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after use and much work for the nurse. Again, severely sub-normal ambulant patients do not tolerate showers readily andare, in any event, cleaned with difficulty in conventional showerbaths. Also, the nurses need protective clothing when showerbaths have to be given.A dwarf shower (see figure) has been designed to overcome the

difficulty. It consists of a fibreglass splash-proof enclosure, fitted witha trapped drain at its lowest level and an easy-fitting drop-in door,sufficiently light to be easily lifted into position by the nurse. Thebath is about 3 ft. 4 in. high and 3 ft. 1 in. square, and thus occupieslittle space.

The shower has a thermostatically controlled water supply, feedingtwo adjustable nozzles which spray water on the patient’s buttocksand legs, and a water brush controlled by a three-way valve. Thevalve is readily accessible to the operator, and thermostatic controleliminates the risk of scalding.

The cycle of operations is as follows: The patient is stripped,and soiled or wet clothing is removed. He then enters theshower and the valve control is turned on to " spray ". Thisremoves urine and will soften any fascal smears in patients withfaecal incontinence. The next position of the valve turns on thewater brush which removes adherent fasces and at the sametime turns off the spray nozzles to ensure that the nurse is not

splashed. After the brush-cleaning, the valve is turned back to

spray, and, on completion of the spray, to the " off " position.

The patient is then dried normally and dressed.The design of this unit presented considerable technical

difficulties. It had to be smooth in finish, easily cleaned, and atthe same time attractive. Messrs. Thermo Plastics of Dunstablehave succeeded in meeting all these requirements.The water brushes are readily detachable, and can be

sterilised in weak disinfectant. The cleaning process is not onlyeffective, thorough, and free of stress and anxiety to the patientbut also allows the person in charge to remain dry throughout.The elimination of sharp angles, the natural give of the materialand the rounding-off of all corners eliminate any risk of injuryin accidental falls, such as epileptic fits.

This shower is useful for ambulant severely subnormal

patients in hospitals or geriatric units, and for children inoccupation centres who are debarred from attending by reasonof incontinence.

My thanks are due to Messrs. Thermo Plastics of Dunstable, forproducing the appliance to our specifications; and to Messrs. A. F.Scott & Son, architects, for collaborating in the design. The applianceis being marketed under the name of the Little Plumstead SpecialShower ’.

J. V. MORRISLittle Plumstead Hospital, M.A., M.D. Dubl.near Norwich, Norfolk Physician-Superintendent

Little Plumstead Hospital,near Norwich, Norfolk

J. V. MORRISM.A., M.D. Dubl.

Physician-Superintendent

Reviews of Books

The London: a Study in the Voluntary Hospital SystemVol. 2, 1840-1948. A. E. CLARK-KENNEDY, M.D., F.R.C.P.

London: Pitman Medical Publishing Co. 1963. Pp. 310. 50s.

IN his second volume, Dr. Clark-Kennedy. takes the story ofThe London from the turn of its first century to its end, as avoluntary hospital, with the coming of the National HealthService. Again, he is in the happy position of a skilled authorwith a good tale to tell: of the steady advance of this greatcharity in the face of pressures, privations, strains, and tribula-tions. The pressures were those of a surrounding populationprogressively swollen by the industrial revolution at home andfamine and persecution abroad; the privations the result offinancial insecurity and shortage; the strains due to unjustattack by the ill-informed and ill-disposed; and the tribulationsthe accompaniments of two world wars which disrupted thehospital’s life, dispersed its patients, staff, and students, anddevastated its fabric.

Any historian would envy him the characters at his disposal:Dr. Barnado, Elizabeth Garrett-Anderson, the Elephant Man,Grenfell of Labrador, Emperor Frederick, King Edward VII,all were of The London or brought close to it by events. Andapart from these household names The London also had a

generous share of the great figures of world medicine. Butwhile Clark-Kennedy does not neglect the famous, wisely hepays them only as much attention as their part in the hospital’shistory strictly merits. The two people who can be said todominate this part of his story do so because without them the

hospital might never have achieved what it did, if, indeed, it hadsurvived at all.One was Eva Luckes, the remarkable woman who trans-

formed nursing at The London from a " calling for thederelict... unorganised, untaught, squalid, and heartless " intoa disciplined, dedicated vocation of a standard seldom equalledand probably never surpassed. This she did despite the moststringent financial restrictions, and criticism which culminatedin public denigration before a select committee of the Lords.The other was Sydney Holland, 2nd Viscount Knutsford and

