- Email: [email protected]
CŒLIAC LUNG DISEASE AND INFLUENZA VACCINATION
434 gress. If the
virus"
particle proves to be a virus, we propose "prsegna-
as a name.
Departments of Microbiology and Obstetrics and Gynæcology, University of Pretoria and H. F. Verwoerd Hospital, Pretoria, South Africa
G. LECATSAS HEATHER CREW-BROWN ELSJE BOES INGRID ACKTHUN J. PIENAAR
that a "deficiency in nerve supply does not interfere with normal development". The transplanted wing buds "attracted" nerve fibres from the host and the nerve fibres which entered the transplant became enlarged to accommodate the increased demand for nervous function. He further demonstrated that the patterning of the nerves within the limb is determined by the transplanted limb bud and not the host
demonstrating
embryo. The three studies cited above demonstrate that:
SIR,-McCredie and her colleaguesl-6 have attempted
(2)
to
reduction malformations of limbs on the basis of to neural-crest cells resulting in subtraction of one or more sclerotomes in the limbs. 1-6 The argument runs: "Assuming a trophic function of embryonic sensory peripheral tissue (neural crest and its derivatives), failure of growth of part of a limb or viscus might be explained by failure of trophic stimulus by the nerve supplying, that part". They suggest that thalidomide embryopathy is due to initial damage to the neural crest with subsequent malformation of the limbs. A critical test of McCredie’s hypothesis would be as follows: a limb bud which has not yet received innervation and which can be demonstrated to contain no neural-crest cells or neuralcrest derivatives, grafted to a location where no neural-crest cells or derivatives can innervate it, should not have the capacity of normal development. Westoncarefully recorded the temporal changes during neural-crest-cell migration. With the use of tritiated-thymidine-labelled cells which had been grafted into host embryos adjacent to the postaxial half of the wing bud of chick embryos, he demonstrated that, although active migration of neural-crest cells in that region could be observed as early as stage 16,8 the cells did not migrate into the limb bud until at least stages 21-23. The first labelled cells approaching the limb could be seen "... extending from the mid-dorsal line to the dorsal margin of the wing bud", by stages 21-23. These were interpreted by Weston as being melanoblasts. Eastlick9 transplanted limb buds from chick embryos ranging in age from 55 to 70 days (stages 15-18) to the coelom of host embryos. These transplants, even the oldest ones, were accomplished before the stage when Weston first observed labelled neural-crest cells approaching the limb bud. Donor limb buds from pigmented varieties were obtained which developed unpigmented plumage when isolated from the neural crest (coelomic grafts), suggesting that no melanoblasts had reached the limb buds before transplant. Slightly more than 50% of the limbs that developed were normal in appearance (i.e., exhibited the normal number of digits). Although melanoblasts do not represent the sensory nerve component of neural crest cells, this study demonstrates that limbs isolated before any neural-crest cells enter them are capable of normal development. Similar results were obtained by Rawleslo after transplanting mouse limbs into chick coeloms. Of even greater importance are 583 limb-bud transplants described by Hamburger" in 1939. This paper summarised transplants of limb buds to the coelom and body wall of host embryos. Careful consideration was given to nerve patterns in the transplants, and both innervated and nerveless limb buds were observed. Hamburger noted that "Nerveless transplants were found to be as perfectly developed as innervated ones"; 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
McCredie, J. Lancet, 1973, ii, 1058. McCredie, J. Med. J. Aust. 1974, 1, 159. McCredie, J. J. Neurol. Sci. 1976, 28, 373. McCredie, J. Birth Defects orig. Art. Ser. 1977, 13, 65. McCredie, J., McBride, W. G. Clin. Radiol. 1973, 23, 204. McCredie, J., Reid, I. S. J. Pediat. 1978, 92, 762. Weston, J. A. Devel. Biol. 1963, 6, 279. Hamburger, V., Hamilton, H. L. J. Morph. 1951, 88, 49. Eastlick, H. L. J. exp. Zool. 1939, 82, 131. Rawles, M. E. Proc. natn. Acad. Sci. U.S.A., 1940, 26, 673. Hamburger, V. J. exp. Zool. 1939, 80, 347.
neural-
prior
ROLE OF NEURAL CREST AND PERIPHERAL NERVES IN LIMB DEVELOPMENT
explain damage
(1)
crest cells or their derivatives do not enter the limb bud to stage 21-23; stage 16-20 limb buds can be isolated from the neural crest or its derivatives and result in limbs which and (3) there have to normal size and
developed
morphology;
is a relationship between development of the limb and size and distribution of peripheral nerves. This relationship, however, is determined by the limb and not by the neural crest. A hypothesis of limb malformations based upon a primary defect in the neural crest is therefore not tenable. Neural-crest cells or peripheral nerves are not required for normal development of the limb. The development of models to explain malformations is praiseworthy, but it is a pity that investigators today tend to overlook important contributions of the past.
