small-pox often occasioning them. " In con- 
 stitutions predisposed to scrofula, how frequently we 
 see the inoculated small-pox rouse into activity that 
 distressful malady. . . . Every practitioner in medi- 
 cine who has extensively inoculated with the small- 
 pox, or who has attended many of those who have had 
 the distemper in the natural way, must acknowledge 
 that he has frequently seen scrofulous affections, in 
 some form or other, sometimes rather quickly, showing 
 themselves after the recovery of the patients, "f 
 
 The hypothesis that vaccination, by rendering per- 
 sons less liable to small-pox, renders them eventually 
 more liable to other diseases, is in fact contrary to the 
 whole current of medical experience. This was clearly 
 brought out when, in 1856, the Medical Officer of the 
 then Board of Health addressed to the same members 
 of the medical profession whom he consulted as to their 
 opinion on the protective power of vaccination, the 
 
 * Papers relating, etc. (op. cit.), p. 33. 
 •J- As quoted by Simon, Preface, etc. (op. cit.), p. lx. 
 29
 
 334 HANDBOOK OF VACCINATION. 
 
 further question, "Have you any reason to believe, or 
 to suspect, that vaccinated persons, in being rendered 
 less susceptible of small-pox, become more susceptible 
 of any other infective disease, or of phthisis ; or that 
 their health is in any other way disadvantageously 
 affected ?" Of 542 respondents, there was not a single 
 one who gave the slightest support to the hypothesis. 
 113. Allegation that Cutaneous and Glandular Dis- 
 eases may be Invaccinated. — Inasmuch as cutaneous 
 diseases and glandular swellings are frequently noticed 
 in children subsequent to their vaccination, parents are 
 often found to allege that these diseases have been 
 introduced by the vaccination. But this again, though 
 a popular, has never been a professional belief. Dis- 
 eases of these classes are met with constantly in in- 
 fancy and childhood, as well in the unvaccinated as the 
 vaccinated, from the influence of various exciting causes 
 acting on constitutional predisposition. No facts exist 
 to prove, or even to render probable, their greater fre- 
 quency among the vaccinated than among the unvac- 
 cinated of the same ages respectively: observation, 
 indeed, tends to show that there is no such greater fre- 
 quency.* When eczematous and other eruptions mani- 
 
 * "As regards the relation of vaccination to the infantile 
 skin diseases of chronic character," says Mr. Hunt, " I can 
 confidently say, after examining and recording the history of 
 upwards of a thousand cases of skin disease in children (oc- 
 curring at the Western Dispensary for Diseases of the Skin), 
 that I find no evidence whatever that vaccination disposes the 
 constitution to cutaneous diseases; these appearing, in fact, to 
 attack indiscriminately the vaccinated and the unvaccinated. 
 Of course, since the Compulsory Vaccination Act has heen in 
 operation, we have had more cases of skin disease after vaccin- 
 ation than we formerly had, simply because children are now
 
 OBJECTIONS TO VACCINATION. 335 
 
 fest themselves, as they may do, shortly after vaccina- 
 tion has been performed, this is in fact usually, if not 
 always, mere coincidence; and the eruption on inquiry 
 is found to be really due to the irritation of teething, 
 or probably to some error in diet, or to some general 
 constitutional tendency. It may be, however, that in 
 some cases vaccination, by the febrile action it sets up, 
 may act as an exciting cause, just as a common cold 
 would do, and thus be the means of sooner evolving 
 some eruptive disorder that was lurking in the system. 
 But such cases are certainly exceptional ; and, assuredly, 
 no professional authorities believe in the transference 
 of glandular or cutaneous diseases from one child to 
 another by vaccination. Parental complaints of such 
 communication arise, as M arson very justly states, from 
 the unwillingness of parents "to believe that there is 
 anything wrong in their offspring : and, when other dis- 
 eases follow, vaccination gets blamed for what is really 
 and truly due to other causes."* In corroboration of this 
 statement, and as illustrating the want of foundation of 
 such complaints, and the prejudices under which they 
 are preferred, I may remark that having myself care- 
 vaccinated at or before three months instead of at six, eight, 
 ten, or twelve months of age. Therefore, a cutaneous disease 
 which breaks out after the third month, necessarily occurs 
 after vaccination. Formerly, it might at that age have oc- 
 curred be/ore vaccination. The date of vaccination has made 
 the disease a sequence, not a consequence, of vaccination. 
 Mothers frequently entertain the belief that any disease of the 
 skin occurring after vaccination is caused by it ; but I do not 
 remember a single instance in which any reasonable evidence 
 of such connection could be produced." (Papers relating, etc., 
 op. cit., p. 71.) 
 * Papers relating, etc. (op. cit.), p. 25.
 
 336 HANDBOOK OF VACCINATION. 
 
 fully investigated many of them I have never yet in a 
 single instance found that the child from whom the 
 lymph was taken was suffering from the disease it was 
 said to have imparted. 
 
 Those who have had most to do with the perform- 
 ance of vaccination, on the one hand, and those who 
 have been most concerned in the treatment of infantile 
 disease, on the other, concur in the belief of the non- 
 communicability of disease by vaccination. Marson 
 stated some years ago that in the performance of up- 
 wards of 40,000 vaccinations he had " never seen other 
 diseases communicated with the vaccine disease, nor 
 did he believe in the popular reports that they are so 
 communicated."* The experience of the late Mr. Leese, 
 whose vaccinations had been scarcely, if any, less nu- 
 merous, was the same.f Sir W. Jenner has put on 
 record that at University College Hospital and at the 
 Hospital for Sick Children he had, in six years, more 
 than 13,000 sick adults and children under observation, 
 and that in no case had he reason to believe, or even 
 to suspect, that any constitutional taint had been con- 
 veyed from one person to another by vaccination. | 
 Dr. West's experience, on 26,000 infants and children 
 under his care in seventeen years, was to the like effect; 
 and in stating that he had seen nothing in that time to 
 make him believe that vaccination excites cutaneous 
 eruptions in any but very exceptional cases, he referred 
 such exceptional cases to a disposition in the children 
 
 * Papers relating, etc. His vaccinations now amount to 
 about 60,000, and his experience remains the same. 
 
 f Seaton on Protective and Modifying Powers of Vaccina- 
 tion {op. cit), p. 365. 
 
 % Papers relating to, etc., p. 75.
 
 OBJECTIONS TO VACCINATION. 337 
 
 themselves, brought out by the vaccination as it might 
 have been by teething.* And Professor Paget, speak- 
 ing from his large experience among children in the out- 
 patients' room at St. Bartholomew's, and enumerating 
 some of the causes which develop cutaneous diseases 
 in young children, says, "Now, vaccination may do, 
 though I believe it very rarely does, what these several 
 accidents may do ; namely, by disturbing for a time the 
 general health, it may give opportunity for the exter- 
 nal manifestation and complete evolution of some con- 
 stitutional affection, which, but for it, might have re- 
 mained rather longer latent." "This is," he adds, "the 
 worst thing that can with any show of reason be 
 charged against vaccination ; even this can very sel- 
 dom be charged with truth, "f 
 
 114. Allegation that Syphilis may be Invaccinated. 
 This is not supported (a) by general Professional 
 Experience. — Syphilis differs from any of the other 
 diseases which, it has been alleged, may be propagated 
 by vaccination, in being an inoculable disease; a dis- 
 ease which, in fact, except in the forms in which it 
 manifests itself hereditarily, is always the result of 
 some inoculation. But the inoculation which produces 
 it is the inoculation of its own infection : and as small- 
 pox produces small-pox; vaccinia, vaccinia; and glan- 
 ders, glanders ; so does syphilis produce syphilis. The 
 causes of all these and of other inoculable infections 
 are specifically so distinct that it has ever been held by 
 medical authorities in the highest degree improbable 
 that the unmixed inoculable products of any one of 
 
 * Papers relating, etc., p. 146. f Ibid., p. 139. 
 
 29*
 
 338 HANDBOOK OF VACCINATION. 
 
 \ 
 
 them should convey any other infection along with it; 
 and when, after the introduction of small-pox inocula- 
 tion during the last century, the objection was raised 
 that that process might be the means of conveying 
 syphilis, enlightened medical opinion rejected such a 
 supposition as not sustainable. The distinguished Dr. 
 Mead represents the conclusions of medical observers 
 of that period when, referring to individuals who " in- 
 fected with an incurable itch of writing, and taking 
 great pleasure in contradicting others to whom they 
 bear envy, . . . still go on to terrify us by saying that 
 there is danger lest, together with the small-pox, some 
 other infection inherent in the blood and humors of 
 the sick person should be transmitted into the sound 
 body ; . . . and such, perhaps, are scrofulous swellings 
 and the venereal disease," he says, "yet I can hardly 
 believe that it ever happens that the seed of one dis- 
 temper should bring along with it mixed the procrea- 
 tive matter of another quite different from it. . . . It 
 is in my opinion more material into what kind of body 
 the venom be infused than out of what it be taken." 
 And Moseley, in one of his diatribes against vaccina- 
 tion, says in reference, not to it, but to small-pox inocu- 
 lation: "Suppose a subject in the small-pox to have 
 inveterate scurvy, scrofula, itch, syphilitic infection, or 
 consumption, certainly no person Ought to take matter 
 from such a person for inoculation. But it might be 
 done with as much safety as if none of these disorders 
 were present. Peculiar circumstances, which I had 
 no share in creating, have rendered me acquainted with 
 some of these facts, and accident the others."* What- 
 
 * See Simon, Preface, etc. (op. cit.), p. lxv. and note.
 
 OBJECTIONS TO VACCINATION. 339 
 
 ever this objection might be worth as against small- 
 pox inoculation, it would of course be worth as against 
 vaccination; but in reference to this latter process its 
 value has been tested on an infinitely larger scale, for 
 where small-pox inoculations amounted to thousands, 
 vaccinations have mounted to millions, and it may be 
 safely affirmed that — prior, at all events, to recent oc- 
 currences which will be presently referred to, and 
 which have caused the question of the communicability 
 of syphilis by vaccination to be reopened — there was 
 the utmost accordance of medical opinion in rejecting 
 the possibility of such communication. This will be 
 at once obvious to any reader who will take the trouble 
 to consult the replies given by between five and six 
 hundred medical practitioners, comprising nearly every 
 distinguished medical authority in Great Britain, and 
 many or most of those in France and Germany, to the 
 question put to them in 1856 by the Medical Officer of 
 the then Board of Health : " Have you any reason to 
 believe or suspect that lymph from a true Jennerian 
 vesicle has ever been a vehicle of syphilitic, scrofulous, 
 or other constitutional infection to the vaccinated per- 
 son?" 'The distinguished and experienced authorities 
 whose opinions I quoted in the previous section, as to 
 the non-coinmunicability of disease generally by vac- 
 cination, not only included syphilis with other diseases, 
 but specially included it ; Dr. West stating that there 
 had never come under his notice " any instance in 
 which there seemed the slightest pretext for supposing 
 that syphilis had been communicated to infants through 
 the medium of the vaccine lymph ;" and Professor 
 Paget, that he does not remember " to have heard in- 
 fautile syphilis ascribed to vaccination, frequent as the
 
 340 HANDBOOK OF VACCINATION. 
 
 instances of it [infantile syphilis] are among the out- 
 patients." Neither Marson nor Leese, in their immense 
 vaccinating experience, ever met with anything to 
 countenance the belief that vaccine lymph had, on any 
 occasion, been the vehicle of conveying syphilitic in- 
 fection. And Mr. Tomkins, the Inspector of Vaccina- 
 tions of the National Vaccine Establishment, who has 
 himself vaccinated nearly 50,000 children, and whose 
 experience of the whole operations of the Establish- 
 ment embraces thirty years of its history, informs me 
 that no instance has ever come to his knowledge of 
 syphilis having been communicated by vaccination. If 
 we pass from the evidence derivable from great expe- 
 rience in vaccination on the one hand, to the evidence 
 supplied by practitioners most conversant with syphilis 
 on the other, we find that neither Acton, nor Lee, nor 
 Langston Parker, daily as they have had to do with 
 syphilis all their lives, have ever seen a case of that 
 disease traceable to vaccination. And though the great 
 leaders of our profession, as Chomel, or Rostan, or 
 Bright, or Latham, or Watson, or Brodie, or Joseph 
 Henry Green, may have had little or no experience in 
 the mere practice of vaccination, and some of them 
 probably little to do specially with syphilis, their vast 
 and intimate knowledge of the nature of diseased pro- 
 cesses and the laws by which such processes are pro- 
 pagated in the human subject gives immense weight to 
 the opinion they unreservedly express, that the specific 
 infection of the one disease cannot convey with it the 
 other. " The suggestion of its being possible," says 
 Latham, in his own forcible way, "amazes me." "I 
 apprehend that persons entertaining such opinion," 
 says Joseph Henry Green "can be only those who are
 
 OBJECTIONS TO VACCINATION. 341 
 
 ignorant of the circumstances under which diseases 
 are ordinarily propagated."* 
 
 No doubt, so far as regards the argument derivable 
 from professional experience in this matter, it may be 
 said that it is worth much less than at first sight it 
 might appear to be, because vaccinators are careful to 
 avoid syphilitic children as sources for continuing their 
 lymph ; and though our vaccinations count now by 
 millions, the vaccinations from syphilitic sources must, 
 after all, have been very few. Unquestionably this is 
 so : comparatively, they must certainly have been very 
 few. We may justly think with pride of the care which 
 for the most part the profession has taken, in this 
 country at all events, to guard the purity of vaccina- 
 tion.- Whatever carelessness or looseness in the per- 
 formance of vaccination there may often have been, it 
 is not in indifference as to the subjects from whom 
 lymph was token that, in professional hands, this care- 
 lessness has in England manifested itself. Still, even 
 among us, there has been so much miscellaneous and 
 non-professional vaccination, and with many practi- 
 tioners the strength of the conviction that it was im- 
 possible to communicate by vaccine lymph any other 
 than its own contagion has been so great, that I cannot 
 persuade ni} r self but that, in the course of seventy 
 years, vaccination from children having some hered- 
 itary taint of syphilis must have occurred often enough 
 to constitute an experiment of quite sufficient magni- 
 tude to give us very positive and very safe conclusions ; 
 nor but that, " if syphilis could be diffused by the vaccine 
 lymph of children with an hereditary taint of that dis- 
 
 * Papers relating, etc. (op. cit.), p. 321-17.
 
