.^^^ 1 LI3RARY OF THE University of California. Class VACCINATION I'L-Vii-: I. Fig. I. — Photoj^raph of agar plate prepared with vaccine material immcdiatelv after Gl.VCERIXATION. Fin. 2. — Photograpli of similar agar plate prepared with vaccine material /(V/;- ivceks after (jlvcekination. VACCINATION ITS NATURAL HISTORY AND PATHOLOGY . BEING THE MILROY LECTURES FOR 1898 DELIVERED BEFORE THE ROVAL COLLEGE OF PHVSICL\NS OF LONDON BY S. MONCKTON COPEMAN M.A., M.D. Cantab., M.R.C.P. Lond. MEDICAL INSPECTOR TO HER MAJESTY'S LOCAL GOVERNMENT BOARD ; LECTURER ON PUBLIC HEALTH IN THE MEDICAL SCHOOL OF WESTMINSTER HOSPITAL ; FOREIGN SECRETARY AND MEMBER OF COUNCIL OF THE EPIDEMIOLOGICAL SOCIETY OF LONDON ; FORMERLY RESEARCH SCHOLAR OF THE BRITISH MEDICAL ASSOCIATION, AND SCHOLAR AND EXHIBITIONER OF CORPUS CHRISTI COLLEGE, CAMBRIDGE Hontion MACMILLAN AND CO., Limited NEW YORK : THE MACMILLAN COMPANY 1899 A II rigJits rese}-ved v^ A G*»^i3^ CONTENTS CHAPTER I INTRODUCTION History of smallpox — Inoculation first introduced into England — Method of — Fee for — Vaccination first discovered by Jenner — His investigations — Pathology of vaccinia — Cow-pox — Horse- pox or "grease" — Cow-pox in the cow — Casual cow-pox in man — Inoculated cow-pox in man . . Pages I -40 CHAPTER H THE RELATIONSHIP OF VARIOLA AND VACCINIA Jenner on vaccinia — Smallpox and cow-pox identical — Variolation of bovine animals — Lymph obtained from, used on the human subject — Retro-vaccination .... 41-66 CHAPTER HI HISTORY OF VARIOUS LYMPH STOCKS Jenner's first vaccination — Arm-to-arm vaccination — Origin of lymph first used on the Continent and in other foreign countries — \i CONTEXTS Lymph of equine origin — Origin of lymph used at the Govern- ment Animal Vaccine Establishment — Variola -vaccine lymph ...... I'''^ges 67-72 CHAPTER IV HISTOLOGY OF THE VACCINE VESICLE Cause of papular stage of vaccination — Description of vesicle — Action of leucocytes — Pustular stage — Gustav Mann's investiga- tions as to changes produced in skin of calf by vaccination — Chemistry and morphology of vaccine lymph . 73-84 CHAPTER V BACTERIOLOGY Granules in vaccine lymph — Micro-organisms in — Specific micro- organism of — Action of glycerine on — Experiments with horse- pox lymph — " Extraneous " micro-organisms in vaccine lymph — Tubercle bacillus in — Variolation of bovine animals — Cultivation of micro-organisms of variola and vaccinia in artificial media — Protozoa . . . . . .85-127 CHAPTER VI VARIOLA AND VACCINIA IN THE MONKEY Investigations as to efficiency of lymph stocks by variolation and vaccination of the monkey — Difference between variolation and vaccination of the monkey — Comparison of effects produced by human and by calf lymph — The " variolous test " . 1 28- 133 CONTENTS Vll CHAPTER VII ANTITOXIN Vaccination with sterilised lymph — Possibility of obtaining tem- porary protection by — No micro-organisms found in plate cultivations of — Experiments on calves with — Subcutaneous inoculation of monkeys and horses with — Immunity conferred by serum from previously vaccinated calves . Pages 134- 14 1 CHAPTER VIII ANIMAL VACCINATION Definition of — History of introduction of — Retro-vaccination — Animal vaccination on the Continent and in England — Grounds on which it has been advocated — English Royal Commission on . •. • • . • . 142-152 CHAPTER IX GLYCERINATED LYMPH Bacteriological purification and preservation of vaccine lymph by glycerine — " Extraneous" micro-organisms in vaccine lymph — Quantity of vaccine material increased by addition of glycerine — Use of glycerinated calf lymph on the Continent — Investigations as to action of glycerine on pathogenic and non-pathogenic micro-organisms — Special investigations as to its action on the tubercle bacillus — English Royal Commission on quality of vaccine lymph — Outbreak of disease, Riigen, following use of vaccine lymph mixed with thymol and glycerme — ^'alue of viii CONTENTS glycerine, lanoline, and vaseline in the preservation and purifica- tion of vaccine lymph compared — Advantages of glycerinated calf lymph — Preparation of — Recommendations as to the use of, in Kngland .... Pages 153-188 APPENDIX I The preparation and storage of glycerinated calf lymph in certain European countries . . . . . 189-236 APPENDIX II The bacteriolog)' of vaccine lymph . . . 237-242 INDEX ....... 243-257 LIST OF PLATES PLATE I Photographs of agar plate-cultivations of gly- cerinated vaccine pulp, before and after its storage ..... To face Title-page PLATE II Photograph of case of casual horse-pox in man To face page 32 PLATE III Photographs of agar plate-cultivations of vase- line vaccine pulp, before and after its storage . . . . . ,, ,, 176 PLATE IV Photographs of agar plate - cultivations of lanoline vaccine pulp, before and after its storage . . . . . ,, ,, 178 PLATES V-IX Photographs of agar plate-cultivations of gly- cerinated vaccine pulp, showing, week by week, the gradual purification of the lymph from extraneous micro-organisms . . >, j> 184 LIST OF PLA TES PLATE X Photograj)!! of child, vaccinated with glyceri- natcd lymph free from extraneous micro- organisms ..... To face page i86 PL-ATE XI Lymph-mixing machine of Dr. Doring, Berlin ,, ,, 214 PLATE XII Lymph -mixing machine of Dr. Chalybaus, Dresden ..... j? >, 222 CHAPTER I INTRODUCTION Just one hundred years ago, in the summer of the year 1798, there was pubhshed a treatise, the appear- ance of which marked a never-to-be-forgotten event in the history of scientific medicine. This truly epoch- making pubhcation was entitled "An Inquiry into the Causes and Effects of the Variolae Vaccinae, a disease discovered in some of the western counties of England, particularly Gloucestershire, and known by the name of the Cow-pox." It was the work of Edward Jenner, a country medical practitioner, living at Berkeley in the vale of Gloucester. But in order adequately to appreciate the far-reach- ing importance of this work, first issued in the com- paratively small compass of a quarto pamphlet of seventy-five pages, it is necessary for us, if possible, to transport ourselves in thought backwards for over a century, in order to realise approximately the truly terrible and far-reaching nature of the scourge, the only efficient preventative of which was first introduced to B VA CCINA TION : chap the human race through the publication of Tenner's Inquiry. It would be difficult to give a more vivid illustration of the state of affairs previously existing than is afforded by Macaulay's oft-quoted passage, in which reference is made to the death in 1694 of Queen Mary, wife of William III. He writes — " That disease, over which science has since achieved a succession of glorious and "beneficent victories, was then the most terrible of all the ministers of death. The havoc of the plague had been far more rapid ; but the plague had visited our shores only once or twice within Hving memory ; and the smallpox was always present, filling the churchyards with corpses, tormenting with constant fears all whom it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to her lover." The ever-present danger, and the lively apprehensions engendered through recognition of the slight chance of any one evading the onslaught of the scourge between childhood and maturity, is also brought out somewhat forcibly in an extract from the " Pages from a Private Diary," in the January number of the Com hill Magazine for the present year. It runs as follows — " I came on a curious passage in a letter of Mrs. Waller's to her banished son, about the marriage of his daughter. She wishes to know what dowry he is prepared to give. ' I am not in haste to marry her, she is young enough to I NATURAL HISTORY AND PATHOLOGY 3 Stay, but the danger is if she should catch the small- pox, or her beauty should change, it would be a great loss to her.' Everybody," adds the writer, "is familiar with the frequent references to smallpox in the letters and memoirs of the seventeenth century. Pepys is full of it ; but I have never met with a passage that brings so keenly home to me the nearness of the risk." In this connection also may be mentioned a record of an epidemic of smallpox in the small town of Ware in 1722. The population at the commencement of the epidemic was 2515, of whom 1601 are stated to have had smallpox previously, the remaining 914 being therefore presumably susceptible to the disease. During the course of the epidemic, of these 914 persons 612 were attacked, of whom 72 died. The remaining 302 persons who escaped attack are spoken of in the record in quaintly dogmatic fashion as "to have the smallpox." We possess also a record of an epidemic which occurred at Warrington in 1773, where out of 473 deaths from all causes during the year, among a popula- tion estimated at 8000, no less than 211 were attributed to smallpox. And from a report by Haygarth of Chester, we learn, as in the case of Ware, how -small a proportion of the population in these places had not suffered from smallpox at one time or another. The actual number of persons attacked at Chester in 1774 was 1202, of whom 202 died, the total population of the town being at that time 14,713. But as the result of an investigation carried out at the commencement of the following year, it becomes fairly certain that, previous i 4 VACCINATION : chap. to the outbreak in 1774, there were in Chester of the whole ])opulation only 2262, or 15 per cent, who had not already had the disease. Consequently, of the re- maining susceptible portion of the inhabitants more than half were attacked before the end of the year. These epidemics at Chester and Warrington further illustrate a marked characteristic of smallpox in the eighteenth century which is also noticeable in the records of preceding periods in which the age of those attacked is given, namely, the large proportion of the deaths contributed by children under ten years old. In the Warrington outbreak of 1773, and also in that which appeared in Chester in the following year, not a single death occurred in persons above this age, while of the 202 deaths at Chester, no less than a quarter of the total number were accounted for by infants of less than twelve months. Other instances of a like condition of affairs, noted in the Final Report of the Royal Com- mission on Vaccination, refer to Kilmarnock, where out of 622 deaths, occurring between 1728 and 1763, of which, with nine exceptions, the ages are recorded, only seven were of those above ten years, and to records obtained from the burial registers of the graveyards of St. Cuth- bert's, Canongate, and Buccleuch Street, Edinburgh, from which we learn that, during the years 1764-83, of every thousand deaths from smallpox at all ages, no less than 993 were of children below ten years of age. In considering the question of ratio of deaths from smallpox to the living population we are beset with several difficulties. In the first place, as McVail points I NA TURA L HISTOR V AND PA THOLOG V 5 out, in no single epidemic in London in former centuries was it possible to see smallpox at its worst, since epidemics followed one another at such rapid intervals that of necessity the material on which at any one period their energy could exert itself was extremely limited. " At any given date the great bulk of the people had already had smallpox, and it was only among a fraction that there was room for the disease to spread. Yet it was among such fractions of the population that small- iy pox every few years slew its thousands in London alone." If we desire to obtain an illustration of the full effects ^ of an invasion of smallpox, when not thus hampered by / the existence of very general immunity, the result of former epidemics, we must turn our attention to some particular locality which, owing to its isolated position, has previously escaped invasion. In illustration of this point we may take the case of Iceland, where, during 1 707-1 709, out of a total population of 50,000, no less than 18,000 persons died of this disease. Concerning the regions whence smallpox was origin- ally derived, and the routes along which it subsequently spread, comparatively little accurate information is avail- able. That the disease is of great antiquity in China and India is generally admitted, but it is fairly certain that it was not indigenous in Europe, where it appears to have been unknown prior to the end of the sixth century a.d., when the disease not improbably extended westwards from Arabia, it having broken out in a virulent form in the Abyssinian army of Abraha, which was besieging Mecca about 569 a.d. Hippocrates and Celsus were FA CCINA TION : chap. apparently ignorant of its characteristics, and the same is probably true of Galen, although the Arabian physician, Rhazes, quotes three passages from Galen's works " kutu. yc'j'os," " On Pulses," and " On the Use of the Members," which he considers to prove that the older observer was not without knowledge of the disease. Rhazes, in his work, quotes from the Pandects of Ahron of Alexandria, who flourished in the time of the Emperor Heraclius (610-641 a.d.), passages in which smallpox is undoubtedly referred to. Another writer, almost a contemporary of his own, also mentioned by Rhazes as having written a description of the disease, is Messua the Elder, who died in 857 a.d. The fact that at these dates smallpox was not of recent intro- duction is evidenced by the circumstance that no note to this effect is made by any of these writers, as other- wise might be expected to be the case. To Gregory of Tours, who wrote in 581 a.d., we owe what is possibly a description of the first outbreak of smallpox on the continent of Europe, since in his description, " De lue quee cum dessicis fuit," he defin- itely differentiates the disease in question from the plague with which it was in early days frequently confounded. It was, in all probability, an extension to France and Italy of the epidemic described by Gregory, which has been handed down by the writings of Marius, Bishop of Averche, who, in the course of his description, makes the statement that "this year (570) a violent fever wuth flux of the bowels and variola affected both Italy and France." I NA TURA L HIS TOR Y AND PA THOL OGY 7 Concerning this statement it is of interest to note that we have here what may be regarded as the earHest employment of the term " variola " in its modern sense. In his Life of Jenner, Baron states, however, that " The first recorded case of smallpox or variola under that peculiar and now appropriate name is probably that of Elfrida, daughter of our English Alfred and wife of Baldwin the Bald, Earl of Flanders : date of her illness is generally fixed as 907 a.d. ; she recovered." The term " variola " has been stated to represent the diminu- tive form of the late Latin varus, a pimple, or, on the other hand, it may be derived from varius, meaning "spotted." By some authorities it is believed to have been first used in its modern sense by Constantinus Africanus in the eleventh century. The Anglo-Saxon equivalent of variola is found in the word pocca, meaning a bag or sack, which has given rise to the modern pock. The first mention of the term pocca would appear to be in a tenth century Leech-Book of the physician Bald ; and subsequently it is employed in the Chronicon Ber- tiniami7ii (1440 a.d.), wherein is set out an account of the illness of Baldwin, son of the Earl of Flanders, who died of smallpox in 961, the disease being described as "variolas sive poccas." Previously to the date of this and certain earlier writings, of which mention has been made, the word variola had apparently been used some- what indefinitely as descriptive of any eruptive disease, inclusive of the plague. This was no doubt in part due to the defects of diagnosis, the study of medicine being at so low an ebb during the Middle Ages. In a reverse VA CCINA TION : chap. manner the Anglo-Saxon equivalent />occa or pock has, since the appearance of syphilis in Europe, become restricted in its meaning, so as to designate the eruption peculiar to this disease alone. For this reason there gradually came about the use of the distinctive term s//ia//-pox, or its French equivalent pefife verole^ as opposed to the hir<:;c pock, or great pock, now exclusively reserved for syphilis. To Rhazes himself, who flourished about the year 900 A.D., and who held the post of physician at the hospital at Bagdad, we owe what is really the first scientific account of the symptoms of smallpox, although he appears to have confounded the disease with measles. The treatise of Rhazes was printed in the original Arabic, together with a translation into Latin by Channing, in 1 766, but it was not until 1847 that, under the auspices of the Sydenham Society, Greenhill published his English translation of this remarkable work. The descriptions of the various forms in which smallpox may present itself given by Rhazes are clear and definite, and the treatment advocated by him is in many respects in harmony with that which is now considered most appropriate. In support of this statement, it may be worth while to quote certain passages from his Treatise 071 the Smallpox and Measles — "As to the modern^, although they have certainly made some mention of the treatment of the smallpox (but without much accuracy and distinctness), yet there is not one of them who has mentioned the cause of the existence of the disease, and how it comes to pass that I NA TURAL HISTOR Y AND PA THOL OGY 9 hardly any one escapes it, or who has disposed the modes of treatment in their right places. " Now the smallpox arises when the blood putrefies and ferments, so that the superfluous vapours are thrown out of it, and it is changed from the blood of infants, which is like must, into the blood of young men, which is like wine perfectly ripened ; and the smallpox itself may be compared to the fermentation and the hissing noise which takes place in must at that time. And this is the reason why children, especially males, rarely escape being seized with this disease. "The smallpox arises from a fermentation that takes place in the blood, when it is undergoing the change from that of an infant to that of a young man ; and it is accompanied by great heat and a disagreeable odour ; and this is when the patient is of a hot tempera- ment. The disease sometimes happens twice or even three times to the same individual, but generally once, especially to males, for the blood of infants must necessarily undergo this change. " I am now to mention the seasons of the year in which the smallpox is most prevalent : which are, the latter end of the autumn and the beginning of the spring ; and when in the summer there are great and frequent rains with continued south winds, and when the winter is warm and the winds southerly. lo VACCINATION: chap. "The eruption of the smallpox is preceded by a continued fever, pain in the back, itching in the nose, and terrors in sleep. These are the more peculiar symptoms of its approach, especially a pain in the back, with fever ; then also a pricking, which the patient feels all over his body ; a fulness of the face, which at times goes and comes ; an inflamed colour, and vehement redness in both the cheeks ; a redness of both the eyes ; a heaviness of the whole body ; great uneasiness, the symptoms of which are stretching and yawning ; a pain in the throat and chest, with a slight difficulty in breathing, and cough ; a dryness of the mouth, thick spittle, and hoarseness of the voice ; pain and heaviness of the head. "When, therefore, you see these symptoms, or some of the worst of them (such as the pain of the back, and the terrors in sleep, with the continued fever), then you may be assured that the eruption ... in the patient is nigh at hand. " Ibn Masawaih says — ' When there is with a con- tinued fever, a redness of the eyes and face, much heaviness of the body and head, itching of the nostrils, sneezing, and a pricking pain all over the body, these are signs of the eruption of the smallpox. Your first care should be directed to the eye, for which you should use a collyrium made of sumach and rose-water, in order to prevent any pustules from coming out in it. I NA TURAL HISTOR V AND PA T HO LOG Y 1 1 "The eruption of the smallpox ... is accelerated by well wrapping the patient up in clothes, and rubbing his body, by keeping him in a room not very cold, and by sipping cold water, a little at a time, especially when the burning heat is very great ; for cold water, when it is sipped a little at a time, provokes sweat, and assists the protrusion of the superfluous humours to the surface of the body. " Extinguishing remedies are to be used when you see that, as soon as any of the pustules come out and appear in the skin, the patient finds himself easier after it, and his pulse and breathing are reheved in propor- tion ; but if you see that the eruption and appearance of the pustules goes on slowly and with difficulty, you must in this case avoid all very extinguishing medicines, for to use them would be acting contrary to Nature, and hindering her from throwing out the superfluous humours upon the skin. " As soon as the symptoms of the smallpox appear, we must take especial care of the eyes, then of the throat, and afterwards of the nose, ears, and joints, in the way I am about to describe. And besides these parts, sometimes it will be necessary for us to extend our care to the soles of the feet, and the palms of the hands ; for occasionally violent pains arise in these parts from the eruption of the smallpox in them being difficult on account of the hardness of the skin. 12 VA CCINA TION : chap. " If a severe pain arises in the soles of the feet, then take care to anoint them with tepid oil, and foment them with hot water and cotton : ... for these and the like things soften and relax the skin and thus facilitate the eruption of the pustules, and lessen the pain. "All those pustules that are very large should be pricked ; and the fluid that drops from them be soaked up with a soft clean rag in which there is nothing that may hurt or excoriate the patient. " When the desiccation of the pustules is effected, and scabs and dry eschars still remain upon the body, examine them well, and upon those that are thin and perfectly dried up, and under which there is no mois- ture, drop warm oil of sesamum every now and then, until they are softened and fall off. "... and in order to efface the pock-holes, and render them even with the surface of the body, let the patient endeavour to grow fat and fleshy, and use the bath frequently, and have his body well rubbed." It appears certain that during the time of the Crusades smallpox spread in a manner that has not unfrequently been witnessed subsequently under similar circumstances of war prevalence ; the numbers of those dying from the scourge during this period, as far as can be learned from the indefinite accounts now available, having apparently been extraordinarily great. There is reason also for the I NA TURAL HISTOR Y AND PA THOLOG Y 1 3 supposition that it was during the epidemic following the Crusades that smallpox houses were first erected. There is some authority for thinking that smallpox first found its way into England in the year 1241-42, although it may be stated that Creighton considers that there is no trustworthy evidence of its existence in England earlier than the sixteenth century. Towards the close of the thirteenth century the disease was referred to by Gil- bertus Anglicanus in his Compendium Medicines, which is probably the earliest medical work produced in England. But although he gives an account of the symptoms of smallpox and measles, he was not, so far as can be judged, himself acquainted with the disease, and he did no more than slavishly follow the early accounts of the Arabian physicians. The same statement applies also to his successor, John of Gaddesden, physician to Edward II., whose work, J^osa Atiglica, appeared about the year 1320. He gives a description of an attack of smallpox from which the King's son ^ suffered. For this, Gaddesden treated him by wrapping him in a red cloth, and by entirely enclosing the bed in hangings of a red colour, with the effect, he says, that no pitting of the skin resulted from the attack. This method of treatment, however, did not originate with Gaddesden, having been suggested by former writers of the Arabian schools, to whom reference has already been made. Baron says of Gaddesden that " his only dogma worth recording with regard to smallpox is 'ahquando variolae ^ Dr. Norman Moore supposes the " King's son" to have been Thomas of Brotherton. 1 4 VA CCINA TION : chap. bis hominem invadunt,' " and Sir Thomas Watson some- what unreasonably opines him to have been a sorry knave. The use of red hangings and wraps was devised by its earliest advocates with the object of drawing the peccant humours of the body to the surface, while puncture of the pustules by means of a golden needle, or even a thorn, was relied on for the prevention of pitting. That Gaddesden knew of this latter method is obvious from his writings, but he does not make any mention of having practised it on the King's son. For this reason Creighton expresses the opinion that the disease, concerning which the old physician says that he obtained a good cure, and sine vesfigiis, was in all prob- ability something of a much less formidable nature than variola. Creighton further asserts that it is not until the year 1 5 14 that a definite reference to smallpox is to be found, this being in a letter in which mention is made of an illness from which the king, Henry VIII., had recently recovered, '■^ twmmee la petitte verolle,'''' The English equivalent of this term, however, is shown by the researches of Dr. Norman Moore to have been in use at a considerably earlier date. The work cited by Dr. Norman Moore is a manuscript copy of the Breviarium Bartholoincei^ compiled by John Mirfield, a canon regular of St. xA.ustin in the priory of St. Bartholomew in West Smithfield, and written about 1387 for the hospital of St. John the Baptist, attached to the Abbey of xA-bingdon. On folio 43^2; of the I NA TURAL HISTOR V AND PA THOLOG Y 1 5 manuscript, which is now in the Hbrary of Pembroke College, Oxford, after the heading '' De variolis et morbilis " the words, "/.^. smal pockes " are written. During the sixteenth century, references to attacks by the disease occur with gradually increasing frequency. It would appear, however, from the perusal of such records as are available, that the disease was not for the most part of extremely virulent type, and also that its power of infectivity had not as yet been sufficiently appreciated to cause it to be feared, at any rate, as was the plague, for instance. In support of this assertion may be mentioned a death-bed statement by a certain Master Richard Allington, recorded by John Stow as having been made in the presence of the Master of the Rolls and four other eminent lawyers, in which the following passage occurs : — " Maisters, seinge that I muste nedes die, which I assure you I nevar thought wolde have cum to passe by this dessease, consyderinge it is but the small pockes. ..." In 1604, the classification of deaths in London by the Company of Parish Clerks was commenced, although their annual and weekly records were not regularly printed until a quarter of a century later. During this interval smallpox made rapid progress in England, the literature of this and succeeding periods now teem- ing with allusions to the "cruel and impartial sickness." \/ Dr. Gee, in an address to the Abernethian Society, quotes numerous instances : — " Even the poets could not avoid the disgusting theme. If they wished to 1 6 VA CCINA TION : chap. bewail the death of a friend, in all probability he died of the smallpox. Dryden wrote elegies upon two of its victims. The first was Lord Hastings, who died, 1649, "^"^ ^^^ ^g^ o^ nineteen. Mrs. Anne Kclligrew died of variola in 1685 at the age of twenty-five, and she attained the honour of being celebrated by the same poet in much nobler verses. Mrs. Katherine Phillips, 'the Matchless Orinda,' died of smallpox in 1664 at the age of thirty-three; she was lamented by Cowley. In 1675 Oldham devoted an ode of extra- ordinary length to the memory of his friend, Mr. Charles Morwent, who was carried off by smallpox. Writers of a satirical turn condoled with ladies upon the sad loss of beauty which ensued when they escaped with life from the dreadful pest. Verses were written, ' Upon a Gentlewoman, whose nose was pitted with the Smallpox,' and so on." It was during the epidemic of 1694 that Queen Mary, the wife of William III., who was then only thirty-three years old, became attacked with what eventually turned out to be haemorrhagic smallpox. To this attack she succumbed on the eighth (ninth ?) day of the disease. The number of deaths from small- pox recorded in London alone during this year was not far short of 1700, but this figure had been exceeded at least seven times during the previous half century, most markedly so in 168 1, in which year no less than 2982 deaths occurred in London from this disease. From 1695 onwards for a series of years, the mor- I NA TURAL HISTOR Y AND PA THOLOG V 1 7 tality from smallpox underwent considerable diminu- tion ; but in 1 7 10 a terrible epidemic accounted for no less than 3138 deaths in London, and we learn, on the authority of Blomefield, that the disease also cut off "great numbers in Norwich." The year 17 14 was also marked by epidemic prevalence of smallpox in London, which resulted in an almost equal number of deaths ; while the record of 17 10 was even exceeded in 1 7 19. Beyond this period it is needless to extend our review, seeing that the history of smallpox pre- valence now becomes intimately bound up with the history of the spread of certain prophylactic measures, the effect of each of which on the disorder will require separate consideration. Aitken calls attention to the fact that since the date of the first accounts by the Arabian physicians of the ravages of smallpox in Mecca, the history of this disease may be arranged in three great stages, each of which is characterised by remarkable epochs. The first of these periods is marked by an improvement in the treatment of smallpox, the merit of this revolution in medical practice being due to Sydenham. In few diseases, indeed, has medical opinion undergone in the course of years a more obviously beneficial change. The second stage is marked by the discovery of the singular phenomenon that the virulence of the poison of smallpox is greatly mitigated by introducing or engrafting the disease into the system through the cutaneous tissues, thereby causing the transference of the disease from one person to another by inoculation. c i8 VACCINATION: chap. To Lady Mary Wortley Montagu in 1721 we owe the introduction of the practice of inoculation into this country, a deed which must be considered as one of no Httle bravery, when measured by the knowledge possessed by physicians in those days. The third great era is characterised by the remarkable discovery, which has rendered the name of Jenner immortal, namely, the modifying and protecting influence of vaccin- ation. With the therapeutic treatment of smallpox we are not on the present occasion concerned. On the other hand, the practice of inoculation, although prohibited by law since the passing of the first Vaccination Act, 1840, is yet deserving of some attention. Having dealt with this matter, we shall be in a position more fitly to discuss the question of the discovery of vaccina- tion, and of the evidence on which its employment was originally based. There will remain for our consideration a review of such accretions to our knowledge of the subject of vaccination, more particularly from the standpoint of pathology, as the progress of scientific research during the century since Jenner wrote has rendered avail- able. To marshal these in order, to try to indicate their relative importance, and to direct attention to their bearing on the necessity for certain changes in the regulation and practice of vaccination, as these obtain at the present time, is the chief aim which I have had in view in the preparation of these lectures. I NA TURA L HTSTOR V AND PA THOL OGY 19 Inoculation Recognition in former times of the certainty that almost every one would suffer attack by smallpox during some period of his or her life, and the lively horror inspired by the disease, by reason not only of the high fatality inseparable from it, but also of the maiming and disfiguring effects on a large proportion of those who sur- vived its invasion, naturally turned men's minds to the question as to whether it were not possible to devise some method for mitigating the virulence of this disorder. Whence, however, was originally derived, or by whom, accidentally or otherwise, was discovered the artificial method of communicating smallpox, which came to be known by the term "inoculation," it is at the present day impossible to determine. ^- According to tradition, the process of inoculation has been in use among the Brahmins in India for centuries, and a similar claim has been made on behalf of the Chinese. There can be little doubt that in China a method of artificially communicating smallpox was in vogue long ages apparently before the disease had obtained recog- nition in Europe; but the process was essentially different from inoculation properly so called, consisting as it did of inserting smallpox crusts into the nostril of the patient, whereby the disease was communicated by way of the respiratory tract. Coming to comparatively recent times, however, we have definite evidence that inoculation was practised in Turkey early in the eighteenth century. 