‘All diseases run into one, old age’
The hieroglyphic for ‘old’ in ancient Egypt in 2800 BC was a bent person leaning on a staff—perhaps the first depiction of the ravages of osteoporosis. Like all humans, our ancestors wanted to know the cause of the things that affected them, and so it was with ageing. They were also looking for ways to prevent it. Different from the legends about immortality, which will be discussed later, were the theories as to why ageing occurred and how to avoid it, and these go back a long time. Originally it was the function of religious beliefs to provide such explanations. Eventually such enquiries led to the true study of ageing and how it might be treated—geriatrics.
As long ago as 1550 BC the Ebers papyrus from Egypt, one of the oldest preserved medical documents, suggested that debility through senile decay is due to accumulation of pus in the heart. This is probably the first non-religious explanation of ageing. The Taoists in ancient China believed that ageing was due to the loss of some vital principle which they equated with the loss of semen in men, and thus taught secret techniques by which men could have an orgasm without ejaculation. Such men, they claimed, would age much less. Plus, if you learned to undertake effortless action, take vital breaths and eat magical foods such as ginseng, you could also slow down the ageing process. In Ayurvedic medicine in India the ancient sage Maharishi Chyavana propounded his idea of anti-ageing therapy. When the Maharishi was bogged down by old age and low energy levels he started taking chyavanaprasha, an astonishing tonic and anti-ageing medicine, and claimed he soon found himself on the road to complete recovery. Gooseberry is the main constituent of this tonic.
Around 400 BC, medicine in Greece was steeped in religious belief. Illness and ageing would automatically be attributed to the activities of gods or demons. But some of the earliest non-mystical explanations for ageing also came from the Greeks. The ‘father’ of medicine, Hippocrates, instead of ascribing diseases to divine origins, discussed their physical causes. He believed that certain diseases afflicted certain ages. His theory was that ageing was due to loss of heat and moisture. Aristotle, who had a very negative view of the old, perceived the aged body as dry and cold, and also thought that old age was due to the diminishing of heat in the body, as heat was the essence of life generated by the heart. Galen, for whom old age was due to the dry and cold constitution of the body, recommended that the old should take hot baths, drink wine and be active. For Galen old age is not a disease, and is not contrary to nature. For St Augustine, some 800 years later, illness and ageing were the result of Adam and Eve being driven out of the Garden of Eden.
It must be remembered that there was no chance in those times of acquiring any scientific understanding of ageing, as it was only some two thousand years later, in the nineteenth century, that it was at last discovered that the body was made of cells. Darwin’s theory of evolution was also of great importance, as we shall see.
The Arabic philosopher Avicenna (981–1037) followed Galen and saw no way to prevent the drying out that caused old age. The Canon of Medicine, written by Avicenna in 1025, was the first book to offer instruction for the care of the aged, foreshadowing modern gerontology and geriatrics. In a chapter entitled ‘Regimen of Old Age’, Avicenna was concerned with how ‘old folk need plenty of sleep’, how their bodies should be anointed with oil, and recommended exercises such as walking or horse-riding. One thesis of the Canon discussed the diet suitable for old people, and dedicated several sections to elderly patients who become constipated. The Arabic physician Ibn Al-Jazzar (c.898–980), also wrote a special book on the medicine and health of the elderly.
Roger Bacon (c.1214–94), a Franciscan friar, was the first to propose a scientific programme of epidemiological investigations into the longevity of people living in different places, and under different conditions. He also noted that the pursuit of knowledge depended on ‘the fresh examination of particulars’, and that there needed to be a systematic observation of nature. He wrote a book on ageing in which he suggested that old age could be warded off by eating a controlled diet, proper rest, exercise, moderation in lifestyle and good hygiene. So far so good, but he also suggested inhaling the breath of a young virgin. Following a common theme in those times, that ageing was the result of the loss of some vital material, Bacon claimed that the breath of young virgins could replenish the loss of this vital essence. This belief most probably came from the biblical story of King David sleeping between two virgins when he was old to restore his youth, though not necessarily having sex. A young virgin could preserve a man’s youth because the heat and moisture of the young woman would transfer to the old man and revitalise him.
