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HOMES FOR OLD PEOPLE
1099
Occasional Book HOMES FOR OLD PEOPLE ARE communal homes for old people necessary in our society, and, if so, what form should they take ? Mr. Peter Townsend’s new book1 attempts to give some answer to these questions. It is chiefly concerned with residential accommodation provided under the National Assistance Act of 1948, though a number of the problems arising in hospitals, nursing-homes, and other institutions are also discussed. Its general conclusion is that communal homes of the kind which exist in England and Wales today are not adequate for the physical, psychological, and social needs of the elderly people living in them, and that alternative services and living arrangements should take their place quickly. Mr. Townsend describes the results of a major survey carried out in England and Wales with the help of all local authorities and many voluntary and professional associations. A random sample of 173 residential institutions and homes were visited, and welfare officers, matrons, and elderly residents were interviewed. The objects of this study were: to describe what residential accommodation there is for the aged in England and Wales at present, and how that accommodation varies from area to area; to ,describe the lives of old people once they enter institutions ; to discover why old people enter these particular institutions and homes; to assess as far as possible the adequacy of the services provided; to explore alternative methods of caring for the aged, and to make recommendations. Broadly speaking, there are four types of institutions or homes, falling within the definition of the National Assistance Act: the former workhouses which were retained by local authorities in 1948; small homes run by local authorities, mostly opened since 1948; homes run by voluntary bodies; and homes run for reward by private . individuals. The last two groups are registered and inspected by local authorities. Rather fewer than half the 3600 residential institutions in Great Britain are owned and managed by local authorities, but they contain two,thirds of the beds available. In 1960 there were in England and Wales 95,500 residents of pensionable age, two-thirds of them living in former workhouses and other local-authority premises, a quarter in voluntarily run, and the remainder in private, premises. This represents about 18 per 1000, persons aged 65 and over. A much higher proportion of the population will probably spend at least some part of their final years in such homes, and the number is likely to increase in the future. More of the elderly residents of institutions are unmarried or widowed than in the general population of the elderly. Probably 140-150 per 1000 bachelors and spinsters aged 85 and over live in residential institutions. There is also a disproportionately large number of childless married or widowed people. The former public-assistance institutions cater largely for the poorest social classes, and for those who lack relatives or who have lost touch with them. Many of the residents would not usually be classified as infirm, though a substantial proportion are. The other local-authority premises cater more often for women and for those from the middle or upper working class. More of the residents 1. The Last Refuge: A Survey of Residential Institutions and Homes for the Aged in England and Wales. By PETER TOWNSEND. London: Routledge & Kegan Paul. 1962. Pp. 552. 60s.
in the other two types of home are middle-class, and more of them are women. There are big differences in residential provision from one area of the country to another. Voluntary and private accommodation is concentrated in the south and south-east, particularly in dormitory areas and in seaside towns. There is more local-authority accommodation in county boroughs than in county-council areas. FORMER WORKHOUSES
Perhaps the most disquieting feature of the book’s statistical review is the extensive use still being made of former workhouses. Nearly half the elderly residents in local-authority accommodation live in such premises. The old workhouse often has stone floors, unplastered interior walls, and long dormitories of ten, twenty, and even fifty beds, with iron frames and hair, flock, or straw mattresses. There is little furniture in the dormitoriesoften only a wooden chair and a battered locker by each bed. Thirty, forty, or more old people sit in huge dayrooms, with very low standards of comfort. Coarse and unpressed institutional clothing is issued. There is no real privacy, and little to encourage self-respect: a man may have his trousers changed in full view of dozens of other people. The staff are too few, and have rarely received any form of training. The turnover of staff is sometimes as much as 100% in a year. The matrons and wardens in charge Mr. of these institutions wield considerable power. Townsend notes that some of them displayed a keen awareness of the needs of residents, and acted with sympathy and tolerant good humour towards them. But two-thirds seemed to be insufficiently aware of the knowledge that has been acquired in recent years about the physical, psychological, and social needs of handicapped and elderly persons. He also notes that over two-fifths of these matrons and wardens seemed to be unnecessarily authoritarian. Specialist staff were scarce, and visits from doctors relatively rare. Arrangements for chiropody, occupational therapy, physiotherapy, and care of teeth and eyes were inadequate. Some personal services, such as hairdressing and shaving, were infrequent, and performed by non-
