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CONTROL OF PUERPERAL SEPSIS
241
LETTERS TO THE EDITOR CONTROL OF PUERPERAL SEPSIS
read with interest the article appearing in of Jan. 6 (p. 52), in which you point out issue your the difficulties, or some of them, created by Memo. 226 Med. recently issued by the Ministry of Health. The memo divided the steps for the prevention of spread of hsemolytic streptococci from the nasopharynx into two groups: (1) general measures to be taken in the absence of puerperal pyrexia; and (2) steps to be taken on the occurrence of puerperal pyrexia. I am not going to quarrel with the steps envisaged by the memo on the occurrence of a case of puerperal pyrexia, provided that any steps required to be taken by a midwife should be equally required of a doctor attending the case. I would point out that in nearly half the cases attended by midwives a doctor is also called, but I am aware of no power to compel a doctor to submit to swabbing or to suspend him from practice, neither can he be compelled to take a vaginal swab. With regard to the general measures to be taken in the absence of puerperal pyrexia, the memo requires that every midwife should be instructed to report any symptoms of acute or chronic inflammatory condition of the nasopharynx, and she must be suspended pending the result of bacteriological examination. On the bottom of the page of the memo on which these requirements are stated reference is made to an article in the Journal of Obstetrics and GynaecologYJ and on looking up that article I find the following words:
SIR,-I
recipient-might reasonably suggest action directed to similar ends in the case of possible carriers of infection likely to cause puerperal pyrexia. The memo states: "The problem as it affects the medical officer of health in relation to the conduct of maternity homes and domiciliary practice is how to apply preventive methods without interfering unnecessarily with the smooth working of the services." The answer can be given in one word—MASKS. The efficacy of masks has been proved time and again. The measures suggested by the memo are on a par with the destruction of mosquitoes by heavy artillery. No-one can say it may not have, to some degree, the desired effect, nor can it be denied that it will cause considerable commotion and a disconcerting amount of devastation in the effort. I am, Sir, yours faithfully, W. M. ASH, County Medical Officer and School Medical Officer, Derbyshire.
’
" We may learn that the healthy carrier who transmits infection is really one who has recently had a slight inflammation of the pharynx" (italics mine).
So that midwives are to be suspended on the occurof a slight inflammation of the pharynx-in common parlance a slight " cold." As colds are almost universal in the winter months, the significance of these requirements will be appreciated by an administrator. It also means that any midwife who rence
requires two or three days off duty can get it by notifying that she has a slight cold, for the medicolegal importance of allowing her to continue on duty
in the face of this memo will be obvious. There is another important paragraph at the top of p. 5 which suggests that in future pupil-midwives should be examined to exclude nasopharyngeal infection. That implies that such infected people are dangerous, but surely those already in the profession are equally dangerous if carriers and must be per-
manently suspended of this importance
from
practice. The medicolegal paragraph appears to have been
overlooked. The bacteriological basis of the memo is admittedly far from complete. It does not seem to have occurred either to the bacteriologist or to the Ministry of Health that what matters is not so much the presence of a carrier as the protection of the recipient against infection. The lessons learnt from experience of cerebrospinal fever may well be applied here. The very limited efficacy and utter impracticability of swabbing are clearly demonstrated in the case of cerebrospinal fever; the efficacy and practicability of swabbing are likely to be no greater in the limitation of puerperal pyrexia. The striking and immediate effect of interposing some obstruction to the spread of droplet infection from a carrier to a possible recipient-which in the case of cerebrospinal fever was effected by a simple method of arranging for a few more inches of air between the carrier and
JUNIOR CONSULTANTS IN THE E.M.S.
SiB,—I have received a number of letters, and many (e.g., the notable letter from A Psychiatrist, Lancet, Dec. 23, p. 1341) have appeared in your columns, demonstrating that there is considerable dissatisfaction amongst honorary officers of the voluntary hospitals who have been graded as receiving salaries lower than those accorded to a large majority of the honorary staffs. It seems to be difficult to assign responsibility for this grading which has, in fact, produced a number of glaring injustices. The position of these officers is rendered more galling by others
the determination evinced by the Minister of Health to exclude the whole of this group from the latest and by far the most equitable offer of part-time service (Circular E.M.S. P.19. Dated Nov. 29)-namely, the arrangement which accords the honorary officer who desires to accept part-time service §ths of the wholetime emolument; and a renewed effort on my part to persuade the Minister to reconsider this unwarrantable discrimination is being thwarted by the now familiar tactics of shifting the responsibility to an unnamed committee. In my letter to you of Dec. 16 I pointed out that for advising the Minister on the chief the Emergency Medical Service seemed to rest with the earliest committee, the Central Emergency Committee of the British Medical Association, later named the Central Medical War Committee. Professor Platt in your issue of Dec. 23 objected to this attribution and was inclined to regard the committee of group officers of the London sectors as the villain of the piece-and Professor Platt is a member of both these bodies. It occurs to me that it may be useful to endeavour to get on the track of the various committees which apparently have taken a hand in the moulding of the E.M.S., and I append an (imperfect) list furnished to me from highly authoritative sources:
responsibility
1. The Central Emergency Committee of the British Medical Association, later named the Central Medical War Committee. 2. The committee of " Group Officers " of the sectors. 3. A committee of " eminent physicians and surgeons " named by the Minister (Hansard Oct. 12) as the " onlie begettor " of the scheme E.M.S. I 53 dated Sept. 18, offering 3rd pay for tth work-which attracted only five applicants out of a possible 800. 4. A " consultants committee " of about twelve persons, which took the field quite early but whose activities are obscure.