" Prince of Beggars ". Chairman of the hospital for twenty-fiveyears, Knutsford concentrated his considerable talents and

energy on the task of maintaining and improving The London’sposition as England’s largest voluntary hospital and a leadingteaching centre, while keeping it financially viable. Hiscontinuous efforts afforded The London several temporaryremissions from that congenital disease of voluntary hospitals-financial insufficiency. But the malady was intrinsicallychronic, progressive, and incurable; and ultimately the public

lost sympathy with a system that " had lived too long already.’The voluntary hospital system, " aged and unwanted,’

passed quietly away at midnight on July 4, 1948, but only novhas someone thought fit to write a just and kindly obituary.

Care of the Rheumatoid HandADRIAN E. FLATT, M.A., M.D., F.R.C.S., F.A.S.C., associate pro,fessor of orthopaedic surgery, University of Iowa. St. LouisC. V. Mosby Co. London: Henry Kimpton. 1963. Pp. 22286s.

THE role of surgery in the management of rheumatoidarthritis is an extremely topical subject, for fashions are rapidlychanging. Instead of concentrating on the reconstructive sur-gery of burned-out and irreversibly damaged joints, the newpolicy is to try to forestall such changes by prophylactic surgery.

There have been greater advances in the management of thehand than of other joints, and Dr. Flatt confines his attentionto the hand in this admirable monograph (an amplificationof a Hunterian lecture at the Royal College of Surgeons in1962). He gives detailed accounts of the mechanisms bywhich joint deformities arise; and he emphasises the importanceof tendon and other soft-tissue lesions as well as those arisingprimarily in the synovium of the joints. The author is afirm advocate of early synovectomy, both of inflamed jointsand of tendon sheaths. On this point, some readers will disagreewith his views. Thus, on p. 86, he asserts "... that if reliefof pain and restoration of function have not been achievedwithin two or three months a synovectomy must be per-formed ". Such a policy is manifestly unnecessary in a highproportion of inflamed joints. Furthermore it contrasts withanother statement (p. 186) that "... an operation is the finaland irrevocable step, when it is clear that no other form oftreatment is available".The choice of the right joint and the right time to operate is,

of course, paramount; and it is on these points that Dr. Flatt,understandably, finds himself unable to give a clear lead. Infuture editions he may be able to produce statistics allowinghim to define indication and contraindication for prophylacticoperations.With this single reservation, the book can be warmly recom-

mended. The descriptions of techniques are uniformly clear andbeautifully illustrated, and Dr. Flatt naturally devotes muchattention to the techniques for inserting metal prostheses intothe metacarpophalangeal and interphalangeal joints, to whichform of arthroplasty he has contributed pioneering ideas. Healso gives detailed accounts of his methods for small-jointsynovectomy, in which, he points out, it is essential to removeseveral recesses of synovial tissue which may be overlookedunless deliberately sought out.

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There is an excellent account of the old problem of thebiomechanics of ulnar drift, and suggestions about how itshould be treated, both prophylactically by splints, and

surgically once it has developed. Also included is a descriptionof the recent developments in chemical synovectomy with theuse of cytotoxic drugs, such as thiotepa and, more recently,osmic acid; and a whole chapter is devoted to lesions of thethumb. The last chapter is probably the most useful of allto the non-surgical specialist. Here Dr. Flatt gives adviceabout splinting and various forms of physiotherapy and

occupational therapy, including a comprehensive list of usefulexercises. He also describes the postoperative rehabilitationmeasures which he uses.

The Body Cell Mass and its Supporting EnvironmentFRANCIS D. MOORE, A.B., M.D., M.CH.; KNUD H. OLESEN, M.D.,D.M.SC.; JAMES D. MCMURREY, A.B., M.D.; H. VICTOR PARKER,A,B., M.D.; MARGARET R. BALL, A.B.; CARYL MAGNUS BOYDEN,B.s., M.S., laboratories for surgical research, and the departmentof surgery of Harvard Medical School, Peter Bent BrighamHospital, Boston. Philadelphia and London: W. B. Saunders.1963. Pp. 535. 161s.