Supported in part by grant HD00836 from the National Institute of Child Health and Human Development. Central Laboratory for Human Embryology, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington 98195, U.S.A.
TRENT D. STEPHENS
CŒLIAC LUNG DISEASE AND INFLUENZA VACCINATION
SIR, There have been several reports of diffuse interstitial
lung disease in association with adult coeliac disease, 12 but the relationship of the two conditions and the relevance of avian antibodies remain speculative.34 We have seen a patient with adult coeliac disease in whom diffuse interstitial lung disease developed after he was inoculated with influenza vaccine produced in chicken embryo. A 57-year-old man presented with a 9-month history of weight loss and diarrhoea. Investigations revealed malabsorption and subtotal villous atrophy. He had serum antibodies to a wide range of food products, including chicken serum. Chest X-ray was normal. He was put on a gluten-free diet, and over the next 2 months his general condition and a repeat jejunal biopsy showed improvement. 6 months later he received an influenza vaccination (’Influvac’) from his general practitioner. 6 h after this he awoke shivering, breathless, and with a severe non-productive cough. These symptoms persisted for 2 weeks before his readmission. On admission he was pyrexial (39-4°C) and chest X-ray showed pronounced diffuse bilateral mottling of the lung fields. The white-blood-cell count was normal and no pathogenic organisms were isolated from sputum or blood. Over the next 2 weeks he was treated with three different antibiotics but his symptoms, chest X-ray, and pyrexia remained unchanged. In view of the temporal relationship with the influenza vaccination and in the knowledge that he had serum antibodies to chicken, the possibility of a type-3 allergic reactiori to the chicken embryo in the vaccine was considered. Lung-function tests confirmed a restrictive defect and marked impairment of transfer factor (Tlco 3.2kPa mmol-1 min; expected 8.3 ± 1 - 7). He was prescribed prednisolone 60 mg/day, and within 12 h he was apyrexial. The improvement was maintained and over the following 6 weeks the chest X-ray returned to normal. Similar improvement was seen in transfer factor 1.
Lancaster-Smith, M. J., Benson,
M.
K., Strickland, I. D. Lancet, 1971, i,
473. 2. 3. 4.
Robinson, T. J. Br. med. J. 1976, i, 745. Eade, O. E., Berrill, W. T. Lancet, 1978, i, 1262. Purtilo, D. T., Bonica, A., Yang, J. P. S., ibid. 1978, i, 1359.
435
rising to 3-9 and 5-0 kPa mmol-1 min on the 7th and 14th days, respectively of steroid therapy. The prednisolone dose could be reduced to 10 mg/day over the ensuing 2 months. The patient denied any exposure to budgerigars, pigeons, or hens. The sequence of events in this case strongly incriminates the influenza vaccine in the initiation of the diffuse pulmonary disease. The most likely component of the vaccine to result in an allergic reaction is the chicken embryo. Before coeliac disease developed the patient had had several similar influenza vaccines without ill-effects. Active coeliac disease, with its associated "leaky mucosa", permits the absorption of dietary antigens and the resultant development of antibodies in serum/ We suggest that this patient’s antibodies to chicken were the result of his diseased intestinal mucosa and that these antibodies may have resulted in an immune-complex reaction with the chicken embryo in the vaccine, the pulmonary microvasculature bearing the brunt of the reaction. We would be interested to hear of any other cases of similar reaction to vaccines produced in chicken embryo in patients with adult coeliac disease, childhood coeliac disease, or other "leaky mucosa" diseases.
Glasgow G21 3UW
K. E. L. MCCOLL G. J. ADDIS T. J. THOMSON
Department of Immunology, Western Infirmary, Glasgow
E. M. KIRKWOOD
University Department of Materia Medica, Stobhill General Hospital,
Correlation of mean daily barometric pressure (mm Hg) with daily percentage of cases of premature rupture of the membranes in spontaneous labour.
n=23; r=-0.444;p<0-OS.
