Ref rinted from the North American Practitioner. 
A CONTRIBUTION TO THE STUDY OF THE ACCIDENTS 
OF VACCINATION. 
Professor of Diseases of Children, Post-Graduate Medical School of Chicago; Surgeon 
By Rosa Engelmann, B.A., M.D. 
to the Charity Hospital. 
This subject is especially interesting, in view of the present small- 
pox outbreak in the English provinces and its well distributed 
sporadic appearance elsewhere, and from the fact that a late number 
of the British Medical Journal has occasion to speak of " Militant Anti- 
vaccinators " and of the " Antivaccination Craze." 
The communicability of variola is unquestioned. The contagium 
enters and is eliminated by an extensive epidermic and mucous 
surface; hence the disease is characterized by excessive tenacity and 
rapid propagation. Let the absorption and discharge of the virus be 
localized and minimized, and a harmless non-contagious affection is. 
established. 
Vaccination accomplishes this purpose and secures immunity from 
both disorders. 
Pasteur explains immunity by the exhaustion of the soil for the 
future growth of this particular micro-organism. 
Fraenkel and Chaveau ascribe it to the part retention in the body 
of the developmental products of the specific germ. Metchinikoff 
gives the credit of immunization to phagocytosis. The questions of 
identity, immunity and etiology in this connection are still under 
discussion. * 
Neither small-pox nor vaccine microbe, protozoon or toxalbumen 
have yet been isolated, although such men as Klebs, Voigt, Koch, 
Fraenkel, Weigert, Feiler, Klein, Cruikshank, Chaveau, Cohn, Gutt- 
man and Pasteur have been bringing a great fund of technical knowl- 
edge and patient investigation to bear upon the subject. They and 
others have found some twenty (20) or more germs in bovine and 
humanized lymph, cow-pox and variolous vesicles. 
Sarcinae, protozoa, countless bacteria, the bacillus of syphilis, 
tuberculosis and tetanus, the staphylococcus pyogenes, aureus, albus 
and cereus, the streptococcus pyogenes and the streptococcus of 
erysipelas represent but half of this number. 
Thus we are forced to the conclusion that vaccination is ofttimes 
accompanied by extraneous infections, the dangers of which are uni- 
versally acknowledged. A mixed infection is indisputably demon- 
strated. Its positive exclusion is rendered difficult from the fact that 
our lymph supply is largely bovine. Even in Europe, where the 
vaccine stations are under government control and ruled to the 
minutest detail by aseptic and antiseptic methods, contamination of 
the virus sometimes occurs. As early as 1888, however, Voigt's 
statistics for Germany show "the rarity of vaccinal ulcers and vaccinal 
gangrene," while pyemia is almost unknown. A report from us in 
this connection would not, I fear, compare favorably, since we cannot 
be praised for the intelligent securement of our vaccine supply nor its 
scientific application to the individual. Until the time shall arrive, 
when by reason of the isolation, cultivation and attenuation of the 
specific germ, a reliable laboratory product shall be at our command, 2 
it becomes our duty to follow the example of our foreign confreres 
with reference to the source of the virus and inoculative methods. 
When every precaution that surgical bacteriology can suggest, shall 
apply to vaccination as it now does to inoculation for rabies, anthrax 
and tuberculosis, then will the laboratory be held responsible for a 
mixed infection and the vaccinator for a secondary one. In the light 
of modern research such a title as the accidents of vaccination must 
disappear from medical literature, and it is now imperative that the 
induction of artificial immunity be stripped of its terrors. 
Robert Steel reports three cases of accidents of vaccination. 
Jonathan Hutchinson mentions " aberrant vaccinia,of special idiopathic 
idiosyncracy." Jenner, in his letter to William Dillwyn, Esq., says: 
"Those herpetic affections which so frequently appear among the 
children of the poor, which are evidently contagious, often prevent 
the vaccine virus from producing its correct action." "The danger of 
insecurity would be at once obviated, if on the appearance of an 
irregular pustule, the disease were subdued by proper applications and 
the patient reinoculated." 
Dr. Beck of Chicago, tells me of a case in his practice where uraemia 
and death succeeded vaccination. The history disclosed a two years 
prior attack of measles that probably had been complicated by an 
unnoticed nephritis. Every physician recognizes the danger of 
awakening a latent eczema by so slight an operation as vaccination. 