IT is now twelve years since the appearance of Moore andBall’s classic monograph The Metabolic Response to Surgery,which described detailed and lengthy metabolic balance studieson large numbers of patients submitted to various operations.They came to some general conclusions which have since pro-foundly influenced the care of surgical patients. This book,from the same stable, is a logical successor. It is devoted tothe composition of the body as revealed by simultaneous meas-urements of total body water, extracellular fluid volume, plasmaand red-cell volume, and total exchangeable sodium, potas-sium, and chloride. The title is not ideal, since intracellularconstituents, other than fat, water, and potassium, are hardlymentioned.The first part of the book is concerned with the relationships

between these body constituents in healthy subjects, and theinfluence of age, sex, and body size. This section is highly con-centrated and unsuitable for casual reading, but it will be

appreciated by the expert. The second part describes the find-ings in many different disease states. A short clinical historyis given, and in most cases serial determinations from severalpoints in the course of the disease are included. Of particularinterest are the details of patients with wasting diseases, heart-failure, and extreme obesity.The authors are to be congratulated on their years of pains-

taking work and on their skill in presenting their results indigestible form. The book will be an indispensable referencemanual for research-workers using these techniques to studybody composition. For the general physician it contains muchfascinating information, but many may be deterred by the gen-eral form of the book, its statistical approach, and the povertyof clinical detail-inevitable drawbacks in a work of this kind.

Human Endocrinology3 vols. HERBERT S. KuPPERMAN, M.D., PH.D., associate professor.of medicine, New York University Medical Center, New York.Oxford: Blackwell Scientific Publications. 1963. Pp. 1191. C 14.

IT is seldom that a modern textbook is based on the personalexperience of one man. The author of these three volumesacknowledges his debt to a number of other writers, but, withthe exception of a chapter on endocrine pathology, the text islargely his own.The scope of endocrinology is always difficult to define.

Here the convention is that obesity is a problem for the endo-crinologist but diabetes mellitus is not (though there is anexcellent chapter on the diagnostic value of carbohydratetolerance tests). Much space is allotted to disorders of men-struation and of the sex glands. It is in these subjects that mostof the author’s own investigations have been made, and thesechapters are among the most authoritative in the book. Auseful addition for future editions might be a critical evalua-tion of the many available cestrogens and progestogens, and acomment on whether androgens should still have any placewhatever in the treatment of menstrual disorders.

The work which has gone into the production of these booksis enormous, and the author’s fresh and personal approach isvery stimulating. The volumes are well printed, contain over athousand illustrations, and are expensively produced andbound.

Introduction to the Work of Melanie KleinHANNA SEGAL. London: William Heinemann Medical Books.1964. Pp. 118. 16s.

Dr. Hanna Segal is one of those lucid lecturers who canwrite to be read, as well as speak to be listened to. This bookis based on courses of lectures she gave to students of theInstitute of Psycho-Analysis. She was speaking to those whowere already well acquainted with Freud’s work, and theyvalued her clear and fascinating expositions of the work of oneof the greatest students of Freud. Fortunately Dr. Segaldecided to write this book, which can be understood andenjoyed by a much wider audience. Her profound love of theEnglish language and her rare capacity to use it creativelymake the book an artistic as well as a scientific pleasure.

Kleinians have at times been criticised because their percep-tion of the consequences of unconscious aggression from infancyonwards has been mistaken for an overemphasis of humandestructiveness. Actually one of the many contributionsMelanie Klein made to human psychology was to develop theconcept of reparation as a human loving and creative way ofcounteracting the ill effects of destructive actions and thoughts.Each clinical example given by Dr. Segal elucidates the themeit has been chosen to illustrate: the dream at the end of thefirst chapter, on Phantasy, and the clinical examples from thechapter on Reparation are particularly striking. There is adetailed description of pathological activity and true reparationin a young child, which also gives a glimpse of the Kleinianmethod of psychoanalysing children.One criticism is that the book presents Kleinian theory

and practice as so easily comprehensible and rewarding that thereader might be tempted to think there would be no difficulty inemulating Dr. Segal. It is not her intention to provide too rosya picture of the work ahead for the intending Kleinian analystand patient; she makes this quite clear in a preface. Dr. Segal’svolume should be given the place in psychoanalytical literaturefor which it is admirably designed-as an introduction to thework of Melanie Klein and an inducement to learn more.

Renovascular HypertensionT. A. STAMEY, M.D., chairman, division of urology, StanfordUniversity School of Medicine, Palo Alto, California. Balti-more : Williams & Wilkins Co. London: Bailliere, Tindall &Cox. 1963. Pp. 237. 116s.

