GERIATRICS GERIATRICS 
A TREATISE ON THE PREVENTION 
AND TREATMENT OF DISEASES 
OF OLD AGE AND THE 
CARE OF THE AGED 
BY 
MALFORD W. THEWLIS, M.D. 
Editor, Medical Review of Reviews; Associate Editor, The Therapeutic 
and Dietetic Age 
WITH INTRODUCTIONS BY 
A. JACOBI, M.D., LL.D. 
AND 
I. L. NASCHER, M.D. 
SECOND EDITION, REVISED AND ENLARGED 
ST. LOUIS 
C. V. MOSBY COMPANY 
1924 Copyright, 1919, 1924, By C. V. Mosby Company 
(All Rights Reserved) 
Printed in U. S. A. 
Press of 
C. V. Mosby Company 
St. Louis TO 
I. L. NASCHER, M.D. PREFACE TO SECOND EDITION 
The text has been revised and several chapters have 
been added to the first edition, the most important of 
which are Electrotherapy, Opotherapy, Senile Heart 
Disease, Asthma, Emphysema, Influenza, Rheumatism, 
Pruritus Senilis and Hepatic Cirrhosis. 
Chronic diseases have minor symptoms which are ob- 
served several years before the disease becomes organic, 
if these symptoms could be properly interpreted at the 
beginning, many chronic diseases of old age could be 
prevented. Thus, the minor symptoms of Brightism 
usually appear ten or fifteen years before the disease is 
discovered, and a physician will seldom be wrong who 
studies them, they will attract his attention to the dis- 
ease. We must detect nephritis, diabetes, cancer, and 
other diseases when they first develop if we wish to ob- 
tain the best results. 
Opotherapy is one of our most valuable aids in treat- 
ing senile diseases and in preventing senile degenera- 
tions and although it was known to ancient Egyptians, 
it is now practically in its infancy. 
I am indebted to Professor Regaud and his as- 
sistants, Doctors Cesbron, Richard, Monod, and Lacas- 
sagne for the courtesies and valuable information given 
me at the Institute of Radium, Paris. 
That interest in Geriatrics is increasing is evidenced 
by the attention given to it by many medical authors. 
Research work will be carried on and in time there may 
be clinics established for the study of senile diseases, 
since we must acknowledge the fact that diseases of old 
age require as much special attention as diseases of 
children. 
9 PREFACE TO FIRST EDITION 
In 1860, when Doctor Abraham Jacobi began his first 
systematic course in pediatrics, very little interest was 
given by the medical profession to this specialty. It 
was a difficult matter to convince physicians that the ail- 
ments of children required special attention and treat- 
ment and Doctor Jacobi met many discouragements be- 
fore he succeeded in firmly establishing pediatrics as a 
special branch of medicine. As public interest in child 
conservation increased, medical interest in pediatrics in- 
creased, 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 tend- 
ency 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- 
cina Gerocomica, appeared in 1724. Our present knowl- 
edge of senile diseases is based upon Canstatt’s Krank- 
heiten des Hoherem Alters und Hire Heilung, which ap- 
10 PREFACE 
11 
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 important American book appeared until Nascher’s 
textbook Geriatrics, The Diseases of Old Age and Their 
Treatment made its appearance in 1914. It is a singular 
fact, showing the universality of medicine, that the late 
Doctor Abraham Jacobi, who, fifty years before estab- 
lished pediatrics as a special branch of medicine, wrote 
the introduction to Doctor Nascher’s work, the first com- 
plete textbook on the subject in the English language. 
My plan in this work is to give a clinical discussion 
of cases, not a textbook presentation of diseases. It is 
really a series of monographs, following the style of 
some French writers, who report cases and then discuss 
them. In this way, the textbook style is avoided, the 
personal views of the writer are presented, the discussion 
is in great part limited to the writer’s experience; there- 
fore, a mass of statistics is omitted. 
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: 
indeed, I had a patient thirty years of age who presented 
senile changes, including arteriosclerosis and calcareous 
degeneration of the arteries, without apparent cause. 
Had there been syphilis, plumbism, or some other causes, 
it would not have come under this head. Being appar- 
ently a case of precocious senility, it fell within the scope 
of geriatrics. Many persons at, or just past forty-five, 
present senile changes which should not appear until 
seventy or later. 12 
PREFACE 
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 of about fifty 
(age 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, The American Journal of 
Clinical Medicine, Urologic and Cutaneous Review, New 
York Medical Journal, and elsewhere. I am indebted 
to the x-ray department of the Boston Dispensary, and 
to Dr. Arial W. George, Boston, for the roentgenograms 
in this work. I am grateful to Doctor I. L. Nascher for 
his assistance in preparing this manuscript and to Doc- 
tor Horace Wilcox for valuable information on the sub- 
ject given to me during the several years that I have 
been associated with him. 
M. W. T. 
114 East 54th Street 
New York City INTRODUCTION 
By I. L. Nascher, M.D., New York 
Three incidents in my career led to the closer study of the se- 
nile organism and the introduction of geriatrics as a special 
branch of medicine. During my student days, 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 suf- 
fering from “old age.” “And what could be done for her?” 
“Nothing.” Suffering from old age and nothing could be done 
to relieve her suffering! Is old age, then, a disease from which 
those who had reached advanced life were doomed to suffer? 
This incident, as vivid today as it was nearly thirty-five years 
ago, laid the foundation for the branch of medicine to which I 
gave the name “Geriatrics.” 
In 1890 Seidel’s monograph Diseases of Old Age appeared. 
It contained the keynote of the subject in the following para- 
graphs : 
“Mistakes are made daily in the treatment of the aged and 
the normal mortality of advanced life is considerably increased 
as a result of the hitherto neglected study of the peculiarities of 
the senile organism.” This monograph epitomized what was 
then known of the diseases occurring most frequently in ad- 
vanced life, but it was altogether too short to serve as a hand- 
book. 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 and 
Loomis’ 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. Fothergill’s Diseases of Sedentary and Ad- 
vanced Life, 1885, was written for the layman as well as the 
physician, and like all such works it omitted the technical mat- 
13 14 
INTRODUCTION 
ter essential for scientific study. Seidel’s monograph gave hints 
and suggestions which could be used as themes for investigation 
and development but there was still lacking something upon 
which the superstructure of a new branch of medicine could be 
built. This was furnished fifteen years later in an apparently 
trivial remark made by the physician of a Home for the Aged 
near Vienna. 
In reply to my question to what he attributed the low death 
rate in his institution he said, “We deal with the aged inmates 
as aged persons just as the pediatrist deals with children.” 
This remark .amplified, gave me the basic principles of geriatrics. 
“Senility is a physiologic entity like childhood; not a patho- 
logic state of maturity.” “Diseases in senility are pathologic 
conditions in a normally degenerating body; not diseases such 
as occur in maturity complicated by degenerations.” “The 
object of treatment of disease in senility is to restore the dis- 
eased organ or tissue to the state normal in senility; not to the 
state normal in maturity. ’ ’ 
Upon these cardinal principles was erected the new branch of 
medicine. The introduction of a new specialty in the already 
overspecialized science of medicine was generally discouraged 
but a few physicians realized that there was a void in medicine, 
that geriatrics was a legitimate and necessary branch. Among 
the first of these physicians to recognize this was Malford W. 
Thewlis, the author of this work. Doctor Thewlis not only en- 
couraged me in my efforts to arouse medical interest in the 
aged and their diseases, but became a close observer of senile 
conditions, did research work, published a number of valuable 
articles and became associate editor of the Department of Geria- 
trics in the Medical Review of Reviews. Doctor Thewlis is to- 
day one of the few recognized specialists in geriatrics in this 
country. Spurred by scientific interest as well as by a deep 
sympathy for the aged, he has given to the medical profession in 
this work the result of many years of study in this neglected 
branch of medicine. INTRODUCTION 
By Abraham Jacobi, M.D., New York 
I have been called upon to introduce another book on the 
diseases of advancing and advanced years. The author does 
not mean to start a new specialty when enlightening us about 
the physiology and pathology of age, but, conversely, thinks that 
our American literature has been rather slow in directing the 
attention of our physicians to the ailments of the old. Some of 
us may have been of the opinion that we have been quite too 
generous in giving consideration to real or alleged specialties, 
for instance, the diseases of infants and children; but there is 
no doubt that certain parts of the maladies of advanced age have 
not been taught or studied to their full merit. 
Now with “infancy,” “childhood,” or “puberty” we connect 
a certain number of years and anatomic and physiologic altera- 
tions which are readily recognized, but in later life there is no 
change known by a certain number of years or changes recog- 
nizable as an epoch. Changes of bones of the same character 
may occur about any age without indicating a certain period of 
life. A “malum coxas 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. Respiratory 
variations, 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 
15 16 
INTEODUCTION 
advanced period of life. A “sepsis,” which we diagnosticate 
so readily, or ‘ ‘ neuritis, ’ ’ which we attribute to the old so often, 
must not be limited to individual epochs. Even a diverticulum 
does not wait for individual local changes or strictures; for at 
any age it may be met with and accompanied by dangerous 
symptoms. 
Maybe the student will do well to be prepared for certain 
changes in the course of a malady when his patient is aged; 
collapse is frequent though a fever is not marked. At that 
period in a feverish affection the temperature may be low. The 
practitioner must not forget that the slovenly way of taking the 
temperature of the body in the axilla or the mouth in a pneu- 
monia will never do when the rectum (or occasionally the va- 
gina) ought to be the only reliable access. Particularly is this 
important when the patient is a male. Infections usually turn 
readily to paralysis. Cerebral affections of the aged are liable 
to be fatal. Local symptoms about the lungs are sometimes 
quite few with little pain, little dullness and insufficient aus- 
cultatory changes. 
In the practice among the old, or the prematurely old, some 
symptoms should always be looked for, though they are rare. 
Such are chills, or pain in gout, or polyuria in diabetes. Some 
must be feared though they are rare, for instance, affections of 
the tonsils, or diphtheria, or maladies connected with the spleen. 
Some must be apprehended because they are frequent and fatal, 
such as bronchitis, which is apt to relapse and be complicated 
with pneumonia either sclerotic or catarrhal; renal disease, 
which is a frequent cause of death; influenza, which kills many; 
parenchymatous tumors or those complicated with concretions, 
or with pus, or with erysipelas. 
Tuberculosis is not at all rare in the aged. Tuberculous 
ulceration of the intestines is frequent. Tuberculous peri- 
carditis, meningitis, osteitis, and arthritis are not infrequent. 
Pulmonary tuberculosis has more of a fibrous than purulent char- 
acter ; 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 introduction 
17 
middle years. It is liable to destroy life before it reaches ad- 
vanced age; that is why it cannot be called a disease of the old. 
The question of the frequency of carcinoma is doubtful so long 
as its diagnosis may be questionable. Indeed we make more 
positive diagnoses of cancer than formerly in intestines, gall 
bladder, thyroid and prostate, and discriminate more correctly 
between sarcoma and carcinoma. Altogether the influence of 
trauma—for instance, phimosis, calculus, fistula, flexure, or 
lupus—on the early development of cancer is not great. 
Modern therapy may also have its influence on statistical 
statements. Roentgenotherapy has cured some carcinomata, 
and caused many. Radiotherapy has cured skin cancer in many 
instances; and the treatment of carcinoma with methyl thionin 
hydrochloride has proved successful at least in retarding the 
development of cancer in hundreds of my cases (Jour. Am. Med. 
Assn., 1906). 
My readers will feel sure that I am much interested in the 
subjects which form the studies of the author. My fragmentary 
remarks were to introduce a few of the schemes he means to 
teach us. I know he will succeed. 
G: tA^clrt^xl CONTENTS 
CHAPTER I 
PAGfi 
Geriatrics 25 
Anatomic Changes, Senile Degenerations, 25; Skin Changes, 26; 
Functional Changes, 29; Blood Impairment, 30; Pathologic Proc- 
esses, 31. 
CHAPTER II 
Neglect of the Aged 33 
Public Neglect of the Aged, 34; Medical Neglect, 35. 
CHAPTER III 
The Value of Old Age 37 
Famous Men and Their Accomplishments in Old Age, 37; Famous 
Women and Their Accomplishments in Old Age, 42; The Lesson 
from These Masters, 46. 
CHAPTER IV 
The Care of the Aged 48 
Hygiene, 48; Atmospheric Influences, 48; Exercise, 49; Sleep, 50; 
Skin, 51; Recreation, 51. 
CHAPTER V 
Work for the Aged 53 
The Psychic Element, 54; Work for the Aged, 55; Work and 
Recompense, 56; Pensions for the Aged, 57. 
CHAPTER VI 
Keep Senile Cases Out of Bed 60 
The Psychic Element, 61; Postoperative Treatment in the Aged, 
62. 
CHAPTER VII 
Senile Mentality 64 
Memory Impairment, 65; Reasoning Power, 66; Brain Fag,' 67; 
Emotions, 67; The Will, 67. 
CHAPTER VIII 
Senile Dementia ' 69 
19 20 
CHAPTER IX 
CONTENTS 
TAGE 
Diet in Old Age 77 
Regularity of Meals Essential, 77; Breakfast, 78; Luncheon, 79; 
Dinner, 79; Calorie Requirement, 80. 
CHAPTER X 
Senile Constipation ..." 82 
Dyspepsia in the Aged, 82; Enemata, 83; Cathartics, 84; Saline 
Laxatives, 85. 
CHAPTER XI 
Toxemia in the Aged 80 
Symptoms, 87; Treatment, 88. 
CHAPTER XII 
Blood Pressure in Senile Cases 92 
Pathologic Senile Pressure, 96; Normal Senile Pressure, 96; 
Tables of Average Pressure, 98; Conclusions, 99. 
CHAPTER XIII 
Arteriosclerosis 102 
Normal Process in Senility, 104; Premature Arteriosclerosis, 105; 
Pathologic Arteriosclerosis, 106. 
CHAPTER XIV 
Senile Heart Disease 112 
The Normal Senile Heart, 112; Nephritic Heart, 113; Syphilis as 
a Cause, 114; Senile Myofibrosis, 114; Treatment, 116. 
CHAPTER XV 
Senile Nephritis 122 
Cases, 122; Symptomatology, 124; Diagnosis, 127; Prognosis, 
127; Treatment, 127. 
CHAPTER XVI 
The Complications of Senile Nephritis 133 
Causes, 133; Minor Symptoms of Brightism, 134; Localized 
Uremia, 136. 
CHAPTER XVII 
Syphilitic Nephritis 140 
Causes, 141; Urinary Findings, 142; Treatment of the Acute 
Form, 144; Syphilo-Brightism, 145; Senile Syphilitic Nephritis, 
146; Treatment, 147. CONTENTS 
21 
CHAPTER XVIII 
PAGE 
Senile Diabetes 148 
Cases, 148; Symptomatology, Diagnosis and Prognosis, 15*1; 
Treatment, 154; Diet List, 155; Conclusions, 157. 
CHAPTER XIX 
Senile Rheumatism 159 
Cases, 159; Forms of Rheumatism, 161; Nephritis and Rheuma- 
tism, 163; Diabetes as a Cause, 164; Treatment, 165; Diet List, 
166. 
CHAPTER XX 
Urinalysis in the Aged 169 
Albuminuria in the Aged, 170; Glycosuria, 170; Microscopic Ex- 
amination, 171. 
CHAPTER XXI 
Senile Asthma 174 
Causes, 174; Prognosis, 176; Treatment, 179. 
CHAPTER XXII 
Senile Emphysema 186 
Causes, 186; Symptoms, 187; Prognosis, 188; Treatment, 188. 
CHAPTER XXIII 
Senile Bronchitis 190 
Cases, 190; Acute Bronchitis, 191; Chronic Bronchitis, 191; 
Treatment, 192. 
CHAPTER XXIV 
Senile Pneumonia 194 
Cases, 194; Symptomatology, 195; Diagnosis and Prognosis, 196; 
Treatment, 197. 
CHAPTER XXV 
Senile Gangrene 199 
Cases, 199; Treatment, 204. 
CHAPTER XXVI 
Senile Chorea 206 
Case, 206; Chorea Gravis, 207; Nephritis and Senile Chorea, 208; 
Habit Chorea in Institutions, 209; Treatment, 210. 
CHAPTER XXVII 
Pruritus Senilis 212 
Causes, 212; Anatomy of the Skin, 214; Treatment, 215. 22 
CONTENTS 
PAGfi 
Senile Prostatic Hypertrophy . 221 
Cases, 221; Etiology, 222; Symptoms, 222; Treatment, 224. 
CHAPTER XXIX 
Functional Recuperation for Senile Paralysis 231 
CHAPTER XXX 
The Curability of Hepatic Cirrhosis and Ascites 240 
Types, 241; Milk Diet, 244; Use of Hepatic Extract, 246. 
CHAPTER XXXI 
Therapeutics * 248 
Tic Douloureux, 250; Senile Debility, 250; Use of Opiates, 251; 
The Use of Coal Tar Derivatives, 252; Hemorrhoids, 254; Cys- 
titis, 256. 
CHAPTER XXXII 
Opotherapy 258 
History, 258; Thyroid Extract, 259; Renal Extract, 263; Hepatic 
Extract, 268; Suprarenal Extract, 268; Pituitary Extract, 269; 
Prostatic Extract, 270; Extract of Bile, 271; Gastric Extract, 
271; Extract of Myocardium, 271; Pancreatic Extract, 272; 
Method of Manufacture, 272. 
CHAPTER XXXIII 
Electrotherapy in the Aged 277 
Methods of Treatment, 277; Cases, 279; Senile Debility, 286; 
Neuritis, 286; Diathermia, 288. 
CHAPTER XXXIV 
Alcohol as a Remedy 295 
Indications, 295; Rules for Administration, 298. 
CHAPTER XXXV 
Influenza in the Aged 300 
Symptoms, 300; Complications, 302; Treatment, 304. 
CHAPTER XXXVI 
The Checking of Hemorrhage, Secretions and Excretions in the 
Aged 308 
CHAPTER XXXVII 
Diagnostic Errors in the Aged 313 
Pain, 313; Counting Respiration, 314; History-Taking, 316. 
CHAPTER XXVIII CONTENTS 
23 
, PAGE 
Senile Malingering 320 
Examination, 321. 
CHAPTER XXXIX 
Syphilis Contracted After Sixty Years of Age 326 
General Considerations, 326; Treatment, 331. 
CHAPTER XL 
The Senile Climacteric: A Typical Case 335 
CHAPTER XLI 
Sexual Life in the Aged 343 
CHAPTER XLII 
Radium Therapy in Senile Cases 357 
Precancerous Lesions, 358; Epithelioma of the Skin, 358; Cancer 
of the Tongue, 361; Epithelioma of the Lips, 366; Epithelioma 
of the Rectum, 366; Cancer of the Uterus, 367; Biologic Studies 
in Radium therapy, 367. 
CHAPTER XLIII 
Surgery of the Aged 369 
Indications and Contraindications, 369; Anesthesia, 371; Post- 
operative Dangers, 373; Roentgenology, 377. 
Bibliography 382 
Index 389 
CHAPTER XXXVIII 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 
at all or is replaced by tissue of a different character. 
25 26 
GERIATRICS 
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 wasted muscular tissue is replaced by fat, in 
some cases by fibrous tissues and in others the waste is 
not atoned for. Muscles actively employed usually 
waste, but the most active of all muscles, the myocar- 
dium, generally undergoes fibrosis. In brown atrophy, 
the cardiac muscle undergoes the same change that oc- 
curs in other solid organs in old age, but this form of 
senile cardiac degeneration is rare. Inactive muscles 
usually undergo fatty degeneration. 
In bone the organic matter wastes, leaving an excess 
of mineral matter and causing the bone to become more 
brittle. The waste of the organic matter in the heads 
of long bones produces a spongy condition, or osteoporo- 
sis. Bone marrow becomes harder, denser, and whiter 
and contains more fat than in young persons. Carti- 
lage either wastes through insufficient repair, becomes 
fibrillated and wastes through attrition, or becomes 
fibrous or osseous. Ligaments and tendons waste, con- 
tract and become stiff and hard. The synovial sacs be- 
come dry and the sac-covering dry and thick. These 
changes in the structure of the joint cause a stiffening 
with diminished motility—a condition designated as 
‘ ‘ arthrosclerosis. ’ ’ 
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 
there has been a waste of fat, as on the forehead, neck, GERIATRICS 
27 
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. 28 
GERIATRICS 
Fig. 2. 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 of the bones,a characteristic of 
old age. 29 
GERIATRICS 
etc. The hair becomes gray and thin, with an occasional 
excessive growth in unusual 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 con- 
sequent dilatation of the organ or tube, and where glands 
are embedded in the walls as in the stomach and 
intestines, they atrophy. In solid organs, as the kidneys, 
liver, pancreas, and spleen, the tissue cells atrophy and 
there is a proliferation of connective tissue fibers con- 
stricting the organ, making it smaller and denser. The 
spleen is thus often reduced to nearly half its usual size. 
The smaller glands atrophy and their secretions are 
diminished. In a few instances organs and tissues do 
not follow the usual course. The prostate gland is usu- 
ally enlarged through excessive proliferation of fibrous 
connective tissue. The ureters undergo fibrosis and be- 
come stiff and hard and the blood vessels become harder 
through waste of muscular fibers and their replacement 
by fibrous tissue. The heart is usually hypertrophied, 
but this is a compensatory and not a degenerative con- 
dition. The sudoriparous glands atrophy, but in some 
locations as in the axilla, in the groin, etc., there is 
excessive perspiration which has a fetid odor. In the 
lungs, the constant inhalation of dust produces pneu- 
monokoniosis and the waste of tissue causes a thinning 
and later complete waste of the walls of the alveoli, air 
cells coalesce and emphysema is produced. The blood 
changes so far recognized are, diminished amount, in- 
creased viscosity and density and increased hemoglobin 
content. 
As a result of the anatomic changes, the functions of 
the organs and tissues are altered, but the functional 
changes do not always correspond to the anatomic 
changes, owing to the hardening of the blood vessels 
and their lessened elasticity. The amount of blood car- 30 
GERIATRICS 
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, 
physical debility is usually far greater than can be ex- 
plained by the wasted muscles or the anatomic changes 
that can be recognized in the nerves or nerve terminals. 
The pronounced physiologic functional changes are 
lessened activity, altered activity, and loss of the har- 
monious interrelation between associated functions. 
The circulation is maintained with difficulty as the ves- 
sels have lost their elasticity and the compensatory in- 
creased activity of the heart is expended in the larger 
vessels and is lost in the smaller peripheral arteries. 
Owing to the atrophy of the muscular fibers of the veins 
and the consequent dilatation and loss of tonicity of the 
veins, the return circulation is impaired and the general 
circulation weakened. At the same time the tissues in- 
volved in the nervous system degenerate and nerve con- 
trol is affected. As a result of the nervous and cir- 
culatory changes, organs and tissues are insufficiently 
nourished, they degenerate, their functions are weak- 
ened, and in some cases altered while the harmonious 
interaction of functions is broken. The respiratory 
capacity is diminished, the amount of air inhaled is in- 
sufficient to completely oxygenate the blood, the carrying 
capacity of the blood, the nutrition of the organs and tis- 
sues are lessened, and waste increased. Geriatrics 
31 
The blood is now incapable of completely repairing 
the lung tissue and consequently lung degeneration is 
hastened, this still further impairs the oxygenating 
power of the lungs. In like manner vicious circles are 
created throughout the organism. The muscular fibers 
of the rectum atrophy, permitting a dilatation of the 
lower bowel. This allows a larger amount of fecal mat- 
ter 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 
still further stretched and further waste and atony en- 
sues with greater distention. Prolonged retention of 
feces with consequent decomposition and absorption of 
toxins produces intestinal toxemia with its train of symp- 
toms 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, pref- 
erential 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 
which occur most frequently in advanced life but may 
occur earlier. Such diseases as paralysis agitans, dia- 32 
GERIATRICS 
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 proclaiming a cure when they have 
succeeded in reducing the blood pressure temporarily. 
Through drugs and other means they will stimulate func- 
tions and congratulate themselves that they have caused 
rejuvenation, when in fact the temporary stimulation 
will be followed by a reaction in which degeneration pro- 
ceeds more rapidly. Drugs and other therapeutic meas- 
ures do not act upon the degenerated tissues in the same 
manner as they do upon the healthy or diseased tissues 
of maturity. Doses are reduced without rule or system 
when most drugs must be given in increased doses. 
Drugs are given which are not assimilated or which pro- 
duce in the senile organism more pronounced secondary 
effects than in earlier life. Inability to recognize these 
factors in the treatment of disease in senility is another 
cause of frequent failure to cure senile patients. CHAPTER II 
NEGLECT OF THE AGED 
That the aged are neglected is very evident. There 
are hundreds of books, journals, and societies devoted to 
the welfare of the child and their 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. This also ap- 
plies to the clothing, sleep, exercise, recreations and to 
every other factor in the lives of aged individuals. 
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 do younger 
ones, perhaps diminishing doses of drugs, without sys- 
tem-or reason. When the patient dies under such treat- 
ment the physician eases his conscience and satisfies the 
family by ascribing death to “old age.” But the con- 
scientious physician who is imbued with the scientific 
spirit is not satisfied with this diagnosis. Old age is not 
33 34 
GERIATRICS 
a disease, and ordinarily it is not a cause of death. 
Death from old age is conceivable. Sometimes there 
will be a gradual degeneration of all the organs and tis- 
sues and their functions will become more and more im- 
paired, cerebral activity and nervous and muscular ir- 
ritability will gradually diminish to the point of complete 
extinction. This is, however, exceedingly rare. It is 
far rarer than vital statistics indicate since many deaths 
ascribed to old age are due to disease which the physi- 
cian did not recognize, or, finding symptoms and signs 
which he could not interpret, he resorted to the diagnos- 
tic placebo, “old age.” 
We can readily account for the public neglect of the 
aged. Human sympathy is universal in its scope, but 
not in its application. Instinctively or subconsciously, 
economic values, social relations, the esthetic sense and 
other factors influence the directions in which sympathy 
is applied. The aged become economically worthless 
and must remain so, while the child has a prospective 
and ever-increasing economic value. Optimistic philos- 
ophers of all ages from Cicero to Jean Finot describe old 
age as being beautiful, but no philosopher has ever de- 
clared that the aged themselves were beautiful. From 
the purely esthetic standpoint the aged are disagreeable, 
often repulsive, and fail to arouse sympathy as long as 
they are not altogether helpless or in distress; from them 
may emanate disagreeable odors, offensive actions; they 
may be justly accused of peevishness, selfishness, wil- 
fulness, suspicion, etc. One or another of these repel- 
ling forces exists in almost every case and overcomes 
sympathy and interest. We find, consequently, that 
there is a universal tendency to shift the responsibility 
and the care of the aged upon others, usually upon the 
community at large. Individuals usually take an inter- 
est in their own, though this interest is often more duti- NEGLECT OF THE AGED 
35 
ful than filial but sympathy for the aged, which is essen- 
tial to their welfare, is altogether lacking. 
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 difference 
between maturity and senility and has devoted himself 
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 so 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 why 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 devote fbeir time and mental efforts to this study 
when other fields giving greater assurance of success 
are open to them, and yet there are problems connected 
with geriatrics, which, if solved, would make this branch 
perhaps as spectacular, as remunerative and as success- 
ful in immediate results as any other branch of medi- 
cine. May there not be causes of ageing which can be 
controlled or minimized, thereby prolonging life? May 36 
GERIATRICS 
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, problems which if solved would revolutionize 
the medical care of the aged, as the solution of the etio- 
logic problem of tuberculosis revolutionized the whole 
science of medicine. Within the memory of old physi- 
cians pediatrics was looked upon as a medical fad. To- 
day 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 thousands of 
young lives. The study of geriatrics gives the same 
promise in regard to the aged. It requires only the 
thoughtful consideration of the underlying principles 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. 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 him encouragements to mas- 
ter his old age. 
A careful analysis, however, will show us that some 
of the greatest works in art, music, poetry, and science, 
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 as it is. 
To “remain 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 key- 
note 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: 
“When a man is old he must do more than when he is 
young.” Emerson: “The high prize of life, the crown- 
ing fortune of a man is to be born with a bias to some 
pursuit, which finds him employment and happiness.” 
It seems, then, that the accomplishments of these old 
persons depend upon their ability to “stay in the har- 
ness.” Many an old man is living today who owes his 
life to occupation. Many old men are our resources of 
knowledge; 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 
37 38 
GERIATRICS 
from the presence of the other. It is incorrect to say 
that the old should step aside in order to give 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 Lyndliurst, when over 
ninety, spoke in the House of Lords. 
Goethe worked until he was past eighty years, his in- 
tellect remained intact and he retained 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 could only write a few paragraphs a day, but 
little by little his great works were written. He was a 
great sufferer for over forty years yet he produced 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 
after three-score years, and one of his most important 
works was not completed until he was eighty-nine years 
old. 
Carlyle refers to the slow development of a rich nature. 
He did not publish any of his great works before he was 
forty years old. The first two volumes of Frederick the THE VALUE 01? OLD AGE 
39 
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 said that ho found he could learn twice 
as easily as in his earlier days, the reason being that he 
had an increased power of concentration. Longfellow 
at forty-eight wrote Hiawatha. After that his writings 
were prolific. At sixty-eight years of age he wrote Mor- 
ituri Salutamus which was written for the fiftieth an- 
niversary of his graduation from Bowdoin College. 
Washington Irving was sixty-six when he wrote the life 
of Oliver Goldsmith. His Life of Washington in five 
volumes was completed only during the year of his death 
at seventy-six years of age. At seventy-five, Dr. S. 
Weir Mitchell was still in active practice and his literary 
labors were in evidence. 
Thomas H. Benton, Senator from Missouri when 
seventy-two years old, was defeated for his -sixth term. 
He started a new life and began a political review of all 
parties from the time of John Quincy Adams to Franklin 
Pierce. Theodore Roosevelt, 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.” 
James Russell Lowell was once passing a great build- 
ing in London which bore the inscription “Home for 
Incurable Children,” whereupon he said to a friend, 
“They’ll take me there some day.” 
It has often been said that Oliver Wendell Holmes 
never had an unhappy 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 40 
GERIATRICS 
was elected Chaplain to the United States Senate. Like 
Emerson’s, his home sheltered many of the world’s liter- 
ary men, who received great stimulation and pleasure in 
his company. 
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 of Horace 
Greeley of the Tribune, Charles A. Dana of the Sun, 
Samuel Bowles of the Springfield Republican, and 
William Cullen Bryant of the Evening Post. These 
editors did a great deal of their best work in their ad- 
vancing years and left a press standard that makes our 
newspapers substantial today. 
Gladstone 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 appar- 
ently no end to his capacity for work, and it has been 
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.” Gladstone lived a simple life and was said 
to have, like Horace Fletcher, masticated his food many 
times before swallowing. He walked a great deal and 
even after his seventieth year 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 governments. He tells of the blind 
Dandolo 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 at the age 
of ninety-seven. 
Daniel Huntington, famous artist who made fine por- 41 
THE VALUE OF OLD AGE 
traits of Lincoln, Grant, Agassiz, Bryant, etc., at the age 
of eighty-seven was still very active in his excellent 
work. 
King Christian of Denmark at eighty-six ruled his 
kingdom with a strong hand. Admiral George Dewey 
was sixty-one when he won the honors at Manila Bay. 
John Hay was sixty-four before he became world re- 
nowned as a diplomat. 
William Cullen Bryant, the famous American poet 
and journalist, remained “in the harness” until his 
death at the age of eighty-nine. Because of his remark- 
able activities few realized his advanced age and his 
death was a great shock to the world. His theory of 
growing young gracefully is well worth reading: 
“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 42 
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 touch 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. 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. 
Famous women who have accomplished some of their 
best works in their old age would make a long list. Mrs. 
Russell Sage, born in 1828, showed great fitness and 
wisdom in her philanthropic work. Mrs. Doremus, THE VALUE OF OLD AGE 
43 
mother of Professor R. Ogden Doremus, at an advanced 
age, spent her evenings in charitable and philanthropic 
labors. Dr. Elizabeth Blackwell, born in 1821, with her 
sister Emily, founded the Women’s Medical College. 
Rev. Antoinette Louis Brown Blackwell, a leading Uni- 
tarian preacher, in her contributions showed that her in- 
tellect increased instead of decreased with her advanc- 
ing 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 fa- 
mous persons of past years. I will devote the remain- 
der of the chapter to famous old people who are living 
or who died recently. 
Doctor Abraham Jacobi, the Nestor of American Med- 
icine, was in active practice past the age of eighty-seven 
after having practiced over sixty-three years. He re- 
mained exceedingly keen and his advice was sought by 
many. His memory was remarkable and he was able 
to remember names and dates with the greatest accuracy. 
His life was one of very hard labor and retained to the 
last the great determination that had been his charac- 
teristic. 
Doctor Stephen Smith, who died recently, was nearly 
one hundred years old. He was an active figure in life 
until a few years before his death. 
Doctor Beverley Robinson, at the age of 78, is active 
and writes on various medical subjects. 
Doctor William W. Keen, a major in the Medical Re- 
serve of the United States Army at eighty, is one of the 
greatest surgeons of the world and his system of Sur- 44 
GERIATRICS 
gery was written when he was past the age of seventy. 
Joseph H. Choate did a great deal of his best work 
past his seventieth year. Chauncey Depew, active at 
the age of eighty-six, has been a leading figure in life. 
Cardinal Gibbons at the age of eighty-four was one of 
the great men of the world. 
Frank B. Sanborn died at the age of eighty-six. This 
famous journalist and biographer of John Brown was 
active 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. 
Charles W. Eliot at eighty-six delivers lectures on 
educational and scientific subjects. He has done 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, past eighty, probably writes the best 
English of any living man, at the age of sixty-five he 
wrote his Life of Gladstone. He has been in political 
activities since past his fifty-fifth year and at the age of 
sixty-six was appointed Secretary of State for India. 
Sir Robert Laird Borden, Sir Wilfred Laurier, George 
Brandes, the Danish author, Herbert H. Asquith, Vis- 
count Bryce, General JoffTe, Washington Gladden, Ly- 
man Abbott, William Dean Howells, Moorfield Storey, 
John Burroughs, Henry Cabot Lodge, James B. Angell, 
Andrew Carnegie, Simeon E. Baldwin, John W. Foster, 
George F. Edmunds and many others accomplished a 
great deal in the latter part of their lives. 
Elihu Root is a figure in American diplomatic circles 
and was president of the New York Bar Association at 
the age of sixty-four. 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 revolu- 
tion. 
Georges Clemenceau, for many years one of the most THE VALUE OF OLD AGE 
45 
forceful figures in French public life, returned to active 
work for the government during the War. He is called 
11 The Tiger ’ ’ and his methods in dealing with labor trou- 
bles have been very drastic. Clemenceau is eighty years 
of age and he is still very active, as shown by his tour 
of the United States. Some time ago he was wounded in 
the chest by a man who attempted to assassinate him 
and the bullet has not been removed. 
Auguste Eodin, famous sculptor, at seventy-seven, 
was still too young to die. Art and life needed the 
supreme inspiration of his genius. 
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 Dr. Crockett, every man 
at eighty can be an athlete if he cares to. Some of the 
feats he has accomplished during the past few years are 
the following: Swam across Boston bay; taking a dip at 
L street in midwinter; walked twenty-five miles in a lit- 
tle more than six hours; put up a thirty-pound dumb-bell 
385 times; stands with arms outstretched horizontally 
for half an hour. Doctor Crockett is practically a vege- 
tarian, very little meat entering into his diet. Most men, 
he says, dig their graves with their teeth. 
We have no better example today of the value of old 
age than in the life of our greatest inventor, Thomas A. 
Edison. At the age of seventy, during the Great War, 
he designed, built and operated several benzol plants and 
was made chairman of the Naval Advisory Board. 
Even though he is deaf, he conducted the meetings of the 
board, and it is said, by a secret telegraphic code given 
him by his assistant, of a finger tapping on his knee be- 
neath the table, enabled him 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 46 
GERIATRICS 
working. His greatest pleasure in life is work and he 
does 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. When his laboratory burned to the ground and 
he lost 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 and have a good laugh. He 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 di- 
version he is ready to resume his work. 
The object of this chapter on the value of old age is 
not, however, to review the work of old persons but to 
show that old age is more beautiful and fruitful than 
we ordinarily think. An inference could be drawn from 
these examples that the riper 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 bene- 
fit of the years of experience that those of advanced 
age have. The purpose of this monograph is to stimu- 
late physicians to look upon old age as a thing worth ac- 
quiring and to stimulate the aged to carry on their work. 
Many old persons have given years of thought to some 
subject yet it has not been developed because they lacked 
encouragement. At the age of eighty, many men have 
not the determination to bring out a book, yet with as- 
sistance this could be accomplished and the world might 
be richer for it. 
The Lesson From These Masters 
On first thought a person might 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, THE VALUE OF OLD AGE 
47 
but brings out what I believe is the most important se- 
cret of geriatrics, that is, keep the aged at work. 
“Staying in the harness’’ is the real secret of bringing 
about the best results from aged minds. Psychologi- 
cally, too, “staying in the harness” keeps their minds 
from lingering on the senile death warrant “old age,” 
and the responsibility of work helps them beyond meas- 
ure. 
Attention to the aged, appreciation of their accom- 
plishments, has a wonderful effect upon them. It stimu- 
lates 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 there is in seeking 
counsel from older physicians, lawyers and other men 
with years of thought stored in their brains, in being 
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 many ways. CHAPTER IV 
THE CARE OF THE AGED 
I will 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 person. Self-preservation is the first law of nature 
and almost every one desires to prolong his life. Metch- 
nikoff said 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, Metchnikotf 
himself died at an age of about seventy. There are 
many other things that enter into longevity, among them 
being 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 an American life, they 
would probably die younger. The habits of life and the 
influence of external factors do a great deal more to de- 
termine a man’s existence than anything else. Regular 
habits of living are essential to the well-being of old 
people. Few aged men enjoy the slight benefits to be de- 
rived from changing their mode of living, and a change 
in their habits may bring disaster to them. 
Old persons are very susceptible to atmospheric influ- 
ences. The sources of their own temperature are dim- 
inished 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 ap- 
propriate repair. Most old people have cold hands and 
feet and in general they are obliged to wear warmer 
48 THE CAKE OF THE AGED 
49 
clothing than younger persons. Flannel or woolen ma- 
terials may be worn with advantage three-fourths of the 
year if the person is susceptible to cold. The aged fre- 
quently suffer from the cold at night and if this is dis- 
tressing to them, they should have an 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. The aged should be especially careful in win- 
ter and any slight infection should be promptly taken 
care of by a physician. If the patient is able to travel, 
a winter in the South is often beneficial. When the most 
opulent of the Romans grew old they were sent to 
Naples. 
Proper care of the skin is essential. Regular baths 
and massage are necessary. A tepid bath is excellent in 
its effect. After the bath, friction 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-six, who takes a 
Turkish bath once a week. He says it revives him and 
it apparently has some effect in relieving bronchial con- 
gestion. 
Exercise is one of our best methods of preventing in- 
testinal toxemia in the aged and in a great many cases 
will relieve it. An old man gives up his work and sits all 
day in a warm house, the lack of exercise in itself 
will cause many symptoms. Many times I have forced 
old persons to walk and busy themselves in their homes 
and when possible, advised them to do something involv- 
ing a little responsibility, such as gardening or taking 
care of an estate. The best time for walking and other 
exercise is after breakfast, and short periods should be 
selected as the aged easily get fatigued if they do one 50 
GERIATRICS 
thing too long. After luncheon a short stroll will ward 
off sleepiness. 
It is difficult to say how much sleep an aged person re- 
quires because each one is a rule unto himself. In gen- 
eral the aged do not require as much sleep as younger 
persons, they are apt to retire early at night and arise 
early in the morning. In many instances eight hours’ 
sleep is sufficient, and many require even less. 
The aged 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 asleep. The noise of 
my entering the room caused her to awaken and when 
she saw me she demanded a hypodermic of morphine and 
denied that she had been sleeping. Many physicians 
have been deceived into giving morphine for this condi- 
tion of apparent sleeplessness, but if the cases were care- 
fully analyzed, physicians would probably find that many 
old patients fall asleep in a chair during the day and 
when they retire at night, naturally, cannot sleep. In 
cases of this kind I usually prescribe a placebo and ex- 
ercise, especially after meals, and perhaps give them a 
glass of wine upon retiring. A little milk with whiskey 
at bedtime may be prescribed and it may be well to have 
a few crackers and a little milk at the bedside to be taken 
on waking in the middle of the night if they find that 
they cannot sleep again. 
Sometimes intestinal toxemia will 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 bad judgment to change this habit. Many old per- 
sons awake in the middle of. the night, to whom a pipe 
is the best nerve sedative they can have. I know per- 
sons Avho give old men presents of tobacco at Christmas THE CARE OF THE AGED 
51 
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 disagree- 
able, 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 surface 
of the body to the respiratory, occasionally to the diges- 
tive and urinary organs, causing congestion of these in- 
ternal organs. 
If the excretions of the skin become suddenly checked, 
it would be advisable to give the aged person a warm 
bath. He should take warm milk or tea and should have 
an 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 disastrous results will 
follow injudicious medication in this line. 
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 with the Emperor of 
Austria, he obeyed court etiquette instead of Nature and 
fell a victim to his temerity. 
Recreation in the aged is an important factor. The 
senile brain becomes easily fatigued, a play or moving 
picture show may have a complicated plot and the aged 
person may not be able to follow it. As a result he falls 
asleep and is apt to miss the whole performance. Mu- 
sical comedies or burlesque shows which do not have 
complicated plots are easy for the aged to witness. The 
senile mind requires something lively and humorous and 52 
GERIATRICS 
the aged forget 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 
together for years is a serious matter. In institutions 
much attention should be given to bathing as the aged 
will often deceive the nurses, leading them to believe 
they bathe frequently, while, in fact, they seldom do. 
Again, in institutions special care should be given to 
the eyes and an oculist should correct errors of refrac- 
tion. Senile persons can pass the day so much better 
when they are reading and not thinking of themselves. 
Old age is not thought of, and 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 
household. He still maintains a little business, just 
enough to say that he is a business man, and 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. 
Needless to say that this man is greatly respected by 
his family, and is certainly a useful citizen in more than 
one way. Being self-supporting he is very independent 
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 de- 
pendent upon others. 
Case II.—A woman, aged seventy, when quiet for any 
length of time develops renal insufficiency, especially if 
she is forced to stay in bed. When she gets up again 
the casts disappear and she improves. I have warned 
her if she ever becomes ill that it would be to her ad- 
vantage to keep out of bed. This person does a great 
deal of work each day, and it seems that exercise is es- 
sential to prevent the development of renal toxemia. 
Case III.—A mariner, aged seventy-five, had chronic 
Bright’s disease, and when the weather prevented him 
from going to his workshop, he complained of various 
symptoms. Whenever he was ill and remained in a chair 
a great deal, I forced him to leave the house and go to 
his workshop. Toxemia always lessened when he was 
taking exercise. 
53 54 
GERIATRICS 
Case IV.—A man, aged sixty-five, lost nis position in 
a factory, after which he immediately developed symp- 
toms of Bright’s disease. He became melancholy, had 
headaches, could not sleep and lost his appetite. His 
position was given back to him and he has been well since. 
Case V.—I once found a letter in the pocket of a man 
who had committed suicide. In his notebook he had ad- 
vertisements from newspapers. A letter he had written 
to his brother said, ‘ ‘ I cannot find work; every one says 
I am too old to work.” 
Unquestionably in the aged, lack of exercise will pro- 
duce toxemia, especially of renal origin. Old men al- 
ways improve when they are forced to move about, and 
work is the best remedy for them. I remember an old 
man who had worked hard for years; his children felt 
that they could support him and it would “look better” 
if they did, so they had their father give up work. The 
old man’s health steadily failed since then 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 eightv- 
three, who has no disease except “aged eighty-three.” 
Because she is old she thinks that she cannot do things 
that people of sixty do. I have a. patient, a man, aged 
eighty-six, who disregards his age and takes a Turkish 
bath every week. Theoretically, because he is eighty-six 
he should not do it. However, he does not think of his 
age, is employed, and accomplishes many things which, 
according to custom, he should not do. In other words, 
he measures himself and governs his activities accord- 
ing to what he knows he can do. 
“Old age” to most persons is a death-warrant'. When 55 
WORK FOR THE AGED 
they begin to think of old age they become depressed. 
The aged are very sensitive, they like attention and like 
to be praised. They need encouragement and we should 
not allow them to dwell on their sad thoughts. 
We should provide some work for our aged friends and 
relatives. I know a man who gives an aged man $10.00 
a month for doing errands and taking care of the mail. 
Another man is janitor in a telephone office; another 
takes care of furnaces. It is wrong to think that because 
a man has worked hard all of his life he should not work 
any more. 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 them 
and there seems to be no place for them. 
There is another side to the question, however. Aged 
clerks, for instance, those who have been in a store for 
a long time, become very independent and do not cater 
to customers, consequently the firm loses a great deal of 
money each year because the owner does not care to dis- 
charge the men who have been working for him for 
years. 
Nevertheless, there are many things that the aged 
could do and we should create-something for them. 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- 
watchman, or any position that will keep him active and 
prevent him from dwelling on “old age.” 
Work for the Aged 
With women the problem is somewhat more difficult, 
yet there are many things they can do such as sewing, 
taking care of a part of the house, and in factories there 
is some work that can be provided for them, if the insti-- 56 
GERIATRICS 
tution is not placed upon an efficiency basis. For ex- 
ample, a chemical company could have a department for 
the aged where they would label bottles or wrap them. 
Although the production would not equal that 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 successful 
man to have a department where the aged could be em- 
ployed in some simple thing like labeling, etc. The effi- 
ciency test would not be 100 per cent, but the aged would 
be greatly benefited. 
Almost every one could find some work for his old 
relatives, but usually they are neglected and very little 
is done for their comfort. 
Work and Recompense 
If possible it is essential to give the aged good recom- 
pense for their labor, although they may not produce 
any great amount of work. The aged like attention and 
praise. Encourage their labors, observe their work and 
the good it will do them will be surprising. 
The aged like to have you ask them to do something 
for you. Ask them to do a little work and it pleases 
them very much. It flatters them to be given this atten- 
tion. The problems of the aged could be solved by at- 
tention, 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 would make them 
feel better than either of those things. Give the aged 
money and they will appreciate it more than anything 
else. It is not, of course, the well-to-do aged who are apt 
to be neglected, not these old persons, who, possessing 
money, demand respect because they are independent. 57 
WORK FOR THE AGED 
These retain their power of determination and force, 
qualities which command respect. On the other hand, 
when aged people have no worldly possessions, they be- 
come depressed, lose their determination, feel dependent 
and lose their “grip” on life, which brings about the so- 
called “childishness.” I believe that the senile mind in 
most instances would be improved if the aged were 
financially independent of others. Lack of money pro- 
duces loss of initiative. 
Pensions for the Aged 
Massachusetts attempted to pass a law to pension the 
aged. Business houses should pension the help who 
have been with them for several years. A firm lost a 
man, on account of illness, who had been in their employ 
for fifty years. They have not given him any pension. 
Another man who has been with a firm over thirty years 
has now developed tuberculosis of the bones and is 
forced to stop working. The company did not give him 
any money or even send to him to see if he was in need. 
This attitude is very unfair to the aged and they are not 
shown the respect and consideration that is due them. 
Business houses that are paying 15 or 20 per cent divi- 
dends could easily spare 1 or 2 per cent to institute pen- 
sions for their aged help. When their old employees 
are ill, it would be an act of kindness to inquire if they 
are in need. 
We could 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, often went through financial tor- 
tures to educate us, or deprived themselves of many 
necessities to see that we had clothing proper for all 
occasions. In fact, if it had come to a critical matter 
they would have given their lives for us. 
As an appreciation of this the majority of aged in- 58 
GERIATRICS 
dividuals are neglected, their children fight amongst 
themselves because none care to take their aged parents 
with them, and it is surprising to see people in the higher 
walks of life who not only neglect their aged relatives but 
are actually cruei to them. Of course, many old persons 
are difficult to live with, the senile mental state produces 
a change in them which is sometimes very disagreeable. 
Oftentimes disease brings about a mental state which 
makes it almost impossible to live with them. However, 
many of their diseases would be modified and many of 
their 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 
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 the 
men for their work. When it was discovered that the 
toy shop was open to all old men the number of workers 
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 repeatedly refused work 
because they were old were given a chance. It seemed 
to open a new life to them. The work was interesting 
and they could see that it was productive. Others were 
interested in it and they took great pride in their work. 
Miss Foster decided that social welfare should nec- 
essarily enter into the care of the aged and besides work, 
pay, food and a warm place during the day, the ques- 
tion came, where did the old men sleep? She experi- 
mented on a housing plan which proved a success. She WORK FOR THE AGED 
59 
rented 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 comfortably 
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 did their 
own housework, making the beds, sweeping, washing, 
ironing, dusting, washing windows and dishes. The in- 
creased cost of living raised the cost per day to about 
twelve cents. 
Every morning, before the toy shop opened, an old 
man was seen with a basket on his arm going toward 
First Avenue. He had eighty cents to spend and he felt 
his great responsibility in making proper purchases. 
The work of old men and women could be made pro- 
ductive if we would give attention to them and many 
other things could be provided for them in the way of 
work. The toy shop has been a success and could easily 
be placed on a larger scale by some person financially 
able and disposed to assist the aged in proving their 
efficiency. It is said that on some Indian reservations 
old persons are literally starved and allowed to sit out- 
side without any attention. The Indians believe their 
aged are useless and give them little or no consideration. 
In a general way this 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 they 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 
attack of senile bronchitis and was failing. He was very 
dyspneic and toxic. I ordered him to get in a. chair and 
forced him out of bed several times a day. The results 
were excellent; he breathed more easily, 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 of 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 at- 
tacks. 
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 renal insufficiency and the urine 
showed many casts. When she was up again the urinary 
sediment became 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 remain in a chair, however, and in order 
60 KEEP SENILE CASES OUT OP BED 
61 
to sleep had to he in a sitting position. For over two 
weeks he was in this state, but he was not allowed to lie 
down. It seemed cruel, since he was apparently too ill to 
sit up, yet I knew this was the only chance of recovery. 
After several days of suffering the old man recovered 
sufficiently to ride in an automobile to the doctor’s office. 
This method of treating senile cases apparently works 
well in most instances and there are very few cases 
where it cannot be applied. It seems cruel many times 
to resort 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 impossible to get 
him up again. 
It is interesting to note in Case IV that casts always 
appeared in the urine 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 uremia, whom I forced to go outdoors 
and demanded that he should go to his work and give 
orders each day. He improved and continued to gain as 
long as he kept up his exercise. 
The Psychic Element 
When old persons are ill in bed they feel that their 
last is approaching and “old age” stares them in the 
face. “Old age” to them is a death warrant. The fam- 
ily usually feels that the end is near; there is no ap- 
parent hope of recovery, owing to the advancing years, 
and therefore neither anxiety nor interest is shown. 62 
GERIATRICS 
Remaining 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 any one 
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 an important 
factor in the process of 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. 
In senile cases much depends upon the encouragement 
given them by the physician. Do not tell them that they 
will get better or they will think you are merely en- 
couraging them. It is better to make plans for them as 
to what they will do when they get out doors, like work- 
ing 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 
We can safely apply the same principles to the surg- 
ery of the aged. 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 rule still 
works. 
Postoperative cases if kept in bed will not do well in 
the majority of instances. Pneumonia, renal or intes- 
tinal toxemia develop more rapidly and there is general 
asthenia as a result. If the aged patient gets out of bed 
the day after the operation, the danger of these complica- KEEP SENILE CASES OUT OF BED 
63 
tions is lessened and although there is some danger in 
allowing him this peculiar privilege, it is the lesser of 
two evils. _ , 
Getting out of bed spurs the aged sufferers to fight 
their battle more courageously. After all, in the treat- 
ment of senile diseases, the important thing is to en- 
courage them and to give them plenty of attention. A 
talk about things that interest them sometimes has a 
better effect than medicines. CHAPTER VII 
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 cannot 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 went around hum- 
ming 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 some one 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 played 
could he remember it. As an encore he sang another 
64 SENILE MENTALITY 
65 
song of the same period, one he had sung but a few 
times forty years before, yet which came to mind with- 
out 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 account for these inconsist- 
encies. 
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, it will not be retained and therefore can- 66 
GERIATRICS 
not be recalled. The mechanism of memory 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 
events and the closest associations, as the existence of 
children, the location of home, the needs of the body, 
may be forgotten. This condition is cabled senile de- 
mentia. 
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. 
A writer who could write for hours without intermis- 
sion must now make frequent stops. After an hour or 
two brain fag sets in and if he continues to write men- 
tal confusion ensues, 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; 
slowly and carefully and the moment brain fag sets in, 
he stops, though it be in the middle of a word. His 
ideas 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 writes a few other sentences. 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 
authors. On other days when reason alone was em- SENILE MENTALITY 
67 
ployed lie 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 ir- 
relevant, of reminiscences, etc., and unless something oc- 
curs to interrupt 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 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 cannot 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 first part of the paper, having dozed 
through the time the latter part was read, or they will 
discuss the latter part having forgotten the first. 
The aged lose control of their emotions and 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 68 
GERIATRICS 
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 resignation to the inevitable and are constantly 
depressed, in others there is an unexpressed rage at 
their impotence. The fear of death is exhibited in vari- 
ous ways, or it may be repressed, 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, gradually 
weakens until he becomes a complete dement, ignoring 
the demands of nature and even losing the fundamental 
instinct of self-preservation. CHAPTER VIII 
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, upon 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, 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 hinges upon the extent of 
memory impairment. In one case the existence of a 
favorite child was forgotten when a will was drawn and 
after his death the man 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 
business affairs. The medical and the legal conceptions 
69 70 
GERIATRICS 
of senile dementia differ, except in 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 simply called senile 
mental impairment. The following is a typical case. A 
lawyer, who died recently, was a national character 
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 
interest in the affairs of the day and became careless in 
his habits. Formerly extremely neat in his personal ap- 
pearance and surroundings he now occasionally went 
out of the house without having his shoes polished or his 
necktie properly adjusted or with his coat or vest un- 
buttoned. His reasoning powers were unimpaired but 
he found it now necessary to look up authorities which 
he formerly could quote offhand. He became egotistical 
and often boasted of what he had accomplished. These 
traits gradually became more pronounced and his ego- 
tism so dominant that a few years ago, upon the occasion 
of an anniversary celebration he requested his friends to 
send him letters of congratulation and commendation 
which he could publish. With his failing memory his 
reasoning power waned, yet under great stress he could 
arouse his reasoning ability and his former power as 
a brilliant speaker. On such occasions 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 be- 
ginning of his speeches were rational he lapsed into 
rambling talks on various subjects, usually reminiscences 
or self-laudation. At a medico-legal meeting 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 SENILE DEMENTIA 
71 
orator, quoting authorities and presenting unanswer- 
able arguments. He referred to a murder 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, 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. This man’s peculiarities 
were looked upon as harmless eccentricities, yet they 
clearly showed weakened mentality. He would call his 
office boy from the anteroom and for an hour would tell 
the boy of his legal exploits revealing secrets which ex- 
posed criminalities, and many indecent actions a sane man 
would not speak of. He made useless purchases which 
he sent to his friends as gifts, wrote them numerous 
letters that showed the progressive mental impairment 
which finally became obvious to the stranger. The first 
few lines of his letters were rational, then they became 
rambling and ended in undecipherable scrawls. He 
grew absent-minded and several times lost his way be- 72 
GERIATRICS 
tween 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 neither read nor 
write and could count up to twenty only. He never was 
a keen reasoner but he possessed good judgment, crafti- 
ness 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 difficulty, 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 
remember every barn fire that he had ever seen. But he 
gradually lost the sense of time and every event whether 
occurring the day before or during his childhood hap- 
pened “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 rak- 
ing, for example, whether a rake, hoe or spade was put 
into his hands. Life-long habits were continued in- 
stinctively without a realization of their import, but he 
could be led away from his purpose 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 memory 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 SENILE DEMENTIA 
73 
answered tlie 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 reasoning 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 granted. 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 
recollection 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 en- 
titled, was not shown her, she became abusive and later 
suspicious 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 persecutions by 
her family developed and one daughter was obliged to 
keep out of her sight for a month. When the daughter 74 
GERIATRICS 
reappeared the mother had forgotten 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 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 off the patient soon after his 
mental impairment becomes so great that he is oblivious 
of 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- 
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 SENILE DEMENTIA 
75 
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, 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 
restored but interest and attention cannot 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 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 76 
GERIATRICS 
absently upon the corpse for a few minutes. Then she 
suddenly 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 be 
roused to a further realization of the proceedings. 
An effort was made to induce a senile dement to sign a 
will. Constant urging annoyed him and he became sus- 
picious that some harm would come to him, this roused 
for a moment his reasoning faculties. He listened to 
the reading of the document and objected to some of the 
provisions. Before 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 attention 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 cannot 
comply with the instinctive measures for self-preserva- 
tion. CHAPTER IX 
DIET IN OLD AGE 
Habits in diet extending over a period of years should 
not be changed no matter how bad they seem to be. It 
is often dangerous to correct habits that may have even 
a pernicious effect. We have seen many cases of men 
who suddenly gave up drinking or the use of opiates and 
died soon after. 
Most aged people ate in their youth a variety of food 
different from that we use today. In the past years the 
coarsest food was the rule and a man who was ac- 
customed to it in his earlier days should not change it 
later. 
Regularity in meals is essential to the aged 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 between 
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 so 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 of 
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. 
77 78 
GERIATRICS 
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 to 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 with 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. A 
glass of wine 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 strength. Bordeaux or Red 
Wine are satisfactory in cases of chronic nephritis and 
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. 
BREAKFAST 
Apples (baked, raw or stewed), oranges, grape-fruit, 
grapes, berries in season, cantaloupe; eggs—soft-boiled, 
shirred, scrambled, dropped on toast; broiled chicken; DIET IN OLD AGE 
79 
bacon; broiled honeycomb tripe; fish—mackerel, perch, 
pickerel, white fish, trout, cod, haddock, halibut; baked 
potato; stale or toasted bread with plenty of butter; tea, 
coffee, or glass of milk. 
LUNCHEON 
Raw oysters or clams, lobsters; soups (preferably 
purees), pea, bean, potato, asparagus, celery; chops, 
beef-steak once or twice a week; roasts—beef, mutton, 
lamb, veal; chicken, ham, tongue; fish, broiled or baked 
in cream; vegetables—potato, spinach, lettuce, stewed 
celery, cauliflower, beets, squash, green peas, asparagus, 
string beans; salads—lettuce, endive, escarole with 
French dressing; dessert—ice cream, 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. 
DINNER 
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. 
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 
is advisable to strive against falling asleep in a chair 
after dinner as it is said to cause cerebral congestion. 
The old rule that when we are ill we should take small 
quantities of food frequently does not apply to the aged. 80 
GEKIATEICS 
The process of digestion being longer, 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 on 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 their mode of living 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. 
The proportion of protein to carbohydrates was 1 to 3y2 
(1 to 4 in maturity), the protein factor being slightly DIET IX OLD AGE 
81 
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 no longer be 
chewed, meat must be finely chopped or omitted alto- 
gether and when omitted, protein from another source 
must be substituted. A sufficient amount can be 
obtained in milk, eggs or 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. It is often perverted and they will feel a 
gnawing Sensation or a sensation of emptiness in the 
stomach shortly after a heavy meal while 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 they like and indifferent to the food when the 
dish is not relished. Owing to the degenerative changes 
in the taste bulbs the food must be highly seasoned, 
either sharp, sour, sweet or salty, otherwise it is taste- 
less 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 to the aged in- 
dividual. CHAPTER X 
SENILE CONSTIPATION 
In hospital clinics attended by old people, it is surpris- 
ing to find that so many diseases can be traced to con- 
stipation. In treating the aged, if we give attention to 
the intestines, we solve 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 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 atrophied and in 
some cases not a trace of it can be found. The villi and 
mucous follicles are atrophied and very little mucus is 
secreted. In lessened power of the muscular coat and 
resulting impediment of the peristaltic motion, we see in 
part the cause of constipation and further diminished 
nutrition of the body in old age. 
Dyspepsia from which we observe aged persons suffer, 
depends partly upon the prolonged retention of food in 
the stomach, a consequence of imperfect mastication, 
and partly upon the modified state of the gastric juice, 
but it is chiefly due to the blunted sensibility of the 
nerves of the stomach, the diminution of nerve power 
resulting in lessening of power of the intestinal muscles, 
causing 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 them as a nurse cares for 
82 SENILE CONSTIPATION 
83 
a child and their uncertainty as to the kind of pill they 
shall take at night is a source of constant worry to them. 