LETTERS TO THE EDITOR CONTROL OF PUERPERAL SEPSIS
read with interest the article appearing in of Jan. 6 (p. 52), in which you point out issue your the difficulties, or some of them, created by Memo. 226 Med. recently issued by the Ministry of Health. The memo divided the steps for the prevention of spread of hsemolytic streptococci from the nasopharynx into two groups: (1) general measures to be taken in the absence of puerperal pyrexia; and (2) steps to be taken on the occurrence of puerperal pyrexia. I am not going to quarrel with the steps envisaged by the memo on the occurrence of a case of puerperal pyrexia, provided that any steps required to be taken by a midwife should be equally required of a doctor attending the case. I would point out that in nearly half the cases attended by midwives a doctor is also called, but I am aware of no power to compel a doctor to submit to swabbing or to suspend him from practice, neither can he be compelled to take a vaginal swab. With regard to the general measures to be taken in the absence of puerperal pyrexia, the memo requires that every midwife should be instructed to report any symptoms of acute or chronic inflammatory condition of the nasopharynx, and she must be suspended pending the result of bacteriological examination. On the bottom of the page of the memo on which these requirements are stated reference is made to an article in the Journal of Obstetrics and GynaecologYJ and on looking up that article I find the following words:
SIR,-I
recipient-might reasonably suggest action directed to similar ends in the case of possible carriers of infection likely to cause puerperal pyrexia. The memo states: "The problem as it affects the medical officer of health in relation to the conduct of maternity homes and domiciliary practice is how to apply preventive methods without interfering unnecessarily with the smooth working of the services." The answer can be given in one word—MASKS. The efficacy of masks has been proved time and again. The measures suggested by the memo are on a par with the destruction of mosquitoes by heavy artillery. No-one can say it may not have, to some degree, the desired effect, nor can it be denied that it will cause considerable commotion and a disconcerting amount of devastation in the effort. I am, Sir, yours faithfully, W. M. ASH, County Medical Officer and School Medical Officer, Derbyshire.
’
" We may learn that the healthy carrier who transmits infection is really one who has recently had a slight inflammation of the pharynx" (italics mine).
So that midwives are to be suspended on the occurof a slight inflammation of the pharynx-in common parlance a slight " cold." As colds are almost universal in the winter months, the significance of these requirements will be appreciated by an administrator. It also means that any midwife who rence
requires two or three days off duty can get it by notifying that she has a slight cold, for the medicolegal importance of allowing her to continue on duty
in the face of this memo will be obvious. There is another important paragraph at the top of p. 5 which suggests that in future pupil-midwives should be examined to exclude nasopharyngeal infection. That implies that such infected people are dangerous, but surely those already in the profession are equally dangerous if carriers and must be per-
manently suspended of this importance
from
practice. The medicolegal paragraph appears to have been
overlooked. The bacteriological basis of the memo is admittedly far from complete. It does not seem to have occurred either to the bacteriologist or to the Ministry of Health that what matters is not so much the presence of a carrier as the protection of the recipient against infection. The lessons learnt from experience of cerebrospinal fever may well be applied here. The very limited efficacy and utter impracticability of swabbing are clearly demonstrated in the case of cerebrospinal fever; the efficacy and practicability of swabbing are likely to be no greater in the limitation of puerperal pyrexia. The striking and immediate effect of interposing some obstruction to the spread of droplet infection from a carrier to a possible recipient-which in the case of cerebrospinal fever was effected by a simple method of arranging for a few more inches of air between the carrier and
JUNIOR CONSULTANTS IN THE E.M.S.
SiB,—I have received a number of letters, and many (e.g., the notable letter from A Psychiatrist, Lancet, Dec. 23, p. 1341) have appeared in your columns, demonstrating that there is considerable dissatisfaction amongst honorary officers of the voluntary hospitals who have been graded as receiving salaries lower than those accorded to a large majority of the honorary staffs. It seems to be difficult to assign responsibility for this grading which has, in fact, produced a number of glaring injustices. The position of these officers is rendered more galling by others
the determination evinced by the Minister of Health to exclude the whole of this group from the latest and by far the most equitable offer of part-time service (Circular E.M.S. P.19. Dated Nov. 29)-namely, the arrangement which accords the honorary officer who desires to accept part-time service §ths of the wholetime emolument; and a renewed effort on my part to persuade the Minister to reconsider this unwarrantable discrimination is being thwarted by the now familiar tactics of shifting the responsibility to an unnamed committee. In my letter to you of Dec. 16 I pointed out that for advising the Minister on the chief the Emergency Medical Service seemed to rest with the earliest committee, the Central Emergency Committee of the British Medical Association, later named the Central Medical War Committee. Professor Platt in your issue of Dec. 23 objected to this attribution and was inclined to regard the committee of group officers of the London sectors as the villain of the piece-and Professor Platt is a member of both these bodies. It occurs to me that it may be useful to endeavour to get on the track of the various committees which apparently have taken a hand in the moulding of the E.M.S., and I append an (imperfect) list furnished to me from highly authoritative sources:
responsibility
1. The Central Emergency Committee of the British Medical Association, later named the Central Medical War Committee. 2. The committee of " Group Officers " of the sectors. 3. A committee of " eminent physicians and surgeons " named by the Minister (Hansard Oct. 12) as the " onlie begettor " of the scheme E.M.S. I 53 dated Sept. 18, offering 3rd pay for tth work-which attracted only five applicants out of a possible 800. 4. A " consultants committee " of about twelve persons, which took the field quite early but whose activities are obscure.