The way we once were The Sheldon Surveys of Wolverhampton and the Birmingham Chronic Sick Regional Hospitals, 1948 and 1961

In 1920 he obtained both MD and MRCP and a year later was appointed consultant to the Royal Hospital, Wolverhampton.  He developed a deep affection for Wolverhampton and its people, and held his outpatient sessions on market days so that patients could visit him more easily.   

In 1928 he was Hunterian Professor of the Royal College of Surgeons, lecturer in medicine at Birmingham University in 1942, councillor of the Royal College of Physicians (RCP) 1948-1950, and chairman of the Consultant Services Committee of the Birmingham Regional Hospital Board in 1948.  His researched endocrine disorders, maternal obesity and mineral elements culminating in a major study of haemochromatosis presented to RCP in its Bradshaw lecture in 1934 and published in 1935.  Later he developed a major interest in older people. 

Sheldon’s 1948 Wolverhampton survey 

Sheldon’s Wolverhampton community survey of elderly people, the first of its kind after the war, was carried out at the behest of the Nuffield Foundation, chaired by Seebohm Rowntree.  The ration card register was used to locate the random 1-in-30 sample of 583 old people (186 men over 65 and 397 women over 60 years).   The survey was carried out between January and April 1945.  Five hundred and fifty two people agreed to take part: those who did not had moved away, died and only a few refused.  

He used a questionnaire to assess physical and mental health, the domestic situation and how illnesses were managed at home.  General practitioners were currently treating nearly a third, while nearly a half had had treatment in the past 3 years, the remainder had never received medical treatment or not for many years.  The vast majority were considered well-nourished and only 3% to be undernourished.  Two thirds of the participants were mobile, one third had some limitation of movement either inside or outside the home while only 2.5% were bed ridden.  Some had difficulty climbing/descending stairs or standing in queues due to arthritis or pain in the feet due to corns or bunions.  The majority ate an ordinary diet and nearly two thirds had adequate dentures.  Many needed spectacles to read, some inappropriately used glasses obtained from parents or friends.  Nearly two thirds of those over 80 years had high levels of impaired hearing.  Just over one third of respondents suffered from falls with the incidence increasing with age.  Faecal or complete urinary incontinence was rare and only a few men and women had dribbling urinary incontinence.

Assessment of the respondents’ mental state showed that the great majority were in full possession of their faculties and most of the remainder were only slightly mentally impaired.  Sheldon admired their mental vigour and ‘guts’ but noted that one in five people were lonely to some degree.

The survey studied the respondents’ domestic structure.  All but 2% lived at home with the minority in hostels or public institutions.  Nearly half were married and a similar proportion was widowed.  One third lived alone and the remainder lived with children.  Widows tended to continue to live in their home but widowers tended to sell up and move in with married children.  Those living alone usually maintained strong contact with their children who often lived close by.  The majority of those living at home tried to maintain their independence for as long as possible.  Up to the age of 75 years the women contributed more to the community than they received.  

The survey explored how early illnesses were managed within the family.  Usually they were handled within its own resources - spouse, children or neighbours - which could be a very heavy burden on younger members of the family.  When the husband was in bed the wife did the nursing but when she was ill in bed she was generally looked by the daughter. Community domestic help would be greatly valued in these situations.   

Sheldon emphasised the positive contribution made by older people and that it was sensible to maintain their independence for as long as possible.  Many would benefit from aids such as spectacles, hearing aids, dentures and access to physiotherapy and chiropody.  Carers would also value relief provided for invalids by short stay hostels or permanent residential homes.  

In his report Sheldon discussed: ‘What is ‘normal’ ageing’, to which he had no clear answer but emphasised to need for research, and ‘The determination to live’, which was the result of mental attitudes and the sense of having something to do.  Importantly he distinguished between ‘chronological’ age and ‘biological’ age.  Chronological old age officially started when a pension was paid but biological old age began when there was definite limitation of activity, which could be after the age of 70 or even 75 years.  Thus a 5 to 10 year age gap could exist between official and natural onset of old age.   

Sheldon’s 1961 survey of the Birmingham Regional Chronic Sick Hospitals

Sheldon’s second survey was carried out at the behest of the Birmingham Regional Health Authority who were concerned about the adequacy of their services for the aged and infirm.  He was commissioned to survey all regional chronic sick hospitals but not those caring for the ‘psychogeriatric’ patients.  The Regional Board expected these surveys to assist planning future hospital requirements, facilitate the discharge of the ‘bed blocker’, assist admission of elderly patients to vacated beds in the chronic sick hospitals and generally improve hospital services for the elderly.  Sheldon’s report was initially confidential and consequently he wrote, in the preface, ‘in many places…the phraseology has not been emasculated to such a level of neutrality as might be thought more apt for general publication’.  

