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point of view. A new method is good if it helps toclassify patients in such a way that we obtain bettertreatment results, and it is superfluous if that is notthe case. New diagnostic methods, especially thosewhich are expensive or liable to cause complica-tions, ought to be subjected to controlled trials inorder to prove that their routine use will be to pa-tients’ advantage.

Schools Do Make a Difference

IT is no discredit to Prof. MICHAEL RUTTER andhis colleagues that the impact of their book on"secondary schools and their effects on children" 1owes as much to the fact that it says what peopleare ready to hear as it does to the evidence whichit adduces. What it says is simple and unsurpris-ing-that children’s social and academic develop-ment is greatly affected by the character of theschool they attend. But it is only a few years sincea different message was coming through fromAmerican sociologists such as J. S. COLEMAN andSANDY JENCKS. The bowdlerised summary of theirwork was: "Schools make no difference". COLEMANshowed on the basis of massive surveys of Americanschools that differences between schools were unim-

portant by comparison with the differences whichthe pupils themselves brought to school. JENCKSemphasised the importance of social class and par-ental attitudes and questioned the value of large-scale programmes aimed at compensating, througheducation, for social disadvantage.Of course, by the time COLEMAN and JENCKS

spelled out their message in the early 1970s,Richard Nixon had succeeded Lyndon Johnson,and there was a reaction against open-handedfederal spending on compensatory education pro-grammes. Daniel Moynahan had coined his bonmot about benign neglect. The evidence collectedby the researchers which produced the glib, short-hand conclusion that "schools don’t make any dif-ference" was largely of a kind which was bound tominimise the school contribution and maximisethat of the home and social environment. In a valu-able introductory chapter to Fifteen Thousand.HoMf RUTTER and his colleagues review the pre-vious work in this sphere and the false conclusionswhich popularisers have drawn. Many of the testsused in the American research depended as little aspossible on the subject content of the school cur-riculum (how could it be otherwise in a vast surveyspread over many school systems?). Many of thevariables the Americans isolated proved to be irrel-evant but measurable; those more relevant weretoo difficult to measure. Most important, the basisof the federal programmes to compensate educa-

1. Fifteen Thousand Hours. By MICHAEL RUTTER, BARBARA MAUGHAN, PETERMORTIMORE, and JANET OUSTON. London: Open Books. 1979. Pp. 279.£7.50, hardback; £3.50, paperback.

tional disadvantage had been a quest for a moreequal society: COLEMAN found little evidence thatcompensatory education could make up for social

inequality generally. But this is not the same as

showing the schools to be impotent or ineffectivewith regard to pupils’ learning.

All this seems no more than common sense. Buta great deal of interest still surrounds the subjectof what schools can and cannot do, and why oneschool is better (or worse) than another. If differ-ences in the quality of the children’s performanceare wholly explained by differences. outside theschool (such as social class and family attitudes) adebilitating determinism hangs over the whole edu-cational system. The sociologists of education havesuccessfully induced just this sense of powerlessnessin many schools-just as, earlier in the century, ageneration of psychologists succeeded in proving toteachers that the children under their instructioncame with rigid predetermined limitations whichcould be expressed in terms of innate i.Q. Boththese forms of pedagogic Calvinism contain enoughtruth to shape the climate of educational opinion.Both in their way are a hindrance to that combina-tion of faith and works on which miracles of learn-

ing depend.RUTTER and his team have countered this with a

longitudinal study aimed at isolating the effect ofthe school. They took the 1970 intake of twelveLondon comprehensive schools and tested, categor-ised, and generally appraised the pupils at the ageof 10 (before they entered the secondary schools),again at the age of 14, and finally at the minimumleaving age of 16. Comparing the assessments at 10with those at 14, and with examination results at16, they found that the children in some schoolsdid much better than those in others, and that thedifferences were not wholly explained by the differ-ence identified at the age of 10. For example,school A received an entry of 65 pupils, 31% ofwhom had "behavioural difficulties". By the age of14, this 31% had been reduced to less than 10%.School B, on the other hand, took in 34% of "badhats" and 3 years later this had risen to 48%-"afive-fold difference between schools".The same kind of evidence was examined for

academic performance, yielding the same conclu-sions about the schools’ direct contribution: theincrement in some schools seems to be very good;in others, very poor, and this did not correspondclosely to the early measure of verbal reasoning.The research design provided for a great deal of

information to be collected by questionnaire, inter-view, and observation about the schools them-selves. This brought out details of academic organi-sation and practice-about the amount of teachingand homework, the zeal or slackness of the staff,the use of the library, the attitude of the head tohis pastoral responsibilities, and about discipline.

