No. 1021.

LONDON, SATURDAY, MARCH 25, 1843. [1842-43.

COURSE OF LECTURES

ON

DISEASES OF THE SKIN;THEIR

HISTORY, PATHOLOGY, AND TREATMENT.

Delivered in the Middlesex Hospital, duringthe Summer Session, 1842, byERASMUS WILSON, Esq.,

Consulting Surgeon to the St. Pancras Infir-mary ; Lecturer on Anatomy and Physio-logy in the Middlesex Hospital School.

LECTURE XVII.

DoES vaccine lymph lose its protectivepowers by indefinite transmission? This isa question which has been much and warmlyagitated, but is unsupported by any veryconclusive evidence. It has been provedthat the lymph introduced into use byJenner its still capable of producing the per-fect Jennerian pock, and that the constitu-tional influence of the inoculation is com-

plete. If, then, we associate this observationwith the multifarious causes of imperfectvaccination which are known to exist, wemay, I think, attribute any loss of power ofthe lymph rather to the latter cause than toany supposed deterioration, the effect oftime. Indeed, it is consistent with our

knowledge of physiological phenomena toexpect that a specific poison introduced intothe animal system shall excite a specificaction, followed by certain specific results ;and that the reproduction of virus, which isthe essence of this process, shall furnish apoison identical with that introduced intothe system, and capable of exciting perfectlysimilar effects. There is nothing in thisprocess that indicates a probability of changein the phenomena, however frequently it maybe repeated. Notwithstanding, the opinionof a decrement in the power of the vaccinelymph is entertained by many practitioners,and has given birth to several ingenious andimportant suggestions for improving vaccina-tion bv the introduction of better Ivmph.

IMPROVEMENTS IN THE VACCINE LYMPH.

The experiments which have been hadrecourse to for improving the vaccine lymphare three in number, namely, Recurrence tothe Cow, Retro-vaccination, and Variolo-vaccination.

RECURRENCE TO THE COW.

From the variety of epizootic disorderswhich affect cattle, it is a matter of consi-derable difficulty to determine the preciseform of eruption which represents the truecow-pox. A widely-spreading and destruc-tive disorder of the vesicular kind, the

aphtha epizootica, has, for the last few years,been prevalent among cattle. By the inex-perienced this disease might be mistaken forthe true disease, and the following remarksare made by Mr. Ceeley on other disorders,or " spurious pocks," to which, accordingto his observations, milch cows are liable :-

" Inflammation and induration, sometimessuppuration of the cutaneous follicles at thebase of the teats ; small hard knots, cutane-ous or subcutaneous, in the same locality,about the size of a vetch or pea, or evenlarger, which often remain indolent for a

time, at length become red, vesicate, enlarge,suppurate, and burst, after attaining, not un-frequently, the size of a walnut or more,occasionally affecting the hands of themilkers, and often the other cows milked inthe same shed by the same hands. Aneczematous eruption, with intertrigo on theudder and near the roots of the teats. Wartygrowths of two kinds; one consisting of

long, narrow, pendulous, and linear-shapedprolongations, easily removed, and oftendetached ; the other of short, thick, com-pact, broad elevations, lighter in colourgenerally than the ground from which theyrise, of various sizes, from that of a pea toa horse-bean, frequently very numeious onthe teats, where they are often found bleed-ing and partially detached. The yellow pock,a pustular eruption, resembling ecthyma, onthe teats and udders, succeeded by thin,dirty-brown or black, irregular crusts. Thebluish or black pock bluish or black, or lividvesications on the teats and udders, followedby; thin, dirty-brown or black, irregularcrusts, and some degree of impetigo on tha

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interstices, near the basis of the teats. Thewhite pock, a highly contagious diseaseamong milch cows and to the milkers,quickly causing vesications and deep ulcera-tions, often, or almost always, confoundedby them with the true vaccine, and certainlynot readily distinguishable in all its stagesby better informed persons than milkers."Of the true variolas vaccinae Mr. Ceeley

remarks, that they are preceded for three orfour days by heat and tenderness of the teatsand udder, without any apparent constitu-tional indisposition. On the heated andtender parts red and hard pimples, of thesize of a pea or vetch, make their appear-ance. In three or four days the pimplesincrease to the size of a horse-bean, and, con-tinuing to enlarge, develop vesicles on theirsummits. The inflamed parts at this periodare exceedingly tender, and milking is bothtroublesome and dangerous. On their firstappearance the vesicles are acuminated,oval, or globular; when broken they giveexit to a viscid amber-coloured fluid, and bythe collapse of the epidermis present a centraldepression with marginal induration. Fromthe injury done to the inflamed parts bymilking, and the consequent inoculation ofthe neighbouring surface, the vesicles pre-sent every variety of size and period of de-velopment ; intermingled with the vesiclesare several dark-brown or black solid, uni-form, embedded crusts, and in situationswhere the latter have been removed there areraw surfaces, with a slight central slough.

