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’s203 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, Leclercq204 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 (Gowers205), 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 Maclachlan206 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 Clarke207). 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. Andrewes208 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 Dupré209 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 Clouston210 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. Quesnel212 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’s213 considered opinion to the contrary, it is probable that pneumonia has been often used to describe what was really bronchopneumonia. For Roussy and Leroux214 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 Nunneley216 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 Osler218).

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; Fenwick219 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 (Hollis220), 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’s222 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 (Jardini224), often accompanies the fibrous pads on the interphalangeal joints of the fingers described by Garrod225 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. Lannelonge227 and Fournier228 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.