I understand that the theme of this course has been the hopeless case; and that my responsibility is to discuss with you problems of old age. I propose to interpret this remit quite widely and to deal with the medical problems of old age pensioners (over 60 for women; over 65 for men) that are often left untreated. Such patients will tell me that their Harley Street consultant has said: “Dear lady, it is a question of anno domini”. Their family practitioner has said: “Look Gran, its your age, you must learn to live with it”.
It is this therapeutic hopelessness that we homeopathic physicians must be prepared to combat. We need the optimism of a Burnett.1 Dr. Burnett had been brilliantly successful in curing a case of panophthalmitis in less than 24 hours, and his grateful patient then asked him. If this is what homeopathy can do, could you cure my cataract? Dr. Burnett was no specialist in eye diseases, and he thought from the nature of the complaint, he could hardly expect medicines to influence it. Two London specialists had diagnosed the cataract but had stated that it was not ripe enough for operation. Burnett however agreed with the patient’s request to try and cure her cataract with homeopathic medicines; he saw the patient once a month and at the end of a year, after a variety of homeopathic prescriptions, the opacities in her lens had disappeared and his patient had recovered her vision.
Senile cataract is an example of an old age process, and it is therefore instructive to note the remedies Dr. Burnett subsequently used in treating other cases (I have excluded the congenital, diabetic and traumatic cataracts from his cases histories). The best results followed the use of such constitutional remedies as Sulphur, Silicea, Phosphorus, Calcarea carb.; other remedies found useful were Causticum, Conium and Lycopodium. As Burnett emphasizes, cataract is a constitutional complaint; it is essential to treat the patient, not the cataract
I have highlighted this old age process of cataract as an example of the many problems of senility. For we should recognize at once that the majority of our elderly patients have often three or more different lesions at the same time.
In my private consulting practice I have 60 subjects who qualify for old age pensions, their ages ranging from 60-88 in women, and 65-89 in men.
Examples are a lady of 81 with a blood pressure of 238/86, angina of effort, osteoarthritis of the spine, diurnal frequency of micturition; or a gentleman of 75 with prolapse of the rectum, diverticulitis, and hiatus hernia. A lady of 70, with coronary thrombosis, congestive heart failure, cataracts in both eyes, and bilateral osteoarthritis of the hips. A gentleman of 85 with an adenoma of the thyroid, auricular fibrillation, a corkscrew esophagus and an inguinal hernia. Not to bore you with the details of the treatment of these cases, I will briefly describe the last case as an ilustration of the prescribing problems.
The large adenoma of the thyroid disappeared in a few months after a course of repeated doses of Spongia. The dysphagia due to the abnormal oesophagus reacted quite quickly to Arsenicum album given just before meals; but then this patient was hit by a small pulmonary embolism. He looked very ill indeed, but Bryonia 200 cleared up the pain and fever in less than 24 hours. After this episode he showed signs of congestive heart failure with edema of the legs, scrotum and prepuce. Apis gave relief, but I noted that inspite of being successful, none of these prescriptions had any influence on the auricular fibrillation.
However, with homeopathic treatemnt, all of these handicapped patients are mobile, move about the country and follow their interests and hobbies.
We need to ask what is normal to expect of our elderly patients. While recently many surveys have been reported from geriatric and mental hospitals, I find the pioneer survey of Sheldon in Wolverhampton the most useful for today’s discussion, as he organized his enquiries on subjects living in their own homes or with relatives, the situation you are most likely to deal with yourselves.
Of the women of 85 or over, he found more than two-thirds had a defect of hearing, nearly 7 out of 10 were liable to tumble, 7 out of 10 suffered from vertigo, and 9 out of 10 had difficulty in getting about in the dark. The failure in recalling surnames he regarded as normal.2
Sheldon classified the old people according to their mental state. Class I he assessed as fully normal mentally and these comprised 81.8 percent of the total number. Class II had faculties slightly imparied; they were subject to mood changes, easy tears, easy laughter, temper tantrums; inclined to be resentful and suspicious. He considered most of them had previously been of dull intelligence, some of them even subnormal; these accounted for 11.2 percent of his group. We would think first of Barium salts for the intellectually dull. Baryta carb. has fear, particularly of strangers, is suspicious. Nux moschata has tears alternating with laughter as an outstanding symptom.
