Planning for Parenthood

858

The follicles are generally large, are more striking in the upper and lower fornices, and may appear in the plica and caruncle as well. Fine or coarse epithelial punctate keratitis may be seen. Preauricular lymphadenopathy and upper-respiratory-tract infection, sometimes accompany the ocular syndrome. TRIC punctate keratoconjunctivitisl6 resembles inclusion conjunctivitis with additional signs of subepithelial punctate keratitis. The keratitis consists of discrete large infiltrations5 in the superficial stromal area of the cornea, resembling the subepithelial opacities which occur in keratoconjunctivitis due to adenovirus types 8 and 19.16,17 The TRIC agent keratitis generally appears in the upper and lower zones of the cornea and may remain for several months. Cases of sexually transmitted endemic trachoma, with pannus and scars, have been reported in the indigenous population of developed countries.3,4,1l,15 The disease is associated with chlamydial infection of the genital tract. Serotypes D-K can be isolated from the eye or the genital

tural tests with irradiated-McCoy-cell culture,23 or with McCoy cells treated with idoxuridine24 or cycloheximide,2s provide highly sensitive methods for detection and isolation of C. trachomatis. These tests take two or three days. Culture in irradiated McCoy cells is at least twice as sensitive as the direct demonstration of inclusions in conjunctival scrapings :26 the cultural test has yielded chlamydia in up to 90% of cases of TRIC ophthalmia neonatorum and inclusion conjunctivitis, in up to 82% of cases of severe hyperendemic trachoma, and from the cervix of up to 90% of women with ocular TRIc infection or mothers of babies with TRIc ophthalmia neonatorum.l4 Lately, DAROUGAR and TREHARNE27 have described a simple and rapid serodiagnostic test for ocular chlamydial infections. It is based on the detection, by a modified microimmunofluorescence test, of various immunoglobulin classes of type-specific antichlamydial antibody -i.e., IgG and IgM in the blood and IgG and in the tears. Finger-prick blood-samples are collected on cellulose sponges and tears are collected by application of small sponges into the lower conjunctival fornix. The specimens can be sent to the laboratory without cold storage. The test takes about 2 hours and is more sensitive than irradiatedMcCoy-cell culture, especially in patients with mild TRic infection of the eye. As to treatment, topical tetracycline or rifampicin eye ointment three times a day for 5 or 6 weeks is highly effective.28 Chloramphenicol eye ointment does not work.2g In patients with paratrachoma, because of the associated genital infections, treatment must be systemic-tetracycline 1 g daily, doxycycline 100 mg daily, or a sulphonamide2-3gg daily, all for 3 weeks.

IgA

tract.

Work in London has shown that inclusion

con-

junctivitis, punctate keratoconjunctivitis, and endemic trachoma of sexual transmission are all manifestations of a single disease. Inclusion conjunctivitis has been seen to change to TRic punctate keratoconjunctivitis and then to a typical picture of trachoma. Inclusion conjunctivitis may be present in one eye, and trachoma in the other eye; and typical trachoma may be associated with subepithelial punctate keratitis.3,4," The clinical features of established TRic infection of the eye-a moderate to severe unilateral or bilateral follicular conjunctivitis, with a large number of follicles in the upper and lower fornices-are helpful in the diagnosis of infection. However, the condition must be distinguished from TRIC

keratoconjunctivitis, herpes keratoconjunctivitis, allergic conjunctivitis, and bacterial conjunctivitis. Laboratory tests may help. In the acute stage of infection, the presence of mixed population of mononuclear and polymorphonuclear cells is highly suggestive of TRic infection. Conjunctival impressions! taken with a plastic spatula, provide a rapid, simple, and painless method for differential cytology.19 In conjunctival scrapings or impressions, chlamydial inclusions can be demonstrated with Giemsa, iodine, or fluorescent-antibody staining. The fluorescent technique is a more sensitive direct method for

detecting

TRIC

agent.20-22

Cul-

Jones, B. R. ibid. 1960, 80, 665. 17. Darougar, S., Quinlain, M. P., Gibson, J. A., McSwiggan, D. A., Jones, B. R. Br. J. Ophthal. 1977, 61, 76. 18. Jones, B. R. Trans. ophthal. Soc. U.K. 1975, 95, 16. 19. Thatcher, R W., Darougar, S., Jones, B. R. Archs Ophthal. 1977, 95, 678. 20. Jones, B. R. Br. J. Ophthal. 1974, 58, 438. 21. Hanna, L., Okumoto, M., Thygeson, P., Rose, L., Dawson, C. R. Proc. Soc. exp. Biol. Med. 1965, 119, 722. 22. Nichols, R. L., McCombe, D. E., Haddad, N., Murray, E. S. Am. J. trop. Med. Hyg. 1963, 12, 223. 16.

