History of Geriatric Medicine: from Hippocrates to Marjory Warren

History of geriatric medicine: from Hippocrates to Marjory Warren

A Ritch Postgraduate Student, History of Medicine Unit, University of Birmingham and Retired Consultant in Geriatric Medicine, Birmingham, UK

ABSTRACT It is widely assumed that geriatric medicine was an invention of the Correspondence to A Ritch twentieth century. However, from the time of Hippocrates, there has been interest 3 Wyvern Road, Sutton Coldfield B74 2PS, UK in the prolongation of the lifespan, the maintenance of health in old age and age- related disease patterns. The debate about whether old age was a natural tel. +44 (0)121 355 2819 phenomenon or a disease state was not resolved until the nineteenth century. Calls e-mail [email protected] for medicine relating to old age to be recognised as a discrete entity at the time when medical specialisation was developing were disregarded until the second half of the twentieth century. This review discusses the history of the theories of ageing and of disease and the practice of medicine for older people from the classical period up to Marjory Warren’s initiative in London in 1935 and the development of geriatrics as a medical specialty.

Keywords Geriatrics, old age, gerocomy, medical specialisation

Declaration of Interests No conflicts of interest declared.

Introduction Antiquity (500 BC–300 AD)

Modern practitioners of geriatric medicine tend to The debate surrounding ageing and disease began with assume that the specialty is a recent development, but Hippocrates and focused on the crucial questions of an interest in the medicine of old age has existed whether old age is a natural or a pathological condition; throughout history. There is disagreement about its if it is an illness in its own right; on whether it is establishment however between some American unalterable or susceptible to being controlled or geriatricians, who assert that it was created with the attenuated; and on whether diseases occurring in old invention of the word ‘geriatrics’ by Ignatz Nascher in age are peculiar to older people or common to those of 1909, and British geriatricians who claim its foundation all adult ages. These debates highlighted the difficulties in London in 1935, with the work of Marjory Warren.1–3 inherent in defining what constituted health or ill-health Several historians of old age take a longer view, but with in old age; the relationship between the ageing process no less diversity of opinion. Thane for example stated and disease in old age still remains difficult to delineate.9 that the study of old age has a very long history linked The Hippocratic Corpus proposed that the ageing process to concern over health and disease in later life.4 resulted from the gradual and progressive loss of heat Ackerknecht agreed that geriatrics was as ‘old as from the body, which became colder and drier, and so medicine’ and ‘no invention of the twentieth century’.5 resembled the properties of earth. ‘In old persons the Stearns, however, placed the birth of geriatrics in the heat is feeble, and therefore they require little fuel, as it nineteenth century, although he acknowledged that it were, to the flame, for it would be extinguished by much existed only at the research level with little contact [food]’.8 This exemplified the view of old age as a time of with real people.6 Schäfer agrees that there was no increased susceptibility and less resistance to disease, specialisation in training, research or clinical practice in mirroring the current concept of ageing as increasing geriatric medicine until the nineteenth century.7 frailty.9 An opposing view, mentioned in two places in the However, some of the principles of current teaching in Corpus, is that the body becomes moist in old age geriatric medicine appear in the Hippocratic Corpus; one because of the tendency to external secretion of of its aphorisms states that ‘fevers are not so acute in moisture, as when coughing, but that theory did not gain old people’.8 Indeed, mankind has been interested in the general acceptance and was later refuted by Galen. The possibilities of extending the individual lifespan from altered picture of disease at an advanced age is time immemorial, but it was in Classical Greece that the recognised by the authors of the Corpus and a number history theories of disease and ageing began to be developed. of illnesses associated with old age are described.

