- Email: [email protected]
OR DOCTOR
674 else that it lies research."
To
improve
beyond
the reach of human
the treatment of
damage
means
of
due to cold,
heat, actinic insults, toxins, and many other agents,
’
a
or reversal of stasis to clinical medicine. LEIV KREYBERG
systematic study of the prevention is of fundamental
importance
Institute of Pathology, University of Oslo.
Director.
CONCENTRATION OF DIPHTHERIA ANTITOXIN IN CORD BLOOD
SIR,—It is regrettable that Miss Barr (Sept. 24, p. 578) missed the main point of my letter of Sept. 17. My intention was not to criticise these workers’ technique but to call attention to a universal biological phenomenon of which their material provided a special example. Whatever antibodies are present in the cord blood have not been formed by the fcetus in utero, but were derived from the mother by placental filtration ; in addition, only univalent antibodies can traverse the placental barrier, whereas bivalent antibodies cannot. Filtration of antibodies continues until an equilibrium is set up-namely, when the titres in maternal and cord sera are equal. It is manifestly impossible, therefore, for the cord sera titres to exceed the maternal sera titres, unless one makes the unlikely assumption that after equilibrium had - been reached antenatally, the maternal antibody titre began to fall and that the reverse process of filtration of antibody from the baby to the mother lagged behind. Whenever findings seem to conflict with an excellent theory it is a good idea to re-examine the data. Even that the laboratory error does not exceed conceding 10%, it is easy to see how a bias of considerably greater magnitude could arise. For example, if all the maternal sera are examined on one day using one animal, while all the cord sera are examined on another day and using another animal, the results would not be strictly comparable. Since the protocols are not available to me, it is of course not possible for me to state what bias if any existed in the present study. A. S. WIENER. New York. DANGERS OF LEAD NIPPLE-SHIELDS are comfortable to the nursing mother. They are pliable and fit like a cap on the nipple. Their danger is set forth in the article by Dr. Gordon and Mr. Whitehead in this issue. They are widely used and readily obtainable in chemist’s shops. In London they are advocated in large maternity units, including at least one important maternity hospital. In the North of England, we are informed, sales are even larger, and in the Midlands they are recommended in a neonatal unit famous throughout the country. The reason given for their use is that the lead assists the healing of cracked nipples ; and so it does, but unfortunately this process occurs at the expense of administering lead compounds to the suckling infant at every meal. We have been told that the use of the shields is recommended only for a week or two, but even so the danger remains. On inquiry we found that mothers who like the shields do in fact take them home on discharge from hospital, and that they are able to obtain them free under the provisions of the N.H.S. Act. The usual form of chronic lead poisoning in the infant is lead encephalopathy, and Dr. Gordon’s article indicates that complete recovery of an infant from this disease is unusual. Generally the infant dies or is rendered mendefective. It is a disturbing thought that, among tally the many infants one sees with fits and mental defect, one may easily have missed cases of lead encephalopathy through failure to bear in mind the possibility of lead poisoning. The use of lead compounds in indus-
SIR,—Lead nipple-shields, unfortunately,
trial processes is hedged about by strict legal safeguards in order to prevent poisoning. There is, we suggest, no room for doubt that the sale of lead nipple-shields should be made illegal. The Ministry of Health has issued an urgent warning against using these shields ; and we acknowledge the generous help received from two large firms towards stopping their sale. Plastic nipple-shields, which are now on sale, might well be given a trial by those recommending the use of a shield. We appeal to doctors and midwives to do all they can to abolish the use of this dangerous metal in nipple-shields for nursing mothers. No mother would risk using them if she knew the facts. London,
HELEN M. M. MACKAY DONALD HUNTER.
E.2.