 342 HANDBOOK OF VACCINATION. 
 
 ease, this possibility must long ago have been made 
 evident on a scale far too considerable for question. "* 
 
 Assuredly, however, neither our great medical au- 
 thorities, nor the profession generally, have arrived at 
 the conviction so almost unanimously hitherto enter- 
 tained by them, of the non-communicability of syphilis 
 by vaccine lymph, solely because there were no well- 
 established cases of such communication having taken 
 place in the ordinary process of vaccination. They re- 
 lied also on the teachings of pathology, and of direct 
 experiment. 
 
 (b) Nor by Pathological Considerations. — Profes- 
 fessor Paget states the pathological grounds for disbe- 
 lieving the possibility of communication of syphilis by 
 
 * Simon, Preface, etc. {op. eit.), p. lxvi. But suppose (as 
 we should have to do if we were to accept unreservedly a 
 number of statements that have been made) that to impart 
 syphilis by vaccination it is not necessary that the child 
 yielding lymph should at the time have any manifestation of 
 syphilis but that it is quite enough that it should be incu- 
 bating that disease, — or much more, that it need not even be 
 incubating syphilis, nor have, either before or at the time of, 
 or at any time after the lymph was taken from it, any indi- 
 cation of syphilis whatever, but only have a parent not then 
 suffering from syphilis, but who might at some former time 
 have had it, — or still further, that it should itself be free from 
 syphilis, and remain free, and its parents equally free, and the 
 child from whom it was vaccinated and its parents equally free 
 (there being, in short, perfect immunity from syphilis as far 
 back as the lymph could be traced) : suppose all this, I say, 
 and at this rate the whole world must have been syphilized 
 long before this. The argument from experience not only 
 then gains immense force, but becomes indeed, on the scale 
 on which we have it, in my opinion, quite unanswerable. 
 Surely this is the sort of evidence that proves too much.
 
 OBJECTIONS TO VACCINATION. 343 
 
 vaccine lymph — supposing always that it is the un- 
 mixed lymph of a true vaccine vesicle — to be (1) be- 
 cause infantile syphilis (which alone need be here 
 considered), though conveyable in some instances by 
 its own peculiar morbid products, does not render the 
 blood of the patient capable of directly conveying the 
 disease ; and (2) because, if the blood of a syphilitic 
 child could so modify the vaccine disease within it as 
 that the vaccine lymph should be capable of conveying 
 any other disease, there is every reason to believe that 
 the vaccine vesicle formed in the diseased child would 
 be modified in correspondence with the modified lymph. 
 "All pathological researches," he remarks, " accumu- 
 late the evidences of the constant correspondence be- 
 tween the material in the blood, on which each specific 
 disease depends, and the morbid structure, by which 
 each is manifested. Thus the transformations of syphi- 
 litic poison are indicated in the successive external 
 characters of the primary, secondary, and tertiary af- 
 fections ; the transformation of the scarlatina poison 
 by its regular symptoms and its sequelae. And so, if 
 the vaccine virus were capable of any transformations 
 besides those which mark its regular influence in each 
 patient, such transformations, we may be sure, would 
 be indicated by corresponding and evident changes in 
 the vaccine vesicle. In other words, if the vaccine 
 were changed into any other virus, there would be no 
 vaccine vesicle."* The opinions of Hebra, and other 
 distinguished pathologists, are equally opposed to the 
 possible communication of any other infection with 
 vaccine lymph. Who ever heard, in fact, of the virus 
 
 * Papers relating, etc., p. 139.
 
 344 HANDBOOK OF VACCINATION. 
 
 of small-pox producing anything besides small-pox? 
 or the virus of measles anything besides measles ? If 
 eases should be alleged to show that they did so, let 
 anybody ask himself what amount of evidence he 
 would require to establish the point : whether it would 
 not be infinitely more reasonable to conclude that there 
 were fallacies in the cases, though we might not be 
 able to point them out, than that an event should have 
 occurred so opposed to universal experience. 
 
 (c) Nor by Experiment. — Direct experiments made 
 on a large scale, at various times, and by many indi- 
 viduals, have led in every single instance to the same 
 conclusion. Vaccination with lymph taken on purpose 
 from syphilitic subjects was experimentally practiced 
 quite early in the century : and the experiments have 
 since been repeated again and again by different ob- 
 servers. The inoculations of this kind which Culle- 
 rier, Taupin, Heymann, and others have performed, 
 have been very numerous. Within the last half dozen 
 years, and since the communicability of syphilis by 
 vaccination has been so warmly discussed, occasion 
 has been taken, by several individuals, further to re- 
 peat them. Unvaccinated persons who happened to 
 be suffering from chancre have been vaccinated, and 
 vaccine vesicles raised, in close contiguity to the 
 chancre: and from the vesicles so raised vaccinations 
 have been performed. But never has it happened, on 
 a single occasion, that syphilis, or that any other result 
 than vaccinia, has followed the use of vaccine lymph 
 thus purposely taken from a syphilitic subject.* Now, 
 
 * I cannot see the advantage, in experiments of this kind, 
 of making the vesicles close to the chancres, and I can see a
 
 OBJECTIONS TO VACCINATION. 345 
 
 the value of these experiments is immense, for in them 
 we know exactly under what conditions we are acting 
 — whether the vacciniferous child was really sj^philitic 
 or not, whether the vaccine vesicle developed on it 
 were a regular vaccine vesicle or not, whether the 
 lymph used was mixed or not mixed with syphilitic 
 products, whether it was mixed or not mixed with 
 syphilitic blood. The difficulties with regard to these 
 points that surround our inquiries when a vaccinal 
 origin is ascribed to a syphilitic case are so great, the 
 fallacies to which we are always exposed in our at- 
 tempts to discover the real origin of cases of syphilis 
 when an unusual origin is suggested are so great, that 
 cases of alleged vaccinal syphilis become, " in contrast 
 with experimental results, almost valueless for instruc- 
 tion." Is it credible that, if syphilis were inoculable 
 through vaccine lymph, it should not have been inoc- 
 ulated on any one of these really innumerable occa- 
 sions ? It is not as though the syphilitic virus were 
 one to which the human system had any repugnance : 
 the exceeding facility with which it is inoculable is 
 well known. Nor would analogy lead us to suppose 
 that syphilis could be thus conveyed. Taupin and 
 others, in their experimental inoculations from diseased 
 subjects, used lymph taken from persons affected with 
 various other contagious diseases besides syphilis ; but 
 not one of these diseases were they able to communi- 
 cate through the lymph. From the earliest days of 
 
 great disadvantage in the risk that, in taking the products of 
 the vaccine vesicles for further experiments, some of the 
 syphilitic virus might accidentally get mixed with the vac- 
 cine lymph, and thus lead to syphilitic results and to most 
 fallacious conclusions. 
 
 30
 
 346 HANDBOOK OF VACCINATION. 
 
 vaccination it has been, moreover, a matter of familiar 
 knowledge, a matter to which I have before had occa- 
 sion to advert (§ 36, p. 85), that if lymph be taken 
 from a vaccine vesicle in a patient suffering from va- 
 riola, with due care to procure it from the vaccine vesi- 
 cle only, and unmixed with the products of any of the 
 variolous vesicles, nothing but vaccinia is ever pro- 
 duced. " Since, then," says Simon, " it is a quite un- 
 questionable certainty that, even when the system is 
 drenched with that subtlest infection of small-pox, the 
 Jennerian vesicle preserves its own contagion pure and 
 isolated, the argument may reasonably be extended. 
 And, even if there were no evidence in relation to 
 other diseases, this analogy would have rendered it 
 eminently improbable that any, the most infectious, of 
 their number, could admix its contagion with the spe- 
 cific products of cow-pox. Indeed, so definitely and so 
 constantly characterized are those local changes which 
 different morbid poisons severally and specifically pro- 
 duce, that to say of a given phenomenon, 'this is a 
 typical Jennerian vesicle,' is, I believe, tantamount to 
 saying this is a vesicle which only one unmodified in- 
 fluence can produce, which no second influence can 
 concur in producing, and in the contagion of which no 
 second principle of infection can possibly reside."* 
 
 (d) Of course Insertion of the matter of Syphilis 
 will produce Syphilis. The harmlessness of Vac- 
 cination is dependent on due care being- used. — 
 Whatever conclusions have at any time been arrived 
 at with regard to the non-communicability of syphilis 
 by vaccination, have proceeded always on the assump- 
 
 * Simon, Preface, etc. {pp. cit.), p. lxiii.
 
 OBJECTIONS TO VACCINATION. 34? 
 
 tion, not only that vaccine lymph was used (without 
 which, of course, there could have been no vaccina- 
 tion), but that it was pure, unmixed vaccine lymph. 
 If the matter of syphilis, or of any other inoculable 
 disease, were used, accidentally, instead of vaccine 
 lymph, who could doubt that syphilis, or the disease, 
 the material of which had been used, would be the 
 disease produced? If the matter of syphilis were 
 mixed with vaccine lymph, we had positive experi- 
 ment to prove to us that syphilis would result. And 
 if a lancet that had been used for syphilization, or had 
 become in any way contaminated with the matter of 
 syphilis, and not properly cleaned, were used for vac- 
 cinating, there would, of course, be the same liability 
 to communicate syphilis. Malpractice in performing, 
 or in attempting to perform, vaccination is one thing: 
 the communication of syphilis by vaccine lymph is 
 another thing. Obvious as the distinction is, it seems 
 very necessary to insist upon it, because instances, 
 that were well known and had never been denied, of 
 culpable carelessness in attempting to vaccinate, have, 
 in recent discussions, been made much of, as though 
 they exhibited the results of the real and proper per- 
 formance of vaccination. There is, however, one re- 
 spect, and a very important one, in which recent facts 
 appear to correct views previously entertained as to 
 the effects of mixed syphilitic and vaccine viruses. So 
 far as experiments had gone, they had led us to believe 
 that whenever a mixture of the two viruses was used, 
 the compound fluid would produce syphilis, certainly, 
 but would not produce vaccinia: that syphilis in its 
 inoculable form prevented, within the sphere of its in- 
 fection, the formation of a vaccine vesicle. In experi-
 
 348 HANDBOOK OF VACCINATION. 
 
 ments with such a mixture, made by Sigmund and 
 Friedinger, nothing but syphilis was ever produced.* 
 Professor Boeck, also, in his experiments on the syph- 
 ilization of children, frequently mixed vaccine lymph 
 with the syphilitic matter, but, like Sigmund, never ob- 
 tained any but syphilitic results ; and the children 
 were afterward successfully vaccinated in the usual 
 way.f In the details of one of Friedinger's experi- 
 ments, however, the pustules which arose from the 
 inoculation of the mixture were noticed as presenting 
 in their development some analogy with a vaccine pus- 
 tule (vesicle) ;J but on this kind of appearance no 
 stress was laid by him, nor indeed ought to be laid, as 
 it might have occurred even if unmixed syphilitic 
 matter had been employed, for we have Ricord's au- 
 thority that a chancrous pustule, " initial lesion of the 
 primary syphilitic ulcer, when it develops itself on the 
 skin," has characters which may readily cause it to be 
 confounded with the vaccine pustule. §' Similar experi- 
 ments made by Bauines and Sperino resulted, like those 
 of Friedinger, always in the development of syphilis, 
 but produced also, in one case, what appeared to them 
 to be like a vaccine effect; and as this case is cited by 
 M. Viennois|| as proving, in his opinion in the clearest 
 
 * Simon, Preface, etc. (op. cit.), p. lxv. 
 
 f De la Syphilis Vaccinale (Paris, 1865), p. 386. This is a 
 report of the discussions which took place in the Acad. Imp. 
 de Med. on this subject in 1864, together with a reprint of 
 various papers, including the very able, interesting, and com- 
 prehensive essays of M. Viennois. 
 
 + De la Syphilis Vacc. (op. cit), p. 277. 
 § Diday, Treatise on Syphilis, translated by Whitley (New 
 Syd. Soc.),p. 54. 
 
 || De la Syph. Vacc. (op cit), p. 280.
 
 OBJECTIONS TO VACCINATION. 349 
 
 way ("de la facon la plus nette"), that both vaccinia 
 and chancre were communicated together, it is of the 
 utmost importance to note what those results were. 
 The subject of this experiment was a young woman, 
 who had never been vaccinated or had small-pox, and 
 the account of the phenomena produced by the inocu- 
 lation with the mixed viruses of chanchre and vaccine, 
 given by M. Baumes, is as follows : " Des le debut les 
 pustules ont offert, d'une maniere sensiblement predo- 
 minante, le caractere vaccinal. . . . Le troisieme jour, 
 au point 011 les piqures avaient ete pratiquees, appa- 
 raissent de petits cercles enflammes, rouges, fonces, 
 assez circonscrits, avec sensation de durete au tact; le 
 quatrieme jour, un point central sedessine en forme de 
 pustule par le soulevement de l'epiderme, refermant 
 au-dessous une matiere moins claire, moins opaline, 
 que le fluid-vaccin, et se rapprochant deja ce jour la et 
 beaucoup plus le lendemain, de la couleur, de la consist- 
 ance de la matiere propre a la pustule variolique et a 
 la pustule chancreuse ; le sixieme jour, toutes les pus- 
 tules sont bicn formees, nettement dessinees, aplaties, 
 largement ombiliquees, avec cercle rouge fonce, d'un 
 aspect cuivreux, gonflement du derme ; le septieme et 
 le huitieme jour, la dimension des pustules d'inflam- 
 mation augmeute ; de fortes douleurs, melees de deman- 
 geaisons, se font sentir; la malade, par le frottement 
 ou en se grattant, rompt les pustules ; celles restees in- 
 tactes sont dechirees par la lancette pour l'inoculation 
 du pus chancreux a d'autres malades." A vaccination 
 performed on this young woman, two days afterward, 
 with lymph taken from the arm of a child, produced no 
 effect. If this be indeed a case of vaccino-syphilitic 
 inoculation, of the production of the two diseases by 
 30*
 