20 VA CCINA TION : chap. In the twenty-ninth volume of the Philosophical Trans- actions of the Royal Society may be found references to the process, as observed in 17 13 by Dr. Emanuel Timoni of Athens, and in 17 16 by M. Pylarini, then Venetian Consul at Smyrna. But it would seem that their descriptions made little, if any, impression at the time, and, although published in the records of the Royal Society, passed almost at once into oblivion. The actual introduction of inoculation into England was, as just stated, brought about through the instru- mentality of Lady Mary Wortley Montagu, who, apart from her social status as wife of the English Ambassador at the Ottoman Court, has achieved for herself lasting recognition in literature, by reason of her attainments in the gentle art of letter-writing. Indeed, Professor Rayleigh, in a recent lecture at the Royal Institution, gave it as his opinion that in this respect she should be placed second only to Madame Sevigne. Writing from Adrianople, in 17 18, she says: " The smallpox, so fatal and so general amongst us, is here entirely harmless by the invention of eng?'afting, which is the term they give it. Every year thousands undergo the operation, and the French Ambassador says, pleasantly, that they take the smallpox here by way of diversion, as they take the waters in other countries. There is no example of any one who has died in it, and you may believe I am well satisfied of the safety of this experiment, since I intend to try it on my dear little son. I am patriot enough to take pains to bring this useful invention into fashion in I NA 7 'URA L HIS TOR V A ND PA 7 HOL OGY 21 England." Lady Montagu had indeed the courage of her opinion, and the first person inoculated in England was her daughter. This first operation, by Dr. Maitland, in April 1721, was shortly followed by the inoculation of a child of her family physician, Dr. Keith. Next an experiment on a larger scale was carried out on certain condemned felons, who were offered the alternative of submitting to the operation. No ill result having been witnessed thus far, King George I., who had been much interested in the matter, was himself inoculated, as also were several members of his family. Apparently, however, the method did not generally commend itself to public taste ; moreover, it was discovered that, contrary to anticipation, persons inoculated with smallpox became themselves centres of infection \ and perhaps for the reason that no serious attempt was made at that time to diffuse information on the subject, it was not until thirty years, or more, subsequent to its introduction into this country, that inoculation as a prophylactic against smallpox became practised to any considerable extent. In his Synopsis MedicincB^ published in 1761, Dr. John Allen, a Fellow of the Royal Society, gives the following curious directions for the inoculation of the smallpox — "First, a little quantity of purulent Matter must be procured, about 5 or 6 drops taken from the Pustles of some young Person, who has the benign Small-Pox of the distinct Kind, which must be brought to the place where the operation is to be performed in a 22 VACCINATION : chap Small Vial or in a little Pill-Box ; and when all Things are prepared, the Surgeon is to make two small Wounds, one on the Arm, and the other on the Leg, of the Opposite Side ; and the aforesaid variolous Matter is to be applied to the Wounds on Dossils of Lint, and a Bandage to be made over it. There is no occasion to make the incisions deeper than just through the Skin, nor any longer than a Barley-Corn. After twenty-four Hours the Dossils may be removed, and the Ulcers dressed with Diachylum Plaister or Cole-Wart leaves once or twice a day, according as more or less Matter is discharged. This being done, the Distemper will gradually be produced ; and it is usual for the following Symptoms to arise. About the eighth day after the Operation some Pustles begin to appear not unlike to those that are commonly seen in the distinct kinds, a little Fever having preceded the Eruption, and the other usual Symptoms but more mild and gentle. As to the places where the Incisions are made the fourth Day they grow red and are inflamed, on the sixth they tend to Suppuration, and discharge an ichorous Pus. Indeed, about the time of the Eruption of the Pustles, whilst the little Fever lasts, the Ulcers discharge somewhat less ; but after the Eruption even until the Decline of the Pustles, the Pus increases daily, and after that it again gradually diminishes ; so that commonly in five weeks' time the Ulcers are quite dried up. By how much the greater the discharge of purulent Matter is by these artificial Ulcers so much the milder will the Distemper be. In the general it is observable that the Small-Pox I NA TURA L HIS TOR Y AND PA THOL OGY 23 procured by Inoculation are of the distinct Kind, for the most part void of Danger, that the Pustles are few in number, and pit very Uttle. Very often however there follow after them Tubercles and Abscesses, some indeed but slight ones but sometimes very malignant ones, and exceedingly difficult of Cure. "To prepare the Body for Inoculation a great many talk much of Bleeding, of giving Emeticks, and Canthar- ticks. But in truth, if the Person to be Inoculated has Youth on his side, is of a good Habit of Body, and in Perfect Health, none of these things seem to be neces- sary. It is requisite only, that he take care to observe a temperate Regimen for some time before the Operation. When the Operation is performed, the Person need not be kept under any strict Confinement, but may live pretty much after his accustomed Manner ; excepting that it will be prudent to forbid him the eating any Flesh-Meat. When the Small-Pox are come out, the same Regimen is to be observed, as is usual in the distinct Kind, got in the common way ; and if there be occasion for anything at all of Medicine, these procured by Art require the same Method of Treat- ment, as the benign Discrete Small-Pox in the natural way." The subsequent extensive diffusion of the practice of inoculation in this country was undoubtedly due in large measure to the labours of two brothers named Sutton, and also of Adams and of Dimsdale, of whom the last named had a barony conferred upon him in commemoration of his having successfully inoculated 24 VA CCINA TION : chap. the Empress Catherine of Russia. For his services he also received a fee of ;£^ 10,000, which has been estimated as equal to at least three times that sum at the present day, and ;£^2ooo as an allowance for travelling expenses. He was also appointed Councillor of State and Physician to Her Imperial Majesty, with an annuity of ;^5oo, which was punctually paid him till his death in the early years of the present century. The Buttons — two brothers, Robert and Daniel, who lived at Bury St. Edmunds, Suffolk, and Ingatestone in Essex, respectively — although not medical men, intro- duced or rather revived the greatly improved method of treating the patients under their charge. They were extraordinarily successful in the results which they obtained, and indeed claim to have inoculated no less than 20,000 persons without losing one as the direct result of the operation. Acting on the instructions originally laid down by Sydenham for the treatment of ordinary smallpox ^ — the form of treatment to which, by the way, his contemporaries obstinately refused their adherence — the Suttons adopted and caused their patients strictly to observe what was known as " the cooling treatment," a method much akin to that which appears to have been pursued with good results by the Turkish operators from whom Lady Montagu first derived the knowledge of the process of "engrafting." In the hands of Daniel Sutton, who became specially famous for his successful inoculations, " the great secret of his success seems to have consisted in his making one puncture only ; exposing his patients much and often I NATURAL HISTORY AND PATHOLOGY 25 to a cool atmosphere ; supplying them freely with refrigerant drinks; and restricting them to a spare diet." By attention to the mode of life and general treatment of persons undergoing the process, together with careful selection of the sources (preferably the primary vesicle), from which the virus was obtained, Adams indeed suc- ceeded in gradually evolving a strain of virus of such tenuity as to produce in a considerable majority of in- stances nothing beyond a single vesicle at the original site of puncture. The general eruption, typical of the disease as contracted in the ordinary manner, was in these cases either entirely absent or represented by, at most, a very few secondary vesicles only. Although, doubtless, the extremely mild form of the disease, thus artificially produced, was none the less contagious, the visible effect produced so closely resembled the results then beginning to be known as following on the Jennerian process of vaccination, that numbers of Adams' patients could hardly be persuaded that he had not, contrary to their desire, intentionally vaccinated rather than variolated them. There has always been considerable controversy as to the efficacy of the process of inoculation in restrain- ing the ravages of smallpox, the matter being rendered the more difficult since it is almost impossible to arrive with any accuracy at what may be thought of as the average death-rate of the natural disease, which in pre- inoculation times is known to have varied greatly in different epidemics. If, as has been frequently asserted. 26 K-/ CCINA TJON : c h a i ■. the average mortality in natural smallpox may be taken as being one in five or six, and, on the supposition that in the majority of cases, at any rate, inoculation prevented subsequent invasion by smallpox, then it is quite evident that the process was of the utmost value to the persons inoculated. The statement of the Suttons, already mentioned, that inoculation in their hands was unattended with fatal results, is perhaps exaggerated, as may also be the declaration of Baron Dimsdale, that in a series of 15,000 cases no death had occurred. Neverthe- less, the records of the Smallpox Hospital for a series of years show that we shall not greatly err, and shall indeed be probably within the mark, if we accept Dr. Gregory's estimate of i death in 500 inocu- lations as approximately correct. There is, however, perhaps ground for suspicion that inoculations performed in the face of epidemic smallpox were more prone to be fatal than were inoculations undertaken when the disease was not prevalent. On the other hand, we must bear in mind that the general diffusion of inocu- lation brought under the influence of the disease, although possibly in a mild form, large numbers of persons who otherwise might probably have escaped infection. It is, I think, hardly possible better to sum up the matter than in the words of Sir Thomas Watson : "The advantages of the practice of inoculation to the indi- vidual, supposing him doomed to have smallpox, were great and obvious ; to the community at large they I NATURAL HISTORY AND PATHOLOGY 27 were very doubtful. It gave the undoomed individual, for certain, an ugly disease, which was comparatively free from danger, in exchange for the chances, on the one hand, of contracting a very hazardous form, and, on the other, of escaping altogether from any form of variola. We need not inquire which is the most eligible branch of this alternative ; we know which was by most men actually chosen. But the practice of inoculation, by carrying the virus and the disease into every village throughout the length and breadth of the land, filled the country with contagion ; ensured the disease to all who were subjected to the operation, and diminished to all who were not the chances of escaping it. No doubt the distemper was produced artificially in many more persons than would have caught it naturally, had inoculation never been thought of. So that while the relative mortality, the percentage of death from smallpox, was lessened by this practice the absolute mortality was fearfully increased. Such at least is the judgment expressed by most who had thought and written on the subject." As there appear to be few, if any, records as to the fees obtained by inoculators, it may be of interest here to insert a copy of a small handbill, which is in the possession of Mr. Parson, the senior medical prac- titioner in Godalming, Surrey. This relates to the practice of inoculation, as carried out by a direct ancestor and predecessor, in the same practice, of Mr. Parson — 28 r^ CCINA TION : chap INOCULATION M R. PARSON, Surgeon, at Haslemere, hav- ing provided a convenient Houfe (within a Mile of that Town) for the Reception of Patients, propofes to inoculate from this Time to May next, at ten Shillings and fixpence each Ferfun. loth^ December, 1783. Petersfield, Printed by T. Willmer. Vaccination It was during Jenner's apprenticeship to J\Ir. Ludlow, a medical man practising at Sodbury, near Bristol, that his attention first became directed to a belief widely prevalent in Gloucestershire during the latter half of the eighteenth century, that those persons who in the course of their employment on dairy farms happened to contract cow-pox, were thereby protected from a subsequent attack of smallpox. Although himself a native of Gloucestershire, he does not appear to have been aware of the local tradition, previously to joining Mr. Ludlow at Sodbury. It was while working here that his interest became aroused by a casual remark made by a young country- woman, who happened to come one day for advice, I NATURAL HISTORY AND PATHOLOGY 29 and who on hearing mention made of smallpox, immediately volunteered the statement that she could not take that disease as she had had cow-pox. On coming up to London in 1770, to finish his medical education, Jenner entered at St. George's Hospital, and became also a pupil of John Hunter, with whom he speedily became a great favourite. With Hunter he discussed the question of the pro- tective power of cow-pox over smallpox, but the great anatomist does not appear to have attached much importance to the matter, although subsequently on several occasions he referred to it both publicly and in private. In 1773 Jenner returned to his native village of Berkeley, where he commenced to practise as a medical man. The impression which had been made on him in his student days as to the possibility of obtaining protection against smallpox still persisted, becoming even stronger as time went on. It would appear, indeed, to have been ever present in his mind, and at length he determined to put the matter to the test of direct experiment. It was not, however, until 14th May 1796, which has been appropriately termed the birthday of vaccina- tion, that he commenced actual experiment. On this day he vaccinated James Phipps, a healthy boy about eight years old, by inserting into two superficial in- cisions on his arms, matter taken from a vesicle on the hand of Sarah Nelmes, a dairymaid, who had been infected while milking her master's cows. The result of this experiment, the details of which are so well FA CCINA TION : chap. known as to need no mention here, must have afforded Tenner the most lively satisfaction, conforming as it did to what, up to that time, had been with him a pious opinion only. " But the most agitating part of the trial still remained to be performed. It was needful to ascertain whether he (Phipps), was secure from the contagion of smallpox. This point, so full of anxiety to Dr. Jenner, was fairly put to issue on the first of the following July." Variolous matter, taken directly from a pustule, was carefully inserted by several incisions, but no result followed. Having succeeded in communicating cow-pox from one human being to another by implantation of the virus in the skin, the next step was obviously to attempt its transference to yet another subject, and so on if possible through an indefinite series, in order to ascertain whether its protective power was hereby diminished. Through lack, apparently, of material, Jenner's work was interrupted until the spring of 1798, when a simultaneous outbreak of cow-pox and " grease " afforded him the further opportunity he desired. A few months later he published his Inquiry^ in which were set out the results of his observations. The appearance of this work was the signal for an extraordinary wave of enthusiasm, which spread so rapidly that, within a few years only of Jenner's announcement, a knowledge of his method of prevent- ing smallpox had extended to almost every portion of the civilised world. The experience of the past century, culminating in I NA TURAL HIS TOR Y AND PA THOLOGY 3 1 the definite pronouncement in 1896 of the Royal Commission on Vaccination, having fully justified the principle of Jenner as to the prophylactic power of vaccination, it may be of interest to determine what light pathology is capable of throwing on the relation- ship which may be thought of as existing between variola and vaccinia. Pathology of Vaccinia Vaccinia is, in the human subject, a specific disorder characterised by the appearance of a local eruption pass- ing through the stages of papule, vesicle, and pustule, associated with more or less constitutional disturbance. These symptoms are produced indifferently, by the inoculation of lymph derived from vesicles similarly brought about in a previous case in the human being, or from the eruptive vesicles of a disease of bovine animals, called cow-pox. Such inoculation process, whichever way induced, is known as vaccination. This name was originally devised by Mr. Dunning of Ply- mouth Dock, inspired doubtless by the terminology of Jenner, who wrote of the disorder under the title of Variolae Vaccinae. In this manner Jenner gave expres- sion to his belief that the malady commonly known as cow-pox was, in reality, nothing more nor less than smallpox of the cow. But soon it was discovered that if there was such a malady as "smallpox of the cow," there was also a smallpox of the horse, which, under the name of "grease," was resorted to as a source of vaccine lymph. 32 VACCINATION : chap. Jenner, indeed, was undoubtedly of the opinion that cow-pox originated from the transmission, most prob- ably by human agency, of infection from a previous case of horse-pox. At the time of publication of his Inquiry^ he had not indeed been able to adduce any direct experimental evidence in support of his conten- tion, although he had collected a number of observa- tions which, in his opinion, afforded reasonable prob- ability as to the correctness of his view. ]\Ir. Tanner, however, shortly after put the matter to the proof, and was successful in communicating the disease to the cow, by employing for its vaccination lymph taken from the heel of a horse suffering from "grease." The attempt resulted in the appearance of a perfect vaccine vesicle on the cow's teat, at the site of insertion of the lymph. Tanner states that : " From handling the cow's teats, I became infected myself and had two pustules on my hand, which brought on inflammation, and made me unwell for several days. The matter from the cow, and from my own hand, proved efficacious in infecting both human subjects and cattle." Dr. Loy was the first to distinguish, in any satisfactory fashion, constitutional "grease" from a merely local affection, with which it was apt to be confounded ; and thus he explained the failure on the part of many experimenters to transmit horse-pox to the cow. Dr. Sacco of Milan, who, in the first instance, had expressed opinions adverse to Jenner's views, subse- quently, in a letter written to him in 1803, withdrew PLATE 11. Casual Horse-Pox. , stableman, (rt. 30, vaccinated in infanc}'. From a photograph taken 6th April 1898 (eighth day of disease). George T- I NATURAL HISTORY AND PATHOLOGY 33 them ; his reasons for which may perhaps be best given in his own words — " Milan, k 25 mars, 1803. " Monsieur — J'etais depuis longtemps occupe k faire des experiences sur le grease pour confirmer votre opinion sur I'origine de la Vaccine. Jusqu'au commencement de cette annee je n'avais jamais pu rien obtenir. La lecture du petit Hvre de Mr. Loy m'encouragea h, repeter une autre suite. L'hiver de cette annee ne pouvait pas etre plus abondante de grease a cause de la quantite de I'eau qu'il y avait, et par consequence de la boue dans les chemins : ainsi presque tous les chevaux souffraient le grease. Mon domestique en fut attaque au deux avant-bras par cinq boutons pansant un de mes chevaux qui avait le grease ; il ne m'en averti que quand les boutons passaient en exsiccation ; celui m'encouragea de plus a continuer mes tentatives. J'ai inocule plusieurs enfans, plusieurs vaches avec le virus qui sortait du grease a differentes epoques, mais toujours inutilement. Un cocher se presenta a I'hopital pour se faire visiter d'une eruption qu'il avait sur les mains. On connait de suite que c'etait vaccine prise en traitant les chevaux qu'efifectivement il pansait. II fut conduit \ I'hopital des enfans trouv^s ou on fit quelques inoculations : il vint le meme jour chez moi, et je fis neuf inoculations sur autant d'enfans, et de plus j'ai inocule les pis d'une vache. Trois de ces enfans ont contracte une eruption toute pareille a la Vaccine. La D 34 / 'ACCIXA TION: ("hap. vache n'a point pris. J'ai fait des autres inoculations avec la maticrc prise de ces enfans, et c'est dejh. la qua- trieiiic generation que se reproduit avec la meme effet comme le Vaccin. J'ai dejh inocule plusieurs de ces individus avec la petite verole, mais sans aucun effet. C'est done bien sCir et consente que le grease est cause de la Vaccine^ et on pouvait bientot changer denomination en equi?ie^ ou en ce que vous croyez mieux. J'ai aussi enfin obtenu avec le virus de grease inocule sur six autres enfans deux boutons tous semblables aux Vaccins. Je continue mes observations. II y a tout pour s'assurer qu'enfin nous aurons du grease le virus pour se mettre a I'abri de la petite verole sans passer aussi par rinter- 7nediiim de la vache. J'espbre que cette nouvelle preuve pourra oter les doutes qu'il y avaient encore sur I'origine de la Vaccine. Je publierai les resultats de ces ex- periences sur un code doctrinal de vaccination, auquel j'ajouterai une planche illumine de grease. J'espere que vous aurez re^u les medailles par Mr. Woodville, a qui je me pris la liberte d'adresser le paquet pour vous le faire obtenir avec certitude. Je renouvellais mes remerci- mens pour les livres que vous m'avez envoyes, avec les regrets aussi de n'avoir pas regu aucune de vos lettres. Je comte a cette heure plus de 25 mille inoculations faites par moi seul. Je vous prie, mon tres-estimable collegue, de me donner quelque nouvelle avec quel- qu'autre enseignement sur cette matiere, mais surtout tout honorez-moi de votre reponse. Tr^s humble serviteur, (Sd.) Louis Sacco, Med. Chirurgy I NATURAL HISTORY AND PATHOLOGY 35 That a constitutional disease of the horse, character- ised by a vesicular eruption, can be induced by the inoculation of this animal with the virus of cow-pox or vaccinia, has been shown experimentally by Chauveau, who injected vaccine lymph subcutaneously and also into the blood-vessels and lymphatics of colts. In nearly half the number of cases operated on, the injec- tion of the lymph was followed by a generalised eruption which Chauveau called "horse-pox." In all probability Jenner was mistaken in his assumption that "grease," in the sense of horse-pox, was a necessary antecedent to cow-pox ; but at the same time there can be little doubt that the two diseases are very closely allied, if indeed they be not identical. That this is so is shown by the fact that numerous strains of vaccine lymph have, from time to time, been raised from the equine source — the protective power of which against smallpox we have reason to believe was equal to that exhibited by lymphs of undoubted bovine origin. As, however, it is obvious that cow-pox was the source of the lymph stocks first introduced into use by Jenner and his contemporaries, it will be of interest to study briefly the nature and clinical appearances of this disease as seen in the cow and also in man ; whether accidentally contracted or intentionally inoculated. Cow-pox in the Coiv. — For a description of cow-pox in typical form, as it was known to Jenner and his con- temporaries, it is necessary to consult the writings of the early part of the century, at which period the attention of the medical and scientific world had been specially 36 VACCINATION CHAP. directed to this affection of cows by the teaching of the apostle of vaccination. Probably the most trustworthy accounts are those published by Bryce of Edinburgh, and later by Ccely ; and it is from their statements that the following description of the malady is derived. According to these observers, this affection, when once set agoing in a herd, tends to spread with con- siderable rapidity, the "matter" of the vesicles being carried by the milkers from one cow to another. It makes its appearance especially in the spring season, and is observed upon the udders and teats of the cows ; at first in the form of small vesicles containing a limpid fluid. These vesicles are of a bluish or livid colour, and are surrounded with considerable erysipelatoid sweUing and inflammation. If ruptured, the vesicles tend to become irregular about the edges, and unless care be then taken are apt to degenerate into foul and troublesome sores. During the course of the affection the cow is not unfrequently observed to be in bad health ; the appetite is impaired, the temperature is above normal, and the secretion of milk may be con- siderably diminished. If the material from the vesicles on the udders or teats of the cows happen to come in contact with an abrasion of the skin of the milker's hand, such person is apt to become infected wdth the disease. When the ailment is communicated in this manner, it is termed casual cow-pox to distinguish it from that form which is intentionally propagated by inocula- tion, under which conditions the affection is less virulent than when communicated in the former way. Probably I NATURAL HISTORY AND PATHOLOGY 37 the more severe form in which casual cow-pox usually appears is to some extent due to the situation of the resulting vesicles, and to the purulent nature of the secretion from the sores on the cows' teats or udders. Casual Cow-pox in Mati. — When cow-pox has been communicated to the milkers in the casual way, small inflamed spots appear in a few days upon the hands, more particularly about the joints and tips of the fingers. These spots quickly assume the appearance of small blisters, somew^hat resembling those from burns, which go on increasing until they become large vesicles of a circular form, with a flat or rather a concave surface ; their edges being considerably elevated above their centre. They have then acquired a somewhat bluish colour, and are found lo contain a limpid fluid. After some days the parts around the base of these vesicles become considerably swollen, hard, and inflamed, and, as the affection advances, they may assume something of an erysipelatous appearance. Pain and some degree of swelling of the axillary glands now denote an absorp- tion by way of the lymphatics, and, with the usual symptoms of fever, mark a constitutional affection which is sometimes so severe as to incapacitate the person from following his usual employment for some days. It does not appear, however, that a general eruption ever follows even on the smartest attack of casual cow- pox. After a few days the pain, inflammation, and hardness of the surrounding parts gradually abate ; but the vesicles not infrequently ulcerate instead of becoming encrusted and drying up. These ulcerations, however, 3S / 'A CCINA TION : chap. gradually heal up in course of time without occasion- ing any lasting injury ; and the constitutional affection, although severe, is always transient and unattended with danger : there is no case on record in which casual cow-pox is known to have been fatal. Inoculated Coiv-pox in Alan. — In the cow-pox induced by inoculation the appearances which present them- selves may differ considerably in some respects from those which have been described as occurring in the casual disease. Thus about the third day after the insertion of the virus of cow-pox, either by puncture or by slight incision in the arm, a small inflamed spot may be observed at the point where the inoculation was performed. Next day this spot appears still more florid, and on passing the point of the finger over it, a certain degree of hardness and swelling is readily perceptible. By the fifth day a small pale vesicle occupies the spot where the inflammation began, and the affection begins to assume the characteristic appearance of cow- pox. The vesicle has now a milky-white colour without any inflammatory zone around it, it is evidently depressed in the centre, and its edges are considerably elevated. For the next two days the vesicle increases in size and retains the same character, so that by the seventh day it has acquired very considerable magnitude ; if the inoculation be performed by a puncture, it assumes a circular form, if done by an incision, an oblong form. But in both cases the margin is regular and well NA TURA L HIS TOR V A ND PA THOLOGY 39 defined, while the centre becoming still more depressed and the edges more turgid, the whole puts on an appearance which is very characteristic of this particular affection. About the eighth day from the time of inoculation an inflammatory zone begins to appear round the base of the vesicle. This increases for two or perhaps three days more, by which time it may be two inches or longer in diameter, and of a bright red colour. At this period, also, the vesicle still retains its concave appear- ance ; the crust in the centre has considerably increased in size, and begins to assume a dark or brownish colour. About the eleventh day the vesicle has attained its greatest magnitude, and the surrounding inflammation begins to abate. The fluid in the vesicle, which before was thin and transparent, is now more viscid and slightly turbid. After this period the whole becomes quickly converted into a smooth, shining, and some- what translucent dry crust of a dark brownish or red colour. This crust, unless forcibly removed, will adhere for a week or more, and then fall off, leaving the skin beneath apparently sound, but livid for a time, and more or less permanently scarred. In children little else than the above local process is usually noticeable, but in adults constitutional symptoms are apt to be somewhat severe. About the eighth day from the time of inoculation the glands in the axilla become a little swollen, and there is pain and stiffness 40 VACCINATION CHAP, i on moving the arm. Headache, shivering, a rapid pulse, and other febrile symptoms present themselves, and these may persist for a period varying from a few hours to two or more days. REFERENCES CoW-Pox : I. Brvcp:. Inoculalion of Coiv-Pox. Edinburgh, 1802, and 2nd