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<p>Prominent amongst the non-medical fraternity offering guidance was John Wesley, the Methodist preacher, who wrote the successful manual: Primitive Physick (1747). He gave advice on sensible life style and suggested herbal medicines for specific conditions. </p>\r\n
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<p>Medical input in the Victorian workhouse was mediocre and improvements waited until activists like Dr Joseph Rogers (1820-1889) were appointed. He became an outspoken, passionate social reformer who carried his convictions to some of the highest in the land. </p>\r\n
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<p>He began his clinical practice with his brother in Soho, London in 1844. There he found a patient dying from sepsis in a room where putrid material from the adjacent graveyard was seeping through the walls. He visited other graveyards, found very unpleasant conditions, successfully persuaded Lord Palmerston to close similar council burial grounds and campaigned for the opening of suburban burial grounds. Later he crusaded successfully for the repeal of the window tax.<br />\r\n
\t <br />\r\n
\tUnfortunately, an outbreak of cholera in Soho in 1854 destroyed Rogers’ practice and in the following year, he became medical officer to the Strand Workhouse, whose entrance had the motto ‘Avoid idleness and intemperance’. </p>\r\n
\r\n
<h4>Starvation diets as a deterrent to sin!</h4>\r\n
\r\n
<p>He found much to criticise - poor medical and nursing care plus such gross overcrowding that residents had to get out at the ends of beds rather than the sides. The Board of Guardians allocated starvation diets for single pregnant women to act as a deterrent. Workhouse medical officers lacked executive power and had to use their meagre salary to pay for patients’ medication. </p>\r\n
\r\n
<p>In the 1860s, Rogers became increasingly politically active. In 1861, he appeared before a select committee of the House of Commons, to discuss the supply and payment of drugs in workhouse infirmaries. In 1866, he founded the Association for the Improvement of London Workhouse Infirmaries where he was supported by Charles Dickens. In 1868, he was dismissed by his Board of Guardians due to his continued outspoken criticisms. The same year he established the Poor Law Medical Officers' Association to improve their prospects and conditions of work. His campaigning did not deter the Westminster Union workhouse who made him their medical officer in 1872. </p>\r\n
\r\n
<h4>Epidemics</h4>\r\n
\r\n
<p>Its Board may have regretted their ‘impetuosity’ because, once again, he exposed shortfalls in management. History repeated itself: he was suspended although later reinstated. He retired in 1886, viewing himself ‘as a child of the New Poor Law’ and published Reminiscences of a Workhouse Medical Officer. </p>\r\n
\r\n
<p>Arguably, Dr Rogers’ most significant actions involved the passage of the 1867 Metropolitan Poor Act. He had given decisive evidence to the 1866 Lancet Sanitary Commission on the state of Victorian workhouses. Its report, together with workhouse scandals, pressure from medical organisations, activists like Florence Nightingale and Louisa Twining, strengthened the influence of the President of the Poor Law Board as he urged the passage of the enabling Bill. The Act influenced services nationally, led to the separation of the medical and welfare roles of Poor Law system and the creation of the first state hospitals. It established the Metropolitan Asylums Board (MAB), which provided new facilities for patients with infectious diseases. The 1891 Public Health (London) Act authorised these hospitals to become the first free-state hospitals. </p>\r\n
\r\n
<p>The major challenge for the MAB was endemic smallpox, which caused major outbreaks. The 1871-72 epidemic killed over 50,000 people in Britain and Ireland. The MAB developed a strategy of swift isolation and prompt vaccination. Unfortunately, local residents resisted building new smallpox hospitals ‘in their back yard’, while parents ignored compulsory vaccination of their children. Nonetheless, by 1877 the MAB opened two new smallpox hospitals, one in Fulham (later named the Western hospital) and the other in Deptford (later the South Eastern hospital). When these proved inadequate, two old wooden battleships (Atlas and Endymion) were converted to medical use, moored at Greenwich before moved to Long Reach near Dartford. When these in turn proved insufficient, a tented camp for smallpox patients was established at Darenth (near the M25 Dartford crossing). A permanent smallpox hospital, Joyce Green hospital, replaced the hospital ships at a site adjacent to their moorings. Two more temporary hospitals to be built adjacent to Joyce Green, the Long Reach and Orchard hospitals, following another smallpox epidemic in 1901-2. Interestingly, when a motorway was planned across the smallpox burial grounds, constructors were banned for fear of disturbing the lethal virus.</p>\r\n