 350 HANDBOOK OF VACCINATION. 
 
 the same operation, if in the peculiarity of pustule 
 noted from the fourth to the sixth day the action of the 
 vaccine virus was manifested, it was surely a case of 
 most irregular vaccination, one which exactly bears 
 out, and exceedingly well illustrates, the statement of 
 Paget that if any other virus were working locally 
 along with vaccine lymph, there would be correspond- 
 ent and evident changes in the character of the vac- 
 cine vesicle. Pus taken from the pustules in this case 
 on the eighth day communicated chancres only. What 
 would have been the effect of matter taken from them 
 two or three days earlier ? I cannot say. Possibly 
 some remains of the vaccine virus might have caused 
 some spurious results of vaccinia to be manifested. 
 But if M. Viennois, in citing this as a typical case of 
 vaccinia transmitted along with chancre, means that 
 vaccine lymph, such as might properly be used in vac- 
 cinating, could be got from such pustules as these, 
 there would surely, where such doctrines were held, 
 be an easy way of accounting for any amount of acci- 
 dents * 
 
 * I am not personally acquainted with the practice of vac- 
 cination in France and Italy, but the accounts one reads of it 
 are not of a nature to give much confidence as to the manner 
 in which a good deal of it is performed. It seems to have 
 been withdrawn, to a large extent, from professional care, 
 and to have been handed over to farriers and midwives. It is 
 a common thing to read of the same child being used two or 
 three days running for yielding lymph, and of fifty, sixty, or 
 a hundred children being vaccinated off" it! In one case 104 
 children were vaccinated from the same child on three differ- 
 ent days! What the kind of vesicles are from which this 
 lymph is taken I cannot say. In professional hands there 
 would be no fear in England of anything being taken from
 
 OBJECTIONS TO VACCINATION. 351 
 
 On the other hand, there is no reason that one can 
 see why the inoculable materials of two different infec- 
 tions, each having a different period of incubation, 
 should not if inserted together produce each its own 
 specific results. If the two contagions were simul- 
 taneously inoculated on different parts of the skin, there 
 can be no doubt, I apprehend, that such would be the 
 consequence; and the like might not unreasonably be 
 expected to occur if they were mixed and inserted to- 
 gether on the same part of the skin. The whole course 
 of vaccinia is over in about three weeks, or before, 
 according to its law of incubation, the virus of syphilis 
 begins to manifest its local action ; and in this way 
 (though as yet intentional experiments have not so 
 demonstrated) the two diseases might possibly be im- 
 planted together. In some such result of an accidental 
 and undesigned experiment exists certainly the most 
 probable explanation of one or two occurrences in which 
 there seems authentic evidence of regular vaccinia and 
 
 any pustules like those, e.g. described *n the text; but who 
 shall say what might not be taken by ignorant people profess- 
 ing to vaccinate? It is not many years ago that I saw a drug- 
 gist, who had in his time done a good deal of vaccination, 
 about to vaccinate some children (and but for my interference 
 he would have vaccinated them) with matter taken from an 
 open sore on the arm of a child, on which there was not a ves- 
 tige of a vaccine vesicle having ever been, but which he as- 
 sumed to be vaccine because he had vaccinated the child on 
 that spot on the arm the week before. It should in justice be 
 stated that the practices above adverted to in the performance 
 of vaccination in France and Italy have come to light in 
 reference to the accidents which (and no wonder) have fol- 
 lowed ; and may by no means fairly represent the way in 
 which vaccination generally is carried on in those countries.
 
 352 HANDBOOK OF VACCINATION. 
 
 of syphilis being received at the same operation. A 
 scandalous transaction of this kind took place some two 
 years ago, at the Academie Imperiale de Medecine at 
 Paris, when, the director of the vaccinations being ab- 
 sent, the day's vaccinations were left to a mere employe 
 of the establishment,* who took, it was found afterward, 
 the material with which he performed a certain portion of 
 these vaccinations from a child covered with syphilitic 
 eruptions and ulcerations, and in such an advanced 
 state of the disease that it died the day following. In 
 eight out of nine children operated on from this source, 
 vaccine vesicles appear to have been developed, and in 
 all the nine unequivocal syphilis manifested itself after- 
 ward. No direct evidence is of course obtainable as to 
 what the material used for these vaccinations really 
 was. But which is the more likely, having regard to 
 the results which have attended every one of the innu- 
 merable experiments in which lymph has been taken 
 from syphilitic children, but in which there was no ad- 
 mixture of syphilitic products, — that the lymph he 
 used was so mixed, V that it was mere lymph ? There 
 was in this case every facility for such careless mixture. 
 But as in twofold inoculations of this kind the two in- 
 fections acting each within its period of incubation 
 would take quite independently one of the other, what- 
 ever lymph might be extracted on the eighth day from 
 a vesicle having the character of a normal vaccine vesi- 
 cle, would of course convey nothing but the vaccine 
 infection. In 18G2, five out of six children vaccinated 
 at Torre del Busi, by M. Quarenghi, with some stuff 
 
 * "Was it the individual whose qualifications are described 
 at p. 206 ?
 
 OBJECTIONS TO VACCINATION. 353 
 
 in a tube which had been lying by for six months, first 
 went through vaccinia in the usual way, and had after- 
 ward syphilitic symptoms of so infectious a kind that 
 their mothers and nurses, and those who handled them, 
 or fed with the same spoons as they used, were syphi- 
 lized ; but yet these children on the eighth day of their 
 vaccination transmitted nothing but vaccine, without 
 any trace of syphilis, to the children who were vaccin- 
 ated from them.* 
 
 (e) Question of Accidental Inoculation of Syphilis 
 by the Blood. — If, again, syphilis be inoculable through 
 the blood, inoculation of the blood of a syphilitic sub- 
 ject along with vaccine lymph might readily be sup- 
 posed capable of conveying with it the syphilitic infec- 
 tion. And this is indeed the explanation usually 
 offered of cases in which some have held that both vac- 
 cinia and syphilis were communicated by the same oper- 
 ation, but in which, according to accounts, the vaccin- 
 iferous child was not at the moment the subject of any 
 external syphilitic manifestation — was in fact only 
 incubating the disease. M. Viennois, who strongly 
 holds the opinion that syphilis may be implanted with 
 vaccinia under such circumstances, does not imagine 
 this to take place through the vaccine lymph, and gives 
 indeed very sufficient reasons why this should not be 
 so; but he holds, and H. Lee and others follow him, 
 that the blood may act like one of the inoculable pro- 
 ducts of syphilis would do in infecting the system. No 
 doubt this is infinitely more probable than that vaccine 
 lymph should be an agent of such infection ; but yet 
 when we reflect (1) that no proof has ever yet been ad- 
 
 * De la Syph. Vacc, p. 303 seq.
 
 354 HANDBOOK OF VACCINATION. 
 
 duced by direct experiment of the communicability of in- 
 fantile (or hereditary) syphilis by blood-inoculation ;* 
 (2) that the inoculation by the blood, of the acquired 
 syphilis of an adult has been found, in direct experiments, 
 to be a matter of very great difficulty, requiring for suc- 
 cess (when it is attained) the exposure of a very large 
 absorbent surface ; and (3) that, in the vaccinations 
 which must in the course of seventy years have taken 
 place accidentally from syphilitic children times innu- 
 merable, blood must often have been invaccinated, and 
 that in many of the experimental vaccinations from 
 syphilitic children either no care was taken to exclude 
 blood, or blood was purposely mixed, and yet no syphilis 
 resulted :f we are justified, I think, in requiring very 
 clear evidence indeed before we can admit that syphilitic 
 infection can be communicated wholesale by the blood 
 which might enter in an ordinary carelessly-performed 
 
 * In all the alleged cases of communication of syphilis in 
 vaccinating, the lymph was taken from a child, except in the 
 cases of J. Lecocq : but Lecocq's cases are very inconclusive 
 (see post). Heim in some of his experiments took the lymph 
 from adults, hut no syphilis followed. (Historisch-Kritische 
 Darstellung der Pockenseuchen, p. 613.) 
 
 f Cullerier particularly mentions that his experiments were 
 made without any special precaution (Gaz. des Hopitaux, 1862, 
 p. 99); and Boeck mixed the syphilitic blood of a child on pur- 
 pose with its own vaccine lymph, and performed with the 
 mixture two revaccinations ; vaccine effect was produced in 
 one of the cases, but no syphilis in either. (De la Syphilis 
 Vaccinale, p. 386.) In conducting an ordinary vaccination, 
 it has ever been the mark of a slovenly and careless vaccinator 
 to allow any blood to be mixed with the lymph used ; but still 
 I do not think that it occurred to many to suppose — at all 
 events before the recent discussions — that there was in the 
 mixture any risk of conveying extraneous infection.
 
 OBJECTIONS TO VACCINATION. 355 
 
 vaccination, as in some of the cases alleged — evidence, 
 I will venture to say, after a careful study of these 
 cases, far stronger than has yet been adduced in any 
 one of them. 
 
 (f) Consideration of Cases of Alleged Vaccino- 
 Syphilitic Inoculation Cases which had been sup- 
 posed to show that syphilis might be introduced into 
 the system by means of vaccination date back to a very 
 early period of the century. They were, however, so 
 few in number — the medical literature of sixty years 
 being unable, when ransacked, to furnish more than a 
 dozen occasions on which such an event was supposed 
 to have occurred — and these when examined were 
 found to depend so much on hearsay and doubtful 
 evidence, and to be so open on all sides to fallacies, 
 that they had done little to shake the belief, entertained 
 till a few years ago by the whole profession at home 
 and abroad, with very rare exceptions, that the two 
 diseases would not pass into the system together. If 
 vaccinia passed, it would be vaccinia only. If syphilis 
 passed (which of course, as then held, could not be 
 without the substitution, or the admixture, of syphilitic 
 matter), it would be syphilis only. I have already 
 stated how far, in my opinion, this belief as to the im- 
 possibility of introducing the two diseases at one time, 
 if the inoculable products of both are used, may be open 
 to correction But such were certainly the opinions 
 generally Entertained, till, in 1861, some occurrences 
 which took place in, Italy and France caused the whole 
 question of the invaccination of syphilis to be reopened 
 for discussion. The event in Italy was an outbreak of 
 endemic syphilis at a little village called Kivalta, 
 clearly traceable, it was said, to a vaccinal origin ; the
 
 356 HANDBOOK OF VACCINATION. 
 
 event in Prance was the occurrence, in the wards of M. 
 Trousseau at the Hotel-Dieu, in Paris, of a case which 
 gave, it was said, direct proof of a vaccine-syphilitic 
 inoculation. It so happened that, at the time these 
 events occurred, the medical profession in France was 
 much divided between two rival schools of syphilogra- 
 phers, and that, from the intimate bearing' which the 
 vaccinal inoculation of syphilis, if shown to be possible, 
 would have on the points in dispute, a very large party 
 existed not only ready, but apparently eager, to accept 
 any evidence of it. A discussion began within the walls 
 of the Academie which is not yet terminated, nor is 
 likely soon to be terminated.* In the course of it 
 every case then on record was brought out for recon- 
 sideration. Other alleged cases of subsequent occur- 
 rence have since been added. And there is now a 
 party there who maintain that by vaccination (meaning 
 thereby vaccination performed with the lymph of a gen- 
 uine Jennerian vesicle) from a subject who has any 
 syphilitic taint, and even from subjects who, so far as 
 evidence can determine, are free from any such taint 
 themselves, and are derived from parents who have no 
 such taint, syphilis may be communicated! The Aca- 
 demie, as a body, is far from having indorsed these 
 
 * The patient reader of these discussions (and it requires 
 some patience to read the whole of them) will see that I have 
 not misrepresented their spirit. The vaccinal inoculation of 
 syphilis, as it is called, is hailed in a sort of jubilant tone 
 ns giving the " dernier coup" to a certain " 6cole syphilogra- 
 phique." Personalities abound, and are not even excluded from 
 the Official Keport, or rather "Projet de Rapport," drawn up 
 by M. de Paul for presentation, according to custom, to the 
 Ministre de 1' Agriculture, etc., but not accepted by the 
 Academie.
 
 OBJECTIONS TO VACCINATION. 35 \ 
 
 opinions In Germany and in England, the inquiry 
 has been taken up in a much more sober spirit, but cer- 
 tainly with no less determination to arrive at the truth. 
 The necessity of reviewing the whole subject has been 
 fully recognized, but it has also been clearly seen that 
 when we are called on to accept, on the ground of cer- 
 tain alleged facts, conclusions which are opposed to all 
 that pathology and experience had heretofore taught us, 
 we ought to satisfy ourselves not only that these facts 
 rest on sufficient testimony, but that they comprehend 
 everything necessary for a complete judgment, and that 
 no other interpretation of them is possible.* 
 
 Among the sources of fallacy against which we have 
 to be on our guard in cases in which syphilis has been 
 said to have been produced by vaccination, one is an 
 erroneous diagnosis. Persons talk very glibly about 
 sores being syphilitic and eruptions being syphilitic, 
 as though the characters of syphilitic sores and syphi- 
 litic eruptions were so made out that there could never 
 be any mistake about them. Yet such mistakes are 
 daily being made by practitioners in general, and are 
 occasionally made by the very highest authorities. 
 About four years ago one of those among us most 
 conversant with syphilis, Mr. Henry Lee, announced 
 to the Medico-Chirurgical Society that he had a case 
 
 * As M. Briquet has well pointed out, a competent observer, 
 and a complete observation, reported with such detail as renders 
 the statements capable of being checked by the reader, are indis- 
 pensable requisites for establishing the reality of an ordinary 
 fact in medicine ; and if for establishing an ordinary fact, how 
 much more when the facts alleged are confessedly so rare and 
 so contrary to all previous experience as these must be ad- 
 mitted to be. 
 
 31
 
 358 HANDBOOK OF VACCINATION. 
 
 under his care in which a syphilitic chancre had been 
 produced on the arm of a child by vaccination. The 
 case was seen by many members of the profession, 
 some of whom agreed with Mr. Lee, while others saw 
 nothing but a sore arm, the result of a degenerated 
 vaccine vesicle. The subsequent progress of the case 
 quite satisfied Mr. Lee that he had been mistaken in his 
 diagnosis, as he publicly acknowledged.* Acton tells 
 us that he has repeatedly seen eczema, lepra, and papu- 
 lar eruptions in children ascribed to a syphilitic taint, 
 which were after all eruptions of a simple non-specific 
 kind. And assuredly I have on various occasions 
 myself known (quite apart from any connection or 
 supposed connection with vaccinia) eruptions called 
 syphilitic, for no other reason than that they were 
 intractable, and had something of a dusky color. In 
 all alleged cases of post-vaccinal syphilis great care 
 must be taken in the first instance with regard to the 
 diagnosis. 
 
