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 CJQFYRIGHT DEPOSIT 
 
GERIATRICS 
 
GERIATRICS 
 
 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 
 

 ^<5 
 
 Copyright, 1919, By C. V. Mosby Company 
 
 V *•* 
 
 ©CU530402 
 JUL 3\ WI9 
 
 ! i 
 
 fVaMojr 
 
 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 suc- 
 ceeded in firmly establishing pediatrics as a special 
 branch of medicine. As public interest in child conser- 
 vation 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 un- 
 derstood that the other extreme of life required special 
 study and care; that the methods and measures success- 
 ful in diseases in earlier life were often detrimental in 
 the same diseases in old age; and that the natural ten- 
 dency 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 condi- 
 tions, 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 knowl- 
 edge of senile diseases is based upon Canstatt's Krarik- 
 heiten des Hoherem Alters und Ihre Eeilung, which ap- 
 peared 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 impor- 
 tant American book appeared until Nascher's textbook 
 Geriatrics, The Diseases of Old Age, and Their Treat- 
 ment made its appearance in 1914. It is a singular fact, 
 showing the universality of medicine, that Doctor Abra- 
 ham Jacobi, who, fifty years before established pedia- 
 trics as a special branch of medicine, wrote the intro- 
 duction 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 med- 
 ical 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 dis- 
 eases. It is really a series of monographs, following the 
 style of French writers, who report cases and then dis- 
 cuss them. In this way, the cut-and-dried textbook style 
 is avoided, the personal views of the writer are pre- 
 sented, 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 geria- 
 trics 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 pres- 
 ent 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 degen- 
 eration 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 senil- 
 ity, it falls within the scope of geriatrics. Many per- 
 sons 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 age- 
 ing, 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 Wil- 
 cox 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 re- 
 lieve 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 ap- 
 peared. 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 consider- 
 ably increased as a result of the hitherto neglected study 
 of the peculiarities of the senile organism." This mon- 
 ograph epitomized what was then known of the dis- 
 eases 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 
 
 11 
 
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 investi- 
 gation and development but there was still lacking some- 
 thing 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 nor- 
 mally 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 legiti- 
 mate 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 en- 
 couraged 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 num- 
 ber 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 rec- 
 ognized 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. 
 
 tC- ^^^A^ 
 
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 en- 
 lightening 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 physi- 
 cians 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 ad- 
 vanced 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 num- 
 ber 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- 
 
 14 
 
INTEODUCTION 
 
 15 
 
 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 "neu- 
 ritis," 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 cer- 
 tain 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 dull- 
 ness 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 ap- 
 prehended because they are frequent and fatal; such as 
 bronchitis which is apt to relapse and be complicated 
 with pneumonia either sclerotic or catarrhal; renal dis- 
 ease which is a frequent cause of death; influenza which 
 
16 INTBODUCTION 
 
 kills many; parenchymatous tumors or those compli- 
 cated with concretions, or with pus, or with erysipelas. 
 Tuberculosis is not at all rare in the aged. Tubercu- 
 lous ulceration of the intestines is frequent. Tubercu- 
 lous 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, thy- 
 roid and prostate, and discriminate more correctly be- 
 tween sarcoma and carcinoma. Altogether the influence 
 of trauma — for instance, phimosis, calculus, fistula, flex- 
 ure, or lupus — on the early development of cancer is not 
 great. 
 
 Modern therapy may also have its influence on statis- 
 tical 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 can- 
 cer 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^ 
 
CONTENTS 
 
 PAGE 
 
 CHAPTER I 
 
 Geeiatbics 21 
 
 Anatomic Changes, Senile Degeneration, 21; Skin Changes, 
 22; Functional Changes, 23; Blood Impairment, 25; Pathologic 
 Processes, 26. 
 
 CHAPTER II 
 
 Neglect of the Aged 27 
 
 Public Neglect of the Aged, 28; Medical Neglect, 29. 
 
 CHAPTER III 
 
 Value of Old Age 31 
 
 Famous Men and Their Accomplishments in Old Age, 31; 
 Famous Women and Their Accomplishments in Old Age, 39; 
 The Lesson From the Masters, 46. 
 
 CHAPTER IV 
 
 The Care of the Aged 47 
 
 Hygiene, 47; Atmospheric Influences, 47; Exercise, 48; Sleep, 
 49; Skin, 50; Recreation, 50. 
 
 CHAPTER V 
 
 Work for the Aged 52 
 
 The Psychic Element, 53; Work and Recompense, 55; Pensions 
 for the Aged, 56. 
 
 CHAPTER VI 
 
 Keep Senile Cases Out of Bed 63 
 
 The Psychic Element, 64; Postoperative Treatment in the 
 Aged, 65. 
 
 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. 
 
 17 
 
18 CONTENTS 
 
 CHAPTER VIII page 
 
 Senile Mentality 71 
 
 Memory Impairment, 72; Reasoning Power, 73; Brain Fag, 74; 
 Emotions, 75; The Will, 75. 
 
 CHAPTER IX 
 Senile Dementia 76 
 
 CHAPTER X 
 
 Diet in Old Age 84 
 
 Regularity of Meals Essential, 84; Breakfast, 85; Dinner, 86; 
 Supper, 86; Calorie Requirement, 87. 
 
 CHAPTER XI 
 
 Senile Constipation 89 
 
 Dyspepsia in the Aged, 89; Enemata, 90; Cathartics, 91; 
 Saline Laxatives, 93. 
 
 CHAPTER XII 
 
 Toxemia in the Aged 94 
 
 Symptoms, 96; Treatment, 98. 
 
 CHAPTER XIII 
 
 Blood Pressure in Senile Cases 100 
 
 Pathologic Senile Pressure, 104; Normal Senile Pressure, 104; 
 Tables of Average Pressure, 107; Conclusions, 108. 
 
 CHAPTER XIV 
 
 Arteriosclerosis 110 
 
 Normal Process in Senility, 111; Premature Arteriosclerosis, 
 112; Pathologic Arteriosclerosis, 114; Treatment, 117. 
 
 CHAPTER XV 
 
 Senile Nephritis ^ 118 
 
 Cases, 118; Symptomatology, 122; Diagnosis, 123; Prognosis, 
 ' 124; Treatment, 124. 
 
 CHAPTER XVI 
 
 Senile Diabetes 127 
 
 Cases, 127; Symptomatology, Diagnosis, and Prognosis, 131; 
 Treatment, 133; Diet List, 134; Conclusions, 137. 
 
 CHAPTER XVII 
 
 Urinalysis in the Aged 138 
 
 Albuminuria in the Aged, 139; Glycosuria, 139; Microscopic 
 Examination, 141. 
 
CONTENTS 19 
 
 CHAPTER XVIII PAGE 
 
 Senile Bronchitis I 4 '* 
 
 Cases, 144; Acute Bronchitis, 145; Chronic Bronchitis, 145; 
 Treatment, 145. 
 
 CHAPTER XIX 
 
 Senile Pneumonia 1*8 
 
 Cases, 148; Symptomatology, 150; Diagnosis and Prognosis, 
 150; Treatment, 151. 
 
 CHAPTER XX 
 
 Senile Gangrene I 53 
 
 Cases, 153; Treatment, 156. 
 
 CHAPTER XXI 
 
 Senile Prostatic Hypertrophy 158 
 
 Cases, 158; Etiology, 159; Symptoms, 159; Treatment, 161. 
 
 CHAPTER XXII 
 Urosepsis — Edema from Prostatic Retention — Enuresis — Cys- 
 
 167 
 
 CHAPTER XXIII 
 
 Therapeutics 170 
 
 Tic Douloureux, 172; Senile Debility, 173; Use of Opiates, 
 174; The Use of Coal Tar Derivatives, 175. 
 
 CHAPTER XXIV 
 The Checking of Hemorrhage, Secretions and Excretions in 
 
 the Aged 178 
 
 CHAPTER XXV 
 
 Diagnostic Errors in the Aged 183 
 
 Pain, 184; Counting Respiration, 184; History-taking, 186. 
 
 CHAPTER XXVI 
 
 Senile Malingering 192 
 
 Examination, 193. 
 
 CHAPTER XXVII 
 
 Venereal Diseases 198 
 
 Syphilis, 198; Gonorrhea, 199; Chancroid, 202. 
 
 CHAPTER XXVIII 
 The Senile Climacteric. A Typical Case 204 
 
20 CONTENTS 
 
 CHAPTER XXIX page 
 
 Sexual Life in the Aged 213 
 
 CHAPTER XXX 
 - 
 Radium Therapy for Senile Epithelioma 218 
 
 Cases, 218; Technic of Application, 220; Prognosis, 221; Does 
 
 Radium Cure Senile Carcinoma? 222. 
 
 CHAPTER XXXI 
 
 Surgery of the Aged 223 
 
 Indications and Contraindications, 223; Anesthesia, 225; Post- 
 operative Dangers, 227; Roentgenology, 232. 
 
 BIBLIOGRAPHY 
 Bibliography 237 
 
GERIATRICS 
 
 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 princi- 
 ples: (1) that senility is a physiologic entity like child- 
 hood 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 re- 
 store 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 pathol- 
 ogy (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 
 
 21 
 
22 GERIATRICS 
 
 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 regen- 
 erated, 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 under- 
 goes fibrosis. In brown atrophy, the cardiac muscle un- 
 dergoes the same change that occurs in other solid or- 
 gans in old age, but this form of senile cardiac degen- 
 eration 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 fibril- 
 lated 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. 
 
GEKIATKICS 23 
 
 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 conse- 
 quent 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 kid- 
 neys, 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 secre- 
 tions are diminished. In a few instances organs and tis- 
 sues 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 re- 
 placement by fibrous tissue. The heart is usually hyper- 
 trophied, but this is a compensatory and not a degenera- 
 tive 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 pro- 
 duced. The blood changes so far recognized are, dimin- 
 ished amount, increased viscosity and density and in- 
 creased 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 
 
24 GEEIATKICS 
 
 and their lessened elasticity. The amount of blood car- 
 ried 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 in- 
 sufficiently nourished. Neither the character nor the ex- 
 tent 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 ad- 
 vanced 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 con- 
 sist 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 con- 
 sequent 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 im- 
 paired. 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 capac- 
 ity 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 narrow- 
 ing 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. 
 
GEEIATKICS 25 
 
 The impaired blood is now incapable of completely re- 
 pairing 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 dila- 
 tation 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. Pro- 
 longed retention of feces with consequent decomposition 
 and absorption of these toxins produce intestinal tox- 
 emia 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 be- 
 come 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, prefer- 
 ential 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 proc- 
 esses or functions. In the second group are diseases re- 
 sulting from the senile changes. Thus, cerebral arterio- 
 sclerosis belongs to the first group while rupture of the 
 sclerosed cerebral vessels causing apoplexy belongs to 
 the second group. The preferential diseases are those 
 
26 GEEIATEICS 
 
 which occur most frequently in advanced life but may 
 occur earlier. Such diseases as paralysis agitans, dia- 
 betes, gout, arthritis deformans, cancer, etc., belong to 
 this group. The fourth group contains most of the dis- 
 eases which may occur at any time of life. 
 
 Owing to the altered anatomic structures and rela- 
 tions and altered functions in old age, pathologic proc- 
 esses affect these structures, relations and functions dif- 
 ferently and the diseases are modified in character and 
 in their symptoms and signs. In the last group are dis- 
 eases 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 at- 
 tempt to convert diseased degenerating tissue of ad- 
 vanced life to the state normal in earlier life. Yet we 
 frequently find physicians attempting to cure senile ar- 
 teriosclerosis and proclaim a cure when they have suc- 
 ceeded 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 tempo- 
 rary 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 with- 
 out rule or system when most drugs must be given in 
 increased doses. Drugs are given which are not assimi- 
 lated or which produce in the senile organism more pro- 
 nounced 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 inter- 
 ested 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 dis- 
 eases 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 per- 
 son, 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 ap- 
 plies 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 
 
 27 
 
28 GERIATRICS 
 
 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 cere- 
 bral activity and nervous and muscular irritability be 
 gradually diminished to the point of complete extinc- 
 tion. 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 pla- 
 cebo, "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 sym- 
 pathy is applied. The aged become economically worth- 
 less and must remain so, while the child has a pros- 
 pective and ever-increasing economic value. Optimistic 
 philosophers of all ages from Cicero to Jean Finot de- 
 scribe 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 disa- 
 greeable, often repulsive, repelling those whose sym- 
 pathy 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. Individu- 
 als usually take an interest in their own, though this 
 interest is often more dutiful than filial and here the in- 
 
NEGLECT OP THE AGED 29 
 
 terest in the children is far greater than in the grand- 
 parents. There is lacking altogether the sympathy for 
 the aged that is essential for their welfare. 
 
 Medical neglect of the aged is as general as is the pub- 
 lic neglect. Here and there some physician thoroughly 
 imbued with the principles of the medical profession, 
 sympathy and science, has made a study of the aged in 
 health and in disease, has recognized the great differ- 
 ence between maturity and senility and has devoted him- 
 self to the care of the aged. But the great mass of the 
 medical profession is still indifferent to their welfare. 
 This is due partly to the causes which lead to the public 
 neglect of the aged and partly to other factors. There is 
 nothing spectacular in geriatrics, it is not as remuner- 
 ative a specialty as other branches of medicine, and the 
 physician's endeavors must end in ultimate failure. 
 Medical knowledge has increased to such an extent dur- 
 ing the last half century that subdivisions and special- 
 ization have become necessary and the physician of to- 
 day must devote himself to a specialty if he wants to 
 keep up with the spirit of the times. And it is but nat- 
 ural that the physician will select a specialty which is 
 either spectacular, remunerative or promising of success. 
 There is another reason that geriatrics is still unpopular. 
 So little has been done in this field and so little has been 
 written about it that the physician taking it up will be 
 obliged to do considerable original observation and re- 
 search work. There are few physicians who are willing 
 to give their time and mental efforts in so unpromising 
 a field when other fields giving greater assurance of suc- 
 cess are open to them and yet there are problems con- 
 nected with geriatrics which, if solved, would make this 
 branch perhaps as spectacular, as remunerative and as 
 successful in immediate results as any other branch of 
 medicine. May there not be causes of ageing which can 
 be controlled or minimized thereby prolonging life ? May 
 
30 GERIATEICS 
 
 there not be some means for stimulating the mental and 
 physical organism thereby causing a rejuvenation, with- 
 out the reaction which hastens degeneration? Can we 
 not lessen and relieve the many little aches and pains 
 which the aged bear with resignation since they have 
 been taught that these are inevitable results of advanced 
 life? 
 
 Here are a few problems well worth the physician's 
 efforts to solve, problems which if solved would revolu- 
 tionize the medical care of the aged, as the solution of 
 the etiologic problem of tuberculosis revolutionized the 
 whole science of medicine. Within the memory of old 
 physicians pediatrics was looked upon as a medical fad. 
 Today it is one of the most important branches of medi- 
 cine and the close study of this branch has resulted in 
 the restoration to health and the saving of life of thou- 
 sands of children. The study of geriatrics gives the 
 same promise in regard to the aged. It requires only 
 the thoughtful consideration of the underlying prin- 
 ciples of geriatrics to convince physicians that it is 
 worth while and that in our present attitude toward the 
 aged and their ailments we are deliberately neglecting 
 our duty toward them. 
 
CHAPTER III 
 THE VALUE OF OLD AGE 
 
 To grow old gracefully is an art which is difficult to 
 acquire, especially in the present day when we are apt 
 to say that the old should make room for the young. It 
 is very common to look upon a man of sixty as too old 
 to be of use in the world, and the present conditions of 
 society really do not offer them encouragements to mas- 
 ter their old age. 
 
 A careful analysis, however, will show us that some 
 of the greatest works in art, music, poetry, etc., have 
 been accomplished by men past sixty, — even past eighty 
 the list is a long one — and without these master minds, 
 the world today would not be as rich in accomplishments 
 as it is. 
 
 To "stay in the harness' ' in ripe old age has been the 
 motto of many of these aged persons. To keep at work 
 in an interesting occupation is in reality the keynote of 
 obtaining the best there is in old age. 
 
 A French philosopher said that a man should keep at 
 his work as though immortal, even if he should know 
 that his death would come the next day. Goethe said, 
 "When a man is old he must do more than when he is 
 young.' ' Emerson said, "The high prize of life, the 
 crowning fortune of a man is to be born with a bias to 
 some pursuit, which finds him in employment and hap- 
 piness." 
 
 It seems, then, that the accomplishments of these old 
 persons rest upon their ability to "stay in the harness." 
 Many an old man is living today who owes his life to 
 occupation. Old age is sweet in its best, notwithstand- 
 
 31 
 
32 GERIATRICS 
 
 ing the horrible examples we observe in everyday life. 
 Many of these old men today are onr resources of knowl- 
 edge; when a young lawyer needs advice he goes to an 
 older lawyer; a young physician consults an older one; 
 the old and young work side by side and each profits 
 from the presence of the other. Advice and activity, 
 knowledge and energy, age and youth, mix well and 
 make the world what it is. It is folly to say that the old 
 should step to one side and give the young men a chance. 
 
 Some men seem to gain in energy as they grow older. 
 Dandolo, when past ninety and utterly blind, stormed 
 Constantinople. Titian was painting his finest pictures 
 before he died in his hundredth year. Brougham was a 
 strong debater at eighty, and Lyndhurst, when over 
 ninety, spoke in the House of Lords. 
 
 Goethe worked "in the harness' ' until he was past 
 eighty years and his intellect remained intact and he re- 
 tained his great energy. Some of his best poems were 
 written when he had passed his seventy-fifth birthday. 
 
 Herbert Spencer died "in the harness' ' at the age of 
 eighty-three. Several years before his death he had a 
 nervous breakdown and practically became an invalid. 
 He worked hard and became master of his affliction. At 
 times he was able to write but a few paragraphs in a 
 day, but little by little his great works were written. 
 He was a great sufferer for over forty years yet he pro- 
 duced some of his best works during this time. 
 
 Sir Joseph Hooker of England, the great botanist, did 
 a great deal of work after he became an octogenarian. 
 Macaulay was forty-eight when he issued the first and 
 second volumes of his History of England, but the third 
 and fourth volumes did not appear until he was fifty-five 
 years of age. 
 
 Darwin did not establish his reputation until he had 
 passed fifty. He wrote Descent of Man at the age of 
 sixty- two. Humboldt's greatest works were produced 
 
THE VALUE OF OLD AGE 33 
 
 after three-score years, and one of his greatest works 
 was not completed until he was eighty-nine years old. 
 
 Carlyle refers to the slow development of a rich nature. 
 He did not begin to publish any of his great works until 
 he was forty years old. The first two volumes of Fred- 
 erick the Great appeared when he was sixty-three; two 
 more when sixty-seven and the last two when he was 
 sixty-nine. 
 
 In many instances it seems that old age produces 
 changes which increase a man's power of energy. Oliver 
 Wendell Holmes in one of his admirable breakfast-table 
 talks said that he found he could learn twice as easily as 
 in his earlier days, the reason being that he had increased 
 power of concentration. 
 
 Oliver Wendell Holmes did not become known over the 
 world until late in his life. The Iron Gate which he wrote 
 for an honor-dinner for his seventieth birthday has been 
 called the finest creation of his genius since the publica- 
 tion of The Chambered Nautilus which was written 
 twenty years before. 
 
 Longfellow at forty-eight wrote the Song of Hiawatha. 
 After that age his writings were prolific. At sixty-eight 
 years of age he wrote Morituri Salutamus which was 
 written for the fiftieth anniversary of his graduation 
 from Bowdoin College. 
 
 Washington Irving wrote the life of Oliver Goldsmith 
 at sixty-six years of age. His Life of Washington in 
 five volumes was completed only during the year of his 
 death at seventy-six years of age. 
 
 Doctor S. Weir Mitchell, like Oliver Wendell Holmes, 
 was an active medical man who spent his spare moments 
 writing. Doctor Mitchell at seventy-five was still prac- 
 ticing medicine and his literary labors were still active. 
 His best literary works were accomplished after he was 
 fifty years of age. His Constance Trescot, regarded by 
 
34 GEKIATKICS 
 
 many as his best work, was written when he was seventy- 
 five years of age. 
 
 Jnstin S. Morrill, of Vermont, at eighty-eight years 
 of age, an active member of the United States Senate, 
 rose in his seat in the Senate and with his old-time en- 
 ergy led the debate on the annexation of Hawaii. It was 
 said of him that he never missed a roll call in the Senate, 
 and, it is said, made fewer mistakes in pnblic life than 
 any other man. 
 
 Thomas H. Benton, Senator from Missouri when sev- 
 enty-two years old was defeated for his sixth term. He 
 started a new life and began a political review of all par- 
 ties from the time of John Quincy Adams to Franklin 
 Pierce. Theodore Eoosevelt, in his biography of Ben- 
 ton, says: "Benton grew in character to the very last. 
 He made better speeches and was better able to face new 
 problems when past three-score and ten than in his early 
 youth or middle age." 
 
 Mr. Beecher says that he does not know of anything 
 that is made sour by frost except man. "They some- 
 times are. October, the ripest month of the year, and 
 the richest in colors, is a type of what old age should be." 
 
 To grow old cheerfully is a great art. To be able to 
 cast one's trouble aside and sleep without worry is an 
 asset worth possessing. Mr. Gladstone locked every 
 affair of state and every other care outs'de of his bed- 
 room door. To his sound sleep he attributed his 
 longevity. 
 
 James Eussell Lowell was once passing a great build- 
 ing in London which bore the inscription "Home for In- 
 curable Children," and with a twinkle of his eye said to 
 a friend, "They'll take me there some day." 
 
 The greatest men of the world have the heart of a 
 child and when they leave all of childhood behind them 
 they no longer see the visions or dreams that make life 
 so pleasant to us. 
 
THE VALUE OF OLD AGE 35 
 
 It has been often said that Oliver Wendell Holmes 
 never had an nnhappy mood. He trained himself to 
 grow old gracefully and was extremely optimistic. His 
 whole object in life was to make the world better. 
 
 Edward Everett Hale published his Memories when 
 he was approaching eighty years of age. At eighty-two 
 he was elected Chaplain to the United States Senate. 
 Like Emerson, his home sheltered many of the world's 
 literary men who received great stimulation and pleas- 
 ure in his- company. 
 
 The world is indeed richer for the accomplishments 
 of men past the three-score mark in life. It is the com- 
 mon thought that a man who has reached the three-score 
 age has passed his field of usefulness. Little attention 
 is commonly given to the aged and for this reason men 
 do not receive the stimulus to accomplish great things 
 that they would under proper encouragement. 
 
 To give the matter casual thought we would not ordi- 
 narily realize that some of our best works of art, poetry, 
 and the sciences were produced by octogenarians. 
 
 In the later days our history was in part shaped by 
 the newspapers which had at their heads men ripe in age 
 and experience. Much could be said for Horace Greeley 
 of the Tribune, Charles A. Dana of the Sun, Samuel 
 Bowles of the Springfield Republican, and William Cul- 
 len Bryant of the Evening Post. These editors did a 
 great deal of their best work in their advancing years 
 and left a standard for newspapers that makes our 
 press substantial today. 
 
 Doctor James Scott of Maine at sixty met reverses in 
 business and decided to enter medical college. Upon his 
 graduation, with highest honors, he practiced for more 
 than twelve years and was very successful. 
 
 Doctor Alonzo Garcelon, at one time governor of 
 Maine, continued active practice of medicine past the 
 age of ninety. 
 
36 GEBIATEICS 
 
 Gladstone was the best type of English gentleman and 
 the great man of the nation. He became famous after 
 the age of sixty and was elected Prime Minister four 
 times, still retaining the office at the age of eighty-two. 
 
 There was apparently no end to his capacity for work, 
 and it was said of him that "no pressure of work made 
 him fussy or fidgety, nor could any one remember to 
 have seen him in a hurry." 
 
 In contrast to Disraeli, however, Gladstone did not 
 possess a fund of satire, irony or humor. Nevertheless, 
 he lived a simple life and was said to have, like Horace 
 Fletcher, masticated his food many times before swal- 
 lowing. He walked a great deal and even after his sev- 
 entieth year he continued this habit. 
 
 In his eighty-ninth year, before his death, he was as 
 fervent as when thirty and possessed a keen mentality. 
 It was said that he was "the most colossal character on 
 the globe/ ' 
 
 Emerson said that men old in years and intellect com- 
 posed the greatest government. He tells of the blind 
 Dandolo N who became chief magistrate of Venice at 
 eighty-four; stormed and captured Constantinople at 
 ninety-four, and after the revolt was again victorious 
 and elected at the age of ninety-six to the throne of the 
 Eastern Empire, which he declined, and died doge at 
 the age of ninety-seven. 
 
 King Christian of Denmark at eighty-six ruled his 
 kingdom with a strong hand and was one of the greatest 
 powers of Europe. 
 
 John Quincy Adams was past sixty-five when he be- 
 came a famous statesman. At this age a great majority 
 of men close their careers instead of beginning them. 
 
 Daniel Huntington, famous artist who made fine por- 
 traits of Lincoln, Grant, Agassiz, Bryant, etc., at the 
 age of eighty-seven was still very active in his excellent 
 work. 
 
THE VALUE OF OLD AGE 37 
 
 Admiral George Dewey was sixty-one when lie won 
 the great honors at Manila Bay. 
 
 John Hay was sixty-fonr before he became world- 
 renown as a great diplomat. 
 
 William Cnllen Bryant, the famous American poet and 
 journalist, remained "in the harness' ' until his death at 
 the age of eighty-nine. Because of his remarkable activ- 
 ity few realized his advanced age and his death was a 
 great surprise to the world. In fact the world was 
 shocked at the news. The author of Thanatopsis kept 
 young to a remarkable degree, and it is well worth read- 
 ing the following statement from him explaining his 
 theory of growing young gracefully: 
 
 "I have reached a pretty advanced period of life — 
 seventy-eight years and four months — without the usual 
 infirmity of old age, and with my strength, activity, and 
 bodily faculties generally in pretty good preservation. 
 How far this is the effect of my way of life, adopted long 
 ago, and steadily adhered to, is perhaps uncertain. I 
 rise early — at this time of year about half -past five; in 
 summer, half an hour, or even an hour, earlier. I imme- 
 diately, with very little incumbrance of clothing, begin 
 a series of exercises, for the most part designed to ex- 
 pand the chest, and at the same time call into action all 
 the muscles and articulations of the body. These are 
 performed with dumb-bells, the very lightest, covered 
 with flannel; with a pole, a horizontal bar, and a light 
 chair swung around my head. 
 
 "After a full hour, and sometimes more, passed in 
 this manner, I bathe from head to foot. When at my 
 place in the country, I sometimes shorten my exercise in 
 the chamber, and going out, occupy myself for half an 
 hour or more in some work that requires brisk exercise. 
 After my bath, if breakfast be not ready, I sit down to 
 my studies until I am called. My breakfast is a simple 
 
38 GERIATRICS 
 
 one — hominy and milk, or in place of hominy, brown 
 bread, or oatmeal, or wheaten grits, and in season, baked 
 sweet apples. Tea or coffee I never tonch at any time. 
 At breakfast, I often take fruit, either in its natural 
 state or freshly stewed. After breakfast I occupy my- 
 self for a while with my studies, and then, when in town, 
 I walk down to the office of the Evening Post nearly 
 three miles distant, and after about three hours, return, 
 always walking, whatever be the weather or the state 
 of the streets. In the country I am engaged in my lit- 
 erary tasks till a feeling of weariness drives me out into 
 the open air, and go upon my farm or into the garden 
 and prune the trees or perform some other work about 
 them which they need, and then go back to my books. 
 
 "At the meal which is called tea, I take only a little 
 bread and butter with fruit. In town where I dine later, 
 I take but two meals a day. Fruit makes a considerable 
 part of my diet. My drink is water. 
 
 "I never meddle with tobacco, except to quarrel with 
 its use. v That I may rise early, I, of course, go to bed 
 early; in town as early as ten; in the country somewhat 
 earlier. For many years I have avoided, in the evening, 
 every kind of literary occupation which tasks the fac- 
 ulties, such as composition, even to the writing of let- 
 ters, for the reason that it excites my nervous system 
 and prevents sound sleep. I abominate all drugs and 
 narcotics, and have always carefully avoided everything 
 which spurs nature to exertions which it would not oth- 
 erwise make. Even with my food, I do not take the 
 usual condiments, such as pepper and the like." 
 
 Bryant did his best work after three-score and ten. 
 He was a wonderful orator besides being a great author. 
 
 While delivering an oration at the unveiling of the 
 statue of Giuseppe Mazzini, he was partially overcome 
 by the heat and when leaving the gathering, fell on a 
 stone and in a few days died of hemorrhage. 
 
THE VALUE OF OLD AGE 
 
 39 
 
 Famous women who have accomplished some of their 
 best work in their old age would make a long list. Mrs. 
 Russell Sage, born in 1828, had a great fitness and wis- 
 dom for her philanthropic work. Mrs. Doremus, the 
 mother of Professor R. Ogden Doremus, at an advanced 
 age, spent the evening of her life in charitable and 
 philanthropic labors. Elizabeth Blackwell, M. D., born 
 in 1821, with her sister Emily founded the Women's 
 Medical College. Rev. Antoinette Louis Brown Black- 
 well, a leading Unitarian preacher, in her contributions 
 such as Philosophy of Individuality and her Tribute to 
 the Ocean showed that her intellect increased instead of 
 decreased with her advancing years. Her whole life past 
 seventy has been spent in useful work of splendid value. 
 
 Mrs. Osier, mother of Sir William Osier, died at a 
 very advanced age. She was a woman of great energy, 
 force of character and retained her faculties to the end 
 of an exceedingly long life. Clara Barton, born in 1830, 
 the head of the Red Cross from 1881 to 1900, did a great 
 deal of work in her advancing years. 
 
 Thus far I have given consideration, in part, to famous 
 persons of past years. I will devote the remainder of 
 the chapter to famous old people who are living or who 
 died very recently. 
 
 Doctor A. Jacobi, the nestor of American Medicine, is 
 in active practice at the age of eighty-six after being in 
 practice for over sixty-two years. He is very keen to- 
 day and his advice is still sought a great deal as evi- 
 denced by his busy office. His memory is wonderful and 
 he is able to remember names and dates with the great- 
 est accuracy. His life has been one of very hard labor 
 and he still retains the great determination that has 
 been his characteristic. 
 
 Doctor Stephen Smith, ninety-four, has been an active 
 figure in life and until recently has delivered addresses 
 
40 GEEIATKICS 
 
 before societies. At the age of ninety-throe he wrote 
 Who Is Insane? 
 
 Doctor William W. Keen, a major in the Medical Be- 
 serve of the United States Army at eighty, is one of the 
 greatest snrgeons of the world and his System of Sur- 
 gery was written when he was past the age of seventy. 
 Today he gives addresses and his advice is sought in 
 many matters. 
 
 Joseph H. Choate, the great diplomatist, died this 
 year (1918) at the age of eighty-four. He was United 
 States Ambassador to Great Britain at the age of sev- 
 enty-two and did a great deal of his best work past his 
 seventieth year. Channcey Depew, active at the age of 
 eighty-two, has been a leading figure in American life 
 and was United States Senator at the age of seventy- 
 five. Cardinal Gibbons at the age of eighty-two is one of 
 the great men of the world today. 
 
 Frank B. Sanborn died recently at the age of eighty- 
 six. 'Jhis famous journalist and biographer of John 
 Brown was in the harness to the last. At the age of 
 eighty- two he wrote the Final Life of Thoreau. His 
 greatest writings were accomplished when past the age 
 of sixty. General James Harrison Wilson, eighty, wrote 
 the Life of Chas. A. Dana at the age of seventy. Chas. 
 W. Eliot at -eighty-two delivers lectures on educational 
 and scientific subjects. He has accomplished a great 
 deal since sixty and at the age of eighty was awarded 
 the first gold medal by the American Academy of Arts 
 and Letters as a recognition of "special distinction. ' ' 
 John Morley (Viscount Morley), seventy-nine, who 
 probably writes the best English of any living man, at 
 the age of sixty-five wrote the Life of Gladstone. He 
 had been in great political activities since past his fifty- 
 fifth year and at the age of sixty-six was appointed Sec- 
 retary of State for India. 
 
THE VALUE OF OLD AGE 41 
 
 Sir Robert Laird Borden, Premier of Canada, at sixty- 
 three is very active. Sir Wilfred Laurier, seventy-six, 
 was Premier of Canada from 1896 to 1911. George Bran- 
 des, the Danish author, seventy-five, did a great deal of 
 his best work past sixty. Herbert H. Asc iuith, sixty- two, 
 was until recently minister and First Lord of the Treas- 
 ury, and has been a very active figure in the present war. 
 Viscount Bryce, seventy-nine, published his University 
 and Historical Addresses at the age of seventy-five. He 
 is very active and has found recreation in mountain- 
 climbing and angling. General Joseph Joffre at sixty- 
 four is one of the greatest men of the present war. The 
 great French soldier, a cooper's son who became gen- 
 eral, was recently honored by the French government 
 with the highest military decoration, 
 
 Elihu Root is an active figure in American diplomatic 
 circles and was president of the New York Bar Associa- 
 tion at the age of sixty-four. This year, at the age of 
 seventy-two, he was sent to Russia by our government 
 on a mission to advise Russia as to the best method of 
 safeguarding the revolution. 
 
 Washington Gladden, very active at eighty-three, 
 author and clergyman, has accomplished a great deal 
 since the age of seventy. At seventy-seven he wrote 
 Live and Learn. Lyman Abbott, eighty- two, has been 
 editor-in-chief of the Outlook since 1893. He is an 
 active figure in American life today and, past the age 
 of sixty-five, has written a great many religious works. 
 William Dean Howells, eighty, was editor of the Atlantic 
 Monthly for sometime. He wrote Years of My Youth at 
 the age of seventy-seven and at this age was given a 
 gold medal by the National Institute of Arts and Letters. 
 Moorfield Storey, lawyer, seventy-two, one of leaders of 
 the Boston bar, wrote when past the age of sixty-six. 
 
 John Burroughs, the American naturalist and writer 
 at seventy-nine, is a keen and accurate observer as well 
 
42 GEKIATKICS 
 
 as master of a peculiarly direct and graceful literary 
 style. He wrote The Breath of Life in his seventy- eighth 
 year and some of his best writings were accomplished 
 when past the age of sixty. Thomas Hardy at seventy- 
 three wrote Satires of Circumstance. 
 
 Henry Cabot Lodge at sixty-seven is an active mem- 
 ber of the United States Senate and although physically 
 frail is one of our greatest and most active statesmen of 
 the day. Henry Watterson, seventy-seven, has been edi- 
 tor of the Louisville Courier- Journal since 1868. He is 
 one of the most fervent of American journalists and 
 keeps in the harness. 
 
 James B. Angell, president-emeritus of the University 
 of Michigan, who recently died, was very active in his 
 eighty-sixth year. At the age of eighty-five he wrote 
 his Reminiscences. Andrew Carnegie, philanthropist and 
 famous steel magnate is active at the age of eighty-two. 
 At the age of seventy he wrote The Life of James Watt. 
 Simeon' E. Baldwin, seventy-seven, was governor of Con- 
 necticut at the age of seventy-one. He wrote The Rela- 
 tion of Education to Citizenship at the age of seventy- 
 one. He is very much like James Bryce in his reasoning. 
 
 George Clemenceau, for many years one of the most 
 forceful figures in French public life, has recently re- 
 turned to active work for the government. It was 
 Clemenceau who instituted the campaign against Ger- 
 man propaganda in France. The "tiger" as he is nick- 
 named, is known as an exponent of the "big stick." 
 His methods in dealing with labor troubles have been very 
 drastic. M. Clemenceau is seventy-six years old and is 
 reported to have upset nearly a score of cabinets. Dur- 
 ing the past few years he has devoted himself largely to 
 his newspaper which has been suspended several times 
 because of his severe criticism of the government. 
 
 Auguste Rodin, famous sculptor, at seventy-seven was 
 
THE VALUE OF OLD AGE 43 
 
 still too young to die. Art and life needed the supreme 
 inspiration of his genius. 
 
 A short time ago there died John W. Foster, our dean of 
 diplomatists, who for fifty years helped make American 
 history and helped to make the history of other nations. 
 He died at the age of eighty-one and his autobiography 
 is a history of American diplomacy and a record of the 
 great movement of the world within the span of his 
 active life. From intimate personal acquaintance Mr. 
 Foster knew more about the affairs of Mexico, Russia, 
 China and Japan than any man living in his day. 
 
 George F. Edmunds, eighty, ex-senator from Vermont, 
 has been an active man in senatorial life. William Eaton 
 Chandler, for fourteen years a United States Senator 
 from New Hampshire, in his eighty-second year was as 
 mentally vigorous as ever, although physically somewhat 
 weakened. He passed most of his time until a few days 
 of his death reading newspapers and other current pub- 
 lications relating to the war and public affairs. He was 
 one of the most striking figures in debates in the Senate, 
 often exercising a sharp tongue, always quick-witted and 
 cheerful. 
 
 Samuel K. Hamilton, one of the leading lawyers in 
 Massachusetts, finds his principal recreation at the age 
 of eighty in getting to his office before any of his clerks 
 arrive and in leaving sometime after they have all gone 
 home. He is a great worker and many men half his age 
 would find difficulty in following the pace he sets for 
 himself. 
 
 Doctor W. E. Crockett, of Boston, at eighty-five years, 
 is a worthy physician and athlete. For many years he has 
 astonished those who know him by his remarkable feats 
 of strength. According to Doctor Crockett, every man 
 at eighty can be an athlete if he takes care of himself. 
 Some of the feats he has accomplished during the last 
 year or so are the following: 
 
44 GERIATRICS 
 
 Swam across Boston bay; taking a dip at L street in 
 midwinter; walked twenty-five miles in a little more 
 than six hours; put np a thirty-pound dumb-bell 385 
 times; stands with arms outstretched horizontally for 
 half an hour. 
 
 Doctor Crockett is practically a vegetarian, very little 
 meat entering into his diet. Most men, he says, dig their 
 graves with their teeth. 
 
 General B. F. Bridges, for twenty years warden at 
 Charlestown State prison, is past the fourscore mark 
 and has been very active. Although now retired he 
 makes visits occasionally to the prison where he greets 
 the old-time prisoners and notes the changes that are 
 being made from time to time. 
 
 L. Clark Seelye, the first president of Smith College, 
 is now active in his eighty-first year. To the thousands 
 and thousands of Smith graduates scattered through 
 the land, his name today has a special shrine of its own 
 in their hearts. 
 
 Julie Eeinhard, actress, orator and suffragist leader, 
 at the age of seventy-three, supports herself, rides, 
 dances, swims and hikes in long parades and is called 
 "America's grand old woman." 
 
 We have no better example today on the value of Old 
 Age than in the life of our greatest inventor, Thomas 
 A. Edison. At the age of seventy, during the present 
 war, he has designed, built and operated several benzol 
 plants and this year was made chairman of the Naval 
 Advisory Board. Even though he is deaf he conducts 
 the meetings of the board, and it is said, by a secret 
 telegraphic code given him by his assistant by means of 
 a finger tapping on his knee beneath the table, he is able 
 to follow each word spoken at the meetings. 
 
 He has a great capacity for work but has not worked 
 in order that he may at some time retire and live without 
 work. His greatest pleasure in life is work and he does 
 
THE VALUE OF OLD AGE 45 
 
 not look forward to a time when he can rest. He is one 
 of the most joyous men in the world and failures and 
 disappointments he has taken as a part of his daily 
 work. Eecently when his laboratory burned to the 
 ground and he lost a great many valuable things, he was 
 not disturbed but the next day began the reconstruction 
 of his plant. 
 
 When he is exhausted from work he will tell a funny 
 story, have a good laugh, and keeps an organ in his 
 library on which he has taught himself to play a few of 
 his favorite airs and after these few moments of diver- 
 sion he is ready to resume his work. 
 
 We have no better example today of the value of old 
 age than we have in Thomas A. Edison, and by keeping 
 "in the harness' ' he shows us the value of work as ap- 
 plied to men of advanced years. 
 
 The object of this chapter on the value of old age is 
 not to review the work of old persons but to show that 
 old age is more beautiful than we ordinarily think. Very 
 little has been written on the' beauty of old age and little 
 thought has been given to the richness of the world in the 
 accomplishments of old persons. An inference could be 
 drawn from these examples that the older the mind the 
 more able it is to produce things of value. A young man 
 may have more energy for production but he has not 
 had the benefit of the years of experience that those of 
 advanced age have. The purpose of this monograph is 
 to stimulate physicians to look upon old age as a thing 
 worth acquiring and that we may stimulate the aged to 
 carry out the theories they have been thinking of for 
 years. 
 
 Many an old person has given years of thought to 
 some subject yet it has not been developed because they 
 have not been encouraged to produce it. At the age of 
 eighty, many men have not the determination to bring 
 
46 GEEIATEICS 
 
 out a book, yet with assistance it could be accomplished 
 and the world would be richer for it. 
 
 The Lesson From These Masters 
 
 On first thought a person would not realize the appli- 
 cation of these examples to a geriatric study. It is a 
 very important lesson, however, because it illustrates not 
 only the great accomplishments of men in their old age, 
 but brings out what I believe is the most important secret 
 of geriatrics, that is, keep the aged at work, and still 
 more if they are sick, keep them out of bed. 
 
 " Staying in the harness" is the real secret of bring- 
 ing about the best results from our aged minds. The 
 older a man gets the more work is necessary to prevent 
 senile changes. I have observed many times, cases of 
 toxemia in the aged which were cured when they were 
 active and at work. 
 
 Psychologically, too, "staying in the harness' ' keeps 
 their minds from the senile death warrant "old age," 
 and the responsibility of work helps them beyond 
 measure. 
 
 Attention to the aged, appreciation and glorification 
 of their accomplishments produce a wonderful mental 
 effect upon them. It stimulates them to "keep at the 
 wheel" and give out from their store of experience 
 something that will make the world better. 
 
 We all know the extreme comfort in seeking counsel 
 from older physicians, lawyers and other men with years 
 of thought stored in their brains, to be able to get from 
 them something that will make our daily life productive 
 of better results. 
 
 Truly old age is sweet in a great many instances and 
 if we give the aged more attention and stimulate them to 
 greater activities we will be richer in a great many ways. 
 
CHAPTER IV 
 THE CARE OF THE AGED 
 
 I devote this chapter to the hygiene of advanced life 
 and include in it attention to the skin and to the simpler 
 things that constitute important details for the old per- 
 son to follow. Self-preservation is the first law of nature 
 and almost everyone desires to prolong his life, Metchni- 
 koff found that the Bulgarians lived to be 150 years of 
 age and attributed it to the use of lactic acid bacilli in 
 the milk. We have tried this in this country but we find 
 that people are dying every day. In fact, Metchnikofr* 
 himself died at an age of about seventy. There are many 
 other things that enter into longevity, among them be- 
 ing environment. The modern method of living, the 
 hustling and noise of a busy world, the telephone, in 
 fact modern business tends to hasten waste in every 
 way. If the Bulgarians lived a life like the American 
 people, they would probably die younger. The habits 
 of life and the influence of external factors do a great 
 deal more to determine a man's existence than anything 
 else. Regular habits of living are essential to the well- 
 being of old people. Few men live to enjoy the slight 
 benefits to be derived from changing their mode of liv- 
 ing, for a change in their habits may mean disaster to 
 them. 
 
 Old persons are very susceptible to atmospheric influ- 
 ences. The sources of their own temperature are 
 diminished and the blood supply to the skin being poor, 
 they become very sensitive to barometric changes. In 
 old age the change in tissue is waste without sufficient 
 or appropriate repair. Most old people have cold hands 
 
 47 
 
48 GERIATRICS 
 
 and feet and in general they are obliged to wear warmer 
 clothing than yonnger persons. Flannel or woolen ma- 
 terials may be worn with advantage three-fourths of the 
 year if the person is susceptible to the cold. The aged 
 frequently suffer from the cold at night and if this is 
 distressing to them, they should have a Simplex electric 
 pad, or a stone, which has been heated, upon which they 
 can rest their feet. 
 
 Quetelet in a table drawn of over 400,000 cases found 
 that the greatest number of deaths in persons past sixty 
 occurred in the colder months, December, January 
 and February. For this reason the aged should be very 
 careful in the winter and any slight infection should be 
 promptly taken care of by a physician. If the patient 
 cares to, a winter in the South would be very beneficial. 
 It is said that when the more opulent of the Eomans 
 grew old they were sent to Naples. 
 
 The proper care of the skin in the aged is essential. 
 Eegular baths and massage are necessary. A tepid 
 water bath is excellent in its effect. After the bath, fric- 
 tion may be given either with the naked hand, flannel or 
 with a flesh-brush and should be continued for one-half 
 hour. 
 
 I have a patient, a man, aged eighty-three, who takes 
 a Turkish bath once a week. He says it revives him and 
 it apparently has some effect in relieving- his bronchial 
 congestion. 
 
