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Special Articles

COMPOSITION OF FLOURTHE panel appointed by the Government in May, 1955,

to investigate the composition and nutritive value of flourlhas now reported.2 Its main conclusion is as follows :

"

Taking into account all the circumstances, and bearing inmind particularly the needs of the vulnerable groups in thepopulation, the Panel concludes that the available evidencedoes not reveal any ascertainable difference between Nationalflour as defined in the Flour Order, 1953, and flours of extrac-tion rate less than National flour, to which vitamin BI, nico-tinic acid, and iron have been restored in the amounts specifiedin the Flour Order, 1953, which would significantly affect thehealth of the population in any foreseeable circumstances.They believe, however, that differences between low extractionflour enriched as specified and low extraction flour not soenriched are significant."

Last week the Minister of Agriculture, Fisheries, andFood announced that the Government had accepted thisconclusion (see p. 810).

National flour is defined under the Flour Order, 1953, asfollows : containing the maximum quantity of wheat germwhich, having regard to the type of milling, can be included insuch flour ; (2) not including any coarse or added bran ; and(3) consisting of wheat flour, being either of 80% extractionor of substantially the same nature and containing substan-tially the same quantities and proportions of constituents asflour of 80% extraction.

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THE CONFLICTING VIEWS S

The panel summarises two conflicting views.On the one hand, the Government’s medical and

scientific advisers and the Medical Research Councilclaim that, since bread contributes, on a national average,a third of the total calories of the diet, National flour of80% extraction makes it virtually certain that the dietas a whole will provide enough protein, vitamin BI,nicotinic acid, and iron, and that, in addition, such flourprovides useful quantities of other essential nutrients forwhich the criteria of adequacy are less well defined. Ifthe extraction-rate were lowered to 70%, there would bea loss of protein, vitamin Bl, nicotinic acid, and iron ;and, even if these two vitamins and iron were restoredby enrichment, a reduced intake of other vitamins

might in some circumstances be reflected in nutritionaldeficiencies.The representatives of the milling industry, on the

other hand, claim that between National flour of 80%extraction and whiter flour of lower extraction, enrichedwith vitamin Bl, nicotinic acid, and iron to the levelsobtaining in National flour, any differences in compositionare insignificant when related to the diet as a whole.

TRIAL IN GERMAN SCHOOL-CHILDREN

The panel refers to the trial in undernourished Germanchildren of flours with different degrees of enrichmentand different extraction-rates (from 70 to 100%).3 The

principals in this trial told the panel that their experiencewould lead them to believe that the difference betweenunenriched low-extraction flour and higher-extractionflours is less than was thought at the time of the Confer-ence on the Post-War Loaf 4 and is probably small enoughto be ignored when the diet is otherwise well balanced.

THE PANEL’S CONCLUSIONS

The panel concludes that a true 80%-extraction flourwill contain, as compared with flour of lower extraction-rate (taking 70% extraction as a reference-point) : (a)1. The members were : Sir HENRY COHEN, F.R.C.P. (chairman) ;

Mr. A. C. CHIBNALL, SC.D., F.R.S. ; Prof. J. H. GADDUM, SC.D.,M.R.C.S., F.R.S. ; Prof. R. A. MORTON, D.SC., F.R.S. ; and Prof.L. J. WITTS, F.R.C.P.

2. Report of the Panel on Composition and Nutrititive Value ofFlour. Cmd. 9757. H.M. Stationery Office. Pp. 34. 1s. 6d.

3. Widdowson, E. M., McCance, R. A. Spec. Rep. Ser. med. Res.Coun., Lond. 1954, no. 287. See Lancet, 1954, ii, 1006.

4. Report of the Conference on the Post-War Loaf. Cmd. 6701.H.M. Stationery Office, 1945. See Lancet, 1945, ii, 789.

more of certain essential nutrients, such as protein,vitamin B1, nicotinic acid, and iron ; (b) more of theother essential nutrients such as pyridoxine, pantothenicacid, biotin, and folic acid ; and (c) a little more ribo-flavine. It is, however, a, simple process to add vitamin B1,nicotinic acid, and iron to lower-extraction flours so thatthe contents of these nutrients amount to or exceed thosein 80%-extraction flour, without impairment of technicalquality. The panel has an open mind about the signifi-cance ofthe other differences : ’’ The history of nutritionreveals many instances where the refinement or over-puri-fication of food has led to ill-health and there is no reasonto believe that this chapter of knowledge is closed."The panel was particularly impressed by the fact that

