of the hospital‐based geriatric team. These revealed that only one in three of the patients on the list required admission on a short‐term basis for investigation and treatment, for terminal care, or to provide holiday relief for caring relatives. Where appropriate, he arranged for a coordinated home‐based service with district nurses, home helps, domiciliary occupational therapists, a laundry service, and the Red Cross library. The local Women’s Voluntary Service set up a hot ‘meals‐on‐wheels’ domiciliary service. He viewed the general practitioner as the key member of the whole support scheme.
Dr Trevor Henry Howell, FRCP Ed. (1909–1988), first encountered elderly patients when he was a general practitioner before the war. What puzzled him was what represented ‘normal’ for age and what represented disease. After his war service, he established a geriatric research unit at Battersea Hospital in London before becoming medical superintendent at Queen’s Hospital, Croydon. He kept meticulous records of his patients, which formed the basis of over 300 papers and four books that he wrote. He kept a handwritten record of every book he read, every patient he saw, and every post mortem held on his patients. Like his colleagues, he firmly supported teaching medical students. He and Sturdee were the driving force behind the creation in 1948 of the Medical Society for the Care of the Elderly, which later became the British Geriatrics Society. Howell was its secretary for many years.
The second wave of geriatricians
These were led by Lord Amulree, KBE, MD, FRCP (1900–1983), who, prior to his appointment as geriatric physician to University College Hospital and St Pancras Hospital in London in 1949, had worked at the Ministry of Health on aspects of care of the older person. This had brought him in touch with all the early pioneers. His appointment in geriatric medicine was, for a long time, the only one at a London teaching hospital. He and his staff classified, diagnosed, and treated elderly inpatients. Assessment visits were made to old people who were on the waiting list for admission. This ensured either appropriate placement of patients in hospital or that the necessary home support was arranged to enable the person to continue to stay at home. The result was a considerable shortening of the average inpatient length of stay, increased patient/bed turnover, and a reduced waiting list.
Amulree was unique amongst geriatricians in having a ‘wide‐angled’ view of the care of elderly people. This resulted from his experience as a clinician, as a medical officer of the Ministry of Health, and as a Liberal peer in the House of Lords, where he spoke on matters relevant to the care of the elderly. He wrote extensively, and his work included one of the first comprehensive articles on care of the elderly.21 He is possibly best remembered for his maxim ‘Adding Life to Years’, in addition to his stature, wisdom, and willingness to help colleagues. He was President of the British Geriatrics Society for 25 years. When all his achievements are taken into account, there is a case for calling him ‘the father of British geriatric medicine’.
Professor Norman Exton‐Smith, CBE, FRCP (1920–1990), was based at the Withington Hospital in London before moving to University College Hospital and St Pancras Hospital when Lord Amulree retired. Like others, he made detailed assessments of his clinical management of sick elderly people. His style of medical management of inpatient care increased patient turnover and reduced their length of stay. He adapted progressive patient care to fit the needs of geriatric medicine. He led and/or encouraged research work, imbuing enthusiasm in his research team, registrars, and colleagues. He established a research unit at St Pancras Hospital and supported work in subjects such as thermoregulation, control of the autonomic nervous system, falls, osteoporosis, osteomalacia, fractures of the femur, nursing of the elderly patient, pressure sores, nutrition of the older person, meals‐on‐wheels, terminal care, predicting mortality, and cognitive assessment. He wrote many papers and a substantive textbook on geriatric medicine and co‐authored several books.
Exton‐Smith considered the components of an effective geriatric department that included having a sufficient number of beds, both in total and in the District General Hospital, practising progressive patient care, having adequate medical and nurse staffing, consulting with other consultant colleagues, making home visits, having a day hospital, and having good coordination with primary care and local authority services to produce a successful planned discharge. He thought that approximately half to two‐thirds of all geriatric beds should be in the main hospital where the main diagnostic and treatment facilities were based, and the remainder should be in smaller units near the patients’ home.
Professor Sir William Ferguson Anderson, OBE, FRCP (Glasgow, Edinburgh and London) (1914–2001), was a strong advocate on behalf of older people. In 1965, he was appointed David Cargill Professor of Geriatric Medicine at the University of Glasgow. He firmly believed in the speciality as an academic discipline and the need to teach medical students about old age. He took geriatric medicine into the community, notably in Rutherglen, where he established health centres for the elderly. He wrote extensively, and his textbook Practical Management of the Elderly went into five editions. He lectured in many countries, spreading the message of the achievements of British geriatric medicine, was a visiting professor in many countries, a major advisor to several medical charities for the elderly, and a superb charismatic ambassador for the specialty.
Third wave of geriatricians
During the latter two decades of the last century, other outstanding geriatricians played key roles in revitalizing the speciality of geriatrics in the UK to lay a solid foundation for further developing the speciality and demonstrating its uniqueness and separation from general medicine. These included Professor Bernard Isaacs, CBE (1924–1995), Professor John Pathy OBE (1923–2009), Professor John Brocklehurst, CBE (1924–2013), and Professor Sir John Grimley Evans (1936–2018). All of these latter physicians were leading lights in enriching the speciality of geriatric medicine.
Geriatrics in the United States
The development of modern geriatrics is strongly based on the Veterans Administration and private foundations, such as the Josiah Macy Jr Foundation, the John A. Hartford Foundation, and the Donald W. Reynold Foundation. The Veterans Administration developed the Geriatric Research, Education, and Clinical Center in 1976. These institutions have been the leaders in developing geriatric faculty, science, and education at major universities in the US. They also played a leadership role in developing palliative care and the teaching nursing home concept. In 1940, the Unit of Aging was started by the National Institutes of Health. In 1958, under the leadership of Nathan Shock and Reuben Andres, this became the Baltimore Longitudinal Study of Aging. The National Institute on Aging was established in 1974. Robert Butler was its first director.
There are three major geriatrics and gerontological societies in the US. Each sponsors a yearly meeting and has its own journal. The Club for Research in Aging was founded in 1939, and it evolved into the Gerontological Society of America in 1945. The Journal of Gerontology was first published the following year. The Joseph T. Freeman Award was first given in 1980 to Robert Butler, and its awardees read like a modern Who’s Who in American Geriatrics (Table 1).
Table 1 The Joseph T. Freeman Award of the Medical Sciences Section of The Gerontological Society of America.
| Year | Recipient |
|---|---|
| 1980 | Robert N. Butler |
| 1981 | Isadore Rossman |
| 1982 | Manuel Rodstein |
| 1983 | R. Knight Steel |
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