- Email: [email protected]
Preparation for Retirement
1057
resorted to after careful clinical and biochemical observation and aspiration liver-biopsy, and when the procedure be followed by operation within three hours. Two types of such cholestatic drug jaundice are recognised, the one attributable to hypersensitivity and the other not. Chlorpromazine jaundice 32 is an example of the hypersensitivity group, and an essentially similar by some other phenothiazine picture is produced derivatives.33 14 Frank jaundice may be anticipated in about 1% of those taking the drug; it usually develops during the first month, and may be heralded by leucopenia, eosinophilia, drug fever, and drug rash. Hypersensitivity is also suggested when the jaundice follows a single dose or one day’s treatment; it may recur when the drug is taken on a subsequent occasion. Chlorpromazine-type jaundice has been noted, too, in can
increasingly popular, it is as well to peculiar effect on the excretory capacity of the liver, and in particular on bromsulphthalein excretion. Otherwise the finding of this biochemical evidence of hepatic dysfunction inthe absence of
properties
become
remember their
clinical evidence of liver disease may lead to the unforpatient being warned about- his health and on placed a rigid " liver regimen ". Unlike chlorpromazine toxicity, which seems to be an allergic reaction to a small dose in the hypersensitive host, steroidal toxicity is a straightforward consequence of dosage and duration of administration. Perhaps the agent which will be used for the longest periodsnamely, over the childbearing years of life-is the new oral contraceptive, norethynodrel, a C17-alkylated C19 steroid. This has already been reported to cause bromassociation with arsphenamine, p-aminosalicylic acid, sulphthalein retention,40 and time will show whether it thiouracil, chlorpropamide, cetylurea, and carbasone.33 can produce cholestatic jaundice. Any organisation Unlike the hepatitis of the monoamine-oxidase inhi- responsible for the widespread dissemination of the bitors, clinical recovery can be confidently anticipated pill" would be wise to include tests of bromsulphthalein in time, although this may take up to three years.35 excretion in its surveys, certainly until all doubt on this Thus the patient can be reassured with confidence-an point has been dispelled. Meanwhile, the pill " should important point in managing those with the types of not be overlooked when the medicine-chest is scrutinised personality which originally needed the phenothiazine for potentially icterogenic drugs. tunate
"
"
drugs. Acute cholestatic drug jaundice also complicates treatment with methyltestosterone and related derivatives 33; but this differs from chlorpromazine jaundice in two respects. There is no evidence that the toxic effects are due to hypersensitivity, which would confine such effects to the 1% of susceptible individuals; instead, most of those receiving enough of the drug for long enough will develop bromsulphthalein retention,3s-3s if not frank cholestatic jaundice. Secondly, although the clinical picture is essentially the same, there are histological differences : the liver lesion is that of simple cholestasis, with slight hepatocellular changes; there is neither the portal-zone cellular reaction nor the eosinophilia which point to an allergic reaction.39 Besides methyltestosterone, steroids reported to cause this type of jaundice have alkyl substitution at the carbon-17 position of the steroid nucleus. Such substitution also provides a group of compounds which are active when taken by mouth. The importance of C17K-alkyl substitution, both in the pathogenesis of cholestasis and in conferring oral activity, sheds light on the old problem of why methyltestosterone is, and testosterone propionate is not, icterogenic. The latter, which is given by injection, does not carry this steroidal configuration. Likewise, nandrolone, which differs from most of the other commonly used nonvirilising anabolic steroids, is given by injection, does not seem to cause cholestasis, and does not have the C17 alkyl substitution. As these orally active anabolic nor-steroids with reduced virilising action or with potent progestational Hollister, L. E. Amer. J. Med. 1957, 23, 870. Popper, H., Schaffner, F. Ann. intern. Med. 1959, 51, 1230. Hollister, L. E. ibid. 1958, 49, 17. Read, A. E., Harrison, C. V., Sherlock, S. Amer. J. Med. 1961, 31, 249. 36. Kory, R. C., Bradley, M. H., Watson, R. N., Callahan, R., Peters, B. J. ibid. 1959, 26, 243. 37. Wynn, V., Landon, J., Kawerau, E. Lancet, 1961, i, 69. 38. Wernze, E. German med. Mon. 1962, 7, 78. 39. Popper, H., Schaffner, F. J. Amer. med. Ass. 1959, 169, 1447.
32. 33. 34. 35.
