Why do we die?

by T. Bodley Scott

CHAPTER III

THE WAY OF SAFETY

The pre-sclerotic state of raised pressure may last a considerable time—two or three years—but this can never be relied upon; every attack means extra work for the heart, and uses up for a time the reserve power of that long-suffering organ. Some hearts will respond well to the call for many years, but others give out and dilate. Continued raised pressure means one of two things—increased resistance and partial obstruction in the small arteries and capillaries, or increased ventricular action and force. An example of the first, which is far the more common, is seen in sclerosis; of the second, in aortic regurgitation. In the one case the heart is overcoming resistance—in the other, compensating for a leak. In the first, the error or departure from the normal is in the pipes—in the second, in the pump; but as both are vital organs and not mere bits of mechanism, they in time react on each other and both become altered. This change is, if vitality be strong, in the direction of conservatism, of accommodation to the new order of things. It is compromise, which may be effectual for a long time, but which, like most compromises, comes to failure in the end. Occasionally we find the sclerosis attacking the heart muscle itself or its arteries; such cases are obviously more serious. This condition generally comes on more or less at the end of the disease, but in a few cases quite early. Probably many of the cases of true angina pectoris occurring in early middle life are of this nature, the coronaries being the chief point of attack.

Besides excess of work and unwise work there is another cause which seems to raise pressure, and that is absorption of ptomaines or of the products of imperfect digestion; the overstrain cause and the absorption cause very often act concurrently, for imperfect assimilation is often the result of the unwise life. We see this more often, perhaps, where the unwise life is accompanied by overeating and injudicious alcoholic stimulation, even if this is not very excessive: such people rarely give themselves time to digest. The supply of nerve energy that is necessary for perfect digestion is turned off at the main long before its proper time. We doctors have a first-hand personal knowledge of this cause, for owing partly to the intensive nature of our work and partly to the exigeant importunity of our patients, we more often practise the vices we deplore than the virtues we praise; this is one of the reasons that our profession is the shortest-lived of all.

It is not quite clear how this absorption causes hypertension, but it is probably through an effect on endocrine glands, chiefly perhaps on the suprarenal and secondly on the thyroid. McGarrison has shown how often Graves’ disease is caused by faulty intestinal digestion, and by the colitis that ensues; this he thinks stimulates the thyroid to overactivity or to faulty secretion. The suprarenals are probably affected still more than the thyroid, and the hyperthyroidism may be due to the upset of the balance of power; for these two glands through the sympathetic act and react on one another. It is fairly established that in some cases of Graves’ disease we get hypertension and in some hypotension, though both conditions vary a good deal. It may be that the hypotension cases are those that are accompanied by suprarenal deficiency and that benefit by suprarenal treatment, and I believe it to be so. This would explain the conflicting opinions as to the value of this treatment. It has certainly succeeded admirably in some cases.

The co-ordination of all endocrine actions is so intricate that we can only puzzle out the way by careful clinical observation and experiment. In sclerosis, as a rule, we get evidence of hyperadrenalism and more certainly of hypothyroidism. Victor Horsley considered premature senility to be a form of myxœdema, which of course means pronounced hypothyroidism.

Biedl says: “A special pathogenetic significance is ascribed to thyroid insuffiency in the changes which occur in later life, and which are included in the term ‘cachexia of old age,’ or senile degeneration. The foundation for the theory that old age results from the changes in the thyroid gland lies in the fact that in old age the thyroid becomes atrophied, its follicles shrink, and retrogressive changes take place in the epithelial cells. This is reinforced by the fact that there is a profound analogy between the signs of advanced old age and myxœdema. The falling of the hair and the dropping out of the teeth, the dry and wrinkled skin, the lowered temperature, the diminished perspiration, the indolent digestion and consequent emaciation, the decrease of mental power and the diminution of the activity of the entire nervous system—these are all symptoms that characterize chronic myxœdema.”

From the old partially true adage, that a man is as old as his arteries, we must go a step further back and say that a man is as old as his thyroid. This statement is probably not a final one, but it gives us a very valuable pointer in the way of treatment. Arterio-sclerosis and arterial degeneration are the almost universal accompaniments of thyroid deficiency, and are in most cases the result of that condition.

There is no main or royal road to the successful management of sclerosis; every little cause must be thought out and righted if possible, but as a foundation nothing is so important, I think, as a clean, healthy intestine, which hitherto has been much neglected. A microscopical examination of the fæces will often show what is wrong, and also the direction and results of treatment.

If the condition is thoroughly bad I begin with this rather drastic regime—twenty-four hours’ absolute starvation in bed, a tenth of a grain of calomel every hour for twelve hours and as much hot water as the patient can comfortably drink. This has a wonderful effect, and one’s subjective feelings after it tell us that evil has gone out of us and that good has taken its place.