to a purplish hue. About the time the vaccinia began to decline, the leprous eruption showed signs of beginning abatement. The first sign noted was a fine wrinkling of the tense shining skin over the infiltrated areas, indicative of a slight lessening of the local swelling. The color disappeared quite rapidly when the decline of the eruption started, and more slowly in the later stages. Desquamation of the epidermis followed in some cases, especially on the face when the eruption had appeared there.

With the appearance of the leprous activity there are constitutional symptoms in most cases, such as chilliness, fever, and general malaise. The fever may reach as high as 40° C., though usually it remains at 38° to 39° C. Some of the constitutional symptoms may be due to vaccinia.

The most severe cruption occurred one week after vaccination (Aug. 30); whereas the least severe eruptions were delayed until the latter part of the second week. The lightest eruptions appeared on September 4, and September 7 (thirteenth and sixteenth days, respectively).

One case (No. 2084) has had frequent outbreaks of this kind; and had this been the only case showing an eruption, no significance would be attached to it. Cases 1963 and 2003 had shown very slight eruptions from time to time, but the eruption following vaccinia was so much more severe than that usually seen, that it points very strongly to vaccinia as the agent exciting the eruption. Cases 2117 and 2168 had shown no eruption for a long period. Case 2194, a relatively recent admission, and a severe nodular case, showed one of the lightest, and the longest delayed, eruptions observed in the whole group.

Cases 2116, 2129, 2080, and 2095, though having shown but little recent activity, were cases that would be expected to show eruptions, if vaccinia would excite such an outbreak. Nevertheless these cases have shown no evidence of any increased activity. Of these four cases, B. lepræ is demonstrable in all except No. 2080.

It appears that the anesthetic cases are affected very little, if at all, by vaccinia, whereas, in these vaccinations, the mixed cases have shown the highest percentage of increased activity.

Of the 18 controls (unvaccinated, without vaccination scars), one, as stated above, was suffering from a leprous outbreak at the time that the examinations for the presence of scars were made, and, therefore, should not be considered. In the remaining 17, no outbreak has occurred, though as a group they are comparable to the vaccinated group.

Of 149 lepers having vaccination scars or evidence of having had smallpox, who were confined in the hospital at the time of the vacci

nations, two have shown temporary increased activity, evidenced by eruptions, during the same period.

After observing this small series of cases, one can not escape the conviction that vaccinia had something to do with the appearance of the leprous manifestations in the successfully vaccinated cases. This phenomenon may also explain some of the opinions held by the older Hawaiian laity, that in many cases vaccination was the cause, or at least the exciting cause, of leprosy. During the days of armto-arm vaccination the possibility of the spread of leprosy by this procedure must be admitted. It is more probable, however, that the vaccination served to bring to light latent or unrecognized leprosy. It certainly can not be said to have caused the disease in the subjects of the test reported herein, the diagnosis having been established before the vaccination was done. The virus was produced by a regularly licensed firm in an eastern State and was obtained from the San Francisco branch office of the firm. Special care was taken to see that the virus was kept on ice during the voyage to Honolulu.

These patients will be observed further to determine whether there is any remote deleterious or beneficial effect shown in those vaccinated.

At the date of writing, September 23, one month after vaccination, all cases that showed eruption have returned to normal, except for some desquamation at the former site of the eruption. Eight of the vaccination ulcers are not completely healed. Six of these showed eruptions, and two did not. As in all vaccination ulcers, the healing has been slower in those cases showing some loss of tissue at the site of vaccination. The leprous eruption does not seem to have had any direct effect on the course of vaccinia.

I desire to acknowledge the courtesy of Sury. N. E. Wayson, who procured the vaccine for me, and of Dr. Charles Fowler, surgeon of the steamship Wilhelmina, of the Matson Navigation Co., who kept the virus under proper conditions on the voyage to Honolulu.

Case Records.

No. 1885, G. K., Hawaiian, age 27, male, single, farmer. Admitted 12/29/19; type, nodular; B. lepræ present; duration, 10 years prior to admission. First symptom, white areas on body; last bacteriological examination, 5/20/22, B. lepra present. This is an advanced case of leprosy with much destruction of tissue in the nose and one eye.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Large vesicle at site of vaccination.

Aug. 31: The vaccination has developed a rather extensive "take" and there is a large zone of redness and infiltration about the site of inoculation. A leprous eruption is evident on the arms and legs, the spots being large, red, indurated, and tender.

Sept. 1: The eruption has extended to the face and ears. Both ears much enlarged. Confined to bed. Has chill and fever.

Sept. 5: The ears are smaller but several very large, red, indurated spots are present on the back.

Sept. 7: The eruption is declining and the vaccination site begins to show evidence of healing, though it will take longer than usual to heal the ulcer at the site of vaccination.

Sept. 9: Arm is healing. Eruption declining slowly.

Sept. 10: The eruption has improved rapidly in past two days. Snip from back and left wrist negative for B. lepra.

