CHAPTER V. Medical Views and Treatment of Old Age

MEDICAL VIEWS AND TREATMENT OF OLD AGE

The self-knowledge that doctors give--Insidious approach of many diseases--Medical views of the old age of body and mind (senile dementia)--Charcot--G. M. Humphry--Sir James Crichton-Browne--H. M. Friedman--H. Gilford--H. Oertel--A. S. Warthin--W. Spielmeyer--I. L. Nascher--Sir Dyce Duckworth--Robert Saundby--Arnold Lorand--T. D. Crothers--C. G. Stockton--W. G. Thompson--M. L. Price--G. S. Keith--J. M. Taylor--C. W. Saleeby--C. A. Ewald--Raymond Pearl--Protest against the prepotence of heredity in determining longevity.

By an instinct that is very deep and strong most old people shrink from realizing just what their stage of life is and means, although most are ready enough to discuss such symptoms as are forced upon their consciousness. Disguise it as we will, old age is now only too commonly a hateful and even ghastly thing. Even those most garrulous and pessimistic about their infirmities are often prone to an almost fetishistic focalization upon certain symptom-groups of their own to the neglect of others by the same mechanism by which general anxiety may come to a head on a single phobia, which is thus exaggerated, because all the affectivity of their more general state finds an outcrop in some special fear. This mechanism is the same, too, as that by which love may find a vent for itself in some amatory fetish. Few, indeed, are the old men, and perhaps fewer still the old women, who do not seek to seem to others younger than their real physiological age, and all even to their innermost selves are prone to dwell more on what the great deprivator leaves behind than on what he has taken away. Childhood and youth long forward, old age longs backward.

Wishing to really know myself as old, I subjected myself upon my retirement to the examination and tests of some half dozen medical experts for eyes, ears, heart, lungs, digestive tract, kidneys, and even sex, but was surprised to find how hard it was to do so. A strong minority of my impulses preferred the ignorance that is often bliss. There are no mental tests of generally recognized validity above the teens, so that we have no criteria for determining psychological age for even the elderly, while psychoanalysts refuse on the express authority of Freud to take on patients over forty. When it was well over I was glad, for most organs and functions were found to be in fair condition, although one was in need of some special care. I realized anew, however, that there are no gerontologists, as there are experts for women, children, etc., and that barring acute attacks I must henceforth, for the most part, be my own physician and that I must give far more attention than ever before to keeping well and in condition. Body-keeping for the old is a very personal and pressing problem requiring much time and attention, and the methods that are successful differ so widely that the diet and regimen good for one might be dangerous, if not fatal, for another. But my chief interest for months centered in rather voracious medical and psychiatric literature upon senility and its disorders till my friends thought me in danger of growing morbid and predicted and feared hypochondria. Gruesome and depressing as it all was, it had nevertheless a certain grim fascination to know what a cohort of disorders encamp about and prey upon the aged, any group of which is liable to assail and perhaps take the citadel of life by storm. Evasion of these enemies gives a new sense of heroism.

Rheumatism, lumbago, varicose veins, calcified arteries, compensated for by enlargement of the heart, its valvular leaks and weakness, high abnormal blood pressure, adiposity or progressive emaciation, shaking palsy, cramps, bronchitis, asthma, shortness of breath, gout, stone, Bright’s disease, diabetes, constipation, piles, hernia, prostate troubles, tuberculosis, cancer, dyspepsias, flatulence, nausea, vertigo, flaccid and atrophied pudenda, feeble voice, defective sleep, failing eyesight and hearing, weakness of muscles, gaps in dentition, rather more hygienic than the complete edentate state; and beyond all these and many more the certain prospect of death just ahead or around the corner, liable to come from many of these causes or from any one of them already so well advanced that to know is no longer to prevent it--these are the things the old face if they have the courage not to flee from real facts. One or more of these maladies is sure to strangle, starve, bleed, poison, or paralyze us suddenly or slowly, and that ere long. Some of us will die from the top down with dementia more or less developed, while for others some vegetative organ will collapse and drag down with it all the rest of our powers, which might otherwise go on for a decade or two. These are the things that often make the old pessimistic. They are the secrets of age that must be kept from the young lest they interfere with their joy of life and which religion and philosophy have done their best from the beginning of history to mitigate. Thus the soul of the old, when it confronts the sternest of all facts at close quarters, grows more and more prone to seek diversion than consolation, for the former in fact is the chief resource of senescence although, as I shall indicate later, modern science is slowly evolving a third and better one.

Meanwhile, since medicine is far from having yet developed any systematic or coherent gerontology, although it has marshaled many facts and given us many hints toward such a science, it has seemed to me that in the present state of knowledge I can serve the reader better by epitomizing, without any attempt at systematization that would be certainly premature, the aperçus and the standpoints of those who seem to me in recent years to have written more wisely than others upon this theme, as follows.

The only attempt at a history of what medicine has done for old age that I can find is in an old book by Charcot in which he attempts to list and characterize the far too few studies of any importance made upon the subject up to that date. He urges that medical science should give far more attention to it.

Dr. G. M. Humphry gives us a memorable study of five hundred old people of over eighty years of age, including an equal number of males and females. He stresses the fact that the descending changes of development are just as orderly as its earlier ascending phases and that civilization enables us to see far more of the natural processes of senescence than was possible when the conditions of life were ruder, for we can now promote the powers of self-maintenance to a degree impossible before. “The chief requisite for longevity must clearly be the inherent or inborn quality of endurance, of steady, persistent, nutritive force, which includes recuperative power and resistance to disturbing agencies and a good degree of balance between the several organs.” That is, each must be sound in itself and have due relation to the strength of other organs. “If the heart and digestive system are disproportionately strong, they will overload and oppress the other organs, one of which will give way.”

His findings indicate that both men and women of average size and stature live longer than those much larger or smaller. He thinks, too, that there must be some trait associated with the development of the tubercle bacillus, “which is not only not incompatible with longevity but is not infrequently associated with it”; and this condition he found in eighty-two of the cases he studied. Most of them belonged to long-lived families, had enjoyed good health, appetite, and digestion, had taken little medicine, eaten little meat, been only very slightly addicted to alcohol, had been good sleepers, and rarely suffered from long or exhausting diseases. Most had been much out-of-doors. The average number of teeth in all these subjects was six for men and three for women, and only fifty-seven were entirely without them. The upper or alveolar part of the jaw tended to be absorbed and only the later, firmer growth of the lower part of it to be retained. In primitive man probably loss of teeth would materially shorten life. The skull, which generally becomes lighter, may also sometimes become heavier and increase inwardly as the brain shrinks. The rate of the heart varies very little as age advances. From eighty to ninety years he found it averaged 73–74 beats per minute in men and 78–79 in women. Respiration was 19–20 times per minute and, like the heart, was very slightly accelerated, although the respiratory change might be due to the prevalence of bronchitis in old people.

He found little tendency to senile dementia and many of even the very aged had their mental faculties intact and took a keen interest in passing events, possessed clear judgment, and were full of thought for the present and future welfare of others. “It is no less satisfactory to find that the active, even severe and long-continued intellectual activity of the matured brain seems in no way to impair its enduring qualities, and that good, earnest, useful employment of the body and mind are not only compatible with but even conducive to longevity.”

Of 157 of the males who replied, only six had ever had diseases of the prostate or bladder, so that in general he thinks that “the aged body does not seem to be, on the whole, prone to disease.” Few of his returns indicate the presence of any special malady. “We know that even cancers, when they attack old people, often make slow progress in them and sometimes fail to make way at all, remaining stationary or even withering, and the susceptibility to contagious disease appears to decrease from infancy to old age. Quite as remarkable is the fact that recovery from wounds, fractures, or operations, seems to be quite as rapid, and sometimes more so than in middle age. Indeed, wounds in the old heal very quickly provided they do not slough, indicating two opposite tendencies.” He also finds evidence of greater vital energy in parts nearest to those diseased provided they are able to live at all, as if nature had recuperative processes of stimulating parts adjacent to lesions. He chronicled few more surprising results than the infrequency of sclerosis.

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Sir James Crichton-Browne’s long article is a classic and is based on very comprehensive statistical and other studies. He tells physicians that it should be their great aim to grow old themselves and to be the cause of old age in others. The marked increase in the duration of life in recent decades has been almost entirely confined to its early stages. After 45 the decline in the death rate has been insignificant; and after 65, as we have elsewhere seen, it has actually increased. Thus the proportion of men ripened by experience has in fact declined. What carries off the old? Not fever, smallpox, or phthisis chiefly, as was once the case, but the following in order of frequency: cancer, heart diseases, nervous troubles, and kidney complaints, and these are all degenerative diseases due not so much to intemperance as to the new strains of modern life, which are less felt in the country and less by women.

