418 WHOSE TURN NOW?
SIR,-Your editorial (Aug. 7, p. 298) sympathetically draws attention to the problems of the handicapped child growing up and seeking a place in society. The plea for a co-ordinator should be warmly supported, but the choice may depend on local circumstances-for instance, the severely handicapped adolescent with spina bifida may benefit greatly by absorption into a paraplegic unit. Nor should the work of the parents’ associations be forgotten when considering community help for such adolescents. The suggestion that spina-bifida children "spawned the specialty of paediatric surgery" must be disputed: they may have encouraged the growth of the specialty and particularly the increase of neonatal surgical centres, but even in those centres where neural-tube abnormalities at their peak accounted for nearly 50% of the neonatal surgical admissions, they still formed rather less than 15% of the paediatric surgical admissions over the age of four weeks. A professional association of psediatric surgeons was formed in Scotland in 1948, and in the United Kingdom as a whole psediatric surgery was so far advanced as a specialty by 1953 that the British Association of Paediatric Surgeons was founded-the first such association in the world. This was some five years before the Holter valve became available and seven or eight years before the introduction of the aggressive approach to the treatment of spina bifida. If this was spawning surely the egg came before the chicken. Department of Paediatric Surgery, University of Liverpool, Hey Children’s Hospital, Liverpool L12 2AP
that while it takes a year to train teachers expertly, individual couples can use the method efficiently within 3 months if taught by a properly trained instructor. The only other prospective survey of the sympto-thermal method of birth regulationzused the couple-to-couple method of instruction. This international two-year prospective study (1971-73) collected data on 21 830 cycles from 1028 couples in five countries. Each departure from the trial, whether dropout or pregnancy during the two-year period, was thoroughly analysed. The rate of failure for the total sample was 7.6 per 100 women-years. It was found that the percentages of effectiveness reached by the couples in the five countries were strongly influenced by the definite intention at the very beginning of the study, either to space births or to avoid any conceptions at all. For instance, in Canada, the couples who merely wished to space births showed a pregnancy-rate of 14.9 per 100 women-years, while those who wished to avoid any conception at all had a rate of 1 -11 per 100 women-years. This shows the influence of motivation on the use effectiveness of the sympto-thermal method. It would be interesting to see whether Marshall’s women showed this trend and whether teaching and motivation can explain the great difference in the pregnancy-rate between these two surveys. Department of Obstetrics and Gynæcology, New Maternity Hospital, Queen Elizabeth Medical Centre, Birmingham B15 2TG
ANNA M. FLYNN JOHN KELLY
Alder
JAMES
LISTER
NATURAL METHODS OF FAMILY PLANNING
SIR,-With reference to Professor Marshall’s article (Aug. 7, p. 282) we would like to make the following points. Professor Marshall suggests in his article, and has confirmed it
verbally, that all the patients in his study were instructed by correspondence service in the cervical-mucus and basal bodytemperature methods of regulating birth. Experienced teachers of natural methods of family planning would disagree that these methods can be taught by correspondence. Moreover, they emphasise that the mucus method should preferably be taught by person-to-person instruction. In a study’ of 29 menstrual cycles in which basal body temperature and cervical mucus were assessed against oestrogen, luteinising hormone (L.H.), and progesterone, we found that, while mucus appeared on an average 5.2 days in advance of ovulation as estimated by the L.H. peak, the range of appearance varied between 3 and 8 days. For the individual patient, however, the a
time of appearance of the mucus was consistent for the three consecutive cycles studied, always appearing in some women 3 days in advance of the L.H. peak and 8 days in others. Whether this is a biological fact or an observational error on the part of the individual women, is now under investigation. What it does demonstrate is the need for expert and careful instruction over the early months of charting in order to ascertain the particular pattern of mucus for any individual. We agree with Marshall that a study of sperm survival is long overdue both for natural family planning and for the setting up of sperm banks. Since the type of teaching and the quality of the follow-up are of such importance to the eventual effectiveness of these methods, we declined two years ago to take part in the World Health Organisation survey because of our insufficiency of trained teachers at that time. In October, a group of 9 doctors, 54 nurses, and 13 lay women teachers will have completed their year’s training course for teachers in natural methods and will be available for the instruction of more couples in our area. Our experience with this course has led to the conclusion 1.
Flynn, A. M., Lynch, S. S. Br. J. Obstet. Gynœc. (in
the
press).
