OLD AGE AND ITS PSYCHOSES*

BY CHARLES W. PILGRIM, M. D.,

Chairman, New York State Hospital Commission.

Old age is a relative matter and the number of years one may have lived has but little to do with the question. Many are old at 50, while in other cases a fair amount of bodily and mental power is preserved beyond the allotted period of the three score years and ten and, occasionally, extreme old age appears to be the time of actual ripeness and perfection.

Ex-Senator Chauncey M. Depew, who only a few weeks ago reached the age of 82, in reply to the question, “What message would you like to give to the American people," said, "Tell them I am infinitely more happy, more healthy, more satisfied with life, more optimistic about the future of this country, and of the world than I was at the age of 50, or any other time in my life, and I expect the same to be more true when I am 90 and more than 90.”

Dr. Stephen Smith, whom many of you know, who was at one time State Commissioner in Lunacy, and who has for more than fifty years been active in the charitable work of the State, is now at the age of 92 as active, as vigorous, and as efficient as the ordinary man in middle life.

"Our friend, John Burroughs", and William Dean Howells are also doing some of their best work at 80, and many similar cases might be cited.

Jacob Grimm, the writer of fairy tales, pronounced an enthusiastic eulogy upon old age.

Dr. Holmes wrote:

"Age has its opportunities no less

Than youth itself, though in another dress."

Longfellow said: "I venerate old age, and love not the man who can look without emotion upon the sunset of life," and Robert Collyer, the noted preacher, was able to say when past the age of 80, that he had never missed an

Read at the annual convention of the State Superintendents of the Poor, held in Poughkeepsie, June 14, 1916.

engagement, had never taken a meal in bed, nor had never gone without a meal since he was born, on account of illness.

Old age under such conditions is not to be dreaded, but the lot of the majority of aged persons is far different, and in all ages there has been a search and a longing for the fountain of youth and the elixir of life. Ponce de Leon gave up his life in the search, and Metchnikoff, and other distinguished investigators have spent their days in seeking in the glands and other substances, a means for the prolongation of youth and the retardation of age. But in spite of all their efforts their quest has not been successful and as the poet says:

"Old age comes on apace to ravage all the clime."

Of course, a good deal can be done by hygienic measures such as purity of life, cleanliness, exercise, fresh air, and temperance in the use of food and drink to delay the approach of age, but nothing can stay it indefinitely. On the other hand "the pace that kills," blood infection, tuberculosis, the intoxicants such as alcohol and tobacco, and conditions which lead to high blood pressure, such as worry, muscular over-work, and overeating, all lead to a degeneration and thickening of the arteries, a condition known as arteriosclerosis, which is the sure precursor of senile changes.

It is often said that "A man is as old as his arteries" and when we remember that the heart, waking or sleeping, never rests, that the blood vessels are always under strain, and that their walls are subjected to a distending force of 21⁄2 pounds to the square inch from 80,000 to 100,000 times in 24 hours, it seems a wonder that our system stands the strain so long instead of breaking down prematurely as it sometimes does.

To the poor and dependent "the sunset of life" is too often bereft of its golden glow. Among primitive people the aged and infirm are often abandoned and left to die of hunger and exposure. Among the Chuckchi and some other primitive peoples voluntary suicide of the aged is committed amid great pomp, and this rite undoubtedly can

be explained as much by the miseries of existence as by the belief in a better life beyond the tomb.

Even among civilized people the aged and physically unfit are often abandoned to their fate even by their own children. Those who have read "How the Other Half Lives" can recall many pathetic cases related by Jacob Riis. Is it a wonder, therefore, that the poor look with dread upon the approach of age with its infirmities, and is it a wonder that philanthropists and others interested in the welfare of their less fortunate fellows have sought, by means of old age pensions and homes for the aged, to banish some of the unhappiness which old age brings?

The exact time at which old age begins can not be stated. The transition is usually gradual and the limit differs with the individual. Usually, however, we may say that in the female the period of general involution which begins at the end of the the menopause is the commencement of old age. Although there is no definite age for this, it may generally be stated to be from the 50th to the 55th year, while in the opposite sex the period is somewhat later and we may assume that senile changes begin in the male sex between the 60th and 65th year.

