514 THE LANCET

there was concurrent bacterial infection, which emphasisesthe importance of bacteria in the aetiology of thisdisorder. Only 4 patients with influenza infection wereamong the groups recommended for vaccination (chronicdisease).Our finding that atypical pathogens were rare was

surprising, since the study took place during a period ofincreased national reporting of Mycoplasma pneumoniaeinfections in one of the 3-4-yearly epidemics of thispathogen in the UK.18 Mycoplasma infection is regarded asa very common cause of respiratory infections during suchperiods. The more severe cases that cause pneumonia andare reported are thought to represent only a small proportionof the spectrum of respiratory illness.19 Our study suggeststhat this may not be the case. We found no legionellainfections; such infections usually cause moderate or severeillness and are more commonly found in hospital-based andintensive care unit studies.No evidence of current infection with chlamydia was

found by either complement-fixing antibody or enzymeimmunoassays for antigen. Enzyme immunoassays are bothsensitive and specific for community-acquired chlamydiapneumonia.9 However, complement fixing is less sensitive,especially for C pneumoniae reinfections in adults, whichmay be important in this population. C pneumoniae maycause 5% of attacks of bronchitis and 10% of communitypneumonias in young people .20 21 Further work needs to bedone to examine the role of chlamydia in this setting and tofind out whether enzyme immunoassays would detect mildinfections.

. We found substantial morbidity associated with

community-acquired LRTI. We were surprised that of the315 patients seen initially in the surgery, a quarter asked tosee the general practitioner again. On a national scale, thismust produce an enormous burden on general practitionersand the health service budget. The fact that further coursesof antibiotics were prescribed for most of these patientssuggests that infection was still perceived to be the problem.It is possible that the follow-up by the practice nurse led tomore patients asking to see general practitioners again, butwe found that a similar proportion of patients not followed indetail also returned, for similar reasons. The range ofpathogens in this group was similar to that of the wholegroup, and most of the bacteria detected were amoxycillinsensitive. The question remains whether the absence of apathogen in half of these patients reflects an undiagnosed ornovel infection or a non-infective problem. The highC-reactive protein concentrations in almost half the patientssupport the possibility of infection. The antibiotics chosen atfollow-up consultations illustrate the difficulties facing thegeneral practitioner, who must decide whether to treat for anatypical infection with erythromycin or tetracycline, as

happened in nearly half of our cases, or whether to try anagent likely to be effective against the common respiratorybacteria, when amoxycillin has failed. Whether or not thesputum was purulent was not related to the presence ofbacterial infection. The extended-spectrum macrolides orquinolones may help by obviating the need to make suchdecisions.

Since the spectrum of pathogens in LRTI is very similarto that for more severe respiratory infection, includingpneumonia, antibiotic treatment strategies should also besimilar. 90% of the identified, antibiotic-responsivebacterial and atypical pathogens were sensitive to

aminopenicillins. Understanding of and managementstrategies for this very common disorder could be improved.

We thank Dr F. Coutts, Dr S. Bolsher, Dr B. Hammersley, Dr D.Thornhill, and Dr K. Hawthorne, practice nurses Mrs Gwen Mills, MrsMarion Broadley, and Mrs Joan Martin, practice manager Mrs Pam Farrell,and research assistant Miss Dawn Hill from Stenhouse Medical Centre forenthusiastic and active involvement; Mr Antony Wisniewski, Ms KathyRichards, and Mr Paddy Riley for invaluable help with questionnaire designand analysis; and Mr Malcolm Baker for technical expertise in the laboratory.

The study was supported by a British Lung Foundation grant.

REFERENCES

1. Black DAK, Pole JD. Priorities in biomedical research. Indices ofburden. Br J Prevent Soc Med 1975; 29: 222-27.

2. Editoral. Antibiotics and respiratory illness. BMJ 1974; iii: 1.3. Howie JGR, Hutchison KR. Antibiotics and respiratory illness in general

practice; prescribing policy and work load. BMJ 1978; ii: 1342.4. Woodhead MA, Macfarlane JT, McCracken JS, Rose DH, Finch RG.