 But, supposing the diagnosis established, the next 
 point is to ascertain the origin. Now there is no 
 medical practitioner who needs to be told, and no 
 medical student can be long in finding out, that, of all 
 subjects of medical inquiry, the ascertainment of the 
 origin of individual cases of syphilis is one of the most 
 perplexing and the most encumbered with fallacies. 
 Hereditary syphilis (unfortunately not uncommon) is 
 yet generally not willingly admitted by either one or the 
 other parent. Its symptoms do not manifest them- 
 
 * A case looked on at first as very doubtful, but recognized 
 afterward to be a simple sore arm, was met with by MM. 
 Bergeron and Cullerier. (De la Syphilis Vaccinale, p. 48.)
 
 OBJECTIONS TO VACCINATION. 359 
 
 selves usually till some weeks, and in exceptional cases 
 not till some months, after birth ; and if in the mean- 
 while vaccination should have been performed, what so 
 convenient as that it should be put forward as the 
 cause ? Nor is it by any means impossible that, in 
 children with hereditary taint, the vaccination might, 
 by its momentary derangement of the health, actually 
 have been the means of first evolving the disease ; or 
 that in some in whom the disease had alreadymani- 
 fested itself before vaccination, but had disappeared on 
 treatment, the vaccination might be the means of again 
 evolving it. This we know may be done by the clean 
 cut of a surgical knife used in an ordinary operation, 
 and presumably, therefore, might happen "at the vac- 
 cine punctures of a child having latent constitutional 
 syphilis. Under the operation of this constitutional 
 taint they, or one of them, might become the seat of 
 secondary syphilitic ulceration, and greatly perplex 
 any observer in ignorance of the real cause; especially, 
 of course, if the parents were endeavoring to disguise 
 the previous facts of the case.* Where syphilis in 
 
 * " Some years ago I performed on a little boy, having no 
 apparent ill health, a very trifling surgical operation — that for 
 phimosis. In a few days the incision was, as is usual, all but 
 well. In a few more it had begun to ulcerate. For some 
 weeks there continued in the part an indolent inflammatory 
 process, with considerable swelling, and slow but progressive 
 ulceration. A variety of treatment failed to do good. At 
 length a suspicion occurred to my mind which led me to pre- 
 scribe iodide of potassium. Within eight and forty hours the 
 wound had thoroughly changed its character — every reason 
 for alarm was gone ; and within a few days complete healing 
 was accomplished. I now learnt that the child had been born 
 with a strong hereditary taint, and had — long before the
 
 360 HANDBOOK OF VACCINATION. 
 
 children is really acquired we know that there are 
 many ways in which this may be brought about; from 
 their nurses, from the persons with whom they sleep," 
 etc. etc. 
 
 In investigation, then, of alleged cases of vaccinal 
 syphilis we have to ascertain (1) whether we are really 
 dealing with syphilis ; (2) whether, if this be so, the 
 syphilis is not hereditary, and a mere coincidence or 
 evolution of the vaccination ; (3) whether, if it be ac- 
 quired syphilis, this has not some other origin, uncon- 
 nected with the vaccination or attempt to vaccinate; 
 (4) whether, if the acquisition of the syphilis be reason- 
 ably traceable to the vaccination or attempted vaccina- 
 tion, there is evidence, direct or presumable, that the 
 so-called vaccination had been done from a genuine 
 vaccine vesicle, and that the products of that vesicle 
 had not been mixed with some of the inoculable pro- 
 ducts of syphilis. Not till all this was settled would 
 any question arise about admixture of blood. The 
 interest and importance, after all, of the cases in which 
 vaccination is alleged to have communicated something 
 besides its own infection, turn entirely upon whether 
 the vaccination had been performed with the unmixed 
 lymph of genuine vesicles, vesicles about which no 
 competent person would make a mistake. 
 
 It must obviously be impossible to discuss at length, 
 within such limits as in a general treatise of this kind 
 could be allowed, all the cases that have been cited as 
 evidences of the communicability of syphilis by vac- 
 operation — required constitutional treatment on account of 
 the usual symptoms of infantile syphilis." (Simon, Preface, 
 op. cit., p. lxvi.,note.)
 
 OBJECTIONS TO VACCINATION. 361 
 
 cination. The most satisfactory course will be, I think, 
 to examine carefully three or four cases, typical of the 
 kinds of proof which have been advanced of this occur- 
 rence: but the reader will find all the cases — at all 
 events, all on which any stress has been laid by the 
 advocates of vaccino-syphilitic inoculation — referred to 
 in the note below.* 
 
 * Many of the following cases had been long known, amply 
 discussed, and set aside as inconclusive, at the time when the 
 general expression of medical opinion as to the harmlessness 
 of properly performed vaccination, before referred to (p. 339), 
 was elicited in answer to the inquiries of Mr. Simon, in 1856. 
 (1) An endemic of syphilis reported by Cerioli as having 
 occurred in 1821 [inquiry made eight months after its origin ; 
 the account given of this endemic is of the loosest kind ; it 
 was not proved, or even alleged, that the child from whom 
 the lymph, supposed to have been the origin of the outbreak, 
 was taken, had ever had syphilis]; (2) another endemic in 
 1841, seen also by Cerioli [investigated likewise after a very 
 long lapse of time ; the child from whom the lymph was taken 
 never had syphilis, but it was said that a year before his father 
 had had syphilis — this one child was used for vaccinating sixty- 
 four children, living in four communes] ; (3) cases reported 
 by Pitton in 1844 and by Ceccaldi in 1845 [worth referring to 
 as showing the sort of evidence which some practitioners rely 
 on to prove vaccinal syphilis, but not cases, it should be said, 
 to which M. Viennois attaches any importance; he points out 
 that the dates are inconsistent with the syphilis being derived 
 from vaccination] ; (4) cases reported by M. Vianit, in which 
 two adults had syphilis, ascribed to revaccination, from a little 
 nephew [details quite insufficient for any complete judgment] ; 
 (5) case of the Veterinaire B., in 1850, stated at length in 
 text ; (6) case of Hiibner, in 1852, also referred to in text ; (7) 
 a case at New York, in 1854, of a child having a sore on the 
 arm, and general symptoms believed to be syphilitic, said by 
 parents to have been from vaccination in Ireland (!); (8) the 
 31*
 
 362 HANDBOOK OF VACCINATION. 
 
 The case which is generally cited as that of " Le 
 Veterinaire B." is a case of undoubted communication of 
 
 cases recorded by Mr. Whitehead, of Manchester [Mr. White- 
 head's book was published some time before Simon's inquiry, 
 but in none of his cases is the evidence at all conclusive, and 
 very little weight, I believe, has ever been attached to them ; 
 M. Viennois himself rejects all of them but four] ; (9) cases 
 said to have occurred in 1856 in an Italian village to Dr. 
 Marone, but not recorded till six year afterward [not till 
 after the Kivalta cases, which in circumstances they resemble] ; 
 (10) case of two soldiers vaccinated, in 1859, by Jules Lecocq 
 [the lymph was taken from an adult, who, it is said, three 
 months before had had chancre, but had quite recovered ; 
 other persons vaccinated from him had vaccinia and no 
 syphilis, but these two had no vaccinia, but sores on the arm, 
 and at the end of six months secondary eruption. In one 
 account, given by Lecocq, these sores are said to have begun 
 on the fourth day of the vaccination, in another account, also 
 by him, to have begun on the eighth day: either of which 
 dates is inconsistent with their being of really syphilitic char- 
 acter, and the origin of the constitutional affection which after- 
 ward followed, but the discrepancy should not pass unnoticed, 
 as showing how little reliance, in a matter of dates, is to be 
 placed on the testimony even of educated and professional 
 persons, when given from mere recollection. How much 
 more, then, is caution requisite in accepting the statements of 
 ignorant and prejudiced persons as to dates, and sequence of 
 events, relating to the origin and progress of the disease] ; (11) 
 the Rivalta cases; and (12) Trousseau's case [both given in 
 text] ; (13) cases of M. Quarenghi [also referred to in text] ; 
 (14) three cases recorded in 1863, one by Chassaignac, another 
 by Devergie, and another by Herard, of children having vac- 
 cine vesicles, and afterward syphilitic sores on the arms [but 
 in each of these, essential particulars with regard to the vac- 
 cination are wanting] ; (15) case of two children vaccinated 
 at Alma in 1863, who, according to the very cursory account 
 given, had vaccine vesicles first and syphilitic sores after-
 
 OBJECTIONS TO VACCINATION. 3G3 
 
 syphilis by a man professing to vaccinate — one of the 
 cases of culpable carelessness already adverted to — but 
 so far from being a case of syphilis communicated along 
 with vaccination, the account affords not the smallest 
 pretext for asserting that there was ever any vaccina- 
 tion at all. It appears that in a town in Germany 
 twenty-four people belonging to different families were 
 in February, 1849 (some on the 13th, some on the 14th, 
 and some on the 15th), revaccinated, as they supposed, 
 by him. There is no statement of vaccine vesicles hav- 
 ing been produced in one of th£ cases, but at the end of 
 
 ward ; (16) case reported in 1864, by M. Sebastian, of Beziers 
 [a case brought forward to show, in conjunction with some 
 experiments, that blood may communicate syphilis, but that 
 lymph will not] ; (17) the cases at the Academie in 1865, stated 
 in text; (18) statement of 104 children vaccinated on three 
 different days off the arm of one child in 1866 by a midwife — 
 all of them, as well as twenty-three who were vaccinated the 
 week following, having syphilis [certainly one of the most 
 extraordinary cases on record. A case unquestionably of 
 great malpractice in vaccination ; but whatever symptoms 
 these children had that were taken to be syphilitic, they all 
 recovered — ninety-seven of them who had no treatment, just 
 as well as thirty who had specific treatment — and there was 
 no secondary eruption in any of them at the end of seventy 
 days. M. Bodelio might well say, "ce serait a faire doubter 
 de la nature syphilitique de cette deplorable vaccination." 
 The child from whom the lymph was taken was ascertained 
 to be quite free from syphilis, and its parents; so also the 
 child from which it had been vaccinated and its parents, 
 which is as far back as the lymph could be traced] ; (19) case 
 of some children having syphilis, ascribed to vaccination from 
 a child acknowledged to be perfectly healthy at the time of 
 vaccination, and before and long after, and never manifesting 
 at any time to the period when inquiry was made a single 
 symptom of syphilis; (20) a similar case.
 
 364 HANDBOOK OF VACCINATION. 
 
 three or four weeks {i.e. the ordinary period of the 
 incubation of syphilis) ulcerations of a syphilitic char- 
 acter began at the points of inoculation in nineteen out 
 of the twenty-four persons operated on, and these were 
 followed in due course by constitutional symptoms. 
 Here was syphilis, but no vaccination; what could 
 have been the cause of it? The vaccinator who was 
 inculpated asserted that the operations were all done 
 with lymph taken from one child, who was 1 fort et 
 sain," and who, having been vaccinated on the 4th of 
 the month, had regular vaccinia. We shall see imme- 
 diately how far this statement was borne out: but it 
 must first be noted — and is an illustration of the want 
 of precision generally attending these accounts — that 
 we are nowhere distinctly told whether the so-called 
 vaccinations, or any, or which of them, were done direct 
 from the child, or whether the stuff taken from it might 
 have not been collected on glasses, points, or tubes. 
 For all that appears to the contrary, there was at least 
 the possibility of a mistake (such as has happened many 
 times with regard to the matter of other inoculable 
 diseases),* of taking lancets, or glasses, or tubes, 
 charged with one kind of inoculable matter instead of 
 another. . But, assuming that the matter used came 
 from the source indicated, what was the state of this 
 source? Though it was said to be from an infant 
 "fort et sain," and that this was " surabondamment 
 
 * In 1854 there was an outbreak of small-pox in a place in 
 France from the unintentional use of variolous, instead of 
 vaccine, matter for inoculation. There had been a similar 
 occurrence about the same time in England. Such mistakes, 
 unfortunately, have on several occasions been known.
 
 OBJECTIONS TO VACCINATION. 305 
 
 demontre par plusiers temoins,"* a different account 
 was given by other witnesses ; and a doctor who saw 
 the child on the 21st of February, a week after the 
 lymph was taken off it, when of course no suspicion of 
 anything wrong had yet arisen, testified to the existence 
 of some erythematous eruption, which was said to be 
 like syphilitic roseola, and it died on the 24th, three 
 days after his visit, of hydrocephalus. But, more im- 
 portantly, what was the state of its arm ? It turned 
 out that, according to an eye-witness, there was on the 
 eighth day of the child's vaccination not a vestige of 
 vesicles, "aucune trace de boutons," and yet two days 
 later, the account tells us, several vaccinations were 
 
 * I need scarcely say that such evidence as one can get in 
 inquiries of this kind is almost always tinged with great pre- 
 judice, and requires to be received with corresponding cau- 
 tion : nor need I point out that evidence may be none the less 
 worthless because it is given without any intention of de- 
 ceiving. The Veterinaire's own testimony, however, with 
 regard to the health of this child was just the kind of testi- 
 mony that proves too much. Before he could think of select- 
 ing it as a source of lymph, he made, we are told, special 
 inquiries about its own health and that of its parents: and 
 having got a very good account of the latter, he took the pre- 
 caution to strip the child, "tout nu, pour pouvoir decouvrir 
 la moindre egratignure sur son corps." Nor was it sufficient 
 to do this once : at the moment of collecting the lymph from 
 him, on the 13th of February, he renewed his scrutiny, "afin, 
 dit-il, de rechercher si l'insertion du virus-vaccin chez cet 
 enfant n'aurait pas favorise" devolution de quelque exantheme 
 cache." Did anybody ever hear of such steps being taken 
 before taking lymph from an apparently healthy child who 
 had genuine vaccine vesicles? Is there any person of com- 
 mon sense who will believe that he really did all this, and did 
 not make up the story afterward ?
 
 366 IIANDBOOK OF VACCINATION. 
 
 performed from it, and lymph continued to be extracted 
 from it for two days more! Is it really meant that 
 between the eighth and the tenth days vesicles ap- 
 peared, the products of which communicated syphilis 
 but no vaccinia, but which were yet genuine vaccine 
 vesicles? The supposition is too absurd. But the 
 case is further instructive in my opinion, because, being 
 one which underwent a tolerably early investigation, 
 the statements about the child's health, and its regular 
 vaccinia, could be examined with some degree of hope 
 of getting at the truth. If four or five months _had 
 passed, or if, as in some of the alleged cases, a much 
 longer time had elapsed before any inquiry had been 
 set afoot, how difficult, or how impossible, it might 
 have been to correct the positive averments of a 
 healthy child and a regular vaccination! 
 