Senile involution commences mostly with slowly developing constitutional changes, such as thickening and hardening of the walls of the blood vessels, changes in the blood such as hydræmia, when the blood becomes thinner and more watery, and atrophy of all the organs. The only exception is the heart, which in old age generally becomes greatly hypertrophied on account of the greater amount of work it is called upon to do in forcing the blood through the thickened arteries. In extreme old age, however, the heart may sometimes atrophy.

The atheromatous changes in the walls of the arteries and the poorer condition of the blood interfere with the nourishment of the brain and other organs and as a consequence we have headache, dizziness, a sense of pressure, weakness and fatigue, subjective phenomena of vision and hearing, difficulty in breathing and asthmatic troubles, especially at night, disturbance of sleep, sleepiness during

the day and disturbances of digestion. There are often perverted sensations and impulses which lead to unnatural cravings for stimulants and sexual gratification.

The objective signs are a slight emaciation or a tendency to corpulence, sluggish circulation, emphysema of the lungs and chronic bronchitis. There will also be the bent back, the shortening of stature, the shrunken gums, the missing teeth, the changes in the eye known as arcus senilis, and the whitened hair.

The mental symptoms will be loss of memory, difficulty of concentration, lack of adaptability and adjustment, increased apprehension and the lack of ability to overcome the ordinary obstacles and difficulties of life. All these symptoms belong to what is called physiological senility, or dotage, and such cases may properly be cared for in homes for the aged or almshouses. They need only kindly oversight and custodial care such as may be given by friends or relatives, and when home care is not available, the attention which they need may be found in any well managed home for the aged or in any well regulated almshouse or country home.

The changes mentioned are so gradual and progressive and the physiological passes into the pathological so quietly that the question as to the line of demarkation, especially in the making of wills, often becomes the subject of judicial inquiry when it requires the best judgment of men of experience and training to decide the delicate question of legal capacity.

When to the symptoms of mental decay which I have described there is added symptoms of mental disturbance, we have what is known as senile insanity. It should, however, be stated that when insanity, due to tissue changes incident to involution, occurs in the male before the 60th year, we have what is known as pre-senile dementia. The symptoms in presenile dementia, differ somewhat from the symptoms usually found in the more common types of senile dementia developing later. There is a rather long prodromal period, during which the patient complains of all sorts of sensations, such as dizziness, general malaise and various symp

toms due to perverted sensibility not unlike the beginning symptoms of involution melancholia. The patient is apt to be irritable, morose, and seclusive. From this condition

delusions of hypochondriacal or persecutory character are developed. As these delusions are founded upon a demented basis, they are apt to be absurd in character. The patients imagine that certain viscera have been removed, that their brains are dried up, that their legs are made of glass, that all their bones are broken, etc. Then come persecutory delusions of poisoning and the like, often with a sexual trend which leads them to believe their partners unfaithful no matter how old and feeble and unattractive they may be. These delusions are not unlike those found in cases of chronic alcoholism, and are often accompanied by fabrications, but they are much more absurd in charThis condition resembles the Korsakow complex and is known as the presbyophrenic type. Patients suffering from this form are emotional and sometimes depressed and as a general thing they are irritable and easily moved to anger.

acter.

In senile insanity of a later period, the signs of involution are more marked and the mental defect more apparent. It has been said that in youth we plan, in manhood we execute, and in old age we remember. Like all such sayings there is an element of truth in it but the remembering which the aged do is of the past. In the senile psychoses the memory for recent events is so weak that events occurring only an hour before are forgotten, and the patients can not remember the day of the week, their own name, or the names of their children, and with this defect there is such a marked tendency to reminiscence that they live entirely in the past; there is marked egotism; an aversion to any change in the routine of life; a disregard of the comfort of others; all these symptoms are accompanied by irritability and resistance to control which makes their proper management extremely difficult. Things become progressively worse until the patient sinks to a vegetative existence, without mental initiative, without judgment, and with no appreciation at all of the present. With this mental fail