Extreme Medicine (26 page)

His heart beats with less force, empties smaller volumes with every beat. The electrocardiogram, which traces the spread of electricity through that vital organ, shows the occasional missed beat.

When he rises from his chair, he cannot pull himself up to his full height. The weakened bones of his spinal column have over the years given way to the forces generated by imperfect posture. The spine itself curls gently forward now, causing a permanent stoop.

When—with assistance—he gets to his feet, you cannot help but worry. The muscles of postural control, those that keep him upright, are less capable now. They labor under the control of the brain, which is unconsciously and perpetually making corrections to keep him on his feet. But that foreman too is less competent than it once was.

The intricate system of accelerometry in his inner ear—that which in youth and health can tell an Olympic figure skater when to emerge from a pirouette—is now prone to playing cruel jokes, occasionally providing illusions of motion when it is absent, leaving him unsteady. And the bones on which his flesh and muscle are hung are less dense, more prone to fracture when exposed to sudden force.

This is the physiology of great age, and the frailty that accompanies it is undeniable. But for all of the above, at 103 Mr. Hudson continues much as he must have done for most of his life. He is the oldest member of his golf course and a man who, until a month ago, still drove a car.

—

I
T IS ENTROPY THAT WE ARE
up against here. Entropy is that property, common to all systems alive or dead, that sees them tend from a state of order to one of chaos. And once the processes of renewal and replenishment that maintain us in our youth begin to run down, we are left open to its ravages.

You can think of the biomolecules that comprise the cells and tissues of your body as though they were thousands of trillions of spinning tops arranged on a vast tabletop. In their initial state, they all stand neatly ordered—upright, spinning fast, and resilient to perturbation. But gradually, as they begin to spin down, they slow and become more unsteady.

Those tops can be respun and prevented from falling over, with a whip. Or those teetering on the brink of catastrophe can be removed completely and replaced with a freshly spun top. Whipping and replacing the spinning tops are processes analogous to the repair and regeneration of biomolecules. It is this perpetual input of energy to the biological system that temporarily staves off the consequences of entropy.

In youth, the process of entropy is held in check by the body's intrinsic system of repair and regeneration—a system, if you like, that is constantly replacing many trillions of molecules and whipping them into shape. But just as a child eventually gets bored with the toy, so the body eventually begins to abandon the processes of repair and regeneration.

Unabated, the entropy of the biomolecules of which the body is composed manifests itself as the process that we experience as aging. According to this model, the state of youth is akin to a forest of spinning tops standing stable, fast and full of energy. Old age sees them slowing down, growing unsteady, oscillating wildly—ready for a passing breeze to knock swathes of them over.

Entropy does not cause disease, nor is it disease, but it leaves an organism vulnerable. And disease takes hold where the system is weakest. For humans that is the cardiovascular system and those cell populations most prone to cancer.

Having made great strides against communicable disease in the opening decades of the twentieth century, we are now up against the limits set by entropy.

In a sense, we have transcended the fate of other organisms, leaving behind the eternal war among species and microorganisms that operates to kill such large fractions of a population in early life, and—barring accident—we are left to behave more like the objects in the physical world around us, winding down as entropy takes hold, left to fail the way a star might.

—

M
R.
H
UDSON'S CHEST
is full of crackles. His cough is worse today, his breathing more labored. The pneumonia that first brought him to the hospital has returned. I am unsure what the kindest intervention might now be.

At the start of the twentieth century, the continent of old age was a destination that stood rarely visited and largely unknown. For nearly the entirety of human history, average life expectancy languished around thirty years of age. This grim statistic remained fairly constant throughout recorded history, about as true of the ancient Greeks as it was of the Victorians of the nineteenth century.

In the time that James Hudson has lived, life expectancy in the United Kingdom has nearly doubled. The oldest person who has ever lived was nineteen years older than he is now when she died at the remarkable age of 122 years and 164 days in 1997.

