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APPENDIX.
         REPORT ON VACCINATION,
Read at the Annual Meeting of the Massachusetts Medical
                   Society.  June 1, 1808.

THE  Committee appointed on the 3d of February 1808,  by the
   Counsellors  of the Massachusetts  Medical  Society " to inquire
   into the firesent state of the evidence respecting the prophylac-
   tic power of the coivpock, and to report such measures as they
   may find to be expedient for establishing the practice on a safe
  foundation" beg leave to offer the following report; *
          ON  examination of  the principal writers  for and
against vaccination  has fully  confirmed, in the opinion of  the
committee, the statement originally  made by Dr. Jenner,  which
•vas in substance as follows, viz.  " that the animal economy is
under precisely the  same laws with respect to the action of vac-
cine and variolous virus, and that both of them are by inoculation
preventives of the smallpox ;  but that the advantages are greatly
in favour of vaccine inoculation, because it is equally safe at all
ages and in every season, and does not occasion confinement,—
because it neither diffuses  contagion nor excites  scrophula, and
because it is  free  from  the  danger attending the inoculated
smallpox, which still proves fatal in one case out of two hundred
and fifty."
   To  quote authorities, or to  adduce  the  experiments which
have been made, in  support of these opinions must be  needless.
The experiments could scarcely be numbered, and for authorities
we have more than  nineteen twentieths of all the practitioners of
medicine, who have investigated the subject.   Let us appeal only
to the test proposed by one of  the  most able opponents of the
practice of  vaccination ;   this is Mr. Goldson,  an English sui-
treon,  who  has  published " cases of  smallpox  subsequent to
                      M 
90
APPENDIX.
 vaccination."  Mr. Goldson makes the following remark ; " The
 full  extent of the powers of vaccination can only be ascertained
 when the smallpox shall again become the prevailing epidemic :—
 when the state of the atmosphere shall again be so far variolated,
 that  seclusion  can  be of little avail; then will be the time to
 prove,  how far the security  vaccination  gives, will  extend."
 To  which Dr. Willan,  in his treatise  on vaccine  inoculation
 applies the following observations ;  " This crisis appears to have
 taken place in the metropolis last year,  when  the smallpox was
 more extensively diffused, and proved more fatal than it had been
 in any of the four preceding years.   All persons resident in  or
 near  London,  who had  been vaccinated since the beginning  of
 1799, but especially the children of the  poor, must  have had
 frequent intercourse with variolous  patients during the time of
 the epidemic.   The primary series of vaccine  inoculations  were
 thus  tried in  the severest manner possible, yet the subjects of
 them, to the amount of many thousands,  or even tens of thou-
 sands, remained proof against the contagion.
   " Whilst we acknowledge that some, who had been vaccinated
 in the preceding years, took the fmallpox at this period, we have
 reason to  congratulate ourselves  that the number was  so small,
 and that so few mistakes had been committed in a mode of prac-
 tice entirely new.   Mr. Goldson himself allows, < It was not ex-
 traordinary such cases should occur in the  early stages of its in-
 traduction.'—< Indeed, prior to the  nature of  the disease being
 sufficiently understood,' he says,  after Dr. Jenner, < many prac-
 titioners took up the lancet, without ever having seen the vaccine
 pustule."
   The high interest which this discovery excited in this country
 at the time of its annunciation, and the evidence, which was im-
 mediately  offered by  Dr. Jenner and his  coadjutors, did,  at a
 very early period, engage the attention of almost every individual
 among us in the medical  profession ;  and that evidence was so
perfectly satisfactory to the public,  that a formal investigation
of the subject by this society, at that period, was altogether
 ':nnecessary. 
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                      APPENDIX.                    91
  The most important laws of the vaccine disease were 3tated by
Dr. Jenner, when he  introduced the knowledge  of it to the
world.  The  principles  he laid down and  the  limitations he
pointed out are sufficient to guide  us in the great majority of
cases.   But it was not possible  that he  should  at the outset
have been minute in noticing every variety of circumstance at-
tending vaccination.   Dr. Jenner foresaw that  many errors
would be  committed and many  difficulties would arise, if this
practice should not be pursued  with the utmost  prudence and
circumspection.   Such errors and difficulties would necessarily
affect the reputation of the practice,  of  which  the rules were
contravened in the production of them.
   Difficulties have arisen, and in reporting the present  state of
evidence on this  subject, it  is proper and  may  be useful  to
state that  the utility of vaccination  has  been much more con-
tested within the last five years, than during the five years, which
preceded them.   The committee have examined the  evidence
offered against  vaccination and have endeavoured  carefully  to
estimate its importance ;  the  result of their examination  they
will state in a manner  as concise as shall be consistent with per-
spicuity.
   From the evidence which has been furnished to the public,  it
appears unquestionably that very many persons,  who have been
supposed to be secured from smallpox by vaccination, have been
subsequently  affected  with smallpox in  a degree more or less
severe ; although the occurrence of that disease under such cir-
cumstances has  very rarely been followed by death.  From the
number of instances of this  sort which have already been made
public there is reason to believe that very many similar ones will
occur,  unless prevented by seasonable caution.   To  whatever
cause these events may be attributed, it  is not to  be presumed
that we shall be exempt from similar misfortunes in this country,
unless we provide against  them;  and as they would  probably
take place during the general prevalence of smallpox among us,
and would therefore happen many of them at the same moment,
they would be peculiarly distressing.
.- w -i  •;:. 
 92                     APPENDIX.
   The committee are happy to say that all real evils of this sort
are capable of being obviated;  and that if this is not true in
every case,  the exceptions  are  at least  as rare, as  those which
happen in the practice of variolous inoculation.
   It appears that a large proportion of those,  who  have had
the smallpox after supposed vaccination, were inoculated by per-
sons not of the medical profession, or by those in it, who  had not
acquired a knowledge of the vaccine disease.   In other countries,
as in this,  persons out of the medical profession have practised
vaccination, many of them from motives of benevolence, although
some have been influenced by those of a very different character.
Whatever motives, may  have influenced  them, the practice of
such persons should be discountenanced; for although in perfect
cases the character of the cowpock is so decidedly marked, that
a very little experience renders it familiar, yet many  equivocal
cases occur, in which a nice  discrimination and a habit of com-
paring the appearances of cutaneous diseases are found requisite.
   It is however true that all  the cases of failure cannot be refer-
red to ignorance  in  the  inoculators ; and that the  smallpox has
appeared with a character more or less  strongly marked even in
those, who have been vaccinated by regular practitioners of medi-
cine j and indeed by practitioners who have had much  experience
and been well-informed on the subject of cowpock.   In support
of this statement  the committee refer among other authorities to
the following, viz ; Willan  on Vaccine  Inoculation ; Medical and
Physical Journal, vol. 14, pages 5, 6,  21,  143, 308,  and 407  ;
Medical and Chirurgical  Review, vol. 13, in  the miscellaneous
part, pages xcii, cxv, and cxvii. ;  vol. 14, miscellaneous, pages
Ixxxv, cxxxiv, and cxxxv.  Many other references might be given
to other pages in the same  and also to other works.  The com-
mittee have selected the following cases, which are  not  however
more remarkable  than many others.
" A Case  of Smallpox after  Vaccination ;  communicated by Mr.
           Blair, Surgeon  of the Lock Hospital, &c.
   " On May 7>  1803, I inoculated a  child, named Alice Gor-
thorpe, with the  vaccine  fluid.   The disease made  its usual pro- 
                        APPENDIX.                     93
  gress, and left a cicatrix on each arm, as may be seen at present.
  On the eighth day after inoculation, I took matter from  this
  child and vaccinated several others.
     " On Monday, June 3, 1805, the mother of the child, residing
  at No. 25, Tower-street,  Seven Dials, came to my house, and
  shewed me the patient covered with a distinct variolous eruption,
  small in size,  but  fairly maturated.  I sent her  immediately to
  Dr. Adams,  (who succeeded  Dr. Woodville at the Inoculation
  Hospital) to prevent my giving an  erroneous opinion respecting
  her case ; he agreed with  me that it was certainly  the small-
  pox  ; and that this instance must be added to the few others
  which have  occurred, of  the'variolous  infection  taking place
  subsequent to complete vaccination.
     "  I have only to add,  that three years  ago  I vaccinated  an-
  other child of the same parent,  and a third on the 21ft of May
  laft;  both of which,  with nine more who had been inoculated
  in the same family, escaped the smallpox on this  occasion ;  and,
  what is deserving of notice, the infant whom I vaccinated on  the
  21st of last month (Thomas Gorthorpe)  had slept in the same
  bed  with his sister during the whole progress of her recent
  disease.
     "  Great Russell-street, Bloomsbury, June 6, 1805."
                           [Med. & Phys. Jour. vol.  14, p.  21.
               Extracts from a paper by  Mr.  Ring.
     " Two other cases of the  smallpox have occurred since my
  last communication, in patients vaccinated by me.   One of them
  is a child  of Mr. Pearse in Great York Mews,  Baker-street,
  who was  inoculated four years ago, with matter taken on  the
  tenth day.   I have long avoided to take  matter at so late a pe-
  riod ; but  at the same time must acknowledge, that in this  case
  I frequently  saw the pustule, which appeared perfect, and to go
  through its regular course.
m    " The subject of the other case is a child of Mr. Stokes, No. 12,
  Orange-court, Swallow-street,  whom I inoculated five years ago,
  at a time when it was not thought of much consequence at what
  period matter was taken, provided a pustule, resembling a vac- 
91
APPENDIX.
 cine pustule, took .place.  Such a pustule took place in the pres-
 ent instance, and afforded matter for a considerable number of
 other successful inoculations ; and those who were thus inoculat-
 ed, have resisted the infection of the smallpox.   I cannot, there-
 fore, but consider it as having been a genuine case.   The small-
pox, in this instance and the former, as well as others, is so very
 benign for the natural sort, that I conclude it is  modified and
 mitigated, though not totally prevented, by the preceding vacci-
 nation."                                      [Ibid.  p. 143.
 Extracts from the Minutes of the Original Vaccine Pock Institution
                         in London.
   " June 10, 1806.   Anna Maber (No. 33, on Dr.  NihelPs
list),  now  ten years  of age, attended the institution, with an
eruption  supposed to be smallpox.   She was vaccinated at this
institution  four years ago,  and there is a very  distinct scar on
the left arm.  She began to be ill eleven days ago, and  in three
days a rash appeared.   On the fourth day, an eruption followed,
with abatement  of the fever, and  the rash disappeared.  The
eruptions continued to come out for some days,  and the fever
went entirely off.  The eruptions are still out, but in a  dried or
scabbed state, and amount in number  to some  hundreds :  they
are more or less on the skin of every part of the body.  The
mother of the child says, that rnoft of them  did contain  yellow
matter :  a few of the scabs  are now the size of  ordinary small-
pox, but most of them not so large.
   " At the same time attended  Mary Maber, eight years old
(No. 34  on Dr. Nihell's list) ;  she was also inoculated at this
institution  at  the same time with her sister above :  a  distinct
scar remains on the arm inoculated.   She sickened the day after
her sister with similar symptoms, and in  four days eruptions ap-
peared,  about twenty in  number,  the illness at the same time
abating.  The eruptions were the same  in size and  appearance
as in the other.
   " No doubt was entertained by the gentlemen present of these
being cases of smallpox, which they appear to have taken from
William Patterson,  a  child inoculated for the smallpox twenty- 
                      APPENDIX.                     95
two days ago,  who sickened at the usual period of nine days,
and had the smallpox in the ordinary way, with a copious erup-
tion.   These three children all lived together in the same room,
while Patterson was under the smallpox.
  "  Both Anna and Mary Maber,  according to the  mother's
account, underwent the chickenpox before vaccination, and both
have had the measles since vaccination.
   " The register  contains the  following report of these cases
during vaccination.
   " No. 33, Anna Maber, five years old, inoculated April 8,
" 1800, with eighth day matter,  from Mary Burrell, No. 24 ;
" one puncture in left  arm.
   " 8th day.   One well-formed pustule—headach and fever on
" the seventh day, but now better.
   " 11th day.  Pustule looks well, with broad red margin—has
had headach and fever  since the  last report.
   " 13th day.  Pustule black—beginning to dry up : very well
since last report.
   " No. 34.   Mary Maber,  three years old,  inoculated from
same patient and same day with the above : one puncture in left
arm.
   " 3d day.  Taken  ; no illness.
   " 8th day.   A well-formed circular pustule, with red margin.
   " 11th day.   Fine  pustule,  with great inflammation  in the
arm—has been poorly  since last report.
   " 13th day.  Pustule black and drying.
   " 14th day.   Well.
   " June 17»   As an additional proof that the two  Mabers were
duly affected with cowpox, they were at the time selected for the
inoculation of five children in one family ;  viz. Mr. Parker's of  \
 Fleet-street, who  also  went through the cowpox, as  was conceiv-
ed,  in a distinct manner,  and were subsequently inoculated for
 smallpox  by  Dr. Pearson without effect.    Farther; the  two
 Mabers were inoculated with eighth day vaccine matter, as above
stated, from Burrell, who  was among the number of patients in-
ocuH-d bv this institution for smallpox  after vaccination,  and 
 96                    APPENDIX.
exposed to variolous infection at the smallpox hospital two years
ago, without effect.   In looking over Burrell's  case, it appears
that he took chickenpox five months after vaccination,  and  yet
was found insusceptible of smallpox, contrary to Mr. Goldson's
