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pregnancy or the puerperium. Here, too, no rapidimprovement is likely, since in many cases there are nowarning signs. 36 of the deaths occurred during preg-nancy, 66 after vaginal delivery, and 27 following cassareansection. Future reports will have more to say about suchdeaths: a special inquiry form has been introduced formaternal deaths ascribed to pulmonary embolism or

venous thrombosis.

Improved antenatal care has contributed to a reductionin deaths from toxaemia; but, even so, avoidable factorswere found in 51 of the 104 deaths in this group. In somecases the patients concealed their pregnancies, or failed toseek medical advice, or refused to enter hospital, or dis-charged themselves against advice. In other instancesthere was inadequate antenatal care, or confusion ofmedical responsibility, or inadvisable booking for a

general-practitioner unit or for home confinement.Despite the rise in birth-rate, deaths from haemorrhage

fell from 130 in 1958-60 to 92 in 1961-63; but some doc-tors have still to learn that it is dangerous to move ashocked patient from home to hospital without preliminaryblood-transfusion; several women who lost their lives inthis way might have survived had the flying-squad beensummoned to their homes.

Heart-disease (81 deaths) continues to be a formidablecomplication of pregnancy, particularly in older and inmultiparous women. Nothing short of the very higheststandard of care throughout pregnancy, labour, and thepuerperium will reduce the number of these deaths: thoseaffected should not be confined at home or in general-practitioner units (as in several of the fatal cases). Anddoctors must see to it that these patients and their hus-bands are fully aware of the extra risks and, wherenecessary, are helped to plan their families. There will

always be irresponsible patients-many examples are

given in this report-but most husbands and wives, if

properly informed, will collaborate fully.A special section is devoted to the booking arrangements

that were made for patients included in the inquiry. Somepatients, despite advanced age, high parity, or a history ofmedical or obstetric complications, were booked forconfinement in places lacking equipment and staff to dealwith emergencies. Other patients, when complicationsarose, were transferred from their homes to small unitswith inadequate facilities, whereas immediate admission toa consultant unit should have been arranged.

It is estimated that there were avoidable factors in

37-9% of all the deaths. Responsibility for these avoidablefactors lay with consultants as well as with family doctors,and in a high proportion of cases the fault lay exclusivelywith the patient herself. There can be no doubt about thepressing need for further education of doctors, midwives,and patients and their relatives. These valuable reportsshould be drawn to the attention of all doctors and nurseswho deal with obstetric cases, and it would be a great helpif they were given publicity in the Press, on the radio, andon television. Here, as elsewhere in medicine, advancewill come largely through the application of what is alreadyknown. And what of the future ? The four reports thathave already appeared have contained a great deal ofinformation that has led to reappraisal of the maternityservices and to improvement in medical care and its

organisation. The number of deaths is falling steadily,and this may now be the time to pass from a regular three-yearly report to a more detailed examination of certainhazards-e.g., pulmonary embolism, abortion, ectopic

pregnancy, and amniotic-fluid embolism-based on

information collected over a longer period. And theseconfidential inquiries would be even more valuable if allmedical officers of health could be persuaded to collaboratein the investigation of maternal deaths in the areas forwhich they are responsible.

EFFECTS OF RADIATION FROM FALLOUT

INCREASING information about the risks of damage tohealth by low doses of radiation has made it possible toreassess the possible effects on populations of fallout fromnuclear test explosions. Such a new evaluation has nowbeen made in a report 1 to the Medical Research Councilby its committee on protection against ionising radiations.The basis for estimating risks is taken from new data

submitted to the International Commission on Radio-

logical Protection, which are expressed as the numbers ofadditional cases of leukasmia, of thyroid cancer, and of allfatal cancers taken together that might be expected overand above the natural incidence if a population of onemillion persons was exposed to 1 rad of radiation to thewhole body or a substantial part of it. 1 rad is about tentimes the average annual background dose. The availableinformation now suggests that, after one million peoplehad been exposed to this hypothetical dose, a total of 20additional cases of leukaemia might arise, spread over thenext ten to twenty years. All other fatal malignanciesmight increase by another 20 cases. Study of the effectsof therapeutic medical irradiation of the thyroid inchildren suggests a risk of 10-20 additional cases of thyroidcancer in a population of one million exposed to 1 rad.The natural incidence in the United Kingdom of all typesof fatal cancer (including leukxmia) is at present about2200 cases per million per year.What are the actual doses from the products of test

explosions ? The report estimates " dose commitments "

for people in Britain-that is, the total doses that they willultimately receive from fallout resulting from all weapontests carried out up to the end of 1965. These estimatesrefer to the country-wide average for persons livingthroughout the entire period 1954-2000. The commit-ments for the important fallout nuclides (other than131I) were:

Thus, the total commitment to bone-marrow of ratherless than 0-15 rad would be associated, on the basis of theI.C.R.P. risk estimates, with not more than 3 additionalcases of leukarmia; and, on an estimated whole-bodycommitment of 0-1 rad, the number of additional casesof fatal malignancies other than leukxmia would be of theorder of 2 per million. Finally, the assessment of the riskof thyroid cancer is put at not more than 2 cases permillion (the mortality from this condition would be less

1. The Assessment of the Possible Radiation Risks to the Population fromEnvironmental Contamination. H.M. Stationery Office. 1966. 1s. 9d.