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punishment, school uniform, prefect systems, and awhole lot more. From this the team built up a pic-ture of how particular practices correlated withpupil behaviour and examination success.The "good" school offers few surprises. It is a

place where discipline is firm but humane and aca-demic emphasis is strong and consistent; teachersturn up on time and work conscientiously; home-work is set and marked; there are likely to be pre-fects, school uniforms, and many of the trappingsof the traditional school (though not much corporalpunishment). There is ample praise and encourage-ment for success. Teachers are not out on a limb,but under the supervision and guidance of theirhead of department.To the layman outside the schools, all this may

sound sensible to the point of banality. The mostworrying thing, perhaps, is that RUTTER and his

colleagues had to devote 9 years to proving it. Notso: this is going to be a book which sets offresonances throughout the education service. Itreinforces the more conservative tendencies now atwork in British education, providing a reasonedbasis for a trend which is already present (andwhich will be reflected in the Department of Edu-cation and Science’s curriculum review to be pub-lished shortly, and by the Inspectorate’s secondaryschool survey later in the year. There are, -of

course, plenty of loose ends-including the statisti-cal arguments which usually linger over the use ofmultivariate analysis in this way. The actual testsand questionnaires need to be examined in detail tosee if the surrogates used to establish particularcharacteristics of schools can bear the weightattached to them. But the importance of this booklies less in the elegance of its research methods thanin the central point it is making-a point which ismore philosophical than statistical-namely, thatresponsibility for teaching and learning cannot beshifted from the individual pupil and teacher toexternal and impersonal forces. Genes and socialclass may be important, but the job_of the schoolsis to help people make the best of whatever handof cards they have been dealt.

MISSING THREADSA SUBSTANTIAL number of women fitted with an intra-

uterine contraceptive device (I.U.C.D.) are referred to

hospital gynaecological departments with the markerthreads missing. The incidence of this complication is

uncertain, but some of the causes are well recorded.Expulsion-rates vary, with device, from 2 to 20%, andabout 20% of patients are unaware of the expulsion.2Translocation occurs in 0.05 to 13 per 1000 insertions.l

Pregnancy may cause the threads to retract, owing touterine enlargement, and the pregnancy-rate with a cor-rectly positioned LU.C.D. is 1-4% of women in the firstyear after insertion, becoming lower in succeedingyears. In most cases of missing threads, the I.U.C.D. is in

1 Gentile, G. P., Siegler, A. M. Obstet. gynec. Surv. 1977, 32, 627.2 Tietze, C. and Lewit, S. Stud. Fam. Plann. 1970, 1, no. 55. p. 1.

the uterus without pregnancy. With the Lippes loop thethreads may become retracted in as many as 10% of in-sertions.4 The packaging of the ’Gravigard’ (copper 7)partly loaded with the thread looped alongside it mayparticularly predispose to thread retraction.I.5

At a family-planning clinic, investigations are usuallylimited to excluding pregnancy and ensuring that thethreads are not accessible within the cervical canal, byexploration of the canal with forceps or a cotton-wool-tipped swab. When pregnancy has been excluded, someworkers sound the uterus in the hope of locating thedevice, though the newer devices are not easily palpatedand the investigation may be inconclusive or franklymisleading. Specialist referral usually follows. Ultra-sound is the safest and most reliable investigation,3,6 6being greatly preferable to previous methods such asplain X-ray,’ hysterosalpingogram,8 fluoroscopy,9 hys-teroscopy,10 or the ‘Beolocator’.4 Ultrasound will alsodiagnose pregnancy within 4 weeks of conception. Ifultrasound fails to show the device within the uterus, a

plain abdomen X-ray will differentiate between expul-sion and translocation. If the l.u.c.D. is correctly pos-itioned and the patient is not pregnant, some workersadvise no further action,’ but most patients request re-placement or removal of the device. This may be spe-cially true of the group who regularly check that theycan feel the threads." Removal is commonly done undergeneral anaesthesia, which means a wait for hospitaladmission, the risks of anaesthesia, and considerableexpense. Evans 12 calculated that in the United States in1972 the hospital cost of this procedure averaged$240’8 and estimated that, if such admissions could beavoided, the saving in hospital costs would exceed halfa million dollars even if there were as few as 600 0001. U. C. D. S in use.

Outpatient procedures for removing LU.C.D.S with

missing threads have been applied with variable successand discomfort to the patient. These include hystero-scopy,to exploration of the uterine cavity with an endo-metrial biopsy curette8 or hook," or even insertion of asecond I:U.C.D. which when removed later may bringdown the thread of the first. I2 Guillebaud andKasonde 14 have reported a method for retrieving missingthreads with a 4 mm disposable vacuum aspiration cur-ette which they believed suitable for use by trained per-sonnel in the normal family-planning clinic milieu. Themethod may require local anxsthesia for cervical dila-tation, which limits its application outside hospital andmay explain why it has not been widely accepted.

This is the background to the work of Dr Husemeyerand Mr Gordon of Northwick Park Hospital, who on p.807 this week describe the use of a simple plastic devicefor the retrieval of missing threads. If their results areconfirmed by larger series, this instrument may provesuitable for clinic use (in women known not to be preg-nant), sparing many patients of anxiety and risk andhealth services of much money.

3. McArdle, C. R. Obstet. Gynec. 1977, 51, 330.4. Rosen, E. Am. J. Obstet, Gynec. 1965, 93, 896.5. Sparks, R. A. Br. Med. J. 1977, ii, 1351.6. Meire, H. B. Renton, P. ibid. 1977, i, 713.7. Frampton, J. ibid. p. 445.8. Ansari, A. H. Obstet. Gynec. 1974, 44, 727.9. Spence, M. R. ibid. 1975, 45, 693.

10. Siegler, A. M., Kemmann, E. ibid. 1975, 46, 604.11. Chamberlain, G. Br. med. J. 1978, i, 23712. Evans, G. T. Obstet. Gynec. 1974, 44, 155.13. Sapiro, A. G. ibid. 1977, 49, 238.14. Guillebaud, J., Kasonde, J. ibid. 1974, iv, 167.