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WHEN TO TIE THE CORD
568
it is unlikely to be absorbed readily on account of the grave condition of the patient. Such cases are usually due to a malignant tertian infection, where speed in diagnosis and treatment is essential to lessen the risk of an early fatal issue.
WHEN TO TIE THE CORD few years ago- there was no difference of about when the umbilical cord should be obliterated and the vascular connexion between mother and infant severed. The standard textbooks usually sald " when the cord has ceased pulsating," and this was an easy rule to follow. The first element of doubt crept in as BARCROFT began to publish the results of his fascinating studies on the respiration of the foetus and newborn baby. It seemed to be a legitimate practical deduction that once the infant’s head was clear of the vulva and the respiratory tract was wiped clean of mucus in its upper reaches the sooner the cord was clamped the better, since this ensured the cutting off of oxygen which BARCROFT had shown was the most important stimulus for the first inspiration. So some obstetricians and their paediatric associates began to urge that the cord should be clamped earlier than hitherto, the paediatricians adding that since the infant spent the early days of life getting rid of his foetal polycythaemia there was no harm in preventing the placental apparatus passing over the last few teaspoonfuls of blood. One paediatrician, asserting that too much blood in the veins (hyperphlebaemia) was the cause of many troubles in infancy and childhood, urged that after the cord was cut some bleeding from the infant’s end should be encouraged. Now certain workers in Chicago are claiming that deprivation of placental blood may be a cause of iron deficiency in infants. According to E. E. WILSON, W. F. WINDLE and H. L. ALT,l when the umbilical cord is clamped immediately after birth, over 100 c.cm. of blood can usually be obtained from its placental end. They argue that this is equivalent to about a third of the blood-volume of the newborn infant, and that the iron liberated from the blood normally destroyed in the early days of life is stored and used for haemoglobin formation in later infancy. If this is so the deprivation of a third of the bloodvolume at birth may be a serious threat to the composition of the blood in the second half of the first year of life. Arithmetic is then brought in to suggest that deprivation of placental blood means that at 6 months of age the infant’s quantum of haemoglobin will be 9-1 g. instead of 12 g. per 100 c.cm. and at 9 months of age 9-7 g. instead of 12 g. per 100 c.om. In order to test the validity of this theory studies were made in a series of infants aged 8-10 months. In 15 of these infants the cord had been clamped immediately after birth and in 13 clamping had been delayed " until the placenta had begun to descend into the vagina." For the former group the average blood values were : red corpuscles 5,060,000 per c.mm., haemoglobin 10-8 g. per 100- c.cm. and mean corpuscular haemoglobin 21-8 tkttg. For the second group the corresponding figures were 4,450,000 per c.mm., 11-9 g. per 100 c.cm. and 27 ttttg. It- is claimed that, although the differences in the average erythrocyte counts and haemoglobin values for the two Up to
a
opinion
1. Amer. J. Dis. Child. 1941, 62, 320.
groups are not highly significant in themselves, the difference between the mean corpuscular ho6moglobin in the two groups is statistically significant and it is considered that the infants in the" immediate clamping " group showed evidence of a mild irondeficiency anaemia. All the infants investigated, however, came from families of a low income group and although nearly all were receiving some carrots, spinach and other green vegetables it would not be unreasonable to suppose that additional iron, as advocated by some experts for all infants, would readily abolish the slight difference between the two groups. As regards a possible anaemia in later infancy the idea of leaving the’ cord until the placenta has begun to descend into the vagina cannot then be said to be strongly supported. What may be called the Barcroft point of view seems to have better claims. Further work is still needed to decide whether any change is necessary in the standard midwifery teaching of tying the cord as soon as
pulsation
ceases.
