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would still be recruited from that source to act as astimulus to local talent. The commission foresees theday when the staff will be derived largely from graduatesof the colonial medical schools who have done post-graduate study in Great Britain ; but for some yearsthe council must look largely to the medical schools ofthis country for teachers. Those who are seconded,for short or long periods, from home universities willfind ample material for research, and not by any meansonly into tropical diseases, for the bulk of the diseasesencountered in the tropics are those familiar in Britain,with variations which would well repay observation.2 2

THE OLD IN AN OVERCROWDED WORLD

THE paper by members of the Glasgow outdoor medicalservice which we published a fortnight ago showedthat " with only a little effort" something could bedone -to make old age a happy and useful time, and thatsuch effort can be engrossingly interesting. At presentmany old people are in difficulties. When they becometoo feeble or ill to fend for themselves, places for themin hospitals and institutions are hard to find, and eventhose who can afford to pay for care may be in troublebecause they cannot run a house by themselves, yetcannot get a maid, and because (as a speaker said in adiscussion at Bath 4) "hotels do not like taking elderlypeople who may become ill at any moment." Provincialnewspapers frequently report great hardship amongthe elderly poor, whose failing powers are ill fitted tobear it. Thus we read of an 80-year-old woman, livingalone, found half conscious by the doctor ; of a man of76, bedridden, living alone ; and of an arthritic womanof 55, helpless and verminous, whose landlady wasunable to care for her. In both Surrey and Middlesex,the same journal says, the problem of housing thosewho cannot look after themselves has become urgent.Surrey has decided to spend f:300,000 in buying privatehouses which can be converted into hospital annexesfor chronically ill patients who need nursing but nomedical care ; and many of these will of course be oldpeople. The annexes will be small and homely, takingabout 50 patients, and, since they will be run by theparent hospital, the patients should be well nursed andmedical care will be at hand.

This plan, however, will not help either those solitaryold people who are getting too feeble to look after them-selves, or those whose increasing senile dementia is

penalising the children and grandchildren among whomthey live. Many institutions for the destitute have beentaken into the health service, and room in them for oldpeople is scanty, even if removal to an institution couldbe regarded as the happiest solution for the destitute.They themselves still dread it, as the Glasgow reviewshowed ; and it is noteworthy that only about a thirdof those studied needed hospital or institutional care.

Many could continue comfortably in their own homesif home-helps of a sympathetic type were provided forthem. Those who undertake such work, the Glasgowwriters suggest, could be outdoor staff of institutionsto which the old people could be admitted either tem-porarily or permanently when they needed nursing.Many old people need better quarters, and many othersneed help in replacing or improving the equipment oftheir homes. Like Dr. Curran and his colleagues, weendorse the suggestion, put forward by Emily D. Samson,in Old Age ,in the N e’l.t’ World, that local authorities shouldbe obliged to include plans for small dwellings for oldcouples and solitary old people in the proportion of10-15% of their total housing schemes. Each such

dwelling should contain its bathroom and indoor water-

2. See leading article, Lancet, Jan. 26, 1946, p. 132.3. Curran, M., Hamilton, J., Orr, J. S., Poole, W., Thomson, E. N.

Lancet, Feb. 2, p. 149.4. Bath and Wilts Chronicle, Dec. 4, 1945.5. Surrey Comet, Dec. 22, 1945.

closet, and the bath should have fixed handles for theold person to hold when getting in and out. Certainlyold people should not be banished entirely to the societyof their contemporaries ; as one frivolous old man putit, old age is catching. They need the society of youngpeople at times to cheer and support them ; and the

young need the mild tax on their sympathy and forbear-ance which age exacts. Nor must we go on thinking ofold people-especially women who often experience along and active old age-as socially useless. The Glasgowwriters would like them to have the chance of doingproductive work of an easy or interesting type, thoughonly to the extent which pleased and satisfied them.For those who must finally be given institutional care,small homely centres, taking only a few people, servebest ; and these should be near enough to their old

haunts-to shops and cinemas and Woolworths-tomake the change from the former life easy and support-able. The fear of being regimented, strong in our peoplethroughout life, can become a sort of passion in the old :for though they like a routine it must be their ownroutine ; they have little liking for discipline imposedfrom without, and should be spared it as much as possible.

