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the symptons exhibited had in all respects corresponded with
those which are known to characterise Syphilis, the proper
inference might have been that there was some error in ascertaining
the facts of the case. But it is beyond question that the
course of events was very different in some respects from that
experienced in undoubted cases of syphilis, and we think the true
conclusion is that it was not a case of that disease. It may
probably be classed with a few others as examples of gangrene
and blood poisoning, the direct result of vaccination, which are
not to be explained by supposing the introduction of any
Syphilitic or other poison. Fortunately, such cases are extremely
rare, so much so that the witnesses concerned knew of no case
precisely parallel.
The evidence given by Dr. Robert Lee and Dr. Coutts, the
former, physician of the Ormond Street Hospital for Children,
and the latter, formerly a resident medical officer to the same
institution, may be taken as relating to one and the same case.
Both these witnesses testify to the abundant occurrence of the
ordinary forms of congenital Syphilis in the practice of that
institution. Each of them mentions one single case in which it
was believed that Syphilis was communicated in vaccination and
that the vaccination sore became a chancre. Although it is not
established in evidence that these witnesses were speaking of the
same case, it is almost certain that they were, as Dr. Coutts
expressly states that the child was Dr. Lee's patient. Neither of
the witnesses knew more of the case than its earliest stages, and
both were subjected to questions the answers to which left much
doubt as to the correctness of the diagnosis. Whilst, however,
Syphilis cannot by any means be said to have been proved, the
case must stand as one of reasonable suspicion, and Dr. Coutts'
statement that another infant (not seen) vaccinated from the same
source was said to have suffered in a similar way gives some
support to Dr. Lee's opinion. It is of much importance to note
that out of an experience of 30,000 children, at an institution
beyond all others likely to attract cases of this kind, this was the