EDITORIAL STAFF GERONTOLOGICAL SOCIETY, INC.

COMMITTEE ON PUBLICATIONS

Roy G. Hoskins, Chairman Boston

Epwakp J. STIEGLITz Washington

WILLIAM DEB. MAcNIpER Chapel Hill

LAWRENCE K. FRANE New York

EDITORS Rosekrt A. Moore, Editor-in-Chief

Pzccy BRonsON

Rrra Noa Correspondent for Great Britain V. KorENCHEvVsEY, Oxford

\ assistants to the Editor

Correspondent for South America B. A. Houssay, Buenos Aires

Correspondent for France R. Courrier, Paris

CONSULTANTS TO THE EDITOR

For the Natural Sciences E. V. Cownry, Washington University

For the Social Sciences H. G. Moutron, Brookings Institution

For the Humanities RicHarp F. Jones, Stanford University

ADVISORY EDITORIAL BOARD

W. M. ALLEN, Obstetrics and Gynecology Washington University

Bert G. ANDERSON, Dentistry Yale University

Davin P. Barr, Internal Medicine Cornell University

E. M. BiusstTong, Hospital Administration Montefiore Hospital

D. E. CAMERON, Psychiatry McGill University

A. J. CARLSON, Physiology University of Chicago

F. Sruart Cuartin, Sociology University of Minnesota

Wiu1am Crocker, Botany Boyce Thompson Institute for Plant Research

Louis I. Dusin, Biostatistics Metropolitan Life Insurance Co.

W. H. Fewpman, Veterinary Medicine Mayo Foundation

J. S. FRrgDENWALD, Ophthalmology Johns Hopkins University

A. C. FurRsTENBERG, Otolaryngology University of Michigan

Wrttiam M. GaFaFeER, Biostatistics United States Public Health Service

E. C. HaMBLEN, Endocrinology Duke University

Frank Hankins, Sociology Smith College

Frank Hrman, Urology University of California

FREDERICK L. Hisaw, Zoology Harvard University Henry JAMEs, Insurance Teachers Insurance and Annuity Association of America Oscar J. KapLan, Psychology University of Idaho GrorcE Lawton, Psychology Old Age Counselling Center Forrest E. LInbDeER, Statistics Bureau of the Census C. M. McCay, Nutrition Cornell University WriLLtiAM MUBLBERG, Insurance Medicine Union Central Life Insurance Co. WINFRED OVERHOLSER, Psychiatry St. Elizabeth’s Hospital OLLI£ RANDALL, Social Work Community Service Society of New York R. REpFIELD, Anthropology University of Chicago Peyton Rous, Oncology Rockefeller Institute for Medical Research Henry Spams, Biochemistry Columbia University OweEN H. WANGENSTEEN, Surgery University of Minnesota ARNOLD WELCH, Pharmacology Western Reserve University Paut D. Wurtz, Cardiology Massachusetts General Hospital W. R. WiLiramson, Actuarial Science Social Security Board

JOURNAL OF GERONTOLOGY

1 |

Volume 1

APRIL, 1946

Number 2, Part 1

Geriatrics EDWARD J. STIEGLITZ

“GERIATRICS, FOR YEARS THE STEPCHILD OF MEDICINE, IS FINALLY COMING INTO ITS OWN. AS A DEFINITE BRANCH OF SCIENCE, IT STRIVES NOT ONLY TO PROLONG LIFE BUT TO ADD HEALTH, VIGOR, AND USEFULNESS TO THE LATER YEARS. UNDERSTANDING THAT HEALTH IS A PRIVILEGE AND NOT A RIGHT, MEDICAL SCIENCE CANNOT GIVE HEALTH TO ANYONE, BUT IT CAN GUIDE PEOPLE IN THE USE OF THEIR ENDOWMENT. GERIATRICS IS AS YET AN INFANT SCIENCE WiTH MANY PO- TENTIALITIES UNDEVELOPED. ONE OF THESE IS PUTTING TO USE, IN OUR NATIONAL CUL- TURE AND ECONOMY, THE ACCUMULATED WISDOM AND EXPERIENCE OF OLDER, FULLY MATURE PEOPLE.

