Two
Alzheimer's Hell
in which Alzheimer's is revealed as a metaphor for old age, senility has a history,; and the relation between witches and kings offers a subaltern physiology
No Aging In America! Leading Scientists Reveal
Well, at least you have a grandmother. Aline has Alzheimer's disease. It's like she's not even there. Enjoy your stay in Hollywood!
VALUE RENT-A-CAR SALESWOMAN HANDING ME THE KEYS AT FORT LAUDERDALE AIRPORT AND NODDING TOWARD MY GRANDMOTHER, AFTER I HAD COMPLAINED ABOUT THE WEATHER
"Dapper Dana Andrews' Alzheimer's Hell" screamed a 1992, headline in the Globe , an American supermarket tabloid.[1] I read the tabloids a lot when writing the first incarnation of this book, their lurid headlines scanned while I waited in line to purchase more caffeine and carbohydrates to fuel my scholarship. Old age was a frequent theme, particularly astonishing tales of age incongruities: centenarian men marrying young women, old women or young gifts giving birth, grandmothers (inevitably described as "grannies") doing daredevil acts. Amid this cavalcade, the Hollywood celebrity with Adzheimer's was a frequent figure. The 'Alzheimer's hell" article chronicles the transformation of the "dashing matinee idol" Andrews into a "pathetic victim of Alzheimer's disease"; the disease is described through a sequence of violent metaphors: mangling, ravaging. Below the headline, two cameo-style photographs of the former actor are placed side by side, with the caption "From this to this in 4 years." In both, Andrews is smiling and well-dressed. In the first, taken we are told when he was seventy-nine, Andrews has jet black hair and stares out at the camera, about to say something. In the second, labeled "his mind and body fail him," Andrews has a head of gray hair and stares off at an angle, looking as if he has just finished speaking. The only apparent signs of mind and body mangling are the hair color and the hint of speech, imminent or completed. Old old Andrews stares past us; we are offered no connection to him. He has already spoken; the wisdom of experience, the possibility on the opening lips of young old Andrews, has flown with the hair color. We are left with
a "pathetic, mindless shell," a truth rooted less in the devastations of brain disease than of a particular vision of old age
Why the turn here to American supermarkets and to Hollywood? The Simplest answer is that the tabloids form part of a disparate collection of texts and events that have helped me both unthink and rethink what is at stake in talking about Alzheimer's, senility, and attempts to improve the welfare of old people. For readers more in sympathy with the North American position at Zagreb than with the others (the Indian position or my own back row pretense of Archimedean distance), this unthinking may be necessary to grasp why the medical practices by which the behavior of certain old people has been comprehended and sometimes altered are locally and historically particular, their analysis exhausted neither by the very real biology of the brain nor the very real political economy of age, the family, professional knowledge and the state. The tabloids help me express why something like culture remains critical, and yet their silliness—a particular kind of irony—renders the whole project of stabilizing and systematizing culture slightly parodic, a necessary stance.
The following two chapters are partial efforts at such rethinking. This chapter isolates several particulars of an American sociology and a European history of senility, particulars that help me tell a specific story about conjunctures and debates in India. It is neither a comprehensive historiography nor a focused sociology of science. Such broader approaches are critical and, at the time of this writing, unrealized, but they are not central to the particular history of the present I am writing, a history in some senses about but never simply located in India. This is an anthropologist's book, and though it eschews the particular unities of either the monocultural or the world systems anthropological text, it nonetheless is rooted in an attempt to provide materials for a genealogy of tile particular[2]
The particular social facts most relevant to how I have chosen not to write about senility and Alzheimer's are the following:
1. During the decade of this project and into the short-term foreseeable future, there has been and remains no effective treatment for most degenerative dementias. Nor does a radical technical or conceptual shift in the treatment of the major dementias appear imminent.
2. As noted in the last chapter, the practices which materialize Alzheimer's and the dementias more generally tend to be attributional, involving two classes of bodies, those in which the disease is located and those (the "caregivers") in which the disease is publicly experienced, through which it is made to matter.
Each of these points will lead me to certain emphases and deferrals. In terms of emphases, I note the second point. Writing about Alzheimer's pushes me to examine the difference between these two classes of bodies and to think about other modes or axes of difference through or against which this difference between the diseased (and usually older) and the care-giving (and usually younger) may be framed. The axis of difference that I will foreground here as most useful to a his-
tory of senility is that of gender. Mutually constitutive relations between age and other axes of difference have already been suggested in the preface and introduction: the colonial, caste, and class difference rearticulated in the moment of the old woman of Balua, the religious difference deployed in the self-construction of working class Hindus on the boat, and the colonial and racial difference materialized in the figures of tropical ripening and softening.
Given the first point, I have chosen not to focus on the Alzheimer's gene, Alzheimer's mouse, or other sites of biological research[3] As the science of senility changes conceptually and technically, these sites will become more relevant to the kind of project undertaken here. Paul Rabinow draws on Baudelaire and Foucauh in cautioning students of science against the easy nostalgia and ressentiment of "despising the present[4] Though what constitutes nostalgia and ressentiment may not be obvious, depending a fair amount upon where one is sitting, the point is critical. I have no a priori interest in deconstructing Alzheimer's or in offering a nativist "Indian" category or conjuncture in its place. But both the stories of Alzheimer's in this chapter and of the Bad Family in the next are uniquely negative stories, about absence and difference, perhaps because they are so critically narratives of loss (of self, of material resources, of culture) and death. Similarly, J. P. S. Uberoi once offered a critique of an earlier version of this material, saying that it was so unrelentingly about negation, a sociology' not of reason but its absence.[5] Yet to the extent medical practice, and in particular the medicine of old age, is a social engagement less with recuperation than with loss and death, it may engage a peculiar type of negative reason and demand a peculiar sort of critical response.
Given these two points, we might say that practical knowledge of Alzheimer's is organized around two maneuvers. First, it involves an iteration of its pathology as opposed to its normality, despite the lack of a cure. Second, it involves a circulation : of legitimate suffering, between diseased and cam-giving bodies. These maneuvers, of iteration and circulation, will be important to keep in mind as the story I tell tacks back and forth between India and other places.
The tabloids I have been referring to are a particular subgenre of' American journalism that appears weekly next to supermarket checkout lines and in convenience stores and combines celebrity gossip with miracle diets, psychic predictions, and a steady reportage of the shocking and weird. Their language of extremity and excess has characterized presentations of senility in the United States that were far more highbrow during the decade (1985–95) in which I was actively engaged in learning about senility. Below I will move from tabloid sensationalism through mainstream journalism and into the language of dementia professionals, stressing the thematic continuities: how a culturally and historically distinct obsession with what the Globe called "Alzheimer's hell" informs more reasonable discourse.
Additionally I will use the tabloids as a shorthand for raising questions about American class consciousness and any attempt to articulate a cultural study in the
United States, even of the potted comparative sort that expatriate anthropologists implicitly engage in. Put simply, through their carnivalesque scenarios American tabloids offer ironic readings of the "leading experts" or "leading scientists" whose ubiquitous revelations suffuse the text but are never quite taken at face value, unlike the expert sound bites of more mainstream media. This irony is not simply the highbrow irony of kitsch, and it will help to trouble the certitudes of mainstream public culture and its partially manufactured consensus on how Americans think.
Finally, I will use tabloids themselves metaphorically, as a sign of the effects of a style of anthropological and social reasoning still prevalent in South Asian studies. The anthropologist's India has its tabloid quality, and its truths are often framed in terms of a similar straight-faced extremity. Graduate students who elect to study India are exposed to a discursive morass with its own hermetic logic, which generates carnivalesque truths that could appear, if there were but a market for them, on the covers of the Globe and its fellow tabloids: "Indians prefer hierarchy to equality, unlike modern French"; "Indians not individuals, leading scientists reveal"; "Indian men ruined by devastating childhood practices: their mothers split in two!"; "Bizarre Hindu village discovered where bodies are fluid," or "Secret pact between British and Brahmans discovered—it's all a colonial plot!" Still, this anthropological India is seldom just the sum of its colonial and postcolonial-rhetoric. It can offer the basis for a "good enough" engagement with the world out there, to borrow again Scheper-Hughes's phrasing of a response to anthropology's obsession with its own reflexivity. Like the tabloids as I read them here, the anthropologist's India signifies powerful truths through the very excess that renders it parodic.
Protesting too much, I return to the senility of the rich and famous. Andrews "can't remember a thing," "has like a five-second attention span and then he's gone," "doesn't know you've even been there," and "started getting lost." Deficits in memory and attention are the key symptoms of the mangling of minds. A 1990 article in the Star tells the same horror story about comedian Harvey Korman, who "mixes up his wife and kids," "began showing up uninvited at his former houses," and has "been knocking on neighbor [and ex-Charlie's Angel] Jaclyn Smith's front door and saying 'I'm home.'" The extreme forgetfulness elaborated in these articles is hell because it implies a loss of self. Not only are the "mindless" victims of Alzheimer's no longer the persons they once were, they are in a sense no longer persons at all. Mind and self come to stand for one another.
Again, the victim is not the one who suffers in this hell: "[T]he only blessing is that the horrible disease destroyed the actor's mind before he could realize what was happening." The disease was "harder on his wife and three grown children." The article suggests that Korman, confusing his wife with sex symbol Smith, could be doing far worse. The relatives are the victims, as in the case of Andrews's wife:
Just as painful was the effect Dana's disease had on his wife. ... She was forced to sell their luxurious $600,000 home in Studio City to help pay for her husband's care.
"It was a big life change for Mom when he had to go in," says Stephen. "It's a shock to the system to suddenly be on your own after all that time together with someone you love."
She had a big house to run without Dad around...."
Illness, Arthur Kleinman suggests in The Illness Narratives , may act like a sponge, soaking up meaning from the life world of the sufferer and recasting it in terms of itself.[6] Alzheimer's soaks up meaning less from the life of the initial "victim" than from those around him or her, casting all effort and experience of relatives—the "other victims"—in terms of the embodied signs of this mangling process. This exchange of symptoms—the body of the caretaker for the body of the Alzheimer's patient—dominates the middlebrow literature on senility.
Yet the irony of Alzheimer's—the suffering of the stricken brain being experienced primarily by those with brains intact—is in its tabloid version underscored by a deeper irony absent in middlebrow and expert versions, a hermeneutic of suspicion regarding the victimhood of rich relatives of famous people. Andrew's wife, forced to give up her then expensive home, becomes in a mocking gesture the poor little rich girl. Suspicion as to family motives mirrors another age-related tabloid genre: the violent contest between generations. Intergenerational squabbles, often invoking a negotiation over the prerogatives of an older generation refusing to hand over its authority; erupt in the tabloids in grotesque fashion. In a delightfully hideous Sun piece from 1988, a struggle over institutionalizing a seventy-two-year-old parent suggests that a family's putative suffering in the mode of the other victim may point to a desire for the old person's disappearance.[7] Tabloid irony forces open the question of King Lear —incoherent within middlebrow and expert variants of Alzheimer's—the question of the relation between a family's gerontocidal desire and the insanity of old age. Whence the loss of self?
The piece begins with an image of the old person as excessive wanderer, "lost 5 years," yet immediately this ubiquitous figure within gerontological literature is grotesquely transformed, the troth of her wandering revealed as lethal immobility.
Granny, Lost 5 Yrs, Found In Murphy Bed!—She Was Mummified
A woman's final trip to her old family home turned into a horrifying nightmare when she discovered her grandmother's mummified corpse stuffed into a folding bed—still wearing her favorite nightgown.
Police in suburban Liverpool, England, say Abigail Larson, 72, died when her fold-away bed—commonly known as a Murphy bed—lurched backward into its cabinet as she slept, pinning the gray-haired granny between the mattress and the wall.
As the granddaughter, the voice of both innocence and irony here, discovers that her wandering grandmother has never left home, she offers us a different trajectory for the old woman's movement, one in which wandering and fixity continually shift refarents:
Abigail's granddaughter, Janet Biggers, told officials she hadn't seen her grandmother for more than five years, and the family assumed the spunky senior citizen had run away after a bitter fight regarding their plans to put her in a nursing home.
