five years of age, in accordance with schemes approved by the Board. As far as expectant and nursing mothers are concerned these consist of the provision of

(1) Home visitation by fully qualified health-visitors; (2) Ante-natal centres;

(3) A service to meet emergency calls by midwives; (4) Arrangements with lying-in hospitals to provide for ante-natal and emergency treatment;

(5) Provision of adequate hospital facilities for cases of puerperal fever;

(6) Provision of dental treatment;

(7) Provision of insulin;

(8) Provision of food and milk;

(9) Provision, where necessary, for normal maternity treatment;

(10) Provision of assistance in domestic work.

3. Varieties and Sources of Infecting Germs. In the vast majority of cases of puerperal fever the infecting organism is the hæmolytic streptococcus, but the question has not yet been settled whether hæmolytic streptococci pre-existent in the maternal passages are the chief source of infection, or whether they are in the main introduced during manipulative procedure by the accoucheur. In rare instances, there are records of other organisms having been isolated, e.g. the bacillus of diphtheria, &c. More often the gonococcus or bacillus coli communis is found, but they are generally associated with the streptococcus. It is therefore against this last-named organism that a converging series of measures must be brought. It has been maintained by some bacteriologists that a specific puerperal streptococcus exists, but Griffith and others who have investigated the matter have not been able to confirm this. More recently Kinloch, Smith and Taylor published an article in which they state that scarlatinal streptococci obtained from the throats of cases of scarlet fever can be divided into groups by agglutination and absorption tests, and that the same type of streptococcus can on occasion originate at least five separate clinically distinguishable diseases, namely, scarlet fever, tonsilitis, erysipelas, puerperal fever and broncho-pneumonia. The essential home of the streptococcus is the nasopharynx, and from there, in a variety of ways, it may gain access to the genital tract. It has been frequently recorded that in a small and varying proportion of anything from 1 to 10 per cent. of cases this organism has been isolated from the genital tract during pregnancy. Other cases are reported where any septic focus throughout the body may serve as the source of infection. At the present time, however, it is believed that the most common mode of infection is extrinsic in nature and that the organism is introduced at the time of confinement or shortly afterwards, either by the careless toilet preparation of the patient or through imperfect sterilisation of the apparatus, instruments, or the hands of the accoucheur. As far back as

1847 Semmelweiss came to the conclusion that puerperal fever was of the nature of a wound infection, and blamed the examining finger for the introduction of the septic material. He insisted even in those pre-Listerian days that all those in attendance on the cases in the hospital (Vienna Maternity Hospital) should thoroughly cleanse their hands with a chlorine solution before undertaking any examination of the patients. The result was an immediate fall in the mortality rate of that institution from about 10 to 1 per cent. In spite of these startling results the theory that puerperal infection was contagious and that the infection was in the main carried by the accoucheur was derided by the average medical man until the advent of Lister and the development of bacteriology revolutionised the ideas of the causation of infections.

In her admirable Report" The Protection of Motherhood," Dame Janet Campbell states:

"It is clear that repeated vaginal examinations, much manipulation, difficult or prolonged labour with the associated bruising and tearing of the tissues, operative procedure, and particularly the manual removal of an adherent placenta, predispose to infection; while a woman who at the end of labour is in a condition of exhaustion or shock from fatigue, pain or hæmorrhage is more than usually vulnerable to the onset of sepsis."

