Part 7

In old animals it is natural for the instinct of self-preservation to fade, as is exemplified in the day-flies which in their larval stage are well endowed with this property, and as their end draws near animals seem to acquire an instinct for death comparable to that for sleep. But in human beings, although they usually dislike old age, there is generally what Matthew Arnold[186] called “a passionate, absorbing, almost bloodthirsty clinging to life.” Metchnikoff specially investigated this point and found hardly any instances in which death was anticipated with the same feelings of pleasure as is sleep by the weary. Considering the discomforts of many old people it is rather remarkable how very seldom they endorse the words of the burial service: “We give thee hearty thanks for that it hath pleased thee to deliver this our brother out of the miseries of this sinful world.” Various explanations have been offered for this want of harmony between the mental and physical states of the old; it has been ascribed to the idea of eternal punishment, and to the presence of pathological conditions which bring on senility and death prematurely and thus alter what should be the normal mental attitude of healthy old age. In speaking of the usual fear of death in old people it should be mentioned that shortly before death this commonly disappears and, as G. E. Day,[187] R. W. Mackenna,[188] and Thompson and Todd point out, the aged when seriously ill commonly regard death as a welcome release; the famous William Hunter’s last words in his sixty-fifth year expressed his sense of resignation: “If I had strength enough to hold a pen, I would write how easy and pleasant a thing it is to die.”

_The Cardio-Vascular System._--The pulse rate is usually rather increased in frequency as compared with that in adult life; extra-systoles are so common in persons who appear otherwise normal that they cannot be regarded as having any important significance. Among Sir George Humphry’s collection of 824 persons over 80 years of age one-fifth had an irregular or intermittent pulse.

Although, like arteriosclerosis, a well-marked high blood pressure without evidence of renal disease, to which Sir Clifford Allbutt has given the name of senile plethora or hyperpiesia, is common in the decline of life, it is a pathological and not a physiological change; and a distinction must be drawn between the gradually rising blood pressure seen from birth onwards and an increase above that normal to an arterio-vascular system that has been active for over half a century. In the same way the venous pressure increases with age (Hooker[189]). That a definitely high blood pressure in the aged is pathological appears to be shown by observations quoted by Councilman from the Peter Bent Brigham Hospital, Boston; among 94 patients (male and female) averaging 66 years of age, 44 per cent with cardiac hypertrophy as shown by necropsy, had an average blood pressure of 158 systolic / 88 diastolic, whereas the 56 per cent without cardiac hypertrophy had an average blood pressure of 130/78. In both series the differences between males and females were never more than 7 mm. Hg. From observation of 102 Chelsea pensioners over 75 years of age Thompson and Todd found that the average blood pressure was 145 systolic / 80 diastolic, estimations varying from 190/100 to 115/70, and that the average pulse pressure, or difference between the systolic and diastolic pressures, was 67 mm. They came to the conclusion that it was not possible to arrive at a normal blood pressure for old people on account of the varying conditions of the heart and arteries.[190]

The urine, in consequence of the lowered metabolism and general atrophy, is somewhat diminished in quantity with a fall in the solids, though the specific gravity remains about normal. The chlorides are stated to be normal and the phosphates and urea to be diminished. Slight glycosuria as a result of a low sugar tolerance (_vide_ Spence[191]) is not uncommon, especially in obesity. Prolonged confinement to bed has been thought to be responsible for casts in the urine. A trace of albumin is not rare; this may be due to various factors, and in itself is not a cause for anxiety; but a well-marked fall in the specific gravity is a sign of renal inadequacy which may be preceded and anticipated by the discovery of nitrogen retention in the blood.

_Sexual activity_ in man wanes generally speaking after 50, but there are great variations in this respect, and sometimes there are periods of considerable excitement in old men, often thought to be associated with prostatic enlargement.