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than this and was included in the estimate for fatal

malignancies).The total dose to the gonads of members of the present

generation from the fallout of all tests up to 1965 " willnot exceed about 0-1 rad ". Many later generations willbe subjected to very low doses from the long-lived 14C-to a total additional dose of about 0-2 rad. The estimate of

genetic risk is 1 additional case of visible genetic abnor-mality in the offspring of each million persons exposed.The report discusses counter-measures that might be

taken against fallout-the substitution of dried for freshmilk (particularly for infants), the use of an ion-exchangeprocess for the reduction of 90Sr and 137CS concentrationsin milk, and the administration of extra calcium in thediet to inhibit the uptake of 9"Sr. It seems unlikely thatany large-scale and prolonged countermeasures against thesomatic effects of radiation could be more than partiallysuccessful. Protection against the genetic effects would bestill more doubtful since they are attributable primarily toexternal radiation as well as to ingested 13’Cs. It is alsonoted that some hazards to health could be associatedwith the remedial measures themselves and that the scaleof any such possible ill effects cannot be estimated inthe present state of knowledge. The report concludesthat it is not feasible to specify fixed radiation levels atwhich appropriate countermeasures should be instituted.Any decision about remedial measures could be taken onlywhen the radiation risks from particular nuclear tests inthe atmosphere could be estimated.

VIRACTIN: THE DEBATE CONTINUES

Two years ago, Leach and his colleagues reportedclinical trials of a distillate of the fermentation productsof Streptomyces griseus which they called " viractin ".When evaporated into room air, this substance apparentlyreduced the incidence of minor upper respiratory diseaseand of influenza. In laboratory tests there was no evidencethat the material inactivated viruses and it acted in mice

only after very large doses were given intranasally; theconclusion was that its effects in man showed that it

prevented viruses attaching to and multiplying in cells.We were not entirely satisfied with the design of the clinical

trials,2 and now an independent group has studied theactivity of viractin supplied by Leach’s group and failedto find any antiviral activity.3 They explored the pro-position of Leach et al. that viractin interacted with cellsand prevented infection, and they found that small dosesof representative strains of rhinoviruses (a frequent causeof common colds), influenza and parainfluenza viruses, andadeno-viruses could multiply in cultures exposed to con-centrations of viractin near the maximum tolerated by theHeLa cells used. Moreover, cultures of ciliated cellsmaintained in the same concentration of viractin producedfull yields of influenza virus. Mice infected with influenzaA were kept in a room where the air was treated withviractin, but they survived no longer than mice in a

normal room, and virus sprayed into such air was notinactivated faster than in normal air.

In view of these results Tyrrell and Walker thoughtthere was too little evidence to justify trials in man, butLeach 4 attacks this view. He points out that certain use-ful drugs, such as digitalis, quinine, and cycloserine,1. Leach, B. E., Hackman, P. E., Byers, L. W. Nature, Lond. 1964, 204, 788.2. Lancet, 1965, i, 37.3. Tyrrell, D. A. J., Walker, G. H. Nature, Lond. 1966, 210, 386.4. Leach, B. E. ibid. p. 387.

would not be regarded as suitable for trials in man on thebasis of tests in animals. This is, of course, true, but thesethree must be contrasted with the large number of newlyintroduced drugs, ranging from tranquillisers to anti-

biotics, the activity of which was demonstrated in vitroand in animal experiments before they were subjected toclinical trial. At least some experienced workers whoselect substances for clinical trials would doubt whetherit is justifiable to make extended trials of viractin in man.Perhaps a small and intensely observed group could bestudied. The odds against viractin being able to preventrespiratory disease seem to be heavier than when we lastdiscussed the matter-but it is probably a subject onwhich one should not gamble.

FAMILY PLANNING AND THE PHYSICIAN

THE concept of ideal family size varies from country tocountry and from one generation to the next, but familyplanning is an almost universal intention-some methodsadmittedly being far from successful. In a lecture at the

Postgraduate Medical School of London last week,Prof. J. R. Willson, a gynxcologist from Michigan, saidthat the physician has a special responsibility to help hispatients have exactly the number of children they want.He cannot dictate how many children a couple shouldhave, for this must remain a personal decision for theparents, but he can help them to reach a decision and toimplement it. It is surely an anachronism that medicalstudents receive no formal training in family counselling,and this is why so few doctors volunteer advice aboutbirth control. Yet many patients are reluctant, for onereason or another, to seek expert advice on contraception,and the doctor is in a unique position to help. A goodtime to approach the patient is at the postnatal examina-tion, and three simple questions-" How many morechildren are you going to have ?" " When are you goingto have the next ?" and " How are you going to work it ?"- will get all the information required about her attitudetowards, and knowledge of, contraception. The physicianshould be familiar with all types of contraceptives, but tohelp his patient fully he must know her as a person. Awoman might ask for an intrauterine device because herfriend is using one, but a little questioning might revealthat she dislikes the idea of something " inside " her.What she really wants is advice, and she might do best on" the pill ". All methods of birth control have a highdiscontinuance-rate, which is quite often due to emotionaldissatisfaction rather than physical discomfort. This canbe uncovered only by patient and sympathetic inquiry.An unconscious need for pregnancy is a fairly commonreason for irregular use of contraceptives, but one that isnot always easily recognised.

Intrauterine devices have been used for some years as a

cheap and reasonably effective method for populationcontrol in developing countries, but they are now becom-ing popular in more affluent societies. Between a quarterand a third of all devices inserted are soon discarded (forreasons other than desire for pregnancy), but thoseretained are effective. Even so, the protection-rate couldstill be improved. Careful insertion is particularlyimportant, for extrusion is more likely if the uterine wallis damaged. An incidental but important finding is thata device inserted 10-12 weeks post partum has a greaterchance of success than one fitted at 6-8 weeks. Of a series