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.