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revision of some well-established therapeutic procedures.Tetracyclines should not be given to pregnant women orto infants unless no other drug can control their infection-a comparatively rare circumstance nowadays. Theyshould not be given for trivial infections, especially tochildren, the more so since recent work by clinical

bacteriologists shows that an increasing proportion ofstreptococci 17 and pneumococci,18 19 hitherto sensitive,are becoming resistant to these drugs. Their usefulnessin long-term medication (e.g., in chronic bronchitics)should be reassessed; and, whenever or wherever theyare prescribed, small supplies only should be dispensed,with instructions to the patient that any unused capsules,powder, or liquid should be returned to the pharmacy ordiscarded. Manufacturers and pharmacists will no doubtdevise a system for routine inspection or even assay ofall supplies in store, especially in warm places or whenbulk purchase is the habit, as in this country at present.

Measles ImmunisationIT is a relatively short time since ENDERS et al.20

showed that measles virus, attenuated by passage inembryonated hens’ eggs and tissue culture, gave rise tomodified measles when injected into children. Thisfirst measles vaccine regularly produced antibody tomeasles virus 21 and protected against natural infection.22But reactions to the vaccine were common; and,although this attenuated measles was much milder thanthe natural infection, the fever and modified measlesrash limited the usefulness of this vaccine.

Further attenuation of the virus would be one reason-able course; and there is now an encouraging report 23 ofa first trial with the Schwarz strain of virus, derivedfrom the Enders strain by further attentuation. In adouble-blind study there was not significantly morefever in children injected with vaccine than in childreninjected with placebo. 971/2% of the vaccinated childrenshowed some antibody response. If the degree andduration of this antibody response prove to be satis-factory, this will be an encouraging step forward. Asecond approach has been to give the vaccine along withhuman immune y-globulin. As a result of careful

investigation, WEIBEL et al. 24 recommended for infantsaged 9-12 months an injection into one arm of 1000tissue-culture doses of Enders virus, followed at onceby injection into the other arm of 40 units of measlesantibody per pound body-weight. The antibody, givenas human immune globulin, was found to reduce greatlythe number of febrile reactions without reducing thevery effective serological response to the vaccine. Ap-parently if vaccination were to be carried out in children9-12 months’ old the yearly requirement of y-globulinin the U.S.A. would be about a fifth of that being used at17. Lane, W. R. Med. J. Aust. 1962, ii, 945.18. Richards, J. D., Rycroft, J. A. Lancet, 1963, i, 353.19. Evans, W., Hausman, D. ibid. p. 451.20. Enders, J. F., Katz, S. L., Miloranovic, M. V., Holloway, A. New Engl.

J. Med. 1960, 263, 153.21. Katz, S. L., Kempe, C. H., Black, F. L., Defow, M. L., Kongman, S.,

Haggerty, R. I., Enders, J. F. ibid. p. 180.22. Kongman, S., Giles, J. P., Jacobs, A. M. ibid. p. 174.23. Andelman, S. L., Schwarz, A., Andelman, J. B. J. Amer. med. Ass. 1963,

184, 721.24. Weibel, R., Halenda, R., Stokes, J., Hilleman, M. R., Buynak, E. B.

ibid. 1962, 180, 1086.

present for attenuation of natural measles in individualsknown to have been exposed.

Quite a different approach has been the developmentof a formalin-inactivated or killed-virus, vaccine. 1111This is less liable to induce febrile reactions than live-virus vaccine, but it is also less immunogenic and extrainjections are necessary. So far it has not proved verypopular. A combination of killed-virus vaccination andsubsequent challenge with attenuated live virus is nowproposed by KARELITZ et al. 2 Their killed vaccine seemsto be more potent than that used by other workers,judging by absence of natural measles in children whohad received two or three doses of inactivated-virusvaccine. When these children were challenged with live-virus vaccine local reactions developed in some, presum-ably as a result of sensitisation. There was little illnessand a good antibody response. Even one dose of killedvaccine followed by challenge with live virus provedeffective.