Society needs to have life lengthened instead of abbreviated at its extreme end but men and women to-day are growing old before their time. We often have deaths reported to be from old age between 45 and 55. Indeed, atrophy and debility often come prematurely. The long-sightedness of old age seems to begin earlier than it used to do and the increased number of those who wear glasses cannot be entirely explained by better diagnosis. It is quite clear that those who live in hot climates show these optical symptoms of old age earlier than Europeans. The teeth, too, are certainly degenerating earlier than formerly, and early baldness is probably increasing still more. Senile insanity or atrophy of the brain is certainly more common and appears earlier. It abounds in our metropolitan asylums where human wreckage accumulates. Very many enter the outer circles of melancholia without proceeding to dementia and still fewer proceed to suicide, the rate of which is also rapidly increasing after 45. Touches of this kind of depression are very often felt at the turning point of life or soon after, perhaps at the first discovery of gray hairs, and many are tormented in private and perhaps in the silent watches of the night by the realization that youth is leaving them. Such, however, is the law of nature, for even the stars and planets grow old, as we know by their spectra. The voice is not normally shrill or quavering but may be very strong unless the crop of wild oats, which always ripens in later years, is too rank. Conscience may awaken near the turn, especially if too many dregs have accumulated in the cup of life or the machinery has been overstrained. The fact is, the infirmities often attached to age may, each of them, in single cases be absent, so that typical old age is rare, and any one of them is far less prevalent than is generally supposed.

Our life is made up of a series of evolutions of a group of different functions that develop serially, beginning at different age epochs, reaching their maximum vigor, and then declining. The hyaline cartilage dies of old age when bone is formed of it, as the milk teeth do. The thymus gland has completed its growth at the third year and slowly atrophies with every sign of age. The nervous system has the most sustained evolution. The infant, child, youth, are learning higher coördinations, and the psycho-motor system is not completely evolved till the end of the teens. The hand and arm centers continue their development and do not attain their perfection before thirty. The writer studied workmen in various factories and found that in many cases proficiency in manipulation grew for a decade and then became stationary at thirty, beyond which it could never be increased, and later declined. This decline took place sooner in highly specialized than it did in more general movements. In some artists, however, manual skill may increase to a great age.

In the brain centers that preside over language there is continuous development, so that it has been carefully estimated that our powers of expression culminate between 45 and 55. Demosthenes’ De Corona, his masterpiece, was delivered at the age of 52; Burke’s impeachment of Hastings, when he was 58; and many authors have thought their vocabulary and command of language at its best during this decade. After this, faint symptoms of aphasia and amnesia begin to show themselves. But it is in the frontal lobes, in which it is now believed that the powers of attention, reason and judgment are located, that the acme of development comes still later, perhaps in the decade ending at the age of 65. Indeed, Moebius and others have shown that the cortical layers believed to be most closely associated with mentation are still developing as late as the age of sixty-three. Bacon produced the first two books of the Novum Organum at 59; Kant’s Critique of Pure Reason was produced when he was 57; Harvey’s great work on the circulation, when he was 72, etc. It is certain that long after memory of names and physical vigor have begun to abate, the power of comparison, inference, and above all a moral sense, which is perhaps the finest and latest of all our powers, comes to full maturity.

The ideal of a greater old age is not an idle dream and Browne insists that physicians should strive themselves to live to be 100 and to make their patients do so. The best antiseptic against senile decay is, he thinks, active interest in human affairs. This, at any rate, should be our working hypothesis. A man of 80 should realize that he has one-fifth of his life before him. He tells us of a man of 84 who attempted suicide because he could no longer support his parents, and of another of 102 who had undergone a successful operation for cancer of the lip without anæsthetics. Of course, senile involution, when cell growth is more than counterbalanced by cell decay, is the natural pathway to death, and a man ultimately dies of it when there is no question of disease. But the brain, like the lens of the eye, may become flatter and more longsighted, focusing better on objects far than those that are near. There is no short cut to longevity. Its achievement must be the work of a lifetime. Sympathy, which goes far deeper than courteous manners, is fundamental for the successful treatment of old age.

H. M. Friedman begins his comprehensive treatise with biological and embryological considerations, and here perhaps he makes his most original suggestions. The higher the plane of the animal, the more marked is cell differentiation or specialization and this affects most cells. Once a degree of differentiation is observed, no backward step to a previous state of generalization, regeneration, or rejuvenation is possible. The higher the ascent of the cell in the plane of differentiation, the lower is its power of rejuvenation. Connective tissue, muscle fiber, and cylindrical cells are the least differentiated and therefore have the greatest power of regeneration. Nerve cells have the least because their work is of a high order and they are most specialized. Nerve fibers are mere conductors and they and epithelial cells have probably the greatest power of regeneration.

Again, the more differentiated the cell, the more rapid is its development, early decline, and death. Precocity even of the separate cell purports early maturity. “So senescence is an increased differentiation of the protoplasm, while rejuvenation is an increase of the nuclear elements at the expense of the protoplasm.” The increase of nuclear material allows fission and the formation of new cells. Thus the degree of differentiation is greatest as fission or mytosis is least. The power of regeneration is in direct proportion to the power of cell fission. Thus “the greater the cell differentiation, the smaller the mytotic index.” With maturity the decrease of the mytotic index, or the number of tissues into the composition of which the cell can enter, becomes restricted. The cells in the original germinal layer have before them the possibility of entering into the structure of any tissue, but as cells differentiate the germinal layers take on a more structural character and leave the field to the entrance of cells into different tissue formations more restricted, since during development the number of tissues yet unformed or undifferentiated becomes less and less and once a cell has assumed a personality it must continue to follow it up and cannot diverge from it. This is the law of genetic restriction. The younger the cells, the greater their multiplying power and the greater the tissue possibilities they can choose. Hence morbid tumors are formed from young cells of higher mytotic index whose genetic restriction has not progressed far enough to inhibit range and rapidity of growth. Before genetic restriction young cells may become one tissue or another. Injuries causing cell degeneration of the young cells are often, therefore, the seats of morbid growths. The young or undifferentiated cells forming malignant amorphous tumors and growing in tissues alien to them develop rapidly, probably because they are deprived of the “social” restriction to overgrowth that they would have in their own cell society. Thus the presence of young cells in out-of-the-way places or where older and more differentiated cells would be expected should excite suspicion. “Young cells, like young children, are safest among their own.”

Generally a cell in an organism lives long enough to reproduce its kind; else the species would die and death does occur in many lower organisms immediately after ovulation. The young thus grow rapidly, while old age is the period of slowest growth; and indeed the rate of growth depends upon the degree of senescence. The tendency to senescence is at its maximum in the very young and the rate of senescence diminishes with age.

As to the cause of senility, physiologically it is desiccation. At birth there is most fluid and gaseous material, but organization demands solidarity. Lactic acid may retard the growth of intestinal flora and the up-keep of the intestinal toilet by larvage. Intoxication of some kind is a factor in many of the changes accompanying senility. Lorand thought age was chiefly due to atrophy and degenerative tissue by failure of the function of the ductless glands, especially the thyroid. The myxedematous look and are old. Thus the limit of life is a matter of excretion. The special organs of elimination cannot act to their full capacity or to that of vital necessity because of the replacement in senility of parenchyma by fibrous or fatty tissue. The retained waste products increase the sclerotic changes and produce a vicious circle--irritation, intoxication, and atheroma. The degeneration of the first stage produces insufficiency of the organs of elimination and the degeneration of all organs.

As to physical manifestations, there is atrophy of the higher and more specialized cells and they are replaced by hypertrophied connective tissue. The heart is enlarged but this is compensatory for the stiffening and narrowing of the lumen of the great vessels near it and so the blood pressure is increased. The changes in bone, ligament, and tendons are extreme, with increased enervation throughout the body and perhaps senile marasmus, which may bring extreme emaciation or osteomalacia and even bone deformity. This may affect nervous and mental elements, like senile asystole and changes in the blood. The temperature, however, is not affected.

As to mental manifestations, this author says they are extremely variable, insidious, and have a very wide latitude. The vitality of the mind should be far greater than that of the body. Old age dulls conscience, may bring vanity and new ambitions, petulance, irritability, misanthropy, and slows down activity. But the best average barometer of mental failure is memory, the loss of which comes as an advance guard of many symptoms. The old have no faith in the young, for example, Virchow and Agassiz would not accept evolution. There is a universal tendency to overeat, although we should “descend out of life as we ascended into it, even as to the child’s diet.” The first sign that food must be reduced is increased blood pressure. If only lower ideals were exercised in early life, the reversion is ominous. Age is never chronological except in the legal sense. It is often called a vascular problem. The old have immunity from certain diseases such as eruptive fevers, typhoid, phthisis, and old tissues do not seem to be good media for these disease agencies, but age is very prone to pneumonic infections and erysipelas.

As to premature senility, in general its symptoms are identical with those of mature senility. The old are particularly prone to flush under very slight emotional strain and cannot throw off care or control patience. As to the causes of premature senility, abuse rather than use is the key. There is an unhealthy tendency to force decline by overtaxing the body and the nerves. It is those who do this who take the pace that kills, taxing themselves beyond their capacities. Alcohol and syphilis are specific forerunners of arteriosclerosis but overeating is worse than alcohol, especially of meat. “Most people eat about twice as much as they need, and the high cost of living is the high cost of overeating.” The dietitian’s table of food values should always be consulted but there has to be wide latitude for individual adjustments. Modern efficiency ideals bring high pressure. Change is the greatest regulator. We now relegate older men to innocuous desuetude to give the younger a chance to forge ahead.