Annotations SALT
WATER
SURGEONS
How old is the profession of ship’s doctor ? Perhaps as old as the ark, if Shem, Ham and Japheth founded that precedent by which three sons distribute themselves between the church, the law and medicine. But striding down a century or two we find the calling well established in the days of Augustus Caesar ; and Surgeon-Commander R. S. Allison, at the opening of the winter session of the Royal Victoria Hospital, Belfast, suggested that St. Luke himself may have been a ship’s doctor. In English ships the surgeon had a precarious status, but by the reign of Henry VIII-a monarch justly celebrated for were doing ratheruniting surgeons and barbers-they well, the " chief sirurgyon " getting a salary of 13s. 4d. a month. Queen Elizabeth chose William Gilbert, one of her own physicians and president of the College, to help to stem the increase of disease in her navy ; and John Woodall, first surgeon general to East India Company, followed " Generall Lancaster in recommending lemon juice as a cure for scurvy 180 years before its use became general. Woodall also wrote a textbook for ship’s surgeons which became a classic, noteworthy no less for its therapy than its piety. In the seventeenth and eighteenth centuries the status of ship’s surgeons was still in the balance. They were not commissioned officers and their pay and quarters were equally poor. Many of them were keen and devoted, striving against disease in their ships’ companies. Commander Allison recalled Smollett’s grim account (in" Roderick Random ") of his experiences, and quoted the vivid picture drawn by William Cockburn in 1697 of the ravages of typhus. He also mentioned Richard Walter, who described how severe scurvy could dissolve the callus of a well-healed fracture and leave it disunited ; and Lind and Anson, who found that " the number of seamen in time of war who die of shipwreck, capture, famine, fire and sword are inconsiderable in respect of such as are destroyed by the sea diseases." Another eighteenth century sea-surgeon, Thomas Trotter, fought well for his sailors, demanding from the Lords of the Admiralty not only the fresh fruits and vegetables which would clear their fleets of scurvy but other amenities. " Give your tars," said he, " Oh my countrymen, their amusements ; and while you enjoy yours on shore remember who they are that gave you security." And how strange that Dover’s powder-that symbol of drowsiness and gentle perspiration-should be the nostrum of a pirate who was presumably his own ship’s doctor : Thomas Dover, physician and privateer, the "
it is unlikely to be absorbed readily on account of the grave condition of the patient. Such cases are usually due to a malignant tertian infection, where speed in diagnosis and treatment is essential to lessen the risk of an early fatal issue.
WHEN TO TIE THE CORD few years ago- there was no difference of about when the umbilical cord should be obliterated and the vascular connexion between mother and infant severed. The standard textbooks usually sald " when the cord has ceased pulsating," and this was an easy rule to follow. The first element of doubt crept in as BARCROFT began to publish the results of his fascinating studies on the respiration of the foetus and newborn baby. It seemed to be a legitimate practical deduction that once the infant’s head was clear of the vulva and the respiratory tract was wiped clean of mucus in its upper reaches the sooner the cord was clamped the better, since this ensured the cutting off of oxygen which BARCROFT had shown was the most important stimulus for the first inspiration. So some obstetricians and their paediatric associates began to urge that the cord should be clamped earlier than hitherto, the paediatricians adding that since the infant spent the early days of life getting rid of his foetal polycythaemia there was no harm in preventing the placental apparatus passing over the last few teaspoonfuls of blood. One paediatrician, asserting that too much blood in the veins (hyperphlebaemia) was the cause of many troubles in infancy and childhood, urged that after the cord was cut some bleeding from the infant’s end should be encouraged. Now certain workers in Chicago are claiming that deprivation of placental blood may be a cause of iron deficiency in infants. According to E. E. WILSON, W. F. WINDLE and H. L. ALT,l when the umbilical cord is clamped immediately after birth, over 100 c.cm. of blood can usually be obtained from its placental end. They argue that this is equivalent to about a third of the blood-volume of the newborn infant, and that the iron liberated from the blood normally destroyed in the early days of life is stored and used for haemoglobin formation in later infancy. If this is so the deprivation of a third of the bloodvolume at birth may be a serious threat to the composition of the blood in the second half of the first year of life. Arithmetic is then brought in to suggest that deprivation of placental blood means that at 6 months of age the infant’s quantum of haemoglobin will be 9-1 g. instead of 12 g. per 100 c.cm. and at 9 months of age 9-7 g. instead of 12 g. per 100 c.om. In order to test the validity of this theory studies were made in a series of infants aged 8-10 months. In 15 of these infants the cord had been clamped immediately after birth and in 13 clamping had been delayed " until the placenta had begun to descend into the vagina." For the former group the average blood values were : red corpuscles 5,060,000 per c.mm., haemoglobin 10-8 g. per 100- c.cm. and mean corpuscular haemoglobin 21-8 tkttg. For the second group the corresponding figures were 4,450,000 per c.mm., 11-9 g. per 100 c.cm. and 27 ttttg. It- is claimed that, although the differences in the average erythrocyte counts and haemoglobin values for the two Up to