Prospective study of the aetiology and outcome of pneumonia in thecommunity. Lancet 1987; i: 671-74.

5. British Thoracic Society. Community acquired pneumonia in adults inBritish hospitals in 1982-1983: a BTS/PHLS survey of aetiology,mortality, prognostic factors and outcome. QJ Med 1987; 62: 195-200.

6. Macfarlane JT, Ward MJ, Finch GR, Macrae AD. Hospital study ofcommunity-acquired pneumonia. Lancet 1982; ii: 255-57.

7. Rodnick JE, Gude JK. The use of antibotics in acute bronchitis and acuteexacerbations of chronic bronchitis. West J Med 1988; 149: 347-51.

8. Verheij TJM, Kaptein AA, Mulder JD. Acute bronchitis: aetiology,symptoms and treatment. Family Practice 1989; 6: 66-69.

9. Sillis M, White P, Caul EO, Paul ID, Treharne JD. The differentiation ofChlamydia species by antigen detection in sputum specimens frompatients with community acquired acute respiratory infections. J Infect1992; 25 (suppl 1): 77-86.

10. Dunlay J, Reinhardt R. Clinical features and treatment of acute

bronchitis. J Family Practice 1984; 18: 719-22.11. Hope Simpson RE, Miller DL. The definition of acute respiratory

illnesses in general practice. Postgrad Med J 1973; 49: 763-70.12. Howie JGR. A new look at respiratory illness in general practice. J R Coll

Gen Pract 1973; 23: 895-904.13. Venkatesan P, Macfarlane JT. The role of pneumococcal antigen in the

diagnosis of pneumococcal pneumonia. Thorax 1992; 47: 329-31.14. Department of Health. Immunisation against infectious disease. London:

HM Stationery Office, 1992.15. Broome CV, Breiman RF. Pneumococcal vaccine—past, present and

future. N Engl J Med 1991; 325: 1506-07.16. Hager H, Verghese A, Alvarez S, Berk SL. Branhamella catarrhalis

respiratory infections. Rev Infect Dis 1987; 9: 1140-49.17. Wallace RJ. Newer oral antibiotics and newer aetiological agents of acute

bronchitis and acute exacerbations of chronic bronchitis. Semin RespirInfect 1988; 3: 49-54.

18. Editorial. Mycoplasma pneumoniae surveillance. Commun Dis Rep 1991; 1:49.

19. Murray HW, Masur H, Senterfit LB, Roberts RB. The proteanmanifestations of Mycoplasma pneumoniae infection in adults. Am JMed 1975; 58: 229-42.

20. Grayston JT. Chlamydia pneumoniae, strain TWAR. Chest 1989; 95:664-69.

21. Marrie TJ, Grayston JT, Wang SP, Kuo CC. Pneumonia associated withthe TWAR strain of Chlamydia. Ann Intern Med 1987; 106: 507-11.

From The Lancet

Up tightIt would still be premature to conclude that we have done with

the practice or the ill effects of tight lacing. Were we disposed todoubt the prevalence of this custom the medical records of every daycould prove its continuance, nor can we see how it should beotherwise as long as the stiff corset retains its place as an article ofdress. Now and then some fatal mischance is found to be traceable toits abuse, while instances in which ill-health has been the penalty arefar from uncommon. Every practitioner is familiar with cases of thiskind, and it needs no searching examination to convince him thatamong the pallid complexions and palpitating hearts which requirehis attention some are directly traceable to the pinching vanity of thecorset. Why this effect should follow such a cause we need hardlyexplain to medical readers. They can well appreciate the viciousinfluence of cramping pressure exercised upon the trunk and itsviscera without cessation for the greater part of every day.

(Feb 11, 1893)