 Exercise in the aged is one of our best methods of 
 preventing toxemia and in a great many cases exercise 
 will relieve it. An old man gives up his work and stays 
 about a warm house in a chair and the lack of exercise 
 in itself causes toxemia. Many times I have forced old 
 persons to walk and busy themselves about their homes 
 and when possible, advised them to do something about 
 the house involving a little responsibility like gardening 
 or the care of an estate. The best time for walking and 
 
THE CAEE OF THE AGED 49 
 
 other exercise is shortly after breakfast, and short periods 
 should be selected as the aged easily get fatigued if they 
 do one thing too long. After luncheon a short stroll will 
 ward off the sleepiness. 
 
 It is difficult to say how much sleep an aged person re- 
 quires because each one is a rule unto himself. In 
 general the aged do not require as much sleep as younger 
 persons and they are apt to retire early at night and 
 arise early in the morning. In many cases eight hours 
 is sufficient time for sleep. 
 
 The aged usually declare that they have not slept in 
 three, four or five nights. A woman told me that she 
 had not slept in five nights but I had occasion to see her 
 one night and when I arrived she was sound asleep. The 
 noise of my entering the room caused her to awaken and 
 when she saw me she demanded some remedy to make 
 her sleep and denied that she had been sleeping. Many 
 physicians have been deceived into giving morphine for 
 this condition of apparent sleeplessness but if the case is 
 carefully analyzed it will be found that they fall asleep 
 in the chair during the day and when they retire at night 
 they can not sleep. In cases of this kind I usually pre- 
 scribe a placebo; make them exercise, especially after 
 meals and perhaps give them a glass of wine upon retir- 
 ing. A little milk with whiskey in it at bedtime may be 
 prescribed and it may be well to have a few crackers and 
 a little weak wine at the bedside to be taken on waking 
 in the middle of the night if they find they can not sleep 
 again. 
 
 Sometimes toxemia will produce an opposite effect 
 from drowsiness and cause irritability and sleeplessness. 
 In these cases a good cathartic is the best soporific that 
 can be administered. Tobacco does but little, if any, 
 harm to the aged and no matter what amount they have 
 used for several years it would be poor judgment to 
 change this habit. Many old persons awaken in the mid- 
 
50 GEKIATKICS 
 
 die of the night and find a smoke from a pipe the best 
 nerve sedative they can find. I know persons who make 
 a few old men presents of tobacco at Christmas and I 
 believe they appreciate it -more than they would gold. 
 
 A great deal depends upon the care of the skin in the 
 aged. The normal skin of senility is wasted and the ex- 
 cretions are lacking. It is usually very difficult to find 
 an old person who perspires. On the other hand, there 
 may be an excessive perspiration which is very dis- 
 agreeable, especially at night. To check this excretion 
 of the skin is a serious matter in the aged as the checking 
 of excretions causes the blood to be forced from the sur- 
 face of the body to the respiratory, occasionally to the 
 digestive and urinary organs, causing congestion of these 
 internal organs. 
 
 If the excretions of the skin become checked suddenly, 
 it would be advisable to give the aged person a warm 
 bath. He should take a drink of warm milk or tea and 
 should have a Simplex electric pad, or a hot water bottle, 
 to maintain heat. Excessive perspiration is at times 
 due to nephritis and as it is a compensatory symptom, 
 active interference should be avoided. Sometimes dis- 
 astrous results will follow injudicious medication in this 
 manner. 
 
 Aged persons should avoid retaining urine too long. 
 Continued failure to observe this may lead to paralysis 
 of the bladder and death may be the consequence if the 
 bladder is not relieved. The illustrious Tycho Brahe 
 died in this manner. While riding in the same carriage 
 with the Emperor of Austria, he followed court etiquette 
 and not nature and fell a victim to his temerity. 
 
 Recreation in the aged is an important consideration. 
 The senile brain becomes easily fatigued and a theatre 
 or moving picture show may have a complicated plot and 
 the aged person is not able to follow it. As a result he 
 
THE CAEE OF THE AGED 51 
 
 falls asleep and is apt to remain asleep during the whole 
 play. Musical comedies and burlesque shows do not 
 have complicated plots and are easy for the aged to wit- 
 ness and they feel better for the fun. The senile mind re- 
 quires something lively and humorous and the aged for- 
 get their old age when they are enjoying themselves. 
 
 In institutions male and female persons should not be 
 separated. To keep old couples apart who have lived to- 
 gether for years is a serious matter. 
 
 Much attention in institutions should be given to bath- 
 ing as the aged will falsify because they dislike to bathe 
 and as a consequence deceive the nurses, leading them to 
 believe they bathe frequently. 
 
 In institutions special care should be given to the 
 eyes and an oculist should correct errors of refraction. 
 Senile persons can pass the day so much better when 
 they are reading and getting their minds off them- 
 selves. Old age then is not thought of, and they have a 
 time that they are not depressed by the dread of their 
 last days. 
 
CHAPTER V 
 WORK FOR THE AGED 
 
 Case I. — A man, aged eighty, is the master of his house- 
 hold. He still maintains a little business, just enough to 
 say that he is a business man, and he takes great pride in 
 being independent of his children. Although they are 
 wealthy he will not buy anything that is not within his 
 own means and will not allow his children to pay his 
 bills. 
 
 Suffice to say that this aged man is greatly respected 
 by his family, and he is certainly a useful citizen in more 
 than one way. Being self-supporting he is very inde- 
 pendent in his manner and he has not yet lost his "grip" 
 on life. This "grip" I would call determination, the 
 power of force that most aged people lack because they 
 become dependent upon others. 
 
 Case II. — A woman, aged seventy, when quiet for 
 any length of time develops a renal insufficiency, es- 
 pecially if she is forced to stay in bed. When she gets 
 about again the casts disappear and she improves. I 
 have warned her if she ever becomes ill that it would be 
 to her advantage to keep out of bed. This lady does a 
 great deal of work each day, and it seems that this 
 exercise is essential to prevent the development of renal 
 toxemia. 
 
 Case III. — A mariner, aged seventy-five, has chronic 
 Bright 's disease, and when the weather prevents him 
 from going to his workshop he develops an increase in 
 his toxemia. Whenever he is ill and is remaining in a 
 chair a good deal I force him to go to his workshop and 
 
 52 
 
WOKK FOR THE AGED 53 
 
 exercise. The toxemia always improves when he is 
 exercising. 
 
 Case IV. — A man, aged sixty-five, lost his position 
 and immediately developed symptoms of Bright 's dis- 
 ease. He became melancholy, had headaches, conld not 
 sleep and lost his appetite. His position was given back 
 to him and he has been well since. 
 
 Case V. — I once fonnd a letter in the coat pocket of 
 a man who had committed snicide. In his book he had 
 advertisements he had taken from newspapers. A letter 
 he had written to his brother said, "I can not find work; 
 everyone says I am too old to work." 
 
 Unquestionably with the aged the lack of exercise will 
 produce a toxemia, especially from renal origin. These 
 old men always improve when they are forced to move 
 about and work is the best remedy for them. I remem- 
 ber an old man who had worked hard for years. His 
 children felt that they could support him and it would 
 look better for them, perhaps more heroic in society, to 
 have their father give up work. The old man's health 
 has steadily failed since he gave up work, and it would 
 have been far better had he kept his position. 
 
 The Psychic Element 
 
 Old people who are inactive and unemployed have 
 nothing to do but think of themselves, and "old age" is 
 the only thing they can see. I know a lady, aged eighty, 
 who has no disease except "aged eighty.'' Because she 
 is this age she thinks she can not do things that people 
 of sixty do because she is eighty. I have a patient, a man, 
 aged eighty-three, who disregards his age and takes a 
 Turkish bath every week. Theoretically, because he is 
 eighty-three he should not do this. However, he does 
 not think of old age, is employed, and accomplishes many 
 
54 GERIATRICS 
 
 things which theoretically he should not do. In other 
 words, he measures himself and governs his activities 
 according to what he knows he can do. 
 
 "Old age" to most persons is a death-warrant. When 
 they begin to think of old age they become depressed. 
 The aged are very sensitive, they like much attention and 
 like to be praised. They need much encouragement and 
 we should not allow them to dwell on their bad feelings. 
 
 We should provide some work for our aged friends and 
 relatives. I know a man who gives an aged man $10.00 
 per month for doing errands and taking care of his mail. 
 Another man is janitor in a telephone office; another 
 takes care of furnaces for a few families It is wrong 
 to think that because a man has worked hard all his life 
 that he should not work any more. All the more reason 
 why he should be kept at work. Never change an old 
 person's mode of living. 
 
 In many instances, labor unions have made it difficult 
 for the aged to obtain positions. This discourages the 
 aged when they find that there is nothing for them to do. 
 There seems to be no place for them. 
 
 There is another side to the question, however. Aged 
 clerks who have been in a store for a good many years 
 become very independent and do not cater to customers. 
 In fact, they do not take interest in their old customers, 
 consequently the firm loses a great deal of money each 
 year because the owner does not care to discharge the 
 men that he has had for years. 
 
 Nevertheless, there are many things that the aged 
 could do and we should create something for them to do. 
 
 If there is an aged father or grandfather a position 
 should be found for him and he should be well paid for 
 his services. It may be taking care of a furnace, the care 
 of a garden or lawn, a position as janitor, night-watch- 
 man, or any position that will keep him active and pre- 
 vent him from dwelling on ' ' old age. ' ' 
 
WORK FOR THE AGED 55 
 
 With women it is more difficult, but they can do many 
 things, such as sewing, taking care of a part of the house, 
 and in factories there is some work that could be pro- 
 vided for them, if the institution is not placed upon an 
 efficiency basis. For example, a proprietary medicine 
 company could have a department for the aged where 
 they could label bottles or wrap the bottles. Although 
 the production would not equal the same work in the 
 hands of younger people, it would be a humane act to 
 have a place where the aged could work. 
 
 It would be an act of philanthropy for every business 
 man who has plenty of money himself to have a depart- 
 ment where the aged could be employed in some simple 
 thing like labeling, etc. Even though the efficiency test 
 would not be 100 per cent, yet the aged would be greatly 
 benefited. 
 
 Almost every one could find some work for their aged 
 relatives, but usually they are neglected and very little 
 is done for their comfort. 
 
 Work and Recompense 
 
 It is essential to give the aged a good recompense for 
 their labor. Although they may not produce any great 
 amount of work, a good recompense does them a great 
 deal of good. The aged like attention and praise. En- 
 courage their labors, observe their work and it will be 
 surprising the good it will do them. It takes a very little 
 thing sometimes to amuse them. An aged lady sits at 
 a door with a stick in her hand. A man who visits the 
 house each day always tries to take the stick from the 
 old lady. They have a good time joking in this manner, 
 and this simple attention does the aged lady much good. 
 
 The aged like to have you ask them to do something 
 for you. Ask them to do a little repairing around the 
 house and it pleases them very much. It flatters them 
 
56 GEKIATEICS 
 
 to give them this attention. The great problems with 
 the aged conld be solved by giving them attention, work 
 and money. 
 
 A charity worker once asked me what she could give 
 an aged couple to help them. She was undecided as to 
 whether she should give food, clothing or fuel. I ven- 
 tured to suggest that a five dollar note in the house would 
 make them feel better than anything else. Give the aged 
 money and they will appreciate it more than anything 
 else. The neglect of the aged, the lack of atten- 
 tion to them does not apply to the aged who pos- 
 sess property or much money. When old people 
 have no worldly possessions in most instances they 
 are neglected. Do not misconstrue this statement, 
 however. I refer to these old persons who, possessing 
 money, demand respect because they are independent, 
 have the power of determination and force and are not 
 dependent upon their children. These qualities command 
 respect in the aged. On the other hand, when they have 
 no worldly possessions they become depressed, lose their 
 determination, become dependent and lose their "grip" 
 on life. This lack of force and determination brings about 
 the so-called "childishness" which does not command 
 the respect for them that they should receive. I believe 
 that the senile mind in most instances would be im- 
 proved if the aged were financially independent of others. 
 Lack of money produces loss of initiative. 
 
 Pensions for the Aged 
 
 Massachusetts attempted to pass a law to pension the 
 aged. Business houses should pension their help who 
 have been with them for several years. A firm has lost 
 a man on account of illness who has been m their employ 
 for fifty years. They do not give him any pension. A 
 man who has been with a firm over thirty years has now 
 
WORK FOR THE AGED 
 
 57 
 
 developed tuberculosis of the bones and is forced to leave 
 work. The company does not give him any money or 
 even send to him to see if he is in need. When he went 
 to the owner of the factory he promised to help him, but 
 he has not given him enough to be of much service. 
 
 This is very unfair to the aged. In fact, it is not show- 
 ing them the respect that is due them. Business houses 
 that are paying 15 or 20 per cent dividends could easily 
 spare 1 or 2 per cent as a pension for their aged help. 
 When their aged employes are taken ill it would be an 
 act of kindness to send a representative to see if they are 
 in need. 
 
 We could all pension the aged, and we owe it to them 
 to take proper care of them. They fondled us in our in- 
 fancy, fought for us, went through financial tortures to 
 educate us, and deprived themselves of many necessities 
 to see that we had clothing proper for all occasions. In 
 fact, if it came to a critical matter they would have 
 given their lives for us. 
 
 As an appreciation of this the majority of aged in- 
 dividuals are neglected, their children fight amongst 
 themselves because none care to take their aged parents 
 to live with them, and it is surprising to see the people 
 in the higher walks of society that not only neglect their 
 aged relatives but are actually cruel to them. Of course, 
 many old persons are difficult to live with, the senile 
 mental state produces a change in them which is some- 
 times very disagreeable. Oftentimes disease produces a 
 mental state which makes it almost impossible to live 
 with them. However, many diseases would be modified 
 and many senile mental conditions would be improved if 
 we gave them attention, work and money. 
 
 Miss Christine S. Foster, of New York, has been ex- 
 perimenting on work for the aged and her work has met 
 with much success. When reverses due to the war 
 
58 GEKIATKICS 
 
 closed the mayor's workshop the old men were not pro- 
 vided for. With her own funds she opened the old men's 
 toy shop in Lafayette Street, New York, bought materials 
 from which toys could be made and paid them a salary 
 for their work. When it was discovered that the toy 
 shop was open to all old men the number increased from 
 60 to 120. From the Bowery, men who seemed human 
 wrecks, timid, doubting, shivering, in fear of rebuff, were 
 met by Miss Foster and every old man was provided 
 with proper clothing and a place to eat. 
 
 In the toy shop the old men worked with great en- 
 thusiasm and men who had been refused work time and 
 again because they were old were given a chance. It 
 seemed to open a new life to them. The work was in- 
 teresting and they could see that it was productive. 
 Others were interested in it and they take great pride in 
 their work. 
 
 Miss Foster decided that social welfare should neces- 
 sarily enter into the care of the aged and besides work, 
 pay, food and a warm place during the day, the ques- 
 tion came, where are the old men sleeping? As a result 
 she experimented in a housing plan which has been a 
 success. She hired an old-fashioned flat with four rooms 
 on the ground floor and three in the basement and gave 
 this to eight old men. Every man was neatly and com- 
 fortably dressed, and the responsibility of the house 
 rested with the eight old men, with one of them as a 
 manager. Ten cents a day from each man was collected 
 by the manager and it actually covered all expenses. 
 They do their own housework, making the beds, sweeping, 
 washing, ironing, dusting, washing windows and dishes. 
 The increased cost of living recently has raised the cost 
 per day to about twelve cents. 
 
 Every morning, before the toy shop opens, an old man 
 is seen with a basket on his arm going toward First 
 Avenue. He has eighty cents to spend and he feels his 
 
WORK FOE THE AGED 59 
 
 great responsibility in making proper purchases. He 
 buys vegetables from push carts and markets. To show 
 how the money is spent the following table is given: 
 
 One pound of coffee . .19 
 
 One pound of butterine .35 
 
 One pound of brown sugar 08 
 
 One-quarter pound of tea 09 
 
 Potatoes 25 
 
 Soap .10 
 
 Oatmeal 12 
 
 $1.18 
 The daily amount is : 
 
 Bread , .10 
 
 Vegetables 10 
 
 Milk .08 
 
 Meat, not to exceed 30 
 
 $0.58 
 
 For seven days this is $4.06, which leaves 36 cents a 
 week for salt, pepper, matches, and a few other articles. 
 This takes care of eight men. 
 
 The following statement from Miss Foster taken from 
 The Sun, is very interesting : 
 
 " There is the result of a little work — yes, I suppose 
 it has been a good deal of work," said Miss Foster, 
 "with men society had cast out, men who came to me in 
 the toy shop cowed and beaten by the world, who had 
 not known a decent meal or decent bed in months, men 
 who" had gone down in the world, some through drink, 
 some through ill health, but gone down nevertheless. 
 They do not want charity, they want a chance, that is 
 all, and personal interest goes a great way. 
 
60 GEKIATEICS 
 
 ' ' These men all come to work dirty, unfit mentally and 
 physically to do more than the light duties of the shop, 
 some of them able only to work a few hours a day. The 
 first change in the appearance I have discovered is a 
 clean collar. They will buy a celluloid collar out of their 
 first money nine cases out of ten. They will manage to 
 get a clean shirt, and I always have tried to have clothes 
 on hand that could meet an emergency. 
 
 " There is but one rule for the house and that is no 
 drinking. This they live up to. Some have been able 
 to save from 15 to 25 cents a day. This is splendid. 
 Some have bought new suits of clothes. All have pur- 
 chased clothing by degrees. 
 
 "Six of my eight old men are now about to take places 
 that have been offered them in different capacities. The 
 man who used to be a pilot is securing a place on a barge 
 at a decent living wage. 
 
 "These are not the first old men who have gained posi- 
 tions through just this aid in getting a grip on life again. 
 I have had three other flats at different times that were 
 used somewhat along these lines, though not exactly. 
 
 "These died a natural death because when the old men 
 left them for work I could not find others to take their 
 places. 
 
 "Now there are two old men to be left. These I hardly 
 fancy will be able to go out in the work again on their 
 own responsibility, and so they will form the nucleus 
 around which to build up another group, 
 
 "There is talk of moving the toy shop further up- 
 town, and in any event it would be best to have the flat 
 nearer it. This location in East Eighteenth street was 
 selected when the shop was in Lafayette street, not a 
 great distance away, but the removal to Mott street has 
 made the distance too great for regular walking. 
 
 "My ambition is eventually to hire a house for old 
 men. With the added numbers that could be accom- 
 
WORK FOR THE AGED 61 
 
 modated the same rates could be arranged, and the re- 
 sult would be that poor old men who have to frequent 
 filthy lodging houses and half starve for lack of funds to 
 buy sufficient food would be well housed and fed. 
 
 "It has been suggested that such a house be in the 
 hands of a committee to run it, but this would never 
 work. Under such conditions the suggestion of charity 
 is manifest and this the men do not want and I can not 
 see that it is either necessary or just to them to place 
 them in such a position. 
 
 "In this plan, as things are run, each man feels a real 
 responsibility, he knows that if he fails to do his part 
 the success of the house is doomed, and he enjoys this 
 responsibility placed on him. 
 
 "I never had it brought home to me so strongly that 
 they are absolutely friendless as I did one day last win- 
 ter when I was summoned to a hospital to see one of my 
 old men. He had been taken ill and removed there. 
 When asked to name his nearest friend he gave my name, 
 and I must say that I felt in one way greatly honored to 
 feel that he considered me as such. 
 
 "My interest in unfortunate men first arose when I 
 sat watching day after day, even in the bitterest of win- 
 ter weather, the men that I could see from my window. 
 Beekman place is on the East Eiver. By my house are 
 ledges of rocks. I have seen men seek shelter from the 
 storms under the rocks. I have seen them remove their 
 shirts even in cold weather and go down to the river to 
 wash them, sitting shivering covered by a thin coat in 
 the cold winds until the shirts dried, spread out on the 
 rocks in what winter sun there might be. 
 
 "Men know that there is always a cup of coffee and 
 some bread at least to be had at our house. No man who 
 ever comes to the door is turned away, and in all the 
 years I have had what some call 'Miss Foster's Bread 
 
62 GERIATRICS 
 
 Line' I have not found that those who come are of the 
 begging class, or will take undue advantage of that which 
 they can secure for nothing. 
 
 "Many of these have been helped to positions. In my 
 heart I most pity the broken man, for who will have him? 
 You can find a place for the average old woman; she can 
 help in a house, mind children, but what can the old man 
 do? Go to the river, for all society cares. Give him a 
 lift by encouraging him, getting him back to health, and 
 he will reward you nine times out of ten by making good." 
 
 It will be seen that Miss Foster's work is the outcome 
 of giving the old man a chance. The work cf old men 
 and women could be made productive if we would give 
 attention to them and many other things could be pro- 
 vided for them in the way of work. The toy shop has 
 been a great success and could easily be placed on an 
 enormous scale by some person who is financially able 
 and disposed to assist the aged in proving that they are 
 useful. It is said that in the Indian reservations old per- 
 sons are literally starved and they are allowed to sit out- 
 side the buildings without any attention. The Indians 
 believe their aged are useless and give them little or no 
 consideration. In a general way this same attitude 
 exists almost everywhere regarding the value of the aged 
 and it will only be by systematic and prolonged labor that 
 we will be educated to the fact that the aged are of value 
 and that we require them in our daily life. 
 
CHAPTER VI 
 
 KEEP SENILE CASES OUT OF BED 
 
 Case I. — A war veteran, aged eighty-three, had an at- 
 tack of senile bronchitis and was failing. He was very 
 dyspneic and toxic. I ordered him to get in a chair and 
 forced him to get out of bed several times a day. The re- 
 sults were excellent ; he breathed easier, slept better and 
 seemed in better spirits. He was down stairs the next day 
 when I visited him. 
 
 Case II. — A man, aged seventy-five, had been ill seven 
 days with senile pneumonia and apparently there was no 
 hope for his recovery. He was forced out of bed on the 
 seventh day and it seemed to relieve him a great deal; 
 it gave him new courage to fight the battle and he re- 
 covered. 
 
 Case III. — I remember a lady, aged seventy, who 
 was taken ill very suddenly and death was apparently 
 near. I forced her out of bed the next morning and on 
 eight different occasions I saw her recover from similar 
 attacks. 
 
 Case IV. — A lady, aged sixty-five, had occasionally 
 been ill in bed from various diseases which did not have 
 any effect on a kidney condition. Each time she was in 
 bed she developed a renal insufficiency and the urine 
 showed many casts. Only after she gets out of bed does 
 the urinary sediment becomes normal. 
 
 Case V. — A man, aged eighty, was very ill with 
 cardiac weakness; he was hardly able to hold his head 
 erect. He was forced to keep in a chair, however, and 
 
 63 
 
64 GEKIATEICS 
 
 the sleep lie obtained was in a sitting position. For 
 over two weeks lie was in this state but he was not al- 
 lowed to lie down. It seemed cruel, because he was too 
 sick to sit up, yet we knew this was the only chance he 
 had for recovery. We knew that a senile case rarely 
 dies of cardiac disease unless cerebral hemorrhage su- 
 pervenes. After several days of suffering the old man re- 
 covered sufficiently to ride in an automobile to the doc- 
 tor's office. 
 
 This method of treating senile cases apparently works 
 well in most instances. There are very few cases where 
 it can not be applied. It seems cruel many times to re- 
 sort to this, but the family must be taught that old people 
 do not do well in bed and when a senile patient remains 
 in bed a short time it is almost an impossibility to get 
 him up again. 
 
 It is interesting to note in Case IV that casts always 
 appeared when the patient remained in bed any length 
 of time. I have seen many cases like this where the 
 urinary abnormalities disappeared when the patient was 
 out of bed. 
 
 Inactivity in the aged predisposes to toxemia whether 
 from renal or intestinal origin. Many of the cases of 
 chronic uremia will not improve unless a certain amount 
 of exercise is taken each day. I remember an old 
 mariner who had a renal toxemia, whom I forced out of 
 doors and -demanded he go to his boat house and give 
 orders each day. He improved and continued to gain as 
 long as he kept up his exercise. It seems that a little 
 exercise was beneficial to him. 
 
 The Psychic Element 
 
 When old persons are sick in bed they feel that their 
 last is approaching and "old age" stares them in the 
 face. ' i Old age ' ' to them is a death warrant. The f am- 
 
KEEP SENILE CASES OUT OF BED 65 
 
 ily usually feel that the end is near; there is no ap- 
 parent hope of recovery, owing to the advancing years, 
 and therefore neither much anxiety nor interest is shown. 
 
 Eemaining in bed the old person sees no future ahead 
 and loses his grip on life. When this grip is broken 
 death is sure to come. When "old age" stares anyone in 
 the face it is far from a pleasant thought. 
 
 On the other hand when a physician orders a senile 
 patient out of bed the old person feels encouraged to 
 think that he is able to get up. The family look at it in 
 another light and in all ways the future for the old man 
 is not so bad after all. More interest is shown in him 
 and he regains his grip on life which is all important in 
 looking for a recovery. 
 
 The psychic element is important in all illnesses in 
 the aged for without attention to this very important de- 
 tail many an aged patient will die. When an old man sees 
 "old age" before him he loses all hope. 
 
 In senile cases much depends upon the encouragement 
 given them by the physician. Do not tell them they will 
 get better or they will think you are merely encouraging 
 them. It is better to make plans for them as to what 
 they will do when they get out of doors, like working in 
 a garden, etc. In this way they get confidence in what 
 you say and it has a very beneficial effect. 
 
 Postoperative Treatment in the Aged 
 
 Surgery in the aged requires the application of this 
 rule as in any other condition. In this particular it may 
 be said that usually the best hope we have of recovery 
 after surgical operations in the aged is to get them out 
 of bed the next day, no matter what the nature of the 
 operation is. If it is a hernia operation or appendectomy 
 the same rule applies. 
 
66 GERIATRICS 
 
 Postoperative cases if kept in bed will not do well in 
 the vast majority of instances. Pneumonia, renal or in- 
 testinal toxemia develops more rapidly and there is a 
 general asthenia as a result. If the aged patient gets out 
 of bed on the next day after the operation, the danger 
 of these complications is lessened and although there is 
 danger in allowing them this peculiar privilege, yet it 
 is the lesser of two evils. 
 
 Getting out of bed gives them the courage to fight their 
 battle more courageously. After all, in the treatment 
 of senile diseases, the keynote is to encourage them and 
 to give them plenty of attention. A kind chat with them 
 about things that interest them sometimes has a better ef- 
 fect than medicines. 
 
CHAPTER VII 
 CAEE OF THE EYES IN THE AGED 
 
 A man, aged seventy, told me that lie thought it would 
 be impossible to obtain properly fitted glasses because 
 of his advanced years. He had always been very fond 
 of reading periodicals and books, but since he has not 
 been able to see well he has spent many a lonely hour. 
 
 He was delighted to find that it was an easy matter to 
 correct his hypermetropia and it has proverbially made 
 a new man of him. He had glasses that he had selected 
 from an optician's scrap-box, but in time had not been 
 able to see reading type at all. 
 
 In the aged a little attention to the eyes will produce 
 not only gratitude on the part of the patient, but will at 
 times entirely change the mentality of the old man. 
 
 Many aged persons will require a strong lens, for 
 example 6.00 or 6.50 convex spherical. However, great 
 care must be exercised in the examination because they 
 are apt to deceive to the extent of taking a lens that is 
 too strong for fear that the glasses will not magnify 
 enough. Their conception of a good pair of glasses is 
 one that will magnify a six-point type to an eighteen- 
 point face. 
 
 When they take lenses too strong they find after they 
 have had them a short time they can not wear them. To 
 prevent this I usually take the lenses that I think are 
 correct and let them read in another room for twenty 
 minutes to see if they fit properly. Many times in this 
 way I will detect the mistake before they have the pre- 
 scription filled. 
 
 67 
 
68 GERIATRICS 
 
 Again, the eyes in the aged are not the same each day. 
 For example, one day plus 3.50 may be the proper lens 
 and a week after a plus 4.00 will be correct. In these 
 cases I take an average at the end of a third examina- 
 tion. 
 
 Senile patients are apt to complain that they can see 
 out of one eye better than the other, but unless the dif- 
 ference is marked I give the same strength lenses for 
 each eye. If too great a change is made the glasses when 
 completed will be useless. 
 
 A senile person should not look at one object over ten 
 minutes without changing the view. There are a few old 
 persons who read " love stories" and when they read 
 them they are apt to read several hours at a time with- 
 out resting the eyes. 
 
 Senile Astigmatism 
 
 Many of these senile patients show varying degrees of 
 astigmatism and unless great care is shown a mistake 
 will be made. If the astigmatism is not very marked, it 
 is better not to correct it for reading alone. For example, 
 if a sphere will give fair results without a cylinder it is 
 better not to use the latter. Simply because there is a 
 refractive error does not necessarily signify that it 
 should be corrected. 
 
 There are some patients who can not be fitted without 
 cylinders. There is also a certain type of senile case 
 that no lens will improve either for reading or distance. 
 It is far better in this not to prescribe any lenses at all. 
 
 Senile Conjunctival Changes 
 
 The conjunctivae in the aged are a barometer of the 
 general health in certain cases. For example, a man who 
 presents red conjunctivae in which the vessels are visibly 
 injected, besides a relaxation and slight eversion of the 
 lids, invariably is suffering from an increase in blood- 
 
CARE OF THE EYES IN THE AGED 69 
 
 pressure. The congestion of the conjunctivae goes with 
 a slight general subcutaneous edema. 
 
 A lid that is everted also indicates general lack of tone 
 and oftentimes gives the indication for the use of iron. 
 
 Senile Retinal Changes 
 
 To a degree, arteriosclerotic changes in the retina are 
 normal in the aged. However, in those cases in which 
 the blood pressure is abnormally high, in diabetes or 
 albuminuria, retinal hemorrhages from the blood ves- 
 sels in which there is endarteritis will be seen. Occa- 
 sionally a thrombus of the central artery will cause 
 blindness in one eye. The sight rarely improves in these 
 cases due to embolism or thrombosis. 
 
 The ophthalmoscopic examination is of great value in 
 the diagnosis and prognosis of senile kidney diseases. 
 It must not be forgotten, however, that an evidence of 
 arteriosclerosis is normal to a degree in all senile 
 patients. 
 
 Arcus Senilis 
 
 It is commonly supposed that the arcus senilis denotes 
 old age and also fatty degeneration. This is not true for 
 it does not always indicate arteriosclerosis or any other 
 disease. It does not interfere with sight or signify that 
 a serious eye disease is in its incipiency. 
 
 Presbyopia 
 
 Presbyopia means difficulty in accommodating to near 
 objects, usually beginning between the ages of forty and 
 fifty. These patients require lenses for reading only. 
 The presbyopia is undoubtedly due to sclerosis of the lens 
 and a weakening of the muscles of accommodation. 
 
70 GEEIATEICS 
 
 The Senile Pupil 
 
 A contracted pupil in the aged, even to the extent of 
 a " pin-point pupil" may not mean anything and may 
 not signify that the person is addicted to opiates. They 
 are due to changes in the nerve supply and in the 
 muscles. 
 
 An irregular pupil may not indicate syphilis ; unequal 
 pupils have no significance and dilated pupils are apt to 
 show a relaxed condition of the body in general. Nor do 
 pupils which have lost their reflexes always indicate lo- 
 comotor ataxia. I have seen several s.enile patients who 
 presented the eye symptoms of locomotor ataxia and even 
 inability to walk with the eyes closed. In these particu- 
 lar cases these symptoms were due to a chronic nephritis. 
 
 The Sclera 
 
 One thing is almost certain in prognosis of the aged. 
 In a senile illness if you can touch the cornea with your 
 finger without any reflex resulting, the patient will pro- 
 bably die. 
 
 The color of the sclera in the aged is not always im- 
 portant. A yellow or bluish colored sclera may not be 
 abnormal but usually a blue sclera denotes anemia and 
 if the yellow color is marked, disease of the liver or 
 pancreas must be suspected. 
 
CHAPTER VIII 
 SENILE MENTALITY 
 
 With advancing years the mental faculties become im- 
 paired but this impairment bears, apparently, no rela- 
 tion to the physical changes in the brain. Despite the 
 advances made in psychology we are still unable to de- 
 termine upon what characteristics of the brain the ac- 
 tivity of the various faculties depend. Nor can we satis- 
 factorily explain why certain faculties or mental powers 
 wane, why others retain their brilliancy or appear 
 stronger in advanced life. Memory fades early and the 
 aged person must make a conscious effort to retain new 
 impressions or recall old ones. Yet the aged frequently 
 exhibit a remarkable power to recall early events that 
 had been forgotten for many years. Usually this is not 
 a feat of memory for the individual can not recall these 
 events by the power of will. They appear unbidden, 
 arising as figures of the imagination emerging from the 
 crypts where the long-forgotten facts have been hidden. 
 At other times an incident will cause them to reappear. 
 
 An aged singer achieved fame during the Civil War 
 by singing a popular song of the day. He sang the song 
 daily, often several times a day for a couple of years, 
 until the song lost its popularity. After a lapse of 
 forty years he was requested to sing that song again but 
 he had forgotten it and for several days he went around 
 humming bars of tunes in the hope that one would recall 
 the old song. He could not recall a bar of the air nor a 
 line of the song until someone played a few bars which 
 he instantly recognized. These few bars did not recall 
 the others and not until he had heard the whole tune 
 
 71 
 
/ 1 GEEIATKICS 
 
 played could he remember it. As an encore lie sang an- 
 other song of the same period, one he had sung but a 
 few times forty years before, yet which came to mind 
 without effort or intention. This man's experience is 
 characteristic of the faculty of memory in the aged. In 
 most cases names are forgotten first, usually the names 
 of casual acquaintances. After names, dates are for- 
 gotten and in some cases the time relation of events can 
 not be recalled. Thus, a Civil War soldier could not re- 
 member if he was married before or after the war. A 
 widow whose husband died while holding a government 
 position during Grant's administration, insisted that he 
 died a few years ago and that only one or two administra- 
 tions intervened since his death, that the Spanish Amer- 
 ican War took place before his death, and that her chil- 
 dren were 10 to 20 years younger than their real age. 
 The woman was intelligent and realized that there was 
 something wrong, that the dates and ages did not co- 
 incide but she could not understand the inconsistencies. 
 Memory usually shows signs of impairment soon after 
 the brain has gained its maximum growth about the 
 thirtieth or thirty-fifth year. After this time it becomes 
 more difficult to retain new impressions and in old age a 
 conscious effort must be made to retain them. A new 
 language may be learned with ease in youth, with dif- 
 ficulty in middle age, while it will be very difficult to 
 learn a new language in old age. A single reading of a 
 book in youth may suffice to produce a clear comprehen- 
 sion of its import; in old age it will be necessary to read 
 each chapter several times. Prolonged or concentrated 
 attention, which is necessary to absorb and retain new 
 impressions, causes brain fag in old age and this is one 
 of the main reasons why it is difficult for the aged to re- 
 member things. Unless it is something which will rivet 
 the attention the event or sight will not be impressed on 
 the mind and it will not be retained and therefore it can 
 
SENILE MENTALITY 73 
 
 not be recalled. The mechanism of recall becomes im- 
 paired about the fiftieth year and thereafter it becomes 
 increasingly difficult to recall recent events, names, dates, 
 etc. The impairment may become so great that the event 
 just past may be forgotten and the closest associations, 
 as the existence of children, the location of home, the 
 needs of the body, may be forgotten. This condition is 
 called senile dementia. 
 
 The reasoning power increases for two or three dec- 
 ades after the brain has reached its maximal strength. 
 In advanced age the quality of this faculty may not be im- 
 paired but the quantity of work that can be done is less. 
 The writer who could write for hours without intermis- 
 sion must now make frequent stops. Now after an hour 
 or two brain fag sets in and if he continues to write men- 
 tal confusion ensues and this ends in mental exhaustion 
 with inability to think. A famous old physician whose 
 writings are well known, recognizes his mental limita- 
 tions today and applies his knowledge to his present day 
 work. Formerly he could write chapter after chapter 
 without intermission, ideas following each other freely 
 and logically and his original manuscripts showed few 
 changes. Now he writes only when his mind is free ; he 
 writes slowly and carefully and the moment brain fag 
 sets in, he stops though it be in the middle of a word. 
 His ideas today are as logical, as brilliant, as clear and 
 decisive as ever. But where formerly he could write a 
 chapter in three or four hours of consecutive work, he 
 will now write a few sentences, then stop and it may be 
 days before he will write a few sentences again. In a 
 comparatively recent manuscript this was shown clearly, 
 each day's work being written on a separate sheet. A 
 chapter containing 140 lines was written on sixteen 
 sheets. The smallest amount of work, containing four 
 lines was a memory task involving references to other 
 
74 GEKIATEICS 
 
 authors. On other days when reason alone was em- 
 ployed he could write ten to twelve and one day fourteen 
 lines. 
 
 A lawyer, now eighty-four years old, shows in his let- 
 ter the result of brain fag. He begins rationally and deals 
 with the specific purpose of the letter but it soon becomes 
 rambling and he talks of matters entirely irrelevant, of 
 reminiscences, etc., and unless something occurs to inter- 
 rupt him he ends at the bottom of the sheet with illegible 
 scrawls. 
 
 We often hear of persons who do marvelous work in 
 their old age. If we examine closely into their mental ac- 
 tivities and compare these with their mental activities in 
 earlier life, we will find that in every instance the brain 
 becomes tired more easily, causing brain fag. In youth 
 several impressions can be received and retained at the 
 same time, in the aged they will confuse and irritate and 
 rapidly produce brain fag. This example has been fre- 
 quently given. An old man can watch a one-ring circus 
 with pleasure, while if he attempts to watch a three-ring 
 circus his mind becomes confused and brain fag results. 
 He can not maintain attention very long and when watch- 
 ing a parade his mind will wander after seeing a few com- 
 panies. When listening to a sermon or lecture he soon 
 falls asleep not through inattention but through exces- 
 sive attention which produced brain fag. If he makes a 
 conscious effort to maintain attention he will forget the 
 early part of the sermon or lecture, an observation which 
 can be made at any medical meeting where old physicians 
 attempt to discuss papers. They will either confine their 
 remarks to the early part of the paper, having dozed 
 through the time the latter part was read, or they will 
 discuss the latter part having forgotten the earlier part 
 of the paper. 
 
SENILE MENTALITY 75 
 
 The aged lose control of their emotions and they will 
 laugh or cry upon the slightest provocation, sometimes 
 without any apparent reason. A sad thought will cause 
 them to weep although the matter is in no way connected 
 with themselves. Aged women frequently cry when see- 
 ing a funeral, sometimes when seeing a wedding cortege 
 or anything else in which an element of sadness exists or 
 can be imagined. The aged are, however, usually serious, 
 often morose or apathetic. Many exhibit a hopeless res- 
 ignation to the inevitable and are constantly depressed, 
 in others there is an unexpressed rage at their impotence. 
 The fear of death is exhibited in various ways or it may 
 be suppressed but it is present in almost every case. 
 After the senile climacteric when the mind becomes dull 
 this fear diminishes or passes away along with other 
 emotions. 
 
 The will, like the other faculties of the mind, becomes 
 altered in the aged. In some cases it becomes weakened 
 and the aged person who was in earlier life a dominating 
 personality, is easily swayed from his purpose or led by 
 the simplest ruses to contradict himself. Occasionally, 
 an aged person will show a dogged determination which 
 neither threats, pleading nor reason can alter, yet after 
 holding out even against argument which he will ac- 
 knowledge correct, or against force he will suddenly take 
 the opposite view or position. 
 
 While most of what has been said on senile mentality 
 applies especially to the intelligent, educated individuals, 
 the dull, uneducated mind reacts in the same way in ad- 
 vanced life. The dull peasant who never was emotional 
 will not become emotional in old age, but he will exhibit 
 eccentricities in will. Intelligence, however, becomes 
 gradually weakened until he becomes a complete dement, 
 ignoring the demands of nature and even losing the fun- 
 damental instinct of self-preservation. 
 
CHAPTER IX 
 
 SENILE DEMENTIA 
 
 There is no sharp dividing line between senile mental 
 impairment and senile dementia, the former a normal 
 physiologic senile condition, the latter, pathologic. The 
 determination of senile dementia depends upon the phy- 
 sician's conception of the disease, and, in the individual 
 case, npon the existing condition as compared with the 
 mentality of the individual when at its best, or with the 
 ordinary mentality of other individuals of the same age 
 and intellectual status. With advancing age the mental 
 faculties, reason, judgment, memory, will, the emotions, 
 are all weakened. There is no uniformity in the order, 
 extent or rapidity of their impairment although memory 
 is usually the first to show weakening. 
 
 The term dementia is applied to marked impairment of 
 reason and judgment. The senile individual can usually 
 make a conscious effort to concentrate his thoughts, to 
 judge and to reason rationally. When he is unable to do 
 so he is suffering from senile dementia. Memory impair- 
 ment alone is not usually an evidence of senile dementia 
 but memory may be so far impaired as to make reason 
 impossible. 
 
 There are, however, medico-legal cases in which the 
 question of senile dementia hinged upon the extent of 
 memory impairment. In one case the existence of a 
 favorite child was forgotten when a will was drawn and 
 after the death of the man he was declared a senile de- 
 ment although at the time he made the will he was able 
 to reason and discuss matters rationally and manage his 
 
 76 
 
SENILE DEMENTIA 77 
 
 business affairs. The medical and the legal conceptions 
 of senile dementia differ except on advanced cases as the 
 law does not recognize border line cases, which under 
 some circumstances would be called senile dementia and 
 under other circumstances would be called simply senile 
 mental impairment. The following is a typical case. A 
 lawyer, who died recently, was a national char- 
 acter from the time of the Civil War until about ten years 
 ago when he was the government representative at an in- 
 ternational congress. A few years later he began to show 
 evidences of mental impairment. He began to lose inter- 
 est in the affairs of the day and became careless in his 
 habits. Formerly extremely neat in his personal appear- 
 ance and in the appearance of his surroundings he now 
 went out of the house occasionally without having his 
 shoes polished or his necktie properly adjusted or with 
 his coat or vest unbuttoned. His reasoning powers were 
 unimpaired but he found it now necessary to look up au- 
 thorities which he formerly could quote offhand. He be- 
 came egotistical and often boasted of what he had accom- 
 plished. These traits gradually became more pro- 
 nounced and his egotism became so dominant that a few 
 years ago, upon the occasion of an anniversary celebra- 
 tion he requested his friends to send him letters of con- 
 gratulation and commendation which he could publish. 
 With his failing memory his reasoning power waned but 
 under great stress he could arouse his reasoning ability 
 and his former power as a brilliant speaker. On such oc- 
 casions he gave no evidence of mental impairment, but if 
 the occasion called for prolonged mental effort he became 
 confused and stopped even in the midst of his speech. 
 Still later he did not realize his mental confusion and 
 while the beginning of his speeches were rational he 
 lapsed into rambling talks on various subjects, usually 
 reminiscences or self -laudation. At a medico-legal meet- 
 
78 GEKIATKICS 
 
 ing he spoke on the subject of insanity as a defense in 
 murder trials. For a few minutes he spoke with the 
 ardor of the trained orator, quoting authorities and pre- 
 senting unanswerable arguments. He referred to a mur- 
 der on a railway train and described the car. This led his 
 thoughts to railroad trains and railroad companies and 
 following the description of the car he described the legal 
 division of a railroad company, then the organization of 
 railroad companies and for several minutes he spoke of 
 his participation in the organization of railroad compa- 
 nies in the United States. His mind was now centered 
 upon himself and the rest of his speech dealt with various 
 matters relating to himself. His speech degenerated into 
 a prattle of self -laudation but his mind was confused and 
 he was called to order. The president's rap with a gavel 
 brought-him momentarily to his senses and he sat down, 
 but kept mumbling to himself during the remainder of 
 the meeting. At the beginning of the meeting this man 
 spoke sanely and rationally without the slightest evi- 
 dence of mental impairment ; half an hour later he was a 
 jabbering dement. Yet after a night's rest he was men- 
 tally as bright as usual and he conducted his business in 
 such a way that one not familiar with his mentality when 
 at its best would have declared him sane and rational. 
 This case is typical of mental decadence approaching the 
 condition of senile dementia. His peculiarities were 
 looked upon as harmless eccentricities yet they showed 
 clearly weakened mentality. He would call his office boy 
 from the anteroom and for an hour he would tell the boy 
 of his legal exploits revealing secrets which exposed crim- 
 inalities, and many acts including indecencies which a 
 sane man would not talk about. He made useless pur- 
 chases which he sent to his friends as gifts. He wrote 
 numerous letters to his friends and these letters showed 
 the progressive mental impairment which finally became 
 
SENILE DEMENTIA 79 
 
 obvious to the stranger. In his letters the first few lines 
 were rational, then they became rambling and ended in 
 undecipherable scrawls. He became absent minded and 
 several times he lost his way between his home and his 
 office, a few blocks apart. Later he forgot the names of 
 his friends and still later when picked up on the street 
 perhaps a mile from his office he could not recall his own 
 name and address. His reasoning power waned with the 
 loss of memory and a year after the medico-legal meeting 
 referred to he was clearly a senile dement. 
 