professionals. Mr. Townsend believes that the failure of the Labour and Conservative Governments after 1948 to replace the former workhouses with small homes helped to perpetuate a form of discrimination between human beings which was neither efficient nor moral. Three suggestions for the future of the old workhouses have been put forward by some of those in charge: material amenities and staffing standards should be radically improved; a much closer link should be forged with the hospital service; or they should be pulled down and replaced by small homes. THE LOCAL-AUTHORITY POST-WAR HOME
By January, 1960, some 1100 residential homes had been opened by local authorities in England and Wales since the war, and they accounted for half their accommodation. On the whole these compare favourably with prewar institutions, and even with many modern hospital units. But there are some disadvantages, including, for example, long corridors, too few small rooms, and too much uniformity in furnishing. The converted homes vary widely in structure and amenities, and are sometimes hard to clean, sparsely furnished, dilapidated, and lacking in adequate sitting-room and dining-room accom-
1100
modation. Washing and lavatory arrangements were in deficient many homes, and nearly two-thirds of the residents slept in rooms with at least three beds. There was too little ground-floor accommodation, and too few lifts. Staff shortages existed in about three-fifths of the homes,and there was a general need for a better system of relief staff. There were no qualified nurses in over half the homes, and almost none of the staff had had formal instruction in the residential care of the handicapped and elderly. As in the old workhouses, there was insufficient provision for medical care, chiropody, physiotherapy, and occupational therapy; and special services were comparatively few. Only about a third of the matrons and wardens had a nursing qualification; three-fifths of the matrons were over 50, and three-quarters were unmarried or childless. Over half were judged to be insufficiently aware of the physical, psychological, and social needs of handicapped and elderly people. VOLUNTARY HOMES
whole, the voluntary homes emerge most favourably. They had better physical provisions and staffing ratios than the local-authority homes, and they also usually offered more freedom of choice to the individual residents. In January, 1960, there were 815 such homes in England and Wales, accommodating over 24,000 people. The large homes were the least satisfactory, and were on the whole much worse staffed than either the old workhouses or the local-authority premises. But the small homes were better staffed. As elsewhere, medical and specialist services tended to be few, but nearly half the old people had private rooms, and followed independent interests and pastimes. The impression was that their social relationships were often more satisfactory On the
than those of the old who lived a more institutional life. None the less, the social life of some homes was meagre, and the residents had few opportunities to follow pastimes, help in running the home, celebrate birthdays, or go on
holidays. PRIVATE HOMES
In 1960 there were 1160 private homes registered in England and Wales, accommodating nearly 12,000 people. They varied strikingly in their amenities, furnishings, staffing, and management. Staffing ratios were better on average than in other types of homes. At the time of the survey average weekly fees were between 5 and 8 guineas in half the homes, 31/2-5 guineas in a quarter, and 8-30 guineas in another quarter. Additional charges were often made for heating, laundry, and nursing, and the staff sometimes received tips and legacies. In some respects the daily routine was more flexible than that of localauthority homes, and residents often had greater privacy; but restrictions were often imposed, and the residents had few relationships with each other or with the local community. Many of them were isolated, insecure, or over-dependent on the rule of a powerful proprietor. Private homes are registered under legislation which is ambiguous. Some homes escape registration; and others fall short of minimum requirements in staffing, physical facilities, and fire appliances, yet, because of the imposition of the National Assistance Act and of Ministry of Health regulations, as well as of local inspection policies, they are nevertheless registered. " Some proprietors are totally unfit to care for such persons, and yet, because no guidance is given as to how their’ unfitness ’ can be defined or proved and registration withheld, they are left to carry on their work."