It would be far better judgment to give more considera- 
tion to the diet and the care of the skin than to concen- 
trate one’s attention on the intestines. It would be bet- 
ter to have an evacuation every two or three days than 
to be in the mental condition some aged persons reach 
as a result of their excessive attention to the bowels. 
A daily action is preferable if it can be obtained with- 
out harsh measures. However, in many senile cases 
careful study of the patients will teach us that a bowel 
movement every other day is sufficient. Violent strain- 
ing should be prohibited because it may cause hernia or 
hemorrhoids. 
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 to be soon after a meal because the 
ingestion of food tends to stimulate peristaltic action. 
When the fecal matter becomes hardened in the rectum 
it is sometimes very difficult to relieve. The rectum be- 
comes obstructed and the old patient dreads a movement 
on account of the pain; the longer he waits the greater 
the accumulation of the hardened substances in the 
rectum. Sometimes enemata of oil will relieve the condi- 
tion 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 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 restored to. I use, for enemata, inspissated ox- 
gall mixed with oil or a mixture containing epsom salts, 
glycerin and olive oil. If the quantity of liquid is not 
great, its use is not dangerous. It has been said that 
enemata are dangerous in the aged, but I have never 84 
GERIATRICS 
seen any bad results due to them. If the patient is very 
weak, I use an adult size glycerin suppository inserted 
into the rectum and repeat this every hour until results 
are obtained. 
If the bowels have not moved in several days, I some- 
times give five grains of calomel with five grains of so- 
dium bicarbonate and a saline laxative by mouth the next 
morning. Occasionally it is necessary to use croton oil. 
One of the best pills I have seen for the aged is the 
official compound rhubarb pills containing aloes, myrrh, 
rhubarb and oil of peppermint. One may be given after 
each meal or two may be taken at bedtime. Podophyllin 
in 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, it acts as a foreign substance in the 
intestines that Nature must eliminate. In this respect 
it does not differ from any other cathartic of mechanical 
action. 
The food we ordinarily eat, the nourishment that en- 
ables us to do our work, almost every diet prescribed 
in the treatment of disease, tend to produce constipa- 
tion and the only way to overcome this is to use the 
proper remedies. 
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 laxatives because they fear 
they will always have to take them may die of toxemia. 
Laxatives do no harm when well selected and if they 
lose their effect we must change to another kind. Later 
by returning to the remedy first employed we again have 
satisfactory results. SENILE CONSTIPATION 
85 
The compound carthartic pills, or a tablet containing 
aloin, strychnine, emetine and podophyllin may work 
well. Cascara sagrada is an excellent remedy for senile 
constipation and old persons can take it for a long time 
before being obliged to increase the dose. The aromatic 
fluid extract of cascara is very satisfactory. 
Bile salts are also satisfactory in many cases. Owing 
to the secondary effects of drugs due to cumulative action 
it is not safe to use belladonna in combination with other 
remedies as continued use may produce undesirable 
secondary effects. 
The simpler the remedy the better, and the compound 
rhubarb pills seems to be very efficacious. The aged 
will misinform you about the true condition of . their 
intestines, stating that they act every day when perhaps 
they do not move oftener than once a week. Sometimes 
they actually forget when the bowels moved last. When 
old persons are 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 is very likely 
not accurate. 
When called to see an old person who is ill and failing 
rapidly, when nothing seems to help him and you can see 
death in the background, when, no matter the disease, 
your remedies do not have the desired effect, open the 
bowels by an enema and also a laxative by mouth and you 
will be surprised to see how many times death will be 
postponed and the old person will recover. 
A word should be added on the use of saline laxatives. 
This form of medication is the most effective to rid the 
body of toxins, but unless the patient is robust its con- 
tinued use will be too depleting. If patients are robust, 
they can take a saline each morning, a so-called “ morn- 
ing refresher,” but if they are frail, tablets are better 
for continued use. CHAPTER XI 
TOXEMIA IN THE AGED 
Case I.—A man, aged seventy, consulted me for general 
weakness which he had experienced for some time. He 
said that he could not sleep at night, had indigestion, 
that his mouth had a bad taste in the morning, that he 
suffered from vertigo, occasional nausea and constipa- 
tion. 
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 greatly 
irritated by music, could not bear ordinary conversation 
and was failing in many ways. 
The tongue had a thick white coating and the odor of 
his breath implied a fermentative condition of the 
stomach; the temporal arteries were tortuous and the 
pulsebeat 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 could not 
sleep. This is very common in the aged, but old persons 
are apt to deny it; if you suggest it to them they will 
not admit that they have been asleep. 
This patient 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 im- 
proved 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. The tongue was 
86 TOXEMIA IN THE AGED 
87 
coated, she had headaches, vertigo, was very drowsy 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 treat- 
ment. 
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 coma for several days, finally recover- 
ing. While in 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, in this case, a 
diagnosis would be made of uremia or diabetes, but re- 
peated and careful examinations failed to reveal any 
evidence of abnormality in the urine. 
It is possible that purinemia or toxemia of intestinal 
origin may be the cause of many cases terminating 
fatally. For this reason a correct diagnosis is impera- 
tive and usually patients will recover if proper treatment 
is promptly given. 
I have seen many aged persons very inactive and ap- 
parently extremely toxic, who were relieved by exercise. 
It is a serious matter to allow an aged person to remain 
quiet and in a warm room. Force aged patients to walk 
in the fresh air and they will usually improve. Inactivity 
and sleep seem to increase the formation of certain 
toxins. 88 
GERIATRICS 
It is difficult to ascertain the origin of the toxins in 
many cases, in the vast majority of cases, however, they 
are of intestinal or renal origin. Indicanuria is present 
in most cases. Lack of exercise and constipation are the 
usual causes, although toxemia may be found in patients 
who have diarrhea, the latter being Nature’s method of 
relieving the condition. 
Most of the senile diseases seen in private practice can 
be traced to constipation. Much depends upon the 
remedy selected, for some 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 very difficult to differentiate them. 
Take, for example, a specimen of urine which shows 
casts in the sediment. Symptoms of toxemia from in- 
testinal origin may be attributed to the kidneys when the 
casts are merely a normal finding, and the kidneys may 
be functioning properly. It is very easy to make a mis- 
take in diagnosis, for a normal urine from a senile 
patient may show albuminuria, casts and leucocytes. 
Also, indicanuria may not be present in senile cases al- 
though there is marked intestinal toxemia. 
Diabetes may cause symptoms similar to intestinal 
toxemia and yet the urine will not show acetone or 
B-oxybutyric acid. The urine may be free from sugar, 
yet the blood sugar examination may show diabetes to 
be present. Urinalysis should be made in all senile cases 
because failure to discover a disease may hasten death. 
The aged frequently become toxic on account of 
absorptions from an internal tumor. For example, car- 
cinoma of the stomach will produce symptoms similar 
to other toxemias. A peculiar odor of the breath makes 
the diagnosis almost certain. 
I once saw a famous old man who, although appar- 
ently in excellent condition, showed certain signs of tox- TOXEMIA m THE AGED 
89 
emia. The temporal arteries were tortuous and pound- 
ing, there was slight puffiness under the eyes, the skin 
had a slight yellow color and the odor of the breath was 
noticeable a short distance away. He suffered from 
brain fag and could not listen to conversation more than 
a few minutes without becoming fatigued. 
Brain fag in this instance was said to be due to old 
age, but in reality was caused by lack of care of the 
bowels. Even though the bowels move each day, it is 
possible to have intestinal toxemia; a course of treatment 
will undoubtedly relieve the toxemia of old patients of 
this type. 
Many of the symptoms commonly attributed to senile 
brain changes are entirely due 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. He became ill, was given a course of elimina- 
tive treatments and greatly improved. As his body was 
rid of toxins he changed mentally and saw good in every 
one and everything. I have observed this in so many 
cases that I believe many of the peculiar traits ordinarily 
associated with such patients are merely symptoms of 
toxemia. 
The first symptom of toxemia is usually a complaint 
of weakness; patients express it by saying they have 
“no strength.” Loss of sleep, loss of appetite and lack 
of strength are the most common things we hear of from 
the aged and they require careful analysis. As a 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 without an eliminative treatment. 90 
GERIATRICS 
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 he is physically frail it is better 
to use pills or tablets because salines are too depleting. 
I have used the compound rhubarb pills 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 
although 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 Mo grain 
podophyllin tablets, one to be taken every three hours. 
If the stools are light in color, I give Mo grain of mercury 
and chalk, one tablet to be given every ten minutes until 
ten are taken, followed by a saline. The podophyllin 
tablets may be continued indefinitely and work well in the 
aged. If the stools are very offensive, I prescribe tab- 
lets containing Mooo 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 TOXEMIA IN THE AGED 
91 
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 hasten the elimination of 
toxins and do not deplete the system. It is a geriatric 
principle that we must stimulate the aged, Nature tend- 
ing to cure the young, and kill the aged. 
I do not as a rule 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 in the 
diseases mentioned above. 
Many theories of the association of the longevity and 
toxemia have been advanced, but one fact remains certain. 
Attention to the correction of intestinal toxemia will 
cause a great deal of comfort to the aged and will pro- 
long life. In some cases it may even add several years 
to their lives, but in time a toxemia of some kind, in most 
instances due to the kidneys, cancer, or pneumonia, will 
cause death. Much can be done to help the aged to live 
more comfortably and longer and the correction of 
toxemia wall improve the mental condition of many 
senile patients. The word toxemia is, of course, very 
vague, but its presence in some form is easily noted by 
such symptoms as headache, dizziness, fatigue, bad odor 
of the breath, coated tongue, etc., and in these cases free 
catharsis is indicated. CHAPTER XII 
BLOOD PRESSURE IN SENILE CASES 
Case I.—A man, aged fifty-six, consulted me for ver- 
tigo. For some time he had a pressure in the occipital 
region; experienced sensations of electric shock on lying 
down, complained of a troublesome buzzing in the ears 
and was quite deaf. He was very drowsy and mentally 
depressed, his case belonged to the plethoric type and 
his appearance indicated toxemia. He had a position 
on a railroad and the time was approaching when he 
would be forced to give up his work. 
Examination showed a systolic pressure of 230 and 
the diastolic pressure registered 140 on the aneroid ap- 
paratus, but the arteries did not show apparent changes 
of degeneration. 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., 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 months, gradually adding a few 
92 BLOOD PRESSURE IN SENILE CASES 
93 
vegetables and fresh fish. Notwithstanding the strict 
diet and depletion, he said that he felt stronger than he 
had in several years and was able to work. 
The blood pressure rose to 160, he increased his diet 
and the pressure remained at this point. The hearing 
improved, his so-called catarrh of the nose disappeared 
as did the other symptoms, the urinary 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 chronic 
nephritis which caused edema of the legs and many 
vague symptoms, such as neuralgic pains, cramps of the 
legs, itching of the skin and numbness. Her blood pres- 
sure was 180 systolic and 100 diastolic. Under a treat- 
ment of, salines and a nonnitrogenous diet, the blood 
pressure became lower and there was an improvement in 
the general condition. 
Case III.—A man, aged sixty, had chronic nephritis 
which caused him a great deal of annoyance. His systolic 
blood pressure registered 220 and the diastolic 140. He 
had purchased a sphygmomanometer and had his valet 
take his blood pressure every day. 
There were 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 
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 94 
GERIATRICS 
blood pressure and apply a little ‘ ‘ skillful neglect ’ ’ to his 
case. 
The fact that his blood pressure was high worried him 
and caused mental depression. He lived for two years 
in this way and traveled quite extensively a part of the 
time. He was very careful of the emunctories, did not 
overeat, but ate the food he liked and used an electric 
light bath each week which facilitated elimination of 
toxins through the skin. From the time he stopped treat- 
ment, which was given 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 frequently misused and 
we make a mistake in thinking of it as 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 resist- 
ance due to the increased work the heart has to do in 
order to force the blood through the congested organs. 
In itself, arteriosclerosis does not always produce high 
blood pressure. If there is cardiac hypertrophy there 
may be an increase in 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, 
while in the parenchymatous form of nephritis there is 
usually a marked increase in 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 accompanying increase in the peripheral 
resistance. It does not always work out in this way 
for in some instances the contracted kidney will cause a 
blood pressure higher than that caused by enlarged BLOOD BRESSURE IX SEXILE CASES 
95 
kidney. Tlie difficulty encountered in diagnosing a high 
blood pressure from the appearance and physique of 
the patient alone without a spliygomanometer is well 
illustrated by the following cases: 
Case IV.—A woman, aged sixty-five, complained 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 natural to infer that she 
would not have a high blood pressure. I saw her in my 
office on several occasions, but she did not appear very 
ill. She was seized suddenly with an attack similar to 
asthma and in my routine examination at the bedside I 
was astonished to find that the blood pressure was 240 
systolic and 170 diastolic. I was alarmed to find a large 
quantity of albumin on urinary examination and also 
blood and casts. She died the next day from cerebral 
hemorrhage and had hardly given a warning of the 
seriousness of the affection until twenty-four hours be- 
fore her death. 
Case V.—A man, aged sixty-eight, robust and of the 
plethoric type, weight 210, presented the classical 
symptoms of high blood pressure and nephritis. The 
pulse was full and could be rolled under the fingers and 
the temporal arteries were tortuous, the pulsation being 
visible. To make a snap diagnosis almost any one would 
have said high blood pressure, but examination repeated 
on different days with a Tycos and Sanborn apparatus 
showed that the systolic pressure was 120 and the dias- 
tolic 80. 
These two cases illustrate the impossibility of depend- 
ing upon the appearance of the patient. It is very com- 
mon to find cases of interstitial nephritis that are ac- 
companied by low pressure. There are several factors 
which are apt to cause high blood pressure; for example, 
thyroid disease, or another factor which must be given 96 
GERIATRICS 
consideration is the viscosity or density of the blood it- 
self. In such diseases as anemia, tuberculosis and 
marasmus, the blood is thin and the specific gravity low, 
with resulting low blood pressure. Nephritis and some 
other diseases produce a higher specific gravity and if 
this is high the blood passes through the arterioles and 
capillaries with resulting increase in peripheral resist- 
ance. All those factors tend to raise the blood pressure 
in the aged and a natural outcome of advancing years is 
higher pressure. 
We must know the normal limits and not mistake the 
pathologic senile pressure for a normal condition. Some 
of the causes which produce high blood pressure, which 
is pathologic, are plumbism, alcoholism, nephritis, 
chronic toxemia of intestinal origin, gout, diabetes, 
syphilis and thyroid degeneration. These are outside 
the normal senile state where high blood pressure is a 
part of the senile change. 
Many physicians have made rules to give normal pres- 
sure reading for old age. Some observers have stated 
that an approximate rule is to add 100 to the age, but 
this is very inaccurate. Many patients live for years in 
comfort with a blood pressure of 220 and after careful 
study I was convinced that it was normal in those per- 
sons. I have even seen higher blood pressure and yet 
the patient would apparently be comfortable. To meddle 
with cases of that kind might give disastrous results. 
A man of ninety would ordinarily have a normal systolic 
pressure of 190 or more. The pressure varies from 
day to day and from month to month. Food, exercise, 
rest and elimination probably affect it. If the old person 
has symptoms that can be traced to high blood pressure, 
he should be treated, but if one simply treats the increase 
in blood pressure, bad results may follow. 
Trousseau said that half the science of medicine con- 
sisted in knowing the natural course of disease. This BLOOD PRESSURE IN SENILE CASES 
97 
applies to old age because we can not differentiate the 
normal from the 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 treatment may cause 
fatal results. We must not interfere too much with 
Nature, and in attempting to cure the condition of an 
aged patient not endeavor to make it similar to the nor- 
mal condition of a man twenty years younger. 
In old age it is very difficult to get an accurate reading 
on the sphygmomanometer because of the differences be- 
tween the sclerosed arteries of each arm, which makes it 
necessary to take the pressure on each arm. Ausculta- 
tion will assist in obtaining an accurate reading, but it 
may be well to repeat it on different days in order to 
make an average. 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. 
The factors which modify blood pressure are cardiac 
hypertrophy, arterial tension, peripheral resistance and 
the specific gravity of the blood. Chronic nephritis 
causes an increase in resistance and in time cardiac 
hypertrophy develops. The best method of relieving the 
overworked heart is to reduce the capillary resistance. 
Imagine a horse who is carrying a heavy load and has be- 
come exhausted, the best stimulant is not to whip the 
animal but to remove a part of his load. 
High blood pressure, except when due to specific causes, 
is almost invariably the result of this increase in resist- 
ance. To treat it by the nitrites would not relieve the 
cause of the condition. 
Diastolic pressure in old age varies, but there are some 
cases in which it is strikingly different from that of 
maturity. Myocarditis, gout, carcinoma, or debility due 
to various diseases, cause a low diastolic pressure. On 98 
geriatrics 
the other hand, high diastolic pressure may be due to 
heart disease and nephritis. Aortic regurgitation may 
cause a low diastolic pressure. In nephritis, the dia- 
stolic 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 hyper- 
trophy has reached its maximum. 
The accompanying tables taken from the monograph 
of L. M. Bowes (The Journal of Laboratory and Clinical 
Medicine, January, 1917), give his experiments on sys- 
tolic and diastolic pressure in old age: 
The Average Blood Pressure of Both Men and Women 
Table I 
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 
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 
The Average Blood Pressure of the Women 
Table III 
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 
0 
— 
— 
— 
90-94 
4 
145 
81 
65 
The Average Blood Pressure of the Men BLOOD PRESSURE in SENILE CASES 
99 
Conclusions 
Dr Bowes’ conclusion, taken from the same journal, 
are well worth reading. They are as follows: 
1. Only repeated readings of both systolic and dias- 
tolic pressure are of value, and both arms should be 
used for observations in old people. 
2. Inequality of the pressure 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 
tfye heart muscle in the process of fibrosis resulting in 
chronic myocarditis. 
4. High systolic pressure associated with high dias- 
tolic pressure indicates cerebral hemorrhage, or ne- 
phritis. 
5. A sustained hypertension, both of systolic and dias- 
tolic 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. 
My own experience is that we may get every kind of 
variation in blood pressure in the aged and yet be with- 
in normal limits. Some patients who have a pressure of 
230 will live several years. The following table shows 
the results of examination of a few cases. They are 
given in the order in which the patients consulted me in 
private practice. My records show that this is a fair 
average of cases. 100 
GERIATRICS 
AGE 
WEIGHT 
SYSTOLIC 
DIASTOLIC 
CLINICAL CONDITION 
Miss B. 
75 
135 
142 
75 
Nephritis 
Mrs. P. 
75 
90 
230 
140 
Normal Senility 
Mrs. G. 
68 
175 
162 
92 
6 6 6 6 
Mr. G. 
70 
150 
130 
90 
6 6 6 6 
Mrs. L. 
54 
165 
90 
60 
Myxedema 
Mr. D. 
76 
158 
184 
90 
formal Senility 
Mr. G. 
76 
138 
230 
110 
6 6 6 6 
Mr. H. 
77 
162 
144 
100 
6 6 6 6 
Mr. D. 
68 
,165 
202 
120 
Nephritis 
Mrs. C. 
79 
120 
138 
70 
Normal Senility 
Mrs. C. 
86 
125 
200 
110 
6 6 6 6 
Mr. K. 
76 
148 
162 
80 
6 6 6 6 
Mr. G. 
86 
120 
490 
98 
6 6 6 6 
Mr. B. 
65 
140 
170 
100 
6 6 6 6 
Mr. S. 
73 
140 
204 
130 
Nephritis 
Mr. P. 
70 
135 
220 
140 
6 6 
Mrs. B. 
72 
160 
230 
140 
Asthma 
Mr. B. 
61 
230 
140 
80 
Emphysema 
Mrs G. 
65 
190 
150 
70 
Asthma 
Mr. Y. 
82 
150 
210 
110 
Normal Senility 
6 6 6 6 
Mrs. J. 
67 
93 
190 
120 
Mrs. M. 
64 
165 
232 
136 
Nephritis 
Mrs. B. 
68 
150 
180 
124 
Normal Senility 
6 6 6 6 
Mr. T. 
79 
160 
142 
70 
Mr. O’H 
74 
140 
170 
120 
Nephritis 
Mr. T. 
78 
145 
160 
100 
Normal Senility 
6 6 6 6 
Mrs. B. 
64 
115 
162 
92 
Mrs. Wi 
74 
124 
198 
94 
6 6 6 6 
Mr. W. 
71 
119 
142 
88 
6 6 6 6 
Mr. L. 
74 
130 
162 
60 
Senile Pneumonia 
Mrs. K. 
70 
123 
142 
77 
Normal Senility 
In my opinion a great many cases of increased blood 
pressure are caused by nephritis and attention to the 
kidneys will give the best results. We may find cases 
where the nitrites are beneficial and if specific disease is 
present the iodides should be administered. The latter 
remedy is very irritating to the stomach and kidneys 
and should not be used except when necessary. The 
treatment indicated 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 the term “hardening of the arteries.” If we do not 
forget that these conditions are not diseases, but merely BLOOD PRESSURE IN SENILE CASES 
101 
symptoms of disease, we will be better equipped to treat 
the conditions in a more intelligent manner. 
The greatest difficulty in geriatrics is to be able to 
differentiate between normal and pathologic senile de- 
generations. Until we recognize this fact we will be 
making serious mistakes in the therapeutics of senile 
cases. CHAPTER XIII 
ARTERIOSCLEROSIS 
Case I.—A man, aged forty-eight, had a marked 
fibrosis of the arteries, cardiac hypertrophy and inter- 
stitial nephritis. His blood pressure was 210 systolic 
and 120 diastolic. 
He was nervous and irritable, had a sensation of pres- 
sure in the occipital region, his vision was blurred and 
he was in a state of extreme mental depression. In 
every way it was apparent that his was a degenerative 
condition consistent with a man of seventy-five. There 
was no history of syphilis, rheumatism, gout or plum- 
bism, but interstitial nephritis had developed since he 
had scarlet fever several years ago. 
Case II.—A man, aged thirty, had marked calcification 
of the arteries. He had tuberculosis of both lungs, with 
a cavity 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 marked arterio- 
sclerosis. He complained of headaches, loss of memory, 
nervousness, blurred vision, and other symptoms com- 
monly described as typical of arteriosclerosis. His 
symptoms were due, however, to parenchymatous 
nephritis. 
Case I describes a man of forty-eight who appears in 
every way like a man of seventy-five. In other words a 
case of premature old age. Case II is very unusual and 
represents a type in which it is difficult to ascertain the 
102 103 
ARTERIOSCLEROSIS 
Fig. 3. Roentgenogram showing marked arteriosclerosis and calcareous 
degeneration of the ulnar artery in a man, aged 68. 104 
GERIATRICS 
cause of the arteriosclerosis. Case III is not unusual, 
for a man of seventy would normally have hardening 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 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 congestion in the internal organs. The lining 
membrane has spots of atheromatous deposits and the 
free margins of the valves are thickened and hardened. 
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, which makes their 
diameter smaller. The pale skin of old age compared to 
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 smaller 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 circulation, the 
heart is forced to carry on additional work. If the 
heart action is too strong, it may cause rupture of the 
vessels and apoplexy. If the heart is weak there will be 
a resulting 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. ARTERIOSCLEROSIS 
105 
Always count the rate at the apex of the heart. It has 
been thought that as years advanced the pulse rate be- 
came 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 usually serious; how- 
ever, sometimes with the aged the faster the pulse and 
the higher the fever the better the prognosis. This 
opinion is based upon the fact that normally the aged 
do not have fever and increased pulse rate and when they 
have there is a possibility that it denotes a stronger 
vitality, but this is not always true. 
Premature arteriosclerosis aside from the usual 
pathologic causes, as syphilis, rheumatism, gout and 
plumbism, usually develops from a definite condition. 
From lack of care of the intestines or from indiscretions 
in diet, the portal circulation becomes somewhat con- 
gested, 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 harder to 
get the blood through the increased resistance. As a re- 
sult, if the process is continued, the second aortic sound 
becomes accentuated and the systolic blood pressure is 
increased. If this condition continues the heart in- 
creases its size in order to carry on the extra work and 
if this continues for a few years the kidneys, in contrast 
to the heart, decrease in size, which causes them to fail 
to perform their functions. The renal insufficiency comes 
as interstitial nephritis develops and in place of func- 
tional insufficiency, true uremia is present. 
The heart is now enlarged, there is high blood pres- 
sure in the arteries, which walls have undergone scle- 
rosis, and, in time, calcareous degeneration. 
We see here the role played by the kidneys in the 106 
GERIATRICS 
production of arteriosclerosis. I believe that the 
arterial changes are in many cases secondary to the 
renal changes. Today we are attributing many things 
to arteriosclerosis and calcareous degeneration of the 
arteries and we do not realize that arteriosclerosis is a 
normal process of ageing and 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 j)hysicians do we may find that nephritis was 
the first disease to appear. 
After sixty years of age we normally develop harden- 
ing of the arteries and it should not be considered 
pathologic unless it develops in young persons. Nature, 
who produced these arterial changes, permits a function 
which is in harmony with the degeneration of other 
organs. Today, when a person of advancing years is ill, 
with various symptoms, the physician is ready to at- 
tribute it to arteriosclerosis and when he dies, harden- 
ing of the arteries is supposed to have caused death. 
This pathologic arteriosclerosis should not be confused 
with the process due to normal senile arterial degenera- 
tion. The term atheroma is not a synonym of arte- 
riosclerosis since it describes a fatty degeneration and is 
localized. A syphilitic aneurysm 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 changes are due 
to gummatous softening. At the beginning of arterial 
degenerations 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 this is the incipiency of an 
arterial fibrosis. 
While arteriosclerosis is a normal change there are 
certain factors which hasten its development. In middle ARTERIOSCLEROSIS 
107 
age, syphilis, infectious diseases, rheumatism, gout and 
plumbism may tend to cause premature arterial changes. 
Roentgenologists are unquestionably prone to have pre- 
Fig. 4. Left coronary artery. Advanced arteriosclerosis, from a case 
of fatal angina pectoris. Magnified 30 diameters. But little of the adven- 
titia 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 accumula- 
tion, most marked in the upper segment, greatly altering the lumen of the 
vessel, lessening its carrying capacity, and rendering it practically in- 
elastic. There was a marked fibroid myocarditis in the area supplied by 
the vessel. (From Hare—Practice of Medicine.) 
mature arteriosclerosis, and thyroid disease may also 
cause it. 
I am convinced that the term cerebral arteriosclerosis 108 
GERIATRICS 
is used to cover a mass of ignorance in diagnosis. I 
have seen many of these cases with symptoms of a clas- 
sical cerebral arteriosclerosis which were due to uremia 
or intestinal toxemia. The elimination of toxins by 
means of free catharsis will relieve many of the symptoms 
due to so-called arteriosclerosis of the vessels of the 
brain. Aged persons are apt to become toxic especially 
when inactive, and failure to discover this will cause us 
to attribute vague symptoms to arterial changes. The 
term arteriosclerosis is too often a loop-hole for a physi- 
cian who is not able to make a diagnosis and in this case 
it is almost as unpardonable as to call a disease “old 
age.” In persons past sixty we use the term because 
we are not interested enough to discover the cause of 
the symptoms. 
Persons of advanced years, who have arteriosclerosis, 
sometimes have a series of symptoms which are 
described as classical. They have headaches, dizziness, 
loss of appetite, furred tongue, blurred vision, drowsi- 
ness to the extent of dozing in their chairs, weakness, 
symptoms of neurasthenia and psycliasthenia. There is 
a change in the mental condition; they become irritable, 
sometimes cannot stand the sound of conversation or 
music, and become melancholic. 
A woman, aged seventy, was taken suddenly ill, losing 
the use of her left arm. The next day she had regained 
its use. 
A man, aged seventy-two, was affected with sudden 
lameness and loss of power in the right leg and was 
obliged to be taken home. The next day he had im- 
proved. 
A man, aged sixty-five, suddenly became maniacal and 
said 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 lie died of cerebral hemorrhage. ARTERIOSCLEROSIS 
109 
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 five years 
since that attack and she is in excellent health, able to 
travel, but has never regained her speech and cannot 
read or write since the attack. She can say three or 
four words and her daughters can understand some of 
the 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, had symptoms 
similar to those of cerebral hemorrhage. His legs were 
powerless, he was unconscious for three days and in deep 
coma. Treatment by hot packs and enemata improved 
the condition, and he lived in comparative comfort for a 
year. 
A man, aged seventy-five, had attacks of mania which 
usually came when least expected. He was given laxa- 
tives and in a few days improved. This man has been an 
inspector of post-office construction and between the 
attacks maintained a normal mental state and was very 
keen in his judgment. 
The cases described have been observed in old persons 
who had marked arteriosclerosis and the symptoms 
given could easily be attributed to this condition. It is 
very evident in such cases that the symptoms, while due 
to cerebral arteriosclerosis, were produced by a cerebral 
congestion, itself due to renal or intestinal toxemia. 
Many cases of cerebral arterial hardening have no 
symptoms until there is a systemic toxemia which causes 
congestion. 
This applies to apoplexy. In the aged, a sudden loss 
of the use of a limb, an unconscious condition combined 110 
GERIATRICS 
with paralysis is commonly termed a “shock’’ or “slight 
shock.” The layman is very apt to call any unconscious 
condition in the aged a “shock” and physicians equally 
apt to label these conditions apoplexy. 
The more I study intoxications in the aged, the more 
convinced I am that true apoplexy is not as common as 
supposed and if cases are analyzed many times we will 
find uremia or intestinal toxemia to be the cause of this 
condition. This has been proved several times where 
active treatment of the toxemia has been instituted and 
the old patient has recovered and returned to 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 manifes- 
tations to apoplexy and it is often difficult to clear the 
diagnosis. On an eliminative treatment the condition 
will usually 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, they are very 
irritating to the kidneys. I have seen better results due 
to a treatment of free elimination through the kidneys, 
bowels and skin than from the use of nitrites. I fail to 
see any great advantage in lowering the blood pressure 
by the continued use of the nitrites, unless attention is 
given to the underlying cause. 
Free catharsis is by means of a saline and potassium 
bitartrate to increase elimination through the kidneys, 
and if the patient 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; hot packs are advisable, however, in some 
instances. 
In summarizing, I would say, relieve the system of ARTERIOSCLEROSIS 
111 
its toxins, restrict the diet, and disregard arteriosclerosis 
as far as therapeutics is concerned, unless in a younger 
person where there is a clear indication for a specific 
remedy. CHAPTER XIV 
SENILE HEART DISEASE 
The heart undergoes senile degenerations like all other 
viscera, but while most organs become atrophied, it is 
usually hypertrophied in old age. One of the earliest 
indications of the onset of senility is the change which 
takes place in the circulatory system and we must not 
overlook the fact that it is a normal senile change. Be- 
ginning with hyperplasia of the connective tissue of the 
intima of the arteries, there is a thickening of the inner 
coat, and, therefore, a diminution of the caliber of the 
vessels. The elastic fibers waste and the deposits of 
calcareous salts deprive the vessels of their proper 
elasticity, changing them into rigid tubes. These 
changes affect the vasa vasorum and as a result the 
nutrition of the larger vessels is impaired and they 
degenerate. Later the outer coats of the arteries be- 
come hardened, calcareous deposits are found in the in- 
ner and middle coats and the entire vessel becomes calci- 
fied, less blood reaches the organs and atrophy begins. 
In old age the heart is called upon to do more work, if it 
is strong there will probably be no apparent deviation 
from the state of health except possibly hemorrhoids or 
varicose veins. If the heart is too strong, the smaller 
arteries, especially those of the brain, may rupture, and 
apoplexy occurs; if the heart is weak, we find dropsical 
effusions and various venous congestions. 
The normal senile heart is somewhat dilated and 
hypertrophied. The capacity of the heart increases 
with the hypertrophy. Pic and Bonnamour note that the 
112 SENILE HEART DISEASE 
113 
capacity of the adult heart is 254 cubic centimeters for 
the male and 220 cubic centimeters for the female, chang- 
ing to 277 cubic centimeters in the male and 299 cubic 
centimeters for the female, in old age. The orifices of 
the heart become larger in advanced life. Hasse ob- 
served: “the progressive enlargement of the two 
auriculo-ventricular orifices is tolerably uniform; that of 
the two arterial mouths differ; both increase equally 
until the meridian of life, but the aortic orifice enlarges 
more rapidly in advanced age than that of the pulmonary 
artery, so that in old persons the latter is even narrower 
than the aorta.” The valves are usually changed in 
advanced life and it is possible to have considerable in- 
sufficiency of the aortic valve which does not give rise to 
symptoms. 
One of the most common causes of cardiac hypertrophy 
is Bright’s disease, which is usually accompanied by en- 
largement and dilatation of the heart. It is difficult to 
state whether the heart lesion is the cause of nephritis, 
or whether Bright’s disease causes the cardiac affection. 
Potain states: “in a fair number of cases it is clear 
that the nephritis is primary, and the hypertrophy of the 
heart is secondary.” Charcot believed that the cardiac 
enlargement was a result of the kidney lesions. In some 
cases of senile nephritis the heart may be normal in size 
and have every appearance of health, yet histologic ex- 
amination might reveal arteriosclerotic lesions. The 
hypertrophy usually affects the left ventricle. There 
may be accompanying endocarditis and dilatation is 
frequently observed. 
In all events, nephritis causes additional work of the 
heart and the organ usually enlarges to carry on its 
extra work. The resulting changes in the valves and 
orifices, which, should they occur in earlier life would 
seem to indicate serious disease, may, in old age, cause 
little trouble. Frequently, we examine the senile heart 114 
GEKIATRICS 
and hear loud murmurs, observe signs of abnormality, 
yet the patient is practically well. 
Syphilis of the heart, first described by Virchow in 
1859, is more common than we realize, occurring about 
ten years after the primary infection, and may be a 
cause of cardiac lesions in old age. I have seen several 
cases of senile syphilitic lesions of the heart and when 
specific treatment is instituted we often see a disappear- 
ance of the symptoms. A man of 60 was infected with 
syphilis forty years ago and had no symptoms after the 
treatment he had taken. He recently had symptoms of 
myocarditis,—arrythmia, dyspnea, anasarca and ca- 
chexia. All remedies failed to relieve him until sajodin, 
eight grains, four times a day, was given, which caused 
the symptoms to disappear. 
The condition is syphilitic gummata in the heart and 
the myocardium is usually affected. There may be 
fibrosis of the heart due to syphilis. In these cases 
potassium iodide or injections of gray oil, one grain, 
should be used. 
When a muscle has increased work to perform it under- 
goes hypertrophy, this general rule applies to the senile 
heart. In advanced age the heart sometimes undergoes 
hypertrophy as a result of normal senile changes. In 
other instances, the hypertrophy may be due to valvular 
lesions of the heart, which may exist for several years. 
Chronic aortitis, aneurysm, chronic diseases of the lungs 
and diseases of the liver will produce cardiac hyper- 
trophy. 
Senile myofibrosis, commonly called myocarditis, is a 
degenerative change of the myocardium which may be a 
result of ordinary degeneration or may be due to in- 
fectious diseases in earlier life which have affected the 
myocardium. Influenza is a common cause of the condi- 
tion, even in old age, this severe infection may bring on 
myocarditis. Bright’s disease and myofibrosis are SENILE HEART DISEASE 
115 
commonly seen together, but it is difficult to determine 
whether one disease is the cause of the other. I have 
seen these conditions combined; in one case I observed 
that when the heart began to fail, the kidneys showed 
signs of insufficiency. Another patient, who had 
nephritis, developed myofibrosis several years later, but 
in this case gout probably was a contributing cause of 
both conditions. Tuberculosis may cause myocarditis, 
but it is usually seen in patients who developed this in- 
fection earlier in life. It may, or may not, give rise to 
symptoms and is often detected only at postmortem 
examination. Sclerosis of the myocardium or cardio- 
sclerosis may be a form of the general senile degener- 
ation. 
The symptoms of myocarditis are dyspnea, sometimes 
accompanying the slightest exertion, and occasionally 
assuming the Cheyne-Stokes* type; palpitation, arryth- 
mia, and sensation of constriction in the chest, with pain 
in the mediastinum. It is often difficult to make a diag- 
nosis of myofibrosis or chronic myocarditis and we must 
depend a great deal upon the history of the case. Heart 
lesions following influenza or caused by rheumatism or 
gout are apt to be myocarditis; a positive Wassermann 
reaction would give a diagnosis of syphilitic myocardi- 
tis. In cases of myocarditis there are periods in which 
the heart is fairly strong, Avhile in fatty degeneration 
there is most often continued weakness of the heart 
action. I saw a man of eighty, who had chronic myo- 
carditis, with dyspnea, cyanosis, weak and irregular 
pulse, and, later, edema of the lower limbs. Diuretin 
quickly relieved him and he lived two years without 
much discomfort. 
In private practice one finds many cases of heart 
disease, but it is often difficult to diagnose the type of 
lesion. Many times physical examination reveals an ab- 
normality, yet the patient presents no symptoms. 116 
GERIATRICS 
Ten years ago I examined a man of sixty-five and 
found a loud mitral murmur at the apex, but it did not 
cause trouble until recently, when the heart showed 
signs of weakening. Dyspnea was so severe that he 
could not sleep at night; he had edema of the lower 
limbs; the pulse was rapid and irregular and the kid- 
neys, which were previously healthy, showed signs of 
insufficiency. Although he had had that heart lesion 
for ten years, he was able to work hard. 
In old age the pulse does not give us much indication 
of the seriousness of the cardiac lesion since arterioscle- 
rosis of the radial arteries affects the rate and quality 
of the pulse. Day found that in 562 healthy women 
whose average age was seventy-three the average num- 
ber of pulsations was a fraction above 73 per minute; 
and that the average pulse of 197 healthy men of the 
average age of sixty-eiglit years was 72.5. It is neces- 
sary to count the heart rate at the apex. As a rule we 
cannot depend upon physical examination of the heart 
to give us much information from a prognostic stand- 
point. One fact seems certain, that is: the senile heart 
stands much use and abuse, and we must try to lessen 
the amount of work it has to perform. 
In most cases of heart disease, where the symptoms 
are few, proper hygienic measures will suffice to relieve 
the condition. The treatment of these affections, in 
most instances, seems to be of a mechanical nature. 
A horse has a heavy load to carry and becomes fatigued, 
if we lighten the load, we enable the animal to continue 
the journey. If the heart has become degenerated, as 
long as there is normal interrelation of the degenerated 
organs, it is able to take care of its work. If any of the 
organs become congested, as for instance, the kidneys, 
this throws additional work on the heart, and broken 
compensation results. 
The 11 Effort Syndrome” or neurovascular asthenia, is SENILE HEART DISEASE 
117 
a common condition in old age. It is said by some 
observers to be the result of an insufficiency of the pit- 
uitary gland, and, possibly of the lack of other internal 
secretions. In many of these cardioasthenic conditions 
the administration of a total extract of the pituitary 
gland or suprarenal extract will give excellent results. 
In certain cases of bronchial asthma, these extracts will 
be of benefit. It is well to begin with small doses, every 
three hours, later increasing the dose. If the blood 
pressure is high, if nephritis is present or marked 
arteriosclerosis, these total extracts should not be used, 
but the anterior pituitary substituted. 
A patient who has cardiac hypertrophy (which is sec- 
ondary to nephritis) suffering from dyspnea, palpita- 
tion, edema of the lower limbs, precordial pain, and who 
is perhaps uremic, should be placed on a milk diet, a 
saline laxative prescribed and a tablespoonful of Trous- 
seau’s diuretic wine should be taken morning and night. 
In many cases the following prescription is of benefit: 
Diuretin 3 ij 
Aquae Cinnamomi q. s. ad. 3 ij 
Sig: Teaspoonful in i2 wineglass of water every three hours. 
Usually after a few doses of diuretin, there will he 
marked diuresis, dyspnea will he lessened and in a few 
days the edema will go down. This preparation can be 
continued for several days, but it is well to discontinue 
its use after forty-eight hours. Diuretin seems to act 
well only in patients who have edema of the lower ex- 
tremity. If it is the upper extremity, compound tinc- 
ture of jalap, from the French codex, in doses of one- 
half ounce at bedtime, will give good results. When 
the patient has improved, we may prescribe pills of 
renal extract, 25 centigrams being given four to eight 
times a day; or we may give 10 centigrams each day, hypo-* 
dermically. Renal extract, by improving the kidney con- 118 
GERIATRICS 
dition, lessens the work of the heart. In some cases of 
myocarditis, the extract of myocardium will have a bene- 
ficial action, 25 centigrams being given from two to six 
times a day. Many cases of nephritis, associated with 
heart lesions, improve on thyroid extract. It is well to 
begin with small doses of this extract and follow its action 
carefully. 
At times, strychnine works favorably and I have 
patients who have taken %o grain three or four times 
a day for several months. Sometimes if there is prostra- 
tion, and yet no kidney involvement, I give them two 
grains of quinine sulphate and %o grain of strychnine 
sulphate every three hours, which seems to tide them 
over the dangerous period. 
It is surprising to see how many combinations of 
remedies some physicians will employ in heart diseases; 
I have seen one prescribe nitroglycerin, strychnine, caf- 
feine and oil of camphor hypodermically, at the same 
time. The secret in treating heart disease is not to force 
the heart, but to lessen the peripheral resistance. This 
is the best means of stimulating the heart we have. After 
all, it is not necessary to employ many heart remedies 
except in certain instances. Milk diet, diuretics, sa- 
line laxatives and rest will sometimes be all that is 
necessary. 
Some cases will be relieved by digitalis, but usually 
small doses will suffice. Digitalis is an uncertain remedy 
in old age and as a rule does not work well. If the pulse 
is irregular, sparteine sulphate, %o grain, may be given 
every three hours. In cases of high blood pressure, and 
when there is acute pain in the precordial region and in 
the left arm, nitroglycerin, grain %oo, every two or 
three hours may be of benefit. Sometimes the headache 
following its use is intense and lasts several hours. At 
times a mustard paste over the apex region will be of 
benefit when there is faintness and pain in the heart. SENILE HEART DISEASE 
119 
Alcohol in its full physiological effect will sometimes be 
of value. 
If there is evidence of syphilis, we should use daily in- 
jections of gray oil, one grain, and potassium iodide in- 
ternally. Arsenobenzol is to be preferred. 
Diseases of the heart which depend upon vascular or 
muscular changes require a treatment different from 
that of simple valvular disease, which is usually relieved 
by digitalis. Patients must avoid anything which pro- 
duces a strain of any kind and the activity must be 
entirely in proportion to the strength they possess. 
Excitement should be avoided especially that of a sexual 
nature. Old men who marry young women usually pay 
the penalty because sexual excesses in the aged cause or 
aggravate heart disease. Old persons with heart disease 
should avoid rapid walks, or climbing stairs. Prolonged 
mental or physical exertion has a bad effect. Life in 
general should be as calm as possible and in hospitals 
old patients should not be in contact with patients who 
are seriously ill or dying. Tobacco, although not advis- 
able, should be continued if the old man has been ac- 
customed to its use for several years. Great care 
should be taken of slight catarrhal infections and old 
patients should avoid contact with those who have in- 
fluenza, since the latter disease is often fatal in old 
age. If possible, the patient should avoid a climate 
which is subject to sudden changes of temperature. As 
a rule high altitudes are harmful. The climate of South- 
ern California is excellent for cardiac patients. In 
winter they should be reasonably far from the sea shore 
and in summer, away from the fumes of cities; the 
country should be sought. 
The Schott, Nauheim and Oertel treatments are usually 
contraindicated in old age. A certain amount of exer- 
cise, however, is necessary, but the patient should never 
reach the point of fatigue. 120 
GERIATRICS 
Great care should be given to the emunctories, 
especially the kidneys, and a nephritic diet should be 
prescribed in most instances. The bowels should be well 
regulated; baths should be taken each day and in some 
cases the patient will find that sponging his chest daily 
with cold water, and rubbing it with a Turkish towel 
relieves him. Overeating should be avoided and the eve- 
ning meal should be light. In the diet it is advisable to 
have as little sodium chloride as possible. 
Heart disease with arterial hypertension demands the 
same treatment as that described for the renal heart com- 
plication. As in cardiopathies the kidneys are usually 
affected, we must not follow the common custom of using 
the iodides for arteriosclerosis because it may produce 
renal irritation. 
In cases of hypotension we must use other remedies, 
particularly strychnine, sparteine or suprarenal extract. 
It is possible to combine the two former remedies for 
hypodermic use as in the following tablets: 
Strychnine Sulphate yG0 grain 
Sparteine Sulphate yiG grain 
Stropliaiithin may also be used. German observers have 
called attention to the use of very small doses of digitalis 
in these conditions, but on account of its cumulative effect 
it is not to be employed as a routine remedy. Digital! 
is a reliable preparation to use. 
I have seen several cases of cardiac attacks in old age 
which seemed almost certain cases of acute gastritis. 
The suffering was intense, severe pain in the region of 
the stomach, in one case I gave morphine hypodermi- 
cally and the patient died a few moments afterward. 
We must be on our guard in these cases of apparent in- 
digestion, which are in reality heart or kidney affections. 
“Acute indigestion,” so commonly spoken of as a cause 
of death, is most often acute gastritis of cardiac or renal 
origin. SENILE HEART DISEASE 
121 
Neuralgia of the heart is not so painful as angina 
pectoris, and is usually associated with palpitation and 
arrythmia. I remember a man of sixty, who had a 
pain over the apex region. I was unable to detect any 
disease of the heart. Blood pressure was normal and the 
kidneys were not affected. I called upon him one eve- 
ning and found him in good spirits, he was apparently in 
good health, except a mild pain over the heart region. 
I left for my office and when I arrived there found a 
telephone message that he was dead. We should give 
a cautious prognosis in the so-called functional diseases 
of the heart. Palpitation may be due to indigestion, but 
many times we find that these cases quickly become fatal. 
A man of seventy had palpitation; he was sitting in a 
chair and it did not seem necessary to make a careful 
examination because he was apparently not ill. How- 
ever, examination revealed an extremely rapid heart 
action, the pulse being over 160 a minute. Usually a 
pulse rate of 160 is fatal. He recovered from this attack 
and was able to work again. As he had diarrhea for 
several years and the bowels were checked, I believe this 
sudden checking of the excretion was the cause of the 
trouble, which was relieved as soon as the bowels were 
freely opened again. I treated a woman of seventy, who 
had attacks of angina pectoris for several years. Her 
systolic blood pressure was 220 and diastolic 130, and she 
had senile nephritis. The attacks came only at night and 
death seemed impending. I prescribed 1/100 grain nitro- 
glycerin by mouth and it brought relief for every attack 
for three years. Diathermia will relieve some cases of 
angina pectoris. As the disease is often associated with 
nephritis, we should treat the latter disease, thereby 
relieving the heart of its additional work. 
In conclusion, the treatment of most heart affections 
in the aged is rest and consists in lessening the peripheral 
resistance, which diminishes the amount of work the 
heart has to do. CHAPTER XY 
SENILE NEPHRITIS 
Case I.—A man, aged seventy, lost his position in a 
factory, and as a result became despondent and began to 
drink. He gradually became weak, complained of head- 
aches, dizziness, loss of appetite, and had difficulty in 
urination. He often cried, and the sound of music and 
laughter caused a severe pain in his head. He contrived 
against his family, saying that he was badly treated and 
would not eat at home, but went 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, the 
old man had fallen on the floor and was having a con- 
vulsion. He was given ether, but during the course of 
the morning had several severe attacks. He was un- 
conscious; the right side of his face was drawn and the 
left arm and leg paralyzed. There was a general sub- 
cutaneous edema. A diagnosis of uremia was made and 
he was given hot packs. For four days he remained un- 
conscious, but in the course of a few days regained con- 
sciousness, free elimination through the emunctories re- 
lieved him, he gradually recovered *tlie use of his arm 
and leg. For several days it was necessary to catheter- 
ize him. In about a month he was able to go out. It 
is now three years since the attack occurred and the man 
is able to do a hard day’s work and is in better health 
than he has been for years. 
Case II.—A woman, aged seventy-three, was extremely 
nervous. She appeared as a child with St. Vitus’ dance. 
The urine showed the presence of blood and granular 
122 123 
SENILE NEPHRITIS 
casts. Extract of pigs’ kidney apparently improved 
her condition. 
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 several severe 
attacks. In this type of nephritis a person may be very 
ill, but not show it in his general appearance. The pres- 
ence of blood, granular casts, some of them containing 
blood gave a guarded prognosis. He was given the 
dried extract of pigs ’ kidney and improved. 
Case IV.—A man, aged seventy-four, was taken ill, 
with cardiac weakness. He then developed facial par- 
alysis 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. 
The old man apparently gained on this treatment, and 
starvation instead of producing weakness, seemed to 
make him feel better. When irritability of the stomach 
disappeared he was given champagne, and peptonized 
milk. He gradually gained, and today is working 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 
her heart, but was in such a condition that she could not 
get out of bed. The aortic second sound was accen- 
tuated. Carefully questioned she revealed that she had 
the minor symptoms of Brightism, such as cramps in the 
calves of the legs, itching of the skin, nocturnal mic- 
turition, sensation of electric shock on lying down, sen- 
sitiveness to cold, dead fingers and dead legs. 
The urine showed numerous granular casts. Un- 124 
GERIATRICS 
doubtedly the heart was overworking to force the blood 
through the congested kidneys. The use of the extract 
of pigs’ kidney, together with free elimination, produced 
excellent results. 
Case VI.—A retired business man, aged sixty-eight, 
consulted me for difficulty in urination. lie 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 toxins his men- 
tal 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 the use of the dried 
powder extracted from the kidney of a pig freed his 
urine from any discoverable abnormality. 
He recently lost the sight of his right eye, through 
retinal hemorrhage, undoubtedly due to nephritis, 
although the urine does not show any abnormality in 
the sediment at present. 
These cases are typical examples of chronic renal 
toxemia. It will be noted that in some of them the men- 
tal state, often ascribed to “old age,” or childishness, 
etc., disappears when proper attention is given to the 
elimination of toxins. Intestinal toxemia will often 
indicate the beginning of nephritis, but it may also de- 
velop during the course of the disease. 
The kidneys, in modern life, perform the greater part 
of the daily elimination. These small organs are 
constantly working, the majority of people neglecting to 
make the bowels and skin do their proper share in the 
elimination of waste. As a result of our overeating of SENILE NEPHRITIS 
125 
excessive amounts of nitrogenous foods, and irritating, 
volatile substances like mustard, horse-radish, etc., the 
kidneys are not only irritated but overworked. 
Naturally, the result is that they are the first organs 
to weaken, and instead of enlarging in order to carry on 
their extra work, they usually become smaller or con- 
Fig. 5. Kidney of chronic interstitial nephritis. The surface is granu- 
lar 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.) 
tracted. Then the heart is forced to pump harder to 
get the blood through the congested organs, owing to this 
increased resistance in the renal blood vessels. This 
condition continues, and, consequently, produces first a 
hypertension; next, a hardening of the arteries, and 
finally hypertrophy of the heart. 126 
GERIATRICS 
Because of the lack of more precise methods of 
diagnosis, the presence of chronic interstitial nephritis, 
in many cases, is only discovered on postmortem examina- 
tion, The microscope and chemical tests will not always 
answer. Sometimes when the kidneys are in bad condi- 
tion the microscope will not reveal it until several ex- 
aminations have been made. 
Nephritis may be due to syphilis,1 and the diagnosis is 
made from the clinical aspect because the urine does not 
show any evidence of abnormality until several weeks 
after the onset of the attack. Also in Case VII the 
retinitis developed when the urine was apparently free 
from abnormality and when the systolic blood pressure 
was 150. 
The more civilized we become the more apt we are to 
develop diseases like nephritis and cancer. Peoples of 
the Par 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. 
Arteriosclerosis is 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 head- 
aches and edema, are usually absent. There is a certain 
kidney degeneration which is normal in the process of 
ageing, and this degeneration attacks all organs, one of 
the miracles of Nature is the function which these weak- 
ened organs will perform. If the harmony is broken, 
however, some organ like the kidney will break down 
more rapidly than the others. It is then the symptoms 
1 American Journal of Clinical Medicine, August, 1916, p. 676. 127 
SENILE NEPHRITIS 
of broken renal compensation arise just as those of lost 
compensation in the case of heart disease. 
The first symptom of nephritis will often be a languid 
feeling. There is mental depression and a general 
evidence of intoxication. The face is flushed at night, 
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 drowsiness. 
The old man sleeps in his chair during the day and com- 
plains that he cannot sleep at night. He may contrive 
against his best friends and tell others that he is abused 
at home. He loses his sense of cleanliness, will not bathe 
himself properly, and may resort to habits that are very 
unclean; he is unlike his former self. 
In the male usually there is difficulty in urination, due 
to prostatic congestion. Senile rheumatism is fre- 
quently a manifestation of senile nephritis, and is due to 
renal toxemia. Sciatica and lumbago are sometimes 
symptoms, and oftentimes chronic indigestion is caused 
by 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 whether the condition is due to 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 nephritis accompanying 
prostatic hypertrophy, both of which were due to syph- 128 
GERIATRICS 
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 
matter the cause, will usually have glycosuria, albumi- 
nuria and casts. 
Prognosis 
A little care and attention to senile patients will pro- 
duce excellent results in many cases, make them infinitely 
more comfortable and in many instances add several 
years to their lives. If there is blood in the urine we 
should give a guarded prognosis. These patients with 
interstitial nephritis, who have blood casts, will suddenly 
become ill, show every symptom of pneumonia and run a 
course similar to that of pneumonia. They rarely re- 
cover. I have seen many cases of apparent senile 
pneumonia which I am sure were an acute exacerbation 
of chronic nephritis. This is my conclusion, because 
these individual cases I had followed for several years 
had chronic nephritis. 
Whenever sugar is found, together with casts and 
blood, convalescence is certain to be protracted. 
Treatment 
The issuance of a strict diet to an aged person is 
usually a very distressing and disagreeable punishment. 
Most of these old patients were accustomed to coarse 
food in their younger days, and to change their mode of 
living might bring disastrous results. 
Although they live on coarse food, such as pork, red 
meats, food rich in nitrogen, I usually give them the SENILE NEPHRITIS 
129 
liberty to eat anything they wish. The old man was 
taught in his younger days that ‘‘food gives strength,” 
and to lose his appetite he thinks means approaching 
death. If a diet is ordered for him, it will usually cause 
mental depression and loss of appetite. Moreover, 
most of these diets are constipating. As a rule non- 
restriction works best in most cases. However, this does 
not refer to acute nephritis, when there is blood in the 
urine. If patients suffering from it are not ill in bed, 
it is better to give them milk, cereals, and light vegetables. 
If acutely ill and in bed, the absolute milk diet is in- 
dispensable in some cases, as in Case IV, absolute star- 
vation is the only treatment. This is because the organs 
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. 
Cases due to syphilis will usually yield to ordinary 
treatment, and seldom have I been obliged to resort to 
arsenobenzol for this particular condition in the aged. 
Eemedies other than mercury or arsenic will give better 
results in a few selected cases of syphilis. 
In some instances, especially in corpulent patients, 
and in those who suffer from intense headache, 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 perspiration. To give cabinet baths to aged 
patients requires great care, and the physician must 
select his cases. 
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 130 
GERIATRICS 
necessary to stimulate the aged, therefore strychnine is 
indicated. 
The matter of changing an old man’s habits is im- 
portant and should be carefully considered. 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 suppressed. 
In Case I it will be remembered that the illness 
developed after the old man had left his position. This 
is an important matter, and the best treatment for aged 
persons, when possible, is to keep them out of bed and at 
work. Even in cases of serious illness I feel that on 
several occasions I have seen aged people saved by 
getting them out of bed, no matter how ill they were. 
Even with senile pneumonia or senile bronchitis, if pos- 
sible, they should be kept in a chair. Keep old persons 
in bed, and the chances are that they will not get up 
again. To allow them out of bed encourages them. 
The bed means to them ‘ ‘ old age, ’ ’ which, in turn, means 
approaching death. 
This treatment of nephritis by means of elimination, 
therapeutic agents, and finally work seems the best means 
of doing away with many of the symptoms that will 
ordinarily be attributed to old age and childishness. 
The toxins in many instances produce the so-called 
senile mental state. 
In the chapter on Opotherapy, I have mentioned the 
use of animal extracts in the treatment of senile nephritis. 
In women, nephritis often begins at the menopause, 
blood pressure increases and if the condition is not 
treated becomes chronic. Oftentimes we find women in- 
creasing in weight at this period of life, and many of the 
symptoms attributed to the climacteric are in reality 
due to nephritis, associated with increased blood 
pressure. SENILE NEPHRITIS 
131 
The urine should be examined and blood pressure re- 
corded in every woman at this time of life and attention 
given to every abnormality. In looking over my records 
I find several women who showed evidences of changes 
ten years ago at the menopause, and observe that many 
who have not continued treatment now have chronic 
nephritis with arterial hypertension. 
At the menopause there are changes in the endocrine 
glands and the diminution in the amount of ovarian or 
thyroid secretions will apparently cause nephritis. 
Ovarian extract will sometimes improve the kidney af- 
fection, which is most often associated with hypothyroid- 
ism. The internal use of thyroid extract seems to 
quickly check the renal irritation, many of the distress- 
ing symptoms will disappear, the weight will decrease 
and the blood pressure will become lower. It is neces- 
sary to begin with small doses and watch the reaction. 
Sometimes the use of thyroid will, the first time, make the 
patient ill, but when it is resumed it will be effective. I 
feel sure that many cases of senile nephritis in women 
can apparently be cured by the use of thyroid extract. 
Sometimes thyroid extract and renal extract have a 
good effect when combined. The use of renal extract in 
senile nephritis gives excellent results in many cases. 
In men, we sometimes find that thyroid extract will 
improve the condition of the kidneys, in many cases the 
blood pressure will fall, and the heart will improve. 
The role played by the thyroid gland in nephritis is an 
important one and deserves great attention. In the 
cases where I have used it with success, I have checked 
the apparent improvement by careful urinalysis and 
noted that a few days after the thyroid extract was given, 
there was a marked diminution in the amount of albumin 
and in the number of casts. It is difficult to determine 
whether hypothyroidism is the cause of the kidney in- 
volvement, but if we note any signs of thyroid insuf- 132 
GERIATRICS 
ficiency we are justified in resorting to opodiagnosis, or 
the use of thyroid extract, awaiting its therapeutic 
action. 
In other cases, there is a lack of secretion from the 
pituitary gland with the thyroid deficiency and the two 
extracts combined will improve the kidney condition. 
The following combination will benefit these cases. 
y8 gr. desiccated thyroid 
/20 gr- entire pituitary 
gr. ovarian extract 
These tablets should be given three times a day, after 
meals. If the blood pressure is high, the anterior 
pituitary substance should be used without the posterior 
pituitary. It is often necessary to combine pituitary 
with thyroid extract. CHAPTER XVI 
THE COMPLICATIONS OF SENILE NEPHRITIS 
Senile nephritis is one of the most treacherous con- 
ditions we are called upon to treat, because there are 
many complications that develop in organs which are 
distant from the kidneys, while the latter organs fre- 
quently display little evidence of disease. In other 
words, we may find serious symptoms, for example, in 
the brain, due to uremia, yet the urinary picture may 
not be serious. 
The causes of the complications can usually be grouped 
under the headings (1) increase in blood pressure due to 
kidney disease; (2) toxins from the diseased kidneys 
affecting other organs, and (3) cardiac complications of 
an overworked heart, due to renal disease. One of the 
first symptoms of senile nephritis is an accentuated 
aortic second sound. The kidneys become slightly con- 
gested and the heart is obliged to work harder to force 
the blood through the renal arteries, which results in 
an increase in blood pressure. In the course of time 
arteriosclerosis develops, and the heart usually enlarges 
to carry on its additional work. On the contrary, the 
kidneys usually become smaller; that is, show the inter- 
stitial form of the disease, and because these organs are 
unable to functionate properly, uremia develops, which 
may be of the acute or chronic type. In old age we find 
the chronic form of uremia a very insidious disease, 
capable of causing many vague symptoms which are 
difficult to diagnose, the difficulty not always arising 
from the symptoms alone, because often we are sure 
that chronic uremia is in the background of paralysis of 
the arm, but urinary examination, even of the micro- 
133 134 
GERIATRICS 
scopic sediment, may reveal nothing of interest. This 
is the treacherous role contracted kidneys play in disease; 
on some days urinary examination is negative and at 
other times it is positive, and in a great many instances 
interstitial nephritis is discovered only at the postmortem 
examination. 
There are a few clinical symptoms that are of great 
value in determining the presence of senile nephritis. 
With these symptoms and a negative urinary examina- 
tion we are almost certain that nephritis is present, and 
a urinary examination should be made daily for several 
days, repeatedly centrifuging the urine as the micro- 
scopic test is the most important. The minor symptoms 
described by Dieulafoy as indicative of nephritis are: 
dead fingers, cramps in the calves of the legs, tortuous 
temporal arteries, sensation of electric shock on lying 
down, deafness, sensitiveness to cold and nocturnal 
micturition. I will now treat upon these minor symp- 
toms. 
