70

wheat berry. The source of the flours used for bakingthe bread was unknown in many of the samples analysed,for in large bakers’ shops this information is not alwaysreadily obtainable.These results, although obtained on bread and by a

different method, agree in the main with the survey offlours made by the Research Association of British Flour

Millers, who found, that the crude-fibre content of 47 onof 303 samples exceeded 0.9%.6 Thus shortly before th.national loaf became compulsory a small but far fropnegligible proportion of millers were supplying a produ<which did not achieve the Medical -Research Councilaim of supplying the maximum nutritive value a,m

palatability with the minimum amount of coarse materialliable to cause digestive troubles.

Since March, when these samples were collected, ther(has been time for the millers to get more used to produc-ing the national flour, and its quality has possiblyimproved. Since a straight-run flour of 85% extractionhas a lower crude-fibre content than the reconstitutedflour,! it might be possible, if millers would produce theformer type, to reduce the upper limit in the specificationof crude-fibre content and thereby ensure for us a

national flour of still higher nutritive value and accept-ability. In any case, a check on the quality of thenational loaf, such as the fragmentary one here described,should be in constant operation, though this will beinapplicable while it is permitted to mix up to 25%white flour with the national flour.We wish to thank the Biochemical Laboratory and the

Field Laboratories, Cambridge, for facilities for carrying out6. Nature, Lond. 1942, 149, 460.

Reviews of Books

A Practical Method of Self-analysisE. PiCKWORTH FARROW, M.A., D.Se. London : GeorgeAllen and Unwin. Pp. 153. 6s.IT is sometimes said that Freud, who created psycho-

analysis, was never psycho-analysed. This is, of course,an error ; he analysed himself, and since then otherslike Roheim have done likewise. An English exponentof the method, Dr. Farrow, now explains how beneficialhe found it, after two abortive attempts to submit tothe more conventional procedure. Professor Freud,in a foreword, describes him as " a man of strong andindependent intelligence, who, probably on accountof a certain wilfulness of character, could not get onwell with the two analysts with whom he experimented."The matter could not be put more simply, and thequalities referred to by Freud are manifest in the book.It is readable, but on many points out of touch withmodern psycho-analytic teaching. When the authorsays, for example, that he prefers to describe " oralerotism " simply as " hunger " he is by implicationattacking the edifice at its base : this comes aboutthrough his very personal approach and reliance on hisown experience, which makes him at once biased andindependent. His experience is intensive ; he tellsus that the book is the outcome of 2800 hours, spreadover 18 years, and of more than twelve million words offree association, which he was accustomed to recordsystematically. The book is fresher and more stimulat-ing than orthodox psycho-analytic manuals.

Roentgen Treatment of InfectionsJAMES F. KELLY, M.D., F.A.C.R., professor of radiology,Creighton University ; with the collaboration of D. ARNOLDDowELL, M.D., assistant professor of radiology in the

university. Chicago : Year Book Publishers ; London :H. K. Lewis. Pp. 432. 33s.THIS book fills a gap in medical literature. Its authors

recognise the importance of X-ray treatment of theinfections and have put together for the first time in bookform the fruits of their own experience and that of manyothers. The first part of the book deals with physical andbiological considerations and here their guidance is lesssure. Their reference to protection, for instance, runs :" All sources of secondary radiation should be ascer-tained and adequate means of protection provided sofar as it is possible to do so " ; and under the heading" Training not always necessary for success," theystate that infections " may be treated by any physicianfamiliar with the operation of X-ray apparatus,- the definition of an r unit, and the disease heis treating "-an odd statement in itself, and a

dangerous one in its implications (the definition of theroentgen given in the text is not that which has nowbeen accepted internationally). The second part of thebook deals with the treatment of, periton,itis, parotitis,

pneumonia and other infections, the main section beingan informative account of the treatment of gas gangreneof which the authors were the pioneers. They make agood case for the further investigation of this type oftreatment, though many of their assertions are con-

troversial. They rightly stress the value of X-ray treat-ment in postoperative parotitis and similar infectionsin which this method of treatment deserves furthertrial. Probably a portable X-ray therapy plant for thetreatment of infections will one day form a- recognisedpart of the equipment of all large general hospitals.The Injured Back and its Treatment