A GLOOMY PICTURE
Mr. Townsend concludes that the general level of achievement is low. The standard reached, according to the scale he devised, was " poor ", " very poor ", or " bad " in all the old workhouses, in nearly three-fifths of the post-war local-authority homes, in over a fifth of the voluntary homes, and in two-fifths of the private ones. But the standard reached by over two-fifths of the voluntary homes, by nearly a quarter of the private ones, and by a very small proportion of local-authority homes is rated as " good " or " very good ". Among all the four types of homes, the smallest are usually better than the largest-having more staff, more toilet facilities, more single and double bedrooms, and offering more means of accommodation and freedom of choice. Mr. Townsend poses some further important questions. How do old people come to be there? What are the effects upon them ? Why does society maintain such homes, and are there any practical alternatives ? To enter a home is a drastic step for anyone. But what exactly does it mean ? When they investigate personal problems, welfare officers are often unable, because of lack of authority and time, to offer any solution other than admission to residential institutions. Often they cannot give proper advice about residential accommodation. The initial interview usually has to be rushed. Many old people are left in ignorance or doubt of when, where, or how they are to take up residence. The information necessary for making responsible decisions is not always provided. Local councils are usually left to their own improvisations, receiving a minimum of guidance from the Ministry of Health about criteria for admission. The admission policies of the local authorities seem to be governed by two assumptions: that old people freely choose to enter residential institutions; and that they want to stay there permanently. The evidence in this book casts doubt on both these assumptions, and suggests the need to change existing policies. People are eligible for admission to residential institutions and homes when they are" in need of care and attention which is not otherwise available to them". This definition is not easy to interpret and apply. Account has to be taken of both physical and social conditions. By using a defined measure of incapacity, Mr. Townsend found that over half of those now admitted to institutions were physically and mentally capable of leading an independent life, though many of them needed help with a few tasks. It was found that physically, and mentally, the elderly residents were much more like people of the same age living at home than those living in hospitals. Only just over a third of them were housebound. Though precise evidence was scanty, it seemed likely that there were ten to twenty times as many bedfast or housebound elderly persons living in the ordinary community as in residential homes. One of the most important reasons for the admission of old people to residential homes was social isolation caused by the lack of close relatives and friends, the loss of supporting relatives, or separation from the family. Other reasons for admission were homelessness, financial insecurity, and the absence of subsidiary help for those living with or near a relative. The important effects of institutional care seemed to be loss of occupation; isolation from family, friends, and communities; tenuousness of new relationships; loneliness; loss of privacy and identity; and collapse of self-determination.
1101 THE FUTURE
There have recently been two important developments in Britain’s approach to institutional care. The first has been to encourage changes in the atmosphere and character of the institution by introducing features of home and community life. The second has been to place greater emphasis on domiciliary and housing services, to provide an effective alternative to institutional care. We are gradually abandoning the social philosophy of the " 19th century, which centred on a belief in custodial " care. But we are not being very successful in providing While rejecting the ideas of the 19th an alternative. century, we have yet to find a coherent philosophy to put in their place. Mr. Townsend believes that the most logical solution would be gradually to abandon the long-term institution He believes that the as an instrument of social policy. responsibilities of society should be to enlarge, or at least to preserve, the individual’s degree of freedom and powers of self-determination; to safeguard or, if necessary, restore his health and capacity to undertake personal and household activities; to help him to live as independently as possible in a home of his own; to ensure that he has adequate means of occupation; to make it possible for him to maintain his relationships with his family and friends, and with the community with which he is familiar; to make it possible for him to establish new social relationships; to protect him from a serious fall in
Special Articles THE CONCEPTS OF
" FREE ACID" AND " TOTAL ACID " OF THE GASTRIC JUICE O. A. A. BOCK M.A., B.M. Oxon., B.Sc. Pretoria OF THE NUFFIELD DEPARTMENT OF CLINICAL RADCLIFFE INFIRMARY, OXFORD
MEDICINE,
IN 1824 Proutdemonstrated that the acid produced by the stomach is hydrochloric acid, and he introduced the terms " free acid ", " combined acid ", and " total acid ". Prout did not indicate the derivation of the terms, but it is probable that the expressions were commonly used by chemists of the time. The nature of the acid was confirmed by Szabo in 1877,2who described a method for titrating stomach juice with sodium hydroxide and litmus. Jaworski and Gluzinski3 extended his method, and postulated " degrees of acidity of stomach juice " because different amounts of alkali were needed to titrate to the same colour point the juice collected from thirty-six
patients. Towards the end of the last century the titration of gastric juice and the concept of free acid was firmly established,45 and general agreement in the interpretation of the results lasted until 1909, when Sorensen6 suggested the pH notation for hydrogen-ion concentration. This led to much confusion in early attempts to correlate pH and millinormal units of gastric acid. Christiansen7 found good agreement, Kopeloffnoted a discrepancy 1. 2. 3. 4.
