844

Operation for flexion contracture of knees (a) before; (b) after.

he could walk as well as before the operation. This was nearly2 years ago, and he is now more stable than before and walkingbetter. The delay, which might well have led to failure, wasprobably caused by a number of factors. The patient’s patternof walking was well established. With his feet flat on thefloor there was a major change in this pattern which was verydifficult for him to appreciate. This operation included a

tendon release, which deprived him of part of his muscle andtendon sense, changing his reflex pattern. His drive andendurance was overestimated.

No doubt there is a place for surgery in the adultspastic, but the advantages must be very carefully con-sidered beforehand, and endless time and patience maybe needed in the after-treatment.

RECREATION

Before their arrival the residents had had almost no

experience of playing games. Their reaction to ball gameswas that they could not and did not want to play. Thisattitude changed very quickly and they now enjoymodified games of tug-of-war, cricket, croquet, and foot-ball, and take part in obstacle races. The team spirit isencouraged and teams are so picked as to balance theirhandicaps as evenly as possible. As a result of this, bigmovements, involving hand and eye coordination andbalance, have improved noticeably.The residents are encouraged to manage their own

affairs through their own social committee. Entertain-ment for those who wish to take part is provided in thelounge in the evening, and there are frequent social out-ings to the theatre and places of interest.

CONCLUSIONS

The treatment and management of adult spastics wasapproached with caution, and no dramatic results wereexpected. In the course of 3 years’ experience the resultshave been encouraging. Only two out of eleven womenresidents could walk when they first came to Prested

Hall. At the end of the first 8 months nine could walk ontheir own or with some mechanical aid. Of the men nineout of eighteen could walk, with or without aids; andthis number was increased to eleven in the same period.

Given a chance to follow an occupation and to learna remunerative trade, most residents have shown an

ability to improve their dexterity. Two have achieved

independence in a sheltered workshop. Four have

improved enough to pass on to another of the society’scentres for more advanced training. Five were dischargedas unlikely to improve with further treatment. Two leftbecause their local authorities withdrew their grants.One died as a result of an epileptic fit.

In seeking employment, one of the most difficultobstacles is the average employer’s reluctance to takeon a spastic-not necessarily because of his physicallimitations, but because of his appearance. This should

improve as the condition is more widely understood bythe lay public. Another difficulty is the trade-union ratefor the job. Most spastics are unable to work economicallybecause they are slow, but they are quite capable ofdoing a good job, if they can be paid what they are worthand if they do not hold up a production team. The

spastic’s appearance suggests that he is accident-prone,but though there are two electric lathes, an electricdrill, many sharp tools in the occupational-therapydepartment, and the usual kitchen ware in the kitchen,there have been no accidents so far. This suggeststhat spastics are not as clumsy as they often appear.

FUTURE

There is undoubtedly a need for assessment and earlytraining of spastics before admission to industry or aspecific training-centre. Unfortunately there will alwaysbe those who cannot live independently or even workeconomically in sheltered conditions. It will be possibleto make these less dependent and more able to appreciatea fuller life by a stay at such a centre, even if theyeventually have to return to their homes or some type ofinstitution. For the future we must look to the children,and if possible prevent or reduce the incidence of spasticdisease; for there is no cure. With a better under-

standing and better treatment of spastic children, weshould see less deformity, both mental and physical.When a child is found to be spastic, the aim must bemaximum capability, making the most of the remainingundamaged part of the brain.

I am grateful to Dr. J. D. Kershaw, a member of the centre’scommittee, for his advice on this paper; to Mr. J. H. Watson, thewarden; and to members of the staff whose cooperation and team-work have made this treatment centre possible.

AN ORAL CONTRACEPTIVE

ON April 9, at the London School of Hygiene andTropical Medicine, Dr. GREGORY PiNCUS gave the secondOliver Bird lecture, on Fertility Control with OralMedication. Sir Russell Brain, president of the FamilyPlanning Association, took the chair.

Experiments five or six years ago, said Dr. Pincus, showedthat though the normal function of progesterone was to helppregnancy by ensuring implantation of the ovum, in large andappropriately timed doses it would inhibit ovulation in all

species and prevent fertilisation. Since injections of pro-gesterone were painful, and oral doses not very effective,allied compounds were sought in the hope of finding one thatwould be more effective by mouth. Three 19-norsteroids

emerged, all especially active in inhibiting ovulation: ’Nor-

845

lutin,’ ’ Enovid,’ and Nilevar ’—or compounds i, 11, and ill

respectively. Of these enovid was the most potent inhibitor offertility in the rat and of ovulation in the rabbit. It had some

progestational effect, but less than progesterone, and some

cestrogenic effect.The three compounds were tested for their effect in inhibit-

ing ovulation in women-first in volunteers, giving one 10 mg.tablet daily from the 5th to 24th days of the menstrual cycle,then in patients in a mental hospital. The indices of ovulation

used were: (1) the peak of temperature; (2) vaginal smears;(3) endometrial biopsy; and (4) urine output of pregnanediol.In the volunteers, with compound I, the mean length of themenstrual cycle was unchanged, evidence for ovulation waslacking in 76% of cycles by endometrial biopsy and in 92% byother tests, and pregnanediol excretion fell to a tenth of normal.At laparotomy in 12 women, no evidence was found of recentovulation, When treatment was stopped, normal cycles wereresumed, though the first was delayed. The findings withcompounds n and ill were similar. In the mental-hospitalpatients, there was some shortening of the cycle with com-pound i, but not 11. The plasma-free corticoids were increasedor unchanged, and the plasma-bound corticoids decreased.With compound 11, there was diminished excretion of cortico-steroids, pregnanediol, and gonadotrophin.A field trial was then begun, in cooperation with the Family

