View report page

58
suspend a midwife from practice on this account. One instance during the year in
which a midwife had five consecutive cases of pemphigus neonatorum in her practice
presents a point of some interest. She had been disinfected after each successive
case, apparently without attaining the desired object. Before resorting, however,
to so drastic a measure as suspension, she was seen once more, and it then transpired
that up to that time her spectacles had not been dealt with. Accordingly these
were disinfected, and as a matter of fact no more cases occurred. Whilst it is reasonable
to point out how very natural it would be for a midwife to peer closely at the
skin of each infant with whom she had to deal, adjusting meanwhile her spectacles
for the purpose, it is not, of course, suggested that the disinfection of the spectacles
was the actual cause of the cessation of the series of cases, but it is quoted to illustrate
the desirability of dealing with absolute minuteness and particularity in the matter
of infection.
Whilst dealing with the question of runs of cases occurring in any given midwife's
practice, it should be mentioned that during the year another midwife had a
series of seven so-called cases. Space will not admit of a minute analysis of this
small outbreak, but certain details in regard to the investigations conducted may be
mentioned. At the onset of the disease history was given of the infant having been
wrapped in a bed jacket borrowed from a neighbour who was attending at a V.D.
clinic, though in the light of clinical evidence afforded by the following six cases
it would not appear that any specific infection was thereby carried. Two of the
cases were of a very slight nature, and had they not occurred in connection with
the others would probably not have been suspected as being cases of pemphigus
neonatorum. The midwife voluntarily relinquished practice. In 1923 a run of
five cases occurred in the practice of two midwives acting in partnership. The
circumstances here made investigation peculiarly difficult, inasmuch as the two
midwives concerned delivered the mothers and washed the infants more or less
as convenience dictated, that is to say, they did not each adhere to any one given
case. Rigorous disinfection of person and property, including household furniture,
would appear to have brought this outbreak to an end.
As has been stated, the number of cases for this year was 35, giving a case-rate
per 10,000 births of 8.3. The figures during the preceding quinquennium were—
1923 (6.6), 1922 (0.9), 1921 (5), 1920 (3), and 1919 (4.5). Altogether the cases during
these six years numbered 127. The season of the year at which they occurred and
the length of time after birth do not yield any very significant information, except
that there did seem distinctly increased incidence during the months of September
to December. These cases, of course, all occurred within the practice of midwives,
but there is no doubt that over and above this number there were, at any rate during
this year, a considerable number of further cases. This was ascertained on chance
enquiry at children's hospitals, but circumstances did not allow of any detailed
investigation in these instances. As regards locality, there was an undoubtedly
high proportion of cases in the western riverside area of London. As has already
been pointed out above, considerable doubt exists as to the cause of this complaint.
In very many cases the staphylococcus is present and is by some thought to be the
causa causans of the condition. Others, again, attribute it to the activities of the
streptococcus. There are, however, three cases within the knowledge of the department
which may have some significance. In one of these the organism obtained
from the fluid of the blister was the pneumococcus, in another it was the gonococcus,
whilst a third yielded a diphtheroid organism, and it does not appear to be outside
the realms of possibility that pemphigus neonatorum is, in fact, due in part to the
presence in the appropriate layer of the infant's integument of some pyogenic
organism. This would, at any rate, account for the undoubted variability in the
incubation period and also the degree of severity of the disease, which is so remarkable,
and furthermore the variability in the colour of the contents of the blisters
which is a noticeable feature of this complaint. The very frequent presence of