Sheldon’s Class III included the forgetful, the childish who were difficult to live with; there were only 2.9 per cent of these. Again Baryta carb. has both childishness and forgetfulness, but other remedies to be borne in mind are Cicuta and Carboneum sulph. Cicuta is notable for its twitchings, jerks, and convulsions and its tendency to skin eruptions. Carboneum sulph. has the flatulence of Carbo veg. and the abdominal soreness of Sulphur; disturbances of vision are quite a feature; defectivememory and inability to find the right word are among its symptoms.
The last of Sheldon’s Classes, Class IV, are the demented, but this was a very small class of not quite 1 percent. The severe deterioration was manifested by the gross forgetfulness, the slow speech, the restlessness and agitation, the contrariness, the malicious resentment, the suspicion, the dislike of being left alone, the tendency to hoard. Remedies to consider for these cases are Argentum nit., Mercurius and Tarentula. The Argentum nit. patients are worse at night; they look withered and dried up. Mercurius too is worse at night, but is sensitive to changes of both hot and cold; sweats and salivation and dribbling are a marked feature and so is tremor. Characteristic of Tarentula is the congested facies, the dysphagia, the choreic movements and the extreme restlessness. This restlessness is aggravated by phenobarbitone which diminishes what cortical control remains in these demented patients. There is a paralled with the hyperkinetic children whose behavior is aggravated by phenobarbitone and improved by amphetamines which speed up cortical control, as child psychiatrists have discovered.
Sheldon has pointed out that deterioration in these old people into a lower class of function may follow a fall, and quotes two cases that became more demented following a fall downstairs, and after being knocked down by a motorcar.
The pathological changes in the brain of these senile patients are attributed to the development of senile plaques in the cerebral cortex.3 This involves the loss of irreplaceable cells,4 but Professor Roth points out that senile plaques are to be found in normal old people; in senile dementia they are much more numerous. Electron microscope studies suggest that senile plaques involve the destruction of dendrities, synapses and axns with the formation of an abnormal protein of an amyloid nature.5,8
Not only are these senile patients handicapped by a defective cortex, but in addition, a Canadian psychiatrist has shown that their adrenal cortex overreacts to provocation.6 Experience at the Cnichton Royal Hospital has shown that elderly organic patients are extremely sensitive to drugs; many of them quickly develop signs of toxicity which though not dramatic may have an insidious fatal outcome.7 Is this not a powerful argument of attempting relief with homeopathic potencies? Professor Forssmann of Sweden has warned against the risks of going too fast with modern drug therapy in these older patients and reminds us of the possibilities of epileptic seizures and of the frequent development of extrapyramidal symptoms of Parkinsonism when using phenothiazines; of the vascular symptoms of raised blood-pressure after monoamine oxidae inhibitiors when used as anti-depressants.9 Recently attention has been drawn to the sudden deaths in patients taking tricyclic anti-depressents.1
This reference to depression raises another important topic: Depression in old age. The depressives are the exception to the rule that patients with chronic brain disease show brain changes such as senile plaques.11 Depressive illness is the commonest psychiatric illness in old age. One survey showed that 12 per cent of patients over 65 suffered from a psychiatric illness; and 60 percent of these had a depressive illness compared with 40 per cent who had a degenerative disease of the brain.12 It is important to recognize these depressives, as the great majority of them are curable. Professor Roth in his opening address to the symposium organized by the World Psychiatric Association on Psychiatric Disorders in the Aged, recounted a dramatic illustration: When he first worked in a mental hospital 25 years ago, he recalled an old lady of 79 who drew attention to her presence in a chronic ward by setting fire to her hair; she had been in the hospital for ten years, having been initially diagnosed as suffering from senile dementia; she proved to be suffering from a severe endogenous depression; she made an excellent response to E.C.T. and was discharged to live with her daughter.12 My brother Paul Bodman described an almost exactly similar case a few years ago.