Blacks it was more frequent in April and less in September.5 How meteorological factors impose their effects requires an
explanation. INFLUENCE OF METEOROLOGICAL FACTORS ON PREMATURE RUPTURE OF FETAL MEMBRANES
SIR,-Premature rupture of the fetal membranes occurs in 2.7-17% of all pregnancies and is largely unexplained.1 The observation that meteorological factors influence the incidence of eclampsia2prompted us to investigate the relationship between meteorological factors and premature rupture of the membranes. We studied pregnant women (gestational age >24 weeks) resident in Athensand its environs who were seen at our clinic between Jan. 1 and Dec. 31, 1977, because of spontaneous rupture of the membranes and who had no signs of onset of labour. The lowest mean daily barometric pressure and relative humidity in the area of Athens and environs for 1977 (the National Observatory of Athens Meteorological Institute) were748 mm Hg and 27% respectively, and the highest were 772 mm Hg and 90%. There were 4494 spontaneous labours during the year (labours induced by oxytocin and csesarean sections were excluded). Cases of premature rupture of the membranes numbered 1593. The daily percentage of cases of premature rupture in spontaneous labours was compared with the daily mean barometric pressure and relative humidity. There was no significant correlation with humidity (r=0-110; p>0-4) but there was a significant correlation with barometric
p<0-05) (see figure). Meteorological factors appear to influence several aspects of human reproductive biology. In addition to the effects on eclampsia,2 data from Great Britain suggested that anencephaly and spina bifida occurred more often during the winter (conception from March to August) with a shorter duration of pregnancy and a greater mean weight of the embryo than in summer (conception from September to February).4 In Hungary conceptions were more frequent in the summer, and in the U.S.A., Australia, South Africa, and southern hemisphere as a whole conception in Whites was more frequent in March, and less in November; in
pressure (r=0-444;
5. Hodgson, H. J. F., Davies, R. J., Gent, A. E., ibid. 1976, i, 115. 1. Gunn, G., Mishell, D., Morton, D. Am. J. Obstet. Gynec. 1970, 2. Louros, N., Panayotou, P. Zentr. Gynæc. 1938, 62, 1078. 3. Neutra, R. J. Obst. Gynæc. Brit. Comm. 1974, 81, 833. 4. Leck, I., Record, R. G. Br. J.prev. soc. Med. 1966, 20, 67.
106, 469.
Department of Obstetrics and Gynæcology, "Alexandra" Maternity Hospital, University of Athens, Athens
(6II), Greece
S. MILINGOS I. MESSINIS D. DIAKOMANOLIS D. ARAVANTINOS D. KASKARELIS
"A-Z PREGNANCY AND BABYCARE"
SIR,—A number of statements have appeared recently in the press to the effect that the Royal Society of Medicine does not support this publication wholeheartedly and, by inference, that it lacks confidence in Health Care Periodicals Ltd and in its managing director, Mr J. Scott-Clark. It should, therefore, be put on record first, that the decision that the Society should engage more actively in health education and in publishing, both for members of the medical profession and for the lay public, was taken by council more than two years ago and has repeatedly been reaffirmed by it and by the scientific and executive committee; second, that the honorary editors of the Society who, under the by-laws are given such authority, approved the publicationof the A-Z Pregnancy and Babycare in February, 1977; third, that its editorin-chief, Dr Hugh Jolly, was invited to accept that position by the honorary editors and did so in order to assist the Society; and fourth, that the Society stands fully behind Health Care Periodicals Ltd in the publication and distribution of the book. It should also be known that, for some years, the Society’s open section has accommodated members from many walks of life and has arranged meetings for the discussion of subjects of common concern to the medical profesion and the general public ; that some of its principal lectures are addressed to the laity; and that it has organised lunch-time lectures by its fellows on medical subjects for lay audiences as a contribution to health care. These activities continue, and they were forerunners of the enlarged publications programme of which the A-Z Pregnancy and Babycare is but one part. The Royal Society of Medicine, 1 Wimpole Street, London W1M 8AE 5. Erhardt, C. L., Nelson, F. G., Pakter, G.
