History of the Development of Geriatric Medicine in the UK a Barton, G Mulley
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229 HISTORY OF MEDICINE Postgrad Med J: first published as 10.1136/pmj.79.930.229 on 1 April 2003. Downloaded from History of the development of geriatric medicine in the UK A Barton, G Mulley ............................................................................................................................. Postgrad Med J 2003;79:229–234 In this review the development of the specialty of built in Victorian times under the 1834 New Poor geriatric medicine in the UK is traced from its humble Law, to curtail public spending on poverty.2 Until 1834 individual parishes were responsible for beginnings. Elderly medicine is now thriving and their own poor. Parishes were united after 1834 represents the largest group of physician members of and larger workhouses were known as unions; the Royal Colleges of Physicians. Geriatric medicine is there were about 700 such institutions. The editor of the Lancet campaigned for improvements essentially about optimising the care and wellbeing of within poorhouses. (A previous editor had fa- older people. A key component of this is teamwork. A mously described the workhouse wards as “ante successful service for old people depends on the skills of chambers of the grave”.2) Joseph Rogers, a reformer of workhouses throughout his career as many people, including nurses, therapists, social a doctor, gave advice on the conditions in workers, and others. The contributions made by nurses Victorian workhouses.3 “Workhouse medicine” and other professionals have been immense, but space failed its occupants, there was no casualty provi- sion, no trained nursing staff, no drugs, and no does not permit a historical review of their important surgical facilities.3 Conditions gradually improved role. for the inmates and laws were passed to .......................................................................... safeguard their wellbeing. The Poor Law ended with the Local Govern- ment Act of 1929. However, a two tier system of n this review we shall concern ourselves with hospital care evolved. Power was transferred to medicine and old age and focus on: local authorities who ran the infirmaries which I developed from workhouses. Other hospitals were A. A historical perspective and the naming of the voluntary establishments, which enjoyed higher specialty. status and preferred not to admit older people. B. Pioneers and heroes of the specialty, the birth Elderly patients were considered as being of less http://pmj.bmj.com/ of the British Geriatrics Society, the development interest for teaching and it was feared that they of old age psychiatry and orthogeriatrics, and the would block beds. These voluntary hospitals expansion of geriatric medicine. became the first teaching hospitals. The care of older people took place in former poor law hospi- C. The question of integration of the specialty tals, where staffing levels were poor and facilities with general medicine. inferior. D. Contemporary themes, including community geriatrics and the National Service Framework Early publications on September 27, 2021 by guest. Protected copyright. (NSF) for older people. One of the first publications on the subject of geriatric medicine was by George Day, whose Dis- A. HISTORICAL BACKCLOTH eases of Advanced Life was published in 1849.45Day In medieval times, sick people were cared for in documented some of the modern day “geriatric monasteries. Some religious orders built hospital giants”,6 including incontinence and dementia. wings where elderly and infirm patients received He also described vascular dementia, which better food and received special care. Later, “ . .follows slight attacks of apoplexy and paraly- convents adopted a nursing role. sis; its progress is then very rapid”.4 Poor Laws were passed in Parliament in 1597 In 1881 Charcot was the first physician to See end of article for advocate a specialty of geriatric medicine, based authors’ affiliations and 1601 to keep the “poor” off the street, and ....................... avoid vagrancy and possible lawlessness. The Poor on his observations of a poorhouse-like institu- Law system became a regime which provided not tion in Paris.7 French physicians had previously Correspondence to: only for those without money, but also provided used the phrase “Gerocomie”—a term used to Dr Alan Barton, Department of Elderly accommodation to those who were ill, chronically describe the need for a separate facility for elderly Medicine, Great George sick, single parent families, and orphans. Work- people, where they could be adequately cared for Street, Leeds General houses (later renamed poorhouses) started in the and treated.8 They recognised that segregation of Infirmary, Leeds LS1 3EX, 1630s and by