Captain of the Men of Death

I

‘IF the present rate of increase in the average length of human life can be maintained, we shall find ourselves, in the course of very few generations, attaining the age of two hundred years.’ These words are taken from a recent public speech, as quoted in the press, delivered by a professor of sociology in a prominent Eastern university.

A dip into vital statistics would seem to indicate no lack of justification for this gratifying prediction. The rapid increase of the life span during the period encompassed by the memory of the generation now grown old has been one of the most important factors contributing to the cocksure confidence in our control over the forces of nature which is so characteristic of the present era. In 1854 the expectation of life at birth in England and Wales was 40.87 years; in 1922 it had risen to 57.59 years. As for America, the Statistical Bulletin of the Metropolitan Life Insurance Company for October 1929 says: ‘Twenty years have been added to the average length of human life since public health work began to be actively practised in the early eighties of the last century.’ At the present time, a newborn babe in the United States may be expected to live about fifty-nine years.

An adequate understanding of the prospects of continuing this increase cannot be had without examining the methods which have brought about these results, of which we may well be immensely proud. Such a survey, unfortunately, leads to the conclusion that the good professor’s hopeful prophecy is not likely to be realized, in spite of the fact that it is based upon the apparently sound logic which assures us that ‘what has been done can be done again.’

An analysis of the noteworthy gains in the prolongation of life during the past five decades shows that they have been almost uniformly of a nature to benefit the young. Practically the solo secret of the expanding average tenure of life is that vast numbers of infants, children, and adolescents who formerly would have died are now being protected and spared to become men and women. This is strikingly illustrated by the vital statistics of Illinois during one brief decade. In that state 106 infants out of every 1000 born alive in 1918 died before reaching one year of age; only 64 out of each 1000 died in 1928.

Throughout the nation a similar trend has been steadily apparent. Supervision of the collection of milk and insistence on its proper pasteurization have saved countless youngsters from tuberculosis and diarrhœal disorders. Tuberculosis, which is preeminently a disease of childhood and youth, has been further curtailed by improved social conditions, segregation of its victims, and training of the public concerning the dangers of promiscuous spitting. Diphtheria, formerly a terrific menace which decimated the ranks of childhood, has dwindled into virtual insignificance before the attack of antitoxin and, more recently, of preventive immunization. Typhoid fever, within the memory of men and women not old, slew its ten times tens of thousands. In the Spanish War the typhoid bacillus was more devastating than the Spanish rifle; but proper protection of water supplies, together with prophylactic inoculation, has recently made this disease so rare that medical teachers can scarcely find cases to show their students. Scarlet fever is in retreat, and smallpox, thanks to increasing vigilance in the application of Jenner’s capital discovery, has all but vanished.

On the other hand, Mr. MiddleAged Citizen has not been vouchsafed any equivalent boon by medical science. His smiles of satisfaction on reading of the lengthening span are a bit pathetic in view of the fact that he is likely to die almost as early as his forbears who survived the miasma which formerly enveloped youth. To revert to the vital statistics of Illinois, during the same recent ten-year period when life was becoming increasingly secure for infants, there was actually a rise of 10 per cent in the mortality rate of persons over forty. The sum total of it all was an increase in the average duration of human life from fifty-eight to fifty-nine years. But what shall it profit a middle-aged man?

II

The Constitution of the United States provides that the holder of the office of President must be at least thirty-five years of age. In practice, we have never trusted our destinies to anyone younger than Roosevelt, who went into office at forty-two. This makes the roster of dead Presidents a convenient measuring stick of the trend of longevity among persons of mature years. The list, arranged in the order of their deaths, with their ages at the time of death, is as follows: —

It will be seen that the Adamses, Thomas Jefferson, James Madison, and Andrew Jackson had no occasion to lie awake nights fearing early dissolution because of the lack of medical advantages in their time. If these ages at death are analyzed and rendered in the form of a straight line according to mathematical computation, the resulting trend does not look like a business graph of boom times; on the contrary, it has a definite downward slope.

