retirement age for all of the ever-increasing older group is economically unsound and will prove ruinous in time. As physicians, we know it often interferes with optimum health for the individual.

The argument that there are not now and will not be enough jobs in the future to go around is just as fallacious as it was when it was offered to keep women from working. Now, 9 million women are working without having impaired the earning power of the male. Automation may dislocate labor on occasion but industrial advances have always been associated with increased employment opportunities. It may well be that industry of the future will hire him for his entire working life and by "inservice training" keep him as a member of the production team in the face of automation, changing products, and changing times.

The medical profession is not opposed to retirement for those who want to retire. As physicians, however, we know that retirement to inactivity, for health reasons if no other, can for many people be an impediment to their health. Inflexible retirement based solely on age is unsound and unfair to many thousands of men and women who deserve better.

Is it too much to ask that the aging, who are no less human because of their age, be reincorporated into the human family? Is there no still healthful and happy motivation that is worthwhile to the total group?

This may sound like an impossible undertaking, but it will be made easier when we produce a new generation of oldsters. A real senior citizen group which will recognize aging for what it is "growing"-and present themselves in the older years with advanced accomplishments, dignity, and rank.

Members of the over-65 group and others will have to shed themselves of the idea that they are "through" merely because they have reached the age of 55 or 65 or 75. If they intend to retire, for reasons of health if no other, they should plan that at least a portion of their retirement be devoted to useful pursuits. Preparation for this should not desire, or be expected to accept, segregation by the family or community simply because of chronological age.

2. Promotion of health maintenance programs and wider use of restorative and rehabilitative services

Dr. Henry A. Holle, of the Public Health Service and former Health Commissioner of Texas, says: "The interest of the apparently well senior citizen in his own health has been grossly underestimated. Our work is thereby made easier.

"For many years we have ignored the so-called 'degenerative' or 'chronic' diseases in the elderly. We accepted them as matters of course in the treatment of more acute symptoms. Now our researchers are studying tissue cells to find out why their rate of replacement slows down with increasing age. Who can say that these mysteries will not be solved? Who can say that atherosclerosis may not some day be reversible, or at least preventable?

"Because of these things, we see a beginning realization on the part of the physician in practice and in health agencies that the development and application of regimens of health maintenance in our oldsters can be tremendously productive. If we can take this positive approach to the 'stitch in time' philosophy, we may avoid being faced with the necessity of doing a complete sewing job later on when it can do little good.

"Too much emphasis cannot be placed upon the need for a medical adviser in the middle and senior years. We need here the individual physician-patient relationship. It pays its greatest dividend during the years when body reserves are dwindling and when advantage should be taken by the physician of intimate knowledge of the individual patient gained through years of experience as his medical adviser.

"Like the management of diabetes, health maintenance in the oldster, or the science of keeping him well, is a long-range undertaking. It must, of necessity, not be limited to the treatment of symptoms when they arise. The approach must be one of sympathetic understanding of what makes him 'tick' and an interest in his overall health problems. One need not add that he must be made to feel that his physician is sincerely interested in him as an individual. "This interest should include such fundamentals of good health as his home; the food he eats; his personal living and recreation habits; outlook on life and motivation for living; and the avoidance of fatigue and the institution of rehabilitation when necessary."

3. Extension of effective methods of financing health care for persons over 65 With the continuing expanding enrollment in prepayment plans and the health insurance industry, the problem of inadequate numbers of aged having protection is a temporary one and is constantly decreasing. At the present time there are more than 6 million persons over the age of 65 who are covered by voluntary health insurance, over 43 percent of the aged population. Most of the growth in plans and coverage for persons over 65 has been achieved in the past 5 or 6 years. It can be assumed that an ever-increasing number of persons will be able to carry their protection into retirement years and that the percent covered will soon be maximal.

This is substantiated by National Blue Shield experience since 1952. It has been the general policy of Blue Shield plans to permit continuation of coverage after retirement. In the past 6 years total enrollment has increased 85 percent but the number of subscribers over 65 has grown 170 percent during the same period, showing not only the results of this continuation policy but also of new enrollment of those over 65.

A number of commercial insurance companies have also made protection available for persons over 65 and a great number have modified their regulations to permit continuation of benefits upon retirement.