suggestion."          [Med. & Chirur. Review, vol. 13, p. cxv.
   " May 8, 1807.   Dr. Pearson reported that  Dr. H-----had
called upon him to communicate the following case of failure in
the instance of his own child.—About five years ago the subject
was inoculated from a person in the cowpock selected by Mr.  K.
of the Army Board and approved by Dr. B----, and in conse-
quence the most distinct vaccinepock  affection was produced.
A few weeks ago it was thought proper to test the patient by
inoculating it with variolous matter obtained  from the  smallpox
hospital.   This inoculation has produced the most distinct small-
pox disorder, the eruptions being decidedly those of the small-
pox, of which there are about forty large and fully suppurated,
besides a number of small ones not suppurated.  Mr.  Bowen of
 Harrow and others of the faculty have  seen this child in  the
smallpox.                            [Ibid. vol. 14, p. cxxxv.
   " Oct. 6, 1807- Mr. Gemmell, surgeon apothecary, Princes-
street, Drury-lane, attended to give information respecting some
cases of failure of cowpock.
   " 1st.   In the family of  Mr. Thorn, an upholsterer,  Bear-
yard, Lincoln's Inn Fields : one of his  children was inoculated
at Pancras hospital about  three  years  ago ;  about nine weeks
afterwards, Mr. Gemmell attended the same child in the small-
pox, which was very distinct and full, and unquestionably small-
pox.
   " 2d case was in the family  of one Weaver, 35, Stanhope-
street, Clare-market.   (See the  particulars of this case below.)
   " The 3d case is now in the scabbing state  of  smallpox,  at
 Xo. 14, Banner's court, Drury-lane.   This child had been vac-
 cinated at the smallpox hospital.
   " Oct. 13.   Ann  Weaver attended  this day with  her son,
 William Weaver, nearly six years of age, whose case is  mention-
 ed above by Mr. Gemmell, (No. 2.)   She says he was inoculated 
                       APPENDIX.                    97
for cowpqx  by Mr.  Wachsel, at the  smallpox hospital, about
three years and a half ago : the scars are visible, but faint.  The
case was considered by Mr. Wachsel at the time to be complete,
and several other patients were inoculated from it.   He was re-
inoculated, however, for cowpox about four or five months after,
because the mother was  dissatisfied, conceiving  there ought to
have been eruptions.  This second  inoculation produced a sore
arm for several weeks.
   " Three months ago this boy was taken ill of fever, followed
by eruptions, which were seen and  declared to be smallpox, of
the confluent kind, by Mr. Wachsel, Mr. Mainwaring, Mr. Sut-
ton,  Mr. Lawrence, Dr. Moseley,  and others.   This boy had
communicated a short time before his illness with persons in the
neighbourhood labouring under smallpox.
   " Mary, the sister of the above, who had been vaccinated by
Mr. Wachsel, fell ill five weeks ago, and  had about twelve erup-
tions, the scabs of some of which remain  at this time.   Other
children in the adjoining houses have since fallen  ill of smallpox.
   " Oct. 26.  A note  was received  from Mr. Gemmell, men-
tioning the case of a child of Moore, a taylor, residing at  No.
17, Great Wild-street, Lincoln's Inn Fields, then lying danger-
ously ill of smallpox after vaccination.   In consequence of this
information, a governor of the institution made inquiry the fol-
lowing day into  the circumstances of the case.   He reported,
that he found the child lying dead of confluent smallpox, which
had proved  fatal on  the twelfth  day.   The father said the child
had been vaccinated  two years before at Dundee, by  Dr. Crich-
ton of that place, who had declared the progress of the vaccine
affection to be perfectly  regular, and had in consequence taken
matter from it to inoculate another  child of the name of Scott.
A distinct scar remained  on the arm, and  was visible at the time
of the child's death.   It was seen in  the smallpox by Dr. Ha-
worth, Mr. Gemmell, and several other gentlemen.
  "  Nov. 6.   Dr. Pearson reported, that he had visited a child
of the name of Beasly, between three and four years  of age, re-
siding at No. 49, Upper Rathbone-place, who was just recovering 
98                    APPENDIX.
from smallpox, so severe as to have been in considerable danger.
The eruption was universal, but distinct, and the pustules large
and perfectly characterized.  The eruption was now in the tenth
day, and had not yet completely maturated  on the extremities.
This child was vaccinated two years and ten  months ago, viz. in
January 1805,  by Mr. Griffiths, of St. George's Hospital, and  -
went through the disease to his satisfaction.   Distinct scars re-
main on the inoculated parts.  It is worthy  of remark, that the
cicatrices were  quite free from  pustules, although almost every
other part of the skin was covered with them.   The fame thing
has been obferved in other cases.
  " Dr. Clutterbuck this day  reported, that he had seen, two
days ago, the  child of Mr. Stiles, No. 7,  Lamb's Buildings,
Bunhill-row, then lying dead of  smallpox.   The disease was of
the most malignant character, the pustules in general remaining
flat and empty, interspersed during life with numerous purple
spots.   They were confluent only about the face.  Many vesi-
cles containing bloody serum were scattered over the skin.
  " This child had been vaccinated at the Golden-lane Jennerian
station, by  Mr. Lewis Leese, surgeon, and was  registered  as
having gone regularly through the disease.   The scar on the in-
oculated part was perfect.
  " Nov. 24,   Robert Purdy, of 45, Upper Rathbone-place, at-
tended the institution this day with his  daughter, Sarah Purdy,
aged four years and two months.  This child has now  an erup-
tion  of pustules amounting to  several hundred, pretty generally
diffused over the whole body, and which first made their appear-
ance five or fix days ago, after three or four  days illness, with
fever.   The pustules on the face are now nearly in a state of ma-
turation : those on the extremities  are less forward.   The gen-
tlemen present, five in number, are unanimously of opinion that it
is smallpox.
  " The father says, that the child was vaccinated by Mr. Ad-
dington, of Spital-square,  four  years ago next  January,  at the
Jennerian station in that neighbourhood, and went through the
affection regularly.   There  is a distinct scar on each arm from
vaccination. 
APPENDIX.
99
  " A younger child in the  same family has just gone through
the smallpox, having been  inoculated three weeks ago  at the
smallpox hospital.  The smallpox has been also prevalent in the
neighbourhood for several weeks past."
                                      [Ibid. vol.  15, p. cxxv.
  Cases like these warrant hesitation and have in the minds of
many excited serious doubts respecting the utility of vaccination.
  It should however be noted that in most of the cases, where
the vaccine disease has exhibited its proper characters, the sub-
sequent variolous affection  is evidently modified and rendered
much more mild by the vaccination.  In short where the small-
pox has not been prevented by the vaccine pock, it has been dis-
armed of its  terrors.
   But the advantages of vaccination are to be  determined  by a
comparison of this practice with that of inoculation for smallpox.
   The advantages of variolous inoculation were these ; first, that
the disease produced by it  was  very much more mild and less
mortal, than when the same disease was produced by casual con-
tagion ;  and secondly,  that  the  disease- having been once pro-
duced, by whatever means,  it will not occur again in the same
subject.   Both these laws  are  generally so true that they have
long ceased to be controverted.   But  to  them both there do,
although rarely, occur exceptions.   In some cases  the smallpox
produced by inoculation is  very severe and even mortal.   Like-
wise  in  some cases  those  who  have  undergone  that  disease,
whether in one way or the other,  have subsequently suffered from
the same again in a greater  or  less degree.   It  is observed in
almost every smallpox hospital, that the nurses are subject to
variolous pustules especially in those parts,  which  have been in
contact with the pustules of others.   In these cases  the disease
has sometimes been so severe as to occasion symptoms of irrita-
tion,  or secondary  fever.   But other cases well  attested have
been published,  in which persons are  stated to have  undergone
 the whole of the variolous disease a second time, in a manner not
to be doubted.  That is, they have had variolous eruptions fol-
lowing the regular symptomatic fever.   In support  of this  ?tate- 
100
APPENDIX.
 ment the committee refer to the authorities subjoined, and have
 also selected the cases which follow as being particularly worthy
 of regard.  Willan on Vaccine Inoculation.  Ring on Cowpock.
 Med. Ac Phys. Journal, vol.  13. p. 570.  Vol. 14. pp. 7, 176,
 251, 404, 405, 407, 436.   Vol. 15. pp. 436, 441, 442, 443,
 444.   Vol.  18. pp. 314, 315.
      " To the Editors of the Medical and Physical Journal.    I
  M  Gentlemen,
   " Thinking the following account of the second appearance
 of smallpox in the same person, interesting ; and that it may be
 usefully conveyed to the publick, through the medium of your
 very useful and widely circulated Journal, I have sent it for in-
 sertion.     I am, &c.
                                        «EDW. LEESE.
   " East Street, Manchester Square,
         August 18, 1805."
   « Mrs. Pidgeon now living as housekeeper with Mr. Jarnet,
 of David Street, the corner of East Street, Manchester Square,
 informs me, that her late husband,  when about fifteen years of
 age, then residing as a gardener with Capt. Markall, of Honiton,
 in Devonshire,  was inoculated for the smallpox by Mr. Buller,
 a surgeon of  that place ; that his arm inflamed very much ; and
 that it was  succeeded by a  thick eruption of pustules all over
 his body ; his feet were so full of them,  that he was unable to
 stand.   He was for some time confined j and so very ill, that Dr.
 Robinson, of Honiton, was requested to see him.   Dr. Robin-
 son and  Mr.  Buller continued to attend him till  his recovery,
 without expressing any doubt of the  nature of the disease.
   " Some years after, a lad in the same family had the small pox ;
 during the progress of which, he slept with him,'and received no'
 inconvenience.
   " When he was about twenty-eight years of age, his own chil-
 dren had the smallpox ;  of which one died.  He lived and slept
 with them, and at length was taken so ill, as to be obliged  to
 leave his work ; complaining of sickness, head-ach, and severe
pains in his back.   The medical gentleman attending the chjl. 
                       APPENDIX.                   101
dren was sent to; who observed, that if he had not already had
the  smallpox,  he  should  think he  was then sickening  for it.
After an illness of two or three days, a full eruption of the con-
fluent smallpox made its appearance ; of which he died on the
eleventh  day."          [Med. &  Phys. Jour. vol. 14. p. 251.
"  Copy of a  Letter from the Earl  of Westmeath, to Dr. Jenner,
                   dated May 23,  1805.
 « Sir,
     " Understanding that a report has been circulated, which,
if believed, would tend much to weaken that  confidence,  which
is at present so generally and so justly entertained by the public,
in your  system of inoculation  for the cowpox, namely, that my
youngest son had taken the natural smallpox, after having been
vaccinated, I think it but justice to you to contradict the report;
and to state,  for your  satisfaction, the real circumstances of the
case, which are as follow :
   " When he was about two months old, he was  inoculated for
the smallpox, in the Suttonian method,  by a physician in Ire-
land, who has been very generally  successful  in inoculation, and
pronounced by him to be perfectly free  from the risk of infec-
tion ; notwithstanding which, lie caught the infection, about a
fortnight since, and is now recovering from the natural smallpox.
   " I beg to inform you,  at  the  same time, that  my youngest
daughter, who  was vaccinated by  you, about four years since,
has not only been frequently exposed to the danger of infection,
but was actually inoculated for the smallpox,  without  taking it.
I have considered it incumbent on me to bear testimony to the
efficacy of the vaccine system, as I consider the report relative to
my son, which  originated in misrepresentation, to have been cir-
culated for purposes obviously  prejudicial to that most useful and
fortunate discovery.
   " I request you will  make  any use of  this communication,
which  you may think necessary.
            4(  I am, Sir,
               *'  Your obedient humble servant,
                                    " WESTMEATH."
                                           [Ibid.  p.  256. 
202                  APPENDIX.
                            " Arundel, September 13, 1805.
       " Sir,
   " I yesterday received your letter,  and shall be happy if any
information I can give, concerning a person's  twice  having had
the smallpox, should  contribute towards removing the doubts
which exist, of the superiority of vaccination.
   " In the year 1738, the smallpox committed its furious ravages
in this place, and is said to have destroyed one out of every seven
whom it attacked.  Amongst  the number  of infected was  Wil-
liam Biit, at that time about eighteen months old.   It has been
a tradition here, as long as the oldest of the inhabitants can re-
member,  that  this  boy was supposed to have been dead ; and
that his body was purchased by Mr. Birch,  a surgeon, for the
purpose of dissection.   He, however recovered ; and for the rest
of his days, was a living monument of the havoc the disorder had
made.   I knew him well;  and do not recollect many instances
of a person more fretted and seamed by the smallpox than he was.
   " The marks  he bore, were  deemed  a  sufficient security
against  any future  infection of the  smallpox.   He was  there-
fore appointed to  attend on variolous patients in the pesthouse;
a kind of lazaretto at the skirts of the town.
   " One woman died of the smallpox in the house, on the  15th
of February, 1799,  and another a few days after.  William Birt,
the subject of your inquiries, sickened on the 28th of the  same
month ; and the eruption  appeared on  the fourth day.   I saw
him on the sixth day of the disease, being sent for by the family
to give my  opinion on the possibility of its being the smallpox ;
which none of them could believe, from the evident marks of his
having had the complaint.
   " On inquiry I found, that he had been  exposed, a short time
before, to variolous contagion ; and that his disorder commenced
with the symptoms  usually attending the worst kind of the small-
pox.   The eruption was confluent;  and his throat was severely
affected.   He was removed from his home, on the day I  visited
him, to the pesthouse :  where he died on  the twelfth day of the
disease. 
                   APPENDIX.                      $03
   " If this detail can be of any service, I beg you will accept it,
with my sincere wishes, that it may contribute towards the ad-
vancement of your pursuits.
                         " I am, &c.
                            « WILLIAM PLOWDEN.
   " Mr.  Ring."
                                           [Ibid. p. 404.