Adenitis is of common occurrence. Bone disease, suppurative arthri- 
tis and pyemia are reported sequelae. 
An article in the Centralblatt f. Chirurgie, 1892, p. 152, cites vacci- 
nation as the exciting cause in a case of tetanus. These are but a few 
instances of an interminably deplorable record. Two years ago, 
during a small-pox endemic, I had various types of vaccinal manifes- 
tations under observation. 
In the majority of the cases, the arms were ulcerated, although the 
operation was antiseptically done. The wounds were not, however, 
hermetically sealed. A recent visit to the stable from whence the 
virus was then procured, throws light on the source of this and every 
other possible infection; for neither knowledge nor effort is brought 
to bear upon the antiseptic preparation of the lymph. The cows 
bought at the stockyards, are brought to the stable fresh from a jour- 
ney across the continent. After a brief rest the rumps are shaved, it 
is true, but here ceases any likeness to a surgical procedure. No 
further cleansing is deemed necessary. 
Scarification is done with an old jack-knife and the wound left ex- 
posed to the excrementitious discharges and the continuous switch- 
ing of the poor beast's tail. No dressing is applied to the wound. 
Upon the seventh or eighth day the sopping of a sponge wet in the 
stable pail expedites the removal of the scab that is considered ripe 
when pus is seen trickling through it. The exuding surface is next 
wiped with the ivory points, defiled by stable air. Thus loaded, the 
points are now deposited upon a dusty tray, and to facilitate the dry- 
ing of the virus this tray remains for Some time upon the stable 
table. When dry, the points are wrapped in absorbent cotton and 
gutta-percha tissue. This, worse than farcical proceeding, shields 
them from air and moisture, true enough; but likewise misleads you, 
as it did me, into the belief of an antiseptic lymph. While the con- 
ditions may be some better at other establishments, still there can be 
no certainty while throughout the breadth and extent of our country, 3 
vaccine establishments are left to private business enterprise, subject 
to no official supervision. 
An immediate change in so pernicious a system must be instituted. 
Physicians should unhesitatingly organize to bring about legislation to 
this end. Government vaccine stations must be established and placed 
under the control of such competent officers that a lymph supply 
commensurate to the demands of bacteriological surgery shall be in- 
sured. In consideration of its present source and methods of obtain- 
ment, it is not surprising that the anti-vaccination cry and hue again 
breaks forth, and that I am obliged to contribute to the accidents of 
vaccination a case of co-incident variola and vaccinia, and a case of 
thrombophlebitis and pyemia. 
A woman lately and successfully vaccinated developed a synchro- 
nously generalized syphilitic psoriasis, and, what I believe, was a con- 
current course of varioloid. I make this inference because, unlike 
other vaccinal papular eruptions then under observation, this case 
was marked by the typical fever, papulation, vesicular umbilication 
and pustulation of variola. 
Pourquier and Brinskey have written papers on "The Simultaneous 
Course of Smallpox and Vaccinia," and " Coincident Vaccination and 
Smallpox." In such an event, non-immunization may be dependent 
upon the presence in the vaccine virus of micro-organisms inimical to 
the life and attributes of the specifically protective organism. 
A nursing babe, marasmatic, and of wretched stock, succumbed to 
thrombophlebitis and pyemia. The scarification wound was about 
healed, and I anticipated no trouble until the nurse called my atten- 
tion to an abscess forming on the superior antero-internal aspect 
of the left arm. 
Other abscesses appeared in rapid and orderly succession in the 
axillary, infrascapular and pectoral regions of the same side. Finally 
and lastly, another abscess located itself over the lower part of the 
internal saphenous vein. In each instance nodulation and ecchymosis, 
involving the affected vein and contiguous tissue, occurred. Nasal 
and aural hemorrhage, and the rapidly progressive prostration con- 
firmed the original diagnosis of pyemia. 
At the autopsy I found a thrombus in the cephalic vein but a few 
centimeters distant from the normally fovealated scar. 
The relations of the cephalic to the basilic, subscapular, thoracic 
and axillary veins explains the course of the embolic process, with its 
final transmission through the heart and lungs into the general circu- 
lation. Pyemia is an unjustifiable contingency, but so is any pus 
infection, whether it arises from the more serious streptococcus inva- 
sion of the deeper structures and tissues, or the less harmful staphy- 
lococcus attack upon epidermal structures that offer satisfactory and 
innocuous lodgments for pathogenic guests until inflamed areas afford 
better ones. The need of rigid antisepsis applied to the making and 
care of vaccination wounds and variolous eruptions is not an un- 
reasonable deduction. 
