Nassim Nicholas Taleb in his groundbreaking work ‘The
Black Swan’ stated that Medicine was the sister of Philosophy & that it
became scientific only during the 20th century. Before you agree or
disagree with that, do read this post. The evolution of Geriatrics happened in
fits & starts (as is the case with many specialities). Now let us look at
the developments that happened in the rest of the 18th century &
the 19th century (reading the previous blog post will definitely
help)…
The Rest of the Eighteenth Century..
The misconception that old age was a disease held sway
for most of the eighteenth century. Jakob Hutter in his doctoral thesis -‘That
Senescence Itself is an Illness’, published in Germany in 1732, supported
the prevailing idea of the times. He was heavily influenced by his eminent
teachers, Friedrich Hoffman and Hermann Boerhaave. Hutter theorised that with
ageing there’s a progressive hardening of all the fibres of the body starting
from youth. This resulted in obstruction of blood supply which in turn led to
stagnation & fatal putrefaction. So old age caused death by direct means,
according to him. However, he strongly believed that this process could be
modified by adopting a ‘correct lifestyle’, based on the principles propounded
earlier by Galen & Francis Bacon. By emphasising that old age was a medical
condition, Hutter paved the way for Geriatrics.
Pathological studies in the late 1700s, particularly
by Giovanni Morgagni, failed to reveal the widespread changes posited by
Hutter. Conversely, they showed local pathology in the majority of the older
people on post-mortem examination. By the late eighteenth century, the concept
that death in old age was due to one illness or the cumulative effect of many
illnesses & not a general marasmus was established. ‘De Sedibus et
Causis Morborum’ by Morgagni published in 1761 described that many diseases
in old age, especially the chronic ones, can remain symptomless for years. Two
centuries later this formed the basis of much clinical research on the
unreported medical needs of the elderly.
American Physician Benjamin Rush, emphasised that old
age was rarely the sole cause of death in his book ‘Account of the State of
the Body and Mind in Old Age, with Observations on its Diseases and Remedies’
published in 17931.
The French Hospices, Pathological Analysis
& Geriatrics (Nineteenth Century)..
France was the world leader in this area at the time.
The basis for much of the research were the institutions known as ‘hospices’.
They were set up by royal edict in the mid-seventeenth century to serve a range
of functions, including prisons, asylums for the insane and residential homes
for the elderly. They were transformed into primarily medical institutions
after the French Revolution of 1789. They were not reserved exclusively for
older patients, but admitted those of all ages with chronic disability,
including children.
Research in age related diseases was buoyed up by the
advances made in Medicine in France between the mid eighteenth & mid
nineteenth century. Much of it was based on pathological studies, relating the
findings to clinical presentation wherever possible, what in modern Medical
jargon is called Clinicopathological Correlation. One of the earlier, more
perceptive studies was published in 1835, on Pneumonia by Hourmann and
Dechambre. They noted how the disease could be present in older people, but
exhibit few physical symptoms. Charles Durand-Fardel’s practical treatise, ‘Traité
Clinique et Pratique des Maladies des Vieillards’, was published in 1854.
It covered the whole field of disease in old age, while attempting to link
pathology with accurate diagnosis, & was way ahead of it’s time.
Although Jean Martin Charcot enjoyed a higher profile
in the field of medicine in old age, his ‘Leçons Cliniques sur les Maladies
des Vieillards’, published in 1866, contained only two lectures
specifically on old age and three on clinical thermometry in older people,
while the remaining were on Rheumatism and Gout. He noted that specific
diseases existed in older people, such as Osteomalacia and Brain atrophy, that
the ‘gravest disorders manifest themselves by slightly marked symptoms’ and
that conditions occurring at any time of life ‘present special characteristics’
in later life.
By the middle of the century, medical men working in
the hospices called for the recognition of old age as a distinct period of life
which required a specific approach and a special branch of medicine, ‘Médecine
des Vieillards’, with its own training and therapy. These calls took place at a
time when the practice of specialisation within medicine was firmly established
in France and, by the end of the nineteenth century, had been introduced into
the curriculum in the Paris Medical School. In the mid-1850s however, only
5–12% of physicians declared a specialty designation; the most common were
surgical, namely General Surgery, Dentistry, Obstetrics, Orthopaedics and Ophthalmology,
but Psychiatry was also popular. Despite the existence of specialty hospitals
for treating older people, Geriatric Medicine was not considered to be a
recognised discipline.
