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 criticised 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 recognised 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 UK. He classified, diagnosed, and treated his elderly patients. He reorganised 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 the 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, FRCP (1896–1957), became the first medical superintendent of the newly built, 800‐bed, St Helier Hospital in Carshalton. The building was hit several times by enemy bombs, his superintendent’s house was destroyed by a flying bomb in 1944, and he was severely wounded and lost an eye, but he returned to duty in due course. In 1953, he was appointed consultant physician to the Southampton group of hospitals.
His approach to his long waiting list for admissions was different from others because he had few hospital beds. He devised a scheme of managing patients at home with a domiciliary ‘inpatient service’ supplemented by increased use of the outpatient department. The process began with a home visit made by a member 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,