Old age, its care and treatment in health and disease (1914)
Although disease remained the main cause of manpower depletion, World War I was the first war of some length in which this statistic was turned around, thanks to for instance hygienic measures, vaccination programmes or blood transfusion. However, for this to happen the army medical corps had to grow rapidly after the war began.
Without medical care, battles would have been shorter and fought with fewer men. Medical opposition to the war was scarce. In , physicians found their way to frontline or military base hospitals en masse. Wounds never seen before, in numbers never seen before, promised there would be unlimited research possibilities, on an individual and societal scale.
War, they said, was not an enemy of medicine; it was its teacher. Some even saw war as a colleague, for, despite the numerous individuals who would be killed or maimed, it would make the people, the nation, and the race physically and psychologically stronger. It is telling that, at least in Germany , the number of doctors in favor of abortion gradually fell as the war lasted. In all warring countries - and many non-warring countries - physicians voluntarily joined the Military Health Service MHS or one of the auxiliary corps in great numbers, making them one of the largest groups of academically-trained professionals participating in the war effort.
During the war the number of doctors and nurses kept increasing, and they took care of millions of sick and wounded in hospital beds, on stretchers, on blankets on the floor, or on the floor itself, either inside or outside field hospitals. No matter how vast healthcare provisions were, and no matter how hard physicians and nurses worked, medical care was no match for the number of wounded: Given the circumstances, not the failures, but the successes were surprising.
Particularly on the Western Front , medical officers had to combat wounds and illnesses of an enormous variety and spanning all degrees of severity. Their successes would have been impossible without a high degree of organization. Despite some national differences, the organization of the medical line was generally the same throughout all armies, with first aid at the front, advanced dressing stations close to the front, followed by field hospitals or casualty clearing stations CCS near the front.
Exceptions were determined by a combination of geography, climate and style of warfare - often determined by the former two. Examples are Gallipoli or the African jungle. The priority was triage and making a patient ready for the journey back. If times were quiet, triage practices followed medical standards, i.
Heavily wounded patients were put aside, given a dosage of morphine if available , and left to die. The slightly wounded cost less time and were considered of greater importance because they could be made fit for battle again. This, to a great extent, also determined the popular policy of treating the wounded as quickly as possible and as close to the front as possible. This methodology of care profited and resulted from static trench warfare, providing health workers a more or less fixed place to work, fairly close to front lines. Recovery rates rose especially for simple wounds. Nevertheless, ambulances and hospital trains, carrying the wounded from one spot in the line to another, became a very frequent sight in warring countries.
According to German writer Leonhard Frank — , the trains were the central metaphor of the war as they literally brought home its horrors. The field hospitals or casualty clearing stations - named so as not get hopes up too high - were the places where not only for the first time in the medial line women could be detected, but also where operations were performed closest to the front, although often in circumstances anything but tidy and hygienic.
Field hospitals and casualty clearing stations were messy, at times filthy, and frequently overloaded. As said, the wounded were often lying on the ground or outside, not far from stacks of amputated arms and legs in a corner. The further away from the line, the better circumstances got, but overpopulation remained a problem even in the base hospitals, in spite of accepting only the most severely injured.
In Britain alone base hospitals expanded from a 40,bed capacity at the end of to , at the end of the war. And in in the Berlin area alone, there were with a capacity twenty-fold greater than in the pre-war years. However, in spite of organization being more or less similar, medical care itself, as said, differed severely from time and place. When examining the medical service of World War I, it is first necessary to determine who is to be included. Stretcher-bearers, although the first responders to injuries, are frequently forgotten.
There were hardly ever enough of them, and their ranks suffered considerable losses. In theory, four stretcher-bearers were expected to bring a wounded man back to the first aid post within the hour, which could only be achieved if the violence had stopped and ground conditions were reasonable. In reality it often took up to eight men, depending on the mud. The stretcher-bearers frequently felt worn out after delivering a single wounded man to a first aid post. Seeing stretcher-bearers taking a break or asleep, while the wounded remained in the field troubled the other soldiers, such as Louis Barthas ,  a hostile attitude certainly not lessened by the order to preferably bring back the wounded they felt had the best change of eventually being fit enough for active service.
Although a task not prioritized by many physicians, nevertheless considerable effort was put into preventive care because sick soldiers posed a threat to healthy ones, and because, as Austrian soldier-novelist Andreas Latzko — wrote, soldiers had to be healthy enough to return to battle and face further injury and death. Nevertheless, in some armies, certain conditions were not treated as much as criminalized. Contracting them was considered an infraction. The care doctors and nurses delivered changed over the course of to as a result of experience gained, a rise in the number of physicians and nurses, more refined medical supplies, and improved techniques.
In August , for instance in the Belgian army and the British Expeditionary Force , improvization ruled the day. Material was qualitatively and quantitatively insufficient. Physicians and nurses short in numbers. Knowledge on specific war-injuries was lacking. Consequently, by the last year of the war, the survival chances of for instance those suffering abdominal wounds - if they were lucky enough to reach the hospital alive - had risen considerably, especially in the Allied armies.