As to the proper sphere of the aged, there have been opposite views. Perhaps there are no more than five hundred really great men in history who were clearly above mediocrity. Galton thinks 70 per cent of their work was completed before 45, and 80 per cent before 50. Dorland analyzed four hundred celebrities and concluded the average age of the commencement of their activities was 24 years--in musicians perhaps as early as 17 and scientists at 32. Science is hard and requires a large fund of experience and knowledge. The greatest average for activity in all endeavors together is about 40. To enjoy life after 40 one must have attained some degree of success, for the saddest thing is to reflect on many years of effort and no accomplishment.

As to medico-legal aspects, eccentricities may prevent the aged testator from being allowed the right of testament, but in general the mental symptoms of advanced senility differ from senile dementia only in degree.

As to the future of old age, those who are not senile have a distinct place as counsellors. They should excel in strength of reason, cool judgment, and breadth of view. One may be past the age of discretion before one is old in years. The conservative tendencies of this period are valuable as checks to the exuberant impulses of youth. The dependent aged are a burden and their support is often a handicap. With modern progress the number who fail to keep pace increases with the speed of advance and this has to be complemented by the fact that the old are increasing in numbers. With few exceptions man lives longest of any animal. Everything does grow old except vanity and the more perfect the organization the earlier the aging and the sooner the end, for it is the perfect more surely than the good that die young. Every stage of life is marked by a limit, but this limit varies greatly. “Every man past forty is a fool, physician, or a divine, and most people practically throw away their lives.” The lower the scale of education, the greater the hazard of life. Longevity among pure muscle workers is rare. We know little of the influence of race, but we know that women, lean people, the married, the religious, on the whole, live longest. Haeckel believed in “medical selection” and pointed to the fact that some have greater power to resist disease. Is this desirable for the integrity of the race? “Death is a process, not an event.” Man does begin to die early in life. The bicycle rider has to keep going to keep erect, and so the old must keep working. The first vacation is often fatal.

Hastings Gilford regards the development of the human body as a whole, or of any portion of the body, as describing a curve that ascends from the time of the union of the two genetic elements to a maximum at which there is the greatest development of specialization in function and the least in the general characters, such as those of multiplication. The curve then begins to descend, with a gradual and progressive loss of differentiation in form and function and an increasing tendency of certain cells to multiply. Decay of certain cells during advancing age leads to their becoming bodies foreign to their host, and this, in turn, calls forth the phagocytes which, walling off the foreign body, become themselves transformed into fibrotic tissue. The three characters of old age are decay, fibrosis, and proliferation of non-specialized cells. As the more specialized cells retrogress, with the loss of specialization they take on an increased tendency to multiplication. “Reversion ... is the keynote of the proliferation in old age wherever it occurs.”

Granting the foregoing statements regarding the anatomy and biology of old age to be true, Gilford even believes that we can explain cancer in terms of senility. He says: “Thus the typical cancer is made up of a collection of cells native to the part, but of more embryonic type, and these cells are surrounded by collections of round indifferent cells derived from fibrous tissue and from other low class structures, such as endothelium and leucocytes.” The fibrous tissue, moreover, is often increased, as it is in the senile organ. These changes may be interpreted as follows. Certain somatic cells become aged while the tissues around them are still in a state of comparative youth. They express their senility by returning to a more embryonic form, and as they do so they increase in number, the faculty of multiplication being one of the manifestations of regression. But as this qualitative change takes place they become alien to their surroundings and, as foreigners or rebels, stimulate into action the mechanism of phagocytosis. Not only is there an incursion of lymphocytes into the parts but the connective tissue and endothelial cells in their vicinity revert to their embryonic state and begin the work of phagocytosis. But as a fact they have to deal with neither the effete products of molecular degeneration nor with an inert foreign body, for though virtually strangers cancer cells are by no means inactive. Hence the attack is abortive, except in so far as the phagocytes, by forming new fibrous tissue, tend mechanically to limit the proliferation of the cancer cells. For in the meantime the fixed connective tissue cells are themselves rapidly proliferating, with the result that when they cease their activity and return to their resting stage, groups of cancer cells are cut off by intersecting bundles of fibrous tissue, while the whole mass is surrounded by an incomplete capsule of the same structure. This tends to limit the encroachment of the growing cancer, and were it not for the lymph spaces or capillaries, which are the gaps through which the growing cells escape, no doubt the limitation and strangulation of cancers would occur far more often than they do.

It will be noticed that the more nearly the cells of a cancer approach the embryonic state the more rapid will be the growth, and the less opportunity for fibrosis the more malignant the cancer. Gilford maintains for this unique theory that it is satisfactory, based as it is, upon facts reasonably interpreted, and that it covers all of the ground.

Horst Oertel holds that the origin of cancer in the liver is a transformation of multiple groups of its cells and that there was a direct change of atrophic, degenerative, existing liver cells into cancer cells while they were still in perfect continuity with each other. In this degeneration of normal to cancer cells the former lose their typical protoplasm, the nucleus grows small and its chromatin structure faint, till little of it remains, with only a faint rim of surrounding protoplasm. At this point some of these cells show a very striking change in rapid, irregular production of rich chromatin arranged in a less structural definition and leading to marked enlargement of them. There is a first destructive stage with extensive loss and granular degeneration of protoplasm. In the second, incipient regeneration shows and the nucleus is markedly enlarged, with irregular production of small chromatin granules; while in the third stage, the carcinomatous, we have a new type of cell following new laws and breaking with the former physiological arrangement and structure. The new functional type involves rapid independent growth with a distinct disregard of original source and surroundings and with progressive loss of continuity and power to secrete bile.

Thus he, too, holds that cancer seems an embryonic reversal and involves no specific changes but is a phenomenon of senescence, a degeneration of cells with an unequal decline in cell functions. Thus races of cells develop that lack the differentiation of undegenerated cells but are still endowed with vegetative and reproductive properties. His idea that the degeneration and injury to cells could be responsible for growth, was severely criticised. It was said that any change that meant injury could never be progressive but would lead to diminution of functions. But the author still holds that injury may produce growth of all kinds of tumors, for example, in the pancreas, growth and cell division is dependent upon the release of certain inhibitory influences that exist in the normal well-balanced cells. This upset may be caused by certain liquid solvents but the idea of formative stimuli on the whole seems to hold; namely, cancer cells arise out of degenerative and atrophic changes, so that injury, degeneration, and growth do not exclude each other but stand in genetic relation.

That organs that have reached full maturity and differentiation are stable and fixed in cell type and organization is false. Our organs are constantly in active regression, degeneration, and progression, and it is difficult to separate pathological from physiological changes. The pancreas is particularly in constant regression and progression. Thus it is peculiarly unstable and the limit of normality in its variations cannot be determined. Senescence is accompanied by multiple degenerative changes in many other organs and tissues, and associated with these are various benign and malignant tumors that seem to result from degenerative changes. Thus Oertel’s idea of endless proliferation as a result of differentiation is not an idle speculation but rests upon an anatomical and experimental basis.

A. S. Warthin says that syphilitic cases are generally regarded as cured if the Wassermann reaction is negative but there are very many cases that this escapes. It is commoner than is supposed, the usual estimates being that from 5 per cent to 15 per cent of deaths are due to it, but this writer for America and Osler for Great Britain, place it at 30 per cent. “Syphilis is the leading infection and the chief cause of death, particularly in males between 40 and 60, and in the great majority of cases its symptoms are myocardial, vascular, renal, or hepatic, and this is often not recognized as a remote result.” The author has never seen a marked case of syphilis cured. Most die as a result of mild inflammatory processes of the viscera and blood vessels rather than from paresis or tabes. It is progressive and marks the individual as damaged goods. Even immunity is bought at a price. All the organs must be examined before it is pronounced certainly absent. It is a spirochete-carrier. It tends to become mild but at any time the partnership between the spirochete and the body may be disturbed and the tissues susceptible to the violence of the spirochete may be increased so that the disease again appears above the clinical horizon. Chronic myocarditis is the most common form of death.

W. Spielmeyer says that in the last decade the clinicians and pathological anatomists have discussed old age more than in preceding decades. We know that organs are used up and that their substance is not fully replaced. The functionally exciting parenchyma is injured by its own function and in this metabolism the quality and sometimes the volume of the organ is reduced. Thus old age is a function of the work of the organism and it seems to be an intrinsic quality of cells to use themselves up. Many do not regard age as a normal physiological process but with Metchnikoff think it is due to injurious substances, that is, endogenous toxins that are more important than the exogenous factors, so that blood vessels, glands, and muscle and ganglia cells degenerate. But the cortical cells, as the most sensitive of the organism, are more often injured. Metchnikoff thinks that the higher elements of the tissues are in conflict with the lower and are overcome by them, the phagocytes being left masters of the field.

Few, however, hold this view. Ribbert, Naunyn, Hansemann, and Nothnagel think that outer and inner injuries should have precedence in accounting for old age. But without these coöperative factors there is a physiological determinant of the organism and its parts to be used up and they become senile and lapse by physiological processes, while Naunyn thinks that it is perhaps a general law that every organ fulfills its functional task only by impairment of its complete organic integrity. This using up of an organism by its own work occurs first in the brain and the central nervous system. There is a general decline in weight, even in the fourth or third decennium, which is accelerated in the seventies and may reach one hundred grams (Naunyn) and, in pathological states, still more. It is, therefore, of great interest for the relation of function and the use-up of organs that brain atrophy is not usually uniform or diffuse but that there is often a difference between the right and left hemispheres in the diminution of their volume. The left hemisphere is more used and usually more atrophied than the right. The left convolutions, therefore, suffer most reduction.

