of the >tate of ^cw ^orh. 
MERRIT H. CASH 
PRIZE ESSAY. 
BY 
A. N. BELL, A. M., M. D. 
REPRINTED FROM TRANSACTIONS OF 1864. 
ALBANY: 
VAN BENTHUYSEN'S STEAM PRINTING HOUSR. 
1864. PRIZE ESSYY. 
How Complete is the Protection of Vaccination, and what are 
the Dangers of Communicating other Diseases with the 
Vaccinia. 
I propose to treat the first part of this question generally and 
specially, and the second part specifically. 
1. The protective powers of vaccination are most evident in 
their results to mankind in general. The comparative exemption 
of all civilized communities, for the last forty years, from the 
most terrible scourge to which mankind was ever liable, is an 
evidence of the protection afforded by vaccination so overwhelm- 
ing as to characterize the discovery of Jenner as the greatest 
boon ever conferred upon the temporal welfare of man. 
In England alone, for nearly a century before the introduction 
of vaccination, no fewer than 30,000 persons were annually cut 
off by small pox; which, in the same ratio, according to the pre- 
sent population, would be equivalent to 100,000 deaths annually. 
Out of every 1,000 deaths, from 1750 to 1800, there were by small 
pox 96 ; from 1800 to 1850, there were, for the same number, 
but 35. 
In Germany, for the same periods of time, there were, out of 
every 1,000 deaths for the former period, by small pox 66.5 ; for 
the latter period, 7.26. 
In Sweden, for the last twenty-eight years before the introduc- 
tion of vaccination, out of each million of the population there 
were 2,050 deaths annually by small pox; for forty years subse- 
quent to the introduction of vaccination, the number of deaths 
annually by small pox, per million of inhabitants, was 158. 
In Westphalia, from 1776 to 1780, the small pox death-rate per 
million of inhabitants, was 2,643. From 1816 to 1850, it was 114. 
In Copenhagan, 1751 to 1800, the rate per million was 3,128; 
from 1800 to 1850, it was 286. In Berlin, for the same periods, 
the rates relatively were 3,442, and 176. 
American statistics, so far as known, are equally conclusive. 
According to a paper read by Dr. Robert Ware, before the Boston 4 
Sanitary Association, we learn that in Boston, in 1721, the year 
in which inoculation was introduced and when the whole popula- 
tion was 11,000; 5,759 or more than one-half had small pox, and 
of these, 844 died. In 1730, there were 4,000 cases and 200 
deaths. In 1752, when the population was 15,684, there were 
5,545 cases and 539 deaths. In 1764, there were 5,646 cases ; in 
1776. 5,292; and in 1792, 8,346. Compared with a subsequent 
period, after the general introduction of vaccination, and when 
it was in a measure compulsory, from 1815 to 1830, the mortality 
from small pox was only fourteen; from 1811 to 1839, it was but 
fifty-two. 
By an approximate average death-rate by small pox per million 
of living population, from 1750 to 1800, and from 1800 to 1850, 
in various countries (collected by the Epidemiological Society 
of London), there were, in the former period, nearly twenty times 
as many deaths by small pox as there were in the latter. And, 
besides, "one obviously beneficial result of vaccination, as re- 
gards its protective influence to the multitude, has not. we think, 
been appreciated or illustrated with sufficient force; namely, that 
the epidemic influence of small pox greatly increased during the 
practice of inoculation, and greatly decreased since vaccination 
has been adopted. Dr. Hebra, Professor of Diseases of the 
Skin, at Vienna, incidently remarks and simply alludes to the 
fact, that ' Epidemics of small pox have been more rare and are 
less malignant since the introduction of vaccination.' But defi- 
nite material for the following statements are to be found in the 
report of the Epidemiological Society, in illustration of our 
remarks :-(1). During 91 years previous to inoculation, there 
had been 65 distinct and well marked epidemics, which is a ratio 
of 71.4 epidemics in 100 years. (2). During 63 years in which 
inoculation was practiced, and that, to a great extent, there were 53 
distinct and well marked epidemics, which is a ratio of 84 epide- 
mics in 100 years. (3). During the last 50 years since which 
vaccination has been practiced, and inoculation been declared 
illegal, there have been 12 epidemics of small pox, which is a 
ratio of 24 epidemics in 100 years."* 
According to the well kept mortality statistics of Sweden, the 
annual small pox death-rate in that country, during the period of 
1841-'50, averaged less than the weekly death-rate from small pox 
• Medico-Chir. Review, October, 1857. 5 
and measles during the period of 1755-'75. This important fact 
introduces us to an indirect benefit of vaccination, which has, 
until recently, been overlooked, namely, the beneficial influence 
of vaccination against other diseases. Drs. Greenhow and Farr, 
under the auspices of the General Board of Health of London, 
have shown that with the decline of small pox consequent on 
vaccination, the general death-rate has greatly diminished from 
all causes; and that too, notwithstanding a severe and fatal epi- 
demic of influenza and two epidemics of cholera; and under this 
diminution, it is especially notable that the two classes of disease 
usually considered the most fatal, namely, scrofulous and typhoi- 
dal affections, have diminished in a remarkable degree. 
The general death-rate per 10,000 of living population, during 
the periods of 1846-'55, was 25 per cent, less than the decennial 
period of 1746-'55 ; and 40 per cent, less than the decennial 
period of 1681-'90, showing a successive decline since the re- 
moter period, from 421 to 355 ; and since the more recent period, 
from 355 to 249. 
According to Dr. Farr's statistics, the average annual death- 
rates in London, from all causes and all ages, per 10,000 living, 
were: 
From 1771-'80 500 
1801-'10 292 
1831-35 (small pox prevailed) 320 
1840-'54 _ 248^- 
The average annual death-rates in Sweden, from all causes and 
all ages, per 10,000 living, were: 
From 1776-'95 268 
1821-'4O .. 233 
1841-'5O .. 205 
In McCulloch's Descriptive and Statistical account of the Bri- 
tish Empire, Dr. Farr has shown that fever has progressively 
subsided since 1771, (at first, under the influence of inocula- 
tion) ; "and that the combined mortality of small pox, measles and 
scarlatina is now only half as great as the mortality formerly occa- 
sioned, by small pox alone." 
