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Reviews of Books

Medical Problems of Old AgeA. N. EXTON-S,MITH, M.A., M.D. Camb., M.R.C.P., physician,Whittington Hospital, London. Bristol : John Wright& Sons. 1955. Pp. 344. 30s.

Dr. Exton-Smith has produced a good book. He keepsclosely to his avowed purpose of providing a textbookdealing with the medical problems of the elderly patient,yet he takes a wide view of the subject in a commendablysmall compass.He starts with the aspects most likely to interest the

general practitioner and health visitor or social worker,and he deals first with the old person at home-the oppor-tunities there for the early recognition of morbidity anddiagnosis of disease, for the maintenance of health, and forthe application of practical measures to prevent accidents.He gives a whole chapter to the general principles of reable-ment after illness, with proper emphasis on the importanceof assessing the patient from the physical, psychological,and social aspects, enlisting the relatives’ help from an earlystage, and the special influences, opportunities, and limitationsof reablement in hospital. The reablement of the hemiplegicpatient is considered more fully than in many larger works,but even so it is doubtful whether the student who has notworked with hemiplegic patients in physical reablement

departments or in an active geriatric unit will learn much ofpractical value. The sections on the psychological and socialaspects of reablement of the hemiplegic contain suggestionsthat are likely to be more helpful. Reablement of the arthriticpatient is only briefly mentioned, but Dr. Exton-Smithdoes not overlook the value of occupational therapy and ofexercises to improve personal independence. The chapterson medical and nursing care should also prove helpful,especially the section on restlessness.

It is increasingly recognised that age need not be a contra-indication to surgery ; but Dr. Exton-Smith wisely indicatesthe special risks of surgery and the postoperative state forthe elderly, and clearly presents the general principles deter-mining immediate or delayed surgical intervention.

Throughout the book Dr. Exton-Smith shows a

clear appreciation of the essential variations of diseasein the elderly, compared with younger patients. He is

especially helpful in assessing which, of a number ofcoexistent pathological conditions, is likely to call for

preferential treatment.

Doctor against WitchdoctorE. W. DOELL. London : Christopher Johnson. 1955.

Pp. 216. 15s.

THIS book contains a number of stories based on theintense belief held by most Africans that disease is caused,not by the agents accepted by modern Western societies,but by malevolent persons using witchcraft. Dr. Doellobviously knows his subject, and indeed he has beenfaced with tragic examples of interference by witch-doctors which can at once be recognised as authentic bythose who have practised in Africa.The book does not leave a cheerful or optimistic

impression. Traditional beliefs work strongly to preventthe application of modern methods of treatment, and stillmore of prevention ; the idea of service to the sick inhospital is hard to instil in the nurses and hospital assis-tants, who may take up these professions for reasons farremoved from the ideals we have painfully evolved. Itseems at times impossible ever to lift this dead hand offear which grips the Africans so closely from infancyonwards. Yet some of them have taken this frighteningstep towards a more rational conception of Nature, inface of the terrible threats inherent in the beliefs ofwitchcraft. It is surely early to expect more than atentative acceptance of Western ideas, linked as they arein the African mind with an alien community. Thepremises which the African accepts from his tribalteaching lead him by valid logical processes to tragic,but not from his point of view criminal, activities. Wecan hope to change his outlook by persuasion andexample, not by scorn and premature legal action. Thisbook is a vivid and sincere contribution to a difficultsubject.

Tubercle Bacillus in the Pulmonary Lesion of ManGEORGES CANETTI, M.D., director of laboratory, PasteurInstitute, Paris. New York : Springer. London : Inter-science Publishers. 1955. Pp. 226. 64s.

Dr. Rene J. Dubos and Dr. Walsh McDermott havedone a valuable service in translating into English theenlarged and revised edition of Dr. Canetti’s originalLe bacille de Koch. The most important part of thisbook correlates the histology of different stages of pul-monary tuberculous lesions with the number of bacillipresent in each type of lesion.To accomplish this, Dr. Canetti has divided the lung

lesions into a large number of types, but he is fully justifiedin doing so by the differing occurrence of bacilli in these types.At the same time, he recognises the difficulties of mixed-

type lesions and of timing the incidence of each type. Fromthis combined histological and bacteriological investigation,he goes on to discuss the pathogenesis of the lesions, and toconsider the problems of hypersensitivity and immunity.He appositely quotes much of the older Continental work,now so often overlooked, and he examines therapeutic methods- resit, collapse, chemotherapy-in the light of his ownstudies.

