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THE MIDWIFERY SERVICE IN LONDON
1430
CORRESPONDENCE postnatal-just as two antenatalwill be needed. Existing confusion will To the Editor of THE LANCET be further increased as the different authorities a SIR,-In recent letter in your columns (Nov. 16th, attempt to decide which shall provide care for p. 1145) Dame Janet Campbell called attention to a the infant while the mother remains under hosnumber of important questions which need solution pital supervision. Solomon himself would be before any plan for a salaried service of midwives There is no limit to the prospect of overlap puzzled. can be launched with good prospects of success. and waste which must result, nor with the best will Dame Janet assumed the establishment of the pro- in the world can it be supposed that friction and posed service under local authorities ; but in the competition can be avoided. The sufferers in such metropolitan area of London the existence of two event, as always, will be the very persons it is desired public health authorities involves a difficulty as to help-the mothers and their infants. great as any she enumerated. Here one of the first This apparently simple and eminently sensible decisions must be whether the London county council proposal to improve the conditions of midwives and or the local borough councils shall inaugurate and the quality of their work is long overdue. It might control the proposed service. well mark a nodal point in the histories ofboth Since no small proportion of hospital midwifery midwifery and public health. Its establishment in has passed already within the administration of the London is intertwined with a number of absurd L.C.C., it would seem to be an obvious and logical anomalies which frustrate effective advance in step to extend the scope and powers of this body to public health in many directions. I submit, Sir, include the new domiciliary service ; for a large that an invaluable opportunity here arises to remove number ofexamples have already made clear how and that the Minister of Health, the London them, great are the advantages of a single unit controlling county council, and local borough councils should at midwifery in a hospital and the homes surrounding this juncture combine, and, subordinating departit. Since, however, the child welfare service is, and mental claims, bring into being a single service seems likely to remain, the responsibility of local all those activities which can be directed uniting authorities, such arrangement would separate offi- with profit towards increasing the safety ofmothers cially and in practice would virtually isolate mid- and children. The difficulties are considerable, but wifery and infant care from each other: two branches they could be overcome. Public opinion is aroused of work whose individual success must depend on and would surely give support to such an endeavour. the closeness of their cooperation. I am, Sir, yours faithfully, If, on the other hand, it be decided that a salaried HAROLD WALLER. service of midwives shall be the responsibility of the of St. Katharine, Poplar, Dec. 9th. College Royal local authorities, its value must be largely diminished CYSTICERCOSIS AND EPILEPSY by hospital and domiciliary midwifery being under separate control. To perpetuate two midwifery To the Editor of THE LANCET services operating in the same area, one serving SiR,-In reading reports on possible cases of women to be confined at home, the other those who cysticercosis one cannot but be impressed by the wideare going into hospital, both requiring the organisation of antenatal care and experts to pronounce on spread miscomprehensions which exist regarding this disease. The biological object of cysticerci while cases of doubtful safety, one service in emergencies in the tissues of the intermediate host is to remain to to the assistance other-this come ofthe having is surely no advance towards efficiency, simplicity, or quiescent ; they may be likened to thieves who have entered some premises where they stay hidden so economy. It is exactly the opposite. Further, as the postnatal care ofwomen develops long as concealment is helpful to their purpose. (beyond, that is, the present rather formal concep- In the same way, cysticerci normally give little or no outward sign of their presence (unless crowded tion of a gynsecological examination at one or two fixed dates after delivery), the importance of the out by their own numbers) while they are alive, present widespread incidence ofmaternal ill-health but after their death they cause symptoms by postwill come to be increasingly realised, with all its mortem swelling and by the liberation of toxic repercussions on the health of infants and the family. products of degeneration. Consequently a period of It may thus be predicted with certainty that post- several years commonly elapses between the invasion natal supervision must comprise not merely a " pelvic of the body and the onset of clinical symptoms, of overhaul " but the attempt to control all those which the most frequent is epilepsy. factors which concern a woman’s general health and During the life of the host, diagnosis for practical influence her ability to succour her child. Further, purposes is at present dependent on only two signs, it must continue to safeguard her so that after an neither of which unfortunately is a necessary part in appropriate interval she can repeat the process. the development and degeneration of the parasiteWhat is needed is a service to which she can turn namely, the appearance of palpable cysts in the throughout the period of her reproductive life with tissues, and their calcification post mortem. As confidence that her particular needs are known and regards the first mentioned there may be no cysticerci understood: a service comparable in fact to what outside the brain, and even if present in muscle, &c., she would receive from her general practitioner if as well they may be too deep for detection and excision when post-mortem swelling occurs; or so she could afford it. Hitherto in the working of the Maternity and Child Welfare Act not much apprecia- few in number as to escape notice ; or the host may tion of this has been shown. come under examination only at a time when he Advance will be rendered as difficult as possible is free from palpable cysts although some may have if women confined in hospital are retained indebeen present months or years before, or may appear finitely as its out-patients, while for those confined months or years afterwards, as determined by the at home a separate service has to be organised; longevity of individual parasites. Calcification is for unless all domiciliary cases are to be referred to found only as a form of post-mortem degeneration, THE MIDWIFERY SERVICE IN LONDON