Since nowadays even natural processes cannot escapethe scrutiny of preventive medicine, the Nuffield Founda.tion has offered the University of Cambridge 1:20,000(with a possible further 18,000) for research, underProf. F. C. Bartlett at the psychology laboratory, intothe causes and results of ageing. We may hope that intime this alternative approach may also provide know-ledge that will be useful in the field.

METHOD OF PAYING ALLOWANCES

FROM next August every mother of two or more youngchildren will be able to draw a family allowance. Butthere is still some uncertainty about the way in whichthe Government propose to distribute this money, andfor that matter some of the other allowances which areto be payable under social insurance. Hitherto, thebroad principle has been that a claimant (e.g., for old-agepension or war pension) selects a post-office at which hewill draw the cash. In due course he receives a book oforders, which he takes to the post-office-if possibleon the particular day of the week when this particularallowance falls due-and draws cash in exchange forone or more orders detached by the clerk. If amountshave not been collected in previous weeks they can bedrawn in arrears, provided each order has been signedby the pensioner in the place provided, something like13 weeks being allowed to accumulate in this way. If £the claimant cannot go to the post-office a deputycan draw the money if the necessary formalities are

complied with, including presentation of a certificate of £

physical inability to attend.Post-offices are widely distributed among the shopping

centres, and there are sub-post-offices in most villages.In theory every household must contain someone ableto do ordinary marketing, and this person will be ableto draw allowances at the same time. Of course, likeother theories, it does not always work out ideally inpractice ; but up till now there has been no considerablevolume of complaints. On the other hand, a busymother with children pulling at her skirts is apt to haveless leisure than an old-age pensioner, and it is to be

hoped that the Minister of National Insurance will beable to make arrangements that will avoid encroaching onit further. The regulations provide for payment bymeans of allowance orders at a post-office, or " in suchother special manner as the Minister may in any par-ticular case and for any particular period determine."To prevent delays at the counter, the post-offices mayneed enlargement of staff and premises, and there mightbe other places from which allowances of this kind couldbe drawn. Perhaps, too, the mother could be given the

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option of laying the money credited periodically to apost-office savings-bank account or a trustee savings-bankaccount.One of the arguments advanced in favour of post-office

cash payments is that the administration retains completecontrol of the operation and can-by a " stop " noticeto the post-office counter clerk-hold’ up the allowanceat any time if a query arises. But the proportion ofcases where people would deliberately draw an allowancebeyond the proper time (for example, after the death of £a child) must be very small indeed, and there is a strongcase for some relaxation of the standard system to enablepersons who cannot easily attend at the post-office tocash their dated orders in some other way, such as

through a friendly tradesman or a landlord. The orderscould then be paid into a banking account like postalorders, and, if stolen or irregular, could be traced back.The late Government, in their white-paper on Social

Insurance, said that " sickness benefit will be payable,according to the claimant’s choice, either by postal draftor in cash at the local office to a deputy appointed byhim, but where in the circumstances of his case neitherof these methods is appropriate it will be paid in cashat his home." Last week the Minister of NationalInsurance said he contemplated that the principal methodof claiming and paying sickness benefit will be " throughthe post," but the system must be elastic to meet indi-vidual needs, including for instance the payment ofbenefit in the home. He is evidently thinking of a

system whereby agents would in suitable cases take thecash to a bedridden patient, and in rural areas or in otherspecial cases the same kind of travelling agent couldperhaps be employed in taking family allowances or

other payments. For this purpose it would be possibleto select some local person who would not be a salariedemployee of the Government but might draw a smallcommission-not greatly exceeding the amount of com-mission payable to the post-office. The agent’s nameand address could then for all purposes be substitutedfor that of the local post-office, and payment could whennecessary be suspended by direct notice to him insteadof the post-office. Once a system of approved agentswas established there might be many ways in which

they could be of service to the local community bothin the distribution of claim forms and the making of £payments.

INNOCENT OR MALIGNANT?