 The following case shows a variation from the usual 
 progress of senile dementia. The man, aged seventy-five, 
 was an ignorant farmer who could not read or write and 
 could calculate only to twenty. He was never a keen rea- 
 soner but he possessed good judgment, craftiness and 
 an excellent memory. He could not learn, but trivial 
 events in his life, such as seeing a neighbor's barn on fire, 
 etc., were remembered in old age. It is usual in advanced 
 life to remember early events but these memories arise 
 spontaneously and can be recalled at will only with diffi- 
 culty, usually through the association of ideas. This old 
 farmer could recall events at will. Asked if he ever saw 
 a barn on fire he could instantly recall every barn fire 
 that he ever saw. But he gradually lost the sense of time 
 and every event whether occurring the day before or dur- 
 ing his childhood happened "long ago." He lost the 
 sense of relation between things and while continuing to 
 work in the fields he did his work perfunctorily, going 
 through the motion of raking, for example, whether a 
 rake, hoe or spade was put into his hands. Life-long 
 habits were continued instinctively without a realization 
 of their import, but he could be led away from his pur- 
 pose by a child. He gradually became mentally and 
 physically weaker and spent most of his time in bed or 
 sitting undressed by the bed. Still he retained his mem- 
 
80 GEKIATBICS 
 
 ory for past events and his neighbors thought it a great 
 joke to put some question to him and leave him while he 
 was answering it at length. He would continue to talk 
 until he had answered the question fully, although there 
 was no one in the room. In this case there was never an 
 exhibition of egotism or thought of self, no emotional 
 outbursts, nothing more than a gradual loss of the rea- 
 soning power. 
 
 The following case presents another phase of senile de- 
 mentia. A woman now past eighty was formerly a domi- 
 nating personality in her home and in social circles, also 
 a shrewd business manager. About ten years ago in- 
 creasing physical disability forced her to give up busi- 
 ness and social affairs and leave the management of her 
 home to her children. She became deeply religious and 
 spent most of her time reading religious literature or in 
 such church work as would not oblige her to leave her 
 house. A few years ago a marked change was noticed in 
 her mentality. Though physically incapacitated she 
 again took an interest in business and society and in her 
 home but was now extremely critical and faultfinding, 
 domineering and stubborn. Opposition or contradiction 
 gave rise to violent outbursts of temper. She made ex- 
 traordinary demands but her memory was failing and 
 she soon forgot them if they were not carried out. Thus 
 she insisted upon going to a ball and purchased a ball 
 dress. Her family, realizing the futility of opposing her, 
 submitted to her whim and made no attempt to persuade 
 her. The exertion of dressing for the ball exhausted her 
 and she fell asleep while partly dressed. They undressed 
 her and put her to bed and in the morning she had no recol- 
 lection of the ball or her preparations for it. She developed 
 an exaggerated idea of her importance and when the 
 deference to which she thought herself entitled, was not 
 shown her, she became abusive and later she became sus- 
 
SENILE DEMENTIA 81 
 
 picious and morose. She would frequently get up at 
 night and ransack drawers and closets but would not say 
 what she was looking for. Delusions of persecution by 
 her family developed and one daughter was obliged to 
 keep out of her sight for a month. When the daughter 
 reappeared the mother had forgotten about the trivial 
 event that had aroused her resentment and suspicion and 
 had even forgotten that she had not seen her daughter 
 for a month. Still the old lady was constantly afraid that 
 her family would put her out of the way and it was neces- 
 sary to place her in an asylum. Here she felt safe and 
 she began again to make extraordinary demands, consis- 
 tent with her delusions about herself. She wanted youth- 
 ful clothes, bright colors, paint and powder, curling irons, 
 perfumes and perfumed stationery, began writing erotic 
 letters to men long dead, never completing a letter or 
 asking if they replied. Later another change occurred. 
 She would sit for hours apathetic or brooding and occa- 
 sionally she became loquacious, talking nonsense. Now 
 she sits most of the time talking to herself and must be 
 forced and helped to eat, dress and go out of doors. She 
 is also growing physically weaker and may soon succumb 
 to general debility. 
 
 These cases present the ordinary forms of senile de- 
 mentia, but the terminal vegetative stage exhibited in the 
 first case is rarely reached. Usually, senile debility or 
 intercurrent disease carries ofr the patient soon after his 
 mental impairment is so great that he becomes oblivious 
 to the demands of nature. The senile dement becomes in- 
 different to the natural call for evacuation of the bowels 
 and bladder and the consequent dribbling of urine and 
 feces frequently causes local irritation and inflammation, 
 which may become gangrenous. Prolonged retention of 
 urine causes cystitis and by extension a pyelitis follows, 
 or the damming back of urine may produce renal irrita- 
 
82 GEEIATKICS 
 
 tion so great that an acute nephritis and uremia is pro- 
 duced. Usually the dement loses control of the sphincter 
 and there is a constant dribbling of urine. Loss of con- 
 trol of the rectal sphincter causes evacuation of feces, but 
 there is usually persistent constipation partly through 
 lack of exercise, partly through failure to make an effort 
 to empty the bowels, in addition to the usual causes for 
 senile constipation. There is consequently autointoxica- 
 tion with its train of sequelae and this may cause death. 
 Bed sores occur frequently and these become infected 
 and a general septic infection may thus be produced. Oc- 
 casionally a hypostatic congestion occurs. Many senile 
 dements die after a short illness or suddenly and 
 the autopsy reveals a pulmonary congestion or acute 
 nephritis. 
 
 There is no successful method of preventing or curing 
 senile dementia, the disease being the progressive con- 
 tinuation of the physiologic senile mental impairment. 
 Many cases are temporarily benefited by mental stimula- 
 tion. Memory may be stimulated by old familiar airs or 
 plays, or by reminiscences of early days. Sights which 
 are of daily occurrence such as visits of members of the 
 family will produce no impression upon the patient while 
 an old-time friend whom he has not seen for years may 
 arouse a train of reminiscences and temporarily restore 
 memory. 
 
 If the hearing is good, aural impressions are more 
 likely to arouse memories than visual impressions. A 
 senile dement who was a Civil War veteran was taken 
 frequently to military parades, but these made little or 
 no impression upon him. The sound of cannon fired upon 
 the Fourth of July aroused him and for a few days he 
 spoke of his war-time experiences. It is very difficult to 
 arouse reason and judgment. Occasionally, under some 
 extraordinary stimulus, reason will be temporarily 
 
SENILE DEMENTIA 83 
 
 aroused but interest and attention can not be maintained 
 as brain fag sets in rapidly. The husband of a senile de- 
 ment died while she was in an asylum. She had not seen 
 him for several months and she did not recognize him 
 when he visited her. She was not notified of his death 
 but was taken to the house on the day of the funeral. She 
 was apathetic when led to the coffin and gazed abstract- 
 edly upon the corpse for a few minutes. She then sud- 
 denly gave a scream, threw herself over the coffin and 
 called her husband's name, begging him to take her with 
 him to the grave. She became quiet in a few minutes, 
 was led to a chair and promptly fell asleep. She was 
 awakened with difficulty, but when awake she again re- 
 lapsed into the apathetic attitude and could not again be 
 roused to a realization of the proceedings. An effort was 
 made to induce a senile dement to sign a will. Constant 
 urging annoyed him and he became suspicious that some 
 harm would come to him and this roused for a moment 
 his reasoning faculties. He listened to the reading of the 
 document and objected to some of the provisions. Be- 
 fore the reading was completed he fell asleep and when 
 awakened his mental powers were so dulled that he could 
 not be induced to hold the pen in his hand or pay any at- 
 tention to what was said to him. 
 
 Proper recreations will help to retard the senile mental 
 impairment, but these as all other measures for improv- 
 ing senile mentality are of temporary benefit, and useless 
 when the mind has become so weakened that it can not 
 comply with the instinctive measures for self-preserva- 
 tion. 
 
CHAPTER X 
 DIET IN OLD AGE 
 
 Habits in eating extending over a period of years 
 should not be changed no matter how bad the habit may 
 be. It is often dangerous to correct habits that may have 
 even a pernicious effect. I have seen many cases of men 
 who suddenly gave up drinking or the use of opiates with 
 the result that they did not live long. 
 
 Most aged people who are now living used a different 
 variety of food when they were young than we use today. 
 In the past years the coarsest food was the rule and a 
 man who was given this kind of food in his earlier days 
 should not change it now. 
 
 Regularity of meals for the aged is an essential and 
 should be carefully observed. Broiled and roast meats 
 are usually well borne. The older people in order to 
 render a mutton chop tender and juicy would cook it be- 
 tween two other chops. In this way the inner chop would 
 escape any hardening from the fire and it would remain 
 tender throughout. Mutton is the most satisfactory 
 meat. Fat or meats that have been pickled are harmful. 
 Tripe is usually easily digested and the animal jellies 
 are allowed. Fried meats are not as readily digested as 
 boiled or broiled meats. 
 
 Milk is the most satisfactory article of diet because it 
 is the most easily digested and contains the least amount 
 of material from which toxins may form. Milk protects 
 the kidneys and furnishes all the principles for good 
 nourishment. In acute gastritis or acute nephritis an 
 absolute milk diet is indispensable. Whey and butter- 
 milk or koumiss or milk and vichy, equal parts, may be 
 used. 
 
 84 
 
DIET IN OLD AGE 85 
 
 Birds are ordinarily satisfactory except ducks and 
 geese. For old persons game should be kept till it is 
 tender but not until it becomes high. Fresh eggs are ex- 
 cellent for the aged. They may be prepared in any way. 
 A raw egg beaten up with a glass of sherry and a little 
 sugar with a piece of toast or dry bread, make an excel- 
 lent and palatable lunch. 
 
 Fresh fish, except bluefish, is permitted for the aged. 
 The oily fishes as eels, herrings, salmon, etc., should be 
 avoided as they are apt to disagree, and pickled or 
 smoked or salted fish should be forbidden altogether. 
 
 Most vegetables may be given, but peas, beans and cab- 
 bage tend to cause gas in the stomach and should be 
 avoided. Cucumbers and tomatoes should be forbidden. 
 
 Plain puddings, such as rice, sago, arrowroot, bread 
 and tapioca are allowed. Rich puddings and pastry 
 should be taken only in moderation. Fruits generally 
 are beneficial. Sometimes a baked apple or prunes will 
 help to regulate the bowels. 
 
 Ale and beer as well as wines are excellent foods for 
 the aged. Malt liquor will do them no harm unless they 
 are of a bilious nature or suffering from nephritis. 
 "Wine is the milk of old age." A glass at luncheon and 
 a glass or two at dinner may be taken. Sherry and port 
 wine do not effect the stomach and seem to give them 
 strength. Bordeaux or Red Wine is satisfactory in cases 
 of chronic nephritis and these are also excellent tonics 
 for the aged. - 
 
 The following diet list includes the foods best adapted 
 for the aged, being nutritious, easily assimilated and 
 leaving little urea-forming refuse. 
 
 Bkeakfast 
 
 Apples (baked, raw or stewed), oranges, grape-fruit, 
 grapes, berries in season, cantaloupe ; Eggs — soft-boiled, 
 
86 GEBIATRICS 
 
 shirred, scrambled, dropped on toast; broiled chicken; 
 broiled honeycomb tripe; Fish — mackerel, perch, pick- 
 erel, white fish, trout, cod, haddock, halibut; baked 
 potato ; stale or toasted bread with plenty of butter ; tea, 
 coffee, or glass of milk. 
 
 Dinner 
 
 Raw oysters or clams; soups (preferably purees), pea, 
 bean, tomato, potato, asparagus, celery; chops, beef- 
 steak once or twice a week; Roasts — beef, mut- 
 ton, lamb, veal, chicken, tongue; Fish, broiled or 
 baked in cream; Vegetables — potato, spinach, lettuce, 
 stewed celery, cauliflower, beets, squash, green peas, as- 
 paragus, string beans; Salads — lettuce, tomato, endive, 
 escarole with French dressing; Dessert — apple, tapioca, 
 sago, blanc mange; crackers and cheese — Camembert, 
 Brie, Roquefort, cream, old-fashioned curd, cottage; one 
 glass of milk or a cup of tea or cocoa. 
 
 Supper 
 
 Eggs ; lamb stew with vegetables ; baked potato, bread 
 (stale or toasted) with plenty of butter; stewed fruit; 
 one glass of milk, stale bread or crackers and milk with 
 blue berries or baked sweet apples. 
 
 Vary the diet from day to day. 
 
 Do not eat fish and meat, meat and eggs, or fish and 
 eggs at the same meal. 
 
 Meat or fish should not be given oftener than once a 
 day. 
 
 Three or four glasses of milk should be taken daily, 
 either with or between meals. 
 
 It is wise for the aged to adhere to regular hours. It 
 may be well to strive against falling asleep in the chair 
 after dinner as it is said to cause cerebral hemorrhage. 
 
 The old rule that when we are ill we should take small 
 
DIET IN OLD AGE 
 
 87 
 
 quantities of food frequently does not apply to the aged. 
 The process of digestion is longer and it takes a few 
 hours more for digestion to be completed. Therefore, it 
 is well with the aged to allow five or six hours to elapse 
 between meals. In this way the stomach has an oppor- 
 tunity to rest. 
 
 In my sections in Senile Diabetes and Nephritis will 
 be found a discussion of diet in these diseases. In many 
 conditions of the aged, I do not change the diet because 
 a change in the mode of living in the aged is not well 
 borne by the system. Old persons who in their younger 
 days were obliged to eat coarse food must have this kind 
 of food now provided they have had it for several years. 
 
 The diet given above is a protective regimen for the 
 senile kidney. This diet is also applicable to chronic 
 nephritis, rheumatism and gout in the aged. 
 
 I have said nothing here of scientific feeding by calo- 
 ries and percentages as we are rarely able to carry out 
 scientific feeding on the calorie basis in the home and 
 seldom in institutions. As a matter of scientific interest 
 it may be stated that the aged require less food of all 
 kinds and less calories than in earlier life. Between the 
 ages of seventy-five and eighty, the female doing light 
 housework and the man doing no work, but taking suffi- 
 cient exercise, require from 1350 to 1500 calories a day. 
 The food quantities in a number of senile cases were 
 found to be about 50 grams protein, between 170 and 180 
 grams of carbohydrates and from 35 to 50 grams fat. In 
 the case of a man eighty-five years old the quantities and 
 caloric value of the food could be fairly determined, the 
 diet consisting almost exclusively of milk and bread, with 
 an occasional baked apple and on rare occasions a small 
 piece of chicken or turkey and a glass of wine. In this 
 case the daily amounts were, protein 50.43 grams, carbo- 
 hydrates 172.8 grams, fat 49.88 grams; calorie value 1415. 
 
88 GERIATRICS 
 
 The proportion of protein to carbohydrate was 1 to Sty 
 (1 to 4 in maturity), the protein factor being slightly 
 less than half the amount required in maturity, the car- 
 bohydrate factor slightly more than one-half, while the 
 amount of fat was but little less than the amount required 
 in maturity. 
 
 When the teeth fall out and meat can not be chewed, 
 meat must be finely chopped or omitted altogether and 
 when omitted protein from another source must be sub- 
 stituted. A sufficient amount can be obtained in milk, 
 eggs or the legumes. 
 
 The sense of hunger is not a good indication in the 
 aged of the necessity for food or the quantity that should 
 be taken. The sense of hunger is often perverted and 
 they will feel a gnawing sensation or a sensation of emp- 
 tiness in the stomach shortly after a heavy meal and at 
 other times there will be no desire for food though the 
 stomach is empty. They are generally like children in 
 their likes and dislikes, gorging themselves when given 
 some article of food that they like and indifferent to the 
 food when the dish is not relished. Owing to the degen- 
 erative changes in the taste bulbs the food must be 
 highly seasoned, either sharp, sour, sweet or salty, other- 
 wise it is tasteless or insipid and they will reject it. An 
 excessive amount of salt is detrimental to the kidneys 
 but the spices, acid and sugar are beneficial in old age. 
 
 While habit is the main factor in the selection of food, 
 when senile changes in taste occur, or when mental im- 
 pairment appears, common sense must be used to select 
 the kind and quantity of food best suited for the aged in- 
 dividual. 
 
CHAPTER XI 
 SENILE CONSTIPATION 
 
 In the clinics of Mt. Sinai hospital, where many aged 
 people attend, I was surprised to find that almost every 
 disease they presented could be traced to constipation. 
 In treating the aged, if we give attention to the bowels, 
 we have solved one of the greatest problems of geriatrics. 
 
 A consideration of the normal degenerative changes 
 accompanying senility will at once give us the reasons 
 why most persons in advanced life are constipated. 
 First, there is a diminished capacity of the stomach and 
 intestines due partly to thickened mucous membranes 
 and partly to the lack of nourishment due to arterial 
 changes. The muscular coat of the intestines is atro- 
 phied and in some cases not a trace of it can be found. 
 The villi and mucous follicles are atrophied and very lit- 
 tle mucus is secreted. In lessened power of the muscular 
 coat and resulting impediment to the peristaltic motion, 
 we see in part the cause of constipation and further di- 
 minished nutrition of the body in old age. 
 
 The dyspepsia from which we observe aged persons 
 suffer is dependent in part upon the prolonged retention 
 of food in the stomach in consequence of imperfect mas- 
 tication, in part upon the modified state of the gastric 
 juice, but in greater part due to the blunted sensibility of 
 the nerves of the stomach. The diminution of nerve 
 pow^r resulting in lessening of power of the intestinal 
 muscles causes flatulence and also constipation. 
 
 Persons who give but little attention to their health in 
 general are apt to concentrate their cares and anxieties 
 on the bowels. They care for these like a nurse cares 
 
90 GEKIATEICS 
 
 for a child and their uncertainty as to the colored pill 
 they shall take at night is a source of constant worry to 
 them and they take great comfort in calling their physi- 
 cian at all times of day or night to make sure of the rem- 
 edy they should take today. 
 
 It would be far better judgment to give consideration 
 to the diet and the care of the skin than to concentrate all 
 their attention on the bowels. It would be better to have 
 a bowel evacuation every two or three days than to have 
 the mental condition some aged persons have as a result 
 of their excessive attention to the bowels. 
 
 Persons who use any means available to have a diurnal 
 motion of some sort usually suffer more from the purga- 
 tive than the constipation and when the habit is changed 
 freely admit that they feel better on the days that the 
 bowels do not move than when they take the cathartic. A 
 daily action of the bowels is preferable if it can be ob- 
 tained without harsh measures. However, in many senile 
 cases we will find from careful study of the patients that 
 a bowel movement every other day is sufficient. Violent 
 straining at stool should be prohibited because it may 
 cause hernia. 
 
 A glass of cold water in the morning may help the 
 bowel action and sometimes a cigar will be the means of 
 stimulating peristalsis. I believe the best time for a 
 bowel movement is soon after a meal because the inges- 
 tion of food tends to increase peristaltic action. 
 
 When the fecal matter becomes hardened in the rectum 
 it is sometimes very difficult to relieve it. The rectum be- 
 comes obstructed and the old man dreads a movement on 
 account of the pain and the longer he waits the more the 
 accumulation of hardened substances in the rectum. 
 Sometimes enemata of oil will relieve it, but usually it is 
 necessary to remove the mass with the finger covered by 
 a rubber finger cot or by means of a scoop. As soon as 
 
SENILE CONSTIPATION 
 
 91 
 
 the obstruction is relieved the bowels will usually be very- 
 loose for several movements. 
 
 When the aged are ill from any other cause it is some- 
 times difficult to obtain a bowel movement and enemata 
 must be resorted to. I use for enemata, inspissated ox- 
 gall mixed with oil or use a mixture containing epsom 
 salts, glycerin and olive oil. If the quantity of the enema 
 is not great, there is no danger from its use. It has been 
 said that enemata are dangerous in the aged, but I have 
 never seen any bad results. If the patient is very weak, 
 I use an adult size glycerin suppository inserted into the 
 rectum and repeated every hour until results are ob- 
 tained. 
 
 If the bowels have not moved in several days, I some- 
 times give five grains of calomel with five grains of 
 sodium bicarbonate and give a saline by mouth the next 
 morning. Occasionally it is necessary to use croton oil. 
 
 One of the best tablets I have seen for the aged is the 
 official compound rhubarb tablet containing aloes, myrrh, 
 rhubarb and oil of peppermint. One may be given after 
 each meal or two may be taken at bedtime. Podophyllin 
 in Vi-grain tablets occasionally works well but is very 
 slow in its action. 
 
 The use of petroleum or Russian oil is not new. In 
 Floyer's, Medicina Gerocomica, printed in London, in 
 1724, mention was made of the use of oil for lubricating 
 the bowels. Russian oil, no doubt, works well in many 
 cases, but it should not be forgotten that its action is not 
 due to lubrication but it acts as a foreign substance in the 
 intestines that nature must eliminate. In this respect 
 it does not differ from any other cathartic that depends 
 upon its mechanical action. 
 
 The food we ordinarily eat, the nourishment that en- 
 ables us to do our work, almost every diet list prescribed 
 in the treatment of disease, tend to produce constipa- 
 
92 GEEIATEICS 
 
 tion and the only way to overcome it is by taking a rem- 
 edy to relieve it. 
 
 It is by far better to take a pill every night than to 
 suffer from toxemia as a result of faulty elimination. 
 Persons who will not take pills for the bowels because 
 they fear they will always have to take them may die 
 from toxemia. Tablets do no harm when well selected 
 and if they lose their effect we must change to another 
 kind. Later by returning to the first remedy employed 
 the results are again satisfactory. 
 
 The compound cathartic pills, or a tablet containing 
 aloin, strychnine, emetine and podophyllin may Work 
 well. Cascara sagrada is an excellent remedy for senile 
 constipation and these old persons can take it for a long 
 time before being obliged to increase the dose. 
 
 Bile salts are also satisfactory in many cases. Owing 
 to the secondary effects of drugs due to cumulative ac- 
 tion it is not safe to use belladonna in combination with 
 other remedies because continued use may produce un- 
 desirable secondary effects from the belladonna. 
 
 The simpler the remedy the better and the compound 
 rhubarb tablet seems to be very efficacious. The aged 
 will misinform you about the true condition of their bow- 
 els by stating that they move every day when perhaps 
 they do not move of tener than once a week. They say they 
 have a pill they take and in this way they can do as they 
 wish in their treatment and sometimes they actually 
 forget when the bowels moved last. When an old person 
 is sick in bed no matter what the cause is, get the bowels 
 open. They may say that they have not eaten anything 
 for several days but this does not matter. 
 
 When called to see an old person who is ill and is fail- 
 ing rapidly, when nothing seems to help him and you 
 can see death is not many days hence, when, no matter 
 the disease, your remedies do not have the desired ef- 
 
SENILE CONSTIPATION 93 
 
 feet, get the bowels open by an enema and also a laxa- 
 tive by mouth and yon will be surprised how many times 
 death will be postponed and the old person will get 
 aronnd again. 
 
 A word should be added about the use of saline laxa- 
 tives. This form of medication is the most effective to 
 rid the body of toxines, but unless the patient is robust 
 their continued use will be too depleting. If they are 
 robust, they can take a saline each morning, a so-called 
 "morning refresher," but if the patient is physically 
 frail, tablets are better for continued use. 
 
 The toxines produced during sleep and inactivity, the 
 fact that elimination has stopped during sleep, the kid- 
 neys, lungs and bowels are resting from their work, has 
 led me to believe that there are more toxines in the system 
 in the morning on awakening than at any other time of 
 day. This led me to prescribe a saline laxative at bed- 
 time in place of the morning and in most cases the re- 
 sults have been excellent. The saline does not usually 
 disturb the patient during 'the night and when he awak- 
 ens in the morning the remedy will have its effect. In this 
 way we have overcome the toxemia by allowing the saline 
 to act while the poison is developing. 
 
 The same principle applies to the use of pills at bed- 
 time, but the latter do not have the effect in relieving 
 toxemia that a saline has. Therefore, for toxemia in all 
 cases use salines if they are well borne and pills or tab- 
 lets if the only requisite is a bowel evacuation and tox- 
 emia does not enter into consideration. 
 
CHAPTER XII 
 TOXEMIA IN THE AGED 
 
 Case I. — A man, aged seventy, consulted me for gen- 
 eral weakness which he had experienced for some time. 
 He said that he could not sleep at night, had indigestion, 
 mouth had a bad taste in the morning, vertigo, occasional 
 nausea and constipation. 
 
 His family had observed, too, for the past few weeks 
 that his mental condition had changed and that he was 
 in the state commonly called " childish.' ' He was much 
 irritated by music, could not bear the ordinary conversa- 
 tion about the household and in many ways was failing. 
 
 The tongue had a thick white coating and there was 
 an odor from his breath, signifying a fermentative con- 
 dition of his stomach; the temporal arteries were tor- 
 tuous and the pulse beat visible. If he was in a warm 
 room after lunch he would fall asleep. Moreover, he 
 would nap several times a day and when night came, 
 naturally, he could not sleep. This is very common in 
 the aged, but these old persons get very angry if you 
 suggest it to them for they will not admit that they have 
 been asleep. 
 
 He was given two compound rhubarb pills each night 
 and a teaspoonful of the compound solution of sodium 
 phosphate before breakfast. In the course of a few days 
 he was better and his mental condition improved very 
 much. 
 
 Case II. — A woman, aged sixty-eight, complained of 
 neuritis of the left arm. She was very nervous and 
 there were many symptoms of toxemia present. The 
 tongue was white, she had headaches, vertigo, was very 
 
 94 
 
TOXEMIA IN THE AGED 95 
 
 drowsy and was very irritable and depressed. She was 
 given a teaspoonful of milk of magnesia every two hours 
 and occasionally a compound cathartic pill at night and 
 she improved on this treatment. 
 
 Case III. — A man, aged fifty, previously in excellent 
 health, was struck by a motorcycle and received a severe 
 blow on the head. He became unconscious immediately 
 and remained in a coma for several days, finally recov- 
 ing. While in the coma he seemed to be very toxic. 
 
 Case IV. — A man, aged sixty-seven, was taken sud- 
 denly ill with convulsions, and later went into a coma 
 and remained in this condition for several days. When 
 he recovered from the coma he was still somewhat toxic. 
 There apparently was much congestion of the prostate 
 for he could not void without being catheterized. His 
 headaches were violent, but in the course of a month he 
 was out and has since been at work. It is now two years 
 since the attack, and he is working a great deal more 
 than before he was taken ill. Naturally, a diagnosis in 
 this case would be made of uremia or diabetes as the 
 cause of the coma, but repeated and careful examinations 
 have failed at any time to reveal any evidence of ab- 
 normality in the urine. 
 
 It is possible that purinemia or toxemia from the in- 
 testines may be the cause of many cases terminating 
 fatally. For this reason a correct diagnosis is impera- 
 tive and usually they will recover if proper treatment is 
 promptly given. 
 
 I have seen many aged persons who were very inac 
 tive and apparently very toxic, who were relieved by ex- 
 ercise. A serious matter is to allow an aged person to 
 be quiet and remain in a warm room. Force these pa- 
 tients to walk in the fresh air and they will usually im- 
 prove. Inactivity and sleep seem to assist in the forma- 
 tion of toxines. There is said to be a fatigue toxine as- 
 sociated with sleep and as a matter of fact a great part 
 
96 GEKIATEICS 
 
 of all toxines formed accumulate at night because a per- 
 son is not exercising and the emunctories are not work- 
 ing. It is for this reason that most toxemias are worse 
 in the morning. 
 
 It is difficult to ascertain the origin of the toxines in 
 all cases, in the vast majority of cases, however, they 
 are of intestinal or renal origin. Lack of exercise and 
 remaining indoors in a warm room predispose to their 
 development. However, constipation is the usual cause 
 although toxemia may be found in patients who have 
 diarrhea. 
 
 Most of the senile diseases seen in a clinic can be 
 traced to constipation. Much depends upon the remedy 
 selected for the intestines, for some remedies may cause 
 free catharsis and yet not rid the system of its poisons. 
 
 There are many cases in the aged that are similar to 
 uremia and it is a very difficult matter to differentiate 
 them. Take for example, a specimen of urine from a 
 senile person, which shows casts in the urinary sedi- 
 ment. Symptoms of toxemia from intestinal origin may 
 be attributed to the kidneys when the casts are merely 
 a normal finding in these cases and the kidneys are func- 
 tionating properly. It is very easy to make a mistake in 
 diagnosis, for a normal urine from a senile case may 
 show albuminuria, casts and leucocytes. Also, indican- 
 uria may not be present in senile cases although there 
 is marked intestinal toxemia. 
 
 Diabetes may cause symptoms similar to intestinal 
 toxemia and yet the urine will not show acetone or 
 ^-oxybutyric acid. This is a finding peculiar to old 
 age. A urinalysis should be made in all senile cases be- 
 cause failure to find a disease may hasten death. 
 
 The aged frequently get toxic from the absorption 
 from an internal tumor. For example, carcinoma of the 
 stomach will produce symptoms similar to intestinal 
 toxemia. There is a peculiar odor of the breath that 
 
TOXEMIA IN THE AGED 
 
 97 
 
 almost makes the diagnosis certain the minnte yon de- 
 tect this odor. 
 
 I saw a famous old man a few days ago and although 
 he is apparently in an excellent condition there are cer- 
 tain signs of toxemia present. The temporal arteries 
 are tortnons and pounding, there is a slight puffiness 
 under the eyes, a slight yellow color of the skin and an 
 odor of the mouth that is noticeable a short distance from 
 him. He gets brain fag easily and can not hear conver- 
 sation for more than a few minutes without becoming 
 tired. 
 
 Brain fag in this instance is said to be due to old age, 
 but in reality it is due to lack of care of the bowels. 
 Even though the bowels may move each day, it is a very 
 simple matter to get toxic and a course of treatment will 
 undoubtedly relieve the toxemia and he will be better 
 able to carry on his work. 
 
 Many of the symptoms commonly attributed to senile 
 brain changes are due entirely to toxemia. I recollect 
 an old man who was in a very nervous condition, and it 
 was said that his mind was unsound. He contrived 
 against his family and told his friends that he was 
 abused at home. In fact, when he had a good thing to 
 say about anyone his family thought surely his mind 
 was not normal. 
 
 He became ill and was given a course of eliminative 
 treatment and he greatly improved. As his body was 
 rid of the toxines he changed mentally and saw good in 
 everyone and everything. I have observed this in so 
 many cases that I believe that many of the peculiar 
 traits ordinarily associated with them are merely symp- 
 toms of toxemia. 
 
 The first symptom of toxemia is usually a complain- 
 ing of weakness. The term they usually use is that 
 "they have no strength." Loss of sleep, loss of appe- 
 
98 GEEIATRICS 
 
 tite and lack of strength are the most common things we 
 hear from the aged and they require careful analysis. 
 As an actual matter of fact they have as much strength 
 as usual but the toxemia produces a feeling of weakness. 
 To overcome this physicians usually prescribe tonics 
 such as gentian, calisaya or strychnine sulphate, but 
 without any results. There is no tonic that would be of 
 benefit to them without an eliminative treatment. How- 
 ever, it is possible to combine the treatments. 
 
 Treatment 
 
 A great deal depends upon the condition of the tongue. 
 If the tongue is coated with a white fur, an alkali should 
 be prescribed. If the tongue is red and the papillae 
 prominent, a mixture of nux vomica and hydrochloric 
 acid is advised. 
 
 A saline laxative is the best method of treatment in 
 almost every case. If the patient is physically frail, 
 though, it is well not to continue the use of this saline 
 too long. An aged person, if robust, can take a saline 
 each morning before breakfast. Citrate of magnesia, 
 Seidlitz mixture, compound solution of sodium phos- 
 phate, magnesium sulphate or Pluto water may be used. 
 
 Salines may be continued as long as necessary if the 
 patient is robust, but if physically frail it is better judg- 
 ment to use pills or tablets because salines are too de- 
 pleting. I have used the compound rhubarb tablets a 
 great deal for the aged, usually prescribing one after 
 each meal or two at bedtime. Compound cathartic pills 
 work well and podophyllin tablets % grain may be used 
 occasionally but they are very slow in their action. 
 
 If the stools are dark in color and the tongue coated 
 with a thick white or brown fur, I prescribe y± grain 
 podophyllin tablets, one to be taken every three hours. 
 If the stools are light in color, I give 1/10 grain of cal- 
 
TOXEMIA IN THE AGED 
 
 99 
 
 omel, one tablet to be given every ten minutes until ten 
 are taken, followed by a saline. The podophyllin tablets 
 may be continued indefinitely and they work well in the 
 aged. If the stools are very offensive, I prescribe tab- 
 lets containing 1/1000 grain bichloride of mercury, one 
 to be taken every three hours. 
 
 As a supportive remedy to be taken with the elimina- 
 tive treatment I give a tonic consisting of tincture of 
 nux vomica and elixir calisaya or tincture gentian com- 
 pound. As a table water I prescribe Vittel Grande 
 Source or Salee, a pint or quart to be taken daily. Celes- 
 tins Vichy may be used in its place. 
 
 The mineral waters seem to aid in the elimination of 
 toxines and do not deplete the system. It is a geriatric 
 principle that we must stimulate the aged, for nature 
 tends to cure the young, but kill the aged. 
 
 I do not usually interfere with the diet. Eggs are 
 usually countermanded, but you will find in my sections 
 on senile diabetes and nephritis that I do not advocate 
 changing the diet of the aged a great deal. The same rules 
 apply, in my opinion, to the diet for toxemia as apply to 
 the diseases mentioned above. 
 
 Many theories of the association of longevity and auto- 
 intoxication have been advanced, but one fact remains 
 certain. Attention to the correction of autointoxication 
 will cause a great deal of comfort to the aged and their 
 families and will prolong life. Several years added to 
 the life in some cases may result, but in time a toxemia 
 of some kind, in most instances due to the kidneys, can- 
 cer or pneumonia, will be the cause of death. Much can 
 be done to help the aged live more comfortably and 
 longer and the correction of toxemia will improve the 
 mental condition of many senile patients. 
 
CHAPTER XIII 
 BLOOD PRESSURE IN SENILE CASES 
 
 Case I. — A man, aged fifty-six, consulted me for verti- 
 go. For some time he had a pressure in the occipital re- 
 gion; experienced sensations of electric shock on lying 
 down and complained of a troublesome buzzing in the ears 
 and was quite deaf. He was very drowsy and mentally 
 depressed. He was the plethoric type of case and his 
 appearance indicated toxemia. He had a position on a 
 railroad and he was approaching the time when he would 
 be forced to give up his work. 
 
 Examination showed a systolic pressure of 230 and 
 the diastolic pressure registered 190 on the aneroid ap- 
 paratus, but the arteries did not show apparent changes 
 of degeneration. The urinary examination revealed the 
 presence of albumin and the sediment showed many hya- 
 line and granular casts. 
 
 Nephritis was undoubtedly the cause of the increase 
 in blood pressure and treatment was given in this direc- 
 tion. He was given a half ounce of magnesium sulphate 
 each morning before breakfast and was placed on a milk 
 and cereal diet. I prescribed the dried substance of 
 pig's kidney, given in tablet form, but gave him nothing 
 to directly reduce the blood pressure, such as the nitrites 
 or iodides. 
 
 On this regimen he improved and the blood pressure 
 was reduced each week about ten mm. on the aneroid ap- 
 paratus, until it was 150. He lost about twenty-five 
 pounds in weight and said that he had never felt better 
 in his life. He remained on this strict diet for two 
 
 100 
 
BLOOD PRESSURE IN SENILE CASES 101 
 
 months, gradually adding a few vegetables and fresh 
 fish to the list. Notwithstanding the strict diet and de- 
 pletion, he said that he felt stronger than he had in sev- 
 eral years and was able to work. 
 
 The blood pressure increased to 160 and he increased 
 his diet and it remained at this point. The deafness im- 
 proved, his so-called catarrh of the nose disappeared as 
 did the other symptoms, and on the continued use of the 
 substance of the pig's kidneys and on the diet, the uri- 
 nary examination showed an improvement but the casts 
 did not entirely disappear. 
 
 He moved to another city and I lost sight of him for 
 a time. Later a letter from his physician said that the 
 blood pressure had returned to 210 and a year afterward 
 when I saw him he said that as soon as he discontinued 
 the treatment the former symptoms returned. 
 
 Case II. — A woman, aged seventy-two, had a chronic 
 nephritis which caused an edema of the legs and many 
 vague symptoms such as neuralgic pains, cramps in the 
 legs, itching of the skin and a numbness of the legs. Her 
 blood pressure was 180 systolic and 130 diastolic. Un- 
 der a treatment with salines and a nonnitrogenous diet, 
 the blood pressure became lower and there was an im- 
 provement in the general condition. 
 
 • Case III. — A man, aged sixty, had a chronic nephritis 
 which caused him a great deal of annoyance. His 
 systolic blood pressure registered 220 and the diastolic 
 190 on the aneroid apparatus. He had purchased a 
 sphygomanometer and he had his valet take his blood 
 pressure every day. 
 
 He had periods when he felt better but during this 
 time his pressure was higher than when he was ill. This 
 fact led me to believe that it was one of those cases that 
 would do better without interference. In other words, 
 there was a certain harmony in the action of the internal 
 
102 GERIATRICS 
 
 organs and as long as this action was not disturbed he 
 maintained a condition which was fairly good and lived 
 in comparative comfort. I advised him to disregard the 
 blood pressure apparatus and apply a little "skillful 
 neglect' ' to his case. 
 
 The fact that his blood pressure was high caused him 
 much worry and mental depression. He lived for two 
 years in this way and traveled about quite extensively a 
 part of the time. He was very careful of the emuncto- 
 ries, did not overeat, but ate the food he liked and used 
 an electric light bath each week to eliminate the toxines 
 through the skin. From the time he stopped treatment, 
 which was directed to lower his blood pressure and lived 
 a life similar to that which he had lived for years, he 
 found he was more comfortable and probably lived as 
 long as if he had resorted to more drastic measures. 
 
 The term blood pressure is misused frequently and we 
 make a mistake in thinking it is a disease while it is 
 merely a symptom of some other condition. There are 
 many causes of an increase in blood pressure, but in the 
 main it is due to an increased peripheral resistance due 
 to the increased work the heart has to force the blood 
 through the congested organs. 
 
 Arteriosclerosis does not in itself always produce high 
 blood pressure. If there is cardiac hypertrophy there 
 may be an increase in the pressure, but if there is no 
 hypertrophy there will be a low blood pressure due to 
 the increased tonicity of the vessels. This is particu- 
 larly true in interstitial nephritis where it is common 
 to find an advanced case which has a pressure of 100 on 
 the aneroid apparatus while in the parenchymatous 
 form of nephritis there is usually a marked increase in 
 the pressure, probably due to the enlarged kidney being 
 also congested causing the heart to work harder to force 
 the blood through it. In the interstitial or contracted 
 kidney there is not always a congestion and accompany- 
 
BLOOD PRESSURE IN SENILE CASES 103 
 
 ing increase in the peripheral resistance. This does not 
 always work out in this way for in some cases the con- 
 tracted kidney will cause a blood pressure higher than 
 the enlarged kidney. The difficulty encountered in diag- 
 nosing a high blood pressure by the appearance and 
 physique of the patient alone without a sphygomano- 
 meter is well illustrated by the following cases: 
 
 Case IV. — A woman, aged sixty-five, came into my of- 
 fice complaining of headaches and dizziness. She did 
 not have many other symptoms and from the fact that 
 she was physically frail, weighing about 110, it was nat- 
 urally thought that a woman of this physique would not 
 have a high blood pressure, especially as she did not have 
 any symptoms. I saw her in my office on several differ- 
 ent days, but she did not appear very sick. I did not 
 take her blood pressure, but prescribed for her symp- 
 tomatically. She was taken suddenly ill with an attack 
 similar to asthma and in my routine examination at the 
 bedside was astonished to find the blood pressure regis- 
 tered 240 systolic and 200 diastolic on a Tycos aneroid 
 apparatus. I was alarmed to find a large quantity of 
 albumin on urinary examination and also blood and casts 
 in the microscopic examination. She died the next day 
 from cerebral hemorrhage hardly giving any apparent 
 warning of the seriousness of the affection until twenty- 
 four hours before her death. 
 
 Case V. — A man, aged sixty-eight, robust and of the 
 plethoric type, weight 210, came to my office presenting 
 the classical symptoms of a high blood pressure and 
 nephritis. The pulse was full and could be rolled under 
 the fingers and the temporal arteries were tortuous and 
 the pulsation was visible. To make a snap diagnosis 
 almost every physician would say high blood pressure, 
 but examination repeated on different days with a Tycos 
 
104 GEEIATKICS 
 
 and a Sanborn apparatus showed that the systolic pres- 
 sure was 120 and the diastolic was 90. 
 
 These two cases illustrate the impossibility of de- 
 pending upon the appearance of the patient. It is 
 very common to find cases of intestinal nephritis that 
 are accompanied by a low blood pressure. There are 
 several factors which enter into the production of high 
 blood pressure. For example, thyroid disease may 
 cause it and another factor which must be given consid- 
 eration is the viscosity or density of the blood itself. In 
 such diseases as anemia, tuberculosis and marasmus, 
 the blood is thin and the specific gravity low with result- 
 ing low blood pressure. Nephritis and some other dis- 
 eases produce a higher specific gravity and if this is high 
 the bloo4 passes through the arterioles and capillaries 
 with resulting increase in peripheral resistance. All those 
 factors tend to raise the blood pressure in the aged and 
 a natural outcome of advancing years is to have a higher 
 pressure. 
 
 We must know the normal limits and not mistake the 
 pathologic senile pressure for a normal condition. The 
 causes which produce a high blood pressure which is 
 pathologic, are plumbism, alcoholism, nephritis, chronic 
 toxemia, gout, diabetes, syphilis, and thyroid degenera- 
 tion. These are outside of the normal senile state in 
 which the high blood pressure is a part of the senile 
 change. 
 
 Many physicians have made rules to give normal blood 
 pressure reading for old age. An approximate rule is to 
 add 100 to the age, but we may add, in some cases, still 
 more and yet be within normal limits. It may also be 
 much lower and yet be normal. The fact is we are all 
 a rule for ourselves and each one has an individual blood 
 pressure which is normal to himself. I have seen men 
 at seventy who had a systolic pressure of 200 and after 
 
BLOOD PRESSURE IN SENILE CASES 
 
 105 
 
 careful study I was convinced that it was normal for 
 these persons. I have even seen it higher and yet the 
 patient would apparently be in comfort and to meddle 
 with cases of this kind would bring disastrous results. 
 A man at ninety would ordinarily have a normal 
 systolic pressure of 190 or more. The pressure also 
 varies from day to day and from month to month and 
 undoubtedly minor things enter into the cause of this 
 variation. Food, exercise, rest and elimination probably 
 effect it. If the old person has symptoms referable to 
 the high blood pressure, he should be treated, but if one 
 is too ambitious and simply treats the increase in blood 
 pressure, bad results may follow. 
 
 Trosseau said that half the knowledge of medicine was 
 to know the natural course of disease. This applies to 
 old age because we can not differentiate the normal from 
 pathologic conditions if we do not know normal senile 
 changes. Too much stress has been laid upon high blood 
 pressure in old age. Within certain limits high blood 
 pressure is normal and meddling with the process by 
 treatment may cause fatal results. Nature has given an 
 increase in pressure for some reason and is annoyed 
 if we attempt to cure the condition to make it compar- 
 able to a man twenty years younger. 
 
 It is very difficult in old age to get an accurate read- 
 ing because of the differences between the sclerosed 
 arteries of each arm which necessitates taking the pres- 
 sure on each arm owing to this difference. I use the 
 Tycos and also Sanborn instruments and do not depend 
 upon the radial arteries or the wrist. Auscultation will 
 assist in obtaining an accurate reading, but it may be 
 well to take it on different days and when it is taken in 
 different ways an average can be made. Occasionally, 
 the radial arteries will be so sclerosed that it will be an 
 impossibility to take it even by the auscultatory method. 
 The artery also may be misplaced. 
 
106 GEKIATRICS 
 
 The factors which enter into blood pressure are cardiac 
 hypertrophy, arterial tension, peripheral resistance and 
 the specific gravity of the blood. Chronic nephritis 
 causes this increase in resistance and in time cardiac 
 hypertrophy develops. The best cardiac stimulant some- 
 times is to reduce the amount of the hearts work by re- 
 ducing the capillary resistance. It is comparable to a 
 horse who has a heavy load on the wagon and has become 
 exhausted. The best stimulant is not to whip the horse, 
 but to remove a part of his load and he is able to go on 
 with his work. 
 
 High blood pressure except when due to other specific 
 cause is almost invariably caused by this increase in re- 
 sistance. To treat it by the nitrates would not relieve the 
 congestion which is the cause of the condition. 
 
 Diastolic pressure in old age varies, but there are 
 some cases in which there is a marked difference from 
 maturity. Myocarditis, gout, carcinoma, or debility 
 caused by various diseases, causes a low diastolic pres- 
 sure. On the other hand, high diastolic pressure may 
 be due to heart disease and nephritis. Aortic regurgi- 
 tation may cause a low diastolic pressure. In nephritis, 
 the diastolic pressure is usually high and up to a certain 
 point in cardiac hypertrophy there is a high diastolic 
 pressure, but later the pressure falls when the degree of 
 hypertrophy has reached its maximum. 
 