These reports give a great deal of information aboutthe antibody responses and reactions to be expected fromdifferent immunisation schedules. A first impression isthat the simplest and safest method would be to use thehighly attenuated Schwarz strain or the Enders straincombined with y-globulin. The combined use of killedand live virus vaccines is slightly more complicated,So far, these attractive possibilities have not

appealed strongly to the Minister of Health, who hassaid 28 that, although large-scale production of measlesvaccine was under way in this country, he would notrecommend its general use until he had been given the" all-clear". While experience with poliomyelitisvaccines has certainly given much support to those whoare not anxious to rush ahead, it would nevertheless be ahelp to doctors if they could be told what are the presentobstacles to the general use of measles vaccines and howsoon their release can be expected.

Maternity-hospital ReportsMANY of the larger maternity hospitals in this country

prepare annual clinical reports; but there are notable

exceptions, and it must be assumed that some obstetri-cians have doubts about the value of such reports.Those in favour of them argue that results from theindividual hospital can be compared with acceptablestandards, that progress can be checked from year toyear, and that attention may be drawn to the need for

improvement in certain aspects of the work of the

hospital. But the current type of report has importantdefects. Hospitals deal with selected clinical material,and the selection may be social as well as medical. One

hospital may draw largely from the middle and uppersocial classes and another from the lower and middleclasses; the outcome of pregnancy is greatly influencedby social background, yet this information is never givenin annual reports. This omission precludes any meaning-25. Feldman, H. A., Novack, A., Warrent, J. ibid. 1962, 179, 391.26. Hilleman, M. R., Stokes, J., Buynak, E. B., Reilly, C. M., Hampil, B.

Amer. J. Dis. Child. 1962, 103, 445.27. Karelitz, S., Berliner, B. C., Orange, M., Penbharkkul, S.,Ramos, A.,

Muenboon, P. J. Amer. med. Ass. 1963, 184, 673.28. Times, July 19, 1963.

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ful comparison between one hospital and another. Veryfew consultant obstetricians take an active share in

checking and coding case-notes; the preparation ofyearly reports is invariably left to junior staff, and, thoughthis may be claimed to be part of their training, it is nota satisfactory arrangement. A constantly high standardwill be achieved only when senior staff take a personaland responsible share in the work. Moreover, with thesmall numbers involved, results may vary considerablyfrom year to year in the same hospital; and the pro-vision of new maternity beds in the area may filter offselected groups of patients and thus influence results.From replies to a questionary sent out with the 1960

Rotunda Hospital report the Master concludes thatannual reports have a limited appeal.1 Tabular enumera-tion of cases was regarded as of little value, but somefound concise summaries and comments of interest;others were sceptical and thought that the informationwas insufficient to warrant important conclusions. In

1. Rotunda Hospital, Dublin: clinical report, 1961.

general, those who replied to the questionary believedthat the information set out in annual reports couldmore usefully be presented at monthly or quarterlydepartmental meetings in the individual hospitals.

Certainly the present type of annual report does notseem to command general support; and there is much tobe said for a change to the form suggested by the Cran-brook Committee,2 which recommended that reportsshould be extended to cover domiciliary practice so thatthe results for a whole area could be reviewed and

cooperation fostered between hospital, local health

authority, and general practitioner. With careful

planning it should be possible to secure simple, basicinformation on all maternities in large communities.The true incidence of various events in pregnancy couldbe established and valid comparisons made betweenareas in different parts of the country. With this in-formation it would also be possible to examine criticallythe uses to which maternity beds are put.2. Report of the Maternity Services Committee. H.M. Stationery Office,

1959.

Annotations

DISTRIBUTION OF H. INFLUENZÆ

THE bacterial species Hamophilus infiuenzae is commonlypresent in the upper respiratory tract of healthy childrenand adults,l-3 but special culture media may be requiredfor its isolation. It is also the commonest pathogen in thesputum of patients with chronic bronchitis.4 Additionalevidence favouring the xtiological role of H. influence inchronic bronchitis is the demonstration of the organism inthe bronchi of patients with the disease 5 (in contrast tothe sterile bronchial tree of normal subjects) and thepresence of specific antibodies in high titre in the serum of66% of bronchitics compared with 6% of controls. 6Most of the strains of H. influenzae isolated from both

healthy subjects and chronic bronchitics are non-

capsulate3’ although it has been suggested that those fromchronic bronchitics may be derived from capsulate strainswhich have undergone partial degradation.8 On the otherhand strains of H. influenzae which cause meningitis,pneumonia, epiglottitis, and certain other acute infectionsare nearly always capsulate and belong to the Pittmansero-type b.9-11 H. influenza type b is also carried in theupper respiratory tract of healthy people, being found inabout 3% of children under five years of age and about 1 %of older children and adults,3 12 although there is evidencethat the .carriage-rate may be higher in the households ofchildren with hasmophilus meningitis.131. Blackburn, R. H., Boston, R. B., Gilmore, E. St. G., Lovell, R.,