edition 1809. — 2. Ceely, Trans. Prov. Med. and Stirg. Assoc, vol. viii. pp. 299-312, 342-352. — 3. Hering. Ueber Kiihpocken an Kiihen, p, 9, — 4. LoY. Experiments on the Origin of the Cow -Pox. Whitby, 180 1. — 5, Rapport siir les vaccin. pratiqules en France pendant 1 84 1. — 6. Sixth Report of Medical Officer to the Privy Council, 1S63, p. 10. CHAPTER II THE RELATIONSHIP OF VARIOLA AND VACCINIA Although it is clear from Jenner's writings that he believed vaccinia to be nothing more nor less than "smallpox of the cow," his theory appears not to have received general support even in his own day, and from that time onwards the value of the practice of vaccina- tion has by some been impugned on the pica that inoculation of one disease — " cow-pox " — could not be expected to exert any really protective influence against the ravages of smallpox, a disease supposed by them to be of totally different origin. And if the thesis of essential difference between these maladies were capable of demonstration, no doubt the objection would be of considerable weight. For there exists but little well- authenticated evidence that the living virus of one disease is capable, when inoculated into an animal, of affording protection against the effects of inoculation of the virus of another and totally different disease, although, no doubt, when two different viruses are inoculated at nearly one and the same time, the incubation period of one or other of them may be modified as to duration. In his first paper, Jenncr, as has been said, advanced 42 VA CCINA riON : c 1 1 a i'. the thesis that smallpox and cow-pox are identical ; but even at the present day controversy wages hotly around this (question, and it still awaits a definite solution. There can, however, be no objection to our speaking of vaccinia as "one with smallpox," since it matters little from our present point of view whether smallpox, on its transference from man to the bovine animal, becomes actually transformed, or, as some would maintain, merely modified. During the long period which has now elapsed since the introduction of vaccination, many observers have set themselves the task of attempting, by experimental methods, to solve the problem of the true relationship of variola to vaccinia. These attempts have all been directed to the possibility of giving rise to cow-pox by the introduction in one or another manner of the virus of smallpox into the system of the bovine animal. In the great majority of such attempts, which are vastly more numerous than is generally supposed, the results have been entirely negative, although so numerous have been the experimenters, who from time to time have attacked the problem, that the total number of instances in which an apparently suc- cessful result has been obtained is now considerable. So far as I am aware, the first recorded experiments are those of Gassner of Gunzburg, in 1801, who suc- ceeded, after no less than ten fruitless attempts, in directly inoculating a cow with smallpox virus. The lymph thus obtained was employed for the vaccination of four children, from whom other seventeen were subsequently vaccinated. None of these exhibited any II NATURAL HISTORY AND PATHOLOGY 43 signs of smallpox. Viborg of Copenhagen, in 1807, is stated to have also been successful in variolating the cow. Basil Thiele of Kasan twice, in 1836 and 1838 respectively, succeeded in inoculating the cow with smallpox matter, and in vaccinating children with the lymph thus obtained. In the light of recent work on this subject, his conclusions are of much interest. As stated by himself, they are : "(i) The so-called vaccine disease is not an eruptive disease peculiar to the cow, but it is produced in it by the transmission of human smallpox to it, and the man and not the cow, as has hitherto been thought, is the source of the disease. (2) The mild disease thus caused in the cow can, by direct transmission from the cow to man, produce in him as mild a disease, which gives protection against the natural smallpox." Thiele also described a method by which he claimed to have brought about such modi- fication of smallpox virus as to render benign its action on the human subject, without the intermediate stage of implantation on the tissues of the cow. This altered potency of the material was brought about, according to his statement, by keeping the smallpox lymph for a period of ten days between two slips of glass, after which milk was added to it, and the resulting mixture employed for the vaccination of children. The same process vras carried through with the lymph obtained from the first and following series of children vaccinated, until after ten generations addition of milk was found to be no longer necessary. Seeing that at this date (1836-38) true cow-pox was 44 VACCINA 770N : (ii Al- so much more widespread than at present that at the commencement of the century Jenner confidentially looked forward to its occurrence every year, and that in consequence the majority of milch-cows were liable to become infected at one or another period of their exist- ence, this empirical method of Thiele's bears a curious and noteworthy resemblance to one of the methods proposed by Koch for the treatment of rinderpest. This consists in the injection into susceptible animals of a mixture composed of a small proportion of virulent blood diluted with a much larger quantity of serum obtained from an immune animal. Milk, of course, is merely an emulsion due to suspension of fatty particles in a fluid which may be regarded as blood serum ; so that it is conceivable that milk obtained from a cow which had suffered not long before from cow-pox, and so become, for the time at any rate, immune, might so far modify smallpox lymph added to it, as to produce some such effect as noted by Thiele when the mixture was used for purposes of inoculation. I have been unable to find any records dealing with a repetition of these experiments, but it would be interesting to make investigation of the possibifity of producing a similar lessening in virulence of smallpox lymph by admixture with the blood-serum of a calf which had been vaccinated some few weeks beforehand. Ceely, in February 1839, inoculated three stirks with variolous lymph, with the result that in two of the three he eventually obtained, in due course, what he considered to be vaccine vesicles. From these, lymph II NATURAL HISTORY AND PATHOLOGY 45 Stocks were established, which at once came into such extensive use that in the course of a few months at least a couple of thousand children had been vaccinated therefrom. In his paper recording these experiments, he states that on former occasions, even though working purposely at different times of the year, he had altogether failed in attempts to variolate the cow. In order to test the measure of protection afforded to these children by his variola-descended lymph, Ceely tried on a number of them the effect of subsequent variolous inoculation at varying intervals of time from their vaccination. In no case did he obtain any greater result locally than, on the authority of Willan, is known to have attended the test-inoculations employed by Jenner and Woodville. Unfortunately, owing to the particular methods used by Ceely in his variolous inoculations of cows, some doubt is thrown on the value of the results obtained by him. He was, according to his own account, working simultaneously with both variolous and vaccine lymph, so that it is difficult to exclude the possibility that his instruments may have unintentionally served to convey the infection of both diseases at one and the same time. Several years before the commencement of his inoculation experiments, Ceely had made trial of a method originally employed by Sonderland of Barmen (1830), who claimed to have infected cows with the contagion of variola, by way, presumably, of the respiratory tract. This he did by enveloping them in blankets taken from the bed in which a patient had died of smallpox, and by hanging other blankets 46 VA CCINA TION : c hap. similarly infected around the head of each cow, in order that the animal might breathe in the effluvium arising therefrom. It is stated that these cows subsequently manifested symptoms of cow-pox, and that from this source lymph was obtained and used on the human subject with the result that typical vaccine vesicles were produced. Ceely failed, however, in his attempt to bring about infection in similar fashion, as, indeed, have numerous observers in various parts of the world. Yet Ceely has himself recorded an occurrence observed by him in 1840, which although apparently but little known is of interest in this connection. He relates an instance in which five out of eight milch cows sickened with cow-pox within twelve and fourteen days of their having been seen to be licking over a quantity of flock from the mattress on which a patient had died of confluent smallpox, and which had been spread out in the field for purification. Careful inquiry at the time appears to leave no doubt that the animals, which had been on the same farm for a considerable period, were in good health at the time of their admission to the meadow in which the bedding was exposed, and also that there had not been any other case of cow-pox in the neighbourhood. The fact that all the animals became affected simultane- ously, and after a period corresponding to the usual incubation period of variola, certainly affords some reason for the assumption that the outbreak owed its origin to the animals being exposed to the " effluvium " from the infected bedding. It is of course possible that infection by way of the digestive tract may have been II NATURAL HISTORY AND PATHOLOGY 47 a factor also in this case, since Chauveau and other observers have shown experimentally that such result may be possible, a number of cases having now been recorded in which vaccinia has been communicated both to the human subject and also to the lower animals by the ingestion of vaccine lymph or powdered vaccine crusts. There surely has seldom been so indefatigable a repeater of experiments as Badcock the Brighton chemist, who during a period of about twenty-five years per- formed more than five hundred variolous inoculations. In December 1840, Badcock, who had commenced his work without knowledge of Ceely's slightly earlier work, first succeeded in variolating a cow, from which he carried on a stock of what was indistinguishable from genuine vaccine lymph. Although he subsequently met with similar success on no less than thirty-seven separate occasions, the difficulty and uncertainty of the work will be appreciated on consideration of the fact that those experiments, which eventuated in success, represent but 7 per cent of the total number.. The lymph obtained by Badcock as the result of his variolation experiments has been largely employed ; he supplied it to hundreds of medical practitioners, and many thousands of children are said to have been successfully vaccinated with it. About twelve years (1852) after Badcock had obtained his first successful result, two American physi cians, Drs. Adams and Putnam, were equally fortunate, and were able in consequence, as reported at the time in a Boston daily paper, to furnish all the vaccine matter requisite for use in the city and neighbourhood. 48 / '.-1 CCINA 7 70 A' : chap. . In 1865 a Commission, appointed by the Society of Medical Sciences at Lyons, having Chauveau as its head, reported the results of a comprehensive series of experiments carried out by it during the two preceding years, the results of which were completely at variance with those obtained by previous investigators. These results have been admirably summarised in the Report of the English Royal Commission on Vaccination. " Inoculation of the cow with smallpox matter in any one of the thirty animals used did not give rise to a vaccine vesicle ; nevertheless, a definite result was obtained in the form, however, not of a vesicle, but of a thickening and inflammation of the wound ; when a puncture had been made this became a papule ; lymph squeezed from such a papule, and inserted into a second animal, gave rise to a like papule ; and this again might be used for a third animal, but often failed ; and the effect could in no case be carried on through more than three or four removes. When the inoculation was re- peated on an animal on which a previous inoculation had produced such a papule, no distinct papule was formed ; and, moreover, lymph squeezed from the seat of the latter inoculation produced no effect at all when used for the subsequent inoculation of another animal." There is evidence that the development of the papule was the result of the specific action of the virus. This inference is strengthened by the fact that no such papule was produced by the Lyons Commission when the smallpox matter was inserted into an animal which had previously had cow-pox naturally or artificially ; as well II NATURAL HISTORY AND PATHOLOGY 49 as by the fact that when an attempt was made to vaccinate, with vaccine lymph of proved efficacy, an animal on which a papule had been so developed by inoculation with smallpox matter, the vaccination failed, though the animal had never had natural cow-pox nor been vaccinated. The specific nature of the lymph of the " Lyons " papule is held to be shown by the fact that such lymph, when used on the human subject, gave rise to smallpox. On the other hand, it has been urged that in this case the virus producing the effect was simply the original smallpox matter used in the inoculation, producing the papule and still clinging to the wound. This, however, is considered to be dis- proved by the experience that lymph from a " Lyons " papule of the second remove also gave rise in the human subject to smallpox. Thus Chauveau and his Com- mission found that smallpox implanted in the bovine animal gave rise to a specific effect which was not cow- pox, but was of the nature of smallpox ; though its manifestations in the cow were different from those of smallpox in man. A few years earlier, in i860, Martin of Boston, U.S.A., appears to have had a somewhat similar experience, as about fifty persons vaccinated by him from vesicles raised on a cow's udder by inoculation of variolous matter taken from a pock on the body of a man who had died of the disorder, were nearly all attacked with smallpox, and three died. Voigt, the Director of the Hamburg Vaccine Establishment, in 1881, brought into extensive use not E 50 / 'A CCINA TION : c 1 1 a i>. only in Hamburg, but also in other parts of Germany, a strain of lymph of variolous origin. In the early summer of that year he inoculated three calves with lymph obtained from a case of smallpox. In two of these the operation was apparently unsuccessful, in view of which it is of interest to note the fact that all three calves were afterwards found to be insusceptible to vaccina- tion. In the third calf, a single vesicle appeared on the site of one, out of five incisions made on the left side of the perineum. Voigt adds, however, that this same animal had been vaccinated in one small place in the right hypochondrium (for what reason is not obvious), and that at this point a normal vesicle developed. Voigt does not consider that this fact invalidates the apparent success of his experiment, for the reason that, as he says, the lymph derived from, as he considers, the variolous source proved to be more potent, as regards its observed effects on children and calves, than the Beaugency vaccine lymph, which he had in current use at the time his experiment was carried out. Both Chauveau and Berthel have, on the other hand, expressed the opinion that Voigt's variolo -vaccine is merely a continuation of the strain of animal vaccine, previously employed in Hamburg. In 1885 Simpson succeeded in an attempt to inoculate a cow with smallpox lymph obtained from a young vaccinated girl, but, so far as I am aware, he did not publish the details of this experiment at the time. Dr. Cory, to whom Simpson sent points charged from the cow on the sixth day after inoculation, has recorded the 1 1 NA TURA L HIS TOR V A ND PA TIIOL OGY 51 results following on their use in his recent volume on Vaccination. Three days after receiving the points, Dr. Cory employed them at the Government Animal Vaccine Establishment, Lamb's Conduit Street, for the vaccination of a young male calf. Three out of five insertions made with the lymph resulted in vesicles indistinguishable from those produced by the current lymph of the Establishment. A second calf and also a child were therefore vaccinated from the first calf, with successful results in each instance, although in the calf only six vesicles resulted from seventeen insertions of the lymph. From this calf a continuous series of calf vaccinations were carried on during a period of six months. With the lymph obtained from these animals, 79 in number, no less than 1247 children were vaccinated, 11 74 of whom afforded an insertion success-rate of 98.4 per cent. Some years later (in 1892) Simpson, then resident in Calcutta, was again successful in raising a stock of vaccine lymph of variolous origin. Lymph was taken from a smallpox patient on the fifth, sixth, seventh, and eighth days of eruption, and each day a young calf was inoculated, the animal having been taken into the smallpox ward for that purpose. The inoculations with the three later lymphs were unsuccessful, but the first calf showed on the sixth day of inoculation three papules on the abdomen and in the groin, at points where no punctures or incisions had been made. These on the following day had developed into vesicles. Two of the incisions and one puncture also contained lymph. On the sixth day lymph was 52 VA CCINA TION : chap. taken (whether from vesicles, incisions, or puncture, or all three is not clear from Dr. Simpson's paper) for the inoculation of another calf, from which again, on the sixth day, a child was vaccinated, the two insertions giving rise in due course to vesicles. From this child the strain of lymph was carried on successfully through nine generations, and Dr. Simpson remarks that each child showed splendid vaccine vesicles, much more typical in every respect than those obtained from the lymph, which had been previously in use. In 1886 and 1890, Fischer, the Director of the Institute for Vaccination at Carlsruhe, obtained two strains of variolo-vaccine, as the result of inoculation of calves with human smallpox lymph. In the first series, Fischer inoculated a young female calf, which he took into the smallpox ward of the Pforzheim Hospital for this purpose. Typical vaccine vesicles had developed on the sixth day, the lymph from which was carried on through twelve generations in the calf, after which it was successfully employed for the vaccination of children. Fischer states that the initial experiment of his second series was carried out in the Carlsruhe Institute, but that the animal was placed in a separate stable, and that every precaution was adopted to secure freedom from vaccine contaminations. In this calf, directly inoculated with smallpox lymph, he again obtained, as in his experiments of four years previously, a vesicular eruption, having the characteristic appearance of ordinary vaccinia. With lymph taken at the third remove from this II NATURAL HISTORY AND PATHOLOGY 53 calf, he vaccinated his own grandson with complete success, and the strain, which has now been continued through a very large number of animals, has been brought by Fischer into general use. Surgeon-Major King in 1889, being then stationed at Madras, inoculated a young bull-calf with fifth day smallpox lymph obtained from a child suffering from the disease. On the eighth day after the inoculation, a crop of vesicles made their appearance, not at points of insertion, but some little distance away, from the lymph obtained from which another calf was then inoculated. In this calf again secondary vesicles appeared, but, in addition, vesicles also formed at each point of insertion of the lymph. The lymph stock was carried on through three more generations in calves, the vesicular eruption being now in each instance strictly localised to the points of insertion. With lymph obtained from the fifth calf of the series, a number of children were vaccinated successfully. Dr. Simpson reports that from the stock thus established by King, 4240 British and native soldiers have been vaccinated, and also a very large number of the native civil population, with most gratifying results ; the percentages of success being much above that obtained from the lymph previously in use. For reasons which are unknown to me. King's investigation appears to have been regarded with disfavour by the Government of Madras, by whom he was ordered back to his regiment and deprived of his special emoluments. Subsequently, however, this injustice was repaired, by the reinstatement of Surgeon- 54 VACCINATION: chap. Major King in his former position as Director of Vaccination in tlie Presidency. In May 1892, Hime published the results obtained by him in a single experiment on variolation. The lymph employed for inoculation of the first calf was collected from a semi-confluent case of smallpox in a previously vaccinated woman of thirty-seven years old. No details are given as to where the experiment was conducted ; but presumably it was the private establish- ment from which Dr. Hime supplies vaccine lymph, as he makes the statement that " the calf was placed on the ordinary vaccination table used for these animals." A number of skin incisions were made, into which the variolous lymph was inserted. Of these incisions all subsequently healed, being on the sixth day only " detectable to the touch by a slight roughness." Several "pocks," however, developed at points for the most part distinct from any of the incisions, and material taken from these on the ninth day of inoculation was employed for the direct inoculation of another calf. All the incisions made on this second calf had " taken " on the fifth day, when lymph was collected in tubes, and pulp removed by scraping. Some of the latter made into "conserve" with glycerine was sent to Fischer of Carlsruhe, who obtained excellent results with it on a calf, from which children were in turn successfully vaccinated. Hime also himself vaccinated a child with a capillary tube of the lymph in two inser- tions, at each of which points a typical vesicle presented itself on the eighth day. II NATURAL HISTORY AND PATHOLOGY 55 The largest amount of research work in this direc- tion during recent years is that of Haccius and Eternod (1893), of whom the former is the Director of the Swiss Vaccinal Institute at Lancy, Geneva, where the work was carried out. Haccius gives an account of no less than seven successful series of experiments, in each of which a strain of variolous lymph, obtained in the first instance from the human being, was carried on from calf to calf through, in some instances, as many as six or seven removes. The general result was that by the second, or at the most the third, remove, the effect produced was altogether indistinguishable from that which we are accustomed to see in a calf that has been successfully vaccinated. With the lymph of the fifth or sixth remove, a number of previously unprotected children were vaccinated with unfailing success. The resulting vesicles could in no way be distinguished from ordinary vaccination vesicles of equal age. The total number of animals employed in these experiments is not mentioned, but from certain statements in M. Haccius' publication, one gathers that it was very con- siderable. It is obvious, therefore, that the Lancy experience, as to the small proportion of success to failures, is similar to that of other observers. It is worthy of note, also, that in those animals in which inoculation of variolous matter appears to have been attended with success, no definite vesiculation was ever observed at the site of any of the punctures or incisions that were made. The usual result in the first remove from the human being was either a single vesicle or 56 VACCINATION: chap. group of vesicular points on the site of a scarifica- tion or denudation of the skin. It is particularly stated that every precaution was taken, as, for in- stance, by the sterilisation of the lancet before each operation, to prevent the accidental transmission of vaccinia. Klein, who in 1879 ^^^^ obtained in thirty-one trials what then appeared mere negative results, renewed his investigations in 1892, employing now calves for inocu- lation experiments instead of milch cows, as in his earlier attempts. Having procured at the Hospital Ships, off Dartford, lymph from the vesicles of two cases of confluent smallpox, one at the sixth, the other at the seventh day after appearance of the rash, this lymph was, on the same day, inoculated by linear cutaneous incisions on two calves at the Brown Institution. The inoculation of one of these calves afforded no indication of success, but on the other calf he obtained a local result in the groin, which, however, consisted not of a distinct vesicle, but merely a thickening and redness, together with a linear crust, at the site of certain of the incisions into which smallpox lymph had been intro- duced. Lymph pressed from the thickened wounds, when inoculated into a second calf, produced also by the fifth day a like but rather more marked result ; while the thickening and redness still further increased as the process was repeated in a third and fourth calf. In none of these animals was there any appearance of vesiculation. At this stage the fourth calf of the series was removed to Lamb's Conduit Street, where Dr. II NA TURA L HIS TOR V A /YD PA T HO LOG Y 57 Cory, with material obtained by clamping and scraping the thickened incisions on the seventh day, vaccinated an infant in five separate insertions, with complete success. Each of these presented on the eighth day appearances characteristic of vaccinia. Moreover, Dr. Cory, who kept the child under observation from first to last, was unable to detect in the course of the dis- order any deviation from the condition of affairs normal to vaccinia. " Crusts " from the arm of this child were preserved and utilised, after being mashed up in sterile salt solution for the retro-vaccination of another calf. In due course there resulted, in about half of the total number of incisions, vesiculation of a character not to be distinguished from that current in the calves vacci- nated in the ordinary course at the Lamb's Conduit Street Station. Finally, after a lapse of six weeks, Klein submitted this retro-vaccinated calf and other calves vaccinated from it to the test of a further and thorough vaccination with current calf lymph, and with the result that all these animals entirely resisted vaccinia. I have learned privately from Dr. Klein that, in his former (1879) experiments on cows, he in more than one instance obtained results somewhat similar to those witnessed in the calf on which his more recent success- ful inoculation was performed. He suggested at the time the advisability of attempting a transference to a second animal, but Ceely, who was superintending the experiments, insisted on the necessity of obtaining a vesicle in the first animal inoculated as the only criterion of success, and tlie suggestion was therefore 58 VACCINATION: chap. overruled. For his own satisfaction, however, Klein endeavoured to vaccinate one of the cows which had shown some local reaction, but entirely without result, the animal apparently being immune. Of my own experiments the most successful series may briefly be described as follows : — With variolous lymph (contained in tw^o capillary tubes) taken on 30th July 1892 from a vaccinated girl, aged sixteen years, at from the fifth to the sixth day of the eruption of discrete smallpox, I inoculated on nth August a cow-calf A, about six w^eks old, by thirty-tw'O linear incisions and two superficial scarified patches made on the abdomen. On 13th August (the third day) this calf presented nothing but a slight scab over the scarified patch. On 15th August (the fifth day) some of the incisions were somewhat red and elevated, more particularly at several definite points which tended to be vesicular. At this date, on the inner aspect of each thigh, and distant in each instance from incisions or scarifications, was a crop of shotty and incipiently vesicular pimples. On 17th August (the seventh day), having clamped three of the incisions, including those with the quasi - vesicular appearance, I removed the lymph with the crusts by scraping, and used the material for the inoculation on this date of calf B. The accessory incipient vesicles I left untouched. From first to last calf A never exhibited any appreciable rise of temperature or indisposition of any sort. On the ninth day the linear incisions, the cross scarifications, and the accessory vesicles of calf A were in their decadence, and in a few days more the II NATURAL HISTORY AND PATHOLOGY 59 whole process was at an end. More than a month later, namely, on 22nd September, I vaccinated this calf A in twenty-three linear incisions, with calf lymph obtained from the Animal Vaccine Establishment. The result was absolutely negative. On 17th August, with the scrapings obtained the same day from calf A, I inoculated a cow-calf B, two months old, in fifty-six linear incisions on the abdomen. On the third day every one of these incisions was distinctly raised and bordered by a delicate pink flush. On the fourth day (20th August) all incisions had evidently "taken," the areola about each being now well marked, and about one-eighth of an inch in width, but there was no definite vesiculation. At this date, after clamping, scrapings were taken from certain of the incisions for further experiment. No accessory vesicles appeared in this calf, which, along with calf A, was vaccinated on 22nd September in seventeen linear incisions with calf lymph obtained from the Animal Vaccine Establishment. The result, as in calf A, was absolutely negative. On 20th August, with scrapings taken the same day from calf B, I inoculated a small cow-calf C (7 weeks old) in twenty-seven linear incisions on the abdomen. On the fourth day (23rd August) every incision had "taken," and in most of them there was evidence of commencing vesiculation. Two days later (25th August) vesiculation was distinct in several of the incisions. At no time were there any accessory vesicles. This calf also was vaccinated (22nd September) with calf lymph 6o VACCINATION : chap. from the Animal Vaccine Establishment. Again the result was altogether negative. I have thus far obtained an undoubtedly successful result in one series only out of four attempts, but I have at any rate been able to satisfy myself that it is possible to variolate the calf, and, further, that the result obtained in the first instance may become greatly modified in the course of successive removes ; and, again, that animals which have been thus treated are no longer susceptible to vaccination. I may perhaps mention here that all my experiments were conducted at the Brown Institution, to avoid any possibility of contamination with vaccinia ; that, as a further precaution, new scalpels were used, which were invariably first carefully sterilised in a flame ; that before and after use the table was thoroughly washed with carbolic acid and hot water, and during the intervals of use kept exposed to the open air. The Royal Commission on Vaccination, in the section of their report dealing with the question of the relation- ship of variola and vaccinia, show that the various series of inoculation experiments, of which I have given a brief account, fall into one or other of three categories. The first category includes the experiments of Thiele, Ceely, Badcock, Voigt, Haccius and Eternod, King, Simpson, Hime, and others. In these experiments " inoculation of smallpox matter into the udder, or adjoining parts, of the bovine animal gave rise, at or near the site of inoculation, to a vesicle, either identical in visible characters with the ordinary vaccine vesicle produced II NATURAL HISTORY AND PATHOLOGY 6i by inoculation with the matter of cow-pox, or to a vesicle the features of which, while not corresponding wholly with those of a perfect vaccine vesicle, so closely resembled it as to justify the recognition of the vesicle as a vaccine vesicle. Also it includes