\r\n
<p>Outbreaks of scarlet fever and cholera prompted building of other fever facilities: the North Eastern, Brook, Fountains, Grove and Park hospitals. The MAB appropriated accommodation and built hospitals outside London to treat tuberculosis. Thus, the old Westminster Union’s infirmary was converted and reopened as Colindale hospital in 1920. Two years later the new purpose built King George V Sanatorium, Godalming, was opened. Many of these hospitals are now housing estates. </p>\r\n
\r\n
<p>The MAB other duties included care of children, the mentally ill, vagrants, and providing an ambulance service. The arrangements for children included offering naval training of pauper boys, treatment units for ringworm, ophthalmia, and general illness. The MAB managed ‘imbeciles’, the feeble minded and those with learning difficulties by building asylums north and south of the Thames. Other accommodation became training centres or colonies for epileptics. In 1912, the MAB took over care of vagrants who had previously been admitted to special workhouses wards for overnight stay. The Board reduced these 24 wards to six and created a central clearinghouse linked with the Salvation and Church Armies. The MAB established a land and river based ambulance service. The former was horse drawn until replaced by petrol driven appliances.</p>\r\n
\r\n
<p>Neville Chamberlain abolished the MAB in 1929 with the Local Government Act, which transferred control of workhouses (now called Public Assistance Institutions) to local authorities. In 1935, the West Middlesex Hospital took over the adjacent Institution, previously administered by the Middlesex County Council, invited Marjory Warren to assess its 874 residents, and so began another saga.</p>\r\n
\r\n
<p><br />\r\n
\t<strong>Michael Denham<br />\r\n
\tBGS Archivist and Historian<br />\r\n
\tand Past President (1992 - 1994)</strong></p>\r\n
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<p>She created the first geriatric unit in the UK. She systematically examined every new patient. Having separated the sick from the healthy, the old from the young, she instituted medical treatment and rehabilitation. Discharges were planned—an innovation at that time. As a result of her work, she reduced her number of chronic beds to 240 with a turnover three times the previous rate, and gave the unwanted beds to chest physicians for treating tuberculosis patients.</p>\r\n
\r\n
<p>Simple measures were used to improve the hospital environment for patients and staff. The wards were repainted. New brightly coloured bed linen and curtains were installed. Lockers for individual patients were acquired, and for the first time patients were encouraged to get out of bed and walk. She attracted the attention of a health minister, who visited her department after her discharge rate reached 25%.<br />\r\n
\t<br />\r\n
\tMarjory Warren published 27 scientific papers on her approaches to rehabilitation in the 1940s and 1950s. These included her ideas on rehabilitation of disabled elderly people, especially stroke patients and amputees. In her two most important publications, she described her approach to the management and classification of chronically sick older people (box 1). She strongly believed that elderly people with these conditions should be segregated from chronically sick patients of other ages, and treated in a separate geriatric assessment unit within the general hospital. This model of care would offer sick older people the best chance of diagnosis and treatment. In addition, their chances of discharge would be optimised. Warren echoed Charcot’s call for a specialty of geriatrics. This would “stimulate better work and initiate research”. She also requested a change in the attitude of all medical and nursing staff towards elderly patients.<br />\r\n
\t<br />\r\n
\t<strong>Warren’s classification of the chronic aged sick</strong></p>\r\n
\r\n
<ul>\r\n
\t<li>Chronic up-patients (that is, out of bed).</li>\r\n
\t<li>Chronic continent bedridden patients.</li>\r\n
\t<li>Chronic incontinent patients.</li>\r\n
\t<li>Senile, quietly confused, but not noisy or annoying others.</li>\r\n
\t<li>Senile dements—requiring segregation from other patients.</li>\r\n
</ul>\r\n
\r\n
