Geriatrics - A Short History- III A (The Big Bangs)...

 

The 20^th century saw developments that catapulted the field of Geriatrics to new heights. This post deals with some of these developments…

The Big Bangs- Nascher & Warren…

Scientists believe that our universe started off after two big bangs. The field of Geriatrics owes its rapid growth to the contributions from two great Physicians in the 20^th Century. It was in 1909 Ignatz Leo Nascher, a New York Physician, published two papers on ageing and disease in the New York Medical Journal. The first one 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 his treatise stating that the length of a person’s life ‘hinged on the mode of living’ in which diet was of paramount importance. It was in his second paper, that he proposed the term ‘Geriatrics’ for this specialty: Geriatrics, from geras, old age, and iatrikos, relating to the Physician. Nascher believed that diseases in old age were completely distinct from those of maturity and he developed his ideas over the next five years in over 30 articles and a book, entitled ‘Geriatrics: The Diseases of Old Age and Their Treatment’. Believe it or not, he struggled to get that book published. It is unclear how Nascher was drawn to the specialty he named; some hint that it was based on his experiences of seeing how well older patients were treated during a visit to Vienna; or perhaps it was the result of Nascher’s trip, during his student years, to an almshouse where his instructor said a woman was suffering from old age for which nothing could be done. In 1916 he was appointed Physician to the New York Department of Public Welfare. He went on to become Chief Physician at the city’s Department of Hospitals. After retiring, he took charge of the New York City Farm Colony, a poorhouse where inmates grew fruits and veggies for themselves and residents of other city institutions. He planned ‘to change the antiquated methods of dealing with aged public dependents (that is, almshouse inmates) and rehabilitate them as far as possible physically as well as mentally’. Nascher was a contemporary of William Osler, the Father of Modern Medicine. Osler was ageist in his outlook (thank God there was no social media back then!!). In his (Osler’s) final address called ‘The Fixed Period’, he declared that men over 40 were relatively useless as the golden period of 25-40 had already elapsed, & that men over 60 were absolutely useless!! Nascher was hell bent on changing these views, which were held widely at those times². Despite his efforts, the practice of Geriatric Medicine did not progress in the US until the development of services for older patients in the 1960s^1,2.

Geriatric Medicine in Britain was greatly shaped by the efforts of Marjory Warren in 1935, Deputy Medical Superintendent at the West Middlesex County Hospital, who took over the care of several hundred mostly elderly and bed-bound patients in a former local workhouse. These patients were usually ignored by the Physicians responsible for their care, as they were felt to be incurable and uninteresting. The abominable conditions in the drab wards inspired Marjory Warren to action, though most doctors tried to avoid these wards. She redecorated the wards in stimulating colours with improved lighting, instituted rehabilitation as a team function and assessed all patients’ state of disability, identifying those who had potential for recovery, even if it was only to a limited degree. She promoted the establishment of Geriatric Units in order to protect the care of the elderly from medical neglect and called for the recognition of Geriatric Medicine as a specialty. Warren ardently believed that ‘until the subject [Geriatrics] is recognised as a special branch of medicine in this country it will not receive the sympathy and attention it deserves’. That recognition took place in 1948 with the appointment of the first Consultant Geriatrician in Cornwall. Thus began the development of modern Geriatric Medicine as a specialty in the UK, born out of a humanitarian concern for chronically sick older people. Warren went on to publish 27 articles on Geraitrics^1,2.

In her early papers, Marjory Warren put forth the following arguments:-

1.    There was a need for the specialty of Geriatrics.
2.    There was a need for a specific approach to the inpatient care of older adults as they have requirements different from those of younger people.
3.  The physical layout of inpatient wards should be suited to their requirements with adequate space for rehabilitation and socialization.
4. Ambulation and reintegration into a daily routine should be undertaken as soon as possible in the course of a hospitalization.
5.   A motivated and skilled multidisciplinary team including Nurses, Occupational therapists, Physicians, Physiotherapists, and Social workers was required for their care.

