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THE THRESHOLD OF AGE
[MAY 15,
THE THRESHOLD OF AGE
These efforts into
JAMES M. MACKINTOSH M.A., M.D., LL.D. Glasg., F.R.C.P., F.R.C.P.E.
SOCRATES : " To tell you the truth, Cephalus, I am very fond of conversation with elderly folk. They have gone before us on the road over which perhaps we also shall have to travel and I think we ought to try to learn from them what the road is like-whether rough and difficult or smooth and easy. And now that you have arrived at that period of life which poets call ’the threshold of age,’ there is no-one whose opinion I would more gladly ask." PLATO : The Republic. Book I. one
of the most
In the same period the total population has gone up from thirty-three million to fifty, and by 1980, it is estimated, a fifth of us will be of pensionable age. Hence it is not surprising that we have become conscious of the social and economic embarrassments of old age. We can no longer afford to ignore the personal needs of the elderly, partly because there are so many of them and partly because we ourselves are vulnerable. In recent years a large number of studies have been made of the problems affecting the aged-statistical, social, economic, and clinical. In 1940 the National Council of Social Service called a group of voluntary societies engaged in helping the aged and formed a specialNational Old Peoples’ Welfare Committee " under the chairmanship of Eleanor Rathbone. Voluntary bodies are always in the van of social effort. It soon became evident that the most pressing need was for investigation. Accordingly in 1944 the Numeld Foundation appointed a survey committee to study the social and medical aspects of the ageing process, and the work already undertaken by public authorities and voluntary bodies. This committee reported in 1946.1 An early result of this movement was the establishment, by the Foundation, of the National Corporation for the Care of Old People: In the medical sphere one of the most striking surveys was that of Dr. J. H. Sheldon, of Wolverhampton.2 Especially valuable also was the pioneer work by the late Noah Morris in Glasgow, the clinical observations by Dr. Marjory Warren, and the statistical studies of McKeown and Lowe in
together
Birmingham.
Research had to be directed towards the maintenance of health and productivity beyond the normal threshold of age. 1. Old People: Report of a Survey Committee on the Problems of Ageing and the Care of Old People, under the chairmanship of B. Seebohm Rowntree. LL.D. London, 1946. 2. The Social Medicine of Old Age : Report of an inquiry in Wolverhampton. London, 1948.
6820
(3)
retirement. To develop means of preventing, or at least stabilising, the chronic diseases and disabilities which tend to speed
(4)
up the ageing process. To develop methods of rehabilitation after among the elderly so as to bring them back as as
possible
into " normal circulation."
illness
quickly
On the psychological and educational side much work has still to be done on the maintenance of morale-e.g., as regards clean habits, proper methods of preparing and eating food, pride in clothes, and so on—and also to break down public prejudices about the elderly so as to induce more favourable attitudes among employers, the community, and the elderly themselves. Some encouraging clinical facts have been brought to light by Sheldon, Morris, Marjory Warren, and others. In the Wolverhampton survey,2 for example, in which old people in their own homes were the primary subjects of study, it was shown that only 3% were undernourished, and only 25% of 450 persons of over sixty-five were bedridden : at sixty only 28% were receiving medical care ; and though at eighty-five years and upwards the percentage rose to 43, at the age of seventy about 30% neither sought nor required medical attention. No very elaborate tests of mental capacity were carried out by Sheldon, and indeed the whole subject of mental testing needs further thought and study ; but he found that more than 75% needed no supervision from the mental point of view. A few were eccentric but harboured only gentle bats in the belfry-little furry things that hang upside down. There was another side to the picture, partly coloured by physical disability. 40% had difficulty with stairs and general trouble in movement ; 40% had foot trouble of some severity, two women to every man. (This tells a tale ; is it Mistress Fashion or overmuch standing-or both ? In this respect a woman is probably at a disadvantage compared with a man because she may have to stand all day at a bench and then does not get an opportunity of putting, her feet up on the mantelpiece when she returns home.) Rheumatism affected more than 55%, mainly in painful and creaking joints. 80% needed dentures and 60% wore them. 40% were worried with respiratory conditions, mainly bronchitis. At that time, before the National Health Service Act had swung into full operation, over 30% of elderly people were wearing bad or useless glasses and no less than 17-5% of their glasses had been obtained " by gift or
inheritance." The Threshold
These
investigations aroused for the first time a sense of urgency, and a feeling of social and medical responsibility ; a national health service cannot ignore the welfare, housing, and other needs of five million people. At the same time it became clear to scientific investigators that social and economic planning for the aged was not enough ; we needed more knowledge of the biology of ageing so that we could take effective delaying action.