"Grandma was starting to fail, and my mother-and uncle both felt it was unsafe for her to live in that big house all by herself," Janet explains. "Mother was especially fearful Grandma would fall down the stairs and hurt herself.
"However, Grandma couldn't stand the idea of selling the family home and living in a nursing home, and she told my mother so in no uncertain terms. She threatened to run away before she'd let them take her away."
According to Janet, the discussion ended on a bitter note, and several days passed before her mother decided to visit the stubborn old woman. But when she arrived, the house was empty and Abigail was nowhere to be found.
"We searched all over, certain she had fallen or hurt herself, but we couldn't find Grandma anywhere," Janet notes.
Mindless wandering may or may not be desperate running away; being stuck in a nursing home becomes being mummified in a Murphy bed. The desire by Larson's children to sell that big house and rid themselves of its burden affirms the disposable figure of the granny. The article evokes the image of Mrs. Fletcher, roughly contemporary with it, a figure from an American advertisement for a communication device designed for old people. In the ad, an old woman has fallen down and pathetically intones, "I've fallen and I can't get up." Repeating Mrs. Fletcher's monotonous cry for help briefly became an American national craze.
"We notified authorities she was missing, but they gave up looking after a couple of weeks. All we could do was hope she would call and say she was all right."
Five years passed, and Janet's family decided there was no use in hanging on to Abigail's three-bedroom home. "My mother cried when she called the real estate agent," she says. "It was one of the hardest things she's ever done. She knew Grandma would be furious, but after five years she felt she had no choice. The upkeep on the house was breaking us financially."
Here is tabloid irony the crocodile tears of the other victim: Janet's mother, all too eager to sell the family home in the first place, now can afford to wait five expensive years with Larson gone. Then, the final revelation:
Janet stopped by later to clean up and walk through the house one last time. On impulse she opened the folding bed in her grandmother's bedroom, and it was then that she made her grisly discovery....
"There was Grandma laid out flat, still wearing her favorite purple and pink nightgown. Her skin was withered and tough like leather, but other than that she looked as if she were still asleep. I guess the Murphy bed just flipped backward and took her with it.... "
With this inverted fall and the image of the dead granny, pathetically lost in her own home, among her own family, the embodiment of conflict shifts once again, from the fallen back to the lost and confused senile body:
Janet notes the family is saddened by her grandmother's passing, but relieved to know she isn't out in the street lost and confused.
"I'm just glad to know Grandma died in familiar surroundings," she declares. "I'm going to miss her a lot."[8]
The absurdity of this piece—suffocation in a Murphy bed transformed into a wholesome death in familiar surroundings—underscores the irony of intergenerational conflict. Care is interchangeable with control; the rhetoric of falling justifies institutionalization, but once Larson is lost and her children are free five years seem blithely to go by. Confusion and wandering are presented as far less dangerous than the lonely and deadly embrace of the family home, where Grandma can be missed because she is fixed, all too literally, in the plans of her children.
Alzheimer's, Subjectivity, And The Old West
I now begin the journey that will lead me into the sunset of my life. I know that for America there will always be a bright dawn ahead .
RONALD REAGAN, LETTER TO THE AMERICAN PEOPLE ANNOUNCING HIS ALZHEIMER'S
The multiple ironies that help sell tabloids were absent from writing on senility in the mainstream American press during the 1985–95 decade, but the same themes—the devastation of Alzheimer's and the transposing of the identity of its suffering onto family members—continued to be elaborated. Missing was a tabloid sensibility that the elaboration of the devastation and the suffering of family members were language games with potential winners and losers. The 1989 set of articles in Newsweek that I referred to earlier, collectively entitled "All about Alzheimer's," framed the disease through similarly violent imagery leading to an erasure of self: stripped of "every vestige of mind and identity," the primary victim simply "ceases to exist."[9]
The threat to selfhood posed by Alzheimer's within the middlebrow text remains dual, both the loss of self of the old individual and the loss of self of the other victim. Newsweek focuses on a seventy-one-year-old Boston woman, Ina, who from the start is represented through a series of losses: she forgets things, is "apathetic," "the logic is gone," "she has lost her sense of temperature," and so forth. These losses challenge our conception of a just world, placing the faux horror of the tabloid article within a far more impressive theodicy:
Her name is Ina Connolly. She is 71 years old and she is a victim of Alzheimer's disease. But that is not ali she is. She is also the mother of six grown children and the grandmother of seven. When her children describe their mother, they invariably mention her strength and her kindness. "She was the Rock of Gibraltar," says her son Frank, 34. "She was always doing things for people," says her daughter Kathy, 39.
But the disease that is slowly destroying Ina Connolly's mind is not a respecter of past deeds. It does not matter that, as a young girl growing up in Boston, Massachusetts, she helped to raise her seven brothers and sisters and that she took care of her
elderly mother. It does not matter that she was once able to fix plumbing, hang wallpaper and prepare a full dinner every night, while keeping six kids out of major trouble. It does not matter that she could once swim faster than anyone in her Family, that she secretly yearned to be a basketball star, that her late husband considered her the most beautiful woman he'd ever seen.
Alzheimer's is unfair . Within the late twentieth-century comparative aesthetics of the plague (until the advent of AIDS Alzheimer's was proclaimed the disease of the century),[10] Alzheimer's is framed as the disease that happens to good people. The contrast with AIDS in this moral sense is often explicit. Our sense of the tragic escalates through the portrayal of a kind of victim very different from the social portrayal of the AIDS sufferer: Ina is a mother, a grandmother, a sister, a daughter, a cook, a homemaker, a woman with secret yearnings, the most beautiful woman ever to her late husband.
The moral outrage the article invokes in its construction of Ina is immediately displaced onto the body of her family. Through the ever-present violent imagery, Ina shifts from being victim to victimizer. For her family, beyond the layered and tragic absences is an ever-present fear should "she ever became violent ... especially toward the baby [her granddaughter]." Ina is a physical threat to the body of little Amanda, as well as a psychological threat to the ability of her son Frank and daughter-in-law Mary Ellen to lead sane and normal lives.
The excess of Alzheimer's is structured not only as an explosion of violence but of time. Newsweek describes Alzheimer's as "a marathon," an "exhausting vigil" given bodies "who need to be constantly watched or restrained," an "ordeal," "round-the-clock," and most tellingly, an "endless funeral."[11] Such terms echo the title of the most well known American how-to book for families of persons with Alzheimer's disease and other dementias, The 36-Hour Day .[12] The suffering conveyed by such temporal language is not that of the old person, who is here the agent but not the subject of disease. What is lacking from the repetitive language of Alzheimer's is much of a sense of the subjectivity of the old person, his or her presence . The Newsweek articles center on "the other victims"; Ina's past self is displayed as an icon of family virtue, but the moral indignation around the unfairness of the disease glides quickly into the family's lament. The continually reiterated discovery of Alzheimer's journalism is that it is the caretaker who is the real victim. The endlessness and virulence of Alzheimer's is her experience.
What of the absent agent of disease? His or her incoherent voice as a person with dementing illness is offered in lieu of an attempt to acknowledge a subjectivity and distinct selfhood. All we know of Ina now is that she can't speak coherently into a tape recorder and claims to be the president of Harvard. The logic of the text denies any possibility of continuity and any meaningfulness in taking Ina—with all her confusion—as still fundamentally a person. All we are allowed to hear is a set of aphasic, confused, and angry sounds presented to us as the sum of Ina and thus confirmation of the death of selfhood.
Within much of the specialized literature, such as The 36-Hour Day , prepared
for families of persons diagnosed with Alzheimer's and other dementias, this erasure generates some reflexive concern. The 36-Hour Day begins with the story of Mary, a woman struggling to cope with memory loss and an increasingly confusing and terrifying world. Her story is prefaced by an admission of the different agendas of families and "sufferers":
Although this book was written for the families of people with dementing illnesses, we recognize that other people, including those suffering from these conditions, may read this book. We welcome this. We hope that the use of such words as patient and brain-injured person will not discourage those who have these illnesses. These words were chosen because we want to emphasize that the people who suffer from these conditions are ill, not "just old." We hope the tone of the book conveys that we think of you as individuals and people and never as objects. [13]
Unlike Ina, Mary as a person is not placed entirely within an idealized past. Alzheimer's is less of a totalizing construct—it neither stands for all dementias nor is it framed in as violent a language. The authors' goal, which they share with support groups like those of the Alzheimer's Association, is to help families through a reconstruction, rather than an outright denial, of the subjectivity of the person with the dementing illness. Perhaps the most compelling narrative of such a reconstruction is a 1994 film by Deborah Hoffmann, Complaints of a Dutiful Daughter , in which Hoffmann shows both the progression of her mother's dementia and of her own efforts to take care of the older woman and to cope. Like the tabloids, Hoffmann uses humor as a critical tool. Her story has an epiphany: before it, she is split between Sisyphean efforts to keep her mother, Doris, the same and a growing frustration at Doris's refusal to remain who she was. But she comes to realize that her mother is changing and to make sense of Doris's actions by learning to reconstruct continually who she is. Humor allows Hoffmann to read the absurdity of her mother's actions as the experience of a self in escalating flux, anti not as the extinction of self.
In practice, the reconstruction of subjectivity is a more contested process, and the best of intentions often produce troubling results. In one family support group meeting I went to, held at the offices of ADRDA of eastern Massachusetts in 1992, there were seven persons besides myself in attendance: a male neuropsychologist who was leading the group; a female nursing home administrator, setting up an "Alzheimer's unit"; four sisters in their twenties through forties, daughters of a woman diagnosed with Alzheimer's the previous year; and a woman in her fifties, married three years ago, who was taking care of a demented mother-in-law.
The meeting lasted over two hours. We each introduced ourselves, starting with the psychologist. Two of the daughters were married, the other two lived together, and their mother was shuttled between their three households. The four women had differences among themselves as to how their mother should be helped and responded to but seemed content to share the task of caring for and watching her. The fiftyish daughter-in-law was less comfortable with caretaking, feeling trapped
by her mother-in-law's illness ("It's disgusting, yes, that is just what it is, disgusting!"), her husband's inability to appreciate what she was going through, and the resistance of his family to putting the old woman into an institution. She told us that she had begun taking tranquilizers to cope. The nursing home representative and I introduced ourselves, and then the psychologist reintroduced himself, this time as a fellow family member of a person with dementia, and described several years of caring for a parent.
As in other support groups for secondarily victimized families, such as those set up for the family members of alcoholics, the process of each of us establishing our credentials as suffering caretakers—through a ritual of going around the room and revealing something personal—created what Victor Turner calls communitas , a temporary sense of community and shared purpose, allowing us to share intimate details and to reach new insights.[14] What differentiates the Alzheimer's Association from other such groups—which name themselves "Parents of," "Children of," or "Spouses of"—is the naming of this familial suffering not as adjunct to but constitutive of the experience of Alzheimer's itself. The organization is not Children or Other Relatives of People with Alzheimer's—it is, simply, the Alzheimer's Association. It is the absent victims, as in the introduction to The 36-hour Day , who are adjunct.
Following introductions, the psychologist introduced the agenda. The discussion was organized around a paired denial and reclamation of the absent victim's subjectivity. Our first goal was to regain control of our own lives, by recognizing dementia for what it is: the loss of self in the old person. Our second goal was to learn to communicate with the person with dementia, in effect by reconstituting a self. The first goal was achieved through an fairly exhaustive discussion by the psychologist of the pathophysiology of Alzheimer's and other dementias. Few questions were asked during this segment. Family members were interested, but did not engage this knowledge, nor did they try to apply it directly to their own situations. Its content as a statement was performative: the discussion did not seem to provide group members with much specific information, but its utterance reinforced their sense that Alzheimer's was something powerful, complex, and wholly other. It did this through the speaker's language, itself powerful, complex, and different from the language we were using as a group.
