Part 8

The physiological involution of the mind and accompanying organic changes in the brain gradually shade off into senile dementia. A regression to the mental state of childhood, which Dupré[209] called puerilism, may occur in widely different conditions, such as structural change of the brain, hysteria, and toxaemia. It may be acute and be transient or come on slowly and be permanent. Just as an old man may relapse into the speech and accent of his youth, so if he had a hard pecuniary struggle in his early days may he become miserly in the evening of his life.

_Senile dementia_ is an exaggeration of the mental changes occurring in old age and due to further changes in the brain from vascular disease or toxic influences. It varies much in its features; some patients are maniacal, others depressed and melancholic, some feeble, some delusional, and a few immoral. The senile mania may be mainly nocturnal and was compared by Clouston[210] to the night delirium of a febrile neurotic child; it may pass into dementia. Of the melancholic group in which suicide may occur Clouston found that 30 per cent recovered.

_Senile paraplegia_ may be divided into four etiological groups: (1) The functional dysbasias or pseudo-paraplegias described by Marie and Léri,[211] which in general terms resemble those met with during adult life, but the varieties are less distinct in the old. Quesnel[212] recognizes three groups of functional disturbance of walking in old people: (_a_) the slight and usually curable, (_b_) severe functional disturbance depending essentially on the mental state of the patient, and (_c_) the organo-functional in which a bony, articular, or nervous lesion is present; thus confinement to bed for a fracture may cause a functional paraplegia. (2) Spastic paraplegia due to sclerosis in the lateral and posterior columns of the spinal cord; the influence of arteriosclerosis, as advocated by Oppenheim, has been the subject of some debate, and Lejonne and Lhermitte point out that the nervous lesions are not necessarily perivascular and that there is a want of proportion between the vascular and the nervous changes. (3) Paraplegia of cerebral origin with descending degeneration in the cord and mental deterioration. (4) Paraplegia from muscular fibrosis and contracture, the central nervous system being intact.

From the presence of emphysema bronchitis is prone to occur in the old. _Lobar pneumonia and bronchopneumonia._ Lobar pneumonia has always been considered the great enemy of the aged; it is often latent, and may be found after sudden death and in persons supposed to have died of old age, because they were walking about or complained not at all or only of trivial symptoms. In spite of Charcot’s[213] considered opinion to the contrary, it is probable that pneumonia has been often used to describe what was really bronchopneumonia. For Roussy and Leroux[214] found that among 300 necropsies at the Hospice Paul Brousse there were 164 cases, or 55 per cent, of bronchopneumonia and only 4 cases, or 1·4 per cent, of lobar pneumonia. The bronchopneumonic areas are triangular with the base towards the pleural surface, and indeed are infarcts, due to pre-existing endarteritis obliterans which disposes to secondary infection. In 110 out of the 164 cases of bronchopneumonia there was arterial thrombosis, which was of older date than the infected areas of infarction and bronchopneumonia.

_Senile tuberculosis_, contrary to what has sometimes been stated, is fairly common though it is often latent; a patient with pulmonary tuberculosis may have little or no cough, expectoration, fever, or night sweats, and the physical signs, if present, may be regarded as those of bronchitis and emphysema or bronchiectasis, unless the sputum is available and examined for bacilli. Such unrecognized cases are an obvious danger in institutions, and it may be added that hereditary disposition plays a much less important part in the aged than in early life. Senile tuberculosis, however, is usually either a persistence of that infection or a recrudescence of quiescent infection, and is seldom primary. The disease may be chronic or acute, and either local or generalized.

The _senile heart_ has attracted much attention, and myocardial degeneration and fibrosis due to past infections or to coronary arteriosclerosis are extremely common. The myocardial change is of great importance in reducing the reserve power of the heart, so that cardiac failure is prone to supervene in acute infections, such as influenzal pneumonia. Chronic valvulitis akin to and associated with arteriosclerosis is common; the mitral valve is often affected and incompetent, with a loud systolic murmur at the apex which is displaced outwards; but the most characteristic lesion of advanced years is pure aortic stenosis; this is commonly regarded as part of the arteriosclerotic process in the aorta, but, as I have often noticed, the aorta may be remarkably healthy and even thinner than usual in old people with extensive calcification of the valves reducing the aortic orifice to a chink; it has indeed been thought that such stenosis of the aortic valves may protect the aorta from strain and so from arteriosclerosis. Although involvement of the bundle of His giving rise to the symptom complex of Stokes-Adams disease, and angina pectoris may complicate aortic stenosis, the presence of this valvular defect is compatible with remarkable prolongation of life. This may be due to the more placid life of these old patients, as is suggested by Sir Clifford Allbutt,[215] who regards aortic stenosis as more unfavourable in persons under 55 years of age than in their elders.