Dead Fingers.—This is one of the first symptoms pres- 
ent, but the patient does not usually mention it to the 
physician; on the other hand, if questioned he may not 
understand to what you refer. I have had many senile 
patients tell me that they never had ‘ ‘ dead fingers, ’ ’ but 
have had a numbness in the fingers. Very frequently 
they will deny having numbness, but will confess to hav- 
ing a prickly sensation in the fingers. It may not affect 
all fingers, and may be on one hand only, or one finger 
only; it usually affects the last joint, and at times the 
numbness is so severe that the patient cannot use his 
fingers, It is undoubtedly due to the effect of urea on 
the nerves of the arm. 
Muscular Cramps.—Cramps in the calves of the legs 
which usually come at night; they awaken the patient 
and may be very severe. The patients state that the 
muscles actually tie themselves in a knot. An old Indian SENILE NEPHRITIS 
135 
told me that his tribe used a rattlesnake skin tied above 
the knee every night to cure these cramps. Another 
“cure” these Indians had for the muscular cramps was 
to place the shoes, soles up, under the bed before retir- 
ing. It is strange to hear the actual “cures” they be- 
lieve to be the result of these measures. 
Tortuous Temporal Artery.—A tortuous temporal 
artery, called by the French the “sign of the temporal 
artery,” is by no means always abnormal. There are 
many persons who have this tortuosity of the artery, 
even with visible pulsations, which does not indicate 
disease. These symptoms alone do not mean a great 
deal, but when combined are of great value in determin- 
ing a diagnosis. 
Electric Shocks on Lying Down.—This peculiar symp- 
tom is a sensation similar to that of grasping an electric 
battery and usually comes at night when the patient is 
lying down; it is very disagreeable. I have seen it in a 
few cases of senile nephritis, but more constantly found 
it associated with uremias of pregnancy. However, in 
the interstitial form of the disease it may be seen in 
old age, but the symptom is so peculiar that the patient 
does not know how to describe it, and it is only when you 
carefully explain it that he recognizes to what you refer. 
Patients have different ways of expressing symptoms 
and it is well to question them carefully. 
Sensitiveness to Cold.—A person suffering from inter- 
stitial nephritis is usually very sensitive to cold. He 
does not realize it until he is questioned, but when his 
attention is called to it, this becomes quite evident. The 
patient finds that he is obliged to wear heavier clothing 
and requires more bed-clothes than the average person. 
The sensation of cold is sometimes evidenced not only 
by coldness in the limbs, but patients feel at times as if 
their legs were paralyzed. 
Deafness and Buzzing in the Ears.—Frequently there 136 
GERIATRICS 
is a buzzing in the ears which may become very severe 
and cause great annoyance. Again, as a result of neph- 
ritis we may get temporary deafness, lasting but an hour 
or two. Some of the older physicians believed that 
chronic nephritis often caused deafness, and I am of the 
opinion that a great many cases of deafness are indeed 
produced by that disease. At any rate, I have seen many 
cases of deafness which improved when nephritis was 
treated, with a resulting lessened toxemia and lowered 
blood pressure. As the toxemia lessened the severe 
buzzing in the ears ceased. I recollect a man, aged 
sixty-five, who consulted me for a catarrhal condition 
of the nose and sinuses. He had severe ringing in the 
ears, chronic rhinitis and severe pain in the occipital 
region, accompanied by deafness. Physical examination 
revealed that he had chronic nephritis; his systolic pres- 
sure registered 230. He was given a saline laxative each 
morning and a diet of milk and cereals was prescribed, 
upon which his condition gradually improved, in the 
course of time his blood pressure dropped to 180. His 
catarrhal condition and deafness were greatly improved 
and his general health became much better. I have seen 
many cases in which an improvement in the condition of 
the kidneys produced corresponding improvement of the 
hearing. 
Nocturnal Micturition.—The patient rises several 
times during the night to urinate, there may be a large 
or small amount at each urination; tins may be as- 
sociated with dysuria. A great many senile patients 
who suffer from this disturbance find that getting up on a 
cold floor at night causes the urine to start with difficulty. 
These minor symptoms of Brightism may not only be 
complications, but are a part of the early manifestations 
of the disease. Many times, when these symptoms were 
combined, I made a presumptive diagnosis of nephritis, 
and usually it was corroborated by repeated urinalysis. 137 
SENILE NEPHRITIS 
One or two symptoms are not significant, but when they 
are combined they are as a rule very important. I re- 
member finding these symptoms in a woman of fifty, and 
felt sure that she was suffering from nephritis. 
Urinalysis revealed that she had suffered from chronic 
nephritis, but after several months I found that nephritis 
was secondary to cancer of the liver. 
I shall now refer to several of the complications of 
nephritis, not taking them up in systematic order, but 
as they occurred most frequently in my practice. It 
is possible to have localized uremia without general 
manifestations of renal disease. For example, we may 
have gastric uremia, cerebral uremia, renal uremia, etc. 
Indigestion.—This is a very frequent complication 
of nephritis and many obscure cases of so-called indiges- 
tion are due to an underlying kidney disease. Renal 
gastritis or gastric uremia may manifest themselves in 
many ways. There may be simple indigestion or dis- 
tress after eating; the patient may have persistent hic- 
cough, nausea and vomiting, or gastritis similar to that 
seen in alcoholics. Commonly it is the ordinary form of 
indigestion, or distress after eating, and there may be 
no other symptom of nephritis. However, the condition 
is corrected only by attention to the renal disorder. 
Gastrointestinal Disorders.—I have frequently had 
patients who suffered from spasmodic pains in the in- 
testines which were very severe at times, simulating ap- 
pendicitis or the crises of locomotor ataxia, and who 
often required U> grain of morphine for relief. Again, 
many forms of diarrhea are caused by Nature’s method of 
,elimination of toxins, or compensatory elimination be- 
cause the kidneys are diseased. Diarrhea may be as- 
sociated with severe pain and is best treated by attention 
to the kidney disturbance. 
Neuritis and Neuralgia.—Although this is not a com- 
mon cause, tic douloureux is occasionally due to chronic 138 
GERIATRICS 
nephritis. More frequently we find neuritis of the arm 
as a result of nephritis; lumbago and sciatica are often 
due to this disease and improve when attention is 
directed to the kidneys. 
Cerebral Uremia.—This condition is manifested by 
headaches, drowsiness, dizziness, delirum, melancholia or 
mania. A person suffering from cerebral uremia may 
suddenly lose the use of an arm or leg during a few 
hours. Again, a man may suddenly develop mania which 
takes the form of believing some one is persecuting him, 
for instance, attempting to poison him. Mania may last 
from a few hours to a few days with complete restora- 
tion to the normal, or it may become permanent. Oc- 
casionally, a person will lose the power of speech for an 
hour or two; these symptoms are partly due to toxemia 
and partly to the secondary congestion caused by in- 
creased blood pressure. Many symptoms commonly 
attributed to cerebral arteriosclerosis are due to cerebral 
uremia. When we have symptoms pointing to the brain 
alone, we must not forget the fact that uremia may be 
localized in one organ without general symptoms. 
Renal Uremia.—Strange as it may seem, it is possible 
to find a kidney poisoned by its own toxin; this has been 
described by French investigators. It is rather a 
violent type of nephritis, associated with severe pains in 
the back, with many casts and erythrocytes in the urinary 
sediment. 
Uremic Fever.—Most senile diseases do not present 
fever, but occasionally we find a typical case of uremic 
fever. This condition is due to uremic poisoning and 
has every appearance of typhoid fever; it may also 
simulate malaria or pyelitis. It is characterized by a 
temperature course similar to that seen in typhoid, and 
may run its course for several weeks before abating. 
It is frequently diagnosed as typhoid fever, because 
physicians, as a rule, do not associate a condition of this SENILE NEPHRITIS 
139 
kind with nephritis. Typhoid fever and malaria are rare 
in the aged, while nremic fever is common and if we make 
the mistake of diagnosing the condition as malaria and 
administer quinine we may get disastrous results. Care- 
ful microscopic analysis is necessary to differentiate the 
conditions. 
Pyelitis.—Pyelitis is occasionally secondary to ne- 
phritis but we must find out whether there is another 
cause in the background. I have said several times that, 
in the aged, cancer of the colon or liver may cause pye- 
litis, therefore one can never be too careful in establish- 
ing a diagnosis. 
Uremic Coma.—I wish to mention one point in partic- 
ular regarding comatose patients. No matter what the 
cause of coma may be, urinary examination usually re- 
veals the presence of albumin, sugar and casts; this fact 
should be remembered when making a diagnosis. CHAPTER XVII 
SYPHILITIC NEPHRITIS 
A few years ago a young man consulted me for a 
chancre, which went its usual course. About four months 
after the initial lesion he complained of several indefinite 
symptoms, such as cramps in the calves of the legs, 
numbness of the fingers, itching of the skin, and head- 
ache. One night I was summoned to his home in haste, 
and found him in coma. The attack occurred while he 
was talking with friends and apparently came out of a 
clear sky, as there was but little warning. He remained 
comatose for four days; urinalysis showed a slight trace 
of albumin and an occasional hyaline cast. A diagnosis 
of syphilitic nephritis was made. 
It was impossible to give any medication by mouth, 
but with enemata and hot packs free elimination was 
established. On the fifth day he recovered from the 
coma, and arsenic trioxide, grain %oo, was administered 
every three hours. He was given an absolute milk diet 
and was kept in bed five weeks on this regimen, to which 
a few vegetables and cereals were finally added. After 
the third week albumin appeared in abundance, and many 
hyaline and granular casts were seen. Five months 
elapsed before he recovered sufficiently to resume work. 
Case II.—A man, aged 30, had a chancre, and during 
the secondary course of the disease developed cerebral 
symptoms, which were diagnosed as cerebral syphilis. 
However, urinalysis showed albumin, and the microscope 
a field literally loaded with blood and casts. A diagnosis 
was made of acute syphilitic nephritis with uremia, caus- 
140 SYPHILITIC nephritis 
141 
ing cerebral symptoms. He presented a very malignant 
form of the disease and died a few days afterward. 
Case III.—A Civil War veteran was infected during 
the War. He had a syphilitic lesion of a toe, which had 
undergone sarcomatous degeneration. At times he 
showed evidence of nephritis with accompanying pros- 
tatitis. This was always relieved by the use of sajodin, 
in doses of eight grains every three hours. 
Case IV.—A college professor had a chancre fifteen 
years ago. He complained of urinary symptoms which 
were due to prostatic hypertrophy and there was ac- 
companying nephritis. Mercury in the form of the yel- 
low iodide, gr. 14, three times a day, would always re- 
lieve him. • 
In the first two cases I point out the toxi-infectious 
nephritis brought on by syphilis, following the primary 
lesion in the course of secondary symptoms. It is ex- 
actly the type of infectious nephritis seen as a complica- 
tion of scarlet fever, smallpox, pneumonia, influenza or 
erysipelas. Like other infections, at times, syphilis as- 
sumes a very malignant form, and may cause great in- 
flammation in kidneys which were previously healthy. 
It is as important to watch the kidneys while treating 
syphilis as it is in a case of scarlet fever. Sometimes 
the renal irritation may be slight and pass unnoticed, 
developing into a chronic form, as seen in Cases III and 
IV. 
Nephritis due to syphilis may come early in the course 
of the disease or may appear late. Many cases of inter- 
stitial or parenchymatous nephritis in old people are due 
to syphilis, bht are rarely diagnosed. Syphilitic 
nephritis may also be hereditary. It may appear during 
the course of the first year of life or fifteen or twenty 
years later. (Fournier.) 
One might attribute nephritis to the use of mercury. 142 
GERIATRICS 
In the first case I described, mercury or potassium iodide 
had not been used. Moreover, mercury will have a 
curative effect upon the condition, while there will be 
relapse if the treatment is discontinued. A study of 
workers with mercury shows that they rarely have a 
kidney irritation, except in acute mercurial poisoning, 
in which death may come from anuria, the result of 
nephritis. Lead workers frequently have nephritis, but 
it is rarely seen with the former. It is safe to use mer- 
cury for the treatment of syphilitic nephritis. 
Syphilitic nephritis comes with little warning. There 
may be a few symptoms, such as headaches, dizziness, 
dysuria, itching of the skin, puffiness of the lower lids, 
cramps in the calves of the legs and * ‘ dead fingers. ’ ’ In 
the case first mentioned there were few urinary findings 
at first, but at the end of the third week the microscope 
showed, an abundance of casts. Sometimes with hyper- 
acute nephritis there will he few urinary findings the 
first few days of the disease, which micfrht lead to an error 
in diagnosis. 
Syphilis may cause a great deal of trouble in the kid- 
neys, more so than any other disease, including diphtheria 
and scarlet fever. When it does prognosis is always 
grave, and it must be considered a dangerous com- 
plication. It may cause but slight apparent dam- 
age to the kidneys, yet leave an organ so weakened 
that it will be easily influenced by another disease, like 
influenza. 
The acute cases that recover suffer from a weakened 
condition of the kidneys. When I see men recovering 
from these attacks I wonder whether some one will 
recognize nephritis thirty years from now to be syphilitic 
and requiring a special treatment. The acute syphilitic 
nephritis today may be a chronic syphilitic nephritis in 
a man of sixty-five years. Do we often recognize syphilis 
as a cause of senile nephritis? I believe we do not, but SYPHILITIC nephritis 
143 
in cases which are recognized, results are usually rapid 
and satisfactory. 
Pew physicians take sufficient interest in old patients 
to analyze a case carefully enough to make an accurate 
diagnosis. The man described in Case III was quickly 
relieved from his symptoms. There are many old men 
suffering today who were infected with syphilis several 
years ago, but it has been forgotten and the doctor does 
not recognize it. To be sure, syphilis in the aged re- 
quires different treatment from that employed at ma- 
turity, but it must be discovered as a cause. An old man 
will seldom admit the disease, yet in history-taking we 
should think of this condition. Sometimes a scar on the 
leg or penis will tell the story. Only the routine ex- 
amination in the aged, an inventory of the system, will 
elicit the cause of many diseases. The patient described 
in Case III was infected over fifty years ago. Paren- 
thetically, I might say that his daughter died of what was 
thought to be pulmonary tuberculosis; his granddaughter 
of tuberculous meningitis; his son of a large syphilitic 
growth of the neck, which had undergone sarcomatous 
degeneration. The old man outlived his family. Had 
I known his history, I might have been able to save his 
daughter and granddaughter, as I am sure the conditions 
were due to hereditary syphilis. Occasionally, however, 
syphilis and tuberculosis will be combined, which makes 
treatment very difficult. I remember a young man who 
had a tertiary lesion of the leg which resisted all treat- 
ment. Several members of the family had died from 
tuberculosis. I prescribed guaiacol after stopping mer- 
cury and later returned to mercurial treatment, which 
then caused some improvement. The man described 
above with a syphilitic growth of the neck resisted all 
treatment because it had undergone sarcomatous de- 
generation. We must not overlook the fact that sarcoma 
or cancer may he engrafted upon a syphilitic lesion. 144 
GEBIATBICS 
Sometime ago I attended a woman forty-six years of 
age, who was infected twenty years before with syphilis 
by a doctor who operated on a sebaceous cyst. A 
chancre developed at the point of incision on the back. 
She complained of the minor symptoms of Brightism, 
such as headaches, nervousness and dyspnea. The 
symptoms in no way differed from ordinary nephritis, 
but resisted treatment. I later prescribed daily in- 
unctions of mercury, and, internally, ten grains of potas- 
sium iodide, taken three times a day. The improvement 
was soon evident, and now each time she complains of 
these symptoms a few days’ treatment will clear up the 
condition. The physician who follows his patients for 
many years is capable of making such diagnosis, while it 
is often difficult to diagnose the condition by modern 
methods. I feel sure that the Wassermann test is not 
always a safe guide in old age. It is difficult to make a 
diagnosis in old age, but we must not overlook the fact 
that many old people, religious and of strict morals to- 
day, led, when young, a life that would make a veneral 
infection easy. Many of them are syphilitics, but show 
little evidence of it. Many cases of senile nephritis and 
heart disease are due to syphilis, and must be carefully 
diagnosed. 
Treatment of the Acute Form 
An absolute milk diet is indispensable, but in the 
mild cases cereals may be added. It is possible to con- 
tinue a milk diet for several months without untoward 
results. Arsenic trioxide, grain Moo, every three 
hours, is employed; later, mercury, in the form of the 
protiodide, may be given in daily doses of y2 to 1 grain. 
At present I am employing novarsenobillon, prepared by 
Poulenc Preres, in Paris, but often use arsenic trioxide 
or sajodin (monoiodobehenate of calcium) eight grains SYPHILITIC nepheitis 
145 
given every three hours. Stokes 1 finds salvarsan or ar- 
senobenzol to be the quickest method of treating syphil- 
itic nephritis. It does not irritate the kidneys unless 
given in too large dosage. He gives salvarsan in doses 
of 0.15 to 0.2 gr., later cautiously increasing to 0.4 gram. 
However, he finds it advisable to follow with mercury to 
obtain lasting results. 
Milk should be skimmed at first and a tumblerful of it 
given every two or three hours, and should be continued 
for a long time. As improvement comes we might wish 
to add more to the diet. It should be continued, howevev, 
a sufficient length of time to permit a full subsidence of 
the renal inflammation. Like diabetes, when it recurs it 
is more difficult to cure. 
‘ ‘ Syphilo-Brightism ’ ’ 
After the acute stage has passed, the patient usually 
goes several years without definite symptoms. There 
may be an occasional malaise, cramps in the calves of 
the legs and blurred vision. Sometimes I have found 
that when mercurial treatment was discontinued the 
symptoms of renal disturbance would reappear. Re- 
cently, I had a man under treatment with novarseno- 
billon. He had a slight nephritis complicating syphilis. 
When the second course of treatment was finished and 
the Wassermann reaction negative, treatment was dis- 
continued for a time. At the end of a month the symp- 
toms of nephritis reappeared and the Wassermann 
was + + +• 
However, as the disease passes into the chronic stage, 
there are few symptoms and it would require a very 
careful analysis to discover any evidence of nephritis. 
The patient will continue, perhaps, in this way for several 
years, and possibly an infectious condition like influenza 
will bring about an acute exacerbation. Then it is very 
l Stokes, J. H., Journal of the A. M. A., 1916, LXYI, 1191. 146 
GERIATRICS 
difficult to distinguish between ordinary Bright’s disease 
and syphilitic nephritis. The latter condition will cause 
all the symptoms of the ordinary type of Bright’s 
disease. In many untreated cases there will be a 
syphilitic hepatitis, which will cause jaundice and ascites, 
a condition similar to hepatic cirrhosis or cancer *of the 
liver. Indeed, I remember a man, aged fifty-nine, who 
was ill in this condition; it had been diagnosed as cancer 
of the liver and as incurable. He had a general subcu- 
taneous edema, jaundice, ascites and retinitis. As he had 
a history of syphilis fifteen years ago, I prescribed 
sajodin, eight grains every three hours and one-fourth 
gr. of mercury protoiodide three times a day. He began 
to improve in the course of two weeks, and has been in 
fair health since. It is surprising to see edema disap- 
pear when treatment is directed to the specific cause. 
Oftentimes nephritis will not be fatal and the patient 
has passed from the acute form to the apparent ordinary 
type of Bright’s disease. As time goes on he has what 
may be termed senile syphilitic nephritis. 
Senile Syphilitic Nephritis 
The condition termed senile nephritis, which in many 
ways differs from that seen in maturity, can easily be 
caused by syphilis. The initial lesion may have occurred 
thirty or forty years ago. To diagnose the disease is 
difficult, since the Wassermann test is not so accurate in 
old age as in youth or maturity. As the disease does 
not differ from the ordinary Bright’s disease of old age, 
the diagnosis is a matter of supposition (Dieulafoy). If 
there is a history of syphilis, it is safe to call the nephri- 
tis syphilitic. It is all-important to make a diagnosis. 
Oftentimes the old person will forget or will not tell 
about a chancre he had several years ago. Most physi- 
cians are content with a diagnosis of nephritis with- SYPHILITIC nephritis 
147 
out establishing a further cause for the condition. 
It requires several years for the tertiary form to de- 
velop, and it is, in fact, a gummatous condition of the 
kidneys resembling amyloid degeneration. 
Notwithstanding the importance of diagnosis, we 
must not overlook the fact that the treatment of syphilis 
in old age is different from that of this disease in 
maturity, and some of the best results in treatment will 
be obtained by means of remedies other than mercury or 
the iodides. Arsenic trioxide, gr. %oo, every three 
hours or sajodin works well in the aged, together with 
free elimination through the emunctories. Novarseno- 
billion or arsenobenzol may be used intravenously, as in 
the acute form. Obviously, it is well to watch the action 
of all remedies as the renal tissues are weakened. It is 
necessary, in order to effect a cure, to stop the treatment 
and resume it from time to time. 
The milk diet is not important unless the patient has 
an acute exacerbation, attended with edema and the 
presence of blood and casts in the urine. The diet 
ordinarily prescribed for chronic nephritis should be 
used. 
In the aged we must look out for the secondary effects 
of remedies. Elimination is poor, and we are apt to get a 
cumulative effect of the drug. Arsenobenzol is the 
safest remedy to use for senile syphilitic nephritis; I 
have never seen any evidence of a renal irritation due 
to its use, no matter how long continued. Vittel water 
may be prescribed, with or without lactose. When the 
patient recovers from the discomfort of the disease it 
is usually difficult to induce him to continue the treat- 
ment. A careful analysis of the cases will show that 
mercury is not the cause of nephritis which occurs in 
syphilitic patients. This has been proved by Mauriac 
and Dieulafoy. CHAPTER XVIII 
SENILE DIABETES 
Case I.—A man, aged seventy-six, had complained of 
general weakness and as glycosuria had been discovered 
he had taken the Allen treatment for diabetes. When 
I first saw him he was extremely weak and the matter 
that gave him the most concern was his loss of appetite. 
He said that his diet did not include anything that he 
cared to eat. The fact that he had diabetes caused him 
great 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 
evident, 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 represented a transient 
glycosuria which very likely 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 
disease because of a similar condition of his wife, which 
had made him familiar with diabetes. He told me that if 
I found sugar he would not alter his mode of living be- 
cause he felt that he was too old to change his habits. 
I found 2 per cent of sugar, but did not advise treatment, 
and today, eight years after the first consultation, he is 
working as well as usual and lives in comfort. In all 
probability to change his diet, which consists of the 
148 SENILE DIABETES 
149 
coarsest food, would produce bad results. In fact, treat- 
ment 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 loss 
of teeth and a persistent balanitis. 
The urine contained albumin, 1 per cent sugar, many 
granular casts and some blood. It was apparent that 
nephritis complicated diabetes; in fact, the symptoms 
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. 
Case IV.—A professor, aged fifty-five, consulted me 
for a ‘ ‘ run-down condition. ’ ’ For some time he had felt 
disinclined to work, inability to concentrate his mind, 
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 
prescribed the elixir of iron, quinine and strychnine phos- 
phates, now unofficial, and treated him according to the 
method advised by Hr. E. P. Joslin, of Boston. 
I started with a diet containing carbohydrates to the 
amount of 150 gm. From this amount he went to 125 150 
GERIATRICS 
gm.; then to 100 gm., and on 75 gm. he became sugar- 
free. I kept him on a strict diet with vegetables of the 
5, 6 and 10 per cent groups, with four ounces of cream. 
He has remained sugar-free and is a most con- 
scientious 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, 
but several times each year he undergoes a thorough 
examination. 
Case V.—A woman, aged sixty, consulted me two 
years ago for pruritus vulvae. I found 2 per cent sugar 
and also every evidence of chronic interstitial nephritis. 
I excluded 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 or- 
gans functioned fairly well, I decided not to treat either 
the nephritis or glycosuria. To interfere with one 
would simply activate the other. 
Case VI.—A woman, aged sixty-seven, had been un- 
der my care for several years for chronic glomerulo- 
nephritis. Her urine was examined each week and al- 
ways showed much albumin, no sugar, and many hyaline 
and granular casts. Two years ago her kidney condi- 
tion abated, the casts disappeared and she felt fairly 
well although she had a troublesome parchness of the 
mouth, and consequently, polydipsia. Repeated examina- 
tions of the urine showed no sugar or /3-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 time 
with the result that when she returned to me the degen- 
erative kidney changes had recurred, but the urine still 
showed no sugar. SENILE DIABETES 
151 
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 pro- 
duced in her a mental depression which will never be 
overcome. Nothing will convince her that she has not 
diabetes. 
Case VII.—An Indian woman, aged fifty-three, had 
gangrene of the left forearm. After examining the 
urine several days in succession and failing to find gly- 
cosuria, on the fifth day I found 3 per cent sugar. She 
would not change her diet and moreover left the gan- 
grenous forearm to be amputated by Nature. She abso- 
lutely refused to consider any surgical intervention. 
The amputation by Nature is as perfect as if performed 
by surgical means. Her health is better today than it 
has been for many years. 
However, at times she experiences pruritus with 
eczema, and 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 presence 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 cannot live on any other. 
She will diet for about a week when she has a pruritus 
sufficiently severe to cause discomfort, then she returns 
to her usual diet. 
In some of these cases undoubtedly diabetes has not 
been of long standing. Diabetes of the aged is entirely 
different from that of young persons. What will cure a 152 
GERIATRICS 
young patient will have the opposite effect on the disease 
of 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, disas- 
trous results will often follow. 
Many cases of senile glycosuria are transient and 
merely a form of senile degeneration. In other in- 
stances we find confirmed diabetes evidenced by all of 
the minor symptoms of this affection. 
In Cases II and III both husband and wife had 
diabetes, which has been termed conjugal diabetes. 
Some of the French physicians who had observed this 
fact, spoke of it as possibly a contagious disease, but it 
is very likely due to the same mode of living. 
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 attract 
attention will be loss of weight. In others there may be 
inaptitude to work, nervousness, neuritis, backache, 
sciatica, muscular pains, melancholia, polyuria, poly- 
dipsia, polyphagia, balanitis and phimosis. Sometimes 
there will be urethritis which looks like that produced 
by the gonococcus. There is usually a tendency to 
drowsiness, pruritus, with or without eczema, ocular 
troubles (amblyopia) gingivitis, loosening and loss of 
teeth. At times there will be a single symptom which 
will cause great discomfort. In one instance I saw a 
troublesome case of balanitis with resulting phimosis. 
The man had made up his mind to take ether and get rid 
of the phimosis. However, the discovery of the cause, 
which was diabetes, probably saved him a good deal of 
inconvenience, for a proper diet checked balanitis and 
in time the phimosis was cured. SENILE DIABETES 
153 
Sometimes these old diabetics will not have polyuria 
or polydipsia. In Case IV practically the only symp- 
toms were sciatica and inaptitude to work. It was only 
through the regular process of routine examination that 
the sugar was discovered. Occasionally, pruritis of the 
genitalia with or without eczema will be the only symp- 
tom 
The estimation of sugar in the blood has given us a 
valuable method of diagnosing diabetes, since it is com- 
mon to find the percentage increased above 0.12%, while 
the urine may be sugar-free. This test, which is easily 
made by a Kuttner-Leitz Microcolorimeter, should not 
only be employed in diagnosis of diabetes but also to 
detect any improvement in the condition after treatment 
is instituted. Blood sugar determination is of great 
assistance in deciding if a surgical operation is ad- 
visable for the aged patient. 
Diabetes of the aged is usually mild, but very difficult 
to overcome. Senile patients rarely develop acidosis or 
kidney complications. Diabetes does not usually cause 
any increase in blood pressure or affect the arteries. 
On the other hand, arteriosclerosis may bring on dia- 
betes, especially by producing disturbance in the arteries 
of the pancreas. Cardiac incompetency is a rare com- 
plication 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, but tuberculosis in the 
aged is a rare complication, and when it is present it is 
usually without symptoms, and is only discovered on 
postmortem examination. The infectious diseases are 
apt to develop, partly because gluco.se makes an excel- 
lent culture medium in the blood and partly because the 
resistance is lowered. 154 
GERIATRICS 
Treatment 
It is advisable not to tell an aged patient that lie has 
sugar in his urine unless one is obliged to. Nothing 
causes more anxiety in senile patients than diabetes. 
The thought of a strict diet, the recollection of friends 
who have -suffered from the disease, worries them 
greatly, but when (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 cases of senile diabetes the Allen treat- 
ment and Joslin’s treatment will give excellent results 
and perhaps add much to the patients’ comfort, in fact it 
may add a few years to their lives. 
The discovery of Insulin for the treatment of diabetes 
may completely revolutionize the therapy for this 
disease. 
In some cases, however, in advanced age, it is bad 
judgment to change the mode of living. Oftentimes a 
radical change in the diet of an aged patient has de- 
cidedly bad results. In senility it is not advisable to 
stop any confirmed habit no matter how bad it is, 
whether it be eating indiscriminately, smoking or drink- 
ing. 
Food such as pork, baked beans, cabbage, pickles, 
corned beef, or any hearty food, may not be especially 
good even for younger people, yet to allow the senile 
patient to eat anything he wishes will be a great help 
in treating his condition. When an old man’s appetite 
is failing it causes him great anxiety, and usually any 
strict diet in the aged will produce anorexia and consti- 
pation. The cases that I do not interfere with do not 
present any symptoms which are very troublesome. 
There are times when it is advisable to place patients on 
a diet and in these cases I use the reduction of carbohy- SENILE DIABETES 
155 
drates according to the method of Dr. E. P. Joslin. I 
know of many 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, and he lived almost a year after this in com- 
parative comfort. 
The following diet list is very convenient to use in pri- 
vate practice where it is difficult to secure the cooperation 
of the patient in weighing food, etc. It is far from an 
ideal diet, but, I repeat, in private practice it is impos- 
sible to follow out hospital rules. Moreover, if the diet 
list is too complicated hardly any one will take enough 
interest in the aged person to prepare the food accord- 
ing to it. 
Diet List 
ALLOWED 
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, daily. 
Cheese, cream cheese, milk curds. 156 
GERIATRICS 
Jellies made of gelatin, calf’s foot, with wine, but 
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, usually not 
over one pint a day; tea, coffee, cocoa. 
Whiskey, brandy, rum, gin, dry Rhine or Moselle wine, 
claret, Burgundy, Apollinaris, Contrexeville. 
Strict Diet. Meat, poultry, game, fish, soups, gelatin, 
eggs, butter, olive oil, coffee, tea; and for variety, 
tongue, sweetbreads, tripe, kidneys, pigs’ feet, ancho- 
vies, lobster, 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. Receipt for 
Gluten Biscuits: Gluten flour, one cup; best bran, pre- 
viously scalded, one cup; baking powder, one teaspoon- 
ful; salt to taste; two eggs; milk or water, one cup. 
Mix thoroughly. 
Substitute for sugar: Saccharin tablets, y2 grain, ob- 
tainable at druggists. Each tablet replaces 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. 
FORBIDDEN 
Sugar in any form—syrup, molasses, candy, jams, 
honey. Rice, bread, sago, tapioca, arrow-root, cornmeal, 
hominy, barley, macaroni, spaghetti. Pastry, cake pud- 
dings and everything made of flour. Peas, parsnips, SENILE DIABETES 
157 
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 elimination through 
the intestines. 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’s skin is bronzed, the solution of two 
grains of pancreatin in an ounce of the mixture of rhu- 
barb and soda, works well in drachm doses four times a 
day. Codeine has a good effect on many cases of dia- 
betes in the aged. If there is any acidosis, a teaspoon- 
ful 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 en- 
deavor to deprecate surgery, but because patients abso- 
lutely refused intervention. Unquestionably surgery is 
the proper treatment for these complications, and 
modern anesthesia applied to diabetic cases has made 158 
GERIATRICS 
great advances so that it is not such a serious problem 
to administer anesthetics to aged diabetics as it was in 
years past. Blood sugar determination has given the 
surgeon a means of solving many problems in surgical 
procedures for diabetic patients. 
In the chapter on opotherapy I have mentioned the 
use of hepatic extract and pancreatic extract in the 
treatment of diabetes. By opodiagnosis, we can deter- 
mine which secretion is deficient; if the patient shows 
improvement after the use of hepatic extract, the disease 
is probably due to the liver; if the hepatic extract ag- 
gravates the condition, pancreatic extract should be used 
and I have seen many cases apparently cured by these 
treatments. The dose is twenty-five centigrams of 
cither extract, given four to eight times a day. 
The discovery of insulin by Drs. Banting and Best and 
the Toronto group is one of the greatest achievements 
we have had in medicine. The treatment itself is ex- 
traordinarily simple and it can be used in all kinds of 
cases, both mild and severe. It is necessary, however, 
to be particularly careful about the diagnosis, since in 
old age many cases of transient glycosuria are seen and 
in these instances insulin may do harm, in fact the indis- 
criminate use of insulin may give fatal results. The di- 
agnosis should be made by blood sugar examination, the 
normal range being between 120 to 150 milligrams per 
100 c. c. blood, while the range in diabetes as a rule is 
from 150 to 500 milligrams. Urinalysis should be made 
for sugar and acetone and diacetic acid. 
In using insulin it is necessary to continue dietary 
measures; the treatment is combined with dietary ex- 
periments in order to ascertain the maintenance diet. 
The treatment should be given in an institution where 
careful laboratory tests can be made before and during 
the treatment. When a reaction is experienced, as evi- 
denced by a tremor, acute hunger, chill or slight visual 
disturbance, the patient should be given orange juice, 
glucose or honey. 
Insulin has reduced the mortality of gangrene follow- 
ing operation. More conservative surgery is possible 
and the prognosis is greatly improved. In coma it may 
be a life-saving measure, but a sufficient dose should be 
given. The diagnosis of coma due to diabetes must be 
certain before treatment is given. CHAPTER XIX 
SENILE RHEUMATISM 
A man, aged fifty-six, consulted me for stiffness in tlie 
joints and lameness; during the past five years he had 
had several acute attacks of what his physician termed 
rheumatism and during these attacks suffered from a 
facial neuralgia and swelling of the larger joints, espe- 
cially the knees and ankles. There was accompanying 
cutaneous erythema, and the joints were so painful that 
he could not bear the weight of bed-clothes on the af- 
fected parts. He had severe occipital headache, back- 
ache, and complained of blurred vision. 
The acute attack in each instance ran a course of 
about two weeks, and, on an absolute milk diet, he was 
able to resume his work at the end of a month. 
Between the attacks he complained of what he termed 
muscular rheumatism. In the morning he was hardly 
able to get out of bed, but after exercising a little became 
limber. Frequently, he complained of pains in the 
sciatic nerve. At night he had severe cramps in the 
calves of the legs, which forced him out of bed because of 
the severity of the pain. The muscles in the calves of 
the legs seemed to knot, he was lame, and walked rather 
slowly, as if measuring his steps. The knees were 
somewhat stiff, which made it difficult for him to rise 
quickly from a chair. He had numbness in the fingers, 
and the legs were cold below the knees, feeling at times 
as if they were paralyzed. He was always cold, requir- 
ing more blankets at night than any one else in the 
house, even in summer. 
A blood examination was negative, blood pressure 
159 160 
GERIATRICS 
registered 175 systolic and 130 diastolic. Urinary exam- 
ination gave the following report: Specific gravity, 
1018; albumin, present; sugar, negative; indoxyl, neg- 
ative; uric acid, increased; chlorides, diminished; ace- 
tone and diacetic acid, negative. Microscopic examin- 
ation showed erythrocytes, leucocytes and many small 
hyaline and fine granular casts. 
It was evident that chronic nephritis was the disease 
causing the symptoms of so-called rheumatism, and 
treatment directed to it gave excellent results. He was 
made to take a saline laxative each morning, a cabinet 
bath twice a week, a diet consisting of milk, cereals, 
vegetables and fish was ordered and when he suffered 
from an acute exacerbation of the disease, he was given 
an absolute milk diet. 
Under careful treatment he lived comfortably for sev- 
eral years. Finally, the time came when the kidneys 
would no longer yield to treatment; he became an in- 
valid, several of his joints becoming ankylosed so that he 
was unable to get out of bed and died of uremia. 
This case represents a very common condition, ordi- 
narily termed rheumatism, but this so-called disease was 
merely a symptom of chronic uremia and when treat- 
ment was directed to the diseased kidneys the patient 
improved. In private practice we see many cases sim- 
ilar to this, but symptoms may vary from one muscle 
affected to several joints involved; in time the patient 
may have definite paralyses as a result of uremia. 
Dr. Solomon Solis-Cohen was fond of asking his classes 
the conundrum, “When is rheumatism not rheumatism?” 
His answer was, “Nine times out of ten.” He asked a 
similar question about sciatica, which he answered in the 
same manner. Senile rheumatism is usually a symptom 
of some other disease, very often nephritis. We should 
not confuse it, however, with senile arthrosclerosis, 161 
SEHILE RHEUMATISM 
which is due to hardening of the cartilages in the joints 
and which is a normal senile change. The differential 
diagnosis is made in the following manner: A patient 
with so-called rheumatism becomes more limber after 
exercising, while a man who has artlirosclerosis finds that 
exercise is harmful to his joint condition and makes it 
more painful. It is important to make a correct diagno- 
sis of these two conditions, as misdirected treatment may 
cause harm. 
Rheumatic fever is very rare in the aged, although 
chronic rheumatism due to nephritis may manifest itself 
by acute articular symptoms, and, when accompanied by 
slight fever, might be diagnosed rheumatic fever. Heart 
complications are common in these cases, and are not 
due to rheumatism, but to hypertrophy of the heart as a 
result of nephritis. The articular symptoms are in 
reality due to an acute exacerbation of chronic nephritis. 
Acute articular rheumatism, in its true form, is caused 
by bacteria, while in the aged it is usually due to tox- 
emia from some underlying disease. 
Nodular rheumatism, also called polyarthritis de- 
formans, is chiefly seen in patients between forty and 
fifty years of age. It is a progressive condition, com- 
mencing usually in the small joints of the hands and 
feet, and proceeding toward the trunk, causing consider- 
able deformity, which is most marked in the fingers and 
hand. 
Partial chronic rheumatism is ordinarily called senile 
arthritis, and usually affects the large joints. When it 
affects the hip, it is called morbus coxae senilis. At first 
the joint affection is painless; even exercise does not pro- 
duce pain; as the process advances the joint becomes de- 
formed, deformity being due to hydarthrosis. Any 
movement of the joint becomes painful and is often 
attended by intra-articular creaking. The end result is 162 
GERIATRICS 
often ankylosis. Again, in old age we get a form which is 
described under the head of chronic rheumatism of the 
phalanges, or Heberden’s nodes. It is usually found in 
old age and is hereditary, being associated with asthma, 
sciatica and migraine. In fibrous chronic rheumatism, 
which affects tendons, ligaments and aponeuroses, we 
find deformities in which the ends of bones are misplaced, 
and form prominences. 
Abarticular rheumatism is a term applied to the mani- 
festations in many organs while the joints are spared. 
In this category is found facial neuralgia, torticollis, 
pleurodynia, lumbago and sciatica. We may find these 
conditions in a patient who has so-called rheumatic 
diathesis, but it requires great care to differentiate them 
from symptoms of other diseases. For example, diabe- 
tes or nephritis may cause them. 
Gonorrheal arthritis is rare in the aged, but arthritis 
due to tuberculosis is not uncommon. I had a patient, 
aged sixty-eiglit, who suffered from tuberculous arthritis 
of the ankles and elbow, she had a tuberculous ulcer on 
the ankle. There had been no other manifestations of 
tuberculosis, and the disease did not inconvenience her a 
great deal. In the aged, we do not find this condition 
secondary to any other tuberculous process. I recollect 
a patient, aged sixty, who had for ten years suffered from 
joint pains in the elbow. It was evident that it was a 
pseudorheumatic process, but the exact cause could not 
be detected. After three years of suffering a tuberculous 
sore came on the skin, clearing the diagnosis. In the 
aged, tuberculosis does not usually produce great de- 
formity, pain or loss of motion; it is rare to see any 
improvement in the condition, and if it is not interfered 
with, it usually does not cause more discomfort. It is 
often difficult to diagnose primary pseudorheumatism, 
but when we are not able to find the cause of the infection, 
we should suspect tuberculosis. The diagnosis is not SENILE RHEUMATISM 
163 
so difficult if the patient has. hydarthrosis, because the 
fluid can be withdrawn and test of the articular fluid 
(cytodiagnosis) made by animal inoculation, and Arloing 
and Courmont’s sero-diagnosis will settle the question. 
Nephritis and Rheumatism 
In private practice, I have found that the most common 
cause of senile rheumatism or pseudorheumatism is 
nephritis. It is in reality chronic uremia, and the joint 
and muscle symptoms are due to renal intoxication; it 
is possible to have a localized condition due to general 
toxemia. For example, I have seen cases in which 
nephritis manifested itself only by torticollis; I recol- 
lect a woman who was suffering from torticollis, and this 
was the only symptom she complained of. I did not 
recognize the true cause of her affection until she sud- 
denly had a convulsion, and developed coma, which 
proved to be due to uremia. 
Again, I have had patients with neuritis in the arm, 
who suffered intense pain and it proved to be a local 
manifestation of chronic uremia. Many times the joint 
symptoms due to cerebral uremia are followed by uremic 
paralyses of various kinds, such as hemiplegia, mono- 
plegia, with or without Jacksonian epilepsy, aphasia, and 
facial hemiplegia. 
It is possible to have chronic uremia affecting one 
organ. For example, we may have cerebral uremia, 
gastrointestinal uremia, respiratory uremia (asthma), 
cardioaortic uremia, characterized by a tendency to col-, 
lapse and by pain, as in angina pectoris. Then we may 
have uremia affecting the joints alone, as in the case 
mentioned at the beginning of this chapter; it may mani- 
fest itself by a painful and swollen joint or muscle, lum-- 
bago or sciatica. In time, coma or convulsions develop, 
but for a while the disease spends its force on one organ 164 
GEKIATBICS 
only, although it is difficult to see why it affects one and 
not another. I remember a man, aged seventy-two, who 
was taken suddenly ill, he had a pain in the right arm, 
and in a few hours the part was helpless. The limb be- 
came swollen and very painful on motion. The next day 
he appeared somewhat dazed and developed coma which 
was diagnosed uremia. Treatment was quickly given 
and in a few days he regained consciousness. The arm 
gradually became smaller, but for seven months he could 
not use it. At the present time he uses his arm and is 
able to do some work with it. 
A gouty kidney will also produce symptoms of rheu- 
matism. In gout the process commences with gravel and 
ends with nephritis. 
A woman, aged sixty-five, complained of symptoms of 
rheumatism in her left arm, which was swollen and pain- 
ful upon motion. An underlying carcinoma of the uterus 
was the cause of it, and I have seen this condition ac- 
company carcinoma in this region so often that I al- 
ways suspect carcinoma of the uterus or stomach when 
I see a woman who has pseudorheumatism in either 
arm. 
Diabetes is a very common cause of rheumatic symp- 
toms, and one of the first manifestations of the disease 
is sciatica, lumbago or pain in the joints. Diabetes is 
often associated with a gouty diathesis, and Bazin has 
grouped them under the name of artliritism. In this 
group he placed, gout, asthma, rheumatism, gravel, gall 
stones, obesity and diabetes. 
A man consulted me for symptoms of sciatica. There 
were no other symptoms, but a routine examination re- 
vealed the presence of diabetes mellitus. 
Diabetes also may cause indefinite muscular pains. 
Plumbism may cause symptoms of rheumatism, as may 
iodism, biliary lithiasis and obesity. I have seen many SENILE RHEUMATISM 
165 
cases of pseudorheumatism which were caused by in- 
testinal toxemia. The latter condition is liable to pro- 
duce symptoms similar to those of nephritis and diabetes, 
and when proper treatment is instituted, improve- 
ment is usually seen. 
In the aged, the question of infection causing pseudo- 
rheumatism is very important, and undoubtedly many of 
these diseases are produced by the toxins developed in 
some focus of infection. Staphylococcus, pneumococcus 
or streptococcus may be the underlying cause, and it is 
sometimes a very difficult matter to discover the focus of 
infection. I believe that the ruthless extraction of teeth 
should be condemned. 
The pseudorheumatism of cancer is very important, 
and not infrequently we see pressure symptoms from a 
cancer of the colon producing a condition in the extremity 
similar to rheumatism. Again, the toxins developed in 
carcinoma may be the cause of neuritis in some distant 
part. 
Treatment 
Believing that nephritis plays the most important 
role in the production of senile rheumatism, I direct at- 
tention to the kidneys in this type of case. If urinalysis 
shows nephritis to be present, I give the treatment for 
senile nephritis, and if the patient is robust, Seidlitz 
mixture, magnesium sulphate and potassium bitartrate, 
magnesium citrate, Pluto, or the like, is prescribed each 
morning before breakfast. If the patient is of the 
physically frail type, I prescribe a compound cathartic 
pill at bedtime. 
The following diet list may be used and although it 
may be lacking in details, it serves a useful purpose in 
private practice when hospital supervision is not pos- 
sible : 166 
GERIATRICS 
ALLOWED 
Wheaten bread, stale or toasted; dry, unsweetened rusk 
or zwieback; soda crackers. Macaroni, oatmeal with- 
out sugar. „£i . , . 
Fats, in moderation only; butter very thinly spread 
and well rubbed in. Sometimes a thin rasher of bacon. 
Vegetables chiefly as purees, thoroughly cooked, made 
of tomatoes, asparagus, or occasionally potatoes or fresh 
peas. Lettuce, mealy, well-baked potatoes, not too young 
or new; spinach, very young, tender fresh peas, very 
young lima beans, asparagus, stewed celery. 
Oysters, fresh boiled or broiled fish without rich 
sauces. May be eaten with a little fresh butter and salt. 
Eggs in any form except boiled or fried. 
Broiled steak or chops, or mutton, chicken roasted or 
boiled, boiled capon, roast partridge, squab. Meats 
should be tender. 
Baked or stewed apples or prunes. Occasionally, a 
little fresh fruit in season, eaten between meals. 
Milk, milk and vichy, cocoa, weak tea taken with hot 
water, malted milk, Koumiss, Apollinaris, Celestins 
Vichy, Vittel. 
FORBIDDEN 
Rich soups, gravies and sauces ; condiments, pickles ; 
fresh soft bread of any kind, hot breads, all kinds of 
pastry, cakes, griddle cakes, doughnuts, muffins. 
Sweets, jams, confectionery and sugar in all forms, 
especially in coffee and tea with milk. 
Raw vegetables such as celery, radishes; potatoes, 
sweet potatoes, corn, peas, beans, eggplant, cabbage, 
cauliflower, turnips, carrots, parsnips. 
Lobsters, crabs, salmon, herring. Smoked or cured 
meats, and pork in every form; corned beef, game, veal SENILE RHEUMATISM 
167 
except as broth. Twice-cooked meats, stews; cheese. 
Very acid fruits and skins and seeds of same. Alcoholic 
beverages. 
In the chronic form of the disease, if the patient is 
robust, cabinet baths once or twice a week are very benefi- 
cial. Occasionally, we find an old man who takes Turk- 
ish baths, but the electric cabinet bath is more beneficial, 
and it does not take so long to obtain the same results. 
A cabinet bath once or twice a week, with an electric 
light cabinet is very effective. 
Salicylates are harmful and irritating to the kidneys; 
aspirin or acetylsalicylic acid is a depressant, causes 
perspiration and constipation, and, therefore, should not 
be used in many cases. Heroin will usually relieve the 
pain of the acute affection; morphine is rarely necessary. 
Diathermy treatments given by means of the auto-con- 
densation chair, and also locally, have yielded excellent 
results. If a general treatment is given, the patient is 
placed in the chair and about 750 milliamperes are ap- 
plied for one-half hour. If a local treatment is desired, 
I use two electrodes, varying in size from one inch square 
to four inches wide by seven inches long, placed on the 
affected parts. The milliamperage required depends 
upon the amount of heat a patient can stand. The treat- 
ment is given for one-half hour and is repeated two or 
three times a week. This form of treatment is very 
beneficial in the tuberculous form of the disease. 
Heat is applied to cases which have a tendency to de- 
formity by the application of superheated air at 130 
degrees, 180 degrees or 200 degrees C., and the results 
are sometimes remarkable. 
Sodium succinate, ten grains given every three hours, 
is of value in some cases of senile rheumatism. Other 
forms of senile rheumatism should be treated by atten- 
tion to the underlying condition. 
In rheumatism caused by nephritis, the results of 168 
GERIATRICS 
eliminative treatment are often remarkable, and if treat- 
ment is instituted before the disease has too firm a hold, 
many old persons will be spared the long suffering which 
accompanies this condition. CHAPTER XX 
URINALYSIS IN THE AGED 
Case I.—A woman, aged sixty-three, consulted me for 
numbness in the right side of her body. She was nerv- 
ous, melancholy, and complained of polyuria, polydipsia 
and polyphagia. Urinary examination showed one and 
one-half per cent sugar and /Loxybutyric acid. She was 
given Dr. Joslin’s treatment and in the course of a few 
days the urine became sugar-free. However, as this was 
brought about it was also observed that the urinary 
sediment, which was normal before the sugar disap- 
peared, became filled with small and large granular casts. 
It was evident that we were dealing with a combined 
condition of nephritis and diabetes and a nephritic diet 
caused the sugar to return. On a non-restricted diet she 
improved although the sugar did not disappear. 
Case II.—A man, aged seventy-six, had glycosuria but 
failed to improve on a strict diet. He had no other 
symptoms of diabetes and on a non-restricted diet the 
sugar disappeared. 
Case III.—A man, aged seventy, 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 any one who is do- 
ing urinalysis for his aged patients knows the frequency 
of these findings. 
Case I undoubtedly represents a case of glycosuria of 
renal origin. Nephritis is the underlying disease and 
glycosuria is merely one of the symptoms. Cases II and 
169 170 
GERIATRICS 
III represent glycosuria which is transient and due to 
the general degenerative changes accompanying old age. 
They do not require treatment. 
There is another type of urinary finding in which the 
symptoms of diabetes are the most evident, yet the pres- 
ence of many casts at different times shows the condi- 
tion to be complicated by nephritis. The urine of coma- 
tose patients usually contains albumin, sugar and casts, 
making it difficult to diagnose Bright’s disease or dia- 
betes. 
Albuminuria in the Aged 
In most instances I do not attach much importance to 
the discovery 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, make the presence of 
albuminuria important. 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; in this way it is possible 
to prevent a confusion with nucleoalbumin. 
Glycosuria 
In many cases the urine will have to be examined 
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 ex- 
amining the urine several days in succession and failing URINALYSIS IN THE AGED 
171 
to find glycosuria, on the fifth day I discovered 3 per cent 
sugar. - j] * - 
In the routine examination of the urine of aged patients 
the number of cases of glycosuria found is surprising. 
I have found sugar in many cases of Bright’s disease, 
a careful study of minor symptoms of Brightism seems 
to indicate that the sugar is a symptom, and possibly of 
renal origin. It is a serious matter to find sugar, albu- 
min, and casts in the same urine. 
Although Fehling’s solution is very safe, Benedict’s 
solution is undoubtedly more apt to reveal smaller 
amounts of sugar. It is well to corroborate the diagno- 
sis by using both tests when there is any doubt. 
In the aged the tests for chlorides, sulphates and phos- 
phates are usually not very important. 
Acidosis rarely develops in cases of senile diabetes, 
therefore /3-oxybutyric and diacetic acids are not often 
encountered. 
The urea test often fails to enlighten us in aged 
patients. Senile patients who are uremic may have a 
normal urea test. Indican is often found and is of great 
importance in determining the presence of intestinal 
toxemia. I have seen, however, some senile cases of in- 
testinal toxemia that did not have indieanuria. 
Microscopic Examination 
An occasional cast, like the presence of albumin, is a 
normal finding in some urines 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 applies to contracted kidney, which is 
a very difficult condition to diagnose. The hyaline casts 172 
GEBIATBICS 
are often so small and transparent that they are only 
found after the most careful examination. In some cases 
of contracted kidney it is only by repeatedly centrifuging 
the specimen that the casts will be detected. 
Erythrocytes may be due to nephritis, cystitis, or 
prostatitis. Many granular casts contain erythrocytes' 
and this indicates a serious condition. 
Pyuria may be due to pyelitis, cystitis or prostatic dis- 
ease. In women the pus may be of 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 Bright’s disease would be more 
important than glycosuria. On the contrary, if sugar is 
combined with albumin and casts, if the symptoms point 
to diabetes a diagnosis of this condition should be made. 
The presence of many red blood corpuscles almost 
always points to nephritis. If there were no symptoms 
attending these conditions a diagnosis of senile degenera- 
tive change would be made. 
A routine examination should be made in all senile 
cases and the practice of depending upon an albumin and 
sugar test should be discouraged. Most physicians do 
these two tests, which are of very little importance in the 
aged unless combined with a microscopic examination. 
I have seen several instances where physicians have 
diagnosed 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 polyphagia 
and polydipsia. He gave her a diabetic diet which ir- URINALYSIS IN THE AGED 
173 
ritated her condition and brought on an acute exacerba- 
tion of chronic nephritis. The patient admitted to me 
that she did not give a specimen of urine for examina- 
tion. 
More attention to the urinalysis of a senile patient 
would give better results. Sometimes proper attention 
to it will be the means of prolonging life. 
An old man had been a burden to his family. So- 
called ‘ ‘ old age ’ ’ had made him very disagreeable in the 
house and life with him was extremely difficult. Atten- 
tion was given to the cause of his “senile mental state,” 
which was due to uremia and careful treatment in this 
direction produced a new man mentally, in time he re- 
sumed his work and became self-supporting. Today, the 
disagreeable mental state has disappeared and undoubt- 
edly the family would feel it if he should be taken away. 
After all, there is no better citizen today than an old 
soldier who is well preserved mentally and physically. CHAPTER XXI 
SENILE ASTHMA 
The possible causes of asthma in old age are many; it 
may be idiopathic or secondary to some other disease. 
At the present time, I am treating a woman, aged fifty- 
nine, who is suffering from asthma. She has two chil- 
dren who have been asthmatic for several years and her 
son’s child also has the disease. She has not had asthma 
before, but for several years has been suffering from 
myxedema, which is quickly checked by thyroid extract. 
At the same time she has glomerulo-nephritis, and, 
strange as it may seem, the kidney condition improves for 
a time on thyroid extract, then kidney extract is given, 
which causes further improvement in the renal condition. 
The asthmatic attack of this patient lasted two weeks 
and I was unable to relieve her. Urinalysis showed no 
albumin, but several hyaline and granular casts; the 
blood pressure registered 160 systolic and 85 diastolic. 
I prescribed a diet of milk and cereals, large doses of 
bromides and she finally recovered. At times the symp- 
toms of myxedema reappeared and seemed to be of more 
importance than the renal condition, which called for the 
use of thyroid extract. It is difficult to differentiate the 
symptoms of myxedema and those of nephritis as the 
anasarca of Bright’s disease resembles myxedema. 
I have seen several cases in which there seemed to be 
an association between thyroid insufficiency and kidney 
disease and it is not uncommon to find that thyroid ex- 
tract will check the renal symptoms. 
The asthmatic sjunptoms in the case last mentioned 
were undoubtedly due to the kidney disturbance and if 
174 SENILE ASTHMA 
175 
sucli symptoms are carefully analyzed, many will show 
that asthma depends upon cardiorenal disease. 
Senile asthma is usually a symptom of another disease, 
although it may be a disease per se. It may be em- 
physema, fibrous phthisis, valvular heart disease, or dis- 
ease of the great vessels, a neurosis which is the mani- 
festation of gout, rheumatism, or possibly due to a latent 
or confirmed uremic condition. It is usually associated 
with high blood pressure, but I have seen cases in which 
the pressure was Ioav. The cause I have most often met 
with is kidney disease, but we must differentiate between 
dyspnea and true asthma. The latter is characterized 
by paroxysmal attacks of dyspnea and oppression, which 
come more or less regularly and are usually worse at 
night, and between the attacks the patients generally 
seem to recover completely. The attacks may come with 
marked regularity; Trousseau had one at about three 
o ’clock each morning, when he was awakened by a sense 
of oppression he invariably noticed that the clock was 
going to strike three. His mother, from whom he be- 
lieved he inherited his asthma, was seized between six 
and eight o’clock in the morning, but during the rest of 
the day Avas very active. 
Professor Rostau, while physician to the Salpetriere, 
Paris, made investigations on asthma in the aged and 
then made no difference between asthma and dyspnea. 
There was a time when he did not believe in idiopathic 
or nervous asthma and regarded asthma as always a 
symptom of some disease of the heart or great vessels. 
The following quotation from Trousseau, the famous 
French clinician, is very instructive: “Asthma is, in 
my opinion, a special and complete disorder, a manifes- 
tation, a peculiar form of a general complaint, having 
very variable local expressions, sometimes giving rise 
to paroxysms of dyspnea, of oppression of the chest, to 
a curious kind of coryza, and to peculiar catarrhal 176 
GERIATRICS 
attacks, which, as I took care to tell you, may constitute 
the whole paroxysm; but at times, also, manifesting 
itself by attacks of articular or wandering gout, by 
fits of gravel, by rheumatism or by hemorrhoidal 
affections.” 
Asthma is dyspnea of a special form and nature, but 
every paroxysm of dyspnea is not asthma. This neuro- 
sis may come on top of an organic disease of the central 
organ of circulation, since many grave heart conditions 
will cause little oppression in the chest, while others 
much less severe will cause great suffering. Asthma 
may accompany any organic affection, even cancer of 
the uterus, and, as in all other diseases, each patient has 
his own way of carrying his complaint. 
It is necessary to differentiate senile asthma from 
senile emphysema, which may produce symptoms similar 
to those of asthma. There are many cases of emphysema 
in old age which are associated with asthma. 
Senile asthma is not usually a fatal disease, although 
many deaths are caused by it. Day notes that out of 
51,048 deaths at or about the age of sixty in London, 
between the years of 1843 and 1848, 3,312 were ascribed to 
asthma. He noted that the number of deaths at or about 
the age of 60 is nearly double that of the whole of the 
earlier period of life. As asthma in the aged is so often 
caused by cardiorenal diseases, it is difficult to state what 
part genuine asthma plays in the condition. Moreover, 
as it is usually a symptom of some other disease, it is 
safe to say that the primary affection is the cause of 
death in most cases. 
Asthma may cause such suffering that the old patient 
may attempt to end his misery by suicide. Indeed, I 
remember a man of seventy who had repeated attacks 
of asthma; he finally killed himself. 
There is an intimate association between asthma and 
skin diseases in old age as I observed in a woman who SENILE ASTHMA 
177 
had psoriasis, which affected the legs and arms. I gave 
her an ointment of ichthyol and calomel and suddenly 
the skin eruption disappeared, which was immediately 
followed by a severe attack of asthma that lasted several 
days and ended completely only when the eruption reap- 
peared. I once saw a woman who had a tuberculous sore 
of the leg which was cured of its discharge, but it was 
followed by an attack of asthma. In old age it is pos- 
sible to attribute many attacks of asthma to the sudden 
checking of an excretion or secretion like diarrhea, dis- 
charge from ulcers or skin eruptions or excessive per- 
spiration which is localized. Such attacks are evidently 
due to an effort of Nature to rid the system of poisonous 
matter through expectoration. 
In old age the most common cause of asthma that has 
come to my attention is Bright’s disease. Patients us- 
ually have scanty urination, constipation and a dry con- 
dition of the skin. There may or may not be edema of 
the limbs, more often there is no albuminuria, but upon 
microscopical examination of the urinary sediment, many 
hyaline and granular casts are discovered. There may 
be no other symptoms of kidney disease and we may see 
uremia affecting one organ only. The attacks usually 
come at night, expectoration is at first scanty, later 
profuse often having a slight urinous odor. 
It may be so clear a picture of nervous asthma, as 
observed in adults, that one would not suspect the kid- 
neys. However, real asthma in the aged is very rare 
and a careful examination will most often show an 
organic disease in the background actually causing the 
trouble. 
Climatic conditions, sudden changes of temperature, 
usually affect asthma even if it is due to kidney or heart 
disease. Almost invariably asthmatic patients have 
dyspeptic troubles and indiscretions in diet may bring 
on or prolong an attack. 178 
GERIATRICS 
Senile asthma is more serious than the adults’ and 
cases of death have been reported during its paroxysms. 