This was mainly due to the introduction of blood transfusion, to a high degree resulting from American war participation. The medical services of the Central armies were far more skeptical about blood transfusion. This left little time for to develop improvements in procedures or practices. There was hardly any time for further education and, consequently, newly arrived doctors were no more or less skilled than their predecessors.
Standards of care actually dropped as the war continued. Furthermore, the ongoing search for soldiers led to a drop in physical and mental requirements for new recruits. Medical tribunals were turned into a variant of industrial conveyor belts, perfectly captured in a drawing by George Grosz in which doctors diagnose a skeleton fit for service. The result was that doctors and nurses got an even harder time than they already had.
The fact that their numbers also constantly rose indicates that, especially in the last year of the war, the doctors, nurses, and orderlies too were not always as qualified as they should have been. So, as the war lasted, more and more hardly qualified caregivers had to cope with more and more soldiers who in fact were physically and mentally unfit to serve.
Even if appropriate treatments and cures for known causes of illness and death were developed over time, new medical puzzles arose, such as gas gangrene, trench foot, and trench fever. These ailments often were caused by the living conditions: In , Spanish influenza compounded these existing issues, leaving medicine virtually impotent and killing soldiers and civilians by the masses.
Then there was the psychological condition now commonly referred to as shell shock , caused by stress that derives from constant violence, a feeling of uselessness, and, above all, fear. The fear was wide-ranging, both physical and psychological: Politics, economy, ideology, culture, religion, ideas about society versus individual, and ideas about the significance of life all determine medical research and practice, and this held true in the diverse medical services of World War I.
There was hardly ever a sufficient number of people available to help, and medical materials often were in short supply. It also depended on the nature of the wounds themselves. For instance, in general a soldier who suffered facial disfigurement received better treatment than psychologically affected soldiers. Medical care also differed depending on which members of society the nation prioritized to receive treatment.
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German doctors, also military ones, voiced their concerns that the civilian health situation was worrying and should be prevented from deteriorating, if only because this would seriously harm home front support. Military medicine - or better: Medical care also differed from place to place. It mattered if the doctors and nurses were stationed near the swamps of the Belgian Yser, the mud of Ypres , the clay of the Somme , the shores of Gallipoli , the sand and heat of the Middle East , the jungle of Africa. At Salonika, the base of the British Balkan campaign, hospitals were in a dreadful state, every once in a while complicated even more so by extreme cold.
Illnesses such as malaria, sand fever, typhoid, and dysentery raged among patients and doctors alike. In Egypt , British supplies fell short, and soldiers were exposed to the severe threats of dust, scorpions, and flies. Medical personnel often considered working in the Eastern Mediterranean a bigger challenge than working on the Western Front. It mattered if they had to treat patients near the trenches in the west, or the much less static fronts in the east. Of course it mattered if they were stationed on land or at sea.
And also healthcare varied depending on whether armies were homogenous or multiethnic and multilingual. If their conditions made transport impossible, patients were left behind with the hope that the enemy would be merciful and take over treatment. These problems also occurred in the west in the opening months of the war, and even more so in For example, it was only because they kept control of the railway system that the Allied medical line did not collapse during the German offensive of Different countries, and even different individuals, had varying definitions of what medical care entailed; this impacted matters such as bacteriology, vaccination, and patient rights.
In general, across national boundaries, patient rights were threatened by the war in the short term. Even ignoring the fact that soldiers had to obey physicians because they were officers, the pressures of total war , the wish to contribute to the war effort, and the sheer volume of soldiers requiring treatment were bound to cause a shift in doctor-patient relationships. Punitive action, however, was rare. To get their will done, in general the doctors relied more on moral persuasion.
Also with regard to prevention, insights differed. For instance, in the de-lousing process, the British set their faith in personal hygiene, while the Germans trusted disinfection. Differences in vaccination practices arose, in part, from the fact that Germany conscripted its soldiers, but the British did not until As a result, vaccination was always obligatory in Germany, but voluntary in Britain. However, British vaccination was really only voluntary in theory; most soldiers actually thought it was compulsory.
It took considerable strength to resist medical and military pressure to get vaccinated, especially since the medical benefits were undeniable: The rate of infection amongst those refusing vaccination in was 15 times higher than the average for the army as a whole. Religious beliefs had a great influence on the ways doctors treated venereal diseases, individually as well as on the state level; some cases led to criminalization. Nevertheless, this affliction constituted between 3 and 8. Did they serve in a conscription army or an army of volunteers, in which facilitating organizations such as the Red Cross were less strictly incorporated?
Were they part of a health service of a warring country or part of a neutral state ambulance e. Furthermore, care depended on whether the sick and wounded were treated at the front or in base hospitals. Young, inexperienced doctors were more likely to be stationed at or near the front, so the more severe cases went to base hospitals, where patients could be seen by university doctors.
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By virtue of education and status, these doctors tended to be more nationalistic and were often unaware of what their patients had gone through during the war. They distanced themselves from patients, in contrast to the more informal and closer doctor-patient relationships at or near the front. Military frontline doctors, in general, viewed treatment pragmatically; they were mainly concerned with crisis management, employing whatever methods would do the trick to heal or at least comfort their patients.
