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THE RESTFULNESS OF CHANGE" Volumes are now written and spoken upon the effect

of the mind about the body. Much of it is true. But I wisha little more was thought of the effect of the body on themind." "

IN setting down this perennially modern reflection,Florence Nightingale was considering the havoc a sickbody can play with mood and judgment. Those who" think that with a little more self-control’ the sick

might, if they choose dismiss painful thoughts ’ ... "fail entirely, she held, to realise what they are asking ofthe patient : " Almost every step that crosses his room13 painful to him ; almost every thought that crosses hisbrain is painful to him ; and if he can speak withoutbeing savage, and look without being unpleasant, heis exercising self-control." It is therefore the business ofhis attendants to alleviate his depressed and irritablestate by satisfying the " craving for variety in the

starving eye "-giving him not merely a " judiciousvariety " of flowers, but a pleasant view, and pleasantthings about him.We do not give much thought to this principle in

hospitals nowadays. Flowers are certainly present, butthere is little other attempt to provide variety : hygiene,in fact, has ridden roughshod over psychology. The

patient in the public ward suffers less in this respectthan the patient in the private ward : for the patient inthe public ward can at least refresh his eye with a varietyof nurses, a variety of fellow patients, and a variety ofnursing techniques as well. This may not be quite whatMiss Nightingale had in mind, but they are better thanthe blank wall set with glazed lavatory-tiles which oftenconfronts the patient in a private ward. The craving forthe return of day, she suggested, is often nothing but thedesire for light, " the relief which a variety of objectsbefore the eye affords to the sick mind." When theseobjects lack variety the mind gets no respite ; and tothis she attributed the depression so commonly seen inthe chronic sick " subjected to a long monotony of objectsabout them." She might have added that the daily inspec-tion of a blank tiled wall sometimes suffices, within aweek or ten days, to convert a convinced optimist into apractising pessimist.Would she had thought that the need for variety

(wiih a small " v ") is sufficiently met by the broadcastprogrammes dispensed to hospital patients 1 It isdoubtful ; for, like so many of us, she seems to havebeen a " visual type," accounting sight the prince amongthe senses. Does television perhaps supply the kind ofnourishment the eyes of the sick crave It is difficultto place a television screen so that all the patients in award can easily see it ; and there will always be some forwhom the content of a given programme lacks appeal.

Miss Nightingale proposed, as she so often did for otherproblems, a simple and practical solution. The ward,whether public or private, is- no place for a medley ofagreeable knick-knacks ; on the other hand its wallsoffer ample hanging space for pictures, and these can bechanged. The changes need not be made unduly often :she pointed out that if you show a patient ten our twelvepictures in rapid succession you merely make him tiredor feverish " but hang one up opposite him, one oneach successive day, or week, or month, and he will revelin the variety."Some hospitals-but not many-have already had

frames fixed to the walls into which pictures can beslipped, and they either keep a supply of good reproduc-tions which are placed in these frames in rotation, or

else they make use of the circulating library of picturesprovided for hospitals by School Prints Ltd.2 This service1. Selected Writings of Florence Nightingale. Compiled by LUCY

RIDGELY SEYMER, M.A., S.R.N. New York and London:Macmillan. 1954. Pp. 397. 35s.

2. 13, Motcomb Street, London, S.W.1.

was established about a year ago, and is steadily gainingsupporters.

gainhi,

School Prints send a set of six pictures at a time, mountedon hardboard and varnished (but unglazed), so edged that the?have the appearance of being framed. They are thin enoughto collect little dust, and are in any case easily wiped over witha damp cloth. Each carries a small neat label giving the nameof the picture, the name and nationality of the artist, and hisdates. Each set of pictures includes one showing people 1aportrait or a scene with characters), two landscapes, two sea orriver scenes, and one decorative subject ; one at least of theseis by an old master, and the rest are by later or living artists.At the end of four months a new set of six pictures arrives,and the original six are packed up and sent off to the nexthospital on the rota.

Some hospitals-Orsett,3 in Essex, for instance-havehad murals painted, which give gaiety and variety to thewards. Miss Nightingale, rightly or wrongly, believedthat such refreshments to the mind act also on the body." Little as we know," she wrote, " about the way inwhich we are affected by form, by colour and light, wedo know this, they have an actual physical effect. Varietyof form and brilliancy of colour in the objects presentedto patients are actual means of recovery." She was acapital observer, and her advice, even after a hundredyears’ delay, is well worth taking.

3. Lancet, 1947, i, 840.4. Lester, C. W. J. Amer. med. Ass. 1954, 156, 1063.5. Evans, W. Brit. Heart J. 1946. 8, 162.6. Daily, J. E. J. Amer. med. Ass. 1952, 150. 1203.7. Chin, E. F., Adler, R. H. Brit. med. J. 1954, i, 1064.

DEFORMITIES OF THE CHEST WALL

CONGENITAL deformities of the anterior chest wall fallnaturally into one of two groups-the protrusional andthe depressional. The protrusional deformity is probablydue to rib overgrowth. When this is bilateral the sternumprotrudes ; when unilateral the ribs are unusually pron-nent at the costochondral junction. Patients with thi&

type of deformity have restricted chest expansion, andmovement of the diaphragm may also be affected. The

deformity may be treated surgically either by, subperi-osteal resection of the sternum, or by resection of thecostal cartilages, after which regeneration is allowed tooccur in the normal position. Lestel 4 has described 22cases in which patients underwent operations of this type ;and he assesses the results as largely satisfactory.

Depression of the chest, which is commoner, is usuallyassociated with shortening of the central tendon of thediaphragm and backward curvature of the sternum.Evans 5 has studied the cardiac changes associated withthis deformity. Most of the patients have a systolicmurmur and an abnormal cardiac outline on radiography,associated with narrowing of the space between sternumand thoracic vertebrse. Lester has operated on 90

patients with sternal depression. In infants the deformitymay be relieved by excision of the xiphoid and the 7thcostal cartilages. In children and adults a more radicaloperation is necessary. The 3rd-7th costal cartilagesare resected, and a transverse-wEdge osteotomy is madeacross the 3rd sternal segment. The xiphoid is removedand the body of the sternum elevated. The sternum maybe retained in position either by stainless-steel wire,;.passed behind it and tied to an anterior support, or

by using a section or rib as a strut. The results of these90 operations are said to be functionally good, but 1

patient died and 4 required reoperation. In this countryChin and Adler have operated on 10 patients withfunnel sternum. They suggest that operation should beadvised for all children over the age of 6 months and foradults with symptoms due to this deformity. They findthat the sternum can be freed from the diaphragm andafter osteotomy can be retained in an over-correctftiposition without external fixation. The costal cartilage-are removed if they are deformed.