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Bacon believed believed Bacon 13 Cure of Old Age and Age of Old Cure Galen developed the Galen developed 14 and his fifth book on fifth book his and Historygeriatric of medicine 15 Ibn Sina believed, as Galen as Ibn Sina believed, 18 17 12 , published in the thirteenth century. , Youth He provided a detailed regimen for maintaining for detailed regimen a He provided De Tuenda Sanitate 7,16 did, that the result of ageing was a cold, dry body, dry body, cold, a was ageing of result the that did, element’ ‘earthy of the predominance the stressing ‘a the partswhich holds into together the body of first his In age’. ‘decrepit of in those form’ compacted a section to a dietary for regimen he devoted book and warm body the render which would people, older in taken be should food that recommended He moist. wine red old, and ginger fruit, that and amounts small particularly beneficial. were The work was the most important was the most at that time to deal The work to it and ‘remedy’ to ways ageing, of with the process wrinkling as such ageing, of the clinical features describe shortness skin and the of breath. of concept of gerocomy, namely the care of the aged, in his of the aged, the care namely gerocomy, concept of treatise The Galenical system of medicine was consolidated The Galenical system of medicine was also Ibn Sina (980–1037), within Islamic medicine by 1012) whose Canon of Medicine (c. Avicenna, as known and in its anatomy ‘Galenic as has been described Hippocratic in its theory’. youth eternal of place a of existence the of idea The the throughout thought Western in became embedded life’. ‘elixir of the for search with the along Ages, Middle Bacon’s It is illustrated in Roger Preservation of Middle Ages and aissance Ren (600–1800 AD) that the life course could be extended to 150 years or course could be extended to 150 years that the life moderation. of life living a by more the late from increased ageing and age in old Interest with into the sixteenth century, period Renaissance in old age to health and disease relating works numerous Ofthe those on ageing, in printed form. appearing Zerbi’s Gabriele was period this of earliest health, which remained influential for many centuries. centuries. many influential for which remained health, be given to not appear did older patients However, partas considered were time and this at mention special many are there Although whole. a as group the adult of the antiquity to of literature medical in the references with old associated and symptoms disabilities physical the medical care on was no specialised focus there age, interests that doctors’ Parkin suggests of older people. of the patient into to taking the age limited were of level Whatever diagnosis. when making a account of older took in their care ancient doctors interest doctors Greek the observations from derived patients, well of older people for the medical treatment governed 1,000 years. over dietetics focused almost exclusively on the care of older of the care on exclusively almost dietetics focused people. considers this to be the only form of geriatric medicine of geriatric form be the only this to considers world. ancient in the practised Aristotle’s Aristotle’s 7,11 7 2012; 42:368–74 2012; 10 13 Despite his teaching, including his theories of ageing Despite his teaching, 12 J R Coll Physicians Edinb Coll Physicians J R © 2012 RCPE which remained authoritative until the Renaissance, the until the Renaissance, authoritative which remained in non- prevalent that old age was an illness remained view medical literature. view of a natural death, as one where so much warmth so much as one where a natural death, of view environmental minor a that body the from lost been had period lengthy a after only but death, cause could stress supporting as the theorybe interpreted could age, old of held belief widely This became a of old age as an illness. many for and it prevailed the ancient world throughout Phormio, play, Terence’s in exemplified is It centuries. says actors the of one when BC, 161 around performed itself’.age old ‘the illness is that Although heat loss was inevitable, Galen believed the Galen believed inevitable, was loss heat Although by delayed could be influenced and process ageing exercise to with attention lifestyle moderate a adopting warmth and moisture. promote which would and diet, Parkin art’. ‘the gerocomic to this as He referred This belief was completely refuted by Galen (131–201 AD). AD). Galen (131–201 by refuted This belief was completely Aristotelian theories He consolidated the Hippocratic and of ageing into one based on the humoral explanation of drya about brought age Old heat. of loss to due imbalance many from resulting body the of constitution cold and a decline in organ function and a with of life years Galen considered strength. in vitality and muscle reduction awas ageing as and contrarywas disease that nature, to it could not be considered process, natural and unavoidable it was completely he did not believe However pathological. health between itself, to peculiar state a rather but healthy, he was certainly ahead of his in this regard, and illness; time. Aristotle’s idea of ageing as a natural process associated as a natural process idea of ageing Aristotle’s looked not that it was morbidity suggests with increased the However, right. its own entity in upon as a disease it has and regard this explicit in not is Corpus Hippocratic all considered Hippocrates that some by assumed been a disease.old people as ill and old age as were the basis of the of the basis in the Corpus were recorded The ideas (384–322 BC), Aristotle theory by expounded age of old with the body, and the soul union of the who postulated Heat was thought to be heart soul. the seat of the as the heartof in the left side generated spread to and of A finite amount the body. throughout there from at birthenergyheat or this internal and present was so that time, over consumed vital spirit was gradually could heat innate Though age. advanced in little remained be completely it could never means, be fortified various by oldthat recognised Aristotle level. original its to restored diseaseto vulnerability increased an it with brought age a fatal minor illnesses could have when even processes, in review major a In shorta in outcome time. of space ‘visionary’and as views Aristotle’s described Grant 1963, of explaining in terms noted that little further progress of the middle the made until had been process the ageing century. twentieth A Ritch