The report revealed a highly unsatisfactory state of affairs, which echoed comments made some 15 years earlier in the 1945 government commissioned Hospital Survey Reports.  Sheldon found both over and under bedded areas.  Thus, for example, only one seventh of the chronic beds were provided for an area containing a one quarter of the population.  Some hospital buildings were not fit for purpose, having been designed as ‘human warehouses’ and were not intended for their present use.  Some were over 200 years old and one was nearly 800 years old.  The quality of some buildings was so poor that he recommended six should be either partially or totally demolished.  

He recorded his concerns.  Many hospitals had no lifts to the upper floors and could only be reached by narrow external stairs, and therefore constituted a fire hazard.  Patients and bodies had to be carried up and down these stairs, as did all food (either hot or cold), linen and perhaps coal.  Rehabilitation facilities were often very cramped.  He found it quite an experience to see bedpans stored for the night in the bath, to find the same room being used for washing bedpans and domestic crockery and being told of nurses having to queue up for the same toilet as the male patients.  He commended the work of the nursing staff.  He found 300 patients in Summerfield Hospital only required supervision and did not require hospital accommodation.  The photographic appendix to his report emphasised many of his points. 

Sheldon thought three types of accommodation were required for the chronic sick: acute assessment units with rehabilitation; long-stay units, and small chronic sick facilities associated with the local cottage hospital.  He recommended the appointment of more geriatric physicians in the Region, the need for postgraduate medical education in the modern treatment of the chronic sick and adequate staffing of all sections of the rehabilitation team.  

The Birmingham RHB promptly appointed a design team to design a new style of geriatric unit to supplement or replace the dilapidated wards.  Later the Board set research scholarships in Sheldon’s name and hospital units were named after him.    

Postscript

Sheldon was impressed by the wealth of clinical material found in older people and stated they were a mine of interest to the observer with the merest tincture of curiosity.  In 1950 Sheldon gave the Royal College of Physicians’ F.E. Williams lecture entitled, The role of the aged in modern society.  Four years later he was elected President of the International Association of Gerontology, which held its 3rd International Conference in London in that year.  His presidential address was The Social Philosophy of Old Age.  He was appointed CBE in 1955, made a fellow of King’s College London (1956), honorary freeman of Wolverhampton (1958), honorary MD at Bristol University (1958), honorary LLD Birmingham University (1965) and was awarded the RCP Moxon medal in 1966  He is said to have refused more professorial chairs than anyone else had ever done.

The first geriatric physician appointed in Birmingham

Sheldon’s representations for specialist physicians for the elderly doubtless led to Dr. Lawrence Nagley appointment as the first Birmingham consultant geriatrician on 5th July 1948.  He had a massive workload of 1,200 chronic sick inpatients, 300 able-bodied destitute people, 50-60 vagrants, 30-40 young chronic sick and 39-40 venereal and skin patients.  None had written medical records.  His junior staff consisted of one full time and two part time medical officers. 

His found grossly overcrowded wards and congested day rooms so packed with beds there was nowhere to sit down.  The floors were highly polished resulting in at least one case of a fractured neck of femur.  There was a system of giving numbers to mixtures of stock medicines e.g. Mist. Expect. Stim. was known as mixture Number 22.  Nagley postulated this arrangement was because the pauper nurses could not read.  Nagley had, on several occasions, to cope with large numbers of people made homeless by air raids and who stayed for one night for shelter and sorting out before they were moved on.  He noted the hospital boasted a very fine orchestra and a top class cricket team.  When a male nurse or a porter applied for a post, more attention was paid to his musical or cricket skills than his prowess pertinent to the post.  He was to claim later that he had spent more years looking after more sick old people in a greater concentration than any other physician.
In 1974 the Regional Board created in the Charles Hayward Chair of Geriatric Medicine in Birmingham and appointed Dr. Bernard Isaacs.  

Sources:

Anonymous. Obituary of J. H. Sheldon, British Medical Journal. 1972, 3: 180-181.  
Anonymous. Obituary of J. H. Sheldon, Munk's Roll, 1982, V1: 402-406.
Nagley L. A History of Summerfield Hospital, Midland Medical Review, 1975, 10: 10-17.
Sheldon J. H. The Social Medicine of Old Age, London:  Oxford University Press, 1948.
Sheldon J. H. Geriatric Services in Birmingham Regional Hospital Board.  1961. Birmingham, Birmingham Regional Hospital Board.