4. Signs of Puerperal Sepsis.-Generally the patient who has been doing quite well after confinement begins to have shivering attacks usually accompanied by a feeling of malaise. Her temperature rises to 100° F. and over; there is tenderness over the lower part of the abdomen; the uterus is larger and more sensitive to pressure than normal, and the character of the lochia alters. Sometimes it decreases in amount and becomes devoid of odour, whereas at other times it is increased in amount and is very foul-smelling. In some cases the infection extends to the fallopian tubes or even to the peritoneum, with the result that a pelvic cellulitis ensues. Even in such cases the infection is localised, and recovery in the majority of cases ultimately takes place. Unfortunately in a proportion of from 10 to 20 per cent. of cases the streptococci gain access to the blood, resulting in a general septicemia. This is by far the most fatal form of the infection. In a number of cases of puerperal infection, whether or not the organism has gained access to the blood, a streptococcal broncho-pneumonia develops which is frequently fatal. One result of this is that the death certificate bears the words broncho-pneumonia, and there is then no record to show that puerperal sepsis was the primary cause of death. For this reason the Scottish Departmental Committee advised that in all cases of death of women which took place within four weeks of delivery the fact of pregnancy should be communicated to the registrar at the time of registration. This is done in at least one of the large cities. In a small number of cases the septic

infection involves the pelvic veins, causing white leg or phlegmasia alba dolens. This, though rarely fatal, generally results in swelling of the legs accompanied by severe pain, and it is usually some considerable time before the patient is able to walk with any degree of comfort.

5. Methods of Prophylaxis.-At the present time a considerable amount of bacteriological work has been and is being done with regard to the investigation of the antigenic properties of the various strains of streptococci; but up to the present the preparation of potent antistreptococcal serum presents difficulties. Unlike the pneumococcus, no single inoculum of killed or living streptococci has produced a satisfactory yield of antibodies; repeated inoculations of living streptococci over considerable periods of time are required to produce this result.

Polyvalent antistreptococcal serum in some circumstances, if given a prophylactic immediately after a labour in which much operative procedure has been necessary and on account of which a septic condition might result, seems to be very useful. Good results from this method have also been obtained in cases of puerperal sepsis so long as the infection has remained localised.

As regards chemotherapy, much more has been done in America than in this country. A definite attempt is made, by injecting various chemical substances, to make the blood an unsuitable medium for the growth of micro-organisms. With none of these above methods have any really decisive results been obtained, though the results are good enough to encourage further efforts. More recently glycerine lymph drainage, as elaborated by Dr. Remington Hobbs, has been advocated as a prophylactic measure following upon confinements in which manipulative procedure has been necessary. This method also augurs well and seems worth encouraging.

Up to the present time the chief method of tackling the problem has been to encourage antenatal supervision. 'To avert difficulties by foresight and foreknowledge or to prepare in advance for unavoidable difficulties is bound in the long run to produce better results than follow from trusting to one's ability to treat unexpected complications as and when they arise " (Professor Johnstone). It is in pursuance of this policy that local authorities have adopted the methods most suitable to their districts to establish ante-natal supervision. This is done in a variety of ways through the medium of district nurses, health visitors, ante-natal centres, &c.

6. Health Visitor.-Among the many duties of a nurse health visitor not the least important is the frequent supervision of all the pregnant women in her district. Unfortunately, as pregnancy is not yet notifiable, the health visitors obtain their information regarding these women in a very haphazard manner. Often the nurse is very popular in the district, and is regarded as a friend, so that the women themselves tell her, but often she just finds them out in the course of her ordinary visiting. This state of affairs is especially true of the cities and larger burghs.

In some of the country districts the health visitor is often the local midwife or district nurse, and she obtains her information when the women come to engage her services for their confinements. Many of them come rather late in their pregnancy, but in a very short time the nurse manages to educate her patients into the necessity for giving information sufficiently early. The health visitor advises the woman as to general hygiene and persuades her to consult her medical attendant or the local antenatal clinic. She keeps a careful watch over the woman's general health and encourages her to report to her or her doctor immediately should she feel unwell.

7. The Ante-natal Clinic.-The purpose of an ante-natal clinic in so far as this problem is concerned is to secure that the puerperium shall be aseptic if possible, because of the dual purpose of restoring the mother to normal health and of securing adequate and natural feeding for her child and the immense advantages which accrue therefrom. Should the mother develop a severe form of puerperal fever, the child must be removed from her, both for her sake and its own, lest it also develop a grave form of icterus neonatorum, which is also a severe form of streptococcal infection.