Preparation
for Retirement
RETIREMENT from work is a 20th-century institution. More older people, mechanisation, pensions and superannuation, and a new philosophy of leisure are all reasons why the number of retired men and women has risen steadily. If current trends continue, by 1980 more than 3 out of every 4 people over sixty-five will be retired. Is retirement " the roleless period " that some writers have described ? Do many retired people find acceptable substitutes for work, and what kind of guidance is offered to those who do not ? Questions of this kind are being asked more and more by men and women who have begun to realise that some advance thinking is a better approach to retirement than blind refusal to prepare for the break from work. Of course, many people make a success of retirement and adjust themselves happily to their new leisure. The reasons for this are sometimes obvious: release from an uninteresting job and an
absorbing hobby; a move to pleasanter surroundings or nearer to kin; freedom to stroll, observe, read, or help in the home. But what about the others who find they have retired to nothing, whose thoughts dwell often and nostalgically on what they have retired from-the wage or salary, the companionship of work, the status ? These are the people who enter retirement unprepared either to cut its losses or exploit its gains. To help them to acquire well in advance a realistic understanding of its true meaning schemes of preparation have been started in this country and America, and Dr. ALASTAIR HERON has lately reviewed their origins, development, and programmes.41 an 40. 41.
The first in this country was started four years ago in engineering firm in Birmingham. Six weekly discussion Marquardt, G. H., Fisher, C. I., Levy, P., Dowben, R. M. ibid. 1961, 175, 851. Heron, A. Preparation for Retirement, Solving New Problems. 1961. Obtainable from the National Council of Social Service, 26, Bedford Square, London, W.C.1. 2s. 6d.
1058
meetings (and a weekend gathering to which wives are invited) are held for employees when they reach the age of 50. The teachers, who include a range of consultants and experienced discussion-group leaders, cover five main topics-personal adjustment, health, work and leisure, living arrangements, and finance. The response has been good, and it is planned to provide short refresher courses each class
towards retirement. different scheme is being run by rather Glasgow Council and the education authority. Retirement Glasgow Each course consists of seven weekly meetings which cover the same main topics as the Birmingham syllabus, but there are also introductory lectures to such subjects as gardening, angling, and musical appreciation and drama. Several firms have agreed to release elderly employees for one day each week so that they can attend the course, in the same way as apprentices are released for study. The retirement courses are run by experts and tutors, and reports on the experiment are very encouraging. as
In
moves a
A third
approach has been tried by Dr. 1. M. RICHARDAberdeen. An evening class, sponsored by the education authority and the university department of extramural studies, was advertised in the newspaper. Anyone within ten years of retiring was invited to attend a series of five meetings. 21 people enrolled, mostly proSON at
fessional men and women who had either just retired or The lecturewere within a few years of doing so. discussions covered such subjects as reasons for retiring, the effects of retirement on income, status, and health, the gains of retirement, the meaning of adjustment to retirement and the factors that hinder and help it, and the different aspects of preparation-economic, medical, social, and psychological. A questionary was sent to those taking part in order to find out their opinions on the value of the course, and a follow-up is planned.
Several other schemes are under way. In Birmingham, for instance, as the result of a survey made by the Lord Mayor’s Retirement Committee, three courses are to be held at large works in the city and two in areas where there are groups of smaller works.42 Interest seems to be spreading quickly, and it is important to try to collect more firm evidence about the effect of different kinds of course. If sound schemes really can prevent anxiety, boredom, and even depression in retirement, and if they can promote satisfaction and contentment among the retired, the medical profession should encourage middleaged and older people who need this help to accept it-if
appropriate, by personal example. 42.
FOUNDER of The Lancet and medical reformer, Thomas and his centenary is being celebrated this month at some of the places where he lived, worked, and fought. Harefield Hall, his country home from 1845 to 1846, is now the house of the residents at Harefield Hospital; and on May 7 Mrs. E. Daniels, chairman of the Harefield and Northwood Hospital Management Committee, presided at a ceremony of remembrance. Dr. Charles Brook, who has been the prime mover in the centenary celebrations, and whose Battling Surgeon is a spirited biography of Wakley, explained the purpose of the occasion; and a brief account of Wakley’s life was given by the present editor of The Lancet. Near the hospital gate is a commemorative tablet set up in 1949, and wreaths were laid there by Mrs. Daniels and by Mr. Thomas L. Wakley, the Founder’s great-grandson. A tribute that would have astonished the recipient, and pleased him particularly, was paid at the monthly dinner of the Royal College of Surgeons on May 9. Making this a Wakley occasion, Sir Arthur Porritt, the president, spoke of some of the issues raised in Wakley’s long campaign against the college authorities, and some of its exciting events-including the time when Wakley headed a protest meeting of members held at the end of a Hunterian oration and was forcibly dislodged by Bow Street runners. Showing the large company the portrait of Wakley (reproduced on p. 1061) which he had borrowed for the evening from the Lancet office, the President described him as belligerent but a man of ideas, who in retrospect could be seen to have done nothing but good to the college. The further celebrations will be on Saturday, May 19, at Membury in Devon, where Wakley was born, and on May 24 at 35 Bedford Square, London, which was his town house for so many years.