in 1489, which revived Galen’s concept of gerocomy.20,21 Itself is an Illness, published in Germany in 1732, Jakob It concentrated on hygiene in older people, accepted that Hutter reflected the prevailing idea of the times, the diseases described could not be cured, and especially that of his more well-known teachers, Friedrich differentiated between natural death, as a result of the Hoffman and Hermann Boerhaave.7,25 Hutter’s hypothesis loss of innate heat, and death following illness.7,11 In his had been proposed by a student of Boerhaave seventeen Opuscula Medica (1627), François Ranchin, of the University years previously, but Hutter provided a more detailed of Montpellier, also distinguished ‘natural senescence’, and systematic analysis. His theory of the ageing process resulting from a lack of heat from ‘accidental senescence’, postulated that there was a ‘progressive hardening of all which was due to disease.7,22 Like Galen, he considered old fibres of the body,’ which started from youth and age to be a condition between health and illness, one resulted in obstruction to the blood supply. As a result which was prone to disease. He made a plea that the of the weakened blood flow, stagnation led to ‘fatal medical needs of old people be taken more seriously: putrefaction’; thus old age caused death by direct means. Despite this, Hutter believed that the process could be Not only physicians, but everybody else attending modified and life prolonged by observing a ‘correct’ old people… realise how noble and important, how lifestyle, reflecting views that had been expressed serious and difficult, how useful and even previously by Galen and Francis Bacon. In a recent indispensable is that part of practical Medicine called analysis, Schäfer stated that the importance of this Gerocomica, which deals with the conservation of theory lay in its emphasis on old age as a medical old people and the healing of their diseases… we condition, which paved the way for the later development get the impression not only that this noblest part of of geriatrics.7 Medicine was not cultivated but even, yes, it has been flatly suppressed and buried.11 Pathological studies later in the 1700s, particularly those of Giovanni Morgagni, failed to confirm the widespread One of the more remarkable works of the seventeenth changes postulated by Hutter, and conversely, century was Francis Bacon’s History, Natural and demonstrated the presence of local pathology in the Experimental, of Life and Death or of the Prolongation of Life, majority of older people at post-mortem. By the late published in 1623.23 He rejected Galen’s humoral theory, eighteenth century, it was generally accepted that death countering it with a new concept of ageing based on in most old people was due either to one illness or ‘spirit, or body pneumatical’ through which the body several with a cumulative effect and not a natural functioned and which declined in old age as a result of marasmus.26 Morgagni, in De Sedibus et Causis Morborum unequal repair to different parts, so that eventually the published in 1761, was sufficiently astute to point out in whole body decayed, leading to natural death. However, his study of anatomy and diseases that many diseases in he believed that life expectancy could be prolonged by old age, but especially chronic ones, can remain pursuing a life of moderation. Among his list of symptomless for many years.11,27 Two hundred years later instructions were: do not get excited; avoid the sun’s this concept formed the basis of much clinical research rays; take baths; eat sweetened but not acid food; take on the unreported medical needs of older people. physical exercise, but do not overdo it.10,13 Despite his Benjamin Rush, an American physician, emphasised that influence in other areas and his reputation as a scientific old age was rarely the sole cause of death in his Account thinker, his views on old age had little impact.10,11 In of the State of the Body and Mind in Old Age, with contrast, Medecina Gerocomica: Or the Galenic Art of Observations on its Diseases and Remedies, published in the Preserving Old Men’s Healths, published in 1724 by Sir USA in 1793.28 According to Grant, his statement that John Floyer of Lichfield (1649–1734), was considered ‘Few persons appear to die of old age. Some of the influential by twentieth-century historians.24 Freeman diseases which have been mentioned generally cut the suggested that it marked ‘the beginning of modern last thread of life’ struck ‘one of the last blows at the idea geriatrics’ and Grant regarded it as the first monograph that old age is itself a disease’.10 However, it was another to be printed initially in English on geriatrics.10,21 Although hundred years before the concept of ‘old age infirmity’ still based on the humoral theory, Floyer’s text elaborated ended and Rosin wrote ‘old-age infirmity is no illness’.26 on the current state of medical knowledge of older people, suggesting many therapeutic remedies. Nineteenth Century