             Extracts from a paper by Mr. Ring.
   " The two following cases were communicated to me by Dr.
Jenner ; and published in my answer to  Mr.  Goldson.   Mr.
Fewster of Thornbury, the celebrated inoculator, had the small-
pox in his youth, and was exposed to the infection with impuni-
ty for forty years ;  yet, happening to  wound his  finger with the
point of a lancet, charged with variolous  matter, the puncture
inflamed and suppurated ; and he had a considerable number of
pustules on his forehead.
   " Mr. Scott, another surgeon in the  same town, had the  small-
pox by inoculation  ; which proved to be of the confluent kind.
Nevertheless, he  caught it again twenty years after, from a pa-
tient  whom he was attending ; and had it with some degree of
severity.
                         << princes Street, Cavendish Square.
      'Sir,
   * I have sent you four cases, containing a plain narrative of
facts.  I  cheerfully submit them to you, from a conviction that
they will be employed, as far as they are capable, for the advance-
 ment of truth and science.
                           ' I am, &c.
                             '  WILLIAM ROYSTON.' .
" Cases of casual Smallpox succeeding to the inoculated disease, af-
                ter an interval of nineteen  years.
   "  Sarah and  Mary Taylor were inoculated for the smallpox ;
 Sarah when two years,  and Mary when four days  old.   Sarah
was inoculated by a Mr. Richardson, who was engaged in prac-
tice with, or was a pupil of Sutton.   She had but few pustules, 
104                   APPENDIX.
and those faded early, but she was pronounced safe.   Mary was
inoculated by Mr. Robert Muriel, a respectable country practi-
tioner, and the virus which he used was taken from a person who
had the disease by inoculation.  She went regularly through the
distemper, had a considerable crop of pustules, and an indelible
mark remains in her arm where the matter was inserted.  During
a period of nineteen  years these young women, perhaps, were not
exposed to the smallpox contagion ; but at the end of that time,
in February 1788,  a general inoculation took place in the vil-
lage where they resided.  Sarah was then attacked with the cas-
ual disease ; the pustules were confluent in her face, but distinct
in other parts ; she was blind some days.   Mary took the dis-
ease at the same time ; the pustules on her were numerous but
distinct, arid turned on the second day.
          " Case of Smallpox occurring a second time.
   " Mary Feakins, of Somersham in Huntingdonshire, had the
smallpox in the year 1769, the disease being then very general in
the neighbourhood.  It appeared in her in its severest form, and
she suffered extremely.  When she was  attacked with the com-
plaint she nursed an infant daughter, then  six weeks old, who
took the smallpox  from her  mother, had a confluent kind, was
much marked, and  lost an eye.   In the year  1788, when this
daughter was nineteen years  old, on being exposed to the accu-
mulated contagion of  the smallpox, she was again attacked with
the disease ; and I attended  her.   This second attack was not
of the slight kind which has been observed to occur in nurses.
The eruptive fever continued four days ; there was considerable
inflammation about the  fauces ;  the number of pustules in her
face amounted nearly to two hundred, with a proportionate crop
over the surface of  the body.  The pustules on the face arrived
at the acme of maturation on the seventh day from their appear-
ance.  Swelling in the face closed the eyes ; the extremities were
tumefied, and some degree of ptyalism took place.   The  accu-
mulated effluvium to which this girl was exposed occurred  from
 her sleeping in the same room with  three younger sisters, v.-hr 
APPENDIX.
105
were down with the disease, one with the casual sort, and two by
inoculation."*                        [Ibid. vol. 15,  p. 442.
   This doctrine, that the small-pox will  sometimes occur twice
in the same subject, is not new ; although it has been controvert-
ed by great authorities  ;•]- but the occurrence is so rare, that it
has not been found during the experience of nearly a  century to
constitute any serious objection to variolous inoculation.  For in
the first place, the question is not whether those who have had
the smallpox once are capable of being affected at all by variolous
matter, but whether they are secure against severe affections by the
application of that matter to them.   If, when  they  have once"
undergone the disease, whether produced by casual infection or
by inoculation, they are not liable to suffer severely from it again,
and if the disease,  when produced in the  latter mode, was far
more mild and safe, than when produced  in the  former, the utili-
ty of inoculation was  sufficiently decided.   Such was found to
be the case generally.  If one exception has occurred to this gen-
eral rule  in a thousand cases, and even if every person  should die,
who experiences a second attack of the disease, such rare excep-
tions could not form any objection to the  practice of inocula-
tion.  The truth has been much  more favourable than these sup-
positions represent it.
   The advantages of variolous inoculation  therefore have long
ceased to be  questioned, and even these objections to the prac-
tice were almost forgotten, till the contest respecting the vaccine
disease has revived the consideration of them.
   If the vaccine disease  affords  equal or nearly equal security
with the variolous, it must be needless to point out its superior

  * The cases of Diemerbrook, and that of Withers in the 4th vol. of the
Memoirs of  the London  Medical Society, have often been quoted. Mr.
Ring remarks " it is worthy of notice that in almost every instance  where
I  have inquired into a failure, or supposed failure, in the inoculation  oi*the
cowpock, I have heard of a failure, or a supposed failure, in the inoculation of
the smallpox." By failure he means a failure to give security from smallpox.
  f Sir William Watson, Dr. Archer, Baron Dim*dale, and Mr.  William Sift*
ton.  See Med. and  Chir.  Rev.
                    O 
106                    APPENDIX.
advantages in other respects.  " It is equally safe at all ages and
in every season, and docs  not occasion confinement; it neither
diffuses contagion nor excites scrophula ; and it is free from the
danger attending the inoculated smallpox, which still proves fatal
in one case out of two hundred and fifty."   That it does in the
great majority of cases afford a temporary security is so generally
admitted even by  its opponents, that on that head it would be
useless to adduce proofs.   Let it suffice to state the principal ob-
jections to the practice, which have been made by the  most saga-
cious antivaccinists, and to describe the methods which have been
proposed to obviate even the few  evil  consequences,  which are
attendant upon it.
  The objections are, first that the security it affords  is  not per-
manent ;  second, that the  occurrence  of other contagious dis-
eases, as hooping cough, measles and chickenpox, in persons who
have been vaccinated will restore the susceptibility of variolous
contagion ;  third,  that  although the genuine cowpock may se-
cure its subjects from smallpox, yet its character is so imperfectly
marked,  that few if  any practitioners are  capable of determin-
ing them with precision and certainty ; fourth, that it is produc-
tive  of horrid and loathsome diseases, which occasion protracted
sufferings and sometimes death.
   We may first remark that these objections are  precisely sim-
ilar to those, which for a long time delayed the universal adop-
tion of variolous inoculation.
   To the first objection, the want of permanence in the security
afforded by vaccination, Dr. Jenner long since offered  a sufficient
refutation by giving a list of persons, who  had been many years
before casually inoculated and  had undergone the cowpock, and
who still resisted smallpox.  Among  many  cases, which have
since been adduced to corroborate his statement, none  is more sat-
isfactory, than those of Mr. Jesty,  an English farmer,  and  his
family.  This man seems to have been among  the first* who
ever practised vaccine inoculation by design.   Having been ac-
  * There is an account of similar  instances on  the continent of  Europe,
 as early and earlier. 
                        APPENDIX.                    107
cidentally  inoculated with the cowpock himself and experienced
the benefits of the consequent security from smallpox, he inocu-
lated his wife and two sons with virus  taken from the cow in the
year 1774.   One of  these sons, Mr.  Robert Jesty, was inocu-
lated with variolous matter in London in the year 1805, thirty-
one  years after  vaccination, and was found unsusceptible of
smallpox.*  The father and  all  the family had frequently been
exposed to the smallpox before,  and the two sons had been inoc-
ulated  for it in the year  1790,  and in  every instance  without
effect.f
   The second objection, that certain contagious diseases follow-
ing  the cowpock restore the  susceptibility of smallpox,  does not
carry with it the semblance of truth ; and it is refuted by direct
observations.  Dr. Willan after relating cases of smallpox sub-
sequent to vaccination, and noticing this objection says,  " I have
found,   on  inquiry, that more  than  half the children above-
 mentioned,  who took the smallpox after vaccination,  had been
 intermediately  affected with the measles,  chickenpox, scarlet
 fever, cynanche parotidaea, or hooping cough,  but that in the
 rest there had  not  been any intervening disease.   The  changes
 of constitution produced between infancy and adult age, might,
 with as much probability, be supposed to remove the effects  of
the  cowpox.  This, however, is not the case in the natural cow-
pox, nor are adults less liable than children to failures in vaccin-
ation."
   Dr. Willan refers  to  some  observations on this subject by

