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decades which follow birth, is unevenly distributed,we must consider that our responsibilities remainimfulfilled."
In his last chapter Professor Ryle touches on a practicethat has troubled many conscientious doctors-that ofthe serious surgical operation undertaken on a wide rangeof patients before its value has been assessed by adequatephysiological study and by thorough follow-up of earlycases. Operations are devised, and then studied by trialand error, by men of limited experience as well as
practised ones. He asks whether, for example, vagotomyand vasoligation have yet been justified either by animalor human experiment, and whether the partial andtemporary successes and the complete failures havebeen judicially studied and reported, as a counterweightto the complete successes. He believes the answer tothese questions, and others equally searching, is either"neo," or " We do not know." Experiments, usuallysimple and safe, carried out on patients who are willingvolunteers and understand the purpose of the investiga-tion are, he thinks, entirely permissible, especially if
they aim to decide whether a given line of treatment willimprove a patient’s condition ; they are harder to
justify if they are designed merely to advance theoreticalknowledge and if the patient must be persuaded to agreeto them. He might have added something about the typeof investigation which carries a risk, whether to life orhealth : cystoscopy in the partially paralysed bladder isperhaps a fair example. Who knows what the risks areexactly ? The patient does not even know that thereare any, and is given no chance of deciding whether hewants to take them ; the surgeon usually has an
impression " about the risks in general, and an
" opinion " about the risks for this patient ; he also haschemotherapy at the back of his mind as a saving measureif things go wrong. Yet the risks, even of temporarydiscomfort, should always be carefully weighed againstthe information which the method is expected to yield.Professor Ryle would like every research clinician con-templating an experiment to ask himself three questions ;and these might well serve, too, for those undertakingroutine examinations : " Would I accept that this
experiment or investigation should be carried out insimilar circumstances on a member of my own family ?If so, would I accept that it should be carried out withouthis full cooperation and consent d In the presence of
appreciable risk, do the possible results for science ormedicine help to justify the risk ?
"
We may also ask, he suggests, that new operationsentailing a danger to life or subsequent health should notbe undertaken by men of limited experience before theirvalue has been proved by others ; and that methods offollow-up should be much stricter, wherever possibleincluding a personal interview by a trained medicalsocial worker.
PATIENTS’ READING
THE International Federation of Library Associationshas a hospital subcommittee which met during the recentconference of the federation in London. The discussionsrevealed differences in various countries in the attitudeof the medical profession and the extent to which readingis held to have a therapeutic value. In Denmark theservice, which is entirely staffed by professional librarians,takes little if any account of the condition of the patient.In Great Britain the general attitude of doctors, withsome notable exceptions, is to leave the patient anentirely free choice, though in tuberculosis sanatoriaand mental hospitals there is a definite movement toenlist reading as a contribution to treatment. InFrance there is a good deal of difference of opinion amongmedical men. In Belgium the service is admirablyorganised by the Belgian Red Cross under the directionof professional librarians, who are encouraged to takea course in social science. The Red Cross librarians
read all the books before circulating them, and have acode to denote any risks which may attach to issuingthem to particular types of patients. In some hospitalsin the United States the conception of the therapeuticvalue of reading has reached the stage of prescribingbooks like medicine, and requiring a report from thelibrarian on the effect on the patient.At the meetings it proved possible to obtain general
agreement to a resolution that, while preserving theliberty of the individual patient, the librarian must
appreciate the possible effect of the book upon him.Also approved were resolutions that public librariansshould have special training for hospital work, that thevoluntary workers who distribute the books should havesome training, and that the attention of doctors and allconcerned with hospitals be directed to the value of thiswork.