Ww is geriatrics? A simple definition such as treatment of the aged is an oversimplification and therefore is not only inadequate but misleading. Geriatrics is already much more than the medical care of the senile. It includes attention to the health of the aging as well. Furthermore, geriatrics is still so young a field of study and understanding of the special clinical problems of later years is growing so vigor- ously that an interpretation of the scope of geriatrics must include consideration of the potentialities of the future. Neither the Science nor the practice of geriatric medi- cine is static (1). To define a child without regard for the fact that he will become an adult would be deplorably inadequate. The potentialities of geriatrics are as significant as its present limitations. The develop- ments of the future will be affected by the breadth of view of the definitions now ap- plied.

Geriatrics is that part of medical science and practice concerned with the health of the aging and the aged, the term “health” being used advisedly, rather than the dis- eases of later years. Geriatrics deals with the medical problems of normal aging and aged people, as well as their illnesses, both mental and physical. Senescence is a geri- atric problem. In many respects the aging are a more important group than the aged: There are many more people growing old than there are those already infirm by reason of senility. Furthermore, far more can be accomplished for the aging than the aged.

The question arises as to the age at which geriatrics should begin to apply. As aging is a part of living, beginning with concep- tion and terminating only with death, this is not an easy question to answer. It is most significant that the changes of senescence, the consequences of which must be dealt with in the later years of life, begin far earlier than is generally appreci- ated. Actually, involutional changes com- mence in youth. However, these are so gradual that manifestations are not appar- ent until after the peak of maturity. It is therefore pragmatic to consider that the clinical problems peculiar to geriatrics do not become sufficiently significant to war- rant special attention until about the average age of forty. This is admittedly an arbitrary dividing line; many people reveal senescent changes prematurely and their problems of health become geriatric in character before this chronologic age; others grow old more slowly and involu- tional changes do not produce difficulties

*153-

154

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Dr. Edward J. Stieglitz received his M.D. | from Rush Medical College in Chicago in | 1921 and served on the faculty there from | 1923 to 1938, becoming associate clinical professor of medicine in 1935. In 1940 he was__| in charge of the Unit on Gerontology at the | National Institute of Health, becoming con- | sultant on gerontology for the United States PublicHealth Service in 1941. Dr. Stieglitz has been chairman of the Department of Medicine at Chicago Memorial Hospital and attending internist at Chicago Lying-in Hospital. At present he is engaged in private medical | practice in Washington, D. C. and is chief of staff at Suburban Hospital, Bethesda, Maryland. His work has included studies on nephritis, hypertension, obstetric medicine,

| experimental therapeutics, geriatrics, and

| gerontology.

until late in life. However, for practical purposes, forty is a convenient age for the line of demarcation.

From the viewpoint of prevention of avoidable disability and the maintenance of health as near the optimum as possible, the two decades from forty to sixty are the critical years in the practice of geriatric medicine.

The relationship of geriatrics to the broader science of gerontology is extremely intimate. Gerontology is divisible into three major divisions: (1) the biology of senescence; (2) geriatrics; and (3) the so- ciologic, economic, and cultural problems of an aging population. In geriatrics man is the unit with which the physician must deal. The biology of senescence is con- cerned with the cells and tissues which make up man. Society is but a collection of men and women, in which the individual units correspond to the cells of the single organism. The motivation for research in the social sciences and fundamental biology is chiefly a desire to improve man’s well- being as an individual. The more that is known about the fundamentals of the biology of senescence the more intelligently can clinical geriatrics be practiced; the more that is learned about the changing capaci- ties and limitations of aging men and

STIEGLITZ

women, the more effectively can the many serious and urgent sociologic problems of old age be attacked (2, 3). Geriatrics is ap- plied gerontology.

From the viewpoint of the practice of medicine geriatrics is not a “specialty” in the usual sense of the term. The specialized subdivisions of clinical practice, such as obstetrics, ophthalmology, orthopedics, or otolaryngology, are based on anatomical limitations or upon therapeutic techniques, as in the instance of internal medicine in contrast to surgery. Geriatrics crosses all these various specialized fields, with the possible exception of obstetrics. Therefore, geriatrics is better described as a point of view or an attitude of mind which takes cognizance of the processes and conse- quences of aging. It is because of this basic difference between geriatrics and the older specialties that it is preferable to use the term as an adjective: geriatric medicine.