began gradually to resolve themselves public-health project in four essential phases :
To learn more about the normal health needs of ageing people-e.g., in terms of diet, rest, recreation, and the physical effects of mental and manual work. (2) To study the question of how best to prepare for the period of age-to enable people to make adjustments early and so proceed by easy gradations to the years of
IN THE UNIVERSITY OF LONDON AT THE LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE
IN the field of health and welfare
a
(1)
PROFESSOR OF PUBLIC HEALTH
striking changes in the short span of two generations in the United Kingdom is the increased number of the elderly members of the community. This simple table gives quite a vivid picture of the situation ; it shows three age-groups and the percentage changes that have taken place between 1891 and 1951 :
1954
Much of the research into the problems of old age has been obscured by a lack of division into categories. We should not think of lumping together in a single syllabus of education the infant, the school child, and the adolescent ; in old age a similar grouping holds good in reverse. So many of our guides have drawn no distinction between a person who reaches the fixed point of sixty-five while, still in the full tide of his activity, the senior who is. becoming garrulous and repetitive, and the doddering ancient. We are faced with the process of decline and most of’ its incidents. Of course one finds precocious senescence:, there be some have an over-early ripeness in their years, which fadeth betimes " ; and on the other hand the "
992 decline may be long delayed. A few may burn brightlier toward their setting day. For these reasons among others I have confined my subject to the threshold of age. At this critical time we may discern some special requirements : firstly, the wish to retain independence as long as possible; secondly, the need to feel of use as long as possible ; thirdly, the need to be ready for retirement and adjusted to it long before the actual event. The portrait of a man or woman at the retiring age varies greatly ; in its more vivid colours it presents those who are still in the active habit of life and look forward with zest to a new world of interest. An excellent example of this was Sir Harold Stiles, who gained distinction in geology after having made the splendid contributions of a lifetime to the art of surgery. At the other end we have the drab picture of a man who has made no preparation, has no inward interests : his retirement leads to a desert of loneliness; he shrinks mentally and even physically when the blow falls. The study of the threshold of age is of immediate practical value ; in the clinical field, at any rate, excellent progress has been made by showing that many crippled and even bedridden folk can be put on their feet again and helped to live useful lives. Nevertheless rehabilitation, valuable as it is, must be regarded as a form of therapy. When we come to examine the retiring age, our minds should be directed towards the prevention of disability, or at least postponement of the wearing-out process. In our present economic stresses we cannot afford to waste the talents and working capacities of any type of worker; we have to face the practical issue of how to maintain productivity without interfering with either the economic structure of our working society or the reasonable prospects of younger people. During the past year or two there have been several important publications concerned with the elderly
worker, notably The Employment of Elderly Workers,
based on the practice and experience of 400 member firms of the Industrial Welfare Society, and Older People and their Employment, by G. Thomas and B. Osborne, published by the Social Survey. These reports should be consulted by those who wish to study the figures and the details of the investigation. I can deal only with the outstanding features of the landscape. The Fixed
Retiring Age
point to note is the remarkable decline in the employment of men over sixty between the years 1945 and 1951. Whereas for women there was practically no change, the proportion of men between sixty and seventyfive who were still at work fell from 44% to 30%. The first
Compared with the general population, fewer men retiring age were manipulative workers and opera-
over
staffs or came into workers. The Social Survey made a distinction between those working in the larger firms (with more than 9 employees) and those working for smaller firms or self-employed. In the larger firms superannuation schemes are becoming increasingly common, and many of them provide for senior executive staff as well as for workers. Such a scheme enables employers to feel that they have made provision for all employees at the retiring age, and at the same time it gives a greater control over the elderly worker. But the insurance company becomes the arbiter of the worker’s destiny, and a new pattern of employment is emerging. The existence of a superannuation scheme tends to hold younger workers at their job, so that they may retain benefits of insurance, but it tends to operate against workers over forty-five who wish to enter a particular employment for the first time. The fixed retiring age has now extended widely beyond the full-time professional group and is an accepted policy in many industrial firms. It is also spreading into smaller
tives, and the
more were on
managerial
category of unskilled
firms. In the Social Survey it was shown that some 37% of the larger firms had established a definite retiring age and 33% had superannuation schemes. In smaller firms the figure had reached about 14%. The result of this is an increasing pressure to retire at a fixed age and greater economic security in retirement. Of those working in firms that had established a retiring age it was found that about half the workers would have preferred to stay on beyond that period: With a superannuation scheme Without a superannuation scheme
..
..
..
..
42% 52%
It is clear that economic factors played a part in the wishes thus expressed. About half the men and women in full and part-time work said that they worked because they must ; 40% of men and 30% of women said that they were obliged to work but at the same time preferred it to idleness. The remainder simply said that they preferred work. Nearly two-thirds of the men in full or part-time employment said that they intended to go on working for as long as they could ; ill health seemed to be the most likely bar to continuing employment. Waste of Potential Workers
In the Industrial Welfare Society pamphlet it was shown that the proportion of male elderly workers (compared with all workers) employed was
This indicates that the potential sources of labour are not being used today so effectively as in 1945. The factors which act against working beyond pensionable age. are stated to be : (1) that the higher National Insurance pension at seventy for those who continue working is hardly worth the effort ; (2) the growing feeling of being unable to compete with younger men; (3) the alleged resentment of younger men to the older people who block promotion ; and (4) the whole sense of diminished physical capacity, the fear of having to learn a new job, and the desire for leisure. On the other hand many workers want to go on working because they dread the loneliness of retirement or because they desire to remain useful members of society. Employers as well as workers had some doubts about the economic value of postponed retirement. There was the fear of increasing accident-rates and of diminishing attendance at work; embarrassment about the trade-union attitude; and considerable doubt as to what work was appropriate for the ageing worker. Unless the employer had very strong feelings about his duty towards older people he was disinclined to face these problems. The survey dealt with 400 member firms, employing 260,000 men and 87,000 women. In the total sample of workers elderly men counted for 2.7% and women for 2%; a distinction made between small, medium, and large firms showed a higher proportion of elderly workers in the small firms. This is to be expected partly because of the higher proportion of pension schemes in the larger industries and partly because of the more intimate relations between the workers and the management in the smaller groups. The general findings about superannuation policy agreed on the whole with those of the Social Survey that schemes were more common in the larger firms, thus leading to a bias in favour of compulsory retirement. They also eased some of the economic difficulties which lead men to continue work. There is some disquieting evidence that the spread of pension schemes has a tendency to encourage premature retirement. The existence of a scheme lends force to the feeling of both management and workers that the elderly man will step down at about sixty-five years of age. The firm has little incentive to look further into the matter and try to create jobs for older men or to adjust existing processes to suit the slower pace of the elderly worker.
993 It is difficult to
assess
the
feeling
of the
elderly worker
himself towards retirement. What I tell you at the age of sixty-three about my future may be entirely different from my opinion a few months before actual retirement at sixty-five. I am ready to urge an early retiring age so long as I feel that the elders stand in the way of my promotion ; my view will be sharply modified when I myself become the obstruction. Again, I may have felt that I needed a rest and so looked forward to retirement, but when the time comes and a few weeks or months have gone by, I may well take the view of Elia: I am Retired I am no longer ... clerk to the Firm of, &c. "
gardens. I am already come to be known by my vacant face and careless gesture, perambulating at no fixed pace nor with any settled purpose. I walk about; not to and from. They tell me, a certain cum dignitate air, that has been buried so long with my other parts, has begun to shoot forth in my person. I grow into gentility perceptibly. When I take up a newspaper, it is to read the state of the opera. Opus operatum est. I have done all that I came into this world to do. I have worked task-work, and have the rest of the day to myself." CHARLES LAMB, Last Essays of Elia. Leisure. I
am
to be met with in trim
Alternatives to Enforced Leisure
We must now turn to another aspect of the retiring age and try to discover if there are any appropriate alternatives to enforced leisure. Let us assume that we are dealing with a manual worker who when he reached the age of retirement had been employed on work at which with his increasing skill he has become dexterous. If the firm, as is often the case, has a rigid rule about the age of retirement, it is unlikely that the workman will be able to secure alternative employment that complies with the simple, desirable conditions of continued satisfaction. The essentials of a good retirement job can be set down as follows:
(1) (2)
(3)
The The
job should be paid. job should be on a part-time basis (becoming, if possible, gradually less onerous with increasing years) or should be lighter in the sense of relieving physical strain or, what is more important, slowing the pace.3 The job should be on a mental level not substantially less than his previous work. We do not wish to draft thousands of intelligent workmen to inferior duties which give them no real satisfaction. A job should be such as to offer interest and stimulation and avoid
monotony.