SMITH President
Am. J. publ. Hlth, 1971, 61, 246.
virus"
particle proves to be a virus, we propose "prsegna-
as a name.
Departments of Microbiology and Obstetrics and Gynæcology, University of Pretoria and H. F. Verwoerd Hospital, Pretoria, South Africa
G. LECATSAS HEATHER CREW-BROWN ELSJE BOES INGRID ACKTHUN J. PIENAAR
that a "deficiency in nerve supply does not interfere with normal development". The transplanted wing buds "attracted" nerve fibres from the host and the nerve fibres which entered the transplant became enlarged to accommodate the increased demand for nervous function. He further demonstrated that the patterning of the nerves within the limb is determined by the transplanted limb bud and not the host
demonstrating
embryo. The three studies cited above demonstrate that:
SIR,-McCredie and her colleaguesl-6 have attempted
(2)
to
reduction malformations of limbs on the basis of to neural-crest cells resulting in subtraction of one or more sclerotomes in the limbs. 1-6 The argument runs: "Assuming a trophic function of embryonic sensory peripheral tissue (neural crest and its derivatives), failure of growth of part of a limb or viscus might be explained by failure of trophic stimulus by the nerve supplying, that part". They suggest that thalidomide embryopathy is due to initial damage to the neural crest with subsequent malformation of the limbs. A critical test of McCredie’s hypothesis would be as follows: a limb bud which has not yet received innervation and which can be demonstrated to contain no neural-crest cells or neuralcrest derivatives, grafted to a location where no neural-crest cells or derivatives can innervate it, should not have the capacity of normal development. Westoncarefully recorded the temporal changes during neural-crest-cell migration. With the use of tritiated-thymidine-labelled cells which had been grafted into host embryos adjacent to the postaxial half of the wing bud of chick embryos, he demonstrated that, although active migration of neural-crest cells in that region could be observed as early as stage 16,8 the cells did not migrate into the limb bud until at least stages 21-23. The first labelled cells approaching the limb could be seen "... extending from the mid-dorsal line to the dorsal margin of the wing bud", by stages 21-23. These were interpreted by Weston as being melanoblasts. Eastlick9 transplanted limb buds from chick embryos ranging in age from 55 to 70 days (stages 15-18) to the coelom of host embryos. These transplants, even the oldest ones, were accomplished before the stage when Weston first observed labelled neural-crest cells approaching the limb bud. Donor limb buds from pigmented varieties were obtained which developed unpigmented plumage when isolated from the neural crest (coelomic grafts), suggesting that no melanoblasts had reached the limb buds before transplant. Slightly more than 50% of the limbs that developed were normal in appearance (i.e., exhibited the normal number of digits). Although melanoblasts do not represent the sensory nerve component of neural crest cells, this study demonstrates that limbs isolated before any neural-crest cells enter them are capable of normal development. Similar results were obtained by Rawleslo after transplanting mouse limbs into chick coeloms. Of even greater importance are 583 limb-bud transplants described by Hamburger" in 1939. This paper summarised transplants of limb buds to the coelom and body wall of host embryos. Careful consideration was given to nerve patterns in the transplants, and both innervated and nerveless limb buds were observed. Hamburger noted that "Nerveless transplants were found to be as perfectly developed as innervated ones"; 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
McCredie, J. Lancet, 1973, ii, 1058. McCredie, J. Med. J. Aust. 1974, 1, 159. McCredie, J. J. Neurol. Sci. 1976, 28, 373. McCredie, J. Birth Defects orig. Art. Ser. 1977, 13, 65. McCredie, J., McBride, W. G. Clin. Radiol. 1973, 23, 204. McCredie, J., Reid, I. S. J. Pediat. 1978, 92, 762. Weston, J. A. Devel. Biol. 1963, 6, 279. Hamburger, V., Hamilton, H. L. J. Morph. 1951, 88, 49. Eastlick, H. L. J. exp. Zool. 1939, 82, 131. Rawles, M. E. Proc. natn. Acad. Sci. U.S.A., 1940, 26, 673. Hamburger, V. J. exp. Zool. 1939, 80, 347.
neural-
prior
ROLE OF NEURAL CREST AND PERIPHERAL NERVES IN LIMB DEVELOPMENT
explain damage
(1)
crest cells or their derivatives do not enter the limb bud to stage 21-23; stage 16-20 limb buds can be isolated from the neural crest or its derivatives and result in limbs which and (3) there have to normal size and
developed
morphology;
is a relationship between development of the limb and size and distribution of peripheral nerves. This relationship, however, is determined by the limb and not by the neural crest. A hypothesis of limb malformations based upon a primary defect in the neural crest is therefore not tenable. Neural-crest cells or peripheral nerves are not required for normal development of the limb. The development of models to explain malformations is praiseworthy, but it is a pity that investigators today tend to overlook important contributions of the past.
