Geriatrics; a treatise on senile conditions, diseases of advanced life, and care of the aged

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A TREATISE ON SENILE CONDITIONS,

DISEASES OF ADVANCED LIFE,

AND CARE OF THE AGED

BY MALFORD W. THEWLIS, M.D,

Associate Editor, Medical Review of Reviews, New York City

WITH INTRODUCTIONS BY

A. JACOBI, M.D., LL.D.

AND

I. L. NASCHER, M.D.

ST. LOUIS

C. V. MOSBY COMPANY 1919

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Copyright, 1919, By C. V. Mosby Company

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C. F. Afos&i/ Company

St. Louia

TO I. L. NASCHER, M.D.

THE FATHER OF GERIATRICS

Preface

In 1860, when Doctor Abraham Jacobi began his first systematic course in pediatrics, very little interest was taken by the medical profession in this specialty. It was a difficult matter to convince physicians that the ailments of children required special attention and treatment and Doctor Jacobi met many discouragements before he succeeded in firmly establishing pediatrics as a special branch of medicine. As public interest in child conservation increased, medical interest in pediatrics increased, and today this is one of the most important branches of medical science.

For many years French and German physicians understood that the other extreme of life required special study and care; that the methods and measures successful in diseases in earlier life were often detrimental in the same diseases in old age; and that the natural tendency of pathologic processes was to spread, become more active, cause further disorganization, and lead to death. It seems to be as difficult to impress these truths upon American physicians today as it was difficult, half a century ago, to make physicians realize the importance and truth of pediatrics. From the time of Hippocrates, whose works contain many references to senile conditions, to this day, philosophers, scientists, and physicians have studied and written about the aged, but the first scientific treatise on diseases of old age, Floyer's Medi-

8 PKEFACE

cina Gerocomiea, appeared in 1724. Our present knowledge of senile diseases is based upon Canstatt's Krarikheiten des Hoherem Alters und Ihre Eeilung, which appeared in 1839. Since then, a number of German and French textbooks on this subject have appeared, but aside from the English translation of Charcot's lectures, given in the late sixties, and Seidel's Monograph on Diseases of Old Age, in Woods' Monographs of 1890, no important American book appeared until Nascher's textbook Geriatrics, The Diseases of Old Age, and Their Treatment made its appearance in 1914. It is a singular fact, showing the universality of medicine, that Doctor Abraham Jacobi, who, fifty years before established pediatrics as a special branch of medicine, wrote the introduction to Doctor Nascher's work, the first complete textbook on the subject in the English language. Like Brettoneau, his pupil Trosseau, and Trousseau's pupil, Dieulafoy who succeeded each other in developing medical science during the greater part of the nineteenth century, the writer has had the good fortune to continue the work of Doctors John A. Wilcox and Horace Wilcox, who for more than half a century have devoted their lives to the advancement of medical science, and who had a wide experience in the care of aged patients.

The plan followed in this work is to make a clinical presentation of cases, not a textbook presentation of diseases. It is really a series of monographs, following the style of French writers, who report cases and then discuss them. In this way, the cut-and-dried textbook style is avoided, the personal views of the writer are presented, the discussion is in great part limited to the writer's experience; therefore, a mass of statistics is omitted.

PKEFACE

One of the most frequent questions asked about geriatrics is, "At what age does the study begin?" At a meeting of the New York Geriatric Society, the surgical aspect of the aged was discussed, and the surgeons present limited their remarks to cases over seventy years of age. This is the general impression, but it is erroneous. The subject may apply to persons of thirty: indeed, I had a patient thirty years of age who presented senile changes including arteriosclerosis and calcareous degeneration of the arteries without apparent cause. Had there been syphilis, plumbism, or other of the pathologic causes for the condition, it would not have come under this head. Being apparently a case of precocious senility, it falls within the scope of geriatrics. Many persons at, or just past forty-five, present senile changes which should not appear until seventy or later.

Geriatrics includes, not only the treatment of senile diseases, but also the care of the aged, the causes of ageing, and measures for prolonging life. Many of the arteriosclerotic and other senile changes begin about the age of forty-five, and proper attention at this time would prevent their too rapid development. The study of geriatrics should then include persons about fifty: about the time when the senile changes first become manifest.