According to the researches of Dr. Greenhow, previous to the 
introduction of vaccination, the death-rate from scrofulous dis- 
eases was five times greater than it is at the present time; and 
the present death-rate of pulmonary consumption, great as it is, 6 
is seven per cent, lower than it was previous to the discovery of 
Jenner. 
2. Jenner was the first to prove, as he was to discover, the pro- 
tective power of vaccination. On the 1st day of July, 1796, he, 
for the first time, inoculated a person with the matter of small 
pox, whom he had before vaccinated. No disease following, he 
many times subsequently repeated the experiment; and from 
about that period of time to 1816, protection from small pox by 
vaccination was scarcely called in question. But succeeding this 
period, or after persons had been vaccinated for a number of 
years, subsequent attacks of small pox began to occur so fre- 
quently that observers were obliged to conclude that the protec- 
tion afforded by vaccination was, at most, only relative., During 
the great epidemics of small pox which prevailed in Europe for 
the next ten years, the advocates of vaccination had abundant 
opportunities for ascertaining its true value. The vaccinated 
and the previously variolated, were both found to be more or less 
subject to the disease. Early in the progress of these epidemics, 
however, an important fact became evident, namely, that there 
was a great difference in the mortality of small pox when it 
attacked these three classes :-1. The vaccinated. 2. The vari- 
olated ; and 3. Those who had neither been vaccinated nor had 
small pox. Of the first class, those who had been previously 
vaccinated, out of every 330 attacked only 1 died. Of the second 
class, those who had previously had small pox, 1 out of every 50 
died. While of the third class, those who had neither been vac- 
cinated nor had small pox, 1 out of every 4 died. Thus proving 
the great superiority of vaccination over small pox itself, in pro- 
tecting the system from the fatality of a second attack. 
Unmodified small pox is not only a very fatal disease, as proved 
by its frequently cutting off one-fourth of all whom it attacks, 
but its tendency is to develope any latent disease which may 
exist in the constitution, particularly scrofula, and it is thus, 
indirectly, the cause of death to a much larger portion of the 
human race than, what at first sight appears. It is not, therefore, 
surprising that small pox, attacking for the second time an already 
enfeebled constitution, should cause a greater proportion of deaths 
than takes place when it occurs after vaccination, a much milder 
form of the same disease, and therefore, proportionately less 
likely to develope any pre-existing constitutional affection. 7 
M. Bousquet,* in his detail of the epidemic which prevailed at 
Marseilles, in 1825, states that the whole population was esti- 
mated at 40,000. Of these, 3,000 had been vaccinated; 2,000 
had had small pox, and 8,000 had neither been vaccinated nor 
had small pox. Of the 3,000 vaccinated, 2,000 were seized with 
small pox; 20 of whom, or one for every hundred affected, died. 
Of the 2,000 who had before had small pox, either naturally or 
by inoculation, 20 were attacked, and of these 4 died, or one for 
every five who took the disease. Of the 8,000 who had not been 
vaccinated nor had small pox, 4,000 contracted it, and 1,000 died, 
or one in every four. By this it appears that one half of the 
non-vaccinated, one fifteenth of the vaccinated, and one one-hun- 
dredth of the variolated took the disease. But such was the dif- 
ference in the comparative mortality of the attack in the vacci- 
nated and the variolated, that while the variolated part of the 
population were cut off in the proportion of one out of every 
500, the vaccinated only lost one out of every 1,500; or, in other 
words, of an equal number of variolated and vaccinated cases, 
three of the variolated died from the second attack, for every one 
that died who had been previous vaccinated. 
Several governments, confident in the anti-variolous power of 
vaccination, and profiting by the experience gained, determined 
upon revaccination as the most likely means of getting rid of the 
epidemics which were desolating their armies. The effect was 
so salutary as to have finally banished small pox from among 
them. But this was not the only benefit. Knowing, as we do, 
that small pox and cow pox are in reality the same disease, the 
latter being merely deprived of its virulence by having previously 
passed through the system of the cow, the results of these 
numerous re-vaccinations are of immense importance not only in 
confirming the identity of small pox and cow pox, but in estab- 
lishing the no less important fact, that the protective power of 
small pox itself wears out of the system in a certain proportion 
of cases, as life advances, in nearly the same ratio as that of cow 
pox. Thus, in all these armies, a certain proportion of the men 
were found to have been previously vaccinated, while no inconsi- 
derable proportion had passed through unmodified small pox. 
Now, if we take the susceptibility to re-vaccination as a test of 
liability to varioloid or to a second attack of small pox, we have 
* Traite de la Vaccine. 8 
these vaccinations proving the fact that after a certain number 
of years, the same proportion of those who have previously had 
small pox become susceptible to a second attack, as those who 
have been vaccinated are to varioloid. So that once having 
passed through all the dangers of unmodified small pox, the per- 
son, at the end of twenty years, for instance, has no better secu- 
rity against a second attack, than the person who has been vac- 
cinated for a corresponding length of time. 
In the Wurtemberg army, of 40,000 cases collected by Dr. 
Heim, on re-vaccination it was found that in every 100 vacci- 
nated after small pox, 32 succeeded, 26 were modified and 42 
failed. In every 100 re-vaccinated, 34 succeeded, 25 were modi- 
fied, and 41 failed. 
According to the Statistical Report of the Medical Department 
of the English Army, from Oct. 1858, to Dec. 1859, 32,510 sol- 
diers and recruits were vaccinated. Of this number, 4,124 bore 
marks of unmodified small pox ; 23,924 bore good marks of vac- 
cination; 1,901 bore doubtful marks of vaccination; and 2,561 
had no marks of either vaccination or small pox. By reducing 
these figures as nearly as possible to the same scale as those above 
given for the army of Wurtemberg, we find that of the 4,124 who 
had previously had small pox, on vaccination, 1,473 or 35 per 
cent succeeded; 799 or 19 per cent took imperfectly; and 1,842 
or 44 per cent failed. Of the 23,924 who had good marks of 
vaccination, on re-vaccination 8,976 or 37 per cent took perfectly; 
5,277 or 22 percent imperfectly; and 9,671 or 40 per cent failed. 
Of the 1,901 with doubtful marks of vaccination, the number of 
good vesicles on re-vaccination was 777 or 40 percent; modified, 
505 or 26 per cent; and 616 or 32 per cent failed. Of the 2,561 
who had no evidence of protection, on vaccination, 1,362 or 53 
per cent took ; 484 or 18 per cent had modified vesicles, and 715 
or 23 per cent failed. 