Editor: JOHN D. ELLIS, M.D. London: Bailli&egrave;re,Tindall and Cox. Pp. 377. 30.9.Tms collection of nine papers by eminent American

orthopsedists deals with the common minor injuries aswell as the more serious fractures and dislocations, withand without cord involvement. The views expressedare orthodox and set out clearly. A chapter on back-ache as a symptom of visceral disease might have beenmore at home in a less practical manual but is welcomeall the same. Proper stress is laid on a systematicexamination of the back ; after reading this chaptermost doctors will feel that their previous efforts havebeen somewhat sketchy, and that there is much more tobe learned from a complete examination than they hadrealised. The role of the articular facets in causing backpain is discussed-a syndrome which has not yet receivedmuch notice in this country but one described as beingfairly common. The editor has minimised overlap andmaintained continuity; there are no significant omissions.

Synopsis of Blood DiseasesA. PINEY, M.D. Birm., M.R.C.P., physician to St. Mary’sHospital for Women and Children, Plaistow. London:Wm. Heinemann (Medical Books). Pp. 120. 10s. 6d.Dr. Piney presents an up-to-date summary of our

knowledge of blood diseases without going into detailabout the changes in the blood-picture. It will beespecially useful to the postgraduate student with anadequate background who wants to revise the subjectquickly, but it is probably too sketchy to help thegeneral practitioner without such a background. Themain difficulty in blood diseases is differential diagnosisand for this a more detailed description of the results ofhaematological examination than Dr. Piney gives isneeded. The treatments advocated are on sound andbalanced lines and reflect modern practice, though theuse of.fortified liver extract occurs in several unexpectedplaces. The four colour plates illustrate blood and bone-marrow cells in a rather unconventional way that ishardly convincing and are unlikely to help the averagephysician for whom the book is intended ; the samemust be said of the extensive tables of the characteristicsof the various types of cells. Nevertheless this bookwill have its place as a quick " brush-up your blooddiseases."

71

THE LANCETSATURDAY, JULY 18, 1942

SOCIAL FACTORS IN ACUTE RHEUMATISMTHE causa causans of acute rheumatism is

unknown ; the role of the h&aelig;molytic streptococcusand of the virus are still not clearly defined. But, asRYLE insisted last week, preoccupation with the

microscopic organism should not lead to neglect ofthe " multiple factors " in production of disease. Ithas long been recognised, on clinical grounds, thatacute rheumatism is to a large extent a disease of

the poorer classes, though it has proved difficult forclinical investigation alone to draw any clear-cutconclusions on the relation that poverty was to it.The Registrar-General’s reports, however, offermaterial for the statistical approach to diseases inwhich social factors are believed to play a part. Asmembers of the Committee for the Study of SocialMedicine, MORRIS and TITMUSS have investigated theproblem of acute rheumatism by analysing the figuresgiven in these reports and their deductions will befound on our opening page. Poverty as a causativefactor has often been stressed in the past, and attemptshave been made to dissect the responsible componentsin the " complex of poverty." It has been shownthat in families removed from poor surroundings theincidence of acute rheumatism is reduced. MORRISand TITMUSS now show that acute rheumatism andrheumatic heart disease must indeed be classed with

high’ infantile mortality and a high incidence of

pulmonary tuberculosis as ills bred by poverty.Deaths from acute rheumatic fever are few, but

deaths from heart disease in young adult life are

many. Rheumatism thus ranks with tuberculosisas an outstanding cause of invalidism and as oneof the major killing diseases in this period of life.It has often been suggested in the past that acuterheumatism affected the artisan class more than

any other large group in the population, even the

very poor. Analysis of mortality from valvularheart disease by social class shows, however, aconsistent rise of mortality with deepening poverty.MORRIS and TITMUSS find no evidence to suggest thatthe selective incidence of acute rheumatism is influ-enced by any factor apart from those associated withpoverty. As with other social diseases, the mortalityfrom rheumatic heart disease is higher in poverty-stricken areas. Roughly speaking it rises with