the end of the 1700s they had elderly people could help in improving their UK; abarton@ 1 health and wellbeing. doctors.org.uk become asylums for the old, infirm, and insane. The conditions within were appalling and very Submitted harsh. At the time, poverty was believed to be 15 October 2002 associated with a decline in moral standards. ................................................. Accepted 19 December 2002 Thus individuals in poorhouses were prejudged Abbreviations: NSF, National Service Framework; UCH, ....................... and treated unfairly. Many more poorhouses were University College Hospital www.postgradmedj.com 230 Barton, Mulley As well as being a pioneer of rehabilitation, Marjory Warren Postgrad Med J: first published as 10.1136/pmj.79.930.229 on 1 April 2003. Downloaded from Box 1: Warren’s classification of the chronic aged was a gifted teacher. She educated junior medical staff and 11 sick consultant colleagues and she took a keen interest in the edu- cation of nursing staff. Many of her ideas remain central to the • Chronic up-patients (that is, out of bed). practice of modern geriatric medicine. • Chronic continent bedridden patients. • Chronic incontinent patients. • Senile, quietly confused, but not noisy or annoying others. Joseph Sheldon (1893–1972) 13 14 • Senile dements—requiring segregation from other patients. Sheldon was the father of community geriatric medicine. He was a consultant at the Royal Hospital in Wolverhampton, where his interest in elderly people was prompted by an out- break of food poisoning. The word “geriatrics” comes from two Greek words; “iatros”, Sheldon observed many of the problems facing elderly a healer and “geros”, an old man. Nascher, a Viennese people at home. He realised the importance of good self care, immigrant to the US, first used the word geriatrics in 1909.9 continence, hearing, and footwear. Of particular importance His seminal paper not only was the first to name the specialty, was his recognition of mobility problems: he documented that but also considered the need for a separate specialty to deal 11% of elderly people were housebound. Sheldon recom- with the problems of “senility”. He used the analogy of medi- mended home physiotherapy. This would eventually be recog- cine of childhood, which had been “assigned to a special nised as standard treatment. He advocated falls prevention branch of medicine” and suggested that geriatrics should be strategies, such as adequate lighting at home and the benefits considered in a similar fashion. Nascher also focused on drug of stair rails. prescribing and warned of the harmful effects that medica- tions (such as antidepressants) could have on the ageing Norman Exton-Smith (1920–90) and Lord Amulree heart. He also described the symptoms and mode of death in (1900–83) older people with pneumonia. An exceptional pioneering clinical scientist and researcher, Though our specialty was first conceived and named in the Exton-Smith worked at University College Hospital (UCH) US, it was in the UK that geriatric medicine was born over 30 London, under the supervision of Lord Amulree.15 UCH was for years later. a long time the only London teaching hospital involved with the development of geriatrics. Amulree had previously worked B. PIONEERS OF GERIATRIC MEDICINE IN THE UK at UCH, but in 1936 had become a civil servant at the Ministry Marjory Warren (1897–1960) for Health. His influence in the House of Lords proved useful The “mother of geriatrics”, Warren was the most influential in improving conditions for chronic sick patients for whom he pioneering geriatrician. Few physicians were interested in cared deeply. With the inception of the National Health Serv- looking after older people at the beginning of the 20th ice he wanted their care transferred from local authority con- century. This situation changed after the appointment of Mar- trol. This occurred in 1948. Following his consultant appoint- jory Warren as assistant medical officer at the West Middlesex ment, and inspired by the work of Marjory Warren, he set Hospital in 1926.10 In 1935, when the nearby Poor Law about improving the plight of elderly disabled patients, and Infirmary was integrated into her own place of work, she was also changing the drab wards of St Pancras Hospital (a part of given the responsibility of caring for 714 chronically ill UCH). His work with Exton-Smith was a huge success. Beds patients, many of them elderly. were made available as a result of hospital discharges. Elderly http://pmj.bmj.com/ She created the first geriatric unit in the UK. She services expanded and UCH attracted some of the brightest systematically examined every new patient. Having separated and keenest junior doctors. the sick from the healthy, the old from the young, she Both Amulree and Exton-Smith were proponents of instituted