<div>As well as being a pioneer of rehabilitation, Marjory Warren was a gifted teacher. She educated junior medical staff and consultant colleagues and she took a keen interest in the education of nursing staff. Many of her ideas remain central to the practice of modern geriatric medicine.</div>\r\n
\r\n
<div> </div>\r\n
\r\n
<div><strong>Joseph Sheldon (1893–1972):</strong> Sheldon was the father of community geriatric medicine. He was a consultant at the Royal Hospital in Wolverhampton, where his interest in elderly people was prompted by an outbreak of food poisoning.</div>\r\n
\r\n
<div> </div>\r\n
\r\n
<div>Sheldon observed many of the problems facing elderly people at home. He realised the importance of good self-care, continence, hearing, and footwear. Of particular importance was his recognition of mobility problems: he documented that 11% of elderly people were housebound. Sheldon recommended home physiotherapy. This would eventually be recognised as standard treatment. He advocated falls prevention strategies, such as adequate lighting at home and the benefits of stair rails.<br />\r\n
\t </div>\r\n
\r\n
<div><strong>Norman Exton-Smith (1920–90) and Lord Amulree (1900–83):</strong> An exceptional pioneering clinical scientist and researcher, Exton-Smith worked at University College Hospital (UCH) London, under the supervision of Lord Amulree. UCH was for a long time the only London teaching hospital involved with the development of geriatrics. Amulree had previously worked at UCH, but in 1936 had become a civil servant at the Ministry for Health. His influence in the House of Lords proved useful in improving conditions for chronic sick patients for whom he cared deeply. With the inception of the National Health Service he wanted their care transferred from local authority control. This occurred in 1948. Following his consultant appointment, and inspired by the work of Marjory Warren, he set about improving the plight of elderly disabled patients, and also changing the drab wards of St Pancras Hospital (a part of UCH). His work with Exton-Smith was a huge success. Beds were made available as a result of hospital discharges. Elderly services expanded and UCH attracted some of the brightest and keenest junior doctors.</div>\r\n
\r\n
<div> </div>\r\n
\r\n
<div>Both Amulree and Exton-Smith were proponents of continuing (that is, long term) care of older people and of home assessment visits (not requested by a general practitioner, undertaken by the geriatrician before hospital admission, and without remuneration). Amulree was present at the inaugural meeting of the British Geriatrics Society and was the first president, a post he held with merit for 25 years.</div>\r\n
\r\n
<div>Exton-Smith also worked with Doreen Norton, who later became the first professor of gerontological nursing. Exton-Smith developed geriatric research and published extensively. He became the first professor of the specialty in London at UCH in 1973. A particular interest was pressure sores (he pioneered pressure mattresses and was involved in the design of the modern Ripple Mattress). Other research interests included temperature regulation, the autonomic nervous system, nutrition, and osteomalacia. His interest in cognitive impairment resulted in the establishment of one of the first memory clinics.<br />\r\n
\t </div>\r\n
\r\n
<div><strong>George Adams (1916–2012):</strong> Another outstanding academic pioneer, he was the first geriatrician to teach geriatric medicine to undergraduates. He worked as houseman for Professor Thomson in Belfast’s Royal Victoria Hospital and was inspired by his chief’s compassion for patients on the chronic sick wards in the Poor Law infirmaries. He attended the first meeting of the Medical Society for the Care of the Elderly, later renamed the British Geriatrics Society. He met Marjory Warren and attended one of her ward rounds. After returning to Belfast, he wrote, “she gave me a practical illustration of what we might one day hope to achieve with the human wreckage in the overcrowded wards of the City Hospital.”</div>\r\n
\r\n
<div> </div>\r\n
\r\n
<div>Adams later opened the first purpose-built elderly rehabilitation unit in the UK, Wakehurst House at Belfast City Hospital. He published widely, his particular research and clinical interests being cerebrovascular disease and disability. He was appointed to the chair of geriatrics in Belfast in 1971, only the second geriatrician at that time to occupy such a position, and served as president of the British Geriatrics Society.</div>\r\n
\r\n
<div> </div>\r\n
\r\n
<div>Article authored by: A Barton, G Mulley</div>\r\n
\r\n
<div>Extract courtesy of the Postgrad Med J2003; 79:229-234 doi:10.1136/pmj.79.930.229</div>\r\n
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