I do not believe true asthma in old age to be more serious 
than in younger individuals, but as the disease is) usually 
symptomatic of some other condition we must give a 
prognosis in accordance with the gravity of the primary 
disease. The attacks may last a few hours, several 
weeks, or months. I recently saw a case of symptomatic 
asthma in a man of 50 who had cardiorenal disease. For 
five months he suffered from pseudoasthma which was 
so severe that he could not lie down, but was forced to 
sit in a chair, head forward, resting on a pillow placed 
on a table in front of him. In this way he could sleep at 
night, but during the day he could not sit straight in 
a chair without having a paroxysm. Although there 
was no extensive involvement of the prostate gland, 
urination at times was somewhat difficult and the act 
of voiding would bring on a paroxysm of asthma so 
severe that death seemed impending. All remedies 
failed, except diuretin, which relieved him temporar- 
ily. He finally died after five months of intense 
suffering. 
The skin test for the detection of hypersensitiveness 
toward the proteins of the common dietary and for the 
mechanical irritants which cause asthma, is a great step 
forward in the diagnosis and treatment not only of this 
latter affection, but hay fever, angioneurotic edema, 
skin diseases and many gastro-enteric disturbances. 
Dr. Robert A. Cooke (Journal Immunology, March, 
1922), gives numerous original and quoted data which 
show that substances absorbed by inhalation play a 
much more important part as the specific cause of 
asthma than is generally supposed. Even house dust 
and hay dust may act as specific allergens and are not 
to be considered as merely mechanical irritants. Dr. SENILE ASTHMA 
179 
Cooke states: “the cutaneous test is accepted today 
as a diagnostic procedure in the study of human hyper- 
sensitiveness. It is indicative of clinical hypersensi- 
tiveness in at least 95 per cent of the cases reacting to 
extracts of such airborne substances as pollens, pow- 
dered root of orris, and animal danders.” He reports 
that of 327 bronchial asthma cases which he studied in 
1920, 26 per cent were diagnosed by the cutaneous test 
as due to absorption by inhalation of pollens, 42 per 
cent by inhalation of animal danders, 16 per cent by in- 
halation of vegetable powders, 3.6 per cent by ingestion 
of foods, and the remainder as bacterial or undiagnosed 
cases. 
Some cases are quickly relieved in a paroxysm while 
others seem to resist all treatment. The renal form of 
asthma is very difficult to treat and when we find a 
remedy which checks one attack it may not have any 
effect on the next. First of all, it is necessary to dis- 
cover the organic cause, if any exists, and treatment 
must be directed to it. Asthma attributable to Bright’s 
disease demands a rigid nephritic diet and during the 
attack it is well to use a milk and cereal diet. Following 
the attack, a fairly liberal diet may be given, but great 
care be taken that the patient does not overeat. 
Many times I have seen a patient relapse after a hearty 
meal. 
Attention should be given to the bowels in every case; 
blue mass, 5 grains, followed in six hours with Pluto, 
Seidlitz mixture or epsom salts, or mercury and chalk, 
one grain every half hour for 5 doses, followed by a 
saline laxative, may be used. If the patient is too weak 
to take a saline laxative, I prescribe five grains of blue 
mass with two compound rhubarb pills. 
If the patient is suffering from a kidney disturbance, 
evidenced by microscopic examination, and scanty urina- 180 
GERIATRICS 
tion, headache, dizziness, swelling of the limbs, I pre- 
scribe the following: 
$ 
Diuretin 3 ij 
Aquae Cinnamomi 3 ij 
Misce: 
Sig: 
Teaspoon in % wingelass of water 
every three hours. 
When suffering is intense I repeat this dose in one hour, 
then give it every three hours. It is advisable not to 
continue diuretin over forty-eight hours, although recent 
investigations have shown that it can be continued over 
a long period of time if necessary. Although theobro- 
mine sodium-salicylate is said to have the same formula, 
and is less expensive, I prefer diuretin as it seems to 
give me better clinical results. 
Hypodermic injections of 10 minims of adrenalin 
solution, 1-1000, will work well in many cases, relaxing 
the bronchial tubes. It works quickly and often it is not 
necessary to repeat the injection. 
I do not like the idea of giving morphine hypoder- 
mically, alone or in combinations, in old age, since it may 
cause sudden death by paralysis of the respiratory center. 
If morphine is combined with atropine, the danger is 
lessened; in some cases where the suffering was intense 
and demanded quick relief I have given a hypodermic 
injection of the following combination: 
$ 
Morphinae Nitratis gr. i^0 
Nitroglyccrini gr. j,j„0 
Strychninae Nitratis gr. 
If the blood pressure is high, a hypodermic injection 
of Koo grain of nitroglycerin will often give almost 
immediate relief and may be repeated in twenty minutes 
if necessary. Occasionally, nitroglycerin will cause an SENILE ASTHMA 
181 
intense headache which will last for several hours. It 
is, however, usually a safe remedy in old age. 
In some cases the following prescription will give good 
results, especially in those where the patient is able to 
walk about: 
n 
Potassii Iodidi , 3 j 
Potassii Bromidi 3 ij 
F. E. Ipecacuanhae 3 ij 
F. E. Lobeliae Inflatae 3 j 
Elixir Gaultheriae q. s. ad. 3 iv 
TTE ft. sol. 
Sig: Teaspoonful in one-half wineglass of water 
every half hour until relieved, then every three 
hours. 
At other times grindelia robusta will be beneficial and 
may be prescribed as follows: 
R 
F. E. Grindeliae Robustae 3 j 
Elixir Sodii Bromidi (gr. X—3 j) 5 j 
Glycerolis “ 3 ij 
Elixir Aromatici—q. s. ad. 3 ii 
Sig: Teaspoonful in one-half wineglass of water every 
three hours. 
Digitalis is an uncertain remedy in old age, but in 
many cases of cardiac asthma it will yield satisfactory 
results. I usually use small doses of fat-free tincture or 
sometimes use an infusion. The following formula con- 
taining digitalis is useful in many cases: 
R 
Tincturae Digitalis 3 ij 
Glycerolis 3 U 
Elixir Aromatici q. s. ad. 3 iv 
Sig: Teaspoonful in one-half wineglass of water 
every three hours. 
To this we may add sodium bromide or the fluid 
extract of grindelia robusta. When an attack is felt to 
be coming on, an emetic may relieve the paroxysm and 
3 ij 
3 ij 
3 j 182 
GERIATRICS 
Kermes mineral often works well with the aged. 4. 
tablet containing Kermes mineral gr. % combined with 
Vi2 grain of powdered ipecac, can be given every five 
minutes until the patient is relieved. It may require 
fifteen or twenty tablets to cause nausea, but when it 
comes relief usually follows. 
Asthma powders containing stramonium and bella- 
donna will sometimes relieve an asthmatic patient. 
When everything fails to check a paroxysm, alcohol in 
its full physiologic action will often relieve the patient. 
A tablespoonful of whiskey or brandy should be given 
every half hour; after several doses a red spot appears 
on each cheek, then alcohol should be taken every two 
or three hours in order to prolong the full physiologic 
effect. 
When the attack is over the patient should be kept on 
a light diet for three or four days and remain quiet dur- 
ing this time. If the kidneys are the cause of the affec- 
tion, dietary treatment must be prescribed and the 
bowels should be opened by a laxative each day. If the 
patient is robust, electric cabinet baths may work well, 
ridding the system of toxins through the skin. 
Treatment must be carefully given, so as not to- affect 
any ulcers or discharges from the skin diseases, or sud- 
denly check any excretion or secretion, which would be 
detrimental to aged patients. 
There are cases of senile asthma that will be relieved 
by the use of thyroid extract. It should be given at first 
in small doses, later increased to its full action. There 
are other cases which are due to renal disease and seem 
to do well on the extract of kidney substance. Recently, 
I treated a case of asthma due to cardiovascular disease 
by the extract of myocardium, each pill containing* 25 
centigrams of the substance, six being given each day. 
This extract is said to contain adrenalin. 
There are other cases in which strychnine seems to be SENILE ASTHMA 
183 
of benefit, perhaps on account of its stimulating effect. 
In some instances, when asthma is associated with 
edema of the lower extremities, a salt-free diet will bring 
about an improvement in a few days. Sometimes, in 
chronic cases, arsenic trioxide, gr. Koo, three times a 
day will help, especially if the disease is accompanied 
by coryza. 
One of the newer and most effective remedies for 
most every form of asthma is benzyl benzoate, which is 
an ester of benzyl alcohol and benzoic acid. Un- 
doubtedly the effects of the aromatic balsamic resins in 
chest are due to this ester,'which is present 
not only in the balsams, but in several of the flower oils. 
In order to be of use in therapeutics, benzyl benzoate 
must be free from chlorine and phosphorus, with an 
ester content of 97 per cent. 
The dose ranges from 5 to 25 minims dissolved in 
alcohol and diluted with milk, chocolate or water. It has 
a disagreeable taste and it is difficult to find a vehicle 
which will cover it. Some manufacturers make 20 per 
cent' aromatic solution; others dispense it in capsules. 
One of the best vehicles which assists in making it more 
palatable, is the syrup of yerba santa. Benzyl ben- 
zoate must first be dissolved in alcohol and then the 
syrup is added. The following prescription is satis- 
factory: 
B ... 
Benzyl Benzoatis (100%) purae g j 
Alcoholis 3 ij. , f, fT 
Syrupi Yerbae Santae 3 j 
Sig: One-half to two teaspoonfuls every three 
or four hours, diluted in one-half glass of 
water, cocoa or milk. 
Benzyl benzoate is slightly irritating to a weak stomach 
and it seems to me that it also irritates the kidneys in 
cases of Bright’s disease. It does not benefit every 
case of asthma; I recently gave it to a patient suffering 184 
GERIATRICS 
from bronchial asthma with excellent results while a 
patient suffering from uremic asthma was not relieved 
by it. 
Dr. Macht in his investigations at Johns Hopkins 
University (Southern Medical Journal, 1919, No. 7) 
makes the following deductions: 
1. That benzyl benzoate treatment of asthma was bene- 
ficial in 75 per cent of the cases. 
2. In some cases the results were striking and equalled 
only by the injections of epinephrine. 
3. A few cases, in which epinephrine failed, were re- 
lieved by benzyl benzoate, administered by mouth. 
4. Curiously, a number of cases failed entirely to react 
to benzyl benzoate treatment. 
5. The above fact was not surprising, as asthmatic 
cases include really a variety of different conditions and 
dyspnea, when due to other causes than bronchial spasm, 
will not be checked by the benzyl treatment. 
Dr. Macht found that in some cases benzyl benzoate 
administered by mouth markedly lowered blood pressure, 
both systolic and diastolic, the effect in practically all 
such cases being more lasting than that produced by the 
nitrites. 
Almost all asthmatic patients suffer from indigestion 
and paroxysms may be brought on by overeating. It is 
well to keep the bowels freely open each day and the diet 
should be restricted. Recently, I had a patient who was 
relieved by chloral hydrate combined in the following 
mixture: 
n 
Potassii Bromidi 3 v 
Chloralis Hydratis 3 ijss 
Fluidextracti Hyoscyami 3 ss 
Fluidextracti Cannabis Indicae 3 j 
Elixir Simplicis q. s. ad. 3 *v 
"1 
Sig: Teaspoonful in one-half wineglass of 
water every three hours. SENILE ASTHMA 
185 
It gave quick relief and was continued several days 
with good results. 
High frequency current may be beneficial in cases 
where blood pressure is high, it should be given in the 
form of autocondensation, about 1000-1500 milliamperes 
for thirty minutes, three times a week. It induces free 
perspiration, lowers blood pressure and improves 
general health. 
Inhalations of steam which contain a few drops of 
guaiacol may check the spasm. Calcium creosote, in 
tablets or solution, given internally will sometimes act 
as a good tonic after the attack. 
Attention should be given to hygienic conditions, ex- 
posures to sudden changes in temperature avoided and 
warm clothing worn the year round. Theaters and over- 
crowded places should be avoided and baths should be 
taken frequently. CHAPTER XXII 
SENILE EMPHYSEMA 
Emphysema is present in most cases of senile asthma, 
but the association between the two is so intimate that 
it is sometimes difficult to diagnose it. Emphysema 
often being of mechanical origin, it is well to remember 
what takes place when a person coughs; first, the glot- 
tis closes, after a deep inspiration, and the muscles of 
expiration contract in order to expel from the bronchial 
tubes the air, mncns or blood, which they may contain, 
and sometimes it requires considerable force to over- 
come the resistance of the bronchial tubes; the pressure 
is exercised from within outwards in the, tubes and pul- 
monary vesicles. The air which is inside the bronchi 
greatly tries the elasticity of the walls of the air cells 
and when powerful pressure is repeatedly sustained, the 
chest expands, the lungs dilate and emphysema follows. 
In some instances the air cells burst, and we have inter- 
lobular emphysema. 
Whooping-cough, chronic bronchitis or asthma, which 
cause coughing, are equally apt to produce emphysema. 
In old age, although we may find emphysema as a cause 
of asthma, it is usually an effect of it. 
An asthmatic person inspires more sloAvly and deeply 
than a normal one, and expires in a more violent manner; 
besides this abnormal expiration, the violent cough of 
asthmatics tends to produce greater respiratory efforts. 
In old age, there are certain anatomical conditions 
which are liable to cause emphysema ; senile degenera- 
tion of the lung, atrophy and perforation of the alveoli, 
and inadequate nutrition of the lobules (due to a lessened 
186 SENILE EMPHYSEMA 
187 
blood-supply from arteriosclerotic pulmonary vessels), 
diminished aeration of the blood in the lungs, tend to 
bring about this condition, trophic changes as well as 
mechanical action will produce it. The rigidity of the 
chest walls has some effect on the compression of the 
lungs. 
Sometimes the emphysematous vesicles rupture and 
if it involves the pleural cavity, pneumothorax develops. 
The characteristic shape of the chest seen in emphy- 
sematous persons at maturity is not noticeable in old 
age unless the condition happens to have existed for 
several years. In senile cases, the chest walls are rigid 
and the diaphragm carries on most of the work of res- 
piration. The most distressing symptom is dyspnea and 
in addition to this we may get violent attacks of suffoca- 
tion. Emphysema combined with asthma, fibroid 
phthisis or heart disease is a very serious condition and 
liable to cause intense suffering. 
Actual measurements of the chest show that the 
respiratory capacity is reduced about 50 per cent. The 
affected areas give forth harsh sounds upon ausculta-: 
tion, inspiration is shortened and expiration lengthened. 
Dyspnea accompanies the least exertion. 
In physical examination it is often difficult to hear 
the heart sounds, but if heard clearly they will usually 
reveal an accentuation of the pulmonic second sound, 
which results from pulmonary congestion. In time the 
heart undergoes changes, due to increased work, the right 
ventricle not being able to overcome the resistance in the 
circulation of the lungs; this heart condition, in turn, 
makes the dyspnea worse and broken harmony with its 
train of symptoms results. The liver becomes congested, 
as well as the kidneys, and the urine shows marked 
changes. Microscopic examination reveals many hyaline 
and granular casts and uremia may develop. 
Symptoms may appear in other organs as a result of 188 
GERIATRICS 
the circulatory disturbance and the patient becomes 
cachectic through loss of appetite. Senile emphysema 
often accompanies diabetes and may be combined with 
other senile diseases, general arteriosclerosis, nephritis 
and influenza are apt to cause serious pulmonary affec- 
tions which are almost invariably fatal. 
As in old age there is atrophy of the lungs, inspira- 
tion is lessened, expiration is delayed and difficult, these 
are the main diagnostic symptoms of senile emphysema. 
An x-ray examination is very important as it not only 
facilitates the diagnosis, but will reveal the presence of 
aneurysm of the aorta which might be a cause of the 
condition. It is in cases of Bright’s disease or chronic 
heart disease that difficulty is met in making a diagnosis. 
A patient suffering from senile emphysema may live 
for several years under proper climatic and hygienic 
care, but the chances of complete recovery are small. 
The treatment of emphysema is somewhat similar to 
that of senile asthma, the same remedies being employed 
to check the distressing symptoms,—dyspnea. Attention 
should be directed to proper hygiene; the patient should 
avoid theaters and other crowded places and not be 
exposed to sudden changes in temperature, which in 
some cases involve a change of climate. 
Expectorants should be given to relieve the accompany- 
ing bronchitis, and Kermes mineral with powdered ipe- 
cac, will often suppress the dry, hard cough. Benzyl 
benzoate will sometimes check in a measure the attacks 
of dyspnea and occasionally iodide of potassium will have 
a favorable action. 
When the heart shows signs of weakness, digitalis may 
be of benefit, it can be given in the form of the fat-free 
tincture or combined as in Trousseau’s diuretic wine. 
Diuretin will be useful when there is edema of the lower 
limbs as a result of broken compensation. Digitan may 
help in some cases. SEHILE EMPHYSEMA 
189 
An interesting case of senile emphysema in a man of 
sixty-one, came to my attention recently. The patient 
had been under treatment for two years without relief, 
and complained of dyspnea, wheezy respiration and 
cough, which were so distressing at night that he could 
not sleep. He finally confessed that forty years ago he 
was infected with syphilis, had taken three years’ treat- 
ment of mercury and potassium iodide and had con- 
sidered himself cured. He later believed that the em- 
physematous condition depended upon the old syphilitic 
infection and I prescribed eight grains of sajodin four 
times a day. In twenty-four hours he was relieved 
and at the end of three days there was no wheezing, 
he could sleep all night without being disturbed by 
the cough. Undoubtedly, this was a case where syphilis 
a part in the production of emphysema and it 
seems incredible that the ailments from which this man 
had been suffering for two years should have disappeared 
in such a short time. We must not overlook syphilis in 
old age, as a cause of diseases of the lungs, heart or 
kidneys. 
There have been several devices made for the 
pneumatic treatment, among which is Waldenburg’s 
portable apparatus. Gerhardt recommended a mechan- 
ical assistance which compressed the thorax and Ross- 
bach made a ‘ ‘ breathing chair. ’ ’ Strumpell in his clinic at 
Leipsic built a simple apparatus by means of which the 
patient could press two boards together, exerting con- 
siderable pressure on the thorax during each expiration. 
Emphysematous patients should rest in an arm-chair 
which will permit them to sit forward, allowing the arms 
to rest easily. In this way, expiration is made easier and 
the pain somewhat alleviated. 
In some cases where suffering is very intense, it will 
be necessary to administer oxygen for temporary relief 
of the condition. CHAPTER XXIII 
SENILE BRONCHITIS 
Case I.—An old man was taken ill with a chill and 
severe pain in the sternum; a deep breath and cough were 
painful; he had a fever of 101° F., pulse was rapid and 
weak. As the condition progressed, expectoration be- 
came more difficult as he raised a small amount of tough, 
viscid, semi-opaque, grayish mucus. 
His shortness of breath became more pronounced and 
he was obliged to sit upright in bed in order to obtain 
relief. The lips and tongue were livid and he failed 
rapidly. Breathing became more laborious, the pulse 
more rapid and irregular, and the old man died on the 
second day of his illness. 
Case II.—A woman, aged sixty-seven, had a pain in 
the chest, and a cough. Her temperature was subnormal 
and the pulse rate very rapid. The expectoration was 
painful, the sputum thick and rusty. Toward evening 
she had a slight elevation 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 most 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 so violent as in Case I, and where the 
patient is not sick enough to make one think of pneu- 
monia, It is difficult to diagnose senile congestion of the 
lungs as there is but little difference in the symptoms of 
190 SENILE BRONCHITIS 
191 
the two conditions. Congestion of the lungs may ac- 
company acute bronchitis, but we often see congestion 
due to nephritis or heart disease. As a result of 
nephritis, we may find a secondary congestion of the 
lungs due to the fact that the heart is not able to send the 
blood through the vessels of the lungs and kidneys. 
Bropchitis due to influenza is often fatal in the aged 
and rapidly develops into bronchopneumonia. It may 
develop from rhinitis, it usually begins as a distinct 
disease. 
In treating acute senile bronchitis the first thing to 
do is to give a saline laxative to deplete the system, to 
combat pulmonary congestion and free the bronchial 
tubes of mucus. I usually prescribe small doses of 
ipecac and Kermes’ mineral to loosen the cough. Am- 
monium chloride or ammonium carbonate work well 
clinically and medicated vapors, for instance, boiling 
water to which guaiacol has been added, may be of bene- 
fit for inhalation. If there is prostration it may be 
advisable to give one grain of quinine sulphate and %o 
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 in 
its full physiologic effect is indicated. Brandy is given 
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 in its full effect may be the 
means of saving the patient, but unless 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 cause, 
as nephritis or heart disease. A moderate amount of 
bronchial secretion is normal in the aged, especially in 
the morning when they clear the bronchi of the mucus 
which accumulated during the night. However, a great 192 
GERIATRICS 
amount is abnormal and may be the only symptom of 
chronic bronchitis. Again, an old man may suffer from 
this condition and a sudden change in the atmosphere 
aggravate the disease, his breath becomes short and he 
has a sensation of pressure in the chest. 
Constipation, causing congestion of the portal 
circulation, or nephritis causing congestion of the kid- 
neys, a secondary congestion of the bronchi results. 
Sudden checking of a skin eruption, or of leucorrhea may 
cause it. Chronic bronchitis may be due to tuberculosis 
but this is rare in old age. There is supposed to be an 
intimate association between bronchitis and piles, gout, 
rheumatism, checking of perspiration, suppression of 
urine, too rapid healing of ulcers, etc. 
Auscultation may show a few scattered rales, but no 
definite changes. Percussion does not reveal any abnor- 
mality and x-ray examination does not give much evi- 
dence in these cases. 
The disease is slow yet progressive, but in many cases 
I fail to see that these patients develop pneumonia more 
often than other old persons. It seems, in most in-- 
stances, to be a harmless affection unless the bronchial 
secretions are suddenly checked. 
In treating senile bronchitis the general condition of 
the patient should be given consideration and warm 
clothing worn. Woolen underclothing is advisable and 
if the patient is able to spend a part of the year in a 
warmer climate, it will be of great benefit. 
The expectoration, no matter how profuse or fetid, 
should not be checked as it may cause paralysis and suf- 
focation. Ammonium chloride combined with elixir cal- 
isaya is advisable, or the elixir of iron, quinine and 
strychnine phosphates may be given. A mixture of cal- 
cium and cresote may help and arsenic trioxide, Moo 
grain every four hours may be of benefit. Cod liver oil 
works well with the aged and should be prescribed. SENILE BRONCHITIS 
193 
Too much cannot be said of the care of the bowels in 
these cases. If we relieve the portal congestion with a 
mercurial and a saline the next morning, the patient’s 
bieathing will be greatly improved. Keeping the emunc- 
tories working and preventing any further congestion of 
the internal organs relieves the heart of this extra load 
so that it 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 for nephritis will be satisfactory 
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 the 
latter is a common cause of senile bronchitis. CHAPTER XXIV 
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, Ilis temperature and 
pulse rate were normal; but the respiration was thirty 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, 
and it was decided to try the last resort for the aged, 
namely: to force him out of bed and get him into a chair. 
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 able to resume his work. 
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 she was rapidly declining. The pulse and temper- 
ature were normal, but the respiration was thirty-six. 
She died two days after from senile pneumonia. It is 
interesting to note in this case that there was no cough. 
Case III.—A woman, aged sixty-eight, had headache, 
cough and shortness of breath. Temperature was 100° 
194 SENILE PNEUMONIA 
195 
F., pulse rate eighty-five and respiration thirty-eight. 
It was a tvpical case of what is ordinarily called pneu- 
monia. The cough, rusty sputum, shallow breathing, 
pain in the side, low muttering delirium, restlessness, 
and picking at the bedclothes were symptomatic. In a 
younger person this might make one think of 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 different from pneumonia in the 
young. In the majority of cases it is a natural termina- 
tion of an old person’s life. The symptoms 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 follows 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. 
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 196 
GERIATRICS 
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 decline of the patient, together with in- 
creased respiration and delirium usually make the diag- 
nosis clear. Pneumonia, however, must not be confused 
with senile bronchitis or pulmonary congestion. These 
latter conditions are very common in the aged and often 
termed pneumonia. 
A patient with senile bronchitis will converse with 
you, but a person ill with pneumonia is too sick to talk. 
In other words, this man is too sick to have only bron- 
chitis and congestion, therefore probably has pneumonia. 
The border line is not sharp and oftentimes it is only a 
matter of degree. 
I have spoken of the analogy with nephritis. Any one 
who is following the urinary examinations of his aged 
patients knows the frequency of pulmonary symptoms 
complicating nephritis. 
Many of these cases of senile pneumonia are in a so- 
called typhoid state, that is, they have every symptom of 
that disease. However, typhoid fever is very rare in the 
aged. 
Senile pneumonia usually causes death. The presence SENILE PNEUMONIA 
197 
of fev ei and a quickened pulse is a good prognostic sign, 
because it indicates more strength in the patient, than 
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 sign. 
Treatment 
Keep senile cases out of bed. No matter how sick the 
patient is it is advisable to force him into a chair. It 
i elieves the circulation and gives him courage to tight 
the battle. Remember that 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 %o grain 
every three hours and later increasing to %0 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, if he is accustomed to taking 
it. 
It is well to use whiskey or brandy early, but if the 
tongue becomes dry during its administration, it should 
be stopped. As long as the tongue remains moist alco- 
hol works well. Digitalis does not work well in most 
cases, and the opiates and coal tar derivatives have a 
harmful action. 
I he matter of daily bowel evacuation is very impor- 
tant. The compound rhubarb pill works well, but salines 
aie contraindicated. Autointoxication of intestinal ori- 
gin dev eloping in the course of pneumonia is a serious 
complication, and many old men owe their lives to a 
few compound cathartic pills. 
In treating cases of accidents, such as fractures, 198 
GERIATRICS 
sprains, etc., where the patients are in bed, we should 
see that they are turned on their sides several times a 
day in order to prevent hypostatic congestion. 
We usually have to wait two months before allowing 
aged patients to go outdoors. However, we are justified 
in granting them many peculiar privileges which would 
seem irrational in treating younger people. CHAPTER XXV 
SENILE GANGRENE 
This affection usually appears on the toes, rarely 
on the fingers and occasionally on the legs. There may 
be 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, 
mummified appearance. 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 Narragansett 
Indians, had attacks of diarrhea for the past five years. 
From the character of the feces it undoubtedly was 
caused by some pancreatic disturbance. She was taken 
ill in November, 1914, with another attack of diarrhea, 
and was ill 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 following day there was a 
cessation of the pulse in that wrist, and the forearm 
was black and gangrenous. She was ill and bedridden 
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 swollen and there 
199 200 
GERIATRICS 
was a general subcutaneous edema. The diarrhea had 
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 dropped from 220 to 150 pounds. There 
was a line of demarcation four inches above the elbow, 
but she was not in a condition which permitted amputa- 
tion. An operation was later suggested, however, but 
Fig. 6. Indian woman who had gangrene of the left forearm, showing 
the separation from the elbow which was made by Nature. This photo- 
graph was taken six years after the attack. 
the family refused to consider any surgical procedure. 
In March, the swelling began to leave the legs and her 
general health was better so that on the first of April, 
1915, she was able to go outdoors. The gangrenous 
forearm was gradually separating from the arm, and 
showed the radius and ulna with the periosteum separa- 
ting 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 SENILE GANGRENE 
201 
had previously been examined several times and was 
found to be normal. I examined the urine several days 
in succession and on the fifth day, after previously fail- 
ing to find glycosuria, discovered 3 per cent sugar. I 
decided to use gas-oxygen anesthesia and operate but 
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, leav- 
Fig. 7. Same patient as Fig. 6, showing perfect amputation of the fore- 
arm by gangrene without surgical procedures. 
ing 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, 
regained her weight of 220 pounds and was able to work. 
In October, she fell and broke the radius segment which 
was thus severed from the stump of the arm and in 
November the other bone was broken in a similar manner. 
This left a stump with two discharging points, which 
healed in three weeks, and is as perfect as any surgical 
operation could have left it. The flap made by Nature 202 
GERIATRICS 
was exactly the same as if the flap-operation had been 
performed by a surgeon. 
Today, six years after this illness, that patient is in 
better health than she had been for several years and 
able to do all of the work in her home. 
Fig. 8. Foot, showing how Nature separated the gangrenous part from 
the healthy tissues. There are two places still unhealed. The patient 
was a man, aged 64. 
Sometime ago I saw a man of sixty-four, who had 
gangrene of the left foot. He had diabetes for several 
years and had suffered a great deal from carbuncles. 
Gangrene developed suddenly in one foot but he was in 
poor condition for an operation. He had been in bed SENILE GANGEENE 
203 
for a long time, had many bedsores, and his general con- 
dition was very poor. He lingered for months in bed, 
finally the gangrenous part of the foot separated from 
the healthy tissues, and, as seen in the accompanying 
photograph, Nature made a good amputation. This 
man at present is able to walk with the aid of crutches. 
There are two small places on the foot that are not 
completely healed but the case is similar in many ways 
to the one first described. 
In some cases of senile gangrene the patient will first 
feel pain in the extremities, perhaps localized in a single 
finger or toe, and often experience a pricking sensa- 
tion or numbness. The pulse disappears in the affected 
part and in the course of a few hours this part is 
dead. 
Before gangrene has fully developed the part may 
have a blue color. Then a small vesicle develops and in 
a few hours several vesicles appear which finally coalesce. 
Considerable pain is felt before these vesicles burst and 
even after they have ruptured. The skin beneath the 
vesicles is red or blue in color, its surface is moist. 
If the surface is not moist it may have a shrivelled ap- 
pearance and if we make an incision, little or no blood 
escapes. It has been said that the dry form of gangrene 
is more common in the poorer classes who are under- 
fed, while in robust persons the moist form is more com- 
mon. 
The adjacent tissues, in any form of gangrene, are 
swollen and red or blue in color. My patient was ex- 
tremely ill, with general symptoms. She was uncon- 
scious for several days, had an extremely high fever, 
rapid and thready pulse, extreme prostration and a cold, 
clammy perspiration on the skin. The excretions were 
of a fetid odor. 
In time, as this period of fever and prostration ended, 
she went into another stage, which was the period of 204 
GElilATlilCS 
reaction. Her general condition improved and Nature 
seemed to grant a truce. 
The symptoms left as they came, and she finally was 
able to walk outdoors. There was an inflamed border 
above the gangrenous part and the line of demarcation 
was found. 
In senile gangrene we may have an extremity which 
has lost sensation for several days before any sign of 
gangrene develops. 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 developing. It 
may be caused by several conditions and anything 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 frequent 
cause. 
In cases of senile gangrene the affected part should 
be elevated and the patient given a diet consisting of 
milk and cereals. Support is given by means of strych- 
nine sulphate, Ygo-Yso 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 essential to get free elimination through 
the bowels as the system is loaded with toxins as a re- 
sult of this acute process. 
When the line of demarcation has formed surgical pro- 
cedure should be resorted to without delay. Gangrene 
is a very serious affection. It is interesting to discover, 
since reporting these cases, several cases treated by 
physicians many years ago which were similar to these 
and patients lived useful lives for a long time without 
having undergone an operation. There is no question, SENILE GANGRENE 
205 
however, that surgery is the best treatment in most cases 
and must be resorted to when the line of demarcation 
forms. 
Old persons easily develop gangrene of the toes from 
the most trivial cause. Sometimes an injury may cause 
it; other times, perhaps the twisting of a nail in cutting 
it may produce gangrene. Aged patients often suffer 
from long, twisted nails and they should not be touched 
since the slightest injury may cause gangrene. CHAPTER XXVI 
SENILE CHOREA 
A man, aged seventy, consulted me for pains in the 
limbs and restlessness at night. A member of his 
family informed me that he was becoming impressionable, 
forgetful and inattentive, and for the past few weeks 
gradually developed a peculiar twitching in one arm and 
at times could not pick up an object, the jerking of the 
muscles causing him to drop his food or spill his milk. 
The movements of the arm were incoordinate, grotesque 
and tossing, first flexion, next extension, which were fol- 
lowed by rotation. Later the choreic movements affected 
the face, and involuntary jerks of the shoulders and neck 
were noticed. The leg on the same side was the next part 
to be affected, which caused the gait to be very clumsy. 
Eyesight was normal and mentality good; speech was 
imperfect, however, and at times he was unable to artic- 
ulate, which was undoubtedly due to the choreic mus- 
cular action. The knee reflexes were normal and there 
was no true ataxia, the movements being involuntary and 
voluntary motion intensified the jerking, but ceased dur- 
ing sleep. 
Examination of the urine revealed no abnormality, in 
fact, he seemed in excellent condition from a pathologic 
standpoint, because no evidence of organic disease was 
discovered, and the ultimate recovery of the patient was 
proof against the presence of a subcortical lesion. He 
was given arsenic trioxide, grain Moo in tablet form, 
before each meal and the condition gradually improved 
so that at the end of four months he had completely re- 
covered. It did not leave him in a nervous state, mus- 
cular action returned to the norm of senility, and he 
206 SENILE CHOKEA 
207 
showed no evidence of cardiac weakness as a result of 
chorea. It is now three years since the attack occurred 
and he has had no recurrence of the symptoms. 
In some respects chorea in the aged does not differ 
from that observed in younger individuals; it may be 
purely a functional disorder, with symptoms of chorea 
minor which last from one week to several months; it 
may be due to a subcortical lesion and follow hemiplegia 
or it may be hereditary. The functional type usually 
ends in recovery in two weeks to four months, and a case 
like this has been reported in a man eighty-six years 
of age. We may have to deal with Sydenham’s chorea. 
Charcot was inclined to consider all cases of senile chorea 
incurable. 
Senile chorea is not likely to cause heart complications 
or rheumatism, but sometimes the movements become 
violent enough to cause the patient to stay in bed, and on 
account of these incessant movements he becomes very 
thin and is apt to develop sores of the skin, the result of 
which may be infection, excoriations, ulcerations and 
abscesses. Again, in old age chorea may become chronic; 
the motor troubles are those of ordinary chorea, but 
they are, however, slower, less extensive and more 
easily controlled by the will. Chronic chorea has a slow 
and progressive course, may not subside, and is often 
accompanied by mental decay. 
In some cases of senile chorea it is possible to elicit 
a history of previous attacks of rheumatism, but, in old 
age, chorea is usually not associated with any other dis- 
ease and the heart complications so often seen in the 
young are rarely observed. 
Chorea Gravis 
A man, aged sixty-one, suffered from senile chorea, 
which presented little difficulty in diagnosis. What 208 
GERIATRICS 
struck me in my observation of the case was the severity 
of the disease. The movements were violent and did not 
stop at night; in twenty-four hours lie performed hun- 
dreds of involuntary movements; he tossed about the bed, 
his head beat the pillows, his face made various grimaces 
and it was apparent that almost every muscle of the body 
was affected. The muscles of the tongue and pharynx 
were involved, and he experienced difficulty in degluti- 
tion, was unable to utter more than a few words, and in 
time became unable to speak at all. The skin, over the 
elbows, spinous processes, hips and heels, was erythemat- 
ous, and later he developed numerous bedsores. 
Control of the rectal and vesical sphincters was lost, 
and he remained in bed, a helpless man, requiring con- 
stant attention on account of the sphincter paralysis. 
The pulse was quick, and insomnia became complete. 
Urinary examination was negative; loss of flesh became 
more rapid, heart action was increased, and the old man 
died of exhaustion. 
In this case, it will be noted that the man died from 
the disease itself and not from a complication. Compli- 
cations of chorea are rare in old age, but it is not un- 
common to see cases which have a malignant character; 
treatment seems to be useless then and it is very difficult 
to relieve insomnia and violent movements. This severe 
condition, according to Charcot, is a status choreicus, re- 
sembling the status epilepticus, but we are not able to 
find the reason of this gravity at the postmortem ex- 
amination. 
Nephritis and Senile Chorea 
Senile nephritis, associated with high blood pressure, 
is often accompanied by choreiform movements. It may 
be localized, for instance, one arm may be affected, or it 
may involve several muscles. I recollect one case of a SENILE CHOREA 
209 
man of 80 who had every symptom of Sydenham’s chorea, 
which was due to nephritis and improved when proper 
treatment was instituted. These cases may be associated 
with psychosis, which might lead to a diagnosis of chorea 
gravis. The symptoms, however, usually wane when 
free elimination through the emunctories is started and 
dietary treatment directed to nephritis. 
In Bright’s disease, this condition is the opposite of 
the paralyses which so often complicate senile nephritis. 
It is probably not due primarily to uremia, rather to 
cerebral congestion, which is secondary to the kidney 
lesion. Sometimes, in nephritis, the choreiform move- 
ments end in paralysis, with accompanying mental decay, 
and when psychosis develops it usually indicates a fatal 
end of the case. 
Habit Chorea in Institutions 
Many cases of senile chorea are very mild in character 
and involve but one arm. The movements are not severe, 
and at times they disappear for a few hours, only to 
return. In institutions for the aged, the suggestibility 
of some old persons who imitate others’ disease is very 
marked, and I have seen cases of apparent senile chorea 
develop after the appearance of one case in an institution. 
Of course, the cases which developed were merely imita- 
tive, and it was an impossibility to cure the old persons 
of their habit until the one who was actually suffering 
from the disease was transferred to another part of the 
institution. Another case of apparent chorea developed 
in a woman seventy-five, who had all the symptoms of 
the disease. Her granddaughter was living with her, and 
since the little girl had suffered from St Vitus’ dance, 
the old lady had the symptoms also; the choreiform 
movements became more violent, it was impossible to 
cure her until the little girl was removed from her care, 210 
GERIATRICS 
and only several weeks after was the condition actually 
cured. 
In treating these cases of habit chorea, harsh measures 
are at times necessary; punishment may be resorted to 
and if this is not successful, separation from the person 
actually diseased must be practiced. It is erroneous to 
believe that these habit conditions are harmless, because 
in time they develop into chronic conditions which are 
incurable. Physicians who are treating old patients ap- 
preciate these statements, because psychic troubles are 
often very difficult to correct. 
Treatment 
True senile chorea should be treated with arsenic, and 
the method I use consists in prescribing tablets contain- 
ing Vxoo grain of arsenic trioxide, before each meal and 
at bedtime. Fowler’s solution may be used in five minim 
doses three times a day, but it is essential to look out for 
the secondary effects of arsenic iii the aged, as elimina- 
tion is very slow, the drug is apt to have a cumulative 
action. In the aged, the secondary effects of drugs are 
fully as important as their primary action, the bowels 
should be kept open by free catharsis to prevent this 
cumulative effect. The symptoms of arsenical poison- 
ing are first a puffiness of the lids and coryza, and when 
these symptoms are noted arsenic should be discontinued 
for a few days. Ordinarily, at the end of three weeks, 
I discontinue arsenic and replace it by elixir of iron, 
quinine and strychnine phosphates, administered in doses 
of a dram before each meal; at the end of two weeks 
arsenic is resumed. In convalescence, elixir of iron, 
quinine and strychnine phosphates makes an excellent 
tonic, but its slight constipating effect must be overcome 
by means of cathartics. SENILE CHOREA 
211 
If nephritis is the cause of the condition, it should be 
treated by dietary methods and free elimination through 
the emunctories. A saline laxative may be prescribed 
each morning before breakfast. CHAPTER XXVII 
PRURITUS SENILIS 
Senile pruritus, localized or general, is one of the most 
annoying conditions of old age and one of the most dif- 
ficult to treat. Ordinarily, when 1 see a case, I think of 
three groups, that is those of (1) senile diabetes, (2) 
senile nephritis, or (3) unknown cause. However, there 
are many diseases in old age which will cause pruritus, 
such as jaundice, leukemia, pseudoleukemia, or it may 
come from lack of proper hygiene of the skin, woolen 
underwear, or there may be some psychic cause for it. 
In institutions, it is not uncommon to find old people 
who scratch themselves because they have seen a case of 
pediculosis. In the army, suggestions of cases of pedic- 
ulosis would cause many soldiers to itch. At present, I 
have a patient, a man aged eighty-five, who has had 
senile pruritus for several months. The itching becomes 
worse at night, the skin is dry, as we usually observe 
in old persons, it not being properly nourished with 
blood. The patient has no evidence of organic disease; 
his sleep is disturbed by itching, but as he dozes off in 
his chair several times a day, he would not sleep well at 
night. I prescribed two compound rhubarb pills in the 
evening for constipation and as his tongue was red and 
the papillae prominent, gave him the following prescrip- 
tion : 
n 
Tincturae Nucis Vomicae 
Acidi Hydrochlorici diluti aa3 ij 
Elixir fiigestici Comp. q. s. ad. g iv 
Sig: Teaspoonful in one-half wineglass of water 
before meals. 
212 PEURITUS SENILIS 
213 
Externally, I prescribed a mixture of the higher 
phenolic ethers, with essential oils, and soap liniment 
as a base. It gave him immediate relief, but it was neces- 
sary to continue its application several times a day. 
Senile pruritus may be localized, as pruritus ani, scroti 
or vulvae, or may be on any part of the body. Senile 
diabetes will often cause these local disturbances and 
attention to the disease may relieve the itching. It is 
not uncommon to find that pruritus ani comes from 
oxyuris vermicularis and treatment must be directed 
to this cause. Oxaluria may be a cause of pruritus 
vulvae. 
Glycosuria in the aged is often a normal degenerative 
change and may only be transient. I have a case of this 
kind; glycosuria lasts only a few days, but while it does, 
it is accompanied by a severe pruritus vulvae. Diabetes 
will cause an intense itching of the skin which is usually 
localized. A careful observer will often recognize diabe- 
tes in cases where there are no other symptoms to point 
to the disease. Eczema is common in old age and causes 
intense itching. 
Usually, pruritus accompanying senile nephritis is 
general, but it may be localized. One of the first symp- 
toms of nephritis is an itching of the skin which may 
cause the patient to think that dandruff is falling on the 
back of his neck. Uremia may have pruritus as its chief 
symptom and the patient may scratch himself so violently 
that it causes bleeding. It is not rare to find the body 
covered with sores, the patient literally digging into the 
skin with his nails. Usually the itching is worse at 
night and may cause so much suffering that the old 
man’s strength becomes exhausted and this may be the 
beginning of a serious physical breakdown. 
Occasionally, the itching of the face becomes so severe 
as to make the skin very red, suggesting facial erysip- 
elas. Seborrhea capitis may cause itching of the scalp 214 
geriatrics 
and tlie scales will fall upon the face, neck and chest, 
causing dermatitis. 
The anatomy of the skin in old age shows why pruri- 
tus is common. The lumen of the arteries being con- 
siderably narrower in senility, the skin is poorly sup- 
plied with blood and the dermis becomes atrophied. 
Subcutaneous fat is wasted, the areolar tissue becomes 
fibrillated, connective tissue is loose, and elastic fibers 
waste; as a result of these various changes the skin is 
dry, loose and flabby. Although the blood supply of the 
skin is poor, there may be areas of local passive hyper- 
emia. The degenerations of the nerve terminals cause 
many sensory disturbances, such as “crawling,” prick- 
ling, itching, sensations of heat or cold. A patient com- 
plained to me that his son had placed pins in his neck. 
The sebaceous glands are often atrophied and they 
always contain less liquid than in adult life. 
There is a form of glossitis—senile pruritus of the 
tongue—which is characterized by itching and burning 
of this organ. The tongue may be quite swollen as in a 
patient I saw some time ago. She had chronic uremia 
and suddenly her tongue become swollen, this swelling 
being accompanied by burning, itching and inflammation. 
She was relieved in three or four days, but all patients 
are not so fortunate. 
There may be a psychic form of pruritis senilis; in in- 
stitutions, when a person begins to itch, it will soon 
spread to all those who are in the same ward. The 
nervousness produced by lack of sleep due to the itch- 
ing, in turn, makes the condition worse. It is a vicious 
circle as the more the patient scratches himself, the more 
irritated the skin becomes, dermatitis develops, and he 
has an eruption which in itself is very painful. 
Senile pruritus affects persons who are apparently in 
good health. I had a patient, a woman aged 75, who de- 
veloped pruritis of the forearm, which later became PRURITUS SENILIS 
215 
general. She was in excellent health in every other way. 
The itching was intense and she suffered during several 
months, used every remedy that I could suggest and con- 
sulted dermatologists, but it was of no avail. Finally, 
after months of agony, relief came. 
Predisposing causes in persons who have no organic 
disease are indigestion, constipation, improper diet and 
lack of proper care of the skin. Most old people do not 
enjoy bathing and many go several weeks without a 
bath, although they will not admit it. This applies to all 
classes of patients, they may have elaborate bathrooms 
and yet not bathe oftener than once a week. Old persons 
are apt to avoid anything which requires any degree of 
exertion. 
There is a form called pruritus hiemalis which occurs 
during the cold months of the year. 
A peculiar form of pruritus is sometimes observed in 
individuals who are effected by the presence of certain 
plants in the house (such as Chinese primrose). I have 
seen some cases of pruritus which were merely due to 
eating pork. 
We must give a guarded prognosis in all cases of pruri- 
tus senilis, although some cases are curable. Usually it 
is chronic and incurable, but some cases are relieved by 
an improvement of the general health. People have 
been known to commit suicide because of the incessant 
suffering caused by itching. 
Treatment 
If we are able to discover a cause, this cause must 
be suppressed. If it is not possible to ascertain a cause, 
we must endeavor to improve the general health. The 
diet should be regulated, laxatives used if there is con- 
stipation ; if the patient is robust, a saline laxative may 
be given each morning; if physically frail, compound 216 
GERIATRICS 
rhubarb pills each night. If the tongue is red and 
papillae prominent, tincture of nux vomica with dilute 
hydrochloric acid should be given; if the tongue is coated, 
an alkaline mixture should be taken before meals. 
Elixir of calisaya or the elixir of iron, quinine and 
strychnine phosphates may be of benefit. If there is 
constipation we may prescribe: 
it 
Fluidextracti Cascarae Sagradae 3 ij 
Glycerini 3 iv 
Elixir Digestici Comp q. s. ad. 3 iv 
Sig: Teaspoonful in one-half wineglass of water before 
meals. 
If the itching is severe and the patient very nervous, 
bromides, ten grains every three hours, are indicated. 
External treatment depends upon the location of pruri- 
tus. Pruritus ani and pruritus scroti may be treated as 
follows: 
R 
Liquoris Calcis 3 viii 
Sig: Use as a wash several times a day. 
After using this solution, the following ointment may be 
employed: 
R 
Hydrargyri Cliloridi Mitis—gr. xxx 
Petrolati 3 j 
Tq. ft. ung. 
It may be necessary to try several remedies before 
results are obtained. Carbolic acid solution, 1-100, may 
relieve the itching and may be combined with sodium 
borate, 5 or 10 grains of the latter to an ounce of solu- 
tion. 
Menthol ointment is sometimes good for pruritus ani 
and may be made as follows: 
R 
Mentholis — gr. x 
Thymolis — gr. v 
Petrolati — 3 1 PRURITUS SENILIS 
217 
Ichthyol ointment, 2 per cent, or in combination with 
calomel ointment, often works well. Oleate of mercury, 
a 5 per cent solution of oleate of mercury in oleic acid, 
will often be of benefit. Unguentum Conii of the old 
British pharmacopeia, or in combination with carbolic 
acid, will often check pruritus ani due to hemorrhoids 
or fissures. Cocaine or novacain solution will often im- 
prove the condition temporarily. It may be used as 
follows: 
it 
Cocainae gr. v 
Mentholis gr. x 
Petrolati S j 
up ft. ung. 
I have seen the high frequency current act well in some 
instances, a surface electrode being applied for seven or 
eight minutes over the affected parts, about three times 
a week. The current is not applied strongly, but gentle 
stimulation is given. Diathermia works well, no matter 
what the location of the pruritus is. A piece of tin foil 
is applied over the anus, and a large one over the pubis. 
From 300 to 500 milliamperes are given and the treat- 
ment should last for a half hour. Diathermia drives a 
new blood supply to the affected areas and will give 
permanent relief in many cases. It may be used in com- 
bination with the surface electrode, but the method of 
deep penetration is better. 
Many cases of pruritus ani are due to improper care 
of the anus. A man may wash his face twice a day, but 
not wash his anal region oftener than once a week. 
Again, many of the toilet papers used are irritating to 
a tender skin. There is an excessive perspiration in this 
part in many people and the excretions are often of an 
irritating nature. Proper hygienic care, i. e., washing 
twice a day with cold cream soap and applying unguen- 
tum aquae rosae after each cleansing, the use of a high 
grade, soft paper after defecation, will often cure the 218 
GERIATRICS 
condition. In very obstinate cases, thorium may be ap- 
Iflied externally and radium applications may help a 
great deal. 
Pruritus vulvae will often be relieved by douches of 
the following powder in solution: 
R 
Phenolis 3 j 
Eucalyptolis 3 ss 
Olei Menthae Piperitae 3 j 
Aluminis 3 iv 
Acidi Borici 3 xvj 
Tip ft. Pulv. 
Sig: One or two teaspoonfuls in a quart of hot 
water as a douche twice a day. 
This is very soothing and cooling and most women find 
it a great comfort. The douches must be taken in a re- 
clining position. As the average woman uses a douche 
in a sitting position, it is valueless. If there is much in- 
flammation on the outside, the following ointment may 
be applied to the vulvae: 
R 
Mentholis gr. v 
Unguenti Aquae Rosae 3 j 
hi. ft. ung. 
The powder described above is useful where an inex- 
pensive, effective lotion is necessary for general use on 
the body. It may be used in various dilutions and can 
be applied to the body with a soft sponge. 
Recently, I have been using a solution of the higher 
phenolic ethers, aromatic bodies and esters, with excel- 
lent results. One part by weight of this preparation has 
the same antiseptic value as forty parts of weight of pure 
phenol. It is not irritating and is very stimulating to the 
tissues. When applied to the skin its anesthetic action 
will be manifest in two minutes and when applied once 
a day for several days it will often improve the condi- 
tion. When the disease is widespread, I employ the 
phenolic ethers and essential oils in a ten per cent alco- PRURITUS SENILIS 
219 
liolic solution. The effect lasts several hours and may he 
fortified by the following ointment: 
n 
Mentholis gr. xx 
Phenolis M. v 
Camphorae gr. x 
Petrolati g ij 
TTL- ft. ung. 
I have seen cases so severe that the patient had to 
sit in a bath tub for relief, in such cases a bran bath is 
often useful. TJnguentum diachylon compound can be 
used as an ointment to cover larger surfaces. It is often 
necessary to prescribe large doses of bromides internally 
to alleviate the pain, but opiates usually aggravate the 
condition. Sometimes a 2 per cent solution of chloral 
hydrate used externally will suppress the itching; choral 
has a marked antiseptic and anesthetic action on the 
skin. 
In France, the hydrotherapeutic treatments at Neris, 
Plombieres, Uriage, Luchon and Cauterets are of value. 
In very rebellious cases it is necessary to resort to 
radium therapy. 
Care must be exercised in the latter; radium should 
be applied for a short time and a reaction awaited. A 
flat applicator of 10 mg. of radium element should bo 
used, screened only with rubber dam, and it should be 
held over one area for ten or fifteen minutes. The en- 
tire area which is affected should be covered in this man- 
ner, but a second radiation should not be given until the 
result of the first treatment is known. 
If the symptoms have not subsided in three or four 
weeks, a longer application should be given with a filtra- 
tion of 3/io mm. of aluminum, but it would not be well to 
employ radium longer than twenty minutes in any area. 
In employing radium around the anal or scrotal regions 
we must not expect the reaction to be immediate; in some 
cases it will occur several weeks after the treatment. 220 
GERIATRICS 
The results obtained with x-rays in the various forms 
of senile pruritus are sometimes remarkable. Small 
doses without filter are employed and 3-4 units are used; 
sometimes one exposure is sufficient; other cases require 
two or three treatments at an interval of two or three 
days. These small doses give much better results than 
the larger ones. CHAPTER XXVIII 
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 he had to make 
an effort in order to void. Later he found that during 
the night he was obliged to walk the floor a few minutes 
in order to start the flow, while during the day there was 
no difficulty. In the course of a few weeks, however, he 
was aware that even during the day he could no longer 
void freely and the bladder became distended, he ex- 
perienced retention of urine. 
In the middle of-the night he felt an intense pain in 
the abdomen, and when I arrived I saw the pitiful con- 
dition he was in. I catheterized him with a flexible metal 
catheter and prescribed a four-grain tablet of chromium 
sulphate to be taken every three hours. He was also 
given two drams of magnesium sulphate and put on a 
milk diet. 
It was necessary to catheterize him for two days, but 
on the third day he was able to void quite freely. He 
improved on the chromium sulphate treatment and for 
the past year has not suffered from his prostatic hyper- 
trophy. 
Case II.—A man, aged eighty, felt a sudden 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 to the time of 
221 222 
GERIATRICS 
his death, due to other causes, he did not experience any 
difficulty 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 became dissatisfied with his condition be- 
cause the symptoms recurred, and insisted upon an 
operation, which was performed against my advice; he 
was operated upon and died the following day. 
Case IV.—A man, aged seventy-five, had chronic 
syphilis. At times he was unable 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 affected. 
As prostatic hypertrophy is a normal senile change, to 
a certain degree, an enlarged prostate may not interfere 
with functions that are normal to old age. When this 
gland, which has undergone hypertrophy, becomes con- 
gested, it causes a train of disorders which can be 
promptly suppressed if proper treatment is given. 
The bladder distends and then cystitis may develop. 
The retention due to the enlarged prostate may cause 
general toxemia that is not associated with nephritis, 
and may also cause cystitis or pyelitis. 
Syphilis may be the cause of hypertrophy and if a 
history of this disease is given, specific treatment should 
be prescribed. 
Nephritis, in my opinion, is a common cause of pros- 
tatic hypertrophy. When these patients, who have 
chronic nephritis, suffer from an exacerbation of the dis- 
ease, the prostate may show acute symptoms due to con- SENILE PROSTATIC HYPERTROPHY 
223 
gestion, which may cause retention. Treatment promptly 
given will usually yield good results. 
I have treated about 200 cases of senile prostatic hyper- 
trophy and never had recourse to the so-called “catheter 
life ’? for over two weeks at a time and have never ad- 
vised an operation or had a patient who has been 
operated upon for this condition. It is not my intention 
to deprecate surgery, in particular prostatectomy, be- 
cause I believe the latter operation to be very necessary 
and successful in a great many instances. 
Nevertheless, with electric treatment and medicinal 
treatment I have kept these old patients in a comfort- 
able condition. I have been greatly impressed by 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 enlargement and the only 
medicine prescribed was a saline laxative which relieved 
the bowels and removed the toxins from the system. 
This man has had several attacks, but each time I found 
that free catharsis relieved him. 
A man, aged seventy, found he was obliged to urinate 
every hour during the day and also had hematuria. He 
was given an alkaline mixture containing fluid extract of 
hydrastis, pancreatin, potassium carbonate and fluid ex- 
tract of rhubarb. This mixture with a saline laxative 
apparently relieved him. 
Some 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 with remedies other than 
the iodides, mercury or arsenic. Many of these cases 
will be relieved by six minims of fluid extract of cascara 
in syrup given three times a day. 
No doubt in private practice a physician does not have 
to deal with the severer types seen in hospitals, there- 
fore, his observations do not always hold good in a gen- 224 
GERIATRICS 
eral way. I am convinced, however, that much can be 
done for senile prostatic hypertrophy and if this treat- 
ment was followed I believe prostatectomy would be un- 
necessary in many cases. It is not my purpose to give a 
complete consideration of the subject, my plan is, as in 
the other sections, to give principally my personal ex- 
perience. 
Treatment 
As I have written above the results of treatment by 
means of the simplest remedies are surprising. A great 
many cases which we see are merely due to congestion, 
and a cleaning of the intestinal tract by a saline laxative 
relieves the prostatic condition in so far 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 
whether any treatment except a surgical one will reduce 
this enlargement. However, the prostate can be very 
large without causing symptoms unless it becomes con- 
gested. It is this type of case that usually manifests 
prostatic symptoms and in time, if neglected, becomes 
chronic and hopeless to treat. 
A man who has prostatic enlargement, is ill, bedridden 
and obliged to be catheterized three or four times a day, 
is given one tablet containing four grains of chromium 
sulphate every three hours. If it is necessary to cath- 
eterize him, I try first a rubber catheter and if this fails 
use a flexible metal catheter rather large in size. Many 
times I have found that a large catheter would go by the 
obstruction while a smaller one would fail. The large 
catheter is left against the obstruction for a few moments 
and usually will go into the bladder without difficulty. 
Very seldom does it cause hemorrhage, but I do not think SENILE PROSTATIC HYPERTROPHY 
225 
that the hemorrhage is always a bad sign. Many times 
a slight bleeding relieves the patient. 
If the old man is suffering intense pain due to frequent 
urination, I give every two or three hours a tablet con- 
taining y24 grain of heroin hydrochloride, or diacetyl- 
morphine hydrochloride. If necessary six of these 
tablets may be taken in two hours. Heroin works well 
with aged patients and alleviates the pain. 
I prescribe, with chromium sulphate the following: 
Fluidextracti Juniperis Communis 3 ij 
Fluidextracti Buchu 3 i 
Fluidextracti Uvae Ursi 3 i 
Fluidextracti Hyoscyami 3 ss 
Glycerini § i 
Potassii Bromidi 3 ij 
Potassii Acetatis 3 ij 
Elixir Aromatici q. s. ad. 3 iv 
Misce et Sig.: Take one teaspoonful in one-half wine- 
glass of water every 3 hours. 
If there is frequent and painful urination, 2 minims of 
tincture of cannabis indica may be added to each tea- 
spoonful of the above mixture. 
If there is cystitis and accompanying nephritis, it may 
be well not to use chromium sulphate because it is some- 
what irritating to the kidneys. In these cases I pre- 
scribe the following mixture: 
n 
Sodii Bromidi 3 ij 
Potassii Acetatis 3 iss 
Fluidextracti Pareirae Bravae 3 ij 
Glycerini 3 iv 
Elixir Aromatici q. s. ad. 5 iv 
Misce et Sig.: Teaspoonful in one-half wineglass 
of water every three hours. 
This has a good effect on the mucous membrane of the 
bladder, relieves the pain and makes micturition less 
frequent. 
In these cases of dysuria a saline laxative will often 226 
GEKIATKICS 
work well. Free elimination through the intestines is 
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 freely, and it will make the use of the 
catheter unnecessary. Further treatment consists, 
especially in obstinate cases that do not yield, of diather- 
mia treatments given with a special type of apparatus, 
the Telatherm apparatus made by Wappler, with a 
Monae Lesser type of electrode, which has a metallic 
surface for the prostate. It is inserted into the rectum, 
and a piece of flexible tin applied over the pubis, the 
Fig. 9. Monae Lesser rectal prostatic electrode. 
treatment lasts one-half hour, 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 and produce from very mild 
warmth to a great amount of heat. Diathermia treat- 
ments (Gk. dia, through; therme, heat) are-given by the 
Telatherm machine by means of two poles on a D ’Arson- 
val current. One pole is attached to the electrode in the 
rectum and the other pole is attached to a piece of tin 
foil about three or four inches square which is placed 
on the abdomen in the suprapubic region. 
Another method consists in applying a flexible metal 
electrode 4x6 inches square on the abdomen in the 
supra-pubic region and another 3x4 inches square over 
the lower part of the spine. The treatment consists in 
using the electric current to the point of discomfort and 
lasts one-half hour. It may be well to continue the treat- 
ments during several months, giving them every other SENILE PROSTATIC HYPERTROPHY 
227 
day for a month and then two or three times a week for 
six months, resuming them 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 
Fig. 10. Telatherm apparatus. 
Telatherm apparatus and in the next treatment the same 
amount can easily he given. Diathermia treatments ap- 
parently are beneficial in many cases and I feel confident 
that many of my patients today live comfortably, who 
would have been obliged to have prostatectomy per- 
formed if they had not been used. 228 
GERIATRICS 
There is a period of warning in prostatic hypertrophy, 
several years elapsing before the serious complications 
develop. In this stage, if the disease could be discovered, 
diathermia treatments would be advantageous and pre- 
vent it from pursuing a chronic course. Usually the first 
treatment will relieve patients of the sensation of con- 
gestion they experience. The heat of the Telatherm re- 
lieves the congestion in the tissues, through its stimulat- 
ing action on the flow of the blood stream. 
With diathermia treatments practically no heat is 
wasted outside, it penetrates the internal tissues. The 
Telatherm produces about two million oscillations a 
second and does not injure the deeper tissues. The 
effect of diathermia on the prostate is to drive away the 
old blood which is replaced by new blood. In this re- 
spect it resembles the hyperemic treatment, but its aim 
is to relieve the congestion and improve the tone of the 
muscles. 
The results of the treatment have been encouraging, 
but if improvement does not take place in a few months, 
operation is necessary. Diathermia may temporarily 
relieve the congestion accompanying adenocarcinoma of 
the prostate and improve inflammatory.conditions of the 
bladder. 
If diathermia does not prove efficient, I employ a 
vacuum electrode from a Campbell Model “E” coil and 
give a mild current for five minutes every other day. It 
is not advisable to allow this electrode to remain in the 
rectum 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 successful 
in some instances. 
Carcinoma of the prostate has been successfully 
treated by radium. Doctor Hugh Young has been using 
it to advantage as has Doctor B. S. Barringer and others. 