(4)
The worker should be prepared to cooperate in simple and effective tests of his mental and physical capacity and, if necessary, undergo a course of training for new
employment. The selection of
an
elderly
man
for his
new
job
should be
based on his positive capacities and not on a list of disabilities. If the question of retirement were merely a matter of years there would be little room for argument; but, just as the child has special characteristics and aptitudes, so too have the aged their special features. We should look at these positively, as we do with a disabled person, and our interest must be directed towards discerning what the man or woman of pensionable age can still do well, perhaps better than his juniors. Rough tests have been devised from time to time to determine the capacity of the ageing as the years go by, but so far there has been little attempt at accurate ascertainment, as in childhood and adolescence. What a glorious field for the psychologist ! I am not for a moment suggesting that these tests of capacity would be easy to devise or to put into 3. " Within the limits of our sample, however, it was clear that older people tended to be found doing work where there was an absence of time-stress—in other words, work which could be done at their own pace, unhurried by pressure for speed, and where there was opportunity for accuracy to be displayed to advantage." From Skill and Age : an Experimental Approach by A. T. Welford and colleagues at the Nuffield Research Unit into Problems of Ageing. London, 1950; p. 144.
use ; many of them perhaps will have to be applied not to the worker in relation to a job but rather to the circumstances of his everyday life. Amongst professional people the trouble often is that the adult is so much more sophisticated than the child and at a personal interview he knows so many of the answers, at least verbally. We may be driven to the kind of tests put forward by Bacon : "
Men of age object too much, consult too long, adventure too little, repent too soon, and seldom drive business home to the full period, but content themselves with a mediocrity of
success."
Another useful kind of test is to compare present accomplishments with the work of the past. Sometimes the thought and speech of the ageing betray them. I always listen carefully to the man who says : "I am as good a man as ever I was," for that is one of the first symptoms of declining mental powers. The dear man has begun to whistle in the growing intellectual dusk. I suspect that Dr. Johnson was one of my examples. He had been to dinner with Allan Ramsay, who was about sixty-five years of age at that time-and then Boswell takes up the story : " Next day, Thursday, April 30, I found him at home by himself. JOHNSON:’Well, Sir, Ramsay gave us a splendid dinner. I love Ramsay. You will not find a man in whose conversation there is more instruction, more information, and more elegance, than in Ramsay’s.’ BOSWELL:’What I admire in Ramsay, is his continuing to be so young.’ JOHNSON : ’Why, yes, Sir, it is to be admired. I value myself upon this, that there is nothing of the old man in my conversation. I am now sixty-eight, and I have no more of it than at twentyeight.’ 130SWELL:But, Sir, would you not wish to know old age ? He who is never an old man, does not know the whole of human life ; for old age is one of the divisions of it.’ JoHNSON : ’Nay, Sir, what talk is this ? ’ BOSWELL:II noon, and I would know night, as well as morning and noon.’ JOHNSON:What Sir, would you know what it is to feel the evils of old age ? Would you have the gout ? Would you have decrepitude ? ’-Seeing him heated, I would not argue any farther ; but I was confident that I was in the right." mean,
Sir, the Sphinx’s description of it ; morning,
night.
Compulsory
Retirement
We must now consider the desirability of a compulsory age ; and here some distinction must be made between those employed mainly in physical labour and those engaged in professional work making heavy demands on the mind. For the manual worker a retiring age is desirable if only as a fixed period for the consideration of physical and mental capacity. Obviously there is nothing physiologically significant about the sixty-fifth birthday ; it is just a matter of convenience. A good pension scheme ought to permit of considerable latitude about the age of retirement, say between sixty and seventy. This would encourage the stronger man to continue work without at the same time forcing the weaker to engage in competition beyond his physical powers. It is easy to convince oneself that the brain matures with age but even the most gullible will not deny that the suitcase becomes heavier. The man himself benefits by continuing his work beyond the retiring age partly from financial gain and partly because he is presumably doing something that gives him satisfaction. The community benefits because, to some extent, it gathers the fruits of his labour. The important thing to remember is that the man himself must not be the arbiter ; unless we accept, and he accepts, a dispassionate, independent assessment of his capacities, physical and mental, we shall go not one inch further towards a reasonable plan for retirement. In the case of the professional worker who is mainly dependent on his mental powers the picture is different. The older man may find that his output is increasing with age and it is natural that he should mistake this for wisdom, since the tongue is perhaps the only organ of the
retiring
994
body that is not slowed down by advancing years. Physsuffering is endured ; mental infirmity is enjoyed. Indeed perhaps the greatest difference between the
ical
manual and the mental worker is the capacity for the latter to do harm. It is a sobering thought that the product of manual labour is mostly good, whereas the results of mental exertion may be disastrous. By the time the mental worker reaches retiring age he is often in a position of authority where his opportunities for doing ill are extensive ; as a rule there is no-one in a position to tell him to go home. One might suggest therefore that a retiring age for professional people should be compulsory ; the difficulty to be solved by mental health experts is what age should be chosen. At any rate, as Dr. Johnson said : There is no state more contrary to the dignity of wisdom "
perpetual and unlimited dependence, in which understanding lies useless, and every motion is received from
Influence of pH The striking difference
MATERIALS AND METHODS
than
external
impulse."
