spots had healed and it was not until about four months had elapsed that it ceased to be felt.

In two cases where the vesicles were moderately large and well formed the patients were said to have had smallpox; one of these was in his seventy-eighth year, the other in her thirtieth year. In neither case, however, Icould I discover marks of the disease. In another case I think there could be no doubt about the patient having had an attack of smallpox, although no marks were to be found. This patient was fifty-eight years of age and had taken the disorder, when very young, from a sister who was passing through an attack at the time and who is still very distinctly pitted. In this instance the vesicles were large and well formed; the limb was very painful and much swollen in the upper part, and altogether this case, like my own, presented a remarkable example of the different degree of susceptibility there is at different periods, for, without knowing that the patient had had smallpox, I vaccinated him in 1865 and again in 1871. The first vaccination scarcely took any effect; the second one, as I have shown above, was very successful.

In 1871 I had a patient under my care who was phthisical. At the time smallpox was said to be very prevalent in the village in which he lived, which was about eight miles from Manchester.

I strongly urged upon him as well as upon all the members of his family the necessity of being re-vaccinated, but as [they had imbibed the extreme notions of the antivaccinationists, they objected to have the operation performed. Early in 1872 I received a message informing me that they had smallpox in the house, and requesting me to go over to see the phthisical patient. Engagements which I could not set aside prevented me going over until the following day. When I arrived I found that one daughter had been attacked and had recovered, but a second and younger one whose illness had commenced only eight days. before had died a few hours before I arrived. The medical man who had been in attendance, probably knowing the strong antipathy the family had to vaccination, had VOL. XXXII, NO. CXXVII.-JANUARY, 1874.

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not urged it upon them, and consequently nothing had been done. The question they wished me now to decide was, whether I would still re-vaccinate the phthisical patient who was then in the last stage of the disease and could, at most, live only a few weeks probably. I decided to re-vaccinate at once, and I did so for the following reasons:— -In the first place the patient had been exposed to almost direct contact with two cases of smallpox, one of which was of the confluent kind, and if unfortunately an attack had come on in his case it would have added immensely to his sufferings without in any sensible degree retarding the progress of the malady from which he was suffering. In the second place if the patient had taken the disorder he would have furnished a fresh centre of infection as well as a means of concentrating the poison.

The change of opinion which the death of one member of the family had wrought made the surviving members just as anxious about re-vaccination as they were indifferent to it before, and having sufficient lymph with me I re-vaccinated four of the family before I left the house; namely, the father, mother, and two sons, one of whom was my phthisical patient. Another son, who lived some distance away, came over and was re-vaccinated before he went to the house two days after. On the fifth day four out of the number sickened, and I was requested to see them again. I found the pulse in each case much quickened; there was pain in the head and back, with nausea and a thickly coated tongue. It appeared as if the vaccination was too late, although in each of the first four cases a tolerably distinct vesicle had formed, which, though small and imperfect, showed that the lymph had in some degree taken effect. Notwithstanding this I made up my mind I was going to have a troublesome time of it.

At the end of about thirty-six hours, however, three out of the number took a sudden turn for the better, and along with this it was noticed that in these cases one or two vesicles had begun to form on the wrists, on the alæ nasi, and on the forearms. These, though not more than

GENERAL

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University

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by Mr. Charles H. Blackley.

two lines in diameter, became quite normal in character and passed through the usual changes, but this they did in a much shorter time than is usual in ordinary attacks of smallpox; and the most noticeable feature in the cases was that after the eruption had come fairly out the patients seemed to have gone at one bound from a state of serious illness to comparative health. My phthisical patient was one of the three and seemed to suffer less than the other two, but as he was suffering from hectic fever at the time, this probably masked some of the symptoms which appeared more prominently on the other two cases.

The fourth patient, a youth of about twenty-one, did not go on so favorably. In his case the symptoms became much more severe; the eruption came out more tardily, but ultimately he passed safely through a somewhat severe attack of semi-confluent smallpox. I learned on inquiry that this patient had been very much attached to the sister who had died, and that he had spent a good deal of his time at her bedside during her illness. I was curious to know what would be the effect of the development of the natural pock on the very imperfect vaccine vesicles which had already formed. A cluster of pocks that came out close to the latter encroached so much upon these that they were soon completely buried, as it were, beneath the cluster. The son who lived away from home escaped entirely, although he was constantly going in and out of the house for three days after being re-vaccinated.