Roger Bacon also claimed that life could be extended and that Methusaleh was an example, that the neglect of hygiene shortened life, and some individuals had used secret arts to prolong their lives. One example was a farmer who drank a golden drink he found in the field and lived a long time, and this supported Bacon’s alchemical convictions. In Italy, in the mid-sixteenth century, Alvise Cornaro said that life could be extended by eating less as it used up less innate moisture, and it was necessary to keep the four humours that had been the basis of Greek medicine—blood, phlegm, yellow bile and black bile—nicely balanced. There was still no serious science of ageing.
It was Francis Bacon, a key promoter of the renaissance of science and author of The History of Life and Death (1638), who first proposed a study of ageing in order to find out its causes and how to prevent it. He was the first to acknowledge the prolongation of life as an aim of medicine. He argued that ageing was a complex process, yet capable of remediation, but ‘It is natural to die as to be born.’ He did not believe that old age was due to a loss of some vital substance. He made little progress, but he did recommended exercise. He also apparently had a light touch: ‘I will never be an old man. To me, old age is always 15 years older than I am.’ There is a story that while travelling in a coach towards Highgate in London he concluded that cold might prevent ageing. He tried the experiment at once, stopped the coach, bought a hen, and stuffed its body with snow. But the cold affected him and he died a few days later. His interest in ageing was an important stimulus to its being studied by others.
Dr George Cheyne, an eighteenth-century doctor, believed the English were dying due to an excess of comfort, wealth, and luxury—the ‘English Malady’—and that the way to prevent ageing was by eating only enough food to allow the body to maintain its heat. A little later the German physician Hufeland argued that fast living led to short living, that you should drink no alcohol, chew your food deliberately, and be positive. He stated: ‘We frequently find a very advanced old age amongst men who from youth upwards have lived, for the most part, upon the vegetable diet, and, perhaps, have never tasted flesh.’ He accepted the view that at birth an individual was endowed with a finite amount of vitality and that this decreased with age.
The scientific study of ageing only began to make progress with the work of Benjamin Gompertz, whose paper in 1825 described human vital statistics from several countries, and showed that the prevalence of many diseases increased in the same way as mortality. He concluded that death may be the consequence of two generally coexisting causes; the one, chance, without previous disposition to death or deterioration; the other, a deterioration, or an increased inability to withstand destruction, namely ageing. Gompertz was interested in the latter situation: how can we model the probability of a person living to a certain age, if nothing unexpected happens to him? His important results showed that mortality increases exponentially as age increases between sexual maturity and old age.
The Belgian scientist Adolphe Quetelet recognised that both social and biological factors determined how long humans live, and made important contributions to life histories. Quetelet began his research by the physical study of the ‘average man’. He laboriously recorded population statistics surrounding the birth, height and physical proportions of men at various ages. Among his findings were strong relationships between age and crime. Charles Darwin’s theory of evolution came out at this period, and Quetelet wanted to know whether selection for those who are better adapted continued after the individual’s reproductive phase. Darwin’s cousin, Francis Galton, was interested in ageing, and collaborated with Quetelet to measure the correlation between age and strength. In 1884 he collected the physical reaction times of some 9,000 people aged from 5 to 80, which were not analysed until much later.
In 1881 August Weismann delivered an important lecture on ageing at the University of Freiburg. It was the first attempt to explain ageing in terms of Darwinian evolution and the behaviour of cells. He was convinced that immortality would be a useless luxury and of no value to an organism, and that the cause of ageing would be a limitation of cells’ ability to reproduce. He regarded ageing as adaptive, as it helped get rid of decrepit old individuals who competed for resources with others in their group. This was wrong, as we shall see. He nevertheless recognised the important principle that once an individual had successfully reproduced and cared for their offspring, it ceased to be of any value to the species. He also made clear that the germ-line cells which give rise to eggs and sperm must not be subject to ageing, for if they were, the species would die out. It was another 60 or so years before there were further attempts to understand the evolution of ageing.