RESISTANCE OF THE BREAST-FED INFANT TO GASTRO-ENTERITIS CONSTANCE A. C. Ross M.D.
*
Glasg.
RESEARCH ASSISTANT, UNIVERSITY DEPARTMENT OF INFECTIOUS DISEASES, AND KNIGHTSWOOD HOSPITAL, GLASGOW
E. A. DAWES B.Sc., Ph.D. Leeds, A.R.I.C. LECTURER IN BIOCHEMISTRY IN THE UNIVERSITY OF GLASGOW
generally recognised that breast-fed babies are relatively resistant to gastro-enteritis (Levi 1941, Alexander 1948). The predominance of Lactobacillus 6t/M-Ms in the stools of the suckling might suggest that IT is
the intestinal environment of the breast-fed infant is unfavourable to the establishment of Escherichia coli, particularly the types associated with infantile gastroThe experiments described here were an enteritis. to attempt study some of the features of the intestinal environment of the infant in relation to the growth of Esch. coli. The Experiments GENERAL PLAN
3letabolic Products in the Tntest’inal 1ract Previous study had shown that there is a qualitative difference in the faecal excretion of amino-acids by the breast-fed infant and by the artificially fed baby (Ross 1951). This suggested that certain amino-acids might either stimulate or inhibit the growth of these types of Esch. coli. An investigation of the growth of a laboratory strain of Esch. coli NCTC5928 on single aminoacids as the sole source of nitrogen in a glucose-salt medium (Dawes 1952) was now extended to certain types of Esch. coli associated with infantile gastro-enteritis. Several investigators have found that a single aminoacid added to a medium otherwise capable of supporting growth may inhibit growth, but that this effect can be presented by the simultaneous presence of certain other amino-acids (Gladstone 1939, Porter and Meyers 1945, Davis and Maas 1949). A study of the growth of different types of Esch. coli on single amino-acids would therefore be of limited value in assessing their ability to grow in the complex mixture of amino-acids present in the intestines of infants. To overcome this difficulty the growth of these organisms was studied in sterile f,4--cal extracts from artificially fed babies, breast-fed babies, and babies with gastro-ellteritis associated with a specific type of Esch. coli. This experiment enabled the growthpromoting effect not only of the amino-acids but also of all the metabolic products in the faeces to be assessed. *
Now working at
the Children’s Hospital, Birmingham, 16.
’
between the pH of the faeces of breast-fed infants and of infants fed on preparations of cow’s milk is well known (Tisdall and Brown 1924, Ross 1951). It therefore seemed relevant to study the pH of the stools in infantile gastro-enteritis and the influence of pH on the growth of these types of Esch. coli in vitro. Dagley et al. (1953) .found that, with Esch. coli in glucose-ammonium sulphate medium, low pH values alone could not account for the cessation of growth, and thought that certain products of metabolism might exert a toxic effect. In particular they showed that formic acid, which is produced during the growth of EI’!f’.h. coli, increased rapidly in toxicity as the pH value decrease d. The organisms used in the investigations were three type strains of Esch. coli (0-111, 0.55, and 0-26) obtained from the State Serum Institute, Copenhagen, and an untypable strain of Esch. coli from a healthy artificially
fed infant. Growth with The
Single Amino-acids
as
Sole Source
of Nitrogen
medium contained potassium dihydrogen phosphate 5-4 g., glucose 12g., magnesium sulphate (MgSO4’ 7H2O) 0-4 g., and either ammonium sulphate 1-2 g. or the required amino-acid 0-6 g., and made up to 1 litre with glassdistilled water and adjusted to pH 7-1. The medium was distributed in 25-ml. amounts in’Pyrex ’ boiling tubes (6 x 1 in.) previously cleaned by boiling with nitric acid and washing with glass-distilled water. The growth of Esch. coli was studied by the method described by Dagley et al. (1950). Bacteria for inoculation were prepared by three serial subcultures in glucoseammonium-sulphate media ; 0.ml. of the third culture, taken at the onset of the stationary phase, was used as inoculum. The tubes were incubated at 37°C without aeration because this would approximate more nearly to the conditions obtaining in the intestines. Samples of about 2 ml. of the growing culture were withdrawn with a Pasteur pipette and killed by the addition of 2 drops of formalin. Bacterial growth during culture was estimated turbidimetrically with a Spekker photo-electric absorptiometer (filters H508 and OB2) calibrated to convert turbidity readings into bacterial counts obtained with a haemoeytometer.
growth
G/-OM’//i in Sterile Focal Extracts As our first purpose was to assess the effect produced on growth by the faecal extracts, independently of their natural pH, phosphate buffer containing potassium dihydrogen phosphate 9 g. and 5N sodium hydroxide 10-4 ml. per litre at a pH of 7-1 was used as the extracting fluid. In preliminary experiments the ratio of fresh faeces to extracting fluid was adjusted to the dry weight of the faeces ; but it was found that the stools of the suckling were always more fluid than those of the artificially fed infant, and that the equalisation of specimens as regards dry weight often necessitated considerable dilution of the faeces of the artificially fed. Further, the test organism might not grow in this diluted extract, whereas there was good growth in an extract from the same specimen diluted on the basis of its fresh weight. We therefore decided to use equivalent weights of wet faeces from all three groups of babies in the proportion of 1 g. of fseces to 5 ml. of phosphate buffer. As sterilisation by Seitz filtration might remove not only bacteria but also some growth substances, portions of each extract were sterilised in three different ways : by Seitz filtration, by tyndallisation at a temperature of 100°C for 20 minutes on three consecutive days, and by Seitz filtration followed by tyndallisation. To 12 g. of a well-mixed specimen of faeces was added 60 ml. of phosphate buffer. This was shaken for 3 minutes and centrifuged : thereafter the supernatant fluid was divided into three aliquots for sterilisation as described above. The sterilised extracts wore then dispensed in 5-ml. portions in bijou bottles under aseptic conditions. In this set of experiments the organism used was the stock strain of E8ch. coli type 0-111, which was the type strain most often associated with our severe cases of gastro-entoritis. A subculture of the organism was made in 10 ml. of nutrient broth and incubated for ]8-24 hours at 37°C. The bacteria
THE THRESHOLD OF AGE
These efforts into
JAMES M. MACKINTOSH M.A., M.D., LL.D. Glasg., F.R.C.P., F.R.C.P.E.