The group of dead presidents comprises twenty-eight men in all. If we omit Lincoln, Garfield, and McKinley, whose deaths by assassination lack statistical value for our purpose, the remaining presidents may be divided into five groups of five. The average age of the first group at death was 79½ years; of the second group, 69; of the third, 73; of the fourth, 64; and of the fifth, 66. This is scanty material for statistics, to be sure, but it illustrates the point which more ample figures prove — namely, that there is as yet no adequate check to mortality among persons of mature years. Indeed, there are those who confidently believe that the middle-aged do not live so long as they did in the more leisurely, ordered days of yesteryear.

III

What are the diseases which have not yet been driven to the wall, as have typhoid and diphtheria? Cancer is, of course, one of them; pneumonia is another. But even more deadly than these is a degenerative condition of the heart and blood vessels which deserves a comprehensive name and rating as a single disease, but actually has no sufficient designation and is therefore rather vaguely defined in the public mind. The term ‘cardiovascular degeneration’ has fairly good descriptive qualities for this disease, which has now usurped the title, ‘Captain of the Men of Death,’ a graphic appellation once applied by Bunyan to tuberculosis.

There cannot be the slightest doubt that cardiovascular degeneration is today the greatest killer of mankind. Although heart disease alone causes one sixth of all deaths among adults in the United States, the heart is only one of the organs liable to the ravages of the process. Cardiovascular degeneration is perhaps most likely to attack men and women of superior ability and restless energy, cutting them down with a suddenness which is dramatic and appalling. A Wilson labors with herculean energy to forge a new order of things, and, while stumping the country to present his cherished plan, is seized with apoplexy and left a helpless cripple with blasted hopes. A Bryan caps his eventful course with a vigorous defense of the faith in the colorful arena of Dayton, and a few days later is borne to his grave. A Morrow attains the heights with surpassing industry and brilliance, but is found lying dead on the very threshold of a political career which promises historic significance. It is worthy of note that cardiovascular degeneration caused the deaths of the last two ex-Presidents of the United States who have died.

The American Medical Association each year assembles and publishes data concerning the deaths of physicians in the United States. There are about 155,000 physicians licensed to practise in this country. In 1930, 2943 physicians died at an average age of 63.7 years. The chief causes of death in the order of their importance and the number dying of each cause were as follows: —

If we group the first, second, fifth, and sixth items of this list, we obtain a total of 1834 deaths which may be ascribed to cardiovascular disease. This reaches the amazing level of over 60 per cent of all the deaths! Unfortunately, these statistics do not permit one to know how many of the deaths listed as ‘heart disease’ were due to the valvular type of disorders resulting from rheumatic fever in childhood as opposed to the degenerative condition in which we are at present more interested. It is safe to say, however, that the degenerative type of heart disease easily preponderates.

The average person of mature years lias a deep dread of cancer. In his mind it seems to loom as his most formidable potential foe. Much contemporary medical comment carries the implication that the solution of the cancer problem will inaugurate a millennium of secure and happy living. Without minimizing the scourge of malignant growths, permit me to point out that, as measured by the mortality figures for American physicians in 1930, a man is over seven times more likely to die of cardiovascular disease than of cancer!

IV

The baneful effects of cardiovascular degeneration show themselves in various ways; for this reason the layman is unaware that many serious and fatal maladies of which he hears are part and parcel of the same process. High blood pressure, arteriosclerosis, angina pectoris or painful heart attacks, sudden heart failure, apoplexy, chronic nephritis, Bright’s disease, and uremia are some of the terms applied to the manifestations of this insidious disease. Behind all these lies the common factor — a gradual stiffening, narrowing, thickening of the blood vessels which causes increasing obstruction to the flow of blood. The changes in the vessels are not uniform throughout the body; the point at which the symptoms make themselves manifest depends upon where the mischief is most advanced.

It is unfortunate that a certain small artery embedded in the brain has the peculiarity of being liable to rupture under the influence of the degenerative process. Such rupture is followed by bleeding into the brain substance. This produces the familiar ‘stroke,’ with sudden death or survival accompanied by paralysis of half the body. When degeneration of the vessels has reached a stage capable of resulting in cerebral apoplexy, the years of the victim are usually numbered and his activities, as a rule, are permanently impaired. A most extraordinary exception is offered by the career of Louis Pasteur, who suffered a stroke at the early age of forty-six. In spite of a palsy which never left his left arm and leg, he did most of the incomparable work which made him forever famous after this misfortune. He died at the ripe age of seventy-three.