Wakley died on May 16, 1862;
1962.
STUDENT HEALTH IN BELFAST
Annotations THOMAS WAKLEY
Birmingham Post, April 16,
THE student health service at the Queen’s University of Belfast is well known. Not only does it provide medical and psychiatric advice and treatment but it welcomes visitors from Great Britain and abroad. Three of the new student health services formed within the past three or four years are using the Queen’s service as a pattern. An even more remarkable tribute is the fact that, during the fourteen years of its existence, there has been no defaulter, either in the compulsory annual chest X-ray or in the
compulsory medical examination. The past year saw a large increase in every branch of the service 1-partly because of the greater number of students and partly because more and more of them are making use of it. This was particularly evident in the number seeking help because of psychiatric illnesses. The incidence of mental ill health among students at Queen’s is relatively low at rather under 5%, and Dr. Wilson Johnston, who has charge of the service, points out that it is not over the diagnosis of major psychiatric illnesses that university officers are apt to differ but rather over the minor psychiatric casualties, of which pre-examination anxiety is by far the
commonest.
Dental defects have also shown a steady increase over the past few years, until it has now become the exception to find a freshman with a full set of healthy teeth. The majority have already multiple fillings and extractions, while dentures, partial or complete, are no longer uncommon. The report says that, since dental hygiene is on the whole good, the cause must lie elsewhere. The accepted view that diet plays the most important part in dental health is confirmed once more by the finding that students living in rural areas and reared on basic foods have by far the better teeth. It is also interesting to note that dental caries in any form was comparatively rare among the foreign students. 1.
Queen’s University of Belfast, Student Health Committee: report ofof medical officer for 1960-61.
resorted to after careful clinical and biochemical observation and aspiration liver-biopsy, and when the procedure be followed by operation within three hours. Two types of such cholestatic drug jaundice are recognised, the one attributable to hypersensitivity and the other not. Chlorpromazine jaundice 32 is an example of the hypersensitivity group, and an essentially similar by some other phenothiazine picture is produced derivatives.33 14 Frank jaundice may be anticipated in about 1% of those taking the drug; it usually develops during the first month, and may be heralded by leucopenia, eosinophilia, drug fever, and drug rash. Hypersensitivity is also suggested when the jaundice follows a single dose or one day’s treatment; it may recur when the drug is taken on a subsequent occasion. Chlorpromazine-type jaundice has been noted, too, in can
increasingly popular, it is as well to peculiar effect on the excretory capacity of the liver, and in particular on bromsulphthalein excretion. Otherwise the finding of this biochemical evidence of hepatic dysfunction inthe absence of
properties
become
remember their
clinical evidence of liver disease may lead to the unforpatient being warned about- his health and on placed a rigid " liver regimen ". Unlike chlorpromazine toxicity, which seems to be an allergic reaction to a small dose in the hypersensitive host, steroidal toxicity is a straightforward consequence of dosage and duration of administration. Perhaps the agent which will be used for the longest periodsnamely, over the childbearing years of life-is the new oral contraceptive, norethynodrel, a C17-alkylated C19 steroid. This has already been reported to cause bromassociation with arsphenamine, p-aminosalicylic acid, sulphthalein retention,40 and time will show whether it thiouracil, chlorpropamide, cetylurea, and carbasone.33 can produce cholestatic jaundice. Any organisation Unlike the hepatitis of the monoamine-oxidase inhi- responsible for the widespread dissemination of the bitors, clinical recovery can be confidently anticipated pill" would be wise to include tests of bromsulphthalein in time, although this may take up to three years.35 excretion in its surveys, certainly until all doubt on this Thus the patient can be reassured with confidence-an point has been dispelled. Meanwhile, the pill " should important point in managing those with the types of not be overlooked when the medicine-chest is scrutinised personality which originally needed the phenothiazine for potentially icterogenic drugs. tunate
"
"
