LITMIR.BIZ

      Introduction: Historical perspectives

       Michael J. Denham1 and John E. Morley2

      ¹Wellcome Trust Centre for the History of Medicine at UCL, London, UK

      ²Saint Louis University Medical Center and St Louis Veterans’ Affairs Medical Center, St Louis, Missouri, USA

      This original chapter from the 5th edition has been lightly edited by Alan Sinclair (Editor).

Introduction

      The broad subject of old age has attracted the attention of writers and philosophers for many centuries. It contains the interrelated topics of the theories of ageing, how to increase longevity, and the medical management of sick elderly people. Initially, the first two themes attracted the most attention. It was not until the twentieth century that literature relating to medical care came to the fore.

The earlier writers on old age

      Early writers such as Hippocrates, Cicero, Galen, Roger Bacon, and Francis Bacon discussed old age in general terms pointing to features such as skin changes, reduction in physical strength, and deteriorating memory, sight, and hearing. None were sure of the cause(s) of old age. Theories ranged from incorrect diet through loss of heat to loss of moisture. Although the basis of growing old was unclear, several philosophers thought that a healthy old age could be promoted by keeping active, eating sensibly, and exercising regularly.

      Later, British writers of the eighteenth and nineteenth centuries, such as Sir John Floyer, Sir John Hill, Sir Anthony Carlisle, Professor George Day, and Sir John Sinclair, wrote about old age and how life might be prolonged, but devoted limited attention to medical management of disease in older people. They generally considered it impossible to turn an elderly man into a young person but agreed that much could be done to make later life healthy. Lifestyle was important. They recommended wise eating of easily digestible foods taken at regular intervals, exercising regularly, ensuring good sleep, keeping clean, wearing warm clothing, and avoiding constipation. In 1863, Dr Daniel Maclachlan, medical superintendent at the Royal Hospital Chelsea, criticised the lack of English literature relating to old age and pointed out that precise diagnosis could be difficult in older people because several diseases could exist simultaneously. In 1882, the English translation of Jean Martin Charcot’s 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

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