In the Prussian army, in 1860, 69,096 soldiers were vaccinated. 
Of this number 57,325 exhibited marks, more or less perfect, of 
previous vaccination, 7,420 being distinct; 4,151 showed no 
marks whatever. Of the whole number, 44,193 took ; 8,256 par- 
tially, and 16,047 failed. These last were vaccinated again, when 
5,577 proved successful, and 11,650 failed. During the year, there 
occurred among those who had been unsuccessfully vaccinated 
and others who had been successfully vaccinated in former years, 
6 cases of chicken pox and 1 case of varioloid; but no case of 9 
small pox. Thus, during the year 1860, out of 69,096 vaccina- 
tions, 49,777 or 72 per cent took. In the entire army, there 
occurred during the year, 17 cases of chicken pox, 23 of 
varioloid, and 4 of small pox. Of these cases, 3 of chicken pox, 
14 of varioloid and the 4 of small pox occurred in persons who 
had not been re-vaccinated ; 8 of the chicken pox, 8 of varioloid, 
and 1 of small pox, occurred among those in whom the re-vacci- 
nation failed ; and the remaining 7, 6 of chicken pox and 1 of 
varioloid, among those who had been re-vaccinated with success. 
In the United States, re-vaccination has received but little 
attention. On the breaking out of small pox among « crew of 
five hundred persons, on board a U. S. frigate, about twenty-five 
years aeo, the surgeon, the late Dr. Samuel Jackson, U. S. N.. 
vaccinated the whole ships company. One in six took. They 
had all been vaccinated or had had small pox before. Those on 
whom vaccination failed, proved to be equally insusceptible to small 
pox, which wholly ceased from the time the re-vaccinations took 
effect. 
Of 686 recruits vaccinated by Dr. Forrey, U. S. Army,* 560 
had been vaccinated before, 74 had had small pox, and 52 had 
not had small pox nor been vaccinated. Of the 560 previously 
vaccinated, 381 exhibited good cicatrices; 134 imperfect, 
and 45 had no marks at all; 196 took, including 55 which 
were modified. Of these 196, 109 had been previously 
vaccinated before the age of five years ; 48 between the ages 
of five and ten, and 39 subsequently to the latter age. Of 
the whole 560 previously vaccinated, 316 were vaccinated 
before the age of five years ; 133 between the ages of five and 
ten, and 111 after the latter period. Hence it follows, though 
not as an exact result, according to Dr. Forry's limited expe- 
rience, that as the ages of the great majority of these men ranged 
from twenty to thirty-three (the average being twenty-five), and 
as the ratio of successful re-vaccination is very nearly the same 
after each interval of age (being about one-third), the limit of 
the protective power of vaccination is not restricted to any pre- 
cise number of years. 
The only statistics of re-vaccination of the present army of 
the United States, I have been able to obtain, are the following, 
furnished by Dr. S. O. Vanderpoel, Surgeon-General of New York 
* American JI. Med. Sciences, April, 1842. 10 
to the U. S. Sanitary Commission,* from the first returns made 
to him in accordance with a general order : 
Total number of recruits examined 9,548 
Bearing marks of previous vaccination.. 7,765 
Total vaccinated or re-vaccinated.. 8,095 
Found to be susceptible.. 2,292 
Number susceptible who had marks of previous vaccina'n 1,338 
It is evident from the foregoing statistics, that no certain 
period of limitation can be fixed for the protective power of vac- 
cination. It is certain, however, that its loss of power bears 
some proportion to the lapse of time, though it seems highly pro- 
bable that this apparent loss of protective power is in the same 
ratio as the varying liability to small pox, independent of vacci- 
nation. Dr. J. F. Marson, the experienced superintendent of the 
small pox and vaccination hospital in London, states that, "but 
few patients urfder ten years of age have been received with 
small pox after vaccination. After ten years, the number begins 
to increase considerably, and the largest number admitted are 
for the decennial period from the age of fifteen to twenty-five, 
and although progressively diminishing, they continue rather 
large up to thirty, and from thirty to thirty-five they are nearly 
the same as from ten to fifteen : but as in the unprotected at this 
period of life, the mortality is doubled, showing the cause to be 
probably as much or more depending on age and its concomitants 
as on other circumstances. In still further advanced life, the 
ratio of mortality will be seen to increase also, as in the unpro- 
tected state."! 
Professor Heim, of Stuttgart, took 1,055 cases of re-vaccination 
and distinguished them under thirty-five heads, corresponding 
severally to the thirty-five years which bad elapsed since primary 
vaccination. He found that the average number for each year 
was, for the first twelve years after vaccination, 12; for the next 
seventeen years, 48; and for the remaining six years, 15. Prof. 
Retzius, of Stockholm, has published a series of 961 cases of 
small pox, divided into eleven successive quinquennials, up to 
the age of fifty-five, which gave successively: 3|, 4|, 13|, 45|, 
51|, 40|, 17 j, 3|, 2| and l.J By reducing these figures to the 
* Sanitary Commission Report, E. 
t Returns of Epidemiological Society, London. 
| Gaz. Med. de Paris, 1843. 11 
same ratio as those given by Dr. Marson and Prof. Heim, the lia- 
bility to small pox is found to be, as regards age, very nearly the 
same as the increased susceptibility to a second vaccination, or 
as will presently be seen, to a second attack of small pox. 
The occasional occurrence of unmodified small pox a second 
time or after a previous vaccination, does not invalidate the gene- 
ral law, that a person who has once been properly vaccinated or 
has once had small pox, in general remains protected against a 
subsequent attack. It is, however, a well established fact that 
certain individuals who have had unmodified small pox in infancy 
or youth, may, especially if frequently exposed to the epidemic 
influence of the disease, have it again in after life ; and such 
attacks are always much more dangerous to life than small pox 
after vaccination. All medical men of much experience have 
met with such cases. Dr. Thompson, of Edinburg, in his own 
practice, met with 85 cases of second attack of unmodified small 
pox; and Prof. Heim, 57. It is in vain, therefore, to expect that 
vaccination will give greater security to the person from a sub- 
sequent attack of small pox than small pox itself unmodified. 
