Clinical Lectures of the Diseases of Old Age was published, which described an extensive range of subjects including the overt signs of old age, rheumatism, gout, arthritis, fever and its feeble response in older people, respiratory infections, cerebral haemorrhage, and cerebral softening. However, his contribution to treatment and management was limited. The early twentieth‐century English writers such as Sir Henry Weber, Dr Robert Saundby, G. Stanley Hall, and Sir Humphry Rolleston continued to describe old age, but again medical management received little attention. Maurice Ernest’s writing in 1938 pointed out that until the nineteenth century, only superficial knowledge existed of how the body worked.
The birth of modern geriatric medicine
A great deal of modern geriatric medicine can be attributed to the United States. Although American writers in the nineteenth century, such as Dr Benjamin Rush, had published on the subject of old age, the real impetus for advance came later when a young medical student, Ignatz Nascher (1863–1944), an immigrant to America from Vienna, was taken to an almshouse to see some interesting cases. An old woman hobbled up to the medical teacher with a complaint. The class was told that she was suffering from old age and that nothing could be done for her. This remark impressed him so strongly that after qualification, he took up the study of the diseases of old age. His lifetime work on the subject resulted in his becoming known as the ‘father of geriatric medicine’. His publication of Geriatrics in 1916 was followed by others, including Dr Malford Thewlis, who published the first edition of his book, Geriatrics, in 1919; Dr Edmund Cowdry, whose Problems of Aging appeared in 1939; and Dr Alfred Worcester, who published a series of lectures in 1940 called The Care of the Aged, the Dying, and the Dead. Dr Nathaniel Shock, in 1951, published the first edition of his classification of geriatrics and gerontology but pointed to the scarcity of material. In 1942, the American Geriatrics Society was formed with a membership of physicians, and in 1945 the Gerontological Society of America was created with a multidisciplinary membership. Each of the societies produced its own journal in 1946. Unfortunately, this momentum for change was not sustained, partly because physicians saw little attraction in the subject. Interest was not reignited until the 1960s, when Medicare and Medicaid were introduced.
Thus, it was that leadership and instruction in modern geriatric medicine in the post‐war era passed to the United Kingdom, where the achievements of a handful of pioneers were becoming known.
British developments
Health care in the UK goes back to that provided by the monasteries until they were dissolved in 1536. After the dissolution, many of the aged and infirm, who could not be managed at home with the help of family members, were left uncared for. The Poor Law Relief Act of 1601 attempted to remedy these problems. Parishes levied a rate on all occupiers of property to provide work for the unemployed and accommodation for the lame, old, and blind. Workhouses were built for these purposes but were made as unpleasant as possible to discourage people from entering them. Infirmaries were established to look after sick inmates of the workhouses. Outdoor relief was available for the poor, but this was curtailed in 1832.
Hospitals did not become central to health care until the nineteenth and twentieth centuries, by which time two different types of hospitals were evolving: the voluntary hospitals and the workhouse/municipal infirmaries.1 Voluntary hospitals, some of which dated back to the tenth century, were financed from endowments, subscriptions, fees, and fundraising. They had a high reputation, with good nursing and medical staff, and acted as a base for clinical teaching of medical students. They were reluctant to admit the chronic sick, fearing that their beds could become blocked because these patients were slower in improving and there could be social problems preventing their discharge. An important consequence was that medical students rarely saw them and, therefore, were not taught about the diseases of old age or how to manage the mixture of medical and social problems they would meet after qualification.
Workhouse infirmaries were funded by local rates. They gradually became long‐stay institutions for the chronic sick. Examples of unsatisfactory conditions and poor care in workhouses and infirmaries surfaced in the 1860s and resulted in visits by the Lancet commissioners and the inspectors of the Poor Law Board. The 1869 report of the Lancet Sanitary Commission was damning, stating, ‘The fate of the “infirm” inmates of crowded workhouses is lamentable in the extreme; they lead a life which would be like that of a vegetable, were it not that it preserves the doubtful privilege of sensibility to pain and mental misery’.2
In 1929, the Local Government Act came into force, which aimed to correct the existing bipartite system of health care of ‘one part for the pauper and the other part for the non‐pauper’. However, Charles Webster concluded that health services between the two world wars were ramshackle and uncoordinated, with hostility between sections of the service, increasingly chaotic funding, and a hospital service that was unevenly distributed and limited in rural areas.3
Further reform came in 1948 with the creation of the National Health Service (NHS), which rearranged British health care into a tripartite system. First, there was the hospital service, which was formed by the nationalization of 1143 voluntary and 1545 municipal hospitals. It became the dominant partner in the Service. Second, there were the general practitioner and the ophthalmic, pharmaceutical, and dental services. The third arm, which was managed by the local authorities, included health centres, health visitors, and ambulance services. Their immensely valuable home help and meals‐on‐wheels services did not really ‘take off’ until some years later. Importantly, health care for all became free of charge.
Voluntary and charitable organizations made important contributions to the care of the older person and research into old age. In 1943, the Nuffield Foundation was created, one of whose objectives was the care of the aged and the poor. This support led to the formation of the National Corporation for the Care of Old People in 1947. The Foundation also stimulated major research into the causes of old age (gerontology). These moves to assist older people became increasingly important as the proportion of older people in the population steadily increased. In 1841, the over‐65‐year‐old people made up 4.5% of the population, which rose to 4.7% by 1901, 7.8% by 1921, 9.6% by 1931, and 10.5% in 1947.
An overview of early geriatric medicine in the United Kingdom
Modern geriatric medicine in the UK dates from 1926, when Dr Marjorie Warren was appointed to the West Middlesex Hospital, where her interests were initially surgical. However, in 1935 the Hospital took over control of the adjacent old Poor Law institution, and Warren was put in charge of 874 patients. The situation she found was described in the first of her many articles on the modern treatment of the chronic sick.4 At about the same time, three other British doctors were also keen to improve the medical care of the elderly: Dr Eric Brooke, Mr Lionel Cosin, and Dr Trevor Howell. Like her, they, too, applied classification, diagnosis, and treatment to their elderly patients, which had previously been missing. After the war, a further wave of enthusiasts, such as Lord Amulree, Drs John Agate, Charles Andrews, Ferguson Anderson (later Professor), Bill Davison, Hugo Droller, Norman Exton‐Smith (later Professor), Tom Wilson, and Lyn Woodford‐Williams, began to make their mark with many publications.
These newly appointed post‐war consultants in geriatric medicine had to embark on a steep learning curve. In the early days, they had the responsibility for very large numbers of inpatients, sometimes many hundreds, who were often kept in bed for no discernible medical reason, which could ultimately lead to a totally bedridden state. Generally there was a massive waiting list for admission, often precipitated by the death or illness of the carer or the person’s inability to prepare meals for him/herself. These new consultants learnt that illness and the presentation of disease in the older person differed from those in younger people, that more time was required to recover, that prescribing drug therapy required great care, that extensive teamwork was needed for successful rehabilitation, and that local social service support was usually essential to provide
