Mohammed T. Abou-Saleh

4 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYVIEWS ON AGEING DURING THE NINETEENTHCENTURYIn 1807 Sir John Sinclair 16 published a major compendium onageing and longevity which included references to most prenineteenthcentury sources. It was, in a way, the last grand glanceto the past. Soon afterwards work started by those who, like Le´onRostan (1791–1866), based their claims on empirical findings.Rostan, one of the most original members of the Paris school,published in 1819 his Recherches sur le Ramollissement duCerveau 17 , where the view commenced that vascular disordersmight be as important as parenchymal ones in brain ageing. Evenmore important was his uncompromising anti-vitalistic positionenshrined in the claim that all diseases were related topathological changes in specific organs 18,19 .During the 1850s Reveille´-Parise 3 saw his task as writing on‘‘the history of ageing, that is, mapping the imprint of time on thehuman body, whether on its organs or on its spiritual essence’’(p. v). In regard to ageing itself he wrote: ‘‘the cause of ageing is agradual increase in the work of decomposition . . . but how does ithappen? What are the laws that control the degradation thataffects the organization and mind of man?’’ (p. 13). Reveille´-Parisedismissed the toxic view defended by the Italian writer MichelLe´vy 20 according to which there was a gradual accumulation ofcalcium phosphates that led to petrification, to an ‘‘anticipation ofthe grave’’. This view, he stated, had no empirical foundation andwas based on a generalization from localized findings. Reveille´-Parise supported the view that ageing results from a negativebalance between composition and elimination which equallyaffected the cardiovascular, respiratory and reproductive organs.Finally, the views should be mentioned of J. M. Charcot, whoin 1868 offered a series of 24 lectures on the diseases affecting theelderly 21 . Charcot dedicated Lecture 1 to the ‘‘general charactersof senile pathology’’; he started by saying that all books ongeriatrics up to his time had ‘‘a particularly literary orphilosophical turn [and had been] more or less ingeniousparaphrases of the famous treatise De Senectute’’ (p. 25). Hepraised Rostan for his views on asthma and brain softening in theelderly, and predictably also mentioned Cruveilhier, Hourmanand Dechambre, Durand-Fardel and Prus. He criticized Canstattand other German physicians because in their work, ‘‘imaginationholds an immense place at the expense of impartial and positiveobservation’’ (p. 26). Charcot’s own contribution was based onthe general principle that ‘‘changes of texture impressed on theorganism by old age sometimes become so marked, that thephysiological and pathological states seem to merge into oneanother by insensible transitions, and cannot be clearly distinguished’’(p. 27).THE DEVELOPMENT OF THE NOTION OF BRAINSCLEROSISWhen in 1833 Lobstein 22 described the basic pathology ofarteriosclerosis, he did not imagine that it would, during thesecond half of the century, become the mechanism of ‘‘senility’’par excellence 14,23,24 . Motor and sensory deficits, vertigo, delusions,hallucinations and volitional, cognitive and affectivedisorder were all attributed to the effect of arteriosclerosis 25,26 .They related to the brain via a two-stage speculative pathophysiology:parenchymal and/or vascular disorders could affectthe brain, and the distribution of the lesions could be diffused orfocal. Vascular changes included acute ischaemia (on whichclinical observation was adequate) 27,28 and chronic ischaemia,invented as a separate syndrome by extrapolating from thesymptoms and signs observed during the acute states 24 . The roleof arteriosclerosis as a causal and prognostic factor in relation tothe involutional psychoses was challenged early in the twentiethcentury 29 but this paper remained unnoticed. Hence, some of theold notions, such as that of ‘‘arteriosclerotic dementia’’, remainedactive well into the 1960s 30 .Alienists during the same period, however, were already able todistinguish between states where a putative chronic and diffusereduction in blood supply had taken place from focalized damage,i.e. what they called ‘‘multifocal arteriosclerotic dementia’’ andwas equivalent to what is currently called multi-infarct dementia24,31,32 .NINETEENTH CENTURY VIEWS ON MENTALDECAY IN THE ELDERLYIt is against this background that the history of the language andconcepts dedicated to understanding mental disorders in theelderly must be understood. In addition to these neurobiologicalframeworks, a psychological theory that explained the manner ofthe decline was required. Such a psychopathology was providedby the heuristic combination of associationism, faculty psychology33 , and statistics 34 that characterized the early and middle partof the nineteenth century.Yet another perspective, originating in clinical observation, wasadded during the 1830s. It led to the realization that, in additionto the well known forms of mental disorder, the elderly mightexhibit specific forms of deterioration, and that these could berelated to recognizable brain changes. There is only space in thischapter to deal with two examples: one typifying a ‘‘specific’’disorder of old age, namely the history of chronic cognitive failureor dementia; the other illustrating the effect of a general mentaldisorder (melancholia) on the elderly.THE FORMATION OF THE CONCEPT OF SENILEDEMENTIAThe history of the word and concept of dementia before thenineteenth century has been touched upon elsewhere 35 . Suffice itto say here that, at the beginning of the last century, ‘‘dementia’’had a ‘‘legal’’ and a ‘‘medical’’ meaning and referred to mostacquired states of intellectual dysfunction that resulted in seriouspsychosocial incompetence. Neither age of acquisition norreversibility was part of its definition. These two dimensionswere only incorporated during the nineteenth century andcompletely changed the semantic territory of the dementiaconcept.Anecdotal observation of cases of senile dementia abound bothin the fictional literature and in historical documents 36 , but theconcept of ‘‘senile dementia’’, as it is currently understood, onlytook shape during the latter part of the nineteenth century.Indeed, it could not have been otherwise, as the neurobiologicaland clinical language that made it possible only became availableduring this period 37,38 . But even after the nosological status ofsenile dementia had become clearer, there were many who, likeRauzier 39 , felt able to state: ‘‘it may appear either as a primarystate or follow most of the mental disorders affecting the elderly’’(p. 615). Following Rogues de Fursac 40 , Adrien Pic—the authorof one of the most influential geriatric manuals during thisperiod 41 —defined senile dementia as: ‘‘a state of intellectualdecline, whether or not accompanied by delusions, that resultsfrom brain lesions associated with ageing’’ (pp. 364–365). It wasagainst this background that the concept of Alzheimer’s disease,which became the prototype for all senile dementias, was createdduring the first decade of the twentieth century 37 . Recent work hasshown that its ‘‘discovery’’ was controlled by ideological forceswell beyond what could be described as ‘‘scientific’’ 37,42 . These