_Aneurysm of the large arteries_ is rare in the aged, although arteriosclerosis is common. Diffuse dilatation especially of the arch of the aorta and of the common iliacs is not infrequent, and occasionally latent saccular aneurysms are present. In rare instances large abdominal aneurysms causing pain or remaining latent until rupture occurs are reported. Among 112 abdominal aneurysms collected by Nunneley[216] 15 were over 50 years of age; these figures included 32 from St. George’s Hospital, three of them being over 65 years of age. Miliary aneurysms are of course extremely common in the subjects of cerebral haemorrhage.

_Spasm_, especially of arteriosclerotic vessels, may be responsible for attacks of giddiness or faintness, particularly on exertion, and there may be some doubt whether such symptoms are the outcome of cerebral anaemia or of cardiac insufficiency. Frequent transient attacks of aphasia or paralysis, due to spasm of arteriosclerotic middle cerebral arteries, may occur in patients with high blood pressure (Peabody,[217] Osler[218]).

_Varicosity_ either localized, like aneurysms, or throughout the length of veins, are common, especially in the lower limbs of women who have borne children and done much standing; this condition disposes to varicose ulcers in the lower third of the leg, and to acute phlebitis. As pointed out by Trousseau, who was an illustration of his own dictum, venous thrombosis may occur in the course of intra-abdominal malignant disease.

Though _dyspepsia_ of adult life often diminishes or passes away in the more tranquil conditions of old age, it is common; Fenwick[219] estimated that it occurred in 21 per cent of the population over the age of 65. Oral sepsis may be responsible for chronic gastritis and much debility in the old. _Constipation_ often comes on after 60 and is mainly due to atonic dilatation and failure of peristalsis in the colon, though diminished secretion of mucus may play a part. Prostatic enlargement has been thought to interfere with peristalsis (Hollis[220]), and in women large fibromyomas of the uterus may have this effect. Gerontal constipation is usually more troublesome in women than in men. Faecal accumulation in the rectum is a frequent cause, especially in bed-ridden subjects, of what they describe as diarrhoea, the real significance of which may be easily overlooked unless digital examination of the rectum is undertaken. The pecten band of fibrous tissue arising in the submucosa of the pecten, inside the external sphincter, narrows the anal orifice and so prevents complete evacuation of the rectum and diminishes the size of the faeces which are generally voided in short pieces. It is usually, but not always, associated with internal piles and due to the attendant congestion. W. E. Miles,[221] who described the pecten band, tells me that it may be regarded as a pathological development of advancing years, and that he has found that it may so reduce the anal orifice in the elderly that it is with difficulty the little finger can be introduced. Pruritus ani, due to piles and local congestion, is not uncommon in the aged.

_Piles_ are common in the aged and are related to the frequency of constipation. Like other diseases, they do not give rise to discomfort so soon or so forcibly as in younger persons. From muscular atrophy hernia, umbilical in both sexes, in men inguinal and in women femoral, is prone to occur.

_Gallstones_ are more frequent in advanced life, especially in women, than at other times of life, gallstones being found after death in about a third of persons over 70 years of age, though, as mentioned elsewhere, biliary colic is comparatively rare in old age.

The _urinary bladder_ in cases of prostatic enlargement shows hypertrophy succeeded by dilatation, fasciculation, and sacculation in response to the obstruction to micturition and degeneration of the muscular fibres. The ureters in similar circumstances become dilated, and the incidence of cystitis and pyelonephritis is thus favoured.