Prout, W. Philos. Trans. 1824, part 1, p. 45. Szabo, D. Hoppe-Seyl Z. 1877, 1, 140. Jaworski, W., Gluzinski, A. Z. klin. Med. 1886, 11, 50. Leube, W. O. in Clinical Lectures on Subjects Connected with Medicine, Surgery and Obstetrics (by various German authors). 1877. 5. Ewald, C. A. Lectures on Diseases of the Stomach; vol. II. 1892. 6. Sorensen, S. P. L. Biochem. Z. 1909, 21, 131. 7. Christiansen, J. ibid. 1912, 46, 257. 8. Kopeloff, N. J. Amer. med. Ass. 1922, 78, 404.
income from the levels enjoyed by those at work; and to equalise the facilities and resources available to different categories of the handicapped, the poor, and the sick, irrespective of income, origin, or class. To apply these principles, Mr. Townsend emphasises some far-reaching proposals: to reduce progressively the number of communal homes (in the first instance by closing the former workhouses), and replace them in part by sheltered housing and in part by a slight extension of the hospital system; to place responsibility on hospital management committees for the management or supervision of all institutions and communal homes; to enlarge greatly the domiciliary services, mainly by creating a local-authority family-help service, and to develop general-practitioner group practice. He is certain that Britain has the means to make these
improvements. At a time when we stand perhaps at the start of a new in social policy, we are in danger of being criticised by future generations for grudging indifference and parsimony to those who are unable, because of chronic illness, disability, loss of family, or inadequate housing, to stand up to the rigours of a competitive society. " It may be worth reflecting, if indeed a little sadly, that possibly the ultimate test of the quality of a free, democratic and prosperous society is to be found in the standards of freedom, democracy, and prosperity enjoyed by its weakest members." era
in the results and favoured the determination of the pH, while Vos9 concluded that the titration method was adequate for the purposes of gastric
entirely
analyses. The dispute continued until 1926, when Michaelis 10 apparently justified the concepts of free acid and total acid of gastric juice. These terms have persisted until the present day, and to understand them it is necessary to recapitulate in detail of Michaelis’s some
experiments: Michaelis
considered
gastric juice to be a solu-
1-The titration curve of 3 ml. of 0.1 M HCI (redrawn from Harvey Lectures for 1926).
Fig.
tion of peptone and an excess of hydrochloric acid. By an excess he meant that amount of hydrochloric acid exceeding the amount which was necessary to form a salt with the peptone. The amount which combined with the peptone he called " combined acid "; the excess hydrochloric acid was, therefore, the " free acid ", and the sum of these represented the " total acid ". He investigated the effect of adding weak acids on the titration curve of a 3 ml. aliquot of 0-M HC1 (figs. 1 and 2). Fig. 2 shows the titration curve of a solution of 3 ml. of 0-1 M HC1, 3 ml. of 0-1 M lactic acid, and 3 ml. of 0-1 M acetic acid, and K andP indicate the individual titration curves of 3 ml. of 0-1 M HCland of 3 ml. of 0,1 1 M lactic acid respectively. 9.
10.
Vos, H. Ned. Tijdschr. Geneesk. 1922, 66, 2364. Michaelis, L. Harvey Lect. 1926, 22, 59.
