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and enterprising in old age, than men. But, as thewriters of the pamphlet point out, the idea ofretirement at 65 or 60 is now ingrained in the

nation, among both employers and employees. Some,employers impose early retirement in their super-annuation schemes, and are reluctant to engageanyone in the middle or later years. Of the presentunemployed most are over 40, and unemployment istwice as common among those over 50 as amongthe population as a a whole. Certainly people in everywalk of life are well aware of a prejudice against theemployment of older men and women. The reasonsmost employers give for this reluctance, the pamphletsays, are a wish to promote younger people, unwilling-ness to adapt employment policies to an era of fullemployment, unwillingness to find suitable tasks forthe old, and difficulties with superannuation schemes.Moreover, many employees regard retirement at agiven age as a right. All the same, 46% of men aged65-70, and 10% of women aged 60-65 stay on atwork, and more might do so with encouragement.At present the " earnings rule," which limits the

pensioner’s additional earnings to 1:2 a week, is aserious deterrent. The scale of increments to pen-sions, for remaining at work longer, is perhaps notsufficiently attractive ; and there are some who wishto go on working but cannot find the work. Again,some could go on with their jobs after retiring ageif they worked fewer hours ; but they cannot liveon the reduced pay they would then earn. Some,having tried retirement, do not like it, and mightcome back to work if the new spell of employmentincreased the final pension. The writers of the

pamphlet believe we might attract a great manyseasonal workers if every 25 stamps, however longit took to collect them, counted towards an incre-ment. Again, a large source of labour might be-

tapped by making a sliding-scale reduction in pensionsfor those undertaking half-time or part-time work.Employers, too, might well spend more thought onproviding appropriate jobs and sheltered workshopsfor those who need a gentler pace. The skills ofthe aged are by no means negligible. Apart from theelderly of the professional, technical, and administra-tive classes, who can put a great fund of knowledgeand experience at the disposal of the nation, thereare all the skilled craftsmen, many of whom are alreadykept on by their employers. But even the rank andfile of the elderly, it seems, have an accuracy and

reliability not so common in the young ; and theyare often capable of being trained in new work,especially if it uses old skills. 2

These writers recognise that the proper care of theelderly includes more than the adequate treatment oftheir disorders when these arise : the resources ofocial medicine can do much to preserve their health,improve their nutrition, and enable them to keep theirindependence. Nowadays, as Mr. JOHN A. OLIVER,PH.D,, has recently pointed out,3 it is generally agreedthat the proper place for old people is in their ownhomes, and this pamphlet, too, advocates the humaneand economic policy of helping them to stay there.Many local authorities now build special cottagesfor old people on their housing estates, but few buildenough of them. The writers quote the experience

2. Lancet, 1949, ii, 469, 753.3. Ibid, Oct. 4, 1952, p. 669.

of Hornsey Borough Council, who built 34. cottagesfor old people, and found when the tenants moved inthat they had released 6 houses with six rooms, 22houses with four or five rooms, and 4 houses withthree rooms-277 rooms in all. Even some old

people living with married children would be gladof a small home of their own. The burden of the oldon the young has often been aired ; this pamphletrefreshingly mentions the burden of the young onthe old. The patter or little and not-so-little feet isnot everybody’s idea of a delightful accompanimentto a swan song.On the question of medical care for the old the

writers are cautious-as they may well be in dealingwith so confused a topic. They note the lack ofbeds for the elderly, but recognise that the demandfor beds could be much reduced by more preventivecare for the old, more residential homes, and more"

half-way " convalescent homes. It is difficult,they say, to develop this last type of institution whilethe responsibility for maintenance cannot be exactlyfixed between the local authorities, the NationalHealth Service, and the National Assistance Board.All the same, one institution of the kind has been

started-Springbok House at Stanmore, set upby the National Corporation for the Care of OldPeople. The experience gained there is bound tobe valuable. The prognosis of the pamphleteers,that perhaps " such problems cannot be finally settledwhile local government areas and hospital areas

differ," seems hardly justified; though things wouldcertainly be simpler if these territories were

conterminous.