Base hospital doctors struggled with the same personnel shortages as on the front lines, but they still wanted to prove their insights right and demonstrate the worth of their specific specialty. The attitudes of non-medical officers towards medical affairs, as well as the attitudes of those on the home front, factored into how patients were treated. Most officers had a keen interest in medical matters because manpower and morale largely depended on the success of treatment. But there were officers - Central and Allied - who totally neglected these matters. To ensure necessary treatment was given, war loans were handed out, collections made, and money transferred.
Still, questions arose about treating men with abdominal wounds because they were unlikely to return to active duty. The support the medical effort received from the home front was reciprocated: The concern often depended on the distance between country and battleground, which sometimes led to catastrophic results. At the Somme in the line did not collapse, at least not on a Gallipoli scale, thanks to at least in part public interest in the Western Front. And last but not least, the care of course differed as much as the different wounds and illnesses did.
Military medical men used to say that they could tell the differences in warfare in the wounds they had to heal. But even within the same war the differences can be significant; World War I was no exception. Most wartime physicians - and contemporary historians of medicine - have focused on wounds, not illness.
Ultimately, though, the latter was the main cause of inactive man-days. The sick not only outnumbered the wounded, but also took longer to recover. Despite the statistics, soldiers tended to be less afraid of illness and more afraid of sustaining wounds, also because of possibly following complications such as gas gangrene, although the Spanish influenza in probably was an exception. World War I was characterized by a multitude of gruesome wounds and the complications resulting from them, the sight of which often flabbergasted doctors and nurses, certainly, but not exclusively, those coming from ordinary civilian surroundings.
Shells maimed tens of thousands of soldiers for life. Splinters and fragments decapitated and eviscerated soldiers in arbitrary patterns. If the wounded survived, they, along with their doctors and nurses, frequently wondered if they would have been better off dead. Invalids came to be a normal sight in all of the warring countries.
Germany alone had about 2. Approximately 67, lost one or more limbs.
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The staggering number of disabilities had serious financial consequences after the war, further increasing the need for and value of prosthetic surgery and occupational therapy. In spite of all the differences in medical care enumerated above, some similarities are to be recognized throughout all armies and fronts. Most physicians - professional military and enlisted or volunteer civilians - wholeheartedly supported the war effort, using their medical skills and apparatus to work toward national victory.
Practitioners of military medicine had to try, as much as possible, to save the state from handing out war pensions, for otherwise they could cause the state to go bankrupt. This was the main force behind creating specialty hospitals all over the warring countries. In other words, these common driving forces were more political and military-minded than of a Hippocratic, patient-directed nature. This is exactly why the differences between for instance frontline and base hospital physicians should not be exaggerated. Not just because clearing stations, field hospitals, and base hospitals all struggled with overpopulation and were, as German medical historian Wolfgang U.
Eckart said, medical factories dealing with the detritus of warfare in all its mental and physical forms. Also they had to boost morale by ensuring the soldiers as well as the home front that if sick or wounded the soldiers would receive the proper care they deserved. Furthermore, they had to detect shirkers and malingerers, serve as witnesses during court-martials and decide whether or not a soldier had suffered a war-related wound or illness, thereby deciding if eventually he would be entitled to a war pension. Wounds or illnesses that could not be seen and this extended beyond psychological afflictions, even including tuberculosis were regularly dismissed as nothing not only by non-medical, but by medical officers as well.
Soldiers knew that healthcare was only an extension of this interest in victory, leading them to view the medical system somewhat ambivalently. Ultimately, care providers had dual loyalty: There were people like the physician-philosopher Theodor Lessing — , who worked in a war hospital because it was the one place he could find the classless society he had longed for, but which could impossibly become reality after August Military doctors had to consider not only the interests of the individual soldier—patient, but also - and primarily - the interests of the state and the military.
Individual doctors balanced this dual loyalty against their own beliefs, as well as the illness or wound they had to treat. The wounded, for instance, could count on more understanding and pity from their doctors than could the diseased. This biased treatment continued after the war, for it was harder for soldiers with chronic illness to be recognized as war invalids and receive a pension. Disfigured soldiers would no longer play a part in the war and would probably never play an economically important role in society.
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This meant the urge to help them and make their life as pleasant as possible, was almost entirely a medical one. On balance, in their case therefore the emphasis seems to have been more on the interests of the patient than on the interests of the state. The fate of the disabled differed slightly: They too would never return to the front, but they could still be useful to the war effort or the general economy.
However, the psychologically diseased or wounded were another story entirely. Soldiers who for instance were unable to speak, walk, or see although organically speaking there seemed to be nothing wrong, were often looked upon with disdain or seen as cowards rather than as patients. Doctors and nurses pushed to get them to the front or weapons factory. In Germany getting them to work at a weapons factory was seen as a satisfactory result, for the mentally damaged soldier was compared to a worker on strike.
As the before mentioned example of Lessing proves, individual doctors responded to this choice between individual well-being and collective responsibility in different ways. Although theoretically physicians often agreed that loyalty should remain with the patient, they also agreed that wartime circumstances did not allow for this to be the case. Consequently, on the whole, most agreed that medicine had to play a role in maintaining manpower.