Enough time has not yet elapsed since the introductionof chemotherapy for a full histobacteriological studyof pulmonary lesions under different treatment regimes,comparing the changes with those before chemotherapy,but Dr. Canetti provides for future comparison an

invaluable picture of the pulmonary lesions beforechemotherapy. His book is no aid to the rule-of-thumbworker for treating individual cases, but it will be mostthought-provoking and helpful to all doctors who areinterested in the possible lines of progress of the tuber-culous lesions in their patients, and the modificationsof those lesions under therapy.

Textbook of Physiology (17th ed. Philadelphia andLondon : W. B. Saunders. 1955. Pp. 1275. 94s. 6d.).-Thisreliable and useful summary of present-day knowledge of

physiology, originally known as Howell’s Textbook of Physio-logy, now appears under the editorship of Prof. J. F. Fulton,who has himself written most of the chapters on the centralnervous system. These are particularly good and up to date;but, rather surprisingly, recent observations on neurosecretionin the hypothalamus are not mentioned. The chapters onblood are good as are also those on metabolism and nutrition.The section on the circulation varies in. quality, but it isuseful to find discussion of the characteristics of blood-flowin a larger number of special regions than usual, includingvoluntary muscle and uterus. The chapters on the endocrinessucceed in being both good and compact where it is only tooeasy to be diffuse. The book as a whole is readable and not merely a close-packed mass of facts ; but it deserves a better

‘

index. The type is clear and agreeable, and, except for repro-ductions of some of the kymograph tracings, the diagrams arewell printed.Diseases Transmitted from Animals to Man (4th ed.

Springfield, III. : Charles C. Thomas. Oxford : BlackwellScientific Publications. 1955. Pp. 717. 90s.).-The newedition, by Mr. Thomas G. Hull, PH.D., of this valuable text-book contains a mass of information on all the diseases butone (foot-and-mouth disease) dealt with in previous editions,as well as seven new chapters describing such diseases asvibrio abortion, vesicular stomatitis, and Newcastle disease.It is enlivened by 104 illustrations, mostly of good quality,and a large number of diagrams and tables. This great task ;has been carried out by 25 authors, all well acquainted withtheir subjects ; but we cannot help regretting that Dr. Hullhas not directed attention to some of the fascinating problemspresented by infections affecting both animals and man, suchas the extraordinary differences in the effects produced by thesame pathogen in different species, the effect of age, sex, andnutrition on resistance to infection, the tendency of certainpathogens to produce permanent parasitism, and the changesin " virulence " of many pathogens after they have becomeestablished in any country. With such questions in theforefront of their minds, general readers, of whom we

hope there will be many, might well find this book a

gateway into a strange, largely unexplored, and fascinatingworld.

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THE LANCETLONDON: : SATURDAY, JULY :23, 1955

LEADING ARTICLES

Design of HospitalsAT the dawn of a new era of hospital building in

this country, the publication of so important a bookas Studies in the Functions and Design of Hospitals is well timed, for it is an addition of great worth toour native-but meagre-literature on hospital plan-ning. This report is not intended to be a general guideto the planning of hospitals ; for its scope is limited tothe investigation of certain services in the acute

general hospital-the ward, the outpatient service,and the operating-theatre suite-and of physicalfactors appertaining to them, such as light, colour,warmth, ventilation, and the control of noise. Threefurther chapters deal with" protection against fire

(a matter which has been rather overlooked in thehospitals of this country) with general considerationswhich may affect design ; and with planning to meetdemand, treated as a statistical problem. On thepractical side of the investigation, experimentalbuildings are being or will be erected at LarkfieldHospital, Greenock, and at Musgrave Park Hospital,Belfast, comprising two ward units, a twin operationsuite, a central sterile supply, and an X-ray depart-ment. If it is to be of value, all new hospital buildingshould be esentially experimental, and this reportbrings to us new and experimental methods of deter-mining the data on which the buildings should beplanned. No reader can fail to be impressed by theimmense amount of careful research which theNuffield team has done, and the report representsthe first major attempt in this country to put theneed for hospitals and their design on a factual andstatistical basis. From the results of the time-and-motion studies made, structural plans have beenevolved resulting in buildings which are more

compact, and which should be more economical incapital and in maintenance costs, than those withwhich we are familiar. This is perhaps the main themeof the report ; but there is also a great deal of variedinformation which will repay study by those who havehospitals to plan.