Given this performative structure, the psychologist's blurring of the nosology of dementia in his presentation was not surprising. He began by contrasting "Alzheimer's" with "pseudodementia," using the latter term to encompass all the potentially reversible dementias and not only those felt to be related to depression. Dementia was transformed from a clinical category into a specific disease through this equation of real dementia with endless suffering, and thus with the existential situation of these families. Multi-infarct and other less reversible dementias were briefly discussed, but despite their epidemiological importance did not carry the same semantic weight of virulence and chronicity as the plaques and tangles of
Alzheimer's disease and so were not elaborated upon. The performative usage of neuropathology was heightened near the end of this segment during a discussion of amyloid deposits. The daughter-in-law, whose open bitterness toward her mother-in-law made the synthesis between control and understanding the psychologist was striving for less appealing, broke in. "You talk about how this protein affects their brains. How about how it affects my brain!" For this woman, discussions of pathology did not engage her own victimization, but rather challenged its authenticity through impersonal medical language. Her goal, placing the origins of her victimization in the old woman's "disgusting" behavior and not in her body and brain, differed from that of the others at the meeting.
The presentation of neuropathology gave way to a discussion of how group members were making decisions and whether these were informed by an honest acknowledgment of Alzheimer's and its progression. Group members united in trying to convince the daughter-in-law that her husband needed to acknowledge the disease; she persisted that he was incapable of doing so. The group's sense that the common reality that "family members often refuse to acknowledge dementia" was at the root of the trouble was of limited success here; in a session "all about Alzheimer's," the relationship between husband and wife as the source of much of the problem could not be addressed.
The conflict between the received wisdom of the Alzheimer's movement and the complex needs of families was more acutely brought out in a debate between the psychologist and one of the unmarried daughters. The psychologist began by invoking clinical knowledge: persons with dementia are often disoriented and are further destabilized with a change of environment. He suggested that to keep shuttling the mother between her daughters was continually to disrupt her environment and do her no good. "For her sake," he suggested, "you need to make some difficult decisions."
Two of the daughters nodded assent. A third objected: "If we don't split the task of caring for my mother, one of us will ending up bearing all the burden; all of us have very busy lives. What you're suggesting means we'll end up putting her in a nursing home, which I don't think would be good for her. She knows each of us, and knows she's with her family. This is her life. That's what's important."
Debate continued along these lines. The dissenting daughter challenged the importance of tending primarily to her mother's cognitive state, viewing her within a network of relationships and through a life history. The psychologist continued to deny the legitimacy of the errant daughter's concerns, repeatedly restating the cognitive facts of the case and suggesting that the daughter needed to separate her needs from those of her mother by unselfishly institutionalizing the old woman.
He then continued with the second objective of the session. To understand and communicate with a demented person, he said, don't look to them but to yourself. Imagine yourself with the disease. "You have Alzheimer's disease. How would you
feel? How would you cope?" The empathetic technique of The 36-Hour Day is invoked, but within a two-part scheme. Only when family members have "acknowledged Alzheimer's," have denied meaningful agency and subjectivity to the person with dementia, can these be reintroduced through the superimposition of their own subjectivity onto the experience of the other: You have Alzheimer's disease.
Against the emphasis on "the other victim" I have been tracing, the seldom heard voice of the person with dementing illness surf aces at critical junctures. I mention two of the mostprominently featured voices. When Janet Adkins, diagnosed with Alzheimer's disease, succeeded in committing suicide as the first known beneficiary of Dr. Jack Kevorkian's "suicide machine" in the back of a van in a Michigan campground in 1990, her last utterance, thanking the maverick pathologist profusely, was widely reported.[15] In the media, Adkins's voice—her gratitude to the physician for terminating her endless funeral at its onset—was meaningful, and her actions could be placed within the context of her life as continuity:
Mrs. Adkins, who had greeted middle age by climbing to the top of Mount Hood and trekking in the Himalayas, had approached her death with the same zest and independence that she had shown during her lift.[16]
Only at the moment when the "Alzheimer's patient" removes herself from being a burden to family and society is her subjectivity acknowledged. In freeing us, she is granted personhood.
When Ronald and Nancy Reagan and their publicists reported the former president's Alzheimer's through a letter purportedly written by Reagan himself, the incident received enormous coverage and was repeatedly lauded as a selfless act of the couple (and especially Mrs. Reagan) in its popularization and destigmatizing of the Alzheimer's confessional. [17] Like Adkins, Reagan is presented in continuity with his pre-Alzheimer's self, and also like Adkins, the images used are those of the rugged American West and the gritty leather-skinned selfhood it is supposed to produce. In the brilliantly crafted letter, Reagan writes of himself riding off into "the sunset of my life."[18] The phrase, read by the news media as quintessential Reagan, collapsed the former president's future decline into a timeless image of the heroic cowboy. The future Reagan is narratively exhausted of any meaning but, rather than being read like Ina as an absence, is continually returned to this iconic moment of the ride into the sunset. In addition to erasing the future, and in a less visceral way than Adkins, Reagan ends the letter by elaborating the only real Victim of the illness, his wife, and by extension, the American people, acknowledging his sorrow at any suffering they may have to bear on his account but affirming their ability, as tough stock, to ride it out.
In the weeks and months prior to his admission of illness, Reagan's utterances had been read by the media as confused or as politically ironic: "Asked [around the time of Nixon's funeral, when Reagan's confusion was publicly noted] what Reagan had finally thought about Watergate, the epic scandal of this age, Reagan fell
silent. 'Forgive me,' he said, 'but at my age, my memory is just not as good as it used to be.'"[19]
But as soon as the whispers and allegations of senility, building on years of criticism by his opponents that as president Reagan was confused and forgetful, were recast as Alzheimer's, the possibility of irony vanished. Though his primary authorship of the letter is contestable, it was cast—in its clarity, its collapse of time and erasure of a future, and its elaboration of the trials of his caretakers—as the one authentic voice.[20] Despite occasional later and poorly publicized rumors (like that of Reagan urinating in the middle of a hotel lobby; surrounded by Secret Service agents keeping photographers at bay), the media respected and retained this voice as Reagan's last and truly presidential word. His back to us, Reagan retreats in silence. His heroism is epic, and in an age of identity through victimization his sacrifice inverts the classic Christian narrative: Reagan demands none of his own victimhood, and offers it all up to us, the nation as other victim. In granting us his suffering, we are redeemed: he rides off into the sunset, Nancy and we struggle through the endless funeral, and yet through the gift of his ennobling victimization he frees us: "I know that for America there will always be a bright dawn ahead."
In contrast to the redemptive aesthetics of the Alzheimer's victim removing herself, the daily experience of the demented person's family is read as Grand Guignol. When in Newsweek Frank and his sister redecorated Ina's bedroom, we learn that "it was an exhausting effort. They were often up late at night, cleaning out the closet and drawers full of the junk that had accumulated." And Frank laments the days when he could just up and leave his job for a month, hitchhiking around America and sleeping on the ground.
The suffering of families is intensely real. The difficulty of approaching the subjectivity of persons with dementing illnesses is enormous. But the intensity of this suffering and the enormity of this difficulty' are culturally constructed and elaborated realities. Frank suffers in large measure because of how he and his society experience the dependency of a parent: on its own terms, cleaning up Mom's bedroom should not be construable as the worst torture the twentieth century has had to offer, and yet here it is. Newsweek cannot reach Ina as subject because its writers share certain assumptions about what constitutes selfhood. The power of Alzheimer's as popular category lies in its expression of a structuring of social relations in which dependency is equivalent to the loss of identity. Ina's non-sense suggests a nonself. Selves, to remain selves, must account for themselves. Ina does not tell us who she is : she cannot be represented, save as an absence.
The second threat to selfhood that Alzheimer's has come to represent is the threat to one's autonomy when one's parents become dependent. Frank has a wife, a steady job, his own children, and other responsibilities, but it is his mother Ina who represents the image of his lost selfhood—figured as a solitary and quintessentially American journey away from home and into the West, sleeping on the ground—and not these others. If one's parents signify the point of departure for a selfhood experienced as a journey, parents who become seriously dependent
challenge the very essence of their children's selfhood, Frank's abandoned backwoods odyssey. The endless funeral is his, not Ina's.[21] Reagan remains heroic; Frank, unable to join him, must watch from Ina's bedroom.
The Geriatric Paradox
In calling such a theory a dogma we do not mean at all to disparage it, but rather to stress its scope and repercussions .
GEORGES CANGUILHEM, THE NORMAL AND THE PATHOLOGICAL (1943)
Despite the insistence of a few geriatric experts that Janet Adldns's future was not as unremittingly bleak as she, her family, and Dr. Kevorkian feared, the popular and professional construction of dementia has framed the case otherwise. Alzheimer's, though cleanly separated from old age by the force of the gerontological ideology that old age is normal, is continually and iteratively identified with the inevitable consequences of old age: decline and death. Alzheimer's comes to replace old age in the structural understanding of the life course . Old age is rendered "normal," freed from its inherent associations with decline and death, but in a paradoxical move that locates decline and death within a disease construct standing vigil at the borders of old age and negotiable only through the language of medical expertise and clinical enumeration: plaques, tangles, functional assessment, and mental status scores. The paradox of Alzheimer's reflects a larger paradox within the modernist understanding of old age, of growing concern in the 1990s, leading in turn for calls for a "postmodern" perspective on old age and even a "postmodern life course."[22] But plus ça change , as we shall see.
The Newsweek articles stress the need to "face the facts": Alzheimer's is fourth leading killer , there are few options for families, there are as yet no effective treatments, it ruins the brain. The articles again and again affirm the radical split of the pre- and postdiagnosis self, through the elaboration of the claim that Alzheimer's is not a normal part of aging. The third of the three Newsweek pieces opens with a picture of a neuropathologist holding a diseased brain up to the camera lens, summing up the essence of the disease. Alzheimer's is a brain disease; that it occurs primarily in old people is registered nonchalantly, as almost incidental.
The pathology of Alzheimer's versus the normalcy of old age is a foundational principle of the Alzheimer's Association and other advocacy groups. Yet in elaborating the enormity and ubiquity of Alzheimer's as plague, these groups unintentionally reaffirm its identity with old age. Newsweek differentiates Alzheimer's from old age by virtue of the former being fatal and incurable, as if death did not linger on the horizons of old age and as if aging, like pseudodementia, were reversible. In playing the numbers game—Alzheimer's as the nation's fourth leading killer, cutting down one out of ten Americans over sixty-five, nearly half of those over eight-five, and the majority of the superannuated—this literature affirms a commonsense view that Alzheimer's is obviously a matter of old age. The older you
get, the more likely you arc to have Alzheimer's: a fact the Alzheimer's advocates will not let you forget. From this to this.
Plaques and tangles form in all aging brains; memory loss occurs routinely in aging. "Benign senescent forgetfulness" (or BSF) emerged in the 1980s as the heir to senility's mantle of normal forgetfulness. Though benign and by definition normal, it remains a medical term. The line between the ambiguous normality of BSF and the unremitting pathology of dementia is itself not clear. How much forgetting is disease? How many plaques does it take?
