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.
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.