Jeanne Calment, born in the 1870s, lived for her entire life in the French city of Arles and, as a young woman, once met Vincent van Gogh. It is hard to make sense of her longevity. She smoked, ate chocolate, drank port, and according to reports, wasn't particularly fussed about exercise—hardly the behavior of an individual attempting to stave off the inevitable running down of her physiological processes.

There are but a handful of people alive today who have approached this great age. Fewer than one in a thousand centenarians reaches the age of 110. Could Mr. Hudson pass this extreme frontier? Statistically, the chances appear slim. But we are in terra incognita here, living at a time when we are seeing remarkable feats of survival and longevity occur more and more commonly.

We are increasingly aware that a patient's chronological age is not the same thing as physiological age and that it's a mistake to underestimate those who've passed their allotted threescore years and ten. After all, John Glenn flew into space aboard the space shuttle
Discovery
at age 77. Jeanne Calment herself took up fencing for the first time at age 85. And at 102 years of age, Dr. James Hudson described himself in the national census as merely “semiretired.” As his doctor, I have no direct way of knowing how well preserved Mr. Hudson is, only that he is resilient enough to have made it this far.

My patient is arguably less likely to die on this day than he was on any day at Arras, Mons, or Ypres, and only slightly more likely to die today than he was in his first year of life. But Mr. Hudson is an individual—more different from the population upon which that statistic is based than he has been at any time in his life. He has seen unthinkable revolutions in health care, science, and technology. He has seen the seemingly impossible achieved over and over again. And for him, the only constant through all of that time has been the fact of his survival.

Tucked up in bed fighting pneumonia, he is still in many ways the same plucky private from the Western Front—keeping his head down, knowing only that this is war and that all wars are hard.

—

“
N
OBODY,” AS SENATOR AND ASTRONAUT
John Glenn once put it, “has yet found a cure for the common birthday.” But for those fortunate enough to live in the developed countries of the world, the continent of old age is, after two million years of human evolution, suddenly open to all. Equipped with only average luck, assisted by the advances that modern living has brought, the vast majority of us will reach it.

We may find difficulty in perceiving old age as a thing of exploration, but that it is—and one in which all of us today can participate. Neither do we regard it in the same way as we do other unexplored destinations: with expectation, hope, and curiosity.

But life is an exploration, and James Hudson is among the greatest explorers of any age, living across three centuries, witness to some of the most significant events of the twentieth century. To him it was all an adventure and one to be enjoyed until the last possible moment.

—

E
NTROPY, DISEASE, AND THE COMPLEXION
of our genes eventually catch up with us all, even those who have walked upon the Moon. On August 25, 2012, Neil Armstrong died in a hospital in the city of Cincinnati, Ohio, having failed to fully recover after cardiac surgery. He was eighty-two. Earlier that month, he had stepped onto a treadmill and walked, while doctors monitored the dance of electricity in his heart through electrocardiogram leads.

They perhaps noticed small upswings and depressions in the waveforms scribbled out before them, symptomatic of constrictions in the arteries supplying the muscle of his heart. They would have gone on to map those tributaries in greater detail, delineating the number and severity of the narrowings, before deciding upon a plan. That plan was for Armstrong to undergo a cardiothoracic operation in an effort to bypass the blockages in his coronary arteries and restore the supply routes to his heart.

Bypass operations were pioneered in the same decade in which Project Apollo reached the Moon. This type of surgery remains among the most invasive that medicine offers—carving into the chest, isolating the heart from its surroundings, and establishing the patient on a heart-lung bypass machine—and it comes with attendant risks. This Armstrong's surgical team would have labored to explain, weighing the alternatives, making clear what might be won and lost in the endeavor.

Precisely how you stratify risk to a man who commanded the first crew to land on the Moon, or how Armstrong himself perceived it, I do not know. Despite his earlier occupation, Armstrong was no adrenaline junky. Unnecessary risks were, in his opinion, best avoided.

