COMPLICATIONS OF

VACCINATION.

BY

Louis Frank, M. D.,

MilwaufreSTTVis.

REPRINTED FROM THE

Journal of Cutaneous and Genito-Urinary Diseases

for April, 1895.

[Reprinted from the Journal of Cutaneous and Genito-Urinary Diseases for April, 1895.]

COMPLICATIONS OF VACCINATION.

By LOUIS FRANK, M. D.,

Milwaukee, Wis.

AT
the present time—in which the value of vaccination as the
only real preventive of variola is greatly questioned by large a

proportion of the public and, I am sorry to say, by not a few

professional men—it may be of interest to study the objections raised
by the opponents. I will, therefore, taking for granted the effectiveness
of vaccination in the prevention or amelioration of smallpox—a fact
firmly established by statistics, and accepted by the majority of un-
biased physicians and laymen, and regarded as a valuable treasure in
all civilized countries of the world—confine myself to the consideration

of one of the principal arguments brought forth and defended by the

antagonists of this measure, the diseases of the skin caused by vacci-
nation.
There can hardly be any doubt in the minds of those who have

had great experience in vaccination that there exists an intimate con-

nection between vaccination and cutaneous eruptions as a sequel there-
of. Happily, when this beneficent operation is properly conducted
there is no great danger of serious accidents and complications. The
only rash which may be properly considered a true vaccine rash is the
erythema vaccinia, which is not an infrequent sequel of vaccination.
Setting aside this true vaccine rash,
sufficiently proved
it has been

that under certain conditions system produced

the disturbance of the

by the introduction of the vaccine virus may result in susceptible sub-

jects in the manifestation of a considerable variety of the ordinary
affections of the skin to which young children are subject.
We know as an undisputed fact that certain cutaneous eruptions

will make their appearance after infectious fevers—foremost, scarlet

fever, then morbilli and variola; and it stands to reason that the pro-
cess of vaccination has a similar action. The skin diseases
attributed to vaccination are exceedingly numerous and rather difficult

Copyright, 1895, by D. Appleton and Company.

2 Original Communications.

of classification. probably a lichenous eczema, or a

Foremost of all is

special variety known as lichen urticatus. Urticaria, erythema multi-

forme, even psoriasis, pemphigus, and prurigo, have been found to occur
after vaccination. Such eruptions are found to be due to the absorp-
tion of the pure vaccine virus ; other skin lesions—as impetigo, syphilis,

lupus, erysipelas, cellulitis, furunculosis, gangrene, and pyaemia—are

due to mixed inoculation, either introduced at the time of vaccination

or at subsequent period through the wound. This classification—(1)

a

eruptions due to pure vaccine inoculation, and (2) eruptions due to

mixed inoculation—has been adopted by Dr. Malcolm Morris, of Lon-

don, in an excellent paper read at the British Medical Association,

July, 1890. It seems to me to fully cover the ground and to include
on a scientific aetiological basis the great number of subsequent cutane-

ous lesions due to vaccination. On the basis of this

general classifica-
tion I have, after careful study of the various lesions secondary to

vaccination, found the following classification a convenient and prac-

ticable one for the comprehension of the complications of vaccination :

Complications of Vaccination.

Erythema localis.
Dermatitis.
Local
Vaccina herpetica.
Adenitis.
I. Due to vaccine virus
Erythema vaccinicum.
Urticaria.
Systemic Erythema multiforme.
Purpura.
Vaccina herpetica.
Impetigo contagiosa.
Furunculosis.
Local
Cellulitis.
Erysipelas.
II. Due to mixed inoculation.... «
1 uberculosis.

Pyaemia.
Systemic
Leprosy.
Syphilis.
Eczema.
Urticaria.
III. Sequelae of vaccination Pemphigus.
Psoriasis.
Furunculosis.