experiments in which, though the local result had not the characters of a perfect vaccine vesicle, yet lymph from it, when carried through a second or third remove in the cow or calf, presented results fully manifesting those characters, and when again transferred to man gave results in- distinguishable from the ordinary vaccine vesicles." In the second category are placed the experiments of Klein and myself. In no instance did either of us obtain any appearance of vesiculation in the animals directly in- oculated with smallpox virus ; although the appearance of the eruption tended to resemble more and more that typical of vaccinia, the further the remove, through a series of calves, from the original strain. In the third category are included the practically negative results of the Lyons Commission, obtained by Chauveau and his fellow workers. A brief account of these has already been given. With the exception then of Martin and of Chauveau and his colleagues of the Lyons Commission, all the observers mentioned claim to have obtained positive results, in a certain number of their experiments, at any rate, as regards the production of typical vaccinia, after one or more removes, as the result of variolation of the cow or calf. By no one, apparently, has success been attained invariably ; but it is among the experiments of 62 VA CCINA TION : ( 1 1 a p. the earlier observers especially, who made use, for the most part, of heifers and milch cows, that the largest pro})ortion of abortive attempts are to be met with. Subsequent experience has shown that success is much more likely to be attained if calves be used instead of heifers or cows. In this way, perhaps, Chaveau's some- what anomalous results may be in part explained. With reference to recent experiments on variolation of the calf, it is worthy of note that, as previously mentioned, different observers have obtained local effects in that animal which, in different calves of a series, have varied considerably. The final result has, however, after a greater or less number of removes from calf to calf, been invariably the same ; namely, a local vesicle is produced which by no means at our command, such as the appearance and course thereof, or the pro- tective power of the lymph derived therefrom, is dis- tinguishable from true vaccinia. Although practically there is unanimity of opinion among those who have worked at this subject, it must be confessed that, seeing the conditions under which they were carried out, many, particularly of the earlier experiments, are of little worth. Some of the main objections are based on the fact that experiments on this subject have almost without exception been per- formed in establishments devoted to the continuous cultivation of vaccinia ; on the use concomitantly of vaccine and of variolous lymph on the same animal ; and on the want of care as to the cleanliness and freedom from vaccine contamination of lancets and 1 1 A^A TURA L HIS TOR V A ND PA THOL OGY 63 " points " used in the experiments. Objection of similar sort against the variolations of the calf, which have been achieved in recent years, is hardly valid. In some of the more recent cases, at least, special pre- cautions have been taken to ensure that the instruments and table were sterilised, and to render the environment of the animal such as to afford no likeHhood of the communication of vaccinia. Most especially was this so as regards Klein's investigations and my own. The number of successful cases which have been recorded is now so large that it is difficult to believe that sources of fallacy of the above sort should have been present in every instance ; and it is therefore well-nigh impossible to resist the conclusion that a change of smallpox into vaccinia must really have come about. Nevertheless, there are found even at the present day those who, like Juhel and Dupuy (1894) and Layet (1895), maintain the essential duality of variola and vaccinia. It is, however, difficult to understand how the results obtained, by the last -mentioned especially, can bear the interpretation he would place upon them, seeing that he obtained, as the result of inoculating heifers with smallpox lymph, a vesicular eruption, the lymph derived from which reproduced the disease on other heifers. Moreover, subsequent vaccination of all his series of animals was either abortive or wholly with- out result. Hervieux (1895), ^^ Director of the Vaccine Institute attached to the Academic de Medecine at Paris, takes up a similar position to that of Layet and his collabo- 64 VA CCJNA 1 ION : chap. rators, Le Dantec and Benech. He asserts that the only point of similarity between variola and vaccinia, which has been brought forward by those who believe in the relationship of these disorders, is the likeness between the vesicles which are found in either case, and denies that this point forms any argument in favour of their identity. He also considers that the use of lymph of variolous origin is fraught with danger, and so, doubt- less, it may be when that employed is derived, as in Chauveau's and Martin's cases, for instance, directly from the animal first inoculated. If, as I believe, it can be conclusively proved that smallpox lymph, by passing through the system of the calf, can be so altered in character as to become deprived of its power of causing a generalised eruption, while inducing at the site of inoculation a vesicle in- distinguishable from a typical vaccine vesicle ; and, more important still, if it be shown that when trans- ferred again to man, it has by such treatment completely lost its former power to produce a general disease, it may fairly be asserted that cow-pox — or rather that artificially inoculated form of the disease which we term vaccinia — is nothing more nor less than variola modified by transmission through the bovine animal. Perhaps the most reasonable interpretation of such results may be that smallpox and vaccinia are both of them descended from a common stock — from an ancestor, for instance, which resembled vaccinia far more than it resembled smallpox. It is conceivable, indeed, that the seeming vaccinia, obtained in the calf by inoculation of small- II NATURAL HISTORY AND PATHOLOGY 65 pox matter into that animal, may after all be but a reversion to an antecedent type ; and in this connection we may call to mind a fact of universal experience, namely, that vaccinia, however it may have arisen in the past, or is made to appear in the present, exhibits little tendency to " sport " (as, for instance, by manifesting a "generalised eruption") in the direction of small- pox. Mr. Picton and Dr. Collins, in their addendum to the Report of the Royal Commission on Vaccination, lay much stress on the want of " evidence to show that inoculation of the pox of the cow on the human skin has ever produced smallpox." Variola and vaccinia may, nevertheless, have a common ancestry, since it is not unlikely that variola may have departed widely from the original type, and have gained an exalted virulence by repeated passage through man under conditions favourable to its propagation and activity. If this evolution of the disease has, in fact, taken place, variola may have suddenly reverted, under greatly changed conditions (as for instance implantation on the bovine animal), to an ancestral type. But the reverse process {i.e. sudden " sport " of vaccinia in the direction of smallpox) is not to be expected. It is most unlikely that a less differentiated form (cow-pox), also emanating from the common ancestral stock, should attain to the most exalted virulence in a single individual, and per saltmn declare itself as smallpox, as the dissentient Commissioners insist that it ought to do. 66 VACCINATION chap, ii REFERENCES Relationship of Variola and Vaccinia: i. Badcock. E.\ peri I) nuts lOiiJiniiiiig the Ponier of Cow-pox^ c/r., 1840. — 2. Ceely. Trans. Prov. Med. and Surg. Assoc, vol. viii. pp. 379- 402. — 3. Chauveau, Viennois, and Meynet. (Rapport par) Mt'/noires et coviptes-rendiis de la Soc. vidd. de Lyott, tome v. — 4. CoFEMAN. Trans, of Epidemiological Society, i?>()2-()'^'. Journal of Pathology and Bacteriology, ^Iviy 1S94. — 5. HiME. Brit. Med. Journal, \o\. ii. p. 117; 1892. — 6. King. Trans. Sotitli Indian Branch Brit. Med. Assoc, vol. iv. No. i ; 189]. — 7, Klein. Report of Medical Officer to the Local Government Board for 1891- 92; (1893). — 8. Macpherson and Lamb. Tracts, Med. and Phys. Soc. of Calcutta, vol. vi. and vol. viii. — 9. M'Michael. Report of the Face. Sec. of Prov. Med. and Surg. Assoc. 1839, p. 24. — 10. Frever. Zeitschrift fiir Hygiene, Bd. xxiii. H. 2, 1897. — II. Simpson. Indian Medical Gaz. May 1892, p. 148. — 12. Sonderland. HHfeland''s Journal, }zin. \%i\. — 13. Thiele. Henke's Zeitschrift, 1839, Heft i. CHAPTER III HISTORY OF VARIOUS LYMPH STOCKS Jenner's first case of vaccination was, as previously stated, that of a boy eight years of age, whom he inoculated in the arm with cow-pox matter taken from the sore on the hand of a dairymaid, who, in turn, had become infected with the disease from milking cows suffering from cow-pox. This was in 1796, and was his first actual experiment purposely performed, though it is evident that for years previously he had taken note of the results of the testing of many experiments unintentionally performed by milkers on their own persons, such experiments being subsequently tested at a longer or shorter interval by inoculation with smallpox, the inoculation being itself in many cases performed not purposely as a test, but as a preventive of smallpox in the course of the ordinary practice of some medical man in the dairy districts. In experiments and tests so conducted, there could be no " personal equation " to confuse the result. It was apparently not until 1798 that he made his first attempt to carry on a strain of lymph from arm to arm. In the spring of this year he inoculated a child 68 VACCINATION: chap. with matter taken directly from the nipple of a cow ; and from the resulting vesicle on the arm of this child first operated on, he inoculated, or, as it may now be more correctly termed, " vaccinated " another. From this child several others were vaccinated ; from one of these a fourth remove was carried out successfully, and finally a fifth. Four of the children were subsequently inoculated with smallpox — the " variolous test " — with- out result. At this point, however, the strain appears to have been allowed to die out; but, in January 1799, Wood- ville, physician to the Smallpox Hospital in London, who had been much interested in Jenner's investigations, discovered the presence of cow-pox in a dairy in Gray's Inn Lane. With lymph taken, in the presence of Sir Joseph Banks, the President of the Royal Society, and other well-known men of the time, from one of the cows in this dairy, he vaccinated seven persons at the Small- pox Hospital ; while in the case of certain other persons, he employed matter from sores on the hand of a dairy- maid, who had become infected from one of the cows at this same place. These cases, from which afterwards in succession many hundreds of persons were vaccinated, were the main source of what is usually spoken of as " Woodville's lymph." These strains of lymph were extensively distributed by Woodville. Dr. Pearson, one of the surgeons to St. George's Hospital, also sent out much lymph. He very early obtained lymph from a dairy in the Marylebone Road. It is not unlikely also that a con- Ill NA TURAL HISTOR V AND PA THOLOG Y 69 siderable part of his lymph was obtained from Wood- ville's cases. Jenner himself used some of Woodville's lymph, and he obtained a further supply from a cow at Mr. Clarke's farm in Kentish Town. The lymph first employed on the Continent and in other foreign countries was undoubtedly supplied in large measure by Pearson and Woodville ; although we learn from Baron and other authors that Jenner, who was naturally much appealed to for supplies of lymph, him- self sent lymph to Stromeyer of Hanover, to De Carro of Vienna, to Berlin, and to Barbados, Newfoundland, and other parts of America. The lymph which Woodville first sent to Paris died out, and he himself visited France with a fresh stock, taken at a time when he had learned to be careful to avoid contamination of his stock by variolous matter. Strains derived from lymph stocks originally supplied by Jenner were also sent abroad by a number of different persons, the original strain being, in large measure at any rate, the lymph obtained by Jenner from the Clarke's farm cow. Thus Ring records that he distributed Jenner's lymph to various places on the con- tinents of Europe and America. It would be erroneous to suppose, however, that all the lymph employed abroad in the early days of vaccination was obtained from England. Indeed, both Sacco and De Carro made extensive use of lymph obtained by the former from a case of natural cow- pox which he discovered in Lombardy. In a letter 70 P'J CCINA TION: chap. to Jenner, under date i6th October 1801, Sacco states that from this source " more than eight thousand inoculations " had already been " performed with the most happy success," and he adds " several hundreds of these have since been subjected to the variolous inocula- tion, and have resisted it." In a postscript he adds that he had sent some of the Lombardy vaccine matter to Woodville. From this stock also De Carro sent supplies to Constantinople, where it was employed for the first vaccinations carried out in this part of Europe. De Carro it was also who first succeeded in conveying a supply of lymph to India. This lymph, again, was not from Jenner's stock, but was of Milanese origin, having been furnished to him by Sacco. It was, moreover, not of bovine but of equine origin, and according to Ue Carro had never been passed through the cow. This strain of equine lymph was originally obtained by Sacco in 181 2, from a crop of vesicles on the hands of a coachman who had not had smallpox, and who had dressed the heels of a horse affected with the "grease." From these vesicles two children were successfully vaccinated, and from these the stock was carried on through a long series of vaccinations. Among more recent strains may be mentioned that obtained in 1836 at Passy in the environs of Paris from the hand of a milker, who had contracted casual cow-pox. The old stock then in use at the Academic de Medecine had evidently degenerated somewhat ; and, when its effects were compared with those of the new Ill NATURAL HISTORY AND PATHOLOGY 71 Passy lymph, the vesicles developed from the latter were found to be manifestly finer. In 1836, Estlin of Bristol put in circulation a stock which at first showed unusual activity. This abated, however, after some transmissions, and the lymph after- wards came into extensive use. From this time onwards the various stocks became so numerous that Ceely, writing in 1841, states that during the preceding three years he had experimented with lymph from more than fifteen distinct sources ; of these six had been taken from the natural disease, either direct from cows or from vesicles on the hands of the milkers, and seven were artificially produced in the cow. The lymph stock in use at the present time at the Government Animal Vaccine Establishment was originally obtained on 26th November 1881 at a farm in the village of Laforet not far from Bordeaux ; whence a sample of lymph from the seventeenth calf in succession from the animal first affected was sent by Dr. Dubreuilh of Bordeaux, to the Medical Officer of the Local Govern- ment Board. Of late years, more particularly, numerous strains of so-called variola-vaccine lymph, obtained by inoculation of human smallpox on the calf, have been introduced, especially by Fischer in Germany, by Haccius in Switzerland, and by King in India. These strains have been successfully transmitted through many thousands of individuals. Those who deny the relationship of smallpox and cow-pox will say that these children have been variolated, 72 VACCINATION chap, hi and not vaccinated. One, of course, admits that they have been variolated, in the sense that they have been inoculated with lymph descended from a case of human smallpox, but differing from the mild inoculations of Adams, Dimsdale, and the Suttons, in that the resulting disease is no longer infectious. Such procedure is also strictly comparable with those methods of protective inoculation by the use of attenuated virus, which of late years have given valuable results in the prevention and treatment of various zymotic diseases. REFERENCES Lymph Stocks: i. Baron. Life of Jenner, vol. i. — 2. BOUSQUET. Nouveau traits de la vaccine, p. 403 et seq. — 3. Crookshank. Histo)-}' and Pathology of Vaccination, vol. ii. — 4. De Carro. Histoire de la vaccine, 1804, p. 23 iv.: ■■'■•:. '":: ZA >. ."••'• Fig. 5. — Photograph of as,^ar plate prepared with vaccine material immediately after admixture with Lanolink. Fig. 6. — Photograph of similar agar plate prepared with vr.ccine material six xveeks after admixture with Lanolink. IX NA 7 URAL HISTOR V AND PA THOLOG V 1 79 its weight of vaseline undiluted, and one part with five times its weight of lanoline undiluted as in the first experiment. Agar- agar plates were established from these emulsions antecedent to their storage, and the number of colonies which appeared on the several plates at this stage were found in close agreement. The three emulsions were then placed in sterile stoppered bottles, some of the glycerinated material being also stored in capillary tubes and pipettes. It was designed to repeat the former experiment with these emulsions, and sample plates were again established from them after they had been stored a week. Again the vaseline and lanoline plates showed at this stage increase in the number of colonies, whereas the glycerine plate showed a diminution. The vaseline plate, moreover, after four days, became covered with colonies of a green mould (Penicillium glaucum), and was useless for photographic purposes. At the end of the second week of this experiment, it was found impossible to continue it as regarded the vaseline and lanoline emulsions. These had become, in their separate sterilised bottles, both covered with a luxuriant crop of the above green mould. No such growth appeared in the bottle containing the glycerine emulsion ; on the contrary, plates established from it after two and three weeks' storage showed a further diminution in the number of colonies, and at the end of the fourth week the comparison plate was altogether free from extraneous organisms. In the foregoing experiments it will have been noted that the plates used for comparison were, in nearly 1 8o V^ CCINA TION : c h a \\ every instance, plates established from agar test-tubes directly inoculated from the emulsion. The exception to this rule was Experiment i, in which the plates used for comparison were established from agar tubes inocu- lated, not directly from the emulsions, but from the primary agar tubes in which loopfuls of emulsion had been, in the first instance, distributed. In that experi- ment the sterile plate obtained at the end of the fourth week of storage of vaccine material i7i glycerine was the only plate of the series established directly from the original emulsion which has been photographed. It remains to be stated in this connection that the results were " controlled " by duplicate plates established at the same time ; and furthermore, that material which in plate culture showed no colonies was always tested again two or three times in similar fashion. Experwmit 3. — Scrapings of vesicles were collected from a calf 120 hours after vaccination, with the same precautions as before. These were weighed, rubbed up, and diluted with fifteen times their weight of 50 per cent sterile glycerine and water, so that the percentage of glycerine present became 46.9. One loopful of this emulsion immediately after glycerination was inoculated into nutrient agar-agar, and plates were established therewith. Plates established from the stock glycerine emulsion a week, a fortnight, three weeks, and four weeks respectively from commencement of storage, showed, as regards the first three, week by week a rapid diminution in the number of colonies which appeared after incubation in the manner described. IX NATURAL HISTORY AND PATHOLOGY i8i while the fourth was found to be quite free from extraneous organisms. Some of this glycerine emulsion, four weeks after manufacture and storage in a pipette, was used by the Government operators at the Animal Vaccine Establishment, Lamb's Conduit Street, for the vaccination of sixty-five infants. All these children's arms " took," Dr. Cory obtaining in his series of thirty- six cases TOO per cent of insertion success. The advantages of glycerinated calf lymph may be set out as follows : — 1. By employing the method of glycerination of lymph-pulp, great increase in quantity can be obtained without any consequent deterioration in quality, the per- centage of insertion success following on its use being equal to that obtained with perfectly active fresh lymph. 2. Glycerinated lymph does not dry up rapidly, as does unglycerinated lymph, thus simplifying the process of vaccination. 3. Glycerinated lymph does not coagulate, so that it never becomes necessary to discard a tube on this account. 4. Glycerinated lymph can be produced absolutely free from the various streptococci and staphylococci which are usually to be found in untreated calf lymph, and which are, under certain circumstances, liable to occasion suppuration. 5. In like manner the streptococcus of erysipelas, in the event of its having been originally present in the lymph material, is rapidly killed out by the germicidal action of the glycerine. 6. The tubercle bacillus is effectually destroyed even iS2 VACCINATION: chap. when large quantities of virulent cultures have been purposely added to the lymph. 7. The possibility of inoculation of syphilis is elim- inated, as the calf is not subject to this disease. 8. The necessity for collecting children together, with the attendant risk of spread of infectious diseases, or of transporting a calf from place to place, is obviated, while the danger of "late" erysipelas in the child is dim- inished by reason of there being no necessity to open the mature vesicles for the purpose of obtaining lymph. 9. The bacteriological purity and clinical activity of large quantities of the lymph can be readily tested prior to distribution. 10. By reason of the possibility of keeping large stocks of glycerinated lymph on hand for considerable periods of time without appreciable deterioration, any sudden demand, such as is Hkely to arise on the outbreak of epidemic smallpox, can be promptly met. ,11. The expense of producing glycerinated lymph is proportionally small, since the amount obtainable from each calf is enormously increased. The Preparation of Glycerinated Calf Lymph The method best adapted for the production of glycerinated calf lymph, which shall be free from all extraneous organisms, of perfect efficacy, and yet affording material for the vaccination of many more children than the original unglycerinated calf lymph, is briefly as follows : — The Preparatmt of the Calf. — ^A female calf of suit- IX NATURAL HISTORY AND PATHOLOGY 183 able age, about from three to six months, should be kept under observation for a week, after which, if found to be quite healthy, it may be removed to the vaccina- tion station. It is there placed on a tilting table, and the lower part of the abdomen, reaching as far forward as the umbilicus, is shaved and thoroughly washed with a solution of carbolic acid and then rinsed with sterile water and dried with soft sterilised towels. Inoculation of the Calf. — With a sterilised sharp scalpel incisions about four inches long and half an inch apart, parallel to the long axis of the body, are made on this clean-shaved area. The depth of the incision should be such as to pass through the epidermis and to open the rete Malpighi, if possible without drawing blood. As these incisions are made, glycerinated calf lymph, which by examination has been proved to be free from extraneous organisms, is run into them by means of a sterilised blunt instrument, and the point of the scalpel is from time to time dipped into the vaccine emulsion. Collection from the Calf. — After five days (120 hours) the vaccinated surface of the calf is first thoroughly washed with warm water and soap, rubbed over it by the clean hand of the operator, and finally the whole area is carefully cleansed with sterile water. The remaining moisture is then removed by sterilised sheets of blotting paper. The vaccinated incisions will now appear as lines of continuous vesicles raised above the surface, each line separated from its neighbour by about a quarter of an inch of clear skin. Any crusts which appear in the vesicular lines are picked off with a blunt 1 84 VA CCINA TION : chap. sterilised instrument. The vesicles and their contents are then removed by means of a sterilised Volkmann's spoon, and transferred to a sterilised bottle of known weight. By going over the lines only once with the spoon, it is quite easy to remove the whole of the pulp without any admixture of blood. The abraded surface is care- fully washed, and may be dusted over with fine oatmeal or starch and boracic powder. Subsequently, the calf is transferred to the slaughter house and the carcase is examined by the veterinary surgeon, who forwards a certi- ficate of its condition. Should this not be satisfactory, the vaccine pulp obtained from the animal is destroyed. Preparatio7i a?id Glycerinatmi of the Lymph-pulp. — The bottle containing the vaccine pulp is taken to the laboratory, and the exact w^eight of the material ascer- tained. A calf vaccinated in this way will yield from 18 to 24 grammes, or even more, of lymph-pulp. This material is then thoroughly rubbed up in a sterilised mortar or in a mechanical triturating machine. ■'^ When it has been brought to a fine state of division, it is mixed with six times its weight of a sterilised solution of 50 per cent chemically pure glycerine in distilled water. The resulting emulsion is then transferred to small test-tubes, w^hich are then aseptically sealed and should be stored in a cool place protected from light. When required for distribution it is drawn up into sterilised capillary tubes, which are subsequently sealed in the flame of a spirit lamp. ^ For description of instruments devised by Dr. Chalybaus of Dresden, and Dr. Doering of Berlin, respectively, see Appendix I. pp. 222 and 213. PLATE v. Series 24. — Photograph of agar plate incubated for seven days sub- sequent to inoculation, with one loopful of rubbed-up vaccine pulp, im- mediaiely after glycerination. The number of colonies is very large. PLATE VI. Series 24. — Photograph of agar plate prepared with similar quantity of vaccine material one week after glycerination. The number of colonies is considerably diminished. PLATE VII. Series 24. — Photograph of similar agar plate, prepared with vaccine material two -weeks after glycerination. A further decrease in the number of colonies is now conspicuous. PLATE VIII. Skkiks 24.— Photograph of siinilar agar plate, prepared with vaccine material three weeks after glycerination. The decrease in the number of colonies is still more marked than in the former plates. PLATE IX. Seriks 24. — Photograph of similar agar plate, prepared with vaccine materisd/our weeks after glycerination. No growth whatever has occurred. IX NA 7 URA L HIS TOR V A ND PA THOLO GY 185 Bacteriological Exafnination of the Lymiph Enudsioii. — As soon as the vesicular pulp is thoroughly emulsified with the glycerine solution, agar-agar plates are estab- lished from it, and, after suitable incubation for seven days, the colonies that have developed on the plates are counted and examined. Week by week this process is repeated, and invariably the number of colonies diminishes with the age of the emulsion, until at the end of the fourth week after the collection and glycerin- ation of the lymph material, the agar-agar plates inocu- lated at that time show no development of colonies. The lymph is then subjected to further culture experi- ments, and if these results of freedom from extraneous organisms are confirmed, the emulsion is ready for distribution. The elimination of the extraneous organ- isms in our experiments has occurred with marked regularity at the end of the fourth week. The only exception to this rule arises when the lymph originally contained a considerable number of spores or bacilli of the hay bacillus or bacillus mesentericus. These organ- isms are very resistant to the action of glycerine, but if the precautions detailed are carried out in the treatment of the calf, their presence may generally be excluded. Duration of Activity of Glycerinated Calf Lymph. — This varies in all probability with atmospheric condi- tions, with the fineness of division of the vesicle pulp, and above all with the condition of the calf itself. Some calves yield an excellent lymph, others a poor lymph, and the problem is to determine the value of the lymph yielded by any given calf. A lymph which was collected i86 VACCINATION : chap. and glycerinated on 13th July 1897, has since been used at intervals of from twenty-four weeks to thirty-two weeks after glycerination, for the vaccination of children. Dur- ing this period, sixty-one children have been vaccinated w'ith this lymph in five places each, with a mean inser- tion success of 98 per cent.^ Thus, by the methods described, glycerinated calf lymph can be prepared which becomes freed from extraneous organisms, is available for a large number of vaccinations, at least 5000 from an average calf, and retains full activity for eight months, and will, under favourable circumstances, continue to do so in all probability for still longer periods, if necessary. From the description which 1 have given, it will, I think, be obvious that the preparation and testing of glycerinated calf lymph, properly so called, is a matter requiring considerable skill and care. Sir Richard Thome insists strongly on this fact in his introduction to our joint Report, recently presented to Government, on the administration of certain of the chief continental vaccine establishments. This Report I reproduce as an appendix, w4th such emendations and additions as more recent information and further experience have shown to be needed. The following conclusions were submitted by Sir Richard Thorne in his introduction to the Report in question : — " I. It is desirable that vaccination, both primary and ^ This same sample of lymph (when forty-two weeks old) gave, in Dr. Cory's hands, an insertion success, based on fifty insertions, of 100 per cent. PLATE X. Photograph of child, taken on the eighth day of vaccination with glycer- inated vaccine lymph, which, as shown in Plate I. Fig. 2, was found, when tested by the method of plate -cultivation, to be free from extraneous micro-organisms. IX NATURAL HISTORY AND PATHOLOGY 187 secondary, carried out under the auspices of the Govern- ment, should be performed exclusively with vaccine lymph derived from the calf. " 2. There will probably be advantage in retaining, for a time at least, the system of calf-to-arm vaccina- tion at the Board's Animal Vaccine Station for such parents and others as may request it, and for the pur- poses of comparing its results with those following the use of calf lymph preserved in one or another way. " 3. The distribution of calf vaccine from the National Vaccine Establishment should be limited to glycerinated or similar preparations of lymph or pulp material, in air-tight tubes or other glass receptacles. " 4. To give effect to the above, it will be requisite that the Board's Animal Vaccine Station should be reorganised, both as regards construction and adminis- tration. Notably will it be requisite that it should include a properly equipped laboratory under the direct supervision of a bacteriological expert." [These recommendations are now in process of adoption by the Government, and already suitable laboratories have been secured, which have been placed in the charge of Dr. Blaxall. I trust, therefore, that the Government will shortly be in a position to supply bacteriologically pure and fully active calf vaccine lymph in any quantity that may be found desirable.] iSS VACCINATION chap, ix REFERENCES Preservation, Storage, and Use of Lymph : i. Adami. Montreal Medical Joio'n., Jan. 1898, vol. xxvii. p. 52. — 2. Bla.XALL. Medical Magazine, April 1S98, vol. vii. p. 253. — 3. BOUSQUET. Noiivean traitt' de la vaccine, p. 240. — 4. Chambon, Menard, and Straus. Gazelle des hopitaux, Dec. 15, 1892. — 5. Cheyne. Medical Times, Old Series, 1850, vol. xxi. ; and New Series, 1853, vol. vi. — 6. Copeman. Trans, of Inter- national Congress of Hygiene, 1 89 1, vol. ii. p. 325 ; Proceedings of Royal Society, 1893, vol. liv. p. 187; B7'it. Med. J own. 1893, vol. i. p. 1250. — 7. Copeman and Blaxall. Report of Med. Officer to Local Government Board, 1895-96, pp. 283-305. — 8. Dreyer. Zeitschrift fiir Hygiene, 1898, Bd. xxvii. p. 117. — 9. Leoni. Revue d^/tygiene, Aug. 20, 1894. — 10. Muller. Med. Times and Gazette, 1866, May 19, p. 526. — 1 1. Seaton. Handbook of Vaccination, 1868 ; Secoiid Report of Med. Officer to the Privy Council, p. 20 et seq. — 12. Steinbrenner. T^-ait^ siir la Vaccine, p. 570. — 13. Warlomont. Bj'H. Med. Joiirn. 