Wilson, S. P., Smith, M. M. Rep. publ. Hlth med. Subj., Lond. 1930,no. 58.

2. Straker, E. A., Hill, A. B., Lovell, R. ibid. 1939, no. 90.3. Masters, P. L., Brumfitt, W., Mendez, R. L., Likar, M. Brit. med. J.

1958, i, 1200.4. Mulder, J. Proc. R. Soc. Med. 1956, 49, 773.5. Brumfitt, W., Willoughby, M. L. N., Bromley, L. L. Lancet, 1957, ii,

1306.6. Glynn, A. A. Brit. med. J. 1959, ii, 911.7. Wilson, G. S., Miles, A. A. in Topley and Wilson’s Principles of

Bacteriology and Immunology; vol. I. London, 1955.8. May, J. R. in Recent Trends in Chronic Bronchitis (edited by N. C.

Oswald); p. 178. London, 1958.9. Pittman, M. J. exp. Med. 1931, 53, 471.

10. Alexander, H. E., Ellis, C., Leidy, G. J. Pediat. 1942, 20, 673.11. Thilenius, O. G., Carter, R. E. ibid. 1959, 54, 372.12. Dawson, B., Zinneman, K. Brit. med. J. 1952, i, 740.13. Good, P. G., Fousek, M. D., Grossman, M. F., Boisvert, P. L. Yale J.

Biol. Med. 1943, 15, 913.

In Jamaica H. influenzae is a common cause of meningi-tis,14 and this has enabled Turk 15 to study carriage-ratesof this organism in families of patients with hasmophilusmeningitis and to compare the findings with those fromother samples of the island’s population. A carriage-rateof 41 % H. infiuenzae type b was found among six families’of patients with hxmophilus meningitis, compared with2-4% in a group of white non-Jamaican children living onthe island and 2-9% in Jamaican children. When a

nursery orphan home, which housed up to 15 babies, wassurveyed continuously for seven months,. H. infiuenzcetype b was isolated from up to 70% of the residents. Nobaby was found to be a carrier on entry to the nursery, andtherefore the organism must have been acquired sub-sequently. Nevertheless no case of meningitis occurred.These findings agree with those of Good et al.,1-3 whoconcluded that an abnormally high carriage-rate ofH. influenzae type b did not necessarily precede or give riseto a case of meningitis. Thus the significance of highcarriage-rates of H. infiuenzae type b is not clear. The highisolation-rate of the organism from families of patientswith haemophilus meningitis resembles the situationdescribed by Glover 16 in connection with meningococcalmeningitis; but here the similarity ends, for, althoughseasonal fluctuations in incidence of hxmophilus meningitishave been described,17 no epidemic has ever been reported.Turk concludes that a high concentration of this organismin a population is compatible with normal health, and thatthe significance of high concentrations in the homes ofpatients with haemophilus meningitis is uncertain.

VIEW OF AMERICAN PLASTIC SURGERY

WHETHER the returned traveller is talking about

churchgoing or the use of frozen foods, we in this countryexpect him to tell us that there is more of it in the UnitedStates than here. But among the impressions of Americanplastic surgery gained by Mr. Noel Thompson 18 in a six-14. Turk, D. C., Wynter, H. H. W. Indian med. J. 1961, 10, 118.15. Turk, D. C. J. Hgy., Camb. 1963, 61, 247.16. Glover, J. A. Spec. Rep. Ser. med. Res. Coun., Lond. 1920 no. 50, p. 133.17. Neal, J. B., Jackson, H. W., Applebaum, E. J. Amer. med. Ass. 1934,

102, 513.18. Thompson, N. Brit. J. plast. Surg. 1963, 16, 109.