With increasing interest in this subject it is not too much to expect special geriatric hospitals, laboratories, and specialists, who will devote themselves exclusively to the care of the aged.

Many of the articles in this work have appeared in the Medical Review of Reviews, Urological and Cutaneous Review, Medical World, and elsewhere. I am indebted to the X-ray Department of the Boston Dispensary, and to Major Arial W. George, Medical Reserve Corps,

10 PREFACE

United States Army, for the roentgenograms in this work. I am grateful to Doctor I. L. Nascher for his assistance in preparing the manuscript and to Doctor Horace Wilcox for valuable information on the subject given to me during the many years that I have been associated with him.

M. W. T.

New York City.

Introduction

By I. L. Nascher, M.D., New York

Three incidents in my career led to the closer study of the senile organism and the introdnction of geriatrics as a special branch of medicine. During my student days back in the early eighties, an instructor took a number of students to the almshouse to see cases. An old woman hobbled up to the instructor with some trivial complaint. He afterwards told us that she was suffering from "old age. ' ' " And what could be done for her ? " " Nothing. ' ' Suffering from old age and nothing could be done to relieve her suffering! Is old age, then, a disease from which those who had reached advanced life were doomed to suffer? This incident, as vivid today as it was nearly thirty-five years ago, laid the foundation for the branch of medicine to which I gave the name ' i Geriatrics. ' '

In 1890 Seidel's monograph Diseases of Old Age appeared. It contained the keynote of the subject in the following paragraphs :

"Mistakes are made daily in the treatment of the aged and the normal mortality of advanced life is considerably increased as a result of the hitherto neglected study of the peculiarities of the senile organism." This monograph epitomized what was then known of the diseases occurring most frequently in advanced life, but it was altogether too short to serve as a handbook. It was a landmark, not a guide post. At this time there was no modern work in English on the subject, the most recent American book on Diseases of Old Age being Charcot's

12 INTRODUCTION

and LoonnV Work which appeared in 1881. This was an English translation of Charcot's lectures on gout and rheumatism, given in Paris in the late sixties, to which Doctor A. L. Loomis added a few lectures. FothergilPs Diseases of Sedentary and Advanced Life* 1885, was written for the layman as well as the physician, and like all such works it omitted the technical matter essential for scientific study. Seidel's monograph gave hints and suggestions which could be used as themes for investigation and development but there was still lacking something upon which the superstructure of a new branch of medicine could be built. This was furnished fifteen years later in an apparently trivial remark made by the physician of a Home for the Aged near Vienna.

In reply to my question to what he attributed the low death rate in his institution he said, "We deal with the aged inmates as aged persons just as the pediatrist deals with children. ' ' This remark amplified, gave me the basic principles of geriatrics. "Senility is a physiologic entity like childhood; not a pathologic state of maturity.' ' "Diseases in senility are pathologic conditions in a normally degenerating body; not diseases such as occur in maturity complicated by degenerations. ' ' " The object of treatment of disease in senility is to restore the diseased organ or tissue to the state normal in senility; not to the state normal in maturity. ' '

Upon these cardinal principles was erected the new branch of medicine. The introduction of a new specialty in the already overspecialized science of medicine was generally discouraged but a few physicians realized that there was a void in medicine, that geriatrics was a legitimate and necessary branch. Among the first of these physicians to recognize this was Malford W. Thewlis, the author of this work. Doctor Thewlis not only encouraged me in my efforts to arouse medical interest in

INTRODUCTION 13

the aged and their diseases, but became a close observer of senile conditions, did research work, published a number of valuable articles and became associate editor of the Department of Geriatrics in the Medical Review of Reviews. Doctor Thewlis is today one of the few recognized specialists in geriatrics in this country. Spurred by scientific interest as well as by a deep sympathy for the aged, he has given to the medical profession in this work the result of many years of study in this neglected branch of medicine.