It would naturally be expected that _wounds_ and _fractures_ of bones would heal more slowly in the old than in the young, and, according to Carrel and Ebeling,[192] the cicatrization of human wounds varies inversely, if accurately measured, with the age of the patient; Humphry, however, found that, provided sloughing did not occur, wounds and ulcers in the aged heal as quickly as in middle life, and that the failure of union in intracapsular fracture of the neck of the femur is due to want of apposition and not to the age of the patient.

In some respects the _reaction to drugs_ in the senescent body is different from that in ordinary adult life. In old people absorption from the alimentary canal is slow and this is particularly so with gelatin-coated pills and drugs, such as cinchona, containing tannin, which should therefore be avoided. The physiological response to drugs is slower and more prolonged than in early life, so that for this reason and from the frequency of constipation an accumulated action is thought to be more likely to occur in the aged. It is sometimes said that large doses are not borne well by the old and that morphine is dangerous as it is in infants, but Nascher[193] states that if, in order to obviate the paralysing effect of morphine on a weakened respiratory centre, atropine is given before the morphine so that their action can be timed to coincide, instead of giving them at the same time when the effect of the atropine comes later, morphine can be given in the same doses as in maturity. Purgatives may be required in larger doses than in ordinary practice. According to Leonard Williams[194] bromides are likely to produce mental confusion in old people and if persisted in, even in ordinary doses, may be followed by vascular thrombosis and permanent impairment of the intellectual powers. Sedatives and hypnotics when necessary should be given in small doses and discontinued as soon as possible; but they may be necessary for restlessness which would otherwise seriously exhaust the failing strength.

VIII

THE DESCRIPTION OF OLD AGE IN THE TWELFTH CHAPTER OF ECCLESIASTES

When first approaching the subject of old age every one must recall the famous description in the first six verses of the twelfth chapter of Ecclesiastes beginning “Remember now thy Creator in the days of thy youth while the evil days come not, nor the years draw nigh when thou shalt say I have no pleasure in them.” Formerly ascribed to King Solomon (977 B.C.) the book of Ecclesiastes (in Hebrew Koheleth = the preacher) has been shown by the higher criticism to date only from the end of the third century B.C., and from internal evidence, namely references to the brain, spinal cord, and other anatomical structures, though expressed with poetic imagery, it may fairly be assumed that a medical man was concerned with its construction. In his attractive work, _A Gentle Cynic_,[195] the late Professor Morris Jastrow, jun., of Philadelphia explained that the book of Ecclesiastes as it appears in the authorized version, consists of (i.) the original, cynical, but good-natured _obiter dicta_ of the unknown dilettante who preferred to veil his identity under the name of Koheleth, and (ii.) additions and modifications made by various hands to render it more orthodox and compatible with the tradition that it was written by Solomon; thus the admonition “of making books there is no end and much study is a weariness of the flesh” may very probably have been intended as a hint that Koheleth’s views should not be taken too seriously. Following this conception Jastrow reconstructed the text of the book of Ecclesiastes to what he argued was its original form, and compared it with the more modern writings of Omar Kháyyám and Heinrich Heine. As we all must have speculated over the correct interpretation of the various metaphors in this description of the last stage of life, the explanations offered by others, such as Andreas Laurentius (1599),[196] Master Peter Lowe (1612),[197] founder of the Faculty of Physicians and Surgeons of Glasgow, Bishop J. Hall (1633),[198] John Smith (1665),[199] Richard Mead (1775),[200] and Jastrow may be very briefly mentioned. The second verse, “While the sun, or the light, or the moon, or the stars, be not darkened, nor the clouds return after the rain,” is regarded by Laurentius, Lowe, and Hall as referring to the ocular disabilities of old age, whereas Smith and Mead consider that mental failure and depression are meant. As regards the third verse, “In the day when the keepers of the house (the hands) shall tremble, and the strong men (the legs) shall bow themselves (become bent), and the grinders (teeth) cease because they are few, and those that look out of the windows (the eyes) be darkened,” there is general agreement, Lowe specially designating cataract as meant in the last sentence. “And the doors shall be shut in the streets,” is regarded as referring to the mouth by Laurentius and Mead, and to the various orifices including the results--constipation and dysuria--by Smith; “when the sound of the grinding is low,” is considered by Jastrow to mean impaired hearing, and by Smith as a lowered rate of metabolic processes, such as assimilation, blood formation, and various secretions. “And he shall rise up at the voice of the bird,” implies, according to Smith and Mead, the early waking of the elderly; “and all the daughters of music shall be brought low” signifies to Laurentius the failure of voice, to Mead deafness, and to Smith all the organs concerned with sounds, namely the lips, tongue, larynx, and the auditory apparatus. “Also when they shall be afraid of that which is high, and fears shall be in the way” is regarded by Smith as describing the general mental attitude of anxiety for things both small and great and a bad head for height, but a more modern commentator suggests that “afraid of that which is high” refers to dyspnoea on climbing a hill. “And the almond tree shall flourish” is by Laurentius, Hall, and Smith thought to refer to the white hair or “churchyard flowers” of the old, but Mead argued that loss of smell is meant. “And the grasshopper shall be a burden” has been very variously interpreted: Hall is content to accept the literal meaning that the least weight is a nuisance; Laurentius and Lowe understand oedema of the legs; John Smith that the aged body undergoes the reverse change of shrivelling, hardening, and angularity; Mead suggests scrotal hernia, and Jastrow, as according to the Talmud the grasshopper is a symbol for the male sexual organ, considers that the sentence refers to the loss of sexual activity. In the sixth verse the words “Or ever the silver cord be loosed,” refers, according to Laurentius, Lowe, Mead, and Jastrow, to kyphosis, but Smith translates them into paralysis of the spinal cord and nerves. “Or the golden bowl be broken,” signifies cardiac failure to Laurentius and Lowe, but cerebral haemorrhage to Smith, who thus explains the next line, “or the pitcher (the veins) be broken at the fountain (the right ventricle), or the wheel (the arterial circulation) broken at the cistern” (the left ventricle), and therefore concludes that King Solomon was perfectly acquainted with the circulation of the blood discovered by William Harvey in 1616. “The pitcher” is regarded as the vena cava by Laurentius, and as the urinary bladder by Mead and Jastrow; “the wheel broken at the cistern” suggests the kidneys and bladder to Laurentius and Lowe, cardiac failure to Mead, and intestinal and hepatic insufficiency to Jastrow.

