GERONTOLOGY: A MODERN SCIENCEWITH A LONG HISTORY

By SONA ROSA BURSTEIN, M.A.(Wellcome Historical Medical Museum)j

Two words, gerontology and geriatrics, have withremarkable suddenness made their home in theEnglish language. The word geriatrics was coinedin I9I4 by the American, I. L. Nascher (from theGreek geron, an old man, and iatrikos, medicaltreatment) to distinguish the special branch ofmedicine dealing with senile diseases, on the analogyof pediatrics, the study of children's diseases. Themedical profession in England sometimes ignoresthe whole subject as a special branch and sometimesuses the word without comment as suitable Englishnomenclature; the lay public has in many casestaken up the word, but tends to use it with thewider connotation of gerontology. Gerontology isthe study of all the problems of ageing: medical,psychological, social, economic, cultural. As aword it has hardly arrived in this country yet, butwith the growing interest in old-age problems, itseems hardly likely that it will remain longunadopted.The present age-conscious generation-with its

national registration, its different identity cards forthe young, middle and old age-groups, its post-warplanning of social security measures and thewarnings of its statisticians on the changing age-composition of its population,-is perhaps moreaware of its higher age-group than any previousgeneration. In less than half a decade, problemsof the condition of the ageing members of oursociety have become a paramount topic of the dayand their solution a target for to-morrow.2Awareness of the earlier age-categories, childhood

and adolescence, has become increasingly acutewithin the last hundred years or so. The earliestpediatricians experienced much difficulty and manydiscouragements before convincing the medicalprofession that the ailments of children requiredspecial treatment and establishing pediatrics as aspecial branch of medicine. With the increase ofinterest in child conservation, medical interest inpediatrics increased and to-day this is one of themost important branches of medical science.Child psychology and the problems and malad-justments of youth have produced endless literatureand'it is now quite outmoded to take the stormsand stresses of adolescence for granted as beingthe inevitable accompaniments of physical changes.It is accepted that the transition of life fromchildhood to adulthood may be full of causes forconflict, fear and defensive behaviour, and manypsychologists have described cases of children who,on the threshold of the new phase of life, haveshrunk back into the refuge of infantile fantasies.

There is, however, a conspicuous lack of apparentinterest on the part of psychologists in the diffi-culties of the passage from maturity to old age.Yet there is surely matter enough for expert con-sideration, experiment and guidance in the conflictpeculiar to the period of entry into old age, theconflict between the fear of death and desire forits postponement, on the one hand, and on theother fear of the ills and losses and disappointmentsof the remaining stretch of life, should the desiredlength of years be vouchsafed. Jung3 stands out asa rare modem psychologist to speak with sympathyand understanding on this subject, and goes so faras to advocate special schools for adults to preparethem for the new responsibilities which await themin the last stage of life.While there is a dearth of objective commentary,

there is no lack of literary evidence of the ambi-valent attitude to old age from the earliest timesto our own day. Down through the ages comes theaccepted paradox: the whole of life is too short, itslast part is too long! In Biblical times, old agewas the repository of knowledge and wisdom("ask thy father and he will show thee, thine eldersand they will tell thee") and the reward ofrighteous living ("that thy days maybe prolonged").But David's dirge of the final years ("yet is theirstrength labour and sorrow") and the vivid pic-ture in Ecclesiastes, of the years "when you shallsay, I have no pleasure in them," are undoubt-edly expressive of the spirit of the times. OfCicero's De Senectute, the classic of consolation-literature on the subject, Montaigne said, "Cicero'sbook gives one an appetite for old age." Yet itwas Cicero who was responsible for the famousdictum, Senectus ipsa morbus est-''old age is itselfa disease"-on which so much later philosophy andscientific effort were based.

