833 well be best. Clearly, if reconstruction of the acetabulum is to be carried out this approach is by itself inadequate, though it may still be a useful preliminary measure.
How often is this procedure indicated ? In Ferguson’s series the age-range was from two weeks to two
years.
spica for at
The children remained in a plaster least four months. If these were children
in whom a satisfactory (i.e., virtually normal) hip would not have been achieved by conservative treatment, his good results represent a considerable advance. Equally there may be a place for operation in cases where it will substantially reduce the duration of treatment.
WHAT DO THE ELDERLY NEED? IT has become
a
truism
to say
that the medical
problems of an elderly patient cannot be treated without having regard to such things as housing, mobility, and social isolation. Frequently the kind of help that the elderly need can be expressed in terms of the kind of accommodation required-independent, geriatric or psychiatric hospital, residential home, or sheltered housing. The fairly wide choice of facilities available for the care of the elderly does not, however, necessarily mean that different kinds of care are provided in different kinds of accommodation, or that the elderly end up in the accommodation best suited to their needs. If one takes into account the fact that the problems of the elderly are usually manifold, it is not hard to see why the difficulties of assessing the level of need (expressed and unexpressed), and of discovering whether the care that is given is effective, are less easy to overcome for the elderly than for most other groups of people. 31 % of the National Health Service expenditure goes on the elderly, but there is very little evaluation as to the outcome of this expenditure. The operational research division of the Institute of Biometry and Community Medicine is at present developing a model for planning and predictive purposes with the object of improving the provision of health, welfare, and care services for the elderly. The project study area is the Exeter and Mid-Devon hospital group, and at a seminar held at the University of Exeter last year a number of papers were given, and have now been published, which sought to define the needs of the elderly. One of the themes that emerges from a reading of the seminar papers is the desire among all the professions caring for the elderly, along with those doing the operational research on them, to get together to establish the levels of need for old people which society in its collective responsibility will wish to reduce as far as possible. A means of classifying the problems of the elderly was also felt to be an urgent requirement, and not only by those engaged in research. Prof. A. L. Cochrane said that he would like to see the development of a simple, reproducible classification of the elderly which could be carried out by a social worker or health visitor in the home and which would Needs of the Elderly for Health and Welfare Services. Edited by R. W. Canvin and N. G. Pearson. Institute of Biometry and Community Medicine, Publication no. 2. University of Exeter, The Queen’s Drive, Exeter EX4 4QJ. £2.
be closely related to the type of housing required. Prof. Peter Townsend described an index of incapacity that he had devised whereby a score was allocated on the elderly person’s ability to carry out a number of key activities in personal care (such as dressing, cutting toenails, getting about the house) and in household care (such as doing light housework, preparing a hot
meal). The question of alternatives of care was pursued by Dr Thomas Arie, who pointed out that, while the elderly form an increasing proportion of inmates of psychiatric hospitals, and though patients with dementia also form a high proportion of the residents in geriatric hospitals and local-authority homes, the overwhelming majority of the elderly mentally ill are at home, and the number is likely to increase greatly over the next 20 years. We can no longer, Dr Arie warned, take it for granted that the fine balance between home and institutional care on which services now depend will endure. But, on the other hand, the majority of the elderly who actually become long-stay psychiatric patients not only could but ought to be looked after not in hospital but in hostels, which do not function on the medical model at all. Dr Arie also urged that the whole range of facilities must be made available according to need, rather than according to the component of the service with which the elderly person happened, often by the merest chance, to have first engaged. Professor Townsend, using data collected in parallel national surveys of people aged 65 and over living at home and living in three different types of
long-stay institution (residential homes, geriatric hospitals, and psychiatric hospitals), questioned whether institutions actually carried out the function they purported to fulfil, and whether, on the contrary, they carried out a different function which would in fact be better fulfilled elsewhere. Old people are usually admitted to institutions because they require and attention which is
not available or cannot be home. Professor Townsend had carried out provided a comparative study of the incapacity of the elderly at home and in institutions, and he found that altogether there were more than twice as many severely incapacitated and bedfast elderly people living at home as there are in all institutions. He also discovered that to a considerable extent the three different kinds of institution catered for patients with similar problems, and that the elderly living at home frequently received better care and attention, were less lonely, and lived in better physical surroundings than those in institutions, especially if those at home had the advantage of attending a day hospital or day centre. Professor Townsend also found that the expectations of old people were not very high and that, perhaps through fear or ignorance, they did not like to complain about their treatment or claim anything as a right. Prof. W. Ferguson Anderson made the point that the elderly often attribute their symptoms simply to the process of ageing and therefore do not report them to the doctor. The utmost vigilance on the part of those caring for the elderly is obviously required if their unexpressed needs are to be met. The situation was aptly summed up by Professor Cochrane, who said that in attempting to discover whether screening the care
at
834