Erythema localis. This torn) of erythema belongs to the class of

—

erythema venenatum, being limited to the region with which the vaccine
virus, acting as irritant, has been placed in contact. It spreads over a
limited area, and passes imperceptibly into healthy skin. If severer

in grade, it passes into the condition termed dermatitis.

The dermatitis often noticed in the course of vaccination is similar

to those inflammations which are the result of the contact of various

poisonous and irritating substances with the integument. In this case
 Complications of Vaccination. 3

the vaccine virus acts as irritating agent, causing a mixed or severe

the
type of inflammation according to the susceptibility of the individual.
It must be diagnosed from erysipelas by its moderate local symptoms
of heat, redness, and swelling; it does not spread with an elevated

abrupt edge, being more diffuse in character and not marked by severe
constitutional disturbances as we find it to be the rule in erysipelas.
It sometimes occurs that a number of papules and vesicles form on
the seat of vaccination and the
surrounding parts, which itch intensely
and pass off* in two or three
days. Dr. Hugh Thomson, of Glas-
gow, has described several cases of such groups of vesicles appearing

in the neighborhood of the vaccination pustules as supernumerary

vesicles, surrounded by a slight areola, which gradually dry up and

fall off’ without leaving a scar. A small amount of lymph was con-
tained in these vesicles. This form of lesion may also be general,
pointing out the fact that the vaccine virus had been absorbed by the
circulation.
Adenitis is quite a common complication of an otherwise normal
course vaccination, and needs but a passing mention.
of

It is a fact often noticed that more or less generalized eruptions

occasionally accompany vaccination, and a host of secondary lesions
of the skin may be mentioned in this connection. Those who believe
that vaccinia is an exanthematic fever and that these eruptions are the
direct outcome of the virus in the system have termed them “
vaccin-
ides,” referring to them as generalisee.
'vaccine
The most common erythema vaccinicum.
of this class is the
Erythema vaccinicum {Roseola vaccinica'). This erythema usually
—

begins at the seat of vaccination, but may appear as isolated patches

and large hypersemic surfaces over the trunk and the extremities. It

usually occurs on the first or second day after the vaccination, or on

the eighth or ninth day after the vaccine vesicle has become mature.
Why there should be two such periods may be explained as follows:
In the course of vaccination the
erythema appearing on the first or
second day is simply due to traumatism from the operation of vaccina-

tion, as may otherwise also occur after irritation of a mechanical or

chemical nature, or after minor operations and slight accidental inju-
ries (described as scarlatina traumatica
by English writers); whereas
the rash which appears on the
eighth or ninth day in all probability

depends on the resorption of particles of the purulent contents of the

vaccine vesicle.

This erythema is usually accompanied by elevation of the tempera-

ture of the skin,
slight febrile disturbance, and always terminates
favorably.
4 Origin al Communications.

It is a complication of vaccination, which is not dependent on any

specific element of the vaccinal virus, but must be ranked as to its
pathology with certain forms of medicinal exanthems. Withregard
to this certain class of erythemas, it is essential that a predisposing
element exists in the individual, or, as we term it, an idiosyncrasy pre-
dominates. In such persons any mechanical chemical
or
trauma, as

that of vaccination, may be liable to produce a erythematous

similar
lesion of the skin. We are therefore hardly justified in explaining
such phenomena as due to local infection or a lymphangitis of the
skin—as Hebra has tried to explain it—but must consider it the effect
of the vaccine virus on the vasomotor nerves, and identical in modus
operandi as the well-known
eruption ingestion
of urticaria after the
of certain solid liquid articles of food. It may therefore, I think,
or

be termed a neurotic disease of the skin, due to vasomotor disturbance ;

a primary contraction, followed by dilatation and paralysis of the ves-

sels affected.