These war-conditions led to a wealth of encounters with bacteria and unhygienic conditions rare in peacetime. And indeed, the years saw medical advancements, plastic surgery and orthopedics being the probably best examples. However, these innovations did not mean that World War I, overall, was good for medicine, if only because every four-year period since the middle of the 19 th century, be it wartime or peacetime, has shown medical advancement.
In fact, the period most hailed for its medical innovations was the decades of peace after the Franco-Prussian War. However, there are questions to be asked regarding the war-years themselves. The conditions seen, the wounds sustained, the illnesses caught, the problems derived from them and the treatments developed; they were often specific for that particular time and place. For instance gas gangrene was a menace, but practically disappeared after the war, as it had been rare before August Other fields of medicine, considered to be of interest particularly to civilians, suffered.
According to some this should even be taken more broadly. The questions, then, include: Was the advancement completely owed to the war? Were wartime inventions of any use outside war circumstances? Were the inventions shared according to international medical ethics, saving the lives of compatriot and enemy soldiers alike?
This led to the foundation of Geron, the first anti-aging mainstream pharmaceutical company by Michael West Claims by a quasireligious sect, the Raelians and their biotech company Clonaid , that they cloned a human being, while sensational, have not been shown to be scientifically valid.
The Journals have published a number of articles pointing out the pitfalls of the anti-aging industry 24— Hippocrates felt that old age was cold and wet. This was perhaps driven by his recognition of the effects of cardiac cachexia and understanding that cardiac failure occurred commonly in old age. Cicero expounded on old age in De Senectute. He offered much common sense advice and was most probably first to recognize the syndrome of anorexia of elderly people Figure 3 This belief most probably came from the biblical story of King David sleeping between two virgins when he was old to restore his youth.
He complained that other physicians had little interest in caring for the ills of the aged Figure 4. This refrain still rings true during the first few years of the 21st century. This, I believe, is more related to the importance of Charcot than the quality of the text. Table 1 lists a number of texts on aging published through the middle of the 20th century. Toward the end of the 19th century, the concept of hormonal reversal of aging processes began to develop Horsley was a neurosurgeon who did the first laminectomy for spinal cancer, and the transcranial approach to the pituitary gland.
He also played a major role in the eradication of rabies from England. Brown-Sequard, at the age of 70 years, found that he was getting tired at night and introduced the first testicular extract injections for rejuvenation Figure 5. In Kansas, Brinkley tried goat testicular transplants These are the historical precursors to the modern use of testosterone replacement therapy for the andropause 33 , Geriatrics was derived from the geronte, a group of men over 60 years who ran the legislative council gerousia of Athens. Nascher was born in Vienna in October 11, He graduated as a pharmacist in and then obtained his medical degree from New York University in He wrote a number of articles on geriatrics 35 , 36 and a book, published in , Geriatrics: He retired in at the age of His interests in geriatrics and his development of treatments for older persons almost certainly came from visits to Austria where care of elderly people was blossoming at the time.
Nascher's interest in geriatrics is even more astonishing as he was a contemporary of William Osler, the famous Canadian physician who was chairman of medicine at Johns Hopkins in Baltimore. Men over 60 years were considered absolutely useless, and chloroform was not a bad idea for this age group. This address is said to have been responsible for a number of suicides. Whether or not Osler meant his address to be taken seriously is unknown. Marjory Warren — is given much credit for the development of modern geriatrics. In , she took over the aged beds at the West Middlesex Hospital Among her innovations was to enhance the environment, introduce active rehabilitation programs, and emphasize increased motivation on the part of the older person.
She wrote 27 articles on geriatrics Lionel Cosin was an orthopedic surgeon who worked in Orsett in Essex. He became successful at rehabilitating older persons after surgery for hip fracture. The first daycare hospital was introduced in Oxford in the s The problems associated with immobility were encapsulated in a poem by one of his contemporaries, Richard Asher Figure 7.
Eric Brooke at St. Hellier Hospital in Charston introduced the concept of domicillary home visits for rehabilitation of elderly persons. Trevor Howell, while working at the Royal Hospital Chelsea, published his research on the physiology of aging in in a book entitled Old Age Joseph Sheldon — , while working at the Royal Hospital in Wolverhampton, undertook a survey of old people, which he published in his book The Social Medicine of Aging in He introduced home physiotherapy and promoted environmental modification to prevent falls.
A seminal event in British geriatrics occurred in when Lord Amulree and Dr. Sturdee addressed the Houses of Parliament on the care of the aged and chronic sick. This led to the inclusion of the care of the aged as part of the National Health System. The travails of the social care of elderly people in the United Kingdom have been recently reviewed in a Future History article in the Journals Lord Amulree was elected president and remained in that position for the first 25 years. In , the society changed its name to the British Geriatric Society. The first chair for geriatrics in the world was the Cargill Chair at Glasgow University awarded to Dr.