MECHANICAL ARTIFICIAL RESPIRATION
THE " iron lung," introduced by Drinker in the UnitedStates in 1929, and its modification the Both respiratorwhich Lord Nuffield generously provided for British
hospitals, are still saving lives which would otherwiseinevitably be lost from respiratory failure. The usesfound for the Both respirator have ranged from thetreatment of overdosage with paraldehyde,l hithertoalmost invariably fatal, to the prevention of post-operative atelectasis.2 Persistent apnoea is no longerregarded as necessarily deadly in hospitals possessing aBoth respirator. In other circumstances the first-aid
teaching, whether in medical school, factory, or policeforce, is to apply manual artificial respiration by themethod of Schafer or Silvester, or by the even simplerand more efficient 3 rocking method of Eve, until thepatient recovers or is transported to a hospital, which inEngland is never, very far. In America, where LordNuffield’s benefaction has not been emulated, and wheredistances are much greater, a Society for the Preventionof Asphyxial Death has for many years been stimulatinginterest in this subject. With their vigorous affection forup-to-date mechanical devices, the Americans have beenattracted to automatic means of artificial respiration,and breathing machines have been widely distributedfor use in the mine, by the canal bank, or even in the gassuicide’s bedroom. Some have ’even been adapted tosupply the airman with oxygen under intermittent
positive pressure at high altitudes. There has thereforebeen a constant search for cheaper, lighter, and morecompact apparatus which is yet sufficiently robust.Commercial competition has stimulated a variety of
designs, all working on the principle of direct inflation ofthe lungs by oxygen under pressure. Controversy hasraged for years over the relative merits of the differentpatterns. Motley and his colleagues 4 show that in
practice all are fairly satisfactory, and that all will
oxygenate the patient better than the traditional manualmethods. The apparatus gradually builds up the pres-sure under the face mask during the inspiratory phaseand allows it to fall rapidly to zero (i.e., atmospheric) atthe start of expiration, so mimicking natural unimpededrespiration. Surprisingly the " suck-and-blow " machines,which inflate the chest during inspiration and- also suckair from it in expiration, proved to have no advantagesover the more usual patterns which only inflate. It
appears that the " suck " is but poorly transmitted tothe interior of the thorax.The possibility that mechanical artificial respiration
may have side-effects on the heart has hitherto beendiscussed largely on the basis of clinical impression.Now Motley and his co-workers have shown how very1. Macintosh, R. R. Brit. med. J. 1939, i, 827. 2. Mushin, W. W., Faux, N. Lancet, 1944, ii, 685.3. Macintosh, R. R., Mushin, W. W. Brit. med. J. 1946, i, 908.4. Motley, H. L., Cournand, A., Werko, L., Dresdale, D. T.,
Himmelstein, A., Richards, D. W. jun. J. Amer. med. Ass.1948, 137, 370.
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dependent is the cardiac output on the variations inintrathoracic pressure during the respiratory cycle. Anydeviation from the normal in this respect is followed bya parallel alteration in the heart’s output, though notalways in the same direction. Thus a raised pressurethroughout the respiratory cycle produces a proportionalfall in the cardiac output. Provided the mask pressuredrops rapidly to atmospheric at the end of inspiration,and provided inspiration and expiration are of equalduration, no cardiac embarrassment need be fearedwhen using mechanical substitutes for normal respiration.The wide distribution of small mechanical respirators
may give the layman a new and perhaps undesirableconception of the treatment of asphyxia. This dangerhas been emphasised repeatedly by Paluel Flagg andYandell Henderson in America. A few years ago, Flaggwrote 5 :
" If a child inhales a peanut or a pin, he is hustled offto the hospital and receives every advantage of the broncho-scopic clinic. Should he be so unfortunate as to inhale
something larger, a marble or a chunk of meat, he is nolonger in need of medical help. Everything will be solvedif the suck and blow apparatus used last week in thestevedore down the street can be secured."
Henderson 6 called the suck-and-blow type of machine" a back-step towards the death of thousands." In this
country, until it is certain that the expense of mechanicalrespirators would be justified in lives saved, we cannotdo better than train our doctors and first-aiders to usethe simpler methods of treating asphyxiated people.
FOR SMOOTHER RUNNING
STORIES of patients annoyed and frustrated by theway they are received at hospitals are too common to beignored. The chilly welcome, the unguided search forthe ward, the long hours of waiting in the outpatientdepartment, and the obligation to repeat the same basicfacts to every hospital officer who asks, are familiarvexations to the people who use, and now own, thehospitals. Such bad hospital manners are often theoutcome of an archaic system of administration in ahospital which has outgrown its floor-space and isscarcely able to deal with the work it is equipped to do.Trouble is caused by out-of-date filing systems, puzzlingmethods of registration and record-keeping, lack of anappointments system, and other remediable defects.
