INSTRUCTIONS FOR VACCINATORS UNDER CONTRACT.

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 nine 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, according to the method of Dr. Husband of Edinburgh, 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 an existing skin-disease, and especially as to any signs of hereditary syphilis. Take lymph only from well-characterized, 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 to areolæ. Open the vesicles with scrupulous care to avoid drawing blood. Take no lymph which, as if issues from the vesicle, is not perfectly clear and transparent, 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 capillary 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 cases wherein the vaccine vesicle is unduly hastened