Among the earliest and most uniform changes due to age is the regressive transformation of the blood vessels as in sclerosis. As the central tissues suffer from a using up of their nervous substance, the central vessels are soon involved. Till lately we have assumed that these disease processes in senium were a result and expression of the primary affections of the blood vessels in these organs. But it now appears that as in other organs, for example, the kidneys, grave age changes can occur while blood vessels are intact. So in the central organ grave independent age changes can occur without being caused by the blood vessels. To be sure, they often concur for the simple reason that the nervous system, like that of the vessels, is found affected oftenest and earliest in old age. But the assumption of a dependence of central nervous degeneration was an erroneous conclusion from the observation that by these frequent degenerative processes in the walls of the vessels there were, at the same time, phenomena of using up of nerve substance. “The changes of both organs can, despite their frequent combination, be the independent expression of age and quite independent one from the other.”

Every study of the psychosis of regression and age must start from this fact and we must seek to distinguish the forms of weakness of old age due to central tissues from those that have their cause in the primary weakness of the blood vessels. For sclerotic senile dementia anatomy has already more or less basis. For the various forms of brain sclerosis it is now possible to propose an anatomical diagnosis, although it is impossible to have a very definite clinical picture of what takes place.

Outside these two chief groups of organically conditioned psychosis and degeneration there are many processes not yet certainly determined anatomically. These belong neither to sclerotic brain disease nor to proper senile dementia. They differ also in their general aspects from the average case of the imbecility of old age, and if they are classified with it, this rests only on superficial grounds and it is the problem of pathological anatomy to help clear up this clinical-psychological question. It is a little here as with innate and childish mental weakness, which we anatomically distinguish as idiocy and imbecility with partial success, just as we are trying to distinguish the psychosis of old age to make it conform to anatomical principles.

With the great recent progress of anatomy we are just at the beginning here, the chief result so far being the possibility of distinguishing senile involution and its morbid traits with a view to eventually being able to make an anatomical differential diagnosis, such as we must do to really get at the root of the problem of senile dementia. From this point of view other processes can readily be derived, and some of them histologically, like regression. The anatomical investigation stands in temporal relations with the idea of senile dementia and it must be defined or widened enough to do this. Perhaps we shall be able to have a good anatomical picture of senile dementia beginning with the fifth and sixth decennium and even to explain atypical forms and show their relation with the central system.

Here, then, the author, starting from an anatomical basis, begins with a study of forms that are atypical in localization, intensity, or temporal onset. Then he can discuss the mental diseases that are based on sclerosis. So he first discusses briefly those psychoses that rest upon clearly recognizable but not yet very distinctly determined brain troubles that deviate from the ordinary senile processes and those, which so far as we can now see, are really sclerotic. Then the long series of psychoses, the anatomical substratum of which we do not yet know, and the functional processes of this age can be discussed. In doing this, more than in the case of many organic processes, we shall find a great difficulty in proving for such diseases their specific senile or climacteric character. We shall constantly face the objection that we have here to do only with mental diseases that usually come in other ages and only have peculiar traits on account of the age of the patient, as is the case with many depressive and paranoiac symptom-complexes of regression that resemble those of age.

Thus the distinction of regressive psychoses from senile changes, this author thinks, cannot be carried through by grouping them in the decennia in which they arise. It would be better to distinguish them as progressive and incurable, or otherwise, but this could be done only with further distinction of our anatomical and clinical data and we shall perhaps still lack that for a long time.

When, therefore, in these regressions we start from anatomy and the psychoses connected with it at this age of life, we may seem to overestimate the achievements of histology. We at any rate do not underestimate our ignorance here. But with the great confusion of opinions based on clinical observations we believe we are justified in this point of departure. Ultimately anatomy will very likely be our guide in all clinical work as well as in the field of psychiatry, physiology, and psychology. We shall doubtless also learn very much more about the localization in which the degenerative processes of age begin.

Senile Dementia.--Textbooks and articles on old age generally state that the changes in psychic personality that occur are identical with normal ones, only in intensified degree. The traits most commonly specified are: limitation of the circle of ideas, qualitative and quantitative loss of elasticity, pauperization of interests, dwelling on gemütlicher activity, lapses in attention, Ziehen’s “egocentric narrowing of the life of feeling,” perhaps hypochondriacal symptoms, mistrust, inflexibility, lowered power of activity, and resistance against everything that is new. Works in general pathology, like Hübner, Ranschenburg, Balint, and Lieske deal with these in more detail.

In general, there is a sinking of psychic activity and change of character which suggest physiological involution, and these occur--in some, earlier, and in some later. If we compare these psychic traits it would seem that there is only a quantitative difference between normal old age and senile dementia, the latter having only gone farther or faster. The decision of this question is for pathological anatomy and here Spielmeyer’s studies coincide with those of Simchowicz. The older an individual is, the less sharply either clinically or anatomically can it be decided whether it is normal or senile dementia. There are the same changes in the nerve cells, neuroglia, the myelin sheaths, and the mesoderm tissues; also in the blood vessels the changes are identical, the difference being only in degree. Fatty degenerations of the ganglion cells also occur in both. Sclerotic changes of elements are general. The neuroglia cells with normal seniles have lipoidal material in abundance, and the gliafibers, especially in their upper surfaces in the cortex, are increased. The walls of the blood vessels have undergone the same regressive changes and acquired the same fatty material by infiltration, and even the so-called senile plaques are found. Thus in general there is the same using up of the central organs. We are, thus, not yet in a position to determine from the brain alone, if we know nothing of the individual, whether he was a senile dement or a very old man. The older a man is, the more we find the Redlich-Fischer plaques. Thus the senile dement shows neither anatomically nor clinically any essential differences from those found in the normal senium.

I. L. Nascher thinks that too little study has been given to the physical changes in involution and still less to the mental. Occasionally the approach of senile dementia gives rise to forensic questions. There is a general neglect of the subject of geriatrics. This author thinks the brain reaches its limit of physical development at about 30, but Bunsen and Mommsen both did much of their best work after their brain had grown quite atrophied, so that quality comes in. The integrity of these cells depends upon nutrition. We have few blood examinations of the aged and these do not show any marked clinical or microscopic differences between maturity and senility, while the process of senile involution rests apparently on defective nutrition of cell tissues. Those who do good work in age generally focus into one channel and their degeneration is shown in other fields. We usually do not think of our somatic state until some discomfort compels us to do so. One may have lessened interest in former hobbies or events of the day; but if impairment of reason keeps pace with that of memory, he will not know that his powers are failing. He then begins to think of his body and its preservation as more important than wealth or fame, wants to live, and gives more attention to prolonging life.

There is often a change of temperament into egoism, perverseness, peevishness, loss of ambition, religiosity, inability to bear slight discomforts and depression. The child thinks little of the future, while in maturity hope tends to paint a future haloed by happiness and in senility the future is death, notwithstanding what all philosophers, poets, and preachers say. Our mental attitude is simply a resignation to the inevitable. One patient had a daughter devoted to him whose absence for a moment he could not bear, and once this so angered him that his total attitude toward her changed to one of dislike and suspicion. In another case a woman of seventy-six underwent a complete change of character. Arrogance gave way to humility; in contrast to her former independence, she now craved sympathy. Then later she changed again and made extraordinary demands upon her children, wanted the latest styles in everything, etc. In another case memory, reason, and will grew weak in an old manufacturer. He lost his way on the street, a child could divert him from his purpose, and he clung to a notebook by day and night till complete dementia came. Another man who was noted for carrying through everything he planned, even breaking up partnerships, when old became not only susceptible to advice but could be easily turned from his purpose.

Thus senile mentality shows temperamental changes. There is introspection, with natural fears and unnatural phobias, hope for strength and vitality or even for beauty, and often overweaning biophilism. Action is slow; fatigue, quick. The mind may be often trivial on all other matters but yet sound in the center of interest. Personal attainments and achievements are often magnified, and complaints are exaggerated as calls for sympathy. Moral deterioration may be first. Lapses are condoned that were once condemned. The old man may slowly come to take interest in what is low and vulgar. This moral decadence is entirely apart from the pathological condition in which the cœundi potentia is lost while the desire remains, and the recrudescence of desire may occur in the senile climacteric but is a forerunner of senile dementia.

The æsthetic sense causes the old often to neglect cleanliness in person and clothes, to be untidy in their room, expectorate, scratch in public, make disagreeable sounds, and disregard proprieties generally. Women show these traits, but in less degree, and depression is less pronounced. There is no sudden realizing of aging and fear of death is more often overcome by religion. Sometimes the intellectual faculties deteriorate more rapidly, but moral and æsthetic impulses change less. Sometimes old women take greater care of their appearance and seem to be vain and to fight old age. Men occasionally at a great age take a new interest in their appearance, dyeing their hair and becoming dandified, which may show recrudescence of sex.