Occasional Book HOMES FOR OLD PEOPLE ARE communal homes for old people necessary in our society, and, if so, what form should they take ? Mr. Peter Townsend’s new book1 attempts to give some answer to these questions. It is chiefly concerned with residential accommodation provided under the National Assistance Act of 1948, though a number of the problems arising in hospitals, nursing-homes, and other institutions are also discussed. Its general conclusion is that communal homes of the kind which exist in England and Wales today are not adequate for the physical, psychological, and social needs of the elderly people living in them, and that alternative services and living arrangements should take their place quickly. Mr. Townsend describes the results of a major survey carried out in England and Wales with the help of all local authorities and many voluntary and professional associations. A random sample of 173 residential institutions and homes were visited, and welfare officers, matrons, and elderly residents were interviewed. The objects of this study were: to describe what residential accommodation there is for the aged in England and Wales at present, and how that accommodation varies from area to area; to ,describe the lives of old people once they enter institutions ; to discover why old people enter these particular institutions and homes; to assess as far as possible the adequacy of the services provided; to explore alternative methods of caring for the aged, and to make recommendations. Broadly speaking, there are four types of institutions or homes, falling within the definition of the National Assistance Act: the former workhouses which were retained by local authorities in 1948; small homes run by local authorities, mostly opened since 1948; homes run by voluntary bodies; and homes run for reward by private . individuals. The last two groups are registered and inspected by local authorities. Rather fewer than half the 3600 residential institutions in Great Britain are owned and managed by local authorities, but they contain two,thirds of the beds available. In 1960 there were in England and Wales 95,500 residents of pensionable age, two-thirds of them living in former workhouses and other local-authority premises, a quarter in voluntarily run, and the remainder in private, premises. This represents about 18 per 1000, persons aged 65 and over. A much higher proportion of the population will probably spend at least some part of their final years in such homes, and the number is likely to increase in the future. More of the elderly residents of institutions are unmarried or widowed than in the general population of the elderly. Probably 140-150 per 1000 bachelors and spinsters aged 85 and over live in residential institutions. There is also a disproportionately large number of childless married or widowed people. The former public-assistance institutions cater largely for the poorest social classes, and for those who lack relatives or who have lost touch with them. Many of the residents would not usually be classified as infirm, though a substantial proportion are. The other local-authority premises cater more often for women and for those from the middle or upper working class. More of the residents 1. The Last Refuge: A Survey of Residential Institutions and Homes for the Aged in England and Wales. By PETER TOWNSEND. London: Routledge & Kegan Paul. 1962. Pp. 552. 60s.
in the other two types of home are middle-class, and more of them are women. There are big differences in residential provision from one area of the country to another. Voluntary and private accommodation is concentrated in the south and south-east, particularly in dormitory areas and in seaside towns. There is more local-authority accommodation in county boroughs than in county-council areas. FORMER WORKHOUSES
Perhaps the most disquieting feature of the book’s statistical review is the extensive use still being made of former workhouses. Nearly half the elderly residents in local-authority accommodation live in such premises. The old workhouse often has stone floors, unplastered interior walls, and long dormitories of ten, twenty, and even fifty beds, with iron frames and hair, flock, or straw mattresses. There is little furniture in the dormitoriesoften only a wooden chair and a battered locker by each bed. Thirty, forty, or more old people sit in huge dayrooms, with very low standards of comfort. Coarse and unpressed institutional clothing is issued. There is no real privacy, and little to encourage self-respect: a man may have his trousers changed in full view of dozens of other people. The staff are too few, and have rarely received any form of training. The turnover of staff is sometimes as much as 100% in a year. The matrons and wardens in charge Mr. of these institutions wield considerable power. Townsend notes that some of them displayed a keen awareness of the needs of residents, and acted with sympathy and tolerant good humour towards them. But two-thirds seemed to be insufficiently aware of the knowledge that has been acquired in recent years about the physical, psychological, and social needs of handicapped and elderly persons. He also notes that over two-fifths of these matrons and wardens seemed to be unnecessarily authoritarian. Specialist staff were scarce, and visits from doctors relatively rare. Arrangements for chiropody, occupational therapy, physiotherapy, and care of teeth and eyes were inadequate. Some personal services, such as hairdressing and shaving, were infrequent, and performed by non-