Supported in part by grant HD00836 from the National Institute of Child Health and Human Development. Central Laboratory for Human Embryology, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington 98195, U.S.A.
TRENT D. STEPHENS
CŒLIAC LUNG DISEASE AND INFLUENZA VACCINATION
SIR, There have been several reports of diffuse interstitial
lung disease in association with adult coeliac disease, 12 but the relationship of the two conditions and the relevance of avian antibodies remain speculative.34 We have seen a patient with adult coeliac disease in whom diffuse interstitial lung disease developed after he was inoculated with influenza vaccine produced in chicken embryo. A 57-year-old man presented with a 9-month history of weight loss and diarrhoea. Investigations revealed malabsorption and subtotal villous atrophy. He had serum antibodies to a wide range of food products, including chicken serum. Chest X-ray was normal. He was put on a gluten-free diet, and over the next 2 months his general condition and a repeat jejunal biopsy showed improvement. 6 months later he received an influenza vaccination (’Influvac’) from his general practitioner. 6 h after this he awoke shivering, breathless, and with a severe non-productive cough. These symptoms persisted for 2 weeks before his readmission. On admission he was pyrexial (39-4°C) and chest X-ray showed pronounced diffuse bilateral mottling of the lung fields. The white-blood-cell count was normal and no pathogenic organisms were isolated from sputum or blood. Over the next 2 weeks he was treated with three different antibiotics but his symptoms, chest X-ray, and pyrexia remained unchanged. In view of the temporal relationship with the influenza vaccination and in the knowledge that he had serum antibodies to chicken, the possibility of a type-3 allergic reactiori to the chicken embryo in the vaccine was considered. Lung-function tests confirmed a restrictive defect and marked impairment of transfer factor (Tlco 3.2kPa mmol-1 min; expected 8.3 ± 1 - 7). He was prescribed prednisolone 60 mg/day, and within 12 h he was apyrexial. The improvement was maintained and over the following 6 weeks the chest X-ray returned to normal. Similar improvement was seen in transfer factor 1.
Lancaster-Smith, M. J., Benson,
M.
K., Strickland, I. D. Lancet, 1971, i,
473. 2. 3. 4.
Robinson, T. J. Br. med. J. 1976, i, 745. Eade, O. E., Berrill, W. T. Lancet, 1978, i, 1262. Purtilo, D. T., Bonica, A., Yang, J. P. S., ibid. 1978, i, 1359.
435
rising to 3-9 and 5-0 kPa mmol-1 min on the 7th and 14th days, respectively of steroid therapy. The prednisolone dose could be reduced to 10 mg/day over the ensuing 2 months. The patient denied any exposure to budgerigars, pigeons, or hens. The sequence of events in this case strongly incriminates the influenza vaccine in the initiation of the diffuse pulmonary disease. The most likely component of the vaccine to result in an allergic reaction is the chicken embryo. Before coeliac disease developed the patient had had several similar influenza vaccines without ill-effects. Active coeliac disease, with its associated "leaky mucosa", permits the absorption of dietary antigens and the resultant development of antibodies in serum/ We suggest that this patient’s antibodies to chicken were the result of his diseased intestinal mucosa and that these antibodies may have resulted in an immune-complex reaction with the chicken embryo in the vaccine, the pulmonary microvasculature bearing the brunt of the reaction. We would be interested to hear of any other cases of similar reaction to vaccines produced in chicken embryo in patients with adult coeliac disease, childhood coeliac disease, or other "leaky mucosa" diseases.
Glasgow G21 3UW
K. E. L. MCCOLL G. J. ADDIS T. J. THOMSON
Department of Immunology, Western Infirmary, Glasgow
E. M. KIRKWOOD
University Department of Materia Medica, Stobhill General Hospital,
Correlation of mean daily barometric pressure (mm Hg) with daily percentage of cases of premature rupture of the membranes in spontaneous labour.
n=23; r=-0.444;p<0-OS.