Sept. 13: Snips from right forearm and right ear lobe show a few lepra dacilli present.

No. 1963, A. K. A., Part-IIawaiian, male, age 15, single, no occupation. Admitted 8/2/20; type, mixed; B. lepra present; duration, 6 years before admission. First symptoms, crooking of fingers; last bacteriological examination, 7/8/22, B. leprä present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Slight vesiculation at site of vaccination.
Aug. 28: Typical vesicle present.

Aug. 31: A leprous eruption is appearing on the face, arms, and legs. Complains of chilliness, fever, and general malaise. Very tender in left axilla.

Sept. 3: The eruption is worse on the face, giving it a bloated appearance.
Sept. 5: Eruption continues as last noted.

Sept. 7: The outbreak of leprous manifestations is beginning to improve. The tenderness in the axilla is gone and the arm is beginning to heal. A bullous eruption has appeared on the right leg.

Sept. 9: Arm healing, redness gone from face, but cheeks are still swollen and puffed and show some desquamation. Vesicles on leg have ruptured, leaving a rather extensive ulcerated surface.

Sept. 11: Swelling of face has subsided, and only traces of the eruption remain. Ulcer on leg does not improve as rapidly as is desired.

Sept. 13; Leg remains about the same.

No. 1965, L. K., Hawaiian, female, age 18, single, no occupation. Examined on 1/27/15 and declared not a leper. First symptom, 1 year previously, white spots on cheek. Admitted 8/3/20; type, mixed; B. lepra present. Last bacteriological examination, 1/23/22, B. lepra present.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 28: Typical “ take,” in vesicular stage.
Aug. 31: Complains of slight chilliness and soreness in left axilla.

Sept. 4: Has shown no eruption until to-day, when a slight eruption was noticed on the forearms.

Sept. 5: Eruption slightly more prominent than yesterday.
Sept. 7: Eruption fading and arm healing.

Sept. 11: Only faint trace of the eruption left. Arm nearly healed. Snip from right forearm at site of eruption negative for B. lepræ. Sept. 13. Bacteriological examination repeated, with negative results.

No. 1992, Y. F., age 15, female, Japanese, single, school girl. Admitted 10/26/20; type, nodular; B. lepræ present; duration, 4 months. First symptom, nodules on face and obstruction of nose; last bacteriological examination, 6, 19/22, showed presence of B. lepre.

Aug. 10: Shows no vaccination scar.
Aug. 23: Vaccinated on left arm.

Aug. 25: Vaccinated area slightly puffy and red and appears as if the vaccination would be successful.

Aug. 26: Site of vaccination slightly red and seems to be approaching vesicular stage.

Aug. 28: The vaccination site has lost its color; the indications are that it will not "take.'

Sept. 5: Frequent inspection of the arm has been made but there is no evidence of a “take.

Sept. 6: Patient has shown no increased activity of her leprous lesions since vaccinated. Her leprosy is practically stationary. She is a severe case of nodular leprosy and her general appearance is suggestive of phthisis, though she show's no evidence of active tuberculosis.

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No. 2003, M. R. L., age 23, female, Portuguese, married, housewife; in Hawaii 15 years. Admitted 11/29/20; type, mixed; B. lepræ present; duration, 3 years prior to admission. First symptoms, swelling of fingers and hands; last bacteriological examination, 7/7/22, B. lepræ not found.

Aug. 10: Shows no vaccination scar.

Aug. 23: Vaccinated on left arm. (This case was added to the vaccinated list at her own request.)

Aug. 26: Slight vesiculation at site of vaccination. Aug. 28: Complains of chilliness and tenderness in left axilla. Well-marked vesiculation, with zone of redness about site of vaccination. Confined to bed.

Aug. 30: There is a profuse eruption, apparently leprous, on both forearms and both legs. The spots are bright red, indurated, and rather tender. The fingers and backs of the hands are swollen and show several large red lumps.

Aug. 31: The red spots are larger and show a tendency to coalesce. Complains of chills, followed by profuse sweating, especially about head and neck, appetite is gone. The erupted areas do not sweat.

Sept. 1: Eruption is profuse on forearms and legs. The forearms are uniformly red; the fingers and hands much swollen. There are some red spots on both cheeks, and the eyes have a puffy appearance. Albumen present in urine. Placed on a restricted diet (milk).

Sept. 2: Condition practically the same as yesterday. Sept. 3: Condition unchanged, except color of eruption is slightly darker. Sept. 4: The skin eruption is beginning to recede. Sept. 5: Eruption fading rapidly; albumen much less. Sept. 7: Improving quite rapidly; the face is beginning to desquamate at site of the red spots. The swelling of the hands is subsiding.

Sept. 9: Improvement continues.

Sept. 11: The color of the eruption has disappeared, though the hands and fingers are still somewhat swollen.

Sept. 13: Bacteriological examination of the site of recent eruption shows a few doubtful granular acid fast organisms.