The clinical problems of later maturity, |

senescence, and senility are complex and extraordinarily numerous. They fall into two major groups: (1) special problems arising because of particular characteristics of older patients, and (2) problems pre-

sented by the nature of the diseases com- —

monly observed in later years. In both these fields medical knowledge is as yet distinctly limited. Certain advances in practice must wait upon extension of the frontiers of knowledge. However, there is much that is already known which can, and should, be applied more effectively (4).

THE NATURE OF GERIATRIC PATIENTS

To age is to change. The involutional changes which are the consequences of se- nescence are insidious and silent in onset. For a long time these alterations in physio- logic functions and in structure are so sub- tle that they are not directly demonstrable by the relatively crude clinical and patho- logic methods of today. The fact that al- terations in the body mechanisms are not readily detected does not justify assuming that these do not exist long before the more obvious changes of senility become appar-

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GERIATRICS

ent. Aging is continuous. Distinction must be made between the processes of aging and the consequences of these processes.

It is a primary dictum of geriatric medi- cine that the older individual is not the same person that he was in his youth, just a little older. Realization of this same con- cept, applied to the other end of the life span, awakened interest in pediatrics and has made possible its astonishing scientific development over the last fifty years. Ap- preciation that the child is something quite different from “‘a little man” was prerequi- site to the discovery that individual peculi- arities in nutrition, immunity, physiologic function and structure are characteristic of a given period of the life span. The same fundamental principle is equally applicable during senescence.

However the changes of aging in the latter half of life are in some respects more complicated than those observed in youth. During the developmental period, altera- tions in structure and function are essenti- ally secondary to growth or evolution. In senescence the involutional changes in- duced by time alone are complicated by the effects of accumulative use, abuse, disuse, and multiple and variable injuries. An indi- vidual is today what he is only in part be- cause of his original endowment; he has been modified by all the things which have happened to him in his yesterdays. The more yesterdays one may have experienced, the more significant is this element in de- termining one’s status. Because no two people lead identical lives, with identical insults, in identical sequence, aging leads to increasing divergence and individual vari- ation. Therefore, the second fundamental principle of geriatric medicine is individu- alization. Awareness of the importance of individual variation is essential to accurate diagnosis, logical prognosis, and effective therapy.

In as brief a discussion as this it is obvi- ously impossible to enumerate all the many identified changes vrhich result from the process of aging and the vicissitudes of existence (1). Some are obvious; others are

155

so obscure that their existence is merely suspected and has not yet been convinc- ingly proved (5). Among the less obvious but extremely significant changes which are universal in aging are alterations in the homeostatic mechanisms, metabolic and nutritional changes, intellectual and emo- tional differences, and variations in im- munity and in the capacity to repair.

Homeostasis, a term coined by the late Walter Cannon (6), describes the mechan- isms and activities of the body in maintain- ing a very nearly constant internal environ- ment. It is now well known that man lives in two environments: an external environ- ment of the air and people about him, and an internal environment consisting of the tissue fluids in which the cells are bathed. The internal equilibrium cannot vary be- yond narrow limits without profoundly af- fecting health. Too great fluctuations are fatal. Since the internal milieu is extraor- dinarily complex and it is essential that all the elements be maintained in equilib- rium, there are a great many mechanisms involved in the maintenance of this balance. Whether it be hot or cold without, body temperature remains constant within a de- gree of Fahrenheit; whether small quanti- ties of water are drunk often or many hours pass without fluid intake, the water balance of the body is maintained within narrow normal limits; whether food is consumed frequently or at longer intervals, the con- centration of nutriment in the blood stream and tissue fluids is permitted to vary but little; any gross drop in the available oxy- gen in the circulating fluids means im- mediate injury to the organism. All these and many other factors have to be kept in balance.

It is conspicuous that the normal range of variation of most of the so-called physio- logic constants remains the same through- . out the life span, with the single exception of the metabolic rate. Normal body temper- ature is the same in youth, middle life, and senility. So also are such constants as the normal blood count, and the concentration of sugar and many other substances in the

156

blood stream. Paralleling the gradual re- duction in the rate of metabolism there tends to be a slowing of pulse rate with ad- vancing years.

Though these factors remain approxi- mately. the same, the ability to maintain equilibrium in the face of forces tending to disturb balance depreciates. Not only are the responses of the homeostatic mecha- nisms less prompt when something occurs to throw the equilibrium off balance, but they are also less powerful. For example, among the many illustrations which might be cited, it is known that the ability to maintain the normal concentration of glu- cose in the blood diminishes and that a uni- form body temperature is less easily main- tained under conditions of extremely warm or cold external environment.