IX

DISTINCTION BETWEEN HEALTHY AND MORBID OLD AGE

In any individual instance the exact line which separates healthy old age (senescence) from old age complicated by a morbid process, _i.e._ by some factor other than the gradual atrophy and restriction of functional activity, or senility, may be difficult or impossible to draw. The dictum of Terence, Cicero, and Sanatorius that old age is a disease probably still finds acceptance with many. It is indeed clear that exposures to infections and poisons would produce changes more easily in cells that are beginning to fail in vitality. Healthy old age should be a normal process of involution with progressive atrophy and loss of vitality, and free from any morbid change due to other factors whether extrinsic, such as infection, or intrinsic and due to abnormal metabolism. As the bodies of the aged usually show a number of changes additional to those of normal involution, some of which, such as arteriosclerosis, are so frequent that they have sometimes been erroneously regarded as part or even the cause of old age, it is essential to recognize and to try to draw a distinction between physiological old age and senility from the effects of disease (_Senium ex morbo_). But about the anatomy and physiology of normal old age much remains to be learnt; more indeed is known about the pathology of the aged, a subject which includes the damage done in the past, perhaps in youth, and morbid processes starting during advanced life.

In attempting to decide when old age should be regarded as a disease or merely as a process of involution or retrogression which naturally follows the earlier and progressive stage (youth) of development, it may be well to refer to the meaning of “disease” and “health.” Disease, or want of ease, has been variously defined as evidence of imperfect function, as discord, and as maladjustment between the individual and his environment (Moon[201]), and Health as the indication of perfect functional activity, as harmony between the individual and his environment. In the different stages of life’s cycle there should be a correspondence between the individual’s desires and his powers so that there is harmonious co-ordination; this should hold good in normal old age as it does in youth.

