Norman Exton-Smith was one of the outstanding clinical scientists of his generation. He did more than anyone to bring geriatric medicine from the medical backwater in which it originated to its present position as a major specialty - the third largest in medicine. He was also a man of profound humanity, determination and courage.
He was born at Ilkeston in Derbyshire. His parents and most of his relations were teachers; his father, Arthur Smith, taught science at Ilkeston Grammar School. Norman was the elder of his two sons, both of whom became medical professors. In such a family there was naturally a love of learning and their mother, Ethel Mary née Robertson, said that her sons would rather read a chemistry book than a novel. Electronics was a special interest and Norman was able later to build a phonocardiograph and a television. This ability underlay much of his work as a clinical scientist and was the basis of his lifelong interest in radio-controlled model aircraft. But the arts were not neglected and Norman also inherited from his father a love of antiques and of early English watercolours.
He was educated at Nottingham High School, where he won an exhibition to Pembroke College, Cambridge. While he was in the science sixth form at school he determined to learn French and before he went down from Cambridge he had read all ten volumes of Proust’s Remembrance of Things Past in the original.
From Cambridge he went to University College Hospital, London, no doubt influenced by his godfather Godfrey Bamber [Munk’s Roll, Vol.VI, p.23] who was dermatologist to the hospital After house appointments he joined the RAMC in 1944 and took part in the invasion of Normandy, landing on D+1. He was subsequently posted to India. He was demobilized in 1947 but in 1953, when he became a consultant, he joined the Army Territorial Reserve. He retired in 1959 with the rank of lieutenant colonel and became an honorary consultant to the Royal Hospital Chelsea.
Norman returned to the UCH in 1947 and a year later obtained his membership of the College. His professor, Max Rosenheim, later Lord Rosenheim [Munk's Roll, Vol.VI, p.394], suggested that he should assist Lord Amulree [Munk’s Roll, Vol.VII, p.12] at St Pancras Hospital. UCH was by many years the first London teaching hospital to concern itself with geriatrics. Lord Amulree had worked at UCH before the war but in 1936 he had become a medical civil servant, becoming involved with the problems of the chronic sick who were then under the administration of the local authorities. He wanted to see them brought into the National Health Service and had been impressed by Marjorie Warren’s work at the West Middlesex Hospital where unprecedented results were obtained by proper medical investigation and rehabilitation. She was the first to advocate a specialty of geriatrics. In 1947 Amulree was elected president of the new Medical Society for the Care of the Elderly, later to become the British Geriatrics Society. In 1948 he put his beliefs into practice and joined the staff of UCH to start a geriatric service based on the chronic sick wards of St Pancras Hospital, which for the past 20 years had been run by the London County Council in what had once been a workhouse.
It is difficult for those who never saw them to imagine what wards for the chronic sick were like at this period. They were always overcrowded, the beds often back to back with inadequate space between them. There were very few chairs and the smallest of bedside lockers. Any equipment was likely to be second-hand, passed on from the more important acute wards. There were, of course, no bed curtains and privacy was non-existent. Decorative standards were poor, drab green or brown institutional paint prevailed everywhere and wards were grossly understaffed.
Most of the patients were bedfast with contractures resulting from immobilization in tightly made beds. Many were apathetic and depressed, with nothing to interest them. None had been properly examined and diagnosis was usually ‘senility’ or ‘hypertension’. None were expected to leave hospital. It was enough to make any self-respecting registrar run a mile away from it but Norman, profoundly impressed by Lord Amulree’s enthusiasm, stayed. He at once got down to writing his MD thesis on ‘The Ecology of old age’, basing it on his experience of domiciliary visiting. It was an early example of his ability to observe, measure and write up whatever came before him. While still a registrar, with his colleague George Crockett he wrote his first paper in The Lancet, ‘The chronic sick under new management’. He stresses not the horrors but the interest and hope of geriatrics, the job satisfaction and the vast field for research. A paper which foreshadowed the concerns which were to dominate Norman’s life for the next 40 years.
In 1951 he was appointed consultant physician to the Whittington Hospital, London, ana in 1959 his responsibilities were increased when he became honorary physician to the Hospital of St John and St Elizabeth. When Lord Amulree retired in 1966, Norman returned to the UCH as his successor. In 1973 UCH created the Barlow Chair of Geriatric Medicine and Norman became the first professor of his subject in London. After retirement in 1985 he moved back to the Whittington to continue his researches into memory.
Norman’s 15 years at the Whittington were very productive. In his early years he was busy with his book Medical problems of old age; Bristol, J Wright, 1955. It was the first comprehensive postwar account of the subject. Perhaps ahead of its time, it attracted little attention and never went into a second edition. But 35 years on it is astonishing how little it has dated.
With his book published he turned his attention to a diversity of clincal topics, always analysing his own experience. Papers on hemiplegia, foot problems, faecal incontinence, barium studies, jaundice, hypnotics, and terminal illness in old age appeared during these years. Any literature review, even today, will show the fundamental importance of his contributions.