Planning IT is

not

for Parenthood

only faulty contraception which results

in unwanted children. Children -

can

become

un-

wanted, too, through faulty parental technique. Moreover, this is a form of reproductive failure which propagates itself. The extent of that failure is revealed in the frequency of ill-treatment and 23.

Darougar, S., Kinnison, J. R., Jones, B. R. in Trachoma and Related Disorders caused by Chlamydial Agents (edited by R. L. Nichols); p. 63

Amsterdam, 1971. Wentworth, B. B., Alexander, E. R. Appl. Microbiol. 1974, 27, 912. Ripa, K. T., Mardh, P. -A. in Nongonococcal Urethritis and Related Infections (edited by D. Hobson and K. K. Holmes); p. 323. Washington. D. C., 1977. 26. Darougar, S., Treharne, J. D., Dwyer, R. St. C., Kinnison, J. R., Jones. B. R. Br. J. Ophthal. 1971, 55, 591. 27. Darougar, S., Treharne, J. D. Paper read at meeting of the European Group for Rapid Laboratory Viral Diagnosis. London, 1977. 28. Darougar, S., Viswalingam, M., Treharne, J. D., Kinnison, J. R., Jones. B. R. Br. J. Ophthal. 1977, 61, 255.

24. 25.

859

child psychiatric disorder, and as a daily experience for paediatricians. TURTLE/ musing on his long psdiatric experience, regrets our failure to prevent the sort of problems which constitute eight-tenths of modern pxdiatric practice. He believes that couples should be educated about their job as parents and taught about child development and children’s needs. Over the three years since his retirement he has found increasing response from parents, who are hungry for the help he is giving through group teaching. "Otherwise" he says, they are left to learn an activity of "incalculable consequence, on the job by trial and error". But CULLEN2 has gone further, and over a nine-year period has been shaping parental behaviour. He now compares the children in his experimental group with controls. The results, though very preliminary, touch on issues of major importance. Parents of the 124 children in the experimental group received twelve interviews spaced over the first five years of the child’s life. Parents of the control group were contacted just often enough to maintain their interest. "The following were accepted as being desirable for the needs of both parents and children: work, creativity, routine, adventure, optimism, responsibility, need of gratification, stimulation of learning, trust vs mistrust, love of people rather than for objects, reason vs irrationality, compassionate regard for living creatures, realism in seeking goals, and protection against recurrent hazards of life." The interviews, though clearly psychotherapeutic in style, were didactic and the material discussed was relevant to the current stage of the child’s development. Only one-sixth of the interviews included the father. There were few differences between the treatment and control group, but there was some evidence that the intervention produced effects. On a familyrelations test girls showed more positive feelings towards mother and boys more negative. All the treatment group had fewer eating problems, and the girls had fewer sleeping problems and fears. Girls were less apt to claim attention through exaggerated tales or by asking their parents to do things for them. Girls were less likely to strike out at people. CULLEN encouraged a more permissive attitude towards boys which was held responsible for their being much more often late for school and for their being, in school, less "intelligent, abstract, and bright" and more "excitable, impatient, demanding" and "shrewd", calculating, and worldly". CULLEN’S subjective judgment agrees with TURTLE’S: this is a service which mothers value. But is it one which medicine should provide? CULLEN applied many tests and obtained significan results in a few. But what if this approach 1 Turtle, W. J. Pediatrics, 1977, 59, 489. 2 Cullen, K. J. J. Pediat. 1976, 88, 662.