As a result of this slowing and diminution of the power of the body to react to forces which tend to disturb its intricate balances, the symptoms of disease become less and less intense with increasing age. Many of the phenomena of disease (the term being used to include subjective discomforts and sensations (symptoms) as well as such ob- jective changes (signs) as variations in blood pressure of which an individual is not necessarily aware) are evidences of activity of the defense mechanisms of the organism. A typical example is the phenomenon of fever. The child with an acute infection presents an abrupt and dramatic rise in body temperature, which tends to fall with comparable speed; the same degree of in- fective intoxication in an older individual induces only minor fluctuations in body temperature. In those of advanced age, full blown pneumonia may occur with almost no fever.

This tendency for symptoms to be less conspicuous is not an unmixed blessing. It encourages procrastination when the pa- tient is ill but does not feel very sick, and is likely to give rise to a false sense of se- curity. Furthermore, as has been pointed out, fever and many of the other phenom- ena of disease are part of the defense mech- anism, and the failure to respond vigorously implies weaker defenses. There is ample

STIEGLITZ

statistic evidence to indicate that the senile individual is a very poor risk in pneumonia, Though this may be attributed in part to depletion of the cardiac reserves, the poorer outlook is also unquestionably affected by the diminishing body responses to insults, The relative silence of symptoms in geri- atric patients is of great importance in diagnosis. The physician cannot afford to wait for obvious and dramatic evidences of disease, but must be constantly alert to detect the more subtle deviations from nor- mal functioning.

Though as yet little is known regarding changes in the requirements and utilization of foodstuffs which probably occur with aging, there is reason to suspect that there are many interrelated variations. Among the things which are known to be particu- larly important in the nutrition of the elderly are the lessened caloric require- ments with diminishing metabolic activity, the hazards of obesity in iater years, the great importance of water to the body economy, aid a diminishing tolerance to reduction in the oxygen delivery to the tissues. It may surprise some to have oxy- gen and water included in a discussion of nutrition because, unfortunately, these two vitally necessary elements have been sadly neglected by nutritionists in recent years. Whether the requirements for the various vitamins and mineral elements are changed greatly in senescence is not yet known (7). It is highly possible that larger quantities may be required because absorption by the aging alimentary tract becomes less effi- cient. Similarly, it is uncertain whether im- pairment of absorption is diffusely uni- versal or selective for certain vitamins. There are some evidences suggesting the latter alternative. Better understood is a very definite but gradual tendency for the skeletal structures to lose calcium; old bones are lighter and more brittle. Obvi- ously, there is more reason to hope that these changes in bone may be prevented by better nutrition in earlier years than that improvement in the diet late in life can cure a long existing situation.

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GERIATRICS

define optimum diets for every age. It must be confessed, however, that the optimum diet for any age is far from certain. There are many obstacles in the path toward de- fining an optimum diet and even more obstructions to the universal application of such knowledge when once it is acquired (8).

Adequate discussion of the mental changes which occur with senescence would require several large volumes (9). It must be emphasized that by mental change, not only alterations in the intellectual functions and capacities are meant but also further maturation of the emotional activities of the organism. These two aspects of the psyche may vary independently of each other. It is not uncommon to see consider- able intellectual ability and emotional im- maturity; the converse can also be ob- served.

For many years it has been assumed that mental efficiency declines in later maturity, and this assumption has led to the perpetu- ation of the faise doctrine that one cannot teach an old dog new tricks. Psychologic activity is composed of many components, and the changes in these various capacities are not symmetric (10). It is true that cer- tain functions become less efficient with the passage of time. For example, memory for recent events becomes conspicuously poor. It is equally true that other capacities be- come stronger; judgement and correlation improve with experience, and the acquisi- tion of experience depends upon time. Very careful psychometric studies have revealed that the rate of learning depreciates very slowly indeed, being about the same at eighty years of age as at twelve, with the peak of this ability occurring at twenty- two. Thus it is seen that the rate of decline during maturity and the senescent period is approximately one-sixth the rate of ascent during adolescence. In other words, it requires sixty years to fall from the maxi- mum to the same level existent ten years earlier. These data, however, are based on studies with individuals who wanted to learn. It cannot be overemphasized that the intensity of the motivating force is a major factor in any functional measure-

157

ment. Here, as in all other of the many facets of geriatric medicine, individualiza- tion is an absolute essential.