In the face of this uncertainty, we might wish to locate the persistent and perhaps scientifically dubious search for the Alzheimer's gene and for other indelible and unitary markers to determine definitively who has or win someday have Alzheimer's and who does and will not: at once the hope for an eventual cure and an attempt to resolve the troublesome resistance of the normal and the pathological to remaining distinct from one another. On the day in 1990 when Janet Adkins's suicide was reported in the New york Times , another article appeared in the same paper on a "puzzling protein" that "shows up only in those with Alzheimer's." Researchers were attempting to locate the protein, at that point detected only in autopsy-derived tissues, in the cerebrospinal fluid of living persons to create a diagnostic test for the disease.[23] Other, less invasive tests have since been developed.[24] Presumably, such a test might have surprised Janet Adkins, revealing to her that she did not have Alzheimer's and sparing her and her family her decision to commit suicide; more likely, the test would have confirmed the diagnosis, and could spur many others at even younger ages to seek out Dr. Kevorkian or to buy and use Derek Humphry's best-selling how-to suicide manual Final Exit .[25]
Jaber Gubrium musters both neurological and fieldwork evidence to suggest that "it is not yet possible to dearly differentiate dementing illness from normal aging, and that the attempt to do so is a social construction to create order from the disorderly aspects of living with dementia."[26] Lyman has presented a comprehensive review of how the "biomedicalization of dementia" reifies as objective and necessary a way of looking at individuals grounded in particular relations of authority and control while it denies the relevance of these relations in the emergence and response to cognitive and behavioral change. In brief, she argues that "the myth of 'senility'" has been replaced by the "myth of 'Alzheimer's disease."' That is, the acceptance of the inevitability and normalcy of cognitive decline in old age has been replaced by a disease model that, even as it challenges ageist presumptions, pigeonholes individuals as Alzheimer's victims through the "ready acceptance by clinicians, service providers, and families of an oversimplified diagnosis and prognosis."[27] Like Gubrium, she questions the ease with which the Alzheimer's movement differentiates the normal from the pathological, and cites studies of institutionalized people considered troublesome wanderers to make the observation that individuals who continue to act as they did before being institutionalized, that is, by the "normal" rules of life outside the nursing home, pose a
challenge to institutional routine and are far more likely to be labeled as demented.[28] Medicalization, Lyman notes, "through medical labels, disease typifications, and medical authority, justifies control as appropriate treatment for the good of the patient."[29]
The maintenance of a sharp distinction between the normal and the pathological in the demarcation of and care for the senile body draws on a tension central to the discourse and practice of geriatric medicine. Like Alzheimer's disease, the explicit idea of geriatrics—of a branch of medicine and its allied professions devoted to the care of the old body—emerged early in this century. I. L. Nascher, a New York physician who during his medical training in the 188Os had been struck by the frequency with which more senior physicians used "It's just old age" to avoid disentangling the complex medical problems of elderly patients, coined the term in 1909 to parallel the nascent field of pediatrics. Nascher's goal was to demonstrate that old age was not equivalent to illness, and that the normal and the pathological were as distinguishable in old age as in younger adulthood.
Nascher later would retell the birth of geriatrics as the narrative of an epiphany, generated by an encounter with an old woman patient he had as a medical student. Visiting a slum workhouse with mostly elderly inmates, young Nascher and his medical preceptor are accosted by a woman complaining of her pain. The preceptor ignores the woman, and finally Nascher gets up the courage to ask why they are not trying to help her. "It's just old age," his preceptor explains. It is at this point that-Nascher recounts the realization that founded (and continues to dominate) the field: it's not just old age . In the declaration of old age's normality, Nascher has the vision of geriatrics.[30]
This separation of the normal from the pathological structures Nascher's founding text, Geriatrics . He separates the text into two sections: Physiological Old Age and Pathological Old Age.[31] His division draws upon a century of medical debate theorizing the relationship between the normal and the pathological;[32] in particular, Nascher draws upon some of the early work of the preeminent French physician J. M. Charcot. Charcot's 1866–67 Leçons Cliniques sur les Maladies des Vieillards et les Maladies Chroniques remained the preeminent text in the field and had been translated and made widely available in English.[33] Like Nascher, Charcot placed the origins of his interest in the old body in an institutional encounter with old women. Take away the employees, the lunatics, the idiots, and the epileptics, he reports noting to his students, most of the remaining residents at the Salpêtrière hospital (formally the Hospice de la Vieillesse-Femmes ) are old women of the socially least favored classes, presenting an ideal population for study.[34]
Charcot built upon the work of C. R. Prus, who had been the head of the medical service at the both the Salpêtrière and the Bicêtre (Hospice de la Vieillesse-Hommes ) in the 1830s and 1840s and who utilized the growing population of the institutionalized old poor in Paris to articulate a natural history of the old body in decline.[35] Prus wrote of the medicine of the elderly in the future tense: as modern,
yet unattainable; his declaration that "la médicine des vieillards est encore à faire " became an aphorism of the mid-nineteenth-century clinic.[36] Charcot's method of clinico-pathological correlation offered a realization of Prus's hope for the Salpêtrière and its human material. Old age provided a particular vantage onto the relationship between norms and pathology: "changes which old age sometimes induces in the organism sometimes attain such a point that the physiological and the pathological states seem to mingle by an imperceptible transition, and to be no longer sharply distinguishable."[37]
Charcot attempts to distinguish between the two; his focus, summarized in his title, is on pathology, and he interpolates from his delineation of the pathological to the possibility of a senile physiology. Yet the distinction is tempered by what for Charcot is the differand of the diseases of' old age: normal and pathological are not easily separable: they implode. Charcot's moral stance is not that different from Nascher's: against their neglect, the diseases of old persons need to be studied, understood, and whenever possible treated. But the system he creates is strikingly different, based as it is on his sense that a rigorous shepherding of bodily processes into the normal and the pathological is not useful in the study of old age.[38]
Charcot places old age at the limits of the project of contemporary Parisian medicine, as depicted by the historian and philosopher Georges Canguilhem. Canguilhem suggested that the mid-nineteenth-century European articulation of the normal and the pathological as "quantitatively identical" (the pathological being a state of excess or deficiency of the normal but not something substantively different) was of a piece with an era in which disease was denied its own separate reality: "The denial of an ontological conception of disease, a negative corollary of the assertion of a quantitative identity between the normal and the pathological, is first, perhaps, the deeper refusal to confirm evil."[39] In Charcot's framing of old age, the ontological conception of disease is not only denied but the quantitative identity of the normal and the pathological collapses altogether: at the margins of life, normality is excess or deficiency.
The historian Thomas Cole, in his discussion of early to mid-nineteenth-century hygienic perfectionism, offers a somewhat different reading than Canguilhem of a related denial in the American construction of the natural death, the "broader cultural effort to eliminate death as a force in life and to remove both the pain and preparation previously considered essential to dying well." Cole charts the ascendancy of a national ethic of self-reliance and the transformation it necessitated: "But how could the ideology and psychology of self-reliance be squared with decay of the body? Only by denying its inevitability and labeling it as failure."[40] The denial of inevitable decay takes a different form in the later nineteenth century as old age becomes the site of scientific management. A language of perfectionism gives way to one of normalization.[41]
Canguilhem suggests the partial reemergence, in late-nineteenth- and early-twentieth-century Europe and America, of an ontological conception of disease,
linked both to shifts in the understanding of infectious disease and neurology and to the violent laboratory of the First World War. Geriatrics emerges not only, as Cole suggests, within the context of the denial of decay, but additionally as disease comes again to take on a qualitative distinctiveness. The difference between the nineteenth-century Charcot, who saw himself as able to collapse the normal and the pathological in old age, and Nascher, who in 1909 attempted unsuccessfully to separate them and to offer disease in old age an independent ontological status, is in this latter context striking.
Nascher begins with the assumption that old age itself is normal. In the section of Geriatrics devoted to physiology, he attempts to quantify the bounds of the normal in old age, system by physiological system. He then moves on to pathology, where he catalogues the diseases of old age. But though the book is divided neatly into two parts, the same symptoms, syndromes, and processes are frequently described under both headings. The division between the normal and the pathological, though carefully nurtured, seeps, leaks, and eventually collapses. Unlike Charcot's Leçons , where the collapse is taken as the point of departure in studying the old body, in the foundational text of American geriatrics the central figure of normal aging runs counter to the demands of its content.
The difficulty of maintaining the separation and Nascher's efforts to do so characterize his writing on dementia as well. Like Charcot, Nascher associates clinical dementia with the pathological finding of cerebral softening, but he is careful to differentiate softening as pathology from softening as "normal senile degeneration." Clinically, however, the distinction between the two states in Geriatrics is unclear, and neither is described in a normalizing language. Ultimately, Nascher must collapse the two, as distinct causes of a single clinical entity, "primary senile dementia."[42]
To maintain a pathological reading of senility, Nascher draws upon a plethora of competing and complexly interlocking concepts coming out of the late nineteenth and early twentieth century. His resulting typology—softening, arteriosclerosis, psychosis, and atrophy—is an attempt to unite these dominant theories of the diseased old mind against some notion of the mind's normal aging.
Softening we have encountered already, in relation to its penchant for the tropics. Descriptions of the "very soft and liquefied" brains of persons who had died with diagnoses of apoplexy or palsy frequent early-nineteenth-century discussions of neuropathology and continue to be used into the twentieth.[43] Léon Rostan wrote Recherches sur le Ramollissement du Cerveau in 1823, analyzing the relationship between apoplectic events, mental symptomatology, and le ramollissement , or softening, through examinations of Salpêtrière women and autopsies of their brains. Unlike the later Salpeêtrière physicians Prus and Charcot, Rostan does not center his researches on the old age of the female cadavers he examines. "Senile dementia" for Rostan, like "mental alienation" more generally, is one of several signs of latent softening in the absence of apoplexy.[44] Dora Weiner has discussed the Revolutionary shift in the formal status of Salpêtrière inmates from indigents to citizen-
patients under the liberal welfare regime of Philippe Pinel, noting the famous physician's attention to the age-specific illnesses of the primarily elderly inmates of the hospital. That the old age of the citizen-patient could be noted and treated was an effective sign of the scope of Pinel's humanism, but the old body and cadaver for Pinel and Rostan were not the sites of the limits of normalization as they would become for Charcot.[45]
Rostan noted that softening was a problem of climactic extremes, most prevalent in very hot or cold climates, but British approaches to the gross pathology imported from France differed. Softening of the brain as a general figure of lay and medical speech did accord well with mounting concerns over the effects of the tropics on European constitutions. Yet as the formal collection of medical statistics became a critical component of colonial administration,[46] London-based physicians like Richard Rowland could reread the tropics against the rhetoric of softening: "Cerebral softening does not appear to be a prevalent affection in warm climates. The Army Medical Reports rather lead to the conclusion that it is less frequent in those latitudes than with us." Rowland's understanding of the temperate and arctic spaces of softening is not simply his reading of available quantitative data, however; it accords with his sense that palsy and apoplexy, the two clinical states correlated with softening, are nervous affections more likely to occur in modern urban settings and among professions involved in mental labor.[47]
J. Hughlings Jackson in 1875 criticized the nonspecific use of softening and the tendency to equate it with general atrophy- of the brain. Softening is local necrosis of brain tissue and its causes are arterial. Attempts like Rowland's to see primary nervous symptomatology as the cause of softening reverse the causal equation. The key to the study of softening is the careful study of the arterial system and its pathology.[48]
Arteriosclerosis , leading to diminished blood flow and increased pressure with effects independent of strokes and hemorrhages, was the second of Nascher's categories; by the early twentieth century, it had become a ubiquitous concept for explaining the changes of aging, so often invoked that its use had become the subject of conscious irony.[49] Like softening, arteriosclerosis had particular resonance for tropical bodies. Both Emil Kraepelin's modernist psychiatric nosology and Eugen Bleuler's later revision examined the relationship between arteriosclerosis, insanity, and heat. Hot climates, hot baths, and the like make blood rush to the head, exacerbating the diminished elasticity and self-regulation of arterial vessels in old age and potentiating not only the likelihood of softening, but more diffuse tissue damage leading to "arteriosclerotic insanity."[50]
Psychosis : Nascher drew on a third set of ideas, engaging the language of madness as primary, independent of softening, arteriosclerosis, or atrophy in framing senility as senile insanity or senile psychosis . Preventing or at least forestalling senility was one of the preoccupations of the nineteenth-century concern with moral hygiene, manifest as two contradictory strategies, a conservation model stressing rest and the prudent expenditure of nervous energy and an activity model stressing continual exercise of the mental faculties.[51] Both strategies drew on a set of ideas
about involutional psychosis and the senile climacteric that structured the onset of old age as a dangerous passage that must be negotiated with forbearance and moral strength to avoid a decline into senile pathology.[52] Both strategies stressed the need for order, and both extended a tradition that looked to Roger Bacon's thirteenth-century exposition on the prevention of old age through an ordered life, translated by the seventeenth-century English physician Richard Browne and frequently reprinted.[53]
Against the moral hygienic discussion of madness as the failure of order and appropriate behavior in old age drawing on traditions of prolongevity is an equally venerable argument that senility is inevitable. Against Browne, another seventeenth-century text frequently cited over the subsequent two centuries is the English physician John Smith's exegesis of the twelfth and final chapter of Ecclesiastes. Smith's reading is lengthy, and complex; its gist is an interpretation of the Biblical chapter as a fairly exhaustive and anatomically detailed description of the physical changes of old age: the decrepit body as memento mori. Moral order can not forestall the process; rather, the process signifies the need for a moral order outside and beyond the body.[54] This other moral economy of old age is deemphasized during the nineteenth century, as Cole suggests, but it does not disappear. The different gerontologies of Browne and Smith are both drawn into later formulations.