   " Med. and Chir. Rev. vol. 12. p.  Ixviii. miscellaneous.
   f Mr. Jesty's experiments were made more than twenty years before those
of Dr. Jenner. While these cases make a valuable addition to the testimony
in favour of vaccination, the limited and unpublished experiments of Mr.
J esty do not detract in the slightest  manner from the claims of Dr. Jenner
on the respect and gratitude of mankind for having originated the  practice of
vaccination.  Mr. Ring says, " Dr. Jenner never has claimed the merit of
discovering the prophylactic power  of the vaccine virus : but he is fully
entitled  to the praise of converting  that discovery to general advantage."
Or. Jenner discovered to the world that this light was hid under  a bushel, 
108                   APPENDIX.
Dr. Stangerof the foundling hospital in London.   Dr. S. after
relating the cases of twenty-one children  in  that hospital who
resisted the smallpox  after vaccination adds the following  re-
marks,  " The same twenty-one patients also supply the most sat-
isfactory evidence to invalidate Mr.  Goldson's supposition, that
eruptive diseases may remove the security  derived from cowpox.
During the period which intervened between their being vaccin-
ated in March  1801, and  variolated in November 1804, six of
them  had  scarlet fever and  four  measles.   Ten of them had
hooping-cough also,  which proves that these contagious febrile
disorders, which so  powerfully  affect the constitution,  have no
influence in diminishing the efficacy of vaccination.   As the first
inoculation with variolous matter, in 1802, produced no consti-
tutional  affection, it  cannot supply  an  argument  against the
durability of the antidote for three years and a half."  Other
authorities  might be adduced to the same point.
   The third objection recounted above states  the  difficulty of
determining when the  disease is genuine.   This objection  was
in some measure just in the first years  of vaccination, and great
care is requisite to prevent it  from being so  at  all  times.  The
appearances at the part inoculated are alone to be  relied on in
determining whether the cowpock is  or is not perfect.  When
the disease takes place  in its most regular form, as with due care
will happen with very few exceptions,  no one will feel any hesi-
tation, who has had a tolerable share of instruction on the subject.
But there are observed in persons  inoculated for  cowpock ap-
pearances  varying from those of the true disease  ; and  thefe
variations  are in different respects and in different degrees.  It
does perhaps require considerable experience to gain an acquaint-
ance with  every  anomaly which occurs in vaccine  inoculation.
But the safe course is to note down every case, which is doubtful,
and at the end of six or twelve  months to  repeat the insertion of
vaccine  virus.    The  necessity of this  precaution  cannot bt
estimated too highly.   The committee think it so important to
point  out the true distinctions, which must determine our  judg-
ments on this subject, that they have quoted at large the remarks 
APPENDIX.                    109
relative to it from two late writers ; the one Dr. Robert Willan,
the accurate and faithful observer of cutaneous diseases;  the
other  Dr. Joseph Adams,  the ingenious and scientific  writer
upon morbid poisons ;  than whom perhaps  no two men now
existing are of higher authority in the case of a morbid poison
producing its effects on the  skin.
Directions for performing vaccination and a description of the regular
                    appearance of the disease.
   " The  general directions already given in smallpox inocula-
tion, as far as they are applicable, may serve in cowpox : but
the most  important consideration is carefully to avoid using fluid
in the smallest degree turbid.  True vaccine fluid is so perfectly
transparent, that on  fine glass, or even on the point of a fine lan-
cet, it cannot always be perceived.   For the most part it escapes
very slowly from the puncture made through the cuticle ; not
being like the fluid  of  a blister contained in a single bag, but in
a number of small cells communicating with each other.   When
it escapes in this gradual manner,  it sometimes forms itself into a
spherical  shape, and retains its figure like a perfectly transparent
jelly.  There are, indeed, some varieties in this respect depend-
ing on the age of  the vesicle,  and the degree of inflammation
with which it was attended; but there is no exception as to its
crystalline transparency.
   " It is generally  thought best to take the fluid  before the
eighth day ;  but when this is  done the vesicle from which we
take it should be watched till scabbing, for if without other vio-
lence than the above puncture, the contents should become mat-
tery or the scab soft, we ought not to depend on the issue of our
vaccination, but to take another opportunity of repeating it.
   " 2dly. The pure matter taken as  above, should  be  inserted
at the end of a clean lancet, by a simple incision.   It is not al-
 ways  easy nor important to avoid drawing a little blood.   No
means whatever for retaining the fluid, either of bandage or plas-
ter, being used, the blood, if any escapes, should  be suffered to
 dry on, as the best  dressing for the little wound.
   i( On  the following day it will sometimes not be easy to ascer- 
110                   APPENDIX.
tain whether our inoculation has succeeded, but on the next, be-
ing the third,  inclusive of the day of inoculation, you may per-
ceive a red point which, being pressed by the finger, will give the
sensation of a very small hardness immediately under the skin.
   " On the fourth day the point should be increased, and some-
what shaded or radiated.  On the fifth a small vesicle or bladder
may sometimes be perceived with the naked eye.   On the sixth
with still more certainty.   This is  gradually increased in size,
the  base rarely exceeding the summit, till the eighth or  ninth,
when the almost level summit will for the most part, exceed the
base.^  During the whole progress a small indentation will usually
appear, preserving the form of the incision.
   " Hitherto  the appearance is  very similar to smallpox,  and in
some cases cannot be distinguished from it.  But from this time
the difference is easily marked excepting in one kind of smallpox.
In all others the  inoculated part,  however regular it may have
proved  till the eighth or ninth day,  now  becomes jagged at its
edges,  and its contents grow more  or less purulent.   In the
cowpox the circular form continues,  or if from the length  of the
puncture the form should be  more oblong, still the edges will be
well defined, the contents remaining  limpid.
   " The  external skin  seems to thicken as the vesicle  acquires
its full  size, and gradually approaches nearer to the amber colour.
At other times the skin seems  more transparent,  and shows a
blue tint beneath  it.   On these  occasions the vesicle is flatter.
This difference appears  to arise  from a higher degree of inflam-
mation, in consequence of which the surface below is  fuller of
vessels  conveying red blood,  and affords a purplish appearance
through the cuticle and lymph.
   " On one of these or the following day a considerable redness
appears round the vesicle ;  this has been very properly denomi-
nated by Dr.  Jenner the areola,  or small area, round the vesicle.
If this redness or  areola has a well-marked edge at the extremity
it never exceeds the boundary it  first formed for itself ;  but if it
is deepest immediately round  the vesicle and  shaded from thence,
its extent is much more uncertain ;  though  from the eighth or 
                       APPENDIX.                   Ill
ninth day the skin appears to thicken, and the vesicle to flatten,
excepting round the edge, yet the contents are still limpid.   The
edge now forms a rim higher than the centre, so that the whole
has been very well compared to a ripe mallow-seed.   The sur-
rounding redness ceases from day to day, the margin of the mal-
low-seed shrivels, the centre acquiring a crustaceous, and after-
wards a stony hardness, at the same time  gradually  contracting
itself, particularly round  its extremities,  so that the centre is
generally  most elevated, and the whole scarcely  fills  the  little
cavity in which it is contained.   In  this  state it has been com-
pared to a tamarind stone.  This  illustration, though for the
most part correct, is less co than that of the mallow-seed, because
the appearance of the scab  is more various.  It is,  however, if
uninterrupted, constantly stony, but varies in colour as much as
the  different  shades  of mahogany.   In  this  state  it remains
sometimes for two or three weeks,  and when it falls off leaves a
scar which though not deep, has in  all the  cases 1 have  seen,
proved permanent like the smallpox.   From the latter it differs
not only in being  more superficial,  but  in  being marked with
small and somewhat regular indentations.   There is some vari-
ety in this appearance, which will hereafter be noticed.
   " When the progress has been so  far regular, the patient has
every security against the smallpox which  our present knowledge
affords.   We shall hereafter take notice of certain deviations
distinguishing between such as are consistent with the security of
the patient, and such as render it doubtful."
                       [Adams on Vaccine Inoculation, p. 110.
      " Deviations from the customary laws of vaccination.
   " Whenever  we find it difficult to ascertain on the third day
by the marks already described, whether our operation has proved
successful, we should first examine the general state of health.
If any symptoms of fever occur, we  may be sure that the effect
of vaccination is superseded by some other  disease  ; and if our
patient has  been  exposed to the measles or chickenpox the
probability is, that he may go through one of those  diseases be-
fore the progress of vaccination commences.  In this manner the 
 112                   APPENDIX.
 vesicle after being formed, may be arrested at any future period
 before the sixth day and  afterwards resume its action when the
 cause which interrupted it ceases.  If the patient has been ex-
 posed to small pox and the feverish disposition should arise from
 that cause, the cowpox insertion will rather  be hastened  in  ita
 progress.  It will afterwards proceed with the smallpox pustules
 retaining its proper figure, but without that surrounding redness
 which marks its genuine character.
   " But if we find no progress in the arm after the third day, nor
 any symptoms of fever, we should examine whether our patient
has  any other local complaints  about him.   Whether he has
eruptions of any kind, and if it should be an infant,  about the
ears particularly.  Whatever may be the issue of our examination
 we should  repeat our insertion, as it cannot be attended with any
injury.   It will often happen that the second inoculation will not
only succeed, but that the first will begin its progress at the same
time, and both will go through the regular stages together.  On
all these occasions a more  than ordinary attention is necessary to
the progress of  the vesicle, for these are  the cases which have
 brought vaccination into the greatest discredit.
  " It will sometimes occur  that after the inoculated part ha9
 proceeded to a certain height with its true character, it will sud-
 denly assume the purulent appearance  of  any  other eruption
 about the body.  In this  case we cannot expect the constitution
 to be secure, as the vaccine  vesicle has not gone through its ne-
 cessary stages.   At other times  the vesicle will complete  its
 stages and  at the end of  the second,  or beginning of the third
 week, or about the period when the scab is completed, the dis-
 tant eruptions will assume the vaccine character,  and  heal in a
 few days after.   In the last case we can have no doubts of the
 security of our patient, but as was before observed whenever the
 inoculated  part becomes purulent from this or any other cause, it
 is absolutely necessary to  vaccinate  again.
   " If after repeating our vaccination, on account of the back-
 wardness of the first, we find the same difficulties in the second,
 we may make a third attempt, but  if this should fail also, the 
                    APPENDIX.                       US
health of the patient should be attended to, and, when restored,
the attempt may be renewed.  If there is no apparent obstacle in
the health, we should still defer our insertion  for a few months,
and after repeating it then,  if the same difficulties  remain, we
mu6t leave it to the patient to determine when and whether he
will wish to make any future trial.  At the same time we should
inquire whether any others  of the  family have  resisted every
exposure to smallpox infection and every attempt at inoculation.
   " It is generally said that vaccination produces no local effects
but at the part to which  the fluid  is  inserted.  This  is for the
most  part  true  ;  but it is unquestionable that what are called
secondary vesicles do sometimes occur :  that  is, an eruption  of
vaccine vesicles at Aisttmt poi-to of the body in the manner  that
smallpox pustules  appear after the inoculation  of that disease.
It has been urged by some  that these  eruptions  after cowpox
are the effect of a  second inoculation by the patient carrying the
fluid of the first to a distant part.  But this is easily distinguished.
When matter is carried in this way, the vesicle formed always
finishes its progress at the same time as at the part first  inoc-
ulated :  whereas secondary vesicles never appear till the close  of
the second  or beginning of the third week,  when the original
vesicle has  begun to scab.
   " Besides these secondary  vesicles a number of small hard ele-
vations sometimes  occur at different periods of vaccination, most
commonly at the commencement of scabbing.  They are of no
consequence, and subside without any  other than the common
remedies."                                  [Ibid. p.  12S.

