192

1. Cullen, T. S. Embryology, Anatomy and Diseases of the Umbilicus.London, 1916.

2. Standards and Recommendations for Hospital Care of Newborn Infants.American Academy of Pediatrics. Evanston, Ill., 1954.

3. Coventry, K. J., Isbister, C. Med. J. Aust. 1951, ii, 394.4. Forfar, J. O., Balf, C. L., Elias-Jones, T. F., Edmunds, P. N. Brit.

med. J. 1953, ii, 170.5. Hutchison, J. G. P., Bowman, W. D. Acta pœdiat., Stockh. 1957, 46, 125.6. Boissard, J. B., Eton, B. Brit. med. J. 1956, ii, 574.7. Kwantes, W., James, J. R. E. ibid. p. 576.8. Jellard, J. ibid. 1957, i, 925.9. Cook, J., Parrish, J. A., Shooter, R. A. ibid. 1958, i, 74.

10. Gillespie, W. A., Simpson, K., Tozer, R. C. Lancet, 1958, ii, 1075.11. Huntingford, P. J., Welch, G., Glass, U., Wetherley-Mein, G. J. Obstet.

Gynœc. Brit. Commonw. 1961, 68, 179.

information which is for ethical reasons unobtainable nowthat even moderately effective methods of treating hyper-tension are becoming available. Like all prognosticstudies of hypertension it is incomplete, because earlyand mild cases may be symptom-free and a completecradle-to-grave study of a representative sample of thecommunity is clearly impracticable. But when fullallowance is made for this factor the work of Dr. Sokolowand Dr. Perloff shows clearly that the term " benign "applied to hypertension must not be taken to mean thathypertension is ever a trivial disorder. And it emphasisesthe importance of making full use of hypotensive measuresand of increasing our efforts to understand and controlthis important disease.

INFECTION AND THE UMBILICAL STUMP

"UNTIL the advent of asepsis, myriads of childrensuccumbed to umbilical infection within a few days or afew weeks of birth." Nowadays we do not see manycases of tetanus, erysipelas, or gas-gangrene of the umbilicus.But in the past decade we became rather overconfident inour treatment of the neonatal navel. It was common

policy in hospital nurseries for the cord stump to be leftuncovered, though the reason for this is not clear. Presum-ably exposure to the air was thought to speed mummifica-tion and separation of the cord and to prevent anaerobicinfection. The American Academy of Pediatrics 2 statedin 1954 that " no dressing or binder is necessary ordesirable ". Exposure to the air is an excellent method ifthe cord stump can be left untouched and free fromcontact with airborne bacteria. But this was impossiblein hospital nurseries; cords not only were subjected to theineffective ritual of daily cleaning with surgical spirit, butwere touched by the ungloved hands of nurses changingnappies and by cot sheets and gowns. When it wasshown 3-5 that the umbilical cord of 50-80% of babiescarried a profuse growth of staphylococci and sometimesstreptococci,6 7 it became obvious that this was a danger-ous source of nursery infection, easily spread both bycontact and in the air. Since then, Jellard and others 9 10have shown that application of antiseptics or antibioticsto the umbilicus reduces the contamination of other siteson the infant as well as the sepsis-rate.

Huntingford et al.11 found that in virtually all infants theumbilicus is colonised at birth or in the first tweny-fourhours. Of three techniques for treating the stump-standard non-occlusive spirit technique, antibiotic or

antiseptic non-occlusive technique, and occlusive tech-nique with or without antibiotics-they showed the lastto be the most reliable and the most effective. They alsofound that when an antiseptic or antibiotic substance wasapplied, separation of the cord was delayed from aboutthe seventh to about the tenth day. Accordingly theyrecommend a keyhole dressing with sterile cord powder,held in place by a binder which is left untouched for aweek. This is very like the method used up to ten yearsago (and still in use in district midwifery. though usually

12. Montgomery, T. L. Amer. J. Obstet. Gynec. 1961, 81, 890.13. Cason, J. S., Lowbury, E. J. L. Lancet, 1960, ii, 501.14. MacCallum, F. O., McDonald, J. R., Macrae, A. D. Mon. Bull. Min.

Hlth Lab. Serv. 1961, 20, 114.

the dressing is changed once or twice in the week).Another suggestion about treatment of the neonatalumbilicus is made by Montgomery 12 from Philadelphia:

" In our clinic we are of the opinion that immediate ligationand severance of the cord locks up culture medium in the bloodchannels which predisposes to bacterial invasion. On the otherhand, non-ligation or later severance and late ligation of thecord permit of complete emptying of vascular channels, col-lapse of vessels, and more prompt desiccation and resistance toinfection. In addition, we feel that the umbilicus of the new-born should be dressed as a surgical wound until it is healed."The last sentence takes us back to a monograph by Runge,written in 1893 and cited by Cullen.1 Runge usuallyrefers to the navel as " the umbilical wound " :

" The umbilical wound is most frequently the point of entryof infective material ... the carrying of infective material to awound in the newborn is almost entirely through contact, andinfection through the air is, to say the least, doubtful ...in the newborn the organisms most frequently found are

streptococci and staphylococci."With the work of Lowbury and his colleagues in

Birmingham on the care of burns and open wounds as anexample,13 there should be no excuse nowadays for carelesstreatment of the umbilical wound.

PRETTY POLLY?

WITHIN three years of the first recognition of psittacosisin this country the essentials of its causation and epidemio-logy had been established by Sir Samuel Bedson and hiscolleagues. As an immediate result the importation ofparrots, except under licence, was forbidden from 1930until 1952. Pressure from the pet trade then ended thisprohibition, and within a few months infections due torecently imported parrots were reported from severalplaces. The ban was reimposed, but licences to import-e.g., for zoological collections-are still granted onoccasion.The disease is not confined to the larger parrots.

Budgerigars (which are, of course, parrots in miniature)have caused infections in man; and the virus (or a verysimilar one) has been isolated from fulmar petrels, ducks,and pigeons. It has been noticeable that human infectionsderived from these birds are on the whole less severe thanthose from imported parrots. In the past three yearsMacCallum and his colleagues in the Virus ReferenceLaboratory 14 have examined a variety of psittacine birdswhich had died from causes unknown. They failed todetect the virus in 101 budgerigars (presumably home-bred) but found it in 3 out of 10 parrots of larger specieswhich had been imported under licence. Other workershave reported similar findings, and it is evident that theban on importation should remain in force. Now that

Jack no longer returns from the sea with a parrot on hisshoulder as a gift for his mother, it is unlikely to causemuch unhappiness. There are a fair number of thesedecorative freaks already in this country, and the highprice that they command should encourage further

attempts to make them breed in captivity.Some features of psittacosis are still unexplained. It is

difficult to account for the difference between the seriousdisease derived from imported parrots and the milder one(ornithosis) from home-bred birds, except on the assump-tion that they are due to different but closely relatedviruses; but of this difference we have no evidence.