MODERN CARE OF OLD PEOPLE

848

Butler

and Cushman obtained by a different method, may " reflect the difference in nutritional level between the post-war British and the pre-war American populations." This is quite unwarranted. It would be much

less unsound to compare Dr. Constantinides’s mean of 29 mg. (on only 7 subjects) with the means of 24-2±0-6 mg. (n=27) or 23-7 ±0-6 mg. (n=27) which Lowry et al.a obtained by the same method6 on two groups of R.C.A.F. personnel who daily received respectively 70 mg. of synthetic ascorbic acid and an average of 78 mg. from their rations ; if this comparison is made would one not conclude that the post-war British diet contains more than 78 mg. daily-which would satisfy even the most vigorous ascorbic-acid gluttons ? Our mean for ascorbic acid in the leucocyte-platelet layer of 1351 samples from British subjects examined by the hydrazine method during the war was 14-0 mg. per 100 g. H. M. SINCLAIR B. B. LLOYD. Oxford. CLICKING PNEUMOTHORAX SIR,-Dr. Thomson describes in his paper of May 10 curious sounds synchronous with the heart-beat audible at some distance from the patient. He thinks the sounds are probably due to a small (spontaneous) leftsided pneumothorax in contact with a pleural adhesion, and he notes that they disappear when the pneumothorax enlarges. In two patients of mine a left artificial pneumothorax had been successfully induced for pulmonary tuberculosis. Refills regularly given formed a good pneumothorax as shown radiologically. Some adhesions were present in the upper zone. It was not until after about six months’ treatment that the patients reported " funny noises " of the type described by Dr. Thomson. The noises were not permanent, but I and some other doctors heard them at a distance of about two feet. The patients felt absolutely well and were only somewhat annoyed that the noises sometimes prevented them from falling asleep. Dr. Thomson’s explanation may be correct, though It seems unlikely that an alternative one is possible. the cause of the manifestations is situated in the pneumothorax. If it were they should be more common, whereas in fact not many physicians have met with an example. The sounds may arise in the pericardial sac, if some air from the pneumothorax enters it through a gap formed when adhesions between the pericardium and pleura are torn. In the pericardial sac some fluid is produced in the same way as in pneumothorax. At every beat the heart then hits the fluid in the hydropneumopericardium and produces the sounds. The condition might to some extent be compared with hippocratic succussion. It is interesting that Dr. Thomson mentions (case 3) " a sound suggesting pericardial friction." L. DUNNER. Hull. MODERN CARE OF OLD PEOPLE SIR,-While welcoming your series of articles, as showing what should be done, I feel that there is a need to mention some of those things which should not be done when catering for the elderly. The most frequent of these sins against the aged is to imagine that " they have had their day, poor dears." I know a number of old folk, some over 80, who are reasonably active, intelligent. and mentally alert. The common practice of putting such patients to bed and keeping them quiet, with sedatives if necessary, cannot be condemned too strongly. As Dr. Marjory Warren has shown, elderly patients are best kept out of bed as much as possible and encouraged to develop interests of their own. The usual excuse of shortage of staff is sheer nonsense. Old people who get up and about need fewer nurses or attendants than those who remain in bed. The second heresy is the view that there is little response to medical treatment in old age, so that any sort of doctor is good enough. My own experience with Chelsea pensioners suggested that while diagnosis was more difficult than in earlier life, prognosis among aged patients depended to a great degree on starting treatment quickly. Pneumonia, for instance, is no longer " the old man’s last friend " in the original sense of the phrase. 6. Bessey, O. A., Lowry, O. H., Brock, M. J. J. biol. Chem. 1947, 168, 197.

Taking a different example, it is surprising how an elderly arthritic patient can be rendered mobile with a little care and persistence. Similarly, many hemiplegics can be rehabilitated if proper remedial exercises are carried out from the start. Part-time general

practitioners

or

newly qualified

medical

men are

not the

doctors for the aged. Old folk need more time, greater skill, and more intense interest than young ones. proper

Their tendency to multiple disorders underlines the fact that nobody can know too much to treat these patients. Extensive clinical and pathological investigation may be necessary, considerable therapeutic judgment is often required. But when these are available a surprising dividend will be paid. Tough old folk are not a bad medical investment. Finally, I would suggest that drab surroundings, limited visiting hours, uncomfortable furniture, and rigid institutional atmosphere are too common in hospitals and homes for the aged. Old men, and still more old women, are made miserable by being cooped in dull barracks. More colour, more comfort, and more freedom An Austrian physician, and elasticity are overdue. Lorand, once recommended life in an English workhouse as a means of attaining longevity. Today, our object should be " to add life to the years, not years to the life." TREVOR H. HOWELL. Purley, Surrey. W.H.O. AND GREECE

SIR,-Dr. Judith Waterlow, in her letter

on

public-

health work in Greece published in your issue of May 31, makes certain strictures on the administration, which, in particular cases, may have some foundation. I must, however, most emphatically deny her very sweeping allegation that " the Greek government will not employ even the humblest clerk if he helped to resist the German occupation." This, of course, is untrue. I myself was in Greece throughout the occupation and can vouch for the fact that a very high percentage of the population, whatever their political affiliations, were engaged in some form of underground resistance against the Italian and German invaders. It is true that, under present conditions, the Greek government is chary of employing Communists in the public services, even if they took part in the resistance, because so many of them have engaged in disloyal activities against the State since the liberation. But the majority of Greeks are not Communists but just ordinary patriotic citizens-we may call them Nationalists-who played their part in the resistance ; and it is as ridiculous as it is unjust to pretend that they are excluded from the public services just because they helped to resist A. A. PALLis. the German occupation. Greek Government Department of Information, 34, Hyde Park Square, London, W.2 ,

SiR,-Dr. Waterlow maintains that, because of the Greek government’s interference with health work, the money of United Nations taxpayers will be wasted if applied to Greek health reconstruction. She believes that it might more profitably be spent in aiding countries such as Poland and Yugoslavia. Her reference to Greece as one of " two countries chosen for special missions on the spot," ignores the fact that the World Health Organisation Interim Commission (WHOlC) has missions not only in Greece but also in China, Ethiopia, Italy, and Hungary, while others are planned for Yugoslavia (for plastic surgery), Poland, and Austria. Further, the choice of countries in which field work should be carried out does not rest solely, or even mainly, with the Interim Commission. The agreement with UNRRA under which WAOZC undertook to continue UNRRA’s work during 1947, to the extent that the$1B million generously provided by UNRRA would allow, specifically mentioned the missions in China, Greece, and Ethiopia as worthy of continuation. Much more important, however, was the very natural condition that programmes must be planned in agreement with the governments concerned. Except that WHOIC is unable to provide medical supplies, no restrictions whatever were placed on the form of assistance that governments might request. That there are no missions in, say, Czechoslovakia or the Ukraine is simply because the