 The following tables taken from the monograph of 
 L. M. Bowes (The Journal of Laboratory and Clinical 
 Medicine, January, 1917), give his experiments on the 
 systolic and diastolic pressure in old age: 
 
BLOOD PKESSUKE IN SENILE CASES 
 
 107 
 
 Table I 
 
 The Average Blood Pressure of Both Men and Women 
 
 number systolic diastolic pulse 
 
 age examined pressure pressure pressure 
 
 65-69 32 151 82 65 
 
 70-74 39 160 86 73 
 
 75-79 38 166 86 79 
 
 80-84 27 175 84 83 
 
 85-89 7 170 90 77 
 
 90-94 7 142 81 61 
 
 Table II 
 
 The Average Blood Pressure of the Women 
 
 number systolic diastolic pulse 
 
 age examined pressure pressure pressure 
 
 65-69 21 154 83 71 
 
 70-74 29 158 83 72 
 
 75-79 24 ' 170 88 81 
 
 80-84 16 183 85 91 
 
 85-89 7 170 90 77 
 
 90-94 3 137 80 53 
 
 Table III 
 
 The Average Blood Pressure of the Men 
 
 number systolic diastolic pulse 
 
 age examined pressure pressure pressure 
 
 65-69 11 145 81 63 
 
 70-74 10 166 91 75 
 
 75-79 14 159 89 77 
 
 80-84 11 163 84 80 
 
 85-89 — — 
 
 90-94 4 145 81 65 
 
108 GERIATRICS 
 
 My clinical experience in old age does not bear out 
 Dr. Bowes' table in detail and I have found in private 
 practice that it ranges higher than he has found it. 
 Bowes' conclusions, taken from the same journal, are 
 well worth reading. They are as follows : 
 
 Conclusions 
 
 1. Only repeated readings of both systolic and dia- 
 stolic pressure are of value, and both arms should be 
 used for observations in old people. 
 
 2. Inequality of the pressures of the two sides is fre- 
 quent in arteriosclerosis. 
 
 3. There may be a high or low blood pressure in ar- 
 teriosclerosis ; the pressure falling with involvement of 
 the heart muscle in the process of fibrosis resulting in 
 chronic myocarditis. 
 
 4. High systolic pressure associated with high dia- 
 stolic pressure indicates cerebral hemorrhage or ne- 
 phritis. 
 
 5. A sustained hypertension, both of systolic and dia- 
 stolic pressures, indicates cerebral hemorrhage, while 
 hypotension indicates cerebral embolism. 
 
 6. A sustained high systolic with a low diastolic pres- 
 sure usually indicates cardiac trouble. A low diastolic 
 pressure is common with aortic regurgitation. 
 
 7. A high pulse pressure is frequent in arteriosclero- 
 sis and aortic regurgitation; and a sustained high pulse 
 pressure usually results in a failing heart. 
 
 8. A systolic pressure of 100 may not keep a man from 
 his daily business. 
 
 9. A lowering blood pressure indicates a failing heart. 
 
 10. Acute enteritis lowers the blood pressure. 
 
BLOOD- PKESSUKE IN SENILE CASES 109 
 
 In my opinion a great many cases of increased blood 
 pressure are caused by nephritis and attention to the 
 kidneys will give better results tban any other way. "We 
 may find cases where the nitrites are beneficial and if 
 specific disease is present the iodides should be adminis- 
 tered. The latter remedy is very irritating to the stom- 
 ach and kidneys and should not be used except when 
 necessary. The treatment I give in the chapter on 
 senile nephritis is, in my opinion, excellent for most cases 
 if there is an increase in blood pressure. 
 
 The term high blood pressure has become a fad today 
 as has the term "hardening of the arteries." If we do 
 not forget that these conditions are not diseases, but 
 merely symptoms of some other disease, we will be bet- 
 ter equipped to treat the condition in a more intelligent 
 manner. 
 
 The greatest difficulty in geriatrics is to be able to diag- 
 nose the difference between normal and pathologic senile 
 degenerations. Until we recognize this fact we will be 
 making serious mistakes in the therapeutics of senile 
 cases. 
 
CHAPTER XIV 
 ARTERIOSCLEROSIS 
 
 Case I. — A man, aged forty-eight, had a marked fibrosis 
 of the arteries, cardiac hypertrophy and interstitial ne- 
 phritis. His blood pressure, registered on the aneroid 
 apparatus, was 210 mm. systolic and 180 diastolic. 
 
 He was very nervous and irritable, had a sensation of 
 pressure in the occipital region, blurring of vision and 
 extreme mental depression. In every way it was appar- 
 ent that he had a degenerative condition consistent with 
 a man aged seventy-five. There was no history of 
 syphilis, rheumatism, gout or plumbism, but the inter- 
 stitial nephritis had developed since he had scarlet fever 
 several years ago. 
 
 Case II. — A man, aged thirty, had marked calcification 
 of all the arteries. He had chronic tuberculosis of both 
 lungs with cavity formation on the right side. Two 
 months before he died he developed a carcinoma of the 
 tongue which was spreading rapidly until an attack of 
 asthma due to the tuberculous condition, brought an end 
 to his suffering. 
 
 Case III. — A man, aged seventy, had a marked arterio- 
 sclerosis. He complained of headaches, loss of memory, 
 nervousness, blurred vision, and other symptoms com- 
 monly described as classical arteriosclerosis. His symp- 
 toms were due, however, to a parenchymatous nephritis. 
 
 Case I describes a man of forty-eight who appears in 
 every way like a man of seventy-five. In other words he 
 has premature old age. Case II is very unusual and rep- 
 resents a type in which it is difficult to ascertain the 
 
 no 
 
Fig. 4. 
 
 Roentgenogram showing marked arteriosclerosis and calcareous 
 degenaration of the ulnar artery in a man, aged 68. 
 
Fig-. 5. Same patient as in Fig. 4, anteroposterior view, also showing 
 rarefaction of the ends of the radius. 
 
ARTERIOSCLEROSIS 
 
 111 
 
 cause of the arteriosclerosis. Case III is not unusual 
 for a man of seventy, for he would normally have hard- 
 ening of the arteries. 
 
 The changes in the arteries accompanying advanced 
 years make arteriosclerosis a normal process in a man 
 past sixty and in some cases a little earlier. As the years 
 advance the size of the heart and the thickness of its 
 walls usually diminish; occasionally, we find that the 
 heart is enlarged owing to the resistance imposed upon 
 it by congested vessels in the internal organs. The lin- 
 ing membrane has spots of atheromatous deposits and 
 the free margins of the valves are thickened and hard- 
 ened. The arteries themselves contain deposits of lime 
 salts and fatty matter which deprive them of their 
 proper elasticity and convert them into mere rigid tubes. 
 The walls of the capillaries are thickened, making the 
 diameter smaller. The pale skin of old age contrasted 
 with the ruddy bloom of youth illustrates the fact that 
 the narrowing of the lumen of the arteries causes a lack 
 of nourishment of the parts with consequent atrophy 
 and degeneration. 
 
 The diminished capillaries impede the free passage of 
 the blood from the arteries to the veins and the propel- 
 ling force of the heart and arteries being deadened, the 
 fluid accumulates in the veins which as a result become 
 distended and tortuous. 
 
 Because of the congestion of the internal organs, in 
 particular the kidneys and liver, and because of this de- 
 rangement of the natural balance of the blood, the heart 
 is forced to carry on additional work. If the heart is 
 strong, the circulation may be kept up with perhaps no 
 greater deviation from health than piles or varicose 
 veins. If the heart action is too strong, it may cause rup- 
 ture of the vessels by the impulse and apoplexy may be 
 the result. If the heart is weak there will be a resulting 
 
112 GEBIATEICS 
 
 venous congestion, dropsical effusions and a general 
 subcutaneous edema. 
 
 The sclerosed condition of the radial arteries makes it 
 uncertain to depend upon the pulse at the wrist. Always 
 count the heart rate at the apex. It has been thought 
 that as years advanced the pulse rate became less. This 
 is not true, unless we are dealing with myocarditis. I 
 recollect a man, aged eighty, who had a pulse rate of 
 twenty per minute. This was due to myocarditis. It has 
 been found that the average pulse rate past seventy 
 years of age is about seventy-eight. A pulse rate of 120 
 in the aged is serious. However, sometimes with the 
 aged the faster the pulse and the higher the fever the 
 better the prognosis. My opinion is based upon the fact 
 that normally the aged do not have a fever and in- 
 creased pulse rate and when they do present it there is 
 a possibility that it denotes vitality but this is not always 
 true. 
 
 Premature arteriosclerosis aside from the usual patho- 
 logic causes, as syphilis, rheumatism, gout and plumbism, 
 usually develops from a definite condition. From lack of 
 care of the bowels or from indiscretions in diet the portal 
 circulation becomes a little congested and secondarily 
 there is a congestion of the kidneys. This damming of the 
 blood around the portal and renal circulation forces the 
 heart to pump a little harder to get the blood through the 
 increased resistance. As a result, if the process is con- 
 tinued, the second aortic sound becomes accentuated and 
 the systolic blood pressure becomes a trifle increased. 
 If this condition continues the heart becomes increased 
 in size in order that it may carry on the extra work and 
 if the condition continues for a few years the kidneys, in 
 contrast to the heart, become decreased in size which 
 causes them to fail in their ability to perform their func- 
 tions. The renal insufficiency comes as interstitial ne- 
 
Fig. 6. 
 
 Roentgenogram of ankle of a man, aged 67, showing calcareous 
 degeneration of the posterior tibial artery. 
 
AKTEEIOSCLEKOSIS 113 
 
 phritis develops and in place of functional insufficiency 
 true uremia is present. 
 
 The heart now has quite a degree of enlargement, there 
 is high blood pressure in the arteries whose walls have 
 undergone sclerosis and in time, calcareous degeneration 
 takes place in the arteries. 
 
 We see here the role the kidneys play in the produc- 
 tion of arteriosclerosis and if I were to say the most fre- 
 quent and constant cause of arteriosclerosis I would say 
 by all means the kidneys. I believe that the arterial 
 changes are in most cases secondary to the renal changes. 
 In the first place, arteriosclerosis, except in rare cases, 
 is not a disease but a symptom of some other disease. 
 Today we are attributing many things to arteriosclerosis 
 and calcareous degeneration of the arteries and we do 
 not stop to consider that arteriosclerosis is a normal 
 process of ageing and is compatible with good health. 
 
 The symptoms said to be due to arteriosclerosis are 
 usually due to nephritis and if we analyze the matter as 
 the French physicians do we will find that the nephritis 
 was the first disease to appear. 
 
 After sixty years of age we normally develop this 
 hardening of the arteries and it should not be considered 
 pathologic unless it develops in young persons. Nature 
 has produced these arterial changes for a reason and 
 permits a function which is in harmony with the degen- 
 eration of other organs. Today, when a person of ad- 
 vancing years is ill with various symptoms the physician 
 is ready to attribute them to arteriosclerosis and when 
 the old man dies it is said that hardening of the arteries 
 produced it. 
 
 I wish to repeat that arteriosclerosis and fibrosis of 
 the arteries is a normal process of advancing years and 
 should not be tampered with. The symptoms we com- 
 monly attribute to arteriosclerosis are due usually to 
 renal insufficiency. There are many cases, unquestion- 
 
114 GEKIATEICS 
 
 ably, where arteriosclerosis is pathologic and should be 
 treated as such especially when it occurs in younger in- 
 dividuals and has a definite cause. 
 
 This pathologic arteriosclerosis should not be con- 
 fused with the process due to normal senile arterial de- 
 generation. The term atheroma is not synonymous with 
 arteriosclerosis since it is a fatty degeneration and is 
 localized. A syphilitic aneurism is in reality not a 
 sclerosis of the aorta but an actual softening and not 
 hardening of the vessel. Fibrosis and calcification may 
 be due to syphilis but usually the change is due to a 
 gummatous softening. At the beginning of arterial de- 
 generations there is a softening of the arteries before 
 fibrosis and calcification take place. Therefore, we may 
 feel an artery at the wrist and because it is soft say that 
 it is normal when in reality it is the incipiency of an 
 arterial fibrosis. 
 
 While arteriosclerosis is a normal change there are 
 certain factors which hasten its development. In middle 
 age, syphilis, infectious diseases, rheumatism, gout and 
 plumbism may tend to cause premature arterial changes. 
 It is my opinion, however,., outside of syphilis and ne- 
 phritis and from the fact that rheumatism and gout in 
 many instances are due to a chronic uremia, the arteries 
 are little effected by other agents. Eoentgenologists are 
 unquestionably prone to have premature arteriosclerosis 
 and thyroid disease may also effect it. 
 
 I am convinced that the term cerebral arteriosclerosis 
 is used to cover a mass of ignorance in diagnosis. 
 I have seen many of these cases with symptoms of a 
 classical cerebral arteriosclerosis which are due to 
 uremia and intestinal toxemia. The elimination of tox- 
 ines by means of free catharsis will relieve many of the 
 symptoms due to so-called arteriosclerosis of the vessels 
 of the brain. 
 

 Fig. 7. Left coronary artery. Advanced arteriosclerosis, from a case of 
 fatal angina pectoris. Magnified 30 diameters. But little of the adventitia is 
 shown. The media is thinned and at points encroached upon, but the most 
 conspicuous change is in the intima, beneath the endothelial layer of which 
 there has been extensive proliferation and leucocytic accumulation, most 
 marked in the upper segment, greatly altering the lumen of the vessel, lessen- 
 ing its carrying capacity, and rendering it practically inelastic. There was a 
 marked fibroid myocarditis in the area supplied by the vessel. (From Hare — 
 Practice of Medicine.) 
 
ABTEKIOSCLEKOSIS 115 
 
 Aged persons are apt to get toxic especially when in- 
 active and failure to discover this will cause us to at- 
 tribute vague symptoms to arterial changes which are not 
 due to them at all. The term arteriosclerosis is a refuge 
 for a physician who is not able to make a diagnosis and 
 it is almost as criminal as to call a disease "old age." 
 I am speaking now of old persons past sixty who have 
 arteriosclerosis and we use this term because we are 
 not interested enough in the old man to discover the 
 cause of the symptoms. These persons of advanced 
 years who have arteriosclerosis present a series of 
 symptoms which are almost classical. They have head- 
 aches, dizziness, loss of appetite, furred tongue, blurred 
 vision, drowsiness to the extent of dozing in their chairs, 
 weakness, symptoms of neurasthenia and psychasthenia. 
 There is a change in the mental condition. They become 
 irritable, can not stand the sound of conversation and 
 music and become very melancholic. 
 
 A woman, aged seventy, was taken suddenly ill with the 
 loss of use of her left arm. The next day she had re- 
 gained its use. 
 
 A man, aged seventy-two, was taken with sudden lame- 
 ness and loss of power in the right leg and was obliged 
 to be taken home. The next day he had improved. 
 
 A man, aged sixty-five, suddenly became maniacal and 
 said that I was poisoning him with medicine. The family 
 thought the mania was due to some drug that I was ad- 
 ministering. In three or four days he had improved. 
 About six months later he died of cerebral hemorrhage. 
 
 A woman, aged seventy, was taken ill suddenly with 
 loss of speech and mental confusion. She was very ill 
 for several days, but recovered. It is now two years 
 since the attack and she is in excellent health, is able to 
 travel, but has never regained her speech and can not 
 read or write since she had the attack. She can say 
 
116 GERIATRICS 
 
 three or four words and her daughter can understand 
 some things she wishes. At times she becomes toxic, but 
 free elimination through the emunctories usually relieves 
 her in a few days. 
 
 This is a typical case due to cerebral arteriosclerosis 
 but undoubtedly the attack was caused by cerebral con- 
 gestion due to renal toxemia. 
 
 A man, aged sixty-two, was taken ill with symptoms 
 similar to cerebral hemorrhage. The legs were power- 
 less, he was unconscious for three days and was in a 
 deep coma. A treatment by hot packs and enemata im- 
 proved the condition, and he lived in comparative com- 
 fort for a year. 
 
 A man, aged seventy-five, had attacks of mania which 
 usually came when least expected. He was given free 
 elimination and in a few days he had improved. This 
 man has been an inspector of post-office construction 
 and between the attacks maintains a normal mental state 
 and is very keen in his judgment. 
 
 These cases described are in old persons who have 
 marked arteriosclerosis and the symptoms given could 
 easily be attributed to this condition. It is very evident 
 in these cases that the symptoms, while due to cerebral 
 arteriosclerosis, were produced by a cerebral congestion 
 due to renal or intestinal toxemia. Many of these cases 
 of cerebral arterial hardening never produce symptoms 
 until there is a systemic toxemia which causes a conges- 
 tion. 
 
 This applies to apoplexy. In the aged, a sudden loss 
 of the use of a limb, an unconscious condition combined 
 with paralysis is commonly termed a " shock' ' or 
 ' ' slight shock. ' ' The layman is very apt to call any un- 
 conscious condition in the aged a "shock" and physi- 
 cians are very apt to label these conditions apoplexy. 
 
 The more I study the intoxications in the aged the 
 more I am convinced that true apoplexy is not as com- 
 
ARTERIOSCLEROSIS 117 
 
 mon as supposed and if these cases are analyzed we will 
 find uremia or intestinal toxemia the cause. This has 
 been proved several times where active treatment of the 
 toxemia has been instituted and the old man has recov- 
 ered and returned to his work with his usual vigor. This 
 type of case could not be called apoplexy. Uremia may 
 be localized in one organ. Thus we may have renal 
 uremia, gastric uremia and cerebral uremia. Cerebral 
 uremia is very similar in its manifestations to apoplexy 
 and it is often difficult to clear the diagnosis. On an 
 eliminative treatment usually the condition will improve 
 if due to uremia. 
 
 It is a mistake in therapeutics to attempt to cure senile 
 arteriosclerosis. The iodides are unnecessary and may 
 cause harm to the stomach. Moreover, the iodides are 
 very irritating to the kidneys. I have seen better results 
 in the treatment of symptoms from free elimination 
 through the kidneys, bowels and skin than by employing 
 the nitrites. I fail to see any great advantage in lower- 
 ing the blood pressure by the nitrites, that is for con- 
 tinued use, unless attention is given to the underlying 
 cause. 
 
 Free catharsis by a saline, as potassium bitartrate to 
 increase elimination through the kidneys and if the pa- 
 tient is in coma a hot pack or enema will be of benefit. Hot 
 packs are dangerous to the aged and should be used only 
 when there is coma. The skin does not respond readily 
 to the heat and it is difficult to start perspiration. It is 
 of benefit, however, in some cases. 
 
 In summarizing, I would say, relieve the system of its 
 toxines, restrict the diet, and disregard the arterioscle- 
 rosis as far as therapeutics is concerned, unless in a 
 younger person where there is a clear indication for a 
 specific remedy. 
 
CHAPTER XV 
 SENILE NEPHRITIS 
 
 Case I. — A man, aged seventy, lost his position in a fac- 
 tory, and as a result became despondent and began to 
 drink quite an amount of liquor. He gradually developed a 
 weakness, complained of headaches, dizziness, loss of ap- 
 petite, and had difficulty in urination. He cried often, and 
 the sound of music and laughter caused a very annoying 
 pain in his head. He contrived against his family, say- 
 ing that he was badly treated and would not eat at home. 
 On the contrary, he would go to a restaurant to give the 
 impression that he was not treated well by his family. 
 
 One night his family heard a noise in his room, and it 
 was discovered that the old man had fallen on the floor 
 and was having a convulsion. He was given ether, but 
 during the course of the morning he had several severe 
 attacks. He was unconscious; the right side of his face 
 was drawn and the left arm and leg were paralyzed. 
 There was a general subcutaneous edema. A diagnosis 
 of uremia was made and he was given hot packs. For 
 four days he remained unconscious, but in the course of 
 a few days he regained consciousness, and by free elimi- 
 nation through the emunctories, the use of the arm and 
 leg gradually returned. It was necessary to catheterize 
 him for several days, but this was finally overcome. In 
 about a month he was able to get out of doors, and he 
 gradually improved in other ways. It is now three years 
 since the attack, and the old man is able to do a hard 
 day's work and is in better health than he has been for 
 years. 
 
 118 
 
SENILE NEPHRITIS 119 
 
 Case II. — A woman, aged seventy-three, was extremely 
 nervous. She appeared like a child with St. Vitus' dance. 
 The urine showed the presence of blood and granular 
 casts. By the use of the extract of the kidney of a pig, 
 she gradually improved. 
 
 Case III. — A man, aged sixty, of the physically frail 
 type, consulted me for dizziness and indigestion. The 
 cause was interstitial nephritis, and he had had several 
 severe attacks. In this type of nephritis a person may 
 be very sick, but not show it in his general appearance. 
 The presence of blood, granular casts and blood scattered 
 in some of the casts gave a guarded prognosis. He was 
 given the dried extract of pigs' kidney and improved on 
 its use. 
 
 Case IV. — A man, aged seventy-four, was taken ill with 
 heart weakness. He then developed facial paralysis 
 and persistent hiccough. The urine showed many 
 hyaline casts, but there, were no other symptoms of 
 nephritis. I ordered free catharsis and absolutely 
 starved him for two weeks. He was not given a drop 
 of water or anything else. This relieved the persistent 
 hiccough. He was in a condition where the kidneys were 
 not able to do any work, and the presence of hiccough 
 and vomiting indicated that Nature did not require any 
 nourishment. 
 
 The old man apparently gained on this treatment, and 
 instead of the starvation producing weakness, it seemed 
 to make him feel better. When the irritability of the 
 stomach ceased he was given champagne and also pep- 
 tonized milk. He gradually gained, and today is work- 
 ing with a great deal of comfort. 
 
 Case V. — I once saw an invalid woman who had tried 
 many different treatments. She could not move without 
 experiencing faintness. She had taken treatments for 
 
120 GEKIATKICS 
 
 her heart, but was in a condition where she could not 
 move out of bed. The aortic second sound was accentu- 
 ated and the heart was overworked. On careful ques- 
 tioning, it was revealed that she had the minor symp- 
 toms of Brightism, such as cramps in the calves of the 
 legs, itching of the skin, nocturnal micturition, sensation 
 of electric shock on lying down, sensitiveness to cold, 
 dead fingers and dead legs. 
 
 The urine showed quite a number of granular casts. 
 Undoubtedly the heart was working hard to force the 
 blood through the congested kidneys. The use of the ex- 
 tract of pig's kidney, together with free elimination, 
 produced excellent results. She soon was able to attend 
 the theatre; in the course of time traveled quite a dis- 
 tance, and during the winter she has been in Florida en- 
 joying good health. 
 
 Case VI. — A retired business man, aged sixty-eight, 
 consulted me for difficulty in urination. He said that 
 he had lost his "grip," and appeared despondent and 
 childish. He was melancholic, and his family annoyed 
 him very much. He complained that they did not want 
 him and abused him. His condition was entirely due to 
 chronic uremia, and on eliminative treatment he im- 
 proved. As a result of the elimination of toxines his 
 mental depression entirely disappeared. 
 
 Case VII. — A man, aged sixty-three, has been under my 
 care for five years for chronic interstitial nephritis. The 
 urine showed casts and albumin. For the .past year he 
 has apparently been well, and by the use of the dried 
 powder extracted from the kidney of a pig the urine has 
 become free from any discoverable abnormality. Al- 
 though he has been in excellent health he has recently 
 been developing a blindnss in the right eye, and now he 
 is totally blind in this eye, due to retinal hemorrhage. 
 
SENILE NEPHKITIS 
 
 121 
 
 The hemorrhage is undoubtedly due to the old nephritis, 
 although the urine does not show any abnormality in the 
 sediment at present. 
 
 These cases represent typical examples of chronic 
 renal toxemia. It will be noted that in some of these 
 cases the mental state, often ascribed to "old age," or 
 childishness, etc., clears by the proper attention to the 
 elimination of toxines. An intestinal toxemia will often 
 be the starting of a nephritis or it may develop in the 
 course of nephritis. 
 
 The kidneys, under the modern way of living, perform 
 the greater part of the daily elimination. These small or- 
 gans are constantly working, day and night, and the 
 majority of people neglect to make the bowels and skin 
 do their share of the elimination of waste. As a result 
 of our overeating, the intake of excessive amounts of 
 nitrogenous foods and irritating, volatile substances like 
 mustard, sauces, horse-radish, etc., the kidneys are not 
 only irritated but overworked. 
 
 Naturally, the result is that they are the first organs 
 to show any weakness, and instead of enlarging to carry 
 on their extra work, they usually become smaller or con- 
 tracted. The next course is that the heart is forced to 
 pump harder to get the blood through the congested or- 
 gans, owing to this increased resistance in the renal 
 blood vessels. This condition continues, and, conse- 
 quently, produces first a hypertension ; next, a hardening 
 of the arteries, and finally hypertrophy of the heart. 
 
 Because of the lack of more precise methods of diag- 
 nosis, the presence of chronic interstitial nephritis, in 
 many cases, is only discovered on postmortem examina- 
 tion. The microscope and chemical tests will not always 
 show the evidence. Sometimes when the kidneys are in 
 bad condition the microscope will not reveal it until sev- 
 eral examinations have been made. 
 
122 GEKIATEICS 
 
 I once saw a case of nephritis due to syphilis, 1 and the 
 diagnosis was made from the clinical aspect because the 
 urine did not show any evidence of abnormality until 
 three weeks after the onset of the attack. Also in Case 
 VII the retinitis developed when the urine was appar- 
 ently free from abnormality and with the systolic blood 
 pressure at 150 on the aneroid apparatus. 
 
 The more we become civilized the more apt are we to 
 have diseases as nephritis and cancer. Inhabitants in 
 the Far East, who live on farinaceous and vegetable 
 foods, rarely have these diseases. The lay press often 
 attributes death to " hardening of the arteries," " heart 
 failure'' and acute indigestion. The vast majority of 
 these cases are due to chronic Bright 's disease. Arterio- 
 sclerosis is merely a symptom and not a disease. In 
 fact, it is a normal process of advancing years. 
 
 Symptomatology 
 
 Chronic nephritis in the aged differs from that of 
 younger individuals. The ordinary symptoms, like 
 headaches and edema, are usually absent. There is a 
 certain amount of kidney degeneration that is normal 
 in the process of ageing, and this degeneration attacks 
 all organs, and one of the miracles of nature is the func- 
 tion which these diseased organs will assume. If the 
 harmony is broken, however, some organ like the kidney 
 will break down more rapidly than the others. It is then 
 that the symptoms of broken renal compensation arise 
 just as the compensation is lost in the case of heart dis- 
 ease. 
 
 The first symptom of nephritis will often be a languid 
 feeling. There is mental depression and a general evi- 
 dence of an intoxication. The face is flushed at night, 
 
 l "American Journal of Clinical Medicine," August, 1916, p. 676, 
 
SENILE NEPHKITIS 
 
 123 
 
 the tongue coated and the odor of the breath noticeable. 
 The temporal artery is tortuous and pulsation visible, 
 and the radial pulse is full and bounding. The patient 
 complains of cramps in the calves of the legs, dead fin- 
 gers, cold legs, shortness of breath and a drowsiness. 
 The old man sleeps in his chair during the day and com- 
 plains that he can not sleep at night. He contrives 
 against his best friends and tells others that he is abused 
 at home. He loses his sense of cleanliness, will not bathe 
 himself properly, and will resort to habits that are very 
 unclean and unlike his former self. 
 
 In the male usually there is difficulty in urination, due 
 to prostatic congestion. Senile rheumatism is very fre- 
 quently a manifestation of senile nephritis, and is due to 
 the renal toxemia. Sciatica and lumbago are sometimes 
 symptoms, and oftentimes chronic indigestion is caused 
 by the nephritis. 
 
 Diagnosis 
 
 The presence of casts, albumin and blood, together 
 with the minor symptoms of Brightism, will clear the 
 diagnosis. The symptoms of toxemia must be traced to 
 ascertain if the condition is dependent upon some other 
 disease. I have seen several cases of pyelitis in the aged 
 that were secondary to cancer of the colon. The pyelitis 
 may cause symptoms of Brightism, but in these cases the 
 possibility of cancer of the colon must be eliminated. 
 
 Occasionally, I have seen the nephritis accompanying 
 prostatic hypertrophy, both of which were due to syph- 
 ilis. At times senile diabetes will be accompanied by 
 nephritis, and it is only by a study of the minor symp- 
 toms that one can detect the disease which is the most im- 
 portant from a therapeutic standpoint. 
 
 In comatose patients it is impossible to make a diag- 
 nosis of nephritis, because any patient in a coma, no 
 
124 GEKIATKICS 
 
 matter the cause, will usually have glycosuria, albumi- 
 nuria and casts. 
 
 Prognosis 
 
 A little care and attention to these senile patients will 
 produce excellent results in many cases, add much to 
 their comfort and in many instances add several years 
 to their lives. The presence of blood in the urine should 
 give a guarded prognosis. These cases of interstitial 
 nephritis which have blood casts will suddenly be taken 
 ill with every symptom and run a course similar to pneu- 
 monia. They rarely recover. I have seen many cases 
 of apparent senile pneumonia which I am sure were an 
 acute exacerbation of a chronic nephritis. This is my 
 conclusion, because in these individual cases I have fol- 
 lowed them for several years and knew that they had 
 chronic nephritis. 
 
 Whenever sugar is found, together with casts and 
 blood, convalescence is certain to be protracted. Also 
 where the urine does not turn red with Fehling's solu- 
 tion, but a muddy green color, the recovery, as a rule, 
 will be very slow. 
 
 Treatment 
 
 The issuance of a strict diet list to an aged individual 
 is usually a very distressing and disagreeable punish- 
 ment. Most of these old persons were accustomed to 
 coarse food in their younger days, and to change their 
 mode of living would bring disastrous results. 
 
 Although these aged persons live on coarse food, such 
 as pork, red meats, food rich in nitrogen, I usually give 
 them the liberty to eat anything they wish. When an 
 old man loses his appetite he is very much discouraged. 
 He was taught in his younger days that "food gives 
 strength,' ' and to lose his appetite he thinks means ap- 
 proaching death. If a diet list is ordered for him, it 
 
2 cm 
 
 Fig. 8. Kidney of chronic interstitial nephritis. The surface is granular 
 and irregular, and contains numerous cysts. The contraction is quite marked, 
 the organ being but little more than half the normal size. (From Hare — 
 Practice of Medicine.) 
 
SENILE NEPHRITIS 125 
 
 will usually cause, by mental depression, a loss of ap- 
 petite. Moreover, most of these diets are constipating. 
 
 The best results I have seen in these cases are from 
 nonrestriction in any way. However, this does not refer 
 to acute nephritis, when there is blood in the urine. If 
 these patients are not ill in bed, it is better to keep them 
 on milk, cereals and the light vegetables. If acutely ill 
 and in bed, the absolute milk diet is indispensable. In 
 some cases, as in Case IV, absolute starvation is the only 
 treatment. This is because the kidneys are exhausted 
 and not able to take care of any food or liquid. 
 
 Free catharsis is essential, by means of a saline each 
 morning if the patient is corpulent, and a pill like the 
 compound cathartic for one who is physically frail. 
 Salines are too depleting for thin individuals. 
 
 Those cases due to syphilis will usually yield to ordi- 
 nary treatment, and seldom have I been obliged to resort 
 to mercury or potassium iodide for this particular con- 
 dition in the aged. Some of the best results in a few se- 
 lected cases of syphilis will be from remedies other than 
 mercury or the iodides. 
 
 I prescribe an extract of the kidney of a pig, said to 
 contain the unchanged elements and enzymes of the cells 
 and cortex and convoluted tubules of the kidney. These 
 are in tablet form, and usually from six to twenty tab- 
 lets are given daily. They give good results clinically 
 and seem to check the process of degeneration. 
 
 In some instances, especially in corpulent patients and 
 also where much headache is experienced, cabinet baths, 
 either with an ordinary bath cabinet or electric light 
 bath, will sometimes give good results. The skin of an 
 aged person is usually dry, and it is difficult to start per- 
 spiration. To give the cabinet baths to aged patients 
 requires great caution, and the physician must select 
 his cases. 
 
126 GEEIATEICS 
 
 The elixir of iron, quinine and strychnine phosphates, 
 now unofficial, will usually work well as a tonic after the 
 eliminative treatment. However, the return of strength 
 will be automatic as the toxins are eliminated. It is nec- 
 essary, however, in the aged to increase stimulation, and 
 for this strychnine is indicated. 
 
 The matter of changing an old man's habits is impor- 
 tant and should be carefully studied. I do not change 
 his mode of living in any way, even allowing him the 
 usual amount of liquors that he is in the habit of taking. 
 A habit which has been for years the pleasure of an old 
 man should not be tampered with. 
 
 In Case I it will be remembered that the sickness de- 
 veloped after the old man had left his position. This is 
 an important matter, and the best treatment for these 
 aged persons, when possible, is to keep them out of bed 
 and get them to work. Even in serious illness I feel 
 that on several occasions I have seen aged people saved 
 by getting them out of bed, no matter how sick they 
 were. Even with senile pneumonia or senile bronchitis, 
 if at all possible, they should be kept in a chair and not 
 in a bed. Keep old persons in bed, and the chances 
 are that they will not get up again. It gives them added 
 courage to get them out of bed. The bed to them means 
 ' ' old age, ' ' which, in turn, means approaching death. If 
 you tell your aged patients that they will get better, they 
 will not believe you, but if they see that you insist on 
 getting them out of bed they feel that they will get better. 
 
 This treatment of nephritis by means of elimination, 
 therapeutic agents, and finally giving them work, is the 
 means of removing many of the symptoms that will ordi- 
 narily be attributed to old age and childishness. The 
 toxines in many instances produce the so-called senile 
 mental state. 
 
CHAPTER XVI 
 SENILE DIABETES 
 
 Case I. — A mariner, aged seventy-six, had complained 
 of a general weakness and as glycosuria had been discov- 
 ered he had taken the Allen treatment for diabetes. When 
 he came under my care he was extremely weak and the 
 matter that gave him the most concern was his loss of 
 appetite. He said that his diet list had forbidden every- 
 thing that he cared to eat. The fact that he had diabetes 
 caused him much anxiety. I advised him to resume his 
 usual mode of living and eat anything he wished. He 
 was given a teaspoonful of the elixir of iron, quinine and 
 strychnine phosphates, before meals. 
 
 In the course of a few days the results were very evi- 
 dent and the patient said that he felt as well as ever, and 
 in a month's time the sugar had entirely disappeared 
 from the urine. This case represents a transient gly- 
 cosuria and probably was only a symptom of a general 
 degenerative change. 
 
 Case II. — A man, aged sixty-five, consulted me for 
 polyuria and lumbago. He had diagnosed his own dis- 
 ease because a similar condition of his wife had made 
 him familiar with diabetes. He told me, above all things, 
 that if I found sugar he would not change his mode of 
 living for he felt that he was too old to give up habits 
 that had for years been his custom. I found 2 per cent 
 sugar, but did not advise treatment, and today, four 
 years after the first consultation, he is able to work as 
 well as usual and lives in comfort. In all probability to 
 change his diet, which consists of the coarsest food, 
 
 127 
 
128 GERIATKICS 
 
 would produce bad results. In fact, treatment does not 
 seem necessary because the rigid diet would be more 
 distressing to him than the few symptoms of which he 
 complains. 
 
 Case III. — A man, aged sixty-three, complained of loss 
 of flesh and inaptitude for work. He had not been feel- 
 ing well for a long time, but the symptoms seemed to 
 him indefinite. Occasionally he complained of backache ; 
 he also had gingivitis, blurred vision, loosening and fall- 
 ing out of the teeth and a persistent balanitis. 
 
 The urine contained albumin, 1 per cent sugar, many 
 granular casts and some blood. It was apparent that 
 the nephritis complicated diabetes; in fact, the symp- 
 toms spoken of were due to diabetes and not to nephritis. 
 
 I gave him a mixture containing two grains of pan- 
 creatin and sixteen grains of potassium carbonate to the 
 ounce, a teaspoonful of this four times a day, but did not 
 change his diet. I allowed him anything he wished to 
 eat, which was coarse food, for he had always been a 
 hard laborer. For the past two years he has been in 
 good condition and is able to work as usual. 
 
 It is interesting to note in this case that this patient's 
 wife had been a diabetic for years. The man described 
 in Case II also had a diabetic wife. I will refer to this 
 later as conjugal diabetes. 
 
 Case IV. — An instructor, aged fifty-five, consulted me 
 for a ' l run-down condition. ' ' For some time he had felt- 
 disinclined to work, had lack of power to concentrate, 
 loss of memory, a tendency to sleep, and occasionally 
 sciatica. He had no polyuria, polydipsia, or loss of 
 weight. The urine showed one-half per cent sugar. I pre- 
 scribed the elixir of iron, quinine and strychnine phos- 
 phates, now unofficial, and treated him according to the 
 diet advised by Dr. E. P. Joslin, of Boston. 
 
SENILE DIABETES 129 
 
 I started him with a diet containing carbohydrates to 
 the amount of 150 gm. From this amount he went to 
 125 gm. ; then to 100 gm., and on 75 gm. he became sugar- 
 free. I kept him on a strict diet with vegetables in the 
 5, 6 and 10 per cent groups, with four ounces of cream. 
 
 He has remained sugar-free and is a most conscien- 
 tious patient; he weighs his food and now has increased 
 his diet to 150 gm. of carbohydrates. It has been over 
 two years since he has had glycosuria, and several times 
 each year he has a thorough examination to discover if 
 any abnormality is present. 
 
 Case V. — A woman, aged sixty, consulted me two years 
 ago for pruritus vulvae, without eczema. I found 2 per 
 cent sugar and also every evidence of a chronic inter- 
 stitial nephritis. I took the sugar from her desserts, but 
 did not interfere in any other way with her usual mode 
 of living. She had probably been in this condition for a 
 long time, but as she had very few symptoms, and as 
 her diseased organs functioned fairly well, I decided not 
 to treat either the nephritis or glycosuria. To interfere 
 with one would simply harass the other into activity. 
 
 Case VI. — A woman, aged sixty-seven, had been under 
 my care for several years for a chronic glomerulone- 
 phritis. Her urine was examined each week and always 
 showed much albumin, no sugar, and many hyaline and 
 granular casts. Two years ago her kidney condition 
 quieted down, the casts disappeared and she felt fairly 
 well except that she had a troublesome parchness of the 
 mouth, and consequently, polydipsia. Eepeated exami- 
 nations of the urine showed no sugar nor P-oxybutyric 
 acid. 
 
 She went to a neighboring city, consulted a physician 
 who immediately diagnosed diabetes and advised a 
 strict diet. There is nothing that an aged person fears 
 more than diabetes. The diet was continued for some 
 
130 GEEIATEICS 
 
 time with the result that when she returned to me the 
 old degenerative kidney changes had returned, but the 
 urine still showed no sugar. 
 
 On questioning the patient I found that the physician 
 had not taken a specimen of her urine, therefore, had 
 not tested it; consequently, had made a snap diagnosis. 
 Moreover, the rigid diet broke up an excellent compen- 
 sation and caused the old nephritis to light up again. 
 To this day the thoughts of diabetes have produced a 
 mental depression which will never be overcome. Noth- 
 ing will convince her that she has not diabetes. 
 
 Case VII. — An Indian woman, aged fifty-three, had gan- 
 grene of the left forearm. After examining the urine 
 several days in succession and failing to find glycosuria, 
 on the fifth day I found 3 per cent sugar. She would not 
 diet and moreover left the gangrenous forearm to be 
 amputated by nature. She absolutely refused to consid- 
 er any surgical intervention. The amputation by nature 
 was a wonderful result and is as perfect as if performed 
 by surgical means. More than this, she is in better health 
 today than in years. 
 
 However, at times she experiences pruritus with 
 eczema, and attention to a noncarbohydrate diet is the 
 only thing that will relieve her. The glycosuria is not 
 present at all times and it is undoubtedly due to some 
 pancreatic disturbance. This is evidenced by the pres- 
 ence of fat in the stools. She has refused to change her 
 mode of living because the forbidden list for diabetics is 
 the only food that she cares for and she has always lived 
 in this way. She declares that Indians who were always 
 in the habit of eating coarse food can not live on any 
 other food. She will diet for about a week when she has 
 the pruritus sufficiently severe to cause suffering, after 
 which she returns to her usual diet. 
 
SENILE DIABETES 131 
 
 In some of these cases undoubtedly the diabetes has 
 not been of long standing. Diabetes of the aged is en- 
 tirely different from this disease in younger persons. 
 What will cure a young person will produce the opposite 
 effect on the disease in an aged individual. The diseases 
 of advanced age require as much special attention as the 
 diseases of childhood and if this fact is not borne in 
 mind, disastrous results will often follow. 
 
 In a good many instances of old age we can not do 
 anything scientifically to cure them, but a little attention 
 and care for their ailments will mean a great deal to- 
 ward adding a few years to their lives. 
 
 Many of these conditions of senile glycosuria are 
 transient and are merely a part of the senile degenera- 
 tion. In other cases we find confirmed diabetes as evi- 
 denced by all of the minor symptoms of this affection. 
 
 In Cases II and III both husband and wife had dia- 
 betes. This is rather a common condition and is termed 
 conjugal diabetes. Some of the French physicians who 
 had observed this fact, spoke of it as possibly a con- 
 tagious disease, but it seems that the same mode of living 
 has much to do with its production. 
 
 Symptomatology, Diagnosis and Prognosis 
 
 Many patients will pass an ounce of sugar daily for 
 several years without knowing it or having any symp- 
 toms. In some cases the symptom that will cause atten- 
 tion will be the loss of weight. In others there may be in- 
 aptitude to work, nervousness, neuritis, backache, sciatica, 
 muscular pains, melancholia, polyuria, polydipsia, poly- 
 phagia, balanitis and phimosis. Sometimes there will 
 be a urethritis which looks like that produced by the 
 gonococcus. There is usually a tendency to drowsiness, 
 pruritus, with or without eczema, ocular troubles (am- 
 blyopia), gingivitis, loosening and falling out of the 
 
132 GEEIATEICS 
 
 teeth. Whenever an aged person complains of any of 
 these symptoms the nrine shonld be examined. At times 
 there will be a single symptom which will cause much 
 trouble. In one instance I saw a troublesome case of 
 balanitis with resulting phimosis. The man had made 
 up his mind to take ether and have the phimosis cor- 
 rected. However, the discovery of the cause, which was 
 diabetes, probably saved him a good deal of inconven- 
 ience, for the proper treatment as to diet corrected the 
 balanitis and in time the phimosis was cured. 
 
 Sometimes these diabetics of old age will not have 
 polyuria or polydipsia. In Case IV practically the only 
 symptoms were sciatica and inaptitude to work. It was 
 only by routine examination, a regular process like a 
 mechanic cleans an engine, that the sugar was discov- 
 ered. Occasionally a pruritis of the genitalia with or 
 without eczema will be the only symptom. 
 
 Diabetes of the aged is usually mild, but very difficult 
 to overcome. Senile patients rarely develop acidosis. 
 It is seldom in the case of kidney complications that they 
 develop acidosis. It is seldom also in the case of kidney 
 complications that they develop uremia. It is unusual 
 for diabetes to cause any increase in blood pressure or 
 affect the arteries. On the other hand, arteriosclerosis 
 may bring on diabetes, especially by producing trouble 
 with the arteries of the pancreas. Cardiac incompetency 
 is a rare complication in the aged. 
 
 The danger from infection, however, is great, because 
 the glucose medium in the blood gives an excellent 
 soil for the fixation and development of the staphylococci, 
 streptococci and tubercle bacilli. Tuberculosis in the 
 aged, however, is a rare complication, and when it is 
 present it is usually without symptoms and it is only 
 discovered on postmortem examination. The infectious 
 diseases are apt to develop, partly from the excellent 
 
SENILE DIABETES 
 
 133 
 
 culture medium the glucose makes in the blood and 
 partly due to lowered resistance. 
 
 Treatment 
 
 It is well not to tell an aged patient that he has sugar 
 in the urine unless one is obliged to. There is nothing 
 that causes more anxiety and dread in these senile 
 cases than diabetes. The thought of a strict diet, the 
 recollection of their friends who have suffered from the 
 disease, is almost equivalent to calling their ailment by 
 the familiar death-warrant, "old age." Wherever, as 
 in Case IV, the cooperation of the patient is essential it 
 is better to inform him. 
 
 In the matter of diet much depends on the individual 
 case. In many instances of senile diabetes the Allen 
 treatment and Dr. Joslin's treatment will produce excel- 
 lent results and perhaps add much to their comfort and 
 a few years to their lives. 
 
 In some cases, however, in advanced age it is bad 
 judgment to change the mode of living. Many times a 
 radical change in the diet has caused bad results in an 
 aged patient. With senility it is not advisable to stop 
 any confirmed habit no matter how bad it is, whether it 
 is in eating, smoking or drinking. 
 
 Food such as pork, baked beans, cabbage, pickles, 
 corned beef, or any hearty food may not be well for 
 younger people, at times, yet to allow the senile patient 
 the liberty of eating anything he wishes will be a great 
 help in treating his condition. Many times I have seen 
 this work well. When an old man's appetite is failing 
 it causes him much anxiety and usually any strict diet in 
 the aged will produce anorexia and constipation. The 
 cases that I do not interfere with do not present any 
 symptoms which are very troublesome to the patient. 
 There are times when it is advisable to place them on a 
 
134 GERIATRICS 
 
 diet and in these cases I use the reduction of carbohy- 
 drates according to the method of Dr. E. P. Joslin. I 
 know of several instances where the Allen treatment has 
 given excellent results in the aged. One case I have in 
 mind was a man, aged seventy, who had diabetic gan- 
 grene of the leg and was given the Allen treatment prior 
 to amputation. When he became sugar-free the leg was 
 amputated, with an excellent result, and he lived almost 
 a year after this in comparative comfort. 
 