SOCRATES : " To tell you the truth, Cephalus, I am very fond of conversation with elderly folk. They have gone before us on the road over which perhaps we also shall have to travel and I think we ought to try to learn from them what the road is like-whether rough and difficult or smooth and easy. And now that you have arrived at that period of life which poets call ’the threshold of age,’ there is no-one whose opinion I would more gladly ask." PLATO : The Republic. Book I. one
of the most
In the same period the total population has gone up from thirty-three million to fifty, and by 1980, it is estimated, a fifth of us will be of pensionable age. Hence it is not surprising that we have become conscious of the social and economic embarrassments of old age. We can no longer afford to ignore the personal needs of the elderly, partly because there are so many of them and partly because we ourselves are vulnerable. In recent years a large number of studies have been made of the problems affecting the aged-statistical, social, economic, and clinical. In 1940 the National Council of Social Service called a group of voluntary societies engaged in helping the aged and formed a specialNational Old Peoples’ Welfare Committee " under the chairmanship of Eleanor Rathbone. Voluntary bodies are always in the van of social effort. It soon became evident that the most pressing need was for investigation. Accordingly in 1944 the Numeld Foundation appointed a survey committee to study the social and medical aspects of the ageing process, and the work already undertaken by public authorities and voluntary bodies. This committee reported in 1946.1 An early result of this movement was the establishment, by the Foundation, of the National Corporation for the Care of Old People: In the medical sphere one of the most striking surveys was that of Dr. J. H. Sheldon, of Wolverhampton.2 Especially valuable also was the pioneer work by the late Noah Morris in Glasgow, the clinical observations by Dr. Marjory Warren, and the statistical studies of McKeown and Lowe in
together
Birmingham.
Research had to be directed towards the maintenance of health and productivity beyond the normal threshold of age. 1. Old People: Report of a Survey Committee on the Problems of Ageing and the Care of Old People, under the chairmanship of B. Seebohm Rowntree. LL.D. London, 1946. 2. The Social Medicine of Old Age : Report of an inquiry in Wolverhampton. London, 1948.
6820
(3)
retirement. To develop means of preventing, or at least stabilising, the chronic diseases and disabilities which tend to speed
(4)
up the ageing process. To develop methods of rehabilitation after among the elderly so as to bring them back as as
possible
into " normal circulation."
illness
quickly
On the psychological and educational side much work has still to be done on the maintenance of morale-e.g., as regards clean habits, proper methods of preparing and eating food, pride in clothes, and so on—and also to break down public prejudices about the elderly so as to induce more favourable attitudes among employers, the community, and the elderly themselves. Some encouraging clinical facts have been brought to light by Sheldon, Morris, Marjory Warren, and others. In the Wolverhampton survey,2 for example, in which old people in their own homes were the primary subjects of study, it was shown that only 3% were undernourished, and only 25% of 450 persons of over sixty-five were bedridden : at sixty only 28% were receiving medical care ; and though at eighty-five years and upwards the percentage rose to 43, at the age of seventy about 30% neither sought nor required medical attention. No very elaborate tests of mental capacity were carried out by Sheldon, and indeed the whole subject of mental testing needs further thought and study ; but he found that more than 75% needed no supervision from the mental point of view. A few were eccentric but harboured only gentle bats in the belfry-little furry things that hang upside down. There was another side to the picture, partly coloured by physical disability. 40% had difficulty with stairs and general trouble in movement ; 40% had foot trouble of some severity, two women to every man. (This tells a tale ; is it Mistress Fashion or overmuch standing-or both ? In this respect a woman is probably at a disadvantage compared with a man because she may have to stand all day at a bench and then does not get an opportunity of putting, her feet up on the mantelpiece when she returns home.) Rheumatism affected more than 55%, mainly in painful and creaking joints. 80% needed dentures and 60% wore them. 40% were worried with respiratory conditions, mainly bronchitis. At that time, before the National Health Service Act had swung into full operation, over 30% of elderly people were wearing bad or useless glasses and no less than 17-5% of their glasses had been obtained " by gift or
inheritance." The Threshold
These
investigations aroused for the first time a sense of urgency, and a feeling of social and medical responsibility ; a national health service cannot ignore the welfare, housing, and other needs of five million people. At the same time it became clear to scientific investigators that social and economic planning for the aged was not enough ; we needed more knowledge of the biology of ageing so that we could take effective delaying action.