1880, vol. ii. p. 499. — 14. Second Report of Med. Officer to Privy Cotaicil. — 15. Fifth Report of Med. Officer to Privy Cotmcil. APPENDIX No. I On the Preparation and Storage of Glycerinated Calf Lymph : by Drs. Thorne Thorne and Monckton Copeman Ititroduction addressed by the Medical Officer to the Right Honourable Henry Chaplin, M.F., President of the Local Government Board Sir — Shortly after the issue of the Report of the Royal Commission on Vaccination last autumn, I received your instructions that I should, together with Dr. Monckton Copeman, visit certain cities in different countries on the Continent of Europe, with a view of obtaining information as to the methods adopted, by the respective authorities and others concerned, in the distribution of vaccine lymph derived from the calf, more especially in reference to the prepara- tion, storage, and distribution of glycerinated calf lymph. The necessary visits were commenced in December of last year, but owing to the fact that in some of the countries to be visited public vaccination is practically limited to certain months of the year, commencing with the spring, it was found impossible to complete the inspections until quite recently. In eliciting information as to the methods adopted in each of the countries visited, we held especially in view two points to which the Royal Commission gave prominence I90 APPENDIX in their Report. The first of these — one which the Com- missioners put " in the forefront," is the recommendation in section 437 of their Report "that parents should not be required to submit their children to vaccination by means of any but calf lymph." The second, which is referred to in section 448, is concerned with experiments which Dr. Copeman made and announced to the International Congress of Hygiene which met in London in August 1 891, as to the effect of the storage of vaccine lymph in glycerine. " The conclusions at which he arrives," say the Commissioners, " are that the addition of glycerine, whilst it leaves the efficacy of the lymph undiminished, or even increases it, tends to destroy other organisms " ; and they add that " The question is one a further investigation of which is obviously desirable." The places visited by us were Paris, Brussels, Berlin, Dresden, Cologne, and Geneva ; and in submitting to you an account of the operations which came under our notice in each of these cities, I beg leave to make the following observations. It will be noted that in each of the countries concerned, vaccination with calf lymph has become the habitual, if not the universal practice. In some, indeed, we were informed that, although vaccination with humanised lymph is not definitely prohibited under any statute or regulation, yet resort to such lymph by any medical practitioner having official responsibility to the Government is altogether discouraged. In only one of the places visited — namely, Paris — did we find that vaccination was carried out under official sanction with crude calf lymph, and even there the process was limited to vaccination direct from calf to arm, all lymph stored for distribution being glycerinated calf lymph. I APPENDIX The circumstances of Paris in the matter of vaccination direct from the calf deserve consideration, because they have a certain similarity to those which may be encountered in this country, in case the use of calf lymph should become habitual. Thus, we were informed that if vaccination had, during past years, been limited to the use of glycerinated calf lymph, stored in tubes or otherwise, it would have been found difficult, amongst certain classes of a population which heretofore had only known of stored humanised lymph, to convince persons whose vaccination it was desirable to secure that the lymph proposed to be used on them was really calf lymph, not humanised lymph. In order to ensure confidence in this respect, it had been the practice to convey calves to the vaccination stations, or to districts infected with smallpox, and to perform the vaccination direct from calf to arm. Perusal of the account which we give as to this practice in the hands of MM. Chambon and Menard will show that it has been brought to a position of very considerable efficiency. In all the other countries visited we found that, acting on the indications announced by Dr. Copeman in 1891, the Governments and other authorities concerned had made sustained investigation as to the preparation, storage, and use of glycerinated calf lymph, and had gradually come to adopt that preparation of lymph for official, and in some cases for all, purposes throughout their jurisdictions. Thus, in Germany we were informed that the system of vaccinating direct from the calf had come to be abandoned as completely as that from arm to arm, the use of glycerinated calf lymph having become general throughout the Empire. The reasons for this change have been two. The governing reason has been the confirmation by competent bacteriologists of the results obtained by Dr. Copeman, to 192 APPENDIX I the effect that, by the admixture to calf lymph of a 50 per cent solution of pure glycerine in sterile water, and by subsequent storage of the lymph material in tubes, under due precautions, for a term of several weeks, the preparation remained quite active as vaccine, whilst a very remarkable germicidal effect was produced on extraneous micro- organisms in the lymph, even including certain pathogenic organisms which had been purposely added to the lymph material. The second reason was that, by reason of the admixture referred to, the amount of vaccine procurable from a given calf could be greatly, even enormously, in- creased, and that, within certain wide limits, this could be done without interfering with the insertion success following on the use of the lymph. At the Board's Animal Vaccine Establishment it has hitherto not been deemed necessary, nor even expedient, to make one calf serve for more than some 200 to 300 vaccinations. It is no unusual thing abroad to provide from a single calf an amount of glycerinated lymph that shall serve for from 4000 to 6000 vaccinations, and in Berlin we were assured that the glycerinated lymph which was prepared in our presence from one calf would suffice for no less than 15,000 vaccinations. We brought some of this Berhn lymph to England, and it was used for the purposes of vaccination at intervals of nine, eleven, and thirty-seven days after its collection, with the result that in 76 vaccinations performed, in each case by five insertions, its use resulted in a mean insertion success of 92.0 per cent. Storage of this particular sample for a much longer period did not give satisfactory results. With other preparations of glycerinated lymph, diluted to about one-third of the amount of the Berlin sample, and which were used in England at intervals varying from seven to thirty-one days after collection and preparation, the APPENDIX 193 insertion success reached 97, 98, and 99 per cent ; and in the case of 1 1 1 vaccinations, all effected with two other supplies of glycerinated lymph, used at intervals of from seven to thirty days after preparation, the success reached 100 per cent, every insertion of lymph being followed with success. In all these cases the vaccination was performed by means of five insertions. In every instance we found that the work of collecting, preparing, and storing the glycerinated lymph was carried out with the greatest care ; a condition of scientific cleanliness was especially aimed at, and a laboratory, fitted with bacterio- logical and other scientific apparatus, always formed an essential part of the vaccine institution. The extent to which the desired end of freedom from extraneous impurity was attained depended largely on whether a first attempt to adapt an existing calf station or similar establishment to its new purposes had been maintained, or whether it had been abandoned in favour of an institution constructed especially for the purposes of that which is in the main scientific laboratory work. Several of the stations which we visited are already under condemnation, because of the difficulty of ensuring that freedom from extraneous micro-organisms which should be aimed at during the preparation of the lymph supply ; the Cologne station is one of the newest, and may well serve, in its main features, as a type of that which should be aimed at. The condition of scientific cleanliness to which I have referred extended to such matters as the following : {a) the construction and administration of the stabling for the calves ; {b) the means for washing or bathing calves before their vaccination ; {c) the construction, cleansing, etc., of the operating rooms ; {d) the cleansing of the vaccinated surface of the calf with germicidal preparations and sterilised O 194 APPENDIX cloths before collection of the lymph ; {c) the use of clean sterilised outer garments by all officials concerned in the processes carried out ; (y) the sterilisation of all instruments, etc., employed ; and {g) the carrying out of the process of admixture of the lymph material or pulp with glycerine, as also its preparation and storage under conditions of laboratory freedom from extraneous organisms. Further, we found that it was an invariable practice at the stations visited on the Continent not to issue any lymph until a report had been received from a veterinary surgeon, after slaughter of the animal, as to the freedom of the calf furnishing it from disease ; in brief, the lymph issued is that of healthy calves only. This practice is mainly with a view of avoiding all risk of conveying tuberculosis along with calf lymph ; though such risk would, under any cir- cumstances, be a very remote one, seeing that tuberculosis is extremely rare in young bovine animals, and seeing also that the tubercle bacillus, when experimentally added to a mixture of lymph and an aqueous solution of glycerine, rapidly loses its vitality. The information which we obtained in the course of our visits does not profess to be complete. Much remains to be ascertained by careful scientific research, in order to learn what are the precise conditions under which glycerin- ated calf lymph can be prepared and stored, so as to secure to the utmost freedom from extraneous, and especially from pathogenic micro-organisms, whilst at the same time retaining to the utmost the undiminished protective value of the lymph material against smallpox. We learned that in every country visited, further research is being made in this direction, and in Germany a special commission of medical and bacteriological experts has been appointed by the Government to study and report upon the subject. I APPENDIX 195 But the information which is now available in this country, and that which, during the course of our visits abroad, was placed at our disposal with a readiness and a courtesy which calls for an expression of the fullest acknowledgment, suffices to enable me to submit the following conclusions for your consideration : — 1. It is desirable that vaccination, both primary and secondary, carried out under the auspices of the Govern- ment, should be performed exclusively with vaccine lymph derived from the calf 2. There will probably be advantage in retaining, for a time at least, the system of calf-to-arm vaccination at the Board's Animal Vaccine Station for such parents and others as may specially desire it, and for the purposes of comparing its results with those following the use of calf lymph pre- served in one or another way. 3. The distribution of calf vaccine from the National Vaccine Establishment should be limited to glycerinated or similar preparations of lymph and pulp material, in air-tight tubes, or other glass receptacles. 4. To give effect to the above it will be requisite that the Board's Animal Vaccine Station should be reorganised, both as regards construction and administration. Notably will it be requisite that it should include a properly equipped laboratory, under the direct supervision of a bacteriological expert. — I have the honour to be, sir, your obedient servant, RICHD. THORNE THORNE. July 1897. 196 APPENDIX APPENDIX No. \— Continued Report on the Results of an Inspection made by Dr. R. Thorne Thorne and Dr. S. Monckton Copeman as to Vaccination Arrangements ADOPTED in certain EUROPEAN COUNTRIES WITH special reference to the preparation and Storage of Glycerinated Calf Vaccine Lymph. (Prepared by Dr. S. Monckton Copeman.) Paris At Paris we spent several days in inspecting the manner in which the work of obtaining, preparing, storing, and distributing calf vaccine lymph is carried out at the Institut de Vaccine Animale and at the Academie de Medecine respectively. The bistitut de Vaccine Animale This establishment is carried on by M. Chambon and Dr. St. Yves Menard. It is, practically, a private estab- lishment, although the municipality of the city of Paris contract with the directors to carry out all such public vaccinations, within their jurisdiction, as may be necessary. The Institut de Vaccine Animale, which is situate in the Rue Ballu, consists of what was originally a dwelling- house, with a courtyard opening to the street alongside, and a stable behind, the portion of the courtyard immediately adjoining the stable being covered over and provided with sliding doors, so as to form an operating room when neces- I APPENDIX 197 sary. Rooms in the dwelling-house on the ground floor are set aside as waiting and operating rooms in which persons are vaccinated direct from the calf, while on the first floor are other rooms in which the calf lymph is manipulated, placed in sealed tubes, stored, and distributed. Stable. — This is a building about 18 feet square, which contains stalls for ten calves. Each stall is some- what narrow, but we were informed that this was advan- tageous, as the animal was thus kept more quiet than would otherwise be the case. Attached to the haiter of each animal is a large iron ring, which runs on a vertical iron rod let into the wall of the building, above and below. This arrangement was devised in order to prevent the calves from being able to lick the inoculated area of their body, while, at the same time, it does not prevent them from lying down. The floor of the stable, which is formed of roughened bricks, slopes slightly to a shallow drain on either side of a footway between the two rows of stalls. The building is heated artificially by means of hot-water pipes, and its ventilation is aided by means of an extraction shaft containing a lighted gas jet. At the time of our visit the temperature was about 15° C. The walls are covered with glazed tiles, and the floor is laid with bricks which are impervious to moisture. Both walls and floor are occa- sionally washed down by the aid of a spray of a solution of perchloride of mercury. Calves. — These animals, which appear to be in ever>' respect well suited for the purpose of lymph propagation, are of a special breed, and are obtained from the Depart- ment of Corr^ze in the southern half of France. They are all of a uniform reddish-brown colour, with fairly long, soft hair. Their skin, when exposed by shaving, is seen to be particularly smooth and supple, and it varies in colour from 198 APPENDIX pink to a pale shade of brown. For the purpose of keeping free from urine the straw-bed which comes into contact with the surface of the body operated on, only cow-calves are employed, which vary in age from four to six months, the average being about eighteen weeks. Prior to being brought to the Institut stable, they are kept for about twelve days in a quarantine shed in the outskirts of Montmartre. They are all weaned at the age of two months, and they receive no milk or eggs while at the quarantine shed or at the Institut stable, the food of each calf consisting of— One litre of crushed oats, Two litres of bran, and Three kilos of hay twice daily, at about 6 a.m. and 4 p.m. At both places water is supplied from the town mains. The calves cost, on an average, about 125 francs, with an additional 22 francs for travelling, etc., making 147 francs in all. After use, they are sold to a butcher, at a loss of from 30 to 40 francs. On the day after arrival at the stable the calves are vaccinated. Injection of tuberculin is not employed, as the directors consider this unnecessary, in view of the fact that immediately after collection of the lymph each calf is sent to the abattoir and slaughtered under the personal supervi- sion of a medical man, whose report is awaited before any of the lymph is distributed for use. In the event of any signs of tuberculosis being found, the whole of the lymph derived from this particular animal would be destroyed. Vaccination of Calves. — For this purpose one or more large tubes of glycerinated lymph, which have been kept for at least a month subsequent to its collection and storage, are employed, the directors considering that better results I APPENDIX 199 are thus obtained than if the operation were carried out directly from calf to calf. For the purposes of the operation the calf is strapped to a tilting table somewhat similar in design to those employed in this country, but the right hind leg of the animal is not elevated, and in consequence the mammary region is not exposed, indeed it is not utilised for inoculation. To prepare a surface for the insertion of the lymph the right side of the animal is thoroughly scrubbed with soap and hot water, and then shaved over an area extending between the internal edges of the fore and hind limbs, and from some 4 or 5 inches below the spinal ridge to the umbilicus. The shaved area is next washed with soap and hot water, then with a hot solution of boracic acid, and, finally, with plain hot water. It is afterwards dried with clean soft cloths. A number of superficial incisions, each about i inch long, are then made in a direction at right angles to the long axis of the body, and about a couple of inches one from another. The incisions of the several rows are made en echelo7i. The lancet employed for the purpose has a spear-headed blade, this shape being specially recommended by M. Chambon. Over each incision a drop of glycerinated lymph is allowed to fall from a glass tube, and the drop is rubbed in with the flat portion of the blade of the lancet. The process is carried out by one of the laboratory servants, and is a somewhat lengthy one. When the lymph has dried, the calf is removed from the table and taken back to its stall. Collection of Lymph. — The vaccine material is always collected on the sixth day. The calf is once more placed on the table ; or, if material is required for immediate use only, it is usually allowed to stand. The vaccinated area 200 APPENDIX is washed with warm water and dried with clean soft cloths. Each vesicle is now clamped separately, and the crust first removed with a lancet, which is then wiped on a cloth pinned to the front of the clean cotton blouse which the operator has previously donned. The vesicle is then thoroughly scraped with the edge of a somewhat blunt lancet, and the resulting mixture of lymph, epithelial tissue, and blood is transferred to a small nickel crucible set in a wide wooden stand on a table close to the operator. The crucible is provided with a cover which is kept over it except at the moment when a further addition is made to its contents. The collection of all the vesicular material obtainable from one calf appears to take about three-quarters of an hour. To the pultaceous mass contained in the crucible there is added about an equal quantity of glycerine, which was described to us as " doubly rectified," but which appeared to be of very thin consistence as compared with the best English glycerine. No accurate measurement of the quantity employed is made. The mixture of pulp and glycerine is triturated in a mixing machine devised by Dr. Chalybiius of Dresden, the particular one that we saw being driven by a small electric motor. (A description of this machine by Dr. Chalybaus himself will be found on pp. 222-224.) The mixture, having thus been rendered thin and homo- geneous, is received in a clean sterilised nickel crucible placed beneath the machine, but with a view of still further improving its appearance and of removing any extraneous matters, such as hairs, it is afterwards pressed through a small brass-wire sieve, consisting of extremely fine gauze, into an agate mortar. This is done by means of a bone spoon, and there is left on the surface of the gauze nothing APPENDIX 20I but a very small quantity of epithelial tissue, together with a few hairs. The mixture is further triturated in the mortar with an agate pestle, and is then ready for filling into the tubes in which it is distributed. Storage of Ly7)iph. — The lymph material is next drawn up into a sterilised glass syringe provided with a metal nozzle of such a size that the tubes to be filled can easily be fitted over it. Slight pressure on the piston of the syringe causes sufficient lymph to enter the tube. Each tube is filled about two-thirds full, and is then placed on a porcelain tray, pending its being sealed. This is done without delay by means of a blow-pipe, the air blast of which is provided by means of a pressure apparatus in one corner of the room. The tube is first tilted until the column of lymph occupies the central portion, and it is then held in a horizontal posi- tion, while each end is successively placed in the blow-pipe flame, and, when sufficiently melted, drawn out by means of a pair of forceps, and so sealed. Distribution of LyiiipJi. — The tubes when sealed are placed with a small surrounding of cotton-wool in small light metal tubes provided with a tightly-fitting cover. These cases, if sent out singly, are fitted into a block of wood grooved on one side, being kept in position by a paper label, which is gummed round the block, and which has on one side space for postal address and stamp, and, on the other, directions for use. A register is kept of persons to whom supplies of lymph are sent, and of the calf from which each supply is derived. Academic de Medecinc We also visited the vaccine station of the Academie de Medecine, of which Dr. Her\neux is the director. The general principles on which this institution is conducted are 202 APPENDIX so similar to those which have been set out at length in the description of MM. Chambon and Menard's establishment, that it is unnecessary to enter into similar details again. It should be mentioned, however, that at the Academic de Medecine the calves employed were not of the same breed as those used at the Institut Vaccinal, neither did the vesicles which we had an opportunity of seeing, on a single visit, appear to be quite equal in character to those which we observed at the latter institution. Calf-to-Arivi Vaccination at Nanterre While in Paris we were afforded an opportunity of seeing an extensive series of vaccinations and revaccinations, carried out directly from calf to arm, at the Nanterre House of Detention. The calf, which arrived at the establishment in a closed van, was brought from the vaccine institute of MM. Chambon and Menard, and the vaccinations were carried out by M. Chambon and by one of the medical officers to the establishment. The operations were performed in a small square room, having a door at each of two opposite angles ; opposite the door of entry the calf was tied up to a post, and, in front of and facing it, an assistant took up his position in order to collect the lymph, by scraping slightly one of the vesicles on the calf s abdomen, to which compression forceps had been applied. On his right hand were placed a tray containing lancets and compression forceps, a rack for holding charged lancets, and a glass bowl containing a pad of cotton-wool floating in perchloride of mercury solution. On either side of him, and so arranged as to be able with ease to reach the tray, sat one of the two operators, each of whom had placed in front of him a chair for the vaccinee. APPENDIX 203 The male inmates, each with his shirt sleeve on the left arm rolled up to the shoulder, were admitted by the door opposite the calf, an assistant, wearing an ambulance badge, giving the upper part of each person's arm a brisk rubbing with a cloth soaked in boracic acid solution as he entered, the arm being afterwards dried with another cloth. Two or three warders were also in attendance, who so directed the stream of inmates that each operation chair was refilled as soon as vacated. On an inmate seating himself, the operator took a charged lancet from the rack, with which he made three punctures in an oblique direction, just beneath the skin of the upper arm. The lancet was then dropped into the glass bowl containing the disinfectant, from which, in turn, it was removed by the assistant, who wiped it on a pre- viously sterilised cloth, and the instrument was then recharged. One assistant was thus able to keep the two operators supplied with charged lancets as rapidly as they were required, and it will be obvious that the w^hole scheme of operation had been well devised, and was skilfully and expeditiously carried out, when we mention that during our visit no less than 480 vaccinations were performed in the short space of thirty-nine minutes. Most of the vaccina- tions were revaccinations, some of the inmates having been submitted to the same operation on the occasion of previous admissions to this or similar institutions. Arrangements for Gratuitous Domiciliary Vaccination in the City of Paris As already stated, MM. Chambon and Menard are entrusted, by the municipality of Paris, with the carrying 204 APPENDIX out of arrani^cmcnts for the vaccination and revaccination of the inhabitants ; and on receiving information of the occurrence of smallpox in any part of the city, they make domiciliary visits for the purpose of offering vaccination to persons who may be unable or unwilling to attend the public stations. The notifications as to the existence of smallpox are at once sent on to MM. Chambon and Menard, who then make arrangements to attend at the house or neighbour- hood in question on the following day ; but in the meantime the day and time of attendance are intimated to the inhabitants by means of printed cards having blank spaces for the insertion of the necessary particulars. In Paris each " house," in most of the quarters occupied by the poor and the working classes, is made up of a series of flats, which, again, are subdivided up into dwellings of one or more rooms, the number of persons inhabiting each house being, therefore, much greater than is the case in this country. Each such " house " has a porter's lodge at the entrance, and it is outside this lodge that the notice previously mentioned is displayed, and it is in this lodge also that, at the pre-arranged time, the vaccinations and revaccinations are generally performed. For these opera- tions calf lymph is invariably employed, the process being carried out direct from calf to arm, a previously vaccinated calf being sent to the house from the Institut Vaccinal in a specially constructed van. Occasionally, from want of space in the porter's lodge or other reasons, the calf, after being removed from the van, is allowed to remain in the street, its halter being held by an attendant, while another assistant, taking his seat on a camp stool, pro- ceeds to collect lymph from the inoculated area of the animal's side and abdomen, with the aid of clamp forceps APPENDIX 205 and lancet. Where such procedure is considered necessary, the persons requiring vaccination, whether infants or adults, also are brought out into the street, and the extraordinary spectacle may be witnessed of vaccinations being carried out by the medical staff surrounded by an interested crowd of sightseers. MM. Chambon and Menard attach much importance to this organisation and practice. They say that, under the immediate influence of existing smallpox, large numbers are willingly submitted, both to primary and secondary vaccination, who would otherwise escape ; and they are of opinion that certain classes who might object to be vacci- nated with lymph from an unknown source, find all their objections on this score removed w-hen they actually see the calf which serves as vaccinifer. We were supplied both by Dr. Hervieux and by MM. Chambon and Menard with samples of the glycerinated lymph, w'hich had been collected and prepared on the occasion of our visits. That which was obtained from the Academic de Medecine was collected on loth December 1896. It was used by Dr. Cory at the Board's Animal Vaccine Station for the vaccination of twenty-seven children on 29th December. All the cases were, as usual, vaccinated by means of five insertions of lymph, and the insertion success obtained was 99.3 per cent. That ■ obtained from MM. Chambon and Menard was collected on 8th December 1896 ; it was used by Dr. Cory on 22nd and 31st December, and on 7th January 1897, for the vaccination of ninety-six children, and every one of the five insertions succeeded in every child. [It should be stated, however, that these specimens of lymph obtained from Dr. Hervieux, and from MM. Chambon and Menard, respectively, were all found to contain large 206 APPENDIX numbers of extraneous microbes wlicn examined by the method of plate-cuhivation, even after the lapse of four weeks from the date of preparation. This fact is, no doubt, to be accounted for by reason of the percentage of glycerine employed not being sufficiently large. MM. Chambon and Menard informed us that they do not profess to attain bacteriological purity in the lymph distributed from their establishment. — S. M. C] Brussels At Brussels the propagation, storage, and distribution of calf lymph is carried out at the Ecole Veterinaire, under the supervision of Professor Degive, the director of that establishment. The building set apart for the calf lymph station contains the director's room, a distributing room, an operating and preparation room, and two stables. As, however, we were informed by Professor Degive that the accommodation at present provided is regarded as very insufficient for the purpose, and that a new vaccinal institute is about to be erected, it would serve no useful purpose to enter into a detailed description of the present building. Stable. — The stable, which is a detached building, con- tain stalls for six calves, three on either side of a central footway, and the stalls are so arranged that a space is also left between them and the side walls of the building. The stalls are very narrow, and, at the end furthest from the central passage, have two iron uprights fastened to the sides of the stall. Iron rings, which are attached to the animal's halter by means of steel clips, slide up and down the uprights. This arrangement permits the calf to stand up I APPENDIX 207 or lie down, but prevents all possibility of its licking the inoculated portion of its body. The stable is warmed by an iron stove, the temperature at the time of our visit being 15° C. It is ventilated by windows opening inwards in the upper part of the two outside walls, and the removal of vitiated air is further facilitated by four outlet ventilators, each about 6 inches square, and placed just above the floor level, the up-draught being aided by means of gas jets in the outlet shafts. Calves. — The calves are not of any special breed, and those that we saw did not seem to be so well suited for the purpose of