Dissolving Illusions
The Encyclopedia Britannica (1890) - Vaccination

Encyclopædia Britannica, The Henry G. Allen Company, New York, 1890, Vol. XXIV, pp. 23-30

Relations of smallpox, cowpox, and grease of horse
VACCINATION (from Lat. vacca, a cow), the name given in France to the Jennerian practice ofcowpoxing, shortly after the practice began in England (1799). The procedure was based almost exactly on theearlier practice of inoculating the smallpox, the matter being inserted under the skin of the arm by a lancet point;
also the continuance of the same stock from arm to arm through a series of cases was an idea taken from some of themore adroit variolators. To replace smallpox inoculation by cowpox inoculation under certain specificcircumstances was Jenner’s tentative project. The history of the introduction of cowpoxing, given in the article
JENNER (vol. xiii p. 623), is here supplemented from the point of view of historical criticism.
It is right to say that the views expressed in the present article diverge in many points from the opinions
generally received among medical men, and must be regarded not as the exposition of established and undisputed
doctrine, but as the outcome of an independent and laborious research.
JennerJenner’s originality consisted in boldly designated cowpox as variolæ vaccinæ or smallpox of the cow, andin tracing cowpox itself to the grease of the horse’s hocks. The latter contention was at length set aside by practicalmen as a crude fancy; the former designation is just as arbitrary and untenable. It was elaborately shown by Pearson
in 1802, and has often been confirmed by subsequent writers, that the vesicle of inoculated cowpox, even while itremains a vesicle, is quite unlike a single pustule of smallpox. But it is only for the vesicular stage of cowpox that
there is even an allegation of likeness to variloa; the vesicle of natural or unmodified cowpox is only the stage of thedisease before it becomes an ulcer, either inflammatory or indurated. Inoculated horse grease has the same vesicular
stage; and so also has the venereal pox when it is inoculated experimentally on the skin. 1 These three very different
infections have the same kind of vesicle, in every case unlike a smallpox pustule, and the same natural termination
in a phagedenic or indurated sore.
Jenner’s originality in starting vaccination in practice is for the most part misunderstood. When hepublished his Inquiry in June 1798, he had twice succeeded in raising vaccine vesicles by experiment, - the first timein 1796 with matter from a milker’s accidental sore, and the second time in March 1798 with the matter direct fromthe cow. The first experiment was not carried beyond one remove from the cow; the second was carried to the fifth
remove, when the succession failed. A third experiment, in the summer of 1798, failed from the outset; 1798, led to
nothing but extensive phagedenic ulceration in two cases out of six vaccinated.
Historical sources of vaccine lymph
In this posture of affairs Woodville of the inoculation hospital, London, succeeded in January 1799 instarting a succession of arm-to-arm vaccinations from a London cow, which were exceptionally free from theulcerative termination. From that source Jenner himself was supplied with lymph in February, while more than two
hundred practitioners both at home and abroad were supplied some three weeks later. There was a quarrel with
Woodville in due course, and an attempt to set up an authentic Jennerian lymph independent of the London stock.
But the merits of the claim (which otherwise rests on the vague evidence of Marshall) may be judged of by the factthat Ring’s application to Jenner in September 1799 of genuine lymph was answered by the latter with a supply ofmatter which was none other than Woodville’s own stock, after six months’ use in the country. Woodville’s stock
was used all over the world down to 1836. By that time there were numerous complaints that the lymph wasdegenerating, and a widespread feeling that it was necessary to “go back to the cow.” Apart from the numerous
original cases of cowpox alleged to have been found in Würtemberg, the first new authentic source was the Passy

1

See Ricord, Traité Complet, 1851, plate I, figs. 6 and 7 and µ 7, 9, and 9; also H. Lee, Med. Chir. Trans., xliv. P. 288, 2d plate,fig. 2.

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The Encyclopedia Britannica (1890) - Vaccination

cow of 1836. From the accidental vesicles on the milker’s hand Bousquet, the director of vaccination in Paris,
started a new stock, which partly superseded Woodville’s lymph hitherto in use in France. In 1838 Estlin of Bristol,after several years’ vain endeavours, heard of original cowpox in Jenner’s own parish of Berkeley (Gloucestershire),
where the disease was so far forgotten that the milkers were for several days unaware that the vesicles on their hands
had been contracted from cows. Estlin’s new geniture is one of the most fully recorded in history of vaccination. In
the same year, and the two following years (1838-41), Ceely of Aylesbury found some half-dozen distinct
occurrences of cowpox in the diary-farms of his district, and cultivated lymph from them. His account of the natural
history of cowpox in the cow, and the effects of primary lymph when inoculated on the human arm, is by far themost comprehensive and candid that has ever been given; without it we should hardly have understood the realnature of cowpox. Bousquet, Estlin, and Ceely are the chief writers who have authentically described theestablishment of new stocks of cowpox lymph since Woodville’s original report of 1799. There are numerous otherreferences, less detailed, to original cowpox in the cow, and to vaccinations therefrom, in England, on the Continent,
and in the United States; some of these came to light in the inquiry of the Epidemiological Society in 1852. One of
the best-known cases of comparatively recent times is the Beaugency cow of 1866, which has been the source ofmuch of the calf-lymph of the Dutch, Belgian, and other vaccine “farms.” Another French case occurred in theGironde in November 1881, and is described in the Bulletin of the Academy of Medicine (p. 17, 1882). In Englandthe editors of the Veterinarian inserted a notice in the number for August 1879 making a request to their readers for
lymph “from vesicles on teats of cows in cases of so-called natural cowpox.” The only answer to it hitherto has
been an intimation in June 1880 that there was a case of cowpox at Halstead in Essex, which was visited by Ceely
and others and pronounced by the former to be of the nature of eczema. In 1876 the disease was found at a farmnear Reykjavik in Iceland, where it had never been seen before; it was of the old type, producing sores on themilkers’ hands, and causing much alarm by its unfamiliar character. 2
Calf lymph
The so-called lymph is as remote from the cow as ordinary humanized lymph; it differs from the lattermerely in the circumstance that the calf (on its shaven belly) becomes the vaccinifer, instead of the child, and thatthe cycle of the disease is very much abbreviated or contracted in the calf: the vesicles are distended with lymph
about the fourth or fifth day, instead of the seventh or eighth, and are almost unattended by areolar redness andconstitutional disturbances, the animal being able to support fifty to a hundred or more vesicles without the smallest
inconvenience. On the child’s arm the vesicles after calf-lymph are slower in development than in the calf, and areattended by areloa, &c.
Anomalous sources of vaccine
Under the influence of theory, “vaccine” lymph has been got from two sources that have absolutely nothing
to do with cowpox; and, oddly enough, the matter from these sources has been so manage as to produce correct
vesicles on the child’s arm. One source is the grease of the horse’s hocks and the other is smallpox itself.
Grease of the horse
The grease of the horse was known to produce vesicles and subsequent ulcers on the hands almost
indistinguishable from those of accidental cowpox. There was also the tradition (which breaks down when tested byfacts) that accidental infection with the grease protected from smallpox. Jenner held that all “genuine” cowpox
came from horse-grease; and, after he had raised vaccine vesicles on the arms of children by matter from the cow’s
teats, he proceeded to try whether he could not raise the same kind of vesicle experimentally by matter once2

Cowpox of the original ulcerating type still occurs, but is now hardly recognized as such. The inquiry into an outbreak ofscarlet fever in December 1885, traced to a dairy at Hendon (Middlesex), elicited the fact that the inculpated cows, as well as
seventy or eighty at two other farms, were affected with what the dairymen called “cowpox” (se Cameron, Trans. Epid. Soc.,
April 1886). A similar outbreak in November 1887, involving 160 cows and 7 milers at four farms in Wiltshire, was clearly
proved by Crookshank to be the historical cowpox of Jenner and Ceely, by the evidence of identity in the sores on the cows’ teats
and in the sores or vesicles on the milkers’ hands or faces, and by the production of correct vaccine vesicles in calves inoculatedwith lymph from a vesicle on the face of a milker (Brit. Med. Journ., 17th December 1887 and 21st January 1888).