In modem times, the two notes still strike.When the psychologist, G. Stanley Hall, retiredfrom academic life, he produced his book, Senes-cence: the Last Half of Life (I922), a masterlyethnographic survey of old age from the vague erasof the past up to the time of defined history.Yet, for all his trained, academic detachment,he was so little able to avoid an atmosphere ofmelancholy that he warned his wife and son notto read the book lest it depress them too much.4Sir William Osler's half-pessimistic, half-jestingremarks in his Farewell Address, on "the relativeuselessness of persons over sixty" roused enoughuneasiness to produce a considerable correspond-ence of protest.S Aldous Huxley, from the stand-

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186 POST-GRADUATE MEDICAL JOURNAL July, I946

point of a younger man, contemplates old age withhorror as "more appalling than death."6 HavelockEllis raises a rare voice in praise of old age as thetime when "the burden falls away. All theanxieties and responsibilities have become light;even if work. remains, practice has made it easy,"and again, "Call no man happy until he is old."7John Cowper Powys, the most recent writer onThe Art of Growing Old (i944), contemplating outof his seventy years' experience a wide range of therelationships of old people-social, domestic andeconomic-offers some philosophic answers to theage-old question of. how to be happy though old.

Religion, philosophy, reverie, reminiscence allplay their part in the problem of coming to termswith old age. Magic and alchemy have beenresorted to for the swifter escapist solutions offountains of youth and elixirs of life. Rejuvenationof the body and restoration of the forces of ageingman have been sought with endless ingenuity andrefusal to accept defeat. The device of contactwith a young girl, recommended to David whenhe "was old and stricken in years; and they coveredhim with clothes, but he gat no heat,"8 wasemployed by the Greeks and the Romans and hashad followers in the medical profession in modemtimes. Cohausen, a doctor of the eighteenthcentury, published a treatise on one Hermippus,a Roman schoolmaster, whose life, passed amidstyoung girls, was prolonged to one hundred andfifteen years.9 Hufeland, the well-known authorof Makrobiotik,io a series of sound enough principlesfor the prolongation of life, quotes this and otherexamples with approval and observes, "adeptsknow well that the breath of young girls containsthe vital principle in all its purity."

Serious scientists have contributed their shareto the search for a specific against senescence andsenile decay. At the end of the last centuryBrown-Sequard, and much more recently Steinachand then Voronoff, have sought to apply theresults of their researches in organo-therapy forrevitalizing the ageing bodies of men. Thoughthe verdict of the scientific world has been at bestdoubtful as to any lasting results, the publicityattained by Steinach's and Voronoff's experimentsand the popularity of their operations bore witnessto the enormous number of elderly persons set onregaining the physical zest of youth.A more hopeful and productive line of attack on

old age has been that arising out of the view thatold age is a disease. This view is reflected in suchtitles as Roger Bacon's Cure of Old Age andPreservation of Youth." Yet the work of thisthirteenth-century Franciscan friar and physician,with its mixture of science with fable andphilosophy, is prophetic with humanitarian under-standing. His account of symptoms, signs and

treatments, showing a fine understanding of Galenand Hippocrates, was rescued by FloyerIn in amore receptive age and presages much of theattitude of modem geriatrics. The doctrine thatthe process of ageing is wholly pathological, whileit shirks the acceptance of inevitability in anydiminution of powers, is a direct stimulus towardshygiene in all its forms. Metchnikoff's theory ofauto-intoxication induced by external factors asthe preventible cause of old age and death gainedimmense popularity of a valuable and constructivekind, since, along with his advocacy of sour milkfor the destruction of putrefactive bacteria, heproposed a life-extension code of orthobiosis-rightliving, physically, mentally and socially.13 Theeagerness with which a regimen for prolongation oflife can be seized by the public is shown by thewave of enthusiasm aroused by Hufeland's book;the word Makrobiotik, and the "Hufelandist move-ment" dominated a generation's thought. Asmuch that is best in the national health measuresof to-day grew out of public fears of the miasmaof disease and the instinct of avoidance, so theindividual fears of burdensome old age and ever-premature death contributed their quota tohygiene and preventive medicine.That old age is a condition that needs care has