lymph propagation as certain of those thus employed at the Institut Vaccinal in Paris. Another point of difference is that at Brussels male animals are used exclusively ; Dr. Degive believing that the finest vesicles are obtained on the scrotum. For the first four days after their reception the calves are kept in a separate " Cjuaran- tine" stable. On the day prior to vaccination they are swung, by means of a belly-band and an arrangement of pulleys, into a wooden, zinc-lined, tank bath, capable of containing sufficient water to cover nearly the whole body. The temperature of the water is kept at about 30° C. In this bath the calves are scrubbed all over with soft soap. After removal from the bath, the skin is thoroughly dried with cloths, and the animal is then placed in the stable adjoining the operating room. Each calf is injected with i }f cubic centimetres of tuber- culin on the day prior to vaccination, but Dr. Degive considers this an unnecessary precaution for the reasons that {(i) tuberculosis is very rare in calves, and that {b) no lymph is distributed until the animal from which it was obtained has been slaughtered, and necropsy has made it 2o8 APPENDIX certain tliat the animal was not the subject of tuberculosis. In the event of tubercle bein^^ found, the lymph would be destroyed. The age of the calves employed averages from ten to four- teen weeks, but animals four months old are sometimes used. The food of the calves consists principally of milk and eggs, each calf receiving, in twenty-four hours, 12 litres of milk and four eggs, together with a little hay, which is placed in each stall for the animal to eat if it is so disposed. Inoculation of Calves. — The calf is fixed, by means of ropes, to a tilting table of somewhat primitive construction, the right hind limb being elevated, as is usually done in England. A leather blinker is also fastened over the head. The right side and the abdomen are washed with soap and water with which lysol is mixed, and the surface is then shaved. The skin is afterwards washed with warm boracic acid solution, then with hot boiled water, and it is subse- quently dried with cloths which are sterilised by steam just previous to use. All instruments are also boiled in a solution of boracic acid. The lancets employed are similar in form to those devised by M. Chambon, while the com- pression forceps appeared to be of somewhat old design and needlessly heavy. The operator and his assistants all wear white blouses, which, just previous to use, have been sterilised in an autoclave. Incisions, about 2 or 3 inches in length, are made at right angles to the long axis of the body, all over the shaved area of the skin, and also on the scrotum ; the average number for each calf being about 150. The incisions, which in each case are double, are made with a dry lancet, and are placed e7t echelon., and about a couple of inches distant one from another. APPENDIX 209 The lymph employed for vaccination is kept in stock for, at least, six weeks previous to its use ; it consists of vesi- cular pulp which, at the time of collection, is simply mixed with twice its weight of glycerine and is then kept in a glass tube, the mouth of which is closed with a cork fixed with paraffin until required. Just before it is needed for inoculation of a calf the pulp is ground up in a small agate mortar with a further small quantity of glycerine. The resulting emulsion is well rubbed into each separate incision on the skin by means of a thin ivory instrument resembling a small paper-knife ; the edge being passed up and down each incision several times. Collection of Lymph. — On the sixth day the calf is again fixed on the operating table, and the vaccinated area is once more washed with warm water or sterilised salt solu- tion and dried with sterilised cloths. The lymph required for stock purposes is then first collected. For this purpose compression forceps are applied to each vesicle separately, and the crust is first carefully removed with the edge of a lancet. These crusts are collected in a watch-glass, and are employed for the vaccination of children. The vesicular pulp is next removed by scraping with the lancet, and the material is collected in another watch-glass or Petri dish and weighed. Glycerine is added to it from a stock bottle to the extent of about twice the weight of the pulp, but the amount is only roughly estimated, no actual measurement or weighing being deemed necessary. The pulp and glycerine are stirred together, and are at once placed in a glass tube of such a size as to ensure its being almost entirely filled with the material available ; it is then fastened down by means of a glass stopper or cork, without further manipulation. When sufficient pulp for stock purposes has been P 2IO APPENDIX I obtained, the remainder of the vesicles are scraped off with a Volkmann's spoon, and the material is mixed, as before, with glycerine, without trituration. The glycerine employed was stated to be of English manufacture, but was much thinner than that usually sold in this country, giving the impression, indeed, that it had been considerably diluted with water. It is sold as being " chemically pure." Storage and Distribution. — Just as is the case with what is termed the " stock " supply, this material is ground down in a mortar, with more glycerine, before being distributed for use. According to the amount required, the emulsion is either stored in tiny stoppered bottles, which are supposed to contain enough material for 25, 50, or 100 vaccinations; or, when a less quantity is desired, the material is placed in a slight excavation on the surface of a small glass plate about I inch square, and a plate of a similar size, but not hollowed out, is slid over it. The edges are sealed with paraffin, and the whole is wrapped round, first with tinfoil, and then with paper. The small bottles are fitted into blocks of wood, bored with holes for the purpose, in order that the parcel may go safely through the post. To each package is attached, by string, a doubled card, which can be addressed outside, and which, inside, has spaces for particulars as to number of vaccinations carried out, the number of insertions in each case, and the amount of success which results. The lymph which was supplied to us by Professor Degive was used for certain bacteriological investigations ; hence we have no record as to its success when used for the pur- poses of vaccination. But, from a number of returns made I APPENDIX 211 by different vaccinators to Professor Degive, we found that these showed a high percentage of insertion success. While at Brussels, we also visited the Municipal Vacci- nation Station, of which Dr. Janssens, the Medical Officer of Health, is director. We were informed that the station, which consists of a waiting and an operating room, is open daily, but that, practically, no children are brought for vaccination during the winter months. This was unfortunately the case at the time of our visit, so that we had no opportunity of seeing the work in actual operation. The lymph employed is received in small glass-stoppered bottles from Professor Degive, of the Ecole V^terinaire. Berlin The Animal Vaccine Establishment at Berlin, of which Dr. Schultz is the director, is situated in the Central Meat Market, on the outskirts of the city. The station consists of three parts connected with each other: (i) A large stable containing stalls for the calves ; (2) a work-room fitted with two tilting tables, somewhat similar to those in use in England, on which the calves are vaccinated, or the " lymph " collected ; and (3) the director's room, in which the lymph is triturated, glycerinated, and stored. This room contains cupboards and benches, and is fitted with all the necessary bacteriological apparatus, glassware, and instruments ; the latter being made entirely of metal, so as to admit of their being readily sterilised. Calves. — Cow-calves are almost invariably used, as less likely, when they lie down, to foul with their urine the vaccinated area of the abdomen than are males. The calves employed are usually from about six weeks to three 212 APPENDIX months old. They are received forty-eight hours before they are required for vaccination, and are at once injected with half a gramme of tuberculin. If their temperature should rise above 41° C. during the next twenty-four hours they are not employed for the production of lymph. The calves are fed on a mixture of milk, eggs, and corn-flour, of which the milk is always sterilised prior to use. Vacciiiatioji of Calves. — When placed on the table, the abdomen is shaved from the \ulva to the umbilicus, and a portion of the inside of each thigh is also shaved. The surface of skin thus exposed is carefully scrubbed with soap and water, washed with a solution of corrosive sublimate i-ioooth, and then again washed with boiled water. The operator also washes his hands carefully, using carbolic soap, and before commencing to operate puts on a white cotton blouse over his coat. The calf s skin having been dried with a clean towel, long parallel incisions are then made over the whole length of the abdomen, and also over the shaved portion of the thighs. These incisions, which are made with a blunt knife, so as to draw as little blood as possible, are hardly a quarter of an inch apart, and are about 18 to 24 inches in length on the surface of the abdo- men. If any blood appears along the line of the incisions it is removed by means of sterilised blotting-paper. A few grammes of stored glycerinated lymph, prepared some weeks or months previously, are next poured on the abdomen and spread over the incised lines with the back of a scalpel. Collection of Lymph. — On the fourth or fifth day (96 or 120 hours after vaccination) the calf is again placed on the table. After a thorough cleansing of the skin in the same manner as before, absolute alcohol is poured over the vaccinated area. When the alcohol has evaporated the surface is treated with ether, which is supposed to exert I APPENDIX 213 a bactericidal, in addition to its anaesthetic action. The use of alcohol and ether has, however, been discontinued since the date of our visit, soap and water merely being now employed. Then the skin is put on the stretch and scraped, in the direction of the incisions, with a rather blunt " Kartoffel Loffel." This spoon is taken over each portion of the vaccinated surface 07ice only, so as to avoid, as far as possible, admixture of blood ; and by this means all the epithelium which has undergone vesicular changes, caused by the action of the specific virus, is removed in long strips of about one-eighth inch wide. Compression forceps are not needed, and the whole operation is completed in a few minutes. Preparatiofi of Lymph. — The whole mass of epithelial tissue removed by the spoon is collected and emptied into a glass Petri dish, and afterwards it is weighed in a delicate balance. Seven times the weight of cold boiled water and a similar quantity of glycerine are then weighed out separately. A small portion of the water is added to the dish containing the tissue scrapings, and after being stirred together the mixture is passed between the small porcelain or glass rollers of a mixing mill, invented by Dr. Doering. Description of Dr. Doering's Lymph-Grinding Machine The apparatus consists of an iron frame, resting on a metal base, and carrying four unsealed glass rollers. These are easily removed and sterilised, but care is taken that each roller is replaced in its original position. The spindles lie in slots, and by means of springs the rollers are pressed against each other. The rollers are 214 APPENDIX made to revolve by cog-wheels attached to the spindles on the exterior of the frame. The whole system is set in motion by turning the wheel No. 3 with the handle (which is screwed to its spindle) in a direction from the operator. The mixture, lymph -pulp and glycerine, on being poured between the upper two rollers soon becomes dis- tributed over the lower system as well. After it has reached roller No. i, it is scraped off by a glass plate placed below, the edge being pressed against the rollers by a spring. From the plate the lymph emulsion flows into a square porcelain dish provided with a spout. To prevent the lymph spreading to the ends of the rollers, glass guides are attached to rollers Nos. 2 and 3, which conduct the emulsion towards the centre. The method of w^orking is as follows : — After loosening the grips, right and left, fold back both arms and remove rollers Nos. 3 and 4. Unscrew both glass guides and lift out the bridge together with rollers Nos. 2 and i. Rollers, glass guides, and glass plate are then sterilised, which process may be accomplished without withdrawing the spindles or removing the glass guides from their clamps. The apparatus can be put together again in a few minutes. To do this, first replace the glass plate and then rollers Nos. i, 2, and 4. Next press roller No. 3 gently back into position. Then fold over both arms, and finally fix the bridge and guides by means of the side-screws. The mixture of lymph-pulp and glycerine is now poured little by little between rollers Nos. 3 and 4, the larger shreds of epithelium being taken up and placed in position by means of forceps. A second person turns the handle, and, in a short time, the mass, now more or less finely PLATE Xr. Lymph-mixing machine of Dr. Doring, Berhn. I APPENDIX 215 triturated, appears on roller No. i, from which it flows into the porcelain dish placed beneath. After the whole quantity of material has passed through, the resulting emulsion is stirred with a sterilised glass rod, more glycerine is gradually added, and the mixture is then passed a second and, if considered necessary, a third time through the machine. The lymph after such further passage through the mill forms a homogeneous emulsion, the individual particles in which are of exceptional fineness. The loss of material during preparation is exceedingly little, and the working up of the produce of a calf, amount- ing to about 20 grsimmes, can be completed in twenty minutes. Formerly, it was the custom at this station to add both glycerine and water to the epithelium partly before and partly during its passage through the mill. For some months past, however, it has been the practice not to add the glycerine until after the material has been twice passed through the mill. This grinding process is effected with more difficulty in the absence of glycerine ; but the reason for the alteration is that much of the lymph is now centrifugahsed,i a method of pro- cedure which would be unduly prolonged if the specific gravity of the emulsion operated on had previously been increased by the addition of glycerine. The centrifuge at present in use is a small two-armed instrument worked by hand ; its use involving the employment of an extra assist- ant for at least a couple of hours. At the end of this time ^ This process, which was only tentative, has now {1898) been in great measure abandoned. 2i6 APPENDIX the minute shreds of epithelium contained in the mixture have settled into a compact mass at the bottom of the tube, and the supernatant fluid is only very slightly opalescent. This is decanted off, and an amount of glycerine equal in weight to that of the water previously employed is in- timately mixed with it, after which the resulting "lymph" is stored in a stock bottle fitted with an indiarubber stopper and cap ; or it is put up in small glass tubes of I cc. capacity, each of which contains, according to Dr. Schultz, sufficient material for loo vaccinations. The amount of vesicle pulp collected from a single calf varies from lo to 15 grammes. This, when intimately mixed with the usual amount of dilute glycerine, is calculated to provide sufficient material for the vaccination of, at least, I 5,000 persons. This process of centrifugalisation is as yet only tentative and experimental. The appearance of the " lymph " is thought to be improved by its adoption, and, when tested by the method of plate cultivation, it is found to be freer from "extraneous" microbes than is an equivalent amount of the emulsion when tested before treatment in the centri- fuge. Objection, however, to the employment of the method might be based on this freedom if, as there is every reason for believing, the microbe specific to vaccine is present in a far greater amount within the cells of the vaccinated dermis than in the intercellular lymph spaces. Even if free in the fluid portion of the mixture, and of exceptionally minute size, the continued action of the centrifuge must tend in time to remove them, just as is found to be the case with other microbes which may be present. The amount of glycerine and water employed in the preparation of vaccine material has been considerably I APPENDIX 217 decreased during the past twelve months, the relative pro- portions being at present : — Epithelial pulp . . . . i part Glycerine ..... 4 parts Boiled water .... 4 parts All " lymph " is now tested bacteriologically by means of plate cultivations, before being distributed. This is done in consequence of the recommendation of a scientific committee of which Professor Koch was a member and which has recently been sitting at Berlin to inquire into the whole subject of the collection, purification, and preserva- tion of vaccine lymph. Seaso7i of Calf Iiiocidatioiis. — Inoculations are only carried out in the months of May, June, and July. The calves being themselves vaccinated with stored glycerinated lymph, it is not necessary to keep going a continuous series ; and in these three months sufficient lymph is manufactured for use during the whole year, throughout one of the largest of the eight districts into which the kingdom of Prussia is divided for vaccination purposes. Disposal of Calves. — After collection of lymph, the calves are sold to the Jewish Rabbi to be slaughtered for food. We were informed that a larger price is given for them than is ordinarily the case with calves brought to the Central Meat Market, owing to the fact that they are in such fine condition as the result of good feeding while at the station. Glycerinated calf lymph, collected and prepared as above stated on the occasion of our visit on loth January 1897, was used by Dr. Cory for the vaccination {a) of thirty children on 19th January, with an insertion success of 97.1 per cent; {b) of six children on 21st January, with an 2i8 APPENDIX insertion success of 86.6 per cent ; {c) of forty children on 25th February, with an insertion success of 92.3 per cent ; and of thirt,y-three children on 4th March, with an insertion success of 67.5 per cent. This sample of glycerinated lymph was again used after having been kept until six months had elapsed since the date of its preparation. It was then found that its activity as vaccine lymph had practically disappeared. It is right to state in this connec- tion that at the Board's Animal Vaccine Station there are, as yet, no means of storing lymph elsewhere than in the somewhat high temperature at which the operating rooms are maintained. Dresden The Animal Vaccine Institute, of which Dr. Chalybaus is director, is situated in the northern suburbs of Dresden. It consists of a small two-storied building, containing, on the ground floor, an operating room and three other rooms, while the whole of the first floor is utilised as a dwelling for the caretaker. Adjoining this building is a small stable containing stalls for the calves. Dr. Chalybaus informed us, however, that the Animal Vaccine Institute was hardly arranged in accordance with modern requirements, having been established more than twelve years ago, when the present methods of preparing lymph were not in vogue. The stable in which calves are placed on arrival contains two stalls and a tank bath in which the animals are thoroughly washed before use. The calves are lifted into and out of this tank by means of belly-bands attached to a system of pulleys fixed to the ceiling. After having been dried with cloths they are vaccinated and then placed in another stable on the opposite side of the house. APPENDIX 219 The calves are bedded in their stalls on fine wood shavings, which are said to have the advantages of being clean, dry, and comfortable. The operating room is about 20 feet square, and contains two tables. One of these is for calves ; the other, of larger size, and fitted with mechanical arrangements for tilting and raising, is for young bullocks, which are occasionally employed for purposes of vaccination, when either an extra amount of lymph is required or when it has been impossible to obtain the required number of calves. By preference. Dr. Chalybaus employs cow-calves of from six to eight weeks old. The calf table is an oblong, shallow trough of wood, provided with straps and with two iron uprights at one end, to which the hind limbs of the calf are fixed in a V-shape. This method of fixation, however, enables the animal to struggle to such an extent as to raise its hind-quarters com- pletely off" the table. After having been shaved, and before vaccination, the animal's skin is washed with soap and hot water containing lysol. The soap suds having been washed off" with more water, and the skin dried with a cloth, benzine is poured over the surface to render it more aseptic, and is rubbed in with sterile sponges of gauze, which are kept for use in a sterilised glass-stoppered bottle. Lengthy incisions are next made with a blunt scalpel, in the long axis of the body, over the inside of the thighs and over the whole surface of the abdomen from the vulva to the umbilicus ; also over the lower ribs. Glycerinated lymph which has been stored in sealed tubes for from three to as long a period as eighteen months is next rubbed in over the area of the incisions w-ith the flat surface of a small trowel-shaped instrument. 220 APPENDIX We were informed that much difficuhy is experienced in this estabhshment in obtaining calves suitable for purposes of vaccination, as throughout Saxony it is the custom to slaughter these animals for food at a very early age, some- times within a few days of birth. This being so, calves have to be imported from a distance, most of those employed by Dr. Chalybaus coming from Berlin or Hamburg. They are obtained by a local cattle-dealer, who charges twenty marks for their use, and who removes them for slaughter immediately after collection of the lymph. Calf-to-arm vaccination is never employed in Saxony, as it is thought to be undesirable to use lymph from an animal until a necropsy has shown it to have been entirely free from disease. CoUectioji of Lymph. — The lymph, or rather the vesicle pulp, is collected after an interval of four complete periods of twenty-four hours. The skin is first washed with white soft soap and hot water, the operation being carried out with the aid of a large house-painter's brush. Such crusts as have formed are removed as far as possible with the edge of an ordinary metal teaspoon, after which glycerine is poured over the skin and rubbed in with gauze sponges. The pulp is collected by scraping with a Volkmann's spoon, but as Dr. Chalybaus goes over the same surface again and again, a not inconsiderable amount of blood becomes mixed with the epithelial scrapings. The raw surface of the abdomen is afterwards dusted over with fine oatmeal. The pulp thus collected is weighed and is then run through a mixing machine invented by Dr. Chalybaus, of which a special description, written by him, together with an illustration, is appended to this report. The necessary I APPENDIX 221 motive power is supplied from a small water motor fixed beneath the floor of the room. After being ground up in the machine, four times the amount of a mixture of glycerine and sterilised water (water 3 parts, glycerine i part) is added to the vesicle pulp, and the whole is then run through once again to ensure thorough admixture. The resulting emulsion is received into a porcelain mortar placed beneath the machine. The mortar is removed when all the material has passed through, and its contents are then taken up by suction into tubes of somewhat large calibre which, when filled, are closed at either end by means of sealing wax. Dr. Chalybaus considers that i gramme of glycerinated emulsion is sufficient for 80 vaccinations. The vesicle pulp obtained from a single calf affords from 50 to 75 grammes of the glycerinated emulsion ; or, in other words, enough for the vaccination of from 4000 to 6000 persons. Glycerinated calf lymph, collected and prepared by Dr. Chalybaus on the occasion of our visit on 12th January 1897, was used by Dr. Cory for the vaccination of 15 children on 21st January. The children were, as usual, vaccinated by means of five insertions, and every insertion gave a successful result. [A further sample of lymph collected on 12th January 1897 was employed by Dr. Cory nearly six months later, for a further series of vaccinations. As a result he again attained complete insertion success. The lymph examined bacteriologically at this date by the method of plate cultivation was found to be completely free from extraneous micro-organisms. — S. M. C] 222 APPENDIX {Translatiofi.^ Report of the Royal Institute for Vaccination IN Dresden. About the Techinqiic of Prepaniig Animal Lymph^ by Dr. Chalybiius^ Dresden. As a rule, the exclusive use of animal lymph for vaccina- tion has been everywhere adopted, whilst the use of human lymph, taken from children, has been almost entirely abandoned, and public institutes for vaccination prepare only calf lymph. The preparation of animal lymph needs special contrivances, because the lymph scraped out of the "smallpox of a calf," in order to make it available, must be triturated and ground to a fine pulp, and with the addition of glycerine, turned into a thin and homogeneous emulsion. When triturated in a dish or bowl, this operation takes, for the quantity of lymph obtainable from one calf, three hours' time, and cannot therefore be done by the physician himself ; nevertheless, great care must be taken, as it is unwise to leave that part of the preparation of lymph to a common workman, who cannot be properly and continuously watched. As far back as 1889 I constructed a machine for triturating lymph, which stood the test of use in the Institute of this country and of those of many others. In 1893 the machine was improved. It is now fitted upon the marble table of a sewing engine, and moved either by foot or, still better, by means of a small hydraulic, steam, or electric motor. A cylinder formed out of two equal parts, having in its inside threads of a screw, is attached to the shank of a column ; a close-fitting spindle, likewise provided with threads of a screw, turns in the cylinder. Through a Pr.ATK XII. Lymph-mixing machine of Dr. Chalybaus, Dresden, as modified for use in the laboratories of the Local Government Board. APPENDIX 223 funnel the raw lymph is put into the upper end of the cylinder ; in turning the spindle the lymph is rubbed and ground to the utmost, and leaves the cylinder on the lower opening, dropping into a glass dish. By means of this contrivance the preparation is com- pleted in about fifteen minutes, although the work is done in a far better way than as usually in a dish. The lymph, consisting of coherent and liquid parts, is thoroughly rubbed, not only squeezed, and turned into homogeneous emulsion. It does not lose its natural colour, nor does it get warm. The apparatus is made of steel bronze, and its parts, comprising cylinder, spindle, and funnel, can easily be separated and disinfected in boiling water or otherwise. The trituration occurring whilst the apparatus is closed — the opening of the funnel is closed by a cover of glass — no dust can enter, and should a calf hair accidentally have dropped into the lymph it can be removed whilst the lymph slowly drops out of the cylinder. No loss of lymph can occur, because the machine retains none of the material with which it is fed. The machine can be obtained through the Royal Institute for Vaccination, in Dresden, price 200 marks. Every machine is tested by the president of the above-mentioned institute, and a certificate is granted to each one sent out, as a proof of its fitness. Directiotis for iesi7ig the Machine for trittirating LyvipJi^ invented by Dr. Chalybdus I. To take the machine to pieces^ slack the screw in claw yon which the driving-wheel g and spindle c are attached. Open the claws and remove the spindle and' driving-wheel g^ taking care not to let the former drop. Take off funnel b^ slack screw of lower clamp d^ and unscrew the middle 224 APPENDIX clamp r, holding the cylinder in the left hand. Take the cylinder out of the support //. In order to separate the two parts of cylinder, use a small piece of wood by inserting it in the hollow, but care must be taken not to drop the parts when separated. Remove the driving-wheel from the spindle, and clean it, as well as the spindle and funnel, with a brush, and sterilise in boiling water. 2. To put the Diachijie together^ first join both parts of the cylinder, put on the lower clamp and turn its screw a little, pass the cylinder vertically through the support, and place the funnel on the top of the cylinder. Then screw the driving-wheel on the upper part of the cylinder, open the claws and insert the spindle so far that the claws grasp the spindle close under the driving-wheel, shut the claws, and screw tight. Bring the lower ends of spindle and cylinder exactly in a line and fasten the lower clamping screw. Finally, adjust the belt on the driving-wheel. 3. To put the j?iackme in niotioji^ move the fly-wheel k outwards, and to avoid friction use vaseline for lubricating the moving parts. It is advantageous first to run some glycerine through the cylinder, after which the lymph is placed in the funnel and the cover adjusted. If preferred, however, glycerine can be added to the lymph, and the mixture passed through the machine. The finished lymph leaves the lower end of the cylinder and drops into a small glass vessel i. Cologne The buildings provided for this Institution are the most recent of their kind in Germany, and, as we were informed previous to our visit, all the fittings are of the most modern description. We visited the Institution with Dr. Vanselow, where we I APPENDIX 225 were also met by the assistant director, the veterinary surgeon attached to the staff, and certain other gentlenien. Dr. Vanselow presented us with a reprint of a paper written by him, showing a description of the buildings, illustrated with blocks giving the elevation and ground plans. 1 We append a translation of this, so that it is unnecessary here to enter into any details as to structure. Stable. — The calf stable, which adjoins the collecting room, contains ten stalls, one of which is reserved for any calf used for experimental purposes, while another is merely a pen forming the platform of a weighing machine. The sides and ends of the stalls are formed solely of a series of iron bars, painted grey, and they are of such narrow width as to make it impossible for a calf to turn round, it being thus prevented from licking the inoculated area of its abdomen. Each stall is provided with a gate at either end, opening outwards, and bears a numbered label of iron. The flooring of the whole stable is formed of cement concrete, over which in each stall is placed a wooden rack or platform which is raised about 3 inches from the floor. These racks are formed of wooden splines about 2 inches square, placed close together, the upper edges of each spline being slightly rounded. On these racks the calves stand or recline, no bedding of hay or straw being employed. Calves.