As an old age pensioner myself, I have lost my hospital beds and outpatient sessions, but I continue in private practice. My present case-load includes 58 patients of pensionable age. Of these, no less than 12 have suffered from depressive illness; some of them had previously been on anti-depressant drugs or been subjected to E.C.T. Two of them were so severely depressed that they could not be managed at home and had to be transferred to mental hospitals. These depressives do not always present as psychiatric patients. One octogenarian consulted me originally about her cataract; a 67-year-old man asked for help about his osteoarthritis; another man in his late sixties complained of hay fever; a 70-year old man approached me about his senile pruritus; a 70-year-old man about recurrent bronchitis, and a 64- year-old woman about hyperpiesia. Only three of the dozen admitted depression as the presenting symptom, but taking a detailed history demonstrated previous depressive phases in seven of these patients.
As you would expect in such an assortment, no one drug was indicated for these depressives, but I found Platina, Argentum nit., Nux vomica, Psorinum, Lycopodium, Natrium mur. were useful when indicated by symptom. While the majority of my patients were suffereing from recurrent depressions of the endogenous type, there was a smaller group of reactive depressions. One woman in her late sixties had suffered a cardiac arrest under an anesthetic, and her abdomen had to be closed with gallstones still in situ. How far the anoxia consequent on the cardiac arrest was responsible, how far the shock of her very close call, which her husband had not ben able to conceal from her, had contributed to her mental reaction, it is difficult to estimate; but from a lively and popular hostess of a big country house, she had given up entertaining, her committees, and sat silent by the fire side.
Another woman, a tall asthenic subject, had recently lost her husband from a coronary thrombosis; she responded to Ignatia and Natrium mur. and made good progress for two years, but relapsed after her greenhouse had been wrecked by vandals; bereft of her occupational therapy, she needed Ignatia and Natrium mur. again and made a good recovery.
But the recent loss of a spouse is not the only cause of social desolation and social isolation; the departure of children to marry and live in a different part of the country or even abroad, or to be the sole survivor of one’s siblings, these can contribute to loneliness and chronic grief.14
For these reactive depressions caused by bereavement, we think of Aurum, Causticum, Cocculus, especially when the bereavement has been preceded by a protracted period of nursing. Ignatia when the depressive broods in silence, protracted period of nursing. Ignatia when the depresive broods in silence, protracted period of nursing. Ignatia when the depressive broods in silence, Lachesis and Natrium mur. for the patients who cannot cry, Phosphoric acid and Staphisagria, particularly the latter, when the bereaved partner feels an irrational resentment at the departure, indeed the desertion by death of his or her partner.
Orthodox practitioners have noted that on prescribing the tricyclic antidepressants, such as tofranil, there may be a time-lag of as much as three weeks before the drug appears to act. I have found a rapid response after Ignatia, but I have noted that improvement after Aurum and Natrum mur. may not be noticed for ten or more days; it is characteristic of Natrium mur. that these patients are reluctant to admit improvement. It requires some judgment to decide on the severity of the depression whether to switch to an antidepressant drug; but I have no hesitation in recommending inpatient treatment for the actively suicidal. To leave such a patient at home is an unfair responsibility to place on the family; the suicidal tendencies disappear quickly after one or two E.C.Ts.
So far, we have considered senility with cerebral predominance, and we have identified the depressive illness of the aged. But we still have to discuss the toxic delirious reactions of old age. These acute confusions are often associated with vascular pathology; less frequently with an acute infection, metabolic disturbances, drug intoxication, hypothermia or uremia. Metabolic disturbances include hypoglyemia; glucose metabloism is upset in old age15 and one American authority recommends a 10 per cent infusion of glucose as a routine.16
Myxedoma sometimes can give rise to a confused state; it is important to recognize mild degrees of hypothyroidism as it is readily treatable.17 Incidentally recent research on immunity suggests that thyroid reinforces some of the natural defence mechanisms18 and the inference could be that thyroid could be prescribed at the same time as the homeopathic remedy.
It is important of course to discover what drugs the confused patient has previously been taking, though the identification of the assortment of tablets, capsules and pulvules produced by anxious relatives can be a problem not always soluble with the help of the MIMS Annual Compendium.