been recognized since the days of Hippocrates,the father of medicine, who differentiated andenumerated a catalogue of ailments peculiar to oldpeople. Just as the goth Psalm caused the wide-spread, fatalistic fixation of the span of life atseventy years, so the i2th chapter of Ecclesiasteshas had enormous influence on later descriptionsof the recognizable ills of approaching senility.From the sixteenth century onwards, books'4 haveappeared, interpreting the allegorical passages andilluminating them with observational recording ofthe outstanding characteristics of old age-thetremor of the hands, the tendency to stoop, theloss of teeth, the inclination to early waking, thefailing eyesight, the growing apprehensiveness ofenvironmental dangers, the greying of the hair, thewaning of sexual desire and potency.The earlier "care" literature of old age has the

same tendency as the "cure" literature-theprescription of temperance for a healthy old ageand prolonged life, with an occasional flash ofinsight into the effect of mind on body. Plutarchadvised his ageing contemporaries to "keep yourhead cool and your feet warm; instead of employingmedicines for every indisposition, rather fast a day;and while you attend to the body, never neglectthe mind." The sixteenth-century "apostle ofsenescence," Luigi Cornaro (I467-I566), in hisSu-re and Certain Methods of Attaining a Long andHealthy Life,'5 written at the age of eighty-three,gives an evaluation of the methods he has used to

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July, I946 GERONTOLOGY 187reach and enjoy a ripe old age, in spite of havingbeen practically broken in health at forty. Hiswork, curiously sane among contemporaries resort-ing to astrology and witchcraft, preaches the samemessage of temperance and fasting.

Floyer's Medicina Gerocomica, which appeared inI724, was the first scientific treatise on Diseases ofOld Age. Present-day knowledge of senile diseasesis based upon Carl Canstatt's Krankheiten desh6herem Alters und ihre Heilung (I839), whichchecked the stream of thought that had outlinedsystems of hygiene based on observation but noton precise information. An important pioneeringeffort of J. M. Charcot, who in the late sixtiesinaugurated a course of study in senile diseases atLa Salpetriere, the home for the aged in Paris,resulted in the publication of his lectures in i867.i6His work is a milestone in old-age study, markingits complete emergence from speculative philosophyto the domain of science, with recognition of theageing body, not as an obsolescent machine, butas having its own type-physiology. Aware of theresponsibility of the trail-blazer, Charcot expressesboth humility and hope as he acknowledges hisdebt to the past and looks forward to the future:"Traditional ties are not sundered; the labour oftimes gone by is not lost; and we shall treasure upthe immense heritage which our predecessorsaccumulated in the course of centuries. Still itmust be confessed that new horizons have openedto us. . . ."I7The new horizons were defined and widened by

Nascher who, in I9I4, gave to the study a disciplineand a name by publishing a textbook entitledGeriatrics. The extended scope of his subject isindicated in his sub-title: "The Diseases of OldAge and their Treatment; including physiologicalold age, home and institutional care, and medico-legal relations."The medical study of old age was continued in

England by Robert Saundby,i8 Leonard Williams'9and others. Williams anticipates something ofthe principles of modern geriatrics by devoting hisbook to "the consideration of the best means ofarriving at old age, together with an inquiry intothe present position of some of the maladies ofmiddle age which militate against the attainmentof a reasonable span of life."'o But it was inAmerica that the subject took living roots.Nascher was followed by his pupil, Malford W.Thewlis, with Geriatrics: a Treatise on SenileConditions, published in I919. This was followedby a greatly enlarged second edition five years later,and in the war years third and fourth editions,"entirely rewritten" and "thoroughly revised" fol-lowed each other in close succession (194I and I942).In the same few years, symposium after sym-posium on the subject of ageing was held in the