Weisz, a Medical Historian, has suggested three
possible reasons for this:
- The
lack of specific therapeutic or diagnostic procedures
- The
inevitability and incurability of diseases of old age
- The
fact that the elderly generated little public interest
In addition, research failed to progress, mainly
because it had been pathologically based. Few therapeutic possibilities existed
to manage disease in old age and Physicians at that time did not interact with
older patients to any great extent, as they only had contact with the small
proportion who were admitted to the hospices. As medical interest in older
people declined, Geriatric Medicine did not become a specialty in France until
after 19501.
Meanwhile, in England…
George Edward Day (1815–1872), a Physician, wrote a
common sense book from the Physician’s perspective on aging in 1848-‘A
Practical Treatise on the Domestic Management and Most Important Diseases of
Advanced Life’. He recognised and provided a clinical description of
Alzheimer’s disease. Day also worked out that the largest proportion of older
people die in the winter and thus cautioned them to be careful during these
months. About dietary supplementation, he recognised that milk with added sugar
& eggs were beneficial in old age. Day posited that women showed signs of
ageing from about forty years of age, whereas men did not start to look old
until they were between forty-eight or fifty. He complained that other
physicians had little interest in caring for the ills of the aged2,3.
‘A Practical Treatise on the Diseases and
Infirmities of Advanced Life’, was published in 1863
by Daniel Maclachlan, who was an attending physician to the Royal Hospital
Chelsea. He included dryness & wasting among the physiological changes of
ageing, but refuted the belief that death resulted purely from age alone,
pointing out that disease usually supervened to ‘sever the cord’(of life). He
drew attention to the difficulty of diagnosis in older people where several
diseases often coexisted. While Maclachlan suggested caution should be taken
when prescribing drugs for older patients, those who were physically active
benefited and tolerated ‘active treatment’. However, dose modification was
necessary in frailer patients as drug action became less certain as old age
advanced. Digitalis in particular required to be administered with great care,
but if done so, was ‘a truly valuable medicine’, according to him.
1882..
Two seminal publications came
out in this year that greatly influenced the development of geriatrics. August
Weissman, a German evolutionary biologist, published his theory on programmed
death. He proposed that death happened because ‘worn out tissue’ due to ageing
could not be renewed indefinitely by cell division. The resulting decline in
functional activity could lead to direct or so-called ‘normal’ death or
indirect death due to reduced resistance to external influences. The theory was
criticised mainly because few animals in natural populations died of old age
and so ageing was not a significant contribution to mortality. With little
experimental evidence to support it, Weismann’s theory did not find general
acceptance.
Charcot’s writings were translated and published in
English in 1882 as ‘Clinical Lectures on the Diseases of Old Age’ and
had a considerable impact in Britain. The reason for this was no doubt the lack
of papers on disease in old age in the English literature & not exactly the
impact of theories put forward in it1. Charcot was world renowned
for his analytical approach in diagnosing neurological conditions & is
considered ‘the founder of modern neurology’. He has at least 15 medical
eponyms associated with his name.
End of a Century, Oh, It’s Nothing Special..
Yes, the subheading is based on the hit number by Blur
(I loved Mancunian Rock)..
Towards the end of the 19th century, the concept of
hormonal reversal of aging processes began to develop. In 1886, Victor Horsley
felt that older persons resembled myxedematous monkeys and that thyroid
deficiency could result in ‘‘mere senility’’. Horsley was a neurosurgeon who
did the first laminectomy for spinal cancer, and the transcranial approach to
the pituitary gland. He also played a major role in the eradication of rabies
from England.
Brown-Sequard, at the age of 70 years, found that he
was getting tired at night and introduced the first testicular extract
injections for rejuvenation. This led to Victor De Lespinasse at the University
of Chicago doing human testicular transplants decades later. The shortage of
humans wishing to donate a testis to be transplanted led to Serge Voronoff
introducing ‘‘monkey-gland’’ transplants to rejuvenate the aging rich. In
Kansas, Brinkley tried goat testicular transplants. These are the historical
precursors to the modern use of testosterone replacement therapy for the
andropause2.
“In the last analysis, we see only what we
are ready to see, what we have been taught to see. We eliminate & ignore
everything that is not a part of our prejudices.”- Jean-Martin Charcot.
To be continued…
References
- J R Coll Physicians Edinb 2012; 42:368–74
- Journal
of Gerontology: MEDICAL SCIENCES In the Public Domain 2004, Vol. 59A, No. 11,
1132–1152
- https://www.cadr.cymru/en/getfile.php?type=site_documents&id=Sara%20Zadrozny%20CADR%20presentation.pdf