With regard to diagnosis of the erythema vaccinicum, there is a

possibility of mistaking it for measles and the macular syphilide.
Anatomically, it is impossible to distinguish the roseola vaccinicum
from that of morbilli and syphilis. But, if we remember that the
eruption of measles is usually abundant in the face and scanty on the

extremities; that the spots are discrete and often arranged in seg-
ments and attended by a slight desquamation; and especially the con-
stitutional disturbance the diagnosis is easily made.
— The roseola

syphilitica is oftenest met on the anterior surface of the body, also on

the palms and soles. It consists of oval, rounded, or irregular blotches,
which in the early stage may be slightly elevated and unattended by
either heat or itching. Here also the general history and duration of

the eruption will tend to render the diagnosis easy.

Urticaria is not at all uncommon, and erythema multiforme has
been noticed at times during the period of vaccination. The rare pur-
pura is said to be of ill omen. Vaccinal herpes has been referred to
under the local action of vaccine virus.

Class Eruptions caused by Mixed Inoculation. Although

II. —

we are not always able to identify the specific germs which with the

vaccine virus produce the mixed inoculation, we are justified, by

knowledge of epidermics, to call the lesions so produced a mixed in-
fection. If such foreign germ is introduced with the lymph, or at a
later period by contamination with the wound, it will not fail to pro-
duce its peculiar manifestations. It may produce only local lesions or

general infection. Among the first class we most frequently meet with

impetigo contagiosa, furunculosis, cellulitis, and erysipelas.

 Complications of Vaccination. 5

Impetigo contagiosa is always due to the inoculation of contagious

pus, independently of its source. Its relation to vaccination, following
it frequently, is another instance of pus inoculation ; the vaccine lesion
is often very itchy in its purulent stage ; the child scratches it and
transfers the pus to other
parts of the body. The contagion flourishes
more easily in the cachectic.

Furunculosis.— The mycotic nature of furunculosis has been dem-

onstrated beyond question. The presence of the Staphylococcus

pyogenes aureus and allyus, the transmission of the disease by con-

tagion, and the successful inoculation of pure cultures, are reported by
Bockhart, Escherich, Ilergot, Chambard, and Voituriez, and its intro-
duction into the system through the vaccine pustule is not at all im-
probable.
Erysipelas in the course of vaccination is the most important and
dangerous complication, and must be dreaded as the principal weapon
in the hands of opponents of vaccination. This was especially true
when the question of aetiology of erysipelas had not been solved. But
ever since the discovery by Fehleisen of the streptococcus, a micro-

organism identical with the pus streptococcus, as the single and inva-
riable causative agent of the disease, its aetiology is no more doubtful.
This germ has no power to penetrate healthy skin, but may effect an

entrance through any abrasion, especially such as rendered by vaccina-

tion. The coccus may exist either in the lymph, or may be introduced
into the system through the vaccinal wound by the vaccinator by
means of the instrument, hands, or clothing. The development of
erysipelas may take place immediately following vaccination, or later
beginning on the fifth day, but usually on or after the eighth day,
with the well-known characters of erysipelas. The erysipelatous in-
flammation begins at the seat of thepustule of vaccination as an ir-
regular, sharp-edged, elevated red patch, accompanied by slight pain
and itching. On pressure, the color of the skin is of a slight yellowish
tinge. In the course of the following days the inflammation spreads
uniformly over the adjacent skin tissue, so that within two or three
days the erysipelatous patch is as large as one or two palms of the hand.
In moderate cases this ends the progress of inflammation. The high
fever, sleeplessness, slight delirium, dryness of the tongue, etc., rapidly
disappear, the livid red color of the skin changes to a bluish brown-
red or light brown, the infiltration diminishes, the brownish colored
epidermis separates itself in fine scales or lamellae, and the skin presents
a normal appearance.