Ferguson Anderson in It was Brocklehurst and Pathy who separately codified the basic principles of geriatrics in their textbooks see Table 2 for the major modern geriatric texts. Alex Comfort, more famous perhaps as a novelist and for writing The Joy of Sex , was the great propagandist for aging research in Europe in the middle of the 20th century His early research was on aging in Drosophila and thoroughbred horses. He then attempted to determine biomeasures of physiological aging 51 , In , he became the founding editor of Experimental Gerontology.
However, it was to take researchers in the United States to provide the scientific validation of the British methods and provide the next steps forward in the development of the sciences of geriatrics. Before reviewing the development of modern geriatrics in the United States, it is of use to review a number of key early events in the social condition of elderly people. These start with the military pension scheme in associated with the Civil War.
The Great Depression led to large numbers of elderly poor in the United States: This was slowly rectified by the passage of the Social Security Act in under President Roosevelt. At this time, the Senate Special Committee on Aging was established, but only obtained permanent status in In , Medicare and Medicaid were introduced, providing finances to drive high-quality medical care for older persons. He was active in aging research, particularly as it related to atherosclerosis In , he edited The Problems of Ageing: Biological and Medical Aspects , and produced two other books, viz.
He was a champion of the special medical needs of elderly persons and opposed the American Medical Association by advocating special care needed for geriatric patients. Kate Macy Ladd formed the foundation, she chose aging as one of the five areas to be focused on for future support. Its leadership included V. As an aside, Korenchevsky, who was born in Russia in , also played a major role in the development of geriatrics in Britain by convincing Lord Nuffield and his foundation to fund geriatric research units at Oxford, Cambridge, and Leeds. As we will see, the development of geriatrics has depended heavily on support of private foundations.
Out of this group grew The Gerontological Society of America, which was founded in with 80 members William MacNider was the first president. The Journal of Gerontology was first published in and, in , was split into four separate sections under one cover, representing the diverse interests of the membership. In , it was split into two separate covers, with biological and medical sciences coexisting as one volume and psychological and social sciences as the other. The Gerontologist was first published in The winners of the medical sciences section, Joseph T.
Freeman Award, are listed in Table 4. The first annual meeting was held in with Lucien Stark of Norfolk, Nebraska, as president. Thompson 55 , Geriatrics had been first published in with an association with the American Geriatrics Society, but the publisher held title to the name and the journal continues to be published today. In , Edward J. This lead to the establishment of the Baltimore Longitudinal Study on Aging in For many years, this program was successfully led by Reuben Andres, who created a generation of geriatric researchers 57 , In , the gerontology branch was moved under the National Heart Institute.
This contrasts with Nathan Wetherwell Shock's own viewpoint enunciated first before his death in We have achieved some degree of success. In , James E. Franklin Williams became the second director in Gene Cohen was acting director for 2 years before Richard J. Hodes became the third director in The first two directors of the NIA had a major national impact, whereas Hodes, a basic scientist, has been much less prominent on the national scene.
He was responsible for creating the first fellowship in geriatric medicine at City Hospital Center a Mount Sinai School of Medicine affiliate in 61 , He introduced resident rotations in geriatrics and started a teaching nursing home in 63— Perhaps the single most important institution in the development of geriatrics in the United States has been the Veterans Administration VA This was due to recognizing the marked increase in aging veterans and its potential effects on the veteran's health care system.
These institutions played a major role in developing geriatric faculty, science, and education at major universities throughout the United States They also supported the first geriatric fellowships in and were later responsible for geriatric psychiatry fellowships.
They developed interdisciplinary team training programs in geriatrics. They subsequently introduced geriatric evaluation and management units throughout most VAs in the United States They have played a leadership role in the development of palliative care Numerous teaching nursing homes were developed in the VA The first professorship in geriatrics was created at Cornell University in In , the first certifying examination in geriatric medicine was offered and, at the same time, the Accreditation Council for Graduate Medical Education accredited 62 internal medicine and 16 family practice programs to offer geriatric fellowship programs.
Many of these programs were extraordinarily weak and had a dearth of faculty. From the s, two distinct schools of geriatrics developed. Also, Robert Kane has been closely associated with the development of geriatrics in Minnesota. The Saint Louis University program was inaugurated in Prior to this, it had one of the earliest GRECCs and a University-wide interdisciplinary geriatrics program under the leadership of Rodney Coe The program has played a major role in geriatric education throughout the Midwest with its geriatric conferences, scholars program, and its newsletter, Aging Successfully.
The geriatric psychiatry division at Saint Louis University under the leadership of George Grossberg was established in The leading academic teaching and hospital programs in geriatrics based on the U. News and World Report rankings are listed in Table 6. In , the 2-year fellowship requirement was lowered to 1 year.
This was created predominantly by the work of William Hazzard and John Burton I am on record as strongly opposing this move 74 , mainly because I thought then, and still do, that it takes longer than a year to train a geriatrician and that it would lower the prestige of geriatrics in internal medicine programs. Others believe that this has been a positive move On the other hand, Robert Kane has argued that we have failed to develop a niche for geriatrics and geriatricians should move to nonchronic disease hospitals Many disagree vehemently with this viewpoint 77— As of , there were accredited fellowship programs with first year fellows and 79 second year fellows Of the trainees, Second to the VA, the John A.