Notwithstanding the difficulties attendanton the discovery of the true vaccine disease,lymph has been procured by several gentle-men, both in this country and on the continent.Of the former, I mention, especially, thenames of Mr. Estlin, of Gloucestershire;Mr. Fox and Mr. Sweeting, of Dorsetshire ; ’,and Mr. Ceeley, of Buckinghamshire; andof the latter, M. Saunoyand M. Bousquet,in France, and S. Griva, in Turin. Theeffects produced upon the human subject bythe primary lymph I have already detailedin a previous lecture. I laid particularstress on the advantages resulting from theinoculation of infants, from their insuscepti-bility of morbid poisons ; and I mentionedthe indisposition which pervades the severalgenera of animals to take on the peculiardiseases of another genus, a circumstancewhich is particularly observable in theattempt at transmitting vaccinia from thecow to the human system. That the ob-stacle, however, is not insurmountable, hasbeen amply demonstrated by experiment, andof all the plans hitherto suggested for im-proving the vaccine lymph this appears tobe the most legitimate, and the best calcu-lated to ensure success.

RETRO-VACCINATION.

A far less satisfactory proposal for im-proving vaccine lymph, when its powers are

supposed to be enfeebled, is to pass it againthrough the system; in other words, to vacci-nate the cow. This operation is attendedwith much difficulty, for a reason to which Ihave had frequent occasion to advert, namely,the indisposition of the system of one genusof animals to be acted upon by morbidpoisons derived from an animal of a differ-ent genus. The experiment has, however,succeeded in the hands of Mr. Ceeley, andthat gentleman, by transmitting the resultingvirus to children, has been enabled to deter-mine the qualities which the lymph had ob-tained by its re-passage through the cow.

" My experiments in retrovaccination,"says Mr. Ceeley, 11 were almost entirely con-fined to the sturk under twelve months old,and the parts selected for the operation werethose in close proximity to the vulva. Theseanimals were easily procured, while milchcows in any number, at least here, are diffi-cult to obtain for such a purpose. The opera-tion was performed either with a lancet or asharp straight bistoury. The lymph waseither dry oeliquid, in capillary tubes. Noother precautions were taken than excludingthe animals from wet and cold immediatelyafter the operation, for a few hours, or per.haps a night. Those of a light colour andwith thin skins were generally preferred,but often without avail, scarcely one half ofthe operations succeeding. Tubercles, nearlyor completely lymphless, were often pro-duced ; but sometimes every puncture suc-ceeded. In the majority of instances thevesicles ran the normal course, declining onthe eleventh day."

In his general observations on the resultsof retro-vaccination, the same author ob-serves :—" Take an abundance of humanisedlymph from one of the finest and most pro-ductive vesicles ever seen, and if you suc-ceed in retro-vaccinating the cow, you mayperhaps be able to charge scantily only avery few points from a vesicle which excitesbut trifling topical inconvenience. Vaccinelymph, it is obvious, therefore, in passingfrom the cow to man, undergoes a changewhich renders it less acceptable and lessenergetic on being returned to many indi-viduals of the class producing it ; some re-fuse it altogether. But this reluctance orabsolute refusal, this difficult inhibition or

total insusceptibility, does not exist to thesame extent as observed in the converse ofthis experiment, viz., in passing primarylymph from the cow to man by the samemeans. Here we have considerable diffi-culty, but when we succeed a severer diseaseis induced. The age of humanised lymphdoes not seem to influence its reception bythe cow. Provided that the lymph be ofordinary activity, and possess the normalqualities, it as likelv to succeed in its opera-tion on the animal whether it may have beencurrent in man a few weeks or many years,

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and will excite equally perfect and produc-tive vesicles."

Of the effects of retro-vaccine lymph onman, Mr. Ceeley remarks, 11 lymph whichhas passed from arm to arm with the greatestpromptness and facility, and produced thefinest effects, in its first removes from thecostive vesicle of the retro-vaccinated cow,is not so readily absorbed by many indi-viduals as current lymph. It rarely fails,but papulation is retarded, and though thevesicle may attain maturity at the normalaverage period, the completion of that stageis frequently postponed. The vesicles areoften smaller, and the disease really not sowell developed as by the stock from whichit was derived. But these changes do notappear after the second or third remove.