INTRODUCTION

By A. Jacobi, M.D., New York

I have been called upon to introduce another book on the diseases of advancing and advanced years. The author does not mean to start a new specialty when enlightening us about the physiology and pathology of age, but, conversely, thinks that our American literature has been rather slow in directing the attention of our physicians to the ailments of the old. Some of us may have been of the opinion that we have been quite too generous in giving consideration to real or alleged specialties, for instance, the diseases of infants and children; but there is no doubt that certain parts of the maladies of advanced age have not been taught or studied to their full merit.

Now with "infancy," "childhood," or "puberty" we connect a certain number of years and anatomic and physiologic alterations which are readily recognized, but in later life there is no change known by a certain number of years or changes recognizable as an epoch. Changes of bones of the same character may occur about any age without indicating a certain period of life. A "malum coxae senile," may not mean exactly the seventh or fifth or fourth decade. Atheromatosis and sclerosis do not mean a certain time of life which may be counted by years or named "youth" or "age" or "maturity." "Age" may reach a man in early years or in retarded periods. That is why from time to time more books or even better books may be written or studied on "age" or "old age"; these titles may mean different objects or conditions. Changes of the heart muscle or the anatomy of the blood vessels may be the same at twenty-five which we report at fifty or eighty. Eespiratory varia-

INTEODUCTION tions, chronic bronchitis, or emphysema will cause the same manifestations and indicate the same therapy at twenty as at seventy-five without the diagnosis of "old age"; cataract or prostatic disease, cystitis or neoplasm need not mean a definite advanced period of life. A "sepsis," which we diagnosticate so readily, or "neuritis," which we attribute to the old so often, must not be limited to individual epochs. Even a diverticulum does not wait for individual local changes or strictures ; for at any age it may be met with and accompanied by dangerous symptoms.

Maybe the student will do well to be prepared for certain changes in the course of a malady when his patient is aged ; collapse is frequent though a fever is not marked. At that period in a feverish affection the temperature may be low. The practitioner must not forget that the slovenly way of taking the temperature of the body in the axilla or the mouth in a pneumonia will never do when the rectum (or occasionally the vagina) ought to be the only reliable > access. Particularly is this important when the patient is a male. Infections usually turn readily into paralysis. Cerebral affections of the aged are liable to be fatal. Local symptoms about the lungs are sometimes quite few with little pain, little dullness and insufficient auscultatory changes.

In the practice among the old, or the prematurely old, some symptoms should always be looked for, though they are rare. Such are chills, or pain in gout, or polyuria in diabetes. Some must be feared though they are rare, for instance, affections of the tonsils, or diphtheria, or maladies connected with the spleen. Some must be apprehended because they are frequent and fatal; such as bronchitis which is apt to relapse and be complicated with pneumonia either sclerotic or catarrhal; renal disease which is a frequent cause of death; influenza which

16 INTBODUCTION

kills many; parenchymatous tumors or those complicated with concretions, or with pus, or with erysipelas. Tuberculosis is not at all rare in the aged. Tuberculous ulceration of the intestines is frequent. Tuberculous pericarditis, meningitis, osteitis, and arthritis are not infrequent. Pulmonary tuberculosis has more of a fibrous than purulent character; the chronic form may last many years, while the general condition of the patient is fair. The temperature is often quite low and should be taken in the rectum. Hemorrhages are scarce, particularly in kidneys and the prostate.

Cancer is not very frequent in the aged ; more so about the middle years. It is liable to destroy life before it reaches advanced age ; that is why it can not be called a disease of the old. The question of the frequency of carcinoma is doubtful so long as its diagnosis may be questionable. Indeed we make more positive diagnoses of cancer than formerly in intestines, gall bladder, thyroid and prostate, and discriminate more correctly between sarcoma and carcinoma. Altogether the influence of trauma — for instance, phimosis, calculus, fistula, flexure, or lupus — on the early development of cancer is not great.

Modern therapy may also have its influence on statistical statements. Roentgenotherapy has cured some carcinomata, and caused many. Radiotherapy has cured skin cancer in many instances; and the treatment of carcinoma with methyl thionin hydrochloride has proved successful at least in retarding the development of cancer in hundreds of my cases (Jour. Am. Med. Assn., 1906).

My readers will feel sure that I am much interested in the subjects which form the studies of the author. My fragmentary remarks were to introduce a few of the schemes he means to teach us. I know he will succeed.