— T\\t. calves range usually from about six to eight weeks old. They are purchased in the meat market which immediately adjoins the establishment. The calves required for the current week are bought on Monday, and they are sold on the following Saturday, after their slaughter and the collection of lymph on the previous day ; so that the stable is always empty from Saturday to the following Monday. The calves are kept under observation in the ^ Plans not reproduced here. — S. M. C. Q 226 APPENDIX stable for twenty-four hours after their reception, and are vaccinated on Tuesday. Only three complete days are allowed for the progress of the local results of vaccination. On Friday the animal is slaughtered in a small slaughter- house opening off from the stable, and immediately it is dead the carcase is brought into the collecting room on a trolley, the abdomen washed, and the epithelial pulp of the vaccina- tion area is removed by means of a sharp spoon. Vacciiiatio?i of Calves. — We did not see the process of vaccinating the calves, but we learnt that it was carried out in an exactly similar fashion to that employed at the Berlin and Dresden stations, namely, by long parallel incisions over which glycerinated lymph is rubbed by means of a spatula or other flat-bladed instrument. The lymph employed for the vaccination of calves is always kept for a period of at least six weeks after glycerination, in order to ensure that it shall be as free as possible from extraneous organisms before it is used to vaccinate the calves. After collection of the lymph pulp, and while it is being prepared for use, the carcase of the calf is taken back to the slaughtering room, where it is skinned and opened. The internal organs are removed and brought in on trays to be examined by the veterinary surgeon. In the event of his forming the opinion that any of the organs presented any condition indicative of disease, the lymph derived from the animal in question would be at once destroyed. In view of this precautionary measure it is not deemed necessary to test the calves by the injection of tuberculin prior to their vaccination. Collection a?id Preparation of Lynipli. — The greatest amount of vaccine is collected during the months of March, April, and May, when from six to eight calves are employed I APPENDIX 227 every week. For the remainder of the year the weekly vaccination of one or two calves is found to be sufficient to supply all the lymph required for human vaccinations and revaccinations in the Cologne district. In the preparation of the lymph material the epithelial pulp from the vaccinated area is removed by scraping with a Volkmann's spoon, and is received in a small glass dish. In this it is wreighed, after which it is turned out into a mortar and thoroughly triturated ; at first without any addition of water or glycerine ; later, small quantities of water are gradually added to the extent oi five times the weight of pulp. The mixture having been ground up still further, double the quantity of glycerine is finally incor- porated. Thus, at the time of our visit, 10 grammes of pulp having been collected from one calf, the composition of the finished emulsion was as follows : — Pulp . . . .10 grammes Water . . . • 33-5 ,. Glycerine .... 66.5 ,, Dr. Vanselow informed us that this quantity would suffice for the vaccination of 5000 children. The emulsion is afterwards forced into small bottles and tubes by means of a machine actuated by water power. This machine, which is manufactured by a Vienna firm, appears to be decidedly useful and convenient, and is capable of being worked in connection with any form of pressure apparatus. The small bottles are of different sizes, and contain lymph sufficient for 50, for 100, and for 150 vaccinations respectively. The bottles and their corks are all of them sterilised prior to use. We were struck with the numerous precautions which 228 APPENDIX are taken in this institution to ensure thorough asepsis throughout the various stages of lymph production. Thus, in the collecting room, the flooring is of cement concrete, the walls are lined internally for about half their height with opaque glass tiles, the upper half being of Parian cement. The shelves are of glass supported on iron brackets, and the surface of all tables consists of thick slabs of glass over green cloth, the glass being removable if necessary. The institution is furnished throughout with electric light, and sterilised hot water is supplied as needed from a small apparatus affixed to the wall of the collecting room. Indiarubber pipes used in connection with the hot- water apparatus and the pressure apparatus employed for filling tubes are kept in a strong solution of carbolic acid when they are not in use. The director and all his assistants wear linen covers over their clothes, but only the sleeves, which are detachable, appear to be sterilised prior to each occasion on which they are used. On the first floor of the building is a bacteriological laboratory, which is reached from the collecting room by an iron spiral staircase. It is fitted up with an autoclave, incubators, etc. But owing to the director being engaged in private practice, he has no time to work in this laboratory, which is, therefore, only used when it is desired to sterilise cloths, instruments, or glass-ware. With the lymph and pulp material collected and glycerinated in our presence on i6th January 1897, Dr. Cory vaccinated thirty-four children on 19th January, with an insertion success of 98.8 per cent, and twenty-one children on i ith February, with an insertion success of 93.3 per cent. APPENDIX 229 ( Translation) The Royal Lymph Station for the Rhine Province AT THE New City Cattle and Slaughtering Establishment, Cologne, by Sanitary Coun- cillor, Dr. Vanselow, Director. The public institution for the preparation of animal lymph to meet the needs of the Rhine Province and the Hohenzollern districts was erected in Cologne in 1889. The rooms at the old slaughtering establishment which were used until 1895 were extremely defective, being narrow, damp, and dark, and rendered any practically uniform arrangement impossible. In building the new cattle and slaughtering establishment, the provision of a suitable annexe for the production of lymph was borne in mind from the very first ; and so the present institution originated, which meets all the demands of hygiene, and may justly be regarded as the prototype of such institu- tions. The annexe is situate at one end of a large cattle shed, both having a common partition. The main front faces the north, so that all the rooms, as there are windows only in the front, receive their light equally distributed from that direction. The building is very solidly built, but under- cellared only, and to the smallest extent, on the eastern side. As, however, the whole of the ground was filled in, and only absolutely dry and permeable material employed, there is no fear of any dampness of the rooms. On the ground floor of the building are the corridor, collecting room, calf stable, slaughter room, doctor's room, office, and a closet. On the first floor, which is reached from the collecting 2;o APPENDIX room by a convenient winding staircase, is the laboratory, adjoining which, on both sides, is a large garret. The entrance to the building is from the street, and so arranged that the cattle establishment has not to be traversed in order to enter ; the wall belonging to the entrance being continuous with the wall which encloses the cattle estab- lishment. The calves are driven into the station through the doorway of the slaughtering room, which lies at the opposite end of the building. While the floors of the slaughtering room, calf stable, collecting room, and laboratory are of concrete, the doctor's room and the office have inlaid wooden floors (parquetry) ; the corridor and closet are laid Avith "Mettlacher" tiles; and, finally, the rooms in the roof (garrets at the sides of the laboratory) are laid with floor boards. In the slaughtering room, calf stable, and collecting room the floor is slightly sloped in one direction, and at the lowest point there is a drainage outlet which is shut off by a small intercepting trap. The height of the rooms on the ground floor is 3^ metres, except the collecting room, however, which is 4| metres in height, and that of the laboratory is 3 1 metres. All the rooms on the ground floor are vaulted with plain solid arches. The laboratory and garrets have rafters and wooden ceilings. The collecting room, calf stable, and closet are lined, to the height of i\ metres from the floor, on all four sides, with white opaque glass tiles ; the slaughtering room, on three sides (the door side is excluded), to the same height with white glazed tiles. The remaining part of the walls in these rooms is painted with white porcelain enamel. The walls in the doctor's room and the office are papered. In the laboratory and corridor the walls are painted with oil paint. The collecting room is brightly lighted by a window 4 metres wide by 3 metres APPENDIX 231 high. The light entering becomes strongly reflected by the brilliant white walls. The laboratory has three windows, the calf stable two, and the doctor's room and office one large window each. The closet and slaughtering room have each one small window. All the rooms are, therefore, amply lighted. The calf stable contains eleven stalls for the reception of the calves, i.e. six on one side and five on the other side of the centre passage. The stalls are so constructed that the wall nowhere forms the boundary of a stall, and a clear passage is thus given all round the stalls ; they are each 70 centimetres wide and 150 centimetres long. The enclosures are formed of iron lattice - work ; at the two narrow sides of each there is a door permitting the calves to be taken in or out by either side according to con- venience. The iron lattice -work is painted a light grey colour, so that every speck of dirt can at once be seen and removed. On the floor of the stalls he wooden gratings. Upon the space which would correspond to the twelfth stall a weigh -bridge is sunk, enclosed with the above- described iron work ; this machine allows of the calf being weighed while being taken through. The hollow in which the weigh -bridge stands has also a smell -preventing arrangement. The ventilation of the stable is obtained by a large tube which passes through the garret above. The collecting room has a flap ventilator in the window, as shown on the plan. Between the calf stable and collecting room there is an arrangement of double doors, one of which is thickly padded. The doors, padding, and through-air draught isolate the collecting room both from smell and noise. The closet is a so-called " Unitas " closet. Water is supplied by the city main, and in every room a sink is provided. The lighting is by electricity ; in the laboratory 232 APPENDIX however, the " Auerches Gliihlicht " (a form of incandescent light) has been found preferable. The heating is effected by means of American stoves ; for the doctor's room, however, a gas stove has been pro- vided by reason of its greater suitability. Large gas stoves serve for the heating of the water and milk. For the storage of considerable quantities of lymph a sufficiently large room is reserved in the refrigerating house of the city cattle establishment. The furniture provided for the institution is worthy of the handsome rooms, and consists throughout of oak. The laboratory is completely fitted for bacteriological investiga- tions, containing all sterilisation apparatus — thermostats, an excellent microtome, microscopes, centrifuge, etc. The extent of the lymph production may be understood from the following figures : — In the year 1894 about 356,000 portions of lymph were issued, and in this year (1895) the number of portions will nearly reach 400,000. Geneva The Institut Vaccinal Suisse, which was visited by one of us (Dr. Copeman) only, is situated at Lancy, on the out- skirts of Geneva. It was founded in 1882 by M. Charles Haccius, the present director of the establishment. Originally a private venture, it is now recognised by the various cantonal Governments, M. Haccius, in considera- tion of an annual subvention, supplying to public vaccinators throughout Switzerland, free of cost, all the lymph required by them in the performance of their duties. The building in which the Vaccine Institute is housed adjoins a model dairy, also established and carried on by M. Haccius. The institute building contains two stables APPENDIX 233 for calves, an operating and collecting room, a laboratory, a room in which the packing and distribution of the lymph are carried out, and the director's room. Stables. — Each of these contains four stalls. The side walls of the reception stable are of concrete ; those of the stable adjoining the operating room are of wood. The floors of both stables are of concrete. The stables are kept at a temperature of 18° C. to 20" C. Calves are received into the first-mentioned stable, and are there kept under observation for four or five days, at the end of which period they are passed into the stable next the operating room. The bedding of the stalls consists of fine wood shavings, this material being, in the opinion of M. Haccius, decidedly preferable to straw as regards both the cleanliness and comfort of the calves. Calves. — These range usually from about three to four months old. They are fed on milk, obtained direct from cows in the adjoining dairy, in addition to which they are allowed oatmeal and a certain number of eggs, but no hay. The calves are purchased from peasants in the surrounding districts. After vaccination and collection of the lymph, they are sold to a butcher in Geneva, at a loss of about ^i on each calf. They are slaughtered in the public abattoir, and the veterinary inspector attached to that establishment furnishes a certificate relating to the healthiness of the calf and the condition of the viscera as ascertained on examination of the carcase. Vacciiiaiioii of Calves. — For the purpose of vaccination the calf is strapped down to a tilting table, similar in its main features to those employed in England. The head of the animal is covered with a leathern mask. The whole of the abdomen, the inside of the thighs, and a considerable area of the right side of the body of the animal are shaved, white soft soap and hot water being used in the process. 234 APPENDIX The skin is next washed with solution of lysol (2.5 parts per 1000), and finally with hot boiled water. It is dried with sterilised gauze sponges. The actual vaccination is carried out in a manner similar to that universally employed in the German Government establishments already described, with the exception that the parallel lines of incision are discon- tinuous at intervals of about four inches. Occasionally a certain numberof incisions are madeat a greater distance from each other, and only about a couple of inches in length, in order that the condition of the resulting vesicle may be more readily observed. Any blood which exudes from the incisions is removed with sterilised gauze sponges, and then the skin is put on the stretch, while glycerinated lymph is rubbed into each incision by means of a small and thin ivory spatula. The lymph employed consists of one part of vesicle pulp incorporated with two parts of undiluted glycerine, and the resulting mixture is stored for about a month prior to use. Collection and Preparatio7i of Lymph. — After the lapse of four days and a half from the time of vaccination, the calf is again placed on the table, and the vaccinated area washed with warm boiled water without the addition of any antiseptic. After drying with sterihsed gauze sponges, the vesicle pulp is removed by scraping with a sharp spoon. The resulting pulp is collected in a glass pot provided with a cover, and when all has been removed the total amount is weighed. Sufficient glycerine (undiluted) is then added to cover the mass of pulp, and the vessel and its contents are set aside for a few days. Subsequently, glycerine and water are added in proportions requisite for attaining the following standard : — Vesicle pulp . . . .1 part Glycerine . . . . .2 parts Water . . . . .1 part I APPENDIX 235 and the mixture is then thoroughly triturated in a mixing machine of the kind invented by Dr. Chalybaus of Dresden. The resulting emulsion is employed for human vaccinations, the " seed material " used for the vaccination of calves, having, as already stated, no water added to it. Occasionally clamp forceps are employed in the collec- tion of lymph from the smaller vesicles, when it is required to store it along with glycerine in fine capillary tubes ; the resulting material, containing comparatively little epithelial tissue, being therefore more readily drawn up into the tubes. When collection is carried out in this manner the " crust " is first removed from the vesicle, which is then gently scraped with a lancet. The material thus obtained is mixed with glycerine in the usual fashion. The emulsion, which is never sent out for use until at least four weeks after collection of the vesicle pulp, is stored prior to distribution in large glass-stoppered tubes. It is sent out in flacons, plaques, and capillary tubes, according to the amount required in any given case. The flacons, small glass tubes made of amber -coloured glass and provided with corks, are of sufficient size to contain enough emulsion for 25, 50, and 100 vaccinations respec- tively. The plaques consist of two small squares of glass, one of which has a shallow excavation on one surface. This is filled with emulsion, then covered with the plain square, and the edges sealed with paraffin. Quantities of emulsion sufficient for five or ten vaccinations are sent out in this way ; while fine capillary tubes, which are sealed with paraffin, are used for sending out lymph for the vacci- nation of one person only. All flacons, plaques, and tubes are sterilised before being filled. In order to send them safely through the post they are enclosed in neat metal cases differing in size and shape. These, together with 236 APPENDIX certain printed matter, including a card to be filled up in accordance with the results obtained from use of the con- tained lymph, are enclosed in a stout glazed orange-coloured envelope secured with a metal clip. M. Haccius stated that he had, especially of late, experienced some difficulty in getting public vaccinators to fill up and return the cards sent with each consignment of lymph, so that it was not possible to obtain full statistics as to the success attending the use of the lymph sent out from the Institute. On looking over with him, however, a number of cards which had come to hand within the last few months, it appeared that in all cases the success attained was very great ; in a not inconsiderable proportion the insertion success had reached loo per cent. M. Haccius further stated that the structural arrange- ments of his Institute were the same as when it was first started in 1882, so that they are not in some respects such as would be considered most desirable at the present time. Nevertheless, it was impossible not to be impressed with the strict precautions taken to ensure the utmost cleanliness in the case both of the premises and of all persons employed in the various details of the work. II APPENDIX 237 APPENDIX No. II Extracts from the Transactions of the Seventh International Congress of Hygiene and Demography: London, 1891. Vol. II. Section II. pp. 319-26. The Bacteriology of Vaccine Lymph : by S. Mojukton Copeniafi, M.A.^ M.D. Cantab.^ Research Scholar of the British Medical Association^ late Assistant Lecturer on Physiology^ St. Thofnas's Hospital. Numerous have been the attempts, ever since bacteriology first took rank as an exact science, to solve the problem as to the nature of the active principle of vaccine lymph, and in consequence of this, and of the great difficulty of the subject, a mass of literature has gradually accumulated sufficient to appal any one newly entering upon the task. The fact, however, that in the absence of any sufficient knowledge on this point, the whole practice of vaccination as at present carried out is more or less empirical, may perhaps furnish excuse for still further attempts in this direction. I therefore venture to bring forward the results of an investigation of this subject, on which I have been engaged at intervals for the last eighteen months. As a first step it appeared desirable to obtain proof, if possible, of the particulate nature, or otherwise, of the essential cause of vaccinia. I next turned my attention to the identification of the 238 APPENDIX II various micro-organisms which can be grown as the result of inoculation of various nutritive media with vaccine lymph. And here I should remark that in all the experi- ments of this series, calf lymph alone was used, as it seemed probable that by these means one would obtain more constant results. As it was evident that more than one organism could usually be obtained by the inoculation of lymph into nutrient media, plate cultivations were made, with the object of separating out the different varieties present, both gelatine and glycerine agar being used for this purpose. In this manner I succeeded in obtaining pure growths of various micro-organisms, of which those which almost invariably occurred included micrococci, apparently much resembling, if not identical with, the following : — (i) M. Pyogenes aureus ; (2) M. Cereus flavus ; (3) M. Epidermidis ( 1 Staphylococcus albus, Klein). In these observations I find my experiments are in agreement with those of Pfeiffer, while doubtless these various micrococci correspond respectively with Buist's so-called orange, yellow, and white vaccine. As it appeared possible that their exuberant growth might be capable of preventing the development of the more important organism for which I w^as seeking, an attempt was next made to isolate it by some method of treating vaccine lymph, which should destroy all extraneous micro-organisms without injuring its potency for vaccination. Having in mind the method by which Kitasato succeeded in obtaining pure cultures of the tetanus bacillus, I con- II APPENDIX 239 sidered whether it might not be possible, in like manner, to isolate the specific organism of vaccinia. For the pur- pose of testing the effect of similar measures, I exposed capillary tubes of fresh vaccine lymph to different tempera- tures for varying lengths of time, afterwards inoculating a portion of the contents of these tubes on the calf, a second portion being used for the making of plate-cultivations in nutrient gelatine and agar-agar. By proceeding in this manner, after numerous experiments, I presently arrived at a temperature at which those organisms which usually grow so luxuriantly when vaccine lymph is inoculated into nutrient jelly, are apparently incapable of continued existence after exposure to its influence for a certain length of time. After a long series of experiments with lymph exposed to various temperatures between the limits mentioned, and for varying periods of time, I have apparently determined that the required temperature is one ranging between 38° C. and 42° C. For exposure to the higher of these tem- peratures for an hour has the effect of preventing the growth in plate-cultivations made subsequently, while at the lower temperature a few points of growth are occasion- ally seen after the lapse of a day or so. At the same time, however, the higher temperature appears occasionally to exert an injurious effect on the lymph, as far as regards the normal vesiculation which should result from the inoculation of vaccine lymph. Further experiments are therefore needed before the most suitable temperature and most desirable length of exposure can be definitely determined. Early in my experiments, my attention was called to the fact that lymph stored in capillary tubes nearly always 240 APPENDIX II becomes cloudy after a longer or shorter interval, while at the same time it often becomes uncertain in its action when subsequently used for vaccination. I endeavoured therefore, in the first place, to determine the reason for the opacity which occurs in stored lymph ; and, secondly, to find, if possible, some means of preventing such an occurrence. As regards the first point, experi- ments were carried out as follows : — A large number of capillary tubes were filled with calf lymph, every precaution as to cleanliness and careful scaling of the tubes being observed. These tubes were then set aside, not, as is usually the case, lengthwise, but on end. After the lapse of a few weeks all the tubes presented little points of opacity, and on careful examination it was obvious that each of these occurred where a surface of the lymph was in contact with a bubble of air. Moreover, it was always at the lower end of the line of lymph that such opaque points were found, thus showing that they were composed of something possessing, a higher density than the lymph itself, as otherwise there was no apparent reason why they should not also be met with at the upper limit of- each thread of lymph where air was also present. This appearance was quite independent of any coagula- tion in the lymph ; indeed, on breaking some of the tubes in which it was most marked, no coagulum was found. On the other hand, where clotting had taken place after the lymph was stored, the opacity was often not in discrete points as in the other tubes, but formed with the coagulum a central whitish thread in the midst of a clear fluid. In these cases, the tiny particles of which an opaque point was obviously composed had apparently become more or less entangled with the fine thread of fibrin which had resulted from the process of coagulation. II APPENDIX 241 Cultivation experiments were then carried out, gelatine tubes being inoculated from opaque points in stored tubes, and also, as a control, from tubes of comparatively fresh lymph, the capillary tubes used in these experiments having been sterilised previous to their being filled with lymph. In each case, plate -cultures were made from dilutions of the gelatine tubes first inoculated. As a result, many more colonies were found in the plates poured from inoculations of the old tubes than from those descended from the fresher lymph. We are therefore apparently justified in considering that the opacity of old-stored lymph is, in the main, the outcome of an enormous multiplication of aerobic bacteria, the ancestors of which are present in the lymph when first taken, although their numbers are then so comparatively small as not to render it in any way turbid. As I have already shown, a certain amount of heat, when applied to lymph in sealed capillary tubes, inhibits the growth of these aerobic bacteria, while a still higher temperature kills them. The exposure of freshly -stored lymph, then, to a proper temperature for a sufficient length of time, ought to prevent the subsequent appearance of opacity, and such is apparently the case. Without great care, however, there is in this method considerable danger of rendering the lymph inert. A simpler method of obtaining the desired result, how- ever, is found in the admixture of the lymph with a certain proportion of 50 per cent glycerine in distilled and sterilised water prior to storage in capillary tubes, which also should have previously been sterilised by heat. ^Miiller showed, long ago, that lymph might be diluted with three times its bulk of such a mixture and still retain its properties unimpaired, a fact which has been taken R 242 APPENDIX II advantage of by more than one purveyor of trade lymph. Experiment shows that not only is this so, at any rate for a considerable time, but also that, in tubes filled with such diluted lymph, opacity does not apparently result. The glycerine appears to inhibit the growth of those aerobic bacteria, which in former parts of this paper I have termed "extraneous," signifying by that term that their presence is not in any way essential, indeed, probably rather the reverse, to the successful action of the vaccine lymph. . . . Another argument, in favour of the use of lymph diluted in this way with glycerine, is found in the fact that, as before stated, such a mixture does not dry up nearly as readily as ordinary lymph, and therefore in the hands of operators, all but the most expert, affords greater facilities towards the attainment of a uniformly successful series of vaccinations. The fact also that a much larger supply of lymph would thus be available is so obvious that it needs not to be insisted on. INDEX Academic de Medecine ; animal vaccination in France, 144- 145 Adams ; inoculation, 25 ,, variolation of bovine ani- mals, 47 Admixture of glycerine with vaccine lymph ; Cheyne, 155- 156 ; no new device, 155-158 Aerobic bacteria cause of opacity in vaccine lymph, 83-84 Aitken ; smallpox, 17 Allen ; inoculation, 21-23 Amsterdam, animal vaccination introduced to, 146 Animal vaccination,. 142-152: Ballard on introduction of, 142-143; Berlin, 211-218; Brussels, 147-148, 206-211 ; Chambon, 143-145 ; Cologne, 224-232 ; definition of, 142 ; Dresden, 218-224 I effect of on erysipelas and tuberculosis, 151-152 ; England, 148-152 ; English Royal Commission, 149 ; France, Royal Com- mission, 144-145; Galbiati, 150 ; Geneva, 232-236 ; Ger- many, 147 ; grounds on which advocated, 149-152; Holland, 146 ; introduced to Amster- dam, 146 ; introduced to Berlin by Pissin, 145-146; intro- duced to Brussels by Warlo- mont, 145 ; introduced to Paris by Lanoix, 143 - 144 ; introduced to Rotterdam, 146 ; introduced to Switzerland by Haccius, 146 ; introduced to Vienna, 146 ; introduction of, Ballard and Negri, 142-143 ; Paris, 143-144, 146-147, 196- 206 Animal Vaccine Establishment, Government, source of lymph used at, 71 ; vaccinations from a single calf at, 192 ; vaccina- tion at, 106 Anthony; micro-organisms in vaccine lymph, 96-97, 99 Antitoxin, 134- 141 Arloing : experiments with horse- pox lymph, 101-102 ; specific micro - organism of vaccine lymph, 102 Arm - to - arm vaccination : and erysipelas, 151-152 ; and tuber- culosis, 151-152 ; deterioration of, 149-150; Jennet's first attempt to carry on, 67-68 ; in England, 149 ; English Royal Commission on risks incurred from, 149-150 ; syphilis con- veyed by, 151 ; W^oodville, 68-70 Athens ; inoculation in, 20 Auchd ; treatment of smallpox by scrum, 140 244 INDEX Austria, quality of glycerine in, 172-173 Babes ; micrococci isolated from vaccine lymph, 90 Bacilli: diphtheria, in lymph, killed by addition of glycerine, 161 ; in calf and variolous lymphs, Klein, 98 ; in vaccine lymph, Anthony, 96-97, 99, Copeman, 100, and Kent, 100 Bacillus, tubercle, action of gly- cerine on, Blaxall and Copeman, 162, 165-168, and Klein, 166- 167; tubercle, in vaccine lymph, 108 Bacteria: aerobic, cause of opacity in vaccine lymph, 83-84 ; in- fluence of glycerine on growth of, Blaxall and Copeman, 162- 168 ; in vaccine lymph, Crook- shank, 95-96 ; specific, of vaccine lymph, Koch, 90-91 Bacteriological examination of gly- cerinated calf lymph, 184-185; purification and preservation of vaccine lymph by glycerine, 153 Bacteriology, 85-127 ; of vaccine lymph in 1891, Copeman, 237-242 Badcock ; variolation of bovine animals, 47, 60 Baillard ; effect of glycerine on vaccine lymph, 99 ; micro- organisms in vaccine lymph, 99 Ballard ; introduction of animal vaccination, 142-143 Baniber and King ; action of lano- line and vaseline on vaccine lymph, 173-174 Baragi ; specific micro-organism of vaccine lymph, 91-92 Baron ; smallpox, 7 Beale, Lionel; granules in vaccine lymph, 85-86 Beaugency, natural cow-pox dis- covered at, 144 B6clere ; treatment of smallpox by serum, 140 Berlin : animal vaccination intro- duced to, by Pissin, 145-146 ; Commission, micro - organisms in vaccine lymph, 108, 115; lymph, results of vaccination with, Cory, 217-218 ; vaccina- tion arrangements at, 211- 218 Berthel ; variolation of bovine animals, 50 Besscr ; specific micro-organism of variola, 96 Beumer ; protective power of serum from vaccinated calves, 138 Blaxall : action of lanoline and vaseline on vaccine lymph, 173- 180 ; micro - organisms in vaccine lymph, 104-108, 114- 117 ; purification and preserva- tion of vaccine lymph by glycer- ine, 173-181 Blaxall and Copeman : action of glycerine ; on certain yeasts, 164-165; on growth of bacteria, 162-168 ; on tubercle bacillus, 165-168 Boureau ; micro - organisms in, and potency of vaccine lymph, 102 Bovine animals : and vaccination, 111-114; inoculation of, with variola, 41-66, 71-72 ; sub- cutaneous injection of vaccine lymph in, Chauveau, 136 Boyce ; protective power of serum from vaccinated calves, 138 Bruce Low ; increase of vaccine material by addition of glycer- ine, 157 Brussels, animal vaccination in, 145, 147-148, 206-211 Bryce ; cow-pox in the cow, 36 Buchanan, Sir George : animal INDEX 245 vaccination in England, 148 ; dilution of lymph withglycerine, 171 ; Rugen outbreak of dis- ease, 170- 17 I Buist ; micro-organisms in vac- cine and variolous lymphs, 92- 93 Burdon-Sanderson : granules in vaccine lymph, 88 Buttersack ; granules in vaccine lymph, 99-100 Calf lymph : bacillus in, Klein, 98; English Royal Commis- sion on, 168-170 ; viscidity of, 82 Calf l}'mph, glycerinated : advan- tages of, Copeman, 1 81-182 ; bacteriological examination of, 184-185 ; collection of lymph pulp, 183-184; duration of activity of, 185-186 ; effect of, on tubercle, 152 ; English Royal Commission, 169-170 ; inoculation of the calf, 183 ; preparation of, 182-187 ; pre- paration of the calf, 182-183 I quantity of lymph pulp ob - tained, 184 ; treatment of lymph pulp, 184 ; use of, de- cided on, in England, 149 ; reasons for use of, 168-169 ; vaccination with, desirable, 186-187 Calf : skin of, changes produced in by vaccination, Gustav Mann, 74-81 ; to-arm vaccina- tion at Nanterre, 202-203 ; vaccination, action of leuco- cytes in, 77-80, 82 ; vaccina- tion, most characteristic feature of, 80-81 Calves : inoculated with smallpox [see Variolation) ; vaccinated, protective power of serum from, B^clere, 138-140, Beumer, 138, Boyce, 138, Chambon, 138-140, Hlava, 138, Houl, 138, Kinyoun, 138, Kramer, 138, M(^nard, 138-140, Peiper, 138 Carmichael ; micro-organisms in vaccine lymph, 93 Casual cow-pox, 36-38 Catherine of Russia inoculated by Dimsdale, 23-24 Causes and effects of variolar vaccinas, Jenner, i Ceely : cow-pox in the cow, 36 ; lymph stocks, 71 ; variolation of bovine animals, 44-47, 57, 60 Chalybiius ; lymph - triturating machine, description of, 222- 224 Chambon : action of glycerine on vaccine lymph, 158-159 ; ani- mal vaccination, 143-145 ; micrococci in vaccine lymph, 96 ; natural cow-pox at St. Mand6, 144-145; protective power of serum from vaccinated calves, 138-140 Chaumier ; micro-organisms in, and potency of vaccine lymph, 102 Chauveau : contagium particulate, proof of, 88-89 ; cow-pox and horse - pox, 35 ; dilution of vaccine lymph, 88-89 ; genera- lised vaccinia in solipeds, 116 ; granules in vaccine lymph, 86- 88 ; subcutaneous injection of vaccine lymph in bovines and horses, 136 ; variolation of bovine animals, 48-50, 61-62, 64. 