The lymph is restored to its former qualitiesand produces its former effects."Let us see what answer Mr. Ceeley re-

turns to the question propounded by himself,namely, 11 its the practice of retro-vaccina-tion of any real value as a means of reno-vating humanised vaccine ? I confess thatfrom my limited experience I am unable todiscover its advantages, or to admit morethan its questionable utility, from one transitthrough the cow. What humanised vaccinemight acquire by repeated and indefinitetransmissions, I am not prepared to say. Ihave no doubt that primary vaccine, passedby artificial means through a series of cows,would lose much of its acrimony, and pro-duce on man a milder, but abundantly activeand characteristic disease; but that human-ised vaccine, by a similar process, shouldever acquire all the attributes of primaryvaccine, or become so much brutalised as todeserve the epithet of renewed,’ is morethan many are prepared to expect."

VARIOLO-VACCI NATION.

Another proposal for renewing the vaccinelymph is founded on the identity of small-pox and cow-pox. I have already dis,cussed the question of identity of these dis-orders in previous lectures ; it is only neces-sary for me now to explain that the proceed-ing termed variolo-vaccination consists in ino-culating the cow with small-pox virus, andemploying the resulting lymph for the ino-culation of man. This variolo-vaccinelymph is very effective, but it is questionablehow far it may possess advantages over theordinary current vaccine lymph. The ex.

periment of procuring it is attended withmany obstacles, both from the difficulty ofprocuring suitable subjects, and from theindisposition they present to the reception ofthe virus, and many failures must naturallybe anticipated. Nevertheless, the operationhas been successful in the hands of severalexperimentalists, and Mr. Ceeley, who wasso fortunate as to succeed on several occa-$!out, give. the following account of the

effects of the lymph when transferred toman :-

The first person subjected to the action ofthe new lymph was his own assistant, Mr.Taylor, who was in consequence the subjectof the following interesting notice :-Thisgentleman, it appears, while Mr. Ceeley" was engaged in the tedious process of

charging points therefrom, punctured theskin of his own hand between the thumb andfinger, with the instrument while moist withlymph. On the fourth day afterwards hedirected my attention to a hard, deep-red,papular elevation on the spot, stating thecause, and at the same time assuring methat he had been vaccinated in infancy, andhad subsequently had modified small-pox.On the fifth day there was a papulo-vesicu-lar elevation, surrounded with a dark redareola, and much uneasiness in the part. Inthe evening headach and other febrile symp-toms appeared, with roseola, and fiery-redpapulae on the face and other parts. On thesixth day a more diffused and lighter areolasurrounded the less abrupt elevation, whichwas now more perfectly vesicular; the consti-tutional symptoms increased, and the pa-puiae on the face, neck, trunk, and limbs, ex-hibited ash-coloured summits, and through alens appeared to have slight central depres-sions. On the seventh day it was manifestthat the disease had reached its acmd on theprevious day; the areola was diminished, thevesicle was more apparent, some of the pa-pulae presented light straw-coloured sum-mits, and the roseola was declining, with anabatement of the febrile symptoms, and adiminution of the tenderness in the axilla.On the eighth day all these changes weremore obvious, although he was not free fromheadach, the papulae were more yellow, andsome were desiccating, the vesicles werelarger but less active, and the areola wascomparatively pale. This was evidentlymodified vaccine in a sanguine habit, withroseola, and vesicular or vaccine eruption."Out of five children inoculated with the

variolo-vaccine lymph in twenty punctures,Mr. Ceeley obtained only six vesicles. Inall these cases the punctures inflamed early,but the papular stage was later, and it wasnot until the sixth, seventh, or eighth daythat it became possible to determine theprobability of success. The primary consti-tutional symptoms were slight, while thesecondary were proportionate to the extentand character or the areola ; thus, in onethere was considerable suffering, and an ex-tensive areola, with vomiting and delirium.The following is a successful case of variolo-vaccination :—" Emma Jaycock, aged 14,dark swarthy complexion, thin skin, ratherflorid; two points of sixth-day lymph andfour of eighth-day lymph were inserted intosix punctures. On the fifth day four of thepapulas had ash-coloured summits andseemed vesicular, two were doubtful. On

