Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-01A Conceptual Historyin the Nineteenth CenturyG. E. BerriosDepartment of Psychiatry, Addenbrooke’s Hospital, Cambridge, UKThe history of geriatric psychiatry can be written from twoviewpoints. The ‘‘externalist’’ approach focuses on the social andpolitical variables that have controlled attitudes towards abnormalbehaviour in old age, and on the professionalization of thosecharged with the care of the mentally infirm elderly. The‘‘internalist’’ approach—to be followed in this chapter—concentrateson the origin of the scientific language of psychogeriatrics.An adequate historical account should include information ontheories of ageing, both physical and mental, brain sclerosis andthe formation of a viable concept of mental illness. On the firstrubric much research has been done 1–9 ; far less work exists on theother two. On psychogeriatric care before the nineteenth century 10,11there is very little: this may simply reflect a historical reality.VIEWS ON AGEING BEFORE THE NINETEENTHCENTURYLike most other aspects of human life, ageing has also beenportrayed in terms of metaphors. Classical views, following thenature—nurture controversy, conceived of ageing as resultingfrom either internal instructions or from the buffeting of foreignfactors 4,8 .The ‘‘wear and tear’’ view happened to be popular during theearly nineteenth century, the period on which this chapter willconcentrate. It was based, as it had always been, on the agelessobservation that all natural objects, whether animate or not, aresubject to the ravages of time. Surprisingly enough, the ‘‘wear andtear’’ view has not always generated an understanding attitude. Infact, across times and cultures great ambiguity has existed inregard to the treatment of old folk. Fortunately, a realisticacceptance seems to have predominated although there is plentyof evidence of hostility. The Hebrew tradition, and indeed itsChristian offshoot, encouraged much reverence towards thewisdom and value of old age. But even in societies which havemade great play of this view, veneration has been reserved forthose in positions of power or influence 12 . Little is known aboutattitudes towards elderly women or old men in humbler stations 11 .So, it can be concluded that, all in all, a view seems to havepredominated that ageing was undesirable and that the identificationof wear factors was important to devising ways of prolonginglife 5,13 .A second ambiguity can be detected in these earlier writings. Itconcerns the extent to which the ageing process necessarilyinvolves the human mind. Whilst it was a palpable fact that allhuman frames decayed, not everyone accepted that this hadnecessarily to affect the soul or mind. Extant descriptions of thepsychological changes brought about by old age suggest thatpeople were aware that the mind also underwent a decline.However, theory and religion encouraged the view that the spiritcould or did escape wear and tear, and that human beings grewever more wise and useful, thanks to the accumulation ofexperience and knowledge. This belief must have been availablein all those societies that felt the need to create adequate spacesfor all manner of intellectual and/or sociopolitical gerontocracies 2 .Some seem even to have separated chronological age andfunctional age in order to justify such concessions. From thepoint of view of the history of psychogeriatrics, it would be usefulto know to what extent this belief was undermined by theoccasional case of dementia amongst those elderly in positions ofpower 1 . Historical evidence seems to show that these situationswere neither more nor less perturbing than mental illnessoccurring at other periods of life. Indeed, fail-safe devices seemto have been available in these societies to cope with the upheavalscreated by such occurrences.Men like Buffon, Darwin and Goethe reshaped ideas on ageingduring the eighteenth century. Buffon 14 wrote: ‘‘All changes anddies in Nature. As soon as it reaches its point of perfection itbegins to decay. At first this is subtle and it takes years for one torealise that major changes have in fact taken place’’ (p. 106).Buffon put this down to an ‘‘ossification’’ process similar to thataffecting trees: ‘‘this cause of death is common to animals andvegetables. Oaks die as their core becomes so hard that they canno longer feed. They trap humidity, and this eventually makesthem rot away’’ (p. 111).Erasmus Darwin’s views resulted from the application of yetanother metaphor, namely, that ageing results from a breakdownof ‘‘communication’’ between man and his environment 15 . Darwinsuggested that such breakdown followed a loss of irritability (aproperty of nerve fibres) and a decreased response to sensation:‘‘It seems our bodies by long habit cease to obey the stimulus of thealiment, which support us . . . three causes may conspire to renderour nerves less excitable: 1. If a stimulus be greater than natural, itproduces too great an exertion of the stimulated organ, and inconsequence exhausts the spirit of animation; and the movingorgan ceases to act, even though the stimulus is continued. 2. Ifexcitations weaker than natural be applied, so as not to excite theorgan into action, they may be gradually increased, withoutexciting the organ into action, which will thus acquire a habit ofdisobedience to the stimulus. 3. When irritative motions continue tobe produced in consequence of stimulus, but are not succeeded bysensation . . .’’ (p. 365).Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd