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in general practice among the wealthier parts of thepopulation there is far less to be done. In the poorerparts I do not know quite what is happening, butthey are certainly not busier than they were before.Before the war we all thought that sickness among thecivil population would increase, but that was basedupon ideas of shortage of supplies and increase of foodprices, with a corresponding increase in d - stitutionand epidemics. These things may come later, but inthe meantime it is clear that there are many peopledoing without doctors who would have gone to themif their thoughts had not been distracted to otherthings. This should make us realise that many canget on very well without us, and make us chary of

treatment approaching the heroic. I take it thatpeople who have a buzzing in the ears settle down toread the Times or Daily Mail and forget their buzzinginstead of coming to someone to have their ears blownup, or if the airway through one side of the nose is notclear they settle down to make pyjamas for thesoldiers in the trenches instead of going from one nosespecialist to another until one operates upon theirseptum. After the war they will come back to us (orit will be a bad thing for me )-but in the meantime itis one up to the Christian Scientists and the faith-healers-if only they knew it.

Might have been written yesterday, mightn’t it ?

PUBLIC HEALTH

Control of Puerperal SepsisTHE Ministry of Health has issued a memorandum 1

on the control of puerperal sepsis, which is presum-ably meant to supplement-and in certain points tocorrect-a circular letter of March 30, 1938, on thesame subject. The object of the memorandum is "toexplain the nature of puerperal sepsis, how it is

spread, and how to identify and group the strepto-cocci responsible." In actual fact, little is said aboutthe nature of puerperal sepsis, and the pamphletdeals only with infections due to the hsemolyticstreptococcus, which accounts for less than half ofall notifiable cases of puerperal pyrexia. In thisfield, it states that knowledge of the nature andsources of puerperal infection 11 is not being appliedin maternity institutions and in domiciliary practicewith the promptitude and purpose required to preventthe spread of infection." This stricture on maternityinstitutions must apply more particularly to smallmaternity homes, for that most of the larger maternityhospitals and units in general hospitals have alreadyput their houses in order is obvious to anyoneacquainted with them, and is reflected in their lowmorbidity-rates. The position in regard to domiciliarypractice is of necessity less satisfactory, and theMinistry’s memorandum serves a useful purpose ingiving definite advice about procedure in circumstanceswhere in the past uncertainty has often prevailed.

This advice is based on the knowledge that strepto-coccal puerperal infections are for the most partcaused by the same haemolytic streptococci (Strepto-coccus pyogenes or group A Lancefield) as are

responsible for scarlet fever, tonsillitis, sinusitis andthe like, and that the natural habitat of these strepto-cocci is the human upper respiratory tract. The

preventive measures to be adopted are consideredfrom two standpoints. (1) In the absence of puerperalpyrexia, routine swabbing of midwives is not recom-mended. Instead, a careful clinical-and presumablybacteriological-examination should be made ofcandidates for training as pupil midwives, so thatthose suffering from chronic streptococcal infectionof tonsils or sinuses may be warned that the persist-ence of such a disability is likely to prevent themfrom becoming practising midwives. The midwifeshould be instructed to report immediately anyinfection of the upper air passages and be forthwithsuspended from duty until a bacteriological examina-tion has been made. If group A streptococci are

found she must not resume duty " until she hasrecovered completely and three negative swabs atdaily intervals have been obtained." Here begin theM.O.H.’s difficulties. When, where, and by whom is

1. Memo. 226 Med. H.M. Stationery Office. 2d.

swabbing to be done 7 Are daily preferable to twice-weekly swabs, and are not two negatives enough? Andwhat is to be done with the midwife who continues togive positive swabs although clinically well7 (2) Onthe occurrence of puerperal pyrexia, it is recom-mended that " until the existence of infection of thegenital passages with haemolytic streptococci has beenexcluded, the attendant contacts must not conduct alabour or nurse any other puerperal woman." Thisis drastic advice, even although the natural corollarythat the bacteriological examination of a vaginalswab must be made in every case of puerperal pyrexiais qualified by "unless the practitioner can be quitecertain that the fever is not due to infection of thegenital tract." Surely a distinction should be madehere between institutional and domiciliary midwifery.The practitioner and the midwife meet many instancesof puerperal pyrexia which, they are pretty certain,are not due to genital-tract infection. Must thesecases be immediately swabbed, and if the swabs haveto be sent to the laboratory by post, is the doctor ormidwife to be entirely precluded for at least two daysfrom attending any parturient or puerperal woman ?Are swabs to be taken from all the considerablenumber of patients with postabortal pyrexia amongwhom group A streptococcal infections are ratherrare ° If the vaginal swab yields haemolytic strepto-cocci, search for a possible source of infection shouldbe confined to contacts who might in the course oftheir duties carry infection to other parturient women-i.e., primarily doctors and midwives. This is reason-able, although it would be a satisfaction to the midwifein domiciliary practice if the search for the" criminal " were extended to the patient herself and toany other suspect member of the household. And letit be stressed, in these days when administrators arebecome Lancefield-conscious, that the finding of groupA streptococci in the throat of a contact does notprove that individual to be the source of infectionunless his (or her) streptococcus has been shown tobe of the same serological type as the infecting strain.

The latter part of the memorandum deals with thelaboratory methods required for the isolation andidentification of the hsemolytic streptococcus togetherwith an evaluation of the findings. Lancefield group-ing can be done in 48 hours—Fuller’s 2 formamidetechnique has advantages over the acid-extractionmethod recommended in the memo.-and is within thescope of any up-to-date laboratory, since groupingsera are now available commercially. Identificationof the serological type is still a specialised researchwhich is practised in only a few laboratories, andprimarily and principally in the Ministry’s own patho-logical department. Medical officers of health are

2. Fuller, A. T., Brit. J. exp. Path. 1938, 19, 130.

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reminded that the Emergency Public Health Labora-tory Service is available for the examination of swabsfrom "evacuated" maternity patients.

Finance of the Emergency Hospital Scheme

The Ministry of Health has sent circulars thisweek to the hospitals and other institutions includedin the emergency scheme, and to local authorities,clarifying the financial provision under the schemeand making certain changes. The circulars again setout the categories of patients for the cost of whosetreatment and maintenance the Treasury will beresponsible. Service patients now include womenmembers of the fighting services, Army, Navy andAir Force Nursing Services, and the voluntary-aiddetachments. Certain officers on half-pay, soldiers’families and others are also included. Hospitalsreceiving ordinary civilian patients transferred underthe scheme must obtain a contribution from themtowards the cost of treatment. The Hospital SavingAssociation and other contributory schemes haveagreed as to the payments they will make to hospitalsfor these patients. No contribution will be collectedfrom unaccompanied evacuated children admitted tohospital since their parents will be expected to con-tinue payment towards the cost of billeting. TheMinistry will pay the railway fare home of dischargedpatients who live more than 15 miles from hospitalwhere the cost might involve serious hardship. Inthe same way it will where necessary contributetowards the expenses of relatives visiting patients whoare dangerously ill.The cost of board and lodging for medical students

attached to hospitals for the purpose of assisting inthe emergency scheme has hitherto been the responsi-bility of the Minister. He has now come to the con-clusion, however, that he is not justified in regardingthe assistance of medical students as necessary to thescheme, and will cease to pay for their board andlodging after Jan. 1. He will allow the presentbilleting arrangements to stand, so that studentsattached for teaching purposes to institutions otherthan their usual teaching hospitals may still be billetedby the local authority’s billeting officer, and billetinghouseholders will still be paid through the Post Officeat the rate of 5s. a week for lodging only and a guineafor board and lodging. Students may also still beaccommodated in the outer hospitals themselves. Butin both cases the students will now have to repay thecost of accommodation. If the situation alters so thatstudents are wanted to help with the treatment ofactual casualties the arrangements for recovering thecost of their keep will be suspended during the periodin which they are employed.

Sulphonamides showing in the Audit

Since the introduction of sulphanilamide and itsrelatives the case-mortality of puerperal sepsis hasfallen everywhere, but it cannot yet be said definitelyhow far this is cause and effect. The significance ofthe recorded rise in the incidence of the puerperalfevers since 1927 is also doubtful, since before thePuerperal Pyrexia Order of 1927 the figures forincidence and mortality were untrustworthy. In hisreport on the health of Newcastle-upon-Tyne for 1938Dr. J. A. Charles attributes the improvement in thematernal mortality-rate to 3-3 per thousand to theeffect of chemotherapy in streptococcal infections. Hisgeneral statistical table for the years 1885-1938showed that until 1929 the recorded fatality-rate frompuerperal sepsis only five times exceeded 1 perthousand live births, and in thirteen years it was below

0,5. From 1929 onwards the mortality from thiscause apparently increased greatly, and the rate didnot again fall to 1 per thousand until 1937. In 1938it was 103. In Cambridgeshire, with 1872 births,there were no deaths at all from puerperal sepsis in1938, and Dr. R. French has no hesitation in ascribingthis success to chemotherapy.