MIDWIFE
AND/OR
SIR,—In your leading
DOCTOR
article last week you have not
succeeded in being entirely objective. With regard to your comments on the mother’s supposedly mistaken preference for a doctor as analgesist, surely the present-day general practitioner is changing over very rapidly to the use of the Minnitt " special attachment " and even more rapidly to trichlorethylene frequently combined with pethidine. Even, however, if he still uses chloroform there is no evidence that in practice this delays delivery as you suggest. Bourne and Williams1 state: ’’ When chloroform was used as a routine for every delivery at Queen Charlotte’s Hospital there was found to be no increase in the time of labour, an unchanged forceps-rate, no greater incidence of postpartum haemorrhage, and no greater stillbirth rate." Rightly or wrongly the midwife is not allowed to use any of these aids and she realises that her own Minnitt apparatus without attachment is already out of date and out of favour with patients who have experience of other methods. What woman doctor or doctor’s wife would deny herself one or the other ? Dr. Grantly Dick Read does not deny them if requested and incidentally is himself present at the confinement. How else could he have made his observations and added to the sum of our knowledge? Surely if the maternal-mortality rate for cases superintended by the Queen’s Institute of District Nursing— 0-74 per 1000 births-includes those transferred to general practitioners as " aid cases," the latter cannot have dealt with them so incompetently ; yet in the next paragraph dealing with the admitted deficiencies in the general practitioner’s training you imply that Sir Eardley Holland’s investigation applied only to booked doctor’s cases. I have not the report by me, but was this so’? Surely, Sir, the answer lies in the will to coöperate between midwife and doctor, the latter’s part in a normal case being mainly with analgesia. But how can a doctor be available in an emergency " such as a catastrophic postpartum haemorrhage unless he is in the house? We cannot do without each other. In this area the late Dr. R. E. Moyes and his colleagues themselves established the professional position of the midwives by refusing to attend a case at which a trained midwife was not in attendance, and so put an end to the era of the handywoman ; but he did not forget the importance of the presence of the practitioner during labour ; and you would do well to re-read his paper2 two appreciate the part played by the general practitioner in improving "
domiciliary midwifery. L
Amble, by Morpeth, Northumberland.
R. P. ROBERTSON.
** We should have made it clear that Sir Eardley Holland’s investigation covered all the maternal deaths (100) notified in a county during three years.-ED.L. 1. Bourne, A. W., Williams, L. H. Recent Advances in Obstetrics and Gynæcology. London, 1945 ; p. 54. Brit. med. J. 1936, ii, 386. 2. Moyes, R. E.
To
improve
beyond
the reach of human
the treatment of
damage
means
of
due to cold,
heat, actinic insults, toxins, and many other agents,
’
a
or reversal of stasis to clinical medicine. LEIV KREYBERG
systematic study of the prevention is of fundamental
importance
Institute of Pathology, University of Oslo.
Director.
CONCENTRATION OF DIPHTHERIA ANTITOXIN IN CORD BLOOD
SIR,—It is regrettable that Miss Barr (Sept. 24, p. 578) missed the main point of my letter of Sept. 17. My intention was not to criticise these workers’ technique but to call attention to a universal biological phenomenon of which their material provided a special example. Whatever antibodies are present in the cord blood have not been formed by the fcetus in utero, but were derived from the mother by placental filtration ; in addition, only univalent antibodies can traverse the placental barrier, whereas bivalent antibodies cannot. Filtration of antibodies continues until an equilibrium is set up-namely, when the titres in maternal and cord sera are equal. It is manifestly impossible, therefore, for the cord sera titres to exceed the maternal sera titres, unless one makes the unlikely assumption that after equilibrium had - been reached antenatally, the maternal antibody titre began to fall and that the reverse process of filtration of antibody from the baby to the mother lagged behind. Whenever findings seem to conflict with an excellent theory it is a good idea to re-examine the data. Even that the laboratory error does not exceed conceding 10%, it is easy to see how a bias of considerably greater magnitude could arise. For example, if all the maternal sera are examined on one day using one animal, while all the cord sera are examined on another day and using another animal, the results would not be strictly comparable. Since the protocols are not available to me, it is of course not possible for me to state what bias if any existed in the present study. A. S. WIENER. New York. DANGERS OF LEAD NIPPLE-SHIELDS are comfortable to the nursing mother. They are pliable and fit like a cap on the nipple. Their danger is set forth in the article by Dr. Gordon