name of medicine, science and public health.21In I939 appeared a vital book, Problems of Ageing,edited by E. V. Cowdry, in the form of a symposiummobilizing and integrating the work of specialistsin different fields. It was sponsored by the JosiahMacy, Jr. Foundation, in New York, which inearlier years was only interested in degenerativedisease.22 The development of interest from themajor pathological hazards to the wider biologicaland psychological aspects of the ageing-process issignificant. Still more significant is the appearanceof a second edition only three years later, withadded contributions on the psycho-social andeconomic aspects of the problems of ageing, notableamong them being one by George Lawton on"Psychological Guidance for the Aged," andanother by Edward J. Stieglitz on the "SocialUrgency for the Research." The pioneer inpsychological guidance to retard and even reversemental decline was Dr. Lillien J. Martin. Dr.Martin provided her own best case-historv bystarting, at the age of sixty-five, the San FranciscoOld Age Counselling Centre, where, until the timeof her death in I943, at the age of ninety-two, shewas still actively engaged in consulting work withaged clients. Her work is carried on and developedby Dr. George Lawton, founder and director of theOld Age Counselling Centre in New York.23 TheUnit on Gerontology of the United States PublicHealth Service published in I942 a survey of threehundred and five active studies in gerontologybegun or projected by American scientists. Dr.Stieglitz, who is consultant in Gerontology to thisUnit, in his introduction to a symposium ongeriatric medicine,24 emphasizes the importance oforientation of the biological, clinical and socio-economic aspects of the study of ageing man.The American branch of the International Clubfor Research on Ageing, founded in I939, hasannual conferences for the discussion and integra-tion of research of leading investigators in thisfield and has established a museum of seniletissues, clinical research on the effect of vitamins onold persons and, finally, a Journal of Gerontology.25

In this country there has been no such steadilyprogressive development in the study of ageing asin America. Nevertheless an increasing socialawareness of the presence, importance and magni-tude of that section of the population which is inthe higher age levels became evident in about themiddle of the war years, and the last two yearsha-ve poured forth a spate of newspaper corre-spondence,26 housing schemes,27 literature and'activities centred round the needs of ageingpersons.28 In the period of heavy air raids, theFriends' Relief Service rose to the occasion withprompt action for the removal of the aged fromthe target areas and the provision of homes and

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188 POST-GRADUATE MEDICAL JOURNAL July, 1946hostels. Other more official arrangements fol-lowed, all intended as temporary expedients.29But the emergency situation had brought tolight disconcertingly extensive evidence of uncared-for old age and the emergency expedients becameabsorbed with other age-conscious activities intothe beginnings of a long-term social work. Organi-zations, both voluntary and statutory, havingdirect contact with old people, began to drawtogether to discuss the common problem. TheNational Old People's Welfare Committee, estab-lished in I94I as a committee of the NationalCouncil of Social Service, gradually became moreand more representative of these organizations andin I944 became an autonomous body working inassociation with the Council. To-day there are 9regional and I20 local Old People's Welfare Com-mittees in different parts of Great Britain, engagedin setting up hostels, visiting the lonely, organizingHome Helps Schemes, meals services, social clubs,holidays, convalescent treatment, making repre-sentations to the local authority regarding housingof old people and drawing public attention to theneeds of old people by means of conferences,publications and exhibitions. An exhibition illus-trating work being done and still needing to bedone for "Old Age in the New World" was held atCounty Hall in March of this year. The report ofthe Assistance Board for I944 (published inDecember I945) is specially devoted to the condi-tions and circumstances of old-age pensioners.While the forces of social welfare are thus