INTRACELLULAR LITHIUM AND CLINICAL RESPONSE
SIR,-Apparently conflicting data on the prediction of lithium response from intracellular lithium concentrations have been reported by Mendels et al. (May 1, p. 966) and Rybakowsky and Strzewsky (June 26, p. 1408). We have studied red-blood-cell (R.B.C.) lithium levels and R.B.c./plasma lithium ratios in patients diagnosed by the research diagnostic criteria of Spitzer et awl. as either primary affective disease or schizoaffective illness. Sixteen patients with symptoms of sufficient severity to warrant a clinical trial of lithium were studied. Multiple determinations (from 3-6 per patient), on specimens drawn 10-12 hours after the last dose of lithium carbonate, were made for plasma and red-cell lithium. The sixteen patients were evaluated by three criteria: (1) they showed a clinically good or excellent response to lithium; (2) they did not require other drugs and were discharged from hospital as recovered on lithium maintenance; and (3) successful maintenance for at least 6 months. Seven of these patients showed a good response to lithium clinically; they were treated with and discharged on lithium carbonate only. The nine patients in the non-responder group failed these criteria-i.e., they responded poorly to lithium and they required other medication before discharge. There was a big difference in the R.B.c./plasma lithium ratio between the patients: good raponders had a ratio of 0-S6±0-04 and non-responders had a Student’s t-test). Most of the ratio of 0.34::t0.05 (p
SIR,-Your editorial (Aug. 7, p. 298) sympathetically draws attention to the problems of the handicapped child growing up and seeking a place in society. The plea for a co-ordinator should be warmly supported, but the choice may depend on local circumstances-for instance, the severely handicapped adolescent with spina bifida may benefit greatly by absorption into a paraplegic unit. Nor should the work of the parents’ associations be forgotten when considering community help for such adolescents. The suggestion that spina-bifida children "spawned the specialty of paediatric surgery" must be disputed: they may have encouraged the growth of the specialty and particularly the increase of neonatal surgical centres, but even in those centres where neural-tube abnormalities at their peak accounted for nearly 50% of the neonatal surgical admissions, they still formed rather less than 15% of the paediatric surgical admissions over the age of four weeks. A professional association of psediatric surgeons was formed in Scotland in 1948, and in the United Kingdom as a whole psediatric surgery was so far advanced as a specialty by 1953 that the British Association of Paediatric Surgeons was founded-the first such association in the world. This was some five years before the Holter valve became available and seven or eight years before the introduction of the aggressive approach to the treatment of spina bifida. If this was spawning surely the egg came before the chicken. Department of Paediatric Surgery, University of Liverpool, Hey Children’s Hospital, Liverpool L12 2AP
that while it takes a year to train teachers expertly, individual couples can use the method efficiently within 3 months if taught by a properly trained instructor. The only other prospective survey of the sympto-thermal method of birth regulationzused the couple-to-couple method of instruction. This international two-year prospective study (1971-73) collected data on 21 830 cycles from 1028 couples in five countries. Each departure from the trial, whether dropout or pregnancy during the two-year period, was thoroughly analysed. The rate of failure for the total sample was 7.6 per 100 women-years. It was found that the percentages of effectiveness reached by the couples in the five countries were strongly influenced by the definite intention at the very beginning of the study, either to space births or to avoid any conceptions at all. For instance, in Canada, the couples who merely wished to space births showed a pregnancy-rate of 14.9 per 100 women-years, while those who wished to avoid any conception at all had a rate of 1 -11 per 100 women-years. This shows the influence of motivation on the use effectiveness of the sympto-thermal method. It would be interesting to see whether Marshall’s women showed this trend and whether teaching and motivation can explain the great difference in the pregnancy-rate between these two surveys. Department of Obstetrics and Gynæcology, New Maternity Hospital, Queen Elizabeth Medical Centre, Birmingham B15 2TG
ANNA M. FLYNN JOHN KELLY
Alder
JAMES
LISTER
NATURAL METHODS OF FAMILY PLANNING
SIR,-With reference to Professor Marshall’s article (Aug. 7, p. 282) we would like to make the following points. Professor Marshall suggests in his article, and has confirmed it
verbally, that all the patients in his study were instructed by correspondence service in the cervical-mucus and basal bodytemperature methods of regulating birth. Experienced teachers of natural methods of family planning would disagree that these methods can be taught by correspondence. Moreover, they emphasise that the mucus method should preferably be taught by person-to-person instruction. In a study’ of 29 menstrual cycles in which basal body temperature and cervical mucus were assessed against oestrogen, luteinising hormone (L.H.), and progesterone, we found that, while mucus appeared on an average 5.2 days in advance of ovulation as estimated by the L.H. peak, the range of appearance varied between 3 and 8 days. For the individual patient, however, the a
time of appearance of the mucus was consistent for the three consecutive cycles studied, always appearing in some women 3 days in advance of the L.H. peak and 8 days in others. Whether this is a biological fact or an observational error on the part of the individual women, is now under investigation. What it does demonstrate is the need for expert and careful instruction over the early months of charting in order to ascertain the particular pattern of mucus for any individual. We agree with Marshall that a study of sperm survival is long overdue both for natural family planning and for the setting up of sperm banks. Since the type of teaching and the quality of the follow-up are of such importance to the eventual effectiveness of these methods, we declined two years ago to take part in the World Health Organisation survey because of our insufficiency of trained teachers at that time. In October, a group of 9 doctors, 54 nurses, and 13 lay women teachers will have completed their year’s training course for teachers in natural methods and will be available for the instruction of more couples in our area. Our experience with this course has led to the conclusion 1.
Flynn, A. M., Lynch, S. S. Br. J. Obstet. Gynœc. (in
the
press).
INTRACELLULAR LITHIUM AND CLINICAL RESPONSE
SIR,-Apparently conflicting data on the prediction of lithium response from intracellular lithium concentrations have been reported by Mendels et al. (May 1, p. 966) and Rybakowsky and Strzewsky (June 26, p. 1408). We have studied red-blood-cell (R.B.C.) lithium levels and R.B.c./plasma lithium ratios in patients diagnosed by the research diagnostic criteria of Spitzer et awl. as either primary affective disease or schizoaffective illness. Sixteen patients with symptoms of sufficient severity to warrant a clinical trial of lithium were studied. Multiple determinations (from 3-6 per patient), on specimens drawn 10-12 hours after the last dose of lithium carbonate, were made for plasma and red-cell lithium. The sixteen patients were evaluated by three criteria: (1) they showed a clinically good or excellent response to lithium; (2) they did not require other drugs and were discharged from hospital as recovered on lithium maintenance; and (3) successful maintenance for at least 6 months. Seven of these patients showed a good response to lithium clinically; they were treated with and discharged on lithium carbonate only. The nine patients in the non-responder group failed these criteria-i.e., they responded poorly to lithium and they required other medication before discharge. There was a big difference in the R.B.c./plasma lithium ratio between the patients: good raponders had a ratio of 0-S6±0-04 and non-responders had a Student’s t-test). Most of the ratio of 0.34::t0.05 (p
