692

a method of termination by injection of sterilised soappaste into the uterus.

Dr. R. ,COHEN believed that there were many undiag-nosed cases of pulmonary tuberculosis among patientsattending antenatal clinics, and that the chest should be

’ radiographed as part of the routine of antenatal care.Pregnancy was not the sinister complication it wasoften deemed to be ; a number of active cases wereimproved after parturition, and all quiescent cases were’’unaffected. Rise of the diaphragm was probably not asimportant as restriction of its movement. Pneumo-peritoneum was not required.

Prof. F. J. BROWNE agreed about the necessity ofantenatal radiography. He thought that in assessingthe effect of pregnancy on tuberculosis confusion arosebecause the patients who became pregnant were on thewhole less ill than those who did not.

Dr. LETITIA FAIRFIELD thought that figures by them-.selves might be fallacious, for one.had to consider whatthe original extent of disease was in each case. Nofigures told what happened to the cases that abortedearly. One must not forget the psychological aspect ;marriage often increased the will to live.-Dr. N.ENGLAND pleaded for the combination of the maternityunit with the sanatorium.-Dr. BRIAN TAYLOR and Dr.HUGH RAMSAY both laid stress on the extra worriesand strains that assailed the tuberculous women witha family.-Dr. A. STEPHEN HALL quoted the saying that’" the load in the crib is greater than that in the womb."But there was no doubt in his mind that pregnancyhad a detrimental effect.

Replying, Dr. LOGG pleaded for the tuberculosisscheme to include adequate facilities for the care of awoman from the beginning of pregnancy till at leastsix months after it.-Referring to the points made bysome speakers, Dr. BARNES protested that one or twochildren did not imply having a large family.

Reviews of Books

Pathogenesis of TuberculosisARNOLD R. RicH, MD, associate professor of pathology,Johns Hopkins University, Baltimore. (Bailliere.Pp. 1008. 588.) _

THIS important reference book sets out the basic factsabout tuberculous infection. Professor Rich discussesthe life-history of different types of tubercle bacilliand their chemical composition ; infection, resistance,hypersensitivity, and desensitisation of the host; andthe application of the principles of pathogenesis totuberculosis of the lungs, meninges, and serous cavities,and to the decline of mortality and the outlook for thefuture. It would have fortified the reader if therehad been at the close a comprehensive summary of thewhole carefully argued 900 pages.The claim that the avian strain may be the causa-

tive factor of Hodgkin’s disease, or Boeck’s sarcoid,or even of other diseases of unknown aetiology, iseffectively disposed of. The chapter on the bovinestrain is an object lesson in what can be done in preven-tive medicine. The incidence of positive reactors inherds in the USA has been reduced from 4-9% in 1918to 0.3% in 1941. Professor Rich criticises the badrecord of the British Isles, where, he says, " humantuberculosis of bovine origin is proportionately morecommon than in any other civilized country in the world."

In his opinion virulence is determined primarily bythe ability of the bacterium to propagate itself pro-gressively in the tissues of the body ; there is no basisfor linking virulence with toxin production, and when wespeak of the virulence of the tubercle bacillus we shouldthink in terms of its power of reproduction and not ofcapacity to produce toxins. There is no evidence, hepoints out, that any strains of tubercle bacilli elaboratean exotoxin or an endotoxin for the normal body ; butonce infection has made the patient hypersensitive bothtubercle bacilli and tuberculoprotein act as thoughhighly toxic. He finds no parallelism between hyper-

sensitivity and the antibody titres for opsonin, agglu-tinin, precipitin, and complement-fixing bodies. Effec-tive acquired resistance, he reminds us, can be estab-lished without hypersensitivity ; and he considers,thatno satisfactory demonstration of the value of protein

hypersensitivity has so far been produced. Why, forinstance, are native races hypersensitive yet poorlyresistant ? Why is hypersensitivity sometimes dele-terious, sometimes indifferent, and sometimes beneficialin its effect ? He discards the word allergy altogether.The book leads us from the half-truth that tuber-

culosis is a local disease to a wider conception of patho-genesis. Despite the spectacular decline in tuber-culosis mortality in western countries since the turn of thecenturv or earlier, Professor Rich is not prepared to saythat the disease will die out. Subclinical or carrierinfection is still so common that the infecting case canrarely be traced, and the better our laboratory methodsbecome, the more sputa are found to be positive..Fractures and Fracture Treatment in Practice

(2nd ed.) KURT COLSEN, MD. (Witwatersrand UniversityPress. Pp. 154. 12s. 6d.)

,

IN the- preface the author informs us that this shortaccount of the essentials of fractures and their treatment’is written for the benefit of senior students preparingfor their final examinations and practitioners wishingto revise the subject quickly. The most valuablecontribution that a book such as this can make is togive a clear explanation of how fractures, and thedeformities that accompany them, are produced, andhere Dr. Calsen has been successful. Good line drawings’provide information that could not be conveyed inwords, and the text itself is concise and not over-

burdened with practical details of technique. Some ofthe treatment advised, however, is open to criticism.The general use of local anaesthesia for the reductionof recent fractures is not favoured in Great Britain, andthe dangers of the skintight plaster might well havebeen given more weight in a book written primarilyfor students. Sayre’s method of treating claviclefractures has so many disadvantages that it hardlydeserved a place, and the complications of skeletaltraction through the lower end of the femur need greateremphasis. The treatment of unstable tibial fracturesby continuous skeletal traction with a weight of 10-15 lb.on a Braun’s frame without plaster immobilisation isunsound, and is likely to produce distraction, a commoncause of delayed union in tibial fractures. But all thesecriticisms apply to somewhat controversial subjects,and do not greatly detract from the value of the bookas a whole. ’

A Synopsis of Medicine(8th ed.) Sir HENRY TIDY, KBE, DM OXFD, FRCP. (W’right._Pp. 1215. 30s.)

THIS, ‘’ the coach’s bible," celebrates its silver jubileeby appearing in its eighth edition. Valiantly trying tosave it from middle-age spread, Sir Henry has prunedhis material to allow space for recent advances ; andeven so he has had to omit any reference to penicillin.The new edition is as comprehensive, reliable, andconcise as ever. The time has come, we suggest, toforgo the administration of pulv. jalap co. in the treat-ment of acute nephritis ; and it is odd that the signifi-cance of changes in the retinal arteries in essential hyper-tension should have been omitted. But in generalthis work is just what it claims to be-a " synopsis "which will be a welcome aid to many in time of trouble.

Medicine and Mankind -

ARNOLD SORSBY, FRCS. (Watts. Pp. 116. 2s. 6d.)THIS book shows man as part of his environment- ,

climatic, occupational, bacterial, and social-and lifeas a balance of processes which have to be kept in equili-brium. These processes are not conducted whollywithin the body : a greater or lesser part of them takeplace in the environment. Control of. environment.in its widest sense, is of vital importance, and is notso well managed as it might be. The book sets outwell the need for what is nowadays familiar as "socialmedicine," though as an abridged edition of a largerwork it has inevitable shortcomings from the point ofview of the non-medical or non-scientific reader.

CORRIGENDUM.—In the leading article of March 31 on

globulin in the control of measles, reference 4 should read :Greenberg, M.. Frant, S., Rutstein, D. D. J. Amer. med. Ass.1944, 126, 944.