increasing density of population, but the mortality issignificantly higher in the poverty-stricken villages ofSouth Wales than in any of the large towns. Urbani-sation thus contributes to the death-rate but plays asecondary role to poverty itself. Climate is at mostof minor importance. Analysis provided no clearevidence that overcrowding increased mortality fromrheumatic heart disease, though it has been clearlyshown to increase mortality from pulmonary tuber-culosis. A possible interpretation of this remarkablediscrepancy is that acute rheumatism does not spreadby droplet infection ; poverty would then play itspart only after infection has been acquired. Statis-tical analysis may thus have provided a clue to the

way in which the disease is transmitl cd that shouldbe looked into.

Since they are the outcome of poverty, acuterheumatism and rheumatic heart disease must be

regarded as preventable. Whether rheumatism iscaused by a streptococcus or a virus, whether heredityplays a part or not, the mortality and invalidism fromthe disease will fall as soon as the load of poverty islightened. This is one aspect of a many-sided problemwhich confronts the new advisory committee,appointed on June 30, whose joint secretaries areMr. NORMAN CAPENER (British Orthopaedic Associa-tion) and Sir FRANK Fox (Empire RheumatismCouncil). Perhaps, too, the social and preventivemedicine committee of the Royal College of Physicians,also formed recently, will consider this question.INCOMPATIBILITIES OF SULPHONAMIDESIN the early days of sulphonamide therapy severe

cyanosis was the most alarming of the toxic effects.It was soon recognised, however, that the outlook inthese cases was rarely as black as it seemed whentaken at face value, and indeed most practitionersdisregarded cyanosis in determining the effective doseof the drug. COLEBROOK and KENNY1 showed thatthe cyanosis was due to methaemoglobin, or more rarelysulphaemoglobin, in the blood. These changes in theblood pigments are representative of a biologicalmechanism previously described by SNAPPER 2 andVAN DEN BERGH.3 In the presence of oxygen sulphaemo -globin can be formed in the blood-stream from sulphideabsorbed from the bowel; and sulphanilamide is onlyone of many drugs which facilitate this reaction byacting as catalysts. The danger of sulphonamidecyanosis arises from the immobilisation of the body’s oxygen carrier. Methaemoglobin in the blood is com-paratively benign, for it can revert to haemoglobinspontaneously in the course of a few days and muchmore rapidly after the administration of methylene-blue. Sulphaemoglobin, on the other hand, is morestable and remains unchanged in the erythrocytesuntil these are destroyed, which may be a matterof 4 months or so. Furthermore, the cyanosis dueto sulphaemoglobin is unaffected by methylene-blue.Earlier workers were often puzzled by the occa-

sional occurrence of sulphonamide cyanosis withoutspectroscopically demonstrable changes in the blood.That this discrepancy originated in faulty techniqueseems probable from the investigations of CAMPBELLand MORGAN,4 who emphasised the necessity forlaking the blood with only a small volume of waterand making the spectroscopic examination soon

after the withdrawal. The present infrequency ofgross cyanosis due to sulphonamide therapy as com-pared with 5 or 6 years ago may, however, be partlyexplained by chemical differences between Prontosilrubrum’ and the sulphonamides now in common use.The absorption of sulphuretted hydrogen is said to

be favoured by the use of saline purgatives whichenhance bacterial activity by keeping the faeces inthe fluid state, but this hypothesis does not bear closescrutiny. In man, at any rate, only the contents ofthe colon are likely to undergo any considerablealteration in consistence, for above the ileocaecal valve1. Colebrook, L. and Kenny, M. Lancet, 1936, i, 1279.2. Snapper, I. Ned. Tijdschr. Geneesk. 1922, 66, 2541.3. van den Bergh, A. A. H. and Wieringa, H. J. Physiol. 1924-25,

59, 407.4. Campbell, D. and Morgan, T. N. Lancet, 1939, ii, 123.