_Arthritic Affections._--Although gout is due to a defect in protein metabolism analogous to diabetes mellitus as regards carbohydrate metabolism and to obesity as a manifestation of disordered metabolism of fat, reference to this disease may be made here. Heredity has a potent influence on the incidence of the disease particularly in early life, but acquired gout is essentially a disease of the latter part of life or the early stage of old age when degeneration is beginning. The first attack may not occur until old age, and is then usually mild in character, and, in Sir William Roberts’s[222] words, appears almost as if it were an incidence of senescence. How far the various conditions spoken of as irregular gout, goutiness, or paragouty diseases, which are so numerous as to recall Murchison’s lithaemia, should be regarded as gouty is uncertain, but that they depend on disordered protein metabolism is highly probable. The connexion of gout with infection, as urged by Llewellyn,[223] has a bearing on the fibrositis and Dupuytren’s contraction often regarded as gouty phenomena. Dupuytren’s contraction of the palmar fascia, which has been thought in some instances to be secondary to arteriosclerosis of the medulla oblongata (Jardini[224]), often accompanies the fibrous pads on the interphalangeal joints of the fingers described by Garrod[225] and Hale-White.[226] The tendency of focal infections, especially oral sepsis, to become more frequent with advancing years also has a distinct bearing on the occurrence of chronic infective arthritis of various forms. The most characteristic is morbus coxae senilis which is not uncommonly associated with Heberden’s nodi digitorum, and sometimes with Morrant Baker’s cysts due to distension of synovial bursae with fluid; it may be confused with sciatica. Heberden’s nodes are unimportant and commonly free from attendant symptoms.

Spondylitis deformans with ankylosis of the articulations and ossification of the ligaments of the spine, in some cases further complicated by an extension of the process to the proximal joints of the limbs (rhizomelic spondylitis), may occur in the aged though also earlier in life.

_Osteitis deformans_ or Paget’s disease of bone begins as a rule in the later half of life, the average age being 50 years. Lannelonge[227] and Fournier[228] argued that it is a lesion due to congenital syphilis; but although luetic periostitis and osteitis may imitate it, there is no convincing evidence in favour of their contention.

FOOTNOTES

[1] _Thomas Linacre_, Linacre Lecture, 1908, St. John’s College, Cambridge, by William Osler, M.D., F.R.S., Cambridge University Press, 1908.

[2] _Life of Thomas Linacre_, by John Noble Johnson, M.D., p. 344, 1835.

[3] _De Temperamentis_, _Galeni Pergamensis_, etc. (translated by Thomas Linacre), by J. F. Payne, p. 5, Cambridge, 1881.

[4] The fourth of the five epidemics of the remarkable disease the English Sweating Sickness between 1486 and 1551 occurred in 1528–1529, and is regarded by Dr. F. G. Crookshank as influenza [_Proc. Roy. Soc. Med._, 1922, xv. (Sect. Hist. Med.) 27].

[5] The portrait of Heberden in his 86th year was painted by Sir William Beechey, R.A., who when he got to Windsor found he had forgotten his canvas and sent for a shirt on which he painted the picture, now in the dining-room of the Master’s Lodge, St. John’s College, Cambridge; there are two copies in the possession of the Heberden family, and one in the Censors’ room of the Royal College of Physicians. For some of this information I am indebted to Mr. W. B. Heberden and to Mr. W. Fleming, Bedell of the Royal College of Physicians of London.

[6] The Cambridge University Press, 1913.

[7] _Vide Gentleman’s Magazine_, 1851, N.S., xxxv. part i. 205.

[8] Γηροκομία βασιλική or _The Pourtract of Old Age wherein is contained a Sacred Anatomy, both of Soul and Body, and a Perfect Account of the Infirmities of Age Incident to them Both_, by John Smith, M.D., London, 1665.

[9] Maupas, _Arch. de zool. expér._, 1899.

[10] Woodruff, L. L., _Proc. Nat. Acad. Sc._, Washington, D.C., 1921, vii. 43.

[11] Woodruff and Erdmann, _Proc. Soc. Exper. Zool._, N.Y., 1913–14, xi. 73.

[12] Child, C. M., _Senescence and Rejuvenescence_, p. 310, Chicago, 1915.

[13] Huxley, J. S., _Journ. Microscop. Sc._, 1921, lxv. 643.

[14] Robertson, T. B., and Ray, L. A., _Journ. Chem. Biol._, 1919, xxxvii. 455.

[15] Drummond and Cannan, _Biochem. Journ._, Cambridge, 1922, xvi. 53.