Jean-Martin Charcot, a famous neurologist at the Pasteur Institute, also promoted the study of old age, which he recognised as being neglected. His lectures on the medicine of old age, Clinical Lectures On Senile And Chronic Diseases, aroused scientific interest in the field, and became available in English translation in 1881. They had a big influence, as Charcot saw old age as the simultaneous enfeebling of function and a special set of degenerative diseases, and these needed to be distinguished. Elie Metchnikoff, a Russian who went to the Pasteur in Paris in 1888, continued Charcot’s work and coined the term gerontology in 1903. Geronte is French for ‘man’ and has nothing to do with ageing but it remains with us as a name for the science of ageing.
Metchnikoff won a Nobel prize for showing how certain cells in our bodies defend us against invaders like bacteria, by eating them and dead material, a process known as phagocytosis, and he saw old age as cellular involution in which cell decay outbalances cell growth. He believed ageing was due to bacterial toxins released from the intestine, and that Bulgarians lived especially long lives because they ate yogurt. He thus touted yogurt as an anti-ageing medicine. Based on his theory, he drank sour milk every day. George Edward Day (1815–72) wrote a common-sense book from the physician’s perspective on ageing in 1848. He complained that other physicians had little interest in caring for the ills of the aged. That refrain still rang true during the first few years of the twentieth century.
Modern geriatrics was born with the invention of the word ‘geriatrics’ by Ignatz Leo Nascher from the Greek word geras for age. Nascher was born in Vienna in 1863, graduated as a pharmacist and then obtained his medical degree from New York University. He wrote a number of articles on geriatrics and a 400-page book, published in 1914, Geriatrics: The Diseases of Old Age and Their Treatment. He described ageing as a process of cell and tissue degeneration. He thought, mistakenly, that all our cells except for the brain were replaced as we aged. A major problem for him was how to distinguish between diseases in old age and diseases of old age. His interests in geriatrics and his development of treatments for older people almost certainly came from visits to Austria, where the care of elderly people was blossoming at the time. He retired at the age of 66.
Nascher’s interest in geriatrics is a bit strange as it contrasted wildly with his contemporary William Osler, the famous Canadian physician who was chairman of medicine at Johns Hopkins in Baltimore. Osler appeared to be remarkably ageist, as shown in his final address, called ‘The Fixed Period’, in which he stated that men over 40 years, beyond the golden age of 25 to 40, were relatively useless. Men over 60 years were considered absolutely useless, and chloroform was not a bad idea for this age group. This address is said to have been responsible for a number of suicides.
While there were scientific studies on child development, ageing was still largely ignored in the early twentieth century. The psychologist G. Stanley Hall was a founding father of psychology as a science. His major work was on child development, but, concerned about his own ageing, he wrote a book about ageing, Senescence, in 1922. He interviewed some elderly adults and found that their attitudes towards death changed as they aged. This was the first analysis of the changing attitudes and thinking linked to ageing:
How different we find old age from what we had expected or observed it to be; how little there is in common between what we feel toward it and the way we find it regarded by our juniors; and how hard it is to conform to their expectations of us! They think we have glided into a peaceful harbor and have only to cast anchor and be at rest.
It was Peter Medawar in 1952 who pointed out that environmental factors progressively reduce an individual’s lifespan, and natural selection would ensure that the good genes that support reproduction act early, and the bad ones that prevent reproduction much later. This was a major advance and it later became the basis for Tom Kirkwood’s disposable soma theory, which recognised that just a small amount of energy was devoted to repair of ageing processes as compared to reproduction, growth and defence. The theory also claims that ageing is due to the accumulation of damage to the body, and that long-living organisms devote more to repair.