drugs. Acute cholestatic drug jaundice also complicates treatment with methyltestosterone and related derivatives 33; but this differs from chlorpromazine jaundice in two respects. There is no evidence that the toxic effects are due to hypersensitivity, which would confine such effects to the 1% of susceptible individuals; instead, most of those receiving enough of the drug for long enough will develop bromsulphthalein retention,3s-3s if not frank cholestatic jaundice. Secondly, although the clinical picture is essentially the same, there are histological differences : the liver lesion is that of simple cholestasis, with slight hepatocellular changes; there is neither the portal-zone cellular reaction nor the eosinophilia which point to an allergic reaction.39 Besides methyltestosterone, steroids reported to cause this type of jaundice have alkyl substitution at the carbon-17 position of the steroid nucleus. Such substitution also provides a group of compounds which are active when taken by mouth. The importance of C17K-alkyl substitution, both in the pathogenesis of cholestasis and in conferring oral activity, sheds light on the old problem of why methyltestosterone is, and testosterone propionate is not, icterogenic. The latter, which is given by injection, does not carry this steroidal configuration. Likewise, nandrolone, which differs from most of the other commonly used nonvirilising anabolic steroids, is given by injection, does not seem to cause cholestasis, and does not have the C17 alkyl substitution. As these orally active anabolic nor-steroids with reduced virilising action or with potent progestational Hollister, L. E. Amer. J. Med. 1957, 23, 870. Popper, H., Schaffner, F. Ann. intern. Med. 1959, 51, 1230. Hollister, L. E. ibid. 1958, 49, 17. Read, A. E., Harrison, C. V., Sherlock, S. Amer. J. Med. 1961, 31, 249. 36. Kory, R. C., Bradley, M. H., Watson, R. N., Callahan, R., Peters, B. J. ibid. 1959, 26, 243. 37. Wynn, V., Landon, J., Kawerau, E. Lancet, 1961, i, 69. 38. Wernze, E. German med. Mon. 1962, 7, 78. 39. Popper, H., Schaffner, F. J. Amer. med. Ass. 1959, 169, 1447.
32. 33. 34. 35.
Preparation
for Retirement
RETIREMENT from work is a 20th-century institution. More older people, mechanisation, pensions and superannuation, and a new philosophy of leisure are all reasons why the number of retired men and women has risen steadily. If current trends continue, by 1980 more than 3 out of every 4 people over sixty-five will be retired. Is retirement " the roleless period " that some writers have described ? Do many retired people find acceptable substitutes for work, and what kind of guidance is offered to those who do not ? Questions of this kind are being asked more and more by men and women who have begun to realise that some advance thinking is a better approach to retirement than blind refusal to prepare for the break from work. Of course, many people make a success of retirement and adjust themselves happily to their new leisure. The reasons for this are sometimes obvious: release from an uninteresting job and an
absorbing hobby; a move to pleasanter surroundings or nearer to kin; freedom to stroll, observe, read, or help in the home. But what about the others who find they have retired to nothing, whose thoughts dwell often and nostalgically on what they have retired from-the wage or salary, the companionship of work, the status ? These are the people who enter retirement unprepared either to cut its losses or exploit its gains. To help them to acquire well in advance a realistic understanding of its true meaning schemes of preparation have been started in this country and America, and Dr. ALASTAIR HERON has lately reviewed their origins, development, and programmes.41 an 40. 41.
The first in this country was started four years ago in engineering firm in Birmingham. Six weekly discussion Marquardt, G. H., Fisher, C. I., Levy, P., Dowben, R. M. ibid. 1961, 175, 851. Heron, A. Preparation for Retirement, Solving New Problems. 1961. Obtainable from the National Council of Social Service, 26, Bedford Square, London, W.C.1. 2s. 6d.
1058
meetings (and a weekend gathering to which wives are invited) are held for employees when they reach the age of 50. The teachers, who include a range of consultants and experienced discussion-group leaders, cover five main topics-personal adjustment, health, work and leisure, living arrangements, and finance. The response has been good, and it is planned to provide short refresher courses each class
towards retirement. different scheme is being run by rather Glasgow Council and the education authority. Retirement Glasgow Each course consists of seven weekly meetings which cover the same main topics as the Birmingham syllabus, but there are also introductory lectures to such subjects as gardening, angling, and musical appreciation and drama. Several firms have agreed to release elderly employees for one day each week so that they can attend the course, in the same way as apprentices are released for study. The retirement courses are run by experts and tutors, and reports on the experiment are very encouraging. as
In
moves a
A third
approach has been tried by Dr. 1. M. RICHARDAberdeen. An evening class, sponsored by the education authority and the university department of extramural studies, was advertised in the newspaper. Anyone within ten years of retiring was invited to attend a series of five meetings. 21 people enrolled, mostly proSON at
fessional men and women who had either just retired or The lecturewere within a few years of doing so. discussions covered such subjects as reasons for retiring, the effects of retirement on income, status, and health, the gains of retirement, the meaning of adjustment to retirement and the factors that hinder and help it, and the different aspects of preparation-economic, medical, social, and psychological. A questionary was sent to those taking part in order to find out their opinions on the value of the course, and a follow-up is planned.
