VACCINATION RASHES 



1495 



no sign of septic infection in the disease, of which the following is a typical 

 case : — 



During the first three days after vaccination there was nothing to report, 

 but on the third day the area became red and swollen, and on the fourth there 

 was a number of small vesicles. 



On the fifth, although there was only slight fever, the patient felt ill, while 

 some of the vesicles ruptured and discharged their contents. 



On the sixth day the vaccination area was covered by a yellow crust, and 

 surrounded by a ring of vesicles and by a congested dark red area measuring 

 about I inch in diameter. The temperature on this day did not exceed 102° F. 



On the seventh day the crusted area became quite black, and extended untilit 

 measured some 2 inches in diameter. It was surrounded by a ring of umbilicated 

 vesicles and by a dark red border measuring i inch in width, outside of which 

 was a light red area of about the same depth. The whole region felt somewhat 

 brawny to the touch, and the temperature rose to between 104° and 105° F. 



On the eighth day the condition of the leg may be described as follows : — 



In the centre there lay a black slough some 2 inches in diameter, surrounded by 

 a ring of collapsed vesicles and by a raised dark red border, which, in its turn, 

 was surrounded by a purplish area of skin some 3 inches in width, while, finally, 

 the whole area was defined by a red zone of about an inch in diameter. On 

 this day the temperature did not exceed 103° F., and the patient felt better, 

 though the leg looked worse. 



On the ninth day there was a decided improvement, the ring of vesicles had 

 dried and formed a circular scab, the brawny resistance was softer and was 

 beginning to disappear at the edges. The purple hue was lighter and showed 

 signs of becoming reddish in places. The surrounding red area had, however, 

 extended down to the ankle and up to the knee. The temperature did not 

 exceed 102° F. 



From this date onwards the signs and symptoms began to steadily improve. 

 The temperature fell slowly, remaining about 101° F. for two days, about 

 100** F. for another day, and then reached 99° F. The purple area became 

 reddish and the reddish area white. 



At this stage an attack of acute gout set in, beginning on the thirteenth day, 

 when the temperature, which had never reached normal, rose to 100° F. The 

 gouty symptoms were marked in the left hip, left arm, left side of the jaw, 

 left wrist, the back, and the right ribs. These symptoms lasted some seven 

 days, but gradually gave way to the usual remedies, and the temperature 

 slowly sank to normal. 



During this time the slough, mentioned above, came away, and a clean, 

 healthy-looking, healing surface was left at the bottom of a depressed ulcer 

 with raised, but not undermined, red edges, while the surrounding skin had 

 returned to its normal colour. 



There were no enlarged lymphatic glands, and no signs of sepsis. The urine 

 was febrile, but did not contain albumen or sugar. 



The patient made a good and rapid recovery. 



etiology. — In attempting to define the causation of the above condition 

 it is important to clearly distinguish between localized gangrenous vaccinia 

 and the condition called dermatitis gangrainosa infantum, as the latter is a 

 generalized eruption probably of septic origin, following Varicella and other 

 pustular eruptions in children, and often assumed to have something to do 

 with vaccination. 



Localized gangrenous vaccinia, on the other hand, is quite different. It 

 is not septic, but vaccinal in origin, and it is not generalized, but localized to 

 the vaccination area. 



Acland, Crocker, Balzer, and Hutchinson have met with similar cases, 

 some of which are stated to have ended fatally. 



In such cases as Chalmers and Archibald have been able to find any account 

 of, there has been some latent infection or disease in the patient. Thus, for 

 example, in Crocker's case there was latent scarlet fever, and in Chalmers and 

 Archibald's case there was latent gout. 



It therefore seems probable that localized gangrenous vaccinia can be pro- 