He did valuable work on pressure sores. His knowledge of electronics enabled him to design a machine which recorded the number of times a person moved when asleep in bed. He could then correlate the degree of immobility with the patient’s risk of pressure sores. He subsequently conducted the only properly controlled trials of Ripple mattresses that have ever been performed in this country. Later, he was to be concerned with the design of the Pegasus Ripple mattress which he himself had occasion to use in the last years of his life.
In 1951 Norman married a nurse, Jean Barbara née Belcher, and they had two children - Howard and Francine. Throughout his life he was sustained by the love of his wife and family.
He was always a good friend to nursing. While he was at the Whittington he met Doreen Norton who was later to become the world’s first professor of gerontological nursing. She had been seeking support for a programme of research into nursing the elderly and had met many disappointments. Norman successfully negotiated a grant from the National Corporation for the Care of Old People, of which he had become a governor. He himself participated in the work and the resulting book An Investigation of geriatric nursing problems in hospital, published by the NCCOP in 1968, 2nd ed Edinburgh, Churchill Livingstone, 1975, remains a most important piece of nursing research. Many pieces of equipment now in universal use - from the hospital nightgown to the King’s Fund bed - spring from this work. The book also contains the first report of a system of progressive nursing care. The Norton Score, used to identify people at risk for pressure sores, has never been convincingly superseded.
The cold winter of 1962-63 led to a number of reports of accidental hypothermia and Norman was quick to recognize the importance of the low reading thermometer and the need to promote awareness of, at that time, a largely unrecognized medical emergency. With Arnold Rosin, he reported his experience at the Whittington; leading to a request from the Ministry of Health to the BMA for a report to draw attention to the problem. A small working party, chaired by Norman, reported and publicized the problem in 1964. Two years later the College published a report on the same subject, and this was followed by another in 1977, Norman leading the investigation. The BMA Care of the elderly report of 1976 owed much to his contribution.
As well as having an inventive mind, Norman also had a genius for collaboration. One of his achievements was the national study of body temperatures in the elderly which involved collaboration with the National Institute of Medical Research, the Centre for Environmental Studies and two London teaching hospitals. He also worked closely in the field of temperature homeostasis with K J Collins of the MRC; their work was a fine example of clinical science in the tradition of Sir Thomas Lewis [Munk's Roll, Vol.IV, p.531].
Another research interest was the effect of age on the autonomic nervous system and Norman wrote many papers on this subject. He was also concerned with nutrition and was a member for 16 years of a government committee on medical aspects of food policy. With D L Scott, he edited Symposium on vitamins in the elderly, London, 1968, and also, with F I Caird, Metabolic and nutritional disorders in the elderly, Bristol, J Wright, 1980. He was co-author and editor of Geriatrics, Lancaster, MTP Press, 1979 and of Practical geriatric medicine, Edinburgh, Churchill Livingstone, 1985. With assistance from the King Edward s Hospital Fund he conducted surveys with Betty Stanton, the dietician, on the diets of elderly women living alone and on the nutrition of housebound old people.
His interest in nutrition made him an expert on osteomalacia and he went on to study bone reabsorption in the elderly and osteoporosis. The work involved removing finger and hand bones post-mortem, making radiographs, measuring and finally ashing the bones. Samples of other bones were taken for histology. Having established correlation between x-ray measurements and ash content the door was open to assessment from radiographs alone. Although densitometry has largely superseded Norman’s method much of our knowledge of bone loss with ageing rests on his painstaking work.
This naturally led to an interest in falls and fractures; a paper written jointly with the professorial department at Manchester was published in the College Journal in 1982 - at the time when Norman himself had become a victim.
In 1972 Norman wrote a paper with John Wedgwood and the teaching machine expert J L Gedye on the use of automated learning to assess the effect of a drug given to patients with mental impairment. This was the beginning of the memory clinic which he established at St Pancras Hospital ten years later, using computerized psychometric tests. When he retired from UCH he was able to continue the clinic at the Whittington with the help of Desmond Sharland and Gurcharan Rai. They established the Geriatric Neurophysiology Unit (GPNU) and sophisticated measurements of visual and auditory evoked responses were added to the armamentarium of the memory clinic. They hoped to find an automated way of assessing medication and possibly a positive test for Alzheimer’s disease to distinguish it from other causes of dementia. The Institute of Laryngology and Otology was involved and Norman’s team consisted of a clinician, a psychologist, a physicist and a nurse.
Norman attracted many excellent trainees, as well as visitors from abroad. He made great efforts to support his proteges and enjoyed the off stage discussions that led to the right appointments. Many future consultants and several future professors passed through his hands.