The frequent complaints of old people show that there is maladjustment and disease, for if the decline of vitality were uniform throughout the body the equilibrium would, though altered as a whole, still be maintained, and there would no longer be a discordant desire for activity, for which other parts of the body are, from a more advanced state of atrophy or morbid change, unable. Thus it would appear that the conscious disabilities of old age are not the necessary results of a true physiological involution, and that the late Sir Andrew Clark’s definition of Old Age as “the period at which a man ceases to adjust himself to his environment” should be regarded as true of senility or morbid old age but not of senescence or healthy old age.

The organs of the body do not all start to grow old at the same time or progress at the same time. That such variations in involution may be so exaggerated as to become morbid without any very obvious cause is highly probable, but the latter event is clearly a departure from the progress of normal old age. The precocious atrophy of some tissues or organs may be ascribed to several factors, such as inherent weakness, the effects of overstrain, though without producing gross changes, or to the influence of a definite infection or intoxication in the past. Thus deafness may be hereditary, senile paraplegia has been known to occur in energetic walkers, and thyroid deficiency may be the outcome of a past attack of enteric fever. These errors in the chronometry of life, as Sir James Paget[202] termed the different ageing of organs, cannot be regarded as a physiological process.

X

DISEASES IN AND OF OLD AGE

Strictly speaking, it cannot be said that there are any diseases special to length of days, for premature senility shows the changes and diseases usually correlated with ordinary old age. Inherent want of vitality and the resulting degenerative atrophy, or Gowers’s abiotrophy, may imitate the results of prolonged wear and tear of the tissues, and thus it appears that Charcot’s[203] group of diseases special to old age, namely senile marasmus, senile osteomalacia, senile atrophy of the brain, senile heart weakness, and arteriosclerosis, are not confined to senescence. Old age, however, is prone to the incidence of diseases which are chiefly but not exclusively seen in the evening of life, such as those due to the degenerative changes resulting from the accumulated effect of past infections and from metabolic disturbance. Thus arteriosclerosis, granular kidney, cardiac failure, cerebral haemorrhage, emphysema, hepatic cirrhosis, prostatic enlargement, and carcinoma commonly appear in the sixth decade. In a series of five publications dealing with the diseases of the age of fifty, which he calls the critical age, Leclercq[204] describes, in addition to some of the above, gout and paragouty affections, obesity, diabetes, cardio-aortic diseases, and albuminuria. Old age, moreover, modifies the manifestations and course of infections, notably of pneumonia and erysipelas. It would be unnecessary and from reasons of space impossible to refer to all the diseases that may attack the aged, but a few remarks will be made about some disorders that appear to call for special notice.

Senescence has some nosological compensations; thus some acute infections, such as measles, scarlet fever, enteric fever, and diphtheria, are very rare, probably because immunity has gradually been developed in the course of time; pneumonia and erysipelas, however, are notable exceptions in being specially prone to occur in the aged. Migraine usually becomes less troublesome or disappears with the march of years. As mentioned on p. 86, malignant disease is comparatively rare in very advanced age; lymphadenoma and leukaemia are rarer than in early life; and as pathological, like normal, processes are slower, carcinoma, especially of the breast, may become stationary.

_Diseases of the Skin._--From atrophy of the skin and its secretory glands the skin is less resistant to infection and accordingly has been thought to be more susceptible to parasitic attack, such as pityriasis versicolor. The aged who are often less scrupulous in cleanliness than their juniors are more prone to skin affections, such as eczema, erythema, and erysipelas. The so-called senile prurigo is largely due to the presence of lice. From the atrophic condition of the skin the cutaneous nerves are more exposed, and this has been regarded as playing a causal part in senile pruritus, which is an exception to the general rule that sensory impressions are less prominent in the aged than earlier in life. It may, like prurigo, be due to an external cause, such as pediculi, or it may be metabolic in origin. In almshouses and institutions for the aged epidemics of scratching may develop from imitation of a genuine case of pruritus. Senile pruritus is usually general and from its obstinate resistance to treatment may be a terrible affliction. Sir Gilbert Blane (1749–1834) suffered from it for the last 13 years of his life, and was obliged to take opium in increasing quantities until his daily dose reached the equivalent of a dram of the solid drug.