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The Encyclopedia Britannica (1890) - Vaccination

removed from the horse’s hocks. The experiment succeeded, just as the accident had done. The vesicle (represented
in plate 2 of the Inquiry) ulcerated, and the boy died of what is vaguely termed a “fever” in one place and a“contagious fever” in another. The same kind of inconsequent logic suggested the experiment of inoculating thematter of horse-grease upon the skin of the cow’s teats, the object being to prove the identity of cowpox with thegrease. That too succeeded in the hands of Loy of Whitby. Loy also inoculated children with the same matter, andraised vesicles on their arms, which were, of course, the same as the accidental vesicles (compared to the blister
raised by a burn). Sacco of Milan actually used the equine matter on a large scale instead of cowpox matter; and De
Carro of Vienna “equinated” many persons in the city with lymph sent him by Sacco. Baron prints a memorandumof Jenner, dated 23rd July 1813, relating to “equine virus which I have been using from arm to arm for these twomonths past, without observing the smallest deviation in the progress and appearance of the pustules from those
produced by vaccine,” and a second note, dated 17 th May 1817, in which Jenner says he “took matter from JaneKing (equine direct) for the National Vaccine Establishment. The pustules beautifully correct.” This is not theplace to enter upon the pathology of horse-grease; and, as a matter of fact, equination has not been much practisedon the whole. According to Jenner’s own data, it was an occasional constitutional disease of the horse’s hocks inwet seasons, which was communicable to the hands of men in the form of large whitish vesicles, ending in corroding
and painful open sores (see the case reported to him by Fewster, op. cit., ed 1800, p. 96).
Humanized pox
The other anomalous source of “vaccine” is human smallpox. Jenner having succeeded in passing off his
doctrine that cowpox is smallpox of the cow, it occurred to some persons about forty years after to prove thedoctrine by experiment, the proof being to variolate the cow on the udder. This was accomplished in 1838, after
much trouble, by Theile in Kazan (Russia), who inoculated several thousands of persons with variolous matter“passed through the system of the cow.” Within a few months of that experiment, the same thing was attempted by
Ceely of Aylesbury, who succeeded, after many failures, in raising a large variolous pock, not on the udder of thecow, but on the mucous membrane of the vulva. The first experiment with the matter of this pock was undersigned;
his assistant pricked his hand with the lancet which has just been dipped into the large pustule and in due course had
and attack of smallpox. Ceely persevered with his experiments (having meanwhile variolated another heifer at fiveplaces on the vulva), and in due time so “managed” his matter as to produce vesicles on the human arm ( without
general eruption on the skin), which were regarded at Cheltenham and other places as on the whole better than the
cowpox vesicle of the period. But the real practical application of this idea was reserved for Badcock, a dispensing
chemist at Brighton. It does not appear that any authentic or fully detailed account of Badcock’s experiments has
been published;3 but thus summarized the results some forty years later (Pall Mall Gazette, Jan. 23, 1880): - “Bycareful and repeated experiments I produced, by the inoculation of the cow with smallpox, a benign lymph of a noninfectious and highly protective character. My lymph has now been in use at Brighton for forty years, and is at thepresent time the principal stock of lymph employed there, being that exclusively used by public vaccinators.” At
Boston, U.S. the same kind of lymph was raised and put in use in 1852. But at Attleborough, Mass., the same
experiment had in 1836 led to disaster. Smallpox was inoculated on a cow’s udder, and the product used tovaccinate about fifty persons. The result was an epidemic of smallpox a panic, and the suspension of business. 4 On
the face of it this method was simply variolating the cow (on a mucous membrane if the hairless or shaven skinfailed) and inoculating the human subject with that curiously disguised smallpox matter. However, it was thought
necessary to hold an experimental inquiry upon it, and in 1865 a commission of the Lyons Society of Medicine
reported that, “in vaccinating according to the method of Thiele and Ceely, we are merely practising the old
inoculation, rendered uniformly benign, it may be, by the care taken to inoculate only the first product (l’accident
primitive), but preserving for certain all its risks in respect to contagion.” 5 A negative result was come to by Klein in
1879, in an inquiry for the Local Government Board, wherein he had Ceely’s cooperation. In 1879 the Irish Local
Government Board prevented the use of similar variolous lymph by threatening to prosecute under the Act making
3

See Hodgson, Brit. Med. Journ., 26yh November 18814

Best. Med. And Surg. Journ., 1860, p. 77

5

Vaccine et Variole, Paris, 1865, p. 101

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The Encyclopedia Britannica (1890) - Vaccination

the inoculation of smallpox penal. Notwithstanding the common sense of the case, and these experimental proofs,
the official view taken by the medical department in 1857, that Thiele, Ceely, and Badcock had established thecorrectness of Jenner’s doctrine of variolæ vaccine, is still held very tenaciously by the profession. It is too simple
and attractive to be soon given up; but perhaps the best way to get rid of it is to state in plain terms what cowpox
itself really is.
Natural history of cowpox
Although there is no difficulty drawing up a complete natural history of cowpox, thanks to the laborious
and exact studies of Ceely, yet the attention has been so much diverted to side issues that the facts to be stated in thissection will come before most readers with the aspect of novelty. The other original authorities besides Ceely are
Jenner himself, Pearson (who collected information by circular in the months following Jenner’s Inquiry), Bousquet(1836), Estlin (1838), and Crookshank (1888). The Würtemberg inquiry, published by Hering (Stuttgart, 1839), is
made up of very indifferently authenticated or incomplete statements, which have not the same value as the rest, andare at variance with them on most essential points.
Its origination [origins]
Cowpox as an infective disease arises in cow-houses here and there, and at side intervals of time, out of acommon physiological or constitutional eruption of some particular cow, usually a heifer in her first milk, very often
in the spring season or at some other crisis of the year or of the animal’s life-history. It never arises except in milchcows; it occurs nowhere in the cow but on the teats, or, by infection, on adjoining parts of the udder. All thecharacters by which we know it distinctively as cowpox are associated with the fact of milking, or with theinevitable traction on teats that are the subject of an otherwise unimportant eruption. The primary disorder, as Ceely
describes it, is an eruption of a few pimples, the size of vetch or larger, hard and solid at first, but at length slightly
vesiculated on the summit. It is only rarely that a series of events ensues on this basis which constitute cowpox as
we know it; they ensue in some one animal out of many in the same byre, and years may elapse before the event
happens again. The pimples on the teats are made to bleed by what Ceely calls “the merciless manipulation of themilkers”; the blood forms crusts, which are dislodged every six hours; and indurated ulcers form on the sites of theoriginal pimples.
Its infective properties
The process being thus made inveterate owing to the incessant interference of the milker’s hands, it
becomes communicable to the other cows. The milkers can usually point out some one cow in which the diseasebegan; and it spreads slowly through a byre, taking sometimes as long as three months to go the round of all theanimals. An animal already infected at one or more-places on its teats may become infected at other places on theteats and body of the udder, either by the traction of milking or by the contact of parts when the cow is lying down.
The ulcers heal sometimes slowly, sometimes more quickly; they may heal under crusts, or as open sores;
induration and rounding of the edges are distinctive, along with much thickening of the base. The scars are also
indurated, rounded and elevated at the edges, and smooth or puckered on the surface; they are often as large as awalnut. It is not easy to see a vesicular stage of the disease even in the cows infected from the initial spontaneous
case; and Ceely had for the most part to be content with the coagulated matter of crusts to vaccinate with. The
process is, in fact, bound up from the first to last in the most intimate and essential manner with the operation of
milking. Cowpox “undisturbed by the milker’s hands” has no existence in the originating cow; it is the persistentirritation that makes a pox. It is communicable, also, to the hands of the milkers themselves, and by their filthy
hands to their faces. Jenner mentions a good many such cases; Pearson has collected several; and Ceely gives there
if very full detail.
Progress of the disease
As in the inoculated venereal pox, the infection proceeds for a time under the skin, making a bluish-whitevesicle; it eats away the tissues round the margin, where the fluid makes the skin bulge out into the characteristic
tumid ring. After the fourteenth day the vesicles will have become an eschar, the average size of a sixpenny piece,4Dissolving Illusions
The Encyclopedia Britannica (1890) - Vaccination