All that can be reasonably asked is, that vaccination shall give 
as good security against a subsequent attack of small pox as if 
the person had passed through small pox itself; and this, if pro- 
perly performed, and with good lymph, the accumulated evidence 
of the last sixty years most thoroughly proves. And with this 
immense superiority in favor of the protective power of vaccina- 
tion over unmodified small pox, namely, that it does not endanger 
life; does not engender scrofulous disease; does not disfigure the 
countenance, nor cause deafness and blindness, and does not cut 
off one in every four to eight affected by it-with all of which 
small pox is justly chargeable. 
By estimating the result of the foregoing statistics (chiefly 
obtained from the returns of the Epidemiological Society of 
London, and more might be furnished), embracing carefully 
recorded and reconcilable points of observation for nearly 200,- 
000 cases, we are justified in accepting this experience as a safe 
criterion by which to base an estimate for any number of cases, 
great or small. 
The conclusions elucidated from the data given, are : 
1. The identity of small pox and cow pox is confirmed. 
2. That vaccination is immensely protective against epidemic 
diseases generally, against small pox in particular; and against 12 
death by small pox, the protective power of vaccination is almost 
perfect. 
3. That of persons wholly unprotected, those who have neither 
been vaccinated nor had unmodified small pox, 20 per cent are 
insusceptible, and 80 per cent liable to unmodified small pox, and 
in an equal degree susceptible to perfect vaccination and capable 
of being protected. 
4. That of any number of persons who have had unmodified 
small pox, the proportion wholly protected from a second attack 
at adult age, is 43 per cent, while 57 per cent are liable to it 
again in some form or other. 
5. That out of any number of adult persons who have good 
marks of vaccination, 40^ per cent are perfectly protected ; while 
59| per cent are susceptible to varioloid, or to re-vaccination to 
such a degree as to render their protection perfectly complete. 
6. That the degree of protection afforded by previous unmodi- 
fied small pox, from a second attack, is only 2£ per cent greater 
than the protection afforded by vaccination ; a proportion too 
small to be regarded as any evidence of real difference in pro- 
tective power, and reasonably attributable to spurious or im- 
paired vaccination from a variety of causes, such as vaccination 
during the progress of other diseases, injury of the vesicle or 
defective lymph. 
7. That out of any number of adult persons with imperfect 
marks of vaccination, 23 per cent only are protected, while 77 
per cent are liable to small pox or varioloid. 
8. The liability to varioloid after ten years of age, of persons 
vaccinated under three years of age; and the increased liability 
again from fifteen to twenty-five years of age, of persons vacci- 
nated or re-vaccinated at from ten to fifteen years of age, demon- 
strates that, generally, protection by vaccination under twenty- 
five years of age is complete for about seven years only. Sub- 
sequent to twenty-five years of age, protection is complete for a 
longer length of time, proportionate to the age of the individual 
at the time of the vaccination. 
9. Protection is known to be complete only when good vaccine 
lymph or scab from a perfect vesicle fails to take on re-vaccina- 
tion. 
3. What are the dangers of communicating other diseases with 
the vaccinia 2 
The alleged danger of communicating other diseases with vac- 13 
cinia was among the earliest objections urged against vaccination, 
even during the time of Jenner. And from that day to this, cases 
of cutaneous disease, syphilis, scrofula, &c., have been occasion- 
ally attributed to this cause. But if it were now possible to 
collect all such cases, even then, their utter insignificance com- 
pared with the multitude that have been vaccinated with lymph 
taken from diseased persons, without contamination, this evi- 
dence alone ought to be sufficient to establish the conclusion as 
a general rule, that there is no danger of communicating other 
diseases with vaccinia. But that nothing might be lacking in 
the extent of the investigations on the subject of vaccination, 
John Simon, Esq., F. R. S., medical officer of the General Board 
of Health, of London, a few years ago,* put the same question to 
many of the most experienced men of Europe. Among the 
replies elicited, was one from Prof. Hebra, of Vienna, whose con- 
clusions are so logical as, it appears to me, to be decisive, and 
therefore worthy of universal adoption. The words of the ques- 
tion, as put by Hr. Simon, were, " Have you any reason to believe 
or suppose (a) that lymph from a true Jennerian vesicle has ever 
been a vehicle of syphilitic, scrofulous or other constitutional 
infection to vaccinated persons; (6) or that unintentional inocu- 
lation with some other disease instead of the proposed vaccina- 
tion, has occurred in the hands of a duly educated medical prac- 
titioner ?" 
"This widely grasping question," answers Hebra, "requires 
several separate answers, because queries are made : 
1. " Whether the lymph of a vaccine vesicle may, besides its pecu- 
liar virus, contain another infectious principle, e. g., that of syphi- 
lis I 
2. " Whether constitutional non-infecting diseases, as, for instance, 
scrofula, may be transmitted by the inoculation of cow pox matteri 
3. " Whether a vaccine vesicle possesses such characters that it 
may easily be distinguished from other similar vesicles, blebs or pus- 
tules ?" 
(I.) The transmissible infectious principles which have hitherto 
been recognized, by means of inoculation, are the syphilitic virus 
contained in the pus of chancre, and the virus contained in the 
cow pox vesicle, and the small pox pustule. The question, there- 
fore, simply is, whether these morbid poisons have ever been 
* Parliamentary Report, 1857. 14 
mixed? Whether inoculations have ever taken place with such 
a mixture? And what results were obtained by such an opera- 
tion ? It is well known that compendious answers have for some 
time past, been offered to these questions, chiefly the result of 
Sigmund's experiments. These answers agree in the following 
respects : 
" Inoculation with secretions of this kind, viz., containing, as 
it were, several special poisons, either produced no effect at all, 
or only generated a chancre, by inoculating a mixture of pus 
from chancre and vaccine lymph; and only cow pox, by inocu- 
lating a mixture of vaccine lymph and blenorrhagic matter. 
Hence one morbid state only was produced, either cow pox or 
syphilis; the latter circumstance being a proof that both poisons 
are not simultaneously transmissible. This opinion is supported 
by the experience of Heim, Ricord, Bousquet, Taupin, Landoury, 
Friedenger and others. 
(II). "It is maintained in many quarters that the blood of 
persons suffering from secondary syphilis, may serve as a vehicle 
to the infectious principle; but were even this theory found cor- 
rect, it would have no prejudicial effect upon the practice of vac- 
cination, because we know from experiments made for the purpose 
(Heim), and from accidental inoculation, that regardless of the 
quality of vaccine lymph, the latter may be inoculated from 
syphilitic upon sound individuals; and on the other hand from 
sound subjects upon such as are under the influence of systema- 
tic syphilis, without propagating syphilis along with the cow pox. 