    " On the characteristics and effects of perfect vaccination.
   " Vaccination is accounted perfect,  when  recent lymph has
been carefully inserted beneath the cuticle, in  a person free from
any contagious  disorder,  and has  produced a semi-transparent,
pearl-coloured vesicle, which after the ninth day, is surrounded
by a  red areola,  and afterwards  terminates  in a hard, dark-
coloured scab.—The form and structure of this vesicle is pecu-
liar.   Its base is circular, or somewhat oval, with a  diameter of.
                  P 
114                    APPENDIX.
about four lines on the tenth day.  Till the end of the eighth
day, its upper surface is uneven, being considerably more elevated'
at the margin than about the centre,  and sometimes indented by
one or two concentric furrows,  but on the ninth or tenth day
the surface becomes plane, and in a very few instances the  central
part  is highest.  The margin is turgid, firm, shining, and round-
ed so as often to extend a  little beyond the line of the base.
The  vesicle consists internally of numerous little cells, filled with
clear lymph, and communicating with each other.  The areola,
which is formed round the vesicle, is of an intense  red  colour.
Its diameter differs in different persons from a quarter of an inch
to two  inches,  and  it is usually attended with a considerable
tumour and hardness of the adjoining cellular membrane.   On
the eleventh and twelfth day, as the aerola declines, the  surface
of the vesicle becomes brown in the centre, and  less  clear at the
margin.   The cuticle then  begins to separate, and  the fluid in
the cells gradually concretes into a hard rounded scab of a red-
dish brown colour. • This  scab becomes at length black,   con-
tracted, and dry,  but it is not detached till after the  twentieth
day  from the inoculation.   It leaves  a  permanent  circular cic-
atrix, about five lines in diameter, and a little depressed, the sur-
face being marked with very minute pits or indentations, denoting
the  number of  cells of which the  vesicle had  been composed.
   " During the  progress  of the  vesicle some disorder  takes
place in the constitution, and there is frequently  on the arms and
back a papulous eruption resembling some forms of the Lichen
and Strophulus.  These circumstances  we should  by analogy
judge desirable;  but  they do not always occur,  nor are they
deemed requisite  to ensure  the  full effect of  vaccine inocula-
tion,—that effect, which, as ascertained and announced by Dr.
Jenner, is allowed to be more important than any event which
 the  history of medicine can furnish."
                        [Willan on vaccine inoculation, p. 9.
                  ," On imperfect vaccination.
   " Vaccination is imperfect, or insufficient,  I. When the fluid
 employed has lost some of  its original  properties.   II. When 
                       APPENDIX.                    115
the persons inoculated are soon afterwards  affected with  any
contagious fever.   III.  When they are affected, at the time of
inoculation, with some chronic cutaneous disorders.
   " I. The qualities of the vaccine fluid are altered soon after
the appearance of an inflamed areola round the vesicle : and the
fluid, although taken out of the vesicle in the best possible state,
may be injured by heat, exposure to air, moisture, rust, and other
causes,
   " When scabs are formed over variolous pustules, and vaccine
vesicles, the matter they afford is often acrid and putrescent, and,
if inoculated, it perhaps neither communicates the  vaccinepock,
nor the smallpox, but produces  a fatal disease, with symptoms
similar to  those which  arise from  slight wounds received in
disse :ting putrid bodies.  Should  the pustules of  smallpox re-
main entire till the  twentieth day of eruption, matter taken from
them, even at that period, will sometimes communicate, by inocu-
lation, the disease in its usual form, though perhaps with consid-
erable virulence.   We  are,  however,  now assured on  good
authority, that matter improperly kept, or the thick matter taken
from  collapsed and scabbing variolous pustules, and used for the
purpose of  inoculation,  does not always produce the smallpox,
nor prevent the future occurrence of that disease,  although the
persons  inoculated may have had inflammation and suppuration
of the arm, and pains in  the axilla, with fever and  eruptions on
the ninth or tenth day.   In like manner if the  vaccine  fluid
employed be  taken at a late period, as from the twelfth to the
18th day, it does not always produce the genuine cellular vesicle,
but is  in some cases wholly inefficient, while in others it suddenly
excites a pustule,  or ulceration, in others an irregular vesicle,
and  in others  erysipelas.   Similar appearances are observed,
when fluid taken from ja perfect vesicle on the sixth, seventh, or
eighth day has been injured, before its application, by some of the
causes above enumerated,  In addition  to them, I  may observe
that if the vesicle be ruptured, at an early period, by friction, or
scratching, the  inoculation sometimes proves imperfect.   Fail-
ures may ha\;e also been occasioned by  repeatedly  puncturing, 
116
APPENDIX.
or  draining the vesicle, on two or three successive day*.   Th«
fluid, which is afterwards secreted into the cells thus exhausted,
may, by a difference of properties, or by too much dilution,  be
rendered incapable of acting  fully, either  on the person  from
whom it is taken, or on those to whom it is communicated.  Some
of  the  early failures,  in persons inoculated  at different publick
institutions, are perhaps referable tp this cause, the demands for
vaccine fluid in 1799, and 1800,  having  been very numerous,
the cases to supply them comparatively few.*
  " II. Eruptive fevers and other febrile diseases, interfere with
the progress of the vaccine vesicle. Themeasles, scarlatina, varicella,
typhus, and influenza, appearing  soon after vaccination,  either
render  it ineffective, or suspend thp articm of the virus, so that, id
some cases, the progress of the vesicle is very  slow, and the areola
is not formed till the fourteenth day or later, and sometimes not
at all.    Dr.  Jenner has recorded the case of  a child, on whom
the  scarlatina, with a sore throat,  appeared  on the ninth day of
vaccine inoculation.  The vesicle enlarged as usual,  ' yet there
was a total suspension of the areola, until  the scarlatina had re-
tired from  the constitution.'    In  a  sister of this patient, the
fever and scarlet efflorescence took place faintly on the same day,
but suddenly disappeared, the areola having been  formed round
the vesicle.   Four days afterwards, on the decline of the vesicle,
the scarlatina anginosa returned with its usual symptoms.
  " III.  The cutaneous diseases which sometimes impede the
formation of the genuine vaccine vesicle, f are herpes (including

  *  It is  an useful caution to vaccinate in two or three places, and to punc-
ture only one of them to procure the virus:  that is to allow at least one
vesicle to go through its whole course undisturbed.
  f  « Variolous inoculation sometimes fails from the same cause.  See Dv.
Jenner, and Mr. Hill, Med. and Phys. Journal,  for  June, 1805. Compare
the  Journal for May, 1803, and Aug. 1804.
  " Dr. Jenner has favoured me with the following instance:—' The child
of a gentleman at Blakeney, Gloucestershire, was at two years of age inocu-
lated for the smallpox with others of the same family.  In this child, there
was a deviation from tfie usual appearances: the arm inflamed  and suppu- 
APPENDIX.                    117
the shingles  and vesicular ringworm), the dry and the  humid
tetter, and the lichen, but especially the porrigo (or tinea) com-
prising the varieties denominated crusta lactea, area, achores, and
favi, all of which are contagious.    To these perhaps should be
added the itch and prurigo.
   " Imperfect vaccination  is not characterized by any uniform
sign or criterion, but exhibits, in different cases, very different
appearances, as pustules, ulcerations, or vesicles of an irregular
form.   The  vaccine pustule is  conoidal; it increases rapidly
from the second to the fifth or sixth day,  being raised on a hard
inflamed base,  with diffuse redness extending beyond it on the
skin.   It is usually broken before the end of the sixth day, and
is soon after  succeeded  by an irregular yellowish brown scab.
The redness disappears within a day or  two,  and  the tumour
gradually subsides.   According   to  Dr. Jenner,  *  Its com-
mencement is marked by  a troublesome itching, and it  throws'
out a premature efflorescence, sometimes  extensive,  but seldom
circumscribed, or of so vivid a tint as that which surrounds the
pustule  (vesicle)  completely organized; and  (which is more
characteristic of its degeneracy than the other symptoms) it ap-
pears more like a common festering produced by a thorn, or any

rated, but not extensively: some slight  indisposition took place, and a few
pimples were scattered over the skin, which did not suppurate.  The parents
not  being quite satisfied, the child  was inoculated a second time, with
variolous matter, about two years afterwards, when the appearances on the
arm, and the disorder of constitution, recurred as at first.  Soon after this
time, the child was put to bed with a person who had a full burthen of small-
pox, but was not infected.  When two years more had elapsed, the child was
vaccinated by Mr. Lauder,  an  experienced and  respectable surgeon  at
Newnham. The puncture produced only an incomplete pustule, surrounded
by considerable inflammation.  Mr. Lauder  then consulted me, and on my
making inquiry respecting the state of the skin, he told me that the child,
from its early infancy, had been affected with eruptions on its head, and
other parts of the body.  Feeling satisfied that he had thus accounted for the
preceding circumstances, I endeavoured first to subdue the eruptions.  As
soon as this was accomplished, the child was again vaccinated,  when a pus-
tule appeared,  which went through all its stages, with the most perfect reg-
ularity and correctness." 
 118                    APPENDIX.
 other small extraneous body, sticking in the skin, than a pustule
 (vesicle) excited by the vaccine virus.   It is generally of a straw
 colour, and when punctured, instead of the colourless transparent
 fluid of the perfect vesicle,  its contents are found to be opaque.'
   " Respecting the ulceration, Dr. Jenner observes,  « In a late
 case, the punctured part on  a boy's arm (who  was inoculated
 with fresh limpid virus,)  on the sixth  day,  instead of shewing,
 as usual, a beginning vesicle, was  incrusted over with a rugged
 amber-coloured  scab.   The scab  continued to  spread  and in-
 crease in thickness  for some days,  when at its edges a vesicated
 ring appeared, and the disease went through its ordinary course,
 the boy having had soreness in the axilla, and some slight indis-
 position.   With the fluid matter taken  from his arm, five persons
 were inoculated.  I"  one,  it  took  no effect ;   in  another, it
produced a perfect vesicle ;  but,  in the  other three, the progress
 of the inflammation was exactly similar to the  instance which
 afforded the virus for their  inoculation :  there  was a creeping
 scab, of a loose texture, and  subsequently the formation of
 limpid fluid at its edges.'*
   " Dr. Woodville has mentioned a similar appearance, and con-
 siders it as indicating an ineffectual inoculation.
   " He refers  * to cases in which it happens, that though the
 local affection does not exhibit much more inflammation than is
 usual,  yet neither vesicle nor pustule supervenes, and, in which,
 about the sixth  or seventh day, it rapidly advances into an irreg-
 ular suppuration, producing a festering or crustaceous sore.'
   " These ulcerations probably  originate from the vaccine pus-
 tule, which on  account of the itching it  excites, is  sometimes
 scratched off at  a very  early period, or being prominent and of a
 loose texture,  is  injured and exasperated by the friction of  the
 clothes, &c.

  * " Dr. J. remarks elsewhere,' In some instances, the ring of vaccine fluid
 fixed a boundary to the extension of the scab, the effloresence followed, and
the constitution was found secure from the smallpox ; but in other instances,
 the process ended  more abruptly,  and then of course the susceptibility of
 the vaccine virus remained, which was proved by subsequent inoculation.' 
                        APPENDIX.                     119
   «* Inoculators are now generally acquainted with the pustule
and ulceration above described ;  but the chief nicety and diffi-
culty of vaccination,  is in distinguishing from the  genuine vesi-
cle, some irregular vesicles,  which have often been mistaken for
it,  and which do not wholly secure  the constitution  from  the
smallpox.
   " I have observed three sorts of these irregular vesicles.   The
first is a single pearl-coloured vesicle, set on a hard dark red base,
slightly elevated.   It is larger and more globate  than the pus-
tule above represented, but much less than the  genuine vesicle:
its top is flattened,  or sometimes a little depressed, but the mar-
gin is not rounded  or prominent.*   The  second  appears to be
cellular like thp genuine vcoiclc, but it ia somewhat smaller, and
more sessile, and has a sharp angulated edge.   In the first the
areola is usually diffuse, and of a dark rose-colour : in the second
it is  sometimes  of a dilute scarlet colour, radiated, and very ex-
tensive, as from the sting  of a wasp ;  at  other  times it has the
form and colour exhibited PI. I. No.  7.f  The areola appears
round  these vesicles on the seventh or eighth day after inocula-
tion, and continues more or less vivid for three days, during which
time the  scab  is  completely formed. J    The scab is  small-
er and less regular than that which succeeds the genuine vesicle ;
it also  falls off much sooner, and, when separated, leaves a smaller