After the climacteric depression may pass to apathy. Death is less fearful as the mind weakens; there is less concern for the future and life is more in the present. Even early recollections grow dim, although such cases may be roused momentarily. There may be marked preference for association with children. There may also be childish acts and garrulity. The family history given the physician by an elderly patient is often unreliable. Insignificant symptoms are magnified; so are former attainments. Old patients often claim they possessed wonderful constitutions, perhaps that they were never ill, despite indubitable marks of disease.

In homes for the aged there is much suggestion. If one scratches, the rest do, without pruritus, so that to isolate the author of this contagion cures it. The same is true of groaning and grunts and even tremor may be acquired by association. In one case, cutting off food stimulated to overcome tremor. Pain, cough, and stiffness are magnified for sympathy. The fear of pain of an operation may cause the denial or hiding of symptoms, although weakened mentality makes sense impression less acute, either from peripheral or central causes, so that it is hard to tell whether this is due to local anæsthesia or weakened mentality. Tests used for malingerers may be necessary to determine sensitiveness and other symptoms or even harshness and threats may bring out the truth. Though cruel, these are sometimes necessary for correct diagnosis.

Friends often observe changes sooner than the immediate family but the latter must corroborate the statements. The physician should determine if an oikiomania exists and so must be alone with the patient, as he will not encourage such an attitude in the presence of the object of his hatred. If the physician tries to reason him out of his delusion, he thinks he is in league with the hated person and therefore hates him more. If the physician has incurred the patient’s dislike, he should leave him for a few days so that he may forget. Sometimes the dislike of seeing the doctor grows from day to day. One had a suspicion that the doctor was in league with a daughter, and so put him out. A few days later the doctor was called for, and only when the wife told the patient why he would not come did he remember his suspicions and thereafter refuse to see him. In one case, having incurred an old woman’s displeasure by excusing her son, whom she feared, the doctor left and was soon called again, all being forgotten. The person hated should stay away and the dislike may pass, especially in the case of a physician who has been necessary to the patient.

The great factor is the senile’s sense of dependence on others. The old man does not realize that one more mouth means less food for the children or that his carelessness makes work or his peculiarities alienate sympathy and affection. Perhaps he feels he is a burden and his death would be a relief to those for whom he provided in earlier years. So delusions of persecution may arise.

What can we do? Symptoms are often bettered at an asylum. Phobias vanish and so do fears for the immediate future. All energies may be guided to one channel and the person may be made useful and his fear of being useless thus cured. The old are thus often anxious to do little services to show they are not worthless and little tasks can occupy them without strain. A patient pensioned after sixty-five years of work could get no other employment, felt useless, instead of being cheery became depressed, and was cured by being re-employed. The influence of young people keeps up interest in life--especially marriage with a young person, the development of a hobby, collecting anything, such as stamps, coins, books; witnessing new sights, but not fairs, where numbers confuse.

Drugs give temporary relief. Small doses of morphine give exhilaration and arouse the imagination, but its effects soon wear off. “Phosphorus in solution is the most effective drug for prolonged use.” It is a mental and nervous stimulant and aphrodisiac, increasing mental power and producing a sense of well-being. One-fiftieth-grain doses several times a day, stopping just as soon as the intellect begins to brighten, are often beneficent. This can be kept up for years. Perhaps amorphous phosphorus may be used.

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Sir Dyce Duckworth asks: Why are some remarkably young for their age and others old? It cannot all be explained by anything in the individual life or habits. Perhaps it is in part because the ancestors lived a hard life. We want the degree of inherent vitality proper to each individual patient. This would be as important for prognosis in pneumonia as are the hæmic leucocytes. Arterial hardening may be local only, for example, radial. There are two kinds of arterial degeneration, namely, the brittle and the tough, the former more liable to cause hemorrhages and fatty degeneration.

Very important is the discovery that the rigidity of calcified arteries is greatly increased immediately after death. The lime is present before, as disclosed by the X-rays, but it is like wet or unset mortar and only sets after death under the influence of carbon dioxide and the rapidly diminishing alkalinity of the blood. The so-called air in the arteries after death is chiefly carbon dioxide and this explains why such arteries do not rupture so frequently as we might expect. Premature death of parts of the body is constantly occurring, for example, baldness, teeth. One may be vulnerable to one and another to another type of injury or bacilli. Syphilis is mainly a conjoined trait or infection and greatly predisposes to tubercle. Indeed, a syphilitic patient may be regarded as a prematurely aged one in spite of a good constitution, because there is always the possibility of sequels or parasyphilis, general paralysis, etc.

Among the early mental signs of interstitial nephritis is an explosive temper. Fits of hilarity and weeping may alternate (first pointed out by Clifford Allbutt). The costal cartilages ossify generally before the sixth decade and this is often premature. A hobby may no longer avail to preserve mental activity, and “the golf ball to-day is not seldom one of the beneficent agencies for this purpose.” Cirrhosis of the liver is longer averted in the patrician than in the plebeian because the laborer becomes senile sooner than others owing to his life of strain in all weathers. In arthritis, the nodosity of joints, especially in the fingers, in the form of Heberden’s nodes, is thought by some an indication of longevity. They are often found in those who have few classical symptoms of gout and few reach eighty or ninety without these trophic changes. Dupuytren’s contractures and the camptodactylia of Landouzy, or incurved little finger, are among indications of a gouty habit and are not truly rheumatic lesions. Indolence of the bladder does not imply prostatic symptoms. Very common are widespread catarrhal disturbances, as for example, tussis senilis, with much flux of mucus, often rich in sodium chloride. Fits of sneezing, also of hiccough and even gaping, are frequent.

The main treatment for early senility is physiological righteousness (Sir A. Clark). We must especially know the degree of vigor, of vitality, and specific habit of body. We must pay attention to the degree of blood pressure and early indications of renal inadequacy, orthostatic albuminuria, the tendency to epistaxis, and maintain as our keynote moderation in all things. The best idea is that of universal service which would bring all the world together on a high plane. The author refers with a good deal of skepticism to Metchnikoff’s Bulgarian bacillus but mentions Saundby’s book with great praise.

Robert Saundby, M.D., has given us what is, to date, the best handbook, both for practitioners and for old people who are intelligently interested in conserving their life and strength, on the common infirmities and care of the aged, exclusive, for the most part, of nervous and psychic symptoms. He first describes normal old age, then its diseases in successive chapters--diathetic infections, and those of the circulatory, respiratory, digestive, and genito-urinal systems. Perhaps most practical are the dietaries he gives for different stages of old age and different diatheses. He commands a wide knowledge of Continental literature on the subjects he treats. He has a just sense of the dangers of stressing specifics from, for example, Pythagoras, who thought there was a special virtue for longevity in honey; Bacon, in sweating; Harvey, in avoiding acids; down to Blanchard, in sal volatile; blood drinking cures, olive oil, licorice, etc. He believes that Metchnikoff’s panacea and the undue stress laid by Lorand on thyroid therapy have not escaped the dangers of undue focalization. He allows a very wide latitude not only in regimen and exercise but food, condiments, and even stimulants, for the aged.

No one can read his account of the changes that take place in each part and organ of the body as they are successively described and the very different treatments that each needs as it goes wrong, without a sense of the fatality with which these vast cohorts of life-quelling symptoms advance and, in view of the many strategies the lethal processes make use of to undermine the fortress of life, without experiencing a profound sense of the hopelessness of watching out in so many directions and realizing that, as differentiation proceeds in the different organs, any regimen helpful to one would almost certainly be harmful to others.

Arnold Lorand, an Australian physician, bases his work on the principle that man does not die but kills himself. He does not philosophize but tells us that while it is impossible to create a young man out of an old one, it is quite within the bounds of possibility to prolong our youthfulness by ten or twenty years. In other words, we need no longer grow old at forty or fifty. We may live on to the age of 90 or 100 years instead of dying at 60 or 70. Old age is just as amenable to treatment as chronic diseases. He has great faith in the present possibilities and still larger hopes for the future of serum therapy, for to him life is most of all connected with the glands. He discourses upon the hygiene of throat, lungs, heart, kidney, liver, stomach, bowels, reproductive organs, and the rest with a bewildering volume of details but good perspective, and the reader is again disheartened to find that the treatment prescribed for one organ is deleterious to another. Indeed, Lorand’s somewhat encyclopedic and undigested data, despite the common sense and practical spirit in which they are presented, bear, on the whole, less upon old age itself than upon general hygiene at all stages of life, so that his title is to that extent a misnomer.

He sums up his practical conclusions in the form of twelve commandments, which are, briefly, to keep in the open and take plenty of exercise; eat according to rule; bathe and move the bowels daily; wear porous underclothes; early to bed and rise; sleep where it is dark and quiet; rest one day each week; avoid emotional strain; get married; be temperate in the use of alcohol, tobacco, tea, and coffee; and avoid over-eating and -heating.

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T. D. Crothers, M.D., thinks we have not sufficiently considered the abilities of old age from a medico-legal standpoint. He also thinks that if we do not live to be 100 something is wrong with us or our ancestors. We all carry a large reserve that many die without drawing upon, and this reserve is especially available in old age (he develops this point psychologically). Many old people with melancholia, hallucinations, and the characteristic physical defects of old age have, nevertheless, a higher kind of sanity to which their juniors do an injustice by the tests they propose. They are quite capable of making wills and otherwise deciding the large questions that come before them and often do so from a broader point of view than younger men. It is possible, then, to rise to a higher level, to a kind of graduate school of life, to use the unused, etc. Again, the varied experiences of long life give mobility of mood up and down what Adler calls the life line, so that the old have a larger assortment of viewpoints and even moods, to say nothing of greater ups and downs in horizon and standpoint generally.