professionals. Mr. Townsend believes that the failure of the Labour and Conservative Governments after 1948 to replace the former workhouses with small homes helped to perpetuate a form of discrimination between human beings which was neither efficient nor moral. Three suggestions for the future of the old workhouses have been put forward by some of those in charge: material amenities and staffing standards should be radically improved; a much closer link should be forged with the hospital service; or they should be pulled down and replaced by small homes. THE LOCAL-AUTHORITY POST-WAR HOME
By January, 1960, some 1100 residential homes had been opened by local authorities in England and Wales since the war, and they accounted for half their accommodation. On the whole these compare favourably with prewar institutions, and even with many modern hospital units. But there are some disadvantages, including, for example, long corridors, too few small rooms, and too much uniformity in furnishing. The converted homes vary widely in structure and amenities, and are sometimes hard to clean, sparsely furnished, dilapidated, and lacking in adequate sitting-room and dining-room accom-
1100
modation. Washing and lavatory arrangements were in deficient many homes, and nearly two-thirds of the residents slept in rooms with at least three beds. There was too little ground-floor accommodation, and too few lifts. Staff shortages existed in about three-fifths of the homes,and there was a general need for a better system of relief staff. There were no qualified nurses in over half the homes, and almost none of the staff had had formal instruction in the residential care of the handicapped and elderly. As in the old workhouses, there was insufficient provision for medical care, chiropody, physiotherapy, and occupational therapy; and special services were comparatively few. Only about a third of the matrons and wardens had a nursing qualification; three-fifths of the matrons were over 50, and three-quarters were unmarried or childless. Over half were judged to be insufficiently aware of the physical, psychological, and social needs of handicapped and elderly people. VOLUNTARY HOMES
whole, the voluntary homes emerge most favourably. They had better physical provisions and staffing ratios than the local-authority homes, and they also usually offered more freedom of choice to the individual residents. In January, 1960, there were 815 such homes in England and Wales, accommodating over 24,000 people. The large homes were the least satisfactory, and were on the whole much worse staffed than either the old workhouses or the local-authority premises. But the small homes were better staffed. As elsewhere, medical and specialist services tended to be few, but nearly half the old people had private rooms, and followed independent interests and pastimes. The impression was that their social relationships were often more satisfactory On the
than those of the old who lived a more institutional life. None the less, the social life of some homes was meagre, and the residents had few opportunities to follow pastimes, help in running the home, celebrate birthdays, or go on
holidays. PRIVATE HOMES
In 1960 there were 1160 private homes registered in England and Wales, accommodating nearly 12,000 people. They varied strikingly in their amenities, furnishings, staffing, and management. Staffing ratios were better on average than in other types of homes. At the time of the survey average weekly fees were between 5 and 8 guineas in half the homes, 31/2-5 guineas in a quarter, and 8-30 guineas in another quarter. Additional charges were often made for heating, laundry, and nursing, and the staff sometimes received tips and legacies. In some respects the daily routine was more flexible than that of localauthority homes, and residents often had greater privacy; but restrictions were often imposed, and the residents had few relationships with each other or with the local community. Many of them were isolated, insecure, or over-dependent on the rule of a powerful proprietor. Private homes are registered under legislation which is ambiguous. Some homes escape registration; and others fall short of minimum requirements in staffing, physical facilities, and fire appliances, yet, because of the imposition of the National Assistance Act and of Ministry of Health regulations, as well as of local inspection policies, they are nevertheless registered. " Some proprietors are totally unfit to care for such persons, and yet, because no guidance is given as to how their’ unfitness ’ can be defined or proved and registration withheld, they are left to carry on their work."