In some quarters it has recently been stated that ante-natal clinics have failed in their object, and that the death-rate of mothers attending them is not much different from those who do not attend. This may be so in a certain number of cases, for undoubtedly it is the experience of everyone who has had charge of an ante-natal clinic that it is unfortunately very difficult to get the women to appreciate the necessity not only for attending but for attending regularly. Too often many of them default for considerable periods and only return when some definite complication has arisen. It is difficult to make them understand that such clinics are primarily health centres whose main object is to keep the woman healthy. Therefore, for the majority of patients attending, their confinements should present no obvious difficulty, and the risk of septic infection should consequently be reduced to a minimum. Women generally have to be made to realise that while pregnancy and labour are normal physiological processes, they are accompanied by considerable strain, so that the physiological condition very easily becomes pathological, and therefore pregnancy is a natural condition which requires more expert supervision than any other natural process. "The late Dr. Studdyford found that over a period of seven years 20 per cent. of the patients attending the antenatal clinic required special treatment, and 12 per cent. were admitted to ante-natal wards. The routine treatment of patients at an ante-natal clinic should be as follows:-At the first visit the social conditions are enquired into, and a thorough general physical examination is made of heart and blood pressure, lungs, kidneys and nasopharynx. The measurements of the pelvis are also taken at this time. If there are any indications for them special investigations are also undertaken, e.g. blood counts,

Wasserman reaction for, syphilis, bacterial examinations of the cervix. The patient is then instructed as to the mode of life best suited for her condition and for the future health of her baby, and she is earnestly requested to pay return visits monthly until the sixth month, fortnightly until the eighth month, and weekly until term. At these visits the urine and blood pressure are always examined, because from such examinations deviations from the normal can be noted and toxæmias can be prevented by proper treatment. Apart from the grave danger to mother and baby from toxæmias there is the undoubted fact that women suffering from these conditions are peculiarly liable to septic infections. Later on in pregnancy any relative disproportion between the size of the head and the pelvis can be estimated and a definite prognosis given to the patient as to whether her confinement is likely to be normal or abnormal."-(Prof. B. P. Watson in Nelson's Loose-Leaf Medicine.)

8. Midwives.-Recent statistics show that in some industrial areas there is an increasing tendency to engage a midwife rather than a doctor for confinements, one reason for this being the saving of expense, while another is the knowledge that medical help is available should the necessity for it arise. Most women are naturally very reticent for some time about the fact of pregnancy. As the midwife is often a personal friend, and on that account is often one of the first people to become aware of the woman's condition, she can be of great help in the establishment of a successful midwifery service. She can persuade the woman to attend her doctor or the ante-natal clinic, and ought if circumstances permit to try to be present at the first consultation with her so that she can be made aware of the prognosis, for no careful midwife contemplates undertaking a case which will be obviously unsuitable for her to attend.

All midwives are compelled to notify the medical officer of health if they intend to practise in his area. He is official inspector of midwives, and one of his duties is to pay periodic visits to all midwives in his area to ensure that the rules and regulations of the Central Midwives Board are adhered to. These rules among other things insist that the midwife shall keep proper equipment, records, &c. One of the principal rules is that she must not interfere experimentally with the natural course of labour, and in the event of a state of emergency arising she must call in the services of a medical practitioner. The fee for such services is guaranteed by the local authority, who have the power of recovering it wholly or in part according to the circumstances of the patient. The frequency of summoning medical aid has increased markedly in recent times, and this has not been accompanied by any fall in the maternal mortality. Dr. Fairbairn's figures show that in 1905 it was 89 per cent. of all the cases attended, and from this it has risen in the last few years until it is now from 18 to 24 per cent. of all the cases. In 1924 in England it was found that 48 per cent. of these medical calls resulted in a forceps delivery. This is a step in the