There are several methods of application. Fifty to one senile prostatic hypertrophy 
229 
hundred milligrams of radium element are usually suf- 
ficient and it should be screened with two millimeters 
of metallic and one millimeter of rubber screening. 
The crossfire method can be used and an exposure from 
four to six hours repeated three or four days in 
succession. 
Doctor Barringer1 in treating carcinoma of the 
bladder lias performed a 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 to 100 millicuries of 
radium. The needle was inserted into the perineum be- 
tween the urethra and rectum and guided by the finger 
in the rectum until the end of the needle had passed into 
the middle lobe of the gland. 
In some instances the results are encouraging and 
many of our best surgeons have successfully used ra- 
dium, I believe, in many cases of prostatic hypertrophy, 
that the so-called “catheter life’’ and prostatectomy are 
unnecessary. There comes a time when operation may 
be a necessity, but I have never seen a case yet that med- 
ical treatment or electric treatment could not relieve to 
the degree of giving comfort. 
Perhaps the patients do not feel perfectly well; the 
majority of cases of prostatectomy suffer months after 
their operation has been performed. The surgeon does 
not see the patient after his discharge from the hospital 
and writes on his index card “uneventful recovery.” 
The family physician is the one who has to deal with 
him after the operation. 
One of our authorities said “the unsatisfactory results 
of medical treatment have removed prostatic hyper- 
trophy from the field of the physician to that of the 
surgeon.” My limited experience in about 200 cases, 
* The Treatment by Radium of Carcinoma of the Prostate and Bladder. Pre- 
liminary report. Jour. Am. Med. Assn., Nov. 11, 1916, No. 20, pp. 1442—45. 230 
GERIATRICS 
leads me to believe that the above statement is not cor- 
rect. Medical treatment lias its place in prostatic hyper- 
trophy and it is a worthy place, provided the cases are 
seen early. CHAPTER XXIX 
FUNCTIONAL RECUPERATION FOR SENILE 
PARALYSIS 
A brief study of the method of “Functional Recupera- 
tion” of Dr. Gabriel Bidou, Paris, will not be out of 
place here since the technic applies to many types of 
paralysis, and is especially useful in dealing with senile 
patients who are suffering from hemiplegia or paraple- 
gia, who can be made effective again by this method. 
I am grateful to Dr. Bidou for the information he has 
given to me and for the careful demonstrations he has 
made for me in his hospital. 
There are many residual paralyses in old age, some- 
times following cerebral hemorrhage, uremia, diabetes, 
senile myelitis, and many other conditions. We fre- 
quently see old men who have one or both legs paralyzed 
and they are bedridden or wheel-chair patients. Through 
Dr. Bidou’s technic carefully followed, many of these 
patients can be made to walk again, and, in many in- 
stances, they can become effectives. 
Dr. Bidou has charge of Dr. Babinski’s clinic in the 
Hopital de la Pitie, Paris, and there one can see the 
remarkable work he is doing. 
Functional recuperation is defined by Dr. Bidou as a 
method consisting in utilizing the normal human seg- 
ments in favor of the defective ones, according to the 
rules of physiology on the one hand, and of mechanics on 
the other. It is not orthopedics such as we have been ac- 
customed to see, used by orthopedic mechanics; it is a 
very scientific application, therefore a very precise one, 
of the general laws of gravity, of the transmission and 
transformation of movements of the human machine. 
231 232 
GERIATRICS 
To quote Dr. Bidou, “Let us imagine the cripples as any 
kind of machine in which certain organs will have to be 
repaired or replaced. A list of these repairs will be the 
result of careful observation, the balance of the physical, 
physiological or moral resources will be established, it 
will become easy for the physician, who is a human 
mechanic since he is an anatomist and physiologist, to 
decide which muscle has to be replaced or helped, which 
part of the structure has to be re-enforced or supplanted. 
“As a matter of fact, orthopedic instruments being 
inspired by the workings of the arsenal of general 
mechanics can replace a muscle by a spring in most 
cases.” 
Dr. Bidou takes as an example illustrating his theory, 
the case of hemiplegia where we find that the limb is 
elevated by means of an artificial psoas magnus and 
quadriceps muscle, which is attached on a belt to its 
superior end and inserted at its inferior end to the fore 
part of the foot. This artificial muscle will have a force 
of three kilograms. This spring passing in front of the 
coxo-femoral axes of oscillation and of the knee will 
draw toward itself, that is in front of the frontal plane, 
the limb which it propels, on condition, of course, that 
the latter has been liberated from the weight of the body. 
Actually, the adherence of the human body to the earth 
is function of the weight, divided by two, the two lower 
limbs. 
If one leans on one lower limb alone, the human 
weight will bear in its entirety on it; the other being re- 
lieved from the adherence to the earth, will no longer 
have any weight; it will remain attached to the coxo- 
femoral articulation; therefore, a comparatively small 
traction will suffice to overcome the inertia and propel it. 
Re-education will teach the patient to throw himself 
forward and to immediately look for his bearing. In 
this way, he will have gone half a step; repeating the FUNCTIONAL RECUPERATION FOR SENILE PARALYSIS 
233 
same effort with the other limb, he will have gone an- 
other half step, and the complete step will then he ac- 
complished. 
What has been said of the control of muscle can be 
demonstrated in the substitution of the structure itself. 
When the control cannot be effected between the brain 
and the segments in the vicinity of the defective part, on 
behalf of the latter, it is possible to establish a complete 
automatism. One no longer uses the paralyzed limbs, 
except as sheathed mandrels of an automatic mechanical 
apparatus. 
Provided with his apparatus of artificial musculature, 
the paralytic rests on the ground on a quadrilateral base 
of sustentation. The base is inscribed between the four 
following points: two feet and two canes or crutches. 
The center of gravity passing through the vertex, falls 
on the point of intersection of the two diagonals unit- 
ing the angles of the quadrilateral. The traction be- 
tween the two chief points of insertion, superior and in- 
ferior, tends to maintain the body in an attitude of verti- 
cal rigidity. It helps to correct the weakness of the 
knee joint, which has a tendency to bend. 
When the patient desires to move, he carries himself 
lightly on one side, thereby transforming his quadri- 
lateral base of sustentation into a triangle inscribed by 
two canes and one foot. The tripod remains sufficient 
for the support of the body. The foot opposite to the 
side toward which the patient has turned, being liberated, 
releases the adherence to the ground. At this moment, 
the springs being no longer held, shorten, and the limb 
is brought forward. The patient rests on it, recon- 
stitutes a new triangle with this support and alternately 
progresses from one triangle toward the other. 
The re-education of paralytics is easy with this mode 
of muscular action. This apparatus is of great value 
in treating senile patients since we see in old age so 234 
GERIATRICS 
Fig. 11. Patient who had anterior poliomyelitis several years ago and is 
now paralyzed in the muscles below the thorax. This photograph illus- 
trates the apparatus made by Dr. Bidou, which enables the man to walk. 
By a special clamp at the knees and hips, he is able to sit down. FUNCTIONAL RECUPEKATION FOR SENILE PARALYSIS 
235 
Fig. 12. Showing Dr. Bidou’s apparatus for 
hemiplegia. Paralyzed muscles are replaced 
by springs. 236 
GERIATRICS 
Fig. 13. Another case of lateral sclerosis, showing Dr. 
Bidou’s apparatus, consisting of springs which replace 
defective muscles. 237 
FUNCTIONAL RECUPERATION FOR SENILE PARALYSIS 
many cases of liemiplagia and paraplegia, and a simple, 
inexpensive apparatus will enable the old person to walk 
again or to use his arms. A study must be made of 
each case and the muscular movements must be analyzed. 
Relying on observation of this type of artificial mus- 
culature, according to Dr. Bidou, it is possible to con- 
ceive the application to 
the upper limbs, isolated 
or associated to the move- 
ments of the trunk, etc. 
Therefore, it becomes pos- 
sible to repair many mus- 
cular deficiencies, locomo- 
tor or other. The obser- 
vations of the physiology 
of movement, combined 
with the mechanical obser- 
vations of the levers and 
of their associated or op- 
posed actions, has deter- 
mined the method of re- 
lief to defectives, termed 
by Dr. Bidou, “orthope- 
die instrumentale. ” 
He states that each case 
is a law unto itself and 
that industrializing of or- 
thopedic instruments is 
impossible. 
The patient represented 
by Figs. 11, 15, 16 and 17 
is very interesting. This 
man had anterior poliomyelitis several years ago, with 
the ultimate result of paralysis of the muscles below the 
thorax. Dr. Bidou arranged the apparatus for this pa- 
tient, who today has charge of his research laboratory, is 
able to walk, can sit and rise from a chair, and when 
Fig. 14. Apparatus for paralysis 
of the left arm. 238 
GERIATRICS 
Fig. 15. Patient described in Fig. 11, taking a walk in 
city attire. One sees clearly the position of forming a tri- 
angle. The left cane will rest in front of the left foot for 
the next step. 
Fig. 16. Same patient, acting as mechanician. The 
weight of the body on the machine is sufficient to assure 
the equilibrium. This man is able to set up an apparatus 
of precision. 239 
FUNCTIONAL RECUPERATION FOR SENILE PARALYSIS 
demonstrating an apparatus to me, sat on the floor to ar- 
range it, afterward raising himself to his feet, assisted 
only by a chair. It does not seem possible that a result 
such as this could be obtained. Fig 15 shows the man in 
street attire, he travels about Paris and frequently rides 
on the street cars. From a paralytic, absolutely help- 
less below the thorax, this man has been made an effec- 
tive who cannot only take care of himself, but is able to 
assist others. 
Fig. 17. Same patient, as an automobile mechanic. This 
same workman is under the machine and is able to get up 
alone, although he is paralyzed below the thorax. CHAPTER XXX 
THE CURABILITY OF HEPATIC CIRRHOSIS 
AND ASCITES 
A man, aged 55, consulted me for a distended abdomen. 
He had been a chronic alcoholic for several years, and 
had begun to notice his abdomen was enlarging. 
He complained of digestive symptoms and there was 
slight jaundice. Urinalysis did not give evidence of 
nephritis and the heart was normal. The Wassermann 
reaction was negative. Upon examination, he presented 
a liver which was considerably enlarged, and the round 
edge of the organ could be felt on a level with the um- 
bilicus. There was distention of the abdominal veins 
and he complained of hemorrhoids. 
A diagnosis was made of chronic alcoholic hypertrophy 
of the liver, with ascites. He was ordered to bed and an 
absolute milk diet was prescribed, two and one-half 
quarts being given daily and alcohol in any form pro- 
hibited. He was given Vittel water with an ounce of 
lactose to the quart. This treatment was continued for 
two months and there was an improvement. Ascites 
gradually disappeared in the course of four months and 
the patient returned to his usual work in a store. He 
continued the milk regimen for six months, then cereals 
and a few vegetables were given. He has been in ex- 
cellent condition for the past three years; the liver has 
returned to nearly its normal size and he has not com- 
plained of any symptoms. 
This case represents the hypertrophic alcoholic cir- 
rhosis described by Hanot and Gilbert and it must not 
240 curability of hepatic cirrhosis and ascites 
241 
be confounded with the atrophic type of cirrhosis de- 
scribed by Laennec. In many ways the two types re- 
semble each other, but it is a very important matter from 
a prognostic standpoint to distinguish between the two. 
I will not attempt to give a minute description of 
hepatic cirrhosis, but will give a classification of three 
types which are of importance from a clinical stand- 
point. I will group the cases into cirrhosis due to heart 
disease, alcoholism and syphilis. The causes may be 
said to be (1) chronic hyperemia of a passive character, 
depending on heart disease or malaria; (2) chronic hy- 
peremia of an active character due to alcoholism; (3) 
chronic active hyperemia depending on syphilis. There 
are other causes, but I shall not attempt to make a text 
book presentation of the subject. The English have 
spoken of “gin-drinker’s liver” as the hypertrophic alco- 
holic cirrhosis. Some of the worst cases of “gin- 
drinker’s liver,” are seen in men who have been total 
abstainers all their lives. 
The name cirrhosis given by Laennec to this disease 
comes from the Greek, Keppoc (russet colored) and re- 
fers to the color of the organ. It had been mentioned 
before his time, however, but had been mistaken for 
tubercle on account of the mammellated aspect it gave to 
the liver. Morgagni noticed the association of ascites 
with this condition of the liver. Baillie observed the 
more common occurrence of the disease in men “because 
they drink more than women,” and called attention to 
its association with drunkenness and with the presence 
of ascites. 
Trousseau observed that cirrhosis originated with 
chronic inflammation and noted that it was commonly 
secondary to a cardiac affection. 
Syphilitic inflammation may occur in the liver just as 
it may occur in the kidneys or testicles and it should 
be suspected as a cause in every case. Syphilis will 242 
GERIATRICS 
cause perihepatitis, an affection of the capsule of Glisson, 
causing a miliary eruption resembling very small warts. 
However, the surface of the liver may be smooth, yet 
syphilitic. 
It is not always easy to point out the exact type of 
cirrhosis we encounter because there are many inter- 
mediate forms. It is necessary, however, to determine 
the difference between the atrophic type (Laennec) and 
the hypertrophic type. It is possible also that alcohol 
may cause either type; from a therapeutic standpoint, 
the hypertrophic type is much more amenable to treat- 
ment than the atrophic. Sometimes there is hypertro- 
phy in the first stage of atrophy of the liver, but it is 
not of long duration. The early symptoms of cirrhosis 
have been described by Hanot and Gilbert as follows: 
“Dyspeptic troubles, alteration of the color of the feces, 
physiological and chemical changes in the urine, the yel- 
low tint of the skin, the appearance of varicose veins 
and of vascular nevi, hemorrhages from diverse tracts 
(especially epistaxis and gastrorrhagia), ascites, dilata- 
tion of the subcutaneous abdominal veins, hemorrhoids, 
splenomegaly, loss of strength and of flesh, belong to 
the hypertrophic as well as the atrophic forms of alco- 
holic cirrhosis.” 
It is difficult to state why alcohol causes atrophy in 
some cases and hypertrophy in others. The form known 
as Laennec’s does not respond to treatment as well as 
the hypertrophic form. The hypertrophy may be in the 
hepatic cells or in the numerous capillary angiectases. 
The two conditions have the same cause, same symptoms, 
but the prognosis is different; the more cirrhosis points 
to the hypertrophic alcoholic form the more likely a cure 
will be effected. 
For many years we have placed a death warrant on 
a man who had hepatic cirrhosis and today it is not rec- CURABILITY OF HEPATIC CIRRHOSIS AND ASCITES 
243 
ognized that hepatic cirrhosis with ascites is cur- 
able. In some forms it is curable. 
In the clinic of Prof. Gilbert, in the Hotel Dieu of 
Paris, in 1918, I saw several cases of hypertrophic alco- 
holic cirrhosis of the liver. He pointed out the first 
case as incurable, and then showed me another that was 
curable. I was quite surprised to find that there was 
some hope for this condition. Thanks to the French 
masters, especially Hanot, Gilbert and Dieulafoy, we 
have a simple classification, and a simple treatment that 
is effective. For several years French clinicians have 
held some hope in these conditions; Trosier, in 1886, 
communicated with the Societe Medicale des Hopitaux, 
on the curability of chronic ascites. He reported the 
case of a man who was admitted to the hospital for as- 
cites, edema of the lower limbs and collateral circulation. 
The quantity of fluid in the peritoneum was estimated to 
be about 12 pints and the liver and spleen were enlarged. 
He prescribed an absolute milk diet; in a few weeks the 
ascites disappeared, and, in time, the edema of the lower 
limbs. 
It will often be necessary to tap the abdomen several 
times before a cure is effected. Dieulafoy reported a 
cure after five tappings; Seailles reported one after 
eighteen tappings. It may be necessary to resort to 
very frequent tappings, but the strict treatment should 
be continued. 
Ascites of cirrhosis can be cured; it is possible to 
cure cirrhosis of the liver, and the more it resembles 
the type described by Hanot and Gilbert as “alcoholic 
and hypertrophic cirrhosis” the more curable it is. In 
atrophic cirrhosis there is such a destruction of tissue 
that the disease is incurable; although regeneration of 
the liver substance, is, as a rule, easy, in the hyper- 
trophic form it quickly regenerates. The new process 244 
GERIATRICS 
supplants the degeneration, and the liver, instead of be- 
coming atrophied, may finally be much larger than nor- 
mal. (Dieulafoy.) In most cases the liver does not 
return to normal size. 
The treatment consists in total abstention from alco- 
hol in any form and an absolute milk diet, two or three 
quarts a day, is given; rest in bed is essential. I have 
used this treatment for acute nephritis several years 
and am sure it has been a life-saving measure in many 
cases. Milk diet is very popular with French clinicians, 
but because it does not measure up to our caloric values 
we do not use it extensively. It acts favorably on the 
patient in many cases, and I have seen patients who have 
been on this absolute milk regimen for several months 
without untoward results; in fact it has been of decided 
benefit. Caloric values are important, but we should 
not overestimate their importance. 
A patient with ascites, caused by hypertrophic alco- 
holic cirrhosis, should be in bed and alcohol in any form 
forbidden. A quart of Vittel water, with an ounce of 
lactose, should be taken each day, and it is well to ad- 
minister diuretics in the form of diuretin or Trousseau’s 
diuretic wine. Theobromin-sodium salicylate, commonly 
said to be the same as diuretin, does not seem to give as 
good results clinically. Trousseau’s diuretic wine works 
well if made properly. Dieulafoy gives the formula as: 
White wine 7 pints 
Alcohol (90 per cent.) 17 ounces 
Juniper berries 12 “ 
Acetate of potash 7 “ 
Digitalis leaves 2 “ 
Squill 1 “ 
It can be prescribed in tablespoonful doses every three 
hours for several days. 
As is often the case, authors leave out the essential 
part of the formula, i. e., the method of preparation. If 
physicians would give their secrets in treatment as the curability of hepatic cirrhosis and ascites 
245 
surgeon gives his technics, there would be less thera- 
peutic nihilism. Too many prefer to keep their thera- 
peutics dark. 
As much depends upon the preparation of a remedy as 
upon its ingredients. I worked on the preparation of 
Trousseau’s diuretic wine for four years and was disap- 
pointed in its use. When, however, I learned the correct 
method of preparation, I found it very valuable. 
In the preparation of this remedy, first make an in- 
fusion of digitalis. Macerate the juniper berries in a 
mortar and add to the infusion. Allow to stand over- 
night and then press out the liquid through a tincture 
press. The squill is dissolved in alcohol and potassium 
acetate is dissolved in a sufficient amount of water; then 
the latter solution is added to the infusion, then the 
white wine, and last the alcohol with the squill, is added. 
The whole mixture is allowed to stand for seven days 
and the container is shaken each day, after which it is 
filtered and dispensed. 
Milk becomes tiresome as a diet, but can be modified 
a little by adding a teaspoonful of coffee, one or two 
drops of vanilla, a spoonful of tea, or it can be aerated 
with a sparkler. Lime water may be added if it pro- 
duces much gas. Koumiss may be prescribed. 
Vittel water is easily obtained in America; it is bene- 
ficial by itself or can be used with lactose, which causes 
diuresis. No food must be given except milk. It is sur- 
prising how long a patient can continue on an 
absolute milk diet. My patient lived on it for six 
months without serious loss of weight and I have used it 
many times without great loss of weight or strength. 
I use it as a routine measure in the treatment of acute 
nephritis or chloro-Brightism; if patients know there 
is no alternative, they will accept this treatment will- 
ingly. 
It is necessary to pay particular attention to the 246 
GERIATRICS 
bowels. If the patient is robust, it would be well to pre- 
scribe a saline laxative each morning in the form of 
Pluto, Seidlitz mixture or citrate of magnesia. If the 
patient is physically frail, tablets of phenolphthalein or 
the compound rhubarb pill (U. S. P.) will be of benefit 
and an occasional enema can be used. 
It may be necessary to tap the abdomen. It may even 
be necessary to tap it several times, but the treatment 
should nevertheless be continued vigorously, as many 
cases of cure have been reported after many tappings. 
Sometimes ascites will disappear spontaneously and not 
reappear. 
If alcohol is resumed in any form, it is apt to cause 
recurrence of the symptoms and the result may prove 
fatal. A man who has been cured, or relieved, of he- 
patic cirrhosis should never return to the use of alcohol 
in any form as if he does ascites will reappear. 
Cirrhosis due to cardiac disease should receive the 
same treatment. If there is edema of the lower extremi- 
ties, diuretin should be used, but it is of little value if 
edema affects the upper extremities. The absolute milk 
diet is indispensible and this also applies to the syphilitic 
form. 
In the latter type, potassium iodide should be added 
to the treatment, and arsenobenzol used intravenously 
will give good results. The milk regimen is necessary, 
and the treatment is essentially the same as in the other 
forms of cirrhosis. 
In some cases opotherapy in the form of hepatic ex- 
tract is of benefit; in others it is of no apparent value. 
The use of liver extract is comparatively new and should 
be well tried. The work of Gilbert, Carnot and Choay, 
in 1896, fixed, in a precise manner, the method of prep- 
aration of hepatic extract. There are many factors to 
be taken into consideration in opotherapy, especially the 
kind of animal the extract is taken from, and its age. CURABILITY OF HEPATIC CIRRHOSIS AND ASCITES 
247 
Hepatic extract is preferably taken from a pig; it may 
be given in bouillon, powder, aqueous extract; alcoholic 
extract or glycerin extract. Perhaps the easiest method 
of dispensing it is to use powder made into tablets. 
Experiments have shown that it has an excellent effect 
on hepatic insufficiency in some cases. Gilbert (Paris) 
reports two cases of improvement of grave hepatic cir- 
rhosis with cerebral symptoms. Gilbert also notes the 
case of a woman who was in a desperate condition with 
a mistaken diagnosis of cancer of the liver; ascites, 
icterus, hemorrhage, and edema of the limbs disappeared 
rapidly when hepatic extract was used. He reports a 
case of atrophic cirrhosis with ascites in which the ex- 
tract had a beneficial action. When there is evidence of 
hepatic insufficiency the extract often does well. It has 
a good effect on the symptomatic hemorrhages accom- 
panying certain diseases of the liver, and its action is 
one of specific excitation of the elements of the liver. CHAPTER XXXI 
THERAPEUTICS 
It is a very difficult matter to teach physicians that the 
aged require a medication different from 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 matu- 
rity that Nature will cure, in the aged we must be con- 
tinually on our guard or the patient will die. 
A man, aged sixty-two, had a pain in his heart. He 
had never been ill before and it was apparent that the 
condition was cardiac. A mistaken diagnosis of gastritis 
probably cost the old man his life for in one hour he 
was dead. Had he received a hypodermic injection of 
nitroglycerin the probabilities are he would be living to- 
day. 
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 of dealing with 
old persons. From some condition apparently simple, 
they will die before you return to your office and it will 
humiliate you because perhaps you have given a favor- 
able prognosis. 
The diseases of senility require as much special at- 
tention as that given to diseases of children. In senility 
we must not only employ different remedies but must 
use them in dosages different from those used in ma- 
turity. 
248 THERAPEUTICS 
249 
Again, it is not only the primary effects of the drugs 
we must observe, the elimination through the emunctories 
is so deficient that the secondary effects are fully as im- 
portant as the primary. 
For example, if we employ heroin to relieve pain, three 
days after administering it we observe drowsiness and 
other symptoms due to this remedy. 
A close observation of the tongue can give us many 
clues. If this organ is red and the papillae prominent, 
it is an indication that we should prescribe nux vomica 
and hydrochloric acid, and if the papillae are very 
prominent, arsenic in some form is indicated. Give two 
minims if Fowler’s solution or a tablet containing Hoo 
grain of arsenic trioxide, before each meal. 
A red tongue indicates gastric irritability and hyper- 
acidity. It is a peculiar fact that hydrochloric acid will 
often check this hyperacidity. Why acids check acids 
is difficult to explain, but probably when the glands of the 
stomach are producing an excess of acid, the ingestion of 
acid in the form of medication will supply the stomach 
with the normal amount and make glandular secretion 
unnecessary. Do not give hydrochloric acid after meals, 
however, or it will cause hypersecretion. 
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 gray powder, or podophylin given in tablets contain- 
ing Ho grain, every three hours. Two teaspoonfuls of 
the compound solution of sodium phosphate may be given 
in place of the milk of magnesia. If the stools are dark, 
podophyllin is indicated, while if light or putty-like in 
consistency, calomel or gray powder is necessary. 250 
GERIATRICS 
Tic Douloureux 
This painful condition will often yield to the use of 
the elixir of iron, quinine and strychnine phosphates, 
one teaspoonful given every three hours. Sometimes 
pyramidon in five-grain doses or butylchloral hydrate 
relieves it. 
$ 
Butylchoralis Hydratis 
Potassii Bromidi aa3 ij 
Glycerini 3 iij 
Elixir Aromatici q. s. ad 3 *v 
Misce et Sig.: Teaspoonful in one-half wineglass 
of water every three hours. 
I have obtained excellent results in this condition with 
diathermia treatment, given by a Telatherm machine. 
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 cannot make a 
diagnosis. Senile debility is usually termed “old age” 
and physicians are apt to say that a disease is due to 
“old age” and that nothing can he done for it. 
This so-called senile debility is usually due to some 
form of toxemia, often intestinal or renal. As long as 
this toxemia exists it is useless to give any tonic, but 
when the toxins are eliminated we can then employ tonics 
with great benefit. 
The elixir of iron, quinine and strychnine phosphates 
given before meals is a good remedy. Again, we can use 
the elixir calisaya or tincture gentian with %o grain 
tablets of strychnine sulphate every three hours or three 
times a day. We must remember, however, that the con- THERAPEUTICS 
251 
tinued use of strychnine, is apt to hasten cardiac degen- 
eration. 
Amorphous phosphorus in gelatin coated tablets has 
been used by Nascher in the treatment of senile debility. 
One or two grains of amorphous phosphorus is pre- 
scribed three or four times a day. 
I have used for some time diathermia treatments in 
senile debility. They are given by means of an autocon- 
densation chair and through two poles of the Telatherm 
machine from 400 to 900 milliamperes are given for one- 
half hour. This seems to revive aged patients. 
Use of Opiates 
Morphine is a rather dangerous remedy for the aged 
and cases of sudden death have been reported from 
respiratory failure following a hypodermic injection. If 
morphine is necessary, it should be combined with 
atropine sulphate, %oo grain. Atropine combined with 
morphine prevents this fatal action on the respiratory 
center. 
In the aged we often obtain results diametrically op- 
posed to those observed in younger individuals. For ex- 
ample, sometimes morphine will make the patient ma- 
niacal and he remains wide awake. Again, the secondary 
effect may come several hours after the primary effect 
and be more pronounced. 
I use very little morphine in treating the aged. They 
are apt to beg for it, saying that they do not sleep at 
night. However, probabilities are that they doze in a 
chair during the day and when night comes cannot sleep. 
There are very few conditions in the aged which can- 
not be relieved by heroin or codeine. Codeine works 
well with them and I have senile patients who have taken 
y4 grain of codeine every night for years. It seems to be 252 
GERIATRICS 
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 work satisfactorily and relieve them 
and there is very little danger of forming a habit or of 
the patient requiring a great increase in dosage. Co- 
deine will not have the disagreeable effect which accom- 
panies t’he use of the stronger opiates and usually does 
not t give the unpleasant dreams often associated with 
morphine. 
Heroin or diacetylmorphine will usually relieve pain, if 
it is not too severe. It can be used hypodermically in 
doses of V>4 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 for 
several years. I have a cancerous patient who has taken 
% grain of heroin every night for the past year. One 
fact which should be remembered is that opiates taken 
in order to relieve pain rarely form a habit, and it is 
only when they are employed for sleeplessness or trivial 
complaints that they are dangerous. 
In peritonitis and other painful conditions I have used 
opiates in huge doses yet the moment the disease abated 
the patient no longer asked for, nor required, 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 depression in the respira- 
tory center and cyanosis. They are seldom required and 
when it is absolutely necessary, pyramidon is the safest 
form to use. Pyramidon does not contain the dangerous 
HO.N radical that is found in acetanilide, acetphenetidin THERAPEUTICS 
253 
and antipyrin. In pneumonia and other conditions, 
where an antipyretic is required, quinine will usually an- 
swer. 
Quinine is a very valuable remedy in the aged and if 
the kidneys are not affected, there is no albuminuria or 
hematuria, it may be used safely. In facial neuralgia 
and headaches, neuritis, pneumonia and especially senile 
debility, it is indicated. In senile debility sulphate given 
in doses of one grain every three or four hours is one of 
our best remedies. Quinine works well in most senile 
conditions and is an excellent stimulant. In extreme de- 
bility 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 this organ. 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 a normal process of advancing years 
and does not usually imply the use of the iodides except 
in 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 in the 
aged. Belladonna when used with cathartics has a sec- 
ondary effect which is noticeable several days after the 
drug is taken. The secondary effects of digitalis, strych- 
nine and arsenic should be watched. We may get a sec- 
ondary effect of aloes or aloin on the pelvic vessels. 
secondary effects of iron on the intestines and the role 254 
GERIATRICS 
played by calcium hastening senile sclerotic changes, are 
extremely important. 
In senile cases the rule in dosage is to decrease depres- 
sants and increase stimulants. We must always stimu- 
late the aged when they are ill because Nature tends to 
kill them. 
It is surprising sometimes to see, however, how small 
the dosage can be in treating the aged. Strychnine in 
Vi2o grain doses sometimes acts better than larger 
doses. Occasionally, the smallest doses of calomel will 
cause diarrhea and salivation. In my experience, digi- 
talis has been a very unsatisfactory remedy in senile pa- 
tients and it is only in well-selected cases that it will be 
of benefit. Small doses of the fat-free tincture, say three 
or four minims per dose are usually sufficient, but the 
ordinary secondary effects should be watched. The old 
rule “children and the aged cannot stand large dosage” 
is in a measure true. 
Hemorrhoids 
Many times a careless observer will overlook the pres- 
ence of malignant disease of the rectum. Again, hemor- 
rhoids and cancer may appear together and only through 
careful examination will carcinoma be discovered. 
Hemorrhoids in old age may be caused by constipation, 
disease of the liver, and sedentary habits tend to pro- 
duce this affection. The hemorrhage following a bowel 
movement is often not discovered and the loss of a small 
quantity of blood each day will in time cause anemia 
which may be mistaken for the pernicious type. I rec- 
ollect a man of 60 who had every symptom of pernicious 
anemia and became so weak that he could not walk. It 
was finally discovered that he was daily losing blood. 
Under treatment for the hemorrhoids he improved and 
in two months his general health was much better. It is THERAPEUTICS 
255 
often a difficult problem to check the hemorrhage, in old 
age, since it is dangerous to do it suddenly. Some cases 
of apoplexy and pulmonary hemorrhage have been re- 
ported following the sudden checking of a hemorrhoidal 
discharge. It is much better not to interfere too actively 
with these hemorrhages unless the patient becomes weak 
and exhausted from loss of blood. 
The treatment consists in giving a laxative which con- 
tains sulphur, and produces a soft and nonirritating 
movement. The compound licorice powder, U. S. P. 
contains washed sulphur, one-fourth to one-half tea- 
spoonful may be used in the morning and at night but 
this dose should not be exceeded since it is apt to cause 
griping pains in the intestines. Ten grains of washed 
sulphur mixed with a dram of confection of senna, 
may be used at bed-time. Besides its softening effect on 
the stools, sulphur is said to have a beneficial action in 
prolapse of the rectum and in piles. In fissure of the 
anus and stricture this treatment may be used. 
Cold or astringent applications must be used in 
advanced life, but with great care; hamamelis sometimes 
works well and will not suddenly check the hemorrhage. 
Suppositories containing two grains of iodoform are use- 
ful in bleeding piles or a 2 per cent ointment may be used 
in a pile pipe, which can be inserted into the rectum. Ex- 
ternal .hemorrhoids may be relieved by the following oint- 
ments : 
n 
Extracti Stramonii 
Extracti Hyoscyami aa gr. xxx 
Adipis Benzoinati 3 i 
TIX. et ft. ting. 
R 
Pulvis Opii gr. xxiv 
Acidi Gallici gr. xij 
Acidi Tannici gr. xx 
Petrolati 3 i 
Tip et ft. ung. 256 
GERIATRICS 
$ 
Extracti Belladonnae 3 i 
Phenolis M ij 
Petrolati 3 ij 
Tq. et ft. ung. 
The above formulas may be used when there is intense 
pain. For internal hemorrhoids a flaxseed enema will 
often be of benefit. Four tablespoonfuls of flaxseed are 
added to one quart of water and boiled for twenty min- 
utes. It is then strained to the thickness of cream and 
used once a day, or an injection of olive oil or mineral 
oil may be substituted. Before using ointment it is 
sometimes advisable to use flaxseed enemata. Calomel 
ointment sometimes works well as an external applica- 
tion. It is advisable to operate on cases that are not re- 
lieved by ordinary methods of treatment when this 
condition is very troublesome. 
Cystitis 
Cystitis in the aged is often due, in the male, to reten- 
tion, and, in the female, to pyelitis. I have sometimes 
used the following mixture to advantage in cystitis and 
pyelitis: 
Pancreatini 3 ss 
Potassii Carbonatis 3 ij 
Fluidextracti Khei 3 ij 
Fluidextracti Hydrastis 3 iss 
Tincturae Cinnamomi 3 ss 
Spiritus Menthae Piperiate 3 ss 
Syrupi Simplicis q. s. ad 3 iy 
Misce. 
Sig.: Take one teaspoonful in one-half wineglass 
of water every three hours. 
Fluid extract of pareira brava, five minims every three 
hours, and occasionally fluid extract pi chi may work well. 
Copaiba and santal oil are beneficial in some instances. THERAPEUTICS 
257 
If micturition is very frequent and painful, I use tincture 
of cannabis indica, one or two minims in a teaspoonful 
of elixir containing sodium bromide, to be taken every 
three hours. CHAPTER XXXTI 
OPOTHERAPY 
Organotherapy, or opotherapy, is not a new method 
of treating disease. It was known to the ancient Egyp- 
tians. Sushrnta, who lived between 400 and 600 b. c., 
described the use of orchitic substance for the treatment 
of obesity, and this was probably the first mention of 
opotherapy. 
It has always been the ambition of an old man to be 
made young and when his sexual powers show signs of 
waning, old age becomes an obsession, and he seeks means 
of restoring virility. Recently, Voronoff brought back 
into light the work of Brown-Sequard, who, in 1889, com- 
municated to the Society of Biology of Paris, the won- 
derful results of the injection of testicular secretion, the 
experiments being made upon himself. A'oronoff’s writ- 
ing in the lay press gave hope not only to old men% but 
to many young or middle-aged individuals, profoundly 
melancholic because they were losing their sexual power. 
Whenever a hope is expressed in some journal of rejuve- 
nating man, the huge army of impotent men, seeks help 
from those who advocate the cure. Thus, when Brown- 
Sequard’s “Elixir of Life” was discovered, factories 
which could produce glandular extracts were working 
day and night to supply the demand until August 16, 
1889, when at Shamokin, Pa., ten deaths were reported 
after taking the treatment. 
Brown-Sequard almost claimed his Elixir was a pana- 
cea ; it was used for fevers, edema, ulcers, pains, locomo- 
tor ataxia, etc. We can readily imagine what the results 
258 OPOTHERAPY 
259 
were. After these failures, organotherapy became al- 
most forgotten,—temporarily. 
The principle itself of organotherapy belongs to an- 
cient medicine. It was the custom of many savage peo- 
ples to eat the organs of animals killed while hunting or 
of conquered foes in order to obtain the qualities these 
organs were supposed to possess. The heart of a lion 
was thought to give a man courage, and the brain of a 
snake, wisdom. Civilized people of the ancient world 
employed the organs and secretions of animals for thera- 
peutic purposes. 
The legend of the “Bezoar Stone,” which was sup- 
posed to be found in “the inner part of a beaste that is 
commonly called a goate of the mountaine, ’ ’ shows an 
early belief in organotherapy. 
Celse advocated the blood of a goat, boiled with vine- 
gar, for serpents’ bites. Naturalists spread the idea of 
organotherapy among the Romans who drank the blood 
of dying gladiators to cure epilepsy. Homer tells of 
Chiron, the Centaur, who gave strength to Achilles by 
administering lion’s marrow. Hippocrates used the bit- 
ter secretion of a bull’s liver in suppositories, with honey, 
in cases of intestinal engorgement. 
Owing to degenerative changes, some senile diseases 
are caused by absence or diminution of secretions of 
the internal organs, old age, therefore, furnishes many 
indications for the use of animal extracts. In normal 
old age, there is lessened secretion of the internal organs, 
but we should not endeavor to bring the old patient to a 
norm of maturity, because it is normal for old persons to 
have organs which are less active. In senility, where all 
organs are degenerated, a certain harmony exists be- 
tween these weakened organs and as long as there is har- 
monious action between them, the old person continues to 
enjoy good health. No doubt certain internal secretions 
affect various organs, thyroid extract administered in 260 
GERIATRICS 
some cases of nephritis, will apparently improve kidney 
diseases; in this instance, hypothyroidism apparently 
caused nephritis. In some cases of insufficiency of the 
liver, the administration of hepatic extract seems to im- 
prove the condition. 
When one organ degenerates more rapidly than an- 
other, there is broken harmony between these organs, but 
as this does not ordinarily happen before the sixtieth 
year, we do not notice the effects of ageing which this 
lack of functional relation brings on. The degeneration 
of an organ may be due to the excessive secretion of 
some other organ or to the lack of it. Our knowledge 
of the interrelated activities of various organs is still 
meagre, but, no doubt, the internal secretions of the 
ductless glands, besides the secretions of other organs 
which have ducts, play an important part in the process 
of ageing. Sometimes the lack of secretion of some or- 
gans will produce degeneration, while the excessive se- 
cretion or the administration of some glandular extracts 
may hasten degeneration. The internal secretions of 
some glands regulate others ; thus the hormone, or in- 
ternal secretion of the thyroid, may effect the adrenal se- 
cretion. There is an intimate relation between the 
testicles and ductless glands. 
Undoubtedly, many conditions in old age affect the 
amount of secretion of glands. Mental conditions, as 
joy, sorrow, and genital disturbances will produce hyper- 
secretion of the thyroid, while quiet, absolute rest, ab- 
sence of genital irritation, milk diet, certain drugs, par- 
ticularly lime and hypnotics, act as depressants. 
It is difficult to know how many cases of senile neph- 
ritis, senile diabetes, senile dementia and many other 
diseases are due to deficient glandular secretions. 
Many skin diseases are probably due to deficient thyroid 
secretion. It is barely possible that some cases of can- 
cer depend upon thyroid deficiency, since in some in- OPOTHERAPY 
261 
stances the administration of thyroid extract in inoper- 
able cancer, has caused the latter to entirely disappear. 
In the British Medical Journal of July, 1911, a case was 
reported where the larynx had been excised for malig- 
nant disease and a second operation had been under- 
taken for removal of the cancer, but it recurred. After 
a course of thyroid treatment, gr. 3, three times a day, 
at the end of three months the growth diminished; at the 
end of six months there was no evidence of tumor. Dr. 
Yates of North Bend, Nebraska, writes me that he has 
had several cases of cancer which disappeared as a re- 
sult of thyroid medication. 
I recently administered thyroid extract in a case of 
nephritis accompanied by asthma, edema and maniacal 
symptoms; a few days after the patient was much better. 
The combination of cystic thyroid and concurrent ne- 
phritis is frequent and thyroid medication will improve 
the latter condition, but when there is true nephritis due 
to cardiovascular, liver disease or infection, thyroid ex- 
tract will not be of benefit. 
At present, I am treating a woman of fifty who has 
had glomerulonephritis for several years. She was taken 
suddenly ill, had uremic symptoms, occipital headache, 
blurred vision, vomiting, numbness of the left arm and 
leg. Urinalysis showed albumin and many hyaline and 
granular casts. The systolic blood pressure was 230 
and diastolic 110. The kidney disease had developed 
several years ago from eclampsia and as time went on 
she had considerable trouble with her heart, so that she 
had taken large doses of digitol for a long time. The 
least exertion brought on dyspnea and she had been un- 
able to go upstairs for a long time. I prescribed a milk 
diet and saline laxatives each morning and in a week she 
had improved. I then gave her thyroid tablets, each con- 
taining 2 grains of desiccated thyroids, one three times 
a dav. She showed further improvement on thyroid 262 
GERIATRICS 
medication, was able to discontinue digitol, edema dis- 
appeared, blood pressure fell to 170 systolic and 100 dia- 
stolic and the urinary examination showed a diminution 
in the number of casts as well as a diminution of al- 
bumin. Her weight fell from 215 to 195 pounds and in 
every way she showed improvement. 
There are many cases of nephritis that improve on 
thyroid medication and some cases of senile heart dis- 
ease also seem to improve under this treatment. In 
obesity, rheumatism, gout, asthma, migraine, anorexia, 
pruritus senilis, eczema, and in constipation, thyroid ex- 
tract is of value. Ten to twenty-five centigrams should 
be given from two to six times a day and if it is impos- 
sible to administer it by mouth, J employ an extract for 
subcutaneous injection, one ampoule being given every 
two days. It is well to begin with small doses of thyroid 
extract, perhaps one tablet a day until we are certain 
that there will be no ill effects, gradually increasing to 
the full dose. If too much is given, we may note an in- 
crease in the pulse rate, headache, restlessness, nausea, 
prostration and pains in the limbs and back. It is then 
well to reduce the dose or discontinue for a few days, 
later resuming its use. 
Basedow’s disease is rare in the aged and does not 
usually develop in women after the menopause. Myx- 
edema may come in old age and in many cases is difficult 
to differentiate from senile nephritis with edema. There 
is general swelling all over the body, the lower lids are 
puffed, the voice is harsh and at times it is difficult for 
the patient to talk; the skin has a peculiar yellow color 
and the face becomes wrinkled. Asthma may be one of 
the symptoms and usually urinalysis reveals albumi- 
nuria and casts, a careless diagnosis would be one of 
nephritis. Under thyroid medication the condition im- 
proves in a few days, but it may leave evidence of renal 
insufficiency. OPOTHERAPY 
263 
Thyroid extract causes an increase in oxidation in the 
body, the nitrogenous substances are excreted as urea, 
fats as carbon dioxide by the lungs; diuresis is produced, 
but as ft is out of proportion to the amount of thyroid 
substance taken, it is probable that it is due to the effect 
on the nervous system and not to direct action on the 
tissues. Blood pressure is reduced, which may be due to 
weakness of the heart action. Results depend on the 
quality of the preparations, as absolutely fresh thyroid 
gland is not poisonous, but if an impure product is used, 
we may get untoward symptoms. 
Renal Extract 
I have observed excellent results, in many cases of se- 
nile nephritis, apparently due to the use of nephrin or 
renal extract. In 1892, Dieulafoy used glycerin extract 
of kidney for uremic coma. After glycerin extracts, the 
dry extracts were used; Renaut of Lyon gave his experi- 
ments of aqueous maceration, and Tessier, guided by 
Turbure of Bucharest, gave the treatment of nephritis 
by aseptic serum of the blood of the renal vein of a goat. 
In 1894, Tessier and Frankel reported cases showing the 
effect of injections of nephrin upon albuminuria. Chip- 
erowitch of St. Petersburg, experimented on 35 cases 
of nephritis, employing the injections of nephrin and had 
excellent results in most cases. (Gazette des BotMnes, 
1895.) 
Brown-Sequard and d’Arsonval found that among rab- 
bits and guinea pigs having had .both kidneys removed, 
those who received subcutaneous injections of diluted 
secretion of kidneys of animals of the same species, 
lived longer than those who had not received these in- 
jections. M. Dubois said: “There is in the kidneys a 
normal antitoxin which ceases to be secreted or is se- 
creted in insufficient quantities when the functions of the 264 
GERIATRICS 
kidneys are perturbed, this antitoxin is not altered 
through its passage in the digestive channels; its role 
would consist of destroying as soon as their passage 
through the kidney, certain toxic principles of the blood 
resulting from the activity of the organism. I think this 
antitoxin principle exists in normal urines.” 
Several methods of application have been suggested 
for renal opotherapy. The following methods of Carnot 
are given: 
1. Eenal tissue—its secretion, its various extracts. 
2. Serum of renal vein. 
3. Antinephrotoxic serum prepared by means of in- 
jections of nephrotoxins. 
4. The kidneys or serum of animals in renal regenera- 
tion. 
Many methods of preparing renal substance have been 
used. Fresh kidnejs have been macerated and admin- 
istered in the form of powder. The pulp of fresh kidney 
is diluted in luke-warm bouillon and administered to the 
patient when his stomach is empty. Another method of 
preparation is the aqueous maceration, but the treatment 
cannot be continued very long because of accidents 
caused by putrefaction of organs during maceration, the 
product has a fetid odor. The simplest and most con- 
venient method of preparation is the dessication of the 
kidney substance; the product thus obtained will keep a 
long time and can be administered in large doses. The 
aqueous extract is given after filtration and dessica- 
tion, in the form of pills or capsules. Gilbert and Cos- 
taigne employ a peptic extract of kidneys as less toxic, 
but it retains the power of neutralizing uremic poisons 
and activates the secretion of the kidneys, whose epi- 
thelium is altered. The glycerin extract is seldom used 
at present. 
In cases of senile nephritis where there is renal insuffi- 
ciency, uremic symptoms, or acute exacerbations of a 265 
OPOTHERAPY 
chronic process, I gave 25 centigrams of renal extract in 
pills or cachets from four to. eight a day. If the patient 
cannot take the preparation by mouth, I use the hypo- 
dermic preparation, which is isotonic and nonglycerin- 
ated, each c. c. corresponding to ten centigrams of renal 
extract. If the case is acute, I give an injection each day 
for a week and then every two or three days._ In many 
cases it will improve the comatose condition and I have 
seen one case of anuria that was relieved by this method 
of treatment. 
I have several aged patients who have been taking pills 
of renal extract for a long time with apparent good re- 
sults. A woman, aged sixty, had nephritis for several 
years. Urinalysis showed albumin and the microscope 
revealed many hyaline and granular casts, as well as 
blood. She has taken renal extract for four years and 
at present urinalysis does not show abnormality and she 
seems in perfect health. Another woman, aged 76, has 
taken renal extract for three years and has good health. 
Recently, I experimented, discontinuing the use of this 
preparation only to find that in a week’s time, she showed 
signs of nephritis with edema, which disappeared when 
she resumed renal extract. 
I was once called to see an invalid, a woman of 55, who 
had been ill for several years. She had been under treat- 
ment in various hospitals and had taken a long course 
of thyroid medication; as a result, she had lost a great 
deal of weight,—when I saw her she weighed about 90 
pounds,—her face was wrinkled, giving her the appear- 
ance of a woman twenty years older. She complained 
that she could not get out of bed without fainting and had 
not been able to walk for two years. Urinalysis showed 
hyaline and granular casts, there was an accentuated 
aortic second sound which showed that the heart was 
overworking. She was in a weakened state and it 
seemed advisable not to give any medication, such as 266 
GERIATRICS 
laxatives, as her stomach would not be able to stand 
them. 1 tried renal extract in pills, giving three a day, 
and used no other remedy; she continued its use for 
some time and her daughter wrote to me that her mother 
had greatly improved, that she was walking and had been 
to the theater. She gained in strength, but not in weight. 
A few months afterward she traveled several hundred 
miles. She spent the winter in Florida and upon her re- 
turn to New York was taken ill with an acute exacerba- 
tion of nephritis, but a milk diet soon relieved the attack. 
She lived three years in good health, but finally died from 
uremia. In this case, the treatment was limited to the 
administration of renal extract, no change in diet was 
made. 
I have used renal extract in several cases of albumin- 
uria and have seen albumin disappear without any 
change in diet. Renal extract can be continued several 
years. I have a patient who has been taking three tab- 
lets a day for eight years and has maintained a norm of 
senijity, after having suffered from interstitial nephritis 
for several years. In some cases which seemed hopeless, 
I have seen this extract apparently cause improvement. 
The simplicity of its administration (the dose does not 
have to be increased and there seldom is gastric intoler- 
ance) makes it a valuable therapeutic agent in senile 
nephritis. 
There are other causes of nephritis in old age, the dis- 
ease may be of hepatic origin or possibly due to insuffi- 
cient thyroid secretions. In 1888, Hanot showed hepatic 
lesions in the course of nephritis. C. Bernard and Lae- 
derich showed that the functional troubles of the kid- 
neys are accompanied by alteration of the liver and that 
the latter organ plays an important part in the patho- 
genesis of uremia. Hepatic extracts possess certain di- 
uretic properties and can be used in some affections of 
the kidneys with good results. OPOTHERAPY 
267 
Lorand concludes that extirpation of the thyroid 
gland gives a true interstitial nephritis. Myxedema is 
often accompanied by albuminuria, which rapidly im- 
proves under thyroid medication. Thyroid extract helps 
renal hypertension and the insufficiency of urinary dep- 
uration. 
The secretion of the suprarenal glands helps in low 
arterial pressure and acts as a diuretic. The internal 
secretion of the pituitary body acts as a diuretic and car- 
diostenic and apparently is beneficial in acute infectious 
nephritis. Ovarian extract and extract of corpus luteum 
sometimes help the kidney condition so often observed 
during the menopause. At this time many women de- 
velop nephritis with high blood pressure and symptoms 
of uremia. In others, the menopause will aggravate 
chronic nephritis. In these cases of renal insufficiency 
ovarian extract will be of apparent value. 
From the above, it will be understood that other in- 
ternal secretions affect the kidneys and it is often well to 
combine those extracts which have a common action; 
thus, we can combine the renal and thyroid, renal and 
hepatic extracts. 
Kenal opotherapy is indicated in subacute nephritis, 
or where we wish to cause diuresis, elimination of 
chlorides, disappearance of edema and albumin. In 
some cases of chronic interstitial nephritis it is contra- 
indicated, renal impermeability exposing the patient to 
toxic accidents. 
Jacques Delor (Theses de Paris, 1911) called attention 
to the fact that the kidney of a pig is often tuberculous 
so that it would be possible to provoke tuberculosis of 
alimentary origin. Great care must be exercised in the 
selection of the animals used. 
The dry extract is the best for internal use, but if rapid 
action is necessary hypodermic preparations should be 
used. 268 
GERIATRICS 
Hepatic Extract 
In my chapter on cirrhosis of the liver, I have spoken 
of the use of hepatic extract in some forms of cirrhosis. 
The works of Gilbert, Carnot and Choay, since 1896, have 
established a definite method of preparation and ad- 
ministration, of diagnosis (opodiagnosis), and of treat- 
ment (opotherapy). Several methods of preparation 
have been employed for aqueous, alcoholic, glycerinated, 
pepsic, saline and alkaline extracts and those prepared 
by the method of Baumann. Gilbert has obtained good 
results from the use of hepatic extract in many grave 
diseases of the liver, such as icterus gravis, hypertrophic 
alcoholic cirrhosis and hepatitis. Hepatic opotherapy 
is very useful in cases of functional insufficiency of the 
liver; it lessens indicanuria, the quantity of urea in- 
creases, urobilinuria often disappears and in other cases 
glycosuria disappears. 
At present, I am treating three cases of diabetes 
mellitus by this method, giving four pills a day, each con- 
taining 25 centigrams of hepatic extract; in each case, 
sugar has markedly diminished. In some cases of dia- 
betes it seems to check such symptoms as pruritus vulvae, 
eczema and rheumatism. There are a number of cases 
of diabetes mellitus which are of hepatic origin and it is 
only in such cases that hepatic extract is of value. It is 
not always possible to select the cases, but opodiag- 
nosis,—that is to administer an extract for purposes of 
diagnosis,—may be resorted to. It will assist in estab- 
lishing a diagnosis of hyperfunction or liypofunction of 
the liver. In the former, hepatic extract will increase 
the amount of sugar and should not be continued. 
Hepatic extract is of value in certain hemorrhages, 
epistaxis and hemoptysis, but particularly in those 
hemorrhages which are of hepatic origin. In some cases 
of hemoptysis of tuberculosis, it will be of benefit. OPOTHERAPY 
269 
Hepatic extract is said to be of value in some cases of 
biliary lithiasis, nephritis, gout, dermatoses, and albu- 
minuria. I give 25 centigrams of the extract four or 
eight times a day. It is administered in the form of pills 
and cachets, also, in hypodermic preparations, which are 
isotonic solutions and nonglycerinated. One ampoule is 
injected every other day until the condition improves, 
then it is used once or twice a week.. 
Suprarenal Extract 
Addison first demonstrated the action of the internal 
secretion of the suprarenal glands on metabolism and 
later Brown-Sequard did research work along these 
lines. In asthma of old age, hypodermic injections of 
suprarenal extract will relieve the attack and may be re- 
peated until it is over. In Addison’s disease, cardiovas- 
cular asthenia, postoperative accidents, hemorrhages, 
suprarenal extract may be of benefit. It can be ad- 
ministered in pills or capsules, in doses of 10 centigrams, 
four to eight pills being given daily. Since the adminis- 
tration of suprarenal extract is apt to produce albu- 
minuria and glycosuria, it is advisable to examine the 
urine frequently. 
Pituitary Extract 
There are some conditions in old age which are re- 
lieved by the use of this extract. In some cases of 
myocarditis, influenza, pneumonia, hypotension, acro- 
megaly, insomnia, it may be of use. Usually, the extract 
of the entire gland is used in pills, or cachets in doses 
of 10 centigrams, two to four doses being given a day. 
If the extract of the posterior lobe is used, five centi- 
grams are given two or four times a day. In some cases 
of obesity it may be used, as well as in various hemor- 270 
GERIATRICS 
rhages. If used subcutaneously, one c. e., which corres- 
ponds to one-half of the posterior lobe of the hypophysis 
of an ox, is given every two days. In many cases it can 
be used with thyroid extract with good results. When 
thyroid medication fails to relieve the patient, the com- 
bination with pituitary extract seems to fortify its 
action. 
Prostatic Extract 
It is reported that after prostatectomy in dogs the 
testicles lose their functional activity, ejaculation ceases 
and the formation of spermatozoa is stopped. If 
glycerin extract of the prostate is administered, these 
changes are said not to occur. 
A patient, aged seventy, consulted me for difficulty in 
urination, especially at night. He was obliged to get 
up several times and micturition was difficult and pain- 
ful. Finally, I was forced to catheterize him. 
Upon examination, the prostate was found to be con- 
siderably enlarged and urinalysis revealed chronic in- 
terstitial nephritis. I gave him a saline laxative daily, 
advised a diet of milk and cereals for a few days, and 
prescribed pills of prostatic extract, each pill containing 
ten centigrams of the substance of the prostate gland, 
one pill being given every three hours. He was re- 
lieved on the second day and catheterization became un- 
necessary. In the course of a week he had nearly re- 
turned to a state of normal senility. He continued the 
use of the prostatic extract and his condition continued 
to improve. 
I have employed the extract of prostate in several cases 
with equal benefit. It is claimed by some to relieve the 
neurasthenia which often accompanies this condition. It 
may also be used in combination with other methods of 
treatment. If necessary, we can employ a hypodermic OPOTHERAPY 
271 
preparation of prostate extract, which will act more 
rapidly. 
Extract of Bile 
This preparation is a valuable aid to digestion and to 
proper intestinal action, facilitating the absorption of 
fats and counteracting flatus and constipation. It is of 
value in mucous colitis and intestinal putrefaction. 
Some cases of acid dyspepsia have been relieved by ox 
bile; pig bile is said to contain more equally balanced 
proportions of the salts of sodium and potassium and to 
more closely resemble human bile. Some cases of biliary 
lithiasis and catarrhal jaundice have been reported im- 
proved after the use of this extract. The pills of extract 
of bile containing ten centigrams should be given from 
four to eight a day. 
Gastric Extract 
This extract is taken from the mucous membrane of 
the stomach of a pig and contains not only pepsin, 
but all of the substances of the stomach glands. It 
is indicated, according to Gilbert, in the following 
cases: 
1. Hypopepsia with hyperchlorhydria. 
2. Hypopepsia with normal chlorhydria. 
3. Hypopepsia with hypochlorhydria. 
It is of benefit in some cases of anorexia, alcoholic gas- 
tritis and the digestive disturbances accompanying tu- 
berculosis. The preparation is given in pills or cachets 
in doses of 25 to 50 centigrams, four to eight being given 
a day. 
Extract of Myocardium 
This extract is of value in some cases of senile myo- 272 
GERIATRICS 
carditis and asystole. I have used it in one case of myo- 
carditis which accompanied senile nephritis and it gave 
good results. Twenty-five centigrams of the extract are 
given in pills or cachets, four to eight being taken daily. 
It is claimed that the myocardium is rich in adrenalin, 
which might account for its action. 
Pancreatic Extract 
In some cases of pancreatitis, pancreatic extract is of 
value, as in diabetes mellitus of pancreatic origin. It 
also is useful in some gastrointestinal disorders. 
Other extracts sometimes employed are extract of 
bone medulla, brain substance, parathyroid, thymus, 
pancreatic-intestinal. 
There is an intimate association between bone marrow 
and part of bone medulla in the formation of red cor- 
puscles. In some cases of pernicious anemia and lym- 
phadenoma, the extract of bone medulla is said be of 
value. The extract of brain substance seems to be of 
no value. 
When a manufacturer places an order for a certain 
amount of fresh glands, in many instances the glands 
are left in a container a day or two until the order is 
filled. As a result some of the glands undergo decom- 
position, which is decidedly detrimental to the making of 
a good product. It is not sufficient for a manufacturer 
to give a doctor a statement of the doses and indications 
for the use of glandular extracts; we should know in de- 
tail the method of manufacture; the kind of animals 
used, their ages, etc., in order to judge whether the 
product is made under proper conditions. Most glandu- 
lar extracts have a bad odor and while it is argued that 
all animal substances have odors, yet I believe that an 
extract made under proper conditions should be odorless. 
If the glands are at all decomposed, there is an odor, 273 
OPOTHERAPY 
and the product is not tit for subcutaneous injections, 
nor is it the best to give by mouth. 
The administration of animal extracts is more ad- 
visable by mouth as the rigorous aseptic precautions, 
indispensable in dealing with the subcutaneous injections 
are not necessary. Injections are necessary in many 
cases where great rapidity of action is essential. 
In France, Gilbert, Carnot and Choay have done a 
great deal for the pharmacologic study of opotherapy. 
In one of his lectures in the clinics of the Hotel Dieu, 
Paris, Gilbert said: “About seventeen years ago, with 
Carnot, then my intern, I made use for the first time of 
hepatic opotherapy in the treatment of tuberculous 
hemoptysis, the medical opotherapic matter did not exist 
then. We had to administer the pulp of the fresh liver 
or the bouillon of liver. But soon, with the aid of Choay, 
we showed the series of forms (powder extracts) under 
which animal, as well as vegetable matter, could be used 
therapeutically. ’ ’ 
Aqueous, alcoholic, alkaline, saline, glycerinated, pep- 
sic, trypsic and papain extracts of various organs were 
prepared, as well as globulins, nucleo-albumins, etc. 
Experiments were performed with these, but Gilbert and 
Carnot preferred total extracts obtained by treating the 
organs with various solvents, preparations which only 
differ from the organs by a mere elimination of water 
and have been named total extracts. These total ex- 
tracts are used in all preparations and represent the 
pulps of the organs merely deprived of water, and the 
manipulations in manufacture are reduced to a minimum. 
The fresh glands are gathered, rid of their surrounding 
tissues, immediately scraped and rapidly desiccated in 
such a way that there are no diastatic destructions and 
no alteration of the glandular secretions. It may be 
done in air or in vacuum. Choay notes that autoclaves 
in which the pulps are spread, in thin layers, on plates, 274 
GERIATRICS 
have poor ventilation; most often the air is nonfiltered, 
carries in the germs- with which it is soiled; the tem- 
perature is ill-regulated, rises too high in some re- 
gions, and destroys diastasis, finally, the extract has a 
gelatinous aspect. The method he advocates consists 
in using an apparatus of concentration in vacuum, caus- 
ing rapid evaporation under low temperatures. 
Important factors are the kind and age of the animal, 
its nutritive condition, sometimes a young animal, the 
organs of the fetus are used, or animals on a milk diet or 
in inanition. In order that an extract should have the 
maximum of active principles, certain conditions are to 
be observed; the pancreas must be taken during the first 
hours of digestion and the liver a little later. Sometimes 
it is necessary to have the animal exercise in order to 
increase glandular activity and in some instances the 
glycogenic function of the liver can be increased by in- 
jecting glucose, it then yields better results in morbid 
glycosuria (Gilbert). Gilbert notes that the methods 
of sterilization by heat are long, and uses hydrochloric 
acid to acidify, later neutralizing it by adding sodium 
carbonate, which leaves harmless sodium chloride. 
