THE ERUPTIONS OE VACCINATION AND RE-VACCINATION.* ISADORE DYER, Pir. B., M. D., New Orleans, La. ReprintedJrom the February, 1896, number of the Nevi Orleans Medical and Surgical 'Journal Vaccinia is a disease sui generis, not at all infrequent in the lower animals, particularly the cow, dog, sheep, pig, horse, goat and monkey (Shoemaker). The history of its discovered similarity to variola, and the application of this discovery in the prophylaxis and prevention of small-pox, is familiar to all of us. In studying the eruptions of vaccination the simplest and best method would be to arrange the eruptions etiologically. Mal- colm Morris has done this so well that I can do no better than reproduce his suggestions for the division of vaccination erup- tions into groups. He first of all makes two general subdivisions, into: i. Eruptions due to pure vaccine inoculation. 2. Eruptions due to mixed inoculation with vaccine, with which an additional virus, or several viruses, has become mixed. In the first group, he arranges the several eruptions which attend and follow the local inoculation. I believe that in some instances this grouping can be expanded, and, with this end in view, I propose taking up in detail Morris' subdivisions. * Read before the Orleans Parish Medical Society, November 9, 1895. 2 i. Eruptions due to inoculation. First in this class comes the lesion of vaccination itself. Following the constitutional impression, this lesion begins with itching and formication, to appear as a papule, in size about that of a pin's head. As the local inflammatory process pro- gresses, this lesion expands, fills with fluid, growing more and more distended, until a lesion of bullous character, about as large as the thumb nail, is developed. Around this an areola begins, gradually increasing in breadth to as much as two or three inches. The bulla becomes a pustule; this in time breaks, crusts; the crust falls, and the vaccination is in time marked by a slightly depressed scar, with irregularly defined edges, and, at times, here and there a pit or two in the body of the scar. This is the normal course of vaccination from start to finish. This is, however, not always the rule. The original lesion of vaccinia may not develop into its completed scar. The lesion may abort at the papule, the ves- icle may dry and scale instead of going on to crusting. There may be no pustulation, and consequently there will be no scar- only a pigmented spot to mark the site of the bulla, and that, only a temporary marking. Instead of a simple pitting and scarring, the process may involve some of the adjacent tissue, induce a more pronounced inflammatory process, still close to the normal, resulting in a hyperplasia of the connective tissue element, causing a tempo- rary ulcer with infiltrated, almost indurated, edges, which give the .lesion a crateriform appearance. There is no wonder, then, that as the process is completed, there re- sults a marked keloidal development at the site of vaccina- tion. All that is required is that the process shall go deeply enough into the corium. As the vaccine virus is at work before the vesicles are developed, acting as a vaso-motor disturbant, producing reflex disturbances, among which temperature, malaise, pain, itching, etc., are numbered, the second division of the first group of vaccination eruptions is manifested. B. Eruptions following within the first three days before development of vesicles. (i) In this division, urticaria is perhaps the most common 3 unavoidable complication. It may appear in the small papular, or in the large wheal variety. (2) Erythema multiforme next in frequency may manifest itself. Here there may appear simply a roseolous eruption, either limited to one region, or it may be diffuse. On this, •papules of various sizes may develop. Even discrete vesicles may form with no particular arrangement or distribution. They may be pemphigoid in size and characteristics. In this group Crocker defines a " vaccine lichen," corre- sponding, however, to these varieties of erythema multiforme ust described. When the vesicle has become apparent in the local region, or when the vaccine virus has become more fully impressed upon the general economy, we see another division of this group, viz.: C. Eruptions following after development of vesicles. (1) Marked diffuse dermatitis may occur, resembling the roseola of measles or the erythema of scarlatina. Even a purpuric eruption may occur (Morris). (2) Just here, as a minimum limit, up to the time of pustu- lation, the generalized vaccinia may occur. In this generalized eruption the lesion of vaccination is reproduced, pursues the same course as the usual vaccine inoculation, and may result in the same kind of scarring. More often the lesion is shorter lived, less severe and more superficial, acting more as the lesions of varicella do. This finishes the divisions of acute eruptions attending, unavoidably, vaccination. As sequelae of a normal vaccination, however, there may be eruptions lighted up, as it were, such as eczema, particularly of the papular and pustular type, and of the reflex variety. Chambard reports (class D) a case of psoriasis determined by vaccination-not at all improbable, as psoriasis is now largely referred to neuropathic origin. Finally, the urticaria deter- mined by vaccination may persist in a chronic variety. In the general group referred to above as that in which the eruptions were due to mixed inoculation, there may be sep- arated two general classes: 4 i. Where the additional virus is introduced at the time of vaccination; and 2. Where the virus is introduced subsequently into the wound. Subdividing the first class, we must recognize : (i) Eruptions due to a local skin