In erysipelas, on the other hand, the benefits of thesulphonamides are easier to assess. In Newcastle theincidence has varied little in the forty years in whichit has been notifiable, and its case-fatality rate hasalso been constant over grouped periods except foran increase in 1927-37, when it averaged 6 per cent.In 1938, with the use of the sulphonamides, the case-fatality rate dropped to 0’5 per cent. Dr Dawson-Walker, medical superintendent of the city infectiousdiseases hospital, says: " In no other conditions arethe results of their administration so consistentlyeffective as in erysipelas, and all the previous formsof treatment have been superseded." Erysipelas isan invasive streptococcal infection, and is littleinfluenced by serum, but figures from all over theworld record the same striking collapse in the mor-tality with chemotherapy. The rate is now probablyapproaching an irreducible minimum.

Dr. Dawson-Walker says that in scarlet feversulphanilamide is useless-it neither reduces thetoxaemia nor prevents complications. This is thegeneral experience in isolation hospitals. Scarlet feveris now mostly a mild streptococcal toxaemia whichyields immediately to serum. The toxic form, clinicallyresembling heliotrope influenza, which used to be fairlycommon and invariably fatal, is now rare and curablewith serum; whether chemotherapy will affect septicscarlet fever remains to be seen, for there has so farbeen little opportunity to try it. Simple and.toxicscarlet fevers are toxasmias without invasion; septicscarlet fever, like erysipelas, is an invasive infection.It seems that the sulphonamides are powerful instreptococcal invasion but useless in streptococcaltoxaemia. It is surprising that they are ineffective inpreventing the complications of scarlet fever, butexperience in the treatment of gonorrhoea suggests thatthey do not act until reaction has started. Somestreptococcal puerperal fevers are toxasmic, like scarletfever, while the majority are invasive, like erysipelas.Natural mortality is low in the former and high inthe latter. We should expect sulphanilamide to givedramatic results in the invasive fevers-septievemia,perimetritis, parametritis and so on-and there is ageneral impression that it does, though we cannot yetbe as dogmatic about it as about erysipelas.

School Health Services

As we have already noted (Dec. 23, p. 1323),circular 1490 of the Board of Education stated inimpressive terms the extent to which the school healthservices, built up with so much labour during thelast 30 years, have been undermined by the impact ofwar. While some local education authorities havemade a determined effort to surmount the difficultiesof evacuation, in other areas, especially those whichseemed likely to be the first targets of the expectedBlitzkrieg, the authority, or some dominant person-ality amongst its officers, seems to have said of air-raid precautions " This one thing I do," and to haveallowed the premises formerly used by the schoolmedical services, such as school clinics, treatmentcentres and feeding centres, to be allocated to otherpurposes, with the result that those services practi-cally ceased to function. At the beginning of thewar this concentration on civil defence was in suchareas inevitable, but the time has now come when

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staff and premises should, as far as possible, berestored to the school health services, subject to theirbeing made immediately available for casualties if thetragic occasion arises. Whilst the reception areas were,at the outset, necessarily the Board’s first preoccupa-tion, their attention is now largely focused on theevacuation areas where the difficulties in restoring theservice to normal are greatest. In these, many schoolsare still closed pending the provision of protection, orstill in occupation for other purposes. Moreover, whenit becomes possible to resume schooling the Governmenthas decided that attendance cannot be made com-pulsory. Some of the children in the evacuation areaswho have returned home have had some schooling inthe reception areas, and have received a good dealof medical and nursing attention. But at least halfof the children in most of the evacuation areas haverun wild since the end of July.Happily, as regards infectious diseases, the autumn

term has been most providentially blessed; theirincidence has been in most cases below that of thenormal expectation, and far better than the precedingyear. But, as regards cleanliness and discipline,deterioration is obvious. In some cases there will beaccommodation only for the senior children; and, asattendance will not be compulsory, many of thosechildren most in need of attention will not receive it.The circular suggests that the cleansing stations pro-vided for air-raid precaution purposes should beutilised for the cleaning up and treatment of school-children-a proposal which has been welcomed by theMinister of Home Security. The admirable showerbaths and the arrangements for rapid transit at thesestations should enable a constant stream of childrento be inspected for uncleanliness and skin diseasesand, where necessary, cleansed and treated. By theend of three months all the children will have beeninspected and treated.