It should be recognized that the majority of the newer programs are being viewed as experimental pilot programs. They are not inflexible and, as additional experience is gained, changes may be effected which will improve the protection which is being provided to this segment of the population.

A significant step toward the accomplishment of this objective was taken by the American Medical Association last December when the house of delegates adopted a resolution urging the development of voluntary health insurance and prepayment programs designed for the low-income aged with modest

resources.

Constituent and component societies, and their Blue Shield plans, throughout the country have responded enthusiastically to the proposal and are moving rapidly and forcefully to fully implement its intent.

When the report was adopted, only eight medical society sponsored Blue Shield plans had coverage available on initial nongroup enrollment for persons over age 65. They have been joined by 13 additional plans, and today there are 21 Blue Shield plans in 19 States which are offering medical societies to define the elements of care to be provided in their specific areas and to establish the scope of benefits to be offered.

The whole area of financing health care has been confused by conflicting claims about the abilities of persons over 65 to pay for medical expenses or health insurance. On the other hand, we are frequently told of the obvious fact that most persons in this age group have reduced incomes. On the other hand, we are told that the older person's need for income is not as great as it was in earlier years; that his accumulation of assets often more than offsets reduced income, that other members of the family are willing and able to help, that reported income is sometimes at variance with the facts, and that in rural areas "income in kind" is sometimes a major factor.

It is also true that by most data the older patient takes up more time in the hospital per illness than does the younger.

This may well be changed somewhat when the physician and patient commence to realize the potentialities for corrective and curative treatment, along with rehabilitation, may be as productive in the oldster as in the youngster and can be accomplished in relatively short time.

4. Expansion of skilled personnel training programs and improvements of medical and related facilities for older people

Since a larger part of modern medicine will be occupied with the treatment of the chronically ill and rehabilitation problems, a whole new generation of health personnel will have to be trained to fill these positions. Because of the impact of geriatrics and rehabilitation, the form and function of the traditional acute hospital is being changed rapidly. The newer concept of the general hospital is growing in popularity. It has intensive care units and recovery rooms and chronic wings. It is set up so that the patient can be rapidly moved from the higher priced acute facility to the chronic wing. This will serve as a distinct advantage to the geriatric and rehabilitation patient.

From the chronic wing of the hospital the next step will be to the rehabilitation center to the convalescent home and then to the patient's own home and occu

pation. This better utilization of hospital and other medical facilities should lead to a downgrading in medical expense totally.

5. Amplification of medical and socioeconomic research in the problems of the aging

Investigation up to a present time has revealed the following:

A. The acid base equilibrium of the blood is maintained within normal limits in the old person.

B. The arterial fasting blood sugar does not change significantly with age.

C. The hematological values of the blood are well maintained in the aged.

D. The basal oxygen consumption per unit of total body water or intracellular water does not change with age. This suggests that in terms of net metabolic activity the protoplasm of the old man is unchanged. He simply has less protoplasm.

E. Total lung capacity corrected for surface area does not change.

F. Measurement in vitamins A and C do not vary significantly between the youthful and the aged.

G. Tests of endocrine gland function at rest show no significant statistical variation between the young and the old.

H. In fact, after the subject has reached adult life there is no satisfactory test or battery of tests that will actually indicate the individual's place on the chronologic time scale.

Dr. Falzone and Dr. Shock conclude in their paper, "The Physiologic Limitation of Age" that "examination of experimental studies on physiologic changes in age indicate that, under resting conditions, the aged human is usually able to maintain uniformity of the internal environment. However, when increased demands are placed on a number of organs and systems, impairment of function can often be detected."

Dr. Shock further states that "Laboratory experiments on learning ability of older individuals offers no substance to the support of the cliche that you 'Can't teach an old dog new tricks.'" Studies by Gilbert, Jones and Ruch, and others confirm the impression that adequate motivation is the key to effective learning and that older individuals can learn although their rate of learning may be somewhat slower than that of the younger adult.

Ability to learn persists in the oldster.