In the mid-nineteenth century, the Scottish physician Maclachlan juxtaposed both approaches in noting that, despite inevitable bodily decay, old people are often the wisest in a society. From this observation he suggested that the brain and the rest of the body decay at different rates. For Maclachlan, the brain's staying power lay in its close relationship to the mind and the soul. He combined a moral hygienic with an arteriosclerotic model: mental distress in most older people, he argued, is either a derangement of character brought on by poor moral hygiene or a disease process, such as softening. However, Maclachlan had also to confront the eventual decay of all flesh, and he posited a two-stage model. Whatever the status of its moral economy, ultimately the brain in extremis must decay: "All flesh is grass, but thus the immortal portion of our nature asserts its independence, and long outlives the decay that surrounds it. A period generally arrives, however, in the progress of years, when, like the frame itself, the intellectual faculties betoken the destructive effects of time."[55] Moral decay, pathological disease, and normal degeneration are all accommodated. The maneuver, to resolve a debate around the pathology of behavior in old age by splitting the life stage into two halves, younger and older, became a frequent structural response to the difficulty of constituting norms.
The opposition between the moral and the degenerative was recast with the emergence of a biological psychiatry. The relation between senile insanity and senile dementia concerned Kraepelin in the formation of his classification of mental illness, ancestor of both the DSM and ICD series. For Kraepelin in 1904, what was translated as involutional melancholia was a psychosis setting in "at the beginning
of old age in men, and in women from the period of the menopause onwards.... About a third of patients make a complete recovery. In severe and protracted cases, emotional dullness may remain, with faint traces of the apprehensive tendency. Judgement and memory may also undergo considerable deterioration."[56]
This psychosis retained traces of its climacteric origin. It is a state passed through, not necessarily an endpoint, and it can be treated and cured. Against the generally good course of involutional insanity, the state of senile dementia or senile imbecility has a poor outcome. Both involutional psychosis and senile dementia were for Kraepelin secondary to "the general failure of strength and vitality in old age ... a time when the power of resistance is reduced."[57] Dementia differed from involutional psychosis clinically in its more variable and labile affect, increased hypochondriasis, and the significant loss of short-term memory. Kraepelin, structuring his nosology through behavioral rather than other clinical or pathological criteria, had far less difficulty than Charcot or Nascher in separating the normal and the pathological. The critical and difficult boundary, for him was between varieties of the pathological, between acute psychiatric illness (insanity or melancholia) and chronic neurological illness (imbecility or dementia).
Insanity, rooted in the reversible and morally weighted effects of a weakened person's melancholic response to the irreversible involution of old age, remains part of Nascher's typology.
The language of the climacteric and of senile involution will be discussed below in terms of the relation between the "senile" and the "female" climacteric; here I would note the late-nineteenth-century emergence of involution as a critical site for the incorporation of Darwinian ideas into discussions of old age. The gross anatomical term involution , a structure turning in upon itself, comes to take on a teleological cast in the mid-nineteenth century primarily in discussions of the involuting uterus as a metonym of the aging woman whose purpose has been fulfilled.[58] The site of involution in succeeding decades both expands to define the old body more generally and diffuses to describe the cellular and subcellular atoms of decline.[59] Involution as a figure comes to embody the late-nineteenth-century reading of moral hygiene, no longer a perfectionist vision of prolongevity but a process of evolutionary' triage in which the old must pass over social and reproductive privilege to the young for the sake of the species.
Nascher's own prewar writings on involution and the climacteric engage a cavalcade of social types, stereotypic depictions of classes, genders, and professions, and their moral ability to negotiate the onset of old age.[60] The old person who has failed to accept old age and act accordingly is framed as hypersexual and pathetic, in the tradition of Renaissance and Restoration pantaloons and bawds, but representing a greater and increasingly eugenic threat. Physicians, not the least of whom was Alois Alzheimer, were being drawn into debates over the dangers of particular classes of persons to the species (and in some settings, to the race) and over the evolutionary meaning of bodily weakness.[61] Following the First World
War, most American discussions of involution centered on the presumed peri- and postmenopausal insanity of older women, but eugenic concerns remained. The pathologist Aldred Warthin, in his 1929 book Old Age: The Major Involution , argued that human development represented an energic balance between growth and involution and cautioned against efforts to disturb this balance by extending the afflicted lives of the oldest old. Warthin differentiated the minor involutions of pre- and postnatal growth, necessary for the survival of the individual, from the major involution of old age, necessary for the survival of what he alternately called the species or the race. Warthin's energics were based upon an understanding of the body as a machine for the propagation of germ plasm through time. In old age, "the individual human machine has fulfilled its function, and, now useless, stands in the way of the progressive evolution of the species.... The Universe, by its very nature, demands mortality for the individual if the life of the species is to attain immortality."[62]
Warthin's explicit concerns were the energy depletion resulting from an aging population and the lowered adaptability of a senescent and backward-looking race, not the explicit degeneration of the germ plasm resulting from aged semen. Yet his book was particularly concerned with a sexualized vision of the old and mortal versus young and immortal bodies. Scientific photographs of naked men, primarily black-and-white full frontal shots, are interspersed through the book. The accompanying descriptions focus on the face and posture, but the photographs themselves additionally present a progression of visible penises. The "lad of eighteen years" stares optimistically upward into the distance, his body thrust forward in anticipation of the future; the "youth of twenty-two years" stares more noncommittally ahead, his body erect. Further stages follow, until one reaches the "father of eighty years and son of thirty-seven years." Both men are standing side by side, naked, with the son's pulled-down pants visible at his ankles. The text notes: "[T]he weary, worn-out machine of the old man contrasted with the insolent aggressiveness of the son at the height of maturity tells the story of the meaning of involution and old age more effectively than any detailed scientific description can do."[63] The unspoken juxtaposition of father's and son's nakedness tells a slightly different story that presumes an interested observer. The hygiene of involution has shifted into a new moral vision of immortal and insolent male bodies.
Atrophy is the fourth of Nascher's considerations. Like Maclachlan and Kraepelin, Nascher positioned irreversible atrophy in late life, against other causes of behavioral change in those less superannuated. Atrophy provided the greatest challenge to the distinctiveness of the normal and the pathological. Even with normal aging, things eventually fell apart. A more clearly pathological understanding of atrophy developed through the work of Alois Alzheimer, a German neuropathologist. Although Alzheimer first located his plaques and tangles in the "presenile" brains of individuals in their fifties and was far more interested in the problem of presenile dementia, within a decade of his initial 1906 report many
European and American pathologists had gone on to note similar findings in senile brains and to suggest a single pathological process across the life course.[64]
Though described as both presenile and senile, Alzheimer's disease did not supplant arteriosclerosis, psychosis, softening, and normal aging as a critical concept in the study of senility. The diagnosis remained "nearly medically dormant until the 1960s";[65] arteriosclerotic models dominated, along with the emergence of a pharmacotherapy based on a class of drugs marketed as vasodilators, which, given the dominant paradigm, were intended to open up arteries to get more blood to the brain. Despite the many studies following immediately upon Alzheimer's own work suggesting that his findings also might explain senile dementia, the model was left largely alone for half a century. Patrick Fox has traced the role of a "handful of neuroscientists' and of the infrastructure of the National Institutes of Health in mobilizing resources for the creation of a popular "Alzheimer's movement" in the United States in the 1960s and 1970s.[66] By the 1980s, with the exception of multi-infarct dementia, vascular models were all but passé,[67] Vladimir Hachinski being all but the only North American who advocated retaining some concept of limited blood flow in the study, of senility; in the 199Os a variant of vascular dementia had returned to acceptability.
Nascher's book was retitled The Care of the Aged by his successor, Malford Thewlis. "Geriatrics" remained a seldom used neologism in the country, where it was' coined until after the Second World War, and large-scale subspecialization did not emerge until the 196Os and 1970s. The term began to return to vogue when the same images that dominate Nascher's retelling of the origins of the term—institutionalized old bodies and an unhearing medical profession—began recurring with great frequency in the American press and in many books "exposing" the situation of old people.[68] Against the ageism of physicians and institutions in an antipsychiatric era, geriatrics' offer of "normal aging" against "It's just old age" emerged as a powerful tool to demedicalize old age. The Alzheimer's era represented a shift in the negotiation of the divide: old age was declared to be entirely normal; benign senescent forgetfulness was offered to neutralize the ambiguity of normality and then allowed to drop out of sight. Those relegated to the victimhood of Alzheimer's now had to bear the dehumanizing brunt of a total and unquestionable pathology Far from demedicalizing old age, geriatrics' insistence on normality instantiated a far more totalizing medical regime.
From its inception, geriatrics presented a paradox—a field insisting on the normality of old people but constructed through their differentiation and isolation, defining them as distinct from adults and requiring a separate and ancillary profession modeled on the care of children. The paradox is evident in both the politics of geriatric practice within the tertiary hospital setting and in the internal contradictions that define the geriatric body as a locus of knowledge.
The language of "normal aging" is critical in gerontological and geriatric training; my field experience here is based on my own training from 1982 to 1986
in geriatric medicine, social work, and nursing home work, and on formal fieldwork with geriatric professionals in hospitals and nursing homes in Boston. In a session I attended as a student, a geriatrician at a community hospital was trying to teach medical students about "normal aging." Most of the students resisted her. If old age is normal, why are old people so frequently hospitalized? Why is so much of internal medical practice geriatric?
The physician persisted; she was used to the objections. Old people often have more health problems, but these are diagnosable and mandate therapy; too often, a physician focuses on a limited differential for the chief complaint when a patient's multiple problems, social situation, and often multiple medications may have direct bearing on etiology, diagnosis, choice of therapy, and outcome. The class was unimpressed. Yes, these are all to the good, but what is the point of all this talk of normal aging if geriatrics is invoked precisely to treat complex pathology? Most students left the meeting without a sense of what defining old age as normal offered. The physician's invocation of the geriatric paradox had deflected her message about the need to rethink the goals of internal medical practice.
Internists and other specialists in Harvard hospitals throughout my own training often remarked with both humor and scorn, "There's no need for geriatrics; internal medicine [or neurology, etc.] is geriatric medicine." House staffand medical students were usually discouraged from seeking geriatric consults; when these were sought, the recommendations of the geriatric team were usually criticized as impractical and having little bearing on what were seen as the critical medical issues: "So they take off a drug or two, big deal." Despite the increasing routinization of geriatrics as a certifiable specialization within American medicine, its legitimacy among tertiary care physicians remains marginal.
Such marginal status is a pity, for the hospital practice of internal medicine remains profoundly ageist, characterized by the rich and well-documented language of "little old ladies," "gomers," "flogs," "slugs" and so forth (institutional elaborations of Mrs. Fletcher, the "I've fallen and can't get up" lady), by the Sisyphus-like determination of many house staff to get patientsoff the service and their consequent resentment of the immobility of sick elderly, and by the almost reflex obsession with obtaining DNR (do not resuscitate) statuses on old patients from them or their relatives. Amid such a milieu, where old bodies often challenge the smooth functioning of house staff practice, the geriatric aesthetic of normal aging does not engage the agenda of house staffnor does it offer a coherent challenge. Geriatric ideology subverts its own goals.