[16] Sisson and Broyles, _Johns Hopkins Hosp. Bull._, Baltimore, 1921, xxxii. 22.

[17] Hopkins, G., _Journ. Physiol._, Cambridge, 1912, xliv. 425.

[18] Osborne, T. B., and Mendel, L. B., _Journ. Biol. Chem._, 1915, xxiii. 439.

[19] Metchnikoff, _The Nature of Man_, English translation, 1903, p. 272.

[20] Browne, T., _Pseudodoxia Epidemica_, p. 396, 6th edition, 1672.

[21] Eugenius Philalethes, junior, F.R.S., _Long Livers: A curious History of such Persons of both sexes who have liv’d several Ages, and Grown Young again_, 1722, p. 27.

[22] Hufeland, C. W., _The Art of Prolonging Life_, vol. i. p. 121, English translation, 1797.

[23] Mahaffy, J. P., _John Stearne_, An Address at the Bicentenary of the Medical School of Trinity College, Dublin, July 1912.

[24] Bacon, R., _The Cure of Old Age and Preservation of Youth_, p. 63, 1683. Translated by R. Browne.

[25] Hufeland, C. W., _Art of Prolonging Life_, 1797, vol. i. p. 176.

[26] Flourens, _De la longévité humaine ou de la quantité de vie sur la globe_, 1856.

[27] Cornaro, L., _Discourses on a Sober and Temperate Life_, p. 101, English translation, 1779, London.

[28] Metchnikoff, _The Nature of Man_, p. 278.

[29] Lankester, E. Ray, _The Advancement of Science_, p. 237, 1890, London.

[30] Easton, J., _Human Longevity_, 1799, Salisbury.

[31] The _Observer_ of March 26, 1922, contained a note on the discovery of a tombstone in the graveyard of Lamas Street Welsh Congregational Chapel, Carmarthen, recording the death on Nov. 14, 1831, of Ann David, aged 181 years.

[32] Sinclair, J., _The Code of Health and Longevity_, Frontispiece to vol. i., account in vol. ii. p. 274, 1807.

[33] King, G., _Census of England and Wales_, 1911, vol. vii. p. xlvi.

[34] Hufeland, C. W., _The Art of Prolonging Life_, 1797, vol. i. p. 168.

[35] Humphry, G. M., _Old Age_, p. 126, 1889, Cambridge.

[36] Hall, G. Stanley, _Senescence: The Last Half of Life_, 1922, London and New York.

[37] Mendel, K., _Neurol. Centralbl._, 1910, xxix. 1124.

[38] Rankin, G., _Brit. Med. Journ._, 1919, i. 63.

[39] Waterhouse, B., Letter to Sir John Sinclair in the latter’s _Code of Health and Longevity_, 1807, i. 33.

[40] Holland, H., _Med. Trans. Coll. Phys._, London, 1813, iv. 316.

[41] Lacassagne, A., _L’Homme vers la fin de sa vie_, p. 7, 1919, Lyon.

[42] Nascher, I. L., _Geriatrics: The Diseases of Old Age and their Treatment_, p. 18, London, 1919.

[43] Gilford, Hastings, _Med.-Chir. Trans._, London, 1897, lxxx. 17. _Disorders of Post-natal Growth and Development_, 1911.

[44] Variot et Pironneau, _Bull. Soc. pédiat. de Paris_, 1910, xii. 307.

[45] Roy, D., _Thèse de Paris_, No. 110, 1910.

[46] _Lancet_, 1889, ii. 349.

[47] Weber, Hermann, _On Longevity and Means for the Prolongation of Life_, 1919, 5th edition, by F. P. Weber, London.

[48] Brownlee, J., _The Use of Death Rates as a Measure of Hygienic Conditions_, p. 51. Special Report Series No. 60. Medical Research Council, 1922.

[49] Savage, G., _Memorial to Sir William Osler_, vol. i. p. 247, 1919, New York.

[50] Butler, S., _Evolution, Old and New_, p. 380, 1911.

[51] Weber, F. P., _Med. Press_, London, 1920, N.S., cix. 271.

[52] Compare Fischer, Martin H., _The Unpopular Review_, 1919, ix. 323.

[53] Paget, J., “Errors in the Chronometry of Life,” in _Studies of Old Case Books_, p. 92, 1891, London.