Eighteenth Century Research in age-related disease benefited from the advances in medicine made in France between the mid- The view that old age was itself an illness remained eighteenth and mid-nineteenth centuries, but its prevalent in the literature well into the eighteenth innovative quality had deteriorated by the 1880s. Much history century, and for some physicians, as late as the twentieth of it was based on pathological studies, relating the century. In his doctoral thesis entitled That Senescence findings to clinical presentation where possible. One of

370 J R Coll Physicians Edinb 2012; 42:368–74 © 2012 RCPE history 37 The 371 33 Historygeriatric of medicine Despite the existence of Despite the existence 35 6 The theory mainly was criticised 36 Clinical Lectures on the Diseases of Old Lectures Clinical In addition, research failed to progress, progress, to failed research addition, In 34 He included drynessincluded He among wasting as well as 38 and had a considerable impact in Britain. a considerable had and specialty hospitals for treating older people, geriatric geriatric people, older treating for hospitals specialty a recognised to be considered medicine was not possible reasons three suggested has Weisz discipline. or diagnostic lack of specific therapeutic the this: for incurability and of diseases the inevitability procedures; little generated elderly the fact that the and of old age; public interest. reason for this was no doubt the lack of papers on this was no doubt the lack of papers for reason the One of literature. English in the age in old disease on the Diseases and Infirmities Treatise was A Practical few Daniel Maclachlan, by in 1863 published of Advanced , Life Hospital the Royal to physician attending who was an Chelsea. the physiological changes of ageing, but did not accept not did but ageing, of changes physiological the pointing out age alone, from purely resulted that death He cord’. the ‘sever supervened to usually disease that in older diagnosis of difficulty the to attention drew While coexisted. often diseases several people where when caution should be taken Maclachlan suggested who were those patients, older for drugs prescribing ‘active benefited and tolerated active physically was modification of the dose However, treatment’. necessaryless became action drug as in frailer patients Charcot’s writings were translated and published in and translated were writings Charcot’s English in 1882 as Age However, interest in the ageing process and life and life in the ageing process interest However, the publication in 1882 by expectancy was encouraged Weismann August by theorydeath the of programmed of He biologist. German evolutionary a noted (1834–1914), a limited designed to have that animals were proposed over- older members prevented removing lifespan; ‘worn- because happened Death species. the of crowding be renewed out tissue’ due to ageing could not decline in resulting The cell division. by indefinitely so-called or direct to lead activity could functional resistance death due to reduced ‘normal’ death or indirect to external influences. mainly because it had been pathologically based. Few Few based. pathologically been it had because mainly in old disease possibilities existed to manage therapeutic at that time did not interact with physicians age and had only they as extent, great patients to any older admitted who were with the small proportion contact people in older medical interest As the hospices. to a specialty geriatric medicine did not become declined, in France until after 1950. because few animals in natural populations died of oldof died populations natural in animals few because tocontribution significant a not was ageing so and age to supportWith little experimental