  * " A vesicle of -this kind appeared in the vaccination of Miss Georgiana
Whitworth (M. and P. Journal, August, 1801.  See the last note.)   ' It was,'
according to Dr. Fawssett, ' more globular, and  seemed to have a  thinner
pellicle than the genuine cowpock.'
  f All these remarks  are illustrated by coloured engravings in Dr. Willan's
work, which we regret very much that we cannot imitate.
  \ "Mr. Whately has well described an irregular vesicle as it occurred after
inoculation, in two persons who had previously had the smallpox.  " A slight
inflammation took place round the punctures on the second day, and  grad-
ually increased to  the  ninth, when its appearance was erysipelatous, and its
exteni round the vesicle was at least a hand's breadth.   It had not the areola
usually met with in the cowpock; but in two places there were red lines of
the breadth of a finger, in the course of the lymphatics.   On the eighth day 
120
APPENDIX.
 cicatrix, which is sometimes angulated.—The third irregular
 appearance is a vesicle without an areola.
    " The vaccine pustule,  and ulceration, may sometimes arise
 from the insertion of effete or altered  virus ; but they mostly
 occur in persons  labouring under the eruptive complaints men-
 tioned page 117-*
    " The irregular vesicles are produced by some  of  the causes
 enumerated page 115-6—The vesicle without  an areola,  takes
 place if the person inoculated have previously received the infec-
 tion of the smallpox, or if he be affected with some other conta-
 gious fever, during the process of vaccination.
    " I observed the co-existence of  an irregular vesicle, and the
 vaccine pustule, in a gi-1 fiw yearc  nlJ,  probably one of those
 who are not susceptible of the smallpox.   She was first vaccin-
 ated without any perceptible effect, although six children of the
 same family had the regular vaccine disease  by means  of fluid
 taken from the person from whom she was vaccinated.   The little
 girl was again  vaccinated in both arms,  about two months after-
 ward, when she had the vaccine pustule from the puncture in the
 right arm, and from that in the left,  a vesicle without  any areola,
 and of an irregular form, one side of it being much more elevated
 than the other.  The  year following  she was inoculated  with
 recent variolous matter, but did not take the smallpox.
   " Professed inoculators, I make no doubt, have observed other
 modifications of the inoculated vaccine disease.   The irregular
 appearances above described, and represented by engravings, may
 serve to put  those who have less experience, on their guard, and

there was much pain in the axilla, with feverish symptoms, anfi  loss of appe-
tite.  From this time, the inflammation declined, and in four days, it wholly
disappeared, leaving on the inoculated part, a horny scab, which did not fa!i
off for some days.'  See Mr. Ring's treatise, p. 711.
  * « See Dr. j£nner's Obs. M. and P. Journal, for Aug. 1804.  Mr. Hutch-
inson's, April 1801.  The effect of cutaneous eruptions on the vaccine vesicle
is frequent, not universal.  Compare Dr. Wood's and Mr. Creased Remark?..
M. and P. Journal, Feb. and April 18C3- 
                        APPENDIX.                    121
induce them,  when there is any deviation from the regular form
and course of the vesicle, to reinoculate at a future period.
   " In  Dr.  Woodville's opinion, * whenever vaccine innocula-
tion excites a pustule of any kind, though it continue but one or
two days, and should  be succeeded by  an ulcer, the inoculation
is as  effectual as  where the tumour  has  proceeded in the most
regular  manner.'—Further  experience  has ascertained  that
neither the  vaccine pustules nor ulcerations sufficiently protect
the constitution from the smallpox, yet that  in a few instances,
matter taken from the pustule has communicated by inoculation
the genuine vesicle, and that, in "some, the vesicle on the sixth or
seventh day succeeded, or took the place of  the pustule,* as if
 the patients had been inoculated from themselves.   In the great-
 est number of ca&cs, however, trie  vaccine pudtule, on inoculation,
produced a pustule of the same kind, and thus laid the foundation
 for a series of inefficient inoculations.   Dr. Odier began to vac-
 cinate at Geneva, with virus taken on threads from the arm of a
 nobleman who had previously had the smallpox.   Twenty chil-
 dren were inoculated successively with this matter, and similarly
 affected.   Their arms inflamed within eight hours, and afterwards
 suppurated  abundantly,  but  with an  exudation from beneath
 a thick crust.   Fever supervened,  with  vomitings, and  other
 symptoms, which, however, ceased in forty-eight hours.   Seven-
 teen of these children being afterwards  inoculated with variolous
 matter, had  the  smallpox with different degrees of virulence, and
 three of them died, having taken  the disorder by casual infection.
    " The effect  of vaccination, when there are  irregular vesicles

   * "Mr. Ring's Treatise, p. 668; p. 370,  from Dr. Cappe ; and p. 941,
 from Dr. Sacco.—I may mention as an  analogical fact, that in some cases of
 variolus inoculation, there are two successive eruptions. The first  consists
 ef large distinct pocks, without fever : in the second, which takes place on
 the ninth or tenth day after the first, the pustules are small and coherent, or
 sometimes confluent.  With these cases I would rank that of  Mr. King's
 child noticed in the Med. and Phys. Journal for Nov. 1S05, p. 405, and by
 Dr. Fraser.  Instances of a similar irregularity in the eruption of the measles
 I have £iven elsewhere.  See Reports on Diseases in  London, p. 106." 
 12'J                   APPENDIX.
 (p. 118)  is different in different cases.   They  appear fully to
 secure some individuals from the infection of the smallpox, in
 others the constitution is but  imperfectly guarded  against the
 smallpox by these vesicles, the disease taking place  after  them,
 at different intervals, under a particular form.*—I may add fur-
ther, that when the fluid they contain is used for the purpose of
inoculation, it  sometimes  produces  an  irregular,  and  at other
times a genuine vesicle.  According to Dr. Jenner, « The vac-
cine fluid,  even in a pustule (vesicle) going through its course
perfectly, if taken in its far advanced stages,  is capable of pro-
ducing varieties, which will be permanent, if we continue to vac-
cinate  from it.'
   " Mr. Mudge's dissertation  on the inoculated smallpox, af-
fords an instance of an irregular and insufficient form of the small-
pox thus perpetuated.   In  a  series of  inoculations, he   says,
 * Thirty were inoculated with crude matter taken from the arm
on the fifth day after inoculation, but, though the infection took
place so as to produce, in each patient, a very large, inflamed, and
prominent pustule, with matter in it, yet not one of them had
 any eruptive fever, or a single subsequent eruption on any part of
the body.'-----* The matter which  was  in these pustules, hav-
ing been used to inoculate others, produced on them exactly the
 same appearances, unattended also with either fever or smallpox.'
 « The  whole number being reinoculated with  matter taken after
 the eruptive fever, the result was that every one of them had the
 eruptive fever and succeeding eruptions : in short, they had the
 smallpox in different degrees, but all in the usual way of inocu-
 lated patients.'
   " Since  the  vaccine virus,  compared with that of the smallpox,
 appears to be more delicate, and more liable to degenerate, or to
 fail in its operation from various causes (page 115),  several prac-
 titioners are of opinion that the  variolous is preferable to the
 vaccine inoculation,  and  that  it may be conducted with equal

    " Persons  thus partially or imperfectly guarded  seem only to take the
 Jiscrder ;-.;t«r repeated or long-continued exposure to infection. 
APPENDIX.
123
safety.   I  need not  at  present recapitulate  the  advantages of
vaccine inoculation, which thousands have attested.   The saluta-
ry effects of this  practice,  under the proper regulations, being
fully established should we now desist from it, because it is found
to require greater nicety  and attention than many persons at first
believed  necessary ? A very different  conclusion ought surely to
be drawn from failures,  which were  not so much the effects of
accident, mistake, or oversight in the early inoculators, as of in-
experience  in  the  business  they had undertaken.   During the
years 1799, and 1800, vaccine inoculation was practised by ten
or twelve thousand persons in the united kingdom, who had never
seen the  vaccine vesicle before they began to inoculate, nor could
be acquainted with its different stages  and appearances.   The
right inference,  from the mistakes or failures above stated,  and
from the nicety of vaccine inoculation, is, that only those should
be inoculators who have had a sufficient education, and who have
particularly attended to the subject of vaccination.
   " By an obvious collateral inference, we must be led to acknowl-
edge the propriety of a strict examination of the persons inoculated
between the 1st of Jan.  1799, and the  1st of Jan. 1802, and the
necessity of re-inoculation in every doubtful case.   In cities, and
large towns, where medical practitioners have easy access to their
friends and patients,  the examination might be performed with-
out  much  trouble, and, if a little address were employed, without
exciting much alarm.  I believe the scrutiny has, in some places,
 been already made ;  but my wish  is,  more particularly to impress
the expediency of it on surgeons resident in small towns,  and
 districts, remote from the original sources of vaccine inoculation.
As they must, at  first, have often received the fluid circuitously,
they could not always be sure respecting its age and state, nor
 could they, being at that time without experience, know whether
 the appearances  it produced  were so decisive, that its effects
 would be  adequate to the intended purpose.   I do not by this
 observation mean  to censure the gentlemen to whom it is address-
 ed.   Whatever credit we may allow  ourselves in the metropolis,
 for skill, correct information, and local advantage, we must confess 
121
APPENDIX.
 that numerous mistakes and failures have occurred with us, some
 will say, more than in all the considerable towns of England taken
 together.   Practitioners in the country having no resource but in
 their own sagacity, often acquire as much professional knowledge
 and experience as  those who seem  to have better opportunities.
 The most expert surgeon or physician, however, cannot at once
 see the whole extent of a new mode of practice or a new  opera-
 tion,  or ascertain, otherwise than by repeated trials, whether it
 will be  effective in every variety of circumstances and constitu-
 tion.   For  this reason,  I wish that practitioners throughout the
 country would, by  revising their primary inoculations with a more
 experienced judgment,  take care to ascertain the safety of those
 who have confided in them, and time secure their own peace  of
 mind ; for what would their feelings be, if the' smallpox, casually
 conveyed,*  should  prove fatal to any of the persons whom they
 first persuaded to make trial of the new inoculation ?"
                      [Willan on Vaccine Inoculation, p. 31.
   The fourth and last objection, viz. that the vaccinepock  is pro-
 ductive of other diseases is refuted by the observations and reports
 of those best qualified to give an opinion on this subject.   Such
are the Royal  Jennerian Society, the  Vaccinepock Institution
 in  London, and  various  other  vaccine  institutions  in   Great
 Britain and  Ireland.   Such also is  Dr. Willan, whom we have
 already quoted very largely, and whose extensive practice in Lon-
 don, particularly in cutaneous diseases, entitle his remarks on this
 subject to peculiar credit.   Pie says, " I have carefully  exam-
 ined,   with  different physicians  and surgeons, various cases  of