Changes in capacity of tissues to repair after injury are both quantitative and qualitative. Old tissues heal well, but more slowly than young. The rate of healing is so precisely correlated with age that DuNoiiy (11) was able to work out a mathematical formula with which he could predict the rate of healing of a clean, noninfected wound if the patient’s age was known, or conversely, estimate the age of the patient very accurately if the rate of healing was known. Repair of parenchymatous tissues following injury by toxins is more likely to reveal qualitative differences in later years in contrast to the regenerations ob- served in youth. The studies of MacNider concerning liver regeneration after injury with chloroform demonstrate that the older animal repairs the damage with different types of cells than do young animals (12).

There can be no question but that nutri- tional status of patients plays a very major role in the effectiveness of repair to injury. It must be remembered that the thickened blood vessels and impaired intracellular en- vironment of older tissues handicap the cells in their reparative activity.

For clinical purposes, it has been found useful and apparently approximately cor- rect to assume that for each five years a pa- tient has lived, one day longer is required for recuperation following a given injury. For example, a child of five can convalesce from a trauma or acute infection in twenty- four hours; a man of sixty will require twelve days to accomplish the same degree of reconstruction. The important implica- tion that adequate time is required for con- valescence of older individuals should be obvious.

Immunity likewise shows considerable variation. Immunities are usuaily specific for certain infective disorders, and the vari- ations depend largely upon previous expo- sures and experiences. Immunity to the acute, communicable diseases of childhood is prone to disappear gradually in later maturity; mumps or whooping cough are

158

not uncommon in grandmothers assisting in the care of ill grandchildren. The titer of immune bodies to pneumococci gradually diminishes with advancing age. It has been falsely assumed by many that there is a high level of immunity to tuberculosis in the aged. This assumption has led to con- siderable diagnostic error, for tuberculosis is rarely considered as a likely source of the continued cough in old patients. However, if the physician is aware of the possibility of tuberculosis, a considerable number of active cases are discovered in old age. These constitute a very serious menace as sources of infection.

One of the most important distinctions between older patients and those in youth and early maturity is that the senescent individual has acquired changes, not through age alone but as a result of inevita- ble previous insults and injuries. No one lives in a sterile vacuum. Each and every infection, intoxication, physical and psychic trauma experienced leaves some residual scarring behind. Man not only ages with time but is battered by many and various storms. Therefore, the physician treating the individual after maturity must assume that the patient was not in perfect health prior to the onset of an acute illness. This is precisely the opposite of the usual and justified assumption of pediatricians. The pediatrician is justified in presuming that all the manifestations of disease in an acutely ill child are the result of that dis- ease and that the child was previously well, unless there is definite evidence to the con- trary. In geriatric medicine it must be assumed that the patient most probably has suffered from silent depreciations in health and functional capacities, and there is posed consequently the problem of dis- tinguishing how much of any present dys- function and symptom complex is due to the acute illness and how much to pre- existent damage.

As health is relative and never absolute, there can be no sharp line of distinction be- tween health and disease. Every person has suffered some depreciations. In later years

STIEGLITZ

the co-existence of several silent insidious disorders is common. Superimposition of two or more chronic disorders complicates the clinical picture. Individualization in diagnostic analysis of the health problems of older persons is requisite unless mere guesses are to satisfy. Clinical diagnosis is much more than pinning a label on a dis- ease. As diagnosis exists only for the pur- pose of directing treatment, it is necessary to know not only what but also why. Fur- thermore, diagnosis has quantitative at- tributes. Measurement of the degree of deviation from the normal and estimation of the probable rate of progression of a progressive disorder are essential to a truly informative and fully useful diagnosis. The more sharply the target is seen, the higher will be the therapeutic score.

THE NATURE OF DISORDERS IN LATER LIFE

Most diseases can and do occur at any phase of the life span. Therefore there are few if any which occur only in old age. Even arteriosclerosis, which is characteristically an abnormality of later years, can, and does, appear precociously in youth or even in infancy. However, the disorders com- mon in early life and in later life are con- siderably different. It is not the rare and unusual exceptions which should be of concern; it is the frequent disorders which demand attention.