No. 2026, M. K. K., part Hawaiian, female, age 14, single, no occupation. Admitted 3/16/21; type, nodular; B. lepra present; duration, 2 years before admission. First symptom, not stated; she is a very marked nodular case of the textbook type. Last bacteriological examination, 8/17/22, B. lepræ present.

Aug. 10: No vaccination scar present.
Aug. 23: Vaccinated on left arm.
Aug. 26: Wassermann strong positive.
Aug. 26: Site of vaccination slightly red.
Aug. 28: Success of vaccination is doubtful.
Aug. 30: Vaccination unsuccessful.

Sept. 7: No leprous outbreak seen thus far, though an old ulcer of the foot broke open again yesterday.

No. 2033, M. K., Hawaiian, female, age 16, single, no occupation. Admitted 4/2/21; type, nodular; B. lepre present; duration, 8 months before admission. First symptoms, red spots on thighs; last bacteriological examination, 6/6/22, B. lepræ not found.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Slight vesiculation at site of vaccination.
Aug. 28: Typical vesicle present.

Aug. 31: Arm is rather sore and there is much tenderness in the axilla. Confined to bed on account of the tenderness.

Sept. 3: Tenderness in axilla is less and she is able to be out of bed and around the compound.

Sept. 5: The arm is healing normally. No eruption has appeared since vaccination.

Sept. 11: Vaccination nearly healed.

No. 2038, R. K., Hawaiian, female, age 13, single, no occupation. Admitted 4/9/21; type, nodular; B. lepræ present; duration, 2 years before admission. First


symptom, swelling of cheeks; last bacteriological examination 6/19/22, B. lepræ

Aug. 10: No vaccination scar.
Aug. 23: Vaccinatel on left arm.
Aug. 26: Slight vesiculation of vaccinated site.
Aug. 28: Typical “take, a large vesicle with area of rexiness about the same.

Aug. 30: A profuse, red, elevated, leprous eruption is present on both arnis and both legs.

Aug. 31: Eruption more profuse; a few spots present on face.
Sept. 1: Face covered with large, red, indurated spots which are beginning to show
slight wrinkles, indicating beginning subsidence of swelling:

Sept. 7: Feels much better, and the color of the eruption is beginning to clisappear.
Sept. 9: Improvement continuing. Able to be up and about her room.

Sept. 11: Has improved rapidly, but still shows definite evidence of eruption lesions. Snip from forehead and cheek, positive for B. lepra.

No. 2045, M. N., male, age 50, Japanese, single, laborer, in Hawaii 20 years. Admitted 4/20/21; type, nodular; B. lepræ present; duration of disease, 5 years prior to admission. First symptom, swelling of face and ears; last bacteriological examination, 6/23/22, shows B. lepra present.

Aug. 10: Shows no vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 25: Vaccination site appears red and pufiy.
Aug. 26: Site of vaccination same as yesterday.
Aug. 28: Redness of site of vaccination less.
Aug. 30: Evidently the vaccination will not “take."

Aug. 31: The scratches inoculated with virus show no evidence of a “take" though within a circle 2 inches in diameter whose center is the site of vaccination, are three red lumps about the size of a pea.

Sept. 1: The red lumps are disappearing. Vaccination not successiul.

No. 2019, S. C. K., Korean, male, age 47, single, laborer, in Hawaii 18 years. Jul-
mitted 4/25, 21; type, mixed; B. lepra present; duration, 1 year before admission.
First symptom, anesthesia in right leg; last bacteriological examination, 6'23 22,
B. lepra present.

Aug. 10: No vaccination scar present.
Aug. 23: Vaccinated on left arm.
Aug. 25: Vaccinated site slightly red.
lug. 28: Success of vaccination is doubtiul.
Sept. 5: Vaccination unsuccessful.
Sept. 7: No exacerbation of leprous manifestations has occurred.

No. 2074, A. K., Hawaiian, female, age 14, single, no occupation. Somittel 76/21; type, mixed; B. lepra, present. Patient's father, grandfather, brother, uncle, and aunt are lepers. Duration, unknown. First symptoms swelling of hands and fingers; last bacteriological examination, 6/19/22; B. lepræ not found.

Aug. 10: No vaccination scar.
Aug. 23: Vaccinated on left arm.
Aug. 26: Slight redness and puffiness at site of vaccination.
Aug. 28: Good vesicle; typical "take."
Aug. 30: Complains of chills and fever.
Aug. 31: A typical red, indurated, leprous eruption present on both arms and legs.

Sept. 1: Eruption appearing on the face as small, red, indurated spots, tender to the touch. Confined to bed with fever and general malaise.

Sept. 2: Eruption on face more pronounced. The forehead shows several large indurated swellings which are very tender.

Sept. 3: Eruption appears the same, though patient is feeling better and able to be out of bed.

Sept. 5: The rash is beginning to fade.
Sept. 7: Improvement continues.
Sept. 9: Face nearly clear of eruption; arm healing normally.

Sept. 11: No eruption noticeable, though traces can be found if searched for. Snip from forearm and forehead positive for lepra bacilli.



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