4 ya^irt^

CHAPTER VII Care of the Eyes in the Aged 67

Senile Astigmatism, 68; Senile Conjunctival Changes, 68; Senile Retinal Changes, 69; Arcus Senilis, 69; Presbyopia, 69; The Senile Pupil, 70; The Sclera, 70.

18 CONTENTS

CHAPTER VIII page

Senile Mentality 71

Memory Impairment, 72; Reasoning Power, 73; Brain Fag, 74; Emotions, 75; The Will, 75.

Chapter I Geriatrics

Geriatrics is the branch of medicine dealing with old age. That the aged require special care and treatment was recognized by Hippocrates, the father of medicine, twenty-three centuries ago. That they require special study has only recently been recognized and even today a large proportion of the medical profession ignores the study of the senile organism.

Geriatrics is based upon three fundamental principles: (1) that senility is a physiologic entity like childhood and not a pathologic state of maturity; (2) that disease in senility is a pathologic condition in a normally degenerating organ or tissue and not a disease such as we find in maturity, complicated by degenerations; (3) that the object of treatment in senility should be to restore the diseased organ or tissue to the state normal to senility and not a restoration to the condition normal in maturity. The correct interpretation of senile pathology (principle 2) is impossible without a knowledge of the normal senile anatomic and physiologic changes (principle 1), and the proper treatment and care of the aged (principle 3) is impossible without a knowledge of senile pathology.

Anatomic changes, called senile degenerations, occur in every organ and tissue of the body. The essential change is a waste of- tissue which is either not repaired at all or is replaced by tissue of a different character. In every case where the waste is repaired by other tissue the new tissue is of a lower order, requiring less blood supply and incapable of doing the work of the wasted tissue. Wasted brain and nervous tissue is not regenerated, but some change occurs in the character of this tissue in old age. The senile brain is shrunken, denser, and contains more fluid and less fat. Nerve fibers are thinner and the nerve cells are atrophied. In some cases the waste of muscles is replaced by fat, in some cases by fibrous tissues and in others the waste is not repaired. Muscles actively employed usually waste, but the most active of all muscles, the myocardium, generally undergoes fibrosis. In brown atrophy, the cardiac muscle undergoes the same change that occurs in other solid organs in old age, but this form of senile cardiac degeneration is rare. Inactive muscles usually undergo fatty degeneration.

In bone the organic matter wastes, leaving an excess of mineral matter and causing the bone to become more brittle. The waste of the organic matter in the heads of long bones produces a spongy condition, or osteoporosis. Bone marrow becomes harder, denser, and whiter and contains more fat than in young persons. Cartilage either wastes through insufficient repair, becomes fibrillated and wastes through attrition, or becomes fibrous or osseous. Ligaments and tendons waste, contract and become stiff and hard. The synovial sacs become dry and the sac-covering becomes dry and thick. These changes in the structure of the joint cause a stiffening with diminished motility — a condition designated as "arthro sclerosis."

The skin becomes dry and thin, it is darker where it has been much exposed to sunlight and owing to the waste of connective tissue it becomes loose, and falls into folds. These folds are especially marked where

Fig. 1. Roentgenogram of wrist of a woman, aged 65, showing atrophy of the cartilages, making the bones very close to each other. This plate also shows rarefaction of the ends of the metacarpal bones.

there has been a waste of fat, as on the forehead, neck, etc. The hair becomes gray and thin, with an occasional excessive growth in nnnsnal places as on the eyebrows, in the ears and nose of men, and on the upper lip and chin of women. The changes in the hollow organs and tubes consist of atrophy of the muscular fibers with consequent dilatation of the organ or tube, and where glands are imbedded in the walls as in the stomach and intestines, the glands atrophy. In solid organs as kidneys, liver, pancreas and spleen the tissue cells atrophy and there is a proliferation of connective tissue fibers constricting the organ, making it smaller and denser. The spleen is thus often diminished to nearly half its usual size. The smaller glands atrophy and their secretions are diminished. In a few instances organs and tissues do not follow the usual course. The prostate gland is usually enlarged through excessive proliferation of fibrous connective tissue. The ureters undergo fibrosis and become stiff and hard and the blood vessels become harder through waste of muscular fibers and their replacement by fibrous tissue. The heart is usually hypertrophied, but this is a compensatory and not a degenerative condition. The sudoriparous glands atrophy, but in some locations as in the axilla, in the groin, etc., there is an excessive excretion of perspiration which has a fetid odor. In the lungs, the constant inhalation of dust produces a pneumonokoniosis and the waste of tissue causes a thinning and later complete waste of the walls of the alveoli, air cells coalesce and emphysema is produced. The blood changes so far recognized are, diminished amount, increased viscosity and density and increased hemoglobin content.