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C. G. Stockton, M.D., suggests family records and pride to avoid mixing good stock with that which decays early. He recognizes the great contributions of the dentist and oculist, deplores the neglect of old age, and insists that the aged do respond to treatment very readily. He also deplores the attitude of many physicians who discourage resolute methods of curing defects and warding off evils because the patient is old. He stresses the value of emunctory procedures both within and without.

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Dr. W. G. Thompson deplores the fact that physicians have given so little attention to old age and that the medical literature upon the subject is so meager. The very old have survived all corroborative evidence as to their age, their failing memories confuse tradition and fact, and they come very often to take pride in their age and so add to it. The author’s study is based on the census statistics of 1910, which record, from 90–94 years, 6,175 deaths; from 95–99, 1,427; 100 years and over, 372. The respiratory diseases as a group took first rank as the cause of death; organic heart disease, apoplexy, and Bright’s disease occurring in frequency in the order mentioned. Among diseases of the digestive system enteritis outranked all others.

As age advances and its activities and diversions become less and less, locomotion is reduced, along with acuteness of sight and hearing, and the pleasures of the table remain the only gratification of a monotonous existence. Very many accustom themselves to the habitual use of laxatives to counteract the effects of overeating, and often we have obstructions, especially of the rectum or colon, that may become fatal. This, however, is more often seen in those who eat too little and become perhaps atrophic and marasmic. These people become careless of matters of the toilet and obstructions often cause death. Apoplexy is relatively rare among centenarians and carcinoma also declines as a cause of death after the ninetieth year. Indeed, the disease that does not develop until after the ninetieth year can scarcely be due to hereditary factors and the infrequency of cancer in the later stages of life emphasizes the constitutional resistance to extraneous influences that the majority of centenarians possess in a high degree. Acute and very quick or fatal pneumonia is not infrequent.

One very peculiar difficulty in treating old patients is their prejudice and obstinacy in matters of diet and hygiene; because they have lived so long they naturally think they know better than anyone else what is good for them and, with a certain irritability, resist interference. As a rule, they are relatively very susceptible to the action of drugs and two-thirds of the ordinary dosage for adults generally suffices. Very often the very aged suffer from the neglect of personal cleanliness. There are many diseases common from the sixth to the ninth decades of life that are very rare later, for example, tuberculosis. Suicide is very rare, the census of 1910 recording only one of a centenarian and nine among nonagenarians. The latter generally have a long-lived ancestry and many families are remarkable for this trait. But this is by no means essential. The aged often exhibit no predominant symptom of any one disease to which their death is attributable, and hence “senility” is so often given as the cause of death. Tranquillity, moderation, and regularity seem to be the chief factors in securing a long life and a peaceful death.

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M. L. Price, M.D., attacks Metchnikoff’s theory of old age by assuming that in addition to all toxins and inflammations there is always an old-age exhaustion of a vital principle that he calls bioplasmine, that may, to be sure, be mainly caused by Metchnikoff’s agencies but is equally affected by effort, exposure, growth, and reproduction. He sagely predicts that the solution of the problem of old age, which he thinks is the central theme of all medicine in the sense in which he conceives it, because every disease brings senile phenomena to some part of the organism or to the whole of it, will be solved by biochemistry, although he admits that it may take many generations of investigation to achieve this final solution.

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George S. Keith, M.D., after a long life of practice, has grown suspicious of current methods. “I purge, I puke, I sweat ’em; and if they die I let ’em.” As to foods, he believes that the old should only eat when they are far hungrier than they usually are and leave off eating when they now habitually begin a meal. Appetite, which seems to give momentum to all the assimilative processes, is never utilized to its full extent. Sick animals often go off alone and succeed in recovering and he believes humans have the same instinct. He is, therefore, bitterly opposed to forced feeding, even for the insane, save under very exceptional conditions. The sick should generally be allowed to eat whatever they wish, perhaps in moderation, or to go entirely without food. Probably primitive man and all animals had to undergo occasional long fasts and this serves to tone up not only the nerves but the entire digestive system. Instinct is a far truer guide than doctors who interfere with it think. Once the fevered patient who reveled in dreams of cold was kept warm; now we know better.

This author has, thus, an almost implicit trust in the cravings and dislikes of the sick and would indulge them almost to the limit, as the German hygienist, Sternberg, would do to a perhaps even greater degree. He is also a great believer in rubbing and massage. Hot water plays an important rôle, too, while he attaches very special value to licorice. Doctors are often too anxious to save patients from all pain, perhaps by the use of means that entail worse consequences. Pain has its place in nature and the doctor should also try to have the patient apply the cure of patience. Pain is nature’s cry for help, to which she often responds as she does not to other stimuli; and benign as is the rôle of anæsthesia, it should not blind us to the tonic effects pain often exercises. So sleeplessness may not be an unmixed evil in certain cases and sleep artificially induced is usually of poorer and less restorative quality. He has found fixating, spontaneous retinal phosphenes a good soporific method. He believes that very many diseases would cure themselves if the patient could be induced to simply rest and starve. Although he is not a homeopathist, he nevertheless believes that dosages of medicine are far too large. He insists that old and experienced physicians ought to, and that the best do, learn a great deal from experience in keeping themselves well, and that every physician should accumulate thus a store of knowledge based on self-observation, and may well, with profit, always be mildly experimenting upon himself. As age advances he would regulate diet and treatment largely to the avoidance of accumulation of uric acid in the system. He found great reinforcement for himself in making a breakfast of coffee only, etc.

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J. Madison Taylor notes the paucity of literature on this subject that he found in trying to read up on it and thinks it warrants far more attention. The foundations for longevity are laid in the first few months of life and bottle-fed babies are shorter-lived and much less likely to reach old age. Those who spend their infancy and childhood, too, in large centers are less long-lived than those brought up in the country. A serene mental view and capacity for deliberate enjoyment of whatever betides he places first of all and advises self-education in serenity. The less we eat and the less variety, the longer we live, and on this the author lays great stress. We must put aside, as we advance, some articles of diet of which we are fond.

He believes dentists have greatly interfered with longevity because man was meant to be more or less toothless and thus to be reduced in old age to childish diet and fluids, while the dentists enable us to eat anything we ever did, which is against Nature. He speaks of fads and their dangers, for example, one old lady thought she prolonged her life by eating a great deal of salt. The indolence and indifference of age is a great difficulty. If one persists in trying to keep up indefinitely, the results are often amazing. Medical aid should be sought more constantly for lesser ills. Man is like an old horse--if he once gets thoroughly out of condition it is hard to bring him back. G. M. Gould has believed that unfit glasses have shortened the lives of many eminent men. But open air is a sine qua non always.

Tessier gives a clinical picture of approaching death--(1) heart and blood vessels, (2) lungs, (3) kidneys, (4) digestive organs, (5) the brain. Most agree that the heart plays the chief rôle in ending life and many used to think that nearly all old-age diseases were from arterial hardening. But this was doubtless much exaggerated. Old age is a progressive diminution of all functional activities. All clinicians recognize diatheses or a tendency toward disease and we can detect them in their incipiency now far more than formerly. Age diathesis means a lessened coefficient of resistance, quick exhaustion, and weak repair. The author devotes great attention to obesity, which shortens life, and he advocates various exercises of the extensor muscles, deep breathing, and thinks much can be done to tone up and increase the activity of the heart.

He thinks the effects of the menopause have been rather overestimated. Exhaustion, especially induced by emotions, fatigue, anger, grief, and fear, weaken the protective powers of the mysterious agents of immunity. The mind is very liable to become fixed upon some ailment and hyper-conscious, particularly near the menopause, and this is due to failure of the organism to offer the same degree of resistance to toxins and to a general lessening of functional activity.

He thinks we can postpone old age by the following agencies. We should develop, not discourage, bodily exercise for without it there is a slow retrogressive change. The more nearly the diet is reduced to bread, milk and fruit, the longer the person will live and enjoy good health. Some can go for long intervals without feeding though more thrive on small quantities taken frequently. He condemns all purgatives and would regulate by salads, nuts, fruit, and thinks the best drink is buttermilk, which has salutary effects on both bowels and kidneys. Next comes koumyss. Fluids are best taken in abundance, but if the heart is weak they should be avoided before exercise, for this increases the cardiac strain. If the skin is dry, he advocates dry rubs rather than cold baths and olive oil occasionally, of which he says it is amazing how much the skin will absorb. He speaks emphatically of the dangers of chills and of the trend of all tissues to harden, stiffen, or lose their elasticity. Tissues about the neck are particularly prone to lose vigor. Regulated movements of the neck and upper truncal muscles often improve hearing, vision, cerebration, and sleep, and the same is true of friction. Most digestive disturbances, even those of early middle life, are due to relaxation of the supporting tissues of the great organs in the abdomen. This dilation is found in at least 60 per cent of adults, and it produces a long train of alterations. The kidneys are supported mainly by their blood vessels, so that if they sag their circulation is impaired, and this kind of ptosis is very common. Hence faulty attitudes are very important for all visceral ptoses, while he finds much to commend in the use of abdominal corsets, even for fleshy men. Elasticity of the ribs should receive attention and the author prides himself on exercises that increase the elasticity of the basal tissues which sclerosis is prone to assail. The capacities of individuals for exercise in the open air can generally lessen the need of medical supervision. With old people, the extensors should receive more, and the flexors, less attention and there should be sufficient stretching, torsion, etc.