[54] Osler and McCrae, _The Principles and Practice of Medicine_, p. 834, 1920, New York and London.

[55] Clifford Allbutt, _Diseases of the Arteries including Angina Pectoris_, vol. i. pp. 164–7, 1915, London.

[56] _Lancet_, 1922, i. 874.

[57] _On the Handicapping of the First-Born_, Eugenics Lecture Series, x., 1914.

[58] Noirot, L., _L’Art de vivre longtemps_, p. 195, 1868, Dijon.

[59] Laurent, O., _Bull. Acad. de méd._, Paris, 1919, lxxxi. 835.

[60] _Annuaire internationale de statistique_, Part II., Europe, Movement of the Population, Table 12, pp. 180–81.

[61] _Statistiska Meddelanden_, Ser. A., Band I. 1 _Dödlighets- och Lifslangdstabeller for Åren 1816–1910 af Kungl. Statistiska Centralbyrån_, Stockholm, 1912, p. 28. (For this reference I am indebted to Dr. Major Greenwood.)

[62] _Public Health Reports_, Treasury Department, Washington, 1922, xxxvii. 487.

[63] Saundby, R., _Old Age, Its Care and Treatment_, p. 21, 1913, London.

[64] Easton, J., _Human Longevity_, p. xxvi, Salisbury, 1799.

[65] Browne, T., _Christian Morals_, Part I. Section XXXIII.

[66] Strachey, L., _Books and Characters_, p. 83, London, 1922.

[67] Finot, J., _Rev. mondiale_, Paris, 1922, xxxiii. 387.

[68] _The Mirrors of Downing Street_, by a Gentleman with a Duster, p. 165, 1920.

[69] Thompson, R. J. C., and Todd, R. E., _Lancet_, 1922, i. 874.

[70] Yeo, B., _XIX. Century_, 1883, xxiii. 390.

[71] _Vide_ F. Adams, _Genuine Works of Hippocrates_, Sydenham Society, vol. i. p. 10, 1849.

[72] Drinkwater, H., _Practitioner_, London, 1914, xciii. 844.

[73] For a consideration of this subject see Sir Hermann Weber’s _Means for the Prolongation of Life_, and Dr. Lapthorn Smith’s book _How to be Useful and Happy from 60 to 90_, London, 1922.

[74] Compare Allbutt, C., _St. George’s Hosp. Rep._, 1870, v. 43, and C. Hilton Fagge, _Principles and Practice of Medicine_, 1886, vol. ii. p. 22, London.

[75] Lacassagne, A., _L’Homme vers la fin de sa vie_, p. 44, Lyon, 1919.

[76] Owen, I., _Brit. Med. Journ._, 1888, i. 1312.

[77] Allbutt, C., _Diseases of Arteries, including Angina Pectoris_, vol. i. p. 250, 1915, London.

[78] Robertson, T. B., and Ray, L. A., _Journ. Biol. Chem._, 1920, xlii. 71.

[79] Williams, L., _Minor Ailments_, p. 319, 1920, London.

[80] Sharpey-Schafer, E. A., Presidential Address, Brit. Assoc., 1912, _Brit. Med. Journ._, 1912, ii. 589.

[81] Salimbeni et Gery, _Ann. Inst. Pasteur_, Paris, 1912, xxvi. 577.

[82] Fischer, M. H., _Oedema and Nephritis_, 1921, New York.

[83] Lumière, A., _Rôle des colloïdes chez les êtres vivants_, 1921, Paris.

[84] Bechhold, H., _Die Kolloide in Biologie und Medizin_, Dresden, 1912.

[85] Marinesco, G., _Études histologiques sur le mécanisme de la sénilité_, 1904; also _Presse méd._, Paris, 1922, xxx. 309.

[86] Campbell, H., _Treatment_, London, p. 153, 1909.

[87] Carrel, A., _Journ. Exper. Med._, Baltimore, 1913, xviii. 287.

[88] Loeb and Northrop, _Journ. Biol. Chem._, 1917, xxxii. 103.

[89] Carrel, A., and Ebeling, A. H., _Journ. Exper. Med._, Baltimore, 1921, xxxiv. 599.

[90] Robertson, T. B., and Ray, L. A., _Journ. Biol. Chem._, 1920, xlii. 71.

