The 20th 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 20th 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 1960s1,2.
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 Geraitrics1,2.
In her early papers, Marjory Warren put forth the
following arguments:-
- There was a need for the specialty of Geriatrics.
- 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.
- The physical layout of inpatient wards should be suited to their requirements with adequate space for rehabilitation and socialization.
- Ambulation and reintegration into a daily routine should be undertaken as soon as possible in the course of a hospitalization.
- A motivated and skilled multidisciplinary team including Nurses, Occupational therapists, Physicians, Physiotherapists, and Social workers was required for their care.
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
- J R Coll Physicians Edinb 2012; 42:368–74
- Journal of Gerontology: MEDICAL SCIENCES 2004, Vol. 59A, No. 11, 1132–1152
- The Gerontologist Vol. 54, No. 1, 21–29
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