Archive for July, 2016

Daniel Schäfer “‘That Senescence Itself Is an Illness'”

Schäfer, Daniel 2002. ‘That Senescence Itself Is an Illness’: A Transitional Medical Concept of Age and Ageing in the Eighteenth Century. Medical History 46(4): 525-548.


Senectus ipsa morbus est …: Jacob Hutter (1708-1768) used this provocative hypothesis to draw attention to his doctoral thesis of the same title which was published in 1732 at the University of Halle in Central Germany. Hutter was an otherwise practically unknown figure, who later worked in his native Transylvania as a doctor and pharamacist. His dissertation was reprinted that same year with the title also translated into German: ‘That senescence itself is an illness’ (Dass das Alter an und vor sich selbst eine Krankheit seye). (525)


Surprisingly, the radical claim that old age constitutes an illness had first appeared, not in a medical text, but in a literary work. Hutter, along with other authors around 1700, quoted a particular passage from the comedy Phormio by Terence, written 161 BC. The old Chremes, when asked by his brother Demiphon what illness he was suffering from, replied, “Why do you ask? The illness is old age itself”. (525)


Although Aristotle dealt with the negative aspects of old age in detail, he mentioned only briefly the physiopathological aspects, which were considered to be partly responsible for the facial characteristics of old people. In his opinion, the word for “old age”, géras, was etymologically related to the word for “earth”, , and old age was thought to have the cold and dry qualities of earth. An “illness” (nósos), such as grey hair, was considered the result of a lack of warmth, something characteristic of old age. If it were possible to restore the health and strength of the person, a change would occur, i.e. the old person would regain his youth. In accordance with this line of reasoning, illness could be described as acquired old age, and old age as a natural illness. (528)


[Galen] made fun of an unnamed contemporary sophist from Egypt who in a lost writing entitled Peri Agerasias (On avoiding senescence) extolled the possibility of eternal youth, on the basis that old age was nothing other than a treatable illness. Galen, who pointed out rather cruelly that the author was unable to treat himself, believed the ageing process was a more or less “natural” one because the decrease of the calor innatus made it unavoidable, although it could be slowed down, but not halted, by diet. (529)


On the one hand, Galen divided the science of medicine into three basic groups: the study of that which is healthy, that which is ill, and that which is in-between (neutrum). He included old age in this last group and classified the health of the old person as being incomplete, due to his lack of vitality. […] On the other hand, Galen also adopted the Aristotelian theory that old age was acquired as a result of an illness; comparing the insidious (cold) type of marasmus, which usually followed a consuming fever (i.e. an illness) and ended in death, to natural old age. Acute marasmus could also cause premature senescence (progeria) and this was described in ancient medicine with the technical term géras ek nósou / senium ex morbo (old age resulting from illness). (529)


Ibn Sina (Avicenna) considered ageing and death not to be a pathological entity, but rather a result of natural decrease of the calor innatus due to the consumption of the humidum radicale. (530)


Not until the High Middle Ages did Western medicine also begin to accept Galen’s evaluation of old age as a natural process. The anonymous author of De retardatione accidentium senectutis (often ascribed to Roger Bacon) in the thirteenth century shared Aristotle’s belief that the ageing process, which causes hair to turn grey, for example, can in principle be reversed by diet or secret medication (occulta). However, he did not explicitly state that old age equaled illness, but cautiously suggested that if the same phenomena associated with old age (accidentia senectutis) were to occur in adolescence, they would be called illnesses. (530)


It is unlikely that Terence had already had an influence on medicine at this time. He had, however, been one of the ancient authors most widely read in the Middle Ages, and his statement about “old age” being an illness was obviously known outside medicine; for instance, old age was described in late medieval texts of religious origin as being an illness of the natural body. (531)


By around 1500, at the latest, the illness “old age” had become a popular literary topos. This seems to have been due to both a certain hostility to senescence in this epoch and the influence of humanism, which idealized authors of the ancient world such as Terence and Seneca. In a deliberate contrast to the idealization of old age in Cicero’s Cato Maior De senectute, Erasmus of Rotterdam composed a poem for the Basle physician Guilielmus Copus about the burden of old age. In his commentary to the book of Ecclesiastes, Martin Luther also stated as if it were self-evident: senectus enim per sese morbus est. (531)


Some fifteen years before the dissertation of Jacob Hutter mentioned at the outset, the Terence quotation was directly presented as a medical hypothesis for the first time in a dissertation. Aegidius Glagau, a disciple of Boerhaave, postulated that old age and illness were on and the same thing in the very title of his dissertation written in Leiden in 1715. But his approach was a very general one. So he viewed things in a relativistic (and also holistic) way, as we can clearly see from this quotation, allegedly from Hippocrates, contained in the preface: “the entire person is ill from the moment of his birth.” (536)