As to the senile heart, it is generally assumed that the old should do no more than they are inclined to do and perhaps even lead a vegetable existence. But he believes that disinclination to movement means and makes under-oxidization and causes decay and he is severe on what he calls senile laziness. The healthier and happier old people are, the more active they become. The life of a hothouse plant is bad. Humphry found in most old people he examined little or no change in the arterial system. Allbutt says there are many old people in whom there is no arteriosclerosis. One common phenomenon of old age is the loss of vascular tone and defective lymph circulation. The bones lose weight and size and the walls of the shaft grow thin from within, especially toward the end of the bones and most near the head of the femur. Trunecek of Prague emitted the thesis that certain salts can be introduced into the blood current that aid in dissolving the calcium phosphate found in the structure of sclerosed arteries. So he injected hypodermically a strong solution of sodium phosphate and magnesium phosphate, which are normally found in the blood serum but only in minute quantities. Others have introduced this by both bowel and mouth. Anything that aids oxidation of tissues helps.

In another article Taylor says almost nothing that is new although there is much that would be practical to aging people. The machinery has become a little worn and weaker in spots but the bare surfaces have been abraded to meet each other so that there is less friction and racking of the joints. The body cells are less irritable. Degenerative diseases are very insidious. They increase in the following order--liver, digestion, apoplexy, nerves, heart, kidneys. One’s enjoyment of food is greater perhaps than discriminative. Many reminders of age are overcome by warming up. Skin emanations may be offensive. Traits of a mature mind are poise, deliberation, economy and the largest output of judgment, like the Roman senators or seniors. Irritability is common. Youth wants to know; age wants to be.

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C. A. Ewald, one of the most eminent of German professors of biology, gives us one of the most condensed statements on the subject of old age. He begins by contrasting the intense life of Berlin, where the lecture was given, with the fact that all paths lead to the door of death, which is nearest in war. The antique conception of death was youth with a reversed torch; the medieval, a skeletal mower taking pleasure in his work. The martyr’s love of death and even the passion for Nirvana are probably more or less pathological. If we assume 15,000 million people on the earth and a death rate of 30 million per year, we should have 81,192 deaths daily; 3,425, hourly; and 57 every minute. The baobab tree of Cape Verde shows a life of 5,000 years. Some have ascribed 500 to the swan. But nearly all data of great age are discredited. Even that of Parr (152), who married with potence at 120, and all the rest, are doubted. But the length of life is increasing. In Sweden, of every 100 children of five at the beginning of the last century, 27 reached 70; at the end of the century, 48 did so. In Bavaria the number increased from 25 to 40; in Germany, in the last twenty years, it increased from 30 to 39, so that we all have a better chance of living long than we would have had if we had been born a hundred years earlier. The average length of life in 1870 in Germany was 37 years and has now increased to 42½. In France and England it is 46 and in Norway and Sweden, 52. Cures of tuberculosis in the last twenty years have reduced the percentage of its victims from 31 to 17 per 10,000, and vaccination has reduced the death per million from smallpox to 5; while in Russia, where it is not compulsory, it is 520. A priori, death does not seem necessary and yet for even protozoa division often involves something like a very rudimentary corpse so that investigators like Götte, Hertwig, and Verworn accept the tenet of Weismann, with some slight reservation, if the corpse is to be taken as the criterion of death.

Bees and the stork and other birds of passage kill or neglect their old, while in ancient German myth old men often slew themselves for the good of the community. Certain species eat their young rather than die themselves and even this is for the interest of the species. A certain wasp lays its eggs in the female plant and its young, when covered with its pollen, fly to a male plant to fertilize it, although this means their death. Thus death is a normative factor of development and to this extent Weismann is correct. Life has three periods. In the first there is an excess of energy and growth; then comes middle age with an equilibrium, while in old age the relation of these energies is reversed, so that the first and third stages contradict each other. But everywhere life is dependent on nutrition and all death, in whatever form, is due to its lack. So we have a kind of biological circulation and a kilogram of body substance evolves a different sum of total energy in each of these periods of life. The author gives us an interesting cut of the contraction of the vertebrae and their padding, which often in the old means ankylosis in the lower part of the spinal column.

He dissents from the Conklin theory of the abatement of metabolism as a cause of old age because he thinks this activity has a wide range of play at all stages of life, monthly and even daily. Nor does he accept without modification the Schilddrüse (thyroid) theory, although admitting that the endocrine glands play a very important function. Nor does he accept Von Hansemann’s view of altruistic nutritive disturbance, namely, that single cell groups are more or less reciprocally dependent upon others for their activity so that they in a sense work for each other. The physiological (that is, without outer stimulation) collapse of groups of cells is especially connected with the generative cells and their departure reacts upon the nutrition of the whole body and in a sense weakens it (the atrophy of age). The loss of the generative cells is physiological because they, in departing from the body, represent the growth of a new organism. Hansemann gives countless examples but they affect only the fact and not the kind or method of growing old, which is a progressive process, and we still are unable to answer the question why the generative cells in the ordinary process of life are so soon destroyed or why so few of them are devoted to this purpose.

The author sees much truth in Minot’s differentiation or cytomorphosis of cells, according to which differentiation, which causes growth, is also the cause of death. Minot himself says that the biologist can no more grasp the essence of death than he can that of life. Science does not know the difference between these two despite the impulsions of our causal instinct. Horsley thinks the condition for a green old age is the conservation of a sound thyroid. With its activity is, of course, connected that of other glands.

He says it might be assumed in a period during which a whole generation dies that the whole mass of putrefaction would cause infection. But in a half-dozen German cities very carefully investigated along this line it was found that those who lived in or near cemeteries were as long-lived as others and even those who drink water that is fed by drainage from well appointed graveyards are not infected; on the contrary, in several places this water is purer than elsewhere. There is only one exhumation in Germany for criminal purposes out of 600,000 corpses, but poison that might be detected by exhumation cannot, of course, be traced after cremation.

Instead of the remorse, anxiety for friends, dread and pain, the author, who says he has seen “many, many hundreds of deaths,” never saw one that was not unconscious. There are often, perhaps even for days, physical signs of great suffering but this is never felt; and the author advocates special death rooms in hospitals because it is so hard for onlookers that it is inhuman to allow patients to die in a ward with only a screen in front of the bed. The review of life by drowning people is a myth. It is the duty of the doctor to mitigate closing pains by morphia and other means, provided these do not shorten but rather tend, as they should, to somewhat prolong life. Even in death by fire and torture the last stages are painless.

The Kamerlengo strikes the Pope on the forehead three times with a silver hammer and calls his name and, if he does not answer, says, “The Pope is really dead.” This is because hearing is supposed to be the last sense to die. But often after death the muscles contract spontaneously, even enough to move the body and this has made survivors believe their friends were alive. The muscles respond to electrical stimuli for hours. The pupil of beheaded people contracts to light. In Charlotte Corday’s head the eyes opened. Dr. Rousseau saw a case in which the heart occasionally beat twenty-nine hours after decapitation. Generally death proceeds from the heart and its last beat marks the entrance of death. Respiration, too, or the last breath is often the mark of death because the carbon dioxide is not removed; hence we say life is in the blood. Everyone at times wonders not only when he will die but how. And it is hard to live so as to avoid pathological death.

A French nobleman, François de Civille, in the time of Karl IX, appended to his monument the inscription: “Thrice dead, thrice buried, and by the grace of God, thrice revived.” The riddle meant that he woke first from his mother’s body at birth and twice in war was thought dead and placed among the dead. But the absence of personal consciousness is very unreliable because after long periods of lethargy many have rather suddenly revived. There never was a doctor present at an exhumation of a living man. Being buried alive is really a ghost that has no justification in civilized lands. This has nothing to do, of course, with simulation. Karl V simulated death in order to enjoy the spectacle of his funeral, as Juliet allowed herself to be buried. By contraction of the muscles of the neck and deep respiration the heart can be checked and the physiologist, Weber, nearly lost his life thus. Dr. Gosch tells of a Colonel Townsend who in the presence of Prof. Cheyne stopped his heart and breathing, the latter tested by a mirror, for half an hour until they were all convinced he was dead. But then he gradually came to, though he died eight hours later.

Herter and Rovighi tested lactic acid and its effects on fermentation of the large intestine and found negative results, so that we do not have an arcanum against death or old age in this sense, although insufficient excretion of toxins has much to do with it.