Hartford Foundation, under the leadership of Donna I. Regenstreif, has been the major force in the development of geriatric programs Their early program on midcareer faculty retraining was an inspiration that provided senior faculty early in the development of geriatrics Their centers of excellence program allowed many struggling geriatric programs, including ours at Saint Louis University, to get off the ground. Their medical student summer research program has allowed many students exposure to geriatrics that will remain with them throughout their career.
They also provided financial support to provide exposure to home visits for medical students. Among the many successes of this program was the development of the student-run geriatric home visit program at Saint Louis University Increasing geriatric awareness in other disciplines has also been successful, particularly their program for emergency department physicians 89— Reynolds Foundation has started to provide large grants to medical schools.
In , this resulted in the formation of the D. The Bureau of Health Professionals, through its Geriatric Education Centers and its physician and dental fellowship programs, and, more recently, the Geriatric Academic Career Awards, has been an important leader in geriatric education. Most direct care for older persons is provided by nurses. Nurses have been leaders in providing and developing home care services. In , the American Nurses Association held a focus group on gerontological nursing that led to the formation of the gerontological nurse practice group in The first geriatric nursing standards were published in This led to the certification of gerontological nurses.
Gerontological nurse practitioners have a master's degree and have become leaders in improving care in nursing homes. The research work of Evans and Stumpf has played a key role in reducing restraint use for confused older persons 94 , leading to a recent call in the Journals for the abolition of physical restraints 95— The modern development of nursing was recently reviewed in a Future History in the Journals The concept of support and comfort for the old comes from the Bible Ruth 4: By the 11th century, these exhortations had led to the development of Jewish Homes in France and Germany to house the aged.
Prior to this, during the Byzantium — A. The workhouse policy was to make the old and infirm as comfortable as they can and the able-bodied, if dissolute characters, as uncomfortable as they can. In , the Nuffield Committee felt that the character of workhouses needed to change and that elderly persons should be accommodated in small homes to enhance their care The concept of convalescent rehabilitation homes was developed in France with the opening of Hotel Dieux in and the Charitie Hospital 10 years later.
The first nursing homes in the United States were charitable institutions run by Catholics or Jews. Louis, and the Sisters of the Third Order of St. Francis opened a home in Buffalo, New York. In , Charless House, a charitable institution, was opened as a home for the friendless in St.
While intended to look after women of all ages, the persons admitted were predominantly older widows. Other elderly people were housed in poorhouses or rural poor farms. In , relatively weak state licensure programs for nursing homes were put in place. In , Federal matching funds to nursing home vendors were made available, stimulating nursing home growth.
Quality was generally poor and, in , President Nixon called for tougher regulation These included the need for physician services, nursing aide training, restraint and psychotropic drug reduction, and guidelines on reducing polypharmacy. In addition, OBRA '87 mandated the development of a resident assessment instrument RAI that is now widely utilized throughout the world. In , many Californian nursing homes were considered to be substandard by the Office of the Inspector General leading President Clinton in to increase fines on, and add surprise inspections to, nursing homes.
By the turn of the 20th century, lawyers had found nursing homes to be a lucrative hunting ground where taking cases on contingency and forcing settlements because they were, in general, cheaper than litigation became their modus operandi. While OBRA '87 resulted in some improvements in care, further legislation and legal action has become a drain on the money and time available to provide care.
Needless to say, the more complex RAI has won, despite questions of its validity as a tool that is useful for individual patient care In , it moved to Washington, D. It has developed a certified medical director program, which requires completion of coursework but no examination or observed training. The latter journal is now produced under the auspices of the American Geriatrics Society.
AMDA has a membership of nearly , which is the largest of any of the aging societies. The oldest home care medical service was begun in from the Homeopathic Medical Center, which went on to become Boston University Medical Center Under the leadership of Knight Steel, this service blossomed into the model for geriatric home care services by a physician. Bluestone and Martin Cherkasky had developed a home rehabilitation service associated with Montefiore Hospital in New York. This home care program had patients with an average age of 80 years.
The s has seen the development of telemedicine for homecare Hospice, as a form of palliative care for the dying, was first developed in when St. Christopher's Hospice was founded by Cicely Saunders in London.
Dysphagia: A Geriatric Giant?
In the United States, Hospice Inc. The National Hospice Organization was established in Palliative care remains undertaught to physicians in the United States, with most hospice organizations being run by nurses and social workers. Recently, there has been a push to extend palliative care from the last 6 months of life to include all persons in the last 2 years of their life.
Unfortunately, physicians are notoriously inaccurate at predicting the time to death, making this a difficult road to follow. The concept of Continuous Quality Improvement was introduced to industry by Deming As the motor industry in Detroit rejected his advice, he went to Japan and used his principles of quality control feedback and empowerment to build industry in Japan to the high standards it now displays. In , Don Berwick introduced the concept that continuous improvement was an ideal paradigm for health care In the early s, Schnelle began to publish articles on the use of quality control techniques for reducing restraints and managing incontinence — In , Morley and Miller wrote an editorial in the Journal of the American Geriatrics Society espousing total quality assurance as an important step in improving quality for older individuals.