Famously he believed that human spaceflight ought to involve no more risk than making a milk shake. Though back in the summer of 1969, as the lunar module
Eagle
sank toward the Sea of Tranquility, running low on fuel, its onboard computers having crashed repeatedly, spaceflight still had a long way to go to catch up with the safety record of the milk-shake industry.

The early days of human spaceflight and heart surgery were watched by the world in wide-eyed wonder. The risks involved in these pioneering endeavors were so great as to be impossible to sensibly quantify. Deaths were expected.

Today the risk of catastrophic failure during the launch of a human-rated orbital space vehicle stands at perhaps 2 or 3 percent, almost the same risk as that involved in coronary artery bypass surgery. Despite these risks being significant, both have, to some degree, come to be viewed by the public as being within acceptable limits. They have become almost routine.

The surface of the Moon, like the anatomy of the heart, had been studied for centuries. Both had stood for millennia in full view and yet unexplored. The Moon was reached by an astronaut crew launched across the void, wrapped in a facsimile of Earth's atmosphere. That same approach—of swaddling physiology in systems of artificial life support—was the key to successful cardiac surgery.

In the few decades that have elapsed since Scott and Amundsen first marched to the South Pole, we have come a long way. Our expectations of the insults we might survive, in the pursuit of geographical conquest as well as on the operating table, have been transformed. Life has never been safer, never longer-lived.

But look closer and the picture gets more complex. Exploration is necessarily a process of trial and error, of taking risks. It appears clear what we have to gain by advancing so boldly as clinicians. But we're growing more circumspect about physical exploration, particularly that which sees us staring out into space at the final frontier. We've begun to wonder if we should continue to boldly go.

—

T
HE AGE OF HUMAN SPACEFLIGHT WAS,
without doubt, brought into being by the nuclear arms race of the midtwentieth century. In the 1960s, with the respective nuclear arsenals of the Soviet Union and the United States of America standing ready to bring about their mutually assured destruction, human spaceflight became a surrogate battlefield for a war that couldn't be fought in any other way.

With the Soviet Union ahead at every point in the space race, there were hard truths for the United States to face. But the reply to Sputnik, Laika, and Gagarin was Armstrong, Aldrin, and Collins. And despite Russia's earlier preeminence, the lunar landing in July 1969 somehow gave the United States victory in this bizarre struggle.

Project Apollo and its lunar exploration missions were conceived, built, and launched before Kennedy's famous decade was out. This feat appears to grow more miraculous as the years roll by. The mission-control room that drove those first forays to another world was stocked with slide rules, pocket protectors, and Bakelite telephones with rotating dials. To contemporary eyes, it hardly seems possible that the technology of the time was up to the task of delivering men to the surface of the Moon. In that regard, it is an achievement that stands outside its time, a feat of anachronism.

But perhaps acts of exploration never fully make sense to rational people. They are, after all, about venturing beyond what is known and safe and to be counted on. In this regard, maybe the greatest feats of exploration must always feel anachronistic.

—

A
FTER HALF A MILLENNIUM,
we still remember Ferdinand Magellan and the straits linking the Pacific to the Atlantic to which he gave his name. We might remember, too, the extraordinary voyage that saw his flotilla of ships become the first expedition to circumnavigate the globe. The legacy of discovery is what we celebrate. What we recall less clearly is the expedition's legacy of loss.

For Magellan, setting sail from the Spanish port of Sanlúcar de Barrameda in 1519 with a fleet of five ships and a crew of 237, the oceans of the world must have seemed as unknown, presenting at least as much threat to life as the ocean of space that lies between Earth and Mars today.

The expedition endured famine, disease, mutiny, and conflict. Magellan himself was slain in the Philippines, in the shallows around Mactan Island, before the circumnavigation was complete. When the expedition finally returned to port in 1522, exactly three years after its departure, only one ship, the
Victoria,
and 18 of the original crew of 237 remained.