In his illuminating articles Professor Raymond Pearl, after showing the novelty of natural death and how even somatic cells now seem possibly immortal if separated from the metazoan body and that heredity is a prime determinant of the length of the span of life, says we must know more of the vagaries of germ plasm before society should assume to control it, although such control sooner or later will be necessary. The death rates for the four diseases that public health and sanitary activities have been most successful in treating, namely, (1) tuberculosis of the lungs, (2) typhoid fever, (3) diphtheria and croup, (4) dysentery, have been materially reduced in the last nineteen years. But if we compare four other causes of death, (1) bronchitis, (2) paralysis, (3) purulent infection and septicemia, (4) softening of the brain, on which health and sanitation have had little effect, it is found that the rate of mortality from these troubles has declined just as much, and probably a little more, in the same period of time, although the numbers in the latter group are far less. “Hence the declining death rate in and of itself does not mark the successful result of human effort.”

Recognizing the fact that the essential cells in our body are inherently capable under proper conditions of living indefinitely, the problem that confronts us is whether environment or heredity has most to do in determining the actual length of life. Pearl concludes that the death rate of the earliest period of life is selective, eliminating the weak and leaving the strong, and that inheritance is “one of the strongest elements, if not indeed the dominating factor, in determining the duration of life of human beings.”

The duration of life in animals also depends on the total amount of metabolic activity or work and it has been proven that rats, at least, live longer under conditions so controlled that their activity is lessened, so that the greater the total work done or total energy output, the shorter is the duration of life and vice versa, work accelerating the aging process somewhat as rise of temperature does. Pearl says: “The manner in which the environmental forces (of sublethal intensity of course) chiefly act in determining the duration of life appears to be chiefly by changing the rate of metabolism in the individual. Furthermore, one would suggest, on this view, that what heredity does in relation to duration of life is chiefly to determine within fairly narrow limits the total energy output which the individual exhibits in its lifetime.” The duration of life of an animal stands in inverse relation to the total amount of its metabolic activity or, put in other words, to the work in the sense of theoretical mechanics that it as a machine does during its life. Or, to put it in another way, if the total activity of a unit of time is increased by some means other than increased temperature, the same result appears as if the increased activity is caused by increased temperature. Pearl thinks that Steinach’s experiments on the sexual glands, whatever their results for rejuvenation, do not prove “any really significant lengthening of the life span.” Nor does he think that Robertson’s experiments with tethelin from the pituitary gland, whatever its effects upon growth, show that it materially increases the length of life to a degree that has much significance statistically, so that inheritance remains a prime determinant of longevity.

We are all born in one way but die in many. By international agreement a mortality code has been developed with fourteen general classes comprising 180 distinct units. Pearl would supplement this very unsatisfactory classification by the following: (1) circulatory system and blood-forming organs, (2) respiratory system, (3) primary and secondary sex organs, (4) kidney and related excretory organs, (5) skeletal and muscular system, (6) alimentary tract and associate organs concerned with metabolism, (7) nervous system and sense organs, (8) skin, (9) endocrinal system, (10) all other causes. This would show organological breakdown rather than pathological causation. The breakdown of the respiratory system is the chief cause of death, and next comes that of the alimentary tract; these together constitute half the deaths biologically classifiable. Next come troubles with the blood and circulation. We may conceive these as three successive defense lines, and it is against the first two of these that better health and hygiene have been chiefly directed, having been most successful with the respiratory system. Child-welfare, both pre- and post-natal, is by all odds the most hopeful direction of public-health activities. Pearl’s very important studies here confirm the conclusions others have reached, that early pubertal years show the lowest mortality rate, and he traces in detail for each age of life the mortality curves for each of the chief groups of disease.

Very interesting are his conclusions touching the embryological basis of mortality in which he attempts to trace the causes of death back to the three primitive tissue elements, concluding that about 57 per cent of biologically classifiable deaths result from the breakdown or failure to function of organs arising from the endoderm, 8 to 13 per cent from those that spring from the ectoderm, while the remaining 30 to 35 per cent are of mesodermic origin. The ectoderm has been most widely differentiated from its primitive condition, as best illustrated by the central nervous system, the endoderm least differentiated, while the mesoderm is intermediate in this respect. Now, degrees of differentiation imply adaptation to the environment and the endoderm, which is least differentiated, is least able to meet vicissitudes. “Evolutionally speaking, it is a very old-fashioned and out-of-date ancestral relic which causes man an infinity of troubles. Practically all public-health activities have been directed toward overcoming the difficulties which arise because man carries about this antediluvian sort of endoderm.” Prior to the age of sixty the breakdown of organs of endodermic origin causes most deaths; next come breakdowns with organs of mesodermic origin, and lastly those of ectodermic origin. The rate for all these germ layers is relatively high in infancy, dropping to a low point in early youth. In infancy the chief mortality is due to endodermic defect; from about the age of 12 on, to faults of ectodermic, and after about 22 to those of mesodermic origin. The death-rate curve rises at a practically constant rate to extreme old age. From about 60 to the end of life deaths from the breakdown of organs of mesodermic origin lead. The heart generally outwears the lungs and the brain outwears both because evolution is a purely mechanical process instead of being an intelligent one. “It is conceivable that an omnipotent person could have made a much better machine as a whole than the human body which evolution has produced. He would presumably have made an endoderm with as good resisting and wearing qualities as a mesoderm or ectoderm. Evolution by the haphazard process of trial and error which we call natural selection makes each part only just good enough to get by.” All this, the author believes, only strengthens the evidence that the most important part in longevity is played by innate constitutional biological factors.

This view so commonly held, that heredity is the chief factor in longevity is doubtless correct in general. But it is fatalistic and directly tends to lessen the confidence of hygienists and physicians in the efficacy of all their methods of prolonging life in the aged. There is, we think, good reason to believe that there is a great and now rapidly growing number of exceptions to this so-called law, cases in which by conformity to right rules of living, age has been increased many years beyond that which our forbears attained. Indeed, the very fact of the gradual prolongation of life shows that the hereditary predisposition to die at a certain age can be, to a great extent, overcome. The psychological effect of this dogma of the prepotence of heredity in determining the length of life is itself not only depressing but may readily become, as psychologists can best understand, a dangerous lethal agent with the old and cause those who have reached the span of years at which their forbears died to succumb to their troubles with less resistance. Indeed, it is one of the chief purposes of this volume to show that the old-age problem is not merely economic, philanthropic, social, or even medical, but also, when all is said and done, perhaps chiefly psychological and that the future welfare of the race depends upon the development of an old age due not chiefly to heredity but to better knowledge and control of the conditions of this state of life.

Senescence is, in no small degree, a state of mind as well as a state of body, and the study of it as such has been so far strangely neglected but is now in order. Even doctors who have told us most about it have made few intensive investigations of its nature and there are very few gerontologists; while the alienists who have described the senile psyche have done so only in general terms that add but little to what is obvious to common experience and observation. None have sought to ascertain empirically from intelligent old people capable of telling how they think and feel about their stage in life, or to determine how far their attitude toward it was indigenous and how far it was really due to the acceptance of current traditions that have come down to us from a remote past and that no longer fit present conditions. How this old tradition still influences even physicians may best be shown by a few instances that have come under my own observation. A friend of 73 fell sick of pneumonia which soon involved both lungs. The excellent family doctor had him removed to a hospital where expert care could be added to his own. Soon all hope of his recovery was abandoned and for a week friends who called or telephoned were told that nothing more could be done and the end was certain and might be expected any time. “He is 73, you know,” the doctor said. To-day he is well and daily active in the very large concern he created. The father of an intimate friend at the age of 69 fell ill from a complication of disorders the family doctor diagnosed as old age and telegraphed his son to hasten home from a distant city if he would see him alive. Upon his arrival, on the morning of the 70th birthday, he found him half comatose and convinced that this day would be his last; but he was cheered up, diverted, partook of a stimulated eggnog, his first food for two days; and when he awoke just past midnight and realized that he had entered upon another decade, revived, made a slow but surprising recovery, and enjoyed not only a comfortable but a very active life for nine years. He could not, however, quite bring his mind to enter the ninth decennium. Strangely enough, my friend’s mother, whom I had also known all my life, two years later passed through almost the same experience. He was called to her deathbed, reaching her three days after all hope had been abandoned. But she recovered and was nearly as well as before, and lived seven years. A friend of mine retired from a college chair at 74 and was told that he was worn out, had several grave symptoms, and must drop work and go South. “You should be satisfied,” his physician told him, “with four years beyond the allotted three score and ten.” But he had unfinished tasks, believed them to be life-preservers, and now at 82 is still engaged upon them. A vigorous old lady of 87 has thrice been given up by her physician within the decade. Are doctors a little falsetto in their treatment of the aged?

Seventy is, on the whole, the most dangerous milestone and the morning of that birthday is probably the saddest of all that those who attain it have known or will ever know. It brings a new consciousness that now indeed we are old; and if we still carry on as before, we are at least under the suspicion of affecting a vigor that we really lack and are liable to lapse to an apologetic state of mind because we do not step aside and give our place to our juniors who often feel that they have a right to it, even though they try not to show or even confess it to themselves. If we make partial withdrawal we find insistencies, conscious and unconscious, in those who supersede us that we might as well make it complete and the sense of being superfluous and no longer needed is bitter. Complete retirement from all our life work, whatever it is, may make us feel that we are already dead so far as our further usefulness is concerned. Yet at no stage of life do we want more to be of service than when we are deprived of our most wonted opportunities to be so. We do not take with entire kindness and resignation to being set off as a class apart.