began gradually to resolve themselves public-health project in four essential phases :
To learn more about the normal health needs of ageing people-e.g., in terms of diet, rest, recreation, and the physical effects of mental and manual work. (2) To study the question of how best to prepare for the period of age-to enable people to make adjustments early and so proceed by easy gradations to the years of
IN THE UNIVERSITY OF LONDON AT THE LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE
IN the field of health and welfare
a
(1)
PROFESSOR OF PUBLIC HEALTH
striking changes in the short span of two generations in the United Kingdom is the increased number of the elderly members of the community. This simple table gives quite a vivid picture of the situation ; it shows three age-groups and the percentage changes that have taken place between 1891 and 1951 :
1954
Much of the research into the problems of old age has been obscured by a lack of division into categories. We should not think of lumping together in a single syllabus of education the infant, the school child, and the adolescent ; in old age a similar grouping holds good in reverse. So many of our guides have drawn no distinction between a person who reaches the fixed point of sixty-five while, still in the full tide of his activity, the senior who is. becoming garrulous and repetitive, and the doddering ancient. We are faced with the process of decline and most of’ its incidents. Of course one finds precocious senescence:, there be some have an over-early ripeness in their years, which fadeth betimes " ; and on the other hand the "
992 decline may be long delayed. A few may burn brightlier toward their setting day. For these reasons among others I have confined my subject to the threshold of age. At this critical time we may discern some special requirements : firstly, the wish to retain independence as long as possible; secondly, the need to feel of use as long as possible ; thirdly, the need to be ready for retirement and adjusted to it long before the actual event. The portrait of a man or woman at the retiring age varies greatly ; in its more vivid colours it presents those who are still in the active habit of life and look forward with zest to a new world of interest. An excellent example of this was Sir Harold Stiles, who gained distinction in geology after having made the splendid contributions of a lifetime to the art of surgery. At the other end we have the drab picture of a man who has made no preparation, has no inward interests : his retirement leads to a desert of loneliness; he shrinks mentally and even physically when the blow falls. The study of the threshold of age is of immediate practical value ; in the clinical field, at any rate, excellent progress has been made by showing that many crippled and even bedridden folk can be put on their feet again and helped to live useful lives. Nevertheless rehabilitation, valuable as it is, must be regarded as a form of therapy. When we come to examine the retiring age, our minds should be directed towards the prevention of disability, or at least postponement of the wearing-out process. In our present economic stresses we cannot afford to waste the talents and working capacities of any type of worker; we have to face the practical issue of how to maintain productivity without interfering with either the economic structure of our working society or the reasonable prospects of younger people. During the past year or two there have been several important publications concerned with the elderly
worker, notably The Employment of Elderly Workers,
based on the practice and experience of 400 member firms of the Industrial Welfare Society, and Older People and their Employment, by G. Thomas and B. Osborne, published by the Social Survey. These reports should be consulted by those who wish to study the figures and the details of the investigation. I can deal only with the outstanding features of the landscape. The Fixed
Retiring Age
point to note is the remarkable decline in the employment of men over sixty between the years 1945 and 1951. Whereas for women there was practically no change, the proportion of men between sixty and seventyfive who were still at work fell from 44% to 30%. The first
Compared with the general population, fewer men retiring age were manipulative workers and opera-
over
staffs or came into workers. The Social Survey made a distinction between those working in the larger firms (with more than 9 employees) and those working for smaller firms or self-employed. In the larger firms superannuation schemes are becoming increasingly common, and many of them provide for senior executive staff as well as for workers. Such a scheme enables employers to feel that they have made provision for all employees at the retiring age, and at the same time it gives a greater control over the elderly worker. But the insurance company becomes the arbiter of the worker’s destiny, and a new pattern of employment is emerging. The existence of a superannuation scheme tends to hold younger workers at their job, so that they may retain benefits of insurance, but it tends to operate against workers over forty-five who wish to enter a particular employment for the first time. The fixed retiring age has now extended widely beyond the full-time professional group and is an accepted policy in many industrial firms. It is also spreading into smaller
tives, and the
more were on
managerial
category of unskilled
firms. In the Social Survey it was shown that some 37% of the larger firms had established a definite retiring age and 33% had superannuation schemes. In smaller firms the figure had reached about 14%. The result of this is an increasing pressure to retire at a fixed age and greater economic security in retirement. Of those working in firms that had established a retiring age it was found that about half the workers would have preferred to stay on beyond that period: With a superannuation scheme Without a superannuation scheme
..
..
..
..
42% 52%
It is clear that economic factors played a part in the wishes thus expressed. About half the men and women in full and part-time work said that they worked because they must ; 40% of men and 30% of women said that they were obliged to work but at the same time preferred it to idleness. The remainder simply said that they preferred work. Nearly two-thirds of the men in full or part-time employment said that they intended to go on working for as long as they could ; ill health seemed to be the most likely bar to continuing employment. Waste of Potential Workers
In the Industrial Welfare Society pamphlet it was shown that the proportion of male elderly workers (compared with all workers) employed was
This indicates that the potential sources of labour are not being used today so effectively as in 1945. The factors which act against working beyond pensionable age. are stated to be : (1) that the higher National Insurance pension at seventy for those who continue working is hardly worth the effort ; (2) the growing feeling of being unable to compete with younger men; (3) the alleged resentment of younger men to the older people who block promotion ; and (4) the whole sense of diminished physical capacity, the fear of having to learn a new job, and the desire for leisure. On the other hand many workers want to go on working because they dread the loneliness of retirement or because they desire to remain useful members of society. Employers as well as workers had some doubts about the economic value of postponed retirement. There was the fear of increasing accident-rates and of diminishing attendance at work; embarrassment about the trade-union attitude; and considerable doubt as to what work was appropriate for the ageing worker. Unless the employer had very strong feelings about his duty towards older people he was disinclined to face these problems. The survey dealt with 400 member firms, employing 260,000 men and 87,000 women. In the total sample of workers elderly men counted for 2.7% and women for 2%; a distinction made between small, medium, and large firms showed a higher proportion of elderly workers in the small firms. This is to be expected partly because of the higher proportion of pension schemes in the larger industries and partly because of the more intimate relations between the workers and the management in the smaller groups. The general findings about superannuation policy agreed on the whole with those of the Social Survey that schemes were more common in the larger firms, thus leading to a bias in favour of compulsory retirement. They also eased some of the economic difficulties which lead men to continue work. There is some disquieting evidence that the spread of pension schemes has a tendency to encourage premature retirement. The existence of a scheme lends force to the feeling of both management and workers that the elderly man will step down at about sixty-five years of age. The firm has little incentive to look further into the matter and try to create jobs for older men or to adjust existing processes to suit the slower pace of the elderly worker.
993 It is difficult to
assess
the
feeling
of the
elderly worker
himself towards retirement. What I tell you at the age of sixty-three about my future may be entirely different from my opinion a few months before actual retirement at sixty-five. I am ready to urge an early retiring age so long as I feel that the elders stand in the way of my promotion ; my view will be sharply modified when I myself become the obstruction. Again, I may have felt that I needed a rest and so looked forward to retirement, but when the time comes and a few weeks or months have gone by, I may well take the view of Elia: I am Retired I am no longer ... clerk to the Firm of, &c. "
gardens. I am already come to be known by my vacant face and careless gesture, perambulating at no fixed pace nor with any settled purpose. I walk about; not to and from. They tell me, a certain cum dignitate air, that has been buried so long with my other parts, has begun to shoot forth in my person. I grow into gentility perceptibly. When I take up a newspaper, it is to read the state of the opera. Opus operatum est. I have done all that I came into this world to do. I have worked task-work, and have the rest of the day to myself." CHARLES LAMB, Last Essays of Elia. Leisure. I
am
to be met with in trim
Alternatives to Enforced Leisure
We must now turn to another aspect of the retiring age and try to discover if there are any appropriate alternatives to enforced leisure. Let us assume that we are dealing with a manual worker who when he reached the age of retirement had been employed on work at which with his increasing skill he has become dexterous. If the firm, as is often the case, has a rigid rule about the age of retirement, it is unlikely that the workman will be able to secure alternative employment that complies with the simple, desirable conditions of continued satisfaction. The essentials of a good retirement job can be set down as follows:
(1) (2)
(3)
The The
job should be paid. job should be on a part-time basis (becoming, if possible, gradually less onerous with increasing years) or should be lighter in the sense of relieving physical strain or, what is more important, slowing the pace.3 The job should be on a mental level not substantially less than his previous work. We do not wish to draft thousands of intelligent workmen to inferior duties which give them no real satisfaction. A job should be such as to offer interest and stimulation and avoid
monotony.
