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ceeded in demonstrating a communication with the

joint; and he attributed the formation of the lesions topenetration of synovial fluid, under pressure, into theinterstices of the bone, displacing the trabeculae and

compressing them into a dense wall reinforced by forma-tion of new bone. Landells suggested that enlargementof a cyst stops when its stoma is occluded, and that thecavity then fills up with granulation tissue. Freund 6

suggested several years ago the possible role of increasedarticular pressure in the production of defects in juxta-articular bone, but his hypothesis is difficult to prove.Vascular changes in relation to osteo-arthritic joints 7include a layer of large thin-walled anastomosing venulesinvesting cystic lesions.

6. Fruend, E. Edinb. med. J. 1940, 47, 192.7. Harrison, M. H. M., Schajowicz, F., Trueta, J. J. Bone Jt

Surg. 1953, 35B, 598.8. Reasons given for Retiring and Continuing at Work. London :

H.M. Stationery Office. 1954. Pp. 136. 5s.

WHEN PEOPLE RETIRE

THE more closely the retirement patterns of our

society are examined, the more artificial and confusedthey seem. The Ministry of Pensions and NationalInsurance, in a new inquiry 8 covering 29,000 insured menand women who in October, 1953, were taking theirpensions either at minimum pension age or later, or whowere staying on at work though just reaching pensionableage, found that 40% of the men took their pensions atsixty-five, and 58% of the women at sixty. More than aquarter of the men who retired at the minimum agesaid (and their employers confirmed it) that they hadbeen required to leave, usually because they had reachedthe official age-limit in a pensions scheme. Governmentpolicy nowadays encourages us all to go on working aslong as limbs, eyes, hands, and wits can serve the country ;yet it is noticeable that the proportion compulsorilyretired at a fixed age was highest among those employedby various public services-railways and other transport,gas, electricity, water, and local and national governmentservices. Other occupations tending to have a fixedretiring age included insurance, banking, and finance,and the chemical and allied industries. On the otherhand, in occupations where physical strain is known tobe great (and where there might be something to be saidfor a fixed retiring age) the trend is reversed : the propor-tion of men compulsorily retired was lowest amongagricultural workers, foresters, fishermen, and miners. It

might be supposed that a fixed retiring age was alwayslinked with an employer’s pension scheme, but even thisrule does not hold. Thus, less than 3% of agriculturalworkers are covered by such schemes (as against wellover half of those employed by local government, gas,electricity, or water services, or by the chemical indus-tries) ; but over 88% of miners are so covered (as againstless than 40% of railwaymen and other transport workers,and national government servants).The highest proportions of men giving strain or ill

health as a reason for retiring at the age of sixty-fivewere found not among miners and those in heavyengineering but among self-employed workers, unskilledworkers, transport workers other than railwaymen,agricultural workers, foresters, fishermen, local-govern-ment servants, and those engaged in retail distributionand catering. Only 14% of the men and 20% of thewomen retiring at the minimum age had asked theirdoctors’ advice about it. Of those-men who gave ill healthor strain as a reason for punctual retirement, nearly athird had no record of incapacity for work during the threeyears and eight months before the inquiry, and gettingon for two-thirds had had no such record during the eightmonths preceding retirement. This opinion, in fact, wasoften not based on medical evidence : it was subjective.Retirement among railwaymen sets in early and dras-

tically : nearly three-quarters of them have left by theage of sixty-five and a half, and nearly 95% of them by

the age of seventy. Among those who run them close inthis respect are local and national government servants,and those employed by the water, gas, and electricityservices. 1Iiners last out much better : by sixty-five anda half only just over a quarter of them have retired, andnearly a fifth are still at work at seventy. The professions,too, retire relatively late : less than 45% give up at theminimum age, and more than a quarter are working atseventy. Those engaged in the clothing trades showgreat staying power, nearly 40% of them being still atwork at seventy. They are almost, but not quite, matchedby those employed in metal manufacture, heavy andother engineering, shipbuilding, manufacture of non-

metal mining products other than coal, printing, and thetextile, furs and wholesale distribution trades.

Onlv women insured on their own account were

studied in this inquiry, and a quarter of them had givenup work more than five years before it was made, so thefindings about them are not comparable with those aboutthe men. The main reasons for retiring at minimum age,however, were the same for the two sexes : " employer’saction " (28% of men and 14% of women), and " strainand ill health " (28% of men and 30% of women) ; 25%of men and 14% of women were already among the chronicsick when they reached retirement age. The reasons givenby both sexes for staying on at work were also much thesame : " financial need " (45% of men and 54% of women)," fit enough to work " (25% of men and 10% of women),and " prefer to work " (20% of men and 29% of women).The increments to the National Insurance pension,

which can be gained by working after the minimum retire-ment age seem to have moved less than 1% to continue.On the other hand about a quarter of the men still atwork said the increments had influenced their decisionto continue. Three-quarters of those retired compul-sorily would have been willing to go on working fortheir old employers and most of them would have beenwilling to adapt themselves to other work.