Actual rupture of the diseased blood vessels is not so common in other regions of the body, with the possible exception of the retina of the eye, where sudden hemorrhages may flood the sensitive visual surface, causing impairment of vision or blindness in the affected eye. It is much more usual for gradual thickening of the walls of arteries simply to narrow the blood-carrying channels until at last the nutrition of the tissues becomes inadequate. Most serious results ensue if the tissues affected are ones highly sensitive to impairment of their supply of oxygen and nutritive fluids. The narrowed vessels may finally become totally obliterated, causing death of the parts they have nourished.

Obliteration of a branch of the coronary arteries, which supply the heart, results in destruction of a section of the heart muscle itself. This is a common cause of sudden death among American business men in the office, at the dinner table, or on the golf links. If the victim does not die immediately, he goes into a state of collapse accompanied by violent pain about the midsection of the body and frequently succumbs within a few hours. Our forefathers were prone to call this ‘acute indigestion,’ a diagnosis which has been written on many a death certificate although the actual cause of death lay above the diaphragm. It has only been within recent years that evidence secured through autopsies has made this clear.

It is a great pity that our bodies were not made according to the famous deacon’s specifications for the OneHoss Shay. The droll conception of Oliver Wendell Holmes is of as much interest to the physician as to the automobile manufacturer, for we do not die because our bodies are all worn out. The human blood vessels and heart have a habit of languishing even while the brain, eyes, liver, lungs, intestines, muscles, bones, and joints are relatively unimpaired.

V

What measures may one invoke to spare his circulatory system and make the machine last longer? First of all, it must be confessed that there are factors beyond the control of the individual. Heredity has a definite and important part in determining the ‘kind of tubing’ through which one’s blood flows. The easiest way to live long is to have one’s parents and grandparents set the example. There is an unmistakable tendency in certain families toward early degeneration of the blood vessels. Those who are subject to this tendency can frequently mitigate it by adhering to a careful régime of living.

The famous Rooseveltian ideal of ‘the strenuous life’ is hard on the arteries. The stress and worry of modern life appear to throw a strain on the blood vessels which makes for high blood pressure and progressive deterioration. A grim, zealous outlook, untouched by the graces of humor and equanimity, is a deadly vice which the preachers have too often overlooked. It is a well-authenticated and probably significant fact that in China, where a serene, leisurely philosophy prevails, the average blood pressure is definitely lower than among Americans. After living in China for long periods, Americans gradually develop blood-pressure levels similar to those of the Chinese, presumably because the more sedate mode of life is contagious.

An absorbing but tangled problem is offered by the question of diet as a factor in the postponement or acceleration of physical decay. For many years students of nutrition have warned against heavy consumption of protein foods such as meat, fish, eggs, and cheese. What we may call the ‘ash’ of proteins apparently is not particularly easy for the body to excrete. It is almost instinctive for physicians when prescribing diets to place a limit on proteins. But a few years ago along came Vilhjalmur Stefansson, the arctic explorer, saying he had subsisted entirely on meat and fish for seven years in the far North with no deleterious effect on his health. Careful examination showed him to be in excellent condition.

Stefansson pointed out that Eskimos, whose diet consists almost wholly of animal food, have not been shown to be especially liable to nephritis, arteriosclerosis, or high blood pressure. He offered to demonstrate the harmlessness of meat by eating nothing else for a year, meanwhile submitting to the most searching physical and chemical examinations. Andersen, who had spent three years with Stefansson in the arctic, consented to the same test. During 1928 the two lived on a diet of meat, including the fat. Occasionally on journeys, when no meat was available, Stefansson ate eggs. Andersen took no eggs. Their only dessert, was bone marrow; their beverages, water, black tea, and coffee without sugar or milk. At the end of the year the most painstaking tests in New York City failed to indicate harmful effects. The men were robust and had a sense of perfect well-being. As far as could be determined, their vital organs were unimpaired. No rise of blood pressure had occurred. On the contrary, Andersen’s blood pressure was twenty points lower than at the start.