Erysipelas, like pneumonia, with which or with bronchopneumonia it may be combined, is less obvious in its symptoms than in ordinary adult life on account of the diminished power of reaction, as shown by the slight degree of leucocytosis in the aged in erysipelas (Lamy) and by its longer course. From want of resistance and arteriosclerosis, especially Mönckeberg’s form with calcification of the media, senile gangrene may follow slight accident or injury, such as occurs in cutting the toe nails. Absorption from the gangrenous area may cause toxic glycosuria, and such cases, when they come under observation at this stage, are sometimes regarded as diabetic gangrene. It is remarkable how well amputations for diabetic gangrene do; in July 1922 I saw with Professor F. H. Edgeworth a man with double amputation of the legs perfectly healed, and in good health though the glycosuria persisted.

Herpes zoster, though far from confined to advanced life, has in the old the unfortunate tendency to leave persistent pain in its site. Rodent ulcer, although sometimes seen comparatively early in life, is specially common in advanced years. It often supervenes on the dry yellow or brown spots (senile keratosis) seen on the face in persons over 60 years of age.

_Vertigo_ is extremely common in later life and may be due to various causes; the most frequent form is that of aural origin, such as labyrinthine or nerve lesions and chronic changes in the middle ear. Increased blood pressure and cerebral arteriosclerosis are frequently responsible. Attacks of giddiness may occur in Stokes-Adams disease or follow exertion in the aged, as if from cerebral anaemia; and gastric disturbance may apparently also be a determining factor. In rare instances epilepsy or migraine may be represented or initiated by vertigo.

_Senile tremor_, rare under the age of 70, begins in the hands, especially in that most used, and spreads to the neck and head, rarely occurring in the lower limbs. It is a slow intention tremor, from 4 to 5 per second, and is distinguished by its relation to movement from that of paralysis agitans which is continuous but diminished on muscular contraction. The tremor of the jaw resembles that of munching food; that of the lips is fine. It is compatible with good health.

_Paralysis agitans_, described by James Parkinson, surgeon and palaeontologist, in 1817 as “the Shaking Palsy,” has now about a century later been shown, largely as a result of S. A. K. Wilson’s work, to be one of the forms of the extra-pyramidal symptom complex and due to degenerative changes in the efferent motor system of the globus pallidus system. Although juvenile forms occur and encephalitis lethargica may show the Parkinsonian syndrome, paralysis agitans is a disease of the early part of the later period of life, the great majority of the cases beginning between 50 and 70 (Gowers[205]), after which there is a small incidence only. It is twice as common in males as in females. Though unfortunately, from the degenerative nature of the lesion, incurable, it is a chronic disease; thus Maclachlan[206] refers to a Chelsea pensioner aged 107 years in whom it was known to have existed for 47 years.

Vascular lesions, haemorrhage or thrombosis, are the most important factors in the production of grave nervous disease between the ages of 50 and 70; among 500 cases of cerebral haemorrhage 321, or 64 per cent, and of 110 cases of cerebral thrombosis 67, or 61 per cent, occurred in the sixth and seventh decades (Michell Clarke[207]). _Cerebral haemorrhage_ increases with frequency from the fourth decade and the largest number of cases occur between 50 and 60. From analysis of 154 cases at St. Bartholomew’s Hospital F. W. Andrewes[208] found that the apparent maximum is in the middle of the sixth decade, but that correction for the age distribution of the population shows that the liability of the individual to this form of death increases steadily up to old age. _Thrombosis of atheromatous vessels_ is an accident of later incidence than cerebral haemorrhage, and thus contrasts with hemiplegia due to syphilitic endarteritis which occurs about the prime of life.