" What has here been proved of syphilis must, a fortiori, hold 
good as regards other constitutional morbid states, as direct 
inoculation with secretions peculiar to these diseases have always 
yielded a negative result. 
" But although it is abundantly proved that scrofula, tubercu- 
lar affections, rickets, cancer and other blood diseases, cannot be 
transmitted by means of their own secretions or along with vac- 
cine lymph, we should, nevertheless, if possible, avoid vaccinating 
diseased persons, because experience has taught us, as regards 
adults and children, that the phenomena of vaccination may 
awake, i. e., render worse, dormant affections, and that moreover, 
the cow pox vesicle, easily degenerates upon such individuals. 
These latter vesicles, are, nevertheless, adapted to further propa- 
gation, even when they take an imperfect development; because 
a positive result, a regular development of the vesicle, and suf- 15 
ficient protection against small pox, have been observed in cases 
where vaccine lymph has been transferred from weakly, scrofu- 
lous, and rickety subjects, upon perfectly sound individuals. 
(III). "Every morbid appearance on the cutaneous envelope 
has its own peculiar characters, by which it may be distinguished 
from other similar phenomena; the vaccine vesicle presents, in 
like manner, sufficiently striking peculiarities as to form, size, 
number, locality, and particularly as regards its course, to enable 
the observer easily to establish a distinction between the same 
and other vesicular, bullar or pustular eruptions." 
Soon after the publication of these view's of Ilebra, Dr. A. 
Viennoise, of Paris, published a paper in the Archives of Medi- 
cine, 1861, on the Transmission of Syphilis by Vaccination. The 
condition of transmissibility he believes to be the taking of 
blood with the lymph from a person affected with constitutional 
syphilis. Such matter, Viennois states, will communicate both 
diseases; the vaccine vesicle appearing first, and after the usual 
period of incubation, the syphilitic tubercle also appears on the 
vaccinated part, and is soon aftei* followed by secondary symp- 
toms. Still more recently,* M. Ricord, at the request of M. 
Trousseau, has delivered a clinical lecture on the subject, illus- 
trated by a case in the wards of the Hotel Dieu : 
" A young woman, aged eighteen, was admitted on the 6th of 
December last (1861), into the wrards of the Hotei Dieu, for the 
treatment of catarrhal metritis and granulating ulceration of the 
cervix. No syphilitic precedent whatever could be traced in her 
history. An epidemic of small pox having broken out while she 
was in the hospital, all the patients liable to contagion were 
repeatedly vaccinated. Although the girl presented unmistakable 
marks of previous successful vaccination, she also underwent the 
operation. The lymph was supplied by a healthy infant, born in 
the wards, and vaccinated a fewdays before with the virus distri- 
buted at the Academy of Medicine; three punctures were made 
in each arm. Three children were also inoculated with matter 
taken from the same infant, and in all four, the pustules were 
developed in the most regular manner. In the young woman, on 
the contrary, the vaccine did not take; this was fully expected. 
She left the hospital, and was lost sight of for a fortnight, when 
she returned to the Hotel Dieu, complaining of pain in one arm. 
♦ The Medical Circular, March 5, 1862. 16 
On examination of the part, two pustules of ecthyma were found 
occupying the seat of two punctures. These were at first referred 
to a somewhat tardy evolution of the vaccination, and perhaps 
to accidental friction. But the pustules, deemed insignificant at 
first, gradually became larger and hard at the base, cervical and 
axillary adenitis set in, and, after an interval of five or six weeks, 
a roseate eruption broke out over the entire body. From the 
beginning, M. Trousseau strongly suspected the syphilitic nature 
of the symptoms, but he was desirous of obtaining the opinion 
of M. Ricord, who fully confirmed his conjecture. It is an un- 
questionable fact, said this last named physician, that this patient 
bears on her arm a most distinct primary sore, an indurated and 
infecting chancre, characterized by an indolent, convex tumour, 
ulcerated at the point (ulcus elevatum), suppurating moderately, 
and supported on a broad, elastic base, well limited at its mar- 
gin, surrounded by uninflamed textures, and, as it were, implanted 
in the healthy tissues. The present tumour is a fair specimen of 
the infecting chancre in a state of transition towards the sec- 
ondary stage, and assuming the aspect of the mucous papula. 
Consider, in addition, the other phenomena which have followed 
each other in rapid and regular succession, the glandular enlarge- 
ments of the axilla and neck, the headache and roseola, and you 
cannot doubt but that the case before you is an unmistakable 
instance of genuine secondary syphilis. With regard to the 
origin of the disease, it is obvious that the punctures in the arm 
have been the portals through which it has entered the system; 
but it is by no means so clear that the poison was introduced 
into these wounds together with the vaccine lymph. M. Ricord 
does not reject this mode of propagation as absolutely impossible. 
But in the estimation of facts which seem to establish such trans- 
mission, "it is necessary," said he, "to distrust the evidence of 
our senses. It is only by taking into account the obscurity which 
must necessarily surround a pathogenic interpretation of an 
usually retrospective character, and carefully guarding against 
the errors that a superficial observation may give rise to, that we 
can hope to discover the solution of so important and intricate 
a problem. We have now entered upon a period of reaction 
against hitherto accepted doctrines, and if we do not take care, 
we will be almost inclined to pronounce a man to be affected with 
syphilis, if he has ventured, without an umbrella, in some of 
the less reputable streets of this capital." M. Ricord then 17 
treated of the contagiousness of constitutional syphilis, and as- 
cribed it in most instances, to the infectious character retained 
by chancres, undergoing transformation into secondary symptoms, 
or by mucous papula, the earliest manifestation of the general 
poisoning of the system, whether developed in situ by a meta- 
morphic change of the primary sore, or at a distance from the 
seat occupied by the latter. However this may be, M. Ricord 
contends that the instances of propagation of syphilis by the 
contagion of secondary symptoms, are far more unfrequent than 
some authors have asserted. Syphilis is widely diffused, and 
were the contagion of its constitutional manifestations as easy 
as has been affirmed, the nineteenth century would far out-rival 
the fifteenth. There may be, perhaps, some other vehicles of 
contagion besides the secretion of chancre, and sometimes of a 
secondary sore ; this, at least, is not impossible, but is not sus- 
ceptible of peremptory demonstration in the present state of our 
knowledge. An erroneous and hasty interpretation of obscure 
facts, in which the true filiation of the symptoms has eluded de- 
tection, is, in M. Ricord's opinion, at the bottom of all the mis- 
taken theories and wandering speculations propounded on the 
subject. Thus some men may escape infection, though they 
have communicated, with a woman affected with chancre, and 
others may be poisoned by one who herself is sound. Such cases 
are, of course, not obviously intelligible at first, but the obscu- 
rity is easily cleared away by the now well-known history of 
mediate contagion, by which we are taught that healthy females, 
who, after intercourse with diseased men are approached by per- 
sons in sound condition, may transmit from the former to the 
latter the virus-themselves escaping scatheless. M. Ricord here 
related several very curious instances which illustrate and con- 
firm, in the most distinct manner, the doctrine so perspicuously 
laid down by M. Cullerier. On the other hand, it is unnecessary 
to expatiate on the innumerable modes of conveyance of the 
virus from one person to another. Every possible contact, every 
imaginable form of communication, may generate chancre. 