Hypothermia has its earnest propagandist, in my county of Somerset. I hope you are all equipped nowadays with low-reading thermometers; the hypothermia may have been aggravated by the previous prescription of largactil, barbiturates or reserpine.19 It is easy to kill this patient by warming her up too rapidly. I would suggest that on the symptomatology of cold abdomen cold thighs, gruff voice, stiff neck, slurred speech and coarse tremor, Camphora is a remedy to be considered.
There is a new rapid test for uremia now available. The blood urea can be measured with an Azostix strip from a drop of blood.20
I have hurried through these relatively uncommon causes of delirium in the aged as I want to spend more time on the more common cause: Arterial disease leading to ischemic destruction of the brain cells, i.e., arteriosclerotic dementia.21 A study of Corsellis’ beautiful microphotographs shows the amyloid thickening and degeneration of the muscular coats of the small cortical vessels.22
Delirium is the most frequent symptom, often occurring at night, when it is most disturbing in the hospital ward. Mayer—Gross has shown that this delirium can be reproduced when these senile patients are placed in a dark room.23 It is interesting to note that Kent’s Repertory lists under delirium in the dark, Calcarea ars., Carbo veg., Cuprum, and Stramonium.
The nocturnal delirium and restlessness is often associated with diurnal drowsiness, and on a ward round the next morning it is difficult to believe that the somnolent patient had ben noisy and overactive, hallucinated and disorientated in time and place.
These arteriosclerotic psychoses often have a sudden onset compared with the slow deterioration seen in the Alzheimer type of primary neurone destruction, and they tend to occur in relatively younger patients.
The loss of orientation in the dark must be a frightening experience for these patients, giving rise to a feeling of helplessness; this impotent fear is often joined or gives rise to anger, and the angry person then fears retaliation, so that paranoid elements in his thinking soon develop and he is suspicious of all attempts to help him.24
Keeping in mind that these delirious patients are often hallucinated, drowsy by day, often doubly incontinent, I think of remedies, giving first place to Hyoscyamus, but bearing in mind Belladonna, Arsenicum, Lachesis, Secale, Veratrum and Stramonium.
I have found Belladonna of most value in robust overweight individuals. In the delirious state Belladonna has fear of imaginary animals. Stramonium which also has a flushed face, is more afraid of being hurt and panics at the sight of the hypodermic syringe, while Hyoscyamus is usually pale; the Hyscyamus patient tends to tear up her clothes and take them off and thee is a sexual element in this behaviour. Arsenicum is too chilly to unclothe, but Lachesis will undo clothing or throw it off because she cannot tolerate any constriction around her body: Lachesis is nearly always cyanosed and refuses medicine because she is afraid of being poisoned. Lachesis wakes out of sleep into a delirious state, complains that the ward is so stifling hot that she will get out of bed to try and force the windows open.
The Secale patient wants cold because of the burning pains in the extremities; Secale is generally a decrepit wrinkled subject with pulseless arteries in the legs and feet and a tendency to gangrene of the toes.
Finally a few comments on the cerebral sequelae of stroke: Dr. Tyler25 recorded a dramatic result in a patient comatose after a stroke. A woman of 80 with cerebral thrombosis, paralysed and comatose for nine weeks; the coma had become so deep that it was almost impossible to get a mouthful of anything down; the consultant advised Nux moschata; a single dose of the 200th potency was prescribed and the patient promplty recovered consciousness, living on for another five years in full possession of her faculties.
In these hemiplegic patients we often see residual disabilities of considerable gravity: the loss of very recent memory must be borne in mind. Such patients forget the instructions of the nurse, the physiotherapist, the speech therapist, and the risk is that they will be labelled unco-operative.26
Then there are the patients who exhibit a cheerful air of unconcern after a stroke27 which should make us think of Opium or Arnica; or they will deny ownership of the paralysed limb, a symptom sometimes observed when the right temporal lobe has been involved; this is not the feverish symptom of the Baptisia patient who has the sensation of limbs scattered over the bed, but it will be found in the symptom lists of Silicea, Petroleum and Agaricus which have this disturbance of the bodyimage. Indeed Agaricus is so unaware of her disability that she will try to get out of bed; these are patients who should be nursed in a cot. Intensive physiotherapy is necessary to combat these patients’ neglect of the paralysed anaesthetic limb and to restore some function to theapraxic hand. The postural instability, the frequent falls, result in a loss of confidence and patients give up too easily, don’t want to do it.