 In Hiibner's case — a case also of malpractice — there 
 could be no doubt of some children having been syphi- 
 lized, but no investigation of the circumstances was 
 made till eight months afterward, and the account of 
 the so-called vaccinations (in most of which it is quite 
 certain and admitted there had been no proper vaccine 
 eifect) was only what could be got from the state- 
 ments and recollections, at that interval of time, of the 
 mothers. 
 
 The case of M. Trousseau is of a different kind, but 
 assuredly very instructive. Its chief strength, in my 
 opinion, consists in the fact that it satisfied that very 
 able and distinguished physician. The circumstances 
 were these. A young woman was under treatment in 
 the wards of the Hotel-Dieu, for a uterine affection ap- 
 parently of a non-specific character, at a time when 
 there were some small-pox cases in the hospital, and
 
 OBJECTIONS TO VACCINATION. 367 
 
 wished to be revaccinated. This was done by three 
 punctures on each arm, from a child, healthy at the 
 time, and which, for anything that was ever known, 
 never exhibited any taint. Four children who were 
 vaccinated with its lymph, at the same time with this 
 young woman, went through vaccinia in the regular 
 way, and never had any subsequent syphilitic affection. 
 On the young woman's arm slight papules only arose, 
 and the revaccination was looked upon as having failed. 
 She remained in the hospital a month after the vac- 
 cination, fully the time necessary for the syphilis, if 
 there had been any imparted by the vaccination, to 
 have incubated, and she went out without anything the 
 matter on her arms. At the end of another month she 
 attended at the hospital for treatment of her uterine 
 complaint, and then showed two sores on one of her 
 arms, the character of which was not at first recog- 
 nized, but which turned out to be undoubtedly syphi- 
 litic. It was not known at the time, but was afterward 
 ascertained, that she was a young woman of very loose 
 character. Now, assuredly no one who knows in what 
 extraordinary situations chancres have been met with, 
 such as the cheek, the corner of the eye, in every sort 
 of situation in which there could not be any, and never 
 was any, suspicion of vaccination, can say that this 
 was a case entirely free from fallacy as to the source of 
 the syphilis : especially when we consider that, in the 
 first place, there was utter absence of proof that the 
 child from whom the lymph was taken ever had 
 syphilis, and every presumption (from the children 
 vaccinated from it at the same time with this young 
 woman having assuredly never been syphilized) that 
 it had not ; and that, in the second place, the period of
 
 368 HANDBOOK OF VACCINATION. 
 
 syphilitic incubation in this case, if the inoculation 
 really "dated from the time of the vaccination being 
 done, was of quite unusual length. But, supposing 
 that the effects were fairly traceable to the operation, 
 which, I would ask, in the name of common sense, is 
 the more probable — that lymph which had vaccinated, 
 without syphilizing, four subjects, should syphilize, 
 without vaccinating, a fifth, or that in an operation of 
 this kind done in the wards of a hospital there might 
 have been some accidental change of instrument, and 
 that syphilitic matter, mixed or unmixed, may have 
 thus found its way into the system ? Though the 
 woman had expressed a wish to be vaccinated, it ap- 
 pears she made a great deal of difficulty about it when 
 it came to the point, and it was in fact not done with- 
 out much urging, — a small circumstance, no doubt, and 
 yet one which may not be wholly immaterial, for it 
 shows that all did not pass in the easy arm-to-arm way 
 of an ordinary series of vaccinations.* 
 
 The occurrences at Rivalta, to which so much inter- 
 est has attached, were of a different kind. In 1861, 
 there occurred in this village a very remarkable syphi- 
 litic endemic. Three similar endemics are said to have 
 been noticed in different places before, in 1814, 1821, 
 and 1841; and if we include an account given (though 
 not till some years after the occurrence took place) by 
 a Dr. Marone, a fourth in 1856. It is certainly very 
 singular that all these endemics should have occurred 
 in Italy ; and none resembling them met with else- 
 
 * It need scarcely be said that the unintentional inocula- 
 tion of animal poisons through foul lancets has been known 
 to occur on various occasions, when neither syphilis nor vac- 
 cination was in question.
 
 OBJECTIONS TO VACCINATION. 369 
 
 where. Whatever their origin, the facts are of the 
 deepest interest — a number of children affected at one 
 time with syphilis, these infecting their nurses and 
 mothers, the mothers infecting their husbands, the 
 children infecting one another by the act of kissing or 
 by the spoons used in feeding, and whole families in- 
 fecting one another by merely being huddled together 
 in confined and crowded dwellings. For it must not 
 be supposed that only persons who were at the time 
 the subjects of vaccination were the sufferers. Various 
 endemics of this kind, quite as singular and quite as 
 inexplicable, have occurred under circumstances en- 
 tirely unconnected with vaccination, and indeed before 
 vaccination was known or heard of. Passing by the 
 very interesting accounts of the spread of sibbens and 
 other syphiloid diseases which will be found on record, 
 I refer particularly to outbreaks of undoubted syphilis, 
 attacking large numbers of people at a time, which are 
 related by various writers, and which Astruc has col- 
 lected together. Anything more puzzling than the 
 origin of these cases it is difficult to conceive. By 
 some they were attributed to the water in which peo- 
 ple bathed : by others, to the use of the same cupping 
 instruments (cupping being in those days a sort of 
 fashionable process).* In the five endemics specified 
 at the beginning of this paragraph a vaccinal origin 
 was alleged : and this was made in the Rivalta case 
 the subject of careful inquiry by a scientific commis- 
 
 * Astruc very sensibly remarks that he does not wonder 
 that suspicion should have fallen on the cupping instruments, 
 but that he does wonder how the momentary contact of the 
 blades should have infused the disease in the manner sug- 
 gested. (Dc Morbis Venereis.) 
 32
 
 370 HANDBOOK OF VACCINATION. 
 
 sion. Unfortunately, however, the inquiry did not 
 take place till four months after the outbreak ; and as 
 in no single case of the children said to have been 
 syphilized by vaccination had any application been 
 made to a medical man on account of the condition of 
 the arm, facts and dates on the exactitude of which 
 everything depends had to be got as they could at such 
 distance of time from the testimony of the villagers, for 
 the most part ignorant and prejudiced. Under these 
 circumstances, it is not surprising that different con- 
 clusions were arrived at : and though Dr. Pacchiotti 
 and the other commissioners, after a most careful and 
 painstaking inquiry, reported themselves satisfied of 
 the vaccinal origin of the disease, Sperino, who also 
 went to Rivalta and there investigated the circum- 
 stances, and treated some of the cases afterward at 
 Turin, was equally satisfied that their origin was inde- 
 pendent of the vaccination. The story, as regards the 
 vaccinal origin, is this : 
 
 A child (Chiabrera) apparently in good health, but 
 really incubating syphilis, was vaccinated with some 
 lymph obtained in a tube ; this child's arm was used 
 on the tenth day for the vaccination of forty-six chil- 
 dren, and one of these forty-six children, named Man- 
 zone, again on the tenth day, furnished lymph for 
 vaccinating seventeen children; of these sixty -three 
 children, forty-six had, within two months, a disease 
 considered by the commission to have been syphilis, — 
 the syphilitic symptoms having manifested themselves 
 in some cases within ten days, and as a mean, at twenty 
 days from the vaccination. Now, in explanation of 
 these events, can we admit that the matter taken from 
 Chiabrera's arm contained the contagion of the consti-
 
 OBJECTIONS TO VACCINATION. 371 
 
 tutional syphilis, which at these intervals of time the 
 children manifested? Not, assuredly, unless we are 
 prepared to give up all we have been taught as to the 
 incubative period of constitutional syphilis. For it 
 would have required from three to five weeks for that 
 disease to manifest its primary symptoms.* But if 
 this teaching has been erroneous, and true constitu- 
 tional syphilis can produce its primary symptoms 
 within ten days, then indeed we can understand how, 
 if syphilitic matter was mixed with the lymph, either 
 in the original tube, or through the lancet employed in 
 Chiabrera's vaccination, an irregular vesicle might re- 
 sult, such as that stated in Sperino's experiment with 
 soft chancre, which Baumes and Viennirs held to con- 
 tain the two viruses mixed. It must be remembered 
 that we have no reliable account whatever of what was 
 the sort of vesicle or result on Chiabrera's arm, from 
 which the so-called vaccinations were done.f From 
 such a result as Sperino's experiment affords (p. 348), 
 a careless man might, a careful man would not, take 
 what he called lymph ; and I have very little faith in 
 the proceedings of any one who evidently habitually 
 used tenth-day cases. We might not really, then (that 
 
 * Lee gives the period of incubation at from three to seven 
 weeks. Kollett gives a mean of twenty-six days, and out of 
 a large number of cases there was only one case in which it 
 was under fifteen days. In four cases in which the inocula- 
 tion was by blood the minimum was twenty-five days and 
 the maximum thirty-five. (Rollet, Traite des Maladies V6n6- 
 ricnnes.) 
 
 f There is only the mother's account that it was regular ; 
 but I have already pointed out into what errors parents often 
 fall on this subject.
 
 372 HANDBOOK OF VACCINATION. 
 
 is, supposing the incubation difficulty got over, which 
 it must be, or else the Rivalta cases as connected with 
 vaccination fall of themselves), have any difficulty in 
 accounting for the propagation of syphilis, for hard 
 and soft chancre would fall in the same category. But 
 we should have more hesitation as to whether vaccinia 
 also might be communicated at the same time ; and, in 
 fact, in what degree the Rivalta children, who were 
 syphilized, were also vaccinated, it is impossible to say. 
 I can quite conceive that if the vesicle on Chiabrera's 
 or Manzone's arm was at all like that produced in 
 Sperino's experiment, some spurious vaccine result 
 might follow in some of those vaccinated from them. 
 There is certainly no satisfactory evidence of any of 
 the children ever having had regular vaccinia. When 
 the arms were first seen (by Dr. Katt), or when they 
 were seen by the commission of inquiry, they pre- 
 sented either so many syphilitic sores, or else cicatrices, 
 which, according to the description given, had no vac- 
 cine character about them ; and the fact that the revac- 
 cination of five of the children was afterward without 
 effect (a revaccination which it is not stated was re- 
 peated) is far from being conclusive.* 
 
 None of the alleged cases, then, have established, 
 in my opinion, that syphilis has ever been imparted in 
 the due and proper performance of vaccination, i.e. 
 with the unmixed lymph of a genuine vaccine vesicle. 
 They are not even, in my opinion, at all conclusive as 
 to this having been done by the inoculation, along with 
 
 * It would be singular, no doubt, provided there had been 
 no previous vaccine effect, but not the least singular if there 
 had been a spurious effect.
 
 OBJECTIONS TO VACCINATION. 373 
 
 lymph, of a small quantity of syphilitic blood — al- 
 though I hope that it is unnecessary for me to say that 
 this is not a matter in which the slightest posssibility 
 of risk should be allowed, and that a practitioner would 
 be indeed highly culpable who should vaccinate with 
 anything but pure and unmixed lymph, or who, in fact, 
 should knowingly vaccinate from a syphilitic child at 
 all. But whether from admixture of blood, or from 
 admixture of the inoculable secretions or products of 
 syphilis, as through foul lancets or in any other way, 
 the real risks are, I believe, entirely risks of careless- 
 ness — risks which, with due regard to the rules which 
 have been laid down for the proper performance of 
 vaccination, could not occur.* 
 
 * The performance of vaccination direct from animals, in 
 whom the cow-pox has been artificially maintained, as already 
 described (§ 12, a, p. 25), has been suggested as a way that 
 would effectually obviate any possibility of invaccinating 
 syphilis. And, following a plan which was previously in use 
 at Naples, animal vaccinations, as they are called, have been 
 practiced to a limited extent of late in Paris and elsewhere. 
 But the difficulties in applying such a plan to the vaccination 
 of the general population are, I apprehend, quite insuperable ; 
 even on the very limited scale on which the practice has been 
 attempted at the Academie (from seven to eight hundred vac- 
 cinations a year), the resources in animals did not allow of the 
 vaccinations being done under the conditions believed to be 
 most favorable for success in more than 60 per cent, of the 
 cases ; and the rest were done under circumstances of great 
 disadvantage. But an objection, in my opinion, even to its 
 limited application, is that it tends to weaken our defenses 
 against small-pox. Small-pox is yet so formidable an enemy 
 that no risk of this must be run, out of fear of small, and
 
 3T4 HANDBOOK OF VACCINATION. 
 
 (g) The Practical and Common-sense View of the 
 Question. — Suppose, however, that there existed risks 
 of vaccino-syphilitic inoculation, greater than I can al- 
 low to have been shown, and that the occurrence is 
 one that, under some unknown conditions, might take 
 place in a properly-performed and careful vaccination ; 
 what, after all, looking at the matter in a plain, practi- 
 cal, common-sense way, do these risks amount to? 
 Suppose we assume that in all the cases that have 
 been advanced, except those in which, on the very face 
 
 almost, if not quite, hypothetical dangers. Our great defense 
 against it consists in making vaccination successful, and fully 
 successful; in taking care that when parents bring their chil- 
 dren to be vaccinated, these shall be infected at once and in- 
 fected completely ; and this is just what animal vaccination 
 does not do. (See ante, p. Ill, note.) There is no one in Eng- 
 land whose opinion on this subject will be received with so 
 much respect as Mr. Ceely's, because there is no one who has 
 nearly the knowledge that he possesses of the disease in the 
 cow and of its transplantation to the human species. He looks 
 upon this proceeding as not only open to the objections of im- 
 practicability, as applied to the general population, and of 
 unsuccess ; but he says also that, so far from being likely to pro- 
 duce fewer ailments and cutaneous eruptions in the predis- 
 posed, he knows from his experience that it would, as being 
 more irritating, produce more. He regards it as uncalled for, 
 either for regenerating lymph or for preventing syphilis. 
 With regard to the latter, he says: "I cannot but think our 
 continental brethren are very careless vaccinators, and that 
 syphilis must be very much more prevalent among their in- 
 fantile population than with us. It is remarkable that so 
 many cases of vaccino-syphilitic inoculation are reported on 
 the continent while we hear of no such thing here. I cannot 
 persuade myself that such inoculations are unavoidable." (See 
 British Med. Journ., Jan. 7, 1865.)
 