Warren had the outlook of a Rehabilitation Physician while dealing with older patients. Her main goals for health care of the elderly highlighted her interest in the prevention & management of disability, which were:-

1.     To prevent disease wherever possible.

2.     To minimise medical disability.

3.     To obtain & maintain maximum independence.

4.     To teach the patient to adapt intelligently to his/her residual disability³.

 

The Initial Expansion..

Soon things started picking up speed in the UK. Lionel Cosin, an Orthopaedic Surgeon who worked in Orsett in Essex, became successful at rehabilitating older persons after surgery for hip fracture. His motto was ‘‘bed is bad’’. In 1950s the first daycare hospital was set up in Oxford. Richard Asher wrote a poem, in 1942, encapsulating the problems associated with immobility, let’s take a look at it:-

Look at the patient lying long in bed

What a pathetic picture he makes

The blood clotting in his veins

The lime draining from his bones

The scybola stacking up in his colon

The flesh rotting from his seat

The urine leaking from his distended bladder

and the spirit evaporating from his soul.

Teach us to live that

we may dread unnecessary time in bed.

Get people up & we may save

patients from an early grave.

 

The concept of domiciliary (home) visits for rehabilitation of elderly persons was started by Eric Brooke at St. Hellier Hospital in Charston. Trevor Howell, from Royal Hospital Chelsea, published his research on the physiology of aging in 1944 in a book titled ‘Old Age’. Joseph Sheldon (1893–1972), while working at the Royal Hospital in Wolverhampton, conducted a survey of 583 old people & published it in his book ‘The Social Medicine of Aging’ in 1948. He went on to introduce home Physiotherapy and promoted environmental modification to prevent falls. In 1946 Lord Amulree and Dr. Sturdee addressed the Houses of Parliament on the care of the aged and chronic sick as a matter of great importance. The inclusion of the care of the aged as part of the National Health System was a direct consequence of this address. The first meeting of the ‘‘Medical Society for the Care of the Elderly’’ in the UK was called by Trevor Howell. The others in attendance included Eric Brooke, Alfred Mitchell, Lawrence Sturdee, Thomas Wilson, George Adams, Lionel Cosin, and Marjory Warren. The elected president, Lord Amulree, remained in that position for the first 25 years. In 1959, this society was renamed the British Geriatric Society. The first chair for Geriatrics globally was the Cargill Chair at Glasgow University awarded to Dr. Ferguson Anderson in 1965. Brocklehurst and Pathy separately codified the basic principles of geriatrics in their textbooks published in 1971 & 1985 respectively. Bernard Isaacs (1924–1995) led the development of Stroke Units & also created the term the ‘‘Giants of Geriatrics’’ to designate the major geriatric syndromes, viz., instability, immobility, intellectual impairment, and incontinence. Alex Comfort, renowned as a novelist and for writing ‘The Joy of Sex’ (1970), was the great propagandist for aging research in Europe in the middle of the 20th century. He attempted to determine biomeasures of physiological aging. In 1965, he became the founding editor of ‘Experimental Gerontology’².

So, the term ‘Geriatrics’ was coined by an American, but most of its basic principles came from the UK. The validation of these principles was by the researchers from the US, as we’ll see in our next post…

To be continued…

References

1. J R Coll Physicians Edinb 2012; 42:368–74
2. Journal of Gerontology: MEDICAL SCIENCES 2004, Vol. 59A, No. 11, 1132–1152
3. The Gerontologist Vol. 54, No. 1, 21–29

Geriatrics- A Short History - II (Do The Evolution!!)...

Nassim Nicholas Taleb in his groundbreaking work ‘The Black Swan’ stated that Medicine was the sister of Philosophy & that it became scientific only during the 20^th century. Before you agree or disagree with that, do read this post. The evolution of Geriatrics happened in fits & starts (as is the case with many specialities). Now let us look at the developments that happened in the rest of the 18^th century & the 19^th century (reading the previous blog post will definitely help)…

 

The Rest of the Eighteenth Century..