As a result of the anatomic changes the functions of the organs and tissues are altered, but the functional changes do not always correspond to the anatomic changes owing to the hardening of the blood vessels and their lessened elasticity. The amount of blood carried to all parts of the organism, especially to the parts supplied by terminal vessels, is lessened and the organs and tissues supplied by these terminal vessels are insufficiently nourished. Neither the character nor the extent of the physiologic changes gives any indication of the extent of the histologic changes in the functionating organs. Very little of the spleen substance is left in advanced life and the character of the bone marrow is greatly altered, yet there is apparently no change in the number or character of leucocytes. The composition of the urine shows little alteration in the aged though the senile kidney is extensively changed. On the other hand, the physical debility is usually far greater than can be explained by the wasted muscles or the anatomic changes that can be recognized in the nerves or nerve terminals. The pronounced physiologic functional changes consist of lessened activity, altered activity, and loss of the harmonious interrelation between associated functions. The circulation is maintained with difficulty as the vessels have lost their elasticity and the compensatory increased activity of the heart is expended in the larger vessels and is lost in the smaller peripheral arteries. Owing to the atrophy of the muscular fibers of the veins and the consequent dilatation and loss of tonicity of the veins, the return circulation is impaired and the entire circulation is weakened. At the same time the tissues involved in the nervous system degenerate and nerve control is impaired. As a result of the nervous and circulatory changes, organs and tissues are insufficiently nourished, they degenerate and their functions are weakened and in some cases altered while the harmonious interaction of functions is impaired. The respiratory capacity is diminished, the amount of air inhaled is insufficient to completely oxygenate the blood and the carrying capacity of blood, of nutrition to the organs and tissues, and waste from the organs and tissues, is lessened.

Fig. 2. Roentgenogram of skull of a woman, aged 72, showing narrowing and atrophy of the jaw and a pointing and prominence of the mandible which is accentuated by atrophy of the ramus.

Fig. 3. Roentgenogram of ankle of a man, aged 70, showing rarefaction of the bones, atrophy of the cartilages making the space between the tarsal bones much less than in younger individuals. There is also a penciling of the outlines and coarse trabecular of the bones, a characteristic of old age.

The impaired blood is now incapable of completely repairing the waste of lnng tissue and consequently lung degeneration is hastened and this still further impairs the oxygenating power of the lungs. In like manner vicious circles are created throughout the organism. The muscular fibers of the rectum atrophy, permitting a dilatation of the lower bowel. This permits a larger amount of fecal matter to accumulate in the rectum, and owing to the atony caused by the waste of muscular fibers, a larger amount accumulates than the normal bowel can hold. The bowel is still further dilated, the weakened muscular fibers are still further stretched and further waste and atony ensues with greater distention. Prolonged retention of feces with consequent decomposition and absorption of these toxins produce intestinal toxemia with its train of symptoms and interwoven vicious circles.

Organs and tissues being in a process of degeneration and their functions impaired in the aged, when they become diseased, the pathologic and the functional changes are different from the changes that occur in the same disease in earlier life. Some diseases are peculiar to the senile organism, others are so greatly modified that they are hardly recognizable in the altered symptoms and signs. In Nascher's classification of the diseases of advanced life the diseases are divided into five groups, primary senile diseases, secondary senile diseases, preferential diseases of old age, modified diseases of old age and diseases uninfluenced by old age or rare in old age. In the first group are defects in the normal senile processes or functions. In the second group are diseases resulting from the senile changes. Thus, cerebral arteriosclerosis belongs to the first group while rupture of the sclerosed cerebral vessels causing apoplexy belongs to the second group. The preferential diseases are those which occur most frequently in advanced life but may occur earlier. Such diseases as paralysis agitans, diabetes, gout, arthritis deformans, cancer, etc., belong to this group. The fourth group contains most of the diseases which may occur at any time of life.