Clearly the age of retirement from different occupationshas little to do with the strain they impose, or the

capacity of the worker to carry on : retiring age is fixedeither by an employer’s pension scheme or by thetraditions of the particular occupation. Miners, farmhands, fishermen, foresters, and engineers all have a

tradition of carrying on ; and while it is true that theseare all hard or daring jobs, calling out the best in men, wemust also bear in mind that those engaged with clothing,furs, and textiles are equally game and obstinate ; where-as that lone and independent wolf, the self-employedworker, closes down early.

1. Beaumont, W. Experiments and Observations on the GastricJuice, and the Physiology of Digestion. New York, 1833.

2. Faber, K. Gastritis and Its Consequences. New York, 1935.3. Schindler, R. Münch. med. Wschr. 1922, 70, 533.

GASTRITIS

GASTRITIS has never been a very satisfactory clinicaldiagnosis. The circumstances which in 1833 affordedBeaumont the opportunity of studying directly thereactions of the stomach-lining of his patient St. Martinmust surely have been almost unique, and in any eventhis observations related to normal rather than to disturbedfunction. Formerly pathological investigation of thestomach was severely restricted by the autolysis of thegastric mucosa which sets in rapidly after death ; andeven the researches of Faber,2 who contrived to checkpost-mortem changes by the intraperitoneal injection offormalin, still left the clinical picture uncertain and

incomplete. Sections taken from operation specimenscould be assumed to show more clearly the effect of

surgical manipulations than the marks of disease.The evolution by Schindler 3 of a safe gastroscopic

technique, by which the lining of the stomach can bedirectly examined during life, opened a new chapter inthe study of gastric disease ; and there seemed to be goodreason to believe that we would quickly solve the puzzle

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of gastritis by carefully matching the clinical pictureagainst the gastroscopic findings. In the early days thewide variations in the appearance of the healthy gastricmucosa were often misinterpreted, but as experienceincreased it became possible to put all cases of chronicgastritis into one of three groups : chronic atrophicgastritis, chronic superficial gastritis, and chronic hyper-trophic gastritis.4 4 But it was the introduction of thevacuum-tube biopsy 5 technique, by which adequatesamples of the gastric mucosa can be obtained in healthand disease, that gave promise of a precision in diagnosisthat had hitherto been largely lacking. Palmer,6 whohas already contributed richly to our knowledge of gastricdisease, has now reported his experience of over 1200 ofthese biopsies, and on the basis of his inquiry to datebravely asks for a complete revaluation of gastritis.On acute gastritis he makes many interesting observa-

tions. To one who miserably endures a " hang-over " it

will be no surprise to learn that the gastric lining isseverely affected by a night’s heavy drinking. Thenecrosis of the cells of the neck of the glands, whichleads to the exfoliation of a surprisingly normal super-ficial epithelium, is of the same order as that seen in acutestaphylococcal food-poisoning. Speedy and completerecovery is the rule. There is, in fact, good evidence forbelieving that the mucous lining of the stomach is

constantly being " superncially eroded from time totime quite subclinically and ephemerally." The tippler,too, can take solace from the evidence of pathology,which in no way confirms the widely held belief thatchronic alcoholism leads to chronic gastritis. But to theclinician chronic gastritis is the more vexing problem.It is good to learn that when the gastroscopist, lookingdown at a slate-grey translucent mucosa through whichhe can readily see the vessels in the submucosa, talks of a" chronic atrophic gastritis," he is in fact accuratelydescribing the histopathological changes : " basicallythe gastroscopist and pathologist seem to be talkingabout the same disease." Gland atrophy, which is themost striking feature, is probably irreversible. It is,moreover, as true of this form of chronic gastritis as ofany other that it cannot be explained on the basis ofchanges resulting from an acute process. On the otherhand, the histopathological findings in no way supportthe not-infrequent gastroscopic diagnosis of " chronichypertrophic gastritis " ; and a considerable amount ofcircumstantial evidence points to this being no morethan a sign of hypertonicity of the stomach wall. " Itappears, in other words, that the symptomaticallyimportant form of ’ chronic gastritis’ is not gastritis atall, but functional disease characterized by a tensestomach." The gross appearance of chronic superficialgastritis is distinct enough, with patchy mucosal hyper-semia, tenacious mucus, and scattered erosions. The