which comes away and leaves a sore. The open sore is a regular part of the infection in the milker’s hand. Various
regions of the face get infected by contact from the hands: Jenner mentions the case of “a poor girl who produced anulceration on her lip by frequently holding her finger to her mouth to cool the raging of a cowpox sore by blowing
upon it”; another of Jenner’s cases had the sore on the wing of the nose; one of Ceely’s cases had an ulcer on thetemple three-quarters on an inch long; in a case observed by Crookshank there was a very large vesicle andsubsequent sore over the left cheek-bone. The local infection is accompanied by constitutional disturbance, more orless severe, including headache, pains in the loins, vomiting, and sometimes delirium. The axillary glands become
painful, usually about the fourth day, and remain hard for some time. Eruptions occurred, but there is very little said
about them.
Humanized cowpox
As might be expected, the effects of experimental infection with cowpox matter were the same as theaccidental. They are spoken of as the effects of “primary lymph,” that is to say, lymph direct from the cow’s teats orfrom the milker’s sore hand, or in the earlier removes from these sources. Jenner’s experience of primary lymph
was very much the same as Bousquet’s, Estlin’s, and Ceely’s forty years later. Woodville’s on the other hand, wasexceptionally reassuring;6 had it not been so, it is not likely that cowpoxing on the large scale would have survived
the initial discouragements entailed by the use of primary lymph. The process on the child’s arm was on the whole
the same as on the milker’s hand, allowing for the more deliberate mode of inoculation and for the different textureof the skin. The vesicle grew to a great size up to the fourteenth day, and often become an ulcer, either excavatedunder the crust or absolutely open. Estlin did not entirely get rid of the ulceration until after the twenty-ninth
remove from the cow. The constitutional disturbance was often severe in infants: axillary tenderness and swellingwere somewhat constant; and eruptions were especially frequent about the second to the fourth week, including
macular roseola, lichen, and pemphigoid bullæ. At each successive remove from the cow the cycle of the process
became more contracted, and the constitutional disturbance, cæteris paribus, became less. Bousquet gives a plate
which shows by parallel series of figures the difference between the vesicles of the old lymph (Woodville’s, nearly
forty years old) and the lymph from the Passy cow. The new lymph induced a process more protracted at every
stage: the vesicle continued to enlarge at the periphery for several days after the common vaccine vesicle of theperiod would have ceased to extend. It was not at its maximum until about the end of the second weak, and it thenbecame an eschar and a sore. Bousquet confesses that he first understood “les frayeurs de Jenner” when he saw theulcerative and other effects of primary lymph. After a certain number of removes from the cow the cycle became socontracted that the vesicle was full at the eighth or ninth day; the abbreviation of its life-history enabled it to heal
without ulcerating. It thus becomes the ordinary vaccine vesicle was we know it, which heals under a scab, andleaves the peculiar punctuated scar of subcrustaceous repair. The abbreviation or mitigation is effected by taking
lymph from each successive vaccinifer at as early a period as it can be got, until the golden mean of safe
vaccination, namely, maturity at the eighth day, is reached. That corresponds to Jenner’s rule of taking the matterfor vaccination before the areola appears; if the vesicle be emptied after that period, the lymph from it is apt to cause
ulceration, or as Ceely puts it, we have “all the inconvenience of primary lymph.” It is thus clear that humanizedcowpox might be easily cultivated back to its original type; and, as a matter of fact, it has sometimes been so
cultivated back by misadventure, with serious consequences to the vaccinated.
Risks of vaccination
The risks of vaccination may be divided into the risks inherent in the cowpox infection and the risks
contingent to the puncture of the skin. Of the latter nothing special requires to be said; the former will be discussed
under the five heads of (1) erysipelas, (2) jaundice, (3) skin eruptions, (4) vaccinal ulcers, and (5) so-called vaccinalsyphilis.

6

But Addington (On the Inoculation of the Cowpox, Birmingham, 1801), who got his lymph from Woodville, was not equally
fortunate: of eleven cases at the beginning of his series fived ended in ulceration; after that the cases all ended in a “dry scab.”

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Erysipelas(1) A Slight degree of erysipelas was recognized by Jenner himself, and even postulated by him, as part of
the natural history of cowpox in man; and it is so recognized by the more unbiased writers of recent data. 7 The usual
time for it corresponds to the appearance of the areola (eighth or ninth day), that efflorescence round the pock being
normally a slight erysipelas. It may start, however, from the puncture or scratch in the skin, after a day or two’s
interval; but that form of it (the “early erysipelas” of German writers) is much rarer than the erysipelas of the areola,or “late erysipelas.” Primary lymph, or lymph in the first removes, is most apt to excite an extensive and spreading
areolar redness. In the ordinary course of vaccination remote from the cow the intensity of the superficial redness
and deep infiltration would seem to depend mostly on the child’s constitution, or on whatever concurrence of
circumstances serves to recall the “inconveniences of primary lymph.” The registrar-general’s tables of mortality
for England and Wales have contained an entry of “erysipelas after vaccination” from 1855 down to 1881, when theentry was changed to “cowpox and other effects of vaccination,” the numbers at the same time nearly doubling. The
fatal cases of erysipelas in infants under one year referred to vaccination are but a small fraction of the wholemortality from erysipelas at that age, a mortality which is far greater than at any other period in life. It is quite
certain that in foundling hospitals, such as that of St. Petersburg, the erysipelas of vaccination has been the startingpoint of disastrous epidemics of erysipelas affecting the inmates generally. There is no means of knowing whether
the same has been the case among the population at large. In Table I. the column of deaths from erysipelas ingeneral, among infants of the first year in England and Wales, is given side by side with the column of deaths from
Erysipelas after
Vaccination

Erysipelas

Erysipelas after
Vaccination

Erysipelas

1855

0

583

1870

20

683

1856

5

610

1871

22

716

1857

0

421

1872

16

617

1858

0

599

1873

19

675

1859

5

569

1874

27

867

1860

2

514

1875

26

796

1861

2

492

1876

21

700

1862

3

458

1877

26

667

1863

7

612

1878

35

582

1864

11

618

1879

31

561

1865

10

579

1880

32

618

8

644

1866

9

527

1881

56

1867

8

467

1882

658

696

8

641
618

1868

8

647

1883

51

1869

19

589

1884

498

erysipelas after vaccination. The post-vaccinal inflammation sometimes takes the form of phlegmon; but there is no
separate entry for that as a special sequel of vaccination. Many of the alleged deaths from erysipelas after
7

Bohn, Handbuch der Vaccination, Leipsic, 1875, p. 174

8

Cowpox and other effects of vaccination.