The misconception that old age was a disease held sway for most of the eighteenth century. Jakob Hutter in his doctoral thesis -‘That Senescence Itself is an Illness’, published in Germany in 1732, supported the prevailing idea of the times. He was heavily influenced by his eminent teachers, Friedrich Hoffman and Hermann Boerhaave. Hutter theorised that with ageing there’s a progressive hardening of all the fibres of the body starting from youth. This resulted in obstruction of blood supply which in turn led to stagnation & fatal putrefaction. So old age caused death by direct means, according to him. However, he strongly believed that this process could be modified by adopting a ‘correct lifestyle’, based on the principles propounded earlier by Galen & Francis Bacon. By emphasising that old age was a medical condition, Hutter paved the way for Geriatrics.

Pathological studies in the late 1700s, particularly by Giovanni Morgagni, failed to reveal the widespread changes posited by Hutter. Conversely, they showed local pathology in the majority of the older people on post-mortem examination. By the late eighteenth century, the concept that death in old age was due to one illness or the cumulative effect of many illnesses & not a general marasmus was established. ‘De Sedibus et Causis Morborum’ by Morgagni published in 1761 described that many diseases in old age, especially the chronic ones, can remain symptomless for years. Two centuries later this formed the basis of much clinical research on the unreported medical needs of the elderly.

American Physician Benjamin Rush, emphasised that old age was rarely the sole cause of death in his book ‘Account of the State of the Body and Mind in Old Age, with Observations on its Diseases and Remedies’ published in 1793¹.

 

The French Hospices, Pathological Analysis & Geriatrics (Nineteenth Century)..

France was the world leader in this area at the time. The basis for much of the research were the institutions known as ‘hospices’. They were set up by royal edict in the mid-seventeenth century to serve a range of functions, including prisons, asylums for the insane and residential homes for the elderly. They were transformed into primarily medical institutions after the French Revolution of 1789. They were not reserved exclusively for older patients, but admitted those of all ages with chronic disability, including children.

Research in age related diseases was buoyed up by the advances made in Medicine in France between the mid eighteenth & mid nineteenth century. Much of it was based on pathological studies, relating the findings to clinical presentation wherever possible, what in modern Medical jargon is called Clinicopathological Correlation. One of the earlier, more perceptive studies was published in 1835, on Pneumonia by Hourmann and Dechambre. They noted how the disease could be present in older people, but exhibit few physical symptoms. Charles Durand-Fardel’s practical treatise, ‘Traité Clinique et Pratique des Maladies des Vieillards’, was published in 1854. It covered the whole field of disease in old age, while attempting to link pathology with accurate diagnosis, & was way ahead of it’s time.

Although Jean Martin Charcot enjoyed a higher profile in the field of medicine in old age, his ‘Leçons Cliniques sur les Maladies des Vieillards’, published in 1866, contained only two lectures specifically on old age and three on clinical thermometry in older people, while the remaining were on Rheumatism and Gout. He noted that specific diseases existed in older people, such as Osteomalacia and Brain atrophy, that the ‘gravest disorders manifest themselves by slightly marked symptoms’ and that conditions occurring at any time of life ‘present special characteristics’ in later life.

By the middle of the century, medical men working in the hospices called for the recognition of old age as a distinct period of life which required a specific approach and a special branch of medicine, ‘Médecine des Vieillards’, with its own training and therapy. These calls took place at a time when the practice of specialisation within medicine was firmly established in France and, by the end of the nineteenth century, had been introduced into the curriculum in the Paris Medical School. In the mid-1850s however, only 5–12% of physicians declared a specialty designation; the most common were surgical, namely General Surgery, Dentistry, Obstetrics, Orthopaedics and Ophthalmology, but Psychiatry was also popular. Despite the existence of specialty hospitals for treating older people, Geriatric Medicine was not considered to be a recognised discipline.