1. Scadding, J. G. Quart. J. Med. 1937, 6, 425,2. Tyrrell, D. A. J. Ibid, 1952, 21, 291.3. Stuart-Harris, C. H., Laird, J., Tyrrell, D. A., Kelsau, M. H.,

Franks, Z. C. J. Hyg., Camb. 1949, 47, 434.

Annotations

PULMONARY COMPLICATIONS OF INFLUENZA

By all the rules, there should be no large epidemicof influenza A in the coming winter ; but the rules areoften broken, as the sharp Liverpool outbreak in 1951showed. The general practitioners, who have to dealwith both the sheer mass of sickness and the pulmonarycomplications that call for special treatment, face thehard task of distinguishing those patients who are

likely to need admission to hospital and urgent chemo-therapy from the many who can be safely left in theirhomes. This task involves the recognition of severe

influenzal pneumonia at an early stage, before the onsetof the rapid deterioration that sometimes occurs. Unfor.

tunately, the clinical picture of influenzal pneumoniais not as clear-cut as some descriptions suggest, and thedoctor is in fact confronted by a whole range of patientswith various forms of chest complication, many of whichwill respond well to the up-to-date treatment for broncho-pneumonia or lobar pneumonia. Indeed, some peopledoubt whether influenzal pneumonia is a distinct entity,differing clinically from other forms of pneumonia, thoughScadding thought that it was.

’

Tyrrell 2 has now reopened the question by making a’detailed analysis of the chest complications of influenza.His results justify the continued use of the name" influenzal pneumonia," but they underline the difficultyof recognising such cases clinically. Before the epidemicof influenza A in Sheffield in March, 1949,8 Tyrrellexamined a number of patients with bronchitis, and

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others with bronchopneumonia or lobar pneumonia, whowere admitted to hospital for treatment and were foundto show no serological evidence of infection with influenzavirus. His work began at the time described by Bradley 4as the influenzal nadir of 1948, and in many cases theillness had a sudden onset, with definite signs of lobarpneumonia. Some patients had had chronic chestdisease in the past, but the response to chemotherapywas good, and only 2 patients died.

His second group included patients who were admittedduring or after the epidemic of influenza A and who werefound to have infections of the lower respiratory tract,including bronchitis or pneumonia. Some were provedto -have influenza-virus infections, either by serologicaltests or by isolation of the virus, and others gave sero-logical evidence of influenzal infection before the onsetof the pneumonia. Tyrrell noted two groups ofinfluenzal cases that could be recognised clinically-those with severe tracheobronchitis, and those withfulminating staphylococcal pneumonia. The other formsof pneumonia seemed more severe than those seen beforethe epidemic, and more patients died. Moreover, inthe pneumonias associated with influenza-virus infection,mental changes, cyanosis, and widespread rales andrhonchi outside the area of consolidation were commonerthan in the non-influenzal cases. Chemotherapy wasless effective in the influenzal cases, as judged both bymortality and by the time taken for the fever to subside.This work emphasises how necessary it is to give

particular care, during an influenza epidemic, to patientswith chronic bronchitis or pre-existing heart-failure, andalso to old people. The rapid deterioration, intense

dyspncea and cyanosis, and bloody sputum of staphylo-coccal pneumonia distinguish this most dangerous formof chest complication, which must be continually bornein mind if it is to be recognised quickly.The way in which the influenza virus alters the clinical

picture of bacterial infection of the lungs was not dealtwith in this investigation. Harford and Hara 5 foundevidence in mice to suggest that the cedema caused bythe influenza virus facilitates invasion of the lung bypneumococci. Moreover, the tracheobronchitis of virusinfection can cause mucus plugs to form in the bronchiand areas of collapse to develop in the lungs. Yet, asothers have shown,6 many less extensive lung changesmay take place in influenza, some resembling atypicalpneumonia ; but these are fortunately benign and hardlyenter into the clinical diagnosis. Now that more out.breaks of influenza are being investigated by clinicaland laboratory methods, two facts are beginning to standout: the staphylococcus is the bacterium to fear in thesputum ; and the virus itself is certainly closely concernedwith the increased severity and mortality of pneumoniaduring an epidemic.