mobilizing to provide palliatives for present ills, thespreading disease of old-age distress receives somecheck and relief but not cure. There is urgent needof finding roots and causes by deeper investigationand of integrating and co-ordinating all results, andso coming to a true cure of a condition of socialpathology. The first real impetus to the scientificexamination of old-age problems has been given byLord Nuffield, and later the Nuffield Foundation,who supported a scheme of clinical research workcarried out in co-operation with the London CountyCouncil at Tooting Bec Hospital;30 inaugurated, inco-operation with the Ministry of Health andAssistance Board, a country-wide survey of thecondition of old people;3, at the end of I944 madea donation of £3,000 which led to the establishmentof the Gerontological Research Unit at Oxford,with Dr. Korenchevsky as its head;3 z and early thisyear gave £20,000 to the University of Cambridge,on the strength of which the Psychological LaboFa-tory is undertaking, under the direction of Dr. F. C.Bartlett, investigations into the causes and resultsof ageing, and measurement of work efficiency andadaptability in relation to age.33 Now Dr. TrevorHowell who, on the basis of his work with Chelseapensioners, has contributed a good deal to en-

courage the co-ordination of geriatrics with institu-tional and home after-care, has been awarded agrant by the Nuffield Foundation, augmented bythe London County Council, for research intochronic pathological changes in the aged.34 Inmedical practice, the profession begins to recognizethat, by extending life and the proportion of thelong-lived, it has helped to create a situation withwide social and economic implications, and to takeits share of the responsibility. The changing age-composition of the population has focused greaterattention on chronic and degenerative diseases andon hospital and home care of the aged and infirm;medical officers are drawn into group surveys ofthe living conditions of their ageing patients.35In gerontology, as in other departments, medicinecan no longer remain an independent, self-containedinstitution but must be linked with other socialprocesses in the culture pattern.While the present preponderance of old and

elderly in the population is historically unique, theeffect of a rapidly changing civilization in preci-pitating a social problem in the form of a sectionof the community has had its parallel in Englishhistory. In the sixteenth century, the rise of thenew economy, the expropriation of the peasantryand the dissolution of the monasteries flooded thecountry with unemployed and unemployablethousands. While methods of driving and harryingcould be used with the so-called "sturdy beggars,"it was perceived that the so-called "impotentpoor," of whom the aged formed a great part,must somehow be provided for or disposed of.The Poor Law Relief Act of Elizabeth in i6oi wasthe first act acknowledging State responsibility inthe matter. There had been hospitals ("God'sHouses") in mediaeval times, maintained by theChurch, for the care of the aged and sick, ratherthan for their treatment, and many almshouseswere founded for the same purpose during thesixteenth century, when charity as a divine injunc-tion made good works a means of grace.

It is rare in the earlier philosophical and medicalliterature to come upon any reference to the agedas a group of people on the high age level. Thewriters are as a rule individuals themselves old,specially gifted, writing subjectively of their ownexperiences and for their own leisured kind. Onlythe remarkable Dr. John Smith of the seventeenthcentury, who only lived to be forty-nine and wrotehis Portrait of Old Age36 in his thirty-sixth year,shows any sympathetic consciousness of the de-pendence and helplessness of the greater group ofold people. "Let none," he says, "give over theirPatients when they come to be burdened withthe infirmities of Age, as though they werealtogether uncapable of having any good done untothem; . . . those that are negligent towards their

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July, I946 GERONTOLOGY 189Ancient Friends are very near to those inhumaneBarbarians and Americans who, with great pompand alacrity, both kill and devour them, thinkingthereby they perform a most charitable office indelivering them from those incurable maladieswhich will forever render them miserable." Atthe end of the same century, the reformer JohnBellers raises a voice for the welfare of the olderworker in his proposed College of Industry.: "thatas they grow in years in the Colledge, they shallabate an hour in a Day of their Work, and whencome to sixty years old (if Merit prefer them notsooner) they shall be made Overseers, which forease and pleasant Life, will equal what the Hoardsof a private Purse can give; and excel, in so muchas it hath less care and danger of losing."37The history of the care and treatment of the

aged groups of society is a history of opinion asto who is responsible-the family, the individualnearest of kin or of neighbourhood, the State, theemployer, private charity, the people-and in thenature of that opinion is reflected the economy,the sanctions, the experience, in short the wholeculture pattern of a given society. The answerwhich seems to be arising to-day to the questioningsof generations is that the aged, with proper co-operation from society, need no longer be thedependent group they have been made in the pastand can take over a great deal of their ownresponsibility and a share of the group-load with it.The centuries-old lament over impaired efficiency

