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any surgeon will confirm). But there are other factors.The umbilical stump is more friable than most pedicles,the tissues are often cedematous, and there is consider-able shrinkage in the first twenty-four hours. These

peculiarities make it hard to ligate the cord securely,and a recent study of the situation by NELIGAN andSMITH 1 is timely. Under strictly comparable conditionsin the laboratory and using lengths of fresh cord, theycompared four methods of cord occlusion: singleligature using commercial umbilical tape tied as tightlyas possible with a reef knot; two such ligatures about1 mm. apart; metal clip applied with special crushingpliers; and plastic clamp applied with finger pressure.The various methods of occlusion were each tested 50times by means of a known hydrostatic pressureapplied between six and twenty-four hours after

ligation when the cord had shrunk considerably. Theleast efficient method was the tape ligature; when onewas used there was leakage in 38 out of 50 cases, andeven with a double ligature there was leakage in 34cases. With the metal clip there was leakage in 10 cases(2 were caused by failure to occlude the vein and theremaining 8 by tearing of the cord and vein duringapplication: quite often these tears were inconspicuousand not noticed until the leak was revealed by thehydrostatic test). The plastic (Hollister) clamp waseffective in all 50 cases, and NELIGAN and SMITHattribute this to the fact that the clamp does not tearthe cord when first applied and it maintains a continuouscompressing action on the stump during shrinkage. Infurther clinical trials NELIGAN et a1.3 saw 2 cases inwhich the plastic clamp slipped off the cord stumpshortly after it was applied. No harm came to thebabies, but after this experience the manufacturersimproved the design of the clamp’s jaws.The standard method of ligating the umbilical cord

with one (or two) inelastic tapes is unreliable and maywell account for a number of avoidable tragedies eachyear. The ideal arrangement is some form of immediatecompression followed by continuous pressure over thenext twenty-four hours. This has long been advocated,and various devices have been described.2-8 The plasticclamp is effective, but its drawbacks are cost, a ratherfrightening appearance in some mothers’ eyes, and theneed to remove it before the cord becomes too

gangrenous.3 Rubber or elastic bands fulfil the require-ments of immediate compression and continuous

pressure and have been used by certain obstetriciansand paediatricians for some time.2 s-lo But many of the

techniques described require a special instrument toapply the band and some manipulative skill. NELIGANet al.3 examined the use of elastic bands in ligating thecord and they have reported on the most suitable typeof band, its reliability when tested in the laboratory,and a simple method of applying it to the cord. The

3 Neligan, G. A., Parkin, J. M., Paul, C. Arch. Dis. Childh. 1964, 39, 630.4. Gigli, A. Mschr. Geburtsh Gynäk. 1902, 16, 659.5 Rothschild, C. Gynäk. Rdsch. 1910, 4, 148.6 Salvatore, J. E. Amer. J. Obstet. Gynec. 1957, 74, 1130.7. Lancaster, Y. ibid. 1958, 75, 428.8. Betheras, F. R. Lancet, 1963, ii, 921.9. Reid, D. Textbook of Obstetrics; p. 469. Philadelphia, 1962.

10. Averbach, L H., Hoffmeir, C. I. Obstet. Gynec. 1964, 23, 146.

most suitable sample tested proved to be a flat elasticband of pure rubber. None snapped after beingcontinuously stretched for up to one month, and whenreleased they reverted virtually to their original length.These properties were unaltered by immersion in a

1 : 500 solution of cetrimide for fourteen days or byautoclaving at 250°F (1200C) for thirty minutes. Thesterilised band is wound four times round the jaws ofa large artery forceps and transferred by means of atape to the umbilical stump. The technique is simpleand easily mastered and gives good control over theultimate position of the ligature on the cord stump.There is no damage to the elastic band or to theumbilical vessels, separation of the cord is accelerated,and the incidence of clinical infection is not increased.One difficulty is the rare but important case where thecord is much thicker than normal. Here the ligaturewhen applied may cut into the cord, and NELIGAN et al.advise that with an abnormally thick cord it is better totransfer the elastic band in stages using two tapes, oralternatively to use a plastic clamp of the improved type.NELIGAN and SMITH noted that the incidence of

umbilical haemorrhage increased in their hospital afterthe introduction of routine shortening of the cord fourto eight hours after birth. As this practice is now

widespread, cord haemorrhage may be commoner thanit has been. In the light of the laboratory and clinicalstudies in Newcastle, the standard method of ligatingthe cord with inelastic tape (even a double ligature) isineffective and potentially dangerous; and the metalclip is little better. Good-quality elastic bands, suitablyapplied, or plastic (Hollister) umbilical clamps are morereliable. With wider acceptance of these methods of

securing the cord, it should in time be possible toeliminate umbilical haemorrhage as a cause of anaemiaand even death in the newborn.

Gerontonomics

ALL political parties agree that welfare services for oldpeople are an important area for Government action.As one Minister of Health succeeds another, there areno drastic reversals of policy-at most, changes in

emphasis and rate of progress. But the financial prob-lems of old people are another matter. COLE andUTTING’S five-year-old survey 12 is still the main sourceof our knowledge, and recent research will help to bringthis up to date,13 Unlike their counterparts in othercountries, neither the Ministry of Pensions and NationalInsurance nor the National Assistance Board regardsresearch as one of its major responsibilities. Moreover,an uncritical defence of the privacy of their recordsprevents outside research bodies from using the massof information in their possession. If too little is knownabout those who receive State pensions and grants,still less is known about old people who rely on privatemeans. Research on occupational pension schemes hasbeen actuarial rather than sociological. There have been11. B.B.28. Manufactured by Berrick Bros. Ltd., 20-24, Kirby Street,

London, E.C.1.12. Cole, D., Utting, J. Economic Circumstances of Old People. Welwyn,

Herts, 1962.13. Wedderburn, D. Gerontologia clin. (in the press).