4. Bradley, W. H. Proc. R. Soc. Med. 1951, 44, 789.5. Harford, C. G., Hara, M. J. exp. Med. 1950, 91, 245.6. Scher, J. M., Jaruszewski, E. Arch. intern. Med. 1952, 90, 201.7. J. Path. Bact. 1952, 64, 529.

MORE HERESY

Dr. Adrianus Pijper of Pretoria is a heretic, and it isfortunate for him that he studies microbiology in the20th century and not theology in the 4th. We have onseveral occasions mentioned his view that the bacterialflagellum is the consequence, and not the organ, ofprogression ; and if this unorthodoxy has had no othermerit it has been the stimulus to many elegant-andinteresting experiments designed for its refutation. Hislatest communication 7 concerns a less outrageous denialof established belief. but will, we hope, have the sameresult. -

Many of us have seen the iridescent sheen on a

confluent culture of bacteria held obliquely to the light,

and most have accepted it without much thought ofits cause. Many years ago Pijper 8 guessed that such athin film of bacteria might act as a diffraction grating,so that the diameter of the spectral halo thrown on ascreen by a beam of light passing through the bacterialfilm would bear an inverse ratio to the size of the bacteriamaking up the film. The principle is not new ; it wasfirst devised by Thomas Young, physician to St. George’sHospital (in the intervals of describing his modulus anddeciphering the Rosetta stone) as an aid to classifyingwool fibres. Pijper’s attention was diverted to the useof this device, the "halometer," for measuring thediameter of red blood-cells ; and older h2emAtologistswill bear witness to its value before the more informativehæmatocrit came into use. That happened thirty yearsago, and now he has given some further observations.on this method. It measures the diameter of cocci andthe breadth of bacilli, and such measurements are betterexpressed in relative than absolute values. If the breadthof Salmonella typhi be given a value 1-0, S. paratyphi Bis found to give a figure of 0-94 and members ofthe coli-aerogenes group figures ranging from 1-08 to1-38. These are constant for each species, providedit is measured at the same stage in the growthcycle.

Since species differ in their least dimension, might theynot be separated by differential filtration ? If a barrierof sterile sand be placed in the loop of a U-tube filledwith nutrient broth and if a mixture of organismsincluding S. typhi be added to one limb, this species isusually the first that can be recovered from the otherside of the sand. But sand is awkward stuff to handle,and a " fairly tight " plug of - cotton-wool in a Craigietube gave more consistent results. All organisms willof course find their way through the obstruction in time,and the medium on the " arrival side " must be sub-cultured at short intervals if S. typhi is to be found inpure culture. Anomalous results revealed some interestingantagonisms between species. Brucella abortus penetratedthe barrier quicker than staphylococci, but when culturesof the two were mixed the brucella never came throughthe barrier at all. Suspended in saline, however, it wonevery time. Similarly S. typhi died in the presence ofBact. cloaccs ; but when the experiment was performedin Wilson and Blair’s liquid medium it was possible toplant these species in a ratio of 1 : 100,000, and yetS. typhi came through the barrier first. Thin bacterianot only get through the fence quicker than the fat,but they ascend higher on a strip of filter-paper dippedin a bacterial mixture. S. typhi reached an altitude of4.1 cm., while Bacillus anthracis could get no higherthan 1-1 cm. and the obese sarcina stopped evenlower. Others have noticed this phenomenon and havegiven diverse explanations. Motility, electrical charges,and " wettability " have all been suggested ; butPijper contents himself with the idea that to climb

through the hairy pores of filter-paper may entail-the same troubles as pushing through a barrier ofcotton-wool. -

Some of these observations are not entirely novel.

Attempts to put them to a useful purpose have beenmade in the past ; and as a result of this paper they willno doubt be made again. But we are better pleased tosee how far uninhibited curiosity has led an inquiringmind in thirty years..Once again Pijper will set manyof his colleagues observing and experimenting-andprobably contradicting-and for this alone he will deservewell of them. We hope he will be careful. He may readof the penalties of heresy in Gibbon ; and we haveheard rumours that there are places even today wherescientific unorthodoxy is curbed with almost byzantineferocity.

’

8. Med. J. S. Afr. 1918, 14, 211.