In spite of the experiment on Stefansson and Andersen, Newburgh, of the University of Michigan Medical School, does not accept without question the doctrine of the harmlessness of high protein diets. By careful microscopic examination of the urine of persons on such diets he finds small albuminous masses called casts which are rarely present in normal urine. He considers his results a definite indication of renal irritation, which justifies the traditional attitude toward protein foods.

An interesting field for investigation has recently been opened by the discovery that hardening of blood vessels is accelerated in many persons with diabetes mellitus. Since diabetes hampers the utilization of carbohydrate foods (sugar and starch), diabetics are forced to turn in larger measure than normal individuals to fats as a source of energy. Their circulating blood frequently contains more than the usual amount of fat. Inasmuch as the hardened patches of diseased vessels are made up largely of cholesterin, a derivative of fats, it has been suggested, especially by Joslin, that an undue proportion of fat in the diet may favor degenerative changes.

These points are still in the controversial state. The exact proportion of protein, fat, and carbohydrate most suited to promote health has not yet been determined. In the present condition of our knowledge, no rigid rule is justifiable. Moderation in proteins is probably wise, but excessive fear of them seems uncalled for. There is one principle of diet, however, which can be stated without equivocation. It is that overeating in general, with the resulting condition of obesity, provides a load which is conducive to cardiovascular degeneration and inimical to great length of days. Actuaries of life insurance companies are unanimous in proclaiming the advantage in longevity of the lean over the fat. This condemnation of excess weight applies with much less force to persons under thirty. For them, tuberculosis is still the greatest cause of death, and ample nutrition the greatest safeguard.

VI

Excessive mental and physical work, with insufficient sleep and relaxation; the nerve-racking drive of overweening ambition; violent exercise by those unaccustomed to it; the intemperate use of stimulants; over-activity of the thyroid gland, acting as a goad to the metabolic processes; chronic infections of teeth, tonsils, and sinuses; severe acute infections such as typhoid fever and pneumonia; syphilis, especially if inadequately treated — all these throw an extra burden on the most vulnerable part of the human economy, the vascular system.

The periodic health examination which is gradually coming into vogue offers some hope of exerting a favorable influence on the mortality of cardiovascular disease by discovery of the condition during its early stages. There are those, to be sure, who think that the extra worry imposed by a knowledge of stiffening vessels and mounting blood pressure more than offsets any advantages. I once knew a most intelligent and capable woman executive of sixty who steadfastly refused to submit to the stethoscope or blood-pressure apparatus. Through association with excellent medical men she was well aware that certain recently developed symptoms were probably due to hypertension and arteriosclerosis. Being informed of the irrevocable nature of such changes, she refused positive knowledge of their extent, fearing it might prey on her mind and impair her working efficiency. One of the best-known physicians in America said in my presence a few years ago, ‘I think the invention of the bloodpressure apparatus has done more harm than good.’ Most doctors, however, would not agree with him.

Although we possess no specific relief for cardiovascular degenerative changes, the probability that they can be retarded by correction of habits and removal of sources of infection makes it of the utmost importance not to ignore them. Doubtless the world would be much poorer if Madame Pasteur had been in a position to apply the brakes by saying, ‘Louis, you must come out of that laboratory; the doctor says your blood pressure is two hundred and ten.’ But there are few Pasteurs, and in most cases it is far wiser to slow down the tempo of life as the rising column of mercury points to diminishing suppleness of the stream bed.

Temperate, hygienic living will undoubtedly prolong life by delaying the onset of degeneration of the heart and blood vessels. To a certain extent, however, the process has something in common with graying of the hair and the coming of wrinkles: it is a part of growing old. The college professor with visions of an average life span of two hundred years was like a father who might say, ‘If my fifteen-year-old Johnny keeps growing as he has grown this year, he will some day be ten feet tall.’ Further increases in the duration of human life must be wrung with increasing difficulty from the hands of the Fates, because what economists call ‘the law of diminishing returns’ now becomes operative. For the first time there are enough middle-aged persons for us to realize what finally becomes of them in the aggregate. There is every likelihood that cardiovascular degeneration will continue to rank high among the causes of death.