  * " This disease appears from time to time in  the remotest vallies and
townships of  Britain,  and makes a dreadful ravage.  The interval seldom
exceeds twelve years.  Mr. Bryce informs us  that  the greater part of  the
children, in two parishes of Scotland, were vaccinated by persons not of  the
medical profession, and who were unacquainted with the vaccine disease :
' The result was, that the smallpox came among them soon afterwards, and
 every one thus inoculated was affected with that dreadful disease ; while those
few that had been inoculated by persons acquainted with the appearance
:n cowpox, entirely escaped.'  Pract. Obs. p. 168. " 
                       APPENDIX.                   125
cutaneous eruptions attributed to vaccination.  Instead of  the
mange, or any eruption communicable from  quadrupeds to  the
human skin, we constantly found diseases,  which  were known,
and have been fully described, by medical writers, more than  a
thousand  years  ago, viz.  the lepra, the dry and the humid tet-
ter, the prurigo, the chronic nettle-rash, and the strophulus can-
didus ; but  more especially the dandriff,  the favus, the crusta
lactea, the scaldhead, and the ringworm.—Some persons maintain
that if the inoculation of vaccine virus does not excite new erup-
tions on the skin, it, at least, increases the number of the cutane-
ous complaints with which we were before acquainted,  and ren-
ders them more  inveterate.   My own experience would author-
ise me to  contradict this assertion. bu«- I shall perhaps  refute it
more satisfactorily by exhibiting the  annexed lists, which Dr.
Bateman, at my request, extracted from the Register of patients
at the Public Dispensary  in London :
                             Total number    Number of chronic
                              of diseases.     cutaneous eruptions.
     In the  year 1797   .  .  .  1730   ...   85
                 1798   .   .  .  1664   ...   82
                 1804   .   .  .  1915   ...   89
                 1805   .   .  .  1974   ...   94
   " This table shews that the proportion of cutaneous eruptions
to all other  diseases, was the same before the publication of Dr.
.Tenner's inquiry, as in the 6th and 7th year of vaccination.
   " The following observations by Mr. Charles Brandon Trye,
Senior Surgeon  to the Infirmary at Gloucester, afford a striking
confirmation of  the above  statement.
   "I.  'A  more healthy description  of human beings  does not
exist, nor one more free from chronic cutaneous impurities, than
that which  suffers most  from cowpox,  by reason of their being
'mployed in dairies.
   " 2.  * The Gloucester Infirmary, one of the largest provincial
hospitals,  is situated in  a county,  in  which accidental  cowpox
has been prevalent from time immemorial:  many hundreds among
the labouring people have  had  that cowpox since the establish- 
iSto                   APPENDIX.
   ment of this institution, and that more severely than is generally
   the case in artificial vaccination ; and yet not a single patient, in
   half a century, has applied to the Infirmary for relief of any dis-
   ease, local or constitutional, which  he,  or she, imputed or pre-
   tended to trace to the cowpox.  And be it repeated and remem-
   bered, that the artificial in no respect differs from the  accidental
   cowpox, except in being generally less virulent.'
    " Glandular diseases are usual,  and often immediate conse-
  quences, both of  the natural and inoculated smallpox.    In  this
  respect,  the vaccine, compared with variolous inoculation, has a
  decided advantage, being seldom succeeded by inflammation and
  suppuration of the glands.  Among children of respectable fam-
  ilies,  I have not seen a single instance of scrophula, which could
  be fairly referred to the cowpox.   The children of the poor arc
  not affected with glandular swellings,  immediately after vaccine
  inoculation, as they frequently  are after  the  smallpox,  measles,
  and scarlatina anginoaa.    Where scrophulous symptoms occur
 one, two, or three years after vaccination, we cannot surely, with
 justice, attribute them to  it, since impure air,  improper  food,
 dirt, confinement,  and virulent  diseases, such as the lepra, scald-
 head, itch, and impetigo, so generally contribute to the produc-
 tion of glandular diseases in the lower class of people?"
                        [Willan on Vaccine Inoculation, p. 81.
   It remains for us to describe the  methods which have been
 proposed to obviate the few evils, which may arise in the practice
 of vaccination.  These evils are the two following, for there are
 not any others worthy consideration.  The first is the risk of the
 inoculator's relying on imperfect vaccination.   The second the
 risk which every individual incurs of his liability to smallpox  a
 second time, or what is the same, of smallpox after cowpock
   As respects the first objection it is to be obviated in future by
 acquiring the requisite instructions, and by revaccinating in all
cases, where there is the least irregularity.  But it is fair to pre-
sume that we have  in times past had our full share of cases  of
-perfect vaccination.   We necessarily undertook  the  practice
without any other-instruction  than that obtained from  books • 
                    APPENDIX.                       127
and the laws of our Commonwealth have prevented our frequent
appeals to the smallpox as a test in doubtful cases, a practice, by
which inoculators in other parts of the world were enabled to ac-
quire knowledge on this subject.   The only remedy is to revac-
cinate at least all those, respecting whom there is the least doubt.
Few of us however can remember with accuracy  all the cases
which have been under our care, and the imperfect cases are most
likely to have been among the first.   Would it not then be pro-
per to offer  to revaccinate  all our patients of the years 1800,
1801/and 1802, agreeably to the proposal made by the very ex-
cellent writer* whom we have so often quoted.
   The  second may perhaps appear the  greatest evil, since it
would seem that all our caution may be  insufficient  to afford us
absolute security against the  smallpox.   We have already stated
that those, who have undergone variolous inoculation, are equally
unsafe.   But while this saves the credit of vaccination, it does not
remove the evil.  The risk is however so small that it may not
to some persons appear to be worthy any remedy.  But it seems
proper to state what remedy there is, and leave it to the parties
most interested to judge for themselves, whether they  will
adopt it.
   The  medical officers of the Original Vaccinepock Institution
in London employ as a test to all their patients  a second inocula-
tion with vaccine matter.   They give  to  each patient a certifi-
cate that  he has undergone  the vaccine disease, with a promise
that if he should afterwards  take the  smallpox the institution
will pay to him the sum of five guineas.   But as the inoculators
have five guineas at risk in each case, they always require that the
patient should submit to this test before they give the certificate.
If the test be of any use, the wisdom of this requisition will not
be questioned.  Is not  the risk to every patient as important as
that of five guineas to the inoculator ? If it is, surely it is reason-
able that every individual should have proffered to him the  securi-
ty, which this test will afford.  The following extracts from the
minutes of the Vaccinepock Institution will show on what ground
" Dr. Willan. 
]2b                    APPENDIX.
this second inoculation is relied as a  test of  susceptibility or
unsusceptibility of smallpox.