In polemical writings of anti-vaccinists such diseases as scrofula,

tubercle, diarrhoea, and other common causes of infantile mortalitv
6 Original Communications.

are alleged owing to vaccination. There is little or

to have increased

no reason, in theory
experience, to suspect that tuberculosis or
or

scrofulous infection is ever communicated by vaccine lymph. As far

as the local development of tubeiculosis is concerned, of which we

may consider lupus a form, Dr. Colcott Fox relates only two or three
cases on record, and Dr. Morrow a peculiar suspicious lesion, which he

terms “raspberry sore,” regarding it as tubercular in origin. These

being extraordinary cases, no conclusion of value can be drawn. It
seems to be an established fact that the germ of tuberculosis does not

exist in the medium of lymph, as was shown by the experiments of

Meyer Acker,
and who vaccinated one hundred and five undoubtedly
phthisical patients antiseptic precautions, and
under in no single in-

lymph.
stance could tubercle bacilli be found in the
It has been believed for a long time that leprosy may have been

communicated by the act of vaccination, but, however suspicious some

of these recorded cases may be, very little definite about it is known.
Probably the clearest evidence point are two cases reported by
on this
Dr. Daubler in the ALonatsheftfur pract. Dermatologic, 1890, which
seem to confirm in a very
strong manner the possibility of the con-
veyance of leprosy in the process of vaccination when lymph is taken
from a leper. Remembering Arning’s important observations of lep-

rosy bacilli in vaccine lymph taken from a leper, it is not to be denied

that such inoculation may be occasionally possible, but it may be said
that we have at present no clear and indisputable facts proving that

leprosy has been spread by means of vaccination.

Next to erysipelas, the communication of syphilis through vaccina-
tion seems to be a forcible argument of opponents of vaccination.
That syphilis has been caused by vaccination is a fact so indisputably
established that it may be considered beyond controversy, but that
as

all vaccinations in which the vaccinifer syphilitic are followed by

is
this disease appears to be by no means the case. The experience of
almost all writers on this subject has been that the eighth-day vac-
cine virus taken from an undoubtedly syphilitic child will not convey

syphilis. It has been ascertained, however, that vaccination some-

times hastens the development of latent syphilis, as it may produce
cutaneous manifestations in those prone to them. Setting aside
this fact, we know that under adverse circumstances syphilis can be

conveyed from one person to another by vaccination. The theories

that have been set forth to explain the method of action have been

manifold. It seems to be a settled question with all observers that the

medium of blood from a syphilitic person is the most important factor

in communicating syphilis, whether the same has been derived from
 Complications of Vaccination. 7

the floor of the vesicle, wounded by unskillful opening of the vesicle, or

after it has been effused into the vesicle partly made up of concreted
blood. Some striking examples of this latter method have been re-

corded, where a number of children had been vaccinated from the pure
lymph of a single vesicle, and only toward the end of the vaccination,
when the pure
lymph had been exhausted, the children so vaccinated
with the residue, probably containing elements of blood and pus, be-

came inoculated with the syphilitic virus.

Again, the poison may be conveyed from the vaccinee to the vac-
cinifer, or from one vaccinee to the other, and it seems to be clearly

established that in most of the well-authenticated cases on record the

conveyance of syphilis was effected in this manner. Another possible

way of infection is by admixture of the secretion of a syphilitic lesion.
Koebner, however, does not share the view that the admixture of
blood is necessary to produce syphilis by vaccination, and seems to ably
maintain this view by a number of experiments. He prefers to con-
sider that the conveyance of syphilis takes place by reason of an ad-

mixture, not of blood, but of the specific secretion from a syphilitic

lesion existing beneath the vaccine vesicle, which is more liable to
occur after the eighth day.

If syphilis has thus been communicated, the chancre appears at

the seat of vaccination after the usual appearance of
incubation, to be
followed by the
customary secondary symptoms. If the person, how-
7

ever, was already latently syphilitic, these symptoms follow each other
in rapid succession, often as soon as the first week, with the charac-
teristic macular, papular, or bullous eruption, condylomata, and lesions
of the mucous membranes.
The course of the vaccine pustule, however, perfectly norma].
runs

Vaccinalsyphilis shows itself after the third week, rarely before

the twentieth day. If there happen to be several vaccine
pustules, but
one is usually affected. The ulcer itself is not very deep, but is marked
by infiltration and induration. The glands show the characteristic,
typical, syphilitic adenopathy, and the diagnosis is confirmed by the
appearance of constitutional manifestations after the usual period of
incubation.