King Edward’s Hospital Fund for London, in the hopeof clearing the way for better customs, recently held ashort course for administrative officers, to enable themto study the admission systems in a number of hospitalswhich have lately been reviewing the subject. The coursewas supervised by Mr. S. W. Barnes, house-governor ofKing’s College Hospital, and he and the members ofthe course have now drawn up a report of their
findings.7 7’Of 8 hospitals visited, 5 made appointments for new
and old patients. The arrangements work well if theyhave the support of the doctors on the staff ; but asthis, unfortunately, is not always ungrudging, the taskof arranging the appointments system must be placedin the charge of " an enthusiastic and tactful officer whowill study their individual needs and gain their activecooperation." It is better, Mr. Barnes and his colleaguesdecided, to make the system compulsory, no outpatientsbeing seen without an appointment unless they are
referred from the casualty department as urgent cases.This helps to make patients and their family doctorsappointment-minded. A patient who arrives without adoctor’s letter, saying he feels ill, is seen by the casualtyofficer and, if his condition is urgent, is referred to a consul-tant. The writers of the report believe an appointments5. Flagg, P. J. Science, 1944, 99, 469.6. Henderson, Y. Ibid, 1943, 98, 547.7. Some Observations on Hospital Admissions and Records.
London : Published for the King’s Fund by Geo. Barber & Son.1948 Pp. 28. 1s.
system, besides saving the patient time and trouble,simplifies the work of the hospital in several ways : itsaves space, eases the work of the records staff, showswhich clinics are overcrowded, and ensures a steady flowof patients to the ancillary departments. The list ofpatients due to attend can be used by the appointmentsoffice when checking misplaced notes, and makes thecounting of outpatient attendances easier. The writersrecommend that there should be one central appointmentsoffice to deal with the attendances at all clinics and
departments. Events can then be made to dovetail, thepatient polishing off his visits to various clinics on asingle day, and special reports on his condition beingcompleted in time for his next consultation.The medical staff, wanting to reserve cases for teaching,
sometimes insist that they cannot do this until they haveread the doctors’ letters. At King’s College Hospitalthe appointments staff, who have been told what typesof case to reserve, open all letters and make appointmentsaccordingly. In the case of old patients, consultantsmark the folders of the cases they need for teaching.The medical committee should be told when clinics arebooked up a long way ahead, since it may be possibleto arrange an extra clinic ; and a margin of time is usuallyleft, when appointments are made, so that urgent casescan be fitted in.Some long-needed strictures on the appearance of
outpatient departments should be appreciated bypatients. To ask a sick person to sit for hours on awooden bench in a cheerless flagged hall, watching thefat neck of the man in front, or listening to the wheezingof a neighbour or the fretful crying of a tired bored child,is as good a way of turning his uneasiness to anxiety,and his anxiety to downright fear, as could well bedevised. The report urges some overdue reforms-light-painted walls, coloured comfortable chairs, odd tables,and plenty of papers and magazines-something morelike a doctor’s waiting-room and less like an approach toa morgue.
Again, " the patients’ opinion of the hospital will belargely formed by the way they are treated at registra-tion " ; hence registration clerks need to be " tactful,kind and patient, with a pleasing personality." Somegood detailed advice on the management of waiting-listsshould also promote the comfort of patients. They shouldbe given some idea of the time they will have to wait,warned to tell their own doctor if they get worse, andgiven a new forecast by letter " at least every threemonths." This last, somewhat ironic, proposal showswhat a wounded snake our waiting-lists have become.Every hospital, the writers consider, should have a
medical records committee to define policy and keep thewayward doctors to it. A standard design of case-sheetis advocated within the hospital, but not between
hospitals, since this would damp initiative and stultifyprogress. Hospitals must go on testing new methods.Details of cabinets, filing systems, and staffing of therecords department need close study. In silent commenton human fallibility, the writers advise that the recordsoffice should be locked after hours, and that thoseseeking-notes at such times should be made to sign forthe key.
The Times reports that the World Health Organisationis arranging a conference of government representativesfrom war-devastated European countries. At the WorldHealth Assembly Soviet Russia supported a largeprogramme of supplies for these countries, and it wasdecided that Europe should have a temporary office " forthe liquidation of war damage " in the field of health.The conference, which will meet at Geneva on Nov. 15,will consider the nature of the services required.
Dr. ROBERT CRUICKSHANK has been appointed to thechair of bacteriology at St. Mary’s Hospital as fromJan.1,1949.
