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Editorials

Science in court

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2254 (Published 03 June 2009) Cite this as: BMJ 2009;338:b2254

Debunking mis-information

Debunking mis-information

I agree that the law court is not the place to settle general scientific or medical issues.

Science, medicine and art are not as distinct as we generally think. When Simon Singh tells me in his book that Andrew Wiles solved Fermat’s last theorem I simply have to take his word for it, persuaded by the fascinating story. I have to have faith in Simon Singh’s investigation and in the integrity of Andrew Wiles and the mathematical community. There is no way I could ever confirm this fact myself. Mathematicians like Wiles, I understand, to prove a theory must go right back to first principles of mathematics and in the course of their proof must make no assumptions. Such an approach is completely impossible in science and medicine. We have to have faith in the integrity of those who have gone before; “On the shoulders of Giants”.

As Singh stated in his book on Fermat’s Last Theorem “Someone who flouts this system” (The integrity of professors at top-flight universities) “can create confusion for a very long time, since no one has the time or the motivation to follow him around and debunk his claims whenever he makes them.”

Such “confusion” has occurred in the physiological description of transitional circulation at birth in the majority of standard physiology, paediatric and cardiology textbooks. Physiology is the study and description of a natural process and cannot include an artificial intervention. It might be appropriate, at the end of the physiological description, to include the effect of a common or routine intervention and perhaps an explanation as to why the intervention takes place. Without such explanation the intervention is perceived by the naïve student as part of natural physiology.

Principles of Physiology (page 349) has a chapter on Circulatory Changes That Occur at Birth. The text describes the constriction of the umbilical vessels as a result of the bradykinins or clamping of the umbilical cord. Other Physiology textbooks (Functional Human Anatomy page 447, Physiology and Anatomy page 595, Textbook of Anatomy and Physiology page 444) describe cutting or application of a cord clamp in the changes at birth to the circulation, without adequate explanation that the clamp is not part of the physiological process.

In Forfar and Arneil’s Textbook of Pediatrics ( page 106-107) in a paragraph entitled “The Normal Fetal-Neonatal Transition” the statement if lung expansion fails, death will occur quite rapidly and shortly after the umbilical cord is clamped. In Heart Disease, A Textbook of Cardiovascular Medicine (page 1512) describing the physiological changes at birth there is the statement that “Systemic vascular resistance rises when clamping of the umbilical cord removes the low resistance placental circulation.”

These are just a few examples, virtually all textbooks include the cord clamp or an indirect referral to it. The only text which gives a full physiological explanation without any referral to a cord clamp or an indirect “removal of the placental circulation” is Gray’s Anatomy ( page 1053).

Why this distortion is so wide I do not know. Why this distortion, which I have pointed out repeatedly, is largely ignored or considered unimportant, I cannot understand. Many of those I ask will respond claiming that “transition at birth” is not a subject that they know much about. It does not take any knowledge to realise that an artificial intervention is not part of physiology. It is as simple as that.

Is it of any importance? Firstly it is importance as a principle. I am not aware that Fermat’s Last Theorem has any real importance. (I could be wrong!) However, I suspect, Wiles was trying to solve it more as a principle, to champion Fermat’s reputation, rather than the amazing effect it would have on world mathematics.
However, distorting transitional physiology does have serious world health consequences. The majority of the world’s obstetricians, paediatricians and some midwives consciously or unconsciously think that the cord clamp is necessary to complete transition at birth. They think that it is a necessity, a recent article in the British Journal of Midwifery claimed it is a “physiological necessity”. Obstetricians and paediatricians are prepared to investigate how quickly the clamp should be applied, the institutions consider delayed clamping is the intervention which needs to be assessed for safety. What evidence there is, all points to harm for the current common practice of immediate or early cord clamping.

There are a few of us prepared to go around to try to debunk the idea that the cord clamp is part of physiology. The law court is not the place to argue the principle of physiology. Let us hope it is not the place where, in years to come, those harmed by the cord clamp will seek redress.

Competing interests:
None declared

Competing interests: No competing interests

08 June 2009
David JR Hutchon
Consultant Obstetrician
Memorial Hospital, Darlington. DL3 6HX