(4)
The worker should be prepared to cooperate in simple and effective tests of his mental and physical capacity and, if necessary, undergo a course of training for new
employment. The selection of
an
elderly
man
for his
new
job
should be
based on his positive capacities and not on a list of disabilities. If the question of retirement were merely a matter of years there would be little room for argument; but, just as the child has special characteristics and aptitudes, so too have the aged their special features. We should look at these positively, as we do with a disabled person, and our interest must be directed towards discerning what the man or woman of pensionable age can still do well, perhaps better than his juniors. Rough tests have been devised from time to time to determine the capacity of the ageing as the years go by, but so far there has been little attempt at accurate ascertainment, as in childhood and adolescence. What a glorious field for the psychologist ! I am not for a moment suggesting that these tests of capacity would be easy to devise or to put into 3. " Within the limits of our sample, however, it was clear that older people tended to be found doing work where there was an absence of time-stress—in other words, work which could be done at their own pace, unhurried by pressure for speed, and where there was opportunity for accuracy to be displayed to advantage." From Skill and Age : an Experimental Approach by A. T. Welford and colleagues at the Nuffield Research Unit into Problems of Ageing. London, 1950; p. 144.
use ; many of them perhaps will have to be applied not to the worker in relation to a job but rather to the circumstances of his everyday life. Amongst professional people the trouble often is that the adult is so much more sophisticated than the child and at a personal interview he knows so many of the answers, at least verbally. We may be driven to the kind of tests put forward by Bacon : "
Men of age object too much, consult too long, adventure too little, repent too soon, and seldom drive business home to the full period, but content themselves with a mediocrity of
success."
Another useful kind of test is to compare present accomplishments with the work of the past. Sometimes the thought and speech of the ageing betray them. I always listen carefully to the man who says : "I am as good a man as ever I was," for that is one of the first symptoms of declining mental powers. The dear man has begun to whistle in the growing intellectual dusk. I suspect that Dr. Johnson was one of my examples. He had been to dinner with Allan Ramsay, who was about sixty-five years of age at that time-and then Boswell takes up the story : " Next day, Thursday, April 30, I found him at home by himself. JOHNSON:’Well, Sir, Ramsay gave us a splendid dinner. I love Ramsay. You will not find a man in whose conversation there is more instruction, more information, and more elegance, than in Ramsay’s.’ BOSWELL:’What I admire in Ramsay, is his continuing to be so young.’ JOHNSON : ’Why, yes, Sir, it is to be admired. I value myself upon this, that there is nothing of the old man in my conversation. I am now sixty-eight, and I have no more of it than at twentyeight.’ 130SWELL:But, Sir, would you not wish to know old age ? He who is never an old man, does not know the whole of human life ; for old age is one of the divisions of it.’ JoHNSON : ’Nay, Sir, what talk is this ? ’ BOSWELL:II noon, and I would know night, as well as morning and noon.’ JOHNSON:What Sir, would you know what it is to feel the evils of old age ? Would you have the gout ? Would you have decrepitude ? ’-Seeing him heated, I would not argue any farther ; but I was confident that I was in the right." mean,
Sir, the Sphinx’s description of it ; morning,
night.
Compulsory
Retirement
We must now consider the desirability of a compulsory age ; and here some distinction must be made between those employed mainly in physical labour and those engaged in professional work making heavy demands on the mind. For the manual worker a retiring age is desirable if only as a fixed period for the consideration of physical and mental capacity. Obviously there is nothing physiologically significant about the sixty-fifth birthday ; it is just a matter of convenience. A good pension scheme ought to permit of considerable latitude about the age of retirement, say between sixty and seventy. This would encourage the stronger man to continue work without at the same time forcing the weaker to engage in competition beyond his physical powers. It is easy to convince oneself that the brain matures with age but even the most gullible will not deny that the suitcase becomes heavier. The man himself benefits by continuing his work beyond the retiring age partly from financial gain and partly because he is presumably doing something that gives him satisfaction. The community benefits because, to some extent, it gathers the fruits of his labour. The important thing to remember is that the man himself must not be the arbiter ; unless we accept, and he accepts, a dispassionate, independent assessment of his capacities, physical and mental, we shall go not one inch further towards a reasonable plan for retirement. In the case of the professional worker who is mainly dependent on his mental powers the picture is different. The older man may find that his output is increasing with age and it is natural that he should mistake this for wisdom, since the tongue is perhaps the only organ of the
retiring
994
body that is not slowed down by advancing years. Physsuffering is endured ; mental infirmity is enjoyed. Indeed perhaps the greatest difference between the
ical
manual and the mental worker is the capacity for the latter to do harm. It is a sobering thought that the product of manual labour is mostly good, whereas the results of mental exertion may be disastrous. By the time the mental worker reaches retiring age he is often in a position of authority where his opportunities for doing ill are extensive ; as a rule there is no-one in a position to tell him to go home. One might suggest therefore that a retiring age for professional people should be compulsory ; the difficulty to be solved by mental health experts is what age should be chosen. At any rate, as Dr. Johnson said : There is no state more contrary to the dignity of wisdom "
perpetual and unlimited dependence, in which understanding lies useless, and every motion is received from
Influence of pH The striking difference
MATERIALS AND METHODS
than
external
impulse."