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vaccination have been the subject of coroner’s inquests; the verdict is often an open one, and even such cases asthese near Gainsborough in 1876 and at Norwich in 1882 were found to have been returned (all but once) by thecertifying medical practitioners as due to erysipelas merely. It may be assumed that “after vaccination” is notcertified unless the case left no doubt in minds of the jury or the certifying medical attendant. The increase in thefirst column of 0 in 1855 to 32 in 1880 is probably in appearance only, and due to more correct diagnosis.
Jaundice(2) It is only within the last few years that jaundice has been recognized as a post-vaccinal effect; and atpresent there is only one accepted instance of it on the large scale. This was the epidemic among re-vaccinatedadults in a large shipyard at Bremen from October 1883 to April 1884. Owing to an alarm of smallpox, 1289
workmen were re-vaccinated between the 13th August and 1st September with the same humanized lymph preservedin glycerin; of these 191 had jaundice at various intervals down to the month of April following. Circumstantial
evidence (agreement and difference) clearly traced the epidemic to the vaccination. 9 In future an outlook will be
kept for this effect of vaccination; at present it has no intelligible theory. It may be noted that the lymph whichcaused the Bremen epidemic was mixed with glycerin.
Skin eruptions(3) The eruptions that follow vaccination are proper to cowpox infection. Although little is said about themin the accidental infection of milkers, they were very common in the practice of Estlin, Ceely, and others withprimary lymph. The eruption is a kind of exanthema, or “secondary” of the local infection, and does not ordinarily
appear before the second week. One of its commonest forms is a patchy rose-rash, or macular roseola, not easily
distinguishable from the macular roseola of syphilis.10 Another form is lichen or dry papules, apt to scale; it may
also occur as a vesicular eruption, and in the form of pemphigoid bullæ or blebs. In one of Ceely’s cases theeruption extended to the whole mucous membrane of the mouth and throat. A peculiarity of the exanthema is that it
may come and go several times before it finally disappears; and, like other skin eruptions, specific or non-specific, it
may become inveterate. The widespread belief that much of the eczema of childhood dates from vaccination is notby any means to be dismissed as a mere fancy. The skin-disorder that followed vaccination in the first years of thepractice were declared by Birch and others to be new in type. At present the vaccinal eruption, especially on thescalp, is sometimes distinguished by the size and form of the crusts, and by scars remaining for a time.
Vaccinal ulcers(4) Ulceration of the vaccine vesicle, or of the site of it, is one of the commoner forms of “bad arm.” It is areturn to the native or untamed characters of cowpox on the cow’s teats, or on the milker’s hands or face, or in thechild’s arm after experimental inoculation with primary lymph. It crops out not unfrequently in everyday practice,and is probably dependent for the most part on the lateness at which the lymph was taken for vaccination, or on
retardation of the process in the vaccinifer, or on emptying the latter’s vesicles too much; however, it may result
from picking the scab or otherwise dislodging it. The ulceration usually proceeds to some depth in the form of acrater under the crust, and is attended with induration and rounding of the edges and induration of the base.
According to Bohn (op. cit., p. 166), it may alarm practitioners by its resemblance to syphilis. In other cases thecrust is wanting and the ulceration has the distinct type of phagedens. The destruction of tissue in either case may bevery extensive, going “down to the bone” and having as much as an inch or more of superficial area. Healing isfrequently an affair of weeks, and may be aided by mercurial treatment. There are no statistics of this sequel ofvaccination; but the frequency or infrequency of it may be learned in conversation with nay intelligent chemist
whose shop is resorted to by the poor, or with a medical practitioner of average experience.

9

See Lürman, Berl. klin. Worchenschrift; 1885, p. 20.

10

Parrot, La Syphilis Héréditaire, 1886, p. 33

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Vaccinal syphilis(5) It has been proved by many experiments, undersigned or otherwise, in Paris (1831 and 1839), Vienna(1854), and elsewhere, that an infant with congenital syphilis develops correct vaccinal vesicles, provided its skin beclear of eruption and the lymph have been take at the usual time; also that the lymph taken from the correct vesiclesof the syphilitic child produces correct vesicles in its turn, but does not produce syphilis in the vaccinated child. The
congenital taint is, in fact, irrelevant to the course of cowpox infection. So far as experiment and casual experiencecan prove anything, that has been proved; the recent attempt to disprove it by an officer of the Local Government
Board (Report for 1882, p. 46) is vitiated by fallacies, and has no value against the overwhelming testimony
collected thirty or forty years ago. What then is the meaning of the numerous outbreaks of syphilis in groups ofchildren or adults vaccinated or re-vaccinated with lymph from one source?
A careful examination of these cases shows that syphilis at the source of vaccine matter was in all cases anafter-thought, that in most of the cases there was no evidence for it, and that in the remaining cases the evidence wasso far-fetched as to be unlikely (apart from the know a priori improbability), or that the traces of constitutional
infection found in the vaccinifer were subsequent to vaccination, and therefore capable of being explained as aneffect concurrent with the more obvious symptoms in those vaccinated therefrom. The effects, however, were verymuch the same as in the venereal pox. The vaccine vesicles either became and indurant or phagedenic sore, as
described in the foregoing section on vaccinal ulcers, or the scare opened into an indurated sore after the usualsubcrustaceous healing was complete, or became indurated without opening. The axillary and cervical glands were
often indurated. In most of the epidemics there were a certain number of cases in which the effects were purely
local, or confined to one only of the seats of puncture; if these had not occurred along with others in a group, theywould have been counted as ordinary vaccinal ulcers. But there were often secondary symptoms as well, including
the roseolar, lichenous, or (rarely) pemphigoid eruption, and not unfrequently condylomata circa anum et genitalia.
In some epidemics (but not in all) there were, in a small minority of the cases, mucous patches on the tonsils,
tongue, or lips, tending to ulcerate; and in some of the Italian outbreaks the infection spread among the mothers andother members of the households in the form of specific sores of the nipples, with or without constitutional
symptoms. Affections of the bones and viscera do not seem to have followed; fatalities were not very common.
It will be very hard to persuade medical authorities that these secondary effects are not the result
exclusively of the venereal pox. The evidence, however, does not allow us to assume any other specific infection
than that of cowpox, which, as we know, has its proper secondary exanthema in the form of macular roseola, lichen,or pemphigus; the eruption has even been known to affect the mouth and throat. The evidence from epidemics ofvaccinal sore arms teaches us that condylomata, mucous patches of the tonsils, tongue, and lips, and even iritis, arealso possible, although far from invariable, among the “secondaries” of the primary vaccinal ulcer. The mostgeneral fact that comes out in these epidemics is that the lymph was taken late from the vaccinifer, or that thevesicles of the vaccinifer were drained dry to vaccinate a large number, or that the same vaccinifer was used forarm-to-arm inoculation on two successive days. It is not difficult to see how, in those circumstances of its become
an infective ulceration (indurated or suppurating) and in its secondary or constitutional manifestations as aninfection in man. But the “bad” lymph has hardly ever been used beyond the second remove; and there the parallelfails.
The following is a list of the so-called syphilitic epidemics after vaccination, including those that have been
considered spurious, because they were either anomalous in type from the point of view of syphitic infection or had
not obvious causal connexion with that disease.
Udine, 1814 (see Viennois, in Syph. Vaccinale, p. 221). Cremona, 1821 (see Depaul, Projet de Rapport,”
in Syph. Vacc.). Grumello, 1841 (ibid.). Coblenz, 1849 (Wegeler, in Pruess. Vereins-Ztg., 1850, No 14; abstracts in
Schmidt’s Jahrb., vol. lxvii., 1852, p62). Upper Franconia (the Hübner case), 1852 (Intelligenzbl. Der Bayre.
Aerzte, 1854; Bohn, loc. cit.). Lupara (Italian prov. Molise), 1856 (see Depaul, loc. cit.). Dispon near Pesth, 185557 (Oester. Zeitschr. für prakt. Heilk., 1862; Bohn, loc. cit., p. 322). Rivalta (Piedmont), 1861 (Pacchiotti, Sifilide
Trasmessa per Mezzo della Vaccinazione in Rivalta presso Acqui, Turin, 1862). Torre de' Busi near Bergamo, 1802
(see Depaul, loc. cit.). United States (troops on both sides in the Civil War), 1861-65 (Jones, Circular II., Louisiana