There exists a group of diseases, the

frequency of which increases rather sharply )

after the peak of maturity is reached, thereby creating problems more or less pe- culiar to geriatric medicine. The chronic

and progressive disorders of senescence may |

be divided into four major groups: (1) cir- culatory and renal diseases, (2) metabolic problems, (3) arthritic disorders, and (4) neoplastic disorders or cancer. Of these the circulatory disorders are of preeminent

importance (1, 13, 14). Arteriosclerosis and |

hypertensive disease involve the transpor- tation mechanism of the body and there- fore interfere with the nutrition of the whole organism. Though arteriosclerosis is

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GERIATRICS

usually generalized, the degree of change in the blood vessels is frequently asymmetric. If the arterial disease is particularly pro- nounced in the vessels of the brain, neu- rologic disease results; if the coronary arteries of the heart are severely narrowed, the chief clinical picture will be that of heart disease; grossly impaired circulation in the pancreas results in diabetes mellitus; if the kidney is starved, renal failure results. Superficially it might appear that these various consequences of arteriosclerosis or hypertensive disease are all quite separate entities. But as they all have a common genesis in interference with the arterial

supply, they should be considered as di-:

vergent manifestations of circulatory dis- ease. It is inconceivable that arterial change will be so localized that there will be degeneration of the brain with fully normal blood supply elsewhere. The localization of symptoms must not permit the physician to ignore the fact that the whole organism is affected by vascular disease, though the degree of impairment in circulation varies. Hypertensive disease (high blood pressure) differs from arteriosclerosis primarily in that the site of vascular damage is in the minute arterioles rather than larger ar- teries. The two diseases may exist sepa- rately, but more frequently they occur simultaneously.

Metabolic disorders common in later years include diabetes mellitus, thyroid in- adequacy, obesity, gout, and, of course, the climacteric in both women and men. The various arthritic problems of geriatric medicine are grouped separately because in some of them infection is involved as an additional factor to metabolic changes in skeletal tissues. The fact that the various forms of cancer increase in their frequency in later years is well known. It should be pointed out, however, that what is popu- larly termed cancer is not a single disease. There are nearly as many forms of malig- nant new growth as there are infections, and each and every type of tissue growth has individual characteristics.

Here is not the place to attempt a com-

159

prehensive description of these significant disorders. It should suffice to point out that they have certain clinically significant characteristics in common.

In the first place, the causation of all these disorders so frequently found in old age is still extremely obscure. They do not arise from external sources, as do the in- fections of youth, but are endogenous rather than exogenous. Furthermore, the causative factors are multiple, accumula- tive, and frequently interdependent. This means that no one will ever discover a single cause of arteriosclerosis, high blood pressure, cancer, or diabetes. There are many causes, and in no two patients is the combination of factors necessarily identical.

The second important characteristic common to the disorders of late maturity is the silent, insidious onset. They start without symptoms and may progress for years before damages become so extensive that subjective complaints arise. All such diseases are chronic and _ progressive. Though the progression is often very slow (hypertension may exist for twenty to thirty years before it becomes disabling), it is typically persistent. Degenerative disorders rarely kill quickly;, the course is usually characterized by a long period of increasing disability and invalidism. There is, however, considerable variation in the rate of progression in different people.

Lastly, it is more often the rule than not that several progressive abnormalities are superimposed in the same individual. Such overlapping confuses the clinical picture and makes diagnosis and treatment much more difficult.

Contrasting the characteristics of de- generative disease, common in older people, with the type of illness commonly en- countered in youth emphasizes the com- plexity of the problems involved in geriatric practice. In youth, iliness is usually acute, with a florid and obvious onset, a self- limiting course, and fairly simple causation. Rarely does the child have more than one disease at a time. The older person seldom suffers from but one disorder.

160 STIEGLITZ

The obvious implication is that in order to detect the appearance of the chronic and progressive diseases in later years early, so that worthwhile control measures may be instituted, these diseases must be anticipated before they are obvious. If nothing is done until symptoms of break- down occur, it will be too late to prevent distressing and protracted disability. Most chronic, progressive diseases can be dis- covered early, but this requires considera- ble diagnostic acumen and special methods of clinical study. For example, before diabetes becomes obvious, there is a long period in which the patient’s ability to utilize sugar is but moderately impaired. This impairment can be revealed only by studying the response to the stress of a large dose of glucose. Because a car seems to run fairly well on the level or down hill does not prove that it is capable of going uphill. If, however, the driver knows that it can climb hills well, he needn’t worry about how it will behave on a level road.