a
opinion
1. Amer. J. Dis. Child. 1941, 62, 320.
groups are not highly significant in themselves, the difference between the mean corpuscular ho6moglobin in the two groups is statistically significant and it is considered that the infants in the" immediate clamping " group showed evidence of a mild irondeficiency anaemia. All the infants investigated, however, came from families of a low income group and although nearly all were receiving some carrots, spinach and other green vegetables it would not be unreasonable to suppose that additional iron, as advocated by some experts for all infants, would readily abolish the slight difference between the two groups. As regards a possible anaemia in later infancy the idea of leaving the’ cord until the placenta has begun to descend into the vagina cannot then be said to be strongly supported. What may be called the Barcroft point of view seems to have better claims. Further work is still needed to decide whether any change is necessary in the standard midwifery teaching of tying the cord as soon as
pulsation
ceases.
Annotations SALT
WATER
SURGEONS
How old is the profession of ship’s doctor ? Perhaps as old as the ark, if Shem, Ham and Japheth founded that precedent by which three sons distribute themselves between the church, the law and medicine. But striding down a century or two we find the calling well established in the days of Augustus Caesar ; and Surgeon-Commander R. S. Allison, at the opening of the winter session of the Royal Victoria Hospital, Belfast, suggested that St. Luke himself may have been a ship’s doctor. In English ships the surgeon had a precarious status, but by the reign of Henry VIII-a monarch justly celebrated for were doing ratheruniting surgeons and barbers-they well, the " chief sirurgyon " getting a salary of 13s. 4d. a month. Queen Elizabeth chose William Gilbert, one of her own physicians and president of the College, to help to stem the increase of disease in her navy ; and John Woodall, first surgeon general to East India Company, followed " Generall Lancaster in recommending lemon juice as a cure for scurvy 180 years before its use became general. Woodall also wrote a textbook for ship’s surgeons which became a classic, noteworthy no less for its therapy than its piety. In the seventeenth and eighteenth centuries the status of ship’s surgeons was still in the balance. They were not commissioned officers and their pay and quarters were equally poor. Many of them were keen and devoted, striving against disease in their ships’ companies. Commander Allison recalled Smollett’s grim account (in" Roderick Random ") of his experiences, and quoted the vivid picture drawn by William Cockburn in 1697 of the ravages of typhus. He also mentioned Richard Walter, who described how severe scurvy could dissolve the callus of a well-healed fracture and leave it disunited ; and Lind and Anson, who found that " the number of seamen in time of war who die of shipwreck, capture, famine, fire and sword are inconsiderable in respect of such as are destroyed by the sea diseases." Another eighteenth century sea-surgeon, Thomas Trotter, fought well for his sailors, demanding from the Lords of the Admiralty not only the fresh fruits and vegetables which would clear their fleets of scurvy but other amenities. " Give your tars," said he, " Oh my countrymen, their amusements ; and while you enjoy yours on shore remember who they are that gave you security." And how strange that Dover’s powder-that symbol of drowsiness and gentle perspiration-should be the nostrum of a pirate who was presumably his own ship’s doctor : Thomas Dover, physician and privateer, the "