Every care must be given to minute details if we ex- 
pect satisfactory results; hoping to build up opotherapy, 
we must use products that are prepared by pharma- 
cologists who have had long experience in this work. 
Doctors sometimes purchase extracts which perhaps 
do not have the maximum of glandular activity, or per- 
haps have been altered by heat or bacteria and therapeu- 
tic results fail to follow their use. This would tend to 
discredit opotherapy. 
Much can be done in old age through opotherapy, but 
unfortunately there is great difficulty in determining the 
functional activity of the various organs and we must de- 
pend in most cases upon clinical experience and opodiag- OPOTHERAPY 
275 
nosis. Opotherapy in geriatrics is one of our most val- 
uable weapons in combating disease conditions and pre- 
venting many senile degenerations. 
EXTRACT 
INDICATIONS 
DOSES 
Bile 
Catarrhal jaundice; gall stones; 
intestinal putrefaction; consti- 
pation 
2-grain tablets, three or 
four times a day. 
Blood 
Anemia; tuberculosis 
3 grain tablets, 4-8 a 
day. 
Brain 
Substance 
Neurasthenia; functional nervous 
diseases; senile dementia 
2 grain tablets, 4-8 a 
clay. 
Duodenal 
Substance 
intestinal indigestion; constipa- 
tion; acute and chronic en- 
teritis. 
2 grain tablets, 4-8 a 
day. 
Gastric 
Substance 
Hypochlorhydria; hyperchlorhyd- 
ria; Atonic conditions, anorexia. 
5 grain tablets, one after 
meals. 
Kidney 
Renal insufficiency; uremia; ne- 
phritis. 
2 grain tablets, 4-12 a 
clay. 
Diver 
Substance 
Cirrhosis; diabetes of hepatic 
origin; albuminuria; dermatoses; 
gout; epistaxis; hemoptysis. 
3 grain tablets, 4-8 a 
day. 
Dung 
Substance 
Abscess of lung; empyema; sup- 
purative hydatid cysts; tuber- 
culosis. 
3 gram tablets, 4-8 a 
day. 
iViammary 
Substance 
Metrorrhagia from uterine fibroids. 
3 grain tablets, 2-8 a 
day. 
Myocar- 
dium 
vsystole; myocarditis 
3 grain tablets, 2-8 a 
day. 
Orciutic 
Substance 
Impotence; neurasthenia 
2 grain tablets, 2-8 a 
day. 
Ovarian 
Circulatory troubles; nervous and 
visceral troubles following re- 
moval of ovaries or at meno- 
pause; arthritis; gout in 
women; chronic rheumatism; 
nephritis at menopause. Often 
combined with thyroid extract 
and pituitary extract for nephri- 
tis and many other conditions 
which begin at the menopause. 
2 grain tablets, 2-8 a 
day. 
Pancreatic 
extract 
Pancreatitis; cancer of pancreas; 
intestinal indigestion; diarrhea, 
gastroenteritis; diabetes associ- 
ated with hyperactivity of liver; 
tuberculosis. 
3 grains tablets, 4-8 a 
day. 276 
GERIATRICS 
EXTRACT 
INDICATIONS 
DOSES 
Parathy- 
Paralysis agitans; nephritis. 
tablets, y50-y10 gr. 2-4 
roid 
times a day. 
Pineal 
Premature decay of mental pow- 
tablets, y10 grain, 3 times 
Gland 
ers; stimulant to mental proces- 
ses. 
a day. 
Pituitary 
Diabetes insipidus; affections of 
y2 grain tablet, 3 times 
(Total Ex- 
myocardium; hypotension; con- 
a day. 
tract) 
valescence from infectious dis- 
eases; acromegaly; Basedow’s 
disease; insomnia; nephritis at 
menopause. 
In cases associated with high 
1 grain tablet 3 times a 
anterior lobe 
blood pressure, where there is 
pituitary insufficiency. 
day. 
Posterior 
Hypotension 
Yio gr. tablet 3 times a 
lobe 
Many cases require a combination 
of total extract of pituitary with 
thyroid and ovarian extracts. 
day. 
Prostate 
Prostatic hypertrophy. 
2 grain tablets, 4-8 a 
Substance 
day. 
Spleen 
Anemia; hemorrhages, tuberculo- 
2 gr. tablets 3 times a 
Substance 
sis 
day. 
Supra- 
Suprarenal insufficiency; Addi- 
3 grain tablets, 2-4 a 
Renal 
son’s disease; cardiovascular 
day. 
asthenia; postoperative acci- 
Subcutaneous injec- 
dents; asthma 
tions, also. 
Thyroid 
Hypertension; myxedema; obes- 
ity; gout; rheumatism; asthma; 
\{q-2 grains, 2-6 a day. 
migraine; constipation; ano- 
rexia; dermatoses; pruritus; ec- 
zema; psychoses; retarded union 
of fractures; Metrorrhagia. 
Combined with pituitary, ova- 
rian, and renal extract in cases 
of nephritis, associated with 
hypertension, which develops 
at menopause. CHAPTER XXXIII 
ELECTROTHERAPY IN THE AGED 
The high frequency current derives its name from its 
extremely rapid oscillations (about one million per min- 
ute) and can be applied to the patient without any dis- 
comfort. The oscillations are produced by a Leyden jar 
or some other condenser which causes a series of sparks 
to pass between the terminals of the spark gap. The 
Leyden jar was discovered by Musschenbrock in 1775. 
Through the outer coatings of the jars the current 
passes to an Oudin resonator or Tesla coil which causes 
an increase in voltage from hundreds of thousands to 
millions. It is possible to pass the current from the 
Oudin resonator or Tesla coil to the patient. Local or 
general treatments can be given, modern apparatus en- 
abling us to give many different kinds of treatments. 
For practical purposes, general treatments are used in 
the form of autoconduction or autocondensation, and 
locally, vacuum electrodes are used over the surface of 
the affected parts, or diathermia, using flexible tin over 
the affected parts, each piece being attached to a pole of 
the d’Arsonval current. 
Autocondensation is very effective in many diseases of 
old age and as no sensation except warmth is felt, it is 
an agreeable form of treatment. The electric chair is 
connected to one pole of the d’Arsonval current while the 
other is attached to a handle which the patient holds; a 
couch or cushion can also be used and is perhaps more 
convenient than the chair as it enables one to give more 
milliamperes, the treatment usually lasts half anjiour, 
repeated every other day and in some cases twice a 
277 278 
GERIATRICS 
week, giving as much electricity as the patient can take 
without having an aching sensation in the wrists; some- 
times, wrapping lead foil around each arm above the 
Fig. 18. Autocondensation treatment. 
elbow, makes it possible to give more milliamperes with- 
out distressing the patient. We can by this treatment 
produce profuse perspiration, which has a beneficial ef- 
fect ; it is difficult to produce perspiration in old patients, 
yet those who have not perspired for several years will ELECTROTHERAPY IN THE AGED 
279 
probably have a moist shin after a half-liour’s treatment 
by autocondensation. The couch or cushion makes it 
possible to give a patient 1500 milliamperes, one pole 
being connected to the cushion and the other attached 
to a handle which the patient holds with both hands. 
Autocondensation is one of the best methods of lower- 
ing blood pressure. I have seen it cause the pressure, 
both systolic and diastolic, fall ten points after one treat- 
ment. I have been treating a woman of seventy-six by 
autocondensation for three years; when she first con- 
sulted me, the systolic pressure was 220, but, after sev- 
eral treatments, it became lower and now is 135. Since 
the pressure has been lowered her general health has 
greatly improved. I have several old patients who take 
these treatments regularly and in most every instance 
it has lowered blood pressure; with this diminution of 
pressure, there is improvement in the general health and 
through increased perspiration, toxins are freely elimin- 
ated, and the waste products in the urine are increased. 
It lias a beneficial action on the nervous system, many 
patients claim that they rest better after a treatment. It 
is said that autocondensation will lower blood pressure 
about ten points in ten minutes, and, although the pres- 
sure may not remain low, it has a more permanent effect 
than any other treatment. The following cases illustrate 
the use of autocondensation: 
Case I.—A woman, aged sixty, weight 120, had inter- 
stitial nephritis and suffered from severe headaches, 
pressure in the back of the neck and many nervous 
symptoms. Her blood pressure was 190 systolic and 100 
diastolic. I gave her a half-hour’s treatment in the 
electric chair, applying 750 milliamperes, and repeated 
this treatment each day for two months. Each treat- 
ment produced free perspiration and in a few days the 
symptoms due to nephritis disappeared; blood pressure 
fell to 150 systolic and 70 diastolic and remained at this 280 
GERIATRICS 
point for several months after the treatments were dis- 
continued. 
Case II.—A woman, aged fifty-eight, weight 200, had 
diabetes mellitus. She was suffering from asthenia and 
had rheumatism in the left knee and left arm, which 
caused great discomfort. After a few treatments by 
autocondensation, giving about 800 milliamperes for one- 
half hour and then applying a surface electrode over the 
knee and arm, her condition was greatly improved and 
she felt able to travel. 
Case III.—A man, aged seventy-six, weight 180, had 
glomerulonephritis, suffered from headaches, dizziness 
and rheumatism. Urinalysis showed no albumin, but 
many hyaline and granular casts; his systolic blood pres- 
sure was 220 and diastolic 140. A few treatments by the 
autocondensation couch, using about 800 milliamperes 
for one-half hour, caused the pressure to fall to 180 sys- 
tolic and 100 diastolic, and in the meantime his general 
health improved. After the treatment his body was 
covered with perspiration and he informed me that it 
was the first time he had perspired in many years. The 
pressure continued at the last mark for several weeks 
after treatments were discontinued and he maintained 
it at the same point by taking six treatments every three 
months. 
Case IV.—A woman, aged seventy-five, who had senile 
nephritis, was suffering from nervousness and many in- 
definite pains in the extremities. Her systolic blood pres- 
sure was 210 and diastolic 140; she has taken the treat- 
ment three times a week for a long time, 500 milliamperes 
being given by autocondensation. Under this treatment 
her systolic blood pressure has fallen to 140 and dias- 
tolic to 75. 
In nearly every case, general health has improved and 
blood pressure has been lowered. In comparing twenty- ELECTROTHERAPY IX THE AGED 
281 
five patients whose blood pressure I have taken, I note 
that ten who have been under treatment have a much 
lower pressure and are in much better general condition 
than the fifteen who have not taken the treatment. 
Many cases of senile nephritis in which the physician has 
used every medication without avail, the kidneys and in- 
testines having been overworked for a long time, will 
possibly be improved by autocondensation, since it will 
eliminate toxins through the skin, thereby relieving the 
internal organs. Autocondensation causes a relaxation 
and dilatation of the capillaries, this in turn causing in- 
creased circulation, increased oxidation, increased 
elimination, increased general metabolism, and improv- 
ing nutrition. 
The apparatus used for autocondensation may be of 
low amperage and high voltage, or high amperage and 
low voltage. In the former, it is necessary to have a pad 
three or four inches thick and 300 to 400 milliamperes 
are sufficient. In the other type of apparatus, with high 
amperage, it is possible to have a thin cushion and from 
500-1500 milliamperes should be used. When beginning 
the treatment, it is well to start with 1000 milliamperes, 
which causes a sensation of warmth to go over the body; 
in a few moments the wrists begin to ache and it is well 
to reduce the number of milliamperes to 500 or 600. By 
wrapping lead foil above the elbows on each arm, we may 
eliminate this aching at the wrists. When the patient is 
seated in a chair, it is well to place a pillow in his lap for 
the metallic handle to rest on, as it might cause a dis- 
agreeable sparking on the skin; moreover, the patient 
should be warned not to remove the hands from the 
handle as they might spark. A glass of cold water taken 
during the treatment will assist in starting perspiration 
and a cold cloth on the forehead will give comfort. It 
is not necessary to remove the clothing and there is no 
danger of a patient’s “catching cold” on leaving the of- 282 
GERIATRICS 
fice while perspiring, even in the winter months. In 
summer, when it is very hot, I sometimes have an electric 
fan near the patient, which reduces his discomfort. Af- 
ter the treatment, temperature by month may be in- 
creased one degree. A treatment should be given for a 
half hour or even one hour, three times a week; at first, 
it is well to give one every day for a week or two. I 
have treated a patient whose blood pressure was 90 sys- 
tolic by giving 250 milliamperes; this improved general 
health, relieved nervousness and insomnia and yet did 
not have any effect on blood pressure; in these cases, 
where autocondensation is given in order to improve nu- 
trition, and where it is not advisable to lower blood pres- 
sure, the desired effect can be obtained by giving a low 
milliamperage. With the hot wire meter it is possible 
to regulate the dosage of electricity so that each time a 
patient comes for a treatment it is only necessary to give 
the same amount of current as indicated on the milliam- 
peremeter. 
Some cases in which both general treatment and local 
application are desired, as in a case of neuritis, associ- 
ated with high blood pressure, it is well to give a general 
treatment for a half hour and then apply a surface elec- 
trode from the Oudin resonator for ten minutes. In 
other cases, vibration on the affected parts will work 
well, but I have not seen many cases which were relieved 
by the latter method. 
In paralysis following apoplexy or due to uremia, in 
which the patient improves sufficiently to walk around, 
but retains a partial paralysis of an extremity, autocon- 
densation combined with local applications will often 
improve the general condition and sometimes cure par- 
alysis. 
For long treatments it is necessary to have an appa- 
ratus in which the spark gap is cooled; some manufactur- 
ers have placed an electric fan under the De Kraft gap; ELECTROTHERAPY IN THE AGED 
283 
another ingenious method is to attach a pump to the gap 
which forces the air through constantly during the treat- 
ment. This pump also works as a spraying apparatus 
and vibrator, thus serving different purposes. 
Much depends upon the temperature of the surround- 
ing air and the increase in perspiration varies in indi- 
viduals; again, it is not always the same with the same 
person under different circumstances. On a warm day, 
it is, of course, easier to induce perspiration, some days 
a patient will perspire freely and on other days, with the 
same milliamperage, there will be no moisture on the 
skin. The blood is caused to rush to the surface of the 
body and as a result venous congestion of the internal 
organs is relieved, the intestines, liver and other organs 
receiving a new supply of blood. Once or twice I have 
observed that a patient felt faint while taking the treat- 
ment, but this faintness was quickly relieved by bending 
the body forward, compressing the abdominal organs. 
Possibly it was caused by a circulatory disturbance due 
to the treatment, but I am inclined to think that the pa- 
tient was not feeling well before taking it. 
As the internal organs receive a new blood supply, they 
functionate better; congestion of the liver is relieved, 
which is very important. The removal of stagnant 
blood from the internal organs causes a great deal of 
waste matter to be eliminated through the skin, which 
relieves the kidneys of the extra work. It is necessary 
to watch the action of the skin as failure to perspire 
might cause harm. 
Autocondensation is advantageous in cases of neph- 
ritis, associated with high blood pressure, rheumatism 
and gouty conditions. It is important to give attention 
to the general health; frequent urinalysis should be 
made; attention directed to the intestines, and the diet 
should be carefully regulated. It is well to give laxa- 
tives and tonics. A good combination, for patients who 284 
GERIATRICS 
are weak and anemic, is hypodermic injections of iron 
and arsenic after each treatment. 
Autocondensation is useful in some cases of persistent 
headache. In some cases of senile asthma and emphy- 
sema it will have a beneficial action, especially if the 
heart is overworked. 
When the chair is connected with the apparatus, the 
patient is seated on a thin dielectric, one pole of the 
d’Arsonval is connected to the chair and the other pole 
connected by a bifurcated split connector to the foot- 
piece and metallic handle, which the patient holds with 
both hands. If a cushion is used, one pole of the d’Ar- 
sonval is connected to the cushion and the other to the 
handle, which the patient holds. 
The local application of the high frequency current is 
a valuable form of treatment in many diseases of old 
age. There are many ways of employing it; perhaps the 
most commonly used is that of the vacuum electrode 
connected to the Oudin or Tesla currents. The tube is 
in direct contact with the skin or can be used through 
the clothing; in the latter instance, there is additional 
sparking since the clothing breaks the contact with the 
skin, which causes counter-irritation of the parts treated. 
There are vacuum electrodes for the various parts, as 
rectal, prostatic, urethral, throat, nose and ear, tongue 
and comb electrode for the head. The latter is used for 
occipital neuralgia and is often effective. When using 
vacuum electrodes for the vagina, rectum and urethra 
it is necessary to lubricate the electrode with lubricating 
jellies. Since it becomes hot in a short time there is dan- 
ger of removing a piece of mucous membrane, therefore, 
the treatment should not last over six or seven minutes. 
Longer treatments are sometimes more effective and I 
then connect the metallic handle with the Oudin resona- 
tor, allowing the current to go into the body through the 
hands and with a vaginal, urethral or rectal electrode in ELECTROTHERAPY IN THE AGED 
285 
the hand, make application to the part to be treated; in 
this way I apply the high frequency current for 15Amin- 
utes or longer without any heating of the electrode. 
No handle is used on the electrode for this application 
as the physician’s hand on the electrode is all that is 
necessary to produce an effluve. It is dangerous to use 
an urethral glass electrode as cases have been known 
where the electrode broke in the urethra because of an 
erection during the treatment. Unbreakable vacuum 
electrodes are now made, however. 
When a large area is to be treated this can be done by 
the method described above, the patient holding a handle 
and the physician attracting a spark from the body by 
means of a vacuum electrode held in his hand. In cases 
of neuritis this form of treatment is often effective. 
Surface treatments are of benefit in cases of neuritis 
and neuralgia, lumbago, sciatica, skin diseases, head- 
aches, insomnia, neurasthenia and many of the paralyses 
of old age. A man of 75 had apoplexy and as a 
result, paralysis of the muscles of deglutition; there was 
no other paralysis and it seemed that if he could swallow 
he would have completely recovered from the attack. I 
treated him each day at the bed-side, with a portable 
high frequency apparatus, applying a surface electrode 
over the throat and in a few days he was able to take 
nourishment. Possibly in this case Nature would have 
cured him, but I have seen several cases of paralysis in 
old age following apoplexy or uremia in which I am cer- 
tain the high frequency current was of great benefit. A 
small portable coil can be taken to the bedside and at- 
tached to any electric light socket. The effluve is applied 
over the affected parts for ten or fifteen minutes daily 
or every other day; it is well not to use a strong appli- 
cation as it may overstimulate the muscles. In cases of 
neurasthenia the effluve is applied to the spine for fifteen 
minutes. 286 
GERIATRICS 
Senile Debility 
One of the most common conditions we are upon 
to treat is senile debility. This condition is rather 
vague; there are cases in which no organic disease can 
be found in the background, but there is a general de- 
generation of all the organs. Most often, however, it is 
due to some organic affection like nephritis or diabetes 
and treatment must be directed to the underlying cause. 
Many of these cases improve under general and local 
treatment and if the blood pressure is high, autoconden- 
sation (500-1000 milliamperes) for one-half hour three 
times a week, supplemented by effluve over the spine for 
ten minutes, should lie used. If blood pressure is nor- 
mal, from 200-300 milliamperes should be used with auto- 
condensation. This treatment improves nutrition. 
Sometimes general vibration, with a regulated apparatus 
which gives gentle vibration, will be of benefit, and 
should be given for five or ten minutes all over the body. 
Neuritis 
Neuritis often resists all forms of treatment and a 
guarded prognosis should be given. If the case has been 
of long standing, treatment must be continued a long 
time. Effluve should be used for 10 or 15 minutes, three 
times a week, and attention should be given to the gen- 
eral health. I have seen some patients relieved after 
six treatments, while others are only cured after nine 
or ten months of treatment. Oftentimes, improvement 
will come after treatment is discontinued and I usually 
inform patients that they may get the results of treat- 
ment several weeks after the applications have been 
stopped. A man, aged sixty-five, had neuritis of the left 
arm; I could not discover any disease in the background. 
I applied effluve on the arm for fifteen minutes three ELECTROTHERAPY IN THE AGED 
287 
times a week seventeen times without results. I told 
him to rest from the treatments for a short time, and a 
week after he had ceased to take them, the neuritis began 
to improve; he had not required further treatment. 
This was five years ago and he is now in perfect health, 
never had a recurrence of the attack. There are many 
cases of this kind in which results followed several weeks 
after treatment; sometimes electricity seems to have a 
tardy action like that of radium, whose work may be 
conspicuous several weeks after its application. 
A woman, aged sixty, had neuritis in both arms for two 
years; she suffered a great deal, was not able to dress 
herself since she could not get her hands back or to 
her head. She had massage, vibration and many other 
treatments without benefit; I advised effluve three times 
a week, but warned her that she might not derive any 
benefit from it. She continued the treatments for seven 
months; at times she was better; at times she suffered 
intensely. A month after she stopped treatment, 
the condition improved and she has continued to 
gain. 
The current should be strong and applied directly to 
the skin. In many cases diathermia is of great benefit; 
electrodes two inches square, on the opposite sides of the 
affected parts, should be moved along the course of the 
nerve. From 500 to 1000 milliamperes should be used 
for one-half hour, three times a week. Diathermia is 
the most penetrating application of the high frequency 
current. 
In some cases, the vacuum electrode introduced in the 
rectum will cure hemorrhoids. Fissure-in-ano will some- 
times be cured by surface treatment and besides the rec- 
tal electrode, stretching the sphincter ani, will have a 
beneficial action. Eczema can sometimes be checked and 
I have seen two cases of seborrhea capitis which were 
greatly benefited by these treatments. 288 
GERIATRICS 
Men past fifty frequently complain of loss of sexual 
power and the usual aphrodisiacs yield no permanent 
results. I have treated several of these cases by ap- 
plying an effluve over the lower part of the spine and 
over the genital organs, also through the rectum, and 
have seen decided improvements in some cases. An- 
other method is to use diathermia, one electrode over 
the lower lumbar vertebrae and the other over the 
pubis, applying from 500-1000 milliamperes for one 
hour. 
Diathermia (Gk dia,—through, therme,—heat) is one 
of the best methods of local treatment. It is produced 
by the d’Arsonval current which is bipolar. When a 
part is to be treated, as for example the knee, a piece of 
flexible tin is placed on one side, another on the opposite 
side and each one is connected by means of a spring clip 
connector. The current varies from 100 to 1500 milli- 
amperes and it is practically an application of electri 
cally generated heat. The temperature of the tissues is 
increased and an entire new blood supply is brought to 
the part-. It is possible to bring about coagulation and 
produce a slough by applying a strong current. Diather- 
mia is the most penetrating of electric treatments and 
enables us to treat deep tissues. When the electrodes 
are applied to the chest, one in front and one in back, 
and increased blood supply is rushed to a part of the 
lung, the internal temperature of the part is increased 
and as the tubercle bacilli do not thrive in parts rich in 
blood, the treatment is effective in many cases of pul- 
monary tuberculosis. This also applies to tuberculosis 
of the bones, it is possible to bring new blood to the 
bones affected. This method of treatment makes it easy 
to treat any part of the body, the application can be 
made so that the same amount of heat penetrates all the 
tissues, or heat can be concentrated on one electrode; by 
means of a hot wire milliamperemeter it is possible to ELECTROTHERAPY IN THE AGED 
289 
regulate the current and it is more convenient to use 
high frequency currents in this form. 
If the electrodes are of the same size on each side of 
Fig. 19. Diathermia treatment of shoulder, showing one metal disc 
on front and one on back. 
the part to be treated, the current is uniform and there 
is the same amount of heat in front as in back. If the 
electrode is smaller on one side, there is more heat on the 
smaller electrode as concentration is greater, therefore, 290 
GERIATRICS 
ill treating bones and other parts where concentration 
is desired in a certain area, the smaller of the two elec- 
trodes is placed on the affected part. Ordinary flexible 
tin can be used and there are metallic plates made for 
this purpose. It is well to use salt solution on the elec- 
trode as it gives better contact; in treating joints and 
other irregular surfaces, a more satisfactory contact is 
obtained by using flexible material, when a large flat 
area like the chest or abdomen is to be treated the metal- 
lic electrodes will answer. If the contact on the skin is 
not perfect, a spark comes between the metal and the 
skin which is not only disagreeable to the patient, but 
is apt to blister the skin. It is possible, by means of 
adhesive plaster to obtain a good contact on the skin and 
a gauze bandage will serve to hold the electrodes next to 
it. Carefully bandaging the electrodes, 1 have not been 
obliged to use salt solution; the patient lies upon a table 
without discomfort during the treatment. 
The average treatment should be given for thirty or 
forty minutes, never less than this, every day or every 
other day at first, later coming down to once or twice a 
week. The average patient will take about 700 milli- 
amperes, although some will stand 1000 or more without 
discomfort. I usually give the treatment to the point of 
discomfort. When the patients say it is too hot. I reduce 
the current to the number of milliamperes that does not 
cause discomfort and continue this dosage throughout 
the treatment. When the electrodes are removed the 
skin underneath is very red and moist. 
In the chapter “Prostatic Hypertrophy,” I have 
spoken of the use of diathermia. I find that some cases 
of prostatic hypertrophy are relieved by this treatment 
when properly given and if continued over a long period 
of time. Sometimes an electrode 3x4 inches over the 
twelfth dorsal spine and one 4x6 inches in front over the 
pubis, employing from 500 to 1000 milliamperes, will ELECTROTHERAPY IX THE AGED 
291 
sometimes relieve a case of simple hypertrophy. It 
is well, however, to remember that many cases of pros- 
tatic hypertrophy are malignant. 
Tic douloureux, which is so troublesome and difficult 
to treat, will often yield to diathermia. A piece of flex- 
ible tin 2x2 inches is used on the affected side and one 
Fig. 20. Campbell Model “E” Portable high-frequency apparatus 
Fig. 21. Campbell Glass vacuum high-frequency electrodes, including 
surface, nasal, urethral, throat, plain vacuum, vaginal and rectal electrodes. 292 
GERIATRICS 
3x4 inches on the opposite side, applying from 500-900 
milliamperes for one-half hour, repeating the treatment 
every other day. In conjunction with this, iron should 
be administered internally in the form of elixir of iron, 
quinine and strychnine phosphates, or hypodermic in- 
jections of iron, arsenic and strychnine may be used 
with benefit. Effluve with a mild current will often help 
these cases after resection or the injection of alcohol has 
failed. Sometimes it will be necessary to continue 
the treatments for a long period of time and when the 
patient has taken a few treatments it is safe to increase 
the dose to 1000 or more milliamperes. It is well to 
have the patient on a table during the treatment and a 
bandage applied on the face will hold the flexible tin in 
contact with the skin. The pain is usually relieved after 
a few treatments and many times the result is a per- 
manent cure. 
Lumbago and symptoms commonly said to be due to 
sacroiliac relaxation will often be cured by diathermia. 
A piece of flexible tin about 3x6 inches is placed on the 
back over the affected area and one 4x7 inches is used 
on the abdomen; adhesive straps hold the tin plates on 
the skin and then a bandage is applied around the waist. 
From 500-1200 milliamperes are given and should be 
used for one-half hour, repeating every other day until 
a cure is effected. Effluve sparks may also be used after 
the treatment with diathermia. Vibration will work well 
in some cases, considerable pressure being exerted over 
the painful parts. 
Senile arthritis will often be relieved by high frequency 
currents and if several joints are involved, autoconden- 
sation, 500-900 milliamperes, should be used, after which 
a surface electrode can be applied for eight or ten min- 
utes. If a single joint is involved, diathermia should be 
resorted to; pieces of flexible tin applied on each side of 
the joint, and made to conform to the shape of the joint. ELECTROTHERAPY IN THE AGED 
293 
Bier’s hyperemia will relieve some cases and heat and 
vibration can be used simultaneously. 
The Morse Wave Generator is another form of treat- 
ment that yields satisfactory results. This apparatus 
gives both a direct and alternating current and is em- 
ployed for neuritis, lumbago, migraine, prostatic en- 
largement, rheumatism and constipation. 
Senile artlirosclerosis, which is a hardening of the 
joints, with stiffening as a consequence, is difficult to 
treat in old age. Diathermia offers one of our best 
means of treatment and the methods described above 
for senile arthritis have given good results. 
Fractures in old age are often followed by a stiffening 
of the joint and pain upon motion. When possible, I 
begin early treatment with diathermia in order to pre- 
vent this. Effluve and vibration will also benefit these 
conditions. 
Some cases of dyspepsia, gastritis and colitis will be 
benefited by diathermia, one electrode being used over 
the affected part and the other on the back. It is well 
to place these patients on a table as the concentration of 
blood in the abdomen may cause them to feel faint. 
I have treated some cases of catarrhal deafness with 
the high frequency current and have seen good results. 
Effluve is used in the ear, a mild current applied for 
eight or ten minutes. In some cases of tinnitus aurium 
this treatment will be of value. 
Dr. A. C. Geyser of New York and others have ob- 
tained excellent results in treating pulmonary tuber- 
culosis by means of diathermia. Geyser has also had 
good results in some malignant growths, healed by dia- 
thermia (Med. Council, April, 1917). He uses for can- 
cer of the breast, a round piece of flexible tin of about 
three inches in diameter, and moistens the electrode 
with soap lather to bring close contact with the skin; 
on the opposite shoulder blade he places another piece 294 
GERIATRICS 
of flexible tin at least four times the size of the one in 
front. About 100 milliamperes for each square inch 
of the smaller electrode is used. 
Some cases of angina pectoris are relieved by diather- 
mia, a piece of flexible tin being applied in front and a 
larger one in back, giving the usual treatment of one- 
half hour as mentioned before. 
The selection of the apparatus is of great importance 
as small machines do not give satisfactory results. 
The larger pieces of apparatus which have a multiple 
series spark gap, cooled by an electric fan or a pump, 
will permit a uniform application of the current for a 
long period of time. At present I am using Wappler’s 
Telatherm, which is cooled by an electric fan under the 
De Kraft spark gap, and the Thompson-Plaster Model 
F cabinet also proves very satisfactory. This has a 
pump which is attached to the spark gap and the cool air 
passing through the gap keeps it fairly cool and clean. 
There are many combined treatments that can be given 
on this apparatus. 
Electrotherapy is developing into an excellent addi- 
tion to our therapeutics. In the Hotel Dieu, Paris, the 
professor of clinical medicine has charge of the radio- 
graphic and electrotlierapeutic departments, and, in this 
way he uses the electric treatments in conjunction with 
his clinical work. CHAPTER XXXIV 
ALCOHOL AS A REMEDY 
Many old men and women have been accustomed to 
take a certain amount of alcohol in some form each day. 
For twenty years, perhaps, a pint of whiskey has been 
as much a part of their daily life as their bread and 
butter. 
It used to be considered natural and legitimate for 
an old man, when the declining point came, to take a 
stimulant each clay; alcohol was frequently prescribed 
by the old doctors for gastric disorders and in convales- 
cence from exhausting disease. If his patients were 
ill, a doctor would insist that they should take the usual 
amount of stimulant, perhaps increasing the dose, yet 
it certainly was unusual to see an old man intoxicated. 
In therapeutics there always have been reactions, and 
these reactions in the use of certain remedies come and 
go. The great French masters, Franck, Laennec, 
Chomel and Trousseau, found alcohol a remedy of im- 
portance and indispensable in certain conditions. I 
know of no observations more reliable than those of the 
late Dr. Abraham Jacobi. He was one of our few thera- 
peutic optimists and one of the first clinicians to advo- 
cate alcohol in its full effect in certain conditions. 
Whiskey, brandy or wine will usually improve diges- 
tion if taken a short time before eating. Old people who 
do not take much exercise often suffer from weak diges- 
tion, and alcohol will improve it. In convalescence from 
acute disease, when recovery is slow, alcohol is often 
useful. Sometimes in acute illness there will be ex- 
295 296 
GERIATRICS 
treme prostration; the cause may be senile bronchitis, 
nephritis, diabetes, or yon may not be able to discover 
it. One fact stands out, the patient is steadily growing 
weaker, and strychnine or other stimulants may be of 
no use. In these cases we should employ alcohol to its 
full physiologic effect, and by this I do not refer to small 
doses. The full effect is observed when a red spot 
comes on each cheek, and then we should give enough to 
keep the patient in this condition until the disease begins 
to abate. Give a tablespoonful of whiskey or brandy 
every half hour to its full physiologic effect, repeating 
every hour if necessary to keep the flushed spots on 
the cheeks. 
Although alcohol may increase congestion in senile 
pneumonia, if the patient is prostrated, I give alcohol to 
its full effect. Often an old man will be in a dying state, 
gasping for breath, and the family calls upon you to 
make the last few hours comfortable. In these cases 
alcohol in its full effect will relieve the extreme suffer- 
ing. This may apply to the last stages of kidney dis- 
ease, heart disease or tuberculosis. I have used brandy 
in the last stages of pulmonary tuberculosis in young 
persons who were facing a horrible death, gasping for 
breath in the last few hours of the disease and yet con- 
scious of everything. 
In some cases of diphtheria where there is great pros- 
tration and dyspnea, alcohol has an excellent effect, in 
addition to antitoxin. In its full physiologic effect it 
may check dyspnea and may be a life-saving measure. 
If profound toxemia is present and the patient is stead- 
ily getting wlorse, in spite of large doses of antitoxin, I 
believe that alcohol in its full effect may save him; it of- 
ten seems to tide him over the critical stage of the dis- 
ease. It is said that when antitoxin fails we may rest as- 
sured there is nothing further we can do; we must not 
overlook the value of alcohol in these cases. 297 
ALCOHOL AS A REMEDY 
I recollect a man, aged seventy, who had bronchopneu- 
monia, with extreme prostration; his temperature was 
subnormal. I gave brandy to its full physiologic effect, 
until a red spot appeared on each cheek, and gave a suf- 
ficient amount to keep him in this condition until the 
disease began to abate. Some days he took a pint of 
brandy. This can be done in many cases of senile pneu- 
monia, where there is great prostration, and in many 
cases of senile diabetes with impending coma. 
In order to obtain the full physiologic effect the doses 
used are most often large—a quart a day in some cases— 
in advanced life. Physicians ordinarily use alcohol in 
too small doses. Small doses may be harmful, and it 
is surprising how large a quantity a patient prostrated 
by fever or in convalescence from an exhausting disease 
will take. However, there is always danger of exciting 
a catarrhal condition of the stomach if too much is used; 
it may cause gastritis or vomiting of food which would 
seriously interfere with convalescence. Alcohol cannot 
be used indiscriminately, but must be carefully meas- 
ured, and it is well to give it with food. A safe proce- 
dure is to lessen the dose when the flushed spots appear 
on the face, as some individuals may not require large 
doses. 
In connection with the use of alcohol as a remedy, the 
question of forming a habit is often mentioned. After 
having taken alcohol regularly for several days one 
might think the patient would want to continue it. I 
have observed, however, that this is not so; I have seen 
many cases where, the moment the disease improved, 
alcohol was discontinued suddenly and the patient did 
not ask for it, nor require it. Alcohol taken for relief in 
an acute disease ivill not form a habit. Nevertheless, 
to continue its use after the patient begins to improve, 
to check some symptom, such as nervousness, would not 
be safe. 298 
GERIATRICS 
In senile debility, especially without organic disease, 
alcohol in some form is of benefit. However, many 
cases of senile debility depend upon diseased kidneys, 
and if there is nephritis, alcohol may be detrimental. 
When a man has been in the habit of drinking a little 
each day, and has nephritis, it is advisable to let him 
use alcohol in the form of red wines, as they are less 
irritating to the kidneys. 
Ale and beer, as wTell as wines, are sometimes good for 
senile patients. A glass at luncheon and one or two at 
dinner will often facilitate digestion; sherry and port 
give tone to a weak stomach. In cases of chronic ne- 
phritis Bordeaux or red wine is well borne, besides act- 
ing as an excellent tonic. 
Many old persons suffer from indefinite symptoms 
which do not point to any particular disease. There 
may be sleeplessness, nervousness, numbness in the legs 
and arms, loss of appetite, indigestion, weakness, melan- 
cholia and indefinite pains at night. This is particu- 
larly observed in town dwellers who lead a sedentary 
life, spending most of their time indoors. In these 
cases wines or whiskey, taken in small doses with food, 
will suppress many of these disagreeable symptoms. 
Physiology has been a failing guide as to the exact 
value of alcohol as a food; there are so many conflicting 
statements the physician has to form his own conclu- 
sions, according to his personal experience. 
Some aged individuals are harmed by the use of alco- 
holic stimulants. In other cases alcohol may be used 
for a few' days with advantage and then be contraindi- 
cated. It is well to watch the tongue carefully, if it gets 
dry and parched, alcohol is usually doing harm and 
should be discontinued. 
The following rules in administering alcohol as a rem- 
edy in fevers were made by Dr. Armstrong, and may be 
of value to the clinician: ALCOHOL AS A REMEDY 
299 
1. If the tongue becomes drier and baked, alcoholic 
stimulants are generally doing harm; if it becomes 
moister, they are doing good. 
2. If the pulse becomes quicker, they are doing harm; 
if it becomes slower, they are doing good. 
3. If the skin becomes hot and parched, they are 
doing harm; if it becomes comfortably moist, they are 
doing good. 
4. If the breathing becomes more hurried, they are 
doing harm; if it becomes more and more tranquil, they 
are doing good. 
Ringer states that alcohol is useful when it produces 
sleep and quells delirium. 
The aged often have formed unsatisfactory habits, yet 
to change them is not advisable. When an old man is 
ill,, no matter the cause of his illness, he should take the 
amount of alcohol he has been in the habit of taking each 
day. It may even be necessary to increase the dose in 
order to get the full physiological action. It may be 
disastrous to change an old man’s mode of living. 
There are many old persons who are suffering for want 
of alcohol in some form. In order to relieve them it 
will be necessary to resort to narcotics; there is a close 
relation between the two. Alcohol is less harmful, as 
it does not check secretions and excretions. CHAPTER XXXV 
INFLUENZA IN THE AGED 1 
Hippocrates described the phenomena accompanying 
an epidemic cough, or influenza which took place in Perin- 
thus, and was complicated with pulmonic affections, an- 
gina, paralysis, etc. He observed that any member who 
was exposed to fatigue was most liable to be attacked and 
noted that women were less likely to be affected than 
men since they were less exposed to the air. In women, 
he found the attacks were mild, but when a febrile rigor 
supervened, the attack speedily became fatal. 
The lowered resistence of the senile organism caused 
by heart disease, emphysema, weakened condition of the 
gastrointestinal tract and nephritis, predisposes to in- 
fluenza. It is frequently the disease which ends the 
life of a chronic sufferer from cancer, Bright’s disease or 
other maladies. 
Influenza is often fatal in old age. An arteriosclero- 
tic patient, or one suffering from emphysema, bronchitis, 
nephritis or diabetes does not bear this infection well 
because the vital spark is already weakened. The com- 
plications are fully as important as the disease itself. 
The various epidemics we have witnessed were in all 
probability due to a mixed infection, although the 
streptococcus pyogenes, pneumococcus, pneumobacillus 
and staphylococcus are secondary agents to Pfeiffer’s 
bacillus. It is not always easy to cultivate the latter, 
and it may lead to a mistake in diagnosis; it is cultivated 
with difficulty on ordinary media, much more easily if 
1 N. Y. Medical Journal, May 1, 1920. 
300 INFLUENZA IN THE AGED 
301 
placed oil blood-agar, with stabs of the staphylococcus 
aureus with it at intervals. 
Around each colony of staphylococci the Pfeiffer’s 
bacilli will be twenty times as large as those of the pure 
control culture (Dieulafoy). This cultural satellism 
(Meunier) is obtained in twenty-four hours and is a 
valuable assistance in finding Pfeiffer’s bacillus. 
An old person who is debilitated as the result of some 
chronic disease will suffer from an aggravation of his 
condition while fighting the infection itself. A man 
with interstitial nephritis may have hyperacute nephri- 
tis, which will give nearly every symptom of pneumonia 
and lead to a mistaken diagnosis. Again, influenza will 
often cause nephritis as a complication and it will be the 
beginning of a long illness. Convalescence in the aged 
is slow, even without any complication. 
Influenza in the aged begins as in maturity; it is 
ushered in with coryza, conjunctivitis and sore throat. 
The preliminary symptoms are headache and general 
aching all over the body, the temperature is subfebrile, 
the aged do not usually have a febrile temperature in 
any illness; the pulse may or may not show changes. 
The temperature and pulse are uncertain and the only 
safe rule in diagnosis is the counting of the heart beat 
with a’ stethoscope since the radial arteries are usually 
sclerosed. The pulse may be irregular and rapid. 
Respiration must be counted as it gives one of the most 
valuable signs of the progress of the disease. Failure 
to count respiration in aged individuals is a serious mis- 
take. There is great prostration at the beginning of 
the disease and the aged person may develop pneumonia 
without showing many local signs. Senile pneumonia is 
different from that seen in adults and examination of 
the chest may not enable the physician to make a correct 
diagnosis. Respiration is increased; there may be 
dyspnea and cyanosis, sometimes a low, muttering de- 302 
GERIATRICS 
lirium and often the patient will hit his chest with his 
hands, seeking relief from his distress. There may be 
little or no cough and the characteristic picture of the 
sputum as seen with pneumonia in adults is lacking. 
The physical signs in the chest are in complete disaccord 
with the gravity of the condition; the temperature runs 
a subnormal course, the pulse-rate may be normal and 
the expectoration the same as that which usually accom- 
panies bronchitis. 
The patient may be apparently progressing well and 
a favorable prognosis given. Sometime ago I saw an 
old man who had influenza and seemed to be progressing 
satisfactorily; I visited him at noon, and at five o’clock 
had a telephone message that he had hemoptysis. His 
breathing was distressed and a few hours later he died 
from pneumonia. It is indeed difficult to make a diag- 
nosis in cases of senile pneumonia and we should de- 
pend upon the respiration chart as our greatest aid, res- 
piration will show considerable increase before the pulse 
gives signs of gravity. 
Some cases end in gangrene of the lungs, but they are 
rare. Pleurisy is usually present, but in the aged it is 
not necessarily accompanied by pain as sensibility is 
greatly reduced. As aged patients often have arterio- 
sclerosis, there is usually a cardiac disturbance and in- 
fluenza accentuates the symptoms due to it; cardiac 
action rapidly becomes affected and the patient may die 
suddenly from asystole which is the outcome of dilata- 
tion ; this causes us to give a cautious prognosis in every 
case of influenza in the aged. 
As the stomach is debilitated the gastrointestinal 
form may be seen either alone or in combination with 
other types. There may be vomiting, diarrhea, cramps 
in the abdomen, gingivitis, stomatitis, aphthous stomati- 
tis and cachexia as a result of the small amount of nour- 
ishment taken. The prostration may resemble that INFLUENZA IN THE AGED 
303 
caused by typhoid fever. Some epidemics are charac- 
terized by a biliary form with jaundice; the epidemic of 
1775 in Vienna showed a marked biliary form (Stell) and 
the Paris epidemic of 1830 presented symptoms resem- 
bling those of cholera. (Hardy and Behier.) 
Cholecystitis is a common sequence of influenza in old 
age and may cause serious trouble. I recently saw a man 
of sixty-three who had had influenza several months ago; 
he had had two attacks of cholecystitis and the last at- 
tack was followed by pneumonia of the right lung and he 
also had auricular fibrillation. He has completely re- 
covered. 
Nervous influenza is common in old age; headache may 
be intense, a severe throbbing pain, and may be associ- 
ated with vomiting, insomnia and photophobia. It may 
cause pseudomeningitis, and, moreover, a genuine men- 
ingitis may develop. Neuritis is a common sequel of 
influenza and may last several months. There is great 
prostration accompanying the nervous type and some 
cases of encephalitis, myelitis, polyneuritis and psy- 
choses following influenza have been reported. 
Influenzal nephritis is one of the most serious compli- 
cations and may be the beginning of chronic Bright’s 
disease. It is well, with the aged, to carefully watch the 
kidneys and an increase in albuminuria is an indication 
of the extent of the toxemia. The condition of the se- 
nile kidneys is so important that it is well to protect 
these organs in every kind of illness. In fatal cases the 
urine is scanty, bloody and the patient dies of anuria and 
uremia. 
Influenzal toxemia is a very serious condition and after 
the first day, patients present a toxic appearance; the 
tongue becomes coated, the breath has a foul odor and 
the skin becomes slightly yellow. Even with active 
catharsis, the toxins will accumulate unless great care 
is taken. The toxemia causes prostration and often- 304 
GERIATRICS 
times in convalescence, tonics are administered with- 
out benefit when an active treatment for toxemia is in- 
dicated. 
Treatment 
In the Medical Review of Reviews, February, 1920, I 
gave an account of the chloral hydrate treatment for in- 
fluenza, as administered during the epidemic of 1919, in 
France, in Mobile Hospital No. 7, with the American Ex- 
peditionary Forces, where the results were excellent and 
rapid in most cases. 
Invariably patients show an inflammatory process in 
the throat, although they do not complain of a sore- 
ness. It is a recognized fact that the throat is the 
portal of entry of the disease-producing germs and it 
is logical to believe that treatment given with this in 
view will produce good results. Eoutine examination 
of the throat will reveal a reddened condition. The 
principle of Fanning’s treatment employed in our hospi- 
tal was (1) to rid the system of toxins already formed 
and (2) to prevent their further development. The 
routine treatment was as follows: 
(1) 4 grains of calomel, followed in three hours with one- 
half ounce of magnesium sulphate. 
(2) gargle every half hour with a 2 per cent solution of 
chloral hydrate. 
A soldier would enter the hospital in the afternoon, 
quite ill, presenting a toxic appearance and perhaps with 
a temperature of 102° F. In many cases, under this 
treatment, the man would be returned to duty in twenty- 
four hours. 
I have used the treatment in private practice and it 
gives excellent results; recently I saw five persons quite 
ill with influenza, in one home. Every one used chloral 
hydrate gargle except the little girl of five years and INFLUENZA IN THE AGED 
305 
the next day there was a decided improvement in all 
cases except the child’s. Clinically, it works rapidly 
in many cases. 
It is difficult to give the theory of the action of chloral 
hydrate. Thus far theory has been of little benefit in 
the treatment of influenza. Chloral was discovered by 
Liebig in 1830, it being the product of the action of dry 
chlorine on ethylic alcohol, a chlorine derivative of al- 
dehyde, closely allied structurally to the group including 
alcohol and chloroform. Horand and Peuch used it as 
a local anesthetic and it was found that it often relieved 
the pain caused by inflammatory conditions of mucous 
surfaces. Externally, chloral hydrate has a marked 
antiseptic action. (Reynolds Webb Wilcox.) Burgraeve 
first pointed out its value in dressing ulcers, but it is used 
chiefly in ulcers of a bad character, particularly gan- 
grenous ones. 
Dujardin-Beaumetz, Hirne, Martineau, Cadet-Casse- 
court and Fereol showed that a one per cent solution 
acted favorably on gangrenous bedsores in enfeebled 
patients; Crequy used it in ulcero-membranous stomati- 
tis. In the throat it has an antiseptic and anesthetic 
action. Chloral may be altered in some way when mixed 
with the secretions of the mouth; possibly its effect de- 
pends upon its chlorine derivative; it might be absorbed 
through the mucous membrane and have some effect after 
absorption. 
It is safe to employ chloral hydrate in private practice, 
even with infants. Eight five-grain tablets in four 
ounces of water will make a 2 per cent solution. It 
can be prescribed as follows: 
$ 
Chloralis Hydratis 5 j 
Aquae f B j 
Elixir Aromatici q. s. ad. 3 ij 
Misce et ft. sol. 
Sig.: One teaspoonful in half a glass of water as a 
gargle every half hour. 306 
GERIATRICS 
This will make a 2 per cent solution and can be used 
frequently, but with care. 
For an aged person suffering from influenza, the treat- 
ment should be the same, but for catharsis, which should 
not be too drastic. If the patient is robust, one grain 
of calomel in divided doses, followed by a saline; if phys- 
ically frail, two compound rhubarb pills may be used. 
The throat should be gargled every half hour with a 2 
per cent solution of chloral hydrate. Supportive treat- 
ment should begin early as prostration comes quickly. 
If there is no evidence of kidney disease, one grain of 
quinine sulphate may be given every 3 hours, but if there 
is prostration, %0 grain strychnine sulphate is given 
every three hours, increased later to %o grain every 
three hours, if necessary. 
Whiskey or brandy is a valuable adjunct to treat- 
ment, I should say a necessity, one-half ounce being 
given every three hours if there is prostration. When 
weakness is extreme, alcohol should be given in its full 
physiologic action, a half-ounce every hour until a red 
spot appears on each cheek, then enough to prolong the 
full physiologic effect. 
Rest is essential, but old people should not be allowed 
to remain in bed if we can permit them to get up. It is 
often difficult to force them to sit in a chair, espe- 
cially when they are prostrated. Old patients will not 
do well in bed and it is a good rule to “keep senile cases 
out of bed.” 
A nourishing diet should be given; milk, egg-nogs, 
broths, etc. If influenzal nephritis accompanies the con- 
dition, it may be necessary to use a milk diet, with 
cereals, and tea and coffee should be taken. 
The heart should be supported early with strychnine; 
if it is irregular %o grain of sparteine sulphate should 
be given every three hours. Digitalis is an uncertain 
remedy to use in old age, but there are some cases in INFLUENZA IN THE AGED 
307 
which it is beneficial. I prescribe the fat-free tincture 
and use five minims every three hours, these small doses 
work fully as well as larger ones in old age. 
It may be necessary to use oil of camphor hypoder- 
mically as a stimulant if there is great prostration. 
Caffeine may be used hypodermically as a stimulant and 
if there are signs of serious toxemia, which is indicated 
by the coating on the tongue, it is well to use mercury 
and chalk, one grain every three hours, five doses, fol- 
lowed by a saline laxative. A bowel movement each day 
will save many old patients from death, and oftentimes 
toxemia being lessened, the heart will be relieved of its 
extra work. 
Convalescence is often protracted and requires great 
attention. Urinalysis should be made frequently and if 
there is a kidney complication attention should be given 
to it. Ordinarily, I prescribe a tonic of elixir calisaya, 
a teaspoonful every three hours, combined with a tablet 
of Yq0 grain of strychnine sulphate three times a day. 
The elixir of iron, quinine and strychnine phosphates will 
work well in many cases, as a tonic. 
Attention must be directed to the intestines in conva- 
lescence as the toxemia following influenza is apt to con- 
tinue for a long time. Vittel water, a pint or more a 
day, will have beneficial action. CHAPTER XXXVI 
THE CHECKING OF HEMORRHAGE, SECRE- 
TIONS AND EXCRETIONS IN THE AGED 
Case I.—A woman, aged sixty-five, liad eczema which 
manifested itself on the arm, leg and chest. There was 
an exudate on the surface of the skin but under treat- 
ment 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. 
The attack lasted only a few hours, hut she complained 
of headaches, dizziness, and a sensation of pressure in 
the chest which would remain several days. Suddenly 
the eruption would reappear, which seemed to relieve her 
immediately. 
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 bring relief within a day or two. These ulcers 
were very painful and 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 con- 
dition worse, ointments acted like poison and dusting 
powders would cause the sore to heal too rapidly, as evi- 
denced by various symptoms. The only treatment that 
seemed to agree with the patient was a wet dressing with 
a small amount of alkaline antiseptic solution in a few 
308 CHECKING OF HEMORRHAGE AND SECRETIONS 
309 
ounces of water. Treated in this way the sore did not 
heal too rapidly, in fact took three or four months 
to heal. During this time she felt much better, and when 
the ulcer had apparently run a certain course it healed 
without causing any untoward symptoms. 
For several months she would be free from ulcers and 
uncomfortable feelings, but in time similar symptoms 
would reappear, to be relieved only by the eruption of a 
sore, sometimes on the finger, once on the face, and some- 
times 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 came to a fatal 
point an ulcer appeared and relieved her in a short time. 
I have seen several cases similar to this, but due to 
tuberculosis, and not of the simple trophic type described 
in this case. Tuberculous sores are very common in the 
aged and if healed too rapidly will produce bad results. 
A tuberculous bone disease which discharges through a 
sinus may be compatible with good general health as long 
as it is not disturbed and not healed. Ulcers of any kind 
should be treated in the same manner and not allowed to 
heal too quickly. 
lii the aged, a discharge from the ears or a chronic 
rhinitis should not be checked, in fact, a safe rule in se- 
nile cases is not to check any secretion or excretion sud- 
denly. Epistaxis should be treated with ice on the neck 
and not by a method that will suddenly stop the hemor- 
rhage. 
Excessive perspiration in the aged is very disagree- 
able, but is not common, because the skin is atrophic 
and as a result usually very dry. However we meet 
cases of excessive perspiration, either general or local- 
ized, and at night perspiration, when patients have to get 
out of bed because of nocturnal micturition, causes a 310 
GERIATRICS 
very uncomfortable chill. This excessive perspiration 
is often a symptom of nephritis, and rids the system of 
urea. If the perspiration is checked the kidneys do not 
respond to the increase in work and there is congestion 
of the respiratory and other internal organs as a result. 
It is often serious to check this excretion and no matter 
how disagreeable the condition it should not be inter- 
fered with. 
In the aged, any form of skin disease which is accom- 
panied with a discharge should not be treated with the 
view of healing the skin quickly. I have seen cases of 
senile cancer, especially 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 drastic treatment, Nature seems to al- 
low the patient to live comfortably. An ambitious sur- 
geon who believes that the cure of an abnormality con- 
sists in its removal from sight, would remove the cancer, 
as a result the patient would fail and die within a short 
time. Radical interference in these cases should be very 
carefully considered before being resorted to. 
Checking a diarrhea in senile cases is also a dangerous 
procedure because, like excessive perspiration, it is fre- 
quently a symptom of nephritis or may be due to any 
form of toxemia, it being Nature’s effort to rid the 
system of certain poisons. It can be readily seen that 
a checking of such a diarrhea would have bad results 
and sometimes a fatal issue. If it becomes necessary to 
check the discharge, for example, in cases where it 
causes extreme prostration, give a remedy for the bow- 
els, administered only after every second or third move- 
ment. In this way the excretion will not be checked too 
rapidly. Sometimes the diarrhea will be a symptom of 
cancer of the bowel, and should not be checked. I rec- 
ollect seeing an old man who had chronic diarrhea for CHECKING OF HEMORRHAGE AND SECRETIONS 
311 
several years, a physician checked the diarrhea, the old 
man died in three days. 
In the aged excessive excretions and secretions are 
usually a compensation of some other function. For 
example, a diseased kidney, which is unable to carry on 
its work, may depend upon the skin or bowels to perform 
a part of its function of elimination, 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 he thrown 
upon the diseased organs which are not able to carry it 
on. Frequently, hyper-excretion of the kidneys is a 
symptom of parenchymatous nephritis. 
Bronchitis and other diseases of the respiratory tract 
often produce excessive bronchial secretions in the aged, 
but as long as the secretion is not checked there is no real 
discomfort. By checking the secretion we may bring on 
an attack of asthma. 
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 oases 
which have been operated upon, healing and checking of 
the discharge produced a general feeling of discomfort 
and loss of weight. In one case I remember a man lost 
twenty-five pounds as a result of a cure of the fistula 
and has never been well since. We must not forget 
that it is not always the object, in the aged, to heal, or 
correct an abnormality. 
In senility, we are frequently confronted with a hemor- 
rhage which we think should be checked. It may be 
epistaxis, acute or chronic intestinal hemorrhage, hem- 
aturia, or metrorrhagia. In any event, unless it appears 
that it may cause death, it is safer not to check it immedi- 
ately. A chronic hemorrhage of the bowel may be due 
to cancer or diverticulitis, but in many cases it does not 312 
GERIATRICS 
seem to interfere with the well-being of the patient. 
Very likely to check it will cause untoward symptoms. 
Hematuria should not he treated with the aim of rapidly 
curing it, in many cases I did not treat it at all and the 
patients lived a long time without discomfort. 
A woman, aged sixty-five, sent for me because she had 
a hemorrhage of the vagina. Several years ago she had 
a cancer of the cervix which was removed, and had 
thought herself well. Suddenly, without any warning, 
she had a hemorrhage which later proved to be due to a 
recurrence of the cancer. In this instance 1 did not 
check the hemorrhage, and, in a short time, with rest in 
bed it stopped naturally and to the time of her death she 
never had another. 
I think that we may safely come to the conclusion that 
all secretions and excretions in the aged should not be 
checked unless in cases of extreme emergency. CHAPTER XXXVII 
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 hypo- 
dermic tablets containing % grain of morphine sulphate, 
which his family physician had given to him upon his 
request for a soporific. Upon questioning his daughter 
I found that the old man slept in his chair several times 
a day and when night came naturally could not sleep. 
When his daughter told him the real cause of his insom- 
nia he became angry. 
The aged do not realize the amount of sleep they get 
and they all make the same complaint; that is, that they 
cannot sleep. A placebo will make them sleep as well as 
morphine, in fact better, for morphine usually makes 
them nervous. 
The aged are apt to falsify symptoms in order to ex- 
cite sympathy, and they may have every symptom of 
which they hear. An old lady told me that she had 
taken six 14 grain tablets of codeine sulphate at night 
without finding relief from a pain in the leg. As a mat- 
ter 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 patient she felt it was no more than fair 
that she also should have attention. 
We must be on our guard, however, and not attribute 
too many symptoms to malingering. I once had an old 
man whom we believed was malingering, but when he 
suddenly died from uremic convulsions we realized our 
grave mistake. In the aged pain is not a safe clue. 
Sometimes owing to decreased nerve sensibility we may 
313 314 
GERIATRICS 
find appendicitis, peritonitis or strangulated hernia with- 
out any pain. 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 painful. 
We may have pneumonia without pain in the chest and 
many fractures are painless, a mistake could easily be 
made in diagnosis. 
A diagnosis of arteriosclerosis or calcareous degener- 
ation of the arteries has little significance in the aged. 
These are normal senile changes and many symptoms 
ascribed to these conditions 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 
excellent pulse, yet may be dying. Always count the 
rate of the heart with a stethoscope. 
Counting respiration is a necessity and if we neglect 
it, many cases of senile pneumonia will escape notice be- 
cause there are few external manifestations of the dis- 
ease. 
Many cases of so-called pneumonia are in reality 
congestion of the lungs. If the patient appears too sick 
to have mere senile congestion of the lungs or bronchitis, 
we think of pneumonia. 
Many cases of uremia and intestinal toxemia are la- 
belled 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 that if the true 
cause of the condition had been ascertained it would 
have been toxemia. Uremia oftentimes causes fever and 
every other symptom of typhoid and if the patient has 
the strength to withstand the severity of the attack, it 
will run a course similar to that of typhoid and take 
about three weeks to abate. From the appearance of the diagnostic errors in the aged 
315 
tongue to the low muttering delirium and cold, clammy 
perspiration, the disease has the symptoms of typhoid 
fever. It is often associated with an acute inflamma- 
tion of the kidneys, and if casts and blood are present 
in the urinary sediment, 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, the temperature remained about 103° F. 
for several days, then abated. If the true cause of the 
affection 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 due to cancer of the colon or 
cancer of the liver. I remember a man who had typical 
clinical symptoms of pyelitis and was treated accordingly. 
He did not respond to treatment and on further examina- 
tion it was discovered that he had cancer of the colon. 
One night he was suddenly taken 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 pye- 
litis. In time she developed symptoms of gallstones, 
was operated upon and cancer of the liver was found. In 
this case nephritis was secondary to cancer of the liver. 
Senile glycosuria may be due to senile degenerative 
changes and not to diabetes. The aged do not usually 
develop acidosis except in coma, caused by some other 
disease. For example, uremic coma may have a ten- 
dency to bring on acidosis. The diagnosis of diabetes in 
the aged is important because injudicious treatment 
may cause fatal results. Ether, chloroform or nitrous 
oxide mav cause acidosis and this should be borne in 316 
GERIATRICS 
mind in anesthetizing patients. It is a great mistake to 
call senile glycosuria due to normal process of degen- 
eration, true diabetes. 
Senile patients are apt to tell you they have not ex- 
perienced certain symptoms because they believe it may 
prevent a painful and disagreeable examination. They 
will deceive you, perhaps, unintentionally, because they 
forget, or do not observe. 
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 greatly disturbed 
by this remark, because she thought that one’s 
bowels should move every day. A case like this is typi- 
cal of a woman who does not have a bowel evacuation 
oftener than once a week. They will ask to take their 
own laxative pills in order to prevent you from prescrib- 
ing a laxative. They will deceive you sometimes be- 
cause they dread the pain which accompanies hemor- 
rhoids. 
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 condi- 
tion. On several occasions I have followed such cases 
for several years and found that in many cases the 
tumors did not produce symptoms. It would be a grave 
mistake to cause aged patients to worry when it is not 
necessary. I now have a patient, a woman, aged sev- 
enty, 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. 