Planning Association of Puerto Rico, to test the contraceptiveeffects of enovid. Women were given tablets and told to takeone daily from the 5th to the 24th day of the cycle, and werevisited monthly by social workers who asked them how many

tablets they had in fact taken; if they had missed any they wereadvised to go on till they had taken all twenty. 70% of thewomen took the tablets daily as prescribed; in these the cyclelength was normal, with a less wide range of lengths than isfound in untreated women; in those who missed one to fivetablets the cycle tended to be shorter or longer than normal,and in those who missed more than five the cycle tended to belonger. The output of corticosteroids in the urine was

decreased; the haemoglobin and clotting-time remained thesame, and the bleeding-time became a little shorter. Themenstrual flow seemed unchanged but there was a tendencyfor dysmenorrhoea to be relieved. Endometrial biopsiesrevealed much the same picture throughout the cycle-thattypical of the 19th day normally-and oedema of the stroma.14% of the women had side-reactions, such as nausea andabdominal pain, which were sometimes severe enough to causethem to abandon their tablets, but which were relieved byantacids in 90%, and by a placebo in 65%, of cases. Theeffectiveness of the drug as a contraceptive is shown by thesefigures :

Dr. Pincus concluded that enovid, by virtue of its actionin inducing a premature luteal phase, is an effective contra-

ceptive ; and most women are happy taking it. The problem inPuerto Rico is to find enough of it to satisfy the demand.

The Widdicombe File

XLV. CAROLINE’S FUTURE

MY DEAR RICHARD,How thoughtful of you to send me your Uncle Tom’s

letter !* And how nice to see that he is still the same dearlittle boy I remember so well-perhaps a little younger,but then time does fly so, doesn’t it ? And what a coinci-dence that it should arrive just at a time when we are allso preoccaspied with our granddaughter Carrie’s future.I do so vividly remember dear Noel sitting beside Jeremyand me on the beach in Capri (or was it the terrace inNaples ?) and giving us the most wonderful advice aboutSylvia. That was Carrie’s mother, of course. And I wishI could remember what exactly his advice was: but Iknow that it had something to do with her going on thestage. And that really was many years before she went toAmerica with Jim (her first) and started to collect thosequaint little ottos (or are they oscars ?) which now clutterup the house so badly.

Well, poor Noel cannot afford to live in England anylonger; so there was nobody to tell me what to do withCarrie until you sent me Tom’s letter. And I was justabout to give her all the wrong advice! Because I didhave misgivings about her wanting to do Medicine. Sucha noble profession, of course! But I never realised what adreadful state it had got into and that you needed youngwomen so badly. Not until I read Tom’s letter. It usedto be so different when I was young. Why, I rememberthat all my doctor friends used to be intense about theirwork: and I cannot remember one who wanted to playwith first-stage rockets (whatever they are) instead of

looking after his patients. But I am sure that’s allbecause today the poor boys are " dragged " and" pushed " and " bullied " and even " cheated " into theprofession, instead of being allowed to stay at home. No

* Reproduced in the Widdicombe File, March 1.

wonder they become such bad doctors. But my dear

Richard, you really must put poor Tom’s mind at rest.There is still Carrie, and some of her friends, who reallywant to do Medicine: and you cannot imagine howwonderfully intense they feel about it: and with so manylives entrusted to them, let us hope that they always willdo. (And surely there must be a few young men leftlike that!)But then, I must confess to you, there was also this

question of marriage that kept worrying me. Not thatCarrie ever consults me or Sylvia about things like that:but watching our own Dr. Misgust, who comes to writeup Jeremy for his sleeping-pills, I did become quiteperturbed. Because the poor man is always so terriblybad-tempered: never a moment even to sit down, thoughhe is really wonderfully kind and insists on sending us tothe very best hospitals even when it’s only a sore throat.And when he did come to tea the other day I felt so sorryfor his poor dear wife; because I am sure that she wasn’tnearly so interested in cancer and yellow fever as Jeremyand I and the Vicar and Mrs. Appleby: and they do havetea together quite often. But I see now how different itwill be for Carrie. After all, it is quite likely that shewill marry a doctor: and then, as Tom says, she and herhusband will be able to forget about their marriage nowand then and talk " shop ". And when I think of all myfriends and their husbands who have had nothing to talkabout for the last thirty years, and when I have to listento Jeremy who still talks tinned fruit (although it’s fiveyears now since he retired) every time I want to talk tohim about something interesting, well, isn’t it going tobe fun for Carrie and her husband to talk the same" shop " to each other any time they feel like talking ?But, of course, Carrie might not marry a doctor ... onlywhy does Tom say that if she didn’t, it would have to bea poor half-wit ? Not that I think that all husbands needto be intelligent, or even bright: but it is really distressingto think that there are only a few Englishmen left who areable to grasp that being a doctor one cannot help learning