and Mr. Whitehead in this issue. They are widely used and readily obtainable in chemist’s shops. In London they are advocated in large maternity units, including at least one important maternity hospital. In the North of England, we are informed, sales are even larger, and in the Midlands they are recommended in a neonatal unit famous throughout the country. The reason given for their use is that the lead assists the healing of cracked nipples ; and so it does, but unfortunately this process occurs at the expense of administering lead compounds to the suckling infant at every meal. We have been told that the use of the shields is recommended only for a week or two, but even so the danger remains. On inquiry we found that mothers who like the shields do in fact take them home on discharge from hospital, and that they are able to obtain them free under the provisions of the N.H.S. Act. The usual form of chronic lead poisoning in the infant is lead encephalopathy, and Dr. Gordon’s article indicates that complete recovery of an infant from this disease is unusual. Generally the infant dies or is rendered mendefective. It is a disturbing thought that, among tally the many infants one sees with fits and mental defect, one may easily have missed cases of lead encephalopathy through failure to bear in mind the possibility of lead poisoning. The use of lead compounds in indus-
SIR,—Lead nipple-shields, unfortunately,
trial processes is hedged about by strict legal safeguards in order to prevent poisoning. There is, we suggest, no room for doubt that the sale of lead nipple-shields should be made illegal. The Ministry of Health has issued an urgent warning against using these shields ; and we acknowledge the generous help received from two large firms towards stopping their sale. Plastic nipple-shields, which are now on sale, might well be given a trial by those recommending the use of a shield. We appeal to doctors and midwives to do all they can to abolish the use of this dangerous metal in nipple-shields for nursing mothers. No mother would risk using them if she knew the facts. London,
HELEN M. M. MACKAY DONALD HUNTER.
E.2.
MIDWIFE
AND/OR
SIR,—In your leading
DOCTOR
article last week you have not
succeeded in being entirely objective. With regard to your comments on the mother’s supposedly mistaken preference for a doctor as analgesist, surely the present-day general practitioner is changing over very rapidly to the use of the Minnitt " special attachment " and even more rapidly to trichlorethylene frequently combined with pethidine. Even, however, if he still uses chloroform there is no evidence that in practice this delays delivery as you suggest. Bourne and Williams1 state: ’’ When chloroform was used as a routine for every delivery at Queen Charlotte’s Hospital there was found to be no increase in the time of labour, an unchanged forceps-rate, no greater incidence of postpartum haemorrhage, and no greater stillbirth rate." Rightly or wrongly the midwife is not allowed to use any of these aids and she realises that her own Minnitt apparatus without attachment is already out of date and out of favour with patients who have experience of other methods. What woman doctor or doctor’s wife would deny herself one or the other ? Dr. Grantly Dick Read does not deny them if requested and incidentally is himself present at the confinement. How else could he have made his observations and added to the sum of our knowledge? Surely if the maternal-mortality rate for cases superintended by the Queen’s Institute of District Nursing— 0-74 per 1000 births-includes those transferred to general practitioners as " aid cases," the latter cannot have dealt with them so incompetently ; yet in the next paragraph dealing with the admitted deficiencies in the general practitioner’s training you imply that Sir Eardley Holland’s investigation applied only to booked doctor’s cases. I have not the report by me, but was this so’? Surely, Sir, the answer lies in the will to coöperate between midwife and doctor, the latter’s part in a normal case being mainly with analgesia. But how can a doctor be available in an emergency " such as a catastrophic postpartum haemorrhage unless he is in the house? We cannot do without each other. In this area the late Dr. R. E. Moyes and his colleagues themselves established the professional position of the midwives by refusing to attend a case at which a trained midwife was not in attendance, and so put an end to the era of the handywoman ; but he did not forget the importance of the presence of the practitioner during labour ; and you would do well to re-read his paper2 two appreciate the part played by the general practitioner in improving "
domiciliary midwifery. L
Amble, by Morpeth, Northumberland.
R. P. ROBERTSON.
** We should have made it clear that Sir Eardley Holland’s investigation covered all the maternal deaths (100) notified in a county during three years.-ED.L. 1. Bourne, A. W., Williams, L. H. Recent Advances in Obstetrics and Gynæcology. London, 1945 ; p. 54. Brit. med. J. 1936, ii, 386. 2. Moyes, R. E.