M. Ricord once attended a magistrate affected with indurated 
chancre of the eyelid, periauricular bubo, and secondary roseola. 
The o-gans of generation were perfectly sound, but the patient 
acknowledged that his hands had wandered into dangerous pre- 
cincts, and that in rubbing his eyes he had inoculated the virus 18 
into the eyelid. Is it entirely impossible that something of the 
same kind may have happened in M. Trousseau's patient ? She 
was lost sight of for a fortnight; the punctures in the arm in- 
duced some local uneasiness, which she doubtless endeavored to 
allay by scratching with her hand. Now, who will say that that 
hand has constantly remained pure, or that the arm may not have 
been exposed to any other suspicious contact ? These are some 
of the points which ought to be cleared up before vaccination 
can, with any show of reason, be assumed to have caused the 
chancres observed in this instance. The possible transmission 
of syphilis by the inoculation of the blood of persons tainted 
with the virus, has, however, been for some time before the pub- 
lic, and derives considerable additional importance from the 
results recorded by M. Viennois, (before referred to). In this 
memoir the author agrees with M. Rollet, that syphilis is not 
transmitted by vaccine 1} mph, but by the admixture of the latter 
with blood. In a recent vaccination, which caused considerable 
sensation beyond the Alps, it has likewise been contended, in 
order to account for the propagation of syphilis, that blood 
oozed out, together with lymph, from the pustules of the child 
who supplied the matter, and that the lancet of the operator was 
therefore charged with a mixed fluid of deleterious nature. M. 
Ricord while admitting the truth of these facts, rejects the inter- 
pretation which has been offered. It is a remarkable circum- 
stance, said he, that as soon as the generating poison of syphilis 
has penetrated into the system, it is fundamentally modified. It 
becomes undiscoverable to chemical analysis or to microscopic 
research, and utterly loses its distinguishing character of repro- 
ducing a pustule similar to that in which it was originally gene- 
rated. Were it otherwise, in a person tainted with syphilis, the 
most trifling wound would be liable to assume the aspect of 
chancre from contact with the blood escaping from the lacerated 
vessels. Nothing of the kind is ever observed. M. Ricord has 
performed operations on many individuals suffering from consti- 
tutional syphilis, and he never noticed, even in a single instance, 
anything particular in the aspect, progress or duration of the 
wounds. It will perhaps be alleged that experiments have been 
instituted which seem to point to the possibility of the transmis- 
sion of syphilis by the blood of diseased subjects. Thus, M. 
Waller, after scarifying the thigh of a patient, dressed the wounds 
with lint impregnated with syphilitic blood; the part healed, but 19 
about three weeks afterwards pustules appeared on the thigh. 
The fact is true, says M. Ricord; but it is proper also to add. 
that at the same time a similar pustule was developed on the 
shoulder. The chancre had doubtless the same origin as the 
others, and entirely invalidates the case. At Lyons, analogous 
experiments yielded conflicting results. Finally, M. Lalagade, 
the head surgeon of the hospital of Albi, who never had been 
affected with syphilis, publicly inoculated in his own arm the 
blood of three soldiers manifestly suffering from this complaint; 
and although on each occasion two wide and deep punctures 
were performed, the results were entirely negative. As to those 
sad instances of vaccination published in Germany, in France, 
and in Italy, M. Ricord does not deny their accuracy; they 
assuredly deserve consideration, but cannot be received as con- 
clusive in the question, until all their attendant circumstances 
have been minutely weighed, and the reciprocal operation of 
cause and effect has been carefully inquired into. 
M. Ricord declared that he gave his full approbation to the 
conclusions of a paper published in the ' Gazette Hebdomadaire,' 
by M. Jacond, on the distressing occurrences observed during 
the course of the last year, in the province of Acqui. M. Jacond, 
after reminding his readers that at the end of the month of May, 
1861, syphilis broke out three weeks after vaccination, in forty- 
six infants, at Rivalta, proceeds to state that an inquest was held 
as to the cause of the calamity, and that despite the apparent 
clearness of the facts, the committee appointed to investigate the 
matter, declined to pronounce on the alleged connection between 
syphilis and vaccination, and declared that in order to form their 
judgment, further inquiry was necessary. He continues thus : 
" These gentlemen were both prudent and wise. Before admit- 
ting that syphilis in this instance was transmitted with the vac- 
cine matter, many difficulties and obscurities have to be cleared 
away; it would further be necessary to solve several important 
questions which at present, it appears impossible to reply to. 