Several other schemes are under way. In Birmingham, for instance, as the result of a survey made by the Lord Mayor’s Retirement Committee, three courses are to be held at large works in the city and two in areas where there are groups of smaller works.42 Interest seems to be spreading quickly, and it is important to try to collect more firm evidence about the effect of different kinds of course. If sound schemes really can prevent anxiety, boredom, and even depression in retirement, and if they can promote satisfaction and contentment among the retired, the medical profession should encourage middleaged and older people who need this help to accept it-if
appropriate, by personal example. 42.
FOUNDER of The Lancet and medical reformer, Thomas and his centenary is being celebrated this month at some of the places where he lived, worked, and fought. Harefield Hall, his country home from 1845 to 1846, is now the house of the residents at Harefield Hospital; and on May 7 Mrs. E. Daniels, chairman of the Harefield and Northwood Hospital Management Committee, presided at a ceremony of remembrance. Dr. Charles Brook, who has been the prime mover in the centenary celebrations, and whose Battling Surgeon is a spirited biography of Wakley, explained the purpose of the occasion; and a brief account of Wakley’s life was given by the present editor of The Lancet. Near the hospital gate is a commemorative tablet set up in 1949, and wreaths were laid there by Mrs. Daniels and by Mr. Thomas L. Wakley, the Founder’s great-grandson. A tribute that would have astonished the recipient, and pleased him particularly, was paid at the monthly dinner of the Royal College of Surgeons on May 9. Making this a Wakley occasion, Sir Arthur Porritt, the president, spoke of some of the issues raised in Wakley’s long campaign against the college authorities, and some of its exciting events-including the time when Wakley headed a protest meeting of members held at the end of a Hunterian oration and was forcibly dislodged by Bow Street runners. Showing the large company the portrait of Wakley (reproduced on p. 1061) which he had borrowed for the evening from the Lancet office, the President described him as belligerent but a man of ideas, who in retrospect could be seen to have done nothing but good to the college. The further celebrations will be on Saturday, May 19, at Membury in Devon, where Wakley was born, and on May 24 at 35 Bedford Square, London, which was his town house for so many years.
Wakley died on May 16, 1862;
1962.
STUDENT HEALTH IN BELFAST
Annotations THOMAS WAKLEY
Birmingham Post, April 16,
THE student health service at the Queen’s University of Belfast is well known. Not only does it provide medical and psychiatric advice and treatment but it welcomes visitors from Great Britain and abroad. Three of the new student health services formed within the past three or four years are using the Queen’s service as a pattern. An even more remarkable tribute is the fact that, during the fourteen years of its existence, there has been no defaulter, either in the compulsory annual chest X-ray or in the
compulsory medical examination. The past year saw a large increase in every branch of the service 1-partly because of the greater number of students and partly because more and more of them are making use of it. This was particularly evident in the number seeking help because of psychiatric illnesses. The incidence of mental ill health among students at Queen’s is relatively low at rather under 5%, and Dr. Wilson Johnston, who has charge of the service, points out that it is not over the diagnosis of major psychiatric illnesses that university officers are apt to differ but rather over the minor psychiatric casualties, of which pre-examination anxiety is by far the
commonest.
Dental defects have also shown a steady increase over the past few years, until it has now become the exception to find a freshman with a full set of healthy teeth. The majority have already multiple fillings and extractions, while dentures, partial or complete, are no longer uncommon. The report says that, since dental hygiene is on the whole good, the cause must lie elsewhere. The accepted view that diet plays the most important part in dental health is confirmed once more by the finding that students living in rural areas and reared on basic foods have by far the better teeth. It is also interesting to note that dental caries in any form was comparatively rare among the foreign students. 1.
Queen’s University of Belfast, Student Health Committee: report ofof medical officer for 1960-61.