Oublier Postmodern Aging
When I first wrote a draft of this section, in 1991, there did not seem to be many critical voices raising similar concerns. Within American medical anthropology, gerontologists took on the project of geriatric normality with little apparent reflex-
ivity, discovering in other cultures oases where the words of Nascher's preceptor, "It's just old age," could never be uttered meaningfully.[69] But the 1990s has seen an efflorescence of a self-consciously critical gerontology.[70] Much of what I am arguing here has been already (and often far more elegantly) put forward. One variant of this turn has been a move away from the normalizing language of the Nascherian epiphany to a recognition of geriatrics' silencing of the existential and embodied abnormality of the last years of the longest human lives. Several scholars have called this a "postmodern" recognition: Cole has charted the move from the modern construction of old age—in terms of liberal capitalism, ideologies of self-reliance, retirement, and the scientific management of aging and both its perfectibility and normalization—to the postmodern, through the failure of liberalism, renewed alarmism about an aging population, the rejection of Nascherian dualism, and the return to a dialogue with death and an ars moriendi .[71]
But there is reason to pause. The rise of critical gerontology in the United States—and of its recognition of the medicalizing and dehumanizing dualism of the geriatric paradox—comes precisely when the political economic apparatus that funds most gerontological research is looking for ways to demedicalize, to deinstitutionalize, and more generally to defund the care of older persons, the majority of whom are not wealthy and face not the withdrawal of futile but of needed health resources. In the United States, the policy debate of the 1990s brings together ethicists like Daniel Callahan who question how much futile medical care a society should be providing the oldest old[72] and political initiatives to cut Medicare and Medicaid without serious attention to the intersection of age, class, race, and gender.
The response of American gerontology, to the paradoxes of its normalization has traditionally been and continues to be the splitting of old age into ever finer categories: the "young old" versus the "old old," "successful aging" versus "the frail elderly," and so forth. Nascher's failed effort to separate out the normal from the pathological is realized by splitting the objects of inquiry and policy into those defined by their normality (and not coincidentally by their constitution as a market segment) and those defined by their pathology (and not coincidentally by their constitution as an economic liability). Within the logic of such a split and its ever more trenchant rematerialization of failed efforts at normal aging as the dehumanized domain of Alzheimer's disease, the "recognition" of the profound ambiguity of old age seems less postmodern revelation than the latest turn of the screw by the professional compradors of gerontology, what I have elsewhere criticized as the "trope of ambiguity" running through much gerontological anthropology.[73]
To find a language to write about old age that fetishizes neither essentialized normality nor essentialized ambiguity, I want to move back a step and examine age itself, as a particular kind of difference made to matter in terms of narratives and practices constituted in terms of other culturally available kinds of difference. To make my meaning clearer, I begin by articulating a provisional European genealogy of senility. Why should it be interesting that the emergence of things like
dotage, the senile climacteric, and Alzheimer's disease as medical problems is rooted in discourses of and debates on the bodies of women?
A Witch's Curse
That it was an old woman who inspired Nascher's epiphany recalls Charcot's rationale for his own interest in old age, the ready material of the many old women of the Salpêtrière. The institutional availability of certain types of bodies differs as an origin story from Nascher's rite of discovery but informs a reading of the latter: concern for the old person in Nascher's case is similarly predicated on her institutionalized immobility. What is the relationship between this recurrent figure of the old woman—the much abused "granny" of popular myth—and the universal old person who is the object of geriatrics?
The relationship might at first seem a result of demography and of the effects of patrilineal household structure: if women live longer and there are more old women than old men, and if old men are more likely to retain property, to remarry and to be able to depend on children and others—and thus less likely to be institutionalized—the recurring old woman of the geriatric text reflects little more than the demographics of old age and the political economy of the household. Women's bodies, however, are notoriously good for men to think with, and I want here to examine briefly three moments in the history of the senile body in western Europe and the United States: the medicalization of the dotard, the rise and fall of senile climacteric, and the question of Alzheimer's women.
Dotage and senility enter medical discourse in Europe as juridical entities—things about which the physician can claim not only knowledge but authority from the state—through an appropriation of the body of the middle-aged and older woman from the gaze of the Inquisitor. Sixteenth-century physicians like Johannes Weyer and Reginald Scot argued that most of those burnt as witches under ecclesiastical authority never did the evil deeds to which they had confessed but were, whether they were possessed or not, melancholic, decrepit, and doting old women. Demonic possession was not ruled out, but was replaced by doting melancholy as the subject of medical—and state—concern.
Weyer, in a letter to his patron Duke William of Cleve accompanying publication of his De praestigiis daemonum , makes the juridical content of this new dotage explicit:
To you, Prince, I dedicate the fruit of my thought. For thirteen years your physician, I have heard expressed in your court the most varied opinions concerning witches; but none so agree with my own as do yours, that witches can harm no one through the most malicious will or the ugliest exorcism, that rather their imagination—inflamed by the demons in a way not understandable to us—and the torture of melancholy makes them only fancy that they have caused all sorts of evil. ... You do not, like others, impose heavy penalty on perplexed, poor old women. You demand evidence.[74]
Weyer returns to these women throughout De praestigiis daemonum . George Mora has catalogued his descriptive terms: "raving, poor, simple, useless, ignorant, gullible, stupid, vile, uneducated, infatuated, toothless, silly, unsteady, decrepit old women."[75]
Weyer details innumerable case histories of alleged witches. They are unpleasant tales. An eighty-year-old woman is accused of practicing enchantments. Suspicion is confirmed when her son gives her a packet of earth so that she might free herself of her chains. Weyer goes to meet her. Though she frequently "seemed to fall into a state of unconsciousness," she managed to explain that the packet was in fact linen, to tend to her ulcerated legs, injured when earlier inquisitors had poured boiling oil on them to generate a confession.[76] Other women are far less lucid, a state that, though indicating a state of sin, implies no threat to any save themselves: "Certain deluded old women ... their brains—the organs of their thoughts and imaginings—so firmly ensnared by rare and deceptive phantasms and forms because of their unbelief ... that they know of nothing else."[77] Weyer invokes the authority of medicine not to deny the relation of sin to behavior, but to transform its valence from threat to pathos.
In England, Reginald Scot invoked melancholy more explicitly in his 1584 work, The Discoverie of Witchcraft . Scot places accusation in the context not of the evil Inquisitor but of daily life in the community: these women are not witches, but melancholics, and their lack of control over their voice raises the suspicion of others when misfortune strikes.
See also what persons complaine upon them ... waie what accusations anti crimes they laie to their charge, namelie: She was at my house of late, she would have had a pot of make, she departed in a chase bicause she had it not, she railed, she curssed, she mumbled and whispered, and finallie she said she would be even with me: and soone after my child, my cow, my sow, or my pullet died, or was strangelie taken.[78]
Scot's attentiveness, like Weyer's, is to the voice of the supposed witch. The identity of witches and women, in the Inquisitorial handbook Malleus Maleficarum of 1486, the embodiment of a woman's carnality and weakness, is in her "slippery tongue."[79] Scot resists explaining the tongue in terms of womanly nature. He invokes a catalog of decrepitude similar to Weyer's:
women which be commonly old, lame, bleare-eied, pale, fowle, and full of wrinkles; poore, sullen, superstitious, and papists; or such as knowe no religion: in whose drousie minds the divell hath goten a fine seat. ... They are leane and deformed, shewing melancholie in their laces, to the horror of all that see them. They are doting, scolds, mad, divelish. ...
These miserable wretches are so odious unto all their neighbors, and so feared, as few dare offend them, or denie them anie thing they aske.[80]
The impossibility of hearing the old woman's request as just that—a request—is central to Scot's analysis, as in the example of the indigent woman coming over to borrow milk. Women accused of witchcraft in England and the English colonies
in America were often solitary, indigent, and dependent on the charity, of neighbors for survival. Alan Macfarlane's 1970 study of witchcraft accusations in the English county of Essex in the sixteenth and seventeenth centuries suggested that the rise of accusations should be understand in the context of shifting definitions of community and the delegitimation of the old woman's claims on her neighbors' resources. The powerful and increasingly angry voice of the indigent older woman demanding what was less and less her due became increasingly unhearable and incoherent.[81]
I do not wish to argue that most, or even some, of the accused witches were demented. The "old women" of these catalogues were not necessarily over sixty; the qualities ascribed to them are numerous. Diverse persons were vulnerable to being named witches. And "melancholy" has many associations. The point is simpler: medical authority, in conjunction with the prince, is invoked to define the signifiably old body when that body is female. Doting, melancholy, and demanding voices of old people are otherwise no strangers to Renaissance texts—Lear has come down to us with all his rage intact—but these voices are heard differently across gender. Lear may rail, but his is an abject voice. The old woman's curse, however, is powerful and must be contained. In the efforts of Weyer and Scot, medicine is invoked to defuse the threat and appropriate the voice. Before Scot's Discoverie and since, English physicians writing as natural theologians or philosophers would detail the signs of dotage and decrepitude as memento mori or social commentary; but in the doting voice of the old witch, medicine claims a different kind of knowledge and hails a different sort of old body.
The Senile Climacteric
The rediscovery and elaboration by Renaissance authors of "the dangerous graduall yeares, called climactericke," seldom referred to the bodies of women.[82] Climacterics were periodic points along the life course—at ages that were usually multiples of seven or nine—when the body was particularly susceptible to humoral excess and its accompanying emotion and morbidity. The ungendered (and thus inevitably male) climacteric continued to be cited well into the nineteenth century, the Irish physician Kennedy remarking in 1844 that
from the time of Galen to the present period it has been nearly universally believed, that certain epochs of human life are very liable to be accompanied by disease of a certain character. A good deal of trouble has been taken to ascertain at what exact periods of life such a disease shows itself, and particular years, such as the forty-second and sixty-third, have been determined on: the latter of these periods has indeed been called the grand climacteric, as being the time above all others when the disease is apt to declare itself.[83]
Increasingly for nineteenth-century analysts, the existence of this grand climacteric and in particular the usefulness of its particular multiplication of sevens and nines was questionable. Kennedy himself concludes the above description by not-
ing that "in the cases of climacteric disease which have come under my own notice, I have not been able to confirm any of these points. ... " Well before Kennedy's time, the ungendered grand climacteric was becoming less tied to the chronological precision of a magical multiplication of sevens and nines and more to the emerging and gendered obviousness of what grew increasingly medicalized as "the menopause."[84] On the one hand, the life course is disenchanted through a process of its rational feminization. On the other, the shift reflects the larger transformation Thomas Laqueur has suggested in European medical constructions of the sexual body, from a unitary anatomy in which the female body is a partial or degenerate but not qualitatively different variant of the male to a binary anatomy in which male and female bodies are mirroring opposites, qualitatively different things.[85] The increasing taken-for-grantedness of the menopause replaces the invocation of Galenic tradition as proof of an ever more elusive and paradoxically ever more male climacteric. Whereas eighteenth-century arguments for the existence of the menopause invoked the Galenic climacteric, by 1865 the climacteric has been unambiguously speciated into male and female varieties and the gendering of what is obvious in the decline of old age has been inverted and split. C. M. Durrant can derive the male climacteric solely through the female: "We are so much accustomed to regard with interest and anxiety the peculiar changes which take place in the constitution of the female at mid-age, that we are apt to forget and overlook the phenomena which, in a more or less marked manner, attend the turning point towards a downhill course in the opposite sex."[86]
The gendered shift in what was obvious and what derivative begins in Britain early in the nineteenth century. In 1813, Henry Halford wrote what became a classic text on the climacteric, splitting the crisis along gendered lines and placing the two newly distinct phenomena side to side. Halford contrasted the different embodiments of each: the male climacteric being a "deficiency in the energy of the brain itself," leading, if not negotiated with care, to chronic mental deficiency. The female transition was not of the brain but of the body, and it was of a sufficiently marked character as to "render subsequent alterations less perceptible"; that is, female energy was so closely tied to the womb as to render the question of mental crisis irrelevant.[87]
Nineteenth-century discussions of the dual climactera continued to cite Halford as the author of the split.[88] The characterization of the male climacteric as cerebral and progressive and the female as visceral and acute lingered for over a century: in 1933, Edward Podolsky could still write that "there is a definite male climacterium in the same sense that there is a female climacterium, with the notable exception of course that in a man there does not occur those physical changes which serve as a visible means of indicating the change of life. In the male real and definite changes take place, but the physical element is negligible; the mental upheaval is quite considerable."[89]
As the obviousness of this male climacteric begins to unravel in turn, in the first decades of the twentieth century, numerous explanatory models are floated by its
proponents to explain the reasons for the dual climactera. Heredity, arteriosclerosis, toxemia, and neurasthenia were invoked.[90] Endocrine explanations dominated, reflecting both the emergence of the gland as a key concept in medical research and more generally the incorporation of evolutionary (climacteric as involution) and ecological (climacteric as reorientation of relations between body and environment) narratives. Gonadal endocrine models exploited the radical differences in the signification of ovaries and testes. Galloway in 1933 argued that involution is a paired process: "the homologous organs which show the changes of involution first in one sex should be those which degenerate first in the other." This principle of equivalence must break down, however, because "in the human female there is no need to follow the subject, the symptoms being so distinctive, culminating in the only objective sign we possess, the cessation of menstruation. It is some centuries since the great Belgian physician, Jean Baptiste Helmont, said 'woman is made what she is by her ovaries.' Thus attention is at once concentrated on them and the ductless glands under whose dominance they act."[91] Men were complex and not uniglandular; Galloway describes a network of testicular, adrenal, and pancreatic secretions. Hormonal logic separated the simpler pelvic and ductless female embodiment of the transition to old age from its more layered and polysemically ducted male embodiment. As male hormones were interacting within a rationally ordered system rather than simply drying up, the male climacteric occurred later than the female.[92]
Nascher turned to the climacteric to help resolve the tension between the normal and the pathological, particularly in regards to the senile mind. In his discussion of normal aging, Nascher offered images of old people as weak, willful, dependent, and decaying. In simultaneously moving to free old age from pathology, he constructed what one might term a subaltern physiology, legitimating the study of the old body as both normal and different by framing its normality in terms of other classes of subordinate bodies. To construct a senile physiology, Nascher drew upon other alternative physiologies, those of the child and of the woman. Old people were normal in the same way women and children could be normal.