10% of British children may pass their childhood incircumstances in which they depend on flour to supplycertain essential nutrients in sufficient amounts. " Thepanel is of the opinion that nutrition in such individualswould fall below the level necessary for good health ifthere were a return to the pre-war practice of makingbread from flour of extraction rates of 70 to 72 per cent.to which vitamin B1, nicotinic acid, and iron had not beenrestored." There is some evidence that the quality of theprotein of 70% -extraction flour is less than that of 80%-extraction flour ; but the panel believes that when 70%-extraction flour is blended with the remainder of the dietits use is most unlikely to give rise to symptoms of

protein malnutrition. Lowering the extraction-rate from80 to 70% is very unlikely to lead to any nutritionaldisturbance from lack of pyridoxine, pantothenic acid,biotin, or folic acid.Compared with a 70%-extraction enriched flour a

true 80%-extraction flour may give a more widely spreadinsurance against possible, but as yet unproved, deficiencyin the rest of the diet ; but 70%-extraction enriched flourgives a more certain cover against possible deficiency ofthe three " token " nutrients (vitamin B1, nicotinic acid,and iron) whose lack is associated with well-recogniseddeficiency states.The panel was impressed by the evidence of demand, by

millers, bakers, and public, for white flour and whitebread. There is a risk, the industry claim, that if peoplecan obtain only bread made from 80%-extraction flourthey may eat less bread and more of other manufacturedfoods which may not be so nourishing.The panel precedes its main conclusion by expressing

its belief that experience has demonstrated that " a

policy of enrichment provides a realistic means of

ensuring that the greatest nutritional benefit is derivedfrom flour." But flours of higher extraction-rate, con-taining no less nutrients than the enriched low-extractionflours, should be also available. The National Food

Survey, it adds, should continue to be of great help inthe periodic review of policy concerning bread.

1. Reports of the Department of Health for Scotland and theScottish Health Services Council, 1955. H.M. StationeryOffice. Pp. 157. 5s.

HEALTH IN SCOTLAND IN 1955EXPECTANT mothers, the newborn, and young children

are singled out, statistically and traditionally, as inneed of special protection against health hazards. The

report 1 of the Department of Health for Scotlandsuggests that to these vulnerable groups we should nowadd " men towards the latter half of middle age."Last year the maternal and infant death-rates each

touched a new low record. There were 4 maternal deaths(compared with 70 in 1954) or 1 maternal death per2200 births. The infant death-rate in 1955 fell to 10.7per 1000 births, compared with 15-6 per 1000 five yearsago. The school medical officers found that infectionswere declining among their charges, while growth wasmore rapid and maturity attained earlier. The majorhazard to these children is now transport accidents.

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The other group of people whose health is endangeredby our present way of living is men of 45 to 64. Coronarythrombosis and cancer are " the leading causes of death "among these men. Illness among employed peoplehas increased steadily since 1952, and the figures for 1955show an increase of 9% over 1954. Tuberculosis wasstill the most important cause of loss of time at work,though notifications continued to fall-to 128 per100,000 of the population, which is a reduction of 7%on the rate for 1954. The number of people on the waiting-list for admission to sanatoria had fallen from 515 in1954 to 148 at the end of 1955. This fall is not matched

by the fall in notifications, and the improvements inthe hospital position is partly due to the increasing efficacyand use of domiciliary and outpatient management.The blue-book also includes the report of the Scottish

Health Services Council and its standing advisorycommittees.

1. Blumberg, B., Ragan, C. Medicine, Baltimore, 1956, 35, 1.2. Connor (or O’Connor) B. Lettre écrite à Monsieur le Chevalier,

Guillaume de Waldegrave, Paris, 1691. See Dictionary ofNational Biography.

3. Hart, F. D. Ann. rheum. Dis. 1954, 13, 186.4. Buckley, C. W. Brit. med. J. 1943, ii, 4.5. Ball, J. Ann. rheum. Dis. 1952, 11, 97.6. Cruickshank, B. Ibid, 1951, 10, 393.

Occasional SurveyANKYLOSING SPONDYLITIS

IN a comprehensive review Blumberg and Ragan 1remind us that this disease was first described by BernardConnor. Born in Ireland in 1666, Connor published in1691 a description of a skeleton with spondylitis-an"extraordinary humane skeleton, whose vertebrae, theribs, and several bones down to the os sacrum, were allfirmly united into one solid bone, without joynting orcartilage." From the time of this description the emer-gency of ankylosing spondylitis as a specific entity wasretarded by confusion with other conditions, notably withdegenerative joint disease of the spine with senile

kyphosis. In the United States the disease, being generallyregarded as a form of rheumatoid arthritis, goes under thename of " rheumatoid spondylitis." In this country mostclinicians prefer " ankylosing spondylitis," and wouldagree with Hart