Magor LIMITATIONS OF GERIATRIC KNOWLEDGE

Until recently geriatrics has been neg- lected as a stepchild by medical science and by society. There are ideas that the aged, like taxes and death, are unavoidable evils and will always be with us, and that since aging is inevitable, nothing can be done about it. Even today one hears comments such as: “There are too many old people already; why should we try to prolong life?” Those who feel thusly fail to appreciate that the objective of geriatrics is not merely to prolong life, but to add health and vigor and therefore usefulness to the later years.

Now that rapid increases in longevity and the numbers of elderly people are es- tablished facts, perspective has broadened and geriatric medicine will become in- creasingly significant. For centuries only philosophers and poets, both notably gar- rulous like the senile, were deeply con- cerned with old age. Science itself is young, and it is therefore natural that it should be interested first in youth and growth. Re-

search into these facets of biology and medicine has proceeded far. As science and scientists mature, more and more attention will be paid to gerontology and geriatrics, Understanding of the biology of senescence and of the disorders typical of later matu- rity is still decidedly fragmentary. There are large blank areas in medical knowledge which are in urgent need of exploration through research. As awareness of ignor- ance is the prelude to learning, there is reason to hope that before long some of these blank spots on the map of knowledge will be filled in. It should be useful to out- line the most urgent gaps in learning.

The gravest handicap to geriatric medi- cine is the lack of knowledge concerning the complex causation of the chronic and progressive diseases so common and so disabling to senescents. Understanding of cause is prerequisite to truly effective treatment, both preventive and curative. There are many methods for alleviating symptoms. However symptoms are not diseases but merely expressions of dis- ordered functioning. One may do much to make a sore heel temporarily comfortable, but one cannot expect it to remain well if the nail is left in the shoe. The study of the causation of degenerative disorders de- serves first place on the agenda for geriatric research.

The second serious gap in present knowl- edge pertains to the early detection of depreciations in functional reserves, which are part of senescence and are accelerated by the degenerative diseases of later years. The discovery of such depreciations in incipiency (the time when therapy may be of maximum effectiveness) is dependent upon the development of new and im- proved clinical test procedures for the measurement of functional capacities of the many activities of the body. It is easy to discover florid disease; it is extremely difficult to predict chronic, progressive dis- orders, the onset of which is so asympto- matic. Delicate functional tests, useful for the mensuration of health, are crucial to the further growth of geriatric medicine.

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GERIATRICS 161

For many years medicine has been satis- fied with the old definition of health as “that state of being existing in the absence of disease.”” It is now known that such a definition is inadequate and that health is always relative. Yet physicians are still be- ing trained to look only for signs of disease. As a result, when no conspicuous signs are evident, the tendency to assume that a person is healthy is so strong that there are only a few physicians who are skeptical. If attention were focussed on the health of the individual and there were means of measuring health, unquestionably disease would be detected far earlier than is now possible. The measurement of health is al- most synonymous with the measurement of physiologic age.

It will not be easy to change the view- point of medical practitioners from con- cern with disease to primary interest in health. The precedents and habits of many generations are not readily altered, and it is admitted that physicians are particularly conservative. Nevertheless, medical schools can focus attention more sharply upon health and what it means, emphasizing its relativity and stressing the potentialities of improving the well-being of apparently well people. Medicine should be as con- cerned with health as with disease. There is great need for improvement in techniques in the evaluation of health.

It is most significant that preventive medicine for adults, in contrast to preven- tive medicine in children, requires that the initiative be taken by the prospective pa- tient. The prevention of the acute infective disorders of youth is largely a question of controlling the environment, for these disorders arise from without. The preven- tion of the degenerative disorders of later years is an individual matter, demanding initiative and effort on the part of the bene- ficiary. Perhaps the most important mes- Sage which physicians can convey to maturing people is that health is not a right, but a privilege, and thereby entails the obligation of exertion to maintain it. Medical science cannot give health to any-

one; it can merely guide people so that they may learn how to use, but not abuse, their endowment.

THE FUTURE OF GERIATRICS

Geriatrics and