For our own part, an attentive perusal of the documents of the 
case has led us to the same conclusion as Dr. Albertetti, who ex- 
onerates from all blame the vaccinations in question. The events 
of Rivalta present to our view two conspicuous but wholly dis- 
tinct facts, viz : the vaccination of the infants and the subsequent 
appearance of syphilis in certain of their number. It is granted 
that these two orders of facts occurred in succession, but for the 20 
present we are not prepared to go any further and to argue, post 
hoc, ergo propter hoc; the coincidence is obvious, not so the infer- 
ence of causality. Whatever interpretation be adopted as to 
these facts, they convey a useful caution, and illustrate in an 
eloquent manner the necessity of taking into account the mani- 
fold elements in the etiological history of vaccinal syphilis and 
the extreme reserve required of the physician in cases of this 
description." "This view," said M. Ricord, "is in such perfect 
harmony with mine that I have nothing to add to M. Jacond's 
remarks. Let us admit and carefully inquire into these cases, 
and let us guard against any predetermined notions on the sub- 
ject ; but as to the interpretation offered, let it be received with 
an amount of hesitation and doubt, increased by the obvious fact 
that if ever the transmission of syphilis with vaccine-lymph is 
clearly demonstrated, vaccination must be altogether discon- 
tinued, for, in the present state of science we are in possession 
of no criterion which may permit the conscientious practitioner 
to assert that the lymph he inoculates is perfectly free from ad- 
mixture with blood tainted by syphilis." 
Such are the views of the most distinguished authorities on 
the danger of communicating other diseases with vaccinia. Sat- 
isfied that none of the more recently published cases of supposed 
inoculation of other diseases with vaccinia, present stronger 
features than those above considered, I deduce the conclusion that, 
as a general law, with carefully taken lymph, or the scab from a 
perfect vaccine vesicle, there is no danger of communicating other 
diseases. 21 
APPENDIX* 
SIGNS OF SUCCESSFUL VACCINATION AND OF SUCCESSFUL REVACCI- 
NATION. 
(Gregor, revised by Ceely and Marson.f) 
(A.) "When vaccination has been successfully performed, 
the puncture may be felt elevated on the second or third day, 
and soon afterwards, if examined with a magnifying glass, 
appears surrounded by a slight redness. On the fifth or sixth 
day a distinct vesicle is formed, having an elevated edge and 
depressed centre. On the eighth day it appears distended with 
a clear lymph. The vesicle, on this its day of greatest perfec- 
tion, is circular and pearl-colored ; its margin is turgid, firm, 
shining, and wheel-shaped. Late on the seventh, or early on 
the eighth day, an inflamed ring or areola begins to form around 
the base of the vesicle, and with it, continues to increase during 
the two following days. This areola is of a circular form, and its 
diameter extends from one to three inches. When at its height, 
on the ninth or tenth day, there is often considerable hardness 
and swelling of the subjacent cellular membrane. On the tenth 
or eleventh day the aerola begins to subside, leaving as its 
fades, two or three concentric circles of redness. The vesicle 
now begins to dry in the centre, and acquires there a brownish 
color. The lymph which remains becomes opaque, and gradually 
concretes; so that about the fourteenth or fifteenth day the 
vesicle is converted into a hard round scab of a reddish-brown 
color. This scab contracts, dries, blackens, and about the 
twenty-first day falls off. It leaves a cicatrix, which commonly 
is permanent in after life, circular, somewhat depressed, dotted 
or indented with minute pits, and in some instances radiated. 
The above described local changes, while in active progress, are 
attended by feverishness: first from the fifth to the seventh day, 
so slightly that often the fact passes unobserved ; and again more 
considerably during those days when the areola is about its 
height; the patient now being restless and hot, with more or 
less disturbance of stomach and bowels. About the same time, 
especially if the weather be hot, children of full habit not un- 
* From U. S. Sanitary Commission, Document E, 1863. 
f Second Report of the Medical Officer of the Privy Council, 1859. (Blue Book), London. 22 
frequently show on the extremities, and less copiously on the 
trunk, a lichenous, roseolar, or vesicular eruption, which com- 
monly continues for about a week. When vaccination is per- 
formed on such adults or adolescents as have not previously 
been vacinated, and likewise when lymph is employed which has re- 
cently been derived from the cow, the resulting phenomena, as com- 
pared with the preceding description, are somewhat retarded 
in their course; and the areola is apt to be much more diffuse. 
There is also more feverishness, but the eruption is less frequent- 
ly seen." 
(B.) "When persons who have once been efficiently vaccinated 
are, some years afterwards, revaccinated with effective lymph, 
there sometimes result vesicles, which, as regards their course 
and that of the attendant areola, cannot be distinguished from 
the perfect results of primary vaccination. But far more usually 
the results are more or less modified by the influence of such pre- 
vious vaccination. Often no true vesicles form, but merely papu- 
lar elevations surrounded by areola; and these results having 
attained their maximum on or before the fifth day, afterwards 
quickly decline. Or if vesicles form, their shape is apt to vary 
from that of the regular vesicle, and their course to be more 
rapid, so that their maturity is reached on or before the sixth 
day, their areola decline on or before the eighth day, and their 
scabbing begins correspondingly early. In either case the areola 
tend to diffuse themselves more widely and less regularly, and 
with more affection of the cellular membrane than in primary 
vaccination; and the local changes are accompanied by much 
itching, often by some irritation of the axillary glands, and in 
some cases on the fourth or fifth day by considerable febrile dis- 
turbance." 
METHOD OF PRESERVING VACCINE LYMPH. 
By Dr. Husband, of Edinburgh.* 
The following method of preserving lymph in capillary glass 
tubes has been found entirely successful. Lymph has been used, 
after being kept for several years, with satisfactory results. 
The tube employed is simple, straight, cylindrical, open at both 
ends, and of such dimensions as to fulfil the following conditions, 
• Second Report of the Medical Officer of the Privy Council, 1859. (Blue Book,) London. 23 
upon which it will be found that its peculiar value, as a means 
for preserving lymph for future every-day use, essentially depends. 
It must be- 
1. In the first place, of such tenuity that it can be sealed in- 
stantaneously 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. 
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 subject- 
ing the contained charge to the heat, and also strong enough to 
bear all necessary manipulations without, breaking : 
Average length 2| to 3 inches. 
Diameter of an inch. 
Thickness of wall of an inch. 
Calibre. 
The vesicles having been opened with a lancet in the usual 
way, the tube held in a position more or less inclined to the hori- 
zontal, 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 vaccination. 
It is now to be sealed in one or other of the following ways : 
Either, 1st, make the lymph gravitate towards 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. 