Jenner in his " Inquiry" foreshadows modern biological principles 
when he says: "Untoward symptoms arise from the irritation of 
sores and not from the primary action of the vaccine virus." 
Dr. John Bach, in the British Medical Journal, b'eb. 1st, 1890, 
pleads for aseptic vaccination. 
Dr. Ballard, in the Lancet, Feb. 9th, 1889, advocates antiseptic 4 
dressings in vaccination. In Virchow's Yahresbericht, Vol. II, 1887,. 
Morriz Bauer is accredited with the same sentiment. 
This subject has been agitated by scores of medical writers of all 
nationalities, and has heretofore produced but little effect upon the 
American mind. Nevertheless, I hope that my call fora more rational 
prophylaxis in so necessary and universal procedure will not suffer 
oblivion, but rather help to a speedy revision of our current methods. 
To sum up: 
1. Variola is communicable as an air borne, and air exit con- 
tagium. 
2. Its specific virus has not been isolated. 
3. Its identity with vaccinia is undetermined. 
4. The failure and non-protective character of vaccination is due 
to vitiation of the vaccine supply. 
5. This vitiation is (T) saprophytic, annulling the specific quality 
of the virus, or (2) pathogenic, inflicting injury upon the individual. 
6. Consequently such change in the lymph supply is demanded 
as to exclude a mixed infection. 
7. Vaccination confers immunity from smallpox, but not from 
other (1) synchronous or mixed, or from (2) secondary infections. 
8. These secondary contact infections are avoidable. 
9. Hence antiseptic methods applied (1) to the present vaccine 
supply, and (2) to vaccination, will make accidents of vaccination a 
thing of the past. * 
10. To procure which end it is desirable, if not necessary, to es- 
tablish government vaccine stations. 
BIBLIOGRAPHY. 
Strumpell, Text-Book of Medicine. 
Smith, Diseases of Children. 
Baginsky, Lehrbuch der Kinderkrankenkheiten. 
Hennoch, Vorlesungen uber Kinderkrankheiten. 
Nil Filatow, Semiotik und Diagnostik der Kinderkrankheiten, translated from the 
2d Russian edition by A. Hippius. 
Crookshank, Vaccination; its History and Pathology. 
Ashby and Wright, Surgical and Medical Diseases of Children. 
Keating, Cyclopedia of the Diseases of Children. 
George Sternberg, a Manual of Bacteriology. 
Archiv fiir Kinderheilkunde, Herausgegeben von Dr. A. Baginsky, Dr. F. Fruh- 
wald, Dr. A. Monte, 1890, 1891, 1892, 1893. 
St. Thomas's Hospital Reports, 1890. Specific Diseases Considered with Reference 
to the Laws of Parasitism, by Joseph Frank Payne, M.D., F.R.C.P. 
St. Thomas's Hospital Reports, 1889-90, Sept, and Pyaem. Three cases of Septic 
Poison of Obscure Origin. 
Berliner Klin Wochenschrift. Nov. 9, 1891. 
Baumgartens Yahresbericht uber die Fortscheritte in der Lehre von den Pathoogenen 
Mikroorganis mem., 1886, 1887, 1889. 
Carl Fraenkel, Grundriss der Bacterienkunde, 1888. 
British Medical Journal, Apr. 30 and Feb. 18, 1893. 
Jonathan Hutchinson, Exceptional Results of Vaccination, in the Archives of Surg., 
Oct., 1889. 
The Lancet, February, 1889. 
Practit. London, 1890, Vol. XV. Vaccination in Holland by Robert Steel. 
Letter from Dr. Edward Jenner to Wm. Dillwyn, Esq., on the effects of vaccination, 
pub. by Phil. Vaccine Society, Wm. Fry, printer, 1818. 
Ziegler, Allg. Pathologic. 
Central Blatt fiir Chirurgie, 1892, p. 152. 
Central Blatt fiir Bakteriologie und Parasitankunde, 1888, 1889, 1890, 1891, 1892, 
1893. 
Baumgarten, Lehrbuch der Pathologischem Mykologie.