evidence it, mortality. theory did not find general acceptance. Weismann’s 1884, the number of specialists had increased by 150% 150% by increased had specialists of number the 1884, to expanded specialties medical of number the and and and neurology venereology include dermatology, respiratory gastroenterology, as such sub-specialties medicine and cardiology. By 5,34 33 It covered the whole It covered 6,30,31 He recognised that specific He recognised 32 Charles Durand-Fardel’s practical Charles Durand-Fardel’s 2012; 42:368–74 2012; 29 Traité Clinique et Pratique des Maladies des Maladies des Clinique Pratique et Traité J R Coll Physicians Edinb Coll Physicians J R © 2012 RCPE treatise, treatise, both to as been referred has published in 1854, , Vieillards a masterpiece.pioneering and diseases existed in older people, such as osteomalacia such as people, existed in older diseases manifest disorders ‘gravest that the brain atrophy, and that and symptoms’ marked slightly by themselves special ‘present life of time any at occurring conditions use the pioneered Charcot life. in later characteristics’ that as he was aware thermometer of the rectal reflect not did measurement peripheral temperature In his first people. in older accurately temperature core the idea of a specialty: promoted he of the series, lecture ‘The importanceold of diseases the of study special a of this day’. at contested be cannot age France was the world leader in this area at the time. The at the time. leader in this area the world France was institutions the were of the research much for basis edict in royal up by set were They ‘hospices’. as known century serve to of range a the mid-seventeenth the insane and for asylums including prisons, functions, were They older people. homes for residential institutions after the medical into primarily transformed reserved not were They 1789. of Revolution French all of those admitted but patients, older for exclusively The children. including disability, chronic with ages became the women, which admitted only Salpêtrière, that time, at geriatric research for single centre greatest Research partly with Charcot. of its association because for which catered Bicêtre, the at place in Paris took also the term nineteenth century, the early From men. the been in use in France to denote had ‘gérocomie’ of By the middle of old age. specialisation in the diseases called hospices in the working medical men century, the a distinct period of life as of old age the recognition for a special branch and a specific approach which required with its own vieillards’, ‘médecine des medicine, of time place at a These calls took therapy. training and within when the practice of specialisation medicine was the end of the by established in France and, firmly the into introduced been had nineteenth century, 1850s mid the In School. Medical Paris in the curriculum specialtya declared physicians of 5–12% only however, namely surgical, the most common were designation; orthopaedic surgery obstetrics, dentistry, general surgery, but psychiatry was also popular. and ophthalmology, the earlier, more perceptive studies was on pneumonia on studies was perceptive more the earlier, disease how noted Dechambre and Hourmann in 1835; but exhibit few in older people, present could be symptoms. physical field of disease in old age, while attempting to link to while attempting age, in old disease field of Martin Although Jean pathology with accurate diagnosis. in the field of medicine a higher profile enjoyed Charcot les Maladies his Leçons Cliniques sur des in old age, lectures two only contained in 1866, published , Vieillards on clinical thermometry three on old age and specifically on were 16 remaining while the people, older in gout. rheumatism and A Ritch