All these patients were said to have been vaccinated in infancy. In three of them cicatrices were very perceptible -the one who had the severe attack of smallpox was amongst the number. In one the cicatrices were very small, and in the remaining one they are not to be seen.

Sir Thomas Watson, when quoting Mr. Marson, says, that if a vaccinated patient inhale the germ of variola on any given day re-vaccination will not be effectual in preventing an attack of smallpox if delayed beyond four days. In reference to the cases cited above, the question naturally occurs to which of the two vaccinations was the modification

seen in three of the cases due ? The experience derived from these is too limited to allow us to draw final conclusions from it, but I think it is highly probable that the modification was, in each case, due to the presence of the lymph recently introduced, and that the severe attack of smallpox which did occur in the one patient was caused by a larger dose of the poison being inhaled. Whatever view be taken of the matter I should, by the experience gained in these instances, if placed in the like circumstances again, be encouraged to adopt the same course.

In some of the cases which came under my care in 1871 I noticed a peculiarity which we do not always see in first vaccinations, namely, that beyond the areola there was an effusion into the subcutaneous cellular tissue which was evidently not inflammatory. It was in fact simple œdema, and pitted on pressure just as cedematous swellings do. In two or three instances this gave rise to a curious appearance of the limb. The swelling was greatest at the spot where the abrasions had been made and gradually diminished towards the elbow, causing the upper part of the limb to have somewhat of an inverted pyriform appearance. At the part nearest the elbow the limb was scarcely, if at all, above the normal size, but curiously enough the part of the forearm just below the elbow was considerably swollen by this non-inflammatory effusion into the subcutaneous tissue. My chief reason for drawing attention to this matter is to notice that along with true inflammatory action we may have, beyond the inflamed area, effusion such as that named by what appears to me to be simple reflex action.

The swelling in the upper part of the limb might have been produced by the continuity of the action set up by the introduction of lymph. The swelling in the forearm, however, could only have been produced in one of two ways, namely, either by the gravitation of the fluid effused in the upper arm, or by reflex action. If the swelling had been caused by the gravitation of the fluid, this would have been greatest at the most dependent part. It was not so, however, and we must therefore conclude that it must have

been due in greater part, if not entirely, to reflex action. It is true it might have been caused by a temporary want of power in the absorbents, but even in this case it must have been due to reflex action. How far this kind of action may be seen to occur in idiopathic inflammations of the integnment I am not prepared to say, and it would be beyond the scope of this paper to attempt to discuss the matter, but I am inclined to think that in some cases of erysipelas of the head and face, and also in cases where strongly acting counter-irritants are used it may become a source of great danger even where the inflammation is not very extensive

or severe.

As previously shown the symptoms produced in 1864 and 1865 were mild. In 1871 these were more severe; the number of persons susceptible to the action of lymph was larger than in the first period, whilst at the same time the vesicles produced in many cases were to all appearance normal. And it should be noted that this was not the case only with those who were advanced in years, and in whom the protective influence of a first vaccination might have been supposed to be exhausted. Neither were these results seen only in those instances where the effect of the primary vaccination had been doubtful. In one case where the cicatrices from the first vaccination were large, and where the patient was not more than seven years of age, the vesicles produced by re-vaccination were large and well formed. In another, who was twelve years of age, the same thing occurred. Then, again, some of those who were revaccinated in 1864 or 1865 were again operated upon in 1871, and, although the operation was performed with the same amount of care on each occasion, the symptoms were more severe in the latter than in the former period.

Along with the facts stated above we find smallpox more prevalent and more virulent in 1871 than in 1864; and if we were to draw our conclusions from this last-named circumstance only, we might say that the smallpox virus had increased in quantity or in power and thus had given rise to the epidemic we had in 1871. The facts I have