Weisz, a Medical Historian, has suggested three possible reasons for this:

• The lack of specific therapeutic or diagnostic procedures
• The inevitability and incurability of diseases of old age
• The fact that the elderly generated little public interest

In addition, research failed to progress, mainly because it had been pathologically based. Few therapeutic possibilities existed to manage disease in old age and Physicians at that time did not interact with older patients to any great extent, as they only had contact with the small proportion who were admitted to the hospices. As medical interest in older people declined, Geriatric Medicine did not become a specialty in France until after 1950¹.

 

Meanwhile, in England…

George Edward Day (1815–1872), a Physician, wrote a common sense book from the Physician’s perspective on aging in 1848-‘A Practical Treatise on the Domestic Management and Most Important Diseases of Advanced Life’. He recognised and provided a clinical description of Alzheimer’s disease. Day also worked out that the largest proportion of older people die in the winter and thus cautioned them to be careful during these months. About dietary supplementation, he recognised that milk with added sugar & eggs were beneficial in old age. Day posited that women showed signs of ageing from about forty years of age, whereas men did not start to look old until they were between forty-eight or fifty. He complained that other physicians had little interest in caring for the ills of the aged^2,3.  

‘A Practical Treatise on the Diseases and Infirmities of Advanced Life’, was published in 1863 by Daniel Maclachlan, who was an attending physician to the Royal Hospital Chelsea. He included dryness & wasting among the physiological changes of ageing, but refuted the belief that death resulted purely from age alone, pointing out that disease usually supervened to ‘sever the cord’(of life). He drew attention to the difficulty of diagnosis in older people where several diseases often coexisted. While Maclachlan suggested caution should be taken when prescribing drugs for older patients, those who were physically active benefited and tolerated ‘active treatment’. However, dose modification was necessary in frailer patients as drug action became less certain as old age advanced. Digitalis in particular required to be administered with great care, but if done so, was ‘a truly valuable medicine’, according to him.

 

1882..

Two seminal publications came out in this year that greatly influenced the development of geriatrics. August Weissman, a German evolutionary biologist, published his theory on programmed death. He proposed that death happened because ‘worn out tissue’ due to ageing could not be renewed indefinitely by cell division. The resulting decline in functional activity could lead to direct or so-called ‘normal’ death or indirect death due to reduced resistance to external influences. The theory was criticised mainly because few animals in natural populations died of old age and so ageing was not a significant contribution to mortality. With little experimental evidence to support it, Weismann’s theory did not find general acceptance.

Charcot’s writings were translated and published in English in 1882 as ‘Clinical Lectures on the Diseases of Old Age’ and had a considerable impact in Britain. The reason for this was no doubt the lack of papers on disease in old age in the English literature & not exactly the impact of theories put forward in it¹. Charcot was world renowned for his analytical approach in diagnosing neurological conditions & is considered ‘the founder of modern neurology’. He has at least 15 medical eponyms associated with his name.

 

End of a Century, Oh, It’s Nothing Special..

Yes, the subheading is based on the hit number by Blur (I loved Mancunian Rock)..

Towards the end of the 19th century, the concept of hormonal reversal of aging processes began to develop. In 1886, Victor Horsley felt that older persons resembled myxedematous monkeys and that thyroid deficiency could result in ‘‘mere senility’’. Horsley was a neurosurgeon who did the first laminectomy for spinal cancer, and the transcranial approach to the pituitary gland. He also played a major role in the eradication of rabies from England.

Brown-Sequard, at the age of 70 years, found that he was getting tired at night and introduced the first testicular extract injections for rejuvenation. This led to Victor De Lespinasse at the University of Chicago doing human testicular transplants decades later. The shortage of humans wishing to donate a testis to be transplanted led to Serge Voronoff introducing ‘‘monkey-gland’’ transplants to rejuvenate the aging rich. In Kansas, Brinkley tried goat testicular transplants. These are the historical precursors to the modern use of testosterone replacement therapy for the andropause².

“In the last analysis, we see only what we are ready to see, what we have been taught to see. We eliminate & ignore everything that is not a part of our prejudices.”- Jean-Martin Charcot.