Syphilis, however, can never follow vaccination with animal lymph.

Numerous experiments by Ricoid, Koebner, Neumann, and others
have proved that syphilis is never
conveyed into the genus bovinum.
If syphilis does follow the use of bovine virus, it is through criminal
carelessness on the part of the vaccinator, the poison being introduced
from without by means of an unclean lancet, a tainted vaccine
point,
or
any other infectious element.
8 Original Communications.

There can be no doubt that the local inflammatory action and feb-
rile disturbance up byset vaccination is frequently the occasion of an
attack of eczema, in those so disposed, which may commence at the

site of the vaccine vesicle or at some distance from it. It would, how-

ever, be erroneous to conclude from this fact that the eczema is pro-
duced by vaccination, as we can often see an eczema after infectious

fevers, as measles, scarlet fever, and other specific fevers. However, it

can not be denied that the act of vaccination determines the outbreak
of an eczema, in those persons who possess a disposition to such a dis-

ease, which would probably have occurred at any rate, though not per-
haps at that particular time. It may also aggravate already existing
eczema to such an delay vaccination for
extent that it is advisable to
an indefinite time. It is likewise mentioning that in
a fact worth
some chronic and inveterate cases it has precisely the opposite effect—-

namely, curative. The following case, related by Dr. Lawson Tait

{Brit. ALecl. Journal, January, 1882), illustrates this peculiar effect of
vaccination : “ The case refers to a child of a commercial gentleman of
great intelligence, who allowed me to try vaccination after everything
else had been done that could be suggested. It was a most obstinate
case of eczema over the whole body, the scalp being the seat of its

worst display. The glands of the neck were chronically enlarged and
at one time suppurated so seriously as to endanger the child’s life.
Temporary benefit was derived from changes of air, but drugs had no
effect. Acting on the usual rule, I put off the vaccination of the child

for three several periods of nine months. I told

the father that I be-
lieved vaccination might cure the child by exercising some influence
on its nutrition. He agreed to the experiment; and to diminish risk
as far as possible, I used the lymph which had passed through one

healthy child from the heifer. The result was most remarkable, for in
a few days a marked improvement was visible in the child; and in a

little more than three weeks all traces of the eruption had disappeared,

save a roughness of the skin which still exists. The hair rapidly grew
on the scalp, and the child now is in all respects as fine an infant as I

have ever seen.”

A similar reported by the same author of a two-year-old
case is
child with chronic eruption all over the body, which was
eczematous

vaccinated and thereby completely cured within a month. Of course,

it is only in exceptional cases that such happy results can be expected.

The cutaneous eruptions of vaccination most commonly met with
are papular, papulo-vesicular, pustular, and very rarely bullous. It
appeal’s from the third to the eighteenth day, mostly on the eighth, be-

gins on the arms in half of the cases, and on the trunk, neck, or face in
 Complications of Vaccination. 9

the rest. The rash lasts from a few days to a week or

two, but in some

of the vesico-pustulous cases fresh crops appear perhaps for months.

Behrend records typical cases of erythema exudativum multiforme in

the first week of vaccination, Napier’s case the erythema was in

and in

rings. Urticaria has also been

frequently noticed. Cases of psoriasis
following vaccination have been recorded by Hyde and Rohe.
I am indebted to several of the members of our society for record-

ing for me some of the cutaneous lesions as witnessed by them during

the period of vaccination.
Dr. Burgess reports two cases of vaccination rashes; one occurring
in a child of five months, the other in a girl of ten years of age. The

eruption was a general one. Unfortunately, the doctor did not see the
cases in that condition, and is therefore unable to describe the rashes.

