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ANTISPERM ANTIBODIES AND FERTILITY

SIR,-Your editorial of Jan. 17 was excellent in many ways, andthis topic does need more coverage now than in the past. However, Imust take issue with several statements which are wrong or highlymisleading.You state that the tube-slide agglutination test (TSAT) "gives a

high incidence of false positive results". Perhaps there will bedebate over the meaning of "high" but the statement implies thatthe incidence is too high for any usefulness. You only cite theoriginal work where the false positive rate was indeed very high;however, later studies, by us and by others, have given much lowerand more reasonable incidences.1-4 You explain false-positiveresults as being due to a non-antibody factor, and we read ofcorrections to be made of this factor. Again, this is misleading, forsurely the very high incidence of positive results found by theoriginal authors was much more the consequence of using undilutedserum and of terming a result positive however few sperm clumpswere present in the incubated mixture. I agree that the newcorrection technique should be applied in future studies, but it willprobably make only small changes. Our own work was done withoutthis correction, and it produced incidences that were never too highand which also showed a much lower value for a fertile populationthan for an infertile population. Finally, the correction factor wouldalso have to be applied to the tray agglutination test, whenever head-to-head clumping is evaluated, and this does not seem to haveappeared in any of the published results thus far.The indication that 1:32 is an obligatory serum dilution for

clinical significance of the results does a disservice to the reader.Although this was the argument in the pioneer work, very carefullydone, subsequent investigators have seen significance at lower

thresholds, down to 1:4 at the lowest.1-3,5,6 A low titre of spermantibody does sometimes coincide with a successful pregnancy butthis does not cancel its significance, for it is usually found that theeffort to become pregnant required more than one year, and thistime delay does indicate a condition of infertilitv.

Sperm Antibody Laboratory,New York Medical College,Metropolitan Hospital,New York, N.Y. 10029, U.S.A. SIDNEY SHULMAN

TRANSPORTING THE HEAD INJURED PATIENT

SIR,-In an otherwise admirable television programme (ManAlive on B.B.C. 2 on March 19), we witnessed a publicdemonstration of the "second injury" to the brain which is all toofrequent and is avoidable. A 10-year-old severely head-injured boywas transported on his back, and a young doctor valiantly tried tointubate the child as the patient thrashed about and vomited. Theinhalation of vomit may damage the brain by hypoxia andhypercapnia as surely as the initial blow. Such cases must be

transported semiprone and kept in that position until an

anaesthetist with good light, good suction, appropriate sizedendotracheal tube, and short-acting relaxant can safely intubate thetrachea.

Department of Neurological Surgery,Frenchay Hospital,Bristol BS16 1LE BRIAN H. CUMMINS

1. Shulman S. Reproduction and antibody response. Cleveland: CRC Press, 1975.2. Shulman S. Agglutinating and immobilizing antibodies to spermatozoa. In: Cohen J,

Hendry WF, eds. Spermatozoa, antibodies and infertility. Oxford: BlackwellScientific Publications, 1978: 81-99.

3. Shulman S, Jackson H, Stone ML. Antibodies to spermatozoa VI: Comparative studiesof sperm agglutinating activity in groups of infertile and fertile women. Am J ObstetGynecol 1975; 123: 139-44.

4. Kolodny RC, Koehler BC, Toro G, Masters WH. Sperm-agglutinating antibodies andinfertility. Obstet Gynecol 1971; 38: 576-82.

5. Fjällbrant B. Immunoagglutination of sperm in cases of sterility. Acta Obstet GynecolScand 1965; 44: 474-90.

6. Dondero F, Bonifacio V, Isidori A. Results with Shulman and Hekman’s capillarymethod in the detection of spermagglutinins in man. Panminerva Med 1974; 16:115-17.

ALCOHOL AND THE FETAL BRAIN

SIR,-Your Feb. 28 editorial on alcoholic brain damage made nomention of the serious effects of alcohol on the brain of the

developing fetus. Even moderate maternal alcohol consumptionduring pregnancy may result in a characteristic pattern of

malformation in the offspring, the "fetal alcohol syndrome". Theabnormalities can be grouped into four categories: nervous systemdysfunction, characteristic craniofacial features, growth deficiency,and a variety of major and minor physical malformations.Alcohol withdrawal symptoms may occur after delivery and are

characterised by tremors, irritability and even overt seizures 2Much more significant are the permanent neurological sequelae.Mild to moderate mental retardation occurs in well over 80% of

cases, signs of cerebellar dysfunction are common, and manychildren exhibit subsequent behaviour disorders. Necropsy studiesindicate not only that affected brains are unusually small, but alsothat they are structurally abnormal, with evidence of disorderedneuroglial migration. These cerebral abnormalities may be presentin the absence of external dysmorphic features. The mechanism bywhich alcohol affects brain growth and morphogenesis remainsunclear. Some investigators suggest that the main teratogen isethanol itself or its metabolite acetaldehyde.4 Others consider thatnutritional deficiencies associated with maternal alcoholism play amajor part.Alcohol abuse during pregnancy is now the most important

preventable cause of mental deficiency in the Western world. 5,6 Asyour editorial pointed out, the number of female alcoholics inBritain is steadily increasing, yet public awareness of the problemremains poor. Women must make their own decision about their

drinking habits during pregnancy, but doctors have a duty to informthem of the risks.

University Department of Child Health,Royal Hospital for Sick Children,Glasgow G3 8SJ J. O. BEATTIE

MUST HEALTH SERVICES RESEARCH BE FUNDEDBY A COMMISSIONER?

SIR,-Perhaps I may use the letter from Professor Buller and DrGowans (March 7, p. 550) as a basis for drawing attention to whatappears to be an unrecognised problem underlying the effectivepromotion of health services research in the U.K.Three (not two) elements or parties may be involved:(1) An originator whose daily work is concerned with planning,

making decisions, or implementing policies, and who has a

problem, the solution of which he considers to be amenable to healthservices research. Rothschild assumed he would always be a civilservant in central government. But equally important, he maybe anofficer at health authority level, or a clinician, administrator, ornurse who wants to innovate, expand, or in some other way modifythe service for which he or she is responsible.

(2) A scientist or group of scientists who have the capacity andwillingness to give attention to the solution of the problem.

(3) A funding body which may want to turn to referees who cangive wise and impartial advice and identify investigations suitablefor support.

If health services research is to be successfully conducted theremust nevertheless be a close working relationship between theoriginators and the investigators regardless of the source of funds. Itis applied research, not research in abstract, and this is the onlcuavof assuring its application.

1. Jones KL, Smith DW, Ulleland CN, Streissguth AP Pattern of malformation in

offspring of chronic alcoholic mothers. Lancet 1973; i: 267-71.2. Pierog S, Chandavasu O, Wexler I. Withdrawal symptoms in infants with the fetal

alcohol syndrome. J Pediatr 1977; 90: 630 - 33.3. Clarren SK, Alvord EC, Sumi SM, Streissguth AP, Smith DW. Brain malformations

related to prenatal exposure to ethanol. J Pediatr 1978; 92: 64-674. Véghelyi PV, Osztovics M, Karods G, et al. The fetal alcohol syndrome: symptoms and

pathogenesis. Acta Paediat Aca Sci Hung 1978; 19: 171-89.5. Clarren SK, Smith DW. The fetal alcohol syndrome. N Engl J Med 1978, 298:

1063-67.

6. Olegard R, Sabel KG, Aronsson M, et al. Effects on the child of alcohol abuse duringpregnancy. Acta Paediat Scand 1979; suppl 275: 112-21