In any hospital, the psychological and physicalneeds of the patient are continuously in hidden-orsometimes open-conflict with the requirements ofefficient administration, and somehow a reasonablebalance has to be struck between the two. There is

today a trend of thought which may well lead togiving the nurse-because of her scarcity value-precedence over the patient, and to evasion of thepatient’s deeper needs for the sake of administrativetidiness and convenience. The experimental wardunits described in chapter 1 of the report are basedprimarily on time-and-motion studies of nursing duties,and from them structural designs have been evolvedto ease the nursing burden and to reduce the capitaland maintenance costs ; but the time has not, ofcourse, arrived when the questions " Do the patientslike them ? Do the staff like them ? " can be answered.

1. Studies in the Functions and Design of Hospitals. Nuffield.Provincial Hospitals Trust. London: Oxford UniversityPress. 1955. Pp. 192. 63s. (in U.K. only).

In these ward units, the siting of the service roomsbetween the two halves of the bed area is unusual.It may be open to criticism on account of noise ;for, however carefully sound-control is planned, thehuman element remains, and in hot weather doors maybe left open and the washers-up may sing and whistleat their work, as they have done from time immemorial.A second point of criticism, especially of the LarkfieldHospital unit, may be the exposure of the patients inone half of the bed area to the traffic which must passbetween the entrance of the unit and the service rooms.In the Musgrave Park Hospital unit this point seems tohave been considered, for the patients are partiallyscreened by cupboards and sanitary units. But thew.c.s are small and have no wash-basins, and if thepatient wants to wash after using them-and he is givenlittle encouragement to do so-he is likely to soil twodoors on his way.

The factual basis of the design for the outpatientservice-to some extent materialised in the Nuffield

Diagnostic Centre at Corby-is founded on time-and-motion studies of the work of the doctors and of themovement of the patients in the clinics, combinedwith an investigation into the efficiency of appoint-ments systems. The major finding of interest wasthat the work of the clinic moved more smoothlywhen the examination rooms were restricted to oneper consultant instead of two or more. Since delayin the outpatient department is still a notable blot onthe hospital service, this chapter should be read

attentively. It would be interesting to know whether,in fact, a whole-time or a part-time medical staffgives the smoother service ; for the part-time staffseem often to be delayed by outside commitments,and frequently too many consultants wish to holdtheir clinics on the same day and are unwilling tochange because of outside engagements. This leadseither to overcrowding and overwork on that day,or else to the provision of accommodation which isunder-used at other times. In the chapter on theoperating-theatre suite, special attention should bepaid to the paragraphs on recovery rooms and thecentral sterile supply department. These are almostnew introductions to this country, though abroad,and especially in America, there has been much

experience of their use. Both seem to decrease risksto the patient appreciably, as well as giving someeconomy by the performance centrally, with trainedteams, of procedures hitherto performed diffuselythrough the hospital by persons of no specialised skill.

In the search for exactness and reason in hospitalplanning, it is easy to forget that facts and figures arerelatively inflexible and apply accurately only to thepresent or the past; until more is known, one shouldperhaps avoid taking them too literally in planningnew hospitals which are to last for fifty or more ofthe years yet to come. The big difficulty of hospitalplanning is the unpredictable-the changing patternof sickness ; changes of policy in dealing with thesick ; the rapid changes in medical and nursingtechniques, the one deriving from the wealth of newdiscovery, the other from the poverty of personnel ; andthe movements of populations naturally or en masseas the overspill of urban districts. And there is the

changing attitude of the patient himself towardsthe service which the hospital provides ; for, as thestandard of living, the level of wages, the degree ofeducation, and the sense of individuality progressivelyincrease, so he will become more critical and moredemanding, even as the patient of today expects far