WHEX the surgeon is consulted for the first time by apatient with a cancer which is already too far advancedfor a cure he often finds that the onset was so insidiousthat the patient saw no need for medical advice. Some-times the patient guessed the diagnosis and was afraidof having the guess confirmed. But in yet other casesa general practitioner was consulted much earlier andcould not be sure by clinical examination alone that thecondition was malignant ; whether because of the expenseof further investigations, or because the doctor hesitatedto raise unnecessary alarm, or for other reasons, he thendecided to defer an opinion until developments clearedaway the doubt. Such postponements may sometimeshave been pardonable in the past, but they will not beso easily overlooked in the days to come. The CancerAct makes financial provisions not only for those who

definitely have cancer but also for those who are sus-pected of having it. The Ministry of Health 1 remarks

that a high proportion of mistaken diagnoses will be asign of keenness and even efficiency in the practitioner,and will indicate effectiveness in cancer propaganda. In

many-perhaps in most-of the suspected cases the

complete diagnosis will rest on histology, and it istherefore proposed to establish a panel of consultant

pathologists to whom material from doubtful cases can

1. Mon. Bull. Min. Hlth, January, 1946, p. 2 .

be submitted. Such a plan will at least abolish the fearof expense as an excuse for delay. Some idea of thedifficulties that arise is given by Professor Stewart 2 inhis paper on conditions which may lead to a provisionaldiagnosis of cancer though they are eventually found byhistology to be innocent. The section on lesions of theskin contains no fewer than 32 conditions, and everypart of the body is considered in the same thoroughmanner. Altogether Stewart includes 129 differenttumours whose nature is apt to be misinterpreted onclinical examination alone.

POSTURAL HEART BLOCK

YET another pitfall awaits the unwary in the detectionof heart disease. The Canadian Air Force 3 have

reinvestigated the electrocardiograms of twenty healthyairmen who had previously been found to have a

prolonged P-R interval. In four of these men the pro-longation only occurred when they were lying down ; if

they stood up the P-R interval was within normal limits.The duration of the P-R interval in these four men inthe supine position was 0-28, 0-24, 0-24, and 0.40 second,while in the sitting position in all four cases it was only0-20 second. In none of the cases was there any appre-ciable change in the heart-rate on change of position.In the man with the longest P-R interval (0-40 second)atropine only reduced the interval to 0-36 second, butexercise in the supine position reduced it to 0-20 second.As a control thirty men with normal P-R intervals wereinvestigated, and in six of these a decrease of 0-02 secondin the P-R interval occurred on changing from therecumbent to the sitting position, but this was accom-panied by an increase in the heart-rate. Comparablefindings have been reported by Holmes and Weill inthree apparently healthy candidates for the AmericanAir Force. In one case the P-R interval was 0-36 secondin the supine position and 0-2 second in the erect

position, the comparable figures for the other two being0-4 (supine) and 0-16 (erect), and 0-36 (supine) and0-28 (erect). In two of the cases the change in theP-R interval was not necessarily accompanied by altera-tion in the ventricular rate, and in two cases atropinerestored the P-R interval to normal limits, while in thethird it only reduced it to 0-28 second. Pressure on the

right carotid sinus and on the eyeball reduced A-V con-duction time in two of these cases ; exercise reduced itin all three, but in the third it only fell to 0-28 second,which was therefore taken to be the physiological lowerlimit of A-V conduction for this man. No evidence ofheart disease could be detected in any of the three men,nor was there anything in their history to suggest cardiacdamage. Manning and Stewart suggest that the changesmay be due to an aberrant conduction pathway or tofluctuations in vagal tone, and it is noteworthy thattheir case which showed the greatest prolongation ofA-v conduction later developed a duodenal ulcer. What-ever the theoretical implications of these observations,however, they certainly emphasise that considerablecare should be taken in interpreting electrocardiographicfindings divorced from clinical observations, and theysuggest that in all patients in whom the electrocardiogrampoints to a partial A-v heart block the effect of postureon the electrocardiogram should be investigated.

Dr. R. D. LAWRENCE will deliver the Oliver-Sharpeylectures at the Royal College of Physicians on Tuesdayand Thursday, March 19 and 21, at 5 P.M. His subjectwill be : A case of lipodystrophy and hepatomegalywith diabetes, lip2mia, and other strange metabolicdisturbances suggesting a new aspect of insulin action.

2. Stewart, M. J. Ibid, p. 2.3. Manning, G. W., Stewart, C. B. Amer. Heart J. 1945, 30, 109.4. Hall, G. E., Stewart, C. B., Manning, G. W. Canad. med. Ass. J.

1942, 46, 226 (see Lancet, 1942, i, 538).5. Holmes, J. H., Weill, D. R. jun. Amer. Heart J. 1945, 30, 291.