and diminishing powers with agemg has at lastbecome outmoded. With the mobilization of alarge percentage of older workers in the war effort,there has been no time to listen to this complaint,unless to seek to improve matters.38 J. H. S.Bossard emphasizes the importance of rememberingthat the aged are not a separate entity in thecommunity but ourselves at a later date.39 Perhapsit is a significant symptom of the new attitude thatthe most active workers on old age problems inAmerica are shown, by a consultation of theAmerican Who's Who (I943) and curricula vitae invarious journals, to be almost all in the fifth decadeof their age. Dr. Martin Gumpert, the author of avivid and challenging book,40 warm with under-standing of the ambivalent nature and difficultiesof both the individual's ageing-experience and thereciprocal relations between the generations, an-nounces himself as forty-six at the time of writing.The recent exhibition of the Old People's WelfareCommittee at County Hall brought the lesson righthome by showing to the visitor as first exhibit,under the label: "Old Age in the New World"-amirror! Provision for old age is not all in pensionsand financial savings. It is in the years of maturitythat the best preparations are made to conservehealth and functional efficiency so that the later

years of life need not be made heavy and hopelesswith handicaps and impairments as of old. Theconcern of those who work to-day for old age inthe new world is to "add more life to the yearsrather than years to the life."41

BIBLIOGRAPHY AND REFERENCES

For the most recent, authoritative review of the position, see:i. CREW, F. A. E. (2946), Lancet, 1, 597.

See also:NOTESTEIN, W., etc. (I944), "The Future Population of Europeand the Soviet Union." (Especially chaps. iv and viii.) PrincetonUniversity.

POLITICALAND ECONOMIC PLANNING (April 1940), BroadsheetNo. I65.

2. Cf. SAMSON, E. D. (1944), "Old Age in the New World" (Targetfor To-morrow Series), London.

3. JUNG, C. G. (1933), "Modem Man in Search of a Soul," 225 ff.4. MARTIN, L. J., and GRUCHY, C. de (1930), "Salvaging Old Age,"

I5.5. OSLER, SIR W. (I906), "The Fixed Period," reprinted in Aequani-

mitas, 389.6. HUXLEY, ALDOUS (2932), "Texts and Pretexts," I49.7. ELLIS, HAVELOCK (1936), "Questions of Our Day," 230 ff.8. Kings I, chap. i.9. COHAUSEN, J. H. (Eng. tr. 744), "Hermippus Redivivus or the

Sage's Triumph over Old Age and the Grave."xo. HUFELAND, C. W. (Eng. tr. 2797), "Makrobiotie or the Art of

Prolonging Human Life."xI. BACON, ROGER (tr. by BROWNE, R., 2683), "The Cure of Old

Age and Preservation of Youth."I2. FLOYER, SIR JOHN (I724), "Medicina Gerocomica or the Galenic

Art of Preserving Old Men's Health."13. METCHNIKOFF, ELIE (Eng. tr. 2903), "The Nature of Man."

Idem (Eng. tr. 2907), "The Prolongation of Life."24. Notably:

LAURENTIUS, A. (I599), "A Discourse of the Preservation of theSight; of Melancholike Diseases; of Rheumes and of Old Age"(translated by Richard Surphlet, London).

LOWE, P. (I6I2), "Discourse of the Whole Art of Chyrurgerie,"London.

SMITH, JOHN (I666), "King Solomon's Portrait of Old Age,"London.

MEAD, RICHARD (I775), "Medica Sacra" (translated from theLatin by Thomas Stark).