hospital
services
two
CORRESPONDENCE postnatal-just as two antenatalwill be needed. Existing confusion will To the Editor of THE LANCET be further increased as the different authorities a SIR,-In recent letter in your columns (Nov. 16th, attempt to decide which shall provide care for p. 1145) Dame Janet Campbell called attention to a the infant while the mother remains under hosnumber of important questions which need solution pital supervision. Solomon himself would be before any plan for a salaried service of midwives There is no limit to the prospect of overlap puzzled. can be launched with good prospects of success. and waste which must result, nor with the best will Dame Janet assumed the establishment of the pro- in the world can it be supposed that friction and posed service under local authorities ; but in the competition can be avoided. The sufferers in such metropolitan area of London the existence of two event, as always, will be the very persons it is desired public health authorities involves a difficulty as to help-the mothers and their infants. great as any she enumerated. Here one of the first This apparently simple and eminently sensible decisions must be whether the London county council proposal to improve the conditions of midwives and or the local borough councils shall inaugurate and the quality of their work is long overdue. It might control the proposed service. well mark a nodal point in the histories ofboth Since no small proportion of hospital midwifery midwifery and public health. Its establishment in has passed already within the administration of the London is intertwined with a number of absurd L.C.C., it would seem to be an obvious and logical anomalies which frustrate effective advance in step to extend the scope and powers of this body to public health in many directions. I submit, Sir, include the new domiciliary service ; for a large that an invaluable opportunity here arises to remove number ofexamples have already made clear how and that the Minister of Health, the London them, great are the advantages of a single unit controlling county council, and local borough councils should at midwifery in a hospital and the homes surrounding this juncture combine, and, subordinating departit. Since, however, the child welfare service is, and mental claims, bring into being a single service seems likely to remain, the responsibility of local all those activities which can be directed uniting authorities, such arrangement would separate offi- with profit towards increasing the safety ofmothers cially and in practice would virtually isolate mid- and children. The difficulties are considerable, but wifery and infant care from each other: two branches they could be overcome. Public opinion is aroused of work whose individual success must depend on and would surely give support to such an endeavour. the closeness of their cooperation. I am, Sir, yours faithfully, If, on the other hand, it be decided that a salaried HAROLD WALLER. service of midwives shall be the responsibility of the of St. Katharine, Poplar, Dec. 9th. College Royal local authorities, its value must be largely diminished CYSTICERCOSIS AND EPILEPSY by hospital and domiciliary midwifery being under separate control. To perpetuate two midwifery To the Editor of THE LANCET services operating in the same area, one serving SiR,-In reading reports on possible cases of women to be confined at home, the other those who cysticercosis one cannot but be impressed by the wideare going into hospital, both requiring the organisation of antenatal care and experts to pronounce on spread miscomprehensions which exist regarding this disease. The biological object of cysticerci while cases of doubtful safety, one service in emergencies in the tissues of the intermediate host is to remain to to the assistance other-this come ofthe having is surely no advance towards efficiency, simplicity, or quiescent ; they may be likened to thieves who have entered some premises where they stay hidden so economy. It is exactly the opposite. Further, as the postnatal care ofwomen develops long as concealment is helpful to their purpose. (beyond, that is, the present rather formal concep- In the same way, cysticerci normally give little or no outward sign of their presence (unless crowded tion of a gynsecological examination at one or two fixed dates after delivery), the importance of the out by their own numbers) while they are alive, present widespread incidence ofmaternal ill-health but after their death they cause symptoms by postwill come to be increasingly realised, with all its mortem swelling and by the liberation of toxic repercussions on the health of infants and the family. products of degeneration. Consequently a period of It may thus be predicted with certainty that post- several years commonly elapses between the invasion natal supervision must comprise not merely a " pelvic of the body and the onset of clinical symptoms, of overhaul " but the attempt to control all those which the most frequent is epilepsy. factors which concern a woman’s general health and During the life of the host, diagnosis for practical influence her ability to succour her child. Further, purposes is at present dependent on only two signs, it must continue to safeguard her so that after an neither of which unfortunately is a necessary part in appropriate interval she can repeat the process. the development and degeneration of the parasiteWhat is needed is a service to which she can turn namely, the appearance of palpable cysts in the throughout the period of her reproductive life with tissues, and their calcification post mortem. As confidence that her particular needs are known and regards the first mentioned there may be no cysticerci understood: a service comparable in fact to what outside the brain, and even if present in muscle, &c., she would receive from her general practitioner if as well they may be too deep for detection and excision when post-mortem swelling occurs; or so she could afford it. Hitherto in the working of the Maternity and Child Welfare Act not much apprecia- few in number as to escape notice ; or the host may tion of this has been shown. come under examination only at a time when he Advance will be rendered as difficult as possible is free from palpable cysts although some may have if women confined in hospital are retained indebeen present months or years before, or may appear finitely as its out-patients, while for those confined months or years afterwards, as determined by the at home a separate service has to be organised; longevity of individual parasites. Calcification is for unless all domiciliary cases are to be referred to found only as a form of post-mortem degeneration, THE MIDWIFERY SERVICE IN LONDON
hospital
services
two