 The following diet list is very convenient to use in pri- 
 vate practice where it is difficult to have the coopera- 
 tion of the patient by weighing food, etc. It is far from 
 an ideal diet, but in private practice it is impossible to 
 follow out hospital rules. Moreover, if the diet list is too 
 complicated it is seldom that anyone will take enough in- 
 terest in the aged person to prepare the food according to 
 the list. 
 
 Diet List 
 
 Allo 
 
 WED 
 
 Soups and broths made of meat of any kind without 
 vegetables; ox-tail, turtle, gumbo, curry. 
 
 Eggs in any form. 
 
 Fish. Fresh fish of all kinds and fish roe, anchovies. 
 Salt fish, cod, mackerel and herring may be taken unless 
 they increase thirst. 
 
 Fats. Olive oil and all animal oils and fats, such as 
 butter, cream, cod-liver oil, bone marrow. 
 
 Fresh meat, fowl and game of all kinds. Ham, bacon, 
 smoked beef, tongue, sweetbreads, kidney. 
 
 Vegetables. Spinach, cress, chicory, pickles, dande- 
 lions, beet tops, celery, artichokes, lettuce, cucumbers, 
 green part of asparagus, cauliflower, French beans, all 
 in moderation. One potato, size of an egg 7 daily. 
 
 Cheese, cream cheese, milk curds. 
 
SENILE DIABETES 
 
 135 
 
 Jellies made of gelatin, calf's foot, with wine, but un- 
 sweetened with saccharin, coffee jelly, lemon jelly. 
 
 Fruits, if acid, not sweet. Sour oranges, lemons and 
 grape-fruit. Olives, sour apples, peaches, raspberries, 
 currants, in very small quantity and occasionally. 
 
 Nuts, all kinds except chestnuts. 
 
 Whipped cream, custards, koumiss, milk, not over one 
 pint a day unless directed; tea, coffee, cocoa. 
 
 Whiskey, brandy, rum, gin, dry Rhine or Moselle wine, 
 claret, Burgundy, Apollinaris, Contrexeville. 
 
 Strict Diet. Meat, poultry, game, fish, soups, gelatine, 
 eggs, butter, olive oil, coffee, tea ; and for variety, tongue, 
 sweetbreads, tripe, kidneys, pig's feet, anchovies, lob- 
 ster, crabs, sardines, shrimp, bologna sausage, smoked 
 and pickeled meat. Oatmeal, cream, cheese. 
 
 Substitute for bread. Gluten flour may be used for 
 thickening broths, egg puddings, etc. Eeceipt for Gluten 
 Biscuits: Gluten flour, one cup; best bran, previously 
 scalded, one cup; baking' powder, one teaspoonful; salt 
 to taste; two eggs; milk or water, one cup. Mix thor- 
 oughly. 
 
 Substitute for sugar : Saccharin tablets, y 2 grain, ob- 
 tainable at druggists. Each tablet equals one lump of 
 sugar. Do not exceed 4 to 5 grains daily. Very acid 
 fruits may be sweetened with saccharin or cooked with 
 a little cooking soda to neutralize the acidity. In cook- 
 ing foods avoid flour. Melted butter may be used as a 
 substitute. Roast beef should not be basted with flour; 
 meat soups must not be thickened. 
 
 Foebidden 
 
 Sugar in any form — syrup, molasses, candy, jams, 
 honey. Rice, bread, sago, tapioca, arrow-root, cornmeal, 
 hominy, barley, macaroni, spaghetti. Pastry, cake pud- 
 
136 GEKIATKICS 
 
 dings and everything made of flour. Peas, parsnips, 
 beets, carrots. Champagne, cider, ale, beer and port. 
 
 The difference between transient glycosuria and dia- 
 betes is only one of degree. In transient cases the urine 
 will sometimes become sugar-free without treatment. 
 When nephritis is complicated by diabetes or vice versa, 
 I usually do not treat it, except by intestinal elimination. 
 It has been my experience that to treat one disease 
 causes the other to become active and may terminate in 
 a serious condition. 
 
 The elixir of iron, quinine and strychnine phosphates, 
 now unofficial, works well clinically. Sometimes, espe- 
 cially if the patient has a bronzed condition of the skin, 
 the solution of two grains of pancreatin and sixteen 
 grains of potassium carbonate to the ounce, works well 
 in drachm doses four times a day. Codeine has a good 
 effect on many cases of diabetes in the aged. If there is 
 any acidosis, a teaspoonful of sodium bicarbonate three 
 or four times a day is indicated. 
 
 There are two complications of which I wish to speak. 
 I have treated several large carbuncles on diabetics re- 
 cently, without excision or incision. An antiseptic solu- 
 tion somewhat similar to the liquor antisepticus alka- 
 linus, N. F., with the addition of phenolic ethers and 
 other essential oils was injected deep into the carbuncle, 
 one cubic centimeter being injected several times through 
 the mass. This is repeated each day until it discharges 
 freely. The Indian woman who had the diabetic gan- 
 grene of the forearm left the amputation to nature and 
 it resulted in a perfect stump ; in fact, it has the appear- 
 ance of a flap operation. 
 
 These cases were not treated nonsurgically in an ef- 
 fort to depreciate surgery, but they were first used in 
 
SENILE DIABETES 
 
 137 
 
 patients who absolutely refused surgical intervention. 
 There is no question that surgery is the proper treat- 
 ment for these complications, and modern anesthesia has 
 made great advances recently in the diabetic cases so 
 that it is not such a serious problem to administer anes- 
 thetics to aged diabetics as in years past. 
 
 Conclusions 
 
 1. Diabetes in the aged differs from that in younger 
 persons. 
 
 2. What will cure diabetes in the young will some- 
 times produce bad results in the aged. 
 
 3. Many cases live longer and more comfortably if left 
 untreated. 
 
 4. Many cases of diabetes are complicated by nephri- 
 tis, and vice versa. 
 
 5. Urinalysis in aged patients is much neglected. 
 
 6. The term diabetes causes much anxiety to an aged 
 person. To them it looks like certain death. 
 
 7. Dr. Joslin's and Dr. Allen's treatment give good 
 results. 
 
 8. Treatment in most cases must be gradual and not 
 vigorous. 
 
 9. Acidosis rarely develops in aged patients. 
 
CHAPTER XVII 
 URINALYSIS IN THE AGED 
 
 Case I. — A woman, aged sixty-three, consulted me for a 
 numbness in the right side of her body. She was nervous, 
 melancholy, and complained of polyuria, polydipsia and 
 polyphagia. A urinary examination showed one and one- 
 half per cent sugar and ^g-oxybutyrie acid. She was given 
 treatment according to Dr. Joslin's method for diabetes 
 and in the course of a few days the urine became sugar- 
 free. However, as this was brought about it was also ob- 
 served that the urinary sediment, which was normal be- 
 fore the sugar disappeared, became filled with small and 
 large granular casts. 
 
 It was evident that we were dealing with a combined 
 condition of nephritis and diabetes. A nephritic diet 
 caused the sugar to return. On a nonrestricted diet she 
 improved although the sugar did not disappear. 
 
 Case II. — A man, aged seventy-six, had glycosuria but 
 failed on a strict diet. He had no other symptoms of 
 diabetes and on a nonrestricted diet the sugar disap- 
 peared. 
 
 Case III. — A man, aged seventy, has had nephritis for 
 several years. The urine recently showed the presence 
 of sugar, but he does not present any other symptoms 
 of diabetes. 
 
 These cases are very common and anyone who is do- 
 ing urinalysis for his aged patient knows the frequency 
 of these findings. 
 
 Case I represents undoubtedly a case of glycosuria of 
 renal origin. Nephritis is the underlying disease and 
 
 138 
 
UKIXALYSIS IX THE AGED 139 
 
 the glycosuria is merely a symptom of this disease. 
 Cases II and III represent glycosuria which is transient 
 and due to the general degenerative changes accompany- 
 ing old age. They do not require treatment. 
 
 There is another type of urinary rinding in which the 
 symptoms of diabetes are the most prominent yet the 
 presence of many casts shows the condition complicated 
 by nephritis. The urine of comatose patients usually 
 contain albumin, sugar and casts, therefore, it is very 
 difficult to make a diagnosis of Bright 's disease or dia- 
 betes in these comatose patients. 
 
 Albuminuria in the Aged 
 
 In most instances I do not attach much importance to 
 the finding of albuminuria in the aged. Its presence in 
 most cases indicates a senile degenerative change which 
 is normal. However, the combination of albumin, sugar 
 and casts in the urine, together with clinical symptoms 
 which point to disease, makes the presence of albumin- 
 uria of importance. Likewise, where there is much pus 
 or blood in the urine the thick layer of albumin is of 
 clinical importance and comparative quantitative tests 
 show whether the condition is improving. 
 
 It is well to use two or three different tests to avoid 
 mistakes. I use the nitric acid test and also the acetic 
 acid, salt solution and heat test. The latter test will pre- 
 vent a confusion with nucleo albumin. 
 
 Glycosuria 
 
 In a good many cases the urine will have to be exam- 
 ined several days in succession, in order to elicit the 
 fact that the patient has diabetes. I had a woman, aged 
 fifty-three, who had gangrene of the left forearm. After 
 examining the urine several days in succession and fail- 
 
140 GEKIATRICS 
 
 ing to find glycosuria, on the fifth day I discovered 3 
 per cent sugar. 
 
 In the routine examination of the urine with all aged 
 patients the number of cases of glycosuria found is sur- 
 prising. 
 
 A great deal, however, depends upon the test solution 
 employed. Very often with the Fehling's solution the 
 sugar will not be seen until the specimen has stood over- 
 night. If this test is employed and conclusions derived 
 without allowing the tested urine to stand for several 
 hours, the results will be misleading. Again, Fehling's 
 solution is very apt to turn the specimen a muddy green 
 color. This is not sugar, but clinically when this is found 
 complicating nephritis a protracted convalescence is 
 certain. * 
 
 I have found sugar in many cases of Bright 's disease 
 so that it would appear from a careful study of minor 
 symptoms of Brightism that the sugar is a symptom, 
 and is possibly from renal origin. It is a serious combi- 
 nation to find sugar, albumin and casts in the same urine. 
 
 Although Fehling's solution is very safe, undoubtedly 
 Benedict's solution is more apt to detect smaller amounts 
 of sugar. It is well to corroborate the diagnosis by using 
 both tests when there is any doubt. 
 
 In the aged the tests for chlorides, sulphates and phos- 
 phates are usually without much importance. 
 
 Acidosis rarely develops in senile diabetes therefore 
 ^g-oxybutyric and diacetic acids are not often encoun- 
 tered. 
 
 The urea test, likewise, does not give much informa- 
 tion in aged patients. Senile patients who are uremic 
 may have a normal urea test. Indican is often found 
 and is of much importance in determining the presence 
 of intestinal toxemia. I have seen, however, some senile 
 cases of intestinal toxemia that did not have indicanuria. 
 
URINALYSIS IX THE AGED 
 
 Microscopical Examination 
 
 141 
 
 An occasional cast, like the presence of albumin, is a 
 normal finding in some nrines and is not important. 
 However, the presence of many casts together with red 
 blood corpuscles indicates nephritis. At times it is im- 
 possible to discover these abnormalities and several ex- 
 aminations may be necessary before the true condition 
 is revealed. This is true of a contracted kidney which 
 is a very difficult condition to diagnose. The hyaline 
 casts are often so small and transparent they are only 
 found after the most careful examination is made. In 
 some cases of contracted kidney it is only by repeatedly 
 centrifuging the specimen, that the casts will be seen. 
 
 Erythrocytes may be due to nephritis, cystitis or 
 prostatitis- Many granular casts have erythrocytes 
 scattered through them and indicate a rather serious 
 condition. 
 
 Pyuria may be due to pyelitis, cystitis or prostatic dis- 
 ease. In women the pus may be from vaginal origin, 
 therefore it is well to use a vaginal douche before col- 
 lecting the specimen. A large albumin ring is apt to be 
 caused by pyelitis. Pyelitis in the aged may be due to 
 cancer of the colon. It is well to add acetic acid to the 
 slide in order not to confuse the leucocytes with other 
 things. 
 
 To make a correct interpretation of the urinary ab- 
 normalities it is essential to follow the clinical symptoms. 
 For example, if symptoms of Brightism are predominant 
 and sugar is also present the Bright 's disease would be 
 more important than the glycosuria. On the contrary, if 
 sugar is combined with albumin and casts, if the symp- 
 toms point to diabetes a diagnosis of this condition should 
 be made. 
 
142 GEEIATRICS 
 
 The presence of red blood corpuscles almost always 
 points to nephritis. If there are no symptoms attending 
 these conditions a diagnosis of senile degenerative 
 change would be made. 
 
 The study of geriatrics does not afford the possibili- 
 ties that practice with younger individuals presents, 
 therefore, it is seldom that a physician takes enough in- 
 terest in his aged patients to make a urinary examina- 
 tion. A routine examination should be made in all senile 
 cases and the practice of depending upon an albumin 
 and sugar test as is commonly done should be discour- 
 aged. Most physicians do these two tests, which are of 
 very little importance with the aged unless combined 
 with a microscopic examination, and if negative findings 
 are made, conclusions are derived without any degree of 
 accuracy. 
 
 I have seen several instances where physicians have 
 made diagnosis without making any examination at all. 
 In a case of nephritis a woman consulted a physician 
 who made a diagnosis of diabetes because she had poly- 
 phagia and polydipsia. He gave her a diabetic diet 
 which irritated her kidney condition and brought on an 
 acute exacerbation of a chronic nephritis. The patient 
 admitted to me that she did not give him a specimen of 
 urine for examination. 
 
 A little more care given to the urinalysis of a senile 
 case would produce better results in the aged. Some- 
 times proper attention to it will prolong life many years 
 and make a new person of an aged individual. 
 
 I remember an old man who had been a great burden 
 to his family. The so-called "old age" had made him 
 very disagreeable about the house and life was not worth 
 living. 
 
 Three years ago attention was given to the cause of 
 his "senile mental state," which was due to uremia and 
 
UKINALYSIS IN THE AGED 
 
 143 
 
 careful treatment in this direction produced a new man 
 mentally and in time lie resumed his work and became 
 self-supporting. Today, old age is dear to him and his 
 family, the disagreeable mental state has disappeared 
 and undoubtedly the family would feel very bad if he 
 should be taken away. After all, there is no better citi- 
 zen today than an old soldier who is well preserved men- 
 tally and physically. 
 
CHAPTEE XVIII 
 SENILE BRONCHITIS 
 
 Case I.— An old man was taken ill with a chill and had a 
 severe pain in the sternum. A long breath and cough was 
 very painful to him. He had a fever of 101° F., pulse 
 was rapid and extremely small. As the condition pro- 
 gressed the expectoration was more painful and with dif- 
 ficulty he raised a small amount of tough, viscid, semi- 
 opaque, greyish mucus. 
 
 His shortness of breath became more pronounced and 
 he was obliged to sit upright in bed to obtain relief. The 
 lips and tongue were livid and he was rapidly failing. 
 The breathing became more labored, the pulse became 
 more rapid and irregular and the old man died on the 
 second day of his illness. 
 
 Case II. — A woman, aged sixty-seven, was taken ill with 
 pain in the chest and cough. Her temperature was sub- 
 normal and the pulse rate was very rapid. The expector- 
 ation was painful and with difficulty she raised a thick, 
 rusty sputum. Toward evening she had a slight eleva- 
 tion of temperature. She gradually improved and on 
 the tenth day was much better. 
 
 These cases represent the acute form of senile bron- 
 chitis which is very common and it is very difficult at 
 times to differentiate between severe bronchitis and 
 pneumonia, especially in the fulminant type in which the 
 patient dies a short time after the onset of the attack. 
 
 The type ordinarily seen is similar to Case II where 
 the process is not as violent and where it can easily be 
 seen that the patient is not sick enough to have pneu- 
 monia. It is difficult to diagnose from senile congestion 
 
 144 
 
SENILE BRONCHITIS 
 
 145 
 
 of the lungs as there is but little difference in the symp- 
 toms of the two conditions. Congestion of the lungs may- 
 accompany acute bronchitis, but the most common cause 
 of congestion is nephritis or heart disease. 
 
 As a result of nephritis we may get a secondary con- 
 gestion of the lungs due to the heart not being able to 
 send the blood through the vessels of the kidney. Bron- 
 chitis may also accompany congestion and it is surpris- 
 ing to see the number of cases of bronchitis due to ne- 
 phritis which improve when the treatment is given for 
 that disease. 
 
 Bronchitis due to influenza is very fatal in the aged 
 and rapidly extends to bronchopneumonia. It may de- 
 velop from rhinitis, but in the aged usually it begins as 
 a distinct disease. 
 
 In treating acute senile bronchitis the first thing is to 
 give a saline laxative to deplete the system, to remove 
 the pulmonary congestion and free the bronchial tubes 
 of the mucus. I usually prescribe small doses of ipecac 
 or Kermes' mineral to loosen the cough. Ammonium 
 chloride and ammonium carbonate work well clinically 
 and medicated vapors with camphor in the water may 
 be of benefit for inhalation. If there is prostration it 
 may be advisable to give one grain of quinine sulphate 
 and 1/60 grain of strychnine sulphate every three hours. 
 It is essential to keep the bowels open. 
 
 When there is extreme shortness of breath (perhaps 
 it may be called suffocative catarrh of Laennec), alcohol 
 to its full physiologic effect is indicated. Brandy is giv- 
 en in one-half ounce doses every half hour until the 
 cheeks are red and in those cases of extreme prostration 
 where death is imminent alcohol to its full effect may be 
 the means of saving the life. Unless it is given in large 
 doses it is of little benefit. 
 
 Chronic bronchitis may develop from the acute form 
 or may be a distinct affection due to some secondary 
 
146 GEKIATEICS 
 
 cause as nephritis or heart disease. A moderate amount 
 of bronchial secretion is normal to the aged, especially 
 in the morning when they clear the bronchial tubes of 
 the night's accumulation of mucus. However, a greater 
 amount is abnormal and may be the only symptom of 
 chronic bronchitis. Again, the old man may have this 
 condition, but a sudden change in the atmosphere ag- 
 gravates the disease and he has a shortness of breath, 
 a fullness in the chest and a sensation of pressure. 
 
 Constipation by causing congestion of the portal cir- 
 culation or nephritis causes congestion of the kidneys 
 and a secondary congestion of the bronchi results. Sud- 
 den checking of a skin eruption or the checking of leu- 
 corrhea in the female may cause it. Chronic bronchitis 
 may be due to tuberculosis but it is rare in old age. 
 There is an intimate association between bronchitis and 
 piles, gout, rheumatism, checked perspiration, suppres- 
 sion of urine, too rapid healing of ulcers, etc. 
 
 On examining the chest, auscultation may show a few 
 scattered rales, but no definite changes. Percussion does 
 not reveal any abnormality and an x-ray examination 
 does not give much evidence in these cases. 
 
 The disease is slow, but progressive, but in most in- 
 stances I fail to see that they develop pneumonia more 
 often than any other old person. It seems, in most cases, 
 to be a harmless affection unless it is suddenly checked. 
 
 In treating senile bronchitis the general condition of 
 the patient should be given consideration and warm 
 clothing worn. Woolen underclothing is advisable in 
 these cases and if the patient is able to spend a part of 
 the year in a warmer climate it would be of great benefit. 
 
 The discharge, no matter how profuse or fetid, should 
 not be checked as it may cause paralysis and suffocation. 
 Ammonium chloride combined with elixir calisaya is of 
 benefit and the elixir of iron, quinine and strychnine 
 
SENILE BRONCHITIS 
 
 147 
 
 phosphates may be given. A mixture of calcium and 
 creosote may help and arsenic trioxide, 1/100 grain ev- 
 ery four hours may be of benefit. Cod liver oil works 
 well with the aged and should be prescribed. 
 
 Too much can not be said for the care of the bowels 
 in cases of senile bronchitis. By relieving the portal con- 
 gestion with a mercurial and a saline the next morning, 
 the patient will be much improved in his breathing. By 
 keeping the emunctories working and preventing any 
 further congestion of the internal organs the heart is 
 relieved of this extra load and does not have to work as 
 hard to force the blood through the lungs. 
 
 A restricted diet should be ordered and overeating 
 prohibited. A diet used for nephritis will be of benefit 
 even though the patient may not have nephritis. A mi- 
 croscopic examination of the urine should be made to 
 discover whether the kidneys are diseased, since kidney 
 disease is one of the most common causes of senile bron- 
 chitis. 
 
CHAPTER XIX 
 SENILE PNEUMONIA 
 
 Case I. — A man, aged seventy-five, had coryza which 
 rapidly developed into bronchitis. The next day he had a 
 severe pain in the right side. His temperature and pulse 
 rate were normal ; but the respiration was thirty times a 
 minute. Although no local signs of consolidation could be 
 detected, the fact that he was rapidly failing, together 
 with the increased, shallow respiration, gave clinical evi- 
 dence that he had senile pneumonia. 
 
 He continued in this condition for several days, and 
 although the temperature and pulse-rate were normal 
 the respiration continued about thirty-five a minute. On 
 the seventh day there was no apparent improvement in 
 his condition, and as there was apparently little chance 
 for recovery, it was decided to try the last resort for the 
 aged, namely; to force him out of bed and get him into 
 a chair. This usually has a beneficial action in senile 
 cases. 
 
 His breathing became easier, and in a few days it was 
 evident that he was gaining. In the course of a few 
 weeks the old man was about his work again. 
 
 Case II. — A woman, aged seventy, had a fall which re- 
 sulted in a fracture of the right hip. The family was 
 warned that the greatest danger was the development of 
 senile pneumonia. 
 
 On the fourteenth day after the accident it was noted 
 that the aged patient was growing rapidly weak and los- 
 ing weight. The pulse and temperature were normal, 
 but the respiration was thirty-six. She died on the sec- 
 
 148 
 
SENILE PNEUMONIA 149 
 
 ond day from senile pneumonia. It is interesting to note 
 in this case that there was no cough. 
 
 Case III. — A woman, aged sixty-eight, was taken ill 
 with headache, cough and shortness of breath. Temper- 
 ature was 100° F., pulse rates eighty-five and respira- 
 tion thirty-eight. It was a typical case of what is 
 ordinarily called pneumonia. The cough, rusty sputum, 
 shallow breathing, pain in the side, low muttering de- 
 lirium, restlessness, and picking at the bedclothes were 
 symptomatic. In a younger person this would possibly 
 be called typhoid fever. 
 
 The urinary picture, however, disclosed another con- 
 dition. The sediment showed an abundance of red blood 
 corpuscles, and many granular casts were filled with 
 blood. 
 
 This case was not pneumonia, but an acute exacerba- 
 tion of chronic nephritis. It is ordinarily called pneu- 
 monia, and if it was more generally observed there would 
 be fewer cases reported as senile pneumonia. 
 
 Senile pneumonia is a different disease from pneu- 
 monia in the young. In the vast majority of cases it is 
 a natural termination of an old person's life. The symp- 
 toms are entirely different, and if care is not shown the 
 patient will die before a diagnosis is made. 
 
 In cases of fracture or any disease which keeps an 
 aged person in bed there is great danger of pneumonia. 
 It sometimes comes secondary to senile bronchitis. In 
 fracture of the hip it is a very common complication and 
 also after ether anesthesia. 
 
 Case III, just described, is well worth our careful con- 
 sideration, because of its similarity to pneumonia. In all 
 cases the urine should be examined to elicit the possibil- 
 ity of renal disease. 
 
150 GERIATRICS 
 
 Symptomatology 
 
 An aged patient in bed, who is rapidly failing, prob- 
 ably has pneumonia. With an increase in the respira- 
 tion and delirium, the diagnosis is almost certain. 
 
 The temperature and pulse rate are usually normal in 
 the aged, no matter how severe the disease may be. In 
 fact, the temperature is usually subnormal. If the rate is 
 taken at the heart with a stethoscope we may find a quick- 
 ened heart beat. Owing to the sclerotic condition of the 
 radial arteries the pulse is unsafe as a diagnostic and 
 prognostic sign. It is usually advisable to take the rate 
 at the apex of the heart with a stethoscope. 
 
 The findings upon auscultation are usually uncertain. 
 It is customary to find principally the symptoms of pul- 
 monary congestion. Tubular breathing is rare in the 
 aged, or if it is present the signs of edema cover it in 
 our examination. 
 
 Diagnosis and Prognosis 
 
 The rapid failing of the patient, together with in- 
 creased respiration and delirium usually make the diag- 
 nosis clear. It must not be confused with senile bron- 
 chitis or pulmonary congestion. These latter conditions 
 are very common with the aged and are often termed 
 pneumonia. 
 
 However, a patient with senile bronchitis will converse 
 with you, but a person ill with pneumonia is too sick for 
 talk. In other words, this man is too sick for bronchitis 
 and congestion, and therefore must have pneumonia. 
 The border line is not sharp and oftentimes it is only a 
 matter of degree. 
 
 I have spoken of the analogy with nephritis. Anyone 
 who is following the urinary examinations of his aged 
 patients knows the frequency of pulmonary symptoms 
 complicating nephritis. 
 
SENILE PNEUMONIA 
 
 151 
 
 Many of these cases of senile pneumonia are in a so- 
 called typhoid state. That is, they have every symptom 
 of this disease. However, typhoid fever is very rare in 
 the aged. 
 
 Senile pneumonia is usually the cause of death of old 
 persons. They rarely recover. The presence of fever 
 and a quickened pulse rate is a good prognostic sign, be- 
 cause it indicates more strength than in those patients 
 who have a normal or subnormal temperature or pulse. 
 
 Cases of the type described in Case III almost invari- 
 ably die. The presence of blood and casts in the urine is 
 a very serious complication. 
 
 Treatment 
 
 Keep senile cases out of bed. No matter how sick the 
 patient is it is advisable to force him into a chair. It 
 relieves the circulation and gives him courage to fight 
 the battle. Usually when old persons stay in bed they 
 will not get up again. 
 
 If there are no casts in the urine, I prescribe one grain 
 of quinine sulphate every three hours. The presence of 
 casts contraindicates this. Stimulation should be started 
 early by administering strychnine sulphate 1/60 grain 
 every three hours and later increasing to 1/30 grain. 
 Spartein sulphate is used if the pulse is irregular. Ev- 
 ery aged person should take the amount of alcohol he is 
 in the habit of taking daily. 
 
 It is well to use whiskey or brandy early, but if the 
 tongue becomes dry during its administration, it should 
 be withdrawn. As long as the tongue remains moist the 
 alcohol works well. Digitalis does not work well in most 
 cases, and the opiates and coal tar derivatives have a 
 harmful action. 
 
 The matter of daily bowel evacuation is very impor- 
 tant. The compound rhubarb pill works well, but salines 
 
152 GERIATRICS 
 
 are contraindicated. The matter of autointoxication de- 
 veloping in the course of pneumonia is an important con- 
 sideration, and many an old man is walking about today 
 who owes his life to a few compound cathartic pills. 
 
 In treating cases of accidents, such as fractures, 
 sprains, etc., where the patient is in bed they should be 
 turned on their sides several times a day in order to pre- 
 vent any hypostatic congestion developing. 
 
 If recovery takes place it is usually two months before 
 the aged patient gets out of doors. However, we are 
 justified in allowing them many peculiar privileges re- 
 garding moving about, and also in the matter of eating. 
 While the privileges would seem irrational in treating 
 younger people, they may be the means of saving an old 
 person's life. 
 
CHAPTER XX 
 SENILE GANGRENE 
 
 This affection usually appears on the toes, rarely 
 on the fingers and occasionally on the legs. There may 
 he premonitory symptoms, such as pain, coldness in the 
 part, and loss of sensation. A dark-colored vesicle forms, 
 accompanied by pain. The surface lesion may extend and 
 remain moist or it may assume a shrivelled, ununified ap- 
 pearance. This classifies it into the dry and moist forms, 
 or we may get a combination of the two. The adjacent 
 tissues are edematous and cold. 
 
 The following interesting case of senile gangrene, or 
 arteritis obliterans, which occurred in my practice, shows 
 the result of a gangrenous forearm in which surgical 
 measures were not used. 
 
 Mrs. W., aged fifty-three, the last of the full-blood 
 Narragansett Indians, has had attacks of diarrhea for 
 the past five years. From the character of the feces it 
 undoubtedly was from some pancreatic disturbance. 
 She was taken ill in November, 1914, with another at- 
 tack of diarrhea, and was sick in bed for one week, when 
 suddenly the left hand became white and painful. The 
 next morning she found the left forearm red and numb, 
 as if it were dead. The pain was intense, and besides 
 numbness there was formication, coldness, edema and a 
 marked diminution in the size of the pulse. The follow- 
 ing day there was a cessation of the pulse in that wrist, 
 and the forearm was black and gangrenous. She was ill 
 in bed for seven weeks, temperature 103° F., and 
 pulse rate 130. A part of this time she was unconscious 
 and at other times delirious. Both legs were badly swol- 
 
 153 
 
154 GEKIATKICS 
 
 len and there was a general subcutaneous edema. The 
 diarrhea ceased after the first day. 
 
 In January, 1915, she was able to sit in a chair, but 
 the fever and pulse rate of 130 continued. The weight 
 of this patient had dropped from 220 to 150 pounds. In 
 February there was a line of demarcation four inches 
 about the elbow, but she was in no condition for an am- 
 putation. An operation was later suggested, however, 
 but the family refused to consider any surgical proced- 
 ure. In March, the swelling began to leave the legs and 
 she showed some improvement in the general health, so 
 that on the first of April, 1915, she was able to go out- 
 doors. The gangrenous forearm was gradually separat- 
 ing from the arm, and showed the radius and ulna with 
 the periosteum separating from the adjacent healthy 
 bones. She continued to improve in her general health 
 and in June, seven months after the onset of the disease, 
 I felt that she might be able to take an anesthetic safely. 
 The urine had previously been examined several times 
 and was found to be normal. I examined the urine sev- 
 eral days in succession and on the fifth day, after pre- 
 viously failing to find glycosuria, I discovered 3 per cent 
 sugar. I decided to use gas-oxygen anesthesia, owing to 
 the bad results from ether in these conditions of gly- 
 cosuria. The family again refused to allow any surgical 
 procedure. 
 
 The arm continued to slough and in July I sawed the 
 gangrenous forearm five inches below the elbow, leaving 
 the radius and ulna exposed. No anesthetic was re- 
 quired for this procedure. In August, I removed two 
 inches more of these bones. She continued to improve 
 and regained her weight to 220 pounds and was able to 
 go about her work. 
 
 In October, she fell and broke the radius segment from 
 the stump of the arm and in November the other bone 
 
Fig-. 
 
 Elbow showing- perfect amputation of forearm by gangrene 
 without surgical measures. 
 
SENILE GANGEENE 155 
 
 was broken in a similar manner. This left a stnmp with 
 two discharging points, which healed in three weeks and 
 is as perfect as any surgical operation could be. The 
 flap made by nature is exactly the same as if the flap- 
 operation were performed by a surgeon. 
 
 The patient today, two years after the attack, is in 
 better health than for several years and is able to do 
 practically all of the work for her home. 
 
 In some cases of senile gangrene the patient will first 
 have pain in the extremity, perhaps localized in a single 
 finger or toe, and it is common for the patient to experi- 
 ence a pricking sensation or a numbness. The pulse will 
 disappear in the part affected and in the course of a few 
 hours the part is dead. 
 
 Before gangrene has fully developed the part may as- 
 sume a blue color. There is a small vesicle which devel- 
 ops and in a few hours several vesicles appear which 
 finally coalesce. There is considerable pain associated 
 with these vesicles before they burst and even after they 
 have ruptured. The skin beneajth the vesicles is red or 
 blue in color and is a moist surface. 
 
 There may not be a moist surface and in its place 
 there niay be a shrivelled appearance and on cutting the 
 part little or no blood escapes. It has been said that the 
 dry form is more common in the poorer classes who are 
 undernourished while in persons who are robust the 
 moist form is more common. 
 
 The adjacent tissues, regardless of the form of gan- 
 grene, are swollen and red or blue in color. There may 
 be vesicles form above the gangrene. My patient was 
 extremely ill with general symptoms. She was uncon- 
 scious for several days, had an extremely high fever, 
 very rapid and thready pulse, extreme prostration and 
 a cold, clammy perspiration on the skin. The excretions 
 were of a fetid odor. 
 
156 GEEIATKICS 
 
 In time, as this period of fever and prostration im- 
 proved, she went into another stage, which was the 
 period of reaction. Her general condition improved and 
 natnre seemed to grant a trnce in her disease. 
 
 The symptoms left as they came and she finally was 
 able to walk ont of doors. There was an inflammed 
 horder above the gangrenous part and the line of de- 
 marcation was fonnd, bnt in this case it was not heeded. 
 
 In senile gangrene we may have an extremity which 
 has lost its sensation for several days before there is 
 any sign of gangrene developing. The fact that there is 
 coldness of the part and that the arterial pulse is like a 
 piece of string, gives evidence that gangrene is develop- 
 ing. It may be caused by several conditions and any- 
 thing which produces thrombosis like atheroma will cause 
 endarteritis obliterans. 
 
 Diabetes perhaps is the most frequent condition asso- 
 ciated with gangrene, but nephritis may cause it in rare 
 instances. Syphilis affecting the vessels is a very fre- 
 quent cause. 
 
 When a person has senile gangrene the part should be 
 elevated and the patient given a diet consisting of milk 
 and cereals. Support is given by means of strychnine 
 sulphate, 1/60-1/30 grain every three hours if the heart 
 shows signs of weakness. 
 
 A wet dressing of the alkaline antiseptic solution or 
 aluminium acetate solution diluted by adding a table- 
 spoonful of either solution to a tumbler of water may 
 be used. It is very essential to get free elimination of 
 the bowels as the system is loaded with toxines as a re- 
 sult of this acute process. 
 
 When the line of demarcation has formed surgical pro- 
 cedure should be resorted to without delay. It is a very 
 serious affection. It is interesting to discover, since re- 
 porting this case, several cases treated by physicians 
 
SENILE GANGBENE 157 
 
 many years ago were similar in results as the case re- 
 ported and the patients lived useful lives for a long time 
 without an operation. There is no question, however, 
 that surgery is the best treatment for many cases as soon 
 as the line of demarcation forms. 
 
CHAPTER XXI 
 SENILE PROSTATIC HYPERTROPHY 
 
 Case I. — A man, aged seventy, complained for a few 
 months that he was disturbed several times during the 
 night to urinate and at first noticed that it was an effort 
 for him to void. Later he found that he was obliged to 
 walk the floor a few minutes during the night in order 
 to start the flow. During the day he had no difficulty. In 
 the course of a few weeks he was aware that during the 
 day he could not void freely and the bladder became dis- 
 tended and he experienced retention of urine and also 
 incontinence. 
 
 He was taken in the middle of the night with great 
 pain in the abdomen and when I arrived I saw the piti- 
 ful condition he was in. I catheterized him with a flexi- 
 ble metal catheter and prescribed for him a four-grain 
 tablet of chromium sulphate to be taken every three 
 hours. He was also given two drachms of magnesium 
 sulphate and a milk diet was prescribed. 
 
 It was necessary for me to catheterize him for two 
 days, but on the third day he was able to void quite 
 freely. On the chromium sulphate treatment he im- 
 proved and for the past year has not suffered any in- 
 convenience from his prostatic hypertrophy. 
 
 Case II. — -A man, aged eighty, was taken suddenly ill 
 with pain in the abdomen and on examination the bladder 
 was found to be greatly distended. He was catheterized 
 with a rubber catheter and the family were taught to use 
 it. He was given the chromium sulphate treatment and 
 in two weeks could void freely and for several months up 
 
 158 
 
SENILE PKOSTATIC HYPEETEOPHY 159 
 
 to the time of his death he did not experience any diffi- 
 culty in urinating. 
 
 Case III. — A man, aged sixty, had retention and it was 
 necessary to use a rubber catheter. It was discovered 
 that his prostatic hypertrophy was due to syphilis and 
 on a potassium iodide treatment he recovered. In time, 
 however, he was not satisfied with his condition because 
 it returned occasionally, therefore, he insisted upon an 
 operation which was against my advice ; he was operated 
 upon in a hospital and died on the following day. 
 
 Case IV. — A man, aged seventy-five, had a chronic 
 syphilitic condition of a finger. He was taken at times 
 with inability to void freely, but was promptly relieved 
 by potassium iodide. 
 
 These cases represent types of senile hypertrophy of 
 the prostate. It is rather strange that a senile prostate 
 hypertrophies while almost every other senile change is 
 degenerative or atrophic. The gland may be enlarged 
 uniformly or the middle lobe alone may be enlarged. 
 
 As prostatic hypertrophy is a normal senile change up 
 to a certain degree, an enlarged prostate may not inter- 
 fere with functions that are normal to old age. It is when 
 this gland, which has undergone hypertrophy, becomes 
 congested either from nephritis, or from the irritating 
 toxines of intestinal origin, it causes a train of symp- 
 toms that can be removed promptly if proper treatment 
 is given. 
 
 From the effects of congestion the bladder becomes 
 distended and then a cystitis may develop. The reten- 
 tion of urine owing to the enlarged prostate may cause a 
 general toxemia or urosepsis that is not associated with 
 nephritis, and which may develop into cystitis or pyelitis. 
 
 Adenocarcinoma or any other malignant growth of the 
 prostate may also cause temporary congestion which 
 makes the symptoms much more pronounced and severe. 
 
160 GEEIATEICS 
 
 However, under proper treatment this congestion which 
 has been added to a malignant growth of the prostate, 
 may be corrected to a degree and the patient will get a 
 little more comfort. Syphilis may be the cause of hyper- 
 trophy and if a history of this disease is given specific 
 treatment should be prescribed. 
 
 Nephritis, in my opinion, is by far the most common 
 cause of prostatic hypertrophy. When these patients 
 who have chronic nephritis suffer from an acute exacer- 
 bation of the disease the prostate may have acute symp- 
 toms due to congestion which may cause retention. 
 Treatment promptly given will usually give good results. 
 
 I have treated about 200 cases of senile prostatic hy- 
 pertrophy and I have never had recourse to the so-called 
 "catheter life" for two weeks' time and have never ad- 
 vised an operation or had a patient who has been op- 
 erated upon for this condition. It is not my intention 
 to depreciate surgery, in particular prostatectomy, be- 
 cause I believe the latter operation to be very necessary 
 and successful in a great many cases. 
 
 Nevertheless, with electric treatment and medicinal 
 treatment I have kept those old patients in a comfortable 
 condition without a ' ' catheter life. ' ' I have been greatly 
 impressed with the simplicity of the treatment in some 
 cases. An old man who had syphilis complained of 
 symptoms which were found to be due to prostatic en- 
 largement and the only medicine prescribed was a saline 
 eliminant which relieved the bowels and removed the tox- 
 ines from the system. This man has had several attacks, 
 but each time I find that free catharsis will relieve him. 
 
 A man, aged seventy, found he was obliged to urinate 
 every hour during the day and also had hematuria. He 
 was relieved by taking an alkaline mixture containing 
 fluid extract of hydrastis, pancreatin, potassium car- 
 bonate and fluid extract of rhubarb. This mixture com- 
 bined with a saline laxative relieved him. 
 
SENILE PEOSTATIC HYPEETBOPHY 161 
 
 Those cases due to syphilis, strange to say, do not 
 always do well on either mercury or potassium iodide. 
 I have made the statement that some of the best results 
 in syphilis have been obtained from remedies other than 
 the iodides or mercury. Many of these cases will be re- 
 lieved by six minims of fluidextract of buckthorn in 
 syrup given three times a day. 
 
 No doubt in private practice a physician does not have 
 the severer types seen in hospitals, therefore, his observa- 
 tions do not always hold good in a general way. I am 
 convinced, however, that much can be done for senile 
 prostatic hypertrophy and if this treatment was fol- 
 lowed I believe prostatectomy would be unnecessary in 
 many cases. It is not my purpose to give a complete 
 consideration of the subject and it is my plan, as in the 
 other sections, to give principally my personal experi- 
 ence and not make a resume of some other physician's 
 methods. 
 
 Treatment 
 
 As I have written above the results of treatment from 
 the simplest remedies are surprising. A great many 
 cases which we see are merely due to congestion and a 
 clearing of the intestinal tract, together with the osmotic 
 effect of a saline laxative, relieves the prostatic mischief 
 insofar as it leaves it in a state that does not cause much 
 discomfort even though hypertrophy still exists. 
 
 When true prostatic hypertrophy is present I doubt 
 if any treatment except surgical will reduce this enlarge- 
 ment. However, a prostate can be very large without 
 causing symptoms unless it becomes congested. The 
 aged are subject to congestion of the portal circulation, 
 which in turn causes more or less congestion of the kid- 
 neys. It is this type of case that usually manifests pros- 
 tatic symptoms and in time if neglected becomes chronic 
 and beyond hopes for treatment. 
 
162 GEKIATEICS 
 
 A man who has prostatic enlargement, is ill in bed and 
 is obliged to have catheterization three or four times a 
 day, is given one tablet containing four grains of 
 chromium sulphate every three hours. If it is necessary 
 to catheterize him, I try first a rubber catheter and if 
 this fails I use a flexible metal catheter of rather large 
 size. Many times I have found a large catheter will go 
 by the obstruction while a smaller one will fail. I leave 
 the large catheter against the obstruction for a few mo- 
 ments and it will usually go into the bladder without 
 using any force. Very seldom does it cause hemorrhage, 
 but I do not think that the hemorrhage is always a bad 
 sign. Many times a little bleeding will relieve the 
 symptoms. 
 
 If the old man is suffering much pain from frequent 
 urination, I give every two or three hours a tablet con- 
 taining 1/24 grain of heroin hydrochloride; or diacetyl- 
 morphine hydrochloride will do as well. If necessary six 
 of these tablets may be taken in two hours. Heroin 
 works well with aged patients and relieves their pain. 
 
 I prescribe with the chromium sulphate a mixture con- 
 taining potassium bromide, fluidextract of buchu leaves, 
 fluidextract of uva ursi, and if there is frequent urina- 
 tion I add two minims of tincture of cannabis indica to 
 each teaspoonful to be taken every three hours. 
 
 If there is cystitis and an accompanying nephritis, it 
 may be well not to use chromium sulphate because it is 
 somewhat irritating to the kidneys. In these cases I pre- 
 scribe a mixture containing sodium bromide, potassium 
 acetate and fluidextract of pareira brava. The latter 
 remedy has an excellent effect upon the bladder mucous 
 membrane and relieves the pain and frequency of mic- 
 turition. 
 
 These cases of frequent and painful micturition will 
 be relieved more often, however, by a saline laxative 
 
SENILE PEOSTATIC HYPEETEOPHY 163 
 
 which relieves the pressure from the contents of the 
 rectum, also relieving congestion by osmosis. Free elim- 
 ination is by all means one of our best weapons in the 
 medical treatment of prostatic enlargement. 
 
 This treatment will usually relieve the old men so that 
 they will void more freely and make the use of the cathe- 
 ter unnecessary. Further treatment consists, especially 
 in obstinate cases that do not yield, of diathermia treat- 
 ments given with a special type of apparatus, the new 
 
 Fig. 10. Monae Lesser rectal prostatic electrode. 
 
 Telatherm apparatus made by Wappler with a Monalis- 
 ier type of electrode which has a metallic surface for the 
 prostate. It is inserted into the rectum and a treatment 
 is given for five minutes, using the greatest amount of 
 current that does not cause discomfort. 
 
 Telatherm (Gk. Tele — at a distance; therme, heat) 
 gives a high frequency current which has an absolutely 
 smooth discharge and this discharge can be varied by 
 means of a milliammeter from very mild warmth to a 
 great amount of heat. Diathermia treatments (Gk. dia, 
 through; therme, heat) are given by the Telatherm ma- 
 chine by means of two poles on a D'Arsonval current. 
 One pole is attached to the electrode in the rectum and 
 the other pole is attached to a piece of lead foil about 
 three or four inches square which is placed on the abdo- 
 men in the suprapubic region. 
 
 Another method is to apply a flexible metal electrode 
 4x6 inches square on the abdomen in the suprapubic 
 region and another 3x4 inches square over the lower part 
 of the spine. The treatment consists of using the elec- 
 tric current to the point of discomfort and a treatment 
 
164 GEKIATEICS 
 
 of five minutes is given. It may be well to continue 
 the treatments for several months, giving them every- 
 day or every other day for a month and then two or 
 three times a week for six months. Then repeat after a 
 rest of three months, continuing the last treatment for a 
 month. The amount of current used is registered on the 
 milliammeter of the Telatherm apparatus and at the next 
 treatment the same amount can easily be given. Dia- 
 thermia treatments apparently work well in most cases 
 and I feel confident that I have many patients today in 
 comfort who would have been obliged to have prosta- 
 tectomy performed if diathermia treatments had not 
 been used. 
 