In , Saint Louis University and the St. A recent attempt to mold critical pathways to be useful for older persons led to the development of Glidepaths for outpatient care Recently, the importance of the computerized medical record and error management has again highlighted the role of continuous quality improvement in geriatrics — As mentioned, geriatric psychiatry had its birth in with the articles written by Benjamin Rush.
He finished his medical studies in and worked at the Municipal Mental Asylum in Frankfurt, where he collaborated with Franz Nissl on histopathological staining techniques. He died in His first patient with the disease that was eventually to carry his name was Auguste D. She presented with jealousy to her husband, paranoia, memory impairment, and, toward the end of life, loud screaming. His decision to do this was most probably motivated by a desire to give credit to his institute rather than historical accuracy. Dementia had been clearly described clinically by Pinel and Esquirol.
In , Gaupp pointed out that most psychiatric disorders of late life were not due to dementia He provided the first clear differentiation of dementia from depression. The Last Half of Life. Felix Port was appointed as a geriatric psychiatrist at Bethlehem Hospital in He developed a ward devoted to persons older than 60 years who had psychiatric disorders. In , Sir Martin Roth described the onset of late-life paranoia. David Kay linked cerebrovascular disease to depression in In the United States, geriatric psychiatry developed at Duke in the s.
Their success was spurred by the Duke Longitudinal Studies on Aging, whose results began to be published in , There he built a particularly strong geriatric psychiatry program. This program was responsible for the training of luminaries such as Murray Raskind and Burton Reifler. Around the same time, the Boston Society for Gerontologic Psychiatry was established, and, in , began to publish the Journal of Geriatric Psychiatry. The International Psychogeriatric Association was formed out of the Nottingham club, which had been created as part of a 2-week course on psychogeriatrics developed by Tom Arie.
It publishes International Psychogeriatrics. The Alzheimer's Disease and Related Disorders Association is a consumer organization, formed in , which has played a major role in improving care, research, and political lobbying for patients with dementia. Two books written for the public have had a major influence on increasing awareness of the needs of patients with dementia. The development of geriatrics in Europe has been somewhat helter skelter with programs developing and then regressing, depending on the leadership.
At the start of the 20th century, Austria was a powerhouse of the emerging field of geriatric care. Arnold Lorund in his book, Old Age Deferred, which was published in He felt that the causes of aging were arteriosclerosis, problems with immunity leading to increased infections, and abnormalities of the secretions of the ductless glands. He felt that being married and having a religious belief were important components in prolonging life. In Sweden, the first chair and department of long-term care medicine was established at Uppsala University in the s and the second at Goteborg University in the s Geriatric specialty training takes 5 years, and a voluntary examination for specialization was first offered in The longitudinal population study of persons 70 years of age was established in Gothenburg in — — The success of this project was largely due to Alvar Svanborg and Bertil Steen.
The Geriatric Society in Italy was founded in under the chairmanship of M. Most medical schools in Italy have a chair of gerontology. In Geneva, psychogeriatric consultation was developed by Dr. Junod, in , who later became the first Swiss professor of geriatrics , This was followed by the opening of the Hospital de Geriatric beds in In , the University Geriatric Institutions of Geneva was formally instituted, and this metamorphosed into the Department of Geriatrics in under the leadership of Jean-Pierre Michel.
The Spanish Society of Geriatry and Gerontology was founded in In Spain, a limited number of persons receive high-quality care from geriatric hospitals, geriatric units, inpatient geriatric consultation services, and geriatric home care teams Geriatrics was recognized as a medical specialty in The training program is of 4 years' duration. Geriatrics has not played a major role in France, although the first geriatric society was formed in under the chairmanship of A.
The exception has been the development of geriatrics and gerontology in Toulouse Subsequently, under the leadership of Professor Albarede and the younger Bruno Vellas, geriatric care focusing on nutrition and Alzheimer's disease was developed in the department of internal medicine and the gerontology clinic at CHU Purpon-Casselardit.
Bruno Vellas has played a major role in increasing geriatric awareness throughout Europe. His work led to the establishment of a medical specialty in long-term care. The Danish Society of Geriatric Medicine was established in Geriatric medicine was recognized as a subspecialty of internal medicine in Denmark in General practitioners have historically carried out home visits for older persons.
Denmark has been a leader in home visit research , Japan has been slow to recognize the specialty of geriatrics, despite the fact that it has the world's longest mean life span and over , centenarians. Most older persons are accommodated in acute hospitals where the length of stay has traditionally been very long.
Many hospitals have lacked adequate rehabilitation facilities. Tokuyo special homes for the care of the elderly are run at public expense. The Tokyo Metropolitan Institute of Gerontology was founded in This Institute focuses on interdisciplinary research on aging, with two thirds being in the biomedical area and the rest in social science and nursing. In , the National Institute of Longevity Science was established.
The development of the senescence-accelerated mouse SAM models by Professor Takeda at Kyoto University has been a major contribution to aging research These models have been particularly useful for exploring memory deficits — These mice are particularly good models of mitochondrial dysfunction and free radical damage — The SAMP8 mouse appears to produce its memory deficit due to an excess production of amyloid precursor protein — Korenchevsky had played a major role in stimulating its development.