Perhaps the greatest impetus for the modern ‘merchants of immortality’ came from Leonard Hayflick’s finding that there were just a finite number of times a fibroblast cell could divide when placed in culture. This eventually became known as the ‘Hayflick Limit’. The original article by Hayflick was rejected by the Journal of Experimental Medicine with a scathing letter from the editor that stated, in part, ‘The largest fact to have come from tissue culture research in the last fifty years is that cells inherently capable of multiplying, will do so indefinitely if supplied with the right milieu in vitro.’ It was eventually published in Experimental Cell Research in 1961.
If Nascher was the father of geriatrics, Marjory Warren was its mother—particularly in relation to care of the aged. She worked at the Isleworth Infirmary, which in 1935 took over responsibility for an adjacent workhouse to form the West Middlesex County Hospital. During 1936 Dr Warren systematically reviewed the several hundred inmates of the old workhouse wards. Many of the patients were old and infirm, and she matched care to their needs. She initiated an upgrading of the wards, thereby improving the morale of both patients and staff. She advocated creating a medical speciality of geriatrics, providing special geriatric units in general hospitals, and teaching medical students about the care of elderly people. Among her innovations was to enhance the environment and emphasise increased motivation on the part of the patient.
Before the Second World War there had been little interest in old peoples’ mental or physical health. Joseph Sheldon, while working at the Royal Hospital in Wolverhampton, undertook a survey of 583 old people sponsored by the Nuffield foundation, which he published in his book The Social Medicine of Ageing in 1948. He found that over 90 per cent were living at home and many had severe problems with respect to care. He introduced home physiotherapy and promoted environmental modifications to prevent falls, which were all too common. Old-age psychiatry was only recognised as a speciality by the Department of Health in 1989. Now, of the 1700 patients each GP typically has, about 6 per cent are over 75 and 2 per cent over 80. There will be around six consultations a year for the over-65s, so old age is quite a burden for GPs.
The first chair for geriatrics in the world was the Cargill Chair at Glasgow University, awarded to Dr Ferguson Anderson in 1965. Alex Comfort, more famous perhaps as a novelist and for writing The Joy of Sex, was a great propagandist for research on ageing. His early research was on ageing in the fruit fly Drosophila and thoroughbred horses. He then attempted to determine biomeasures of physiological ageing.
In the US the first head of the Unit on Aging within the Division of Chemotherapy at the National Institutes of Health, Nathan Wetherwell Shock, was appointed in 1940. In 1948, the gerontology branch was moved to be under the National Heart Institute. An attempt was made to have an Institute of Ageing established with Heart as a subsidiary, but this failed, as a physician to the Senate stated, ‘We don’t need research on Ageing. All we need to do is go into the library and read what has been published.’ This contrasts with Nathan Wetherwell Shock’s own viewpoint, enunciated just before his death in 1989: ‘I would remind you that we were formed and nurtured in the firm belief that the biological phenomenon we call “ageing” was worthy of scientific pursuit. We have achieved some degree of success. I would caution, however, that our future will be determined only, and only, by the quality of our scientific research on understanding the basic mechanisms of ageing processes.’ In 1974, Congress granted authority to form the National Institute of Aging to provide leadership in ageing research and training.
Research on ageing expanded significantly as it was realised that life expectancy was increasing, and thus the number of elderly. The Gerontological Society of America was founded in 1946 and the field has grown very fast. There are now many scientific journals devoted to the topic, such as Gerontology and Age and Ageing. But compared with certain fields of medical research, this topic is still relatively neglected. In the words of Professor Tom Kirkwood:
I think doctors struggle with ageing as their training is to diagnose and treat diseases—they want to cure someone. For them ageing is a medical failure. There is a little progress with age-related diseases. It may be possible to cure Alzheimer’s but this is very difficult and prevention is more promising. There has not been enough research on very old people, which is what we are doing in Newcastle. Not a single person in our study over 85 has zero age-related disease, most have four or five.