 There is a period of warning in prostatic hypertrophy 
 that takes several years before the serious complications 
 develop. In this stage if the disease could be discovered, 
 diathermia treatments would work well and prevent the 
 disease from pursuing a chronic course. Usually the first 
 treatment will relieve them of the congested sensation 
 they experience. The heat from the Telatherm relieves 
 the congestion in the prostatic tissues and disperses the 
 edema through the stimulating action on the flow of the 
 blood stream. 
 
 With diathermia treatments practically no heat is ap- 
 plied to the outside, but penetrates the internal tissues. 
 The Telatherm produces about two million oscillations 
 a second and does not injure the deeper tissues. The ef- 
 fect of diathermia on the prostate is to supply new blood 
 and remove the old blood. In this way it resembles the 
 hyperemic treatment, but the end result is to relieve the 
 congestion and improve the tone of the muscles. 
 
 The results have been very encouraging in this treat- 
 ment, but if improvement does not take place in three 
 months, operation is necessary. Diathermia also tempo- 
 rarily improves the congestion accompanying adenocarci- 
 
Fig. 11. Telatherm apparatus. 
 
SENILE PEOSTATIC HYPEETKOPHY 165 
 
 noma of the prostate and improves inflammatory condi- 
 tions of the bladder. 
 
 If diathermia does not work well, I employ a vacnnm 
 electrode from a Campbell Model "E" coil and give a 
 mild current for five mimites every other day. It is not 
 advisable to allow these instruments to remain in the rec- 
 tum over five minutes because the heat may cause a piece 
 of mucous membrane to come off on the electrode. This 
 form of electric treatment has also been very successful. 
 
 Eecently good results have been obtained in carcinoma 
 of the prostate from the use of radium. Doctor Hugh 
 Young has been using it to advantage as has Doctor B. 
 S. Barringer and others. There are several methods of 
 application of the radium. Fifty to one hundred milli- 
 grams of radium element is usually sufficient and it 
 should be screened with two millimeters of metallic and 
 one millimeter of rubber screening. The cross-fire 
 method can be used to advantage and an exposure from 
 four to six hours repeated three or four days in succes- 
 sion is an excellent method. 
 
 Doctor Barringer* in treating carcinoma of the blad- 
 der has performed laparotomy, opened the bladder and 
 treated the cancerous surface for three hours. 
 
 Doctor Barringer also treated the prostatic condition 
 by means of a needle containing 50 or 100 millicuries of 
 radium. The needle is inserted into the perineum be- 
 tween the urethra and rectum and guided by the finger 
 in the rectum until the end of the needle has passed into 
 the middle lobe of the gland. 
 
 In some cases the results are encouraging and many 
 of our best surgeons are obtaining good results from 
 the use of radium. I believe in most cases of pros- 
 tatic hypertrophy that the so-called "catheter life ' ' and 
 
 * The Treatment by Radium of Carcinoma of the Prostate and Bladder. Preliminary 
 report. Journ. A. M. A., Vol. LXVII, No. 20, pp. 1442-45. Nov. 11, 1916. 
 
166 GEEIATKICS 
 
 prostatectomy are unnecessary. There comes a time 
 when operation may be a necessity, but I have never 
 seen a case yet that medical treatment or electric treat- 
 ment could not relieve to the degree of giving comfort. 
 
 Perhaps they do not feel perfectly well; the majority 
 of cases of prostatectomy suffer enough for months after 
 their operations. The surgeon does not see the patient 
 after his discharge from the hospital and he marks on 
 his index card "uneventful recovery." The family phy- 
 sician, however, is obliged to see the man work out of 
 his difficulty and it takes, in many instances, months to 
 recover from the operation. 
 
 One of our authorities said "the unsatisfactory re- 
 sults of medical treatment have removed prostatic hy- 
 pertrophy from the field of the physician to that of the 
 surgeon.' ' From my limited experience in about 200 
 cases with satisfactory results I believe that the above 
 statement is not correct. Medical treatment has its 
 place in prostatic hypertrophy and it is a worthy place. 
 
CHAPTER XXII 
 
 UROSEPSIS — EDEMA FROM PROSTATIC 
 RETENTION— ENURESIS— CYSTITIS 
 
 Case I. — An Indian, aged sixty, consulted me for a gen- 
 eral edematous condition of the body. For some time lie 
 had been unable to empty his bladder completely although 
 he micturated frequently. He suffered no pain, but had 
 a heavy feeling over the pubis. The edema was quite 
 marked; his heart was apparently normal as was his 
 blood-pressure; repeated examinations of the urine 
 failed to detect any abnormality either by chemical or 
 microscopic tests. 
 
 He was placed in a hospital where he could be cathe- 
 terized frequently and was given no medication at first. 
 "When the bladder was emptied by repeated catheteriz- 
 ing him, the edema rapidly disappeared as did his symp- 
 toms of urosepsis, that is, headaches, chills, vertigo and 
 malaise. However, if catheterization was neglected the 
 edema returned. He was later given chromium sulphate, 
 eight grains every three hours, catheterization was no 
 longer necessary and the improvement was lasting. 
 
 Case II. — A man, aged sixty, had retention due to pros- 
 tatic hypertrophy, which resulted in a dribbling of 
 urine. It was very disagreeable and caused an odor to 
 his clothing. Besides chromium sulphate medication he 
 was given high frequency treatments with a vacuum elec- 
 trode applied on the perineum for five minutes and five 
 minutes with a special prostatic electrode in the rectum. 
 The condition improved under this treatment. 
 
 Case III. — A woman, aged seventy, had enuresis which 
 was very troublesome to her. Whenever she coughed or 
 
 167 
 
168 GEEIATKICS 
 
 hit a pebble in walking the nrine would dribble. I pre- 
 scribed before meals a teaspoonful of the elixir iron, qui- 
 nine and strychnine phosphates, now unofficial in our 
 pharmacopeia. 
 
 Case IV. — A man, aged sixty-three, consulted me for a 
 very troublesome symptom. He did not have a frequent 
 desire to micturate, but when he did have the desire he 
 was obliged to go at once or he would lose control of it. 
 I prescribed 1/60 grain of strychnine sulphate before 
 meals and he improved. 
 
 Case V. — A woman, aged fifty-five, had a frequent de- 
 sire to micturate. There was no pain and no evidence 
 of cystitis. I gave her a mixture containing five drops 
 of tincture of nux vomica in each teaspoonful to be taken 
 before meals and the result was excellent. 
 
 Case VI. — A man, aged fifty-eight, consulted me for 
 severe headaches, vertigo, chills, numbness in his fingers 
 and malaise. He had prostatic hypertrophy, but I was 
 unable to find any other cause for his symptoms. I made 
 a diagnosis of urosepsis, or absorption from prostatic 
 retention, and prescribed an eliminative treatment con- 
 sisting of magnesium sulphate and potassium bitartrate 
 twice daily. The symptoms disappeared as the prostatic 
 condition improved. 
 
 These cases are very common in private practice and 
 the results of treatment are usually satisfactory. Many 
 of the symptoms of frequent urination and enuresis, 
 even prostatic retention, are improved by strychnine 
 sulphate which improves the tone of the vesical sphincter. 
 Some cases of prostatic retention are occasionally re- 
 lieved by the elixir of iron, quinine and strychnine phos- 
 phates. 
 
 Cystitis in the aged is usually due in the male to pro- 
 static retention and in the female is often due to pyelitis. 
 
DISEASES OF THE BLADDEB 169 
 
 I have used the following mixture to advantage in 
 cystitis : 
 
 B 
 
 Pancreatini 3ss 
 
 Potassii Carbonatis 3ij 
 
 Fluidextract Rhei 3ij 
 
 Fluidextract Hydrastis 3jss 
 
 Tinctura Cinnamomi 3ss 
 
 Syrupi qs ad %iv 
 
 Misce. 
 Sig.: Take one teaspoonful in one-half wineglass of water every three 
 hours. 
 
 Fluidextract of pareira brava, five minims every three 
 hours, and occasionally fluidextract pichi may work well. 
 Copaiba and santal oil capsules work well in some cases. 
 If the micturition is very frequent and troublesome, I use 
 tincture of cannabis indica, one or two minims in a tea- 
 spoonful of elixir containing five grains of sodium bro- 
 mide to be taken every three hours. 
 
 High frequency treatments will sometimes relieve trou- 
 blesome conditions which are noninflammatory, especially 
 when they involve the vesical sphincter. In these cases 
 either diathermia treatments with one electrode on the 
 pubis and the other on the spine, or a surface electrode 
 applied to the perineum will help. 
 
 I do not use the remedies ordinarily used for bladder 
 conditions and never prescribe urotropin or ever found 
 that medical treatment had failed to the extent to require 
 bladder irrigations. 
 
 I remember once treating a severe infection of the pel- 
 vis of the kidney and bladder and when every other rem- 
 edy had failed I used 1/20 grain tablet of calcium sul- 
 phide every hour to the point of saturation. The effect 
 was excellent and in the course of a few days the condi- 
 tion had greatly improved. 
 
 On two occasions I have been deceived in cases I be- 
 lieved typical of pyelitis and cystitis. They were second- 
 ary to cancer of the colon and treatment was of no benefit. 
 
CHAPTER XXIII 
 THERAPEUTICS 
 
 It is a very difficult matter to teach physicians that the 
 aged require different medication than that employed in 
 treating younger persons. "In maturity nature tends to 
 cure while in senility nature will kill. ' ' In other words 
 while there are many conditions in maturity that nature 
 will cure, in the aged we must be on our guard or the 
 patient will die before we have an opportunity to give 
 much medication. 
 
 A man, s aged sixty-two, was taken suddenly ill with a 
 pain about the heart. He had never been ill before and 
 it was apparent that the condition was due to the heart. 
 A mistake in calling the condition gastritis probably cost 
 the old man his life for in one hour he was dead. Had he 
 received a hypodermic injection of nitroglycerin the prob- 
 abilities are he would be living today. 
 
 A woman, aged seventy, was taken ill with symptoms 
 of acute gastritis. The pain was severe and her physician 
 gave her a hypodermic injection of morphine. In fifteen 
 minutes she was dead. Undoubtedly the effect of mor- 
 phine on the respiratory center caused her death. 
 
 These two cases illustrate the danger in dealing with 
 old persons. From some condition apparently simple 
 they will die before you return to the office and it will 
 humiliate you because perhaps you have given a favor- 
 able prognosis. 
 
 The diseases of senility require as much special atten- 
 tion as that given to children. In senility we must not 
 only employ different remedies but must use them in 
 dosages different from that used in maturity. 
 
 170 
 
THERAPEUTICS 
 
 171 
 
 Again, it is not the primary effects of the drugs we 
 must observe, but the elimination through the emunctories 
 is so deficient that we get an accumulation of the drugs in 
 the system causing secondary effects which are fully as 
 important as the primary. 
 
 For example, in employing heroin for pain, two or three 
 days after administering it, we get a drowsiness and other 
 symptoms due to the heroin. With alcohol it is the same. 
 We use it and the old person's tongue remains moist and 
 as long as this moist condition is present we are safe in 
 using it. After a few days in administering alcohol we 
 may notice the tongue has become dry and the mouth is 
 parched. This is undoubtedly due to the cumulative ef- 
 fect of the alcohol and if we do not discontinue its use 
 harmful results will follow. 
 
 Alcohol is an excellent remedy in the aged and makes 
 an excellent food for them. Most aged people feel that 
 they must have their whiskey and it is not well to counter- 
 mand it. Allow them the amount they are in the habit of 
 taking daily because to stop it, no matter the illness, may 
 lead to disastrous results. Alcohol forms one of our best 
 weapons in treating the aged, especially where there is 
 much debility. I usually administer it to its full physio- 
 logic action, that is, until the cheeks become red and 
 the mouth becomes parched. In pneumonia or even in 
 some forms of chronic nephritis where there is extreme 
 weakness, it is of value. 
 
 Many aged people take a certain amount of alcohol 
 daily and if they become ill the family believes it should 
 not be continued. A safe rule with the aged is not to in- 
 terfere with any habits they have formed no matter how 
 undesirable they may be. Habits that have been their cus- 
 tom for years should not be tampered with. 
 
 A great many indications can be found by observing 
 the condition of the tongue. If the tongue is red and the 
 
172 GEEIATKICS 
 
 papillae prominent, it is an indication for mix vomica and 
 hydrochloric acid and if the papillae are very prominent, 
 arsenic in some form is indicated. Give two minims of 
 Fowler's solution or a tablet containing 1/200 grain of 
 arsenic trioxide, before each meal. 
 
 A red tongue indicates gastric irritability and hyper- 
 acidity. It is a peculiar therapeutic fact that hydrochloric 
 acid will relieve this hyperacidity. Why acids check acids 
 is difficult to explain, but probably when the glands of the 
 stomach are overworking and causing an increase in acid, 
 the ingestion of acid in the form of medication will sup- 
 ply the stomach with the normal amount and make 
 glandular hypersecretion unnecessary. Do not give hy- 
 drochloric acid after meals, however, or it will cause hy- 
 persecretion. 
 
 The opposite rule works out. If the tongue is coated, 
 it indicates an alkaline condition of the stomach and an 
 alkali is required. If there is a white fur on the tongue, 
 give one drachm of milk of magnesia every hour for three 
 hours, then stop three hours, after which a similar dose 
 is given for three hours. If there is a very thick coating 
 on the tongue, it is well to give either mercury in the form 
 of calomel or podophyllin given in tablets containing 1/40 
 grain every three hours. Two teaspoonfuls of the com- 
 pound solution of sodium phosphate may be given in place 
 of the milk of magnesia. If the stools are dark, podophyl- 
 lin is indicated, while if light or putty-like in consistency, 
 calomel is necessary. 
 
 Tic Douloureux 
 
 This painful condition will often yield to the use of the 
 elixir of iron, quinine and strychnine phosphates, one tea- 
 spoonful given every three hours. Sometimes pyramidon 
 in five-grain doses or butylchloral hydrate may relieve it. 
 I have obtained excellent results in this condition by the 
 use of a diathermia treatment given by a Telatherm ma- 
 
THEKAPEUTICS 173 
 
 chine. One electrode is applied over the painful area and 
 the other on the opposite side. A treatment is given three 
 times a week for one-half hour each time. 
 
 Senile Debility 
 
 This term is commonly used when we do not know what 
 the matter is. Senile debility is usually termed ' ' old age ' ' 
 and physicians are apt to say that the disease is due to 
 "old age" and that nothing can be done for it. 
 
 Senile debility is usually due to some form of toxemia 
 such as intestinal or renal. As long as this toxemia exists 
 it is useless to give any tonic, but when the toxines are 
 eliminated we can then employ tonics with great benefit. 
 
 The elixir of iron, quinine and strychnine phosphates 
 given before meals is an excellent remedy. Again, we can 
 use the elixir calisaya or tincture gentian with 1/60 grain 
 tablets of strychnine sulphate every three hours or three 
 times a day. Continued use of strychnine, however, is 
 apt to hasten cardiac degeneration. The latter is a 
 normal condition in the aged arid if we stimulate with 
 strychnine we are simply hastening degeneration of the 
 heart muscles. 
 
 Doctor I. L. Nascher conceived the idea that amorphous 
 phosphorus in gelatin coated tablets would answer indi- 
 cations for treating senile debility, and I have seen ex- 
 cellent results in its use. One or two grains of the amor- 
 phous phosphorus is prescribed three or four times a 
 day. 
 
 Amorphous phosphorus may be combined with arsenic, 
 and strychnine. Arsenic iodide also can be used in 1/30 
 grain doses. Arsenic works well in the aged and if there 
 is any specific condition of the blood, the addition of the 
 iodide may help. 
 
 I have used for some time diathermia treatments in 
 senile debility. It is given by means of an autocondensa- 
 
174 GEEIATKICS 
 
 tion chair and through the two poles of the Telatherm 
 machine from 400 to 750 milliamperes are given for one- 
 half hour. This seems to revive them and the stimula- 
 tion is of great benefit to them. 
 
 Use of Opiates 
 
 Morphine is a rather dangerous remedy for the aged 
 and cases of sudden death have been reported from res- 
 piratory failure following a hypodermic injection. If mor- 
 phine is necessary, it should be combined with atropine 
 sulphate, 1/50 grain. Atropine combined with morphine 
 prevents fatal action on the respiratory center. 
 
 In the aged we often obtain results diametrically op- 
 posite to the effect seen in younger individuals. For 
 example, sometimes morphine will make the patient 
 maniacal and he remains wide awake. Again, the sec- 
 ondary effect may come several hours after the primary 
 effect and is more pronounced than when first adminis- 
 tered. 
 
 I use very little morphine for the aged. They are apt 
 to beg for it especially by saying that they do not sleep 
 at night. However, the cause is that they fall asleep in 
 their chair during the day and when night comes they 
 can not sleep. 
 
 There are very few conditions in the aged that can 
 not be taken care of by heroin or codeine. Codeine 
 works well with the aged and I have senile patients who 
 have taken 1/4 grain of codeine every night for years. 
 It seems to be a necessity for some of these patients and 
 relieves them of pains that prevent them from sleeping. 
 
 For pain in the aged, whether due to gastrointestinal 
 disorders or accidents such as fractures and contusions, 
 codeine will usually relieve them satisfactorily and there 
 is very little danger of forming a habit or requiring a 
 great increase in dosage. Codeine will not produce the 
 
THEEAPEUTICS 
 
 175 
 
 disagreeable effect accompanying the nse of the stronger 
 opiates and usually does not give them the unpleasant 
 dreams experienced with morphine. 
 
 Heroin or diacetylmorphine will usually relieve pain 
 if it is not too severe. It can be used hypodermically in 
 doses of 1/24 grain and can be repeated frequently until 
 the desired effects are obtained. 
 
 Heroin does not lock up the secretions and excretions 
 as morphine does and it can be employed indefinitely for 
 several years. I have a patient who has a cancer who 
 has taken % grain of heroin every night for the past 
 three years. One fact which should be remembered is 
 that opiates taken for the relief of pain rarely cause a 
 habit and it is only when they are employed for sleep- 
 lessness and the like that they are dangerous. 
 
 In peritonitis and other painful conditions I have used 
 opiates in huge doses yet the moment the disease abates 
 the patient does not ask for, nor require, any further 
 administration of the narcotic. 
 
 The Use of Coal Tar Derivatives 
 
 It is very dangerous to employ these derivatives in the 
 aged as they are apt to cause great depression to the 
 respiratory center and may cause cyanosis. They are 
 seldom required and when it is absolutely necessary 
 pyramidon is the safest form to use. Pyramidon does 
 not contain the dangerous HON radical that is found in 
 acetanilide, acetphenetidin and antipyrin. In pneu- 
 monia and other conditions where an antipyretic is re- 
 quired quinine will usually answer the indications. 
 
 Quinine is a very valuable remedy in the aged and if 
 the kidneys are in good condition and there is no albu- 
 minuria or hematuria, it may be used with safety. In 
 facial neuralgia and headaches, neuritis, in pneumonia 
 and especially senile debility, quinine is indicated. In 
 senile debility quinine sulphate given in doses of one 
 
176 GEEIATEICS 
 
 grain every three or four hours is one of our best reme- 
 dies. Quinine works well in most senile conditions and 
 is an excellent stimulant. In extreme debility there is 
 no better combination than quinine and strychnine. 
 
 Alteratives used in senile cases are usually undesir- 
 able because of the bad effect they have on the stomach. 
 The iodides especially are harsh on the stomach. There 
 are very few conditions, however, that require the use of 
 the iodides. Even in syphilis arsenic usually works 
 better in the aged than the iodides. 
 
 Arteriosclerosis is the normal process of advancing 
 years and does not usually require the iodides except in 
 those cases due to syphilis. 
 
 For constipation special remedies are required because 
 the weakened condition of the intestinal muscles causes 
 lack of peristalsis and remedies usually employed in ma- 
 turity do not work satisfactorily in the aged. Aloin is 
 an excellent peristaltic stimulant as is also cascara and 
 the bile salts. An increase in dosage becomes necessary 
 in time. 
 
 The secondary effects of drugs are important consid- 
 erations in the aged. Belladonna when used with cathar- 
 tics gives a secondary effect which is noticeable several 
 days after the drug is taken. The secondary effects of 
 digitalis, strychnine and arsenic should be watched. We 
 may get a secondary effect of aloes or aloin on the pelvic 
 vessels. The secondary effects of iron on the intestines 
 and the role played by calcium hastening senile sclerotic 
 changes are extremely important. 
 
 In senile cases the rule for dosage is to decrease de- 
 pressants and increase stimulants. We must always 
 stimulate the aged when they are ill because nature tends 
 to bring death to their door. 
 
 It is surprising how small the dosage can be in the 
 aged. Strychnine in 1/120 grain doses sometimes acts 
 better than larger doses. Occasionally the smallest doses 
 
 ■^H 
 
THEEAPEUTICS • 177 
 
 of calomel will cause diarrhea and salivation. Digitalis 
 has been a very unsatisfactory remedy in some senile 
 cases in my experience and it is only in well selected cases 
 that it will help. Small doses of the fat-free tincture, 
 say three or four minims for a dose are usually suffi- 
 cient, but the secondary effects should be watched. The 
 old rule "children and the aged can not stand large dos- 
 age' ' is in a measure true. 
 
 Support the aged heart in illness with small doses of 
 strychnine sulphate and increase the dose if necessary. 
 If the pulse is irregular, give 1/40 grain of sparteine 
 sulphate every three hours. If there is cardiac distress, 
 if the pulse is bounding and the temporal arteries are 
 tortuous and pounding, give 1/100 grain of nitroglycerin 
 hypodermically or a small dose of erythrol tetranitrite. 
 A good combination in bronchial asthma or any extreme 
 cardiac distress is a hypodermic tablet containing mor- 
 phine sulphate grain 1/6, strychnine nitrate grain 1/60, 
 and nitroglycerin grain 1/100. This can be used with 
 comparative safety. If there is- much general edema 
 with an irregular heart action, give a dessertspoonful of 
 Trousseau's diuretic wine every three hours. This con- 
 tains digitalis in such a combination that it does not give 
 the untoward effects when given alone. 
 
 Watch the heart and not the pulse. Sometimes the 
 pulse will be very good and regular and the patient will 
 die in ten minutes. Owing to the sclerosed condition of 
 the radial arteries, it is unsafe in most cases to depend 
 upon the pulse rate or quality. Follow the heart beat 
 with a stethoscope and count the respiration. In the aged 
 it is almost a crime not to count the respiration, for 
 many times it is the only way of detecting pneumonia 
 and frequently the respiration will become of poor qual- 
 ity before the heart fails in its work and we are able to 
 get a warning in this way. 
 
CHAPTER XXIV 
 
 THE CHECKING OF HEMORRHAGE, SECRE- 
 TIONS AND EXCRETIONS IN THE AGED 
 
 Case I. — A woman, aged sixty-five, had eczema which 
 manifested itself on the arm, legs and chest. There was an 
 exudate on the surface of the skin but under treatment 
 the condition improved and at times the eruption would 
 entirely disappear. When the oozing was checked or 
 when the eruption entirely disappeared she always had 
 a severe attack of asthma. 
 
 She would find relief from this in a few hours, but 
 complained of headaches, dizziness and a sense of pres- 
 sure in the check which would remain several days. 
 Suddenly the eruption would reappear and she would 
 immediately find relief from her suffering. 
 
 Case II. — A woman, aged seventy, complained of dart- 
 ing pains in the arms and legs, a severe backache and 
 headache. She had edema of both legs and a general 
 feeling of malaise and would remain in this condition 
 for several days until an ulcer appeared on the leg which 
 seemed to give her relief within a day or two. These 
 ulcers were very painful and were always accompanied 
 by an intense redness in the surrounding tissues. In the 
 center of the ulcer there formed a black area which 
 would take several days to separate from the sore. 
 
 Every kind of treatment seemed to make the condition 
 worse, ointments were like poison and dusting powders 
 would cause the sore to heal too rapidly as evidenced by 
 various symptoms. The only treatment that seemed to 
 agree with the patient was a wet dressing with a small 
 
 178 
 
HEMOKKHAGE, SECKETIONS, AND EXCKETIONS 179 
 
 amount of the alkaline antiseptic solution in a few ounces 
 of water. In this way the sore would not heal too rap- 
 idly and it would take three or four months for it to 
 heal. During this time she would feel much better and 
 when the ulcer had apparently run a certain course it 
 would heal without causing any untoward symptoms. 
 
 For several months she would be free from the ulcers 
 and uncomfortable feelings, but in time similar symp- 
 toms would reappear to be relieved only by the eruption 
 of a sore, sometimes on the finger, once on the face and 
 sometimes on the legs. These ulcers were of the trophic 
 type and not due to syphilis or tuberculosis. I have seen 
 this patient very ill for several days and on one occasion 
 felt that death would soon come unless nature caused 
 one of the sores to appear. Before the illness would 
 come to a fatal point an ulcer would appear which would 
 give her relief in a short time. 
 
 I have seen several cases similar to this, but due to 
 tuberculosis and not to the simple trophic type as de- 
 scribed in this case. Tuberculous sores are very com- 
 mon in the aged and if healed too rapidly will produce 
 bad results. A tuberculous bone disease which dis- 
 charges through a sinus may be compatible with good 
 health as long as it is not disturbed and not healed. 
 Ulcers of any kind should be treated in the same man- 
 ner and not allowed to heal too quickly. There is a dis- 
 charge from all of these ulcers which seems to eliminate 
 a toxine of some kind and as soon as it is healed untoward 
 symptoms are noticed. 
 
 A discharge from the ears or a chronic rhinitis in the 
 aged should not be checked, in fact, a safe rule in senile 
 cases is not to check any secretion or excretion. Epis- 
 taxis should be treated with ice on the neck and not by 
 any method that will suddenly stop the hemorrhage. 
 
 Excessive perspiration in the aged is very disagree- 
 able, but is not common because the skin of the 
 
180 GEKIATKICS 
 
 aged is atrophic and very dry as a result. How- 
 ever, we meet cases of excessive perspiration, either 
 general or localized, and in the night the perspiration, 
 together with the getting ont of bed because of nocturnal 
 micturition, cause a very uncomfortable coldness. This 
 excessive perspiration is often a symptom of nephritis 
 and rids the system of urea. If the condition is checked 
 the kidneys do not respond to their increase in work and 
 there is a congestion of the respiratory and other inter- 
 nal organs as a result. It is often a very serious matter 
 to check this excretion and no matter how disagreeable 
 the condition it should not be disturbed. 
 
 Any form of skin disease in the aged which has a dis- 
 charge should not be treated with the view of healing 
 quickly. s I have seen many cases of senile cancer espe- 
 cially of the breast which would not apparently interfere 
 with an old person's general health for several years as 
 long as the discharge, no matter how offensive, was not 
 checked. As long as there is free drainage and no treat- 
 ment instituted which was too healing, nature seemed 
 contented to allow the patient to live comfortably. On 
 the other hand, an ambitious surgeon, one who believes 
 that the cure of any abnormality consists in its removal 
 from sight, would remove the cancer and as a result the 
 patient would rapidly fail and die within a short time. 
 Radical interference in these cases should be very care- 
 fully considered before being resorted to. 
 
 Checking a diarrhea in senile cases is also a danger- 
 ous procedure because, like excessive perspiration, it is 
 frequently a symptom of nephritis or may be due to any 
 form of toxemia, it being nature's effort to rid the sys- 
 tem of certain poisons. It can be readily seen that a 
 checking of this diarrhea would produce bad results and 
 sometimes lead promptly to a fatal issue. If it becomes 
 necessary to check the discharge," for example, in cases 
 where there is extreme prostration as a result, give a 
 
HEMORRHAGE, SECRETIONS, AND EXCRETIONS 181 
 
 remedy to check the bowels, administered only after 
 every second or third movement. In this way the excre- 
 tion will not be checked too rapidly and there will be but 
 little danger associated with it. Sometimes the diarrhea 
 will be a symptom of cancer of the bowel, and it should 
 not be checked. I recollect seeing an old man who had 
 a chronic diarrhea for several years and a physician 
 checked the diarrhea and the old man died in three days. 
 
 Excessive excretion of any kind in the aged is very 
 uncomfortable and many old persons consult you to ask 
 you to check it for them. In the aged these excessive 
 excretions and secretions are usually caused by a com- 
 pensation to some other function. For example, a dis- 
 eased kidney which is unable to carry on its work may 
 depend upon the skin or bowels to carry on a part of its 
 function of elimination. As a result nature changes the 
 channels of elimination and in time this change in func- 
 tion is in fixed paths, in other words, a perverted func- 
 tion in time assumes an action normal to itself. To in- 
 terfere with this would cause extra work to be placed 
 upon the diseased organs which are not able to carry on 
 any additional work. Frequently, hyperexcretion from 
 the kidneys is a symptom of parenchymatous nephritis. 
 
 Bronchitis and other diseases of the respiratory tract 
 often jDroduce excessive bronchial secretions in the aged, 
 but as long as the secretion is not checked there is no 
 discomfort. By checking the secretion an attack of 
 asthma may result. 
 
 Fistula-in-ano in the aged is often of a tuberculous 
 nature and the discharge may be serous, purulent and of 
 a fetid character. I have seen several of these cases 
 which have been operated upon by surgeons and the re- 
 sult of healing and checking the discharge has produced 
 a general feeling of discomfort and loss of weight. One 
 case I remember a man lost twenty-five pounds as a re- 
 
182 GERIATRICS 
 
 suit of a cure of the fistula and lie has never seen a well 
 day since. We must not forget that it is not always the 
 object in the aged to heal or correct an abnormality. 
 Frequently, as with fistula, nature seems to use the dis- 
 ease to rid the system of some toxine and as long as it 
 is not disturbed they remain in good condition. 
 
 We are frequently confronted with a hemorrhage in 
 the aged which we think should be checked. It may be 
 epistaxis, acute or chronic hemorrhage from the bowel, 
 hematuria or metrorrhagia. In any event unless it ap- 
 pears that the hemorrhage may cause death it is far safer 
 not to check it immediately. A chronic hemorrhage from 
 the bowel may be due to cancer or diverticulitis, but in 
 many cases it does not seem to interfere with the well- 
 being of the patient. However, to check it will cause un- 
 toward symptoms. Likewise, hematuria should not be 
 treated with the intention of rapid cure and in many 
 cases I did not treat it at all and the patient lived a long 
 time without any discomfort. 
 
 A woman, aged sixty-five, sent for me because she had 
 a hemorrhage from the vagina. Several years ago she 
 had a cancer of the cervix removed and had observed no 
 trouble since. Suddenly, without any warning, she had 
 a hemorrhage which later proved to be due to a return 
 of the cancer. In this instance I did not check the hem- 
 orrhage and in a short time with rest in bed it stopped 
 and to the time of her death there was no recurrence of 
 the bleeding. 
 
 It seems to me that we may safely make the rule that 
 all secretions and excretions in the aged should not be 
 checked unless an extreme emergency requires the 
 checking of a hemorrhage. 
 
CHAPTER XXV 
 DIAGNOSTIC ERRORS IN THE AGED 
 
 A man, aged ninety, complained that he was unable to 
 sleep at night. His daughter showed me a tube of hy- 
 podermic tablets containing % grain of morphine sul- 
 phate which his family physician had given to him upon 
 his request for a soporific. Upon questioning the 
 daughter I found that the old man slept in his chair sev- 
 eral times a day and when night came he naturally could 
 not sleep. When his daughter told him the real cause of 
 his insomnia he became angry. 
 
 The aged usually deny having slept. An aged lady 
 sent for me to come at night to give her a hypodermic 
 for her pain. When I arrived she was sleeping and on 
 awakening she asked for the hypodermic injection. 
 When I went into another room to arrange my hypoder- 
 mic outfit she fell asleep and I left her this way without 
 administering a hypodermic. 
 
 The aged do not realize the amount of sleep they get 
 and they all make the same complaint; that is, that they 
 can not sleep. A placebo will make them sleep as well as 
 morphine, in fact better, for morphine usually makes 
 them more awake. 
 
 The aged are apt to falsify symptoms in order to ex- 
 cite sympathy and they may have every symptom every- 
 one else has. An old lady told me that she had taken six 
 % grain tablets of codeine sulphate at night without any 
 relief from her pain in the leg. As a matter of fact she 
 had not taken any tablets and probably had no pain, but 
 as a physician was coming to the house to see another 
 
 183 
 
184 GEKIATEICS 
 
 patient she felt it no more than fair that she also have 
 attention. 
 
 We mnst be on our guard, however, and not attribute 
 too many symptoms to malingering for I once had an 
 old man whom we believed was malingering, but when 
 he suddenly died from uremic convulsions we saw our 
 grave mistake. 
 
 Pain in the aged is not a safe symptom to measure. 
 Sometimes owing to decreased nerve sensibility we may 
 find appendicitis, peritonitis or strangulated hernia 
 without any pain. Pain is a very uncertain symptom. 
 Many cancers of the gastrointestinal tract are painless, 
 but on the other hand a senile basal-cell carcinoma of 
 the skin which has been painless for a long period of 
 time as age advances becomes more painful. We may 
 have pneumonia without pain in the chest and many 
 fractures are painless and a mistake could easily be 
 made in diagnosis. 
 
 A diagnosis of arteriosclerosis or calcareous degen- 
 eration of the arteries has little significance in the aged. 
 These are normal senile changes and many symptoms 
 ascribed to this condition, are due to other causes. 
 
 It is very unsafe to depend upon the pulse rate or the 
 quality of the pulse because of the sclerosed condition of 
 the radial arteries. Many old persons will have an ex- 
 cellent pulse yet they may be dying. Always count the 
 pulse rate from the heart with a stethoscope. 
 
 Counting respiration is a necessity and without it 
 many cases of senile pneumonia will escape notice be- 
 cause the disease does not give many manifestations. 
 
 Many cases of so-called senile pneumonia are in reality 
 congestion of the lungs. The best way to diagnose pneu- 
 monia is to know that the person is too sick to have 
 senile congestion of the lungs. 
 
DIAGNOSTIC EEEOBS IN THE AGED 185 
 
 Many cases of uremia and autotoxemia are called 
 typhoid fever. In the aged the latter disease is very 
 rare. I have heard physicians make a diagnosis of 
 typhoid fever in the aged, but believe if the true cause 
 was ascertained a toxemia would be found the cause. 
 Uremia oftentimes causes a fever and every other symp- 
 tom of typhoid and if the patient has the strength to 
 withstand the severity of the attack, it will run a course 
 similar to typhoid and take about three weeks to abate. 
 From the appearance of the tongue to the low mutter- 
 ing delirium and cold, clammy perspiration, the disease 
 has the appearance of typhoid fever. Many times it is 
 associated with an acute inflammation of the kidneys 
 and if casts and blood are present in the urinary sedi- 
 ment, death is almost certain. 
 
 Again, intestinal toxemia may produce the same symp- 
 toms and present the classical picture of typhoid. I 
 recollect a man who had frequent attacks of a fever of 
 this kind and the temperature remained about 103° F. for 
 several days, then abated. If the- true cause of the affec- 
 tion had not been discovered and treatment had been 
 given for typhoid fever, the patient would probably have 
 succumbed. Pyelitis also may cause similar symptoms 
 and easily be mistaken for typhoid fever. Chills are not 
 common in cases of senile pyelitis, but a high fever with 
 prostration is very common. Some cases of pyelitis and 
 pyelonephrosis are in reality due to cancer of the colon. 
 I remember a man who had a typical clinical presenta- 
 tion of pyelitis and was treated accordingly. He did not 
 respond to treatment and on further examination it was 
 discovered that he had a cancer of the colon. One night 
 he was taken suddenly ill with very severe pain in the 
 right side and died in two hours. I knew a woman who 
 had been suffering from nephritis and pyelitis. In time 
 she developed symptoms of gall stones, was operated 
 
186 GEEIATEICS 
 
 upon and a cancer of the liver was found. In this case 
 the nephritis was secondary to the cancer of the liver. 
 
 Senile glycosuria may be due to senile degenerative 
 changes and not due to diabetes. The aged do not 
 usually develop acidosis except in coma from some 
 other disease. For example, uremic coma may have a 
 tendency to form acidosis. Much care must be given to 
 the diagnosis of diabetes in the aged because injudicious 
 treatment may cause fatal results. It has been said that 
 ether, chloroform or nitrous oxid may cause an acidosis 
 and this should be borne in mind in anesthetizing pa- 
 tients. It is a great mistake to call senile glycosuria due 
 to a normal process of degeneration, a true diabetes. 
 
 In examining senile patients they are apt to tell you 
 they have not experienced certain symptoms because 
 they believe it will prevent a painful and disagreeable 
 examination. In taking the history they will deceive 
 you, perhaps, unintentionally, because they forget, do 
 not observe, and therefore will tell you something that 
 is not correct. 
 
 History-taking in the aged is very uncertain. For ex- 
 ample, I asked an aged woman in a hospital how fre- 
 quently her bowels moved. She was much disturbed by 
 this remark, because she said that everyone's bowels 
 should move every day. A case like this is typical of a 
 woman who does not have a bowel evacuation oftener 
 than once a week. They will ask to take their own laxa- 
 tive pills in order to prevent you from prescribing a laxa- 
 tive. Sometimes from fear of pain from hemorrhoids 
 they will falsify about their bowel movements and say 
 that they have been very regular in this respect. 
 
 I have found tumors in the abdomen of aged patients 
 when making a routine examination and as they experi- 
 enced no symptoms I did not tell them of this condition. 
 On several occasions I have followed these cases for 
 
DIAGNOSTIC ERRORS IN THE AGED 187 
 
 several years and found that the tumors did not produce 
 symptoms. It would be a grave mistake to worry them 
 with this when it is not necessary. I now have a pa- 
 tient, a woman, aged seventy, who has had a cancer of 
 the breast for the past three years. It does not enlarge 
 nor does it cause her any symptoms, not even loss of 
 weight. She does not know that it is a cancer and she is 
 contented. 
 
 Another woman, aged eighty, had a carcinoma of the 
 breast for several years, but it did not cause her any 
 trouble. Nature had protected her well and she was in 
 comparative comfort. An ambitious surgeon operated 
 upon her and she died a few days after the operation. 
 I believe she would be living today but for the mistake 
 in judgment on the part of the physician. Surgeons 
 make a great mistake in believing because an abnormal- 
 ity exists it must be removed. Many old persons have 
 some apparently serious affliction such as cancer, but 
 there is a compensation on the part of Nature that keeps 
 them comfortable, provided no one tampers with them. 
 
 In my experience the most common cause of mistake 
 in diagnosis in the aged is in cases of interstitial ne- 
 phritis. The latter condition is very difficult to diagnose 
 at times and is capable of deceiving us to the extent that 
 we may get symptoms in another organ as the only 
 symptom of the kidney disease. 
 
 For example, we may have indigestion, gastrointesti- 
 nal pain, neuritis, neurasthenia or psychasthenia due to 
 nephritis. I am convinced that the symptoms in half the 
 cases commonly called senile pneumonia are in reality due 
 to an acute exacerbation of a chronic nephritis. Lung 
 symptoms and heart manifestations are commonly due 
 to nephritis. We depend too much upon chemical uri- 
 nalysis when we should depend upon the microscope for 
 the diagnosis of kidney disease. 
 
188 GERIATKICS 
 
 Tuberculosis in the aged is not infrequent but does 
 not usually cause symptoms and is discovered, usually, 
 only at postmortem examination. Nephritis with lung 
 symptoms frequently simulates pulmonary tuberculosis. 
 Senile debility from any cause frequently looks like 
 phthisis and senile bronchitis may have every appear- 
 ance of a miliary form of tuberculosis. The latter dis- 
 ease often complicates diabetes in the aged, but does not 
 usually cause symptoms. Tuberculous ulcers may appear 
 especially on the skin over the ends of long bones. 
 
 Deafness in many senile patients is not due to the ears 
 primarily, but due to the diseased condition of the kid- 
 neys. I am firmly convinced that nephritis plays an im- 
 portant role in deafness and a temporary deafness last- 
 ing an .hour or two is one of the first symptoms of 
 nephritis. 
 
 Hepatic colic is not common in the aged although gall- 
 stones may be present. The decreased sensibility of the 
 nerves in the aged makes it possible to have the passage 
 of a gall stone through the ducts without pain. Renal 
 colic, on the other hand, is quite frequent in the aged 
 and is usually attended with great pain requiring opiates 
 for relief. Renal colic may be mistaken for the gastro- 
 intestinal pain due to nephritis or may seem like a crisis 
 of locomotor ataxia. Pains which have been described 
 as due to arterial spasm may effect the kidneys and sim- 
 ulate renal colic. An attack of renal colic may not be 
 followed by another attack for several years. 
 
 Hematuria is common, but does not always signify 
 nephritis. It may be of unknown cause and be compati- 
 ble with good health in many cases. Hematuria is very 
 frequent in the aged and frequently is due to prostatic 
 congestion. It is not usually of serious omen and even 
 if it does not improve it is usually of little detriment to 
 the health of the patient. 
 
DIAGNOSTIC ERRORS IN THE AGED 189 
 
 Skin diseases in the aged are usually due to lack of 
 nutrition due to the narrowed lumen of the arteries in 
 their sclerosed condition. Senile pruritus may be para- 
 sitic in origin. Eczema may be due to diabetes or ne- 
 phritis and psoriasis is frequently associated with 
 asthma in the aged. I have seen a few cases where in- 
 terfering with the skin condition brought on an attack of 
 asthma. 
 
 Rheumatism is commonly due to nephritis. I think 
 the vast majority of cases of senile rheumatism can be 
 traced to renal toxemia and sometimes it is the only 
 symptom of nephritis. I have been impressed in many 
 cases commonly attributed to senile rheumatism and 
 gout to find that by urinalysis there was an underlying 
 disease of the kidneys causing a chronic uremia. An 
 eliminative treatment and proper diet may cause a great 
 improvement in the condition. Dr. S. Solis-Cohen 
 was very fond of asking his students the following co- 
 nundrum, "When is rheumatism not rheumatism 1 ' ' The 
 answer was, "Nine times out of' ten." This applies to 
 senile rheumatism. Many of these aged persons have 
 been given the salicylates in some form which pro- 
 duced bad effects on the kidneys and stomach. As the 
 eliminative treatment was indicated and not the salicy- 
 lates, the mistake in diagnosis was serious. This does 
 not apply to cases of rheumatoid arthritis, but to the 
 forms most commonly seen in patients who have a so- 
 called rheumatic or gouty diathesis. Diabetes is also a 
 frequent cause of rheumatism. In fact, the disease fre- 
 quently manifests itself by sciatica and so-called mus- 
 cular rheumatism. Again, syphilis is frequently a cause 
 of rheumatism and in these cases a diagnosis is very im- 
 portant in order to institute proper treatment. 
 
 The pancreas in the aged may cause disease, but un- 
 fortunately very little is known today of pancreatic dis- 
 ease. I have observed in several cases of senile disease, 
 
190 GEBIATKICS 
 
 such as diabetes, senile gangrene, etc., that there were 
 definite symptoms pointing to the pancreas. The most 
 frequent symptom is the presence of fat in the stools. 
 
 Carcinoma of the gastrointestinal tract is easily over- 
 looked as it frequently causes no symptoms. Again, we 
 may have every symptom of carcinoma yet a roentgen 
 diagnosis would be diverticulitis. Frequently the latter 
 condition will cause blood to appear in the stools. Can- 
 cer of the stomach is frequent while gastric ulcer is rare 
 in the aged. The scirrhus type of carcinoma in the aged 
 is very difficult to diagnose at times. 
 
 Tic douloureux may be due to an unerupted molar 
 tooth. I recollect finding this condition in a man aged 
 fifty-six and a dentist told me he discovered it in a man 
 aged seventy-five. Neuralgia is frequently due to 
 anemia and also toxemia and neuritis is a frequent symp- 
 tom of renal or intestinal toxemia. 
 
 Vague symptoms of neurasthenia or psychasthenia 
 may be due to lack of sexual comforts. I have a patient, 
 a man, aged seventy, who was gradually failing and I 
 could not discover the cause. He finally confessed that 
 he required a sexual companion. He also complained of 
 a large, painful testicle which he said was always re- 
 lieved by sexual intercourse. 
 
 The most frequent mistakes in diagnosis we make, 
 however, are due to an ignorance of the normal senile 
 state. Trousseau said, to know the natural course of dis- 
 ease is to know half of medicine. "We commonly say that 
 a senile condition is due to arteriosclerosis and calcare- 
 ous degeneration of the arteries. Sclerosis is a normal 
 senile degenerative process and we must not overlook 
 the fact that a person normally has arteriosclerosis in 
 senility and that degenerated organs may work in har- 
 mony. As long as the harmony is not broken these de- 
 generated organs functionate in a way which is normal 
 to themselves. 
 
DIAGNOSTIC EEKOES IN THE AGED 191 
 
 To call the normal senile degenerative changes a dis- 
 ease is a mistake and is apt to lead to many disastrous 
 results in therapeutics. For example, iodides for senile 
 arteriosclerosis would not only produce severe gastro- 
 intestinal symptoms, but may produce a severe irrita- 
 tion of the kidneys. 
 
