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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 June 9; 334(7605): 1225.
PMCID: PMC1889946
Medical Classics

Geriatrics: The Diseases of Old Age and Their Treatment

A Mark Clarfield, head of geriatrics

Geriatrics has a long and fascinating history, going back to the epic of Gilgamesh, through the Jewish Bible and up to the 19th century studies of Jean-Marie Charcot. However, many believe that the field entered the modern era with the publication in 1914 of Ignatz Leo Nascher's seminal text. The book's origins are interesting in that it began with a ward round. As a medical student in New York, Nascher was part of a team that came to an acutely ill woman, whose condition Nascher's professor described in words that can still be heard today: “Old age.” When our young hero asked what could be done to help the patient, he was shocked by his teacher's response: “Nothing!”

Several years later Nascher wrote his definitive text, in which he first formulated the clumsy term “geriatrics” from the Greek “geron” (old man) and “iatrokos” (medical treatment). While apologising for his awkward formulation, Nascher offered that “euphony and mnemonic expediency were considered of more importance than correct grammatical instruction.”

I have always held that paediatrics and geriatrics have much in common and have written about this elsewhere. But it seems that, alas, I was not (as is usually the case) the first to arrive at such an insight. Almost a century ago Nascher obviously felt this to be the case and invited his colleague and friend Abraham Jacobi, who many believe to have been one of the fathers of American paediatrics, to pen the book's preface. Among other things Jacobi called for geriatrics to develop in the future as had paediatrics recently in his day.

Nascher divided the book, at over 500 pages, into three sections: “Physiological Old Age,” “Pathological Old Age,” and “Hygiene and Medical Legal Relations.” Many but not all of the diseases known to us today are described. Some that at the time were not yet named are alluded to. For example, Alzheimer's disease was not described as such. (Alzheimer had, only a few years before, published his paper—not much noticed at the time.) However, Nascher clearly understood the syndrome of dementia. For example, “In determining the extent of senile impairment (in cognition), the normal mentality (pre-morbid status) of the individual should be known.” This is not bad advice, even in our day. Nascher goes on: “The impairment, though manifested in any direction, may progress for years before it becomes obvious to friends and family . . . An early symptom is a hesitancy in recalling names, dates and events, fabricating others . . . The patient will forget where he puts things, will repeat questions that had just been answered . . . He becomes careless about details and loses the sense of neatness, leaving his desk disordered, his room untidy, his clothing disarranged.”

Moving to a more acute disease, Nascher describes the contemporaneous “old man's friend” of Osler—pneumonia—providing an excellent description of how this condition often presents atypically. Once again, the fact that disease in elderly people does not always present as it is described in the medical textbooks—an observation still often ignored today—was well known to Nascher: “The usual sudden onset . . . with a chill followed by a high fever is infrequent in the aged . . . Many senile patients will swallow the expectoration unless watched. Pain is usually slight . . . cerebral symptoms are pronounced.” I wish all doctors knew this today.

The book makes for fascinating reading. Much material, especially that on therapeutics, is of course dated. However, the clinical approach described and, above all, the spirit of hope expressed in the book are as relevant today as they were almost a century ago. Just as we have learnt that the paediatric patient is not merely a little adult, Nascher's book shows us that the older patient is in many ways very different from the middle aged person she once was. The book is a testimony to this pioneer's dedication and an appropriate rejoinder to his pessimistic professor of medicine. We remember Nascher. Who knows the name of his teacher?

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