 OBJECTIONS TO VACCINATION. 375 
 
 of the story, there was manifest malperformance, the 
 vaccination had been properly done, what proportion 
 do these bear to the millions upon millions of vaccina- 
 tions that have been performed? If men who have 
 been all their lives professional vaccinators, as Marson, 
 or Leese, or Tomkins; if men whose professional lives 
 have been spent in the midst of syphilis, as Lee, or 
 Acton, or Langston Parker, have met with no cases in 
 which syphilis originated in this way, the conditions 
 under which the occurrence can take place must be 
 indeed of rare exceptionality. During the eight years 
 in which there has been systematic inspection of public 
 vaccination in England, some millions of vaccinations 
 have been performed; but the inspectors have no 
 knowledge of any such accident having occurred in 
 any one instance. 
 
 "Either," as Simon has well put it, " it is the case 
 that — even with reprehensible carelessness as to the 
 source of lymph, vaccination (so long as in any sense 
 of the word it is vaccination) cannot be the means of 
 communicating any second infection ; or else it is the 
 case that in the world of vaccinators, care is almost 
 universally taken to exclude the possibility of danger."* 
 The fifty-six thousand lives which at the least are now, 
 on an average, saved annually from small-pox in Eng- 
 land alone, are not gained without here and there a 
 child getting erysipelas from its vaccination, and even 
 in cases, of excessive rarity, dying of it ; but what 
 reasonable man ever hesitates on account of this risk 
 — "risque," as Trousseau says, "bien plus grands que 
 les chances a peu pres nulles de la syphilis" — to have 
 
 * Simon, Preface, etc. (op.cit.), p. lxxxi.
 
 376 HANDBOOK OF VACCINATION. 
 
 his child vaccinated ? The danger, if indeed there be 
 any at all, of communicating through vaccine lymph, 
 as in an ordinary well-performed vaccination, any- 
 other infection than its own, must be so infinitesimally 
 small, that for all practical purposes we may regard it 
 as non-existent.
 
 INDEX. 
 
 Abrasion, forms of vaccination by, 130; 
 the most successful mode when dry lymph 
 is used, 134. 
 
 Academic de Medecine, lymph in use at, 
 in 1836, 203 ; vaccination, how performed 
 at, 206 n., 352; discussions on vaccinal 
 syphilis, 356; reports, referred to peusim. 
 
 Accelerated vaccination, 89. 
 
 Age at which vaccination should be per- 
 formed, 117; at which revaccination 
 should be performed, 301. 
 
 Age, influence of, on the protective power 
 of vaccination, 250. 
 
 Alfort, outbreak of the horse-pox at, 38. 
 
 Alison, Professor, his observations on the 
 protective power of vaccination, 234; on 
 its value in preventing the scrofula con- 
 sequent on small-pox, 332. 
 
 Animal vaccination, 109, 373 n. 
 
 Areola, its color in the cow influenced by 
 the hue and texture of the skin, 13. 
 
 Areola in the human subject, 81 ; import- 
 ance of its regular development, 81, 86. 
 
 Arm-to-arra vaccination, 125; its vast 
 superiority, 140, 180, also 111 n.; con- 
 trasted with use of stored lymph, 170, 
 191. 
 
 Army, cases and deaths from small-pox 
 in the, 273, 284; vaccination in the, 271; 
 results of revaccination in the, 311. 
 
 Arnott, Dr., his cases of strong family dis- 
 position to small-pox, 256. 
 
 Arrangements for vaccination, 140. 
 
 Artilicial production of cow-pox in the 
 cow, 25. 
 
 Artificial production of the horse-pox, 40. 
 
 Aylesbury, cow-pox in the Yale of, 24. 
 
 Badcock's successful variolations of cows, 
 60; numerous vaccinations with his 
 variola-vaccine lymph, 66. 
 
 Baron, Dr., on liability of cattle to malig- 
 nant form of cow-pox, 74. 
 
 Baron's Life of Jenner, referred to ptmaim. 
 
 Bath Union, deaths from small-pox in the, 
 2112 n. 
 
 Bavarian army, compulsory revaccination 
 in the, 304 ; its results, 304. 
 
 Bengal army, statistics of small-pox in, 
 279. 
 
 Berlin, decline of small-pox in, since the 
 introduction of vaccination, 280. 
 
 Black-pock, 19. 
 
 Blister-pock, 19. 
 
 Blood, question of inoculation of syphilis 
 by the, 353. 
 
 Blot's account of vaccination as practiced 
 at the Academic, 206 n. 
 
 Bohemia, decline of small-pox in, sinco 
 the introduction of vaccination, 280. 
 
 Bombay army, statistics of small-pox in, 
 279. 
 
 Bouley's experiments, 40, 72. 
 
 Bridgewater Level, cow-pox in the dairies 
 of, 24. 
 
 Brighton Union, deaths from small-pox#n 
 the, 292 n. 
 
 Brown's inoculations with lymph from a 
 cow in India, 78. 
 
 Bryce's proposal of a special class of " vac- 
 cinators," 186. 
 
 Bryce's test, 98. 
 
 Buchanan and Seaton's observations on 
 vaccination in London, 247; on the 
 importance of having special "vaccina- 
 tors," 187. 
 
 Burton-on-Trent Union, deaths from small 
 pox in the, 292 n. 
 
 Bussunt, disease of, in cattle in India, 75. 
 
 Camel, pock analogous to cow-pox in the, 
 54. 
 
 Canterbury Union, deaths from small-pox 
 in the, 292 n. 
 
 Cardiff, deaths from small-pox in, 319. 
 
 Cardiff Union, deaths from small-pox in 
 the, 292 a. 
 
 Care in vaccinating, Marson on importance 
 of, 196. 
 
 Carelessness, dangers of, 346. 
 
 Carmarthen Union, deaths from small-pox 
 in, 319. 
 
 Carnarvon, deaths from small-pox in, 320. 
 
 Cattle, inoculation of, with small-pox, 57 ; 
 infection of, by variolous effluvia, 58, 88 : 
 not shown to be subject to any other 
 variolous affection than cow-pox, 74. 
 
 Ceely, Robert, his description of cow-pox, 
 9; his enumeration of different kinds of 
 spurious pock, 19 ; his drawings of 
 casual blister-pox on the hands of milk- 
 ers, 20 ; his inoculations of cattle with 
 various kinds of vaccine lymph, 25, 30; 
 his experiments with sheep-pox lymph, 
 47; his success in variolating cows, 60; 
 his account of the phenomena induced, 
 63; his case of infection of cows by 
 variolous effluvia. 62; his account of 
 the effects of variola-vaccine lymph on 
 the human subject, 107 : his experiments 
 and observations on different lymphs, 
 210; his observations on animal vaccina- 
 tion, 374 n.; his essays referred to pnimini. 
 
 Ceylon, epidemics of small-pox in, 277. 
 
 Chauveau's experiments on horso-pox, 41 ; 
 
 33 
 
 (37*7)
 
 378 
 
 INDEX. 
 
 his experiments in inoculating cattle 
 with variolous matter, 66. 
 
 Chiabera, alleged case of vaccinal syphi- 
 lis, 370. 
 
 Childhood, circumstances under which re- 
 vaccination is called for in, 301. 
 
 Children specially the victims of natural 
 small-pox, 212, 286; post-vaccinal small- 
 pox of, is generally a very trivial affec- 
 tion, 250. 
 
 China, small-pox in British army and 
 navy in, 2">7. 
 
 Christ's Hospital, proofs of protective 
 power of vaccination from, 275. 
 
 Cicatrices left after the falling of the cow- 
 pox crusts in the cow, 15. 
 
 Cicatrix, vaccine, in the human subject, 
 characters of the, 82 ; importance of 
 the, as a test of the quality and protect- 
 ive value of the vaccination, 241. 
 
 Claveau, le, the sheep-pox of the French, 
 44. 
 
 Clavelization, 45. 
 
 Climate, effects of, on the course of vaccin- 
 ation, 94; effects of, on the keeping of 
 lymph, 95, 276; change of, its influence 
 on the liability to small-pox, 257 ; pro- 
 tective power of vaccination against 
 small-pox is seen in all, 275. 
 
 Coleman's experiments with lymph from 
 the horse, 35. 
 
 Constitutional symptoms of vaccinia, 81. 
 
 Copenhagen, decline of small-pox since 
 the introduction of vaccination in, 280. 
 
 Cow, vaccinia or cow-pox in the, 9; the 
 cow-pox not considered by Jenner as a 
 natural disease in the, 21 ; artificial pro- 
 duction of cow-pox in the, 40; change 
 which the variolous virus undergoes in 
 passing through the, 65; vaccination 
 from the natural orcasual disease in the, 
 136 ; how to establish a stock of lymph 
 from the, 139; recurrence to the, for 
 lymph unnecessary, 199. (See Cow- 
 pox.) 
 
 Cow-lymph, inoculation of cows with, 25; 
 inoculation of horses with, 41 ; phenom- 
 ena of vaccinating with primary, 101 ; 
 with secondary, 109; Ceeley's observa- 
 tions as to collecting it, 137; it should 
 be taken before acuminatum of the vesi- 
 cle, 138. 
 
 Cow-pox, the "variolas vaccinae" of Dr. 
 Jenner, 9 : natural history of, 9 ; a spe- 
 cific eruptive disease, 9; yonng cows and 
 milch heifers more subject to it than 
 older cows, 10 ; not peculiar to the milch 
 cow, 10 n.; course of local phenomena at- 
 tending it, 11 ; earliest symptoms of the 
 disease, 11 ; number, size, etc. of the 
 vesicles in different animals, 12 ; amount 
 of eruption, and consequent severity of 
 the disease, depend much on the state of 
 the teats, etc., 12 n.; formation, color, etc. 
 of the areola, 13; acurai nation of the 
 vesicle, 13 : cicatrices left after the fall- 
 ing of the crusts, 15 ; effects of handling 
 on the local affection, 15 ; progress and 
 character of the disease, 16: duration of 
 the various stages of the disease, 16; 
 structure of the vesicle, 17; constitu- 
 tional symptoms, 18; spurions pocks, 
 18; diagnosis of the disease, 19; casual 
 
 blister-pox on the hands of milkers, 
 20 n.; supposed origin of, from "grease," 
 21 ; has a common specific infection with 
 the horse-pox, 21 ; geographical distri- 
 bution of, 22 ; its frequent recurrence in 
 some localities, 24 ; artificial production 
 of, in the cow, 25; by inoculation with 
 cow-lymph, 26; by equination, 28; by 
 retro-vaccination, 30; relations of horse- 
 pox to, 33; of some pocks in other ani- 
 mals to, 44, 54 ; of human variola to, 56 ; 
 Dr. Jenner's views on the subject, 56; 
 cow-pox produced in cows by variolous ef- 
 fluvia, 58; produced by successful vario- 
 lation of cows, 63 ; cattle not shown to 
 be subject to any other variolous affec- 
 tion than, 74; can only be communica- 
 ted to the human subject by inoculation, 
 '80; course of, in persons not previously 
 infected by it, 80 ; usual course, 81 ; con- 
 stitutional symptoms, 81 ; abnormal 
 course, 85; simple retardation, 85; re- 
 tardation from incubation of measles, 
 scarlatina, etc., 86 ; from incubation of 
 small-pox, 88 ; simple acceleration, 89 ; 
 spurious form, 89 ; effects on its course 
 of mechanical interference with the ves- 
 icle, 92; degeneration of the vaccine 
 vesicle, 93; effects of climate on the 
 course of vaccination, 94; supernumer- 
 ary vesicles, 96 ; reinsertion of vaccine 
 lymph (Bryce's test), 98 ; its history, 99 ; 
 its analogy with some of the phenomena 
 of natural cow-pox, 101 ; vaccination 
 with primary cow-lymph, 101 ; local phe- 
 nomena and general symptoms, 102; 
 progress of humanization of lymph, 104; 
 varieties in amount of constitutional 
 disturbance, 104 ; symptoms, etc. of the 
 casual cow-pox of milkers, 106 ; vaccin- 
 ation with variola-vaccine lymph, 107 ; 
 with secondary cow-lymph, 109; diffi- 
 culties attending the transplantation of 
 primary cow-lymph to the human sub- 
 ject, 102, 111 n.; vaccination with retro- 
 vaccine lymph, 112; phenomena and 
 course of revaccination, 113 ; treatment 
 of revaccination, 114 (see Vaccina- 
 tion) ; the natural cow-pox still not in- 
 frequent on the dairy-farms of the 
 Bridgewater Level and the Vale of Glou- 
 cester, 24, 209. 
 
 Cows, attempts to ovinate, 51 ; difficulties 
 of infecting, with variolous virus, 58 ; 
 Dr. Thiele's success, 59; Ceely's suc- 
 cess, 60; Badcock's success, 60; phe- 
 nomena of successful variolation of, 
 63. 
 
 Cross's observations on the protection af- 
 forded by vaccination, 262. 
 
 Crusts, vaccine, fall from the 14th to the 
 20th day in the cow, 28 ; from the 20th 
 to the 25th day in the human subject, 82 ; 
 used for vaccinating, 174. 
 
 Cutaneous diseases, on the allegation that 
 they may be invaccinated, 334. 
 
 Death-returns of small-pox in England, 
 
 analysis of the, 286. 
 De Carro, Dr., his successful introduction 
 
 of the vaccine lymph into India, 176. 
 Degeneration of lymph, and decadence of
 
 INDEX. 
 
 379 
 
 Tftccine power, allegations respecting, 
 
 not supported by facts, 2(10, 270, 884. 
 Diagnosis of true cow-pox in the cow, 19. 
 Disinfection, measures of, indispensable 
 
 to extinguish small-pox, 31C>, SB. 
 Districts for public vaccination, 143. 
 Dogs, vaccination of, 54. 
 Dover Union, deaths from small-pox in 
 
 the, 292 n. 
 Dry-lymph, how to be used, 131 : its 
 
 advantages as compared with tube- 
 
 lymph, 170. 
 Dudley Union, deaths from small-pox in 
 
 the, "291. 
 Duncan, the, infected by small-pox from 
 
 Portsmouth, 292. 
 
 Earle's cases of small-pox after inocula- 
 ted small-pox, 22.">. 
 
 East Indies, small-pox in the army and 
 navy in the, 2.">7, 278. 
 