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Board of Health, Baton Rouge, 1884). Argenta near Ferrara, l866 (Gamberini, in Gaz. des Hôpitaux, 1870, p 505).
Morbihan (neighbourhood of Vannes and Auray), 1866 (Depaul, Bull. de l'Acad. de Méd., xxxii, 1866-67, p. 201;
Bodelio, ibid., p. 1033). Cardaillac (Lot), 1866 (Bull. de l’Acad. de. Méd., 28th February 1867). Schleinitz (Styria),
1870 (Kochevar, Allgem. Wiener Med. Ztg., 1870, Nos. 21 and 24 ; abstract in Arch. für Dermatologie und Syph.,
1870). London (two series), 1871 (Hutchinson, Med. Chir. Trans., liv., 1871). Switzerland, 1878 (Bull, de la Soc. dela. Suisse Romande). Algiers, 1880-81 (Journ. d'Hygiène, 25th August 1881). Lyck (East Prussia), June 1878
(Pineus, Vierteljhschr. f. gericht. Med., 1879, p. 193). Asprieres (Aveyron), March 1885 (P. Brouardel, Rapport,
Paris, 1886).
Attention was drawn to these cases because the occurred in groups varying in number from 10 to 100 or
more, which made considerable stir, especially in the country districts. It is unlikely that all cases have beenreported. In the third Report of the clinical hospital of Manchester, Whitehead states the results of his inquires on
post-vaccinal illness in children. Setting aside most of the cases of illness vaguely alleged by the mothers to havebeen the consequence of vaccination, he admits as truly post-vaccinal 34 cases of syphilis or pseudo-syphilis; ofthese he enumerates only 14 in his table of 63 cases of children’s syphilis of all kinds, the other 20 cases being
omitted, it would appear, not because there was any double of their being post-vaccinal, but that there were not of
the perfect type of infantile syphilis. Such was the experience of a competent observer at a single hospital during aperiod of 20 months. Whitehead’s Report was published in 1859; but, when Hutchinson published his first series of
London cases in 1871, the subject was considered to be quite new. Here again it was the concurrence of some tencases in a group that helped the reluctant assent of the profession. The first group of London cases had hardly began
to be talked of when one of Hutchinson’s colleagues was led by two cases of skin disease at a hospital to follow up
the traces of another group, the very existence of which was unsuspected by the public vaccinator or generalpractitioners in whose district the eleven patients with vaccinal ulcers and occasional secondaries resides.

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Infantine Death-Rate from Syphilis (England and Wales).

Infants under
One Year.

All Other Ages.

Infants under
One Year.

All Other Ages.

1847

255

310

1858

1364

522

185211

380

11

243

1869

1361

498

380

242

1870

1422

436

185411

591

373

1871

1317

425

1855

579

368

1872

1410

421

1856

579

300

1873

1376

467

1857

656

301

1874

1484

513

1858

684

322

1875

1554

530

1859

778

311

1876

1580

554

1860

767

300

1877

1550

524

1861

798

379

1878

1647

535

1862

867

378

1879

1498

536

1863

968

408

1880

1588

571

1864

1089

461

1881

1540

557

1865

1155

492

1882

1665

561

1866

1180

482

1883

1813

500

1867

1241

457

1884

1733

547

1853

In the registrar-general’s tables of mortality for England and Wales about one-half of the deaths from“cowpox and other effects of vaccination” or nearly thirty per annum, may be put down to effects of vaccination
other than erysipelas; but there is nothing to show that these were fatal cases of vaccinal ulcers with constitutional
symptoms or marasmua. On the other hand, the table of deaths from syphilis shows an enormous and steadyincrease in the number of deaths of infants under the age of one. In the first year of compulsory vaccination (1854)
the deaths suddenly increased by one-half, and the increase has gone on steadily since then (see Table II.) The
interpretation of the fact is by no means easy or free from fallacies. There are doubtless other and better reasons forthe increase besides vaccination; and it is significant that the tables for Scotland show the mortality to be chiefly inthe first three months of life, whereas the statutory limit for vaccination in that country is six months.
Other alleged effects of vaccination
In the polemical writings of anti-vaccinists, such diseases as scrofula, tubercle, hooping-cough, diarrhœa,and other common causes of infantine mortality are alleged to have increased owing to vaccination. There is little tono reason, in theory or experience, to suspect that tuberculous or scrofulous infection is ever communicated by
vaccine lymph. As regards the above and other infantine maladies, vaccination may predispose the child to fall into
them, is so far as it produces, or ought in theory to produce, a considerable constitutional disturbance and
11

The proportion assigned to the first year of life is calculated from the specimen table for 1852 (females only) and from thetables of London mortality.

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The Encyclopedia Britannica (1890) - Vaccination

presumably a loss, for a brief period, of the natural power to resist the various noxious influences by which the ageof infancy, especially among the poor, is beset.
The value of cowpox as a protection against smallpox may now be judged of apart from the fanciful
doctrine of variolæ vaccinæ by which it was originally recommended. It has been put to a test extending over eighty
years; and in some circumstances it has been possible to apply the logical methods of agreement and difference witha good deal of cogency. The besetting fallacy of all vaccination logic is that of post hoc ergo propter hoc; and theonly way to escape it is to hold intelligent views of history, the natural history, and the epidemiology of smallpox.
This will necessitate a brief excursus.
Smallpox
Smallpox, which is really a tropical skin disease of the nature of lichen turned pustular, or of ecthyma, mustbe judged according to what we know of foreign pestilences in general. Perhaps we are safest to take a line throughthe behavior of the plague. Plague in western Europe had the start of smallpox by a good many years, if we speak
only of prevalence of the large scale. “Throughout the 16 th century,” says Hirsh, “the plague was a permanent formof disease of the continent of Europe… During the first two thirds of the 17 th century we still meet with it over an
equally wide area and equally often. But in the last thirty years of that century the plague was observed to be
retreating gradually from the soil of Europe.” It was not only in London after the fire of 1666 but also in Denmarkand Sweden, in Italy, in Holland and Belgium, in Switzerland, in France, in western Germany, and in Spain that theyears 1660-1680 saw the last of plague; it lingered only in the Levant, in Poland, and in other parts of north-eastern
Europe, with occasional epidemic visits, such as those of Messina and Marseilles. Now it has left the Levant andEgypt, has abandoned even Mesopotamia and Arabia, and retreated to a few poor villages on the Perso-Armenian
frontier. Or, take the example of leprosy, which owed its existence rather to the widespread or national concurrenceof the same causes in various countries than to the travelling of an infection: Italy had it first and lost it first, andnearly every other country in Europe saw its rise, its general prevalence, its decline, and its extinction, the northerncountries keeping it longest. Again, typhus fever was a standing disease so long as Europe was the theatre of
protracted wars and all their consequences; but, like other infections, typhus gradually declined and has almost
disappeared since the conditions on which it depended ceased.
Leaving these parallels and coming to the facts of smallpox itself, it rose to prominence in western Europe
in the 16th century, and in England in the 17th. 12 From the early part of the 18th century a remission was noted; but
the latter half of that century saw a considerable extension of the area of the disease, for which the practice of
inoculation has been blamed. It is a mistake to suppose that smallpox has shown a tendency towards a universal
infection; for all its chances it has kept within moderate limits of age and place, and extended only by repeatedprovocation. Thus, Hirsch says of the western hemisphere, "A still more terrible source for America was theimportation of Negro slaves, so much so that in after years, particularly in South America and the West Indies, notonly the first appearances of smallpox, but every fresh outbreak of it, could be traced to importation from Africa,"—the African continent being then, as now and always, one of its principal native seats. In Europe it has been
peculiarly a disease of infancy and of the most crowded parts of cities. It has had victims among the upper classes,
just as cholera has had; but, like that disease, its habitat is among the crowded poor; and it would have touched thewell-to-do-classes less in former times if there had always been spacious west-end quarters in cities or the modern"passion for clean linen," personal ablutions, and fresh air. Tenement houses and ill-ventilated courts or alleys havebeen the natural harbourage of smallpox; in proportion as these have been demolished the disease has disappeared or
been circumscribed in its area. It is fallacious to estimate its prevalence now in ratio of the whole population; for ajust comparison of one period with another, we have to take into account, not the death-rate per million living, but
the death-rate per million still living under the old-world conditions. From the earliest period of its history in
12