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the seventh day there were five small, distinct, the texture and degree of translucency yieldedreddish-grey or ash-coloured vesicles, one by its desiccating epidermis. On the thir-very small. On the eighth day the vesicles teenth and fourteenth day, particularly onwere advancing, of unequal size and of irre- clear skins, moderately thick, the vesiclesgular form. Here I was forcibly struck attained a considerable size, measuring oftenwith the strong resemblance some of those in their longest diameters six and a half orvesicles bore to those of the eighth day de- seven lines, and acquired a light brownpicted in Jenner’s work on the arm of centre from commencing desiccation, whichHannah Excel, which he thought so re- was surrounded by a dull margin of dullmarkably like the results of small-pox ino- white or pale dirty-yellow, soft and flaccid,culation. My patient stated that she felt and still possessing fluid contents. Duringslightly indisposed on the fifth and sixth this period, the areola, of a dull red or damaskday, that the axilla was painful on the hue, would revive and decline again andseventh day, and that she was then giddy again, and even to the sixteenth or eighteenthand sick, but felt worse on this, the eighth day, the period to which complete desicca-day. On the ninth day the areola com- tion was frequently protracted. The crustmenced, and she complained only of head- commonly partook of the form of the vesi-ach ; on the eleventh day it was fully deve- cle ; it was often prominent and bold, vary-loped, when all her symptoms returned in ing in colour from that of a chesnut to thatan aggravated form. On the twelfth day it of a tamarind-stone. It fell generally aboutdeclined, but the turgid vesicles having burst the twenty-third or twenty-fifth day, oftenthe flimsy cuticle, renewed inflammation and later."induration, with circumscribed sloughing " The cicatrices were of variable depthand ulceration of the skin ensued, and rather and extent. When the vesicles remained

deep scars are now visible." unbroken on a thick sanguine skin, theyAs a type of the effects of this lymph after were deep, but on a thin skin shallow, they

having passed through several individuals, were not always proportionate in width toMr. Ceeley gives the following example of that of the vesicle, the smallest cicatrix oftena case illustrative of the fourteenth remove, succeeding the largest vesicle, but the laterin "an infant fourteen months old, florid, the crust fell of course the deeper the cica-plump, and healthy, with a fine, clear, thick, trix, which on these occasions was oftensmooth skin. In the majority of instances beautifully striated. I need scarcely sayin propagating from arm to arm distinct that when the vesicles were accidentallypapulation was apparent on the second day ; broken or spontaneously burst, much mis-on the third it was not only visible but well chief ensued, deep sloughing of the skin,defined ; on the fifth and sixth vesiculation &c. Spontaneous bursting did not oftenwas abundantly obvious, and lymph was occur except in those subjects possessing theoften taken on those days. On the seventh before-mentioned obnoxious constitutionalday vaccination was frequently performed, and dermic characteristics, upon whom weand points were often charged; on the must always use active lymph with someeighth the vesicle commonly exhibited a risk."bold, firm, and glistening aspect; between 11 When the lymph in the first remove pro-this period and the ninth day the areola duced normal vesicles, and as soon as it hadgenerally commenced (but in young infants passed readily from arm to arm, the consti-with tense and sanguine skins it appeared tutional symptoms, though mild, were mostearly on the eighth); by the tenth day the commonly well marked. In infants restless-vesicle was commonly in its greatest beauty ness, fretfulness, and inappetency, about theand highest brilliancy, glistening with the fifth or sixth day, were very common, some-lustre of silver or pearl, having the translu- times as late as the seventh day, very fewcency and appearance of crystal, or shining escaped feverish symptoms on the ninth andwith a pale blue tint, occasionally of a dull tenth days, many had vomiting and diar-white or cream colour, bold and elevated, rhoea. From childhood up to puberty thewith a narrow centre and broad margin, or primary symptoms from the fifth to theflat and broad in the centre with an acute seventh day were unequivocally visible andmargin, occasionally not raised above the often complained of ; fever, vomiting, deli-level of the skin. On this and the eleventh rium, and diarrhoea, were not unfrequentlyday an extended and generally vivid witnessed at the commencement or duringareola existed, with more or lesd tension and the progress of the secondary symptoms. Ininduration on the integuments ; at this time adults, of course, more complaint was made,the lymph was frequently pellucid and often headach, chilliness, anorexia, and sometimesperfectly efficient. From the eleventh to the thirst, on the fifth or sixth day, increased onthirteenth day, gradually increasing in many the seventh day, with axillary tenderness,individuals both children and adults, some- but on the ninth and tenth days much gene-times the entire vesicle, at others only the cen- ral febrile complaint, disinclination and eventral parts reflected a blue or slate-coloured inability to leave the bed. But in severaltint, from the congested or ecchymosed subja- instances among young children, little or nocent adventitious structures, proportionate to complaint was made or indicated. All the