Another woman, aged eighty, had a carcinoma of the 
breast for several years, yet lived. A 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 DIAGNOSTIC ERRORS IN THE AGED 
317 
make a great mistake in believing that because an abnor- 
mality exists it must be removed. Many old persons 
have some apparently serious affliction such as cancer, 
Nature keeps them comfortable, provided no one inter- 
feres with her. 
In my experience, the most common cause of mis- 
taken diagnosis in the aged is interstitial nephritis. 
This condition is sometimes very difficult to diagnose 
and the symptoms of kidney disease may be localized in 
other organs. 
For example, we may have indigestion, gastrointest- 
inal pain, neuritis, neurasthenia or psychasthenia due to 
nephritis. I am convinced that the symptoms, in half 
the cases commonly called senile pneumonia, are in re- 
ality due to an acute exacerbation of chronic nephritis. 
Lung symptoms and heart manifestations are commonly 
caused by nephritis. We depend too much upon chemi- 
cal urinalysis when we should depend upon the micro- 
scope in the diagnosis of kidney disease. Tuberculosis 
in the aged is not rare but does not usually cause symp- 
toms and is often discovered only at postmortem exam- 
ination. Nephritis with lung symptoms frequently simu- 
lates pulmonary tuberculosis. Senile debility due to 
any cause frequently appears like phthisis and senile 
bronchitis like the miliary form of tuberculosis. The 
latter disease often complicates diabetes in the aged, but 
does not usually cause symptoms. Tuberculous ulcers 
may appear, especially on the skin covering the ends of 
long bones. 
Deafness in many senile patients is not due primarily 
to the ears but to the diseased condition of the kidneys. 
I am firmly convinced that nephritis plays an important 
role in deafness and a temporary deafness lasting 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 318 
GERIATRICS 
nerves in senility makes possible the passage of a gall- 
stone through the ducts without pain. Renal colic, on 
the other hand, is quite frequent in the aged and usually 
accompanied by intense pain which can only be relieved 
by opiates. Renal colic may be mistaken for the gastro- 
intestinal pain due to nephritis or a crisis of locomotor 
ataxia. Pains which have been associated with arterial 
spasm may effect the kidneys and simulate renal colic. 
An attack of renal colic may not be followed by another 
attack for several years. 
Hematuria is common, but does not always imply 
nephritis. It may be of unknown origin and is com- 
patible with good general health in many cases, it is often 
due to prostatic congestion, and not usually of serious 
omen. 
In senility the narrowed lumen of arteries in sclerosed 
condition accounts for a lack of nutrition of the skin 
which predisposes it to skin affections. Senile pruritus 
may be of parasitic origin. Eczema may be due to dia- 
betes or nephritis and psoriasis is frequently associated 
with asthma. I have seen a few cases where interfering 
with the skin condition brought on an attack of asthma. 
In the aged the pancreas may be a cause of disturb- 
ances which unfortunately have not been thoroughly in- 
vestigated so far. I have observed, in several cases such 
as diabetes, senile gangrene, etc., that there were definite 
symptoms pointing to the pancreas, the most important 
being 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 one of diverticulitis. Frequently the 
latter condition will cause blood to appear in the stools. 
In the aged cancer of the stomach is frequent, while 
gastric ulcer is rare. The scirrhus type of carcinoma is 
sometimes very difficult to diagnose. DIAGNOSTIC ERRORS IN THE AGED 
319 
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 of seventy-five. Neuralgia is frequently due to 
anemia or toxemia, and neuritis is a frequent symptom 
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 
disease is to know half the science of medicine. We 
commonly say that a senile condition is due to arteri- 
osclerosis and calcareous degeneration of the arteries. 
Sclerosis is a normal senile degenerative process and 
we must not overlook the fact that degenerated organs 
may work in harmony, and as long as the harmony is 
not broken these degenerated organs functionate in a 
way which is normal to themselves. 
To call a normal senile degenerative change a dis- 
ease is a mistake which is apt to have disastrous results 
in therapeutics. For example, in senile arteriosclerosis 
the iodides would not only produce severe gastrointes- 
tinal symptoms, but might produce a severe irritation of 
the kidneys. CHAPTER XXXVIII 
SENILE MALINGERING 
A difficulty frequently encountered in 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 physi- 
cian, not familiar with the normal senile changes, finds a 
senile emphysema, dilated stomach, visceroptosis, or 
hypertrophied 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 imita- 
tive and readily influenced by suggestion; that the nor- 
mal senile changes may cause distress; that a pathologic 
condition may have existed for so long that the organism 
is adapted to it so that it has become normal to the in- 
dividual. 
The most frequent form of malingering is the ex- 
aggeration of pain in order to secure sympathy. The 
following is a typical case: 
A man, aged seventy-two, says that he was never ill 
(has pock marks on his face). He complains of “feel- 
ing sick all over/’ says he has headache, backache, and 
pain in the joints, feels cold and has no appetite. There 
is a history of constipation, slight incontinence of urine 
320 senile malingering 
321 
and dyspnea. There is no cough or expectoration, no 
palpitation or other cardiac symptom, but an account 
is obtained from the family of occasional attacks of 
vertigo, which he denies, presbyopia and evidently pres- 
byacnsia. 
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 
objective symptoms give any clue. He was irritable and 
insisted on his family leaving the room while he was 
being examined. 
Examination.—Temperature normal, 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, liver atro- 
phied, spleen not palpable, prostatic hypertrophy. 
Upon my pressing over various parts of the body he 
gave no evidence of pain but said it hurt, when ques- 
tioned. It was possible to exert considerable pressure 
upon such parts without his giving evidence of pain if 
his attention was distracted in conversation. He for- 
got the location of a painful spot on the back a few min- 
utes after complaining of it and pointed to a spot six 
inches away. Considerable pressure upon the knees 
during conversation brought out no evidence of pain 
until I called his attention thereto, then he immediately 
winced and pushed my hand away. Before my leaving 
him he requested me to suggest to his family that he 
should be sent to a hospital or home. His family in- 
forms me that he did not complain of being ill until 
shortly after a petty quarrel. 
This was a case of pure malingering to obtain sympa- 
thy. 
In some cases the dread of pain makes the patients 322 
GERIATRICS 
hypersensitive and they suffer acutely from a slight le- 
sion, as a scratch or bruise. In one case of chronic ulcer 
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 
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 former 
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 which is in real- 
ity due to unconscious mimicry is occasionally seen in 
homes and institutions where inmates pair off with com- 
panions. If one has some form of tremor, impediment 
in gait or speech, or a peculiar motion of the body or 
limbs, the companion will frequently acquire it. 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 patient’s food was taken away whenever 
he spilt it, and tempting dishes were offered which he 323 
SENILE MALINGERING 
could have only if he completely controlled the tremor. 
He would lapse into the tremor when he thought lie 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 
stimulated 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 obvious symptoms and signs are 
denied. The aged frequently boast of their good health 
and wonderful constitution and will deny ailments and 
discomforts that are obvious and usually painful. On 
the other hand they will exaggerate former affections 
from which they recovered “because of their strong 
constitution. ’ ’ 
The histories given by the aged are generally unre- 
liable, their statements being almost invariably exag- 
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 324 
GERIATRICS 
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. 
Superficial sensitiveness is generally lessened in the 
aged, while the pain due to inflammation of internal 
organs and tissues is felt less acutely on account of 
mental impairment, which is more marked in inflamma- 
tion with high temperature. On the other hand, the 
anticipation of a painful examination will cause the 
patient to hide lesions and deny painful spots. 
A patient, aged seventy-five, told 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 was filled with pus 
and slough and 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. 
The family will ask you what harm would result if the 
patient continued to limp or shake so long as it is only 
habit. Habits acquired in old age rapidly become worse 
and less controllable. The slight tremor, which can be 
controlled in the beginning, becomes an uncontrollable 
coarse and persistent tremor. The slight limp may be- SENILE MALINGERING 
325 
come a complete monoplegia. Drugs are useless in these 
cases and liarsli measures with constant watching neces- 
sary to effect a cure. The conscious malingerers, who 
exaggerate symptoms, usually have a slight basis for 
their complaints and require medical treatment for some 
underlying disease, but where there is no basis for com- 
plaints as in the case described above a disagreeable 
placebo will usually suffice. CHAPTER XXXIX 
SYPHILIS CONTRACTED AFTER SIXTY 
YEARS OF AGE 
We do not often think of old persons developing 
syphilis, as we overlook the fact that sexual life in the 
aged is often conducive to the development of veneral 
diseases. Syphilis may be contracted in old age as in 
maturity. Many old patients do not consult a physician 
and little attention has, therefore, been given to the 
subject of syphilis iii the aged in this country; in France, 
MM. Pic and Bonnamour have given considerable at- 
tention to this condition in senility. In 1878, Sigmund 
of Vienna concluded, upon a study of 118 cases, that, 
“The forms of syphilis in advanced age are less grave 
than in the young and the issue of the disease is more 
favorable.” Dulac of Paris, in 1878, on the contrary, 
concluded that syphilis was more serious in old age. 
Quinquaud, 1881, noted the frequency of malignant 
syphilides and serious visceral localization in old age. 
Regoby, in 1886, demonstrated that in old age chancres 
and mucous patches follow a natural course for some 
time and then become ulcerous. Fournier insisted upon 
the seriousness of the disease in old age. 
Perhaps one of the reasons why we do not encounter 
more cases of syphilis in old age is because sexual in- 
dulgence is then lessened. In my opinion, there is no 
reason why an old man should not be infected with 
syphilis, as abrasions of the penis make as good a 
portal of entry for the Spirochete pallida as in younger 
persons, and, moreover, vitality is lowered, which makes 
infection easier. However, the disease does not usually 
326 SYPHILIS CONTRACTED AFTER SIXTY YEARS 
327 
develop as soon after exposure as it does in maturity 
and it may be five or six weeks before it breaks out in 
old age, as compared to twenty-five or thirty days in 
adults. 
The chancre may be a typical sore or may become 
ulcerated, often phagedenic, and it may be so ulcerated 
that it is difficult to distinguish it from epithelioma 
(Merklen). Often the sore is very small and may pass 
unnoticed, but it is always indurated, which is one of 
the diagnostic points, and the induration may remain 
several months after the lesion. In old patients, ex- 
tragenital chancres are more common than in adults. 
Some cases have been reported where grandchildren 
infected their grandparents with syphilis. It is often 
difficult to make a diagnosis of chancre of the face in the 
aged as it may have every appearance of epithelioma. 
In fact, several years ago, a man, aged sixty-five, con- 
sulted me for a sore of the right cheek, which had every 
appearance of epithelioma, but a diagnosis of chancre 
was made. I did not treat the local condition except 
with antiseptic washes and as the old man was anxious 
to have the sore removed, he consulted another physi- 
cian, who made a diagnosis of cancer, advised operation, 
which was performed, but several weeks after, the con- 
dition proved to be syphilitic. It behooves us to use 
great care in treating sores of the aged; we must not 
overlook the possibility of syphilis and must nol con- 
clude that every sore an old patient has is epithelioma- 
tous. 
The secondary symptoms usually come three or four 
weeks after the initial lesion but may occur earlier. 
Horand reports a case where a pustulous eruption 
showed fifteen days after the appearance of the chancre. 
It is usually maculous or may be squamous, but always 
not marked and may be so light that it passes unnoticed 
(Pic and Bonnamour). It may last three or four weeks 328 
GERIATRICS 
and disappear, but will reappear, especially if tlie parts 
are exposed to the cold, even an exposure to the air 
may be sufficient to bring it on. Syphilitic papules may 
develop three or four months after the disappearance 
of the chancre. They are usually small and may spread 
all over the body. One of the diagnostic signs is the 
appearance of the eruption upon the palmar and plantar 
surfaces, while most skin diseases do not produce an 
eruption on these parts. The eruption is usually sym- 
metrical and may disappear and recur frequently. 
A man, aged sixty-three, consulted me for an eruption 
of the skin, which had the appearance of psoriasis. He 
denied having had syphilis, yet upon routine examina- 
tion, an indurated spot was found on the penis. He had 
noticed a small sore, but had paid no attention to it; he 
admitted that he had been living with a woman, but 
felt sure that she could not have infected him. A diag- 
nosis of syphilis was made since the Wassermann re- 
action was positive. 
When the eruption appeared, the patient complained 
of a feeling of lassitude, muscular pains, headache, ver- 
tigo, loss of appetite and insomnia. He was extremely 
nervous and at times delirious at night. He gradually 
grew worse, prostration was extreme and cachexia pro- 
nounced, he became profoundly anemic and finally died 
from malignant syphilitic toxemia in spite of active 
treatment. 
The toxins of syphilis are often of a malignant nature 
in the aged and may cause meningitis, or nephritis. 
Quinquaud notes a condition which he terms typhosyph- 
ilis, characterized by a state similar to that of typhoid 
fever or a picture of pernicious anemia. The general 
symptoms usually come with the secondary eruption and 
disappear as the cutaneous and mucous symptoms abate. 
Almost invariably in old age, syphilis causes profound SYPHILIS CONTRACTED AFTER SIXTY YEARS 
329 
anemia as well as severe nervous symptoms, Syphilitic 
iritis appears in about one-third of the cases and may 
last several months after the disappearance of the 
chancre. Fournier has observed that the ears are often 
affected; he had a case with suppurative otitis media. 
Acute senile syphilitic nephritis may develop in the 
course of secondary syphilis and is usually a grave com- 
plication. The syphilitic toxins are apt to cause 
nephritis as those of scarlet fever in children. Again 
the aged often have a latent kidney disturbance which 
is aggravated by the syphilitic toxins. The renal filter 
is already impaired and uremia is easily brought on. 
Senile heart disease will be aggravated by syphilis or 
syphilis may cause aortitis or myocarditis. Syphilitic 
heart disease is more common than it is supposed to be. 
Other complications which may be caused by senile 
syphilis are phimosis, paraphimosis, prostatic hyper- 
trophy, cystitis and pyelitis. The poor condition of the 
teeth in senility predisposes to an aggravation of the 
lesions in the mouth. 
Cerebral syphilis is often difficult to diagnose because 
in old age uremia will present the same clinical picture. 
Gummata often undergo sarcomatous degeneration in 
the aged which leads to many difficulties both in diag- 
nosis and treatment. I have seen several cases of epi- 
theliomata that had been engrafted upon a syphilitic 
lesion and resisted all treatments with radium. It is 
difficult to make a diagnosis in those cases and we must 
depend a great deal upon the history of the case. Small 
epitheliomata of the skin in old age will usually yield to 
radium treatment but if they resist the radiations, 
syphilis should be suspected as a possible remote cause 
of the condition;. The cancero-syphilific combination 
may be observed in any part of the body. 
The diagnosis of syphilis in old age is not always easy. 330 
GERIATRICS 
The Wassermann test, even of the spinal fluid, is not 
always to he depended upon in old patients; and it is 
essential to make an accurate diagnosis in order that 
early treatment may be given. 
Syphilitic hepatitis is similar to the hypertrophic 
alcoholic type and difficult to diagnose, again, there may 
be a mixture of the two varieties. Its diagnosis, like that 
of syphilitic nephritis, can only be established by most 
careful observations and laboratory tests. Syphilitic 
nephritis may be engrafted upon ordinary senile nephri- 
tis and an amelioration of the syphilitic condition may 
not affect the disease of the kidneys, which was present 
before the syphilitic infection. 
The prognosis of senile syphilis is very grave. Even- 
tually, complications add to its seriousness, asthenia 
and cachexia are often fatal. The toxins of syphilis 
hasten senile degenerations in all organs and may cause 
death through senile nephritis, or severe inflammatory 
reactions in any organ. 
The treatment must be as active as possible, but as 
the stomach of the aged patient cannot stand irritating 
remedies, we must resort to intravenous medication or 
subcutaneous injections of the soluble mercurial salts. 
We must always bear this in mind as elimination is very 
poor in the aged, we may get the secondary effects of the 
remedies used, which can be very annoying. Sometimes 
when specific remedies fail, we may obtain results in 
using remedies which are not ordinarily employed in the 
treatment of the disease. 
Although in senility I have not seen many encouraging 
results due to salvarsan in chronic cases, it will often 
work well in acute cases. I have used Novarsenobillon, 
which is the dioxydiamidoarsenobenzolmonomethylene 
sulphoxylate of soda, the salt described by Ehrlich under 
the name of “914.” It is freely soluble and can be 
quickly used without complicated apparatus. In old SYPHILIS CONTRACTED AFTER SIXTY YEARS 
331 
age, we must use the remedy with caution and it should 
not be employed if there is acute nephritis, icterus or 
cardiovascular affections. In senility it is well not 
to begin treatment with salvarsan or novarsenobillon 
until the acute symptoms have subsided. Early treat- 
ment with mercury is perhaps better unless the indica- 
tions point to serious complications. An eighth of a 
grain of the yellow iodide of mercury given three times 
a day, gradually increasing the dose, will be advisible 
as soon as the diagnosis is made. Novarsenobillon can 
be used early if nephritis, icterus or cardiovascular 
diseases are of syphilitic origin. 
In using novarsenobillon a safe rule would be to 
commence the treatment with 0.10 or 0.15 gm., and note 
whether there is a strong reaction. If there is no reac- 
tion, the second injection should he 0.2 gm. and if no 
untoward symptoms appear, the dose can then be pro- 
gressively increased so as to gradually reach the normal 
dose of 0.015 gm. per kg. of weight (0.9 gm. in the 
case of a man or woman weighing 120 pounds.) 
If there are signs of reaction after the first dose, we 
repast the same dose instead of giving a larger one. 
Normally, there may be a reaction, but it is not severe; 
there may be headache, fever and lassitude for a short 
time. Intolerance would be manifested by an aggrava- 
tion of the reactive phenomena, which is rare if the same 
dose is repeated over again. In some cases, a few min- 
utes after the intravenous injection of novarsenobillon, 
the patient may experience an itching and burning 
around the anal region. 
The treatment should be commenced with a small dose, 
with an interval of eight days between each injection. 
The day following the injection, an injection of gray oil, 
one grain, should be given in the buttocks. 
The following course of treatment shows how it may 
be carried out: 332 
GERIATRICS 
Nov. 29, 1918 Novarsenobillon 0.10 gram 
Nov. 30, 1918 Gray oil 0.065 “ 
Dec. 7, 1918 Novarsenobillon 0.15 “ 
8, “ Gray oil 0.065 “ 
15, “ Novarsenobillon 0.20 “ 
16, “ Gray oil 0.065 “ 
23, “ Novarsenobillon 0.30 “ 
24, “ Gray oil 0.065 “ 
Jan. 1, 1919 Novarsenobillon 0.45 “ 
2, “ Gray oil 0.065 “ 
9, “ Novarsenobillon 0.60 “ 
10, “ Gray oil 0.065 “ 
Feb. 9, “ Novarsenobillon 0.15 “ 
10, “ Gray oil 0.065 “ 
17, “ Novarsenobillon 0.30 “ 
18, “ Gray oil 0.065 “ 
25, “ Novarsenobillon 0.45 “ 
26, “ Gray oil 0.065 “ 
Mar. 4, “ Novarsenobillon 0.60 “ 
5, “ Gray oil 0.065 “ 
12, “ Novarsenobillon 0.80 “ 
13, “ Gray oil 0.065 “ 
20, “ Novarsenobillon 0.90 “ 
21, " Gray oil 0.065 “ 
This ends the second course of treatment and if the 
case is progressing satisfactorily, two months after a 
third course can be given as the preceding, of six in- 
jections of novarsenobillon and of gray oil. 
After the third course of treatment, I have used the 
yellow iodide of mercury by mouth for several weeks, 
increasing the dose until there was pain in the umbilical 
region, slight salivation or painful condition of the 
teeth. If there is gastric intolerance, sajodin, the 
monoiodobehenate of calcium may be given, eight grains 
three times a day. Sometimes, when other remedies 
fail, arsenic trioxide, /4oo gr. every 3 hours, may be 
given, or Fowler’s solution prescribed. The bowels 
must be kept open, which will offset many symptoms due 
to the secondary effects of drugs as a result of cumula- 
tive action. Too much arsenic will produce symptoms 
similar to those of coryza and the lower lids will become 
puffed. 
Novarsenobillon has been satisfactory when used with SYPHILIS CONTRACTED AFTER SIXTY YEARS 
333 
caution. For a few hours after the injection the pa- 
tient should remain in the recumbent position and his 
temperature by mouth and rectum should be taken every 
two hours. In some cases, the injections may give rise 
to marked symptoms of reaction, if those symptoms have 
disappeared by the eighth day, the dose may be repeated, 
but not increased. If, eight days after the second injec- 
tion, there is evidence of reaction, it is advisable to give 
a smaller dose or postpone the date of the injection 
until the symptoms of reaction have subsided. 
Iodide of potassium is effective in treatment, but must 
be administered with caution since it is irritating to the 
stomach and sometimes to the kidneys. Sajodin, eight 
grains every 3 hours or three times a day, is a substi- 
tute for the iodides and causes no gastrointestinal irri- 
tation. 
In some cases I have seen extreme prostration and 
cadhexia, the stomach was not able to stand strong 
remedies; in these cases, I gave four grains of sajodin 
every two hours and the following prescription: 
n 
Fluidextracti Cocae % ss 
Syrupi Chocolate q. s. a. d. § iv 
Sig: Teaspoonful in milk every two hours. 
Cinnabar decoction, known as Zimmerman’s decoc- 
tion, will work well in many cases. I have seen patients 
who would not be benefited by the specific remedies of 
syphilis, yet would improve on two grains of lime phos- 
phate and two grains of iron phosphate in tablet form, 
prescribed every two hours. Elixir calisaya or the 
elixir of iron, quinine and strychnine phosphates may 
work well. 
Silver nitrate, 30 grains to the ounce of water, will 
heal the mucous patches in the mouth and a mouth wash 
of chloral hydrate, a 2 per cent solution, is an effective 
antiseptic. Because of the tendency of these local sores 
to become malignant, attention must be directed to the 334 
GERIATRICS 
local treatment in old age, it is more important than in 
maturity. 
Alcohol, in the form of brandy or whiskey,- is a valu- 
able adjunct to the general treatment, if there is great 
prostration. Bromides should be given for insomnia 
and other nervous symptoms and they may be used to 
fortify the action of the iodides. 
The cases of combined cancer and syphilis are difficult 
to treat. We must use antisyphilitic remedies, and 
should wait to see the results of specific treatment before 
operating, but they are seldom encouraging and may 
come to surgical intervention. Some patients do well 
after surgical treatment. It has been my experience that 
radium-therapy does not benefit a case of sarcoma or 
carcinoma which has been engrafted upon a syphilitic 
lesion. CHAPTER XL 
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 besides checking and countersigning reports, etc.; 
has held this position twelve years and formerly held a 
similar one in another department for ten years. The 
routine duties of his position can be performed by a 
subordinate and his absence would cause no disarrange- 
ment in his office. 
He is religious, abstains from alcohol and tobacco and 
has always been a 11 stickler” in observing the propri- 
eties of social life. He was formerly cheerful, but never 
communicative, had many acquaintances, few friends 
and no intimates. While tactful and pleasant he was 
strong-willed, short and decisive in argument, as in giv- 
ing orders. He was exactingly methodical, neat in ap- 
pearance and in surroundings, almost miserly economi- 
cal, 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 remained away from his office 
for a few weeks. This depression was gradually over- 
come and no change in his mental or physical condition 
was noticed until about six months ago, when it was 
noticed that he was not as regular in his habits as for- 
l The Senile Climacteric, New York Med. Jour., Dec. 2, 1911. 
335 336 
GERIATRICS 
merly, neither as methodical nor as correct in his work. 
He was not 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 instead 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 notice slight in- 
firmities, aching in the ankles while walking, shortness 
of breath when going upstairs, palpitation of the heart 
when the door slammed or the head of the department 
approached his desk. He became occasionally dizzy, 
vertigo lasting but a moment. Noticing cloudiness in 
his urine when it had been standing overnight he con- 
sulted a physician who diagnosed chronic interstitial 
nephritis. He then worried about his physical condition 
and watched all sorts of somatic disturbances, fre- 
quently felt his pulse, looked at himself in the mirror to 
note any change in his appearance and made repeated 
visits to his physician. He felt that he was getting 
worse and changed physicians. 
He still presented an erect bearing, but would occa- 
sionally permit himself to sink into a slouching attitude, 
with arms hanging loosely in front of him and a slight 
stoop. He was restless, apparently afraid of some un- 
known danger. The skin was slightly wrinkled, but soft 
and showing the extreme care he had always taken of 
it. Physical examination showed no marked degenera- 
tive changes. 
The principal change was in his mentality.1 Here I 
was obliged to depend mainly upon the statements of his 
friends and neighbors. He had formerly been very ret- 
icent, now he frequently asked them if they noticed any 
change in him. He sought their company and became 
talkative, his conversation being confined exclusively to 
l Senile Mentality, Intern. Clinics. Yol. IV. Series 21. THE SENILE CLIMACTEBIC: A TYPICAL CASE 
337 
his health and his work. He took no interest in any con- 
versation which did not relate to himself. His conver- 
sation was rational and when he made mistakes in fig- 
ures, names, places or dates acknowledged his mistakes 
when corrected. 
The process of mental deterioration was rapid but 
irregular, he is now passing out of the climacteric period 
and entering the stage of senility with steadily increas- 
ing senile changes. During this climacteric period his 
memory weakened and he replaced forgotten facts by 
inventions, insisting upon their accuracy. These would 
be forgotten the next day and new fabrications substi- 
tuted to them while the statements made the day before 
were denied. During this time a persecutory delusion 
developed. 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, for instance, that this subordinate 
had agents in his room to kidnap him, that men were 
watching him from behind a lamp post, etc. The per- 
secutory delusion was sometimes forgotten, the hallu- 
cinations could only be evolved through suggestion when 
the delusion was present. He was loquacious when 
speaking of his own importance, but spoke cautiously and 
in evident fear of an imaginary danger. Only once did he 
speak voluntarily 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 a prolonged conversation, casual references to this 
substitute in his office would arouse the delusion. 
He developed exalted ideas of his importance, exag- 338 
GERIATRICS 
gerating tlie value of his services, believing that his 
absence from his desk would seriously hamper the gov- 
ernment. These were not, however, insane delusions 
such as those which appear in the paretic, but mere 
egotistical opinions. The fear that his absence would 
interfere with the routine of his office and that he would 
be discharged became a persistent 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 occasionally lucid intervals lasting from several 
hours to a few days, during which he was cheered by 
letters from his superiors, assuring him that his posi- 
tion was safe. Yet even then he would suddenly become 
depressed, call up his superiors on the telephone for 
corroboration of their letters, and then doubt their sin- 
cerity. During the lucid intervals the patient’s conver- 
sation was rational and he sometimes realized that he 
had said or done irrational 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 hampered the govern- 
ment, and speak of his dread of being discharged, he 
would repeatedly ask if his listeners could detect any 
signs of insanity, and frequently sent for me insisting 
that I should examine his heart, blood pressure, urine, 
mental condition, etc. Several foolish infatuations fol- 
lowing sexual recrudescence, added to his agitation and 
depression.1 
Sexual recrudescence has been frequently noticed in 
advanced age, there being sometimes a prolonged, more 
1 Medico-legal Relations of Old Age, New York Med. Jour., May 25, 1912. THE SENILE CLIMACTERIC: A TYPICAL CASE 
339 
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 so 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 liv- 
ing 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 of 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 meet- 
ings, or perhaps while watching the house, he became 
absent-minded, wandered aimlessly and twice crossed 
the river unconsciously. At one meeting he lost his 
month’s salary and thereafter she failed in her appoint- 
ments. The fear of losing his position and his infatua- 
tion for the woman who failed him, kept him almost 
constantly depressed even when his mind was clear. 
A few weeks ago he heard that she was going to Europe 
and for several days went repeatedly to the house in 
which he supposed she lived but failed to see her. He 
was extremely 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 340 
GERIATRICS 
few days later he had apparently forgotten his infatua- 
tion for her and when reminded of it, spoke 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 
and reaching the somatic state of senility and the mental 
state of senile dementia. His appearance bears out the 
statement 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 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 slower 
and he makes shorter steps. The degenerative changes 
have been quite uniform. 
During the climacteric there were maniacal out- 
bursts, periods of depression and amentia, delusions, 
hallucinations, and phobias with lucid intervals. The 
mental aberrations gradually disappeared leaving a 
weakened mind, true dementia. He is pliant, so that a 
child can lead him away from his purpose. He is losing 
interest 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 episodes of his early life. The sexual 
recrudescence 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 de- 
pressed. He has been able to resume work because his 
age and his long association with his fellow-employees 
have secured for him concessions which virtuallv re- THE SENILE CLIMACTERIC: A TYPICAL CASE 
341 
lieve him from all active duties. What he does now is 
routine work requiring little mental effort. He is sus- 
ceptible to flattery and keenly feels criticism though 
formerly indifferent to both. When questions involving 
reason and judgment arise, he makes an evident effort 
to concentrate his thoughts and still reasons rationally, 
but slowly. Continued effort causes mental confusion 
and brain fag. When speaking of himself his ideas are 
still exalted, he holds an exaggerated opinion of his 
importance and of his work, but there are no delusions. 
From a strong, aggressive personality he has become a 
passive, pliant nonentity. 
The senile climacteric being one of the critical phy- 
siologic periods it cannot 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 re- 
lieve distressing symptoms. Psychic measures are 
sometimes effective, more often drugs must be used. 
The psychic measures to be employed depend upon the 
temperament of the individual and the particular form 
of aberration present. In this 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 treatment consisted of amorphous (red) phos- 
phorus in two-grain doses three times a day given con- 
tinuously for two months, chloral hydrate, bromide of 
potassium, and incidental remedies for constipation. 
Bromide of potassium was given for a week when 
the sexual stress appeared to be most at its climax and 
the patient spent hours in front of the woman’s house. 
During this time veronal was given as a hypnotic, at 342 
GERIATRICS 
other times chloral was used. I fortunately secured the 
patient’s confidence through producing appreciable ef- 
fects, 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 any one else. 
He is continuing to take fjhosphorus 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. 
In this as in other similar cases, the most lasting 
mental stimulation without reaction was produced 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 rhythmic ballet, fireworks, single 
novelties, as an air ship or ocean liner, simple sports as 
tennis, croquet, billiards, etc., which produce neither 
mental strain nor aural or visual confusion, are bene- 
ficial. Confusing sights as a ball, a race with many con- 
testants, a circus, confusing sounds as the jangle of 
city noises and recreations which involve mental effort 
as chess, scientific card games, problem plays, etc., cause 
rapid brain fag and hasten brain exhaustion.1 While 
this question of recreations applies more particularly to 
the period immediately following the senile climacteric 
when the mind can still interpret sensory impressions, 
it can be made to apply to the climacteric period. These 
measures are not very effective, however, if there is 
a persistent cause for mental confusion as there was in 
this case. 
l From chapter on Hygiene “Diseases of Old Age,” P. Blakiston’s Son & Co., 
Philadelphia, by Nascher. CHAPTER XLI 
SEXUAL LIFE IN THE AGED 
Senility in a man does not necessarily mean a loss of 
sexual power; contrary to what happens in women, where 
the function of reproduction disappears at the meno- 
pause, the man usually preserves his sexual power until 
an advanced age. In the female, the desire rapidly 
wanes after the menopause and her sexual life thereafter 
is usually confined to a passive submission to sexual 
congress, in which there is neither pleasure nor response. 
There are, however, many old couples who find pleasure 
in sexual intercourse until the ages of seventy-five or 
eighty. 
If we believe what we read we find that Thomas Parr, 
who lived until the age of 152, was accused at the age 
of 102 of immoral behavior; he was tried and convicted. 
He married eighteen years later a widow who said that 
she could not notice any indication of old age. We are 
told that the Dane, Drakenberg, lived to the age of 
146 and at the age of 111 married a woman of sixty. 
A shoemaker by the name of Gian was said to have died 
at the age of 114, leaving a wife (his third one), who did 
not complain of his lack of virility. 
However, many old men who boast of their sexual 
strength find themselves in a nervous state and the fre- 
quent repetition of the act is certain to cause debility 
and degeneration. Increased sexual power may be the 
first sign of senile dementia. 
Senility does not imply sterility. Many authors have 
noted the presence of spermatozoa in old men, although 
it is not the rule after the age of sixty. Duplay, Wagner, 
343 344 
GERIATRICS 
Bebrou, Rayer have noted their presence in men very 
advanced in age. Duplay has found them as numerous 
in old men as in adults, in 37 out of 52 cases: Desnos in 
50 per cent of cases; Dieu noted an absence in 6/1 per 
cent of cases and according to him this absence would be 
constant after eighty-six years of age. Demange has 
noted their existence in a man ninety-four years of age 
and Casper in a man of ninety-six. Metchnikoff in his 
“Studies of Human Nature” stated that men aged 
ninety-nine to one hundred and three had spermatozoa 
in large quantities. 
History notes a certain number of cases of old men 
at a very advanced age who had children. Pic and 
Bonnamour have noted that in the ancient world, Cato 
was said to have had a son at eighty years of age; Mas- 
sinissa at ninety; Lakanal, Marivaux, the English histor- 
ian Dadwel, President Tyler had children after the age 
of seventy. Duplay noted a case of procreation at ninety- 
four. Dr. Deforrnelle, who died in 1809 at the age of 
one hundred and twenty, married at one hundred and 
two and had children. Foissac and Finot reported the 
history of Baron Baracivine de Ceyrelli, who died at 
one hundred and four, leaving his fourth wife pregnant 
from an eighth child. Joseph Surrington who died at 
Bergheim, Norway, at the age of one hundred and sixty, 
had several children of whom the oldest was one hundred 
and five and the youngest nine. 
We often read of old men marrying girls of twenty 
or thirty and of men of eighty having children. As a 
general rule, men lose their reproductive powers at the 
age of sixty; perhaps there are cases where old men past 
that age have children with young women, but I always 
feel there is a strong possibility that another man may 
be the real father of the child. 
Why some old men desire the company of young 
women is a difficult question to answer and I believe it is sexual life in the aged 
345 
decidedly detrimental for an old man to attempt to re- 
juvenate himself. On the other hand, it is difficult to see 
how a young woman can marry an old man. Surely in 
some cases it is merely a matter of money; in others, that 
of having a companion and a home; in some women, who 
are jealous, there may be a sense of security with an 
old man. 
In Paris, I heard of an old professor in the medical 
college who was disliked by all the students for his 
harshness. Upon his marriage to a girl of twenty, the 
students made bets with one another that he would die 
in a month’s time. He died suddenly of heart disease 
six weeks after his marriage and the students suggested 
erecting a statue to the young lady for having rid the 
medical school of such a pitiless professor. 
It seems to be true that women age more rapidly than 
men and in many instances (especially when marriage 
rests upon a physical basis) a difference of a few years 
between man and wife is best; if the basis is spiritual 
or intellectual, age does not matter. However, the old 
man who marries a young woman will usually pay the 
penalty, for nothing tends to lower vitality like this and 
it may take several years from a man’s life. In America, 
married couples are usually of about the same age and 
not infrequently the woman is older than the man. In 
France, a man is usually about ten years older than 
his wife and I believe this is more advisable since women 
usually seem to age more rapidly than men. 
Normal sexual life in the aged, in couples who have 
been married for several years and where each had be- 
come accustomed to the other, is not harmful to either the 
man or woman, but the act should not be repeated too 
frequently. The activity of spermatozoa ordinarily ends 
at the approximate age of sixty, which would apparently 
indicate that sexual indulgence should be lessened at this 
time. 346 
GERIATRICS 
We strive to discover what Nature planned for us, 
hut it is impossible as each individual is a Taw unto him- 
self; we cannot make a rule that will apply to all. 
Again, marriage has different foundations in different 
persons, being based upon the physical, spiritual or intel- 
lectual side. The intellectual foundation is the strong- 
est and nothing can destroy the happiness of such a 
union. On the contrary, the physical side is easily 
changed by certain conditions which may lead to diffi- 
culties in married life. 
Bright’s disease seems to increase sexual power in 
some old men. I have observed it in a few cases. One 
man, aged sixty-five, had a mistress and indulged fre- 
quently in sexual intercourse. It had a decidedly bad ef- 
fect on his general health; finally, he contracted syphilis 
from her and died from syphilo-toxemia. 
A man of sixty-five was unable to have satisfactory 
intercourse with his wife because she had an inoperable 
tumor of the uterus. He developed neurasthenia, as a 
result of this, and suffered from many indefinite pains. 
He lost his appetite and had insomnia. Neither medica- 
tion nor electric treatment were of benefit to him. He 
finally consorted with a young woman and a few days 
afterward consulted me for frequent and painful urina- 
tion and told me that there was a discharge at the 
urinary meatus. Careful examination by microscopic 
methods did not reveal gonorrhea, but it was impossible 
to convince him that he did not have the disease. On 
another occasion, he had intercourse with another 
young woman and informed me that he had contracted 
a chancre. Again, it was difficult to convince him that 
he did not have syphilis. He later sent his wife to me, 
seeking relief for her condition which being remedied 
would permit him to have sexual congress; but I was 
unable to help her in any way. On another occasion, he 
consulted me for what he called atrophy of the penis and SEXUAL LIFE IN THE AGED 
347 
testicles, but examination did not reveal anything ab- 
normal. He realized that his extreme nervous condi- 
tion was due to lack of sexual gratification, but could 
not derive any pleasure from intercourse with women 
other than his wife because of fear of venereal disease. 
The condition continued to cause melancholia and he 
was later found dead in a stable where he had hanged 
himself. I had known him for several years, as well as 
his family, and there were no signs of nervousness or 
insanity in any of them. 
Case II.—A man of seventy-six still retains his sexual 
power and occasionally has intercourse. For the past 
year each time he has performed the act, he has been 
obliged to use a catheter for twenty-four hours after. 
Case III,—A man, aged eighty-two informed me that 
he did not lose the power to have satisfactory inter- 
course until the age of seventy-four. 
Case IV.—A man, aged seventy-three, suffering from 
senile nephritis, could perform the act of sexual inter- 
course until the age of sixty-eight. He told me that he 
could begin the act now, but lost the erection before the 
act was completed. 
Case V.—A man, aged sixty-five, married a woman of 
forty. A few weeks later he developed angina pectoris, 
the attacks became more frequent and he died within a 
year. Sexual intercourse invariably brought on an 
attack of angina pectoris. 
Case VI.—A man aged fifty-five had nephritis and a 
systolic blood pressure of 210. His wife was a strong 
and healthy young woman of thirty-seven. One eve- 
ning upon being hastily summoned, I found him in a very 
weak condition, breathing with difficulty, with pulse rapid 
and weak, and there was a cold perspiration. He 
was suffering from pulmonary congestion. He had felt 348 
GERIATRICS 
very well a short time before, but while having sexual 
intercourse this attack came. A few days after, he 
had an attack of angina pectoris and during the week 
several followed. He remained very quiet and benzyl 
benzoate was prescribed. Sexual intercourse was pro- 
hibited and he gradually improved; he has not had an 
attack of angina pectoris for the past three months. 
I have asked numerous old men about their sexual life 
and I have found that many of seventy or seventy-five 
are performing the act of coition occasionally. We must 
remember, however, that old men are apt to deceive us 
and prone to brag about their strength. As a rule, 
Women at this age do not enjoy the act although there 
are exceptions. 
Prof. Charles Green in his “Case Histories in Dis- 
eases of Women,” stated that in his early professional 
life he performed an extensive plastic operation for 
uterine procidentia on a woman of seventy, whose hus- 
band was somewhat older; the vagina was greatly nar- 
rowed and barely admitted one finger; the result to the 
surgeon was very gratifying; but some days after the 
usual convalescence the husband appeared with the com- 
plaint that coitus was no longer possible, and the profes- 
sor had the chagrin of being required to incise the pos- 
terior wall he had so effectually narrowed. He states: 
“This experience is thus given for two reasons: first, for 
the guidance of young surgeons who may be as ignorant 
as the writer was, in supposing that sexual life neces- 
sarily ceases soon after the climacteric; and secondly, to 
show that women at the menopause, overcome with de- 
pression by the thought of presumed loss of womanhood 
and womanly attractiveness, may safely be told some 
years may elapse before the connubial relationship 
passes into final abeyance.” 
The work of Dr. Armaingaud of Paris, is well known 
in France and has been somewhat similar to that of Dr. SEXUAL LIFE IN THE AGED 
349 
Trudeau in America. I spent several moments with him 
in Paris when he was preparing an important contribu- 
tion on ‘ ‘ Love in Old Age, ’ ’ for the Academy of Medicine. 
Although past seventy-five years of age Dr. Armaingaud 
is most active and his contributions are very important. 
One is so valuable that I am translating it. It is en- 
titled “Love in Old, discussed from the Medical and So- 
cial Standpoint,” printed in the Bulletin of the Academy 
of Medicine, Paris, No. 21, May 27, 1919, and the trans- 
lation runs as follows: 
“I hope each of you will acknowledge that at the age 
when business men usually abandon their career, after 
having made a fortune, to rest and quietly enjoy life, 
these men, if they are in good health, have reached the 
maximum of their value, in so far as professional experi- 
ence and life experience are concerned. It would, there- 
fore, be most useful, from the business standpoint as well 
as from the family and personal standpoint, that these 
old men should live as long as possible, so as to impart 
the benefit of their disinterested experience to those who 
replace them in the careers which they are abandoning 
(those who, deprived of advice, would only acquire that 
experience at their own expense and tardily, could thus 
acquire it easily), to enable their families to take advan- 
tage, in the conduct of life, of all that years have 
taught them, and ultimately to give their fellow-citizens 
—as town counsellors, general counsellors, deputies, or 
mere citizens—advice and to impart to them the views 
they have developed through long intercourse with men. 
What an increase in wisdom and riches, human health 
could be benefited with if we could find a way to aug- 
ment the number of these beautiful elders, who, over 
eighty years of age, remain healthy, high-spirited, 
wholesome in mind and body, and only die, as said Fon- 
tenelle of extreme old age, experiencing but a difficulty 
to live, not painful and free from ailments and diseases! 350 
GERIATRICS 
Well, gentlemen, it seems to me that physicians can con- 
tribute, to a certain extent, to such a result, since one of 
the causes of premature senility is due to unfortunate 
habits and mistakes, which, especially in cities, old men 
contract and make, and that physicians can effectively 
combat, since, as I will show you, I myself have had 
some success in that line. 
“I have, during thirty-five years, practiced medicine 
in a very large city, and like many other physicians I 
was the friend and confidant of numerous families of 
patients who were mainly business men, tradesmen, or 
intellectuals. I preserved all their faculties, all their 
moral dignity, and, to a great extent, their physical 
strength, until a very advanced age. 
“But those I will mention, who are all dead now, were 
exclusively business men. I have observed the facts 
which I will discuss in men who, more easily than others, 
become unoccupied and bored. This seldom happens 
amongst intellectual or professional men, especially phy- 
sicians, who continue to practice until an advanced age. 
These men I will speak of were either inhabitants of the 
city, or natives of the neighboring communities and even 
states, as my appointment of college physician had grad- 
ually acquainted me professionally with a great number 
of families who came to visit the sick youths and took 
advantage of the opportunity to address themselves to 
me. 
“Usually these men, whose ages ranged between sixty 
and sixty-nine years, were healthy and intelligent. I 
always regretted to observe that a year or two after 
their withdrawal from active life their spirits began to 
lower in a noticeable manner, their physical strength 
being equally impaired, and their disposition changed. 
Their wives often confided this latter point to me. 
Such old men, hence so charming, kindly, who so readily 
took their grandchildren in their laps and loved them SEXUAL LIFE IN THE AGED 
351 
greatly, began to grow indifferent, often even sad and 
‘grumpy,’ depressed and exacting toward the house- 
hold, often came home at one in the morning, and if I 
did not guess it, the wives would tell me that they had 
mistresses usually between twenty and thirty-five years 
of age. Ever since my first year of practice, experience 
showed me that erotic excesses in men of sixty, sixty-five 
and seventy years of age played an important part in 
causes of apoplexy, cerebral congestion, softening, car- 
diac affections, and ultimately in the rapid weakening of 
intelligence and will-power. As soon as I had suffi- 
ciently numerous professional relations and friendly and 
amiable patients, as were easily found in the city I lived 
in, I resolved to follow up the study of this question, to 
which I was sufficiently prepared. When the first wife 
came to confide in me, I listened to her with an interest 
increased by the fact that I knew the senile love which 
had got hold of the husband’s heart and senses; the 
object being a pretty girl of twenty-five, whom he treated 
most liberally, I had noticed that my patient was begin- 
ning to decay. I will not go into details and speak of the 
38 cases, identical in kind, on which my comparative 
statistics bear, all I will say is that as my experience in 
this matter spread and completed itself, each day I 
learned how better to act in order to obtain the results 
I sought, i. e., to have- my patient decide to leave his 
mistress. I will relate all these cases to the typical one, 
as they are all identical in essentials. 
“Having decided with my patient’s /wife that she 
would send him to me as soon as he would feel slightly 
unwell, I soon succeeded, following the natural course 
of the medical cross-examination, to make him confess 
that he had a mistress, usually young. Speaking of our 
friendly relation, and the affectionate feelings that I 
entertained towards himself and his family, of the inter- 
est I took in his physical and mental health, I made a 352 
GERIATRICS 
true and attractive picture of the joy that reigns in a 
numerous family, where three generations lived side by 
side, where the grandfather, amiable, kind, debonair, 
knows how to fulfill in a dignified manner his role of 
patriarch, being through long years an incarnation of 
respected, dignified, elegant even, old age, useful and 
pleasant to all. I recalled the sudden death of one of 
his contemporaries and showed him that it was due, not 
indeed to old age, but to the excesses, either real, or com- 
parative (the practice in itself being almost an excess 
after sixty years of age), adding that it is to old men 
especially that applies the dictum, ‘post coitum omne 
animale triste. ’ I made use of my historical remem- 
brances, and told him what happened to a certain num- 
ber of great men, the greatest in the history of the world, 
who tardily gave themselves up to women. Far from 
trying to deceive him, I also spoke of the existence of 
some exceptional cases, comparatively rare, of men who 
in spite of those excesses continued a beautiful career, 
either political, military, civil, or literary. But saying 
that in most of the men who so acted, the intercourse 
with women weakened and belittled, I explained to him 
the physical results of acts too frequent which can 
often be traced up to a desire to be true to a whim, and 
I reminded him of the moral standards natural to a 
man who feels rightly, if he did not realize it himself, 
told him that the woman, in spite of his generosity, was 
not faithful to him. I also spoke of old men, chosen 
amongst his contemporaries, who were examples of wise 
old age, sober and chaste, and thus I succeeded, in a 
great number of cases, in inducing him to take this seri- 
ous determination, to abandon his mistress absolutely 
and forever, and if some need, most often fictitious and 
the result of auto-suggestion, made itself felt, I advised 
him to satisfy it in a special house, so as not to think of 
it often. SEXUAL LIFE IN THE AGED 
353 
“Out of 38 old men I only speak of those who were 
worth the care I gave them because they were, I repeat, 
well-preserved physically and morally at the time of 
their withdrawal from active life. 
“Twelve could not give up their mistresses. 
“Seven listened to my advice for a few years, then 
relapsed. 
“Nineteen took my advice and followed it with con- 
sistency, never going back to their illegitimate compan- 
ions. The first twelve, whose ages ranged between 
sixty-two and sixty-six years, averaged sixty-three, when 
according to the tables of the French companies (1878) 
which are used by the insurance companies of the 
‘rentes viageres,’ they should have lived an average 
of fourteen years more, i. e., reach seventy-seven, died 
at an average of seventy-three, thus losing four years of 
life, one with a single exception reaching seventy-nine 
years of age; out of the seven who partially followed 
my advice, during a few years only, and whose ages 
ranged between sixty and sixty-nine years, averaged 
sixty-five, and who according to the insurance tables 
should have lived thirteen years more, consequently 
until seventy-eight, six died at the age of seventy-five 
(average) thus losing three years of life, with a single 
exception who reached eighty. 
“Of the nineteen whose ages ran between sixty-three 
and sixty-nine, average sixty-six, three exceptions died 
at sixty-eight, seventy and seventy-two, but the sixteen 
remaining ones, who, according to the insurance tables 
should have died (average) twelve years later, i. e., at 
seventy-eight, lived, always striking an average, until 
eighty-six, thus gaining thirteen years of life on the 
first group and eleven on the second group. 
“Such are the facts I observed, the results I obtained, 
needless to mention, the great moral satisfaction I de- 
rived from preparing and convincing my patients, 354 
GERIATRICS 
through energetic will-power and successful efforts of 
perseverance, satisfaction increased by the expressions 
of gratitude of the subjects themselves and their fami- 
lies, who thanked me warmly and blessed me for having 
so rapidly transformed vacillating elders, on the way to 
decadence, dissatisfied with themselves, into kindly old 
men, amiable, in high spirits, real patriarchs, in a word, 
making the happiness of families in whose midst I my- 
self enjoyed seeing them. 
“Let us not forget the physiological conclusion which 
emanates from these facts. 
“Human life regulated by reason, instead of being 
dominated by passions and fictitious needs, is not, ac- 
cording to the laws of Nature, as short as it actually is. 
“It is not the number of years, it is not normal senil- 
ity, the inevitable decay of the organs which causes old 
men to die at sixty-five or even seventy years of age, 
and the Arab proverb, quoted by our colleague, Profes- 
sor Lacassagne, in his most remarkable memoir on ‘Man 
toward the end of his life’ saying ‘the worst enemies of 
an old man are a good cook and a young wife,’ ex- 
presses with great accuracy a great truth. 
“It is, in fact, a private instance of a general law 
demonstrated and developed by all true moralists, and 
more especially, and with great charm, by Montaigne, 
that we are the very cause of many of our misfortunes, 
and that it is true in a measure to say ‘Man does not 
die, but kills himself.’ 
“Nothing is more important, in order to avoid most 
of these inevitable misfortunes, than to be convinced of 
that great truth. 
“I think, gentlemen, that these facts which are the 
result of an experience, I can almost say a professional 
experimentation, that I am proud to call fortunate, de- 
serve to be brought to the knowledge of physicians. 
What I have done others can do, and so augment the SEXUAL LIFE IN THE AGED 
355 
number of good and beautiful old men, whose life will 
be agreeably prolonged and usefully so, for our own 
good. The rate of rentes viageres for old men will per- 
haps be cut down by companies, fall from 15 per cent 
to 20 per cent, but the interest and value of human life 
will be notably increased. Allow me, gentlemen, in clos- 
ing, to cite two historical facts, which, selected amongst 
those I quoted to my patients, uphold my conclusions. 
Julius Caesar, the greatest captain of the world, great 
orator and writer, after some glorious victories, reaches 
(at fifty-six years of age) Egypt, to conquer it, and this 
conquest is so easy that after a short sojourn there, he 
has nothing to do but to go home, yet he forgets him- 
self in the arms of the very young queen, Cleopatra, and 
long resists the entreaties of his generals, who press him 
to proceed towards Rome, menaced by invasions. Am- 
bition for the first time is conquered by love, and he is 
about to lose the fruit of his victories and dishonor him- 
self when his generals decide to tell him that if he does 
not choose to leave they will put to sea and save the 
country. So, compelled to leave Cleopatra, who had 
given birth to little Caesarion, he returns to Rome and 
repulses the foe. Soon three triumphs are to be cele- 
brated to honor his victories, but he thinks of bringing to 
Rome the beautiful queen, Cleopatra, to attend them. 
So, he gives her the most abode in Rome, the 
villa Tibur, which belongs to him, forgets all cautious- 
ness, and has a gold statue erected to her in the Temple 
of Venus. These extreme and unseemly favors bestowed 
on a stranger shocked the Roman sense of dignity, and 
roused such an anger against him that the historian 
Dion relates that the Roman matrons, senators’ wives, 
stirred up their husbands until they contributed in the 
arming of Cassius and Brutus. But for this the cross- 
ing of the Rubicon would perhaps never have roused 
such indignation and such a doom as took away his life. 356 
GERIATRICS 
“As to Henry IV, at fifty-seven years of age, his 
senile and extravagant love for the young Charlotte de 
Montmorency, 16 years old, caused the most extraor- 
dinary events to pass, during which he completely ridi- 
culed himself in the eyes, not only of his subjects, but of 
all the European courts. He even went so far as to 
have invented and denounced by his ministers, Villeroy, 
Sillery and Jeannin, a plot of Conde against the state, 
intending to force the Dutch to surrender that prince 
who had sought refuge in the low-countries with his 
wife who was pursued by the King. It made a mental 
wreck of him. He even went so far as to dress like a 
stable-lad in order to see Charlotte who had left the 
court to escape from him. The results of this mad ad- 
venture, so well related by Colonel Henrard, were that 
he was ready to wage war against all Europe when 
Ravaillac, for his own good, and that of France killed 
him. ‘Never before or since in modern history,’ wrote 
Hanotaux, ‘had a great country seen its fate depend on 
the slightest whim of a senile lover.’ ” 
I wish to emphasize Dr. Armaingaud’s statement that 
experience has shown him that erotic excesses in men 
of sixty, sixty-five, and seventy years of age played an 
important part in causes of apoplexy, cerebral conges- 
tion, softening, cardiac affections, angina pectoris, and 
ultimately in the rapid weakening of intelligence and 
will power. In my experience I have found this to be 
true in most cases and I believe sexual intercourse 
should be limited after the age of sixty. CHAPTER XLII 
RADIUM THERAPY IN SENILE CASES 
The natural process of arterial degeneration, which 
impairs the blood supply of the skin, predisposes to the 
development of epithelioma in old age, especially if there 
is traumatism. Superficial cancer in the aged fre- 
quently develops from certain conditions which are 
termed precancerous dermatoses. For instance, simple 
keratosis, leukoplakia, cutaneous horns and senile warts 
often become malignant and in these cases we should 
endeavor properly to diagnose and treat the early con- 
ditions. Leukoplakia lingualis, often due to excessive 
use of tobacco or syphilis, frequently ulcerates and is 
the beginning of epithelioma of the tongue. In old age, 
many of these conditions are due to syphilis, but histo- 
logic examination often reveals cancer in combination 
with it. 
We must not overlook the fact that in old age low- 
ered resistance predisposes to infection, and many of 
these epitheliomas become infected with Streptococcus 
pyogenes or Staphylococcus aureus or albus. This 
secondary infection often has fatal results due to 
septicemia, extensive local suppuration, erysipelas, 
thrombosis, edema of the glottis or pneumonia. These 
infections may determine the rapidity of metastasis 
since they spread very rapidly by the lymphatics. 
The general health is always poor in such cases and we 
must endeavor to improve it. It is well to cure these 
secondary infections before commencing treatment, em- 
ploying vaccines, and in staphylococcic infections pre- 
357 358 
GERIATRICS 
scribing stannoxyl. At the same time stannoxyl liquid 
and ointment may be used locally. 
It is absolutely necessary to make a biopsy in every 
case, since we are not able to diagnose it clinically, and 
because the treatment depends upon the type of cancer. 
We must determine whether radium, x-rays or surgery 
is to be employed. Although it is not advisable to in- 
jure any senile carcinoma, we may, under cocaine, re- 
move a V-shaped piece of tissue for histologic exam- 
ination and the treatment should be given as soon as 
possible after a diagnosis has been made. A histologic 
examination should be made in all cases of dermatoses 
that are classed as precancerous. The type of cancer 
also gives us the prognosis; sometimes two kinds of 
diseased tissue may appear in the same growth, for ex- 
ample, syphilis and epidermoid carcinoma may co-exist. 
Senile warts, keratoses and cutaneous horns may exist 
for a long time before changing, but under the influence 
of traumatism may undergo an epitheliomatous trans- 
formation. In old age it is well to cure these conditions 
before they become malignant. An application during 
24 hours with a flat apparatus containing four milli- 
grams of radium element for each centimeter of surface 
to be treated, filtering the plaque with one millimeter 
of lead and one-half centimeter of gauze is often bene- 
ficial. The apparatus is kept in place by adhesive tape 
and removed at the end of 24 hours. 
Precancerous Lesions 
Epithelioma of the Skin 
A woman, aged sixty-nine, had a neoplasm of the left 
cheek and histologic examination showed that it was a 
basal-celled epithelioma. Its diameter was one and one- 
half centimeters and its elevation above the surface of 359 
RADIUM THERAPY IX SENILE CASES 
the skin one centimeter. There was an area of indura- 
tion around it and the surrounding tissues were in- 
flamed. The crust was removed, the neoplasm cleansed 
with ether and an applicator containing ten milligrams 
of radium element was prepared as follows: The plaque 
was covered with 1 mm. of lead over which was 0.2 mm. 
of aluminum. Six millimeters of cork was placed over 
this with another piece of cork 3 mm. thick in which a 
place was cut exactly the size of the epithelioma. 
Thread was wrapped around this applicator which Avas 
then dipped in wax. The distance from the radium to 
the neoplasm Avas one centimeter. 
This applicator Avas strapped on the face by adhesive 
tape, then a bandage Avas applied; it A\7as left on the face 
constantly for 120 hours. This gave a dose of 1200 
milligram hours, Avhich multiplied by 0.00751 gave 9.01 
millicuries destroyed in five days. In the surface ap- 
plicators one-half of this is lost in the air; the actual 
dose Avas therefore 4.50 millicures destroyed. 
Tavo Aveeks after the treatment the epithelioma had 
entirely disappeared, leaving a raAv surface A\7hich Avas 
entirely healed in another Aveek. The indurated area 
also disappeared. 
Basal-celled epithelioma may also be treated by a 
plaque containing four milligrams of radium element 
for each centimeter of surface to be treated, filtering by 
one-tenth millimeter of lead or six-tenths millimeter of 
aluminum. It is not necessary to eliminate the second- 
ary rays of lead since the tissues of the neoplasm will 
arrest many of them. This apparatus may be left in 
place for 10 or 15 hours. This is the technic of 
Simone Laborde, and she notes that if there is an indu- 
rated base, or if it is difficult to protect the healthy 
tissues surrounding the groAvth, it is better to employ a 
filter of four-tenths or five-tenths millimeter of platinum. 
In treating spino-celled epitheliomas it is necessary to 360 
GERIATRICS 
use a much stronger dose varying from 20 to 60 milli- 
curies destroyed. From 100 to 150 milligrams of ra- 
dium element distributed in several platinum needles of 
four-tenths millimeters in thickness should be used. 
Fig. 22. Basal-cell carcinoma of left temple, of two 
months’ duration. 
These needles may be imbedded in gutta-percha and ap- 
plied as a flat applicator for 24 to 60 hours. Many 
times, in spino-celled epithelioma, it is better to excise 
the neoplasm by surgical procedure, possibly using ra- 
dium or x-rays preceding and following the operation. RADIUM THERAPY IN SENILE CASES 
361 
Cancer of the Tongue 
In the Institute of Radium, Paris, I was astonished to 
see the number of senile cases for treatment of cancer of 
Fig. 23. Same patient as Fig. 22, taken four years after 
radium treatment, showing no trace of the disease. 
the tongue, and I believe that Professor Regaud’s work 
is one of the most important in the world. Professor 
Regaud has given a great deal of study to the treatment 
of cancer of the tongue and the results obtained by him 
are often remarkable. 
Cancer of the tongue is frequent and very serious in 362 
GERIATRICS 
old age. It is often caused by excessive use of tobacco, 
defective teeth, or syphilis. The sharp edges of defec- 
tive teeth cut the tongue and one of these cuts will 
eventually be the starting point of cancer; leukoplakia, 
Fig. 24. Patient, aged 65, treated the same as patient in 
Fig. 22, for basal-cell carcinoma of the nose, showing com- 
plete healing four years after the application of radium. 
frequently caused by tobacco smoking, is sometimes the 
beginning of epithelioma. 
Leukoplakia lingualis should always be looked upon 
with suspicion and a histologic examination made. 
Often caused by syphilis, it does not respond to anti- 
syphilitic treatment. As pointed out by Professor Re- RADIUM THERAPY IX SENILE CASES 
363 
gaud in. the Paris Medical, April 2,1921, it is of no prac- 
tical interest in cancer, to give treatment for syphilis. 
It is useless and much valuable time is lost, and it may 
even hasten the neoplastic process. A good biopsy, made 
by a competent histologist, is all that is necessary and if 
cancer is present there is no need of a Wassermann test, 
treatment with mercury, arsenic or the iodides. 
Failure to recognize the precancerous stages in old 
age may cause great harm. The pearly white thicken- 
ing of the epithelium in leukoplakia should lead us to 
suspect cancer. Fournier stated that 30 per cent of 
cases of leukoplakia are followed by cancer and should 
be treated as malignant. 