Owing to the altered anatomic structures and relations and altered functions in old age, pathologic processes affect these structures, relations and functions differently and the diseases are modified in character and in their symptoms and signs. In the last group are diseases such as the infectious diseases of early life and diseases which do not differ materially at any period of life. The treatment of disease in the aged must be based upon the third principle; restoration to the norm of senility, not to the norm of maturity. It is folly to attempt to convert diseased degenerating tissue of advanced life to the state normal in earlier life. Yet we frequently find physicians attempting to cure senile arteriosclerosis and proclaim a cure when they have succeeded in reducing the blood pressure temporarily. Through drugs and other means they will temporarily stimulate functions and congratulate themselves that they have caused rejuvenation when in fact the temporary stimulation will be followed by a reaction in which degeneration proceeds more rapidly. Drugs and other therapeutic measures do not act upon the degenerated tissues in the same manner as they do upon the healthy or diseased tissues of maturity. Doses are reduced without rule or system when most drugs must be given in increased doses. Drugs are given which are not assimilated or which produce in the senile organism more pronounced secondary effects than in earlier life. Failure to recognize these factors in the treatment of disease in senility is another cause for the frequent failure to cure senile patients.

Chapter II Neglect Of The Aged

That the aged are neglected is very evident. There are hundred of books, journals, and societies devoted to the welfare of the child and the number is increasing year by year. Aside from the small organizations interested in particular homes for the aged and one small medical society interested in senile diseases, there is no general body interested in the welfare of the aged. There is not a journal in the world devoted to the aged, while the few books dealing with the conservation of the aged are either medical works concerned with senile diseases or scientific works too technical for popular use.

The layman understands that the food suitable for the young, active individual is not suitable for the aged person, yet he looks in vain through the standard works on feeding and food for dietetic rules or formulae for the aged. Neither can the physician who is not familiar with the changes in the digestive organs and in their functions, formulate a suitable dietary. The same applies to the clothing, sleep, exercise, recreations and to every other factor in their lives.

A large proportion of the medical profession is still ignorant of the peculiarities of the senile organism and physicians still treat aged persons as they treat younger ones, perhaps diminishing doses of drugs, without system or reason. When the patient dies under such treatment the physician eases his conscience and satisfies the family by ascribing death to "old age." But the conscientious physician who is imbued with the scientific spirit is not satisfied with this diagnosis. Old age is not a disease, and ordinarily it is not a cause of death. Death from old age is conceivable. It is possible that there will be a gradual degeneration of all the organs and tissues and their functions become more and more impaired, that cerebral activity and nervous and muscular irritability be gradually diminished to the point of complete extinction. This is, however, exceedingly rare. It is far rarer than vital statistics indicate since many deaths ascribed to old age are due to disease which the physician did not recognize, or, finding symptoms and signs which he could not interpret, he resorted to the diagnostic placebo, "old age."

We can readily account for the public neglect of the aged. Human sympathy is universal in its scope, but not in its application. Instinctively or subconsciously, economic values, social relations, the esthetic sense and other factors influence the directions in which sympathy is applied. The aged become economically worthless and must remain so, while the child has a prospective and ever-increasing economic value. Optimistic philosophers of all ages from Cicero to Jean Finot describe old age as being beautiful, but no philosopher has ever declared that the aged themselves were beautiful. From the purely esthetic standpoint the aged are disagreeable, often repulsive, repelling those whose sympathy can be aroused only by the sight of helplessness or sound of distress. This repulsiveness appears also in other directions, in disagreeable odors, offensive actions, in peevishness, selfishness, wilfulness, suspicion, etc. One or another of these repelling forces exists in almost every case and overcomes sympathy and interest. We find consequently that there is the universal tendency to shift the responsibility and the care of the aged upon others, usually upon the community at large. Individuals usually take an interest in their own, though this interest is often more dutiful than filial and here the in-