 

To be continued…

References

1. J R Coll Physicians Edinb 2012; 42:368–74
2. Journal of Gerontology: MEDICAL SCIENCES In the Public Domain 2004, Vol. 59A, No. 11, 1132–1152
3. https://www.cadr.cymru/en/getfile.php?type=site_documents&id=Sara%20Zadrozny%20CADR%20presentation.pdf

Geriatrics- A Short History- I (from Mythology to ‘Medicina Gerocomica’)..

 

Old age, the dusk of life, where people tread on cautiously down the meandering road of life, thanks to diseases, financial issues, & other matters that could all cramp out a healthy life. Nearly 75% of the elderly in our country suffer from one or the other chronic disease, 40% have a disability & 20% go through issues related to mental health, revealed the India Report on Longitudinal Aging Study of India in 2021¹. Human beings have been looking for ways to break away from vice-like grip of old age since eons.

Geriatrics is a field of modern medicine dealing with the health & care of old age. As the aging population is rising rapidly, this is a field of great impact & importance.

This blog post traces the origins of this field of medicine from Mythology upto a seminal work in the 1720s..

Mythology..

Mythology is teeming with tales of demigods trying to avoid old age & death. Let’s look at a couple of them..

Gilgamesh, the Babylonian demigod, prayed to gods to help him to live forever. The gods asked him to avoid sleeping for seven days, a task at which he couldn’t succeed. The gods, benevolent as they’re meant to be, gave him another chance. They asked him to get a plant from underwater & eat the same. He was so amused by the joy derived from swimming around, that he forgot to eat the plant which he got after much trouble, which was eventually eaten by a snake. As Winston Churchill observed, death & taxes are inevitable.

In Greek Mythology, Tithonus was the morning lover of the goddess of dawn, Aurora. He was apparently so good at what he did for her that she went to her father, Zeus, and asked if Tithonus could have eternal life. Zeus, being a doting father, immediately granted Tithonus immortality. The problem is that she had not asked for eternal youth. So, over time the aging process took its toll and when Tithonus reached 100, he had mild cognitive impairment and went around Aurora’s castle babbling incessantly. She no longer loved him and one day she turned him into a grasshopper²! Blessings & curses in Greek Mythology need at least two blog posts (maybe more!!)…Lol..

Walk Like an Old Egyptian..

Ancient Egyptian civilizations had been way ahead of the others. They used orthotic devices or splints, had ways of preserving dead bodies & knew a thing or two about the ravages of old age as well. Old people develop kyphosis due to osteoporosis & have balance issues. The hieroglyphic for ‘‘old’’ in ancient Egypt (2800 B.C.) was a bent person leaning on a staff—perhaps the first depiction of the ravages of osteoporosis. In 1550 B.C., the ‘Ebers Papyrus’ suggested that ‘‘debility through senile decay is due to purulency on the heart.’’² More on heart, heat & the soul below…

Hippocrates & Aristotle on Aging..

‘The Hippocratic Corpus’ posited that the ageing process resulted from a gradual and progressive loss of heat from the body, which became colder and drier, and so resembled the properties of earth. It promoted the view of old age as a time of increased susceptibility and less resistance to disease, mirroring the current concept of aging as increasing frailty (frailty is now a recognised syndrome).

The ideas recorded in the Corpus were the ones to fuel the theory of old age expounded by Aristotle (384–322 BC), who postulated the union of the soul and body, with the heart as the seat of the soul. Heat was thought to be generated in the left side of the heart and to spread from there throughout the body. A finite amount of energy was present at birth and this internal heat or vital spirit was gradually consumed over time, so that little remained in old age. Though innate heat could be fortified by various means, it could never be completely restored to its original level. Aristotle recognised that old age was associated with increased vulnerability to disease processes, when even minor illnesses could have a fatal outcome in a short span of time³.

Galen, Ibn Sina & Aging Like Fine Wine..