[91] Nathan, _Ann. de méd._, Paris, 1922, xi. 59.

[92] Drew, _Brit. Journ. Exper. Path._, London, 1922, iii. 20.

[93] Hufeland, C. W., _The Art of Prolonging Life_, 1797, vol. i. p. 227.

[94] Lorand, A., _Old Age Deferred_, pp. 51, 114, Philadelphia, 1921.

[95] Biedl, A., _Endocrinology_, Los Angeles, 1921, v. 523.

[96] Berman, L., _The Glands Regulating Personality_, p. 260, The Macmillan Co., 1921, New York.

[97] Lydston, G. F., _Journ. Amer. Med. Assoc._, Chicago, 1919, lxxii. 396.

[98] Stanley and Kelker, _Journ. Amer. Med. Assoc._, Chicago, 1920, lxxiv. 1501.

[99] Stanley, _Endocrinology_, Los Angeles, 1921, v. 708.

[100] Gilford, H., _The Disorders of Post-natal Growth and Development_, p. 643, 1911, London.

[101] Bouin et Ancel, _Compt. rend. Acad. Sc._, Paris, 1903, cxxxvii. 1289, 1904, cxxxviii. 110.

[102] Lipschülz, Ottow, Wagner, and Bormann, _Proc. Roy. Soc._ Lond., 1922, ser. B, xciii. 132.

[103] Kuntz, A., _Endocrinology_, Los Angeles, 1921, v. 190.

[104] Nathan, _Presse méd._, Paris, 1922, xxx. 237.

[105] Sand, K., _Journ. de physiol. et de path. gén._, Paris, 1921, xix. 525.

[106] Blair Bell, _The Sex Complex_, p. 28, 1920.

[107] Sternberg, _Berl. klin. Wehnschr._, 1921, lviii. 556.

[108] Mott, F. W., _Brit. Med. Journ._, 1919, ii. 658; _Proc. Roy. Soc. Med._, 1922, xv. (Sect. Psychiat.), 1–30.

[109] Aron, _Compt. rend. Soc. biol._, Paris, 1921, lxxxv. 107.

[110] Retterer, E., _Compt. rend. Soc. biol._, Paris, 1919, lxxxii. 423.

[111] Walker, K., _Brit. Med. Journ._, 1922, i. 297.

[112] Steinach, E., _Verjüngung durch experimentelle Neubelebung der alternden Puberstätsdrüsen_, J. Springer, Berlin, 1920.

[113] Benjamin, H., _New York Med. Journ._, 1921, cxiv. 687.

[114] Simmonds (quoted by Marinesco), _Deutsche path. Ges._, Jena, 1921.

[115] Tiedje, H., _Deutsche med. Wehnschr._, 1921, xlvii. 35.

[116] Romeis, B., _München. med. Wehnschr._, 1920, lxvii. 600, 1821.

[117] Marinesco, _Presse méd._, Paris, 1922, xxx. 309.

[118] Lenz, L., und Schmidt, P., _Deutsche med. Wehnschr._, 1921, xlvii. 327.

[119] Moullin, C. W. M., _Enlargement of the Prostate_, p. 194, 3rd edition, 1904.

[120] Harrower, _Practical Hormone Therapy_, p. 344, 1914.

[121] Frank, _Journ. Amer. Med. Assoc._, Chicago, 1922, lxxviii. 181.

[122] Marinesco, _Études histologiques sur le mécanisme de la sénilité_, 1904.

[123] Léri, _Le cerveau sénile_, 1906.

[124] Ribbert, H., _Der Tod aus Alterswäche_, Bonn, 1908.

[125] Salimbeni et Gery, _Ann. Inst. Pasteur_, Paris, 1912, xxvi. 577.

[126] Lane, W. A., _The Operative Treatment of Intestinal Stasis_, 1918, London.

[127] Abernethy, J., _The Constitutional Origin and Treatment of Local Diseases_, 1811.

[128] Clarke, E., in _The Operative Treatment of Intestinal Stasis_, p. 246, London.

[129] Vide Saundby, _Old Age, its Care and Treatment_, pp. 5, 28, London, 1913.

[130] Pearson, K., _Arch. Middlesex Hosp._, 1902, ii. 127.

[131] Lazarus-Barlow, W. S., _Ibid._, 1905, v. 43.