A GLOOMY PICTURE
Mr. Townsend concludes that the general level of achievement is low. The standard reached, according to the scale he devised, was " poor ", " very poor ", or " bad " in all the old workhouses, in nearly three-fifths of the post-war local-authority homes, in over a fifth of the voluntary homes, and in two-fifths of the private ones. But the standard reached by over two-fifths of the voluntary homes, by nearly a quarter of the private ones, and by a very small proportion of local-authority homes is rated as " good " or " very good ". Among all the four types of homes, the smallest are usually better than the largest-having more staff, more toilet facilities, more single and double bedrooms, and offering more means of accommodation and freedom of choice. Mr. Townsend poses some further important questions. How do old people come to be there? What are the effects upon them ? Why does society maintain such homes, and are there any practical alternatives ? To enter a home is a drastic step for anyone. But what exactly does it mean ? When they investigate personal problems, welfare officers are often unable, because of lack of authority and time, to offer any solution other than admission to residential institutions. Often they cannot give proper advice about residential accommodation. The initial interview usually has to be rushed. Many old people are left in ignorance or doubt of when, where, or how they are to take up residence. The information necessary for making responsible decisions is not always provided. Local councils are usually left to their own improvisations, receiving a minimum of guidance from the Ministry of Health about criteria for admission. The admission policies of the local authorities seem to be governed by two assumptions: that old people freely choose to enter residential institutions; and that they want to stay there permanently. The evidence in this book casts doubt on both these assumptions, and suggests the need to change existing policies. People are eligible for admission to residential institutions and homes when they are" in need of care and attention which is not otherwise available to them". This definition is not easy to interpret and apply. Account has to be taken of both physical and social conditions. By using a defined measure of incapacity, Mr. Townsend found that over half of those now admitted to institutions were physically and mentally capable of leading an independent life, though many of them needed help with a few tasks. It was found that physically, and mentally, the elderly residents were much more like people of the same age living at home than those living in hospitals. Only just over a third of them were housebound. Though precise evidence was scanty, it seemed likely that there were ten to twenty times as many bedfast or housebound elderly persons living in the ordinary community as in residential homes. One of the most important reasons for the admission of old people to residential homes was social isolation caused by the lack of close relatives and friends, the loss of supporting relatives, or separation from the family. Other reasons for admission were homelessness, financial insecurity, and the absence of subsidiary help for those living with or near a relative. The important effects of institutional care seemed to be loss of occupation; isolation from family, friends, and communities; tenuousness of new relationships; loneliness; loss of privacy and identity; and collapse of self-determination.
1101 THE FUTURE
There have recently been two important developments in Britain’s approach to institutional care. The first has been to encourage changes in the atmosphere and character of the institution by introducing features of home and community life. The second has been to place greater emphasis on domiciliary and housing services, to provide an effective alternative to institutional care. We are gradually abandoning the social philosophy of the " 19th century, which centred on a belief in custodial " care. But we are not being very successful in providing While rejecting the ideas of the 19th an alternative. century, we have yet to find a coherent philosophy to put in their place. Mr. Townsend believes that the most logical solution would be gradually to abandon the long-term institution He believes that the as an instrument of social policy. responsibilities of society should be to enlarge, or at least to preserve, the individual’s degree of freedom and powers of self-determination; to safeguard or, if necessary, restore his health and capacity to undertake personal and household activities; to help him to live as independently as possible in a home of his own; to ensure that he has adequate means of occupation; to make it possible for him to maintain his relationships with his family and friends, and with the community with which he is familiar; to make it possible for him to establish new social relationships; to protect him from a serious fall in
Special Articles THE CONCEPTS OF
" FREE ACID" AND " TOTAL ACID " OF THE GASTRIC JUICE O. A. A. BOCK M.A., B.M. Oxon., B.Sc. Pretoria OF THE NUFFIELD DEPARTMENT OF CLINICAL RADCLIFFE INFIRMARY, OXFORD
MEDICINE,
IN 1824 Proutdemonstrated that the acid produced by the stomach is hydrochloric acid, and he introduced the terms " free acid ", " combined acid ", and " total acid ". Prout did not indicate the derivation of the terms, but it is probable that the expressions were commonly used by chemists of the time. The nature of the acid was confirmed by Szabo in 1877,2who described a method for titrating stomach juice with sodium hydroxide and litmus. Jaworski and Gluzinski3 extended his method, and postulated " degrees of acidity of stomach juice " because different amounts of alkali were needed to titrate to the same colour point the juice collected from thirty-six
patients. Towards the end of the last century the titration of gastric juice and the concept of free acid was firmly established,45 and general agreement in the interpretation of the results lasted until 1909, when Sorensen6 suggested the pH notation for hydrogen-ion concentration. This led to much confusion in early attempts to correlate pH and millinormal units of gastric acid. Christiansen7 found good agreement, Kopeloffnoted a discrepancy 1. 2. 3. 4.