 England, deaths from small-pox in, 280, 
 291. 
 
 Epidemic influence, effect of, on the pro- 
 tective power of vaccination, 269. 
 
 Epidemics of small-pox in Ceylon, 277 ; in 
 the Mauritius, 278 ; frequency of recur- 
 rence in London, 280 n. 
 
 Equination. vaccine disease may be in- 
 duced in the cow by, 25, 28. 
 
 Erysipelas, occurrence of, after vaccina- 
 tion, 93. 
 
 Estlin's lymph-stock, 105, 208. 
 
 Europe, statistics of small-pox in, showing 
 the power of vaccination, 279. 
 
 Kiri/iihi.i, small-pox on board the. 266. 
 
 Exposure to the small-pox infection, fre- 
 quency and extent of their influence on 
 post-vactinal small-pox mortality, 261. 
 
 Family tendency to small-pox, 254 
 Farr, Dr., on the diminution of febrile and 
 
 scrofuious diseases, 332. 
 Febrile diseases, diminution of, 331. 
 Fever, present death-rate of, as compared 
 
 with former rate, 332. 
 France, practice of vaccination in, 349. 
 
 Gardner's report of the Mauritius epi- 
 demic. 278. 
 
 Geographical distribution of cow-pox, 22. 
 
 Gil ham's experiments w ith Estlin's lymph, 
 208. 
 
 Glandular diseases, allegation that they 
 may be inraccinated, 334. 
 
 Glasses used for preserving lymph, 162. 
 
 Gloucester, cow-pox in the Vale of, 23, 
 
 Goat said to be susceptible of vaccination, 
 
 55. 
 Gotce, disease of, in cattle in India, 75. 
 "Grease," supposed origin of cow-pox 
 
 from, 21 ; relations of horse-pox to. 33. 
 Grove's cases of post-vaccinal small-pox, 
 
 255. 
 Guardians, Boards of, their responsibilities 
 
 in reference to small-pox, 327. 
 
 Health, an important consideration with 
 regard to performance of vaccina ion, 
 li:.. 
 
 Hereditary tendency to small-pox, I 
 
 Ilering's observations on cow-pox, 22 n., 
 23. 
 
 Horse, subject to disease identical with 
 cow-pox, 36 ; experiments in proof, 36 ; 
 inoculations of, with variolous virus, 42. 
 
 Horse-pox, its relations to cow-pox, 33; 
 and to "grease, "33; various experiments 
 in producing, 34 ; direct inoculation from 
 horses' heels, 35; distinguished by the 
 appropriate name of "variolas equi- 
 na;," 37 ; outbreaks of the disease among 
 horses at Alfort and Rieumes, char- 
 acter and course of the disease. 38 ; 
 to be distinguished from "grease" on 
 the one hand, and aphtha epizootica on 
 the other, 40; artificial production of, 
 by inoculation, 40 ; by injection of lymph, 
 42 ; Chanveau's various experiments for 
 producing, 41 ; the pocks in other animals 
 which have been considered analogous 
 to, 44 ; relation of, to human variola, 56. 
 
 Hughes, Dr., of Mold, the statistics of 
 vaccination in his district, 289 ».; im- 
 munity of the district from small-pox. 
 288. 
 
 Human subject, attempts to ovinate the, 
 45; vaccinia or cow-pox in the, 80. 
 
 Humanization of lymph, difficulties attend- 
 ing the, 102, 111 «.; effects of lymph in 
 progress of being humanized, 104. 
 
 Husband, Dr., his description of capillary 
 tubes and the method of using them, 163 ; 
 his table showing the reBnlts of lymph 
 kept in tubes for different periods, 173. 
 
 Imperieuse, small-pox on board the, 266. 
 
 Incubation of measles, etc., its effects on 
 vaccination, 86. 
 
 Incubation of small-pox, its effects on vac- 
 cination, 88. 
 
 India, experiments with lymph taken from 
 cattle in, 75; establishment of vaccin- 
 ation in, 176; statistics of small-pox, 
 279. 
 
 Infantile vaccination, the laws respecting, 
 should be administered with the utmost 
 strictness in large towns, 280. 
 
 Inoculation of small-pox in animals, 42, 
 55, 57. 
 
 Inoculation of small-pox in the human 
 subject, its introduction, 216; its results, 
 217. 
 
 Inspection of results after performance of 
 vaccination, its great importance, 134. 
 
 Insusceptibility of vaccination, 196. 
 
 Italy, practice of vaccination in, 350. 
 
 Jen i-vkk, Dr., his inquiries about the cow- 
 pox, 21, 21; his belief that the disease 
 originated in the horse, 21, 34; con- 
 founded at first the equine-pox with 
 "grease," 21, 33; but afterward noted 
 their merely accidental connection, 36: 
 his views on the relation of these dis- 
 eases to variola, 56: his discovery of 
 vaccination, 219: his observations on 
 the influence of herpes and other erup- 
 tions on the course of vaccination, 93, 
 116; his rule to have the skin freo from 
 eruption, Iwforc vaccination, 117; his 
 "golden rule'' about lymph-taking, 123; 
 his remarks on the arrangements neces- 
 sary for vaccination, 141 ; on the use of
 
 380 
 
 INDEX. 
 
 the vaccine crust, 174 ; on the training 
 required bj vaccinators, 182; no believer 
 in the degeneration of lymph, 199; proofs 
 of the correctness of liis views in this 
 respect, 101 ; his demonstration of the 
 protective power of vaccination, 221; 
 his opinion as to the extent of this, 222 ; 
 small-pox itself does not always prevent 
 small-pox, 226; showed that cow-pox 
 may be taken again and again by human 
 subjects, but that a second taking did 
 not prove them to be liable to variola, 
 312; his anticipation that vaccination 
 would indirectly diminish scrofula, 333 ; 
 shown to be correct, 333; his proposal 
 for conveying vaccination to India, 176. 
 Jenncr. Sir Wm., cutaneous and other dis- 
 eases, ..'it induced by vaccination, 336. 
 
 Kaiu.kht, of Prague, his observations on 
 the horse-p>x in Bohemia, 37. 
 
 Kendrick, Dr., his cases of post-vaccinal 
 small-pox, 255. 
 
 Kite's cases of small-pox.after inoculated 
 small-pox, 226. 
 
 La Font's experiments with lymph of 
 horse-pox, 35. 
 
 Lafosse, M., description of phenomena 
 induced in cows by equination, 29. 
 
 Lee, Mr. II.. his mistaken announcement 
 of a case of vaccinal syphilis, 357. 
 
 Leith's statistics of Bombay, 279. 
 
 Lichen, vaccine, 83. 
 
 Lincoln General Dispensary, facts from 
 its practice, showing the imperfect per- 
 formance of vaccination, 195. 
 
 London, decline of small-pox in, since the 
 introduction of vaccination, 280; epi- 
 demics in, 289 «.; annual mortality from 
 small-pox, 280. 
 
 Loy's experiments with lymph from the 
 horse, 34. 
 
 Lymph, equine, used by Jenner and others 
 for vaccinating, 34; the lymph first con- 
 veyed effectually to India was equine, 
 177 ; used for experiments, 29, 34, 40, 42. 
 
 Lymph, vaccine, inoculation of cows with, 
 25, 30; of horses with, 41; injection of, 
 into the blood-vessels of horses, 42; 
 effects of insertion of, in different ani- 
 mals, 54 ; inoculation of human subjects 
 with, 80; fallacies which may arise in 
 trials of new lymph, if small-pox is pre- 
 vailing, 79 n.; variola-vaccine, 66, 107 ; 
 retro-vaccine, 112; selection of, for vac- 
 cinating, 123; collection of it, 124; vac- 
 cinating with stored lymph, 125 ; various 
 methods of inserting lymph, 126; by 
 puncture, 126; by scarification, 129; by 
 abrasion, 130; particular steps necessary, 
 when it is dry-stored, 131 ; is any one 
 mode of inserting it better than another, 
 13 1 ; arrangements for the maintenance 
 of supply of, 140; selection of, necessary 
 to prevent its degenerating, 141,200 ; con- 
 tinuous supplies, depend on arrange- 
 
 • ments for public vaccinations in large 
 towns, 143; proper arrangements for sup- 
 ply in large towns,147; great want of such 
 arrangements hitherto, 151 ; arrange- 
 ments for supply of, in small, urban 
 populations, 152 ; in still smaller towns, 
 
 and in rural districts, 153; conveyance 
 and storage of, 158 ; vaccine bottle, 159 ; 
 poiius, 161 ; glasses and tubes, 162 (see 
 Tubes) ; the best mode of storage, 168 ; 
 great uncertainty attached to its success 
 when long kept dry, 172; length of 
 keeping does not damage it when kept 
 in tubes, 172 ; Dr. Husband's table of its 
 effects, when kept for different periods, 
 173 ; transmission of, to tropical climates, 
 cautions respecting, 174; successfully 
 introduced into India, 176 ; standard of, 
 when stored lymph is used, 181 ; illus- 
 trations of use of stored lymph, 168; of 
 alleged degeneration of, 199; Jenner's 
 opinion on, 199; Simon's opinion on, 
 200 n.; the vesicles produced by Jenner's 
 lymph have the same character and 
 course as he described, 201 ; and leave 
 the same kind of cicatrices, 203 ; when 
 accidentally degenerated lymph should 
 be at once changed, 204 ; particular kinds 
 of, 205; the Passy lymph, and other more 
 recent French stocks, 205; Estlin's 
 lymph, 208; Bousquet's account of the 
 lymph of the Academie de Medecine, 
 with which the Passy lymph was com- 
 pared, 205; Ceely's experiments with 
 different kinds of, 210; primary lymph- 
 stocks differ in their action, 210. 
 Lvinph-stock set in circulation by Mr. 
 Estlin, of Bristol, 208. 
 
 Macpherson's experiments in vaccina- 
 tion with lymph from cows, 76. 
 
 Madras army, statistics of small-pox in, 
 279. 
 
 Marshall's cases of post-vaccinal small- 
 pox, 255 ; inquiry into epidemic at Chel- 
 sea, 263. 
 
 Marson's experiments with ovine lymph, 
 and vaccination of sheep, 47, 50; his 
 standard of successful vaccination, 180; 
 his statements of the amount of bad 
 vaccination in England, 187 ; his obser- 
 vations on the severity and danger of 
 post-vaccinal small-pox as influenced by 
 cicatrices after vaccination, 244 ; his re- 
 port of the proportion of cases of second 
 small-pox, 296 n. 
 
 Measles, effects of incubation of, on the 
 course of vaccination, 86. 
 
 Mechanical interference, effects of, on the 
 course of vaccination, 92. 
 
 Merthvr Union, deaths from small-pox in 
 the, '292 n. 
 
 Milch cow particularly liable to vaccinia, 
 10. (See Cow-pox.) 
 
 Milkers apt to contract cow-pox, and con- 
 vey it from animal to animal, 23; de- 
 scription of the casual cow-pox of, MB; 
 mistakes into which they fall from con- 
 tracting spurious pocks, 20. 
 
 Mold, district of, statistics of vaccination 
 in the, 289. 
 
 Moravia, decline of small-pox in, since the 
 introduction of vaccination, 280. 
 
 National statistics of small-pox, showing 
 the protective power of vaccination, 279. 
 
 National Vaccine Establishment, success- 
 ful practice of vaccination atits stations, 
 180 «., 181; its rule as to the perform-
 
 INDEX. 
 
 381 
 
 ance of vaccination, 189 ; demands on 
 it for lymph-supply by practitioners in 
 England, 146 «., 151 «.; its lymph is 
 chiefly of Jenner's stock, 202; compari- 
 son of this lymph with more recent 
 lymphs, 207; appointment of teaching 
 stations in connection with the Estab- 
 lishment, 185. 
 
 Navy, vaccination in the, 271 ; small-pox 
 in the, 257, 266, 274, 291. 
 
 Neath Union, deaths from small-pox in 
 the, 292 a. 
 
 Newport Union, deaths from small-pox in 
 the, 292 n. 
 
 Northampton, scandalous neglect of vac- 
 cination in, and fatal epidemics of small- 
 pox, 281 n., 292 n. 
 
 Northampton Union, deaths from small- 
 pox in the, 281 n. 
 
 Ortmiii, small-pox on board the, 268. 
 
 Urination of the human subject, 45; Sac- 
 en's experiments, 45; Marson'sand Cee- 
 ly's, 47 ; of cows, etc., 51. 
 
 Paget, Professor, his opinion that skin 
 diseases and syphilis are not communi- 
 cable by vaccination, 337, 339, 342. 
 
 Paine, Dr., his observations at Cardiff, 
 showing the protective power of vaccin- 
 ation, 264. 
 
 Papulo-vesicular eruptions attendant on 
 vaccination, 84; more frequently seen 
 when cow-lymph is used, 103. 
 
 Passy lymph, use of, 205. 
 
 Pearse, Dr., his table of results of tube- 
 lymph compared with vaccination from 
 the arm, 170. 
 
 Photoshootur, the small-pox of camels, 54. 
 
 Pocks in animals which have been consid- 
 ered analogous to cow-pox and horse- 
 pox, 44 ; the sheep-pox, 44 ; the camel- 
 pox, 54. 
 
 Points used for preserving lymph, 161. 
 
 Pontypool Union, deaths from small-pox 
 in the, 292 w. 
 
 Pontypridd Union, deaths from small-pox 
 in the, 292 ft. 
 
 Portsmouth, serious consequences of neg- 
 lect of vaccination in, 291. 
 
 Private vaccination, hints concerning ar- 
 rangements for, 155. 
 
 Privy Council, teaching stations appointed 
 in connection with National Vaccine 
 Establishment, 185. 
 
 Protection from small-pox afforded by vac- 
 cination, 220,231. 
 
 Provincial Medical Association, cases of 
 recurrent small-pox collected by the, 
 227. 
 
 Puncture, methods of vaccination by, 126. 
 
 Recurrent small-pox (see Small-pox). 
 
 Registrar-General's facts, showing the de- 
 crease in small-pox from the increased 
 observance of vaccination, since compul- 
 sory act. 212 
 
 Retro-vaccination of cows, 25, 30. 
 
 Retro-vaccine lymph, vaccination with, 
 112. 
 