CHAPTER XXVI 
 SENILE MALINGERING 
 
 A difficulty frequently encountered when dealing with 
 senile cases is the determination of the pathologic condi- 
 tion which gives rise to the symptoms present. In many 
 cases the subjective symptoms, the objective symptoms 
 and the physical signs do not harmonize, or the physician, 
 not familiar with the normal senile changes, finds a senile 
 emphysema, dilated stomach, visceroptosis, or hypertro- 
 phied prostate and ascribes to one of these the symptoms 
 present. More often the subjective symptoms point in 
 many directions and in the absence of objective symptoms 
 the physician does not know what to look for. 
 
 The difficulty is increased when we remember that the 
 aged frequently exaggerate symptoms, especially pain, 
 while owing to the weakened mentality and the changes in 
 the skin and the nerve terminals, pain is often absent in 
 ordinarily painful diseases; that the aged are imitative 
 and readily influenced by suggestion; that the normal 
 senile changes may cause distress ; that a pathologic con- 
 dition may have existed for so long a time that the organ- 
 ism has accommodated itself to such abnormal condition 
 and it has become normal to the individual. 
 
 The most frequent form of malingering is the exaggera- 
 tion of pain to secure sympathy. The following is a 
 typical case : 
 
 A man, age seventy-two, says he was never sick (has 
 pock marks on his face and marks of a scarifier on his 
 back). He complains of feeling sick all over. He says 
 he has headache, backache and pain in the joints, feels 
 cold and has no appetite. There is a history of constipa- 
 
 192 
 
SENILE MALINGEKING 193 
 
 tion, slight incontinence of nrine and dyspnea, going back 
 for months or years. There is no cough or expectoration, 
 no palpitation or other cardiac symptom, but a history is 
 obtained from the family of occasional attacks of vertigo, 
 which he denies, a presbyopia and evidently presbyacusia. 
 
 The subjective symptoms did not point to any clearly 
 defined disease except cerebral atheroma if we accept the 
 statement of the family as to vertigo. Neither did the ob- 
 jective symptoms give any clew. He was irritable and 
 insisted that his family leave the room while he was being 
 examined. 
 
 Examination. — Temperature rectal 98.6, mouth 97.6. 
 Blood pressure systolic 170. m. m. Urine, S. G. 1020, 
 trace of albumin, indican, no casts. Chest showed senile 
 emphysema, heart hypertrophied, no murmurs. Tortuous 
 temporal arteries and filled superficial veins, varicose 
 veins in legs. Abdomen tympanitic, stomach dilated, liv- 
 er atrophied, spleen not palpable, prostatic hypertrophy. 
 Upon pressing over various parts of the body he gave no 
 evidence of pain but says it hurts when he is asked if 
 there is any pain. It was possible to exert considerable 
 pressure upon such parts without evidence of pain if his 
 attention was distracted in conversation. He forgot the 
 location of a painful spot on the back a few minutes after 
 complaining of this pain and pointed to a spot six inches 
 away. Considerable pressure upon the knees during con- 
 versation brought out no evidence of pain until I called 
 his attention thereto when he immediately winced and 
 pushed my hand away. Before leaving him he requested 
 me to suggest to the family that he be sent to a hospital 
 or home. His family informs me that he did not complain 
 of being ill until shortly after a petty quarrel. 
 
 This was a case of pure malingering to obtain sym- 
 pathy. 
 
 In some cases the dread of pain makes the patients 
 hypersensitive and they suffer acutely from a slight les- 
 
194 GEEIATRICS 
 
 ion as a scratch or bruise. In one case of chronic nicer 
 of the leg the patient trembled when I approached her 
 with a forceps to remove the slough and screamed when 
 she saw me lift it out of the ulcer, yet when the bed cov- 
 ers were so arranged that she could not see what was 
 being done she gave no evidence of pain. Suggestion 
 and unconscious mimicry are frequent causes of malin- 
 gering. In a small home for the aged one woman had a 
 senile pruritus. Several other women in the ward see- 
 ing this one scratch did likewise, each accusing the first 
 of having lice. It was necessary to remove the one 
 woman and subject the others to a bath. The sugges- 
 tion of itching is often sufficient to create the impression 
 and sensation of pruritus. Malingering due to uncon- 
 scious mimicry is seen occasionally in homes and insti- 
 tutions where inmates pair off with companions. If one 
 has some form of tremor, impediment in gait or speech, 
 or makes peculiar movements of the body or limbs, the 
 companion will frequently acquire the same. In a case 
 that had been diagnosed and treated as Parkinson's 
 disease, there was the gait, attitude and the mask-like 
 expression of this disease. The rapidity with which the 
 symptoms developed after the patient began to associate 
 with a true case of paralysis agitans led me to question 
 the diagnosis. The men were separated and the malin- 
 gerer was threatened with an operation if he did not 
 stand erect and control the tremor. The threat pro- 
 duced the desired result and the facial aspect changed 
 when he was placed with a cheerful companion. 
 
 I have seen a senile tremor and a hemiplegia, acquired 
 through unconscious mimicry, cured through separation 
 from the original cases, but threats and actual depriva- 
 tion of food were necessary in the senile tremor case. 
 In this case the food was taken away whenever he spilt 
 any from his spoon or cup and tempting dishes were of- 
 fered which he could have only if he completely con- 
 
SENILE MALINGEEING 195 
 
 trolled the tremor. He would lapse into the tremor 
 when he thought he was not watched, but a word from 
 the attendant sufficed to cause him to control himself. 
 He was finally completely cured. 
 
 A lisp which an aged couple acquired from a lisping 
 grandchild living with them was not cured until the 
 grandchild was cured. Nothing was done in this case, 
 as the old people imitated the child in its talk and as the 
 child's speech improved the grandparents dropped the 
 lisp. 
 
 It is generally difficult, sometimes impossible, to cure 
 these habits in the aged. Abnormal motion habits are 
 quickly formed. A few days ' companionship with a per- 
 son who limps will suffice to cause the companion to limp 
 in step with the other and it will take many days or 
 weeks to cure him. Sound or voice habits develop 
 slowly, but once acquired it is almost impossible to com- 
 pletely cure them unless the imitative propensity is stim- 
 ulated in the opposite direction. The lisping couple to 
 which I referred were thus cured. 
 
 The term malingerer can hardly be applied to a class 
 of senile cases where the opposite condition prevails, 
 where obvious symptoms and signs are denied. The aged 
 frequently boast of their good health and wonderful con- 
 stitution and they will deny ailments and discomforts 
 that are obvious or usually painful. On the other hand 
 they will exaggerate former ailments from which they 
 recovered "in consequence of their strong constitution." 
 
 In the case quoted at length the patient denied small- 
 pox in spite of the pock marks and he denied any pul- 
 monary disease though the scarifications were probably 
 produced as a blood letting measure in pulmonary dis- 
 ease. 
 
 The histories as given by the aged are generally unre- 
 liable, their statements being almost invariably exag- 
 
196 GEKIATEICS 
 
 gerated. This applies to past as well as to present con- 
 ditions. In a few cases pathologic states and symptoms 
 are minimized. The discerning physician should be able 
 to distinguish between exaggerated symptoms to obtain 
 sympathy and minimized symptoms, though it is often 
 difficult to determine if the patient's denial of symptoms 
 arises from weakened mentality, local degenerations in- 
 volving sensory and other nerves, fear or a foolish exhi- 
 bition of fortitude. 
 
 Surface sensitiveness is generally lessened in the aged, 
 while the pain in inflammation of internal organs and 
 tissues is felt less acutely on account of mental impair- 
 ment which is more marked in inflammation with high 
 temperature. On the other hand the dread anticipation 
 of a painful examination will cause the patient to hide 
 lesions and deny painful spots, fearful that the physi- 
 cian will make a closer examination of the same. 
 
 A patient, aged seventy-five, gave a history of having 
 struck his shin on the edge of a car step about a month 
 before I saw him. He said nothing about this at home, 
 but the family noticed that he bandaged his leg and found 
 dried blood and pus on one of the bandages. The patient 
 declared it was nothing, it did not hurt and there was no 
 need to call the physician. He still refused to have a 
 physician when he was unable to walk and the removal 
 of the bandage caused pain. It was through subterfuge 
 that I was able to see the injury. It was an ulcer which 
 extended to the periosteum, the ulcer filled with pus and 
 slough and was surrounded by a wide ring of erysipelas. 
 He denied having any pain but screamed when I touched 
 the ulcer with a piece of cotton. 
 
 The problem how to deal with senile malingerers is 
 often more difficult than the determination of their con- 
 dition. It seems inhuman to subject an aged individual 
 to a painful test, and more so to institute a painful 
 method of treatment when that method has for its pur- 
 
SENILE MAMNGEKING 197 
 
 pose the production of pain or distress. The family will 
 ask what harm would result if the patient continues to 
 limp or shake so long as these are only habits. Habits 
 acquired in old age rapidly become worse and less con- 
 trollable. The fine slight tremor which may be controlled 
 in the beginning becomes an uncontrollable coarse and 
 persistent tremor. The slight limp may become a com- 
 plete monoplegia. Drugs are useless in these cases and 
 harsh measures with constant watching are necessary to 
 effect a cure. The conscious malingerers, who exagger- 
 ate symptoms, usually have a slight basis for their com- 
 plaints and require medical treatment for the underly- 
 ing disease, but where there is no basis for their com- 
 plaint as in the case I described, a disagreeable placebo 
 will usually suffice. 
 
CHAPTER XXVII 
 VENEREAL DISEASES 
 
 A war veteran, aged seventy, consulted me for an 
 ulcer of the leg. He complained of symptoms which 
 were due to prostatic congestion and he was apparently 
 toxic. About fifty years ago he was infected with syph- 
 ilis and had tertiary lesions on the leg. In time they 
 healed and he has not experienced any inconvenience or 
 return of symptoms for nearly fifty years. A small dose 
 of arsenic trioxide, 1/200 grain, was given every four 
 hours and in the course of a few days he was much im- 
 proved. The ulcer was healing and the prostatic symp- 
 toms improved. While taking the arsenic I advised free 
 catharsis because in the aged the secondary effects of 
 drugs, owing to faulty elimination, are often more pro- 
 nounced than the primary effects, and should be offset 
 by the use of laxatives. 
 
 A man, aged sixty-two, was infected thirty years ago, 
 but did not go through a course of treatment. At times 
 he has attacks of ulcerative stomatitis which are relieved 
 by the administration of 1/100 grain of arsenic trioxide 
 before meals. , 
 
 In senile cases, syphilis may be the underlying cause 
 of many conditions. On the other hand, there are a 
 great many old syphilitics that never experience any 
 difficulty. Syphilitic ulcers in the aged are prone to have 
 sarcomatous degeneration engrafted upon them. In a 
 few instances I have been at a loss to know the reason 
 why antisyphilitic remedies were of no benefit and in 
 these cases I discovered that sarcoma had been engrafted 
 upon the syphilitic sore. 
 
 198 
 
VENEREAL DISEASES 199 
 
 I now have a man who has a large syphilitic tumor of 
 the neck which has undergone sarcomatous degenera- 
 tion. Mercury and the iodides as well as Salvarsan 
 have been of no benefit to him and he has taken x-ray 
 treatments and radium therapy, but remains in the same 
 condition. The tumor does not spread and he has had 
 it for several years. It seems that when a man gets old 
 some of these sarcomatous processes are less malignant 
 than in maturity. I have seen a few cases of carcinoma 
 that have lived for several years and are apparently not 
 failing. I believe the secret is that I do not interfere 
 with them by surgical procedures which would be fatal 
 in many cases. 
 
 The iodides and also mercury do not work as well as 
 when given to younger persons, but are at times indis- 
 pensable. To repeat, many of the best results in syphilis 
 are from remedies other than mercury or the iodides. 
 These remedies are very harsh on the stomach of an old 
 person. I have not seen many encouraging results from 
 Salvarsan when used in senile patients. Arsenic seems 
 to be well-borne and may be given in the form of the tri- 
 oxide or as Fowler's solution. If the bowels are free, 
 we are not likely to get the cumulative action, causing 
 secondary effects. Too much arsenic will produce symp- 
 toms similar to coryza and the lower lids will become 
 puffed. 
 
 A combination of lime phosphate and iron phosphate, 
 each two grains, given three times a day will benefit 
 many cases of syphilis. If mercury or the iodides are 
 used, small doses, one-fourth the usual dose, will usually 
 be as effective as larger doses and will produce less dis- 
 turbance to the stomach. 
 
 Gonorrhea is very rare in the aged as there is not only 
 lessened opportunity but the senile organism is more re- 
 sistant to infection. In several instances where old men 
 were exposed to infection they escaped although younger 
 
200 GEEIATEICS 
 
 men who had been with the same women just before or 
 immediately after the old man, were infected. The few 
 cases reported in advanced life were almost without ex- 
 ception men who had had the disease in earlier life. The 
 disease is very rare in aged females. The following are 
 typical cases: 
 
 A Civil War veteran who attended the grand reunion 
 at Gettysburg in 1913 visited a house in the village which 
 he had visited during the battle. Here he met a woman 
 with whom he had sexual congress, but he was intoxi- 
 cated at the time and he did not know if she was old or 
 young, a mulatto or a white girl. Upon his return to the 
 city four days later he felt a burning pain when urinat- 
 ing, there was also some dribbling of urine and two days 
 later he. noticed a thick discharge which he recognized 
 immediately, as he had had gonorrhea in his youth. The 
 old man insisted upon the treatment that cured him on the 
 former occasion, namely: Lafayette mixture and lead 
 and zinc injection. The discharge ceased and the treat- 
 ment was discontinued, but a few days later this dis- 
 charge reappeared. In the course of a month there was 
 some difficulty in urination, the stream emerging small, 
 twisted and expelled with little force. The introduction 
 of a sound revealed a stricture a short distance behind 
 the meatus and this was treated by gradual dilatation, the 
 treatment being continued for a month. During this 
 period the urethra was washed out daily with a solution 
 of permanganate of potash to which a small amount of 
 glycerine was added. The profuse discharge stopped 
 in a few days, but occasional drops of pus could be ex- 
 pressed for a few weeks afterward. By the end of the 
 third month there was no more pus and there were no 
 more shreds in the urine. 
 
 A man, aged sixty-two, virile and libidinous, boasted 
 of his apparent immunity to veneral disease as he had 
 escaped since his only attack of gonorrhea at the age of 
 
VENEKEAL DISEASES 201 
 
 twenty. In a spirit of bravado he visited a woman who 
 had infected a friend. Within a week there were all the 
 symptoms of acute gonorrhea and a balanitis increased 
 his suffering. Gonorrheal vaccine was administered 
 without any apparent effect and the treatment by injec- 
 tions and prolonged washing out of the urethra was in- 
 stituted. After an initial irrigation of the urethra with 
 a 5 per cent solution of argyrol, irrigations with per- 
 manganate of potash were made several times a day and 
 the discharge cleared up in four weeks. The balanitis 
 cleared up in a few days under local application of the 
 alkaline antiseptic solution. 
 
 An elderly man had a mistress for several years and 
 had unbounded faith in her fidelity. A few days after 
 one of his weekly seances, he noticed a urethral dis- 
 charge, but there was no burning or other symptom of 
 the disease. The discharge was glairy and colorless, not 
 at all like the creamy discharge of acute gonorrhea. The 
 microscope revealed gonococci. The woman permitted 
 vaginal and urethral smears to be made, but these did not 
 show the pathogenic germs. The man had a varicocele and 
 an enlarged prostate and the discharge resembled the 
 discharge of prostatorrhea or an old gleet. The man had 
 had gonorrhea during youth, but not since. It was im- 
 possible to determine the source of the infection and it 
 was treated as gleet. Argyrol and later permanganate 
 of potash solution caused disappearance of the gonococci 
 but the glairy discharge persisted for seveal months and 
 afterwards it occasionally appeared for a few days then 
 disappeared without treatment. 
 
 The following case of gonorrhea in the female pre- 
 sents nothing unusual except the age of the patient. 
 The woman, aged sixty-eight, was infected by her hus- 
 band who was two years her senior. For two weeks she 
 had felt a burning on micturition, but neglected it until 
 the meatus became inflamed and the act of urination 
 
202 
 
 GERIATRICS 
 
 caused intense pain. She had suffered from dribbling 
 due to an atonic sphincter for years and ascribed the 
 inflammation to "sharp"' urine. There were slight 
 vaginal and urethral discharges which under the micro- 
 scope revealed the pathogenic organism. Argyrol tam- 
 pons and permanganate of potash irrigations caused dis- 
 appearance of the vaginal discharge in a few days. 
 
 Chancroid is extremely rare in the aged. The penis 
 is shrunken, erections are weaker, and there is less likeli- 
 hood of abrasion of the epidermis during intercourse. 
 There is also greater resistance to pathogenic organ- 
 isms. The following case is the only one that came to 
 the attention of the writer. The man, a bachelor, aged 
 sixty-five, was obliged to masturbate to arouse an erec- 
 tion before penetration. By this act he produced abras- 
 ions on the surface which furnished the point for infec- 
 tion. A few days after connection he noticed a slight 
 swelling behind the corona and this became a pustule 
 three days later. He opened the pustule, exposing an 
 ulcerating base. After a few days of self-treatment he 
 came to the physician. The ulcer was shallow, irregular, 
 about the size of a small finger nail and covered with 
 pus. The ulcer was cleaned and covered with a powder 
 consisting of calomel and bismuth subnitrate. Cleans- 
 ing the ulcer daily with peroxide of hydrogen solution 
 and applying this powder caused a contraction of the 
 sore and healing of the base, leaving a depressed but 
 healthy surface. Slight induration of the inguinal 
 glands occurred but they did not suppurate. The entire 
 treatment lasted two weeks and the patient was then dis- 
 charged cured. 
 
 I remember an aged man who consulted me for an 
 urethal discharge that had every appearance of being 
 gonorrhea. Upon careful examination it was found that 
 the discharge was not gonorrheal, but due to diabetes 
 
VEKEKEAL DISEASES 
 
 203 
 
 and treatment for this disease caused the discharge to 
 disappear. Senile diabetes is frequently the cause of 
 balanitis and treatment directed to diabetes will some- 
 times help the other condition. 
 
CHAPTER XXVIII 
 THE SENILE CLIMACTERIC. A TYPICAL CASE 
 
 The following case is typical of the state described as 
 the senile climacteric. 1 
 
 A man, aged seventy-three, single, holding a political 
 position involving some responsibility, but little actual 
 work aside from checking and countersigning reports, 
 etc. ; has held this position for twelve years and for ten 
 years before held a similar position in another depart- 
 ment. 
 
 The routine duties of his position can be performed by 
 a subordinate and his absence would cause no disar- 
 rangement in his office. 
 
 He is religious, abstains from alcohol and tobacco and 
 has always been a stickler for observing the proprieties 
 of social life. He was formerly cheerful, but never com- 
 municative, had many acquaintances but few friends and 
 no intimates. While tactful and pleasant he was strong- 
 willed, short and decisive in argument as in giving or- 
 ders. He was exactingly methodical, neat in appear- 
 ance and in surroundings, almost miserly economical, 
 except in his expenses upon himself. He was at one time 
 an officer in the army and preserved an erect, dignified 
 bearing, reserved and reticent. 
 
 He had typhoid fever during the Civil War. Has had 
 no serious illness since, but became morbidly depressed 
 when his sister died and he remained away from his of- 
 fice for a few weeks. This depression passed away and 
 no change in his mental or physical condition was no- 
 ticed until about six months ago. 
 
 l The Senile Climacteric, New York Med. Jour., Dec. 2, 1911. 
 
 204 
 
THE SENILE CLIMACTERIC 205 
 
 About six months ago, it was noticed that he was not 
 as regular in his habits as formerly, neither as method- 
 ical or correct in his work, nor as careful about himself 
 or his surroundings. His desk was littered with papers 
 and scraps were thrown upon the floor instead of in the 
 waste basket, clothes were thrown upon the chairs in- 
 stead of being hung up, he preserved useless letters and 
 papers, became peevish and complaining, forgetful, and 
 occasionally dozed off at his desk. He now began to no- 
 tice slight infirmities, aching in the ankles on walking, 
 shortness of breath when going upstairs, palpitation of 
 the heart when the door slammed or the head of the de- 
 partment approached his desk. He became occasionally 
 dizzy, the vertigo lasting but a moment. Noticing cloud- 
 iness in the urine when standing overnight he consulted 
 a physician who diagnosed chronic interstitial nephritis. 
 The patient was now worried about his physical condi- 
 tion and watched for all sorts of somatic disturbances, 
 frequently felt his pulse, looked in the glass to note any 
 change in his appearance and made repeated visits to 
 the physician. He felt that he was getting worse and 
 changed physicians. 
 
 I first saw him three months ago. He presented an 
 erect bearing, but would occasionally permit himself to 
 sink into a slouching attitude with arms hanging loosely 
 in front of him and with a slight stoop. He was restless, 
 apparently fearful of some unknown danger. The skin 
 was slightly weatherbeaten, but soft and showing the 
 extreme care he had always taken of it. Physical exami- 
 nation showed no marked degenerative changes. 
 
 The principal change was in his mentality. 2 Here I 
 was obliged to depend mainly upon the statements of his 
 friends and neighbors. He had formerly been very re- 
 ticent, now he frequently asked them if they noticed any 
 
 2 Senile Mentality, Intern. Clinics. Vol. IV, Series 21. 
 
206 GEEIATKICS 
 
 change in Mm. He sought their company and became 
 talkative, his conversation being confined exclusively to 
 his health and his work. He took no interest in any con- 
 versation which did not relate to himself. His conversa- 
 tion was rational and when he made mistakes in figures, 
 names, places or dates acknowledged his mistakes when 
 corrected. 
 
 The mental deterioration proceeded rapidly but irreg- 
 ularly, but he is now passing out of the climacteric peri- 
 od and entering the stage of senility with steadily pro- 
 gressing senile changes. During this climacteric period 
 the memory became weakened and he supplied forgotten 
 facts by inventions, insisting upon their correctness. 
 These would be forgotten the next day and a new set of 
 fabrications would be substituted while the statements 
 made the day before were denied. The fabrications were 
 rational. During this time a persecutory delusion de- 
 veloped. He began to worry about his position and 
 thought that a certain subordinate might be selected to 
 fill it. He conceived the pleasure of this subordinate 
 and from this arose the idea that this subordinate was 
 in some way responsible for his illness. Carrying this 
 conception further, he believed that this man would have 
 him sent to an asylum if he returned to work. When 
 this stage was reached it was possible by suggestion to 
 create hallucinations, that this subordinate had agents 
 in his room to kidnap him, that men were watching him 
 from behind a lamp post, etc. The persecutory delusion 
 was sometimes forgotten while the hallucinations could 
 only be evolved through suggestion when the delusion 
 was present. He was loquacious when speaking of his 
 own importance, but spoke guardedly and in evident fear 
 of his supposed danger. Only once did he speak volun- 
 tarily of it; at other times I was obliged to lead up to 
 the subject. If I broached it at the beginning of our 
 conversation he usually denied any such fear, but after 
 
THE SENILE CLIMACTERIC 207 
 
 prolonged conversation, casual references to this sub- 
 stitute in his office would develop the delusion. 
 
 He developed exalted ideas of his importance, exag- 
 gerating the value of his services, believing that his ab- 
 sence from his desk would seriously hamper the govern- 
 ment. They are not, however, insane delusions such as 
 appear in the paretic, but the opinions of the egotist. 
 The fear that his absence would disarrange the routine 
 of his office and he would be discharged became a per- 
 sistent phobia. This was the only mental aberration 
 which was constantly present and remained unchanged 
 until he returned to work a few days ago. 
 
 During this period the mental attitude was sometimes 
 depressed, agitated or apathetic, rarely cheerful. There 
 were sometimes lucid intervals lasting for hours or days 
 during which he was cheered by letters from his superi- 
 ors, assuring him that his position was safe. Even at 
 such times he would suddenly become depressed, call up 
 his superiors on the telephone for corroboration of their 
 letters and then doubt their sincerity. During these 
 lucid intervals the patient's conversation was rational 
 and he sometimes realized that he had said or done ir- 
 rational things, but if conversation was prolonged it was 
 possible by suggestion to arouse a persecutory delusion 
 along the lines of the suggestion. 
 
 The usual mental attitude was agitated depression. 
 In this state he sought listeners to whom he would ex- 
 plain how his absence from work hampers the govern- 
 ment, and the fear of his discharge, he would repeatedly 
 ask if his listeners could detect any signs of insanity, he 
 frequently sent for me insisting that I examine his heart, 
 blood pressure, urine, mental condition, etc. Another 
 matter, several foolish infatuations following sexual re- 
 crudescence, added to his agitation and depression. 8 
 
 3 Medico-legal relations of Old Age, New York Med. Jour., May 25, 1912. 
 
208 GERIATRICS 
 
 Sexual recrudescence has been frequently noticed in ad- 
 vanced age, there being sometimes a prolonged, more 
 often paroxysmal libido without functional potentia. It 
 is in the paroxysmal form of recrudescence that an in- 
 dividual is driven by sexual fury, unrestrained by rea- 
 son, to attempt rape, and a child being usually available 
 the attempt is made upon the child. It is safe to say 
 that most, if not every case of atrocious but unsuccess- 
 ful attempt at rape upon a young girl by an old man oc- 
 curs as a result of sexual recrudescence during the 
 senile climacteric. When the recrudescence is prolonged 
 the sexual stress is apparently not as great and the in- 
 dividual is more likely to become infatuated with one 
 woman, than to attempt indiscriminate or forcible inter- 
 course. Such infatuation may lead to a mesalliance and 
 give rise later to medico-legal questions. In this case 
 the main infatuation was apparently for a middle aged 
 woman, who told him that she was married and living 
 with her husband, yet consented to meet him secretly. 
 During his rational hours he realized the folly and the 
 immorality of his relations although declaring that 
 there had been no sexual relations. At other times he 
 spoke for hours about her charms, virtues, etc., carried 
 her picture, stood in front of the house in which he 
 thought she lived and met her by appointment. After 
 some of these meetings or perhaps while watching the 
 house, he became absent-minded, wandered aimlessly 
 and twice crossed the river unconsciously. At one of 
 these meetings he lost his month's salary and thereafter 
 she failed in her appointments. These two matters, the 
 fear of losing his position and his infatuation for the 
 woman who failed him, kept him almost constantly de- 
 pressed even when his mind was clear. A few weeks ago 
 he heard that she was going to Europe and for several 
 days he went repeatedly to the house in which he sup- 
 posed she lived but failed to see her. He was extremely 
 
THE SENILE CLIMACTEKIC 209 
 
 agitated on the sailing day, kept her picture constantly 
 before him, and said over and over again that he would 
 never be able to see her again. A few days later he had 
 apparently forgotten his infatuation for her and when 
 now reminded of it, he speaks of it as an insignificant 
 episode of the past. 
 
 Now, six months after the initial manifestations of 
 the senile climacteric, he is passing out of this period 
 into the somatic state of senility and the mental state of 
 senile dementia. His appearance bears out the state- 
 ment of his friends that he has aged ten years in six 
 months. His bearing is less erect and when not watched 
 he falls into a slouching attitude. He has lost weight, 
 his face is wrinkled, his expression is generally apathetic, 
 occasionally anxious when he makes an effort to con- 
 centrate his mental faculties upon his condition. He is 
 becoming careless about his person and surroundings 
 except on Sundays when he goes visiting or expects vis- 
 itors, he is more sluggish in his movements, there is an 
 occasional tremulousness of the hands, his walk is slow- 
 er and he makes shorter steps. The degenerative 
 changes have been quite uniform. 
 
 During the climacteric there were maniacal outbursts, 
 periods of depression and amentia, there were delusions, 
 hallucinations, and phobias with lucid intervals. The 
 mental aberrations gradually disappeared leaving a 
 weakened mind, the true dementia. He is pliant, so that 
 a child can lead him from his purpose. He is losing in- 
 terest in the events of the day, in everything and every- 
 body except himself. His infatuations are all but for- 
 gotten, and other recent events are but dim memories 
 while he recalls events of his early life. The sexual re- 
 crudescence has subsided. 
 
 It is still possible to arouse persecutory delusion 
 through frequent suggestion, but it is mild and quickly 
 forgotten. His mental attitude is apathetic or depressed. 
 
210 GERIATRICS 
 
 He has gone back to work where his age and his long as- 
 sociation with his fellow-employees have secured for him 
 concessions which virtually relieve him from all active 
 duties. What he does now is routine work requiring lit- 
 tle mental effort. He is susceptible to flattery and feels 
 keenly criticism though formerly indifferent to both. 
 When questions involving reason and judgment arise, 
 he makes an evident effort to concentrate his thoughts 
 and he still reasons rationally but slowly. Long contin- 
 ued effort causes mental confusion and brain fag. When 
 speaking of himself his ideas are still exalted, holding 
 an exaggerated opinion of his importance and of his 
 work, but there are no delusions. From a strong, ag- 
 gressive personality he has become a passive, pliant 
 nonentity. 
 
 The senile climacteric being one of the physiologic 
 critical periods it can not be prevented nor need any- 
 thing be done if the mental and physical deteriorations 
 proceed uniformly and no active or distressing mani- 
 festations appear. When such manifestations appear 
 as they did in this case it is generally possible to relieve 
 distressing symptoms. Psychic measures are some- 
 times of avail, more often drugs must be used. The 
 psychic measures to be employed depend upon the tem- 
 perament of the individual and the particular form of 
 aberration present. In my case the mental condition 
 sometimes improved under flattery, praise or conces- 
 sions, at other times criticism, censure, even threats were 
 necessary to restrain, quiet or arouse him. Delusions 
 could be developed through suggestion, but could not be 
 dispelled that way. They were usually forgotten. 
 
 The drug treatment consisted of amorphous (red) 
 phosphorus in two-grain doses three times a day given 
 continuously for two months, chloral hydrate, bromide 
 of potassium, and incidental remedies for constipation. 
 
THE SENILE CLIMACTERIC 211 
 
 The bromide of potassium was given for a week when 
 the sexual stress appeared to be most urgent and the 
 patient spent hours in front of the woman's house. Dur- 
 ing this time veronal was given as a hypnotic, at other 
 times chloral was used. I fortunately secured the pa- 
 tient's confidence through producing appreciable effects, 
 catharsis, sleep and relief from pain. It was not difficult 
 afterwards to induce him to take medicine when he 
 thought he did not need it and would not take it from 
 anyone else. 
 
 He is continuing to take the phosphorus and takes the 
 chloral and potassium bromide at night when agitated 
 or " nervous' ' as he calls it. Libido and potentia have 
 disappeared and such psychic measures as the musical 
 play and burlesque produce sensuous but not sensual 
 impressions. I have not employed aphrodisiac drugs as 
 I fear that such forced erotic stimuli would cause a 
 harmful reaction. (The amorphous phosphorus has ap- 
 parently little or no influence as an aphrodisiac.) 
 
 In this as in other similar cases; I found that the most 
 lasting mental stimulation without reaction was pro- 
 duced by appropriate recreations. The apathetic dement 
 holding a fishing line is roused to action by the sudden 
 tug at the other end of the line. A popular or an old 
 familiar air, the musical play, the rythmic ballet, fire- 
 works, single novelties, as an air ship or ocean liner, 
 simple sports as tennis, croquet, billiards, etc., which 
 produce no mental strain nor aural or visual confusion 
 are beneficial. Confusing sights as a ball, a race with 
 many contestants, a circus, confusing sounds as the 
 jangle of city noises and recreations which involve men- 
 tal effort as chess, scientific card games, problem plays, 
 etc., cause rapid brain fag and hasten brain exhaustion. 4 
 While this question of recreations applies more partic- 
 
 4 From chapter on Hygiene "Diseases of Old Age," P. Blakiston's Son & Co., Philadel- 
 phia, by Naacher. 
 
212 GEEIATEICS 
 
 ularly to the period immediately following the senile 
 climacteric when the mind can still interpret sensory im- 
 pressions it can be made to apply to the climacteric pe- 
 riod. These measures are of little service, however, if 
 there is a persistent cause for mental confusion as there 
 was in this case. 
 
CHAPTER XXIX 
 SEXUAL LIFE IN THE AGED 
 
 Sexuality, like other factors in the life of the aged, is 
 modified. In some cases there is a gradual diminution 
 in desire and power to the point of complete extinction. 
 In other cases desire or power diminishes slowly while 
 the other diminishes rapidly. Occasionally, the recogni- 
 tion of the failing power causes the mind to dwell upon 
 it and a morbid desire is produced and during the senile 
 climacteric there is often a recrudescence of desire and 
 sometimes of power. 
 
 The occurrence of a male climacteric corresponding to 
 the menopause in the female is now recognized although 
 it does not produce such marked mental and physical dis- 
 turbances. About the forty-fifth or fiftieth year the man 
 finds that the libido and the potentia both are lessened 
 and a more powerful stimulus is necessary to arouse them 
 to activity. About this time, the erectile power is les- 
 sened, greater exertion is required to bring on the 
 orgasm and this occurs later or may not occur at all, the 
 amount of semen expelled is less, while the character of 
 the semen is altered. It is darker in color, has a strong 
 odor and contains fewer spermatozoa. The spermatozoa 
 are apparently not altered and are capable of fructify- 
 ing the ovum. Ordinarily, the desire and power dimin- 
 ish together and in old age both may be extinguished to- 
 gether. In the female, the desire rapidly wanes after 
 the menopause and her sexual life thereafter is confined 
 to the passive submission to the sexual congress, in 
 which there is neither pleasure, desire nor response. 
 
 233 
 
214 GEEIATKICS 
 
 The following cases exhibit variations from the ordi- 
 nary senile changes: 
 
 Case I. — Female, aged seventy-three, was always in- 
 tensely erotic and soon after her first marriage at the 
 age of nineteen she had a paramour. When her first 
 husband died she married this paramour and besides 
 had other lovers. Her second husband left her and she 
 lived with various men, her last lover leaving her when 
 she was sixty-five years old. She retained her erotic dis- 
 position and is still willing to submit to any man who 
 will consort with her. She has been a persistent mastur- 
 bator, the right labia minor being in consequence thick 
 and flabby and hanging down like a fold while the mem- 
 brane covering it is thick and coarse like the skin of the 
 palm of the hand. 
 
 Case II. — Male, aged seventy-five, married a young 
 woman after fifteen years of widowerhood. She left 
 him a week later and he came for treatment for impo- 
 tence. There was a morbid desire brought on by the 
 humiliation of the knowledge of his physical inability to 
 satisfy his wife. The penis was small and flaccid, scro- 
 tum shriveled and the testicles appeared to the touch 
 like small, rough, irregular marbles. He had a vari- 
 cocele and an enlarged prostate. For several years he 
 had what he called nocturnal emissions, but the dis- 
 charge proved to be prostatic secretion. He had such a 
 discharge when attempting intercourse with his wife, 
 but there was no erection. In this case spinal faradiza- 
 tion, cold sounds and the administration of strychnine 
 produced satisfactory erections, but there was no dis- 
 tinct orgasm and the discharge was prostatic, not 
 seminal. 
 
 Case III. — Male, aged seventy, began to notice the wan- 
 ing sexual power at the age of fifty. He thought he 
 
SEXUAL LIFE IN THE AGED 215 
 
 needed a change and lie sought the association of young 
 women. This was effective for a few years but before 
 the age of sixty neither this nor drugs, sounds or elec- 
 tricity had any effect. The penis became shrunken and 
 flabby and he resorted to masturbation. At the age of 
 seventy he was a confirmed masturbator helping along 
 the psychic stimulation by suggestive pictures. About 
 this time he had lost all desire for normal intercourse 
 and declined this when he had the opportunity. 
 
 Case IV. — The following case is reported as a typical 
 case of recrudescence of sexual desire during the senile 
 climacteric. An inmate of a soldier's home visited the 
 city and spent the night at the home of a friend. Dur- 
 ing the night he went to the room of a girl of sixteen and 
 attempted to assault her. She resisted and cried for 
 help. When the family went to her room they found the 
 old soldier naked, in a state of erotic exaltation, appar- 
 ently unconscious of everything except the gratification 
 of his desires. He shortly afterwards was sent to an 
 asylum suffering from senile dementia. 
 
 Case V. — A case of persistent libido, male, age eighty- 
 three, married his third wife at the age of seventy-two, 
 a year after the death of his second wife. The third 
 wife, a woman of fifty-four, complained that he insisted 
 upon daily congress with her and if she refused he either 
 ill-treated her or he brought another woman to the house. 
 He still does this although intercourse is followed by a 
 depressing reaction and he must remain in bed for an 
 hour before he recovers. He has had no children with 
 any of his wives. 
 
 Case VI. — A prominent merchant, now seventy-five, 
 says he can have no successful sexual congress with his 
 wife who is near his own age unless he thinks of her as 
 she was in youth. If she speaks during intercourse the 
 illusion is dispelled and all desire and power disappears. 
 
216 GEEIATEICS 
 
 Case VII. — The following case shows the influence of 
 habit upon the sexual life in old age. A commercial trav- 
 eler, now over seventy, has followed the same routine 
 mode of life for nearly forty years. His work takes him 
 out of the city for three weeks and in the city for one 
 week. During this week he has sexual relations with his 
 wife daily while during the three weeks he has neither 
 desire nor power. His desire and power during the 
 home week are as strong as in earlier life. The wife, 
 who is now about sixty-five, declares that their sexual 
 relations are in no way different from what they were 
 formerly, that she still has orgasms and only the subse- 
 quent exhaustion gives them any indication that they 
 are ageing sexually as well as physically. 
 
 Case YIII. — A case of satyriasis. A merchant, aged 
 seventy-eight at the time of his death, was until his fif- 
 tieth year normal in his sexual life and relations. Then 
 finding that the power was waning while the desire was 
 as keen as ever he sought the association of young 
 women. At first a mistress sufficed to arouse the de- 
 sired power, later he had two girls. His desires in- 
 creased and could not be satisfied with two girls and he 
 maintained an establishment where he kept several 
 girls. He spent most of his time at this establishment 
 and would sometimes use them all in the course of the 
 day. Sexual exhaustion finally ensued and when med- 
 ical treatment was unavailable he brooded over his con- 
 dition and senile dementia followed. 
 
 Case IX. — Secret perversions. A broker was supposed 
 to have led an exemplary life up to the time of his death 
 at the age of sixty-seven. He had been a widower for 
 ten years and after the death of his wife he became a 
 strict church-goer, a harsh disciplinarian, condemning 
 the slightest infraction of the moral code, and he be- 
 came associated with or interested in a number of agen- 
 
SEXUAL LIFE IN THE AGED 217 
 
 cies for the promotion of purity among the sexes. After 
 his death a trunk was found filled with obscene litera- 
 ture, pictures and also letters from perverts of both 
 sexes mentioning orgies in which he had taken part. 
 Letters indicated that these orgies began soon after his 
 wife died, occurred most frequently when he was sup- 
 posed to be on his vacation or on business trips, but were 
 also carried on during business hours with certain cus- 
 tomers with whom he was believed to have personal 
 business relations. All of these perverts were middle 
 aged and old men and women and most of them belonged 
 to a fashionable stratum of society. 
 
 Case X. — A woman, aged seventy, was operated upon 
 for a tumor of the uterus and as a result cicatricial tissue 
 formed in the vagina. No thought was given to this by 
 the surgeon until the husband, aged seventy-two, con- 
 sulted him and made a complaint because he was not able 
 to have satisfactory intercourse with his wife. The sur- 
 geon was much surprised because he did not realize that 
 a couple at that age could enjoy sexual life. Inquiry 
 elicited that they were in the habit of performing coitus 
 twice a week previous to the operation and when they 
 found that their pleasure was prevented both regretted 
 that the operation had been performed. 
 
 It should be remembered, however, that unusual 
 sexual power in the aged may be the first symptom of 
 senile dementia. Whenever a man past sixty is telling 
 about his unusual power this disease should be suspected. 
 
CHAPTER XXX 
 RADIUM THERAPY FOR SENILE EPITHELIOMA 
 
 Case I. — A man, aged seventy, consulted me for a basal- 
 cell carcinoma of the nodular type on the left temple. It 
 had been developing rapidly for the past two months, be- 
 ing quite painful at night, disturbing his sleep. The sur- 
 rounding tissues were infiltrated and indurated. 
 
 I applied a plaque containing 10 mg. of radium ele- 
 ment. The applicator was screened with 0.8 mm. brass 
 and covered with rubber tissue. He was given a two- 
 hour treatment every third day until three treatments 
 were given. 
 
 At the end of three weeks a sharp reaction occurred, 
 the inflammation around the growth had inreased and 
 the patient was alarmed because it looked much worse 
 than at first. In another month the reaction had sub- 
 sided and a crust had formed on the carcinoma. In time 
 this crust separated from the growth, leaving a small 
 ulcerated surface on which I again applied the applica- 
 tor for one-half hour, this time screened with 1.2 mm. 
 of brass. In a few days the ulcer had completely healed, 
 the surrounding inflammation had disappeared, leaving 
 a smooth and scarcely perceptible scar. 
 
 It is now several months since the carcinoma was 
 treated and there is no sign of its return. Considering 
 the rapidity of its development, without treatment, it 
 would undoubtedly by this time have affected quite a 
 large area on the face. 
 
 Case II. — A man, aged seventy-five, had a small, flat 
 basal-cell carcinoma on the upper part of the left ear, 
 
 218 
 
Fig. 12. Patient described in Case I. Basal-cell carcinoma of left 
 temple, of two months' duration. 
 
Fig. 13. Same patient as Fig - . 12, after six and one-half hour's treatment 
 with 10 mg. of radium element screened with 0.8 mm. of brass; no recurrence 
 to date. 
 
RADIUM THERAPY FOR SENILE EPITHELIOMA 219 
 
 There was a crusting and a slight oozing from its sur- 
 face which led to the diagnosis of epithelioma. 
 
 A flat applicator containing 10 mg. of radium element 
 was applied for twenty minutes and repeated in ten 
 days. 
 
 There was a crust formation which disappeared at the 
 end of five weeks, leaving a perfectly healed surface. It 
 is now almost impossible to detect where the epithelioma 
 originally existed. 
 
 Case III. — A man, aged seventy-two, consulted me for 
 a sore on the forehead which was a morphea-like basal- 
 cell carcinoma. 
 
 An application with a plaque containing 10 mg. of 
 radium element was made every other day for one-half 
 hour each time for three treatments. At the end of a 
 month the growth had entirely disappeared, leaving a 
 flat surface in place of the previous elevations formed 
 by the carcinoma. 
 
 Case IV. — A man, aged sixty-nine, had' a large, ulcerat- 
 ing basal-cell carcinoma of the right cheek. It caused 
 him great pain and his physician could not relieve it in 
 any way and as the patient refused to use morphine, the 
 doctor was at a loss to know the next step to take as the 
 carcinoma was inoperable. 
 
 An application of radium was made and a treatment 
 given twice a week for several weeks. 
 
 After two applications of radium there was no pain and 
 the old man was able to sleep at night and work during 
 the day. However, it has not improved the condition in 
 any other way. Nevertheless, in a very large basal-cell 
 carcinoma an improvement could not be expected, but the 
 fact that the pain had disappeared is a great triumph in 
 this individual case. 
 
 These cases represent the common types of epithelio- 
 mata seen in the aged. The natural process of degen- 
 
220 GEKIATEICS 
 
 eration, together with the narrowed lumen of the scle- 
 rosed arteries causing a poor blood-supply to the surface 
 of the skin predisposes to the development of epitheli- 
 oma, especially if there was a slight injury. 
 
 New growth in the aged requires different treatment 
 from that employed in the treatment of younger persons. 
 The usual treatments selected for younger individuals 
 will usually do mischief to the senile case. In the aged 
 a great many of these so-called rodent ulcers are compat- 
 ible with good health for a long time and occasionally 
 the patient will live longer and in less discomfort if the 
 carcinoma is left untreated. This statement must be 
 modified, however, for since employing radium in these 
 cases I find that I do not get the untoward effects that I 
 formerly experienced with other methods. 
 
 The basal-celled variety is the best type for radium- 
 therapy. In most of these cases operation is unjustifi- 
 able because of the difficult situation to operate and the 
 mutilation necessary. Moreover, usually this type of car- 
 cinoma does not metastasize, but if treated improperly it 
 will quickly spread to the surrounding tissues. 
 
 Technic of Application 
 
 For the treatments over twenty minutes the radium is 
 screened with 1 mm. brass and covered with rubber tis- 
 sue. For short treatments it is not necessary to screen 
 it. While it is permissible to treat the condition every 
 other day for three treatments, in many senile cases it 
 is advisable to wait two weeks after the first treatment 
 in order to gauge the individual reaction. 
 
 Senile patients respond quickly to radium treatment, 
 but on the other hand the effect is cumulative and if care 
 is not exercised a severe burn will result several weeks 
 after the application, due to the peculiar action of the 
 gamma rays. 
 
RADIUM THERAPY FOE SENILE EPITHELIOMA 221 
 
 In many senile cases it is advisable to use the alpha, 
 beta and gamma rays of radium, therefore in its appli- 
 cation the plaque is covered only with rubber tissue. 
 These treatments should not be given over twenty min- 
 utes at a time. When the effect of the alpha and beta 
 rays are desired it is accomplished by not screening the 
 applicator. 
 
