14                                  ANNUAL VACCINATION REPORT

                                                  APPENDIX A.

                              INSTRUCTIONS FOR VACCINATORS .

                (Prescribed by the Order of the Privy Council, 29th July 1871.)

1.    Except so far as any immediate danger of small-pox may require, vaccinate only subjects who
are in good health. As regards infants, ascertain that there is not any febrile state, nor any irritation
of the bowels, nor any unhealthy state of skin; especially no chafing or eczema behind the ears, or in
the groin, or elsewhere in folds of skin. Do not, except of necessity, vaccinate in cases where there
has been recent exposure to the infection of measles or scarlatina, nor where erysipelas is prevailing in
or about the place of residence.

2.     In all ordinary cases of primary vaccination, if you vaccinate by separate punctures, make
such punctures as will produce at least four separate good-sized vesicles, not less than half an inch
from one another; or, if you vaccinate otherwise than by separate punctures, take care to produce local
effects equal to those just mentioned.

3.     Direct care to be taken for keeping the vesicles uninjured during their progress, and for
avoiding afterwards the premature removal of the crusts.

4.     Enter all cases in your Register on the day when you vaccinate them, and with all particulars
required in the Register up to column 9, inclusive. Enter the results on the day of inspection. Never
enter any results which have not been inspected by yourself or your legally qualified deputy. In
cases of primary vaccination, register as "successful" only those cases in which the normal vaccine
vesicle has been produced; in cases of re-vaccination, register as "successful" only those cases in which
either vesicles, normal or modified, or papules surrounded by areolæ, have resulted. When the
vaccination of an unsuccessful case is repeated, it should be entered as a fresh case in the register.

5.     Endeavour to maintain in your district such a succession of cases as will enable you
uniformly to vaccinate with liquid lymph directly from arm to arm; and do not, under ordinary
circumstances, adopt any other method of vaccinating. To provide against emergencies, always have
in reserve some stored lymph; either dry, as on thickly-charged ivory points constantly well protected
from damp, or liquid, in fine, short, uniformly capillary (not bulbed) tubes, hermetically sealed at
both extremities. Lymph, successfully preserved by either of these methods, may be used without
definite restriction as to time; but with all stored lymph caution is necessary, lest in time it have
become inert, or otherwise unfit for use. If, in order to vaccinate with recent liquid lymph, you
convey it from case to case otherwise than in hermetically-sealed capillary tubes, do not ever let more
than eight hours intervene before it is used.

6.     Consider yourself strictly responsible for the quality of whatever lymph you use or furnish
for vaccination. Never either use or furnish lymph which has in it any, even the slightest, admixture
of blood. In storing lymph, be careful to keep separate the charges obtained from different subjects,
and to affix to each set of charges the name, or the number in your register, of the subject from whom
the lymph was derived. Keep such note of all supplies of lymph which you use or furnish as will
always enable you, in any case of complaint, to identify the origin of the lymph.

7.     Never take lymph from cases of re-vaccination. Take lymph only from subjects who are in
good health, and, as far as you can ascertain, of healthy parentage; preferring children whose families
are known to you, and who have elder brothers or sisters of undoubted healthiness. Always carefully
examine the subject as to any existing skin disease, and especially as to any signs of hereditary syphilis.
Take lymph only from well-characterised uninjured vesicles. Take it (as may be done in all regular
cases on the day week after vaccination) at the stage when the vesicles are fully-formed and plump, but
when there is no perceptible commencement of areola. Open the vesicles with scrupulous care to avoid
drawing blood. Take no lymph which, as it issues from the vesicle, is not perfectly clear and trans-
parent, or is at all thin and watery. From such a vesicle as vaccination by puncture commonly
produces, do not, under ordinary circumstances, take more lymph than will suffice for the immediate
vaccination of five subjects, or for the charging of seven ivory points, or for the filling of three capilla-
ry tubes ; and from larger or smaller vesicles take only in like proportion to their size. Never squeeze
or drain any vesicle. Be careful never to transfer blood from the subject you vaccinate to the subject
from whom you take lymph.

8.     Scrupulously observe in your inspections every sign which tests the efficiency and purity of
your lymph. Note any case wherein the vaccine vesicle is unduly hastened or otherwise irregular in
its development, or wherein any undue local irritation arises; and, if similar results ensue in other
cases, vaccinated with the same lymph, desist at once from employing it. Consider that your lymph
ought to be changed, if your, cases, at the usual time of inspection on the day week after vaccination,
have not, as a rule, their vesicles entirely free from areolæ.

9.     Keep in good condition the lancets or other instruments which you use for vaccinating, and
do not use them for other surgical operations. When you vaccinate, have water and a napkin at your
side, with which invariably to cleanse your instrument after one operation before proceeding to
another.