In the case of the child, discipline as metaphor was supplanted by disciplinary object as metaphor. Less relevant for the new geriatrics were the formal congruencies between the child and the old person, and more relevant were substantive similarities between their behavior, their demeanor, and the degree of autonomy of which they were or should be capable. Nascher opened Geriatrics by declaring: "Senility is often called Second Childhood."[93] He used the term loosely, as a synonym for old age; elsewhere in Geriatrics he defined it more narrowly as the domain of those oldest old who have passed through the "senile climacteric." In equating very old age with second childhood, Nascher did not so much demonstrate the common structural concerns of pediatrics and geriatrics, as play on a powerful sign of the mentally impaired elder as legitimation for a new field of knowledge. In appropriating the child, Geriatrics positioned childish behavior at the center of the new physiology.
Nascher explored the climacteric at length in a 1915 article, "Evidences of Senile Mental Impairment." The piece is a discussion of both normal and pathological old minds through the presentation of eight cases, a progression of stock characters: "The oldest in this series of eight is a retired minister; of the others, one is a retired merchant, one is a manufacturer still in active business, one is a physician, one is a lawyer, and one is a humble shopworker. There are two women (widows), one living alone, the other living with her daughter."
The eight exhibit "various phases of senile mental impairment": the physician's mind is "extremely clear and alert"; both the minister and manufacturer are egotistical and forgetful; the lawyer is similarly so, and additionally "becomes confused or rambles"; the shop worker has "moments where the mind seems like a mental blank"; and the merchant is in the terminal stages of senile dementia. Nascher finds it difficult to place the two women along this progression; their vignettes stress less cognitive status than demeanor and the type of relationships the women have created.[94]
In delineating a "senile" as opposed to a "male" climacteric, Nascher attempted to routinize the senile body within a rational and ungendered discourse of geriatrics. Yet the possibilities of the normality he articulated remain rooted in a gendered logic. Unlike Galloway, he did not contrast the simple gonadal decline of women with the higher glandular embodiment of men. Rather than both sexes declining—albeit in different sites and at different rates—old men and old women, in Geriatrics , approached one another: "In childhood the growth force is exerted in two directions, or rather with two distinct purposes, accumulation of tissue and differentiation of the sexes. In old age ... this growth force is now mainly exerted toward the approximation of the sexes and in old age they approach a neutral type."[95]
Not quite neutral, for the process "is more pronounced in the virilescence of the female." In noting the heightened masculinity, of old women, Nascher may have been responding to more than their mustaches (to which, however, he had a tendency to return throughout Geriatrics ). Whether the enhanced power of old women has been a universal archetype[96] or a culturally and politically located strategy of resistance,[97] it presented for Nascher a concern that challenges the central meaning of old age and its physiology of decline. He responded by interpreting the strong female old body as performative health, the failure of women to look as senile as they really are: "The obvious manifestations of senility appear later in the female, for the reason that she makes an effort to remain attractive, the psychic factor involved in the production of the senile slouch in the male being overcome by her vanity."
Beyond strategic vanity, the performance of the wrong normality was an indication of a woman's cognitive limitation: "Women being more impressionable than men, they are more amenable to religious teachings, they become more readily resigned to the inevitable through their faith and hope of eternal life hereafter, and being more cheerful they do not present the disagreeable, gloomy appearance of aged men." The performance of health masked the process of decline, depriving women of what limited brain power the terms of discourse granted them in
the first place. Thus "the mental changes in the female generally include all of the intellectual faculties and proceed to the extent of complete dementia far more often than in the male."[98] One could not so easily, therefore, measure and rank women's cognitive status, it being a matter of all or nothing, performative health shifting quickly to complete dementia.
Dementia more generally is the result of the poorly negotiated climacteric. Negotiation is dependent on one's moral sense: "Occasionally there is a recrudescence of sexual desire, to gratify which he may attempt rape upon little girls. Such crimes do not arise from depravity, but through weakened mentality involving a weakened moral sense, inability to realize the nature of the act or its consequences, loss of control over conduct, and an irrepressible sexual fury."[99] If the climacteric represents a sexual gauntlet conditioned by a moral sense, dementia is the end stage of having failed to control one's sexuality. Unlike Warthin, Nascher retains the legacy of Victorian perfectibility. Mental control is an explicitly economic process of the prudent management of limited resources. The physician—not surprisingly, the hero of the "Evidences" article—whose thinking is clear and alert, has negotiated the climacteric successfully. His old age is characterized as conservative: "more serious, less aggressive, less energetic."
The merchant and the shop worker pass through the climacteric inefficiently and at great cost. Unproductive emotional excess at their retirements depletes their vital resources and sets the stage for their poor negotiation of the climacteric. The lawyer, the minister, and the manufacturer are all still negotiating their respective climacterics. They are all emotionally excessive and somewhat egotistical. The women resist climacteric readings. The eldest
has been living alone since the death of her husband nearly twenty years ago. Before his death, she was hospitable, sociable and charitable, but soon after his demise she became irritable and suspicious. ... For the past ten years there has been coming on a slow mental impairment. Her interests in life have become restricted, until today she cares about nothing except her life and her little home, including a cat—her sole companion. ... Aside from [buying food], she does not leave her house, admits no one to her rooms, and in fact leads a hermit life.
The woman's struggle at the time of her becoming a widow is analogous to the preclimacteric dilemmas of the merchant and shop worker. But no eruptive climacteric follows, just steady decline. Has the meaning of the climacteric been exhausted in her undergoing the menopause? The one hint we have here is the archetype through which Nascher presents her, that of the crone: willfully alone, her irritable voice, the hermit hut, the telltale cat. In Nascher's offering us—through the solitary and demented old woman—a figure of the witch, we come full circle to Weyer's substitution of the witch for the doting old woman. Female physiology is relevant primarily to anchor construction of a (male) body subaltern in its old age; its climacteric language of gonadal weakness and absent cognition is exhausted in the signification of old men. There is an unsignifiable gap between this
senile physiology, predicated upon a naturalized rhetoric of gender difference, and the bodies of women Nascher encounters. If old men are normal but weak, and to be normal and weak is to be like a woman, what are old women like? They seem to be like men: independent, mustachioed. But this must be performance, a magical physiology Nascher falls back upon the archetype of the witch.
Similarly, the second widow, "82 years of age, is fond of society, especially of the young, and tries to appear young by resorting to facial artists, hair-dressers, beautifiers, and dressing in youthful garments and conducting herself like a young woman. She takes seriously the joking propositions of marriage made by young men who know her weakness."
Now "her memory is weak, she loses her way," and yet "on the whole her conversation is rational and coherent, though inappropriate for a woman of her age."[100] Her cognitive state is difficult to assess; she is presented as alternately rational and confused. Her state in some ways seems analogous to that of the mid-climacteric "egotistical" lawyer and minister. But Nascher does not use a language of pathological selfhood—he does not call her "egotistical," as he called the three men—so much as he stresses her social pathology, her inappropriateness. She is the old bawd, and her role encompasses her pathology, more seamlessly than its mirror, the old pantaloon, can represent the experience of climacteric men. Bawd and witch: the two women are offered not as a series, not as a moral economy of aging as for the men, but as totalizing caricatures that obviate a processual physiology negotiating the normal and the pathological through moral choice. The male body is made to contain the distinction through the invocation of the taken-for-granted logic of the female climacteric. The female body is made to contain the distinction through a set of archetypes preventing counterhegemonic readings of its sexuality. Throughout, the fusion of physiology and pathology is not threatening to geriatric ideology, for it is read as difference in gender and not difference in age.
Alzheimer's Family
A compelling historiography of Alzheimer's disease has been emerging, one that centers on Kraepelin's motives in naming an "eigenartige " 1906 finding of his student and colleague Alzheimer as a distinct disease.[101]Eigenartige has been translated as characteristic or peculiar. The standard narrative of Alzheimer's assumes the former gloss, that Alzheimer was conscious of identifying a pattern of neural degeneration and plaque formation suggestive of a pathological syndrome distinct from the "normal" anatomical findings of senile dementia, and that Kraepelin was merely honoring his achievement in eponymously naming the syndrome Alzheimer's disease. G. E. Berrios has convincingly and rather elegantly suggested the latter gloss, that Alzheimer was struck by the peculiar characteristics of the symptomatology of the middle-aged housewife brought into his clinic by her husband and of the neuropathology of her sliced and silver-stained brain.
For Berrios, the critical and still-opaque moment is the decision of Kraepelin and his colleagues to in effect rewrite Alzheimer's case materials, stressing only cognitive symptoms rather than cognitive, affective, and delusional symptoms, only a degenerative etiology and not arteriosclerotic and degenerative etiologies, and only onset in middle age rather than a span encompassing middle and old age. Through this set of exclusions Kraepelin could construct a distinct disease category, whereas for Alzheimer and most of his contemporaries the case of the middle-aged housewife was peculiar precisely in its early onset and extreme presentation of an existing disease category. Berrios notes: "The most common interpretation by those living and writing during Alzheimer's period was that the 'new' disease simply named cases with early onset, marked severity and focal symptoms. As the cognitive paradigm consolidated, a clear move toward narrowing down the syndrome by, for example, dismissing the presence of delusions and hallucinations can be detected. Likewise, arteriosclerosis was quietly dropped, and became an exclusion criterion"[102]
Kraepelin's motives remain a puzzle for Berrios, perhaps given his tendency to split Kraepelin's practice into distinct and fairly seamless "scientific" and "nonscientific" realms.[103] His analysis, however, still helps clarify the central puzzle of the historiography of the disease, its disappearance and rebirth. As Berrios notes, the correlation of plaques and tangles with the symptoms of dementia preceded Alzheimer's 1907 report,[104] and subsequent work demonstrated the same constellation of symptoms and pathology with clinical onset in old age.[105] The classic narrative of the modern Alzheimer's movement—that the great pathologist was limited by the ageism of the time and could only see presenile dementia as pathological, awaiting the late 1960s for medicine to recognize that Alzheimer's was also an apt characterization for senile dementia and thus to inaugurate the separation of normal aging from pathological dementia—presumes Kraepelin's exclusions. Yet the disappearance of Alzheimer's disease, its failure to capture the language of senility treatment and research for half a century, suggests two alternative processes not adequately framed by "ageism," the first of which Berrios illuminates: Kraepelin's exclusionary construction of a presenile nosology ran against an emerging consensus and failed to provide a fruitful site for the laboratory or clinic.[106]
The other critical process, of course, was the development of arteriosclerotic dementia, which far from being relegated to the sidelines by Kraepelin's exclusion, became the dominant concept in senile dementia research and clinical practice for much of the twentieth century. Unlike the degenerative changes of Alzheimer's, the vascular changes of arteriosclerosis were central sites of pharmaceutical research and intervention, and new classes of vasodilatory drugs emerged as senility treatments. Conceptual and commercial practices sustained one another well into the 1970s, in the United States, and later in much of Europe, Asia, and elsewhere.
