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

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

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

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

The only attempt at a history of what medicine has done for old age that I can find is in an old book by Charcot143 in which he attempts to list and characterize the far too few studies of any importance made upon the subject up to that date. He urges that medical science should give far more attention to it.

Dr. G. M. Humphry144 gives us a memorable study of five hundred old people of over eighty years of age, including an equal number of males and females. He stresses the fact that the descending changes of development are just as orderly as its earlier ascending phases and that civilization enables us to see far more of the natural processes of senescence than was possible when the conditions of life were ruder, for we can now promote the powers of self-maintenance to a degree impossible before. “The chief requisite for longevity must clearly be the inherent or inborn quality of endurance, of steady, persistent, nutritive force, which includes recuperative power and resistance to disturbing agencies and a good degree of balance between the several organs.” That is, each must be sound in itself and have due relation to the strength of other organs. “If the heart and digestive system are disproportionately strong, they will overload and oppress the other organs, one of which will give way.”

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

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

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

Sir James Crichton-Browne’s long article145 is a classic and is based on very comprehensive statistical and other studies. He tells physicians that it should be their great aim to grow old themselves and to be the cause of old age in others. The marked increase in the duration of life in recent decades has been almost entirely confined to its early stages. After 45 the decline in the death rate has been insignificant; and after 65, as we have elsewhere seen, it has actually increased. Thus the proportion of men ripened by experience has in fact declined. What carries off the old? Not fever, smallpox, or phthisis chiefly, as was once the case, but the following in order of frequency: cancer, heart diseases, nervous troubles, and kidney complaints, and these are all degenerative diseases due not so much to intemperance as to the new strains of modern life, which are less felt in the country and less by women.

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

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

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

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

H. M. Friedman146 begins his comprehensive treatise with biological and embryological considerations, and here perhaps he makes his most original suggestions. The higher the plane of the animal, the more marked is cell differentiation or specialization and this affects most cells. Once a degree of differentiation is observed, no backward step to a previous state of generalization, regeneration, or rejuvenation is possible. The higher the ascent of the cell in the plane of differentiation, the lower is its power of rejuvenation. Connective tissue, muscle fiber, and cylindrical cells are the least differentiated and therefore have the greatest power of regeneration. Nerve cells have the least because their work is of a high order and they are most specialized. Nerve fibers are mere conductors and they and epithelial cells have probably the greatest power of regeneration.

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

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

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

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

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

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

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

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

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

Hastings Gilford147 regards the development of the human body as a whole, or of any portion of the body, as describing a curve that ascends from the time of the union of the two genetic elements to a maximum at which there is the greatest development of specialization in function and the least in the general characters, such as those of multiplication. The curve then begins to descend, with a gradual and progressive loss of differentiation in form and function and an increasing tendency of certain cells to multiply. Decay of certain cells during advancing age leads to their becoming bodies foreign to their host, and this, in turn, calls forth the phagocytes which, walling off the foreign body, become themselves transformed into fibrotic tissue. The three characters of old age are decay, fibrosis, and proliferation of non-specialized cells. As the more specialized cells retrogress, with the loss of specialization they take on an increased tendency to multiplication. “Reversion ... is the keynote of the proliferation in old age wherever it occurs.”

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

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

Horst Oertel148 holds that the origin of cancer in the liver is a transformation of multiple groups of its cells and that there was a direct change of atrophic, degenerative, existing liver cells into cancer cells while they were still in perfect continuity with each other. In this degeneration of normal to cancer cells the former lose their typical protoplasm, the nucleus grows small and its chromatin structure faint, till little of it remains, with only a faint rim of surrounding protoplasm. At this point some of these cells show a very striking change in rapid, irregular production of rich chromatin arranged in a less structural definition and leading to marked enlargement of them. There is a first destructive stage with extensive loss and granular degeneration of protoplasm. In the second, incipient regeneration shows and the nucleus is markedly enlarged, with irregular production of small chromatin granules; while in the third stage, the carcinomatous, we have a new type of cell following new laws and breaking with the former physiological arrangement and structure. The new functional type involves rapid independent growth with a distinct disregard of original source and surroundings and with progressive loss of continuity and power to secrete bile.

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

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

A. S. Warthin149 says that syphilitic cases are generally regarded as cured if the Wassermann reaction is negative but there are very many cases that this escapes. It is commoner than is supposed, the usual estimates being that from 5 per cent to 15 per cent of deaths are due to it, but this writer for America and Osler for Great Britain, place it at 30 per cent. “Syphilis is the leading infection and the chief cause of death, particularly in males between 40 and 60, and in the great majority of cases its symptoms are myocardial, vascular, renal, or hepatic, and this is often not recognized as a remote result.” The author has never seen a marked case of syphilis cured. Most die as a result of mild inflammatory processes of the viscera and blood vessels rather than from paresis or tabes. It is progressive and marks the individual as damaged goods. Even immunity is bought at a price. All the organs must be examined before it is pronounced certainly absent. It is a spirochete-carrier. It tends to become mild but at any time the partnership between the spirochete and the body may be disturbed and the tissues susceptible to the violence of the spirochete may be increased so that the disease again appears above the clinical horizon. Chronic myocarditis is the most common form of death.

W. Spielmeyer150 says that in the last decade the clinicians and pathological anatomists have discussed old age more than in preceding decades. We know that organs are used up and that their substance is not fully replaced. The functionally exciting parenchyma is injured by its own function and in this metabolism the quality and sometimes the volume of the organ is reduced. Thus old age is a function of the work of the organism and it seems to be an intrinsic quality of cells to use themselves up. Many do not regard age as a normal physiological process but with Metchnikoff think it is due to injurious substances, that is, endogenous toxins that are more important than the exogenous factors, so that blood vessels, glands, and muscle and ganglia cells degenerate. But the cortical cells, as the most sensitive of the organism, are more often injured. Metchnikoff thinks that the higher elements of the tissues are in conflict with the lower and are overcome by them, the phagocytes being left masters of the field.

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

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

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

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

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

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

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

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

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

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

I. L. Nascher151 thinks that too little study has been given to the physical changes in involution and still less to the mental. Occasionally the approach of senile dementia gives rise to forensic questions. There is a general neglect of the subject of geriatrics. This author thinks the brain reaches its limit of physical development at about 30, but Bunsen and Mommsen both did much of their best work after their brain had grown quite atrophied, so that quality comes in. The integrity of these cells depends upon nutrition. We have few blood examinations of the aged and these do not show any marked clinical or microscopic differences between maturity and senility, while the process of senile involution rests apparently on defective nutrition of cell tissues. Those who do good work in age generally focus into one channel and their degeneration is shown in other fields. We usually do not think of our somatic state until some discomfort compels us to do so. One may have lessened interest in former hobbies or events of the day; but if impairment of reason keeps pace with that of memory, he will not know that his powers are failing. He then begins to think of his body and its preservation as more important than wealth or fame, wants to live, and gives more attention to prolonging life.

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

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

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

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

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

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

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

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

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