Galen (131–201 AD) propounded that as ageing is a natural process, & as it was unavoidable, it was definitely not a pathological entity. He had a conviction that it was an interim state between health & illness. Although he seconded that the aging body lost heat, Galen believed the ageing process could be modified by adopting a moderate lifestyle with attention to exercise and diet, which would promote warmth and moisture. He referred to this as the Gerocomic art.

Ibn Sina (980–1037) believed, as Galen did, that the result of ageing was a cold, dry body. In his first book he devoted a section to a dietary regimen for older people, which would render the body warm and moist. He recommended that food should be taken in small amounts and that fruit, ginger and old, red wine were particularly beneficial³.

Early Search for the Elixir of Life.. 

The notion of the existence of a place of eternal youth became embedded in Western thought throughout the Middle Ages, & with this began the search for the ‘elixir of life’. It is well depicted in Roger Bacon’s ‘Cure of Old Age and Preservation of Youth’, published in the thirteenth century. The work was the most important at that time to deal with the process of ageing, ways to ‘remedy’ it and to describe the clinical features of ageing such as wrinkling of the skin and shortness of breath. Bacon believed that the life span could be extended to 150 years or more. How exactly? By living a life of moderation. By moderation he meant - eating a controlled diet, proper rest, exercise, moderation in lifestyle, good hygiene, and inhaling the breath of a young virgin!!^2,3

 

Early Printed Works on Ageing & Health… 

The period from late Renaissance to the 16^th century saw many works relating to health and disease in old age appearing in printed form. Two works which were greatly influenced by Galen’s theory need to be mentioned:-

Gabriele Zerbi’s ‘Gerontocomia’, in 1489, which revived the concept of Gerocomy. It emphasised the importance of hygiene in the elderly, accepted that the diseases described could not be cured & differentiated between natural death as a result of loss of heat & death associated with an illness.

In ‘Opuscula Medica (1627’), François Ranchin, of the University of Montpellier, also distinguished ‘natural senescence’ attributed to a lack of heat from ‘accidental senescence’, which was due to disease. Like Galen, he considered old age to be a condition between health and illness, one which was prone to disease. In this work he rallied the cause of promoting Gerocomia, a field focusing on the promotion of health of the elderly³.

Francis Bacon’s Contribution…

Francis Bacon gave us the scientific method. He also put forth a new concept of aging. In his work ‘History, Natural and Experimental, of Life and Death or of the Prolongation of Life’, published in 1623, he propounded ageing based on ‘spirit, or body pneumatical’ through which the body functioned and which declined in old age as a result of unequal repair to different parts, eventually leading to the decay of the whole body, culminating in natural death. A life of moderation, he believed could prolong life. Among his list of instructions were: do not get excited (well, there was no internet back then!!); avoid the sun’s rays; take baths; eat sweetened but not acid food; take physical exercise, but do not overdo it.³ Suffice to say, his ideas in this field didn’t have much impact…

Medicina Gerocomica…

In ‘Medicina Gerocomica: Or the Galenic Art of Preserving Old Men’s Healths’, published in 1724 by Sir John Floyer of Lichfield (1649–1734), an elaborate description of the current state of medical knowledge of the older people was laid out. What makes it even better is the fact that it was in English, or what it used to be back then!! Although based on the humoral theory, it went out to even offer therapeutic options for various ailments…

"Every man is a fool or becomes his own Physician at 40 or 50 years of age"- from Medicina Gerocomica.

Despite his asthma, on which he wrote a groundbreaking treatise, Floyer lived to the ripe old age of 85^3,4…

To be continued…

 

 

References

1.  https://www.livemint.com/news/india/75-elderly-suffer-from-chronic-diseases-quarter-live-with-co-morbid-conditions-11609952001889.html#:~:text=Around%2075%25%20of%20the%20elderly,union%20health%20ministry%20on%20Wednesday.

2.     2. Journal of Gerontology: MEDICAL SCIENCES In the Public Domain 2004, Vol. 59A, No. 11, 1132–1152

3.     3. J R Coll Physicians Edinb 2012; 42:368–74

4.     4.Thorax 1984;39:248-254