JASTROW, MORRIS (I929), "The Gentle Cynic."25. CORNARO, LUIGI (I550), "Sure and Certain Methods of attaining

a Long and Healthy Life."i6. CHARCOT, J. M. (i88I), "Clinical Lectures on the Diseases of Old

Age" (translated by Leigh H. Hunt, with additional lectures byA. L. Loomis, London).

27. Idem.i8. SAUNDBY, ROBERT (I9I3), "Old Age, its Care and Treatment in

Health and Disease," London.I9. WILLIAMS, LEONARD (I925), "Middle Age and Old Age" (Oxford

Medical Publications).20. Cf. STIEGLITZ, E. J. (I940), Science, 92, 50o: "In man, probably

the most significant period of life for gerontologic study is latematurity, approximately the two decades between 4o and 60."

2I. E.g.: Medical Clinics of North America (I940), 24, I-I64. Amer. J.Orthopsychiatry (I940), 10, 2786.Univ. of Pennsylvania Centennial Celebration (Sept. 2940).Nat. Inst. of Health (May I94I), Washington.Amer. Chem. Soc. (Sept. 294I), Atlantic City.Chicago Med. Soc. (Dec. I942).

22. Cf. COWDRY, E. V., ed. (I933), "Arteriosclerosis: A Survey of theProblem."

23. MARTIN, L. J., and GRUCHY, C. de (I930), "Salvaging Old Age,"New York.

Idem (I933), "Sweeping the Cobwebs," New York.LAWTON, GEORGE (1943), "New Goals for Old Age," New York.Idem (April I944), "Mental Decline and its Retardation," in Scientific

Monthly (Washington), 323.24. STIEGLITZ, E. J., ed. (2943), "Geriatric Medicine," Philadelphia

and London.25. Brit. Med. J. (2945) II, 659.26. Cf. The Times (2945), July 7th, gth, zith, 12th, x4th, i6th, 27th.27. FITZGERALD, MARION (2944), "Housing with Amenities for

Elderly Women," in Friends' Quarterly Examiner, July 2944,177-283.

Public Assistance J. (June 25, I945), 377, "Hostels for the Aged."SCOTTISH HOUSING COMMITTEE (I944), "Planning our NewHomes," p. 26 et passim.

28. BUCKINGHAMSHIRE OLD PEOPLE'S WELFARE (I945),"Putting them on the Map," Aylesbury.

NATIONAL OLD PEOPLE'S WELFARE COMMITTEE (I946),"Old People's Welfare," N.C.S.S., London.

PECK, F. E. (2945), "The Recruitment, Training and Organizingof Voluntary Visitors to Old People," Manchester (Selnec House).

PLYMOUTH COUNCIL OF SOCIAL SERVICE (2944), "OldPeople's Welfare in Plymouth," Plymouth.

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190 POST-GRADUATE MEDICAL JOURNAL July, I946THOMASON, PETER (I945), "Old Age: A Burden or a Joy?"

Manchester.29. FRIENDS' RELIEF SERVICE (I945), "Hostels for Old People,"

London.RACKSTRAW, MARJORIE (I944), "An Old People's Hostel,"

reprint from Socia Work, N.C.S.S., London.30. See note 25.3I. Lancet (March 4, 1944).32. See note 25.33. The Times (Feb. 3, I946), etc.34. Lancet (I946), I, 595.35. BANKS, A. LESLIE (I945), "The Care of the Infirm and the Long-

Stay Patient," in Monthly Bulletin of the Ministry of Health andEmergency Public Health Service, 4, II2-II8.

Idem (Oct. 6, 1945), "Geriatrics: A New Branch of Medicine," inPharm. J., 158.

CAHILL, JOHN (Feb. 27, 1946), "The Last Stage of All: HospitalCare of the Aged," in Med. Press and Circular.

CREW, F. A. E. (I946), V. supra, note I.

HOWELL, TREVOR H. (I944), "Old Age: Some Practical Points inGeriatrics," London.

LEWIS, A. J., and GOLDSCHMIDT, H. (July-Oct. I943), "SocialCauses of Admission to a Mental Hospital for the Aged," in Socio-logical Review, 86-98.