disease; and (2) Eruptions due to constitutional diseases. In the first subdivision, the condition of more frequent occurrence is impetigo contagiosa. Of such frequent occur- rence, in fact, is this complication, that it often misleads, and for a time excites a suspicion of variola. The finding of the staphylococcus pyogenes aureus and citreus in vaccine lymph readily accounts for the production and dissemination of impetigo, which is directly due to and spreads after the local contact of the staphylococcus pyogenes aureus. Incident with the infection of the vaccine lesion at the time of inoculation, an abnormal erythema may develop, spread- ing over the whole arm, or even to other regions, due to septic origin. In the second subdivision are included such constitutional diseases as may be inoculated at the time of vaccination. Syphilis takes the first place in rank, and numerous cases of vaccinial syphilis are in evidence. Fournier has contributed an exhaustive work on this subject. While the question of contagiousness of leprosy is still in abeyance, the quotation of leprosy as one of the constitu- tional diseases which may be transmitted by vaccination will, perhaps, be received with a question mark. Nevertheless, popular resistance to community laws regulating vaccination is still strong in those leprous countries where it is still the custom to vaccinate from person to person. Beaven Rake, of Trinidad, reported fully on this subject only last year, arguing that vac- cination was a contributing cause in the spread of leprosy. Bacilli leprae have been found (Arning, Journ. Lepr. Inves. Com. No. 2, February, 1891, p. 131) in the vaccine lymph taken from a leper. On the other hand, however, the infre- quency of leprosy is incomparable to the frequency of vac- cinatien, and even in leprous centres the existence of leprosy 5 would or should make the vaccinator more careful in selecting his vacciners. Finally, tuberculosis may be transmitted in this way, either evidenced by a localized tuberculosis cutis, or in a general in- fection. Each of these conditions just described presupposes, of course, that vaccination has been done from humanized lymph or by means of instruments, used on successive cases of infection. With the more modern preparation of bovine virus and its general use, with individual points, these constitutional accidents must, perforce, be reduced to a negative quantity. The second class of our second group is meant to include such accidental, and avoidable conditions as may arise from the introduction of additional virus, or infection, at some time subsequent to the vaccination. This class includes such appreciable conditions as : i. Erysipelas, at and near, or even remote from the wound. 2. Cellutitis, more or less extensive, depending upon the social scale and habits of the patient, and upon the tone of health of the patient. 3. Furuncle, or furunculosis. 4. Gangrene, for the occurrence of which, the bacillus septicus has been held accountable, and its presence demon- strated in the original lymph even. 5. Finally pyaemia,with all the complications it may entail, is a possibility. Thus the course of a developing vaccination lesion may be attended with any, or all, of a series of eruptions, each differ- ent, but each referred directly to the wound as a causative factor. Nor is this the end. Sequelae of an abnormal vaccina- tion are by no means few. The senses may be involved in a reflex reaction. So the nervous system may be involved. We have seen that recurrent attacks of urticaria may follow. Like- wise pemphigoid eruptions may from time to time occur. The pyaemia may entail nephritic conditions temporary or perma- nent. 6 In this category belong cases of herpetiform eruptions, with classical distribution, symmetrical and bilaterally so, made up of distinct bullae, grouped in crescents and in clusters, sug- gesting a peripheal irritation of nervous reflex, or of vaso- motor origin, which could be referred to any toxine as a caus- ative factor, and particularly to that of pus infection, main- tained in any organ of such functional activity as the kidneys. In a case of mine there was a clear history of vaccination in a child placed in the worst possible conditions of hygiene, followed, three weeks after the cicatrix was formed, by an eruption of bullee, the distribution and extent being plainly shown in the photograph presented. Concerning the question of revaccination, there remains but little to be said. Opinion is freely expressed by some au- thorities that revaccination runs a milder course than the origi- nal, and that a keloidal condition is more apt to supervene than the customary cicatrix with pitted centres. Be this as it may, it is acknowledged that any vaccination may run a mild course, abort even, as I have said above, at the papular or vesicular stage. Keloidal scars will occur in any vaccination where connective tissue hyperplasia has been stimulated. In my own experience and from my own observation, I must say that I find little difference in the course or the result in original or repeated vaccination. I have vaccinated my- self tour or five times, always successfully and always with a pit. Up to the time that I began using myself as a subject, I was vaccinated at least four times, successfully, as the scars attest. The eruptions otherwise, of revaccination, should in all reason be identically the accidents of original vaccination. In conclusion, for a clinical interest I would like to relate that quite recently I have vaccinated two persons who had had small-pox some ten or fifteen years back. In both cases the vaccine lesion ran a typical course, with characteristic vesicu- lation, areola and pustulation, scabbing and healing with a pit.