does influence parents’ behaviour? As part of a medical service, prophylaxis of this sort would be most efficient if concentrated on high-risk groups. Essentially, the high-risk mothers seem to be those under stress. They lack support, a wanted husband, money, and decent accommodation.3They or their children are sick;4-6 they are intolerant of meeting dependency needs. But restricting our intervention to deviants might have the extremely undesirable results observed by KLEIN and BENYAMINI7 in projects designed to help potential delinquents and slow learners. Both stigma and self-fulfilling prophecy play a powerful antitherapeutic role. Faced in Jerusalem with deviancy-rates around 20%, these workers concluded that an "ecologically" rather than clinically orientated approach is necessary, changing and sustaining the whole orientation of the community. RUTTER,8 faced with similar rates and asking why London children are so disturbed, hazards there must be something about life in an inner London borough which predisposes to deviance, discord, or disorder. If, on the other hand, parenthood breaks down under stress then a crisis-intervention programme would be appropriate. Shades of the child-guidance clinic; but that, if we believe what we are told,9 is not effective. In view of the cognitive basis to postnatal behavioural development, a pessimist would argue that children will emulate their parents and their peers and that deviance will propagate itself. But CULLEN would say that we need not, like BUTLER’S Pontifex,1O give the children to be fostered to break-up transgenerational morbidity. Perhaps the best place to teach parenthood is in school." If parenthood could be given some of the time now allotted to home economics, sex education, and citizenship this captive audience (including potential fathers) could be taught the rudiments of child development and something of the need for:

really

"patience, clarity of communication, spontaneous expression of warmth, approval and acceptance through acts of affection and words of love and praise; consistency of statements, actions and discipline; techniques of discipline involving reasoning rather than force or threats of withdrawal of love, expectations of obedience, resistance to the child’s coercive demands, compliance to the child’s requests; and the needs for warmth, attendance to the child’s difficulties and desires concerning learning, supervision and guidance of the child’s activities, routine and orderliness in the home; time allotted 3.

Giovannoni, J. M., Billingsley, A. Annual Progress in Child Psychiatry and Child Development (edited by S. Chess and A. Thomas); p. 323. London,

1971. 4. Wilkes, J. R. Can. med. Ass. J. 1976, 115, 528. 5. Goodall, J. Devel. Med. Chld Neurol. 1976, 18, 94. 6. Lynch, M. Lancet, 1975, ii, 127. 7. Klein, Z., Benyamini, K. Mental Hlth Soc. 1974, 1, 275. 8. Rutter, M. Proc. R. Soc. Med. 1973, 66, 1221. 9. Shepherd, M., Oppenheim, B., Mitchell, S. Childhood Behaviour and Mental Health. London, 1971. 10. Butler, S. The Way of All Flesh; chap. LXXIX. 11. Tooley, K. M. Am. J. Orthopsychiat. 1977, 47, 184.

860

for joint play between mother and child, and kindly demands upon the pre-school child for acceptance of 2 some responsibility, self sufficiency and self control".

epilepsy (apart from benzodiapoorly), sodium zepine drugs advance. an valproate may represent important One advantage of sodium valproate is its apparent freedom from -serious adverse effects, as might be predicted from its relation to naturally occurring substances, which is closer than that of the usual antiepileptic drugs (the usual cautionary note is necessary, as with any new drug). It can cause dose-related gastric irritation and nausea, and it occasionally produces thrombocytopenia with reduced platelet aggregation, although clinically important disturbances of hamiostasis seem

these types of childhood

which children tolerate

In such a programme, the whole population could be reached. No one would have to feel a failure or a deviant. In particular, boys would be made aware of their role as fathers whose role is other than pseudomothering.12 Not only might such a programme prepare the young for their major responsibility in life, the care of the next generation; it might also help them with their own adolescence.

SODIUM VALPROATE IN EPILEPSY THE antiepileptic activity of valproic acid (dipropylacetic acid) was recognised serendipitously when the agent was administered to animals as a vehicle for a series of test compounds.’ After clinical trials in man2 the sodium salt was introduced as a therapeutic agent in France in 1967, and was marketed in the United Kingdom in 1972. Sodium valproate is a simple two-chain fatty acid and its structure is very different from that of the established antiepileptic drugs. There is evidence that it increases cerebral concentrations of the inhibitory transmitter, y-aminobutyric acid (G.A.B.A.), possibly by inhibiting its breakdown, and this may account for its

therapeutic effect.3 Although sodium valproate has been given to many patients in the past decade, only three controlled trials have been reported"-7 (several are in progress) and its efficacy and indications in the various types of epilepsy have not yet been clearly defined. General experiences-1o indicates that it has a wide spectrum of antiepileptic activity, although it may be of least value in temporallobe and other partial (focal) epilepsies; these, however, tend to resist the most energetic therapy with all the drugs. In tonic-clonic seizures sodium valproate is effective, but whether it matches phenytoin or carbamazepine in potency has not yet been determined in the setting of a controlled trial. In true petit mal absences accompanied by 3-per-second spike-and-wave in the electroencephalogram, it seems as effective as ethosuximide, which it may replace if further experience is favourable. Similarly, atypical petit mal and myoclonic epilepsies have been reported to respond well, and since there has never been an entirely satisfactory drug for 12. First Report from the Select Committee p. lviii. H.M. Stationery Office, 1977.

on

Violence in the

Family; vol.