Although the authorities of ancient times had considered it to be an untreatable condition, he [Hutter] claims that experience has shown that life expectancy could be improved by a correct lifestyle. He believes that the first principle is to maintain a free and regular circulatory system in order to protect against illness. Furthermore, secretion and excretion should not be impeded and the production of suitable new humours should be stimulated. This could supposedly be achieved by a diet based on the “six non-naturals” (Sex res non naturales) and by moderate dosages of various drugs. (539-540)


This brief description of Hutter’s analysis of old age clearly shows the influence of iatromechanics, which was gaining a hold in Germany as a result of the influence of Descartes and Harvey. Hutter’s professor, Friedrich Hoffmann, was one of its main supporters, in that he developed a comprehensive physiological and pathological system based on its principles. His student, in turn, tried to explain old age as a result of a disturbance in the equilibrium between tension and extension, a diminishing of strength and a restriction in the flow of humours. The Galenic theory of a dyscrasia of the humores seems, on the other hand, significantly repressed, as to be expected for this period, and the Aristotelian flame metaphor is not mentioned at all. The role of Hippocrates as an authority for the integrality of the person is now more predominant. (540)


In this, Hutter and Glagau were exceptional, in that they accepted the widely disseminated controversial Phormio quotation in a literal sense and based a physio-pathological concept of old age on it. But most other medical university texts on old age from the first half of the eighteenth century did quote Terence and did not refute his statement. Therefore it can be regarded as a common idea, which was both well-known and accepted by specialists, and as a popular belief held by practicing physicians until well into the twentieth century. (541)


[…] it should be stressed that, at least in the first half of the eighteenth century, the traditional concept of illness as a general process beyond nature (res praeternaturalis) became blurred in the texts. The iatromechanical theory of a progressive hardening of the fibres opened the way for “new” concepts: illness as any malfunction or disruption of the human machine, and illness as a constitutive factor beginning at birth (also in keeping with ancient ideas). This explains the reasoning behind the strange academic debate organized in Paris around 1750 on the topic of whether illness was an inherent part of the human condition. (543)


While there was still some variation among the concepts of illness around 1700, physicians were for the most part agreed on the pathogenesis of death from old age: it was caused by the restriction of the circulation and an impairment in or weakness of the heart. This traditional idea was so widely recognized that it even appeared in the London Bills of Mortality from the seventeenth century, and until well into the nineteenth century in other statistics, which listed old age as one of the most important causes of death (accounting for 5 to 10 per cent of fatalities), along with numerous illnesses. (543)


[…] this type of death was no longer regarded as a “natural” fading away of body and spirit, like a flame that burns itself out, but rather as an end to life brought about by the morphological effect of the illness “old age” alone. Friedrich Hoffmann, therefore, did not mention natural death in an even earlier dissertation of Christian Blüdorn (1715) nor in his other work. Of course, it had not been clearly established in the eighteenth century whether this concept of death from old age concerned a natural or a pathological process. But in relevant university texts, fragile, extreme old age and feverish marasmus are completely merged with the idea of an “old age marasmus” (marasmus senilis / naturalis), characterized by a slight fever (febris lenta), consumption, soporific state and the painless transition to death, a fusion, which was still rejected in Galenism. (543-544)


The most important blow to the short-lasting comprehensive concept of “old age” as an illness was the study of the pathology of bodily organs by Giovanni Battista Morgagni (1682-1771) based mainly on post-mortems on old people. Morphological changes in individual organs rather than an illness of the organism as a whole were now increasingly seen as the original “seat and causes of illnesses” (sedes et causae morborum). […] And Burkhard Wilhelm Seiler (1779-1843), who was later to become a professor at Wittenberg, stressed at the turn of the nineteenth century that most people did not die because of the weaknesses of age but rather as a result of some illness. (544)


In view of the lack of therapeutic innovation and of the pathology-based pessimism surrounding the complete restoration of health, it is not surprising that the theses discussed did not call for any changes in medicine and certainly did not suggest that there should be any “geriatric” specialization in training, research or clinical practice. One can agree unhesitatingly with Peter N Stearns’ claim: “Geriatrics was born in the nineteenth century.” (545)


Along the way, it is possible to distinguish some important steps taken in medicine towards the present-day comprehensive medicalization of human existence (birth, childhood, women, psychological disturbance, lawbreakers, old age, death), which began in earlier centuries, but is clearly identifiable from the eighteenth century onwards. The illness “old age” could be regarded as one of these steps because old age is recognized for the first time by physicians on a theoretical level as a pathological, and as such, an indisputably medical process. (547)