A recent press release from the Division of Gerontology at the University of Michigan, under the chairmanship of Dr. Wilma Donahue, states the following. "There's a mounting evidence that mental powers don't decline after middle age. Popular belief in the inevitability of mental decline after the age of 40 or 50 stems from early tests conducted on cross sections of the total population several years ago. These early tests showed younger persons were more intelligent than their elders. But now 30 years after the first test, a recheck of some of the youngsters by Iowa State College researchers has shown a considerable gain in the average intelligence scores. In fact, none of those taking the test the second time did poorer than on their first attempt three decades before." Dr. Shock goes on to say that "The problems of personal adjustments of older people has been studied in some detail by Dr. Havighurst and his coworkers. Although wide individual differences exist in the personal characteristics of older people, present information would lead us to question whether there are changes that can be attributed to age alone. In large measure, it seems that the personal reactions of older people, their feelings of frustration, neglect, etc., are more the result of our cultural emphasis on youth and all its attributes, with a concomitant rejection of maturity and age, constitutes the major source of dissatisfaction among older people. Obviously this is a problem whose solution depends on education in its broadest sense."

The application of what we already have learned and what we are about to learn may bring about results as startling in the field of chronic disease as the discovery of the antibiotics in the field of infectious diseases.

6. Cooperation in community programs for senior citizens

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The problems of the older citizens have placed an increased demand on the physician. The change in the type of practice for the family physician now, more than ever before, means he is challenged to leave his traditional occupation of diagnosis and treatment and enter actively into the field of prevention. is challenged more than ever before to take an active part in the total health problems of his community. More than ever before he will be called upon to provide leadership in these health fields and to cooperate fully with other disciplines trying to accomplish the same end.

It should be remembered that the problems of the aging constitute a challenge that is not new. To Plato and Socrates they had an intensely personal significance. Until very recently they were largely more personal than community in character. An unusual interest is aroused now in everyone because many more of us are living longer. Continual change in our economy from rural and selfemployed to salaried and wage earners has brought retirement and segregation of oldsters.

When authorities differ on terms one can be sure much needs to be learned. Dr. Edward J. Stieglitz in his new book, "Geriatric Medicine," calls aging a part of living. "All living matter ages, and as it ages, it changes. Aging involves every one of the innumerable aspects of life. It begins with conception and ends only with death. Thus growth, development and maturation are just as much the consequences of the occult processes of aging as are the atrophies and degeneration of senility. Evolution and involution are both affected by aging; pediatrics and geriatrics are closer than many realize. Gerontology is the science of aging in its broadest sense."

Dr. Henry Simms of Columbia University suggests the following workable definition of aging as synonymous with senescence-"The process of aging consists of those changes with time which result in progressive loss of abilities and in progressive increase in death rate."

Dr. P. B. Medawar of University College, London, says, "It will be convenient for the 17th century word 'senescence' to stand for the deterioration that accom panies aging, and to leave aging itself to stand for merely growing old."

One could go on quoting definitions from the different authors. By and large there would be some major or minor variance in their concepts of aging and senescence.

One wonders if a sharper delineation of fundamental terms would not lead to a better understanding of some of the problems of gerontology and permit a more enlightened approach to their solutions. Scientists as well as football coaches may be penalized for not paying enough attention regularly to fundamentals.

The scientist must attempt to free himself of preconceived ideas and prejudices.

As every scientist realizes the thing he knows, constitutes probably the greatest hurdle he must get over in his efforts to arrive at the truth. If it is possible to set aside such thoughts as outlined in the previous definitions and to examine the material at hand with the tools of logic and experience, we will have had some measure of success in explaining the reasons for this paper. In earlier times competition for survival kept the life span quite short. In spite of this trend through ages of time, the competition for survival all along the line has been so intense that the thus termed problems of gerontology did not exist in any practical sense. Those unprotected from natural elements, natural enemies, and the competition from friendly neighbors were eliminated in a high percentage of cases. Truly, only the fittest and fortunate lived to contribute much to the race.

The merging of man's strength and interest removed some of the competition for survival and permitted some few to live longer.