Blacks it was more frequent in April and less in September.5 How meteorological factors impose their effects requires an
explanation. INFLUENCE OF METEOROLOGICAL FACTORS ON PREMATURE RUPTURE OF FETAL MEMBRANES
SIR,-Premature rupture of the fetal membranes occurs in 2.7-17% of all pregnancies and is largely unexplained.1 The observation that meteorological factors influence the incidence of eclampsia2prompted us to investigate the relationship between meteorological factors and premature rupture of the membranes. We studied pregnant women (gestational age >24 weeks) resident in Athensand its environs who were seen at our clinic between Jan. 1 and Dec. 31, 1977, because of spontaneous rupture of the membranes and who had no signs of onset of labour. The lowest mean daily barometric pressure and relative humidity in the area of Athens and environs for 1977 (the National Observatory of Athens Meteorological Institute) were748 mm Hg and 27% respectively, and the highest were 772 mm Hg and 90%. There were 4494 spontaneous labours during the year (labours induced by oxytocin and csesarean sections were excluded). Cases of premature rupture of the membranes numbered 1593. The daily percentage of cases of premature rupture in spontaneous labours was compared with the daily mean barometric pressure and relative humidity. There was no significant correlation with humidity (r=0-110; p>0-4) but there was a significant correlation with barometric
p<0-05) (see figure). Meteorological factors appear to influence several aspects of human reproductive biology. In addition to the effects on eclampsia,2 data from Great Britain suggested that anencephaly and spina bifida occurred more often during the winter (conception from March to August) with a shorter duration of pregnancy and a greater mean weight of the embryo than in summer (conception from September to February).4 In Hungary conceptions were more frequent in the summer, and in the U.S.A., Australia, South Africa, and southern hemisphere as a whole conception in Whites was more frequent in March, and less in November; in
pressure (r=0-444;
5. Hodgson, H. J. F., Davies, R. J., Gent, A. E., ibid. 1976, i, 115. 1. Gunn, G., Mishell, D., Morton, D. Am. J. Obstet. Gynec. 1970, 2. Louros, N., Panayotou, P. Zentr. Gynæc. 1938, 62, 1078. 3. Neutra, R. J. Obst. Gynæc. Brit. Comm. 1974, 81, 833. 4. Leck, I., Record, R. G. Br. J.prev. soc. Med. 1966, 20, 67.
106, 469.
Department of Obstetrics and Gynæcology, "Alexandra" Maternity Hospital, University of Athens, Athens
(6II), Greece
S. MILINGOS I. MESSINIS D. DIAKOMANOLIS D. ARAVANTINOS D. KASKARELIS
"A-Z PREGNANCY AND BABYCARE"
SIR,—A number of statements have appeared recently in the press to the effect that the Royal Society of Medicine does not support this publication wholeheartedly and, by inference, that it lacks confidence in Health Care Periodicals Ltd and in its managing director, Mr J. Scott-Clark. It should, therefore, be put on record first, that the decision that the Society should engage more actively in health education and in publishing, both for members of the medical profession and for the lay public, was taken by council more than two years ago and has repeatedly been reaffirmed by it and by the scientific and executive committee; second, that the honorary editors of the Society who, under the by-laws are given such authority, approved the publicationof the A-Z Pregnancy and Babycare in February, 1977; third, that its editorin-chief, Dr Hugh Jolly, was invited to accept that position by the honorary editors and did so in order to assist the Society; and fourth, that the Society stands fully behind Health Care Periodicals Ltd in the publication and distribution of the book. It should also be known that, for some years, the Society’s open section has accommodated members from many walks of life and has arranged meetings for the discussion of subjects of common concern to the medical profesion and the general public ; that some of its principal lectures are addressed to the laity; and that it has organised lunch-time lectures by its fellows on medical subjects for lay audiences as a contribution to health care. These activities continue, and they were forerunners of the enlarged publications programme of which the A-Z Pregnancy and Babycare is but one part. The Royal Society of Medicine, 1 Wimpole Street, London W1M 8AE 5. Erhardt, C. L., Nelson, F. G., Pakter, G.
SMITH President
Am. J. publ. Hlth, 1971, 61, 246.