RESISTANCE OF THE BREAST-FED INFANT TO GASTRO-ENTERITIS CONSTANCE A. C. Ross M.D.
*
Glasg.
RESEARCH ASSISTANT, UNIVERSITY DEPARTMENT OF INFECTIOUS DISEASES, AND KNIGHTSWOOD HOSPITAL, GLASGOW
E. A. DAWES B.Sc., Ph.D. Leeds, A.R.I.C. LECTURER IN BIOCHEMISTRY IN THE UNIVERSITY OF GLASGOW
generally recognised that breast-fed babies are relatively resistant to gastro-enteritis (Levi 1941, Alexander 1948). The predominance of Lactobacillus 6t/M-Ms in the stools of the suckling might suggest that IT is
the intestinal environment of the breast-fed infant is unfavourable to the establishment of Escherichia coli, particularly the types associated with infantile gastroThe experiments described here were an enteritis. to attempt study some of the features of the intestinal environment of the infant in relation to the growth of Esch. coli. The Experiments GENERAL PLAN
3letabolic Products in the Tntest’inal 1ract Previous study had shown that there is a qualitative difference in the faecal excretion of amino-acids by the breast-fed infant and by the artificially fed baby (Ross 1951). This suggested that certain amino-acids might either stimulate or inhibit the growth of these types of Esch. coli. An investigation of the growth of a laboratory strain of Esch. coli NCTC5928 on single aminoacids as the sole source of nitrogen in a glucose-salt medium (Dawes 1952) was now extended to certain types of Esch. coli associated with infantile gastro-enteritis. Several investigators have found that a single aminoacid added to a medium otherwise capable of supporting growth may inhibit growth, but that this effect can be presented by the simultaneous presence of certain other amino-acids (Gladstone 1939, Porter and Meyers 1945, Davis and Maas 1949). A study of the growth of different types of Esch. coli on single amino-acids would therefore be of limited value in assessing their ability to grow in the complex mixture of amino-acids present in the intestines of infants. To overcome this difficulty the growth of these organisms was studied in sterile f,4--cal extracts from artificially fed babies, breast-fed babies, and babies with gastro-ellteritis associated with a specific type of Esch. coli. This experiment enabled the growthpromoting effect not only of the amino-acids but also of all the metabolic products in the faeces to be assessed. *
Now working at
the Children’s Hospital, Birmingham, 16.
’
between the pH of the faeces of breast-fed infants and of infants fed on preparations of cow’s milk is well known (Tisdall and Brown 1924, Ross 1951). It therefore seemed relevant to study the pH of the stools in infantile gastro-enteritis and the influence of pH on the growth of these types of Esch. coli in vitro. Dagley et al. (1953) .found that, with Esch. coli in glucose-ammonium sulphate medium, low pH values alone could not account for the cessation of growth, and thought that certain products of metabolism might exert a toxic effect. In particular they showed that formic acid, which is produced during the growth of EI’!f’.h. coli, increased rapidly in toxicity as the pH value decrease d. The organisms used in the investigations were three type strains of Esch. coli (0-111, 0.55, and 0-26) obtained from the State Serum Institute, Copenhagen, and an untypable strain of Esch. coli from a healthy artificially
fed infant. Growth with The
Single Amino-acids
as
Sole Source
of Nitrogen
medium contained potassium dihydrogen phosphate 5-4 g., glucose 12g., magnesium sulphate (MgSO4’ 7H2O) 0-4 g., and either ammonium sulphate 1-2 g. or the required amino-acid 0-6 g., and made up to 1 litre with glassdistilled water and adjusted to pH 7-1. The medium was distributed in 25-ml. amounts in’Pyrex ’ boiling tubes (6 x 1 in.) previously cleaned by boiling with nitric acid and washing with glass-distilled water. The growth of Esch. coli was studied by the method described by Dagley et al. (1950). Bacteria for inoculation were prepared by three serial subcultures in glucoseammonium-sulphate media ; 0.ml. of the third culture, taken at the onset of the stationary phase, was used as inoculum. The tubes were incubated at 37°C without aeration because this would approximate more nearly to the conditions obtaining in the intestines. Samples of about 2 ml. of the growing culture were withdrawn with a Pasteur pipette and killed by the addition of 2 drops of formalin. Bacterial growth during culture was estimated turbidimetrically with a Spekker photo-electric absorptiometer (filters H508 and OB2) calibrated to convert turbidity readings into bacterial counts obtained with a haemoeytometer.
growth
G/-OM’//i in Sterile Focal Extracts As our first purpose was to assess the effect produced on growth by the faecal extracts, independently of their natural pH, phosphate buffer containing potassium dihydrogen phosphate 9 g. and 5N sodium hydroxide 10-4 ml. per litre at a pH of 7-1 was used as the extracting fluid. In preliminary experiments the ratio of fresh faeces to extracting fluid was adjusted to the dry weight of the faeces ; but it was found that the stools of the suckling were always more fluid than those of the artificially fed infant, and that the equalisation of specimens as regards dry weight often necessitated considerable dilution of the faeces of the artificially fed. Further, the test organism might not grow in this diluted extract, whereas there was good growth in an extract from the same specimen diluted on the basis of its fresh weight. We therefore decided to use equivalent weights of wet faeces from all three groups of babies in the proportion of 1 g. of fseces to 5 ml. of phosphate buffer. As sterilisation by Seitz filtration might remove not only bacteria but also some growth substances, portions of each extract were sterilised in three different ways : by Seitz filtration, by tyndallisation at a temperature of 100°C for 20 minutes on three consecutive days, and by Seitz filtration followed by tyndallisation. To 12 g. of a well-mixed specimen of faeces was added 60 ml. of phosphate buffer. This was shaken for 3 minutes and centrifuged : thereafter the supernatant fluid was divided into three aliquots for sterilisation as described above. The sterilised extracts wore then dispensed in 5-ml. portions in bijou bottles under aseptic conditions. In this set of experiments the organism used was the stock strain of E8ch. coli type 0-111, which was the type strain most often associated with our severe cases of gastro-entoritis. A subculture of the organism was made in 10 ml. of nutrient broth and incubated for ]8-24 hours at 37°C. The bacteria