 Extracts from the minutes of the Original Vaccinepock Institution.
  " Feb. 3,  1807.   It having been intimated by several of the
members of the committee of the College of Physicians for in-
vestigating the state of the vaccine practice, that they would be
extremely glad of the opportunity of witnessing the trial of in-
oculating a certain number of persons with the  variolous matter
in one arm, and the vaccine in the other, after having undergone
the  cowpock, with  the view of ascertaining the susceptibility for
the one or the other of these ; it was proposed that at least twelve
persons, before  vaccinated at  this institution, should be desired
to attend on  Saturday, February 1*, for that purpose."
                                 [Med. & Chir. Rev. p. lxiv.
  "  Tuesday, Feb. 17, at a weekly board :—
  "  In a letter sent to the committee  of the Royal College of
Physicians by the medical establishment, on the subject of vacci-
nation, it was proposed to submit to the decision, by experiment,
the question—Whether a person, after cowpock inoculation, is
not in the same state of susceptibility or unsusceptibility of the
cowpock as of the  smallpox, agreeably to the experience of this
institution for several years back.  For if the publick can be sat-
isfied with regard to this fact, the test by inoculation with cow-
pock matter will  then afford a proof of security equal to that by
smallpox matter ; and, consequently, the  practice of inoculation
with variolous matter after the cowpock, which has been objected
to as tending to the dissemination  of that matter,  -will become
unnecessary.
  "Accordingly, the following fellows of the  college attended
yesterday  (Monday the 16th)  for their private satisfaction, to-
see  this question  determined  by experience ; namely, Dr.  Ash,
Dr. Heberden, Dr. Pemberton, and Dr. Warren.
  " The members  of the medical establishment who  conducted
the experiments were, Mr. De Bruyn, Mr. Doratt, Mr. Payne.
 Dr. Pearson, and Dr. Shaw. 
                       APPENDIX.                   129
   " The variolous matter used in the experiment was taken from
the vesicle of the inoculated part of the arm of Mrs. Allen's child,
4, Knightsbridge, aged five months, the eleventh day from inoc-
ulation.    It  had been ill for the last two days, and eruptions
were already coming out.  There were two distinct vesicles in
the parts inoculated, in the usual state at this period.
   " The  patient who furnished the  cowpock matter was Mr.
Holder's child,  10,  Bateman's buildings,  who had on  the arm
three most distinct  cowpock vesicles, which were ascertained to
be in an efficacious  state by producing the cowpock in several
subjects.
   " The subjects of the trial were,
   " 1.  Edward Baldock,  aged  ten  years :  three scars, now
scarcely visible, were on the l«ft «.-™, but kad been very evident :
inoculated at this institution Oct. 30, 1803.
   " 2.  Charles  Baldock, aged eight years : had one just per-
ceived scar, but two others were now obliterated.
   " 3.  Joseph Baldock, aged six years : three scars on one arm,
and  one on the other.
   " 4.  Benjamin Baldock, aged five years : only one superficial
scar remained  from the former inoculation.
   " 5.  Sarah  Baldock, aged two years : two barely visible scars
remained from the former inoculation.
   " These five children of Mr.  and Mrs. Baldock, residing at
Palace Green, Kensington, were all in a state of good health.
   "  6.  Elizabeth Mc Donald, aged six years :  had three scars,
distinct but very superficial, from the former inoculation.
   " 7.  David Mc Donald, aged four years :   had only one su-
perficial scar from the former inoculation.
   "  8.  Anne Mc Donald, aged three years : had  one superficial
scar from the  former inoculation scarcely visible.
  "  These three were from the same family, at  1, Tufton street,
Westminster:   they had been  inoculated at  this  institution
October 30, 1803.
   "  9.  William Mc Donald, brother of the three last mentioned
children, aged eleven years, who had gone through the smallpox
R 
130                  APPENDIX.
when a year and a half old, happening to be present, he and the
eight above  named  children were all inoculated by Mr. Doratt
in the right  arm, by three punctures with variolous matter, and
in the left by three punctures with vaccine, immediately from the
patients affording the matter present (except William Mc Donald,
who, by miftake,  was inoculated in the left arm with variolous
matter, and in the  right with vaccine.)
   " There were also inoculated on this occasion, Anne, James,
and  Richard Hodgson, of 1,  Wimpole-street, who  had gone
through the cowpock at this institution.
   " 10.  Anne, aged  three years, was inoculated with smallpox;
matter in three places  in the  right arm, and in the left in three"
places with cowpock matter.
   "11.  James,  aged  four yesrc s tad two deep scars on the left
arm,  and one on the right, from the former inoculation ;  was
inoculated in three places in the left  arm with smallpox matter,
and in the right  in three places with cowpock matter.
   " 12.  Richard,  aged five years :  had three scars on the left
arm from inoculation, and one on the right;  was inoculated in
three places in the left arm only with variolous matter, an objec-
tion being made to inoculating the other arm.
   " These  twelve subjects were directed to attend on Saturday,
at one o'clock,  at which time the' gentlemen  present proposed
to meet again for the examination of the  effects of the inocula-
tion."
   " Second meeting, Saturday, Feb. 21, 1807.—Present, Dr.
Afh, Mr. De Bruyn, Mr. Carpue, Dr. Clutterbuck, Mr. Payne,
Dr. Pearson, Dr. Shaw,  Dr. Warren.
   " The vaccine matter inserted this day was from the child
Shuker, ninth day after inoculation.
   " The variolous matter was from Allen's eruptions of the sev-
enth day.
   "  1st.  Two new patients attended for trial who had been inoc-
ulated at this institution  December,  1803 ; viz.
   "13. Thomas Pearson, aged nine years.  By three punctures
in the right arm,  variolous, and by three punctures in the leF 
                      APPENDIX.                    131
arm, vaccine  matter  was  inserted.   Had one superficial  scar
from the former inoculation.
  " 14.  William Pearson, aged  three years.  Three punctures
in the right arm  received variolous matter,  and three punctures
in the left received vaccine.  Had a superficial scar on each arm
from inoculation  formerly.
  4t 2d. The Hodgsons inoculated at the last meeting attended.
Richard Hodgson had now  in the left arm three pimples,  not
unlike the fourth day  of inoculated smallpox or cowpock.   No
effect till yesterday.
   " James Hodgson  ill the day before yesterday ;  to-day is
 recovered.  Has three large  pimples, which seem to be scabbing,
 on  the right arm ; three pimples  ltiii more decidedly  scabbing in
the left arm.
   " Anne  did  not attend;  but Mrs. Hodgson  reported  that
 there was no effect at all.
   " 3d. Elizabeth Mc Donald.   On  the left arm were three
 pocks much like those of the former patients, Richard and James
 Hodgson ; on the right arm three larger pocks than on the other
 arm.
   " Anne Mc Donald.   The left  arm bore  three pocks much
 the 6ame as the  former; on the  right arm much the same pocks
 as the former : Anne's appeared infected the day  after insertion.
   " William Mc Donald.   There were three pimples in a scab-
 ing state in  each arm, but less defined than the former subjects.
 The arms inflamed the next  day  after insertion.   Quite well.
    " 5th.  The three following, inoculated at the former meeting,
 were examined.
    " Edward Baldock.  On the right arm were three pocks ex-
 actly  like the fifth or sixth day of the cowpock, well defined.
 Left arm ; just  marks of the punctures remain.  There had been
 no  inflammation of the arms.
    " Charles Baldock.   Right arm, three small pimples in the
 scabbing state.   Left arm, three  scabbing  pimples much like
  the other.  Quite well.
    " Joseph Baldock.  Right arm, three pimples like the former,
 but inflamed ; probably from scratching.   Left, red marks only, 
132                  APPENDIX.
   " Benjamin and Sarah Baldock did not attend.
   « Third meeting,  Thurfday, Feb. 26, 1807.—Present, D<.
Ash, Mr. De Bruyn, Mr.  Thompson Forster, Dr. Heberden,
Dr. Nelson, Mr. Payne, and Dr. Pearson.
   " The family of the Baldocks all attended, being the eleventh
day after insertion.
   " 1st. Edward Baldock.  Right arm  had three pocks  in the
inoculated part in a  semi-purulent state, not very unlike ninth
day smallpox.
   " On the ninth and tenth days, it is said, there was much red*.
ness and inflammation round the part inoculated, but which is
now totally gone off.                           v
   " Five or six days ago, complained of a swelling in the axilla
of the right arm,  with  pain :  now gone  off.   Matter was taken
from these pocks upon  glass for trial.  The outline of the areola
is barely visible.
   " In the left arm the marks of the punctures are just visible ;
has had no pain of the  axilla in that arm,  nor of the shoulder.
Was heavy, dull, and  poorly,  particularly on the seventh and
eighth days, but  was pretty well on the ninth,  on which day
the redness upon the arms was pretty considerable.
   " Charles Baldock.  On the right arm two of the three small
scabs have fallen off;  one, of  the size of a pin's head, remains.
There has been no redness of this arm.   On  the left arm scarcely
any traces of the pimples now remain.  No illness.
   " Joseph Baldock.   On the left arm three small scabs from
the pimples.  There has been no inflammation nor pain  of  the
arm-pits.   Right arm,  only traces of  the  punctures left; pain
of the arm-pits or shoulders on this side.  No illness.
   " Benjamin Baldock.  Right arm, three extremely small scab-
bed pimples.  Left arm, three ditto ; no inflammation of the arm
nor pain of the arm-pit.   Was poorly on  the seventh day, when a
few fleahite like spots appeared, of which some now remain.
   " Sarah  Baldock.  The traces of the three pimples  upon each
arm just remaining.  No illness, and quite well.
   « 2d, William Mc Donald,  aged eleven years, who had had 
                       APPENDIX.                   133
the smallpox in the natural way nine years  ago, by which he is
distinctly but slightly scarred.  The three  pimples in each arm
exactly alike.  There has been no redness,  pain, nor illness.
   " Elizabeth Mc Donald.  Three very distinct marks in each
arm from the punctures, and much alike.   Those on the left arm
are on the three scars from former inoculation.   There has been
no redness in either arm, nor pain of the arm-pits, nor illness.
   " David Mc Donald.   Marks on each arm from the punctures,
only more evident in the right arm than the left.   No redness
since the day after the insertion, nor any  pain nor illness subse-
quently.
   " Anne Mc Donald.   The  right arm exhibits three scabbed
pimples.  On the left,  three scabs as large have fallen  off, and
left three larger marks.
   " 3d.  Thomas Pearson.  Several days  after insertion on  the
 right  arm were two distinct pimples only.  There has been no
 redness.  Left arm, two similar but smaller pimples.
   " William Pearson.    Right arm, two elevated pimples,  not
 unlike the third or fourth day variola or vaccine ;  a third larger,
 with red irregular areola  round it.   On the left arm similar pim-
 ples to the former,  but smaller.  No  inflammation nor redness,
 but  ill ever since Saturday,  the day of inoculation  ;  probably
 from  cold.
   " 4th. The  Hodgsons.   Richard had  three scabbing pocks,
 containing matter not like either cowpock or  smallpox ;  James,
 only small scabbed pimples in  parts inoculated  ; Ani.e, no traces
 of inoculated parts.
    " The following cases  were reported,  being relative  to  the
 question under determination.
    " Tuesday, Feb. 24, two boys,  Robert Brush, nine years  old,
 No. 3044, and James Brash, No. 3045, from 10, Margaret-street,
 Cavendish  Square,  having gone through the cowpock in  the
 usual way, by inoculation at the Institution in  January last, were
 inoculated in three  places in the right arm with smallpox  matter,
 and in three places in the left arm with vaccine.
    « Eleventh  day, Friday 6th of March : James (13,) three 
134
APPENDIX.
 large scabbing pocks appeared on the left arm, unlike vaccine
 scabs ;  and on the right, no effect from the insertion of variolous
 matter.
   " Robert Bruin.   On the right arm were three large scabbing
 pimples, much like those of his brother, but smaller.   On the
 left arm no effects were perceived from the insertions.
   " Tuesday, 10th March, fifteenth day.   James Brush :  Three
 scabs on the left arm,  unlike  either vaccine or variolous*   On
 the right arm no traces of the insertions.
   " Robert Brufh :  Two scabs on  the  right arm  irregularly
 figured, otherwise like fifteenth day vaccine, although from va-
 riolous matter.  Left arm, nothing  seen  from the insertions of
 vaccine  matter.
   " Conclusion.—According to these trials, which sewe to con-
 firm several hundred others already instituted  by this establish-
 ment, the constitution is alike susceptible or unsusceptible of the
smallpox and cowpock ; of course, the matter of the latter may
 be relied upon as a test, as much as that  of the former.  How-
ever, as  the local affection of the cowpock without constitutional
disorder  not unfrequently resembles the cowpock attended by
constitutional affection ; and  as, in a certain proportion of cases,
the smallpox carrHake place after distinct cowpock, as well  as
the cowpock ; it  has been asserted that a  person  is susceptible
repeatedly of the cowpock, though not of the smallpox,  and in
this way the error may be explained.
   " Remarks,—I. From the preceding cases, it appears that nei-
 ther the smallpox nor cowpock could be excited by insertion of
 what  is efleemed the most efficacious  matter, in thirteen persons
 who had undergone the cowpock about three  or four years be-
 fore, nor  in two who had been vaccinated only a few weeks pre-
 viously.
   " 2. A local affection, viz.  a pimple which enlarged into an
 irregular-figured pock, or at least a. larger pimple, was excited by
 the punctures with variolous matter in  the arms  of seven pa-
 tients ;  and in the same patients, the punctures  with vaccine
 matter excited nearly similar pimples. 
APPENDIX.
i:vi
   l<*3.  A local affection which was at first a pimple, but became
an irregular-figured pock, was excited in the arms of three  pa-
tients by the insertion of variolous matter ; and by the insertions
of vaccine matter in the same patients,  only very  small pimples
were  produced.
   " In  one patient, a  local affection was excited in one arm by
vaccine  matter, but not in the other by variolous.
   " 4.  In three patients, ho local affection at  all was produced-,
of at least red marks only of two or three day's duration.
   " 5.  Neither constitutional disorder, nor affection of the axil-
lary glands, was produced in any of the subjects of trial, except-
ing one on the seventh  and eighth day.
   " This patient on the  eleventh day had three pocks from the
variolous matter, not unlike inoculated smallpox, in a semi-puru-
lent state, attended by  the characteristic areola ;  while on  the
left arm, from the vaccine matter, were only red marks.
   " 6.  One  patient,  inoculated by three punctures with  vario-
lous matter only, had three irregular-figured pocks excited, two
of which afforded rather permanent scabs.
   " 7.  One  patient, who had  undergone  the natural smallpox,
had three pimples excited in each  arm, all much  alike, by the
cowpock and variolous matter.
   " 8.  In some  cases the local affection was more considerable
from the variolous than from the vaccine matter, but in none more
from the vaccine than the variolous.
   " 9.  The local  affection, both from  the variolous matter and
vaccine, sometimes resembles the cowpock, but never the regular
variolous pock of the inoculated part."
                   [Med. and Chir. Review, vol. 14. p. lxxxij.
   Opinions similar to those here maintained were long since ad-
vanced by Mr.  Ring, and admitted  by many vaccinists in  Eng-
land.  The experiments related ought at least to add to the in-
ducement to revaccinate  all those who  underwent  the cowpock
in 1800, 1801, and 1802.   It would indeed be proper to extend
the offer of revaccination, or of testing  with vaccine matter, tu
*U whom we  have heretofore vaccinated ;  and to state to  those 
 136                   APPENDIX.
 who may hereafter be vaccinated  the  advantages  of this  test.
 In employing this test we ought to introduce the vaccine matter
 into at least four different places.
   The committee are aware that few persons in this country arc
 prepared to hear from this society that the vaccine disease is not
 in all cases a perfect security against  the smallpox ; and they
 presume it will be feared by some  that suggestions of this sort,
 which must accompany any remedy that shall be proposed, may
 deter our fellow-citizens from  submitting to vaccination, and
 thus deprive us of the security, which this practice will undoubt-
 edly afford.  But the committee  feel assured  that this society
 cannot desire to make any statement  on this subject,  which is
not perfectly  accordant  with truth ; and that the friends of vac-
cination can have no interest other than that of diffusing a most
important blessing under such precautions,  that it shall not  be
alloyed by any future disappointments.   To the  committee it
appears that the advantages of vaccination are, under the circum-
stances they state, sufficiently decided to justify the expectations
of any reasonable inquirer.  The cowpock does not produce any
 sufferings in the subject of it,  which  are worthy consideration,
 and it does not in any case put life at risk.  The precautions
which are proposed go only to obviate  an evil, which would not
occur once in a thousand cases.
   As respects the practice of vaccination in this commonwealth
the committee regret to state that  it has been much less exten-
sive, than the welfare of the community requires.  Although
 the laws and  customs long since established ordinarily prevent
 the prevalence of smallpox among us,—from which the commu-
 nity have and do derive most abundant advantages,—yet it has
 been found necessary at times to permit this disease to be intro-
 duced into our large towns ; that is, when  its inevitable occur-
 rence has occasioned many individuals to be exposed to its con-
 tagion.   As  the cowpock cannot  be  communicated except  by
 inoculation, there is no inconvenience  to the community in the
 practice of that inoculation.   Could we destroy in every individ-
 ual the  susceptibility of smallpox by this benign remedy, we 
                        APPENDIX.                    137
should prevent  even the occasional prevalence of that disease
among us—an event which can never take place without a most
injurious interruption of business, great expense, trouble and anx-
iety to every family concerned in it; and, what has usually hap-
pened on these occasions, a most lamentable proportion of deaths
among those who undergo the disease.*
   From the statements  and opinions contained in the foregoing
report the committee are induced to propose the following reso-
lutions, as declaratory of the sentiments of this society ; viz.
   First—That in the opinion of this society persons who under-
go the cowpock are thereby rendered as incapable  of  being af-
fected by the virus of smallpox, as if  they  had undergone the
 latter disease.
   Second__That it is be feared that in  the  early  and even in
some of t\ic ltiie practice of inoculating for the  cowpock, the
disease may not have been produced in the most perfect manner,
 and particularly in cases, where the inoculators have  not been
 well instructed in this practice,  nor been accustomed to observe
the  appearances of cutaneous diseases.
   Third—That the mofl perfect and  absolute security is  to be
derived from  subsequent inoculation ;  and in all cases in which
the operation was performed before inoculators  had  sufficient
experience on this subject, as in the years 1800, 1801 and 1802,
it is indispensably necessary to ascertain the security by this test.
   Fourth—That it be  and  it hereby is recommended  by this
 Society, that all persons who have been vaccinated, especially at
the period alluded to above,  call on those who inoculated  them
 to perform a second inoculation ;  for which service the fellows
of this society will not charge any additional fee.

  * In 1792, when inoculation for smallpox  was permitted in Boston, tJhe
deaths were more than two in a hundred of the number inoculated.  Tin's
great mortality is easily explained, when it is remembered that half a town
were inoculated at once without regard to age or circumstances of health,
and that many of them had not any such advantages as are to be desired h\
respect to situation and attendance.
                         S 
138
APPENDIX.
  If the foregoing resolutions be adopted by  the Society,  the
Committee recommend that the Recording Secretary be directed
to publish the same in four newspapers  in the town of  Boston.

     All which is respectfully submitted,

  Signed,              JOHN WARREN,    T
                     A. DEXTER,         I       .
                     JAMES JACKSON,   \^ommitee-
                     JOHN C.  WARRENJ
       ^iT the O'nni'riJLmeeling Q^jthx- -If-t^e-BHCtfUSETTS JMeDICAJ
Socizrr, held June 1, 1808,  the foregoing report,  inns rmd;  aruf
after some observations it was voted unanimously that the said report
should be accepted, and that the resolutions therein  proposed should
be adopted.

                   JOHN C. WARREN, Recording Secretary.
            ERRATA—No. II. Part II.
Page 7 line  8 for aquaa   read aqua
    10     13     aquai       aqua
    19     20     rub.       peruv.
    —     21      minthaj     menthas
    50      6      half an hour, read, half an hour or an hour. 
                  AD VER TISEMEJVT.
      THE medical papers, already published by this Society,
may now be conveniently  bound in  one  volume,  to  be  entitled
" Medical Communications of the Massachusetts Med-
ical Society, Vol.L";  and which  may be conveniently lettered
" Mass. Med. Communications"   The publications of the Society will
in future be more frequent than they have been, and more regard will
be had to method. With this are issued one title page for the volume,
and a tide page to each part of No. 2;  also tables of contents to each
of those parts; which tables may be placed, when bound, immediately
after the table of contents of No. 1.  with which it will be perceived
that the paging accords.                #      11'»%

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