3 that " in the meantime it is, perhaps,more profitable to study these disorders as differentunsolved problems than to put them all into one diag-nostic cauldron." The syndrome, by whichever nameit is known, still lacks complete uniformity and atypicalcases have quite recently been distinguished. Buckley 4held that the predisposition of ankylosing spondylitisto attack men more than women, its characteristic

tendency to produce bony ankylosis, its centrifugalspread, and its failure to respond to gold, made it unlikelyto be a variant of rheumatoid arthritis. To these pointsmay be added the responsiveness of ankylosing spondy-litis to treatment with X rays (at any rate in terms ofrelief of pain) and the rarity of a positive differentialagglutination (Rose-Waaler) test (which was positivein only 3 of Ball’s 203 cases 5). The only good evidencefor the opposite view is that peripheral joints may beinvolved and that the histopathology of the diarthrodialjoints of the spine is strikingly similar to that of rheu-matoid arthritis. Cruickshank 6 found certain minordifferences ; there was a greater liability to hxmorrhagein ankylosing spondylitis (perhaps a result of the earlierformation of adhesions and their rupture by movement)and a tendency to thickening of small vessels, usually inthe form of endarteritis obliterans. He argued that thehistopathology of rheumatoid arthritis is not entirelyspecific, and that a similar picture in ankylosing spondy-litis need not imply a common aetiology. Subcutaneousnodules-lesions much more specific for rheumatoidarthritis-are unknown in ankylosing spondylitis. van

Swaay proposed a different view of the pathogenesis ofankylosing spondylitis, believing that the essential

process in the sacro-iliac joints is a proliferation of newcartilage, which replaces the old without evidence ofinflammation. The joint-space is finally ossified.The cause of ankylosing spondylitis remains unknown.

Various agents have been suspected, including tubercu-losis, brucellosis, and gonococcal infection. These con-ditions can certainly produce lesions in the sacro-iliac

joints which in some ways resemble those of ankylosingspondylitis ; but they cannot be accepted as aetiologicalagents. Parathyroid dyscrasias, genito-urinary disease,allergy, and metabolic and hormonal factors have allbeen put forward, but none has been convincingly estab-lished. Several groups of workers 11-10 have failed toconfirm the finding of Davison et al.11 that the excretionof 17-ketosteroids is increased in ankylosing spondylitis.Inheritance is known to play a part, and Hersh et al.12decided that the factor involved was an " autosomaldominant which has about 70% penetrance in malesand about 10% or slightly greater in females."

DiagnosisIn many cases the diagnosis of ankylosing spondylitis

is not difficult, and a story of pain or stiffness in the lowerback or buttocks (perhaps with sciatic radiation) in ayoung man raises immediate suspicions. The lumbar

segment of the spine should be examined for flatteningand loss of movement, and the chest for impairedexpansion.13 X-ray examination of the sacro-iliac jointsis essential, and a normal erythrocyte-sedimentationrate should not be accepted as excluding the diagnosis.There are, however, important deviations from theclassical picture. In Hart’s series 3 the earliest symptomsin 13% of patients were in the peripheral joints ; andthere was swelling of these joints in over 20%. The kneesand ankles are most commonly involved and thedistribution of affected joints is rarely that of classicalrheumatoid arthritis. For example, the wrists were

involved in only 7% of Blumberg and Ragan’s cases andthe hands usually escape. Iritis may be the presentingsign, and this again helps to differentiate ankylosingspondylitis from rheumatoid arthritis, in which lesionsin the eyes, if present, are those of episcleritis or kerato-conjunctivitis sicca. In Blumberg and Ragan’s series,25% of patients had one or more attacks of iritis duringthe course of their disease, and this complication wasoften the only reason for admission to hospital and fortreatment with hormones. In this country iritis has beenobserved in 6-24% of cases,14-17 Pain over the angleof Louis is not uncommon, and Savill18 described a

sequence of radiographic changes starting as erosions ofthe bone ends and ending in bony ankylosis. Changes inthe manubriosternal joint may, however, be found inrheumatoid arthritis. Among other features of ankylosingspondylitis, tenderness over bony prominences, notablythe ischial tuberosities and iliac crests, is common 10 ;and the radiographic accompaniments are irregular lyticdefects, with a punched-out appearance, irregular zonesof increased density, and " whiskering " or " fringeing "

7. van Swaay, H. Spondylosis ankylopoietica : een patho-genetische studie. Leiden, 1950 ; p. 182.

8. Pond, M. H. Ann. rheum. Dis. 1954, 13, 67.9. Mowbray, R., Latner, A. L., Middlemiss, J. H. Quart. J. Med.

1949, 18, 187.10 Hart, F. D., Robinson, K. C., Allchin, F. M., Maclagan, N. F.

Ibid, p. 217.11. Davison, R. A., Koets, P., Kuzell, W. C. J. clin. Endocrin.

1947, 7, 201.12. Hersh, A. H., Stecher, R. M., Solomon, W. M., Wolpaw, R.

Hauser, H. Amer. J. hum. Genet. 1950, 2, 391.13. Hart, F. D., Bogdanovitch, A., Nichol, W. D. Ann. rheum.

Dis. 1950, 9, 116.14. Birkbeck, M. Q., Buckler, W. St. J., Mason, R. M., Tegner,

W. S. Lancet, 1951, ii, 802.15. Campbell, A. M. G. Ibid, 1947, i, 406.16. Simpson, N. R. W., Stevenson, C. J. Brit. med. J. 1949, i, 215.17. Buckley, C. W. In Textbook of the Rheumatic Diseases.

London, 1955 ; p. 336.18. Savill, D. L. J. Bone Jt Surg. 1951, 33B, 56.