Prout, W. Philos. Trans. 1824, part 1, p. 45. Szabo, D. Hoppe-Seyl Z. 1877, 1, 140. Jaworski, W., Gluzinski, A. Z. klin. Med. 1886, 11, 50. Leube, W. O. in Clinical Lectures on Subjects Connected with Medicine, Surgery and Obstetrics (by various German authors). 1877. 5. Ewald, C. A. Lectures on Diseases of the Stomach; vol. II. 1892. 6. Sorensen, S. P. L. Biochem. Z. 1909, 21, 131. 7. Christiansen, J. ibid. 1912, 46, 257. 8. Kopeloff, N. J. Amer. med. Ass. 1922, 78, 404.
income from the levels enjoyed by those at work; and to equalise the facilities and resources available to different categories of the handicapped, the poor, and the sick, irrespective of income, origin, or class. To apply these principles, Mr. Townsend emphasises some far-reaching proposals: to reduce progressively the number of communal homes (in the first instance by closing the former workhouses), and replace them in part by sheltered housing and in part by a slight extension of the hospital system; to place responsibility on hospital management committees for the management or supervision of all institutions and communal homes; to enlarge greatly the domiciliary services, mainly by creating a local-authority family-help service, and to develop general-practitioner group practice. He is certain that Britain has the means to make these
improvements. At a time when we stand perhaps at the start of a new in social policy, we are in danger of being criticised by future generations for grudging indifference and parsimony to those who are unable, because of chronic illness, disability, loss of family, or inadequate housing, to stand up to the rigours of a competitive society. " It may be worth reflecting, if indeed a little sadly, that possibly the ultimate test of the quality of a free, democratic and prosperous society is to be found in the standards of freedom, democracy, and prosperity enjoyed by its weakest members." era
in the results and favoured the determination of the pH, while Vos9 concluded that the titration method was adequate for the purposes of gastric
entirely
analyses. The dispute continued until 1926, when Michaelis 10 apparently justified the concepts of free acid and total acid of gastric juice. These terms have persisted until the present day, and to understand them it is necessary to recapitulate in detail of Michaelis’s some
experiments: Michaelis
considered
gastric juice to be a solu-
1-The titration curve of 3 ml. of 0.1 M HCI (redrawn from Harvey Lectures for 1926).
Fig.
tion of peptone and an excess of hydrochloric acid. By an excess he meant that amount of hydrochloric acid exceeding the amount which was necessary to form a salt with the peptone. The amount which combined with the peptone he called " combined acid "; the excess hydrochloric acid was, therefore, the " free acid ", and the sum of these represented the " total acid ". He investigated the effect of adding weak acids on the titration curve of a 3 ml. aliquot of 0-M HC1 (figs. 1 and 2). Fig. 2 shows the titration curve of a solution of 3 ml. of 0-1 M HC1, 3 ml. of 0-1 M lactic acid, and 3 ml. of 0-1 M acetic acid, and K andP indicate the individual titration curves of 3 ml. of 0-1 M HCland of 3 ml. of 0,1 1 M lactic acid respectively. 9.
10.
Vos, H. Ned. Tijdschr. Geneesk. 1922, 66, 2364. Michaelis, L. Harvey Lect. 1926, 22, 59.