Kent writes that once the coma following a cerebral hemorrhage has been relieved by Opium he relies on Pulmbum, Phosphorus and Alumina. The Plumbum patient typically has a dry, yellowish, wrinkled skin, has a partial aphasia, is constipated; tends to exaggerate her disabilities until her relatives suspect her of malingering. The Phosphorus patient has much more drive to recover; typically a pale face with blue rings round the eyes; is thirsty, better for eating; likes to be rubbed, enjoys her physiotherapy sessions; the ophthalmoscope reveals retinal hemorrhages. The Alumina patient is like the Plumbum patient in that he is constipated; has difficulty in passing even a soft stool; prefers dry food in spite of dry mucous membranes; theere can be depersonalization and derealization; familiar surroundings seem strange.
Areminder that we must take the total situation into account. I remember a 70-year-old retired headmistress who lived alone in the country. She had made a recovery from a cerebral thrombosis and a depressive illness; she complained of severe pains in her legs and with some reluctance she unrolled her stockings to display the petechiae and subcutaneous hemorrhages of scurvy. I did not hesitate to prescribe large doses of ascorbic acid.
Dr. Irene Rogers28 has emphasized the importance of adequate feeding “If more doctros would visit their patients instead of handing out pills and would go and look in the kitchen, they would see the answer to some of their questions. Some have ghastly old stoves on which they cannot cook; while in modern old people’s homes there may be a super modern electric stove which they cannot work; they have to switch on but they cannot see whether it is hot or cold; they have said ‘Doctor, the kettle won’t get hot and things won’t cook’; and I look and say, ‘Well, dear you have not switched it on’.” Dr. Rogers describes people who were very disturbed mentally but who improved after adequate feeding.
Some one has said there are three
ways of growing old29:
As homeopathic physicians, it should be our function to make it easier for our elderly patients to accept their limitations and to prescribe so as to reduce those limitations to the minimum.
- Burnett, J.C. (1880). Curability of Cataract with Medicines. London.
- Sheldon, J. H. (1948). The Social Medicine of Old Age. Oxford.
- Blessed, G. et al. (1965). Psychiatric Disorders of the Aged.
- Roth ibid.
- Kidd, M. ibid.
- Kral ibid.
- Robinsn, R. A. ibid.
- Corsellis, J. A. ibid.
- Forssman ibid.
- Coull, D. C. et al. (1970). Lancet, ii, 590.
- Simon and Malamud (1965). Psychiatric Disorders of the Aged.
- Roth ibid.
- Roth Ibid.
- Townsend, P. (1957). The Family of Old People, London.
- Andres et al. (1966). Internat. Congress Geront, i, 284.
- Robinson (1945). Mental disorders in Later Life. Stanford.
- Exton-Smith (1969). Medical Annual, 251.
- Wolstenholme, G. E. W., and Knight, J. (1970). Hormones and the Immune Response. London: Ciba Foundation.
- Burston, G.R. (1971). Health in Bristol, vii, 1.
- Knox, J. (1969). Practitioner, ceii, 281.
- Blessed, G., el al. (1965). Psychiatric Disorders of the Aged.
- Corsellis, J. A. ibid.
- Mayer-Gross, W. (1944). Recent Progress in Psychiatry. London.
- Goldfarb (1965). Psychiatric Disorders of the Aged.
- Tyler, M. (1937). Homeopathy.
- Adams, G.F. (1965). Psyshiatric Disorders of the Aged.
- Adams, G.F. (1971). British Medical Journal, i, 92.
- Rogers, I. (1965). Psychiatric Disorders of the Aged.
- Kent, P.P. (1965). Gerontologist. ii, 51.