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 0-470-84641-04aThe Development in the USA, 1600–1900W. Andrew Achenbaum, Crystal Cederquist, Vicki Kahl, Kathryn RosenbergUniversity of Michigan, Ann Arbor, MI, USAThere is a dearth of information about the care of mentally illolder persons in the USA from the seventeenth through thenineteenth centuries. Despite an extensive literature on the historyof the various stages of the mental health movement during theperiod, little is known about the treatment of the aged, membersof ethnic and religious minority groups, or of women of any agewho became ill between 1600 and 1900. Much reported here refersto a largely white, male, New England data set. Virtually noevidence comes from the south or from west of the Mississippi.In colonial times the mentally ill, along with other classes ofdependents, were treated as a local responsibility, primarily placedwith their own or other families. Clergy and physicians alikesubscribed to a belief in demoniacal possession that was widespreadin seventeenth century America. Few colonial doctorsinvestigated other possible causes of mental disorders; no‘‘scientific’’ theory for dealing with the mentally ill was yet invogue.Legal cases involving persons suffering from mental illness weredecided on an individual basis. In 1639, the MassachusettsGeneral Court was empowered to determine settlement forwandering individuals. Six years later, as a result of the need forsuch rulings, three men were selected to form a committee toconsider provisions of a law for ‘‘disposing of inmates and settlingimpotent aged persons and vagrants’’ 1 . It is probable that asignificant minority of the people affected by this law werementally ill, but the extant records do not yield adequatedocumentation to verify the incidence or treatment of such cases.The ‘‘violent’’ insane among public dependents were ordinarilytreated as common criminals. The harmless mentally ill weretreated almost the same as other paupers. Records have beenfound as early as 1676 of the levy of a small tax on a village inMassachusetts to help one man build and maintain a small blockhouse for his son, who was ‘‘bereft of his natural senses’’ 2 .In an effort to deal with its indigent and insane citizens, Bostonin the late 1600s established the first almshouse in New England.Following English custom (which was to continue in America wellinto the nineteenth century), indigents and petty offenders wereherded indiscriminately into this poorhouse—the sick and well,the able-bodied and impotent, and law-breaking and law-abiding,young and aged, ‘‘worthy poor’’ and vagrants, sane and insane. In1736, the ‘‘Poor-House, Work-House, and House of Correctionsof New York City’’ was built in Manhattan. Elsewhere, poorhousesand houses of corrections also served as repositories forthe mentally ill. The founding of the Pennsylvania Hospital in1752 (with its special section for the insane in the basement) and in1773 the opening of the Virginia Eastern Asylum (the firstAmerican institution exclusively for mental patients) at Williamsburg,Virginia, provided crucial steps in a more humane treatmentorientation for the mentally ill. No special treatment for theelderly on account of their age, however, was instituted.Besides attempts to effect reforms to help the insane during theRevolutionary period (c. 1765–1820), a few Americans challengedprevailing beliefs. Dr Benjamin Rush, who joined the staff ofphysicians at Pennsylvania Hospital in 1783, became known asthe Father of American Psychiatry, in part because he advancedthe humane and intelligent treatment of the insane. In addition tostudying the effects of the moon on mental illness, Rush proposedthat ill women and men engage in meaningful work, a forerunnerof occupational therapy. He wanted patients to write down allthat troubled their minds. Rush believed in kind treatment:asylums were to hire intelligent men and women to attend thepatients. All visitors who had a disturbing effect on patients wereto be excluded.Rush’s views on mental health in late life are worth mentioning,because they anticipated later views and because so few of hiscontemporaries took an interest in the subject. Older people, hefelt, were naturally protected against certain maladies; madness,he observed, tended to attack mainly between the ages of 20 and50. In his Medical Inquiries and Other Observations on Diseases ofthe Mind 3 , Rush claimed that ‘‘the moral faculties, when properlyregulated and directed, never partake of the decay of theintellectual faculties in old age, even in persons of uncultivatedminds’’. Potential, not just decline, characterized even those past80 years of age.Ironically, the ‘‘enlightened’’ view that older persons did notsuffer as greatly as younger people from the scourges of mentalimpairment justified, for many Americans, the view that it wasacceptable to treat elderly persons who did need help as ‘‘invisiblelunatics’’. This perception was reinforced by two trends. First, inthe wake of the Revolution, a rising tide of humanitarianismdominated reformist thought in the early 1800s. Officials removedrestraints in mental hospitals in the expectation that more humanetreatment would facilitate recovery. This ‘‘moral treatment’’concept dominated psychiatric practice for over 20 years untilthe 1830s, when it was abandoned. Karl Menninger 4 attributes itsdecline to the influx of immigrants crowding the hospitals and theemergence of a new scientific perspective. Second, physicians suchas Dr Weir Mitchell and Dr Pliny Earle assembled a battery ofstatistics to convince the medical profession that mental illnesswas incurable 5,6 . If so, lifetime follow-ups would inevitablydisclose recurrences of mental illness in a patient. This prognosisstruck a death blow at moral treatment, and ushered in a long eraof therapeutic nihilism. ‘‘Psychiatrists tended more and more,’’claims Gerald Grob, America’s foremost scholar of the history ofmental illness, ‘‘to disregard the psychogenic aspects of mentalillness and to emphasize its somatic etiology’’ 7 .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