elderly was effective it was particularly important to use a placebo control-group, since, because of widespread neglect, they usually reacted favourably to anyone doing anything at all. If there was one fact established about the needs of the elderly beyond doubt at the seminar it was that they were not at present being met, and there was general agreement that the two things needed most were more housing for the elderly and a higher cash income. ANTILYMPHOCYTE GLOBULIN THE advantage of antilymphocyte globulin (A.L.G.) over other immunosuppressive drugs lies in its ability to suppress cell-mediated immunity without or resistance to bacterial infection. It may have the further advantage of being able to induce a long-persisting immunological tolerance-as suggested by the chimaerism which may follow experimental marrow transplantation in animals which have been treated with A.L.G.1I The disadvantages of A.L.G. include the lack of a standard preparation, the presence of antiglomerular-basementmembrane antibody in certain batches, 2,3and the reactions caused by the prolonged administration of foreign serum. In spite of earlier hopes, reactions to foreign serum cannot always be prevented by the use of deaggregated globulin. 4,5 Claims have been made for the efficacy of A.L.G. in a wide variety of clinical immunological disorders 6,7 and especially in renal transplantation.8,9 When A.L.G. is added to a standard immunosuppressive regimen of azathioprine and prednisone, Sheil and his colleagues 10 have produced further evidence that the incidence of acute renal rejection episodes can be diminished. In this study A.L.G. did not diminish the incidence of complications or of chronic rejection. When the donated kidney was grossly mismatched, A.L.G. had little or no effect. In other clinical situations the evidence has been less convincing, and there has been a disappointing lack of controlled trials. Although useless in chronic lymphatic leukaemia,l1A.L.G. has been reported to have an encouraging effect in myasthenia gravis, 12 chronic hepatitis,13 and multiple sclerosis. 14,15 It
greatly affecting antibody production
1. Bau, J., Thierfelder, S. Transplantation, 1973, 15, 564. 2. Fortner, J. G., et al. Transplant. Proc. 1971, 3, 383. 3. Wilson, C. B., Dixon, F. J., Fortner, J. G., Cevilli, G. J. J. clin. Invest. 1971, 50, 1525. 4. Rossen, R. D., Butler, W. T., Nora, J. J., Fernbach, D. J. J. Immun. 1971, 106, 11. 5. Wolf, R. E., Remmers, A. R., Sarles, H. E., et al. Transplantation,
1971, 11, 418. Trepel, F., Pichlmayr, R., Kimura, J., Brendel, W., Begemann, H. Klin. Wschr. 1968, 16, 856. 7. Pirofsky, B., Reid, R. H., Bardana, E. J., Jr., Bayrakci, C. Transplant. Proc. 1971, 3, 769. 8. Sheil, A. G. R., Mears, D., Kelly, G. E., Rogers, J. H., Storey, B. G., Johnson, J. R., May, J., Charlesworth, J., Kalowski, S., Stewart, J. H. Lancet, 1971, i, 359. 9. Birtch, A. G., et al. Transplant. Proc. 1971, 3, 762. 10. Shell, A. G. R., Kelly, G. E., Mears, D., May, J., Johnson, J. R., Ibels, L. S., Stewart, J. H. Lancet, Aug. 4, 1973, p. 227. 11. Pfisterer, H., Lani, K., Demmler, K., Thierfelder, S., FatchMaghadam, A., Land, W., Brendel, W., Stich, W. Dt. med. Wschr. 1971, 96, 1468. 12. Pirofsky, B., Reid, R. R., Ramirez-Mateos, J. C., Bardana, E. J., August, A. Clin. exp. Immun. 1972, 12, 89. 13. Gateau, P., Eyquem, A., Hecht, Y., et al. Presse méd. 1971, 79, 51. 14. Frick, E., Angstwurm, H., Spath, G. Münch, med. Wschr. 1971, 113, 6.
221. 15.
Brendel, W., Seifert, J., Lob, G. Proc. R. Soc. Med. 1972, 65, 531.
remains doubtful, however, whether there are clear advantages over standard methods of treatment in these conditions. The reasons for continuing to study A.L.G. remain compelling. It is more selective in its effects than even such substances as procarbazine and other methylhydrazine derivatives. 16,17 It has been remarkably well tolerated in laboratory animals; and the earlier toxic effects seen in man have been avoided with the newer types of globulin, raised against thoracic-duct lymphocytes and cultured lymphoblasts.18 By using membrane fractions of lymphoblasts, it is possible that an even more selective effect will be achieved. As in other attempts to manipulate the immune response, it remains to be seen whether this form of suppression will be accompanied by a long-term increase in virus infection and in cancer. The experience of the transplant surgeons encourages the hope that these dangers will not be great enough to prevent the use of this treatment whenever it is clinically indicated.
POPULATION AND THE NEW BIOLOGY THE discovery of the chemical nature of the gene 20 years ago heralded a new era of fruitfulness in
biological research. Developments in organ transplantation and extrauterine fertilisation, research in genetic disease and ageing, and improvements in contraceptive techniques and methods of abortion -these
are some
of the
areas
of progress which have
given hope, at least, of improving the quality of human life. Speakers at the Eugenics Society’s symposium in London last month discussed how human beings, both as individuals and as populations, are likely to be affected by the new biology ". Prof. J. A. Beardmore (Swansea) was concerned about the possibility of a rise in the mutational load of the human gene pool by the increasing use of ionising radiation and by the introduction of novel molecules, such as flavourings, drugs, and birth-control chemicals, most of which were brought into use before their mode of action was known. Man, having had no previous experience of these hazards, has not yet been able to build up a protective genetic system, Professor Beardmore was also somewhat pessimistic about the consequences of treating serious genetic diseases. Although the relief of individual distress is important, he said, the population effects must also be taken into account. Phenylketonuria, a recessive disease which has a gene frequency of about 0-6 °o in the U.K., can now be treated ;but, if all patients survived to reproduce, the gene frequency would soon rise to 1.4 %, although it would take many generations for the population frequency of the disease to double. With dominant diseases, however, changes in gene frequency have a much more rapid and dramatic effect. If 95% of achondroplasia patients survived to reproduce, the frequency of the disorder would increase tenfold in a few generations. Considerations such as these, thought Professor Beardmore, would "
16. 17. 18.
Floersheim, Floersheim, Taylor,
G. L. Transplantation, 1969, 8, 392. G. L., Brune, K. Acta hœmatologica, H. E. Med. Clins N. Am. 1972, 56, 419.
1971, 46, 92.