Proceed with the other end in the same way, but first plunge 
it suddenly, say half an inch into the flame, and as quickly with- 
draw it till it touches the surface, and hold it there till it too 24 
melts over. It is necessary to plunge it first into the flame, for 
this reason, that if it be at 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 
afterwards, in consequence of its extreme tenuity of wall, by the 
slightest touch. Mr. Ceely has suggested, that while this pre- 
caution 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 of the 
column of lymph and protecting it from the heat, and draw 
nearly the whole of the empty portion through the flame, so as 
to rarefy the contained air ; and in withdrawing it, seal the fur- 
ther extremity. The column now passes quickly along towards 
the middle of the tube as the contained air cools, and you com- 
plete the process by sealing lastly the orifice by which it entered. 
It should be observed, that in no case is a tube to be laid down 
until the lymph has been made to pass towards the middle of it, 
for the fluid concretes quickly about the orifice, and you cannot 
afterwards 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; only if you delay the sealing 
process too long, more than five or ten minutes perhaps (a delay 
which need never happen), the lymph within the tube is apt, from 
evaporation, to become adherent, especially if it be more than 
ordinarily viscid, and it cannot afterwards be blown out when 
you come to.use it. 
If the lymph do not exude freely, the tube may require to be 
drawn several times more or less obliquely 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 arm, charge five or six 25 
tubes in almost as many seconds, with perfectly pure and limpid 
lymph, which shall contain neither epithelial scales, nor pus 
globules, nor blood disks, and therefore be, so far, in the best 
possible condition for preservation. 
In order to obtain the lymph from a tube for the purpose of 
vaccinating, the sealed ends are broken off, and the contents 
blown out gently on the point of the lancet or vacinator. 
The tubes may be easily and safely sent by post in the follow- 
ing manner: 
A flat piece of soft fir, about three inches and a half long, an 
inch and a half wide, and one-sixth of an inch thick, has a nar- 
row and shallow groove made in it about a quarter of an inch 
wide, into which the charged tubes, two or more of them, are 
placed, with perhaps a few filaments of cotton beside them to 
prevent motion. Another piece of wood of the same size, but 
which need not be quite so thick, is then laid above the groove 
and its contents, and the two pieces are joined in any way that 
is thought most convenient, by being tied or pinned together. 
NEW MODE OF PRESERVING VIRUS. 
Dr. Collins.* 
Having experienced much trouble, particularly of late, in 
keeping a reliable supply of vaccine virus for public vaccina- 
tions, I was glad to meet with any suggestions which would aid 
me in accomplishing this very desirable object. I immediately 
made some experiments, which have convinced me that, by the 
use of glycerine, we can probably preserve vaccine virus for a 
great length of time, and that when we desire it for more imme- 
diate use, this liquid is by far the best solvent for the solid mat- 
ter that we possess. It saves us both time and trouble, and ena- 
bles us to use the matter with much greater economy, which is 
of importance when our stock happens to be small. I think that 
no one who has once used glycerine for this purpose would desire 
to use anything else. 
In my first experiment, I pulverized about one-eighth of an 
ordinary scab upon a glass plate, and moistened it with a small 
drop of glycerine. It is better that the matter be pulverized, 
as it otherwise dissolves very slowly. The quantity thus pre- 
pared served for my vaccinations for several days, amounting, 
• Boston Medical and Surgical Journal, 1858. 26 
in all, to twenty-four, among which there were about two fail- 
ures-a success which I have rarely attained when using water 
as the solvent. There was, of course, no drying up of the mat- 
ter, after the solution, requiring renewed applications of the sol- 
vent, and so long as any remained upon the plate it was ready 
for immediate use. 
I next pulverized another one-eighth of a scab, and dissolved 
it in about two drops of glycerine, placed at the bottom of a 
very small phial. From this I filled, by suction with the mouth, 
four of the usual capillary glass vaccine tubes, and sealed them 
hermetically-using for this purpose but about one-half the two 
drops. From one of these tubes I have since vaccinated three 
children successfully, using less than one-half its contents. The 
other three tubes I shall keep for some time, to see if age will in 
any degree impair its quality. 
I see no reason why, when thus dissolved in glycerine, and 
hermetically sealed in glass tubes, it should not retain its virtue 
for a great length of time. The antiseptic qualities of the gly- 
cerine, I should judge, would render it less liable to change than 
is the pure vaccine lymph when treated in the same way, which 
we know can thus be kept for many months. 
If I am correct in the foregoing conclusions, which a little 
time will determine, the preservation of vaccine virus, and the 
distribution of it, when desired, to distant sections of the coun- 
try, will become an exceedingly simple and easy affair. A single 
scab, prepared as above, would be sufficient to fill some fifty 
tubes, each of which would be capable of vaccinating ten or 
more persons. 
I would suggest that the glass tubes, for this purpose, should 
be drawn with a little larger bore than those in use for the pure 
lymph, both for the convenience of filling, and that the solution 
may be used in a little more concentrated form than is practica- 
ble with the very fine capillary tubes, which answer well for the 
latter purpose. 
HOW TO VACCINATE. 
Henry A. Martin, M. D., of Roxbury, Mass. * 
" Make, with the point of a clean lancet, some groups of trans- 
verse scratches-or, rather, very delicate incisions. The number 
• Boston Medical and Surgical Journal, April, 1860. 27 
of these will vary according as few or many vesicles are consid- 
ered necessary. The length of the individual scratches will 
determine, of course, the size of the resulting vesicle, and, to 
some degree, the soreness of the arm. 
"The incisions should be so slight as barely to result in the 
faintest possible exudation of blood, and that only after the lapse 
of a second or two ; but, if a greater flow of blood does ensue, 
the operation will be no less certain in its results, although a 
little neatness will have been needlessly sacrificed. To that 
group of scratches from which the blood first exudes, the charged 
point of a quill is to be applied ; the lymph thereon will be 
immediately absorbed ; the particle of blood with the lymph in 
solution, is to be then taken up on the point of the quill, applied 
to, smeared over, and pressed into the other scratches, in succes- 
sion, two or three times. 
" When the dissolved scab or fluid lymph is employed, it is to 
be applied on the point of the lancet, precisely as the dissolved 
lymph on the point of the quill." 
Vaccine lymph on a quill-point is best introduced by inserting 
it about a quarter of an inch into a flat, superficial valvular inci- 
sion under the cuticle, made by a narrow-bladed lancet in the 
skin over the attachment of the left deltoid muscle, keeping the 
quill-point there for a minute or two, wiping it off on the edges 
of the cut as it is withdrawn, and avoiding, in the whole opera- 
tion, the effusion of blood, as far as possible.