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surveys of pension schemes 14 15 but no surveys of

pensioners. Neither the income-tax age allowance northe higher tax-exemption limit for old people is based onany real knowledge of their needs.

In view of the dearth of hard facts about the financialneeds and resources of the old, it is not surprising thatdiscussion of pensions policy is emotional in tone andirrational in content. The Government apparentlyintends to remodel the whole social security system, torelate contributions to earnings, and to greatly increasebenefits. Before the merits and demerits of such a

reform are buried, as they are in danger of being,beneath the weight of Parliamentary (or unparliament-ary) invective, it is worth considering whether theredoes not already exist an area of agreed principle onwhich rational discussion could be based.

Few people, and no political party, would now disputethat retirement income should be related to previousearnings. Even the Labour Party’s " half pay on retire-ment " slogan today sounds remarkably modest; itwould be regarded as a minimum for any private " finalsalary " pension scheme. But agreement extends

beyond the actual moment of retirement. All partiesaccept that the pensioner must not only be protectedfrom the erosion of his standard of living by risingprices: he should also share in the higher standardsproduced by an expanding economy. Here the politicalgulf has narrowed since 1958, when a white-paper 16 setout the present graduated pension scheme, with itsimmutable sixpenny pension units. The weaknesses ofsuch a scheme have been recognised on both sides of thepolitical fence," 18 and no Government, of whatevercolour, is likely to repeat this fundamental mistake. Allparties agree, too, that there must be some redistributionin favour of the lower-income groups-though someagree more vocally than others. Another principlewhich commands general assent is the right of anemployee to change his job without losing his pension.The view that a pension scheme is a legitimate deviceto tie a man to his employer has been replaced by a newconcern for occupational mobility, even though themoral issues are still too often disregarded.There is, in short, a fairly wide area of agreement as to

ends. Unfortunately there is no such agreement as tomeans. In particular, there are radical differences ofview on the roles of the State and private employer.The Labour Party pays lip-service to the concept of"

contracting-out ", but it is hard to see how anyoccupational scheme could guarantee pensions equiva-lent to those proposed in the Labour plan of 1957,which is still the basis of the party’s policy. Essentiallythis is a plan for self-sufficient "

dynamic " State

pensions, with supplementary private schemes limitedto the higher salary levels. The Conservative viewtends to the other extreme. It regards the growth of14. Occupational Pension Schemes: A Survey by the Government Actuary.

H.M. Stationery Office, 1958.15. Pilch, M., Wood, V. New Trends in Pensions. London, 1964.16. Cmnd. 538. H.M. Stationery Office, 1958.17. Lynes, T. Pension Rights and Wrongs. London, 1963.18. MacGregor, J. Crossbow, 1964, 7, 29.

occupational schemes as thoroughly desirable andwould limit the role of the State to providing a basicminimum and to filling the gaps left by occupationalschemes. The Labour proposals would relate pensions inpart to career earnings, and weight them to take accountof current national average earnings. The pension wouldcontinue to rise after retirement (though whether itwould be tied to an index of prices or of earnings is notclear). The reduction in the scope of private schemeswould go far towards solving problems of transferability.To achieve these objectives by extending privateschemes would require more radical changes than is

generally recognised. Not only would the presentabortive graduated State scheme have to be wound up(which anyway seems inevitable), but occupationalschemes would have to offer dynamic- pensions, relatedto current living standards at the time of retirement andregularly revised. Complete transferability would beessential, as well as a vast extension of coverage. At

present occupational schemes cover (often inadequately)about 11 million people,19 or less than half the workingpopulation. As at present organised, most occupationalschemes cannot satisfy -the conditions which all politicalparties accept as the basis of pensions policy.

Objections to the Labour proposals, on the other hand,are not so much questions of principle as of practicality.It is easy to talk about the wholesale winding-up of privateschemes, but a scheme which has liabilities stretchingseveral decades ahead cannot be abandoned overnight.A minority of employees, moreover, will inevitably be(or believe themselves to be) worse off under NationalSuperannuation than in their existing occupationalschemes. Again, what effect would the change have onthe supply of investment capital ? Does the Govern-ment seriously contemplate the creation of a NationalPension Fund with the same freedom of investment as a

private fund ? The proposal for a transitional incomeguarantee for those who have been unable to build upan adequate pension in the new scheme also raises

practical difficulties. Is it really possible to demand thecompletion by every retired person of a regular incomereturn ? Can an adequate and workable system of checkson the accuracy of the returns be devised ? Can theanomalies resulting from the use of a past year’s incomeas the basis of the guarantee be avoided ?

These questions and many others must be answeredbefore the Government’s plans can be presented inlegislative form. Indeed, since pensions are only part ofthe general review of the social security system on whichMr. DOUGLAS HOUGHTON is now engaged, we mayexpect several months to elapse before the detaileddebate begins. This breathing-space can best be usedby all as an opportunity to think out afresh what arethe true objectives of social security, and the extent towhich those objectives stand on common ground. Ifthe Government is ready to plan on the basis of facts,and to share these facts with both the planners and thepublic, we may hope for a constructive discussion of thereal issues.

19. Bacon, F. W. Paper read to the British Association, 1964.