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, criticized 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.

Modern geriatric medicine commenced in 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.

Health care in the United Kingdom 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–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 fund raising. 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 nonpauper’. 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 with a hospital service which 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 comprised 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.

Modern geriatric medicine in the United Kingdom 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 alternative accommodation or domiciliary support services. They had to provide a service although they lacked adequate resources and staffs, had poor ward accommodation, inadequate investigative/treatment facilities, and were not always based on the main hospital site. They had to fight antagonism and resistance from their fellow consultants and some hospital management committees. One chairman of such a committee refused a consultant geriatrician the use of empty beds in general medical wards: ‘Over my dead body’, he said. When he died, the geriatrician got the beds. Another consultant had to fight for proper washing facilities in the wards and for curtains to be placed around the beds of elderly patients. Yet others had to struggle to get heating installed in the wards and repairs made to the leaking ward roofs.

Important studies of the elderly living at home or in residential homes appeared shortly after the war. Dr Joseph Sheldon, a general physician, published The Social Medicine of Old Age in 1948, which was the result of his research into the health of the elderly living in the community in Wolverhampton. In 1955, Professor William Hobson and Dr John Pemberton published The Health of the Elderly at Home, which was a study of older people living at home in Sheffield. In 1962, Professor Peter Townsend published The Last Refuge, a seminal study of old people living in residential homes.

The British Ministry of Health, which was created in 1919, and its medical officers supported the newly emerging style of medical care of the sick elderly patient with official circulars, memoranda, meetings and documents. These highlighted its firm belief in modern management of elderly patients and the drive to establish a geriatric unit in every health district. The Ministry organized surveys of hospitals in England and Wales, which were to be the basis of the forthcoming NHS. The reports, published in 1945, were generally very critical of services and accommodation for the chronic sick. ‘The worst and oldest buildings were set aside for the chronic sick’.5 ‘The buildings are old, dark, devoid of modern sanitary conveniences, death traps in the case of “fire”, and unfit for the nursing of the chronic sick’.6 ‘The first essential is that every patient should be thoroughly examined and treated with a view to restoring a maximum degree of activity’.7 Later, Lord Amulree and Dr Edwin Sturdee, both medical officers of the Ministry, presented a paper on the care of the chronic sick to the Parliamentary Medical Committee in 1946.8 In it they stated, ‘Not only is the problem of the treatment of the chronic sick not being met, but also most people do not realize there is a problem’. In 1957, Dr Christopher Boucher, a Principal Medical Officer at the Ministry, published the result of an important survey of services available to the chronic sick and elderly.9 However, the Ministry realized that it could not force change, but could only use persuasion to improve proper medical services for older people.10 Perhaps this was why that, even in 1978, 42 health districts in England still lacked geriatric beds in general hospitals.

The British Medical Association played its part in planning the medical care of older people with a series of very specific reports. A coordinated geriatric service was recommended to the newly created Regional Health Authorities, supported by a wide range of domiciliary services, which would be needed by the infirm elderly to enable them to stay at home for as long as possible.11–13

However, commentators looked back to the old Poor Law and the new NHS with mixed feelings.14–17 They pointed out that whereas the old Poor Law system had given a coordinated personal service to its clients, the tripartite structure of the NHS service led to lack of cooperation and coordination between the arms of the service. Chronic and mental services received a smaller share of capital and revenue, and clear guidelines for the treatment of old people were lacking. The political will to produce a nationwide effective geriatric service was lacking. On the other hand, the new service did provide the less well off with forms of care to which previously they had only limited entrée, and the elderly now had access to consultant services.

In 1935, Dr Marjorie Winsome Warren, CBE, MB (1897–1960), was placed in charge of 874 patients from the adjacent Public Assistance Institution. These included 16 maternity patients and about 144 ‘mental observation’ patients, who were subsequently transferred to their appropriate departments. She assessed and examined the remainder. She described the situation as follows: ‘Having lost all hope of recovery, with the knowledge that independence has gone, and with a feeling of helplessness and frustration, the patient rapidly loses morale and self-respect and develops an apathetic … temperament, which leads to laziness and faulty habits, with or without incontinence. Lack of interest in the surroundings, confinement to bed … soon produces pressure sores … inevitable loss of muscle tone make for a completely bedridden state … [leading to] disuse atrophy of the lower limbs, with postural deformities, stiffness of joints, and contractures … in this miserable state, dull, apathetic, helpless, and hopeless, life lingers on, sometimes for years’ (Warren, 1946).18

She criticized the medical profession: ‘It is surprising that [it] has been so long awakening to its responsibilities towards the chronic sick and aged, and that the country at large should have been content to do so little for this section of the community’.18

She recognized the importance of the environment in helping patients recover. She improved ward lighting, arranged repainting of the wards from the previous drab colour to cream, replaced old-fashioned beds, provided modern bedside lockers, bed tables and headphones, and also bright red top blankets, light-coloured bedspreads and patterned screen curtains. Wards were equipped with handrails attached to the walls, and suitable armchairs provided. Floors were no longer highly polished and steps were avoided. Special chairs and walking sticks and frames were provided for arthritic and heart patients. Some equipment that she designed herself is still used today. She was the first British geriatrician to publish admission, death and discharge data. By 1948, Warren reported that the general medical staff acknowledged that their ‘chronic’ elderly patients actually did better in the geriatric unit than in their own wards.

Mr Lionel Zelick Cosin, FRCS (1910–1993), came from a surgical background to the care of the elderly chronic sick.19 At the outbreak of war, he was drafted to Orsett Lodge Hospital in Essex, which had been upgraded to an Emergency Medical Service Hospital in 1939. He became responsible for 300 chronic sick patients in addition to his surgical commitments. He found that they were fed and kept clean but no other treatment was given. When ordinary admissions restarted in 1944, he admitted elderly women with fractured femurs, successfully operated on them, gave them rehabilitation and discharged them home.

In 1950, he was invited to establish a geriatric unit at Cowley Road Hospital in Oxford, where he became its first clinical director and established the first day hospital in the United Kingdom. He classified, diagnosed, and treated his elderly patients. He reorganized inpatient accommodation, creating an acute geriatric ward for investigation, treatment and physiotherapy, and also a long-stay annex ward for the permanently bedfast, long-stay wards for the frail ambulant, and ‘residential home’ type of accommodation for the more robust patients. These methods resulted in the average length of stay falling from 286 to 51 days. The proportion remaining in hospital longer than 180 days declined from 20 to 7%. Admissions increased from 200 to 1200 per year through the same number of beds. The average age of the patients increased from 68 to 75 years. Approximately 10% of his patients became permanently bedfast.20

Dr Eric Barrington Brooke