 Reraccination, phenomena and course of, 
 113: purposes lor which it is necessary, 
 299 ; carelessness in primary vaccination 
 
 not to be excused on the ground that re- 
 vaccination will make good its defects, 
 300 ; age at which it should be performed, 
 301 ; circumstances under which it is 
 called for in childhood, 301 ; it should be 
 performed on all persons after puberty, 
 303; requires the same care and pains 
 in its performance as primary vaccina- 
 tion, 306 ; the performance of, should not 
 be left to periods when small-pox is 
 epidemic, 308: the local results produced 
 by it in individuals give no indication 
 as to the person's liability to small-pox, 
 310; table representing the results of, in 
 the Wirtemberg and British armies, 311. 
 
 Rieumes, outbreak of the horse-pox at, 38. 
 
 Roseola, vaccine, 83. 
 
 Royal Military Asylum, illustration of the 
 protection of vaccination from, 275. 
 
 Sacco, his observations on cow-pox, 22 n., 
 
 23; his ovinations of human subjects, 45; 
 
 his great services in the diffusion of 
 
 vaccination, 49 n. ; his experiments 
 
 showing that lymph did not degenerate, 
 
 285. 
 St. Giles's, London, small-pox routed out 
 
 of, 324. 
 Sanitary Act, 1866, prohibits exposure of 
 
 persons affected with small-pox, 317 n. 
 Scarification, modes of vaccination by, 
 
 129; probably the most effective way of 
 
 vaccinating, 134. 
 Scarlatina, effects of incubation of, on the 
 
 course of vaccination, 86. 
 Scotland, mortality from small-pox in 
 
 different kinds of districts in, 261. 
 Second small-pox, 224, proportion of deaths 
 
 to coses of, 296 ft. 
 Sheep, vaccination of, 51 ; variolation of, 
 
 53. 
 Sheep-pox, short description of, 44. (See 
 
 OVINATION.) 
 
 Sheffield, deaths from small-pox in, 319; 
 gross neglect of vaccination in, 319 n. 
 
 Shrewsburv Union, deaths from small-pox 
 in the, 292 n. 
 
 Silesia, decline of small-pox in, since the 
 introduction of vaccination, 280. 
 
 Simon, M., his preface to "papers rela- 
 ting to the history and practice of vaccin- 
 ation," referred to and quoted pastim. 
 
 Simonds, Professor, his experiments in 
 vaccination of sheep, 51. 
 
 Skin diseases in children, not attributable 
 to vaccination, 334. 
 
 Small-pox, Jenner's hypothesis of its 
 origin in the horse, 56; its relation to 
 cow-pox and horse-pox, 56; fatality of 
 the natural small-pox in man, 211 ; pro- 
 portion of deaths to attacks, 214. 23S; 
 the ravages it made before the discovery 
 of vaccination, 211 ; its characters when 
 uncontrolled by vaccination still the 
 same, 213; introduction of variolous in- 
 oculation, and its results, 216; small- 
 pox may recur after natural small-|«ix, 
 224; orafter inoculated small-pox, 225; 
 frequency or infrequency of recurrent 
 small-pox 227; the protection against 
 small-pox afforded by vaccination, 221 ; 
 medical testimony respecting it, 239; 
 modes in which the power of vaccination
 
 382 
 
 INDEX. 
 
 over small-pox is manifested, 233; 1st, 
 by conferring on the majority of the 
 vaccinated complete immunity from, 
 233: 2d, by modifying its course or 
 diminishing its danger, 236: modifica- 
 tions exhibited by post-vaccinal small- 
 pox, 231, 231, 236; influence of the 
 quality of vaccination on these modifica- 
 tions, and on the protective power of 
 vaccination generally, 240; influenoe of 
 age, 250; of personal, hereditary, or 
 family tendency, 254 ; of climatic change, 
 257; of amount of exposure, 259; of epi- 
 demic intensity, 269 ; the mortality from 
 small-pox natural, secondary, and post- 
 vaccinal, in Small-pox Hospital, an- 
 alyzed, 242: mortality in the British 
 army and navy, 253, 257, 271; in Nor- 
 wich, analyzed, 262; in epidemic at 
 Chelsea, analyzed, 268 ; in Cardiff", an- 
 alyzed, 264; in particular ships in the 
 navy, analyzed, 266 mortality in India 
 and tropical climates, 276 ; rate of mor- 
 tality affected by epidemic intensity, 
 238 n., 270; decline of small-pox mor- 
 tality in correspondence with the adop- 
 tion of vaccination, 279; summary of 
 annual deaths by, in England and Wales, 
 282; annual rate of deaths per million 
 of the population, 283 ; evidence that the 
 present small-pox mortality in England 
 is due to neglect of vaccination, and to 
 its inefficient performance, 286; from 
 analysis of death returns, 286 ; from the 
 results of special inquiries, 287; small- 
 pox mortality in particular places, where 
 there had been very gross neglect of 
 vaccination, 281 n., 290, 318; of stamping- 
 out local outbreaks of, 314; universal 
 vaccination would render the dangers 
 of small-pox inconsiderable, 314; dan- 
 gers arising now from neglect of that 
 practice, 314 ; steps that should be taken 
 to prevent small-pox spreading, 315; 
 importance of isolating the early cases, 
 316 ; steps to arrest it when it has begun 
 to spread, 318"; steps necessary when it 
 is extensively diffused, 322; measures 
 of thorough disinfection steadily pur- 
 sued, indispensable, 317, 323; responsi- 
 bility of local authorities for preventing 
 the spread of, 327. 
 
 Small-pox Hospital, observations made at, 
 on small-pox natural and post-vaccinal, 
 214, 237, 242, 252, 270; on second small- 
 pox, 231, 212; experience of the, in re- 
 vaccination, 308. 
 
 Small-pox reported as "after vaccination," 
 frequent mistakes about this, 240 ; and 
 frequent erroneous entries to this effect 
 in death-registers, 122 »., 241 »., 251 n. 
 
 Soldiers (see Army). 
 
 Sperino disbelieves the vaccinal origin of 
 the syphilitic endemic at Rivalta, 370; 
 his experiments on vaccinal syphilis, 
 348, 371. 
 
 Spring, cow-pox manifests itself chiefly in 
 the, 24. 
 
 8purions pocks in the cow, 18. 
 
 Spurious vaccination, 91 n.\ causes of, 90. 
 
 Steele's comparative experiments of lymph 
 supplied by Jenner, with other lymph, 
 202. 
 
 Storage of lymph, 158 ; various modes of, 
 160; points, 161; glasses and tubes, 162; 
 the best mode of, considered, 168. 
 
 Stored lymph, vaccinating with, 125, 131 ; 
 standard of success when this is used, 
 181 ; failures of, in unskillful hands, 
 191 ; unnecessary and injurious extent 
 to which it is used in England, 156. 
 
 Supernumerary vesicles, 96. 
 
 Sweden, decline of small-pox in, since the 
 introduction of vaccination, 280. 
 
 Syphilis, allegation that it may be invac- 
 cinated, 337 ; not supported by general 
 professional experience, 337 ; may be 
 produced of course by accidental inser- 
 tion of its own virus, 346 ; question of 
 accidental inoculation of, by the blood, 
 353 ; errors of diagnosis respecting, 357 ; 
 frequent difficulty of ascertaining its 
 real origin, 358; cases of alleged pro- 
 duction of, by vaccination, 360; prac- 
 tical and common-sense view of the ob- 
 jection to vaccination, founded on such 
 cases, 374. 
 
 Syphilitic endemics, of unascertained ori- 
 gin, 368. 
 
 Tanner's experiments with lymph from 
 the horse, 34. 
 
 Thiele, Dr., his successful attempts to in- 
 oculate the cow with variolous virus, 
 59. 
 
 Tomkins, Mr., on syphilis not being at- 
 tributable to vaccination, 3K>. 
 
 Trousseau, M., his case of alleged vaccinal 
 syphilis, 366. 
 
 Tubes used for collecting and preserving 
 lymph, 162 ; wood-cuts of, 165, 166, 168 ; 
 comparison of this method of storage 
 with other methods, 186. 
 
 Vaccinal Syphilis, alleged cases of, 360. 
 
 Vaccination (see also Cow-pox) of cows, 
 25 ; of horses, 40 ; of sheep, 51 ; of other 
 animals, 54; of the human subject, 80; 
 phenomena and course of, in the human 
 subject, 80 ; usual course, 81 : abnormal 
 course, 85 ; retarded, 85 ; accelerated, 
 89 ; spurious, and its causes, 89 ; effects 
 of mechanical irritation on the course 
 of, 92 ; degeneration of the vaccine vesi- 
 cle, erysipelas, etc, 93: effects of climate 
 on the course of, 94 ; supernumerary vesi- 
 cles, 96; effects of reinsertion of vaccine 
 lymph within five days of a successful 
 insertion (Bryce's test), 98: its history, 
 99; vaccination with primary cow- 
 lymph, 101 ; local and general phenome- 
 na, 102; progress of humanization of 
 lymph, 104 ; varieties in amount of con- 
 stitutional disturbance, 104 ; vaccination 
 with variola-vaccine lymph, 107 ; with 
 secondary or inoculated cow-lymph, 109 ; 
 animal vaccination, 109 ; with retro- 
 vaccine lymph, 112; phenomena and 
 course of revaccination, 113; treatment 
 of, 114; origin of the term, 115. 
 
 Vaccination, insusceptibility of, 196. 
 
 Vaccination, objections to, and alleged 
 dangers of, 328; the allegation that it 
 has produced new diseases, 328, and led 
 to increase of mortality, 329 ; allegation
 
 INDEX. 
 
 383 
 
 that cutaneous and glandular diseases 
 may be invaccinated, 334; allegation 
 that syphilis may be invaccinated, 337 ; 
 harmlessness of, is dependent on due 
 care being used, 346; practice of, in 
 France and Italy, 348, 350 n. 
 
 Vaccination, performance of, things to be 
 attended to in vaccinating, 115; state of 
 the individual to be vaccinated, 115; 
 health and age of the patient, 115, 117; 
 circumstances which call for the imme- 
 diate performance of, 119; selection of 
 the lymph to be used in, 123; collection 
 of the lymph, 124 ; whether and under 
 what circumstances to be done, from the 
 arm, or with stored lymph, 125: various 
 methods of inserting the lymph, 126 ; its 
 course to be watched, and the results 
 closely inspected, 134; performance of, 
 from the natural or casual disease in the 
 cow, 1%; arrangements for the opera- 
 tion of, and the maintenance of lymph- 
 supply, 140; advantage of arm-to-arm 
 vaccination, 140; methods and suitable 
 arrangements requisite for, 140; selec- 
 tion of lymph necessary, 141 ; of skill 
 and success in the, 179 ; necessity for a 
 standard of comparison as to what is 
 success, 179; Marson's standard, 180; 
 standard when stored lymph is used, 
 181 ; skill of the operator the most im- 
 portant of all the conditions for success, 
 182; advantages of appointing professed 
 vaccinators, 186; consequences resulting 
 from want of proper instruction in, 187 ; 
 official inquiry respecting, 188; repeated 
 failures of, from want of skill, 190. 
 
 Vaccination, protection a Horded by, against 
 small-pox, 221 ; summary of its advan- 
 tages, 29."> (see Small-pox); its univer- 
 sal performance would render the dan- 
 gers of small-pox quite inconsiderable, 
 295,314. 
 
 Vaccination, public, in large towns, 147; 
 in smaller towns, 152; in rural districts, 
 153; illustrations of the disadvantages 
 which have frequently attended the ar- 
 rangements for, heretofore in force, 156. 
 
 Vaccination, quality of, extreme import- 
 ance of attention to this, 187, 19.">, 241 ; 
 illustrated by observations at Small-pox 
 Hospital, 242; by inquiries of Epidem- 
 iological Society, 247; by observations 
 of Seaton and Buchanan.* 247. 
 
 Vaccination in England, results as regards 
 neglect of, 286 ; as regards its imperfect 
 performance, 188; as regards the ar- 
 rangements existing, 156. 
 
 Vaccinators, the skill of, the most im- 
 
 portant of all the conditions for success- 
 ful vaccination, 182; necessity for their 
 special instruction, 182; advantages 
 which would attend the appointment of 
 professed "vaccinators," 186. 
 
 Vaccine crusts, use of the, 174. 
 
 Vaccine lichen, 83. 
 
 Vaccine lymph (see Lymfb). 
 
 Vaccine roseola, 83. 
 
 Vaccine vesicle, degeneration of the, 93. 
 
 Vaccinia, or cow-pox, never met with in 
 the human subject but as the result of 
 inoculation, 9. (See Cow-pox Vaccina- 
 tion.) 
 
 Vaccino-syphilitic inoculation, alleged 
 cases of, 355. 
 
 Variola, human, relation of cow-pox and 
 horse-pox to, 56. 
 
 Variola ovina (see Sheep-pox). 
 
 Variola vaccine lymph, vaccination with, 
 62, 64, 107. 
 
 Variolse equinae, a name applied to the 
 horse-pox, 37. 
 
 Variola? vaccinae, name given by Jenner 
 to cow-pox, 9. 
 
 Variolation, vaccine disease may be in- 
 duced in cows by, 59; phenomena of, 
 successful in cows, 63; attempted vario- 
 lation of horses, 41; of sheep, 53; of 
 other animals, 54. 
 
 Variolous affection, cattle not shown to 
 be subject to any other than cow-pox, 74. 
 
 Variolous effluvia, case of infection of cat- 
 tle by, 62. 
 
 Variolous inoculation, introduction of. 216; 
 not wholly void of risk, bnt not so dan- 
 gerous as the natural small-pox, 297. 
 
 Vesicle, vaccine, structure of the, 17, 81. 
 
 Vesicles, supernumerary, 96. 
 
 Vesicles produced by Jenner's lymph, 201 ; 
 
 Produced by the lymph of the Academie 
 e Medecine, 206; produced by various 
 lymphs, 207. 
 Vleminkx's observations on revaccination 
 in Belgium, 312. 
 
 West, Dr., his opinion that neither cuta- 
 neous nor syphilitic diseases are commu- 
 nicated by vaccination, 336. 
 
 Westphalia, decline of small-pox in, since 
 the introduction of vaccination, 280. 
 
 White pock, 19. 
 
 Whitehaven Union, deaths from small-pox 
 in the, 292 n. 
 
 Woodville, Dr., mistakes into which he 
 fell an to the characters of the cow-pox, 
 79 n. 
 
 Yellow pock, 19.
 
 757 
 
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