THE title is a little misleading, for the book is almost entirelyconcerned with the now well-known phenomenon that partialocclusion of the vascular supply to a part or whole of a kidneycauses an increased amount of water to be reabsorbed from thefiltrate formed in the affected area. Conversely, therefore, if ina patient with hypertension ureteric specimens of urine showthat more water has been reabsorbed from the glomerularfiltrate of one kidney than of the other, it is presumed that apartial occlusion of the renal arterial supply may be the causenot only of the urinary changes but also of the hypertension.The techniques involved in obtaining this clinical informa-

tion accurately have been the subject of some contention, muchof it in our correspondence columns. Dr. Stamey sets out indetail the reasons for his particular choice. And he makes outa very good case. He prefers to collect urine from each ureterduring the intravenous administration of a solution of urea,P.A.H., and vasopressin. His demonstrations of the superiorityof this technique over others are convincing. The text containsmany case-histories of great interest. In addition to the maintheme there are chapters on the collateral circulation to anischaemic kidney; the functional changes in the non-occludedkidney after nephrectomy for unilateral renal-artery occlusion;and some observations of the extraction ratio of P.A.H. in

patients with occlusive disease in the renal arteries. The illus-trations of radiographs and renal biopsies are excellent. The

648

writing is vigorous, with touches of evangelism, but it is

extremely readable.The author does not think aortography is of much help. He

points out that if an occlusion of the renal artery is found in theabsence of excessive water reabsorption, the anatomicalocclusion is not causing a functional change, and is thereforeunlikely to be causing hypertension. On the other hand, hebelieves intravenous pyelography to be the best of the manyscreening manoeuvres for detecting what he calls " function-ally significant " occlusive disease of the main renal artery. Heagrees with a growing body of opinion that the z1 renogramis not a good screening test.

His work has convinced him that essential hypertensionmust be of renal origin, though he offers no new evidence.The last chapter, on his interpretation of the relation betweenthe macula densa and hypertension, is an interesting specula-tion. For those involved in these problems this book is

certainly worth reading.

Year Book of Neurology, Psychiatry, and Neurosurgery1962-63 Series. ROLAND P. MACKAY, M.D. ; SAM BERNARDWORTIS, M.D. ; OSCAR SUGAR, M.D. Chicago: Year Book MedicalPublishers. London: Lloyd-Luke (Medical Books). 1963.

Pp. 631. 75s.

THE publisher’s bookmark invites the reader to test hisfamiliarity with the current literature by answering a series ofquestions. " Do young smokers have a higher i.Q. than non-smoking peers ?

" is one that may puzzle the English reader inmore ways than one. But a mass of useful information is

packed into this book. Dr. Mackay begins his introduction tothe section on neurology by saying that his task " requires aquixotic self-assurance that is quite artificial". But, despite hismodesty, he and his fellow editors have done an excellent job.New readers, unfamiliar with the arrangement of the Year

Book, may like to know that the work is not, and is not intendedto be, a series of critical reviews: it is a succinct summary ofselected papers, with ocasional, brief, practical, and often

pointed editorial assessments.

Elsevier’s Medical DictionaryCompiled and arranged by A. SLIOSBERG, consulting physicianof the Institution Nationale des Invalides, Paris. Amsterdamand London: Elsevier Publishing Co. 1964. Pp. 1588. E12 lOs.

THIS dictionary contains 18,341 medical terms. The Englishversion of each is followed by its equivalent in French, Italian,Spanish, and German. An appendix, in each language, givesthe possible synonyms for every entry. Strongly bound andeasy to use, the book is clearly going to prove invaluable toworkers all over the world. On looking through its pages theywill, however, note that the more abstruse a technical expression,the simpler is the problem of translation. Achalasia (to take anexample from the first page) becomes in Italian, Acalasia.Zuckerkandl’s gland (on the last page) is rendered into Frenchas glande de Zuckerkandl. The real difficulty lies with medicalexpressions from the vernacular, and the English tongue is

particularly rich in these. (This book lists eight vivid synonymsfor what the Frenchman can only prosaically describe as

diarrhée des voyageurs.) In their own country, British patientsfind it hard enough to describe what they mean by " a nervousbreakdown "; abroad even Elsevier’s Dictionary will not helpthem.