135 Chemistry and morphology of vaccine lymph, 82-.84 Chester, smallpox epidemic, 1774 ; Haygarth, 3-4 Cheyne ; admixture of glycerine with vaccine lymph, 155-156 China, artificial communication 246 INDEX of smallpox by respiratory tract in, 19 China, smallpox of great antiquity in, 5 Clarke, Jackson : protozoa, 121 Clarke ; lymph obtained from, by Jenner, 69 Cohn : morphology of vaccine lymph, 89-90; opacity of stored vaccine lymph, 90 Collins : cow-pox and smallpox, 65; the variolous test, 132-133 Cologne : vaccination arrange- ments at, 224-232 ; lymph, results of vaccination with, Cory, 228 Commission, English Royal : animal vaccination, 149 ; calf lymph, 168-170 ; glycerinated calf lymph, 169-170 ; quality of vaccine lymph, 168-169 I risks incurred from arm-to-arm vaccination, 150-151 Commission, German : action of glycerine on vaccine lymph, 160-161 ; extent of lymph dilution by glycerine, 161 Congress, International, of Hy- giene, London ; glycerinated lymph, 153 Constantinople, first vaccination performed at, 70 Contagium particulate, proof of ; Chauveau, 88-89 Continent, etc., source of lymph first used on, 69 Copeman : advantages of glycerin- ated calf lymph, 181- 182; bacteriology of vaccine lymph in 1 89 1, 237-242 ; cultivation of variola vaccine, 109-114 ; glycerinated lymph, 153-187 ; micro - organisms in vaccine lymph, 95, 100, 104- 117; Riigen outbreak of disease, 1 71- 172 ; treatment of small- pox by serum, 141; variolation of bovine animals, 58-61, 63- 65 Copeman and Blaxall : action of glycerine ; on certain yeasts, 164-165; on growth of bacteria, 162-168 ; on tubercle bacillus, 165-168 Copeman and Sir Richard Thorne ; foreign vaccination arrangements, 196-236 Cornil ; micrococci isolated from vaccine lymph, 90 Corpuscles, red, in vaccine- lymph. Husband, 82 Cory : animal vaccination in England, 148 ; results of vac- cination with Berlin lymph, 217-218 ; with Cologne lymph, 228 ; with Dresden lymph, 221 ; with Paris lymph, 205 ; variolation of bovine animals, 50-51, 56-57 Cow - pox : and horse - pox, Chauveau, 35 ; and smallpox identical, controversy as to, 42; casual, 36-38; Collins, 65; derived from horse-pox, 32-34 ; Hunter, 29 ; in the cow, Ceely and Bryce, 34-36 ; inoculated in man, 38-40 ; Jenner, 28- 29, 31-32, 43-44 ; natural, dis- covered at Beaugency and St. Mand^, 144 ; Negri, 143 ; Picton, 65 ; references, 40 ; variolae vaccinae known as, i Cows inoculated with smallpox {see Variolation) Cozette ; micro - organisms in vaccine lymph, 103 Creighton ; smallpox, 13-14 Crookshank ; bacteria in vaccine lymph, 95-96 Crusades, spread of smallpox during, 12 Crust, vaccine, description of, 74 Cultivation of variola vaccine ; Copeman, 108-114 INDEX 247 Deaths from smallpox : Iceland, 1707-1709, 5 ; large proportion contributed by children under ten years, 4 ; London, 1694- 1719, 16-17; McVail, 4-5; Norwich, 17 10, 17 De Carro ; lymph obtained from Lombardy, 69-70 Delobel ; micro-organisms in vac- cine lymph, 103 Depaul ; animal vaccination in France, 144-145 Dilution of vaccine lymph : Chau- veau, 88-89 ; Reiter, 89 ; Schultz, 89 Dimsdale : inoculation, 26; in- oculation of Catherine of Russia, 23-24 Diphtheria bacilli in lymph killed by addition of glycerine, 161 Doering's lymph - grinding ma- chine, description of, 213-215 Domiciliary vaccination, Paris, 203-206 Dresden: lymph, results of vac- cination with ; Cory, 221 ; vaccination arrangements at, 218-224 Edinburgh: smallpox, 1764- 1783. 4 England : admixture of glycerine with lymph patented by Warlo- mont in, 158; animal vaccina- tion in, 148 - 152 ; arm- to -arm vaccination in, 149 ; quality of glycerine in, 172-173 ; smallpox first introduced into, 13 ; smallpox in seventeenth century in, 15-17 ; use of calf lymph decided on, in, 149 English Royal Commission : animal vaccination, 149 ; calf lymph, 168-170 ; glycerinated calf lymph, 169-170; risks incurred from arm - to - arm vaccination, 1 50-151 ; variola- tion of bovine animals, 60- 61 Epidemic smallpox : Chester, 1774 ; Haygarth, 3 ; Iceland, 1707-1709, 5 ; Ware, 1722, 3 ; Warrington, 1773, 3 Epidemics, Kilmarnock, 1728- 1763, 4 ; McVail, 5 Equine origin of Lombardy lymph, 70 Erysipelas : and arm-to-arm vac- cination, 151 -152; effect of animal vaccination on,i5i-i52 ; streptococcus of, in vaccine lymph, Klein, 95 Estlin ; distribution of lymph, 71 Eternod ; variolation of bovine animals, 55, 60 Europe, smallpox unknown in prior to end of sixth century, 5 "Extraneous" organisms: in- fluence of glycerine upon the growth of, 153-182 ; in vaccine lymph, 104-108 ; removal of, by heat not advantageous, 154- 15s Fee for inoculation, 27-28 Feiler ; specific microbe in vaccine lymph, 91-92 Ferroni ; protozoa, 122 Fischer ; variolation of bovine animals, 52-54 Foreign vaccination arrangements ; Sir Richard Thorne and Cope- man, 189-236 Foster, Michael ; efficiency of lymph stocks, 128 France : animal vaccination in ; Acad^mie de M^decine, 144- 145 ; smallpox in, 6 Freyer : specific organism of vac- cine lymph, 115-116; vaccina- tion by spleen juice, etc., 115- 117 Galbiati : propagation of other 248 INDEX human diseases with vaccinia, 150 ; retro-vaccination, 143, 150 Gassner ; variolation of bovine animals, 42-43 Garrfe; micro-organisms in vaccine lymph, 94 Generalised vaccinia in solipeds ; Chauveau, 116 Geneva, vaccination arrangements at, 232-236 German Commission : action of glycerine on vaccine lymph, 160 -161; extent of lymph dilution by glycerine, 161 Germany, animal vaccination in, 147 Glycerinated calf lymph : advan- tages of ; Copeman, 181 -182; and International Congress of Hygiene, London, 153 ; bac- teriological examination of, 184- 185 ; collection of lymph pulp, 183-184 ; Copeman's investiga- tions, 153-187; duration of activity of, 185-186 ; effect of on tubercle, 152 ; English Royal Commission on, 169- 170 ; inoculation of the calf, 183 ; preparation of, 182-187 '. preparation of the calf, 182- 183 ; quantity of lymph pulp obtained, 184 ; treatment of lymph pulp, 184 ; use of, de- cided on, in England, 149 Glycerinated vaccine lymph, dilu- tion of, Schultz, 89 Glycerine, action of : on certain yeasts, Blaxall and Copeman, 164-165 ; on growth of bacteria, Blaxall and Copeman, 162-168 ; on " extraneous " micro-organ- isms, 153-182 ; on tubercle bacillus, Blaxall and Copeman, 165-168, and Klein, 166-167 ! on Vaccine Lymph, Baillard, 99, Chambon, 158-159, Frosch, 160-161, German Commission, 160-161, Kitasato, 161, Klein, 160 ; Koch, 160-161 ; Leoni, 99, 159-160; Menard, 103, 158-159; Pfeiffer, 160-161 ; Schmidtmann, 160-161 ; Straus, 159 ; admixture of with vaccine lymph, Cheyne, 155-156 ; ad- mixture of with vaccine lymph, no new device, 155-158 ; ad- mixture of with vaccine lymph, patented in England, W'arlo- mont, 158 ; analyses of, Wilson Hake, 172-173 ; and thymol, lymph mixed with, cause of dis- ease in Riigen, 170- 171 ; diph- theria bacilli in lymph killed by addition of, 161 ; germicidal value of, 161-162; increase of vaccine material by addition of, Bruce Low, 1 57, Mackenzie, 1 57, and Miiller, 156-157 ; potency of lymph impaired by chemical agents other than, 161 ; purification and preservation of vaccine lymph by, 153, 173-18 1 ; purity of, past and present, 171-172 ; quality of, in Austria and in England, 172- 173; Sir George Buchanan on dilution of lymph with, 171 ; Startin's advocacy of thera- peutic applications of, 156 Gourny ; micro - organisms in vaccine lymph, 103 Government lymph laboratories, 187 Granules in vaccine lymph ; Beale, Lionel, 85-86, Burdon -Sander- son, 88, Buttersack, 99-100, Chauveau, 86-88, Hallier, 86, Kebcr, 86, Sacco, 85, Zurn, 86 " Grease," or horse-pox, 31-35 Gregory ; inoculation, 26 Grigorieu ; micro-organisms in vaccine 13'mph, 94 INDEX 249 Guttman ; micro - organisms in vaccine lymph, 92 Guarneri ; protozoa, 118-119 Guarneri's "parasites," tj, 119- 123, 125-126 Haccius : animal vaccination in- troduced into Switzerland by, 146 ; variolation of bovine ani- mals, 55-56, 60 Hallier ; granules in vaccine lymph, 86 Haygarth ; smallpox epidemic, Chester 1774, 3 Her\ieux ; variolation of bovine animals, 63-64 Hime ; variolation of bovine ani- mals, 54, 60 Histology of the vaccine vesicle, 73-84 Hlava: micro-organisms in vaccine lymph, 93-94; protective power of serum from vaccinated calves, 138 ; protozoa, 117 Holland, animal vaccination in, 146 Horse-pox : and cow-pox, Chau- veau, 35 ; cow - pox derived from, 32-35; experiments as to, Tanner, 32 ; Ley, 32 ; lymph, experiments with, Arlo- ing, 101-102; Sacco, 32-34, 70 Horses, subcutaneous injection of vaccine lymph in ; Chauveau, 136 Houl ; protective power of serum from vaccinated calves, 138 Human diseases, other, propaga- tion of, with vaccinia, 150-152 Hunter ; cow-pox, 29 Husband ; red corpuscles in vac- cine lymph, 82 Hygiene, International Congress of, and glycerinated lymph, 153 Iceland, smallpox deaths, 1707- 1709. 5 India, lymph conveyed to, 70 ; smallpox of great antiquity in, 5 Inoculated cow-pox in man, 38-40 Inoculation, 19-28, 67 : Adams, 25; Allen, 21-23; brothers Sutton, 24-26 ; controversy as to efficiency of, 25-27 ; diffusion of ; Adams, Dimsdale, and brothers Sutton, 23 ; Dimsdale, 26 ; fatality from, 26-27 ; fee for, 27-28 ; first introduced into England by Lady Montagu, 18, 20-21 ; Gregory, 26 ; in Athens and Smyrna, 20 ; Eng- land, first operation ; Maitland, 21 ; of condemned felons, 21 ; George I., 21 ; origin of, un- known, 19 ; practised in Turkey, 19 ; prohibited since 1840, 18; Sir Thomas Watson, 26-27 Italy, smallpox in, 6 Jenner : cow-pox, 28-32, 43-44 ; deterioration of arm - to - arm vaccination, 149-150; full degree of activity of vaccine lymph, 150 ; his first attempt at arm-to-arm vaccination, 67- 68 ; his first vaccination, 29-30, 67 ; proved vaccination to be a protection from smallpox, 30 ; vaccinia, 41-42 ; varioloe vac- cinae, I Juhel ; variolation of bovine animals, 63 Keber ; granules in vaccine lymph, 86 Kent ; bacilli in vaccine lymph, 100 ; vaccine vesicle, 74 Kilmarnock, smallpox, 1728- 1763. 4 King and Bamber : action of lanoline and vaseline on vaccine lymph, 173-174; variolation of bovine animals, 53-54, 60 Kinyoun : protective power of 250 INDEX serum, from vaccinated calves, 138 ; treatment of smallpox by serum, 141 Kitasato ; action of glycerine on vaccine lymph, 161 Klebs ; micro - organisms in vaccine lymph, 90 Klein : action of glycerine on tubercle bacillus, 166-167 ; and on vaccine lymph, 160 ; bacilli in calf and variolous lymphs, 98-99; streptococcus of ery- sipelas found in vaccine lymph, 95 ; variolation of bovine animals, 56-58, 61, 63, 135 Koch : micro-organisms in vaccine lymph, 90-91 ; rinderpest, 44 ; specific bacteria of vaccine lymph, 90-91 Kramer ; protective power of serum from vaccinated calves, 138 Laboratories, Government Lymph, 187 Landmann : micro-organisms in vaccine lymph, loo-ioi ; treat- ment of smallpox by serum, 140-141 Lanoix ; animal vaccination intro- duced to Paris by, 143-144 ; natural cow-pox at St. Alandd discovered by, 144 Lanoline, action of, on vaccine lymph; Blaxall, 173-180 ; King and Bamber, 173-174 Layet ; variolation of bovine animals, 63-64 Le Dantec : micro-organisms in vaccine lymph, loi ; variola- tion of bovine animals, 64 Leoni : action of glycerine on vaccine lymph, 99, 159-160 ; micro - organisms in vaccine lymph, 95 Leucocytes, action of, in calf vaccination, 77-80, 82 London, 1694- 17 19, deaths from smallpox in, 16-17 I smallpox epidemics, McVail, 5 Loy ; horse-pox, 32 Lymph : Berlin, results of vaccina- tion with, Cory, 217-218 ; calf, viscidity of, 82 ; Cologne, results of vaccination with, Cory, 228 ; dilution of, with glycerine, extent of, German Commission, 1 6 1, and Sir George Buchanan, 171 ; diphtheria bacilli in, killed by addition of glycerine, 161 ; Dresden, results of vaccination with, Cory, 221 ; glycerinated,Copeman's investi- gations, 153-187 ; granules in, Beale, Lionel, 85-86 ; Burdon- Sanderson, 88 ; Buttersack, 99- 100; Chauveau, 86-88; Hallier, 86 ; Keber, 86 ; Sacco, 85 ; Zurn, 86 ; International Con- gress of Hygiene, London, 153 ; grinding - machine, Doering's, description of, 213-215 ; leuco- cytes present in, 82 ; Lombardy, of equine origin, 70 ; mixed with glycerine and thymol cause of disease in Riigen, 1 70-171 ; obtained from Clarke by Jenner, 69 ; Lombardy, Sacco, and De Carro, 69-70 ; micro-organisms in, 82-83; Anthony, 96-97, 99 ; Babes, 90 ; Baillard, 99 ; Berlin Commission, 108, 115 ; Blaxall, 104-108, 114-117; Boureau, 102 ; Buist, 92-93 ; Carmichael, 93; Chambon, 96; Chaumier, 102 ; Copeman, 95, 100, 104-117 ; Cornil, 90 ; Co- zette, 103; Crookshank, 95-96; Delobel, 103 ; Garr6, 94 ; Gourny, 103 ; Grigorieu, 94 ; Guttman, 92 ; Hlava, 93-94 ; Kent, 100 ; Klebs, 90 ; Klein, 98 - 99, 106 ; Koch, 90 - 91 ; Landmann, 100 - loi ; Le Dantec, loi ; Leoni, 95 ; Mai- INDEX 251 jean, 97; Marotla, 92; Martin, loi ; Meguin, 92 ; Mc^nard, 96, 102-103 ; Paul, 103-104 ; Pfeiffer, L. , 94 ; Protopopoff, 95 ; Quist, 91 ; Ruete, 100 ; Sacqu^p^e, 103 ; Straus, 96 ; Tenholt, 93 ; Woitow, 94-95 ; microscopical examination of, 82 ; morphology of, Cohn, 89- 90 ; Paris, results of vaccination with, Cory, 205 ; Passy, origin of, 70-71 ; potency of, Boureau and Chaumier, 102 ; potency of, impaired by chemical agents other than of glycerine, 161 ; potency of, unimpaired by addi- tion of glycerine, Miiller, 156- 157 ; source of, first used on Continent, etc. , 69 ; source of, used at Government Animal Vaccine Establishment, 71 ; specific micro - organism of, Arloing, 102 ; Baragi, 91-92 ; Feiler, 91-92; Freyer, 115-116 ; Koch, 90-91 ; Quist, 91 ; Sere- briakoff, 91-92 ; Voigt, 92 ; sterilised, experiments with, 134-135; stocks, Ceely, 71; stocks, efficiency of, Michael Foster, 128 ; stocks, various, history of, 67-72; stored, opacity of, Cohn, 90 ; streptococcus of erysipelas found in, Klein, 95 ; subcutaneous injection of, in bovines, horses, and monkeys, 136; triturating machine, Chaly- baus, description of, 222-224 '■ tubercle bacillus in, 108 ; used in vaccinal and variolous tests in the monkey, 131 ; variola vaccine, 71 ; variolous, micro- organisms in, Buist, 93 ; Wood- ville's, 68 Lymphs, calf and variolous, bacilli in, Klein, 98 Lyons Commission ; variolation of bovine animals, 48-49, 61 Macaulay ; smallpox, 2 MacElliot ; treatment of smallpox by serum, 141 Mackenzie ; increase of vaccine material by addition of gly- cerine, 157 McVail ; deaths from smallpox, 4-5 Maitland ; first to inoculate in England, 21 Maljean ; micrococci in vaccine lymph, 97 Mand6, St. ; natural cow-pox dis- covered at, 144 Mann, Gustav ; clianges produced in skin of calf by vaccination, 74-82 Marotla ; micro - organisms in vaccine lymph, 92 Martin ; micro - organisms in vaccine lymph, loi ; variolation of bovine animals, 49, 61, 64 Massari ; protozoa, 122 Measles, smallpox confounded with, 8 Meguin ; micro - organisms in vaccine lymph, 92 Mdnard : action of glycerine on vaccine lymph, 103, 158-159; micro - organisms in vaccine lymph, 96, 102-103 ; protective power of serum from vaccinated calves, 138-140 Micro-organisms : " extraneous," influence of glycerine upon the growth of, 153-182 ; removal of, by heat not advantageous, 154-155 ; in vaccine lymph, 82-83 ; Anthony, 96-97, 99 ; Babes, 90 ; Baillard, 99 ; Berlin Commission, 108, 115; Blaxall, 104-108, 114-117; Boureau, 102 ; Buist, 92-93 ; Carniichael, 93 ; Chambon, 96 ; Chaumier, 102 ; Copeman, 95, 100, 104- 117; Cornil, 90; Cozette, 103 ; Crookshank, 95-96 ; Delobel, 252 INDEX 103 ; Gane, 94 ; Gourny, 103 ; Grigorieu, 94 ; Guttman, 92 ; Hlava, 93-94 ; Kent, 100 ; Klebs, 90; Klein, 98-99, 106; Koch, 90-91 ; Landmann, 100- loi ; Le Dantec, loi ; Leoni, 95 ; Maljean, 97 ; Marolla, 92 ; Martin, loi ; Meguin, 92 ; Menard, 93, 96, 102-103 ; Paul, 103-104 ; Pfeiffer, L. , 94 ; Protopopoff, 95 ; Quist, 91 ; Ruete, 100 ; SacqiK^p^e, 103 ; Straus, 96 ; Tenholt, 93 ; Woitow, 94 - 95 ; in variolous lymph, Buist, 93 ; specific, of vaccine lymph, Baragi, 91-92 ; Feiler, 91-92; Freyer, 115- n6 ; Koch, 90-91 ; Quist, 91 ; Serebriakoff, 91 - 92 ; Voigt, 92 Monkey : complete vaccination and variolation in the, proved, 130-132 ; course of vaccinia and variola in the, 129-130 ; difference between vaccinia and variola in the, 130 ; lymph used in vaccinal and variolous tests in the, 131 ; method of vaccination in the, 128-129 ; subcutaneous injection of ; vaccine lymph in the, 136 ; susceptibility of, to vaccinia and variola, 128-130 ; variola and vaccinia in the, 128-133 ; vario- lated, blood plasma of, as pro- tection against vaccination, 136- 138 Montagu, Lady, inoculation first introduced into England by, 18, 20-21 Monti ; protozoa, 119 Moore, Norman ; smallpox, 14 Morphology and chemistry of vaccine lymph, 82-84 ; mor- phology of vaccine lymph, Cohn, 89-90 Miiller : potency of lymph un- impaired by addition of gly- cerine, 156-157 ; protozoa, 124 Nanterrc, calf-to-arm vaccination at, 202-203 Negri^: introduction of animal vaccination, 142-143 ; natural cow-pox, 143 ; retro-vaccina- tion, 143 Norwich, 1710, deaths from smallpox in, 17 Ogata ; protozoa, 121 Opacity in vaccine lymph, causes of, 83 ; in stored vaccine lymph, Cohn, 90 Papular stage of vaccination, 73 " Parasites," Guarnieri's, 'jj, 119- 123, 125-126 Paris : animal vaccination at, 146- 147, 196-206 ; animal vaccina- tion introduced to, Lanoix, 143-144 ; crude calf lymph in use at, 190-191 ; description of Institut de Vaccine 'Animale at, 196-201 ; domiciliary vac- cination at, 203-206 ; lymph, re- sults of vaccination with, Cory, 205 ; street vaccination at, 204- 205; vaccine station of Acad(^mie de M^decine at, 201-202 Passy lymph, origin of, 70-71 Pathology of vaccinia, 31-40 Paul ; micro-organisms in vaccine lymph, 103-104 Pearson ; lymph distributed by, 68-69 Peipcr; protective power of serum from vaccinated calves, 138 Pepys ; smallpox, 3 Pfeiflfer, E. ; protozoa, 121 Pfeiffer, L. ; micro-organisms in vaccine lymph, 94 ; protozoa, 118, 120-121 Picton : cow-pox and smallpox, 65; the variolous test, 132 133 INDEX 253 Pissin, animal vacciiialiou iiiUo- duced to Berlin by, 145-146 Plague, comparison with small- pox ; Macaulay, 2 Plasma, blood, of variolated monkey as protection against vaccination, 136-138 Plimmer ; protozoa, 119-120 Potency of lymph ; Miillcr, 156- 157; BoureauandChaumier, I02 Propagation of other human diseases with vaccinia, 150-152 Protopopoff; micro-organisms in vaccine lymph, 95 Protozoa, 1 17-126 : Clarke, Jack- son, 121 ; Ferroni, 122 ; Guarnieri, 11 8- 119 ; Hlava, 117; Massari, 122; Monti, 119; Midler, 124; Ogata, 121 ; Pfeiffer, E. , 121; Pfeiffer, L. , 118, 120-121 ; Plimmer, 1 1 9- 1 20 ; Reed, Walter, 123- 124 ; Renault, 118 ; Rieck, 118 ; Ruffer, 1 19-120 ; Salmon, Paul, 122-123 I Stokes, 124- 125 ; Van der Loeff, 121 ; Von Sicherer, 121 ; Wegefarth, 124 Pustular stage of vaccination, 74 Putnam ; variolation of bovine animals, 47 Quist's experiments ; vaccine lymph, 91 Reed, Walter ; protozoa, 123-124 References : animal vaccination, 152 ; antitoxin, 141 ; bacteri- ology, 126-127 ; cow-pox, 40 ; histology of smallpox and vaccine vesicles, 84 ; lymph stocks, 72 ; preservation, stor- age, and use of lymph, 188 ; protozoa, 127 ; relationship of variola and vaccinia, 66 ; variola and vaccinia, 133 Reiter ; dilution of vaccine lymph, 89 Relationship of variola and vaccinia, 41-66 Renault ; protozoa, 118 Rhazes ; smallpox, 6, 8-12 Rieck; protozoa, 118 Rinderpest ; Koch, 44 Rotterdam, animal vaccination introduced to, 146 Royal Commission, English : animal vaccination, 149 ; calf lymph, 168-170 ; glycerinated calf lymph, 169-170 ; risks in- curred from arm-to-arm vac- cination, 150-151 ; variolation of bovine animals, 60-61, 65 Ruete ; micro - organisms in vaccine lymph, 100 Ruffer; protozoa, 119-120 Rugen, lymph mixed with gly- cerine and thymol, cause of disease in, 170-171 ; Cope- man, 171-172, and Sir George Buchanan, 170- 171 Sacco : granules in vaccine lymph, 85 ; horse -pox, 32-34, 70 ; lymph obtained from Lom- bardy by, 69-70 Sacquepee ; micro-organisms in vaccine lymph, 103 Salmon, Paul; protozoa, 122-123 Schultz ; dilution of glycerinated vaccine lymph, 89 Serebriakoff ; specific micro-or- ganism in vaccine lymph, 91-92 Serum from vaccinated calves, protective power of : Beclere, 138-140; Beumer, 138; Boyce, 138 ; Chambon, 138-140 ; Hlava, 138 ; Houl, 138 ; Kinyoun, 138 ; Kramer, 138 ; Menard, 138-140 ; Peiper, 138 Serum, treatment of smallpox by : Auche, 140 ; Beclere, 140 ; Copeman, 141 ; Kinyoun, 141 ; Landmann, 140-141 ; MacElliot, 141 254 INDEX Simpson ; variolation of bovine animals, 50-53, 60 Skin of calf, changes produced in, by vaccination ; Gustav Mann, 74-81 Smallpox : Aitkcn, 17 ; and cow- pox identical, controversy as to, 42 ; artificial communica- tion of, by respiratory tract, China, 19 ; Baron, 7 ; Chester, 1774, Haygarth, 3 ; Collins, 65 ; comparison with plague, Macaulay, 2 ; Creighton, 13- 14 ; death of Queen Mary, 1694, from, 2 ; deaths, Ice- land, 1 707- 1 709, 5 ; deaths, London, 1694-1719, 16-17; deaths, McVail, 4-5 ; deaths, none above ten years in War- rington T773 and in Chester 1774, 4 ; deaths, Norwich 1 7 10, 17 ; deaths, quarter amongst children, 0-12 months, Chester 1773, 4 ; during i6th century, 15 ; Edinburgh 1764- 1783, 4 ; England, 17th cen- tury, 15-17 ; eruption, stages of, 73 ; first introduced into England, 13 ; Gaddesden, John of, 13-14 ; Gregory of Tours, 6 ; history of, 1-18 ; history of in three stages, Aitken, 17-18 ; houses, first erected, 13; India, China, Europe, Arabia, Italy, France, 5-6 ; inoculation of bovine animals with, 41-66 [see also Variolation) ; in 17th century, 3 ; Kilmarnock 1728- 1763, 4; London, McVail,- 5; Macaulay, 2 ; Marius, Bishop of Averche, 6 ; Moore, Nor- man, 14 ; Pepys, 3 ; Picton, 65 ; poets on, 15-16 ; ravages of, 2, 12 ; red hangings as curative treatment for, 13-14 ; Rliazes, 6, 8-12 ; seasons in which prevalent, 9 ; spread of during Crusades, 12 ; treat- ment of, by serum, Auche, 140, Beclere, 140, Copeman, 141, Kinyoun, 141, Land- mann, 140-141 and MacElliot, 141 ; treatment of, Sydenham, 24; Waller, Mrs. , 2-3; M^are, 1722, 3 ; Warrington, 1773, 3 Smyrna, inoculation in, 20 Solipeds, generalised vaccinia in ; Chauveau, 116 Spleen juice, etc., vaccination by, Freyer, 11 5-1 17 Startin's advocacy of therapeutic applications of glycerine, 156 Sterilised lymph, experiments with, 134-135 Stokes ; protozoa, 124-125 Straus : action of glycerine on vaccine lymph, 159 ; micro- organisms in vaccine lymph, 96 Subcutaneous injection of vaccine lymph in bovines and horses, Chauveau, 136 ; in the mon- key, 136 Susceptibility of the monkey to vaccinia and variola, 128-130 Switzerland, animal vaccination in, 146 Sutton brothers ; inoculation, 24-26 Sydenham; treatment of small- pox, 24 Syphilis conveyed by arm-to-arm vaccination, 151 Tanner ; experiments as to horse- pox, 32 Tenholt ; micro - organisms in vaccine lymph, 93 Thiele, Basil ; variolation of bovine animals, 43, 60 Thorne, Sir Richard ; Foreign vaccination arrangements, 189- 236 Thymol and glycerine, lymph INDEX 255 mixed with, cause of disease in Riigen, 170- 171 Troja ; retro-vaccination, 143 Tubercle bacillus, action of glycerine on ; Blaxall and Cope- man, 165-168 ; Klein, 166- 167 Tubercle bacillus in vaccine lymph, 108 Tuberculosis : and glycerinated calf lymph, 1 51-152 ; and arm- to-arm vaccination, 151- 152 Turkey, inoculation practised in, 19 Vaccinal and variolous tests in the monkey, 130- 131 Vaccinated calves, protective power of serum from : B(!clere, 138-140; Beumer, 138 ; Boyce, 138 ; Chambon, 138-140; Hlava, 138 ; Houl, 138 ; Kinyoun, 138 ; Kramer, 138 ; Menard, 138-140 ; Peiper, 138 Vaccination, 28-40 Vaccination, animal, 142-152 : and erysipelas and tuberculosis, 151 - 152 ; Berlin, 211 -218; Brussels, 147-148, 206-211 ; Chambon, 143-145 ; Cologne, 224-232 ; definition of, 142 ; Dresden, 218-224 ; England, 148-152 ; English Royal Com- mission, 149; France, Academic de M^decine, 144-145 ; Gal- biati, 150; Geneva, 232- 236 ; Germany, 147 ; grounds on which advocated, 149- 152; Holland, 146; intro- duced to Amsterdam, 146, Berlin by Pissin, 145-146, Brussels by Warlomont, 145, Paris, Lanoix, 143-144; Rotter- dam, 146, Switzerland by Haccius, 146 and Vienna, 146 ; introduction of, Ballard and Negri, 142-143 ; Paris, 146- 147, 196-206; at Government Animal Vaccine Establishment, 106 Vaccination, arm -to -arm : and erysipelas, 151 - 152 ; and tuberculosis, 151 -152; de- terioration of, 149-150 ; in England, 149 ; risks incurred from, English Royal Com- mission, 1 50-151 ; syphilis conveyed by, 151 ; Woodville, 68-70 Vaccination arrangements : Berlin. 2 1 1-2 1 8 ; Brussels, 206-211 ; Cologne, 224-232 ; Dresden, 218-224 ; Foreign, Sir Richard Thome, 189-236 ; Foreign, Copeman, 196-236 ; Geneva, 232-236 ; Paris, 196-206 Vaccinations from a single calf : at Government Animal Vaccine Establishment, 192 ; when lymph is glycerinated, 186, 192, 216, 227 ; when lymph is not glycerinated, 192 Vaccine crust, description or, 74 Vaccine lymph : action of glycer- ine on, Baillard, 99 ; Chambon and Menard, 103, 158-159; Frosch, 1 60- 161; German Com- mission, 160-161 ; Kitasato, 161 ; Klein, 160 ; Koch, 160- 161 ; Leoni, 99, 159-160 ; Pfeiffer, 160- 161 ; Schmidt- mann, 160 - 161 ; Straus, 159 ; action of lanoline and vaseline on, Blaxall, 173-180; King and Bamber, 173-174 ; admixture of glycerine with, Cheyne, 155-156; no new device, 155-158 ; patented in England, Warlomont, 158 ; appearance of, before maturity, 82 ; bacteriological purification and preservation of, by gly- cerine, 153 ; causes of opacity in, 83 ; chemistry and mor- 256 INDEX phology of, 82-84; Copeinan, in 1891, on bacteriology of, 237-242 ; dilution of, Chau- veau, 88 - 89, Reiter, 89, Schultz, 89, and Sir George Buchanan, 171 ; diphtheria bacilli in, killed by addition of glycerine, 161 ; "extrane- ous " micro-organisms in, 104- 108 ; from equine source, 32-35, 70 ; full degree of activity of, Jenner, 150 ; glycerination, extent of, German Commission, 161 ; lymph, granules in, Beale, Lionel, 85-86 ; Burdon - Sanderson, 88 ; Buttersack, 99-100 ; • Chauveau, 86-88 ; Hallier, 86; Keber, 86; Sacco, 85 ; Zurn, 86 ; leucocytes present in, 82 ; micro-organisms in, 82-83 ; Anthony, 96-97, 99 ; Babes, 90 ; Baillard, 99 ; Berlin Commission, 108, 115 ; Blaxall, 104-108, 114- 117; Boureau, 102 ; Buist, 92-93 ; Carmichael, 93; Chambon, 96; Chaumier, 102 ; Copeman, 95, 100, 104- 117 ; Cornil, 90 ; Crookshank, 95-96 ; Cozette, 103 ; Delobel, 103 ; Garr^, 94 ; Gourny, 103 ; Grigorieu, 94 ; Guttman, 92 ; Hlava, 93-94 ; Kent, 100 ; Klebs, 90 ; Klein, 98-99, 106 ; Koch, 90-91 ; Landmann, 100 -101 ; Le Dantec, 10 1 ; Leoni, 95 ; Maljean, 97 ; Marotla, 92 ; Martin, loi ; Meguin, 92 ; Mc^nard, 93, 96, 102-103; Paul, 103-104; Pfeiffer, L. , 94 ; Protopopoff, 95 ; Quist, 91 ; Ruete, 100 ; Sacqu6p(§e, 103 ; Straus, 96 ; Tenholt, 93 ; Woitow, 94-95 ; microscopical examination of, 82 ; mixed with glycerine and thymol. cause of disease in Riigen, 170- 171 ; morphology of, Cohn, 89-90 ; potency of, Boureau and Chaumier, 102 ; unim - paired by addition of glycerine, Miillcr, 156-157 ; purilication and preservation by glycerine, Blaxall, 173- 18 1 ; quality of, English Royal Commission, 168-169 ; Quist's experiments, 91 ; red corpuscles in. Hus- band, 82; specific organism of, Arloing, 102 ; Baragi, 91-92 ; P'eiler, 91-92; Freyer, 115- 116 ; Koch, 90-91 ; Quist, 91 ; Serebriakoff, 91-92, and Voigt, 92 ; sterilised or filtered, effects of, 84 ; sterilised, experiments with, 134-135 ; streptococcus of erysipelas found in, Klein, 95 ; stocks, efficiency of, Michael Foster, 128 ; stored, opacity of, Cohn, 90 ; subcu- taneous injection of, in the monkey, bovines, and horses, Chauveau, 136 ; tubercle bacil- lus in, 108 ; vesicle, description of, 73-74 ; vesicle, histology of, 73-84 Vaccinia and variola : in the monkey, 128-133; relation- ship of, 41-66 Vaccinia: generalised, in solipeds, Chauveau, 116 ; in the mon- key, course of, 129, 130 ; Jenner, 41-42 ; pathology of, 31, 40 ; propagation of other human diseases with, 150-152 ; specific organism of, Blaxall and Copeman, 114-117 ; sus- ceptibility of monkey to, 128- 130 Vaccinococcus, description of ; Voigt, 92 Van der Loeff ; protozoa, 121 Vanselow ; animal vaccination in Germany, 147 INDEX 257 Variola : earliest employment and derivation of, 7-8 ; specific organism of, Besser, 96 ; Blaxall and Copeman, 114- 117 ; susceptibility of monkey to, 128-130 ; vaccine, cultiva- tion of, Copeman, 108 -114; vaccine lymph, 71 Variolce vaccinas, Jenner, i Variolated monkey, blood plasma of, as protection against vac- cination, 136-138 Variolation : complete, in the mon- key proved, 130-132; of bovine animals, 41-66, 71-72 ; Adams and Putnam, 47 ; Badcock, 47, 60 ; Berthel, 50 ; Ceely, 44-47, 57, 60 ; Chauveau, 47-50, 61-62, 64, 135 ; Cope- man, 58-61, 63-65, 108-114; Cory, 50-51, 56-57; Dupuy, 63 ; English Royal Commis- sion, 60-61, 65 ; Eternod, 55, 60; Fischer, 52-54, 71; Gassner, 42-43 ; Haccius, 55-56, 60, 71 ; Hervieux, 63-64 ; Hime, 54, 60 ; Juhel, 63 ; King, 53-54, 60, 71 ; Klein, 56-58, 61, 63, 135 ; Layet, 63, 64 ; Le Dantec, 64 ; Lyons Commis- sion, 48-49, 61 ; Martin, 49, 61, 64; Simpson, 50-53, 60; Thiele, Basil, 43, 60 ; Viborg, 43 ; Voigt, 49-50, 60 Variola, treatment of, by serum : Auch(^, 140; B6clere,i4o; Cope- man, 141; Kinyoun,i4i; Land- mann, 140-141 ; MacElliot, X41 Variolous lymph : bacillus in, Klein, 98 ; micrococci in, Buist, 93 Variolous test, 68 : Collins and Picton, 132-133; in the monkey, 130-131 Vaseline, action of, on vaccine lymph: Blaxall, 173-180; King and Bamber, 173-174 Vesicle, vaccine : description of, 73-74 j histology of, 73-84 Viborg ; variolation of bovine animals, 43 Vienna, animal vaccination intro- duced to, 146 Voigt ; vaccinococcus, described by, 92 ; variolation of bovine animals, 49-50, 60 Von Sicherer, protozoa, 121 Waller, Mrs. ; smallpox, 2-3 Ware smallpox epidemic, 1722, 3 Warlomont : admixture of gly- cerine with lymph patented in England by, 158 ; animal vac- cination introduced to Brussels by, 145 Warrington smallpox epidemic, 1773. 3 Watson, Sir Thomas ; inocula- tion, 26-27 Wegefarth ; protozoa, 124-125 Wilson Hake ; analyses of gly- cerine, 172-173 Woitow ; micro - organisms in vaccine lymph, 94-95 Woodville ; arm-to-arm vaccina- tion, 68-70 Yeasts, certain, action of glycerine on ; Blaxall and Copeman, 164- 165 Zurn ; granules in vaccine lymph, 86 THE END Printed by R. 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