Sunday, April 18, 2010

Geriatrics by David Hackett Fischer

A mild jeremiad against 'medical commerce' first; then a brief a survey of geriatrics in American Literature from the first major publication of a popular contemporary historian.

At the same time that the social insurance movement in America grew from small beginnings in the 1920's into a potent (though restrained) political force in the 1920s, other people were attacking the problem of old age from different directions. Not the least was a parallel movement among American physicians, who made old age into a special branch of medical science.

Physicians had long been interested in old age, primarily as a part of a perennial search for ways to prolong youth. In every scientific generation, there have always been a few investigators who have dreamed of discovering the secret of eternal life, and many more who have hoped merely to make death wait a little longer. In America, one of the first was Doctor Benjamin Rush (1745-1812), an eccentric Philadelphia polymath who published promiscuously on many subjects, among them old age ["An Account of the State of the Body and Mind in Old Age", 1793].* For a long life he recommended temperance, equanimity- and matrimony. In the nineteenth century, other physicians began to study old age in a new spirit- not so much to keep it from happening as to understand its effects. European scientists broke the first ground but by the early twentieth century, the scattered work of individuals began to be brought together to form a new medical disciple called "geriatrics". It's birthplace was New York City and its father was an Austrian immigrant, I.N. Nascher, who founded a professional group called "Society of Geriatry" in 1912.

From Nascher's time to our own era, geriatrics has grown steadily as a science. No epic discoveries have been made. No revolution has been wrought in either diagnosis or therapy. The process of aging still remains not merely unknown, but a mystery. It's cause continues to be elusive. But it has been studied with more rigor than before, and many of its operations are understood with increasing clarity. As a therapeutic discipline, geriatrics, broadly conceived, has had many successes. If aging cannot be 'cured", it can be eased and made more comfortable. The physical pain of growing old, which was so intense in early America, has been much reduced. The invention and improvement of eyeglasses, false teeth, hearing aids, and other prosthetic devices have made a major difference in the physical experience of growing old.

At the same time, the practitioners of geriatric medicine have labored to change the attitudes of physicians towards their elderly patients. American doctors have tended to share the general prejudices of their society, and added a few of their own. Aesculapius proposed a principle of medical ethics that physicians should seek to cure only those patients who can be restored to active life. In a more moderate form, that attitude is still widespread. The very old have often found it difficult to obtain a physician's attention, unless they are also very rich. Geriatric medicine has struggled against those attitudes. If it has not succeeded in reversing them, perhaps it has made some difference.

Yet surrounding the science of geriatrics, as a circle of darkness surrounds the light, is a twilight zone inhabited by hucksters and healers of every shape and hue. Always, men have hunted the fountain of youth with a determination equal to their distance from the object. In the twentieth century many panaceas have been peddled to the elderly as remedies for aging. For the very rich, society doctors have prescribed all manner of injections, ointments and potions. In the 1920s, a popular geriatric fad was monkey glands; in the 1940s, Fletcherizing; in the 1950s, cortisone injections; in the 1960s, estrogen. In the 1970s, vitamin E was prescribed by country-club physicians in kidney-killing doses. Some of those fads (even the most scientifically respectable) may actually have shortened life. The rapid rise of cancer among affluent, middle-aged American women in the 1970s was due in part to the use of estrogen by physicians who were treating the symptoms of menopause.

For Americans too poor to afford those expensive nostrums, antidotes to aging were bottled and sold across the drugstore counter. Patent medicines have had a long and fascinating history in America. By the 1970s they had become a billion-dollar business. In Massachusetts in October 1975, twelve ounces of a concoction named Geritol cost nearly $4- more than the best bonded Bourbon. One popular tonic, Serutan ("nature's spelled backward') cost $2 for seven ounces.

The vast health industry in America has exploited the elderly in an ingenious variety of ways. One example is what might be called the arthritis racket- a huge business all in itself. More than twenty million Americans are thought to suffer from some form of arthritis. They spend perhaps $400 million a year in hope of finding relief from its painful and crippling symptoms. The health hucksters have offered them arthritis clinics, vibrating devices, exotic diets, and many drugs and liniments. But most of what Americans buy for arthritis has no helpful effect upon that condition, and may actually make it worse. Regulatory agencies and private clinics have become more active in policing this vast industry, but the problem always outruns the remedy.

Government has also taken a hand in dealing with the medical problem of old age in a more direct and important way. The National Health Surveys, which were first taken in 1935-36, showed for the first time the full extent of disability among the elderly. Nothing much was done at the national level to diminish it for thirty years. In the 1930s the health care which was available to the elderly was what they could buy from their physicians or beg from a charity.