There are multiple ways to think about the events of the 1960s through 1980s, chronicled at length by Fox, Gubrium, and Lyman: the emergence of a profes-
sional and later a popular Alzheimer's movement in the United States, its powerful and in some senses ironic medicalization of old age, and the various routes of its attempted globalization. The 1970s and 1980s movement chronicled by Fox and Gubrium emerges explicitly in terms of the anti-ageist critique—stressing the normalcy of old age—of geriatrics. But the ideology of geriatrics and Fox's careful micropolitical analysis beg the question of why Alzheimer's was rediscovered as senile pathology precisely when it was and why the popular culture of Alzheimer's hell spread so quickly.
In part, Alzheimer's reemerges in the United States at an interesting time: the middle- and upper-class "young old" were appropriating the mantle of the elderly in the creation of a social movement, and popular and official concern in wealthier industrialized countries was increasingly taking up the imminent burdensomeness of a growing gray wave. On the one hand, groups like the American Association of Retired Persons (AARP) formed powerful and well-heeled lobbies, promoters of pedophobic Sun Cities created planned gerontopoli where children and not the elderly were marginal, and resistance to ageist economic practice such as forced retirement spawned an "aging and work" subfield of social work and fairly class-specific senior employment agencies like the American group Operation ABLE. The normalcy of decline—central to Nascher's physiology despite the ideology of the new field—was increasingly resisted, and normal aging came to signify the wealthy retirees having fun pictured on the pages of Modern Maturity , the AARP's magazine. Normal aging signified an extension of the ideology of the American Dream and of its dominant mood of fun.[107]
On the other hand, rejecting the burdensomeness of the dependent elderly and preserving society's collective ability to leave home and roam America's byways—like Frank in his fantasy of authentic pre-Alzheimer's personhood—was legitimated through a redefinition of the most needy elderly as encompassed by the nonpersonhood of their disease. The thematic of Macfarlane's analysis of village communities in Tudor and Stuart Essex is repeated: as the legitimacy of the gift—no longer the giving of food to widows by individual householders but the guaranteed provision of income to all elders by the state—becomes contestable, so the mind of old people—no longer marginalized older women but the so-called frail elderly—becomes the object of unambiguous pathology, here not the subterranean associations of witchcraft but the earthly hell of Alzheimer's disease.
Given their rough class logic, the two turns—gerontocratic and gerontophobic—are not usually in opposition to one another. When an old American named John Kingery was abandoned, apparently by his daughter to avoid the costs of maintaining him at a nursing home, at a dog track in Idaho hundreds of miles from his family, a spokesperson for the AARP lamented that such an action had to happen but sympathized with the daughter:
"granny dumping, as it's called, was unheard of 15 years ago but now the anecdotal evidence tells us it has become somewhat of a trend," said John Meyers, a
spokesman for the American Association of Retired Persons, which has 33 million members. "Not a day goes by when a hospital emergency room somewhere in America doesn't have a case where some elderly person has been abandoned, usually by the children".... "The fact that children abandon their parents, as horrible as it is, is indicative of the terrible balancing act that care-givers are stuck with."[108]
Meyers advocates federal support to families for adult day care centers, giving beleaguered children a break. AARP members are at least as likely to be givers as recipients of care; one can join and begin receiving various senior citizen discounts at age fifty. Meyer's response, like the Newsweek articles, reminds us that being a caregiver is experienced as the hell of the tabloids by older as well as younger children, that the desire behind the hegemony of Alzheimer's pathology and its denial of subjectivity to certain old bodies is located less in the politics of age per se than of generation. His response again underlines the critical role of gender in the structuring of pathology. Mr. Kingery is granny-dumped; his expendability is reinforced through the figure of the pathetic old woman. The Murphy bed reappears as a generational collective fantasy.
The language of legitimate pathology reflects not only the view under the microscope but the social construction of the person identified with the slice of tissue. The vascular damage and necrosis of multi-infarct dementia and the plaques and tangles of Alzheimer's continue to share the etiologic limelight, but it is plaques and tangles that become the key signs of the demented brain, and "Alzheimer's" that becomes a medical idiom for dementia and lay idiom for senility. The power of Alzheimer's over other medicalizations lies in part, as Gubrium and Lyman have pointed out, in its clear drawing of the line between normality and pathology and its legitimation of control as therapy. Beyond this, Alzheimer's is structured as an embodiment of excess. Its "gold standard" remains the plaques and tangles that appear in most aging brains but in excess in Alzheimer's.[109] Plaques are real, demonstrable, and countable. Given the emphasis within the Alzheimer's movement on the continual reiteration of the disease's pathology—one of the two "enumerative obsessions" present at Zagreb—plaques and tangles become the enumerable source of proof. Old parents place demands on their children; these demands do not make Frank's dream of freedom any more realizable. The behavior that has come to be called dementia makes particularly enormous demands on children; these are far from the only demands, but contribute critically to a moral economy in which the oldest old demand too much. Daughter Regan says to Lear, "I pray you, father, being weak, seem so."[110] The legitimacy of the claims of old persons on their children is inevitably contested. Excess plaques and tangles are demonstrable signs of a condition of this existential excess of the old. They come to stand for the person with dementia not because of their universality—vascular or multi-infarct and other types of dementia do not necessarily present with the pathology of Alzheimer's—but because of their semantic potential, as conveyers of what the patient means to others. The neuropathology of Alzheimer's—an unambiguous disease that can be counted, excess that can be re-
vealed for all to see—proves the logic of senility. The interpersonal and existential crises of aging—its excessive demands—can be reduced to the disturbance of excessive mind. As the contest to define a person's old age is increasingly appropriated by children, Alzheimer's becomes the quantification of excess.
Unlike the language of climacteric excess, the modern concept of Alzheimer's resists the deployment of gendered pathology, in naturalizing its claims to speak of age. Whereas Charcot and Nascher locate the conditions of possibility for a science of the old body with the institutionalized body of the old woman, Alzheimer's first patients are defined by him not as a priori institutional material for a science but persons from the outside whose reason for entry into the institution is in itself the critical fact anchoring a reading of their cellular pathology. The patient of the 1906 report had been "a woman, 51 years of age," who
presented as the first most striking mental symptom, ideas of jealousy concerning her husband. Soon after, a rapidly developing mental weakening was noticed; she would lose her way about in her own home, throw things around and hide herself for fear of being killed.... In hospital she seemed perplexed, was disoriented for time and place, occasionally complained that she understood nothing.... The patient finally was completely demented; confined to bed with contractures of the lower extremities; and passed urine and feces involuntarily. In spite of greatest care decubitus developed. Death after a duration of 4 1/2 years.
Subsequently, "after the Bielschowsky silver impregnation method" Alzheimer noticed two features on slides of her cortical brain tissue: "tangled bundle[s] of fibrils" and "a deposition of peculiar stuffs."[111]
The second case of what had already become known as Alzheimer's disease, published in 1911, was of Johann F., a fifty-six-year-old day laborer and "moderate drinker" sent in 1907 to the Munich psychiatric clinic "by the overseers of the poor." For the previous six months he had "been forgetful; lost his way easily; could either not perform simple tasks or executed them awkwardly; stood about in an aimless manner ... and no longer bathed." Over the course of the next three years Alzheimer documented Johann F.'s "manifest deterioration," efforts to pack his clothing and leave the institution, increased incontinence, continual weight loss, and eventual death "from symptoms of pneumonia."[112]
The fact that pathology is first searched for and discovered in a jealous and initially hysterical woman and then in an unproductive day laborer does not allow one to reduce either the materiality of dementia or Alzheimer's reasoning as a scientist to the equally material subalterity of these first "Alzheimer's patients." Yet behind the inquiry of the scientist wait the concerns of the husband and the overseer; Alzheimer's at its moment of origination is rooted in a specific need to explain the progressively more demented minds of the already dependent. Its indelible pathology—its incontrovertible plaques and tangles—demonstrates a pathology that is rooted in far more than the very real changes Alzheimer recognizes and reconstructs as clinical signs. The possibility of the neuropathological sign as stigmata draws on the social dependency of the person being redefined
through it as unambiguously pathological. From its very first two cases, Alzheimer's has been situated at the moment of institutionalization and the conditions of its possibility.
This moment and these conditions are overdetermined. Social artifacts of shifting categories of dependency and technobiological artifacts of new drugs, new mice, and new clinical tests will affect and transform each other. Alzheimer's may take hold as clinical reality in India even in the absence of a so-called health transition. The impact of these new technobiological artifacts upon the local construction and negotiation of dependency across age, gender and class might well be studied as an ongoing process. At the moment and site of this research, such technobiological artifacts were of limited relevance to questions of local biology or local politics, and the following chapter turns to a narrative and set of practices of greater immediacy, those of the Bad Family.
Yet at this moment of enchantment, in which globalizing agents like the missionary physicians of Alzheimer's Disease International and multinational marketers of senility drugs proffer Alzheimer's as the answer to India's inevitably backward treatment of old people, the body of Alzheimer himself takes on unexpected and perhaps local forms. The Bangalore-based journal of the Indian Academy of Sciences, Current Science , devoted a 1992 issue to Alzheimer's disease, billing it as "an emerging issue for the developing countries."[113] The articles included were a mix of review articles, clinical overviews, and recent research and in their relative comprehensiveness suggested that a different kind of Alzheimer's practice had replaced the "better brain" project. On the cover of the special issue was a photograph of Alzheimer, but not the usual head shot accompanying books and articles on the topic in the United States and Europe.[114] The usual narrative of Alzheimer's life is one of tragedy, the template generated by Kraepelin's own essay on his junior colleague's various family losses and his own premature death. But the Alzheimer who may be coming to matter in Indian science and whose invocation promises to restore aging in India is envisioned differently here. In his inaugural appearance in India, the great pathologist is pictured en famille , holding his son on his lap, seated next to his wife and daughter, and gazing through his ubiquitous monocle at their newborn baby.
Nuns and Doctors
A history of dotage wrested through the substance of old women's cries, gestures, bodies, and brains: the captive material of the Salpêtrière, for Charcot's theater of clinico-anatomical correlation, the old women who offer us knowledge, and through their inexhaustible numbers the possibility of a science of old age and of the boundaries of the pathological. But for a twentieth-century science of vivisection and recombination, the surplus material of old women was not enough; their live bodies could not circulate into the laboratory, and the search was on for the animal model, culminating in the arrival of several subspeciated brands of Alzheimer's mouse on the business pages of the Wall Street Journal and New York Times in 1995.
It is no longer a question of relative ethics, mice versus doting old women. Old women could not serve as the materialization of Alzheimer's as Alzheimer's was increasingly less a metonym of old age than a metaphor for it, its structural replacement. No one ever dies of old age anymore, but of the nation's fourth leading yet most insidious killer, and the material for a science can no longer be limited to the old. One looks for clues, rather, among the young: skin tests or other quick and painless assessments of future hell.
But the history of dotage still exacts its occasional pull: its reliance on the subaltern physiology of woman did not disappear with Alzheimer's plaques or with the celebrated arrival of genetically engineered mice. Like Scot with his witches and Charcot with his vieille femmes , a group of researchers at the University Of Kentucky discovered the disciplinary possibilities of old nuns. One-third of the elderly School Sisters of Notre Dame were diagnosed with Alzheimer's, but all had kept written traces of their youth—autobiographical essays they had been instructed to write as novices, under the confessional authority of the church.
The Kentucky doctors found that the demented of the old nuns had, as young
women, been more likely to have written simple sentences devoid of grammatical complexities; the old "mentally sharp" nuns when novices had in contrast written complex sentences. "Study Suggests Alzheimer