Sometime, somewhere in the dim unrecorded past something happened. What it was and how it will be described will depend upon the discipline making the investigation. The scientist may say it was the first effort of a new creature to find the eternal truth. Religious disciplines will point to the birth of religious principles, especially the concept of the brotherhood of man. In any case, man by his own acts began to interfere with the balance of power and natural selection as maintained by the law of the jungle. The moment he did this certain individuals who were given a longer life span were unprepared for it. The pace may not have been slowed any, but a helping hand was offered to those who faltered. Those who were unable to carry on in the usual style of the tribe caused a change in the philosophy of living and as their numbers grew became the first gerontologic problem. The great number of individuals involved seems to have interested most of the investigators. Does it not seem, however, that the real problem is the lack of preparation of these individuals for their increased life span rather than the increased number of individuals or the increased number of years? Today's rush to counsel and advise the aging and retiring emphasizes the validity of this concept, but the counseling overlooks the important factors.

This presented a new frontier. It called for a new race of pioneers to map the pathways for the millions who were to come after. As yet there have 44432-59-20

been very few who have had the vision to meet the challenge. Like the flotsam and jetsam of the deep washed upon the shore or floating the calmer inlets, most of the present oldsters are being pushed out of the stream of life. Instead of making an effort to extend this age frontier into a land of new experience, enjoyment, and compensation they are constantly looking backward as if all life had been left behind them. What this concept appears to fail to take into account is that a great many of these older persons are not looking backwards in any weak sentimental effort to recall the past, but in a blind serious struggle to find themselves, to regain a lost hold on life. Looking backwards is not at all a phenomenon of old age; it is a symptom of spiritual damage or illness that can befall anyone in any walk of life at any time. We associate it with the old because frequently they do not survive it. But age itself does not cause it. Function has more to do with structure than does the passage of time. Aging, as presently maintained by the gerontologists, constitutes a rather vague condition or state representing a balance between evolution or growth and involution or atrophy. They go hand in hand, growth being in ascendency in the young and atrophy being in ascendency in the old. This is further elaborated on to include the involution or atrophy that occurs when certain structures like the thymus or ovary cease to function. They get old. Thus, we become more mixed up trying to understand and account for varying degrees or rates of evolution or involution of certain parts of a whole that is itself of one age.

At first many diseases were thought to be due to the passage of time and therefore could not be halted.

Would it not be simpler to use those proved tenets of physiology and anatomy which have taught that structure depends on function? Thus, the varying degree of evolution or involution in organs would represent a varying degree of need and function and would not be related to time or age. This, at least, gets us out of the dilemma of having one part of the whole older or younger than the remainder.

The family took care of the early "oldster" and agriculture provided him an occupation.

In earlier times, the number who reached the advanced years was not large. The society was largely based on agriculture, and it was comparatively easy for the oldsters' efforts, diminishing in amount as they were, to be utilized and appreciated in the total farming effort. In the main, the general philosophy of these times was for the family to take care of its own. The "leftover" oldsters who were unable to care for themselves were provided for by the almshouses, the poorhouses, and the poor farms.

The number of oldsters grew. Society changed from agriculture and became industrial. Family responsibility lessened and retirement raised its ugly head. As the refugees from infant mortality and the infectious diseases crowded the confines of the aged and aging, many things happened.

1. Great numbers of younger people forgot their responsibility for the care of the aging members of their family. How much of this phenomenon was born of recessions and depression thinking cannot be estimated. There can be no doubt, however, that this attitude has an infectious quality and leads to a diminution of those qualities of altruistic love which binds families and groups together for the benefit of all.

2. Society has changed from agricultural to industrial. As pointed out above, agriculture has a built-in method of taking care of most of its aging workers. Youthful industry, interested as it was in production and competition, saw no obligation at first to assume a social responsibility for its older workers. This change produced an increase in the size and intensity of the problems of aging. 3. Retirement methods, as they are practiced today, add to the size and complexity of the problem. This is true in spite of the efforts made to insure some degree of economic security for the older worker.

4. The so-called miracle drugs worked their charms among the older as well as the younger groups and continued the status of many as refugees from the infectious diseases.

As a result of the above and many unenumerated factors, we now have a segment of our society that includes an excess of 15 million people whose one mark of similarity is that they are 65 years or older. Reports from the U.S. Census statistics, social security agencies, health agencies, medical clinics, and hospital and medical research, all indicate that the aged are not a homogenous group whose status can be simply described in a few words.