The first known use of the term "small pocks " is in Holinshed's Chronicle (1577), an epidemic of pestis in 1365 being so
rendered, although it was probably the ordinary bubo-plague of the period. The pox of Elizabethan writers was the French pox orgreat pox (syphilis), which overran Europe as an epidemic in 1494. Its prominent character at its first appearance was theloathsome affection of the skin (especially the face); hence when variola came on the scene it was called the lesser pox, or
smallpox.

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Europe, the disease has had its seasons of quickening or revival, with long intervals of quiescence; only in the most
crowded parts of Western cities has it ever been endemic from year to year. These epidemic outbursts have variedmuch in intensity and in area, the conditions of variation being mostly unknown. In that respect, it need hardly be
said, small-pox is like other epidemic diseases.
Influence of vaccination upon smallpox
During the early years of the 19th century there was a marked remission of the epidemic outbursts of thedisease in most parts of Europe. The amount of vaccination during those years was inconsiderable; in particular it
hardly touched the poor. Thus, at the time of the Norwich epidemic of 1819, it was estimated (by Cross) that only
one-fourth of the inhabitants were vaccinated, and these almost exclusively the well-to-do. At the same time thepractice of inoculating smallpox, which was with good reason blamed for keeping the contagion generally diffused
and active among the non-inoculated, began to be discontinued and soon ceased altogether. Undoubtedly there was amarked decline in smallpox during the first fifteen years of the century, but associated circumstances are as complex
as the fact itself is simple. We have to bear in mind the old law of periodic exacerbation and dormancy, thecessation of a practice (inoculation) which almost certainly interfered with the natural tendency of smallpox as aforeign pestilence to die out, and the unusual prevalence of typhus fever (on the Continent), and other displacing or
substitutive factors in the death-rate. To what extent vaccination was a factor will have to be decided by theexperience of a period when the practice was much more generally in vogue. For that purpose we may here restrict
the inquiry to England and Wales, premising that the experience of other European countries where vaccination has
been equally practised is not different.
The following table (III.) begins with the year 1847; the registration reports go back to 1838, but there is abreak in the tables for five years near the beginning.

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Deaths from Smallpox from 1847 to 1884, with the number among Children under five.
Year.

Total ofAll Ages.

Childrenunder Five

All Other
Ages

Year.

Total ofAll Ages.