There were attendees from 14 nations. This first Congress focused on the definition of aging, the dichotomy between aging and disease, and the social aspects of aging. The second International Congress was held in St. Louis, Missouri, in under the presidency of Dr. There were attendees from 51 countries. These included six from Argentina, who had formed their formal geriatrics society in Geriatrics is also strongly developed in other parts of the world such as Canada, Australia, and Hong Kong.
There is also an increasing need for geriatrics in the developing countries of the world The first major advance in modern geriatrics has been the codifying of the geriatric assessment into a number of widely used screening tools Table 7. The first of these was developed by Dorothea Barthel, a physical therapist at Montebello State Hospital in Baltimore, in Tables 8 and 9 list the articles in the Journal of the American Geriatrics Society and the Journal of Gerontology that have been cited or more times.
These give a broad view of the areas that have had the most impact from the gerontological literature. It should be noted that few of the papers on Alzheimer's disease or depression have been published in these journals. The evidence that geriatric assessment and management units are effective — , and that geriatric assessment in the home also can improve outcomes — , perhaps represents the major component of the success of geriatrics in the last half of the 20th century.
Within hospitals, the development of units for Acute Care of the Elderly and innovative approaches to the management of delirium appear to be the sentinel geriatric events From the therapeutic viewpoint, the importance of exercise therapy, especially resistance exercise, would appear to be the major impact area , The role of hormone replacement, both positive and negative, has occupied a large amount of the geriatrician's time , Of the seminal theoretical underpinnings of modern geriatrics, I believe we should identify Fries' theory of compression of morbidity — , Rowe and Kahn's successful aging hypothesis , and the controversial emergence of frailty as a syndrome — Finally, the enormous advances of medicine in general in the treatment of diseases from cardiovascular diseases — to neuropsychiatry conditions — has had a tremendous impact on the care of the older person.
In this century, we will hopefully obtain the evidence-based medicine necessary to allow us to make appropriate treatment choices for 70, 80, and even 90 year olds. The increasing studies on the factors genetic and environmental that allow centenarians to age successfully will certainly be one of the major scientific successes in the next 50 years — It is hoped that this brief review of the history of geriatrics, together with the commentaries that follow, will provide a foundation for geriatricians of the 21st century to view their origins. Like all histories, this one is somewhat epochcentric, focusing on the last 50 years.
However, in the case of geriatrics, this is less of a problem, as the flourishing of geriatrics has been a relatively recent phenomenon. For those wishing more detail of more distant history, I recommend Roots of Modern Gerontology and Geriatrics: This history focuses on the physician history, and geriatrics is clearly par excellence an interdisciplinary endeavor. As such, there is a need for a future history that provides a less physician-centered viewpoint. Finally, this history is somewhat geocentric, focusing on the Anglo-American development of geriatrics and, to some extent, a Californian-Midwestern perspective.
It is hoped that the commentaries will help to offset some of these shortcomings. Cicero together with the first quotation recognizing a physiological anorexia of aging. Address correspondence to John E. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Close mobile search navigation Article navigation. P rehistory of G eriatrics. T he B irth of G eriatrics.
T he H istory of N ursing H omes. P hysician -D irected H ome C are and H ospice. C ontinuous Q uality I mprovement and G eriatrics. T he D evelopment of G eriatric P sychiatry. G eriatrics in the R est of the W orld. M odern A dvances in G eriatrics. The Journals of Gerontology: Chesterton In the end, each of our endeavors is only a product of those who went before us trailblazing the path to the present.
T he D evelopment of M odern G eriatrics —T he U nited K ingdom Marjory Warren — is given much credit for the development of modern geriatrics. T he D evelopment of M odern G eriatrics —T he U nited S tates of A merica Before reviewing the development of modern geriatrics in the United States, it is of use to review a number of key early events in the social condition of elderly people.
T he D evelopment of G eriatric P sychiatry As mentioned, geriatric psychiatry had its birth in with the articles written by Benjamin Rush. G eriatrics in the R est of the W orld The development of geriatrics in Europe has been somewhat helter skelter with programs developing and then regressing, depending on the leadership. M odern A dvances in G eriatrics The first major advance in modern geriatrics has been the codifying of the geriatric assessment into a number of widely used screening tools Table 7.
C onclusion It is hoped that this brief review of the history of geriatrics, together with the commentaries that follow, will provide a foundation for geriatricians of the 21st century to view their origins. View large Download slide. Brown-Sequard and a quotation from his article on the effects of testicular injections. Ignatz Leo Nascher and his quotation arguing for the use of the term geriatrics. Poem written by Dr. Richard Asher in on the hazards of bed rest. Vincent Cowdry and an early edition of The Gerontologist with his photograph in it.
James Armbrecht, Rodney M. The best Histo Book in the Land! Have you tried Cowdry? University of Michigan Med Ctr. Louis University Hospital, St. Ageless Body, Timeless Mind: The Quantum Alternative to Growing Older.