The major change came in 1965, with the passage of the Medicare and Medicaid programs. Medicare provided federal money for most of the health care needs of people over sixty-five; Medicaid paid the bills of the poor. But in our modern world of social engineering, every solution becomes another problem. So it has been with Medicare and Medicaid. Those programs brought a revolution in the "health care industry", as it was coming to be called. They had been bitterly opposed by conservatives as a form of "socialized medicine". But the result has not been socialism at all- rather, a corrupt form of state capitalism, which has combined the vices of both ideological worlds without the virtues of either. The American health system has encouraged physicians to become medical entrepreneurs- except that it is the patient who assumes the risk and the physician who takes the profit. Proprietary hospitals and nursing homes have become business corporations more profitable than Exxon or United States Steel. Drug companies have driven up prices of medicine by conspiracy and collusion. No other society in the world has tolerated a system of medical care which is so expensive and so corrupt.


  1. Gerontophobia is a highly destructive attitude, destructive most of all for those who adopt it- for in the end it is always directed inward upon the mind it occupies. Gerontophobia begins as a loathing of something in others; it ends as a loathing of something in oneself. In the end, the discovery that one is old is inescapable but most Americans are not prepared to make it. Instead, their age suddenly becomes apparent to them in a brutal way which allows no vestige of dignity and pride to survive the discovery. The result is an orgy of self-pity and contempt... in the end the cult of youth consumes all of its believers.

    At the same time that old age became more common in American society, it also came to be regarded with increasing contempt. Where the Puritans had made a cult of age, their posterity made a cult of youth instead. The clergy of New England had made veneration of the aged a sacred duty but the New England literati of the nineteenth century began to offer their readers opposite instructions. At the extreme of Transcendentalism was Henry David Thoreau. At the arrogant age of thirty, Thoreau expressed the most perfect and finished contempt for all seniors:

    "Age is no better, hardly so well, qualified for an instructor as youth, for it has not profited so much as it has lost. One may almost doubt if the wisest man has learned anything of absolute value by living. Practically, the old have no very important advice to give the young, their experience has been so partial, and their lives have been such miserable failures, for private reasons, as they must believe; and it may be that they have some faith left which belies that experience, and that they are only less young than they were."

    In Emerson's writings, Nature abhorred old age, and Emerson agreed with Nature. But he was also a moralist so he argued strenuously against contempt for the aged by insisting that a person could grow younger in spirit even as he grew older in every other way. It was a silly sort of argument, an absurdity in the same way that so much of Emerson is absurd when the clouds of rhetoric are stripped away. But that is what makes Emerson so fascinating as an historical phenomena- a first class mind caught by the contradictions of a transitional era.

    Some major 19th American writers were much more conservative on the subject of age. Nathaniel Hawthorne was one: he filled his stories with old characters, from great "grey champions" to pathetic 'white old maids'. Although his aged characters are rarely attractive, they are always interesting. Hawthorne was one of a handful of modern novelists- Dickens another, and Balzac a third- who allowed his aged characters to possesses a truly individual existence. Most modern authors make old people into cardboard characters- stereotypical figures put together from the prejudices of the age. Longfellow was sympathetic to old age, however uphill such work as a 19th century poet may have been. For Whitman, age was a species of spiritual affliction. The poems he wrote on the subject when he himself had reached old age are suffused with ugly moods of anger and self-pity.

  2. In major works of twentieth-century American literature, old age has rarely been a central theme. Ernest Hemingway's Old Man and the Sea is one of the few modern novels in which an old man is the protagonist; A story in which the young spirit conquers the old body and ends on a classical note of Emersonian triumph. When old age appears at all in a twentieth- century literary work, it is apt to not be tragic put pathetic, with the central theme of weakness and dependence. The classic example is the dying old man in the last two pages of John Steinbeck's The "Grapes of Wrath", a horrible scene- one of the most powerful and hideous in modern American fiction. A similar scene is found in Robert Frost's "Death of the Hired Man". An even more corrosive theme is the emptiness of old age, the central idea in T.S. Eliot's "Gerontion".

    At least four scholars have studied this literature in a systematic way. All of them have found more or less the same pattern- a continuing decline in the literary status of old age. Traditional attitudes of veneration - if not of love -disappear more slowly from popular writing than from high literature, but the direction of the trend was more or less the same. The pace of change accelerated slowly as time passed- moving slowly in the early nineteenth-century, faster in the late nineteenth century, and fastest in the early twentieth century. The waxing of proverbial usage and historical changes in word connotations reflect similar trends, from respect- if never entirely warm- to contempt or indifference.

  3. Growing Old In America (old edition) by David Hackett Fischer; Oxford University Press, 1977