Childrenunder Five

All Other
Ages

1847

4227

3114

1113

1866

3029

1662

1367

1848

6903

4782

2121

1867

2518

1370

1149

1849

4644

3146

1498

1868

2052

1234

818

1850

4665

3265

1400

1869

1565

392

673

1851

6997

4869

2128

1870

2690

245

1375

1852

7320

5076

2344

1871

23126

7770

15356

1853

8151

2164

987

1872

19094

6758

13336

1854

2808

1659

1149

1873

2364

587

1777

1855

2525

1323

1202

1874

2162

543

1619

1856

2277

1299

978

1875

950

271

679

1857

3936

2335

1601

1876

2408

612

1796

1858

6460

3585

2875

1877

4278

1056

3222

1859

3848

2247

1601

1878

1856

472

1384

1860

2749

1544

1205

1879

536

130

406

1861

1320

723

597

1880

648

170

478

1862

1628

931

697

1881

3098

740

2358

1863

5964

3267

2697

1882

1317

275

1042

1864

7684

4294

3390

1883

957

225

737

1865

6411

3262

3149

1884

2234

503

1737

In the first years of the table the deaths from smallpox of children under five were to those of all other ages
in the ratio of 3 to 1 or of 5 to 2 (at Norwich in 1819 there were 530 deaths, of which half were in infants under two,and all the rest save ten were in children under ten years); the disproportion lessened gradually, until about 1864 it
was nearly 4 to 3; in 1870 the proportion was nearly equal; and from that time onward the preponderance leaves theage of infancy and childhood, so that in 1884 the deaths under five were three times fewer than those at all otherages. The great epidemic of 1871-72 brought out that remarkable change of incidence most decidedly. Taking the
mortality of 1871 as an instance, the significance of the changed incidence on the periods of life is that the 7770
deaths under the age of five would, in pro-compulsion times, have had a complement of no more than 2500 deaths in
the later periods of life, or that the actual mortality of 15,356 above the age of five would have had a complement ofsome 40,000 or 45,000 deaths below that age. (In British India in 1884 of 333,000 deaths 72 per cent, were ofchildren under 12 in Bengal, and 64 per cent, in Madras.) Apart from the changed incidence of smallpox, Table III.
shows merely the caprices of the disease as an epidemic. After every epidemic outburst the disease declines andsometimes looks as if it were about to die out altogether. The alarm attending each severe epidemic has induced thelegislature to make the vaccination law more stringent and vaccinators to insert more of the virus, so that theperiodic subsidence has corresponded to, and has seemed to be owing to, the better enforcement of the practic ; but
there have always been alternating periods of quiescence and ex-acerbation, irrespective of any prophylactic.
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Moreover, smallpox being a foreign contagious skin disease lurking in congenial haunts, it would be quite according
to precedent that it should one day cease absolutely in a community where sanitary progress had advanced so far as
to take the ground from under the feet of the pestilence; such absolute cessation would have no more necessaryconnexion with almost universal vaccination than the alternating quiescence and recrudescence of epidemics havebeen connected with each new Act of-Parliament. The epidemic of 1871-72 was one of the worst in the whole
history of European smallpox; and it may be that it was one of the last flickers of a slowly expiring flame. The
universal practice of cowpoxing, however, is based upon the assumption that this contagious skin disease imported
from the tropics is a thing that Europe must reckon with for an indefinite time. On the other hand, the teaching of
epidemiology is that a foreign pestilence never stays unless it finds quarters suited to its existence, and that it may
even take its departure capriciously, as in the case of the plague, after it has had a certain career, or on being
displaced by some congener such as typhus. Vaccination is considered to have turned smallpox in great part aside
from the early years of life and thrown it more than ever upon the later ages, while measles and other maladies
proper to childhood have at the same time increased. 13
Its utility to the individual
Thus far as regards the utility of vaccination to the state; we have now to consider its utility to theindividual. Do the vaccinated escape in an epidemic? or, if they do not escape an attack of smallpox, do they escapedeath from it? In answer to the first question, apart from the familiar negative experience of everyone, we have thestatistics of smallpox hospitals, which relate to the poorer class and probably do full justice to the fact of nonvaccination, inasmuch as the unvaccinated residue is mostly to be found in those slums and tenements of the poor
where smallpox (now as always) is apt to linger. At the Eastern Metropolitan Hospital (Homerton) from its opening
early in 1871 to the end of 1878 there were 6533 admissions for smallpox, of which 4283 had vaccination marks,
793 had no marks although vaccinated, and 1477 were unvaccinated, giving a proportion of 0.29 unvaccinated. In
the epidemic hospitals of Liverpool, Glasgow, and Dublin the proportion was 0.25 during the same period. For someof the German states the proportion of unvaccinated cases comes out a good deal less than one-fourth ; thus, inBavaria in 1871 of 30,742 cases 29,429 were in vaccinated persons, or 95.7 per cent., and 1313 in the un-vaccinated,or 4.3 per cent.14 In some of the small local outbreaks of recent years the victims have been nearly all vaccinated(e.g., at Bromley in 1881, a total of 43 cases, including sixteen confluent, all vaccinated.15 In the army and navy,
where vaccination and re-vaccination are absolutely without exception, the proportion is accordingly 0. It would
thus appear that the rather excessive proportion of cases among the small residue of unvaccinated in the civil
population must have other associated circumstances besides non-vaccination; and these are not far to seek.
Death rate among vaccinated and unvaccinated
The next question is the death-rate among the vaccinated and unvaccinated respectively. The total deathrate from smallpox in modern times is almost the same as it was in the 18th century; large aggregates collected byJurin and others in pre-vaccination times show a mortality of 18.8 per cent., and corresponding aggregates inEnglish and American hospitals, mostly since 1870, show a mortality of 18.5 per cent. It has, however, to be bornein mind that the division into discrete, confluent, and malignant smallpox is an old one; that a mild type was quite
common in the 17th and 18th centuries, and was now and then characteristic of whole epidemics, just as in the caseof scarlatina; and that the vaccinated are at present liable to be attacked by the confluent and malignant disease as
well as by the discrete. But are the vaccinated liable to the fatal forms of smallpox in the same proportion as theunvaccinated? It is only since 1879 that the registrar-general's tables for England and Wales have attempted to13

See Farr, Reg. Gen. Report for 1867, p. 213: "To operate on mortality, pro-tection against every one of the fatal zymotic
diseases is required; otherwise the suppression of one disease-element opens the way to another" (p. 219). He quotes Watt (1813)
to show that the decrease of smallpox mortality among infants in Glasgow from 1783 to 1812 was balanced by a great increase in
the infantine deaths from measles. See also Guy, Journ. Statist. Soc., 1882, p. 430.
14

Majer, Vierteljahrschrift für gericht. Med., xxii. 355.

15

Nicolson, Lancet, 27th August 1881.

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supply data bearing on this; and it will be seen from the following abstracts (Tables IV-VII.) that the data are still far
from being sufficient :—Table IV. - Deaths from Smallpox, showing the Number of Unvaccinated

Year.

Total
Deaths.

Unvaccinated

Vaccinated

Notstated.

Year.

Total
Deaths.

Unvaccinated

Vaccinated

Notstated.

1879

535

231

117

188

1882

1317

325

176

816

1880

648

232

121

243

1883

957

162

73

717

1881

3096

1068

652

1378

1884

2234

595

493

1146

Table (V.) - Same for the Provinces (Metropolitan Deaths deducted).

Year.

Total
Deaths.

Unvaccinated

Vaccinated

Notstated.

Year.

Total
Deaths.

Unvaccinated

Vaccinated

Notstated.

1879

36

20

9

57

1882

887

143

66

678

1880

171

43

14

114

1883

821

111

35

675

1881

731

133

90

506

1884

1336

282

239

815

Table VI. - Deaths from Smallpox in Infants under One Year

Year.

Total
Deaths.

Unvaccinated

Vaccinated

Notstated.

Year.

Total
Deaths.

Unvaccinated

Vaccinated

Notstated.

1881

319

144

14

161

1883

126

32

1

93

1882

129

43

2

84

1884

254

118

7

129

Table (VII.) - Same for the Provinces (Metropolitan Deaths deducted).

Year.

Total
Deaths.

Unvaccinated

Vaccinated

Notstated.

Year.

Total
Deaths.

Unvaccinated

Vaccinated

Notstated.

1881

66

13

1

52

1883

106

21

1

36

1882

90

20

1

69

1884

146

56

5

85

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These figures may be made to prove anything, according to the bias of the individual; the column of "notstated " commands the situation. The official figures16 for Bavaria in 1871 are more precise: among the 29,429 casesof smallpox in vaccinated persons there were 3994 deaths, while among the 1313 unvaccinated cases there were 790
deaths; of the latter no fewer than 743 deaths were of infants in their first year. The mortality among both thevaccinated and the unvaccinated is always excessive for infancy. Feeble health, as well as non-vaccination, is afactor in the very excessive smallpox mortality at that tender age.
The returns from special smallpox hospitals make out a very small death-rate (6 per cent.) among thevaccinated and a very large death-rate (40 to 60 per cent.) among the unvaccinated. The result is doubtful qua
vaccination, for the reason that in pre-vaccination times the death-rate (18.8 per cent.) was almost the same as it is
now in the vaccinated and unvaccinated together (18.5). At the Homerton Hospital from 1871 to 1878 there wereadmitted 793 cases in which "vaccination is stated to have been performed, but without any evidence of its
performance"; the deaths in that important contingent were 216, or 27.2 per cent., but they are not permitted to swell
the mortality among the "vaccinated.”17 Again, the explanatory remarks of the medical officer for Birkenhead in1877 reveal to us the rather surprising fact that his column of "unvaccinated" contained, not only cases that wereadmittedly not vaccinated, but also those that were "without the faintest mark"; of the 72 cases in that column nofewer than 53 died. His column of "unknown" contained 80 per cent, of patients who protested that they had been
vaccinated (28 deaths in 220 cases or 127 per cent.). Those who passed muster as veritably vaccinated were 233, ofwhom 12 died (51 per cent.). With reference to this question of the marks, it has to be said that cowpox scars may be
temporary, that their "goodness "or "badness " depends chiefly on the texture of the individual's skin and thethickness or thinness of the original crust, and that the aspect of the scar, or even its total absence some years oreven months after, may be altogether misleading as to the size and correctness in other respects of the vaccine
vesicle, and of the degree of constitutional disturbance that attended it. This was candidly recognized by Ceely, 18
and will not be seriously disputed by anyone who knows something of cowpox and of how it has been mitigated,and of the various ways in which the tissues of individuals may react to an inoculated infection. In confluent cases
the marks on the arm would be less easily seen.
The following statistical table (VIII.) shows death from smallpox to be comparatively rare where the marks
are many and "good."

16

Majer, op. cit.

17

Parliamentary Return, 24th February 1880.

18

Trans. Prov. Med. And Surg. Assoc., viii., 1840.

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Table VIII., showing the Number and Kind of Arm Marks in 379 •Fatal Cases of Smallpox at Homerton Hospital,
1871-80 (Gayton).