WALKER, J. V. (I944), "Annual Report of the Medical Officer ofHealth," Ramsgate, 8.

See also: The Times (Feb. 9, 1946); Brit. Med. J. (Mar. 2, I946);Lancet (Mar. 9, I946), etc.

36. SMITH, JOHN (I666), "King Solomon's Portraiture of Old Age," I66.37. BELLERS, JOHN (I695), "Proposals for Raising a Colledge of

Industry of all useful Trades and Husbandry," 6, London.38. See STIEGLITZ, E. J. (June-July I944), "Senescence and Industry,"

in Scientific Monthly.39. BOSSARD, J. H. S. (I934), "Social Change and Social Problems,"

chap. xv.40. GUMPERT, MARTIN (I944), "You are Younger than You Think,"

New York.41. PIERSOL, G. M., and BORTZ, E. L. (I939), "The ageing process:

a medical-social problem," Ann. Inst.-Med., 12, 964.

INFANTILE ECZEMABy I. R. MARRE, M.R.C.S., L.R.C.P.

(Skin Physician to the Acton and Evelina Hospitals)This is a common disorder, which embraces

a number of different conditions, and in myexperience can most reasonably be divided up intofour unequal groups. These are:

a. Atopic or allergic group.b. Seborrhoeic group.c. Ichthyotic or Xerodermic group.d. Infected group.

of which the first two groups comprise by far thelargest number of cases.

I have found it useful to attempt to place eachcase in its special group, as treatment and prognosisvary a good deal. Occasionally one does seep;.tients who show characteristics of more thanone group, but this is by no means usual.

a. Atopic or Allergic GroupThis is the largest group and consists of those

children with true infantile eczema. There iscommonly a history of family allergy such asasthma, hay fever or eczema, and really severecases can give a history of allergy in the familiesof both parents.The child is well at birth but shows first signs

of skin trouble when about eight to twelve weeksold. This consists of a papular, papulo-vesicularor vesicular eruption involving the face and body,with a special tendency to affect the limb flexures.Typically a patch consists of an ill-defined ery-thema, closely set with vesicles, which is intenselypruritic and the child makes frantic efforts toscratch. Trauma leads to removal of the tops ofthe vesicles and to the exposure of a raw weepingsurface which becomes crusted with dried serum.Persistent rubbing and scratching lead to an ex-tension of the inflammation with infiltration andfissuring, and the child finally presents an ex-coriated, wizened, woebegone appearance that is

characteristic. The disease is persistent andchronic, and prone to relapses and recurrences,but there is often a spontaneous improvement orhealing towards the end of the second year.

It is in this group that eczematous infants mayexchange their skin condition for asthma or hayfever as they get older, and they may go on to thechronic atopic eczema of later childhood, adoles-cence and adult life, with thickening and lichenifi-cation of the skin flexures. It is in this group, too,that the eczematous infant will give positive skintests to proteins more frequently than in the othergroups or than in normal children, but in my viewthis sensitivity is not specific, since I have foundthat the skin in infantile eczema will tend to showa positive result to a large number of protein skintests, and that the withdrawal of these proteinsseems to make little difference to the course of thedisease. Occasionally one will find a child benefitmarkedly by the withdrawal of the protein towhich it is especially sensitive. Substances whichcommonly give positive skin tests in these infantsare Egg (particularly Egg-white), Milk, Wheatand Barley.

TreatmentThe importance of local treatment is hardly to

be overestimated, and all efforts must be made toprotect the infant's skin from the environmentalchanges to which they seem unable to adjust them-selves in their journey from the uterus to theoutside world.The infant must not be exposed to direct sun-

shine, strong winds or severe changes of tem-perature, and the temperature of the room shouldbe kept evenly about 700 F. Clothing should beloose, light and soft, and wool should never beworn next to the skin; smooth cotton garmentsshould be used in preference.

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