 Prognosis 
 
 Although my experience has been very limited I am of 
 the opinion that the older the patient the better the re- 
 sults with radium in the basal-cell variety of carcinoma. 
 
 A great many of these senile patients respond quickly 
 to treatment and sometimes the growth does not recur 
 at all; at other times they recur but will often yield again 
 to radium therapy if promptly applied. In time, no 
 doubt, in many cases the growth will reappear. 
 
 Does radium cure these senile cases? Does not the epi- 
 thelioma recur with renewed force and in time prove to 
 be worse than at first 1 Are not many' of the improve- 
 ments in the general health due to the encouragement 
 the old man gets from being treated? 
 
 It was discussed by some at the last meeting of the 
 American Eadium Society that if a cancer does not re- 
 cur five years after treatment it may be considered 
 cured. 
 
 No doubt in some cases the cancer grows faster when 
 it recurs, but in the majority of cases it does not, espe- 
 cially if radium is again used. 
 
 There is no question that with radium therapy the 
 general health usually improves. On the contrary, with 
 many other treatments the patient will lose weight and 
 not feel as well generally. 
 
 It seems to me, although I may be wrong, that with the 
 improvement in the local condition with the use of ra- 
 dium there is usually an improvement in the general con- 
 
222 GERIATRICS 
 
 dition also. No doubt some of the improvement is com- 
 parable to the old soldier who braces up on Decoration 
 Day while passing the flag, but the next day goes about 
 with his usual stoop. Attention to his condition gives 
 him encouragement. 
 
 Does Radium Cure Senile Carcinoma? 
 
 In some cases it does cure carcinoma. I do not feel 
 that it is necessary for radium to cure cancer to be of 
 value. It is a selective remedy and we must learn its 
 field of usefulness and application. We could not expect 
 quinine to help typhoid fever nor the remedies employed 
 in typhoid to modify the course of malaria. 
 
 If we select the cases for application and do not take 
 the cases that are not only inoperable, but hopeless in 
 every other way, we surely will see the great value of 
 radium. 
 
 The patient described in Case IV obtained relief from 
 the pain after everything else had failed. Even though 
 it did not improve the local condition the relief from the 
 great suffering was well worth its trial. 
 
 If radium will relieve the pain and improve the dis- 
 charge attending ulcerating types of epithelioma; if it 
 will add in any way to the comfort of the last few months 
 of hopeless cases; if it will remove a rodent ulcer only 
 for a year ; if it does a very little to relieve this horrible 
 affliction, it has served a very useful purpose. If the 
 cases are selected and applications properly made we 
 have a remedy that is one of the best additions to our 
 armamentarium. 
 
CHAPTER XXXI 
 SURGERY OF THE AGED 
 
 Surgical procedures in senile cases present many 
 peculiarities that make the work more difficult and the 
 prognosis graver than in earlier life. These peculiari- 
 ties include constitutional changes (greater resistance to 
 infection, when the individual is in fairly good condition 
 and greatly lowered resistance when the body is debili- 
 tated, more profound surgical shock, slower reaction 
 from shock, slow and incomplete repair, deleterious after 
 effects, etc.), and local changes (degenerations, atrophy, 
 larger proportion of inorganic salts in bone making, bone 
 more brittle, lessening its power of repair, cardiac 
 and respiratory degeneration, increasing the danger 
 from anesthesia, etc.). 
 
 Bearing in mind these factors which increase the diffi- 
 culties of operation the surgeon is confronted by such 
 questions as these: Is immediate operation necessary 
 to save life? Will delay convert an operative condition 
 into a nonoperative one? Is the condition one which is 
 becoming rapidly worse so that a later operation under 
 less favorable conditions will be inevitable? does the 
 benefit to be derived warrant the dangers attending op- 
 erative procedure? Will nonsurgical measures afford 
 temporary relief without increasing the dangers of op- 
 eration later; do cosmetic or nonessential reasons for 
 the operation warrant the dangers? After an operation 
 is decided upon the method of procedure must be deter- 
 mined and here again there are vital questions which 
 must be carefully considered. Can the patient stand 
 prolonged anesthesia? Is a radical operation imperative 
 
 223 
 
224 GEEIATEICS 
 
 or will a minor operation afford prolonged relief? Shall 
 it be a one-stage or a two- or three-stage operation? 
 Where there are several methods of procedure, which 
 presents the least difficulties, the best clinical results and 
 the best prognosis? 
 
 In many cases where operation is advisable, but not 
 imperative the decision will depend upon the presence 
 or absence of pathologic conditions that occur frequently 
 in the aged such as diabetes, nephritis, cardiac or pul- 
 monary disease, cerebral or nervous conditions and ex- 
 treme debility. There can be no question when nonin- 
 terference will result in speedy death, but even in such 
 cases measures should be taken to minimize the dangers 
 from accompanying complications. Diabetes for exam- 
 ple is especially liable to coma, shock and infection. 
 The danger from infection can generally be guarded 
 against by strict aseptic precautions at the operation 
 and afterwards. The danger from shock can be mini- 
 mized by the use hypodermically of morphine and atro- 
 pine immediately before operation and whiskey and 
 strychnine immediately afterwards. The anoci-associa- 
 tion method of anesthesia minimizes surgical shock and 
 should be used whenever possible. The great danger in 
 operations upon diabetes is the development of coma and 
 this is especially liable to happen if ether is the anesthe- 
 tic. The coma is believed to be due to rapid acidosis and 
 this can often be prevented by placing the patient upon 
 alkaline treatment for a few days before operation, but 
 in emergency cases in which delay would be fatal, the 
 work should be done under local anesthesia, or nitrous 
 oxide-oxygen anesthesia. 
 
 As a general anesthetic in senile cases ether is safer 
 than chloroform, but it must be used cautiously in cases 
 where there is diabetes, nephritis, atheroma or pulmo- 
 nary disease. Chloroform is a cerebral, cardiac and 
 respiratory depressant and it must therefore be avoided 
 
SUEGEEY OF THE AGED 225 
 
 or employed cautiously where such depressant effects 
 may be dangerous. The nitrous oxide-oxygen combina- 
 tion is a safe anesthetic in most senile cases. The A. C. 
 E. mixture (alcohol 1 part, chloroform 2 parts, ether 
 3 parts) is occasionally used in senile cases, but pos- 
 sesses no advantages over chloroform or ether used 
 alone. Local anesthesia is attended by little danger, but 
 it is not applicable to major operations except when used 
 by the Crile method of anoci-association. Ethyl chlo- 
 ride is of service only when the operation does not in- 
 volve the deeper tissues; in one case the frozen area 
 became gangrenous. Spinal anesthesia owing to its un- 
 certain action, difficult technic and danger of innerva- 
 tion of the muscles of respiration should not be employed. 
 The principal operative dangers are shock, hemorrhage 
 and infection. The danger from hemorrhage is slight 
 if the ordinary precautions are taken. Occasionally, a 
 serous effusion about the site of the operation due to 
 the degeneration of the vessels, may be observed. This 
 effusion is slowly reabsorbed. 
 
 The aged possess a strong immunity to infection and 
 under the usual aseptic precautions, infection will occur 
 only if resistance is lowered through debility or disease. 
 Septic infection in the aged is always a grave condition, 
 but erysipelas about a surface lesion can usually be con- 
 trolled without much difficulty. The great danger in 
 surgical operations upon the aged is shock. Death from 
 shock usually occurs during or immediately after the op- 
 eration. In some cases there is apparent recovery for a 
 few days when sudden collapse occurs. In a few cases 
 there is mental and physical depression after operation 
 and a slow progressive deterioration ending in death 
 weeks later. In guarding against shock the care of the 
 mental state is as important as the care of the physical 
 condition of the patient. The dread of an unfavorable 
 outcome is depressing and the patient going to an opera- 
 
996 GEEIATKICS 
 
 tion in a state of dread is more liable to succumb to shock 
 than the hopeful patient. Nascher has pointed out the 
 depressing effect of the hospital ward where the patient 
 is obliged to hear the groans and cries of patients and 
 see the dead carried out of the ward. It is impossible to 
 instill hope in such surroundings. Sad leave-taking by 
 members of the family, the suggestion that the patient 
 make his will, stories of other cases that turned out un- 
 favorably, a doubtful attitude of the surgeon, a lengthy 
 discussion of the case in the presence of the patient, all 
 tend to instill fear of the outcome. "Hope is the most 
 powerful psychic stimulant known." 
 
 The improvement of the general condition depends 
 naturally upon the existing physical condition. The ro- 
 bust, well-fed prostatic needs no building up before 
 going to the operating table, while the emaciated, debil- 
 itated cancer patient should undergo intensive treat- 
 ment to improve the physical condition. In the latter 
 case forced feeding, with predigested or partly digested 
 food if necessary, phosphorus and arsenic as tonics, and 
 mild alcoholic stimulation should be employed. If the pa- 
 tient is nervous about the operation small doses of mor- 
 phine should be given for a day or two before the opera- 
 tion. The danger of morphine medication is its liability to 
 produce respiratory paralysis and this is obviated by add- 
 ing small doses of atropia. A dose of atropia, say 1/150 
 grain, should always be given before chloroform or either 
 anesthesia if there is senile emphysema or myofibrosis 
 or if morphine has been administered shortly before. It 
 should not be necessary to caution the surgeon about the 
 state of the stomach, bowels and bladder, yet cases have 
 occurred in which patients were almost asphyxiated or 
 in which a deglution pneumonia occurred from vomiting 
 the contents of the stomach during anesthesia when a 
 heavy meal had been taken shortly before the operation. 
 During deep narcosis there is relaxation of the sphincters 
 
SUEGEEY OF THE AGED 227 
 
 and if the bowels and bladder have not been emptied, 
 they will empty themselves. 
 
 Various measures have been recommended to prevent 
 shock during the operation or counteract it when it oc- 
 curs. In the aged shock is sometimes so great that sud- 
 den death occurs during the operation. When sudden 
 death does happen it is not possible to say that it was 
 due to shock or to cerebral, respiratory or cardiac paral- 
 ysis brought on by the anesthetic. Occasionally, there 
 will be signs of threatened collapse as cold sweat on the 
 forehead, ashy pallor, shallow respiration and a weak, 
 slow pulse. Any one of these should serve as a warning. 
 Cardiac, respiratory and cerebral paralysis usually give 
 no premonitory signs and the first sign of their occur- 
 rence is the sudden cessation of respiration or of the 
 pulse or else a convulsive stiffening of the body followed 
 by complete relaxation in death. The convulsive seiz- 
 ure points to cerebral paralysis and the immediate paral- 
 ysis of other vital centers. The cautious surgeon and 
 anesthetist have at hand means and measures to over- 
 come shock and threatened paralysis of the vital centers 
 but there is no known method of preventing cerebral 
 paralysis. When this occurs death follows in a few 
 seconds. 
 
 The postoperative dangers can usually be met suc- 
 cessfully but postoperative shock or collapse following 
 hours or days after the operation, perhaps after a period 
 of apparent convalescence, may occur in spite of every 
 precaution. Just what this collapse is due to, is un- 
 known. In one senile case sudden death occurred on the 
 twelfth day after an emergency operation for strangu- 
 lated hernia. The patient was making favorable prog- 
 ress, and the day before death he was permitted to sit 
 up in bed. He was found dead a few minutes after he 
 had gone to sleep. In a case of cancer of the rectum the 
 patient rallied after the operation but the next day be- 
 
228 GEEIATEICS 
 
 came weaker and two days later he died. A few hours 
 before, he appeared brighter and more cheerful than at 
 any time since the operation, made plans for the future 
 and seemed to be on the road- to recovery. The collapse 
 occurred while he was talking to the nurse. Apparent 
 improvement followed by collapse is not unusual in 
 senile cases which rallied after grave operations. 
 
 Secondary hemorrhage rarely occurs in senile cases, 
 and under modern aseptic precautions infection is also 
 rare. Uremia is another of the postoperative dangers 
 which can be neither foreseen, prevented nor cured. It 
 usually sets in with a persistent serous diarrhea but 
 some cases give no premonitory symptoms before the 
 final convulsions or coma preceding death. The urine 
 is diminished and shows a diminution in the amount of 
 urea excreted. Diuretics may increase the amount of 
 urine, but they will not increase the total amount of 
 urea and there is no known method by which the output 
 of urea can be increased. A slowly progressive uremia 
 generally ends in coma and a rapidly progressive uremia 
 ends in convulsions. Large doses of bromides given as 
 soon as the first slight twitchings appear may prevent 
 the more active convulsions but will not prevent the final 
 outcome. Chloroform inhalations have been employed 
 to relieve the severe convulsions, possibly hastening 
 death. Postoperative pneumonia, usually a broncho- 
 pneumonia, is especially liable to occur if there is a pul- 
 monary disease complicating the surgical condition, and 
 ether was used as the anesthetic. It may be due to the 
 intense irritation produced by the anesthetic, but most 
 cases are probably due to emboli causing infarction. 
 Like uremia it can be neither foreseen nor prevented, 
 and death usually occurs in a few hours or days. There 
 is no routine method of treatment, various measures hav- 
 ing been employed in the few recorded recoveries. Hypo- 
 static congestion is one of the few postoperative dangers 
 
SUKGEEY OF THE AGED 229 
 
 which can be foreseen and should be prevented. The ne- 
 cessity for frequently changing the position of the patient 
 in bed is so well understood that hypostatic congestion 
 seldom occurs. 
 
 The most frequent surgical condition requiring opera- 
 tion are prostatic disease and hernia in the male and can- 
 cer and gall stones in the female. Senile gangrene, cal- 
 culus, intestinal obstruction, fractures and cataract also 
 occur rather frequently in the aged. In addition to these 
 conditions requiring major operations there are many 
 minor pathologic conditions requiring surgical inter- 
 ference. Varicose veins, chronic ulcers, hemorrhoids 
 and bed sores all claim the surgeon's attention. Trau- 
 matic conditions, except fractures, are infrequent in the 
 aged, and appendicitis, perhaps the most frequent sur- 
 gical condition in the young, is very rare in advanced 
 life. 
 
 It is not possible to offer suggestions as to the advis- 
 able procedure where there are several measures, each 
 having its advocates and its opponents. In prostatec- 
 tomy, for example, there are some surgeons who adhere 
 to the one-stage operation, some who prefer the two- 
 stage operation, some who adhere to the perineal opera- 
 tion, some who use only the suprapubic method. Sta- 
 tistics are unreliable. The only safe rule is to let the 
 surgeon carry out the method with which he is most fa- 
 miliar, avoiding experiments and guarding especially 
 against shock and postoperative dangers. "Age is no 
 bar to surgical operations. ' ' But age carries with it 
 complicating factors which make operations more diffi- 
 cult and more dangerous than in earlier life. Not the 
 age of the patient but these complications must be con- 
 sidered when deciding upon the advisability of an opera- 
 tion. In every case where paliative measures will give 
 relief and promise little or no shortening of life such 
 
230 GEEIATKICS 
 
 measures should be employed in preference to grave 
 major operations. 
 
 One of the most difficult things in the aged is to select 
 the proper anesthetic, and if we possessed a satisfactory 
 method, our mortality rate would be much less. I have 
 used the nitrous-oxide-oxygen narcosis for the aged and 
 have never seen any bad effects from its use, and have 
 always felt if certain improvements could be made on 
 the apparatus for administering it we could perform 
 many major operations by its use. 
 
 Doctor F. A. Bardwell of Boston has devised an appa- 
 ratus combining several methods for administering 
 nitrous-oxide-oxygen in which he has eliminated the 
 bulky stand, making the attachments on any straight 
 back chair by means of a strap. His inhaler is unique 
 in that it combines several methods for administering 
 anesthetics. A Bennett bag is attached near the inhaler, 
 instead of two or three feet from the cone. The oxygen 
 tank is connected to the inhaler and not to the bag, so 
 that he can administer it at once if necessary without 
 mixing it with the nitrous-oxide. As there is no pressure 
 on the Bennett bag from the flow of gas into it, it is pos- 
 sible for the patient to rebreathe into the bag without a 
 loss of the gas, as occurs in the ordinary apparatus. 
 
 There is a frame within the inhaler which is covered 
 by gauze and there is an opening in the top of the cone 
 through which ether can be poured upon the gauze if 
 necessary. By a telescopic arrangement the bag can be 
 detached from the cone in order that the inhaler could 
 be used for ether narcosis. 
 
 Doctor Bardwell has found that a small amount of 
 ether, for example, a drachm or two, will give the desired 
 amount of relaxation for the surgeon, and at any time, 
 if there is rigidity of the muscles, this very small amount 
 of ether will give a result satisfactory to the surgeon. In 
 this way it is possible to operate upon strangulated her- 
 
SUEGEEY OF THE AGED 231 
 
 nia or in fact to perform almost any major operation. 
 Doctor Bardwell is obtaining some excellent results with 
 his method of administering nitrons-oxide-oxygen anes- 
 thesia and it apparently overcomes certain obstacles, 
 which makes it an ideal anesthetic for the aged, one which 
 is safe in almost every instance. 
 
 Novacain with suprarenin is a safe and satisfactory 
 local anesthetic for the aged, and is employed in a weak 
 solution, but a large amount is required. It may be used 
 for strangulated hernia or operations upon the testicle, 
 and may be used in combination with the nitrous-oxide- 
 oxygen narcosis, thereby preventing surgical shock. In a 
 woman, aged eighty-two, who had an extensive burn on 
 the arm, I applied a solution of novacain to the raw sur- 
 face before applying the dressing, which made the latter 
 painless. When novacain is combined with suprarenin 
 the effect lasts about three hours. Alypin is a satisfac- 
 tory local anesthetic in some cases, in fact some surgeons 
 have performed suprapubic cystotomy with its use. 
 Many surgeons employ alypin applied to the urethra be- 
 fore performing cystoscopy. 
 
 Strangulation of a hernia is very common in the aged, 
 and may be operated upon with nitrous-oxide-oxygen an- 
 esthesia with a very little ether, or under the influence 
 of a local anesthetic. Cocaine is a dangerous local anes- 
 thetic in the aged and novacain should be used in its 
 place. It is possible to resect the bowel with this method 
 if it is necessary. 
 
 The removal of a carcinoma of the gastrointestinal 
 tract in the aged is not often possible and if operated 
 upon and an obstruction is found an abdominal "anus" 
 becomes necessary. This is a horrible result and in most 
 cases death would be preferable to it. In some cases of 
 cancer of the stomach a gastroenterostomy has been per- 
 formed with excellent results. I had a patient, aged 
 seventy, who had a carcinoma of the stomach, with com- 
 
232 GEKIATKICS 
 
 plete obstruction. Gastroenterostomy was performed 
 and the patient is now living in comfort, a year after the 
 operation. 
 
 Eoentgenology assists ns a great deal in determining 
 the condition and also what surgical procedures will be 
 necessary. By this method many carcinomata will be 
 discovered in their incipiency. Gastric and duodenal 
 ulcers are not common in the aged and when they are 
 present they may undergo carcinomatous degeneration. 
 By means of the Eoentgen ray it is possible to diagnose 
 a pathologic gall bladder with or without stones, and 
 also the presence of renal stones. If there are gall stones 
 which are causing symptoms, cholecystotomy may be 
 the best procedure. Many cases of gall stones will be 
 confused with cancer of the liver, and a diagnosis will be 
 difficult. Courvoisier 's law is of much help in diagnosis : 
 deep jaundice associated with palpable enlargement of 
 the gall bladder means carcinoma; without distention of 
 the gall bladder it usually means stone. 
 
 Adenoma or carcinoma of the prostate may cause com- 
 plete obstruction, and immediate operation becomes 
 necessary. Even in some cases of this kind a large metal 
 catheter if held for sometime, especially with nitrous-ox- 
 ide-oxygen-ether narcosis to the point of relaxation, may 
 relieve the urinary obstruction. A large, flexible metal 
 catheter will sometimes work successfully when other 
 methods fail. If operation becomes a necessity, it is pos- 
 sible to perform it with nitrous oxide anesthesia, employ- 
 ing oxygen with it if there is cyanosis. A drachm or two 
 of ether with it will give the desired amount of relaxa- 
 tion. Suprapubic cystotomy may be performed under 
 local anesthesia if other methods are contraindicated. 
 
 From my chapter on Senile Gangrene it may be in- 
 ferred that it is not always necessary to make haste in 
 amputation for senile gangrene. In many instances ex- 
 pectant treatment is justified, free drainage may be made 
 
SUEGEEY OF THE AGED 233 
 
 and a wet dressing applied. In many cases of gangrene 
 of the toes if we wait several weeks before operating up- 
 on the patient the result will be better. While the 
 disease is in the active stage operation often hastens 
 death. One thing is certain, it is a very fatal con- 
 dition and we are justified in taking a chance in waiting 
 to see how far nature will go in taking care of the patient. 
 It is surprising what nature will do in many cases; the 
 great trouble is, we are too ambitious and do not give 
 her a chance. My case of senile gangrene is undoubtedly 
 an exception, but the patient made an excellent recov- 
 ery without surgery. It is advisable in our expectant 
 treatment, however, to be prepared at any moment for 
 amputation if the occasion demands it. If the patient 
 is a diabetic the outcome is usually fatal and we are justi- 
 fied in waiting until the active period has subsided be- 
 fore operating. If the nitrous-oxide-oxygen narcosis is 
 employed the result may be encouraging. If the cellu- 
 litis is extending, operation should be performed as 
 quickly as possible. 
 
 In some cases carbuncles will be cured without sur- 
 gical procedures by making multiple injections of an 
 antiseptic solution containing phenolic ethers and by 
 using a combined vaccine subcutaneously. Free incision 
 is advisable, however, and a cross-incision covering the 
 entire diameter of the carbuncle should be made. 
 
 I had an aged lady, seventy-five, who fell and had a 
 fracture of the neck of the femur as a result. This was 
 not corrected and no treatment by means of extension 
 apparatus was given. At the end of two months she was 
 in a chair, and after a few weeks in the chair she was 
 able to take a few steps with the aid of crutches. The 
 result of the fracture was not good, but she is able to 
 get around a little. On the other hand, I had a lady, aged 
 seventy-four, who had a fracture of the neck of the femur. 
 I gave more attention to the fracture than to her general 
 
234 GEEIATKICS 
 
 condition. She was tortured with painful extension ap 
 paratus with weight, and the pain caused by the treat- 
 ment required the use of opiates for relief. She died at 
 the end of the second week. 
 
 These experiments led me to believe that in many cases 
 where we try for an excellent result with the fracture, the 
 patient dies, while if the fracture is not treated vigor- 
 ously, and all the attention is concentrated on the gen- 
 eral health, we may get an excellent result physically 
 and a bad result with the fracture. Open operation 
 would hardly be advisable in the aged, and immobilizing 
 with plaster does not yield encouraging results. If the 
 patient is of unusual physique, it may be possible to per- 
 form open operation (either nailing or bone drilling) 
 but in most cases we must be content to keep the patient 
 in as good physical condition and be contented with get- 
 ting the patient about the best we can. More attention 
 should be given to the general health than to anything 
 else, and the patient should have massage and should be 
 moved as much as possible in bed. It becomes necessary 
 in time to force the patient out of bed, and in most cases 
 it is very painful at first. Later it becomes easier to get 
 into a chair and the patient can move a little without the 
 extreme pain experienced at first. 
 
 Senile epitheliomata are frequently operated upon and 
 the results in many cases are very encouraging. A great 
 many of these so-called " rodent ulcers" are in the tem- 
 poral region and are inoperable. Again, the operation is 
 oftentimes very mutilating. In my experience, radium 
 therapy has succeeded in the healing of senile epithelio- 
 mata to the extent of not making operation necessary in 
 most cases. In many cases the patient fails rapidly and 
 the epithelioma spreads after a surgical procedure of 
 this kind. Cancer of the tongue and larynx will yield to 
 radium therapy better than from surgical procedure in 
 most cases. Although radium does not act as well on 
 
SURGERY OF THE AGED 235 
 
 mucous surfaces as on the skin, the results in the mouth 
 and throat are encouraging provided large doses are em- 
 ployed. 
 
 Doctor Joseph Bissell (The International Journal of 
 Surgery, May, 1914) reports the case of a professional 
 man who had a rapidly growing epithelioma of the larynx. 
 The malignant growth returned after each operation and 
 his general condition became much worse and he was 
 sent back to his home in a distant city to die. About ten 
 or eleven months afterward he returned to New York, 
 stout, ruddy and a healthy looking individual. He said 
 that he was going back to resume his business, having 
 been cured by localized radium applications. He had 
 employed large doses, first using a tube containing fifty 
 milligrams of radium element placed in his larynx for 
 two hours, and he also had block applications of large 
 dosage of radium applied to the outside of his throat. At 
 one time as much as 961 milligrams had been used on 
 him for twenty hours. This case was an apparent cure of 
 cancer by the local use of radium. 
 
 Of great importance, a fact recognized by Doctor Rob- 
 ert T. Morris, is that we can not keep senile cases in bed 
 after surgical operations. In some cases it is advisable 
 to get the aged patient out of bed the next day after the 
 operation, no matter if it was a major operation. Ap- 
 pendicitis is very rare in the aged, but when present we 
 should have the senile patient in a chair the next day. 
 This rule applies to almost every operation upon the 
 aged. Senile patients will not do well in bed, and often a 
 patient who is failing rapidly will improve almost imme- 
 diately when he is allowed to get into a chair. The psycho- 
 logic effect of allowing them to get out of bed is excellent, 
 and they believe they will rocover. If we tell them they 
 will get better, they will not believe us, but if we show we 
 mean it by allowing them out of bed and also planning 
 things for them to do when they recover they are assured 
 
236 GEKIATKICS 
 
 of our good faith in telling them that they will recover. 
 It may not seem logical to allow them to get out of bed 
 the next day after an operation, but in treating the aged 
 we must make allowances that we would not make in 
 younger individuals. All senile patients fail rapidly 
 while in bed, so I have made a keynote in geriatrics to 
 "Keep Senile Cases out of Bed." 
 
^■^■HH 
 
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 Importance of Geriatrics, J. Am. M. Assn., Chicago, 1914, lxiii, 2248. 
 
 Lane's Autointoxication Complex and the Manifestations of Senility, 
 
 New York Med. Jour., 1914, c, 253-256. 
 Diagnostic Errors in Senile Cases Arch. Diag., New York, 1916, lx, 
 
 130-139. 
 
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INDEX 
 
 
 Accomplishments of some promi- 
 nent aged people, 31 
 Acidosis may be formed in uremic 
 coma, 186 
 rarely developed in senile dia- 
 betics, 132 
 Acute senile bronchitis, 144 
 Adenocarcinoma of the prostate 
 causing temporary conges- 
 tion, 159 
 Age, old, value of, 31 
 Aged, albuminuria in, 139 
 atmospheric influences on, 47 
 blood pressure in the, 100 
 bronchitis in the, 144 
 care of, 47 
 eyes in, 67 
 in institutions, 51 
 skins in the, 48 
 chancroid rare in the, 202 
 checking of excretions in the, 178 
 of hemorrhage in, 178 
 of secretions in the, 178 
 coal tar derivatives in treatment 
 
 of, 175 
 constipation in the, 89 
 cystitis in the, 167 
 dementia in the, 76 
 diabetes in the, 127 
 diagnostic errors in the, 183 
 diarrhea, danger of checking in 
 
 the, 180 
 diet in the, 84 
 edema from prostatic retention 
 
 in, 167 
 emotions in the, 75 
 enuresis in the, 167 
 exaggerate symptoms, 183 
 
 Aged — Cont'd 
 
 fistula-in-ano in the, 181 
 
 fractures in the, treatment of, 233 
 
 gangrene in the, 153 
 
 glycosuria in the, 139 
 
 gonorrhea rare in the, 199 
 
 hygiene in the, 47 
 
 mentality in the, 71 
 
 neglect of the, 27 
 
 nephritis in the, 118 
 
 pensions for the, 56 
 
 perspiration, excessive, in the 
 aged, 179 
 
 pneumonia in the, 148 
 
 postoperative dangers in the, 227 
 
 postoperative treatment in the, 65 
 
 prostatic hypertrophy in the, 158 
 
 psychic element of work in the, 
 53 v 
 
 recreation in the, 50 
 
 retention of urine in, 50 
 
 sexual life in the, 213 
 
 sleep in the, 49 
 
 surgery of the, 223 
 
 syphilis in the, 198, 199 
 
 therapeutics in the, 170 
 
 toxemia in the, 94 
 
 urinalysis in the, 138 
 
 urosepsis in, 167 
 
 use of opiates in, 174 
 
 value of, 31 
 
 venereal diseases in the, 198 
 
 work for the, 52 
 Albuminuria in the aged, 139 
 Alcohol, effect of, in the aged, 171 
 Amputation of forearm by gan- 
 grene, 154 
 Anatomic changes in the aged, 21 
 Anesthetic in senile cases requiring 
 surgery, 224 
 
 243 
 
244 
 
 INDEX 
 
 Aneurism, syphilitic, 114 
 Apoplexy, caused by too strong 
 heart action rupturing 
 blood vessels, 111 
 in the aged, 116 
 Arcus senilis, 69 
 
 Arteries, changes in, accompanying 
 old age make arteriosclero- 
 sis a normal senile pro- 
 cess, 111 
 Arteriosclerosis, 110 
 
 advanced, in case of angina pec- 
 toris, 114 
 blood pressure in, 102 
 enlargement of heart in, 113 
 premature, 112 
 Arteriosclerotic changes in retina, 
 
 normal in the aged, 69 
 Astigmatism, senile, 68 
 Atheroma, 114 
 
 Atmospheric influences, aged sus- 
 ceptible to, 47 
 Atrophy of cartilages, 22 
 
 B 
 
 Basal-cell carcinoma of left temple, 
 218 
 
 Baths in the aged, 48 
 
 Bed, keep senile cases out of, 63 
 senile surgical patients to be kept 
 out of, 235 
 
 Beer in old age, 85 
 
 Bile salts in constipation in the 
 aged, 92 
 
 Bladder, diseases of, in the aged, 
 167 
 
 Blood, impaired in aged, 25 
 pressure in senile cases, 100 
 pressure, tables of average, 107 
 
 Blue color of part before gangrene 
 has fully developed, 155 
 
 Bone, changes in, in aged, 22 
 
 Bowels, care of, in senile bron- 
 chitis, 147 
 
 Brain fag in the aged, 74 
 
 Bronchitis, chronic, may develop 
 from acute form, 145 
 senile, 144 
 
 due to influenza fatal in the 
 
 aged, 145 
 treatment of, 145 
 
 Calcareous degeneration and ar- 
 teriosclerosis of the ulnar 
 artery in old man, 110 
 
 Calories of food required in old age, 
 87 
 
 Carbuncles may be cured without 
 surgical intervention, 233 
 
 Carcinoma, senile, does radium 
 cure, 222 
 of the gastrointestinal tract, 190 
 of the prostate, radium in treat- 
 ment of, 165 
 prognosis of, under radium 
 
 therapy, 221 
 radium therapy in, 218 
 
 Care of the aged, 47 
 
 Cascara sagrada as remedy for sen- 
 ile constipation, 92 
 
 Catharsis, free, essential in ne- 
 phritis, 125 
 
 Cathartics for the aged, 91 
 
 Catheter life, avoided by treatment 
 of prostatic hypertrophy, 
 160 
 
 Chancroid, rare in the aged, 202 
 
 Cigar stimulates peristalsis, 90 
 
 Climacteric, senile, 204-213 
 
 Coal tar derivatives, use of, in 
 treating the aged, 175 
 
 Congestion, bronchitis accompany- 
 ing, 145 
 of internal organs compel heart 
 to carry on additional 
 work, 111 
 
 Conjunctival changes, senile, 68 
 
 Constipation, senile, 89 
 attention to diet in, 90 
 indirect cause of bronchitis, 146 
 
INDEX 
 
 245 
 
 Cystitis in the aged, 167 
 treatment of, 169 
 
 Deafness, senile, due to other 
 causes than the ears pri- 
 marily, 188 
 Debility, senile, therapeutics of, 173 
 Demarcation line in senile gan- 
 grene, 156 
 Dementia, senile, 76 
 Diabetes, senile, diagnosis of, 131 
 cases of, 127-131 
 diet in treatment, 134, 135 
 prognosis of, 131 
 symptomatology of, 131 
 treatment of, 133 
 simulating intestinal toxemia, 96 
 Diagnosis of senile nephritis, 123 
 of senile diabetes, 131 
 of senile pneumonia, 150 
 Diagnostic errors in the aged, 183 
 Diarrhea, danger of checking in the 
 
 aged, 180 
 Diastolic pressure in case of ne- 
 phritis, 100 
 varies in old age, 106 
 Diathermia treatments in senile 
 
 prostatic hypertrophy, 163 
 Diet in aged, 84 
 in nephritis, 124 
 in treatment of senile bronchitis, 
 
 147 
 lists, 85, 86 
 
 in treatment of senile diabetes, 
 134, 135 
 radical changes in, sometimes bad 
 in senile cases, 133 
 Diseases, venereal, in the aged, 198 
 Drugs, effect of, in the aged, 171 
 Dyspepsia in old age, 89 
 
 E 
 
 Edema from prostatic retention in 
 
 the aged, 167 
 Electrode, Monae Lesser rectal pros- 
 tatic, 163 
 Emotions, loss of control of in the 
 
 aged, 75 
 Enuresis in the aged, 167 
 Epistaxis in the aged, 179 
 Epithelioma, senile, radium therapy 
 
 for, 218 
 Epitheliomata, senile, operation 
 
 upon, 234 
 Erythrocytes in the urine, 141 
 Excretions, checking of, in the 
 
 aged, 178 
 Exercise in aged in preventing 
 
 toxemia, 48 
 in prevention of toxemia, 95 
 Eyes, care of, in the aged, 67 
 
 F 
 
 Female, sexual desire wanes after 
 menopause, 213 
 
 Fistula-in-ano in the aged, 181 
 
 Fractures, treatment of, in the aged, 
 233 
 
 Functions of organs and tissues im- 
 paired by anatomic 
 changes in aged, 123 
 
 G 
 
 Gangrene, amputation of forearm 
 by, 154 
 senile, 153 
 
 surgical treatment of, 156 
 
 Geriatrics, definition of, 21 
 
 Gleet, in the aged, 201 
 
 Glycerin suppository inserted in 
 rectum in cases of patients 
 weak from diseases prefer- 
 able to enemata, 91 
 
246 
 
 INDEX 
 
 Glycosuria in the aged, 139 
 senile, may be due to senile de- 
 generative changes and not 
 diabetes, 186 
 transient difference between dia- 
 betes and, 136 
 Gonorrhea in the aged, 199 
 
 H 
 
 Heart action, too strong, may cause 
 rupture of vessels causing 
 apoplexy, 111 
 enlargement of, in arteriosclero- 
 sis, 113 
 
 Hematuria in aged, not always in- 
 dicative of nephritis, 188 
 
 Hemorrhage, checking of, in the 
 aged, 178 
 
 Hepatic colic in the aged, 188 
 
 Heroin, effects of, in the aged, 171 
 
 History-taking in the aged, very un- 
 certain, 186 
 
 Hunger sense, not indication for 
 necessity of food in aged, 
 88 
 
 Hygiene in the aged, 47 
 
 Hypertrophy, senile prostatic, 158 
 
 Infection, danger of, increased in 
 
 diabetes, 132 
 Institutions, care of aged in, 51 
 Interstitial nephritis, errors in 
 
 diagnosing, 187 
 Intestinal toxemia simulating ty- 
 phoid, 185 
 starting point of nephritis, 121 
 Intestines as origin of toxemia, 96 
 Iodides and mercury in syphilis in 
 aged do not work as well 
 as in young, 199 
 
 K 
 
 Kidney of chronic interstitial ne- 
 phritis, 124 
 
 Kidneys, role played by, in arterio- 
 sclerosis, 113 
 
 Languid feeling first symptom of 
 
 nephritis, 122 
 Local anesthesia in surgery in the 
 
 aged, 225 
 
 M 
 
 Male climacteric, 213 
 
 Malignant growths of the prostate 
 
 causing congestion, 159 
 Malingering, senile, 192 
 Massage in the aged, 48 
 Meals, regularity of, essential in the 
 
 aged, 84 
 Meat as article of diet in old age, 
 
 84, 85 
 Medical neglect of the aged, 29 
 Medico-legal cases involving senile 
 
 dementia, 76 
 Memory in the aged, 72 
 Menopause, sexual desire wanes 
 
 after, 213 
 Mentality, senile, 71 
 
 Microscopic examination of urine, 
 
 141 
 Milk as food in old age, 84 
 Mimicry, tremor acquired by, 194 
 Monae Lesser rectal prostatic elec- 
 trode, 163 
 
 N 
 
 Neglect of the aged, 27 
 Nephritis as cause of increase in 
 blood pressure, 100 
 
INDEX 
 
 24' 
 
 Nephritis — Cont'd 
 due to syphilis, 122 
 prostatic hypertrophy accompany- 
 ing, 123 
 senile, 118 
 
 diagnosis of, 123 
 prognosis, 124 
 symptomatology, 122 
 treatment of, 124 
 Nitrous-oxide-oxygen anesthesia in 
 
 the aged, 230 
 Normal senile degenerative changes, 
 190, 191 
 
 O 
 
 Oil enemata in constipation caused 
 by rectal obstruction with 
 feces, 90 
 
 Old age (see Aged; also Senile) 
 value of, 31 
 
 Opiates, use of, in old age, 174 
 
 Organic matter, waste of, in aged, 
 22 
 
 Pain in the aged not a safe diagnos- 
 tic symptom, 184 
 
 Pathologic blood pressure, 104 
 processes in organs functionally 
 and anatomically changed, 
 26 
 
 Pensions for the aged, 56 
 
 Perspiration, excessive, in the aged, 
 179 
 
 Perversions, sexual, secret in aged, 
 216 
 
 Petroleum, use of, constipation, 91 
 
 Physiologic functional changes in 
 aged, 24 
 
 Pneumonia, postoperative, in the 
 aged, 228 
 senile, 148 
 
 Pneumonia, senile — Cont'd 
 diagnosis of, 150, 184 
 prognosis of, 150 
 symptomatology of, 150 
 treatment of, 151 
 Postoperative dangers in the aged, 
 227 
 treatment in the aged, 65 
 Presbyopia in the aged, 69 
 Prognosis of senile carcinoma un- 
 der radium therapy, 221 
 of senile diabetes, 131 
 of senile nephritis, 124 
 of senile pneumonia, 150 
 Prominent aged men and their ac- 
 complishments, 31-46 
 Prostatectomy, suffering after, 166 
 Prostatic hypertrophy accompany- 
 ing nephritis, 123 
 due to syphilis, 160 
 senile, 158 
 treatment of, 161 
 Psychic effect upon aged, of diag- 
 nosing conditions not pro- 
 ducing symptoms, 186, 189 
 element in keeping senile cases 
 out of bed, 64 
 of work in the aged, 53 
 Psychologic effect of allowing senile 
 cases to get out of bed, 235 
 Public neglect of the aged, 28 
 Pupil, senile, 70 
 Pulse rate in the aged, not good in 
 
 diagnosis, 184 
 Pyelitis simulating typhoid fever, 
 
 185 
 Pyuria, causes of, 141 
 
 Quinine in treatment of the aged, 
 175 
 
248 
 
 INDEX 
 
 Radium in treatment of carcinoma 
 of the prostate, 165 
 of epithelioma, 235 
 of senile prostatic hypertrophy, 
 165 
 technic of application, 220 
 therapy for senile epithelioma, 
 218 
 prognosis of senile epithelioma 
 under, 221 
 
 Rarefaction of bones in aged, 24 
 
 Reasoning power in the aged, 73 
 
 Recompense for work in the aged, 
 55 
 
 Recreation in the aged, 50 
 
 Recreations help retard senile men- 
 tal impairment, 83 
 
 Rectum, obstruction of, treatment 
 of constipation caused by, 
 90 
 
 Red blood corpuscles in urine points 
 to nephritis, 142 
 
 Renal colic in the aged, errors in 
 diagnosing, 188 
 insufficiency as consequence of ar- 
 teriosclerosis, 112 
 toxemia, chronic, cases repre- 
 senting, 118-121 
 
 Respiration, counting a necessity, in 
 diagnosis in the aged, 184 
 
 Retinal changes, senile, 69 
 
 Rheumatism in the aged, errors in 
 diagnosis, 189 
 
 Rhubarb tablet in treatment of con- 
 stipation in the aged, 92 
 
 Roentgenology in treatment of car- 
 cinoma, 232 
 
 S 
 
 Saline laxatives in treating consti- 
 pation in the aged, 93 
 
 Salvarsan, success of, in senile 
 
 syphilis, 199 
 Satyriasis, case of, in aged man, 216 
 Sclera in the aged, 70 
 Secretions, checking of, in the aged, 
 
 178 
 Secondary hemorrhage rarely oc- 
 curs in the aged, 228 
 Senile arteriosclerosis, mistake to 
 try to cure, 117 
 astigmatism, 68 
 bronchitis, 144 
 
 carcinoma, does radium cure, 222 
 cases, blood pressure in, 100 
 keep out of bed, 63 
 psychic element in keeping out 
 of bed, 64 
 climacteric, 204-213 
 
 drug treatment of, 210 
 conjunctival changes, 68 
 constipation, 89 
 debility, therapeutics of, 173 
 degeneration, occur in every or- 
 gan, 21 
 dementia, 76 
 diabetes, cases, 127, 131 
 epithelioma, radium therapy for, 
 
 218 
 gangrene, 153 
 malingering, 192 
 mentality, 71 
 nephritis, 118 
 pneumonia, 148 
 prostatic hypertrophy, 158 
 pupil, 70 
 
 retinal changes, 69 
 Septic infection in the aged, 225 
 Sexual life in the aged, 213 
 power in aged, unusual, may be 
 first symptom of senile de- 
 mentia, 217 
 recrudescence during senile cli- 
 macteric, 208 
 Shock, danger of, in surgery in the 
 aged, 225-227 
 
INDEX 
 
 249 
 
 Skin, care of, in aged, 48, 50 
 changes in aged, 22 
 disease having discharge, in the 
 aged, 180 
 Sleep, aged will deny, 183 
 
 required in old age, 49 
 Spinal anesthesia in the aged not to 
 
 be employed, 225 
 Stimulants essential in treating the 
 
 aged, 176 
 Strangulation of a hernia in the 
 
 aged, 231 
 Suprapubic cystotomy performed 
 under local anesthesia, 232 
 Surface sensitiveness, 196 
 Surgery in the aged, shock in, 225, 
 227 
 of the aged, 223 
 when indicated, 223 
 Surgical treatment of senile gan- 
 grene, 156 
 Symptomatology of senile diabetes. 
 131 
 of senile nephritis, 122 
 of senile pneumonia, 150 
 Syphilis as factor in fibrosis and 
 calcification, 114 
 senile, treatment of, 199 
 Syphilitic ulcers in the aged, 198 
 Systolic pressure in case of ne- 
 phritis, 100 
 
 Technic of application of radium 
 
 therapy, 220 
 Temperature, influence of, on aged, 
 
 47, 48 
 Therapeutics in the aged, 170 
 Tic douloureux, causes of, 190 
 therapeutics in, 172 
 
 Toxemia, cause of some mental dis- 
 turbances, rather than 
 cerebral arteriosclerosis, 
 115, 116 
 caused by absorption of internal 
 tumor, 96 
 by lack of exercise in the aged, 
 52, 53 
 in the aged, 94 
 treatment of, 98 
 Toxines, origin of, difficult to de- 
 termine, 96 
 Treatment in senile climacteric, 210 
 of acute senile bronchitis, 145 
 of cystitis, 169 
 of senile diabetes, 133 
 of senile gangrene, 156 
 of senile nephritis, 124 
 of senile pneumonia, 151 
 of senile prostatic hypertrophy, 
 
 161 
 of syphilitic tumor, 199 
 of toxemia in the aged, 98 
 postoperative, in the aged, 65 
 Tremor acquired through uncon- 
 scious mimicry, 194 
 Tuberculosis in the aged, errors in 
 
 diagnosing, 188 
 Typhoid fever, differentiation from 
 uremia, 185 
 intestinal toxemia simulating, 185 
 pyelitis simulating, 185 
 
 U 
 
 Urea test in senile cases, 140 
 
 Uremia, 113 
 a postoperative danger, 228 
 errors in diagnosis of, 185 
 
 Uremic coma may produce acidosis, 
 186 
 
 Urinalysis in the aged, 138 
 
!50 
 
 INDEX 
 
 
 Urine, microscopic examination of, 
 141 
 retention of, in aged, 50 
 Urosepsis in the aged, 167 
 
 Value of old age, 31 
 
 Venereal diseases in the aged, 198 
 
 W 
 
 Water, cold, glass of, in morning 
 stimulates peristalsis, 90 
 
 Weakness, first symptom of toxemia, 
 
 97 
 Will power, changes in, in the aged, 
 
 75 
 Wines in old age, 85 
 Work and recompense in the aged, 
 
 55 
 Women, famous accomplishment of 
 
 old age, 39 
 Work for the aged, 52 
 in old age, 45 
 psychic element in the aged, 53