Dr. Lemon has seen a vaccination rash

occurring in a four-year-old
boy, and describes it as follows: “The eruption appeared on the thir-
teenth day. The arm was slightly swollen, with a smooth pink hue to
the skin of the outer external surface between the elbow and shoulder.

There were also discrete papules on the extensor surface of the arms

and legs and two circles of the same on the face, one on each cheek.
The scab was oflarge size, but clean, and the skin about it was intact.”
I judge from this description of Dr. Lemon’s case that the rash be-

longs to the group of eruptions caused by the systemic absorption of

the vaccine virus. Dr. Kaumheimer has favored me with the report
of the following case: child, aged
“The about six years, had been
vac-

cinated at school. On the eighth day, when I saw him, he was

cov-

ered with numerous blotches somewhat larger than a split pea, irregu-
lar in shape, and resembling in color the petechiae of purpura. He
was somewhat febrile, but complained of no pain in the
spots, which
were from one to two inches
apart all over the body except the face.
His mother informed me later that the blotches had disappeared a few

days later.” Dr. Kaumheimer has also seen a number of cases of in-
tense erythema or even dermatitis confined to the seat of vaccination.

Undoubtedly the doctor’s description of the first case is one of true

vaccine erythema or roseola vaccinicum, and is perhaps remarkable for

the large extent of surface involved.

Dr. Wingate informs me that he can recall perhaps half a dozen

cases of roseola vaccinicum, and has seen one or two cases of a general

eruption of a vesicular or pustular character.

Dr. McDill writes that he has seen but one marked case of general
erythema following vaccination with intense itching, which appeared
with the pustulation and subsided only with the drying up of the
pus.
The following cases of interest in connection with the subject of vac-
10 Original Communications.

cination eruptions have been reported to me by Dr. Tower. The doctor

estimates the number of vaccination cases seen by him during the past
few years to be about five thousand, and cites the following cases as

having important bearing

an topic:
on this The first a case is that of

twelve-year-old German girl, healthy and of a very light complexion,

who was seen by Dr. Tower on the ninth or tenth day after vaccina-

tion, with a temperature of 103°, a very accelerated pulse, and an erup-

tion of about forty vesicles distributed over the back, chest, and
thighs
of the size of a small pea. There were two or three similar vesicles of
the same size on the vaccinated arm. Besides this particular case, Dr.

Tower has seen a number of of vaccinia herpetica.

cases The other
case mentioned illustrates in striking manner the way in which
a

mixed inoculation may take place. It is a case of erysipelatous infec-

tion occurring in three children of one family after the eighth day of
vaccination in the following manner: The mother of the vaccinated

children had had several attacks of erysipelatous inflammation of the

nose and adjoining parts. At the time of vaccination she was again
suffering from a similar attack, and applied carbolated vaseline to the
parts affected by erysipelas. On the eighth day the arms of the chil-
dren vaccinated became very much inflamed, and the mother applied
the same ointment she had been using to the inflamed vaccine pustules,

producing in each child a typical infection of erysipelas.

Dr. Friend has furnished me with the particulars of the following
peculiar condition after vaccination : A female child nine years of age
was vaccinated February 27th, and was again seen by the doctor on

March 9th, when she had all the symptoms of vaccination. About one
inch and a half above the vaccine pustule there was almost a complete

circular eruption, consisting of slightly raised papules, which gradually

moved toward the pustule, surrounding it almost entirely, disappearing
on the fourth day after apparently gradually fading away.

I had intended to speak of the treatment of these various forms of

vaccination lesion, but found that my paper had already become too
elaborate. What I desired to prove was that those rashes could not

offer any reasonable objection to vaccination,, as the majority and most

harmful ones can easily be avoided by care and antiseptics. I am

strongly in favor of vaccination.