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Reviews of Books

ComplianceThe Dilemma of the Chronically Ill. Edited by Kenneth E. Gerber andAlexis M. Nehemkis. New York: Springer Publishing Co. 1986. Pp 239.$26.95.

AN intelligent patient was asked, after he had completed a trial ofan oral antihypertensive agent, if he had been able to tell which wasthe active agent and which the dummy tablet. No, he hadn’t, but hedid observe a difference. When he threw them down the lavatory, ashe did every tablet he was ever given, one lot had floated, the othersank. This book deals with that type of problem. It concentrates onthe chronically ill, particularly haemodialysis patients and theelderly. It is very readable. Six of the eleven chapters have one orboth of the editors as author and five are contributed by others,including a -challenging essay by Norman Farberow on

Noncompliance as Indirect Self-Destructive Behavior. Despite thejargon title this reads easily and presents interesting supporting datato support the thesis of the title.A splendid, brief, but racy foreword by A. Kaplan De-Nour, a

psychiatrist, observes, nay laments, that all the authors are

psychologists not physicians. But they all write commendably toassist medical readers. Richard Hanson on Physician-PatientCommunications and Compliance justifies careful attention. Fromtime to time, when discussing such issues with the half-dozenstudents on my firm I say to one of them starkly, quietly, butimperatively, "Stand up". There is usually a moment of hesitationbut he does so. Then we all talk about why he should have done so,whether they have to develop the ability to exact such compliance,and what such ability relies upon. Hanson’s essay, too, is builtaround attributes of the physician. Other contributors focus on thepatient’s make-up and on social attitudes.

This book, because it is so informative, can be confidentlyrecommended to all those interested in the subject. It should go onthe "must" list of any doctor who has perpetrated the conversationreported as having been heard many times by Callard, a physicianhimself on dialysis: Doctor: "How are your doing?" Patient: "I’mfeeling rotten." Doctor: "You’re doing just fine". ,

Department of Psychiatry,University of Manchester NEIL KESSEL

Fitness and Health in IndustryMedIcine and Sport SCIence vol 21. R. J. Shephard. Basel: Karger. 1986.Pp 316. SwFrl95;$83.

Now that an increasing number of people are taking up exercisein private to promote their health, should they be given anopportunity to exercise at work as well? To those corporate bosseswho have been uncertain about the profitability of such an

endeavour, this book offers an answer. According to Dr Shephard’scalculation, for every$20-70 per employee-year put into a

fitness/lifestyle programme the return is$784. This is the balancebetween the cost of the personnel and facilities commonlycommitted to employee fitness programmes and the likely fiscalbenefits, mainly through changes in immediate hospital andmedical costs, employee turnover, and productivity.

These are impressive figures, but Shephard has his ownreservations. If we leave aside the impreciseness of the economicanalysis, there is the fact that as a rule only about 20% of acompany’s employees adhere to the programmes once they areinitiated, and this 20 °o is a highly self-selected group, typicallywhite-collar workers. The persistence of the positive effects is notknown, nor is the exact mechanism of the beneficial changes. Thepresented conclusions are based on evidence limited in both amountand quality. And, importantly, basic ethical questions call for.attention: to what extent can an individual’s health behaviour beintervened with and by whom? If a programme is a profitableinvestment, how should the economic gain be shared?

Shephard considers his work an introductory review of thisimportant health promotion issue. The presented evidence comeslargely from North America and, in particular, Canada. The book isstrong in the principles and practices of health screening, fitnesstesting, exercise prescription, and programming and weaker in itspresentation of historical aspects and in its description of jobdemands. The rich history of Scandinavian, German, and otherEuropean workplace sport and exercise is only superficially touchedupon, and the revolutionary new changes in work after the

application of automation in industry are hardly mentioned.As the first of its kind, this book is an important contribution to

the body of existing knowledge. It presents a thoroughly arguedview based on extensively referenced recent, even though limited,evidence and serves at the least as an excellent start for a "vigorousdiscussion". In addition, it should be useful to all parties whocontemplate establishing a workplace fitness programme.UKK Institute,SF-33500 Tampere,Finland PEKKA OJA

Medical Care of the Elderly2nd Edition. M. R. P. Hall, W. J. Maclennan, and M. D. W. Lye.Chichester: John Wiley. 1985. Pp 187. 9.95 (paperback).

SICK elderly people pose enormous medical, administrative, andsocial problems to us all, whether we encounter them as doctors oras individuals caring for frail elderly relatives or neighbours. Theaim of this book is to demonstrate the attitudes and cooperativeskills needed by an effective multi-disciplinary team treating oldpeople who are ill. The text starts with some typical case historiesand their proposed management-case histories of a kind that arefamiliar to general physicians as well as geriatricians. The analysis ofthe medical problems which they pose and their possible treatmentinterventions by doctors, nurses, occupational therapists,physiotherapists, and social workers demonstrates the

multidisciplinary approach based on accurate clinical diagnosis-the kernel of good geriatric practice.The first six chapters cover well the broad topics of demography

and population statistics, health services for the elderly and theirsocial problems, and the special features of disease in old age interms of presentation, investigation, and treatment. Eightsubsequent chapters highlight specific problems of ageing such asbrain failure and incontinence and the effects of ageing on variousorgan systems. Throughout the text, the reader is referred back tothe earlier case histories to illustrate the analysis and treatment of themultiple troubles of sick old people. The final chaptersympathetically covers various aspects of terminal care. The

specifically clinical chapters suffer by being brief and

oversimplified. The chapter entitled Homoeostasis covers an

unusual combination of thyroid disorders, diabetes, hypothermia,and urinary tract infections but not dehydration or electrolytedisturbances. The text is clear and easy to read, while each chapterends with a useful bibliography for further reading.

This book makes no claim to be a textbook of geriatric medicine,but Professor Hall and his colleagues have provided an excellentintroduction to the integrated management approach essential tothe care of the elderly, well worth reading by medical students andclinicians entering the specialty.

Department for the Health Careof the Elderly,

Dulwich Hospital,London SE22 8DF A. M. BLACKBURN

New Editions

High Technology Medicine, Benefits and Burdens.-New edition. By B.Jennett. Oxford: Oxford University Press. 1986. 1986. Pp 317. 5.95.

Catalog of Teratogenic Agents.-5th ed. By T. H. Shepard: Johns HopkinsUniversity Press. 1986. Pp 710. ,C36.65.

Anesthesza vols 1, 2, 3.-2nd ed. Edited by R. D. Miller. Edinburgh:Churchill Livingstone. 1986. Pp 2414. ,C135.