Armstrong – Table of Contents

vaccinations were definitely primary or initial vaccinations. The inoculation method used
was the outmoded scarification method which was locally traumatic. This consisted of
multiple cross-hatching scratches of a wide area (about ½ to 1 square centimeter) of skin
of the left upper deltoid or mid-thigh region. Following vaccination this often left a
visible scar euphemistically labeled “a sanitary dimple”. In the cases described,
Armstrong reported local, severe, foul smelling tissue damage that undoubtedly provided
the necessary anaerobic conditions for the emergence of toxin producing vegetative
bacilli from the contaminating tetanus spores. In this initial paper, Armstrong concluded
and strongly advised that bunion pads should not be used as vaccination dressings.
In a later paper in 1929 (6, 2) Armstrong stressed the expanding role of the
vaccination dressing as conducive to the production of post-vaccinal tetanus. Among 116
collected and investigated cases following vaccination, Armstrong found that all had
developed following primary “takes” that had been covered for all or part of their active
course by some type of dressing strapped to the vaccination site. The types of dressings
used on these 116 cases were as follows: celluloid shields, 53; gauze, 40; bunion pads,
17; gauze and shields, 5; adhesive bandage; 1. The source of the tetanus organisms was
unknown except in a small proportion of cases. In 1917 McCoy and Bengston (13) traced
an outbreak of postvaccinal tetanus to the use of ivory bone point scarifiers. By the time
of the 1929 manuscript, Armstrong had collected additional cases related to the use of
infected bunion pads (1) for a total of 17 cases. Prolonged search by members of the
Hygienic Laboratory among commercial vaccine virus disclosed no contamination with
tetanus organisms. The source of the tetanus organisms in areas of vaccination was thus
still unknown. The entrance of tetanus into the vaccination area would have to be