Regaud’s treatment of cancer of the tongue is most 
remarkable. Depending upon the histologic examina- 
tion, he usually employs needles containing emanation 
tubes of radium, but prefers needles containing sulphate 
of radium; the needles are made of platinum which 
has been fortified by iridium, the thickness of the walls 
being four-tenths millimeter. Radium puncture,—by 
means of needles inserted into the tongue,—enables one 
to completely sterilize the neoplasm by including all of 
the tumor, besides treating one to one and one-half centi- 
meters of the area surrounding the epithelioma. The 
dose given is 20 to 30 millicuries destroyed of emana- 
tion of radium (this corresponds to 5000-6250 milligram 
hours of crystallized bromide of radium, and 2660-3330 
milligram hours of radium metal), filtered by four- 
tenths millimeter of platinum. This dose of one milli- 
curie destroyed for three to four cubic centimeters of 
tissue, with this filtration, will not dangerously affect 
normal tissues. Sometimes 15 needles are placed at 
regular intervals in surface and depth. 
Regaud teaches that the intensity is a matter of great 
importance and his experience indicates that a feeble 
intensity is of the greatest value in treating cancer of the 364 
GERIATRICS 
tongue. He believes the best duration of irradiation to 
be about eight days. One hundred milligrams of radium 
in 10 hours gives the same dose as 10 milligrams for 100 
hours but these different intensities give different re- 
sults. He states that a certain case of epithelioma of 
the tongue was apparently cured by a dose of 10 milli- 
curies of emanation of radium destroyed in eight days 
with one dose in five needles of radium puncture. It 
would have been aggravated, on the contrary, with a 
dose of 10 millicuries destroyed in one day by one or two 
punctures. A certain case of epithelioma of the neck of 
the uterus, not invading the surrounding tissues, was 
apparently cured with one dose of 20 millicuries of eman- 
ation destroyed in three days in one intracervical focus. 
It would probably not have been cured by the same doses 
administered in fractions in four weeks.1 
The needles used vary in length from five to 30 
millimeters and are Vw millimeter thick, and the emana- 
tion tubes of radium are placed in these needles, previ- 
ously dipped in wax, which holds the tubes in the needles. 
The needles are then inserted into the tongue at a dis- 
tance of about one centimeter from one another, care 
being taken to include the tissues outside the indurated 
area. These needles are then sewn into the mucosa of 
the tongue and the ends of the thread placed over the ear 
and held there by adhesive tape. The needles are left 
in place for eight days, then removed. 
The adenopathy which usually follows is an important 
matter. In some cases several needles containing eman- 
ation of radium tubes are inserted into the glands at the 
same time the needles are placed in the tongue. In other 
instances it is advisable to remove the glands by sur- 
gery; sometimes radiotherapy will cure these enlarged 
glands. In a patient 80 years of age it is often imprac- 
l Regaud, Cl.: Radiotherapy des Cancers. Report presented to the Fifth Con- 
gress of International Society of Surgery, Paris, July, 1920. RADIUM THERAPY IN SENILE CASES 
365 
ticable to remove the glands by surgical means. In such 
cases we may try radium-puncture, or, x-rays may be of 
benefit. 
It is preferable to use radium sulphate in the needles 
as the radiation is much more constant than with the 
emanation of radium tubes. Inserting the needles into 
the tongue can often be done under local anesthesia with 
cocaine or under general anesthesia with gas-oxyg’en. 
One millicurie of emanation of radium destroyed is 
equivalent to 132 milligram hours with radium sulphate. 
The total amount of energy expended in milligram hours 
is for radium element and millicuries of emanation 
destroyed for the emanation tubes. It is, however, con- 
venient and possible in both cases to use the term “milli- 
curies destroyed.” For example, an application of 20 
hours with 100 milligrams of radium salts or with an 
equivalent quantity of emanation of radium can be ex- 
pressed in average quantity: 
One hundred milligrams of radium element for 20 
hours. 
One hundred millicuries for 20 hours. 
We can say that the quantity of emanation of one milli- 
gram of radium element in one hour is equal to 0.00751 
millicuries, the same quantity destroyed during the same 
time. This quantity would be for 100 milligrams in 20 
hours (2000 milligram hours) 0.00751 X 2000 — 15.02 
millicuries of emanation destroyed, and 100 millicuries 
during 20 hours corresponds to 0.00751 X 2000 = 15.02 
millicuries of emanation destroyed. The intensity is 
obtained by dividing the total dose by the time, thus 
15.02:20 = 0.751 millicuries destroyed per hour. With a 
tube of radium this number expresses a constant inten- 
sity; with a tube of emanation of radium it expresses an 
average intensity. 
The investigations of Prof. Regaud regarding inten- 366 
GERIATRICS 
sity are very valuable in radium therapy, and our suc- 
cess often depends upon the observance of this important 
fact. 
Epithelioma of the Lips 
This is usually a disease of elderly people and may be 
papillary or ulcerative and infiltrating in form. Sec- 
ondary infection by the Streptococcus pyogenes often 
complicates the trouble. The majority of cases are 
spino-celled epithelioma and the small, superficial lesion 
which precedes this condition should be treated by small 
doses of radium in a flat applicator as a preventive meas- 
ure. For the infiltrating type it is better to introduce 
into the mass small needles containing radium element or 
emanation tubes. The needles should be about 27 milli- 
meters in length and four-tenths mm. thickness of 
platinum. From two to five needles are inserted into the 
mass, each one containing from 1.33 to 3 milligrams of 
radium element, giving a total dose of about 10 to 20 
millicuries destroyed in eight days. The submental, 
submaxillary and deep cervical chain of glands may be 
treated by radium-puncture with the same kind of nee- 
dles, or it is often possible to treat them afterward with 
x-rays. 
Epithelioma of the Rectum 
It is often possible to cure cancer of the rectum and in 
hopeless cases to relieve suffering. Dr. M. H. Cesbron, 
of Paris, sometimes employs platinum needles 5 c.m. in 
length, and three emanation tubes in each needle. Sev- 
eral short needles are also used, each one containing 
about 16 millicuries of emanation of radium. The dose 
is about 50 millicuries destroyed in 96 hours. Another 
method is to imbed platinum needles containing radium 
element, filtered by two-tenths mm. of aluminum, in 367 
RADIUM THERAPY IN SENILE CASES 
dental composition, which is placed into the rectum, 
removed each day and cleaned, giving the same dose as 
described above. 
Cancer of the Uterus 
Many inoperable cases in old age will be relieved by 
radium therapy. The emanation tubes covered with two- 
tenths mm. of aluminum may be placed in a blind cath- 
eter of pure rubber for intrauterine application and at 
the same time an emanation tube covered by two-tenths 
mm. of aluminum is inserted in a gold tube 2.5 mm. thick. 
The latter is then placed in a cork which has been cut for 
the purpose. This is to be applied to the cervix. For 
the parametrium an apparatus made of two corks 
between a wire spring is used, each cork containing the 
gold tube (with 15 per cent of platinum mixed with the 
gold) and the emanation of radium, or the salt of radium 
in a glass tube. In this way the parametrium is treated 
while the intrauterine and intracervical application is 
made. The whole apparatus is left in place for a period 
of four to eight days. For these treatments of long dur- 
ation it is necessary to use great care in the filtration of 
the rays. It is possible, in many instances, to cure can- 
cer of the uterus in senile cases, and in others life will be 
prolonged and suffering greatly diminished. Regaud’s 
treatment of cancer of the uterus at the Institute of Rad- 
ium, Paris, is most valuable. 
Biologic Studies in Radium Therapy 
The studies of Professor Regaud, assisted by 
Dr. Lacassagne, on the effect of radium on the tissues, 
may mark a great advance in radium therapy. The 
investigations are made to determine “why radium cures 
cancer,” and at the laboratory of biology Professor 368 
GERIATRICS 
llegaud and his assistants are experimenting on animals 
and making studies in cancer of man. 
Professor Regaud notes that cancerous cells are more 
sensitive to the gamma rays of radium than the healthy 
cells, yet we ignore the actual cause of this radio-sensibil- 
ity. It is very likely physiochemical, or more precisely, 
electrochemical. 
A cell is not equally sensitive to radium during all 
the periods of its development. Professor Regaud has 
studied the biologic problems connected with the use of 
this substance and has proved that the sensibility to ra- 
dium is at its climax at the moment when the nucleus of 
the cell divides itself. This theoretical observation en- 
ables us to draw a practical conclusion. The applica- 
tions of radium should if possible, be prolonged so that 
the cycle of evolution of the cells we must reach should 
include a division of the nucleus. 
It is not enough to possess a substance whose radia- 
tions have a favorable action on malignant tumors, we 
must be able to spread its energy accurately throughout 
the cancerous mass and the external application only 
enables us to reach the surface of large tumors. Thanks 
to radium-puncture, we are now able to act upon the 
mass itself. 
In giving one treatment of long duration, with feeble 
intensity, we will probably obtain better results than 
with massive doses given for a short time. 
Radium therapy has a wide application in geriatrics, 
since cancer so often occurs in old age. Many old peo- 
ple, hitherto given a death warrant because of cancer, 
owe to radium therapy several years of life. CHAPTER XLIII 
SURGERY OF THE AGED 
Surgical procedures in senile cases present many 
peculiarities which make the work more difficult and the 
prognosis graver than in earlier life. These peculiar- 
ities include constitutional changes (greater resistance 
to infection, when the individual is in fairly good condi- 
tion, and considerably lowered resistance when the body 
is debilitated, more profound surgical shock, slower re- 
action from shock, slow and incomplete repair, deleteri- 
ous after effects, etc.), and local changes (degenerations, 
atrophy, larger proportion of inorganic salts in bone 
making, bone more brittle, lessened power of repair, 
cardiac and respiratory degeneration, increasing 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 impera- 
369 370 
GERIATRICS 
tive 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, and promises the best 
clinical results? 
In many cases where operation is advisable, but not 
imperative, the decision will depend upon the presence 
or absence of pathologic conditions common in the 
aged, such as diabetes, nephritis, cardiac or pulmonary 
disease, cerebral or nervous conditions and extreme 
debility. There can be no debating when noninterfer- 
ence will result in speedy death, but even in such cases 
measures should be taken to minimize the dangers of 
eventual complications due to the chronic disease. 
Diabetes, for example, is especially liable to cause coma, 
shock and infection. The danger of shock can be mini- 
mized by the use of morphine and atropine hypo- 
dermically immediately before operation, and whiskey 
and strychnine immediately afterwards. The anoci-as- 
sociation method of anesthesia minimizes surgical 
shock and should be used whenever possible. The great 
danger, in operations upon diabetic patients, is the 
development of coma and this is more likely to happen 
if ether is the anesthetic. 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 routine measure before operating on an aged 
patient an estimation of the quantity of sugar in the 
blood and the determination of the alveolar air carbon 
dioxide tension in acidosis, should be made by reliable 
tests. Many times the quantity of sugar in the blood 
will be increased but the urine may give no evidence of 
the condition. Before operating on a diabetic, treat- SURGERY OF THE AGED 
371 
ment should be given and the operation delayed until 
the blood sugar has been reduced. Normal blood con- 
tains from 0.06 per cent to 0.12 per cent sugar. Dr. 
Marriott’s apparatus for the determination of alveolar 
air carbon dioxide tension shows that a normal tension 
varies from 45 down to 40 millimeters. Those running 
from 35 down to 30 millimeters indicate a mild degree of 
acidosis and when the tension is as low as 20 millimeters, 
the patient may be considered to be in imminent danger. 
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 pulmon- 
ary disease. Chloroform is a cerebral, cardiac and res- 
piratory depressant and it must therefore be avoided 
or employed cautiously where such depressing 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 possesses 
no advantages over chloroform or ether used alone. 
Local anesthesia is attended by small danger, but it is 
not applicable to major operations except when used by 
the Crile method of anoci-association. Ethyl chloride 
is of service only when the operation does not involve the 
deeper tissues; in one case the frozen area became 
gangrenous. Spinal anesthesia owing to its uncertain 
action, difficult technic and danger of innervation of 
the muscles of respiration, should not be employed. 
The principal operative dangers are shock, hem- 
orrhage and infection. The danger of hemorrhage is 
slight if ordinary precautions are taken. Occasionally, 
a serious 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 372 
Geriatrics 
only if resistance is lowered through debility or disease. 
Septic infection in the aged is always a grave condition, 
but erysipelas on 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 
operation. In some cases there is apparent recovery for 
a few days, then sudden collapse occurs. In other cases 
there is mental and physical depression after opera- 
tion and a slow progressive deterioration ending in 
death. To avoid 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 de- 
pressing and the patient facing an operation 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 unfavorably, 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 go- 
ing 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, phosphorous and arsenic as tonics, and 
mild alcoholic stimulation should be employed. If the 
patient is nervous small doses of morphine should be SURGERY OF THE AGED 
373 
given for a clay or two before the operation. The dan- 
ger of morphine medication is its liability to produce 
respiratory paralysis and this is obviated by adding 
small doses of atropia. A dose of atropia, say Vi50 
grain, should always be given before chloroform or ether 
anesthesia if there is senile emphysema or myofibrosis 
or if morphine has been administered shortly before. 
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 seizure 
points to cerebral paralysis and the immediate paralysis 
of other vital centers. The cautious surgeon and anes- 
thetist have at hand means and measures to overcome 
shock and threatened paralysis of the vital centers but 
there is no known method of preventing cerebral paral- 
ysis. 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 
unknown. In one senile case sudden death occurred on 
the twelfth day after an emergency operation for strang- 
ulated hernia. The patient was making favorable prog- 374 
GERIATRICS 
ress, and tlie 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- 
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 no»t 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 
and 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 quan- 
tity of urine is lessened and there is 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 progres- 
sive uremia generally ends in coma and a rapidly prog- 
ressive uremia ends in convulsions. Large doses of 
bromides given as soon as the first slight twitchings ap- 
pear 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 bronchopneumonia, is especially liable to occur 
if there is a pulmonary disease complicating the surgical 
condition, and ether was used as the anesthetic. It may 
be due to the intense irritation produced by the anes- 
thetic, but most cases are probably due to emboli causing 
infarction. Like uremia it can be neither foreseen nor 375 
SURGERY OF THE AGED 
prevented, and death usually occurs in a few hours or 
days. There is no routine method of treatment, various 
measures having been employed in the few recorded re- 
coveries. Hypostatic congestion is one of the few post- 
operative dangers which can be foreseen and should be 
prevented. The necessity of frequently changing the 
position of the patient in bed is so well understood that 
hypostatic congestion is not frequent. 
The most common conditions in which operation is 
necessary are prostatic disease and hernia in the male, 
and cancer and gallstones in the female. Senile gan- 
grene, calculus, intestinal obstruction, fractures and 
cataract also occur frequently in the aged. In addition 
to these conditions requiring major operations there are 
many minor pathologic conditions which necessitate 
surgical interference. Varicose veins, chronic ulcers, 
hemorrhoids and bed sores all claim the surgeon’s at- 
tention. Traumatic conditions, except fractures, are 
rare in the aged, and appendicitis, perhaps the most 
frequent surgical condition in the young, is rare in ad- 
vanced life. 
It is not possible to offer suggestions as to the ad- 
visable procedures when there are several methods, each 
having its advocates and opponents. In prostatectomy 
for example, there are some surgeons who prefer the 
two-stage operation, some who cleave to the perineal op- 
eration, some who employ only the suprapubic method. 
Statistics are not always reliable. The only safe rule is 
to let the surgeon select the method which will give a 
minimum of shock and postoperative dangers. “Age is 
no bar to surgical operations.” But age implies com- 
plicating factors which make operations more difficult 
and more dangerous than in earlier life. Not the age of 
the patient but those complications must be considered 
when deciding upon the advisability of an operation. 
In every case where palliative measures will give relief 376 
GERIATRICS 
and promise little or no shortening of life such measures 
should be employed in preference to grave major opera- 
tions. 
One of the most difficult problems in senility is to 
select the proper anesthetic, and if we possessed a satis- 
factory method of anesthesia, our mortality rate would 
be greatly reduced. I have used the nitrous-oxide- 
oxygen narcosis for the aged with good results, and have 
always felt that if certain improvements could be made 
on the apparatus we could perform many major opera- 
tions with it. 
Doctor F. A. Bardwell of Boston lias devised an ap- 
paratus, 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. A Bennett bag is at- 
tached near the inhaler, instead of two or three feet 
from the cone. The oxygen tank is connected to the in- 
haler 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 possible for the patient to 
rebreath into the bag without a loss of gas, as occurs in 
the ordinary apparatus. 
There is a frame within the inhaler which is covered 
by gauze and 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, so that the inhaler can be used for ether 
narcosis. 
Doctor Bardwell has found that a small amount of 
ether, for example, a dram or two, will give the desired 
amount of relaxation, and at any time, if there is rigid- 
ity of the muscles, this small amount of ether will give 
a result satisfactory to the surgeon. In this way it is 
possible to operate upon strangulated hernia or in fact SURGERY OF THE AGED 
377 
to perforin almost any major operation. Doctor Bard- 
well obtained good results and his method of administer- 
ing nitrous-oxide-oxygen apparently overcomes certain 
obstacles, which makes it an ideal anesthetic for the aged, 
in almost every instance. 
Novocaine with suprarenin is a safe and satisfactory 
local anesthetic for the aged, and is employed in a weak 
solution, but a large amount of it is required. It may 
be used for strangulated hernia or operations upon the 
testicle, 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 novocaine to the raw sur- 
face before the dressing, which made the latter painless. 
When novocaine is combined with suprarenin the effect 
lasts about three hours. Alypin is a satisfactory local 
anesthetic in some cases. Many surgeons apply alypin 
to the urethra before performing cystoscopy. 
Strangulation of a hernia is very common in the aged. 
The operation can be performed with nitrous-oxide-oxy- 
gen anesthesia and very little ether, or under a local an- 
esthetic. Cocaine is a dangerous local anesthetic in the 
aged and novocaine should be used in its place. 
The removal of a carcinoma of the gastrointestinal 
tract in the aged is not often possible, if the operation re- 
veals an obstruction, an abdominal “anus” becomes nec- 
essary. This is horrible and in most cases death would 
be preferable. In some cases of cancer of the stomach a 
gastroenterostomy has been performed with excellent re- 
sults. One of my patients, aged seventy, had a car- 
cinoma of the stomach, with complete obstruction. Gas- 
troenterostomy was performed and the patient is now 
living in comfort, a year after the operation. 
Roentgenology assists us a great deal in determining 
the condition and also what surgical procedures will be 
necessary. By this method many carcinomata will be 378 
GEBIATKICS 
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 Roentgen ray it is possible to diagnose a 
pathologic gall bladder with or without stones, and also 
to detect the presence of renal stones. If there are gall- 
stones which are causing symptoms, cholecystotomy may 
be the best procedure. Many cases of gallstones will be 
confused with cancer of the liver, and a diagnosis will be 
difficult. Courvoisier’s law is that deep jaundice associ- 
ated with palpable enlargement of the gall bladder means 
carcinoma; without distention of the gall bladder it usu- 
ally means stone. 
Adenoma or carcinoma of the prostate may cause com- 
plete obstruction, and immediate operation becomes nec- 
essary. 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 Avith nitrous oxide anesthesia, employ- 
ing oxygen with it. A dram or two of ether with it 
will give the desired degree of relaxation. 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 hastily decide on 
amputation in senile gangrene. In many instances ex- 
pectant treatment is justified, free drainage may be made 
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 results will be better. While the dis- 
ease is in the active stage operation often hastens death. 
One thing is certain, it is a very grave condition and we 
are justified in taking a chance, Availing to see hoAV far SUKGERY OP THE AGED 
379 
Nature will go in protecting the patient. It is surprising 
to see what Nature will do in many cases; the great trou- 
ble 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 recovery without sur- 
gery. It is advisable in our expectant treatment, how- 
ever, to be prepared at any moment for amputation if the 
occasion demands it. If the patient is a diabetic the out- 
come is usually fatal and we are justified in waiting until 
the active period has subsided before operating. If the 
nitrous-oxide-oxygen narcosis is employed the result may 
be more encouraging. If the cellulitis is extending, op- 
eration should be performed as quickly as possible. 
Blood sugar examinations have done a great deal in 
enabling surgeons to cope with senile diabetes. The pa- 
tient can be given treatment and by following the blood 
sugar it is possible to know wlien it is safe to operate. 
In some cases carbuncles will be cured without surgi- 
cal procedures by multiple injections of an antiseptic 
solution containing phenolic ethers, and an autogenous 
vaccine. Tablets or hypodermic injections of stannoxyl 
often work well in these conditions. Stannoxyl works 
particularly well in staphylococci infections. However, 
free incision is advisable, and a cross-incision covering 
the entire diameter of the carbuncle should be made. 
An aged lady, seventy-five, fell and had a fracture of 
the neck of the femur. This was reduced and no treat- 
ment by means of extension apparatus was given. Two 
months after she was in a chair, a few weeks later she 
was able to take a few steps with the aid of crutches. 
The outcome of the fracture was not satisfactory but 
she is able to walk a little. A lady, aged seventy-four, 
had a fracture of the neck of the femur. I gave more 
attention to the fracture than to her general condition. 
She was tortured by the painful extension apparatus 
with weights and the pain caused by the treatment had to 380 
GERIATRICS 
be relieved by opiates. She died at the end of the sec- 
ond week. 
These experiences led me to believe that in many cases 
where we aim at an excellent reduction of the fracture, 
the patient dies, while if the fracture is not treated vig- 
orously, and all the attention is concentrated on the gen- 
eral health, we may get an excellent result physically 
and a bad result where the fracture is concerned. Open 
operation is not always advisable in the aged, and immo- 
bilizing with plaster does not yield encouraging results. 
If the patient is of unusual physique, it may be possible 
to perform open operation (either nailing or bone drill- 
ing) but in most cases we must be content to keep him in 
a good physical condition even though we fail to enable 
him to walk. Attention should be directed principally 
to the general health, the patient should have a massage 
and be moved as much as possible in bed. It becomes 
necessary in time to force him out of bed, and in most 
cases it is very painful at first. Later it becomes easier 
for him to get into a chair, he can move a little without 
intense pain. 
Senile epitheliomata are frequently operated upon and 
the results in many cases are very encouraging. How- 
ever, a great many of these so-called “rodent ulcers” 
are in the temporal region and inoperable. Again, the 
operation is oftentimes of a mutilating nature. In my 
experience, radium therapy has succeeded in the heal- 
ing of senile epitheliomata to the extent of making opera- 
tion unnecessary in most cases. Often the patient fails 
rapidly and the epithelioma spreads after a surgical pro- 
cedure. Cancer of the tongue and larynx will yield to 
radium therapy better than to surgical interference in 
most cases. Although radium does not act as well on 
mucous surfaces as on the skin, the results in the mouth 
and throat are encouraging provided large doses are 
employed. SURGERY OF THE AGED 
381 
Doctor Joseph Bissell (The International Journal of 
Surgery, May, 1919) reported the case of a professional 
man who had a rapidly growing epithelioma of the lar- 
ynx. The malignant growth recurred after each opera- 
tion, his general condition became rapidly 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 also had block applications of large 
doses of radium 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 
Robert T. Morris, that we cannot keep senile cases in bed 
after surgical operations. In some cases it is advisable 
to get the aged patient out of bed the day following the 
operation, even though it was a major operation. Ap- 
pendicitis is rare in the aged, but when present the senile 
patient should be in a chair the next day. This rule ap- 
plies 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 immediately when 
he is allowed to get into a chair. They believe they will 
recover if we allow them to get out of bed. 
It may not seem rational to allow them out of bed the 
day after an operation, but in dealing with the aged we 
must make allowances we would not make in dealing with 
younger individuals. All senile patients fail rapidly 
while in bed, therefore I have made a keynote in geria- 
trics to “Keep Senile Cases out of Bed.” BIBLIOGRAPHY 
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Geriatrics 
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GERIATRICS 
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Functional Stimulation of Senile Tissues, Med. Times, New York, 
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The Treatment of Diseases in Senility, Med. Rec., New York, 1909, 
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A Plea for the Study of Geriatrics, Ibid., 1910, lxxviii, 536-538. 
Geriatrics; a Neglected Branch of Medicine, Tlierap. Med., Mew 
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Dosage in Old Age; an Important Contribution to Geriatric Therapy, 
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Sources of Error in Diagnosis in Senile Cases, Arch. Diagnosis, New 
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The Danger of Routine Practice in Senile Cases, Am. Jour. Clin. Med., 
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Geriatrics, Med. Rec., New York, 1912, lxxxi, 752-755. 
Errors in Treatment of Senile Cases, New York Med. Jour., 1912, 
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Diagnostic Hints in Senile Cases, Am. Pract. New York, 1913, xlvii; 
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Therapeutic Problems in Senile Cases, Med. Rev. of Rev., New York, 
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Importance of Geriatrics, J. Am. M. Assn., Chicago, 1914, lxiii, 2248. 
Lane’s Autointoxication Complex and the Manifestations of Senility, 
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A 
Abdomen, tapping of, for ascites, 
246 
Accomplishments of some famous 
aged people, 37 
Acetanilide, danger of in old age, 
252 
Acid, hydrochloric, for hyperacid- 
ity of stomach, 249 
Acidosis, senile patients rarely de- 
velop, in diabetes, 153, 315 
may be caused by ether, chloro- 
form or nitrous-oxide, 315 
test for, 371 
Addison’s disease, suprarenal ex- 
tract for, 269 
Adenopathy, following radium ther- 
apy of cancer of tongue, 
364 
Adrenalin for senile asthma, 180 
Age, value of old, 31 
Aged, albuminuria in, 170 
Alcohol as a remedy in, 295 
atmospheric influences on, 48 
blood pressure in the, 92 
bronchitis in the, 190 
care of the, 48 
in institutions, 52 
checking of secretions in the, 51, 
308 
chorea in the, 206 
cirrhosis, hepatic, curability of 
in old age, 240 
coal tar derivatives in treatment 
of, 252 
constipation in the, 225, 256 
dementia in the, 69 
diabetes in the, 148 
diagnostic errors in, 313 
diet in the, 77 
electrotherapy in the, 277 
emotions in the, 69 
emphysema in the, 186 
exaggerate symptoms in the, 320 
Aged (Continued) 
gangrene in the, 199 
glycosuria in the', 152, 153, 157, 
170, 315 
heart disease in the, 112 
hygiene in the, 47 
influenza in the, 64 
mentality in the, 64 
neglect of the, 33 
nephritis in the, 122 
opotherapy in the, 259 
paralysis in the, 231 
pensions for the, 57 
pneumonia in the, 194 
postoperative treatment in the, 
62 
prostatic hypertrophy in the, 
221 
psychic element of work in the, 
54 
radium therapy in the, 357 
recreation in the, 51 
rheumatism in the, 159 
sexual life in the, 343 
shock, methods of prevention in 
the, 373, 377 
sleep in the, 50 
surgery of the, 369 
syphilitic nephritis in the, 140 
syphilis in the, 326 
therapeutics in the, 248 
toxemia in the, 86 
typhoid rare in the, 139, 314 
uremia in the, 138 
urinalysis in the, 169 
use of opiates in, 251 
value of the, 37 
work for the, 53 
Albuminuria in the aged, 170 
use of renal extract for, 266 
Alcohol, as a remedy in old age, 
78, 295 
for pneumonia and diphtheria, 
197, 296 
389 390 
INDEX 
Alcohol (Continued) 
in senile bronchitis, 191 
in syphilis of old age, 334 
ordinarily too small doses given, 
297 
relation to cirrhosis of liver, 242 
rules for administration, 299 
should be used to full physiologic 
effect, 297 
use of in senile debility, 298 
Amputation of forearm by gan- 
grene, 200 
Anatomic changes in old age, 25 
Anemia in old age, caused by syph- 
ilis, 329 
caused by hemorrhage from rec- 
tum, 254 
Anesthetic, selection of in old age, 
371, 376 
Novocaine with suprarenin as a 
local anesthetic, 377 
Aneurism, syphilitic, 106 
Angina pectoris, caused by sex- 
ual excesses in old age, 
356 
Anoci-association, method of anes- 
thesia, 370 
Anus, improper care of as a cause 
of pruritus ani, 217 
Apoplexy, due to sexual excesses, 
*356 
caused by too strong heart ac- 
tion, 104 
Arsenic for senile chorea, 210 
symptoms of poisoning, 210 
Arsenobenzol for syphilitic ne- 
phritis, 129 
uses of in old age, 145, 147, 330 
Arterial spasm, 318 
Aiteries, changes in, in old age, 
104, 112 
coronary, 107 
normal senile degenerative 
changes, 106 
Arteritis obliterans, 199 
Artery, sign of temporal, 135 
Arteriosclerosis, in the aged, 102 
causes of premature, 105 
cerebral, term covers a mass of 
ignorance in diagnosis, 108 
does not always cause increased 
blood pressure, 94 
Arteriosclerosis (Continued) 
normal and pathologic, 106 
not a disease, 126 
relation of nephritis to, 106 
treatment of, 110 
use of iodides for, 253 
Arthritis, 161 
due to tuberculosis, 162 
treatment by diathermy, 292 
Ascites, curability of in old age, 
240, 243 
treatment of when due to hyper- 
trophic alcoholic cirrho- 
sis, 244 
Asthma, senile, 174 
as a symptom of another dis- 
ease, 175 
associated with skin diseases, 
177 
hygienic influences on, 185 
prognosis of, 178 
protein sensitization for, 178 
relation of nephritis to, 177 
treatment of, 179, 183 
Atheroma, 106 
Atmospheric influences, aged sus- 
ceptible to, 48 
Atrophy of cartilages, 26 
Atropine, combined with morphine, 
251 
Autocondensation (see also dia- 
thermy; electrotherapy) 
apparatus used for 281, 283 
in paralysis following apoplexy 
and uremia, 282 
for persistent headache, 284 
for senile debility, 286 
uses of, 277, 278, 282 
Autointoxication of intestinal ori- 
gin in course of pneu- 
monia a serious complica- 
tion, 197 
B 
Baths, for the aged, 49 
cabinet, for nephritis, 129 
Turkish, 49 
Bed, keep senile cases out of, 60, 
381 
surgical patients to be kept out 
-of, 62 
Bed-sores, 75 391 
INDEX 
Beer in old age, 78, 298 
Belladonna, use of in cathartics, 
253 
Benzyl benzoate for senile asthma, 
183 
Bibliography, 382 
Bidou, Dr. Gabriel, Method of 
Functional Recuperation 
of, 231 
Bile, extract of, uses of, 271 
salts, use of for senile constipa- 
tion, 85 
Biopsy, necessary in every case of 
cancer, 358 
Biological studies, in radium ther- 
apy, 368, 369 
Bladder, aged should avoid reten- 
tion of urine too long, 
51 
Blood, as a symptom 94 
diastolic variations, 97 
factors which modify, 97 
impaired in the aged, 29 
methods of ascertaining, 97 
normal and pathologic, 96 
pressure In senile cases, 92 
sugar, estimation of, 153 
importance of, 158, 379 
necessary as a routine meas- 
ure in surgery of aged, 
370 
table of averages, 98, 100 
Blue color of part before gangrene 
has fully developed, 203 
Bones, changes in old age, 26 
Bowels, care of in influenza, 203 
care of in pneumonia, 197 
care of in senile bronchitis, 193 
Brain, changes in old age, 26 
fag in the aged, 65, 89 
Brandy for senile pneumonia, 197 
Breast, cancer of, treatment of, 
310, 316 
Brightism, minor symptoms of, 
127, 134 
Bronchitis, acute, difficult to dif- 
ferentiate from pneu- 
monia, 190 
secretions of should not be 
checked in old age, 311 
senile, 190 
chionic, 191 
Bronchitis, senile (Continued) 
due to influenza, fatal in aged, 
191 
treatment of, 191 
Brown-Sequard, work of, 258 
Butyl chloral hydrate for tic dou- 
loureux, 250 
C 
Calcareous degeneration and arter- 
iosclerosis of ulnar artery 
in old man, 103 
Caloric requirements in old age, 80 
Campbell Model “E” Coil, 228, 290 
Camphor, oil of, hypodermic use 
of, 307 
Cancer, see carcinoma 
Cannabis indica for dysuria, 257 
Carcinoma, and syphilis combined, 
difficult to treat, 334 
engrafted on syphilitic base, 143 
infection of, 357 
of gastrointestinal tract easily 
overlooked, 318 
of prostate, surgery for, 378 
of stomach, 318 
of tongue, 361 
precancerous lesions, 358 
predisposing causes, 357 
technic of application of radium 
for, 358 
use of opiates for, 252 
Carbuncle, may he cured without 
surgical interference, 157, 
379 
•Cardiorenal disease, 115 
Care of the aged, 48 
Cascara sagrada as a remedy for 
senile constipation, 85 
Catharsis, free, essential in ne- 
phritis, 129 
Cathartics, for aged, 84, 85, 90 
Catheter life, avoided by treatment 
of prostatic hypertrophy, 
223 
use of metal catheter for, 224 
Chancre, 327 
Checking of secretions in old age, 
51 
Childishness, cause of, 57 
Chloral hydrate treatment of in- 
fluenza, 304 
theory of action of, 305 392 
INDEX 
Chloral (Continued) 
used in syphilis of mouth, 333 
Chloro-Briglitism, milk diet for, 
245 
Chorea, senile, 206 
course of, 206 
gravis, treatment of, 210 
habit in institutions, 209 
may become chronic, 207 
not accompanied by heart com- 
plications, 207, 208 
relations of nephritis to, 208 
symptoms of, 207 
Chromium sulphate for senile pro- 
static hypertrophy, ‘221 
Cigar, stimulates peristalsis, 83 
Circulatory system, changes in, 112 
Cirrhosis atrophic type, 241 
description of, 241 
due to cardiac disease, 246 
early symptoms of, 242 
hepatic, curability of, 240 
mistaken for cancer of liver, 247 
treatment, 244 
Civilization, as a cause of disease, 
126 
Climacteric, senile, 335 
Clothing for the aged, 48, 49 
Coal tar derivatives, use of in 
aged, 252 
Codeine, for pain due to various 
conditions in old age, 253 
use of in old age, 252 
Codliver oil for the aged, 192 
Coma, danger of in surgery of dia- 
betes, 370 
uremic, urinary examination in, 
139 
Complications of senile nephritis, 
133, 317 
Congestion of internal organs com- 
pel heart to carry on addi- 
tional work, 105 
Constipation, 82 
attention to diet, 83 
special remedies required, 253 
Convalescence from influenza pro- 
tracted. 307 
Cough, mechanism of, 185 
Cramps, muscular, as a symptom 
of nephritis, 134 
Creosote, calcium, in senile asthma, 
185 
Curability of hepatic cirrhosis, 240 
Cystitis, 225 
retention as a cause, 74, 25G 
treatment of, 256 
D 
Deafness, associated with nephritis, 
135, 317 
catarrhal, treatment by electric- 
ity, 293 
Debility, senile, 250 
caused by toxemia, 250 
causes of, 286 
electrotherapy for, 286 
simulating tuberculosis, 317 
therapeutics of, 286 
use of alcohol for, 298 
Degeneration, normal kidney, 126 
Demarcation, line of, in senile 
gangrene, 204 
Dementia, senile, 69 
Diabetes, in old age, cases of, 148- 
151 
diagnosis of, 152 
diet in, 155 
different from that at maturity, 
152 
Joslin’s treatment of, 149, 150 
prognosis of, 152 
symptomatology, 152 
treatment of, 154 
use of hepatic extract for, 268 
Diacetylmorphine for pains in old 
age, 252 
Diagnostic errors in the aged, 313 
Diagnosis of senile diabetes, 152 
of senile nephritis, 127 
of senile pneumonia, 196 
Diarrhea, checking of. dangerous 
in old age, 310 
may be due to nephritis or can- 
cer, 310 
Diathermy (see also Electrother- 
apy ; Autocondensation) 
defined, 288 
for lumbago, 292 
for rheumatism, 167 
for senile arthritis, 292 
for senile arthrosclerosis, 293 
for senile prostatic hypertrophy, 
226, 227 
for senile pruritus, 217 
for tuberculosis, 293, 294 INDEX 
393 
Diathermy (Continued) 
for tuberculosis of bones, 288 
technic of application, 288, 
290 
Digitalis, for heart disease, 178 
not always a satisfactory rem- 
edy in old age, 197, 307 
Diseases of old age, Nascher’s 
classification, 31 
Diuretin, in cardiac hypertrophy 
secondary to nephritis, 
117 
for senile asthma, 180 
Diverticulitis, 318 
Dosage, rules for in old age, 254 
Drugs, action on degenerated tis- 
sues, 32 
assimilation of, 32 
effects of in old age, 249 
secondary effects of, 147 
Dyspepsia and nephritis, 137 
in old age, 82 
E 
Ears, “buzzing in,” sign of ne- 
phritis, 135 
Eczema, in old age, causes of, 318 
Effort Syndrome, common condi- 
tion in old age, 116-117 
Electrode, Monae Lesser rectal 
prostatic, 226 
vacuum used in local applica- 
tions, 291 
Electrotherapy (see also di- 
athermy; autocondensa- 
tion) 
for senile arthritis, 292 
for senile arthrosclerosis, 293 
for senile asthma, 185 
for senile catarrhal deafness, 293 
for senile debility, 250, 286 
for senile fractures, 293 
for senile gastrointestinal dis- 
orders, 293 
for senile lumbago, 292 
for senile neuritis, 286 
technic of application, 287 
for senile prostatic hypertrophy, 
223, 226 
for senile pruritus, 217 
for sexual impotence, 288 
for tic douloureux, 250 
Elimination of drugs, slow in old 
age, 249 
Emanation of radium, 365 
Emotions, loss of control of in the 
aged, 69 
Emphysema, senile, 86 
anatomic causes, 186 
treatment of, 188 
Endocrinology, 258 (see opother- 
apy) 
Epistaxis, treatment of, 309 
Epithelioma, basal-celled, technic 
of radium therapy, 359 
of lips, 366 
surgery for, 380 
of skin, due to syphilis, 329 
spino-celled requires longer treat- 
ment, 360 
treatment by radium, 358 
Erythrocytes in the urine, 172 
Excretions of skin, serious matter 
to check in old age, 51 
checking of, in old age, 308 
Exercise to avoid toxemia, 49. 61 
Extracts, animal (see opotherapy) 
of bile, as an aid to digestion 
and proper intestinal ac- 
tion, 271 
combination of several extracts 
necessary, 267 
gastric, indications for use of, 
271 
hepatic, 246, 268 
for diabetes, 158, 268 
for hemorrhage, 268 
for malfunction of liver, 268 
for nephritis, 266 
for other conditions, 269 
hypodermic use of, 269 
method of preparation of, 247, 
268, 272, 274 
works well when there is he- 
patic insufficiency, 247 
of myocardium, 118, 271 
pancreatic, used in diabetes, 158, 
272 
indications for use of, 272 
of prostate, 230, 270 
Pituitary, indications for use of 
in old age, 269 
renal, 265 
suprarenal, 269 394 
IND3X 
Extracts (Continued) 
for asthma, 269 
hypodermic use of, 269 
other indications for use of, 
269 
in low arterial pressure, L67 
table showing ndications and 
doses of, in diseases of old 
age, 275—276 
Eyes, special attention should be 
given, 52 
F 
Famous aged men and women and 
their accomplishments, 37- 
47 
Femur, fracture Of, 379, 380 
Fever, uremic, 1J8 
Fibrosis and calcification due to 
syphilis, 106 
Fingers, ‘‘dead,” as a symptom of 
senile nephritis, 134 
Fish, as diet for aged, 78 
Fistula-in-ano, due to tuberculo- 
sis, 311 
Foot, gangrene of, Nature’s sepa- 
ration of gangrenous part 
from healthy tissues, 202 
Foster, Miss Christine S., work of, 
58 
Fowler’s solution for senile chorea, 
210 
Fractures, danger of pheumonia in, 
195 
electrotherapy for, 293 
of femur, 380 
Functional recuperation for senile 
paralysis, 231 
definition of, 231 
G 
Gallstones may exist with nit tin 
in old age, 31$ 
Gangrene, in old age, mav (lev-IOp 
from most trivi 1 cause, 
205 
senile, 199, 379 
dry and moist forms, 203 
Nature’s treatment of, 200 
relation to diabetes, 201, 204 
surgery best treatment for, 
205 
Gangrene (Continued) 
symptoms of 203 
syphilis as a cause, 204 
treatment of, 204 
Gastric extract, indications for use 
of, 271 
Gastritis, acute, milk diet for, 77 
mistaken for Bright’s disease, 
248 
Gastrointestinal disorders and ne- 
phritis, 135 
Geriatrics, definition of, 25 
fundamental principles, 25 
Gla'ids, relation of endocrine to 
disease, 131 
Glossitis, senile pruritus as a 
cause, 214 
Glycerin suppository inserted into 
rectum in cases of pa- 
tients weak from disease, 
preferable to enemata, 
84 
Glycosuria in old age, 153, 157, 170 
may be due to senile degenera- 
tive changes and not to 
diabetes, 152, 315 
transient, difference between dia- 
betes and, 157 
Gummata, often undergo sarcoma- 
tous degeneration, 329 
H 
Habits in old age, change of, 77, 
130, 219 
Habit chorea in institutions, 209 
Hair, changes in, in old age, 28 
Hamamelis for hemorrhoids in old 
age, 255 
Headaches, persistent, autoconden- 
sation for, 284 
Heart disease; action, too strong, 
may cause rupture of ves- 
sels, causing apoplexy, 104 
diseases of, 112 
due to sexual excesses in the 
aged, 356 
enlargement of in arteriosclero- 
sis, 104 
neuralgia of, 121 
senile changes in, 104, 112 
support of in influenza, 306 
syphilis of, 114 395 
INDEX 
Heart (Continued) 
treatment of diseases of, 117, 
118, 119 
Hematuria, 312, 318 
Hemiplegia, due to unconscious 
mimicry, 322 
Dr. Bidou’s apparatus for, 235 
Hemorrhage, checking of in old 
age, 308, 311 
hepatic extract for, 268 
in old age, often dangerous to 
check too quickly, 255 
suprarenal extract for, 269 
Hemorrhoids, 254 
mistaken for malignant disease, 
254 
treatment of, 255 
Hepatic cirrhosis, 240 
Hepatic extract, 268 
hypodermic use of, 269 
in treatment of hemorrhages, 
268 
other indications for use of, 269 
preparation of, 268 
treatment of senile diabetes, 
268 
Hepatitis, syphilitic, 146, 330 
Hernia, strangulation of, opera- 
tion for, 377 
Heroin, effects of in old age, 252 
High frequency current, local ap- 
plications of, 284 (see 
also diathermy; autocon- 
densation ; electrotherapy) 
defined, 277 
History-taking in the aged, very 
uncertain, 316 
Hormone of thyroid, 260 
Hunger-sense, not indication for 
necessity of food, in the 
aged, 81 
Hydrochloric acid, for hyperacidity 
of stomach, 249 
Hydrotherapy for senile pruritus, 
219 
Hygiene of advanced life, 47 
in asthma, 185 
in heart disease, 116 
Hypertension, arterial, 92 
Hypertrophy, cardiac, nephritis as 
a cause, >13 
senile prostatic,'221 
I 
Impotence,, sexual feleetrotherapy 
for, 288 
Indigestion, acute, due to heart dis- 
ease, 120, 126 
as a complication of nephritis, 
135 
asthma associated with, 184 
Indicanuria, 88 
Infection, danger of, increased in 
diabetes, 153 
aged have strong immunity for, 
371 
septic, in aged, is grave condi- 
tion, 372 
Influenza in the aged, 300 
as a cause of nephritis, 301 
convalescence often protracted, 
307 
gastrointestinal form, 302 
nervous type common in old age, 
303 
neuritis as a sequel to, 303 
often fatal, 300 
symptomatology, 301, 302 
treatment of, 304 
Insomnia, intestinal toxemia as a 
cause, 50 
Institutional care of aged, 52 
Insulin for diabetes, 154 
Intestinal toxemia, simulating ure- 
mia, 88 
starting-point of nephritis, 124 
Intestines, care of in pneumonia, 
197 
changes in, in old age, 82 
Iodides, few conditions in old age 
require use of, 253 
use of in arteriosclerosis, 253 
use of in syphilis, 333 
Ipecac and Kermes’ mineral for 
bronchitis, 191 
Iritis, syphilitic, 329 
J 
Jalap, tincture of, in cardiac hy- 
pertrophy, 117 
K 
Kermes’ mineral for bronchitis, 
191 396 
INDEX 
Kidney, gouty, 164 
Kidneys, diseases of, 122 
of chronic interstitial nephritis, 
125 
role played by, in arteriosclero- 
sis, 100, 106 
L 
Larynx, epithelioma of, radium 
therapy for, 381 
Languid feeling, first symptom of 
nephritis, 127 
Laxatives, use of in old age, 84, 
85, 90 
Leukoplakia, 357, 362 
Licorice, compound powder, for 
hemorrhoids, 255 
Lips, epithelioma of, 366 
secondary infection of, 366 
radium therapy for, 366 
Liver, cirrhosis of, 240 
chronic alcoholic hypertrophy of, 
240 
syphilitic inflammation of, 241 
Longevity, association of and tox- 
emia, 91 
Lumbago, caused by nephritis, 138 
Lungs, congestion of, 191 
nephritis as a cause of, 191 
gangrene of, influenza as a cause, 
302 
M 
Malaria rare in the aged, 139 
Malignant growths of prostate 
causing congestion, 228 
Malingering in old age, 320 
treatment of, 324 
Massage for the aged, 49 
Meals, regularity of, essential in 
aged, 77 
Meat, as article of diet in old age, 
77, 78 
Mechanotherapy, 234 
Medical Neglect of the aged, 35 
Medication, secondary effects in old 
age, 147, 249, 253 
Medicolegal aspects of senile de- 
mentia, 69 
Memory in old age, 64, 66 
Menopause, changes in endocrine 
glands at, 131 
Mental state preceding operation, 
372 
Mentality, senile, 64 
Mercurial treatment of syphilis, 
332 
Metrorrhagia should not be checked 
in old age, 312 
Micturition, nocturnal, a symptom 
of nephritis, 136 
Milk as food in old age, 77 
for diet in nephritis, 147 
tiresome as a diet, can be modi- 
fied, 245 
Mind, changes in, 68 
Monae Lesser prostatic electrode, 
226 
Morphine in treatment of asthma, 
180 
a dangerous remedy in old age, 
251 
combined with atropine to pre- 
vent respiratory failure, 
251 
Morse Wave generator., use of in 
old age, 293 
Muscles, artificial, made of springs, 
233 
waste in, 26 
Myocarditis, symptoms of, 115 
extract of myocardium for, 271 
influenza as a cause, 114 
nephritis as a cause, 114 
Myocardium, extract of, 118, 271 
Myofibrosis, senile, 114 
N 
Neglect of the aged, 33 
Nephritis, senile, 122 
as a cause of additional work 
for the heart, 114 
as a cause of increase in blood 
pressure, 92 
cases, 122-124 
complications of, 133 
diagnosis of, 127 
due to influenza, 303 
may be of hepatic origin, 266 
most common cause of mis- 
taken diagnosis, 317 
prognosis of, 128 INDEX 
397 
Nephritis (Continued) 
(prostatic hypertrophy accom- 
panying, 222 
relation to arteriosclerosis, 106 
symptomatology, 126 
senile syphilitic, 146 
syphilitic, 126, 140, 329 
treatment of, 128 
use of renal extract for, 265 
Neuralgia, 137 
Neurasthenia, due to lack of'sexual 
comforts, 319 
Neuritis, due to influenza, 303 
electrotherapy for, 286 
Nerve terminals, degeneration of, 
as a cause of pruritus, 214 
Nitroglycerin in asthma, 180 
Nitrous-oxide-oxygen anesthesia in 
old age, 376 
Dr. Bardwell’s method, 376 
Novarsenobillon for syphilis, 144, 
330 
rules for use of, 331 
Novocaine with suprarenin as a 
local anesthetic, 377 
Nux vomica for stomach, 249 
O 
Oil enemata in constipation caused 
by rectal obstruction with 
feces, 83 
Oil, use of petroleum oil for con- 
stipation not new, 84 
Old age (see also Aged; Senile) 
anatomic changes in, 25 
death from, 34 
diet in, 77 
special treatment of, 248 
value of, 37 
Opiates, use of in old age, 251 
Opodiagnosis, 268 
Opotherapy, 258 
for hepatic cirrhosis, 246 
for senile diabetes, 158 
history of, 259 
renal, 267 
Organic matter, waste of in old 
age, 26 
Organotherapy (see opotherapy; 
extracts, animal) 
history of, 259 
Orthopedic Instrumentale, 237 
Oxygen for relief of senile emphy- 
sema, 189 
P 
Pain in the aged, 152 
Pancreas, as cause of symptoms, 
318 
Pancreatic extract, indications for 
use of, 270 
Paralysis, causes of, 231 
of arms, apparatus for, 237 
senile, functional recuperation 
for, 231 
use of antecondensation for, 231 
Paralytics, reeducation of, 233 
Pathologic blood pressure, 96 
Pathologic changes in old age, 31 
Pensions for the aged, 57 
Petroleum oil, use of not new, 84 
Peritonitis, use of opiates for, 252 
Perspiration, excessive, cause of, 
309 
as a symptom of nephritis, 310 
Physiologic functional changes in 
the aged, 30 
Pituitary extract, combined with 
thyroid for nephritis, 132 
indications for use of in old 
age, 269 
Pleurisy with pneumonia, 302 
Pneumonia, confused with Bright’s 
disease, 128 
after fracture of hip, 195 
after ether anesthesia, 195 
differs from that of younger per- 
sons, 195 
senile, 194 
diagnosis, 196 
prognosis, 196 
symptoms, 195 
treatment of, 197 
Pneumonokoniosis, 29 
Pneumothorax, caused by rupture 
of emphysematous vesi- 
cles, 187 
Podophyllin, use of, in intestinal 
toxemia, 90 
Postoperative dangers, 373-374 
treatment, 62 
Precancerous lesions, 358 
Primrose, Chinese, as a cause of 
senile pruritus, 215 398 
INDEX 
Prognosis of senile diabetes, 152 
of senile nephritis, 128 
of senile pneumonia, 196 
Prostration from senile bronchitis, 
quinine and strychnine 
for, 191 
Prostate, senile changes in, 29 
Prostatectomy, suffering after, 229 
necessary and successful in a 
great many instances, 
223 
Prostatic hypertrophy, senile, cases, 
221 
a normal senile change, 222 
electrotherapy for, 223, 290 
extracts, uses of, 270 
radium therapy for, 229 
syphilis as a cause, 222 
treatment of, 223-224 
Protein sensitization for senile 
asthma, 178 
Pruritus senilis, 212 
ani, 217 
causes, 212, 215 
diet for, 216 
due to Chinese primrose, 215 
due to nephritis, 213 
due to improper hygiene, 217 
external applications for, 216- 
219 
localized, 213 
glycosuria and, 213 
may cause serious breakdown, 
213 
of face may simulate facial 
erysipelas, 213 
of vulva, 218 
predisposing causes, 215 
prognosis of, 215 
psychic forms, 214 
treatment, 215 
Pseudorheumatism, 165 
Psychic element of work, 54 
of keeping senile patients out of 
bed, 62 
Public neglect of aged, 35 
Pulse, at wrist may be soft because 
of incipient arteriosclero- 
sis, 106 
rate uncertain, in old age, 105, 
116, 196, 314 
usually normal in aged no mat- 
Pulse (Continued) 
ter how severe disease 
may be, 196 
Pyelitis, 139 
confused with typhoid, 315 
Pyramidon, substitute for acetanil- 
ide, 252 
Pyuria, 172 
Q 
Quinifie as a remedy in old age, 
253 
for prostration of senile bron- 
chitis, 191 
R 
Radiotherapy for senile pruritus, 
220 
Radium puncture for cancer of 
tongue, 363 
Radium therapy in senile cases, 
357 
biologic studies in, 367, 368 
for cancer of lips, 366 
for cancer of prostate, 228, 229 
technic, 229 
for cancer of rectum, 366 
for cancer of tongue, 361 
causes of, 362 
for cancer of uterus, 367 
for pruritus, 219 
in precancerous lesions, 361 
in Regaud’s treatment, 363 
intensity of, 364 
Rarefaction of bones in aged, 28 
Reasoning power in the aged, 66 
Recompense for aged, 56 
Recreation for the aged, 51 
to retard senile mental impair- 
ment, 76 
Rectum, atrophy of muscular 
fibers, 30 
epithelioma of, 366 
radium therapy for, 366 
Recuperation, functional, for se- 
nile paralysis, 231 
Reeducation of paralytics. Dr. 
Bidou’s method, 233 
Respiration, counting of a neces- 
sity in old age, 314 
Rest essential in treatment of in- 
fluenza of old age, 306 INDEX 
399 
Renal extract, use of in heart dis- 
ease, 265 
indications and contraindica- 
tions, 267 
Renal insufficiency resulting from 
arteriosclerosis, 105 
Rheumatism, nodular, in old age, 
161 
diabetes as a cause, 164 
relation of nephritis to, 160, 163 
senile, 159 
diet list for, 166 
treatment of, 165 
Rhubarb pill for constipation, 84 
Roentgenologists prone to arterio- 
sclerosis, 107 
S 
Saline Laxatives, 85, 90 
Salvarsan for syphilitic nephritis, 
145 
Sarcoma, engrafted upon a syphi- 
litic base, 143 
Sciatica, caused by diabetes, 164 
caused by nephritis, 138 
Sclerosis, lateral, apparatus for, 
236 
Seborrhea capitis, 213 
Secondary effects of drugs, 253 
Secretions, internal (see opother- 
apy) 
diminished in old age, 259 
of some glands, regulating 
others, 260 
checking of in old age, 308 
checking of skin eruption as a 
cause of bronchitis, 192 
Senile (see aged) 
arteriosclerosis, mistake to try 
to cure, 110 
asthma, 174 
bronchitis, 190 
cases, blood pressure in, 92 
keep out of bed, 60 
chorea, 206 
•climacteric, 335 
constipation, 82 
debility, 250 
dementia, 69 
diabetes, 148 
diagnosis of, 152 
Senile (Continued) 
diet in, 155 
prognosis of, 152 
symptomatology of, 152 
emphysema, 186 
gangrene, 199 
heart disease, 112 
mentality, 64 
nephritis, 122 
paralysis, functional recupera- 
tion for, 231 
pneumonia, 194 
prostatic hypertrophy, 221 
pruritus, 212 
Sensitiveness to cold, in nephritis, 
135 
Sexual life in the aged, 343 
cases, 346, 347 
Dr. Armaingaud’s essay, 349 
effect of nephritis on, 346 
excesses as a cause of apo- 
plexy, etc., 356 
normal life, 345 
old men marrying young 
women, 344 
senility does not imply ste- 
rility, 343 
women age more rapidly than 
men, 345 
Shock, electric, on lying down, 135 
danger of, minimized, 370 
methods of preventing surgical, 
373, 377 
Shoulder, diathermy for, 289 
Silver nitrate, use of locally for 
syphilis of mouth, 333 
Skin, eruptions accompanied with 
discharge should not be 
healed too quickly, 310 
anatomy of, 214 
care of, in the aged, 49, 51 
changes in, 26, 51, 214 
diseases due to deficient thyroid 
secretion, 260 
Sleep, aged will deny, 50 
abuse of morphine for, 313 
amount required in old age, 50 
Sparteine sulphate, if pulse is ir- 
regular, 197 
Spermatozoa, activity in old age, 
345 
Spleen, changes in, 29 400 
1NDEX 
Stannoxyl, for staphylococcic infec- 
tions, 358, 379 
Stimulants essential in treating 
aged, 254 
Stools, color as indication for rem- 
edies, 249 
Strychnine, may hasten senile de- 
generation, 251 
use of in heart affections, 118 
Sulphur, washed, for hemorrhoids, 
255 
Suprarenal extract, as a cause of 
albuminuria and glycosu- 
ria, 269 
hypodermic use of in asthma, 
269 
in Addison’s disease, 269 
in asthma of old age, 269 
in cardiovascular asthenia, 
postoperative accidents and 
hemorrhage, use of for, 
269 
in low arterial pressure, 267 
gland, effect on arterial pres- 
sure, 267 
Surgery of the aged, 369 
blood sugar examination neces- 
sary as a routine proce- 
dure in the aged, 370 
peculiarities of, 369 
postoperative dangers, 373 
shock, danger of, minimized, 
370 
when indicated, 369 
Surgical after-care, 62 
Sydenham’s chorea, 207 
Symptomatology, of senile diabetes, 
152 
of senile nephritis, 126 
of senile pneumonia, 195 
Syphilis, as a cause of nephritis, 
126, 141 
as a cause of prostatic hypertro- 
phy, 222 
contracted after sixty years of 
age, 326 
cerebral, 329 
diagnosis, 329 
complications of, 328 
effect on heart, 329 
of liver, 330 
primary lesions, 327 
Syphilis (Continued) 
secondary symptoms, 327 
toxines often of a malignant na- 
ture, 328 
Syphilitic nephritis, 140 
prognosis of, 142 
symptoms of, 140, 142 
treatment of, 144, 147 
Sypliilo-Brightism, 145 
T 
Teeth, ruthless extraction of, for 
rheumatism, 1G5 
Telatherm, apparatus for treat- 
ments, 227 
Temperature usually normal in old 
age no matter how serious 
disease is, 19G 
Temperal artery, sign of in 
Bright’s disease, 135 
Therapeutics, in the aged, 248 
Thyroid, effect of mental condi- 
tions on, 260 
effect on senile dementia, 260 
extirpation of causes true inter- 
stitial nephritis, 2G7 
extract for cancer of larynx, 260 
for nephritis at menopause, 261 
use of extract at menopause, 131 
use of extract in nephritis, 131, 
261 
Tic douloureux due to unerupted 
molar, 319 
Tissue changes in the aged, 48 
Tobacco, does little if any harm 
. to aged, 50 
Tongue, senile pruritus of, 214 
cancer of, radium therapy for, 
361 
Prof. Regaud’s technic for, 363 
indications of treatment from ob- 
servation of, 249 
when moist indicates alcohol is 
working well, 197 
Toxemia, cause of some mental 
disturbances rather than 
cerebral arteriosclerosis, 
110 
caused by absorption of internal 
tumor, 88 
caused by lack of exercise in the 
aged, 88 INDEX 
401 
Toxemia (Continued) 
due to influenza a serious con- 
dition, 303 
intestinal confused with typhoid, 
315 
Toxins, origin of, difficult to deter- 
mine, 88 
Treatment, basic principles of, 32 
postoperative, 62 
of acute senile bronchitis, 191 
of heart affections is rest and 
lessening of the peripheral 
resistance, 121 
of senile dementia, 75 
of senile diabetes, 154 
of senile gangrene, 204 
of senile nephritis, 128 
of senile pneumonia, 197 
of senile prostatic hypertrophy, 
223, 224 
of toxemia in the aged, 90 
postoperative, in the aged, 62 
Trousseau’s diuretic wine, 244 
method of preparation of, 245 
Tumors in abdomen causing no 
symptoms in aged, 316 
Tuberculosis, pulmonary, diath- 
ermy for, 293, 294 
rare in the aged as a complica- 
tion of diabetes, 153 
Typhoid, confused with senile 
pneumonia, 196 
rare in the aged, 139, 314 
U 
Urea test in senile cases, 171 
Ulcer of leg, 308, 309 
due to tuberculosis, 309 
Uremia, cerebral, symptoms of, 138 
fever simulating typhoid, mala- 
ria or pyelitis, 138, 314 
postoperative, 374 
renal, symptoms of, 138 
Urinalysis in the aged, 169 
microscopic examination, 171 
Urine, should be examined fre- 
quently during adminis- 
tration of suprarenal ex- 
tract, 269 
composition of shows little alter- 
ation in the aged, 30 
Urine (Continued) 
retention as a cause of cystitis, 
74 
Uterus, cancer of, 367 
inoperable cases relieved by ra- 
dium, 367 
technic of radium therapy, 367 
V 
Vacuum electrodes, use of in elec- 
trotherapy of prostatic 
hypertrophy, 228 
Value of old age, 37 
Vegetables in diet in old age, 78 
Vibration, use of in senile debility, 
286 
Vittel water for cirrhosis of liver, 
245 
Voronoff, renewing work of Brown- 
Sequard, 258 
W 
Wassermann reaction not so ac- 
curate in old age, 146, 330 
Water, cold, glass of, in morning 
stimulates peristalsis, 83 
mineral, for elimination of tox- 
ins, 91 
Vittel, for nephritis, 147 
for cirrhosis of liver, 245 
Weakness, first symptom of tox- 
emia, 89 
Whiskey, for senile pneumonia, 197 
in diphtheria, 295 
use of for improving digestion, 
295 
Will power, changes in, in the 
aged, 68 
Wines in old age, 78, 298 
Women, famous, who have accom- 
plished a great deal in old 
age, 42 
Work, and recompense for aged, 56 
for the aged, 53 
X 
X-ray, examination for senile em- 
physema, 188 
for senile pruritus, 220 
Z 
Zimmermann’s decoction for syph- 
I ilis, 333