histopathological changes, however, vary widely. As inthe acute form of the disease, it is the cells of the neckof the glands that seem to be most vulnerable. In the

early stages degenerative changes in this region are clearlyapparent ; but later there are signs of epithelial regenera-tion-a feature much in evidence in the gastritis which isconstantly found as a sequel to gastro-enterostomy or togastrectomy. Chronic superficial gastritis seems mostoften to lead to complete atrophy of the gastric glands(chronic atrophic gastritis) and occasionally to the

subsequent development of long thin glands.Although this fascinating attempt to unravel the

mysteries of chronic gastritis has brought to light newbits of knowledge and challenged some earlier concep-tions, it underlines once again the inadequacy of ourknowledge of what we continue with proper humility tocall " idiopathic gastritis."4. Schindler, R. Gastritis. London, 1947.5. Wood, I. J., Doig, R. K., Notteram, R., Hughes, A. Lancet,

1949, i, 18.6. Palmer, E. D. Medicine, Baltimore, 1954, 33, 199.

LIFE-ASSURANCE UNDERWRITING

To be classed for life assurance as an " impaired life "is sometimes surprising and always discouraging. Manyan impaired life must have wondered how a companyassesses the extra premium required for his policy. Howin fact does an actuary decide what extra premium, ifany, is called for by a given impairment or combinationof impairment *? He may, now and then, look atAmerican statistics ; in Great Britain there have beenno statistical inquiries into the extra mortality of under-average lives, classified by the causes of impairment. Inthe main he follows the tradition of his office, which atleast gives consistency. He asks the chief medical officer,whose advice is based on his impression of current medicalopinion-a shrewd guess at what statistical inquirymight reveal. The assessment of under-average livesin the light of modern knowledge was fully discussed ina paper 1 to the Faculty of Actuaries last February, bya physician and an actuary with great experience in thisfield-Dr. A. Fergus Hewat and Mr. Colin S. Penn.Actuarial opinion is acutely divided on the value ofstatistical studies of the mortality of impaired lives.Fergus Hewat and Penn take the view that on the wholesuch studies would have little or no value beyond securingsimilar treatment by all offices of a given proposal.Some 50% of these under-average lives are so classed

because of overweight, hypertension, or peptic ulcer.Except perhaps for short-term endowment policies, allproposers whose weight is more than about 20% abovethe average are rated up. The conviction that an extrarisk is involved is based on American statistics which seemto show an excess mortality in this group. But thereseems to be a case for compiling fresh statistics, separatingthe obese from those with heavy bone structure. With

regard to blood-pressure little is really known about thenormal ranges at various ages, or of the effect on mortalityof raised pressures without other abnormalities. Duringthe past thirty years most offices have taken 140-150mm. Hg as the upper limit for systolic pressure, and90-95 mm. Hg as the upper limit for diastolic pressure,irrespective of age ; and the practice of one office, withregard to the diastolic pressure, seems to be that " 90passes, 92 is suspect, and 95 is out." Actuaries complainthat medical guidance is not clear ; and certainly here,if anywhere, is a case for statistical analysis.When we look for the effects of recent advances on

life-assurance practice, we find that they are surprisinglyfew. It would seem that easier terms are now offered to

people with a history of duodenal ulcer; but com-

paratively few of these are accepted without extra

premium. Therapeutic advances have brought more

liberal treatment to proposers with a history of amoebicdysentery, chronic otorrhcea, osteomyelitis, or syphilis.Some offices will now give terms to people with milddiabetes ; and most will accept at normal rates peoplewith renal glycosuria. Anaesthetic risks are now dis-

regarded by some offices. In recent years a history ofpsychoneurosis has been viewed more leniently. Spon-taneous pneumothorax, regarded twenty-five years agoas almost invariably a manifestation of tuberculosis, isno longer a bar to acceptance at ordinary rates after aninterval in which no evidence of tuberculosis has beenbrought to light.

This review should prove of great value to thoseconcerned with the day-to-day problems of life assurance.The impact on them of medical progress in the last quarter-century does seem depressingly small. One cause may bethe lack of exact statistical data. As Mr. G. A. Kingsnorthremarked, in discussing this review, an actuary wouldlike to be able to assess the risk in a group of lives similarto the life that is being assessed. Without such statisticaldata life-assurance practice will remain empirical.

1. Trans. Fac. Act., Edinb. 1954, 22, part 4 (no. 181).