Admissions.
Vaccinal
Marks.

Deaths.

Mortality Percent

Under 10
Years.

Over 10
Years.

Under 10
Years.

Over 10
Years.

Under 10
Years.

Over 10
Years.

4 good

56

247

0

4

0.0

2.5

3 good

44

388

0

12

2 good

41

528

1

19

2.4

4.1

1 good

43

422

1

20

4 imperfect

91

317

3

17

3.0

6.9

3 imperfect

107

545

3

43

2 imperfect

142

930

17

92

12.5

12.6

1 imperfect

133

820

18

129

Re-vaccination
The practice of re-vaccination was first recommended in England by G. Gregory, and in Germany for thearmy by Heim (1829). It has been more or less the law in Prussia since 1835; 19 "re-vaccination of school pupils at
the age of twelve is an integral part of the vaccination law." Notwithstanding the fact that Prussia was the bestrevaccinated country in Europe, its mortality from smallpox in the epidemic of 1871 was higher (59,839) than in any
other northern state. The efficacy of re-vaccination is sometimes sought to be proved by the immunity of nurses insmallpox hospitals. The experiment of not re-vaccinating the nurses was tried at the small-pox hospital of the South
Dublin Union in 1871-72; 29 out of the 36 attendants had not been re-vaccinated, and these all escaped smallpox aswell as the other seven.20 But nurses are not rarely chosen from among those who have had smallpox, and cases ofsmallpox in re-vaccinated nurses are not unknown.21 The evidence as to re-vaccination on a large scale comes fromthe army. According to a competent statistician (A. Vogt), the death-rate from smallpox in the German army, inwhich all recruits are re-vaccinated, was 60 per cent, more than among the civil population of the same age; it was
ten times greater among the infantry than among the cavalry, and sixty times more among the Hessians than among
the Wurtembergers. The Bavarian contingent, which was revaccinated without exception, had five times the death
rate from smallpox in the epidemic of 1870-71 that the. Bavarian civil population of the same ages had, althoughrevaccination is not obligatory among the latter.
The susceptibility to cowpox infection diminishes with age; among the pupils of twelve years in Prussian
schools it fails in about one-fourth of the attempts, and at later periods of life the proportion of failures is still
greater.

19

Hern's Medicinal-Wesen in Preussen, ed. Eulenberg, Berlin, 1878-74, pp. 160 and 215.

20Med. Press and Circ., 27th March 1872.

21

Sweeting, Rep. Fulham Hosp., 1881.

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The Encyclopedia Britannica (1890) - Vaccination

It is often alleged that the unvaccinated are so much inflammable material in the midst of the community,
and that smallpox begins among them and gathers force so that it sweeps even the vaccinated before it. Inquiry into
the facts has shown that at Cologne in 1870 the first unvaccinated person attacked by smallpox was the 174th inorder of time, at Bonn the same, year the 42nd, and at Liegnitz in 1871 the 225th.
Legislation
State-supported facilities for vaccination began in England in 1803 with the National Vaccine
Establishment. In 1840 vaccination fees were made payable out of the rates. The first compulsory Act was passed in
1853, the guardians of the poor being intrusted with the carrying out of the law; in 1854 the public vaccinations
under one year of age were 408,824, as against an average of 180,960 for several years before. In 1867 a new Act
was passed, rather to remove some technical difficulties than to enlarge the scope of the former Act; and in 1871 the
Act was passed which compelled the boards of guardians to appoint vaccination officers. The guardians also
appoint; a public vaccinator, who must be duly qualified to practise medicine, and whose duty it is to vaccinate (fora fee of not less than eighteen pence) any child resident within his district brought to him for that purpose, toexamine the same a week after, to give a certificate, and to certify to the vaccination officer the fact of vaccination
or of insusceptibility. The Local Government Board awards a considerable sum in premiums for totals of successful
vaccination, at a higher scale of one shilling for each case, and a lower scale of sixpence. The vaccination officer
sees that all infants are vaccinated, either publicly or privately, before they are three months old (in Scotland six
months), unless there is reason for postponing the operation. He acts also as registrar of vaccinations. Parents
refusing to obey the summons taken out by the vaccination officer are liable to a penalty of twenty shillings for each
offence. In 1880 the president of the Local Government Hoard brought in a bill to repeal the part of the Act relating
to cumulative penalties; but the bill was withdrawn owing to protests from the medical profession. In a number of
populous unions of England a majority of the guardians are decided not to prosecute under the Vaccination Act; inother unions prosecutions are not unfrequent, the convictions having amounted in 1885 to upwards of two thousand,and having usually led to distraint of goods (rarely to imprisonment) in default of paying the fine. In England about
two-thirds of all infants are vaccinated at the public expense.
Vaccination was made compulsory in Bavaria in 1807, and subsequently in the following countries :—Denmark (1810),.Sweden (1814), Wurtemberg, Hesse, and other German states (1818), Prussia (1835), Roumania(1874), Hungary (1876), and Servia (1881). It is compulsory by cantonal law in ten out of the twenty-two Swisscantons; an attempt to pass a federal compulsory law was defeated by a plebiscite in 1881.
In the following countries there is no compulsory law, but Governmental facilities and compulsion onvarious classes more or less directly under Governmental control, such as soldiers, state employees, apprentices,
school pupils, &c.:—France, Italy, Spain, Portugal, Belgium, Norway, Austria, Turkey.
In a few States or cities of the American Union there is a vaccination statute. In Lower Canada there is nocompulsion; but vaccination has been compulsory in South Australia since 1872, in Victoria since 1874, and inWestern Australia since 1878. In Tasmania a compulsory Act was passed in 1882. In Now South Wales there is nocompulsion, but free facilities for vaccination. Compulsion was adopted at Calcutta in 1880 and since then at eighty
other towns of Bengal, at Madras in 1884, and at Bombay and elsewhere in the presidency a few years earlier.
Re-vaccination was made compulsory in Denmark in 1871 and in Roumania in 1874; in Holland it wasenacted for all school pupils in 1872. The various laws and administrative orders which had been for many years inforce as to vaccination and revaccination in the several German states were consolidated in an imperial statute of1874.
Authorities.— Jenner, Inquiry, London, 1798, and Further Observations, 1799) ; G. Pearson, Inquiry
concerning the History of Cowpox, London, 1708 ; Woodville, Reports of a Series of Inoculations of the Variolae
Vaccinae or Cowpox., London, 1799; Baron, Life of Edward Jenner, M.D., 2 vols., London, 1838; Bousquet, Sur le
Cow-pox, decouvert a Passy, Paris, 1886; Estlin, in Lond. Med. Gazette, 1838-39; Ceely, Trans. Prov. Med. and.
Surg. Assoc., viii. (1840) and x (1842); Hering, Ueber Kuhpocken an Kuhen, Stuttgart, 1839; Viennois and others,
in Syphilis Vaccinale, Paris 1865; Bohn, Handbuch der Vaccination, Leipsic [Leipzig], 1875; E.C. Seaton,

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The Encyclopedia Britannica (1890) - Vaccination

Handbook of Vaccination, London 1868; Reports on Sanitary Measures in India, 1884-85; W. White, Story of aGreat Delusion, London 1885; McVail, Vaccination Vindicated, London 1887; Lotz, Pocken und Vaccination, 2nded., Basel, 1880; G. Fr. Kolb, Der heutige Stand der Impffrage, Leipsic [Leipzig], 1879; A. Vogt, Der alte u. d.
neue. Impfglaube, Bern, 1881; and Creighton, Natural History of Cowpox and Vaccinal Syphilis, London, 1887. (C.
C.)

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