certain as old age advanced. Digitalis in particular required to be administered with great care, but if done so, was ‘a truly valuable medicine’. Maclachlan concluded by stating that the medicine of old age was an important branch of medical knowledge.38 The most notable publication of the nineteenth century was A Practical Treatise on the Domestic Management and Most Important Diseases of Advanced Life by George Day, professor of anatomy at St Andrews. In his book he complained that the diseases of old age had been neglected by physicians in the previous fifty years.39 The next significant English language publications on medicine and old age did not appear until the twentieth century in the USA, where the main advances in medical understanding of old age now originated.11

Twentieth Century

In 1909 Ignatz Leo Nascher (Figure 1), a New York physician, published two papers on ageing and disease in the New York Medical Journal. In the first, he revived the idea that natural death could result from old age per se, due to decay of all the body’s organs, with an accompanied ‘diminishing nervous force to the point of cessation of nervous activity’. He concluded that the length of a person’s life ‘hinged on the mode of living’ in which diet figure 1 Ignatz Leo Nascher. Image courtesy of the was the most important factor.40 In the second paper, he Wellcome Library, London. proposed the term ‘geriatrics’ for this specialty: subjects he had shown sympathy for those who were Geriatrics, from geras, old age, and iatrikos, relating to underprivileged. In 1916 he was appointed physician to the physician, is a term I would suggest as an addition the New York Department of Public Welfare, later to our vocabulary to cover the same field, in old age, becoming Chief Physician at the city’s Department of that is covered by the term ‘paediatrics’ in childhood. Hospitals. After his retirement, he took charge of the Senility is a distinct period of life having general New York City Farm Colony, a poorhouse where inmates features normal to it… it should be considered apart grew fruits and vegetables for themselves and residents and distinct from maturity, and as a special branch of of other city institutions. He aimed ‘to change the medicine. To such specialty I would apply the term antiquated methods of dealing with aged public geriatrics.41 dependents (that is, almshouse inmates) and rehabilitate them as far as possible physically and mentally’.1,43 Despite The term was chosen to reflect the growing specialty of Nascher’s initiatives, the practice of geriatric medicine paediatrics in the hope that the two would develop did not progress in the USA until the development of together. Nascher believed that diseases in old age were services for older patients in the 1960s.44 completely distinct from those of maturity and he developed his ideas over the next five years in over 30 The practice of geriatric medicine in Britain began in articles and one book, entitled Geriatrics: The Diseases of 1935 when Marjory Warren (Figure 2), deputy medical Old Age and Their Treatment (for which he had some superintendent at the West Middlesex County Hospital, difficulty in finding a publisher).41 He continued to struggle took over the care of several hundred mostly elderly for general acceptance of geriatrics as a specialty.42 and bed-bound patients in a former local workhouse. It had been usual for these patients to be ignored by the It is uncertain how Nascher became interested in the physicians responsible for their care, as they were felt to specialty he named; some suggest that it was based on be incurable and uninteresting. The appalling conditions his experiences of seeing how well older patients were in the drab wards deterred many doctors from going treated during a visit to Vienna; or perhaps it was the back after their first visit but inspired Marjory Warren to result of his trip as a student to an almshouse where his action. She had the wards redecorated in stimulating history instructor said a woman was suffering from old age for colours with improved lighting, instituted rehabilitation which nothing could be done. In his writing on other as a team function and assessed all patients’ state of

372 J R Coll Physicians Edinb 2012; 42:368–74 © 2012 RCPE history This 373 37 Historygeriatric of medicine , in Aristotle’s writing in Classical Aristotle’s in , Corpus Hippocratic sion Conclu a progressive, as been defined recently Ageing has of loss in a resulting function impairment of generalised risk of age- in a growing and to stress response adaptive to giving rise loss of adaptability the disease, related death. of probability the frailty and increased concept can be seen in the theory of ageing proposed in theoryin the seen be can concept proposed ageing of the physician American of the in the work and Greece The the late eighteenth century. in Benjamin Rush, to response in temperature rise in body reduced to the known age was increasing with infection were fevers that stated when they Hippocratic authors that know now although we not so acute in old people, That system. in the immune of a decline this is the result in older can be different of disease the presentation pathologythat and patients was asympomatic be can and Morgagni including authors, several by noted in their and Dechambre as Hourman as well Charcot, In the study on pneumonia in nineteenth-century Paris. the century mid-nineteenth recognised Maclachlan importancethe in older people and co-morbidity of The majority of the therapy. to drug response altered humoral the on based were ageing of theories early Aristotle, from their proponents, and theorydisease, of were and Francis Bacon, to Roger Avicenna Galen and inevitable, although process, ageing the that convinced of a moderate remedies Their suggested could be delayed. and adequate with to healthier food attention lifestyle today. still widespread are exercise She 45 Copyright Copyright 49 Thus began the development the development Thus began That recognition took place in took That recognition 48 46,47 2012; 42:368–74 2012; Dr Marjory Warren CBE, MRCS, LRCP (1897– LRCP MRCS, CBE, Warren Dr Marjory

(2012) Royal Society of Medicine Press, UK Medicine Press, Society of (2012) Royal figure 1 figure 1960): the mother of British geriatric medicine.of mother the 1960): J R Coll Physicians Edinb Coll Physicians J R © 2012 RCPE 1948 with the first appointment of a consultant consultant a of appointment first the with 1948 geriatrician in Cornwall. disability, identifying those who had potential for for potential had who those identifying disability, to a limited degree. if it was only even recovery, promoted the establishment of geriatric units in order of geriatric units in order the establishment promoted medical neglect of older people from the care to protect a medicine as geriatric of recognition the for called and ‘until the subject that believed Warren specialty. as a special branch of medicine [geriatrics] is recognised and the sympathy in this country it will not receive attention it deserves’. of modern geriatric medicine as a specialty in the UK, geriatric medicine as a specialty in the UK, of modern sick chronically concern for humanitarian a out of born people.older A Ritch

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