In his introduction Dr. Sliosberg modestly quotes Littre’swords: "un dictionnaire n’est jamais fini". No doubt he andLittre are correct, but meanwhile medical readers in manyparts of the world will be grateful for this formidable interimstatement.

Convulsive Disorders in ChildrenEditor: HADDOW M. KEITH, M.D., professor of pediatrics, MayoFoundation, Rochester, Minnesota. London: J. & A. Churchill.1963. Pp. 311. 85s.

THIS excellent review of epilepsy in infancy and childhoodwill be of interest to all caring for epileptic children.The relation between seizures and age is discussed; and a

chapter on seizures in newborn infants, and even before birth,

leads to the puzzling condition of hypsarrhythmia. Febrile con-vulsions and their significance, photogenic epilepsy (includingtelevision-precipitated attacks), autonomic attacks, migraine,narcolepsy, and convulsions caused by a multiplicity of condi-tions are concisely described. Dr. R. G. Bickford and Dr.D. W. Klass give a short readable account of electroenceph-alography in children, with excellent examples of 8-channeltracings and comments on activation techniques and sleep-recordings. In the assessment of the anticonvulsant drugsethosuccimide was found effective in many patients with petit-mal. In his description of surgical treatment of epilepsy Dr.R. H. Miller stresses the importance of resection of the tem-poral lobe and hemispherectomy for uncontrolled seizures. Inthe chapter on intellectual and mental state of epileptic childrenand on inheritance an appeal is made for more studies into theextent of the increased risk in a family whose members have aconvulsive disorder, compared with that in the general popula-tion. Only the section on the ketogenic diet may be of littlepractical value; for most pxdiatricians and neurologists haveprobably never used it, and with every new anticonvulsantdrug the possibility of using it becomes even more remote.The lavish references at the end of each chapter make the

book a good source of information for both the paediatricianand the neurologist.The Control of Diseases (Social and Communicable)

(2nd ed. Edinburgh and London: E. & S. Livingstone. 1964.

Pp. 538. 75s.).-Dr. Hugh Paul’s book in the classical mouldhas been enlarged and largely rewritten. It begins with ageneral account of the characters of infectious disease and ofsome of its more dramatic effects on human history. It goes onto deal individually and at some length with the commontransmissible diseases and their control. Many of these chap-ters benefit by illustrations drawn from outbreaks within theauthor’s own experience, and some of them-measles and small-pox, for example-are excellent. An especially valuable chapteris that on the control of disease in schools. The book ends witha section on neo-epidemiology-the study of the non-infectioussocial diseases. Taken as a whole it would make an admirableintroduction to epidemiology for anyone who has ambitions inthat direction. It is less suitable as a work of reference. Manywish to know the " best " method of immunising againstdiphtheria or enteric fever and the arguments which lead to thisconclusion rather than a list of the available methods. Threemethods of diagnosing mumps specifically are mentionedwithout much guidance on their relative usefulness. In thedifferential diagnosis of meningococcal meningitis there is noword of meningitis due to Streptococcus pneumoniae or Hamo-philus infiuenzae, both of which are now at least as common.There are minor inaccuracies: tsetse flies do not breed in

ponds; and disinfection of a room with formalin vapour hasmore than psychological value. We recommend anyone whohas a concern for epidemiology to read this book with care.Few people in this country have seen so much of the practicalproblems of checking infectious diseases as the author.Donald Paterson’s Sick Children (8th ed. London:

Cassell. 1963. Pp. 724. 50s.).-A radical revision of thisfamous book, first published in 1930, has been undertaken byDr. Reginald Lightwood and Dr. F. S. W. Brimblecombe.

They have aimed not at a complete reference book but at" a working manual for the medical student, the postgraduate

undergoing pxdiatric training, and the practising doctor at

home or overseas". Dr. Mildred Creak has contributed a

new chapter on emotional disorders of childhood.British National Formulary 1963 (Alternative edition,

London: British Medical Association and PharmaceuticalSociety of Great Britain. Pp. 335. 10s. 6d. [interleaved15s. 9d.]).-In the revision of this edition based on a pharmaco-logical classification, the sex hormones have been transferredto the section on metabolism; and a new section has beenadded on the drugs used in rheumatic conditions (this replacesthe former subsection on pain-relieving remedies). The scopeof the psediatric section has been enlarged and now includespreparations for children up to twelve years.