I,

1. Meunier, G., Carraz, G., Meunier, Y., Eymard, P., Aimard, M. Therapie, 1963, 18, 435. 2. Carraz, G., Fau, R., Chateau, R., Bonnin, J. Ann. med. Psychol. 1964, 122, 577.

Lust, W. D., Kupferberg, H. J., Passonneau, J. V., Penry, J. K. in Clinical and Pharmacological Aspects of Sodium Valproate (Epilim) in the Treatment of Epilepsy (edited by N. J. Legg). Tunbridge Wells, 1976. 4. Meinardi, H. Psychiat. Neurol. Neurochir., Amst. 1971, 74, 141. 5. Richens, A., Ahmad, S. Br. med. J. 1975, iv, 255. 6. Suzuki, M., Maruyama, H., Ishibashi, Y., Ogawa, S., Seki, T., Hoshino, M., Maekawa, K., Yo, T., Sato, Y. Med. Prog., Japan, 1972, 82, 470. 7. Gram, L., Wulff, K., Rasmussen, H., Flacks, A., Wurtz-Jørgensen, A., Sommerbeck, K. W., Løhren, V. Epilepsia, 1977, 18, 141. 8. Lance, J. W., Anthony, M. Med. J. Aust. 1977, i, 911. 9. Pinder, R. M., Brogden, R. N., Speight, T. M., Avery, G. S. Drugs, 1977, 13, 81.

3.

An unusual adverse effect is hair loss,’fortunately reversible. Sodium valproate can interact with phenobarbitone leading to a rise in the serum-phenobarbitone level, accounting for the sedation which has been observed when sodium valproate is added to a regimen with phenobarbitone or primidone (which is partly metabolised to phenobarbitone). Teratogenic effects have been reported in animals but experience is so far too limited for the risk to be assessed in man. The drug is completely absorbed orally and has a plasma half-life of 10-15hours; the half-life is shorter when phenytoin is administered concurrently, probably owing to a plasma-protein-binding interaction," and it is shorter also in children. Twice-daily dosage nevertheless seems to give adequate control, and therefore the inconvenient and often forgotten lunchtime dose is avoided. Plasma levels can be measured but the therapeutic range has not yet been determined in a prospective study. The temptation simply to add this new drug to existing therapy should be resisted. One drug alone is effective in most patients12 and polypharmacy may be unhelpful.13 If existing therapy is ineffective, it should be gradually replaced by the new drug in full doses. One disadvantage is the cost of sodium valproate-about twenty times that of phenytoin for an average dose. Nevertheless, z120 per year per patient is a small price to pay for good control of epilepsy.

rare.

OF MICE, MEN, AND TRYPANOSOMES EXCESSIVE accumulation of cholesterol within the arterial wall is the histological and biochemical hallmark of atheroma. Thus any information about the regulation of the cholesterol content of cells is bound to be of interest, however unlikely the source. Lately, Venkatesan and his colleagues1.2 put forward the intriguing suggestion that the inability of trypanosomes to restrict their uptake of cholesterol is a fatal flaw in their makeup. These workers inoculated rats with strains of T. brucei rhodesiense and found that the transition from the slender, actively dividing form of the parasite to the stumpy, mature form was accompanied by striking changes in lipid content.’ The main difference was a threefold increase in cholesterol, together with a shift in the ratio of free to esterified cholesterol from 3/1 in the 10.Simon, D., Penry, J. K. Epilepsia, 1975, 16, 549. 11.Perucca, E., Gatti, G., Frigo, G. M., Crema, A., Calzetti, S., Visintini, D Br. J. clin. Pharmac. (in the press). 12. Reynolds, E. H., Chadwick, D., Galbraith, A. W. Lancet, 1976, i, 923. 13. Shorvon, S. D., Reynolds, E. H. Br. med. J. 1977, i, 1635. 1. Venkatesan, S., Ormerod, W. E. Comp. Biochem. Physiol. 1976, 53 B, 481 2. Venkatesan, S., Bird, R. G., Ormerod, W. E. Int. J. Parasitol 1977, 7, 139