Antedating the war by some two years a gradualincrease in scabies has been noticed in many parts ofthe country, and it is to be feared that war conditionsmay have produced some further increase in thisdisease. As regards pediculosis the condition of someof the evacuated children at the end of the summerholidays should be a warning that the condition ofthe non-evacuated children after nearly six monthsmay well call for some thorough and intensiveattention.

TAVISTOCK CLINIC.-A postgraduate course of

weekly lectures in psychopathology and psychotherapy willbegin at this clinic on Monday, Jan. 8. The subject ofthe lectures will be announced in our Medical Diary,and further particulars may be had from the educationalsecretary of the clinic, which has found a temporary homeat Westfield College, Kidderpore Avenue, London, N.W.3.

SCHOOL HEALTH SERVICES IN SCOTLAND.-Amemorandum issued to Scottish education authoritiespoints out that the school health services which have beenbuilt up with so much labour during the last 30 years mustnot be allowed to deteriorate because of the stress of war.Measures of reorganisation are urgent in order that healthservices may be adapted to new conditions. Everyauthority is advised to endeavour to secure a school healthstaff equal to the needs of the local situation by augment-ing the ordinary staff. This may in some instances be

possible by obtaining the services of doctors and nursesattached to first-aid posts, but where such are not availablenew appointments may be necessary. On the subject ofnutrition the memorandum reiterates the view of the valueof a good mid-day meal. It is hoped that authorities willmake provision to recommence mid-day meals in schoolsand to return to the provision of milk in schools at theearliest possible moment.

ObituaryEDWARD SABINE TAIT

M.D. LOND.

Dr. Tait, who died in London on Dec. 14, qualifiedfrom St. Bartholomew’s Hospital in 1879, taking auniversity degree with honours two years later andbecoming M.D. in 1888. Before entering on generalpractice he was house-surgeon at Bart’s and heldresident appointments at the General Lying-In Hos-pital and St. Luke’s Hospital for Lunatics. W. L. B.writes: "By the passing of Dr. E. S. Tait at theripe age of 83 a link with the past is broken, forhis father and brother were both Bart’s men; buthappily the tradition goes on, for two of his nephewsare members of that hospital. Edward Tait practisedall his life in Highbury where his home and the charm-ing garden created by his wife are remindful of thedignified past of that neighbourhood. He was some-thing more than a good physician; surprisinglymodern in outlook and infinitely painstaking, hisapproach was that of the fine courtesy natural to him.To consult with him was to witness that relationshipbetween doctor and patient which must abide if theart of medicine is to continue. Tait was a connoisseurand delighted in the arts, himself a sculptor of nomean talent in whose delicately perceptive work wasmade plain his great love of beauty and respect forcraftsmanship. He made an admirable collection ofetchings, among them some fine examples of theFrench, English and Swedish masters. He will begreatly missed, for he had a personality-rare inthese turbulent days-which endeared him to all whoknew him."

JOHN STEDWELL STANSFELD

M.A. OXFD, ]B’I:.R.C.S.

THE memory of John Stansfeld, who has died atthe age of 86, is kept green by the medical missionin Bermondsey which he founded. His approach tomedicine was not through the usual channels. ALondoner by birth and education, he tried variousoccupations, including engineering, until at 22 heentered the civil service and was appointed to theinland revenue at Horncastle, Lines. Here he formeda friendship with Henry Lunn, who was already at18 showing great business ability inside his Methodisthome. The influence of Stansfeld sent Lunn to Dublinto train for medical missions. Stansfeld himself wastransferred to Oxford where while still a civil servanthe took a degree from Exeter College and a theologicalcourse at Wycliffe Hall, and began to study medicine.He was sent to Glasgow and continued his medicalstudies at the infirmary there for three years. Aremoval to London led to the completion of his medicalcourse at Charing Cross Hospital, during which heworked in Bermondsey. This was in 1897 when hewas already 42. For the next eight years while stillkeeping his civil-service appointment, he remained incharge of the Oxford and Bermondsey Mission whichwas constantly adding to its branches and clubs. In1910 Stansfeld was ordained and became rector ofSt. Ebbe’s in the poorer part of Oxford, where heopened a dispensary. He also built a convalescenthome on Headington Hill just outside Oxford. Latein life e he went out as a medical missionary in CentralAfrica till ill-health compelled his return home. Atthe time of his death he was rector of Spelsbury inthe Cotswold country.