He was also an enthusiastic organizer of meetings, nationally and internationally. In 1976 the Anglo-American Conference on the Care of the Elderly was held in Washington DC, jointly run by the American Institute of Medicine and the Royal Society of Medicine, and Norman was one of the three British members on the committee. He took a large part in the preparation of the programme and, with Grimley Evans, edited the proceedings. He made links with the British Council, running courses which attracted physicians from many countries and promoted British medicine. These contacts enabled him to set up several joint conferences in Belgium, Holland, Germany and Italy. The meetings organized with Giuseppe Barbagallo-Sangiorgi of Palermo at Erice, in Sicily, were particularly enjoyable.
He was intimately involved with the affairs of the British Geriatrics Society from the time, in 1952, when he was elected deputy secretary. In that year the Society had just over 100 members; when he retired there were 1500. He became secretary in 1954 and president 1978-81. From 1959-85 he was editor of the Society’s journal Age and Ageing; he always had a seat on the executive and often chaired it. He was not a forceful chairman, never dominating discussions, yet his quiet authority and wisdom shaped the Society and guided it to its present standing.
Through his past association with Lord Amulree he was at home in political circles. For 15 years he was consultant adviser in geriatric medicine to the Department of Health and a member of the committee on medical aspects of food policy. For some years the British Geriatrics Society committee meetings were held in the House of Lords.
Within the College he was a well known figure, latterly with his elbow crutch. He was elected to Council in 1969, the first geriatrician to be a councillor. He was the first secretary on the committee on geriatrics and its chairman from 1975-85. During this time he stimulated the College to produce two reports on the care of the elderly, persuading it to acknowledge geriatrics as a true specialty of medicine. He was secretary of the first College working party on stroke and he chaired the committee on organic mental impairment in the elderly. He was also a prime mover in the report on medication in the elderly. As a mark of esteem, the College gave him a lunch at the time of his retirement.
Norman received many honours. He was appointed a CBE in 1981. In 1983 he received the Henderson Medal of the American Geriatrics Society and in 1984 the College awarded him the Moxon medal; previous holders include some of British medicine’s most famous names. In the same year the British Society for Research in Ageing awarded him the Lord Cohen of Birkenhead medal and in 1986 the British Geriatrics Society awarded him the Dhole Eddleston prize. Three years later he received its prestigious Founder’s medal. He was joint winner of the Sandoz International prize for medical research in 1988. But perhaps what gave him the greatest pleasure was the honorary DM bestowed on him in Nottingham, his old home and the first such honour ever awarded to a geriatrician.
In his obituary for the BMJ Tom Arie wrote of Norman: ‘Respect for him before his illness was such that it seems hardly possible that it could grow greater still. But the honour in which he was held grew even more in his last illness which lasted for eight years and which he bore with heroic courage.’ At Christmas time in 1981 he was helping to push a car when he slipped and broke his hip. The fracture proved pathological due to a metastasis from a slow growing hypernephroma, and later he had a pathological fracture in his knee joint while lecturing in Edinburgh. These incidents, and others, were followed by a series of operations to remove new secondaries as they appeared. Norman took each incident as it came and talked about them with a wry, detached humour - almost as if he were discussing someone else. For the last three years of his life he walked on one-and-a-half artificial femurs, yet when one visited him one was hardly aware of his problems so well had he adapted to disabled living. His drawing-room was on the first floor and he came down to answer the bell riding on his stair-climber. He would then go to the kitchen and make tea, refusing any help. He would demonstrate his hydraulic bath seat and the Pegasus airbed, and for a long time he continued to drive. When in hospital, he gave his secretary instructions by phone soon after a major operation.
Through all this long period he continued to write and to lead research at the Whittington, and never ceased to take an interest in the British Geriatrics Society, and in the careers of his friends and proteges.
His wife was not well herself for several years and survived him less than six months; concern for her added to his burden, but he seldom spoke of it. Eventually Norman became too ill to stay at home and he died peacefully at Edenhall Marie Curie Home, a few months after his 70th birthday.
Despite all his achievements and honours Norman never ‘talked down’ to anyone, he was always approachable and never too busy to listen to others. His most notable characteristics were modesty and diffidence - almost to the point of shyness. He had a dry humour and deep wisdom, as well as a great concern for others.
It was fitting that the College should be the scene of a Thanksgiving for Norman’s fife and work. At a memorable meeting, chaired by his son Howard, various people including his brother David Robertson Smith, Doreen Norton, Peter Millard - who had been trained by him -and Tom Arie all spoke of his life, his work and his friendship. A remarkable tribute to his wonderful modesty came from the president of the Luton and District Model Aeroplane Society who knew Norman for many years as an enthusiastic member - but had no idea that he was one of the great physicians of his time.
R E Irvine
[Brit.med.J., 1990,300,1009; The Lancet, 1990,335,p.965; Times, 5 Apr 1990; The Daily Telegraph, 6 Apr 1990;The Guardian, 11 Apr 1990; The Independent, 2 Apr 1990]