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members of the same family vaccinated fromthe same source might be differently affected;one, for instance, would not cease frompastime, occupation, or meals, while another,particularly if older, would be indisposedfor several days. Neither the number northe magnitude of the vesicles seemed to de-termine the amount of the primary disturb-ance. If properly developed, small vesiclesoften gave rise to marked constitutionalsymptoms, and the most splendid vesicleswere often seen with trivial, sometimes

scarcely appreciable disturbance."" The secondary symptoms were often as

active with three or four as with six or

eight vesicles. Acceleration of the pulsewas frequently noticed when no other symp-tom appeared ; both primary and secondarysymptoms very commonly showed a remittingtype." 11 In no case, excepting that of Mr.Taylor, was there any attendant eruption."

Other observers besides Mr. Ceeley havesucceeded in performing variolo-vaccination,and have recorded the results of their expe-riments. Dr. Basile Thiele, of Kasan, inSouth Russia, remarks that the effects pro-duced by this lymph were more intense thanthose which resulted from ordinary vaccinelymph. Sometimes there were two febrileattacks, the one between the third and fourthday, the other between the eleventh andfourteenth ; and these severe effects werenot lost until the sixth remove. In one casethe lymph produced an attack oftrue variola,and lymph taken from the pocks of this I

patient and inoculated in the arm of an-other reproduced vaccinia. This latter ex-periment is a marked illustration of the

identity of variola and vaccinia.In concluding the interesting and import-

ant subject of vaccination, and the considera-tion of the defeiaces against small-pox, I maymention a singular statement made by Dr.Lichtenstein, and published in Hufeland’sJournal for 1841. The paper in which thisstatement occurs is entitled, " On theSources from which Matter preservativeagainst the Small-pox has been derived,"and the author asserts that limpid lymphtaken from the pustules produced by tarta-rised antimony and inoculated in a personwho has not been vaccinated, occasions apock that cannot be distinguished from vac-cinia. These pocks, he states, are equallyprotective against small-pox, and the lymphmay be transmitted from person to person inthe same manner with cow-pox. Dr. Lich-tenstein inoculated and reinoculated thirty-one persons from this source, and none ofthese persons took the small-pox, althoughthey mingled freely with the infected duringthe epidemic prevalence of small-pox.

THE glands, properly so called, separatefluids from the body, and discharge them bya duct. They are all situated on the heador trnnk,-Dr. Alison.

CLINICAL REMARKS

ON CASES OF

EXCISION OF DISEASED BONE,DELIVERED AT

KING’S COLLEGE HOSPITAL

BY

MR. FERGUSSON.

CASE 1.—EXC!S!ON OF A PORTION OF THESCAPULA.

HENRY PARRY, aetat. 2S, a sailor, was

admitted under Mr. Fergusson October 10,1842. Twelve months ago, being then inCalcutta, had an attack of what he callsrheumatism of the right shoulder; the partsswelled much, accompanied with great pain,and he was uuable to use the arm, whichconsequently became much emaciated. Inthe course of a few weeks the swelling andpain partially subsided, becoming, however,more remarkable on the posterior surface ofthe joint. Fluctuation being felt, an opening,two inches and a half in length, was made,and exit was given to a large quantity of fetidpus. The wound has never entirely closed,and six or seven pieces of bone have beendischarged at intervals, the last about threemonths ago.

There are now two sinuses, one just belowand behind the acromion, the other a littlelower, from which there is a constant dis-

charge of thin fluid ; there is also an openingin front of the shoulder, an abscess havingformed in that situation. All movements inthe shoulder-joint have ceased, and he hasbecome totally unfit for service. The spineand acromioa scapulae are considerablythickened, and a probe passed along one ofthe sinuses over these parts grates againstbare bone.

]8. To-day a free incision was made,which permitted a more complete examina-tion of the spine of the scapula, and with theaid of the gouge and forceps, a portion ofnecrosed bone was removed from a shell-like cavity in the spine, formed by a deposi-tion of ossific matter around the necrosis.The cavity and wound were stuffed with

lint; cold was applied to check the oozingof blood, and on the succeeding day warmwater dressings were used over clean charpie,with which the wound was filled daily.Granulations soon occupied the space, andas cicatrisation became complete the relieffrom pain and facility of moving the shoulderbecame more and more apparent. The

puncture in front of the shoulder showed nodisposition to heal, and from time to time,under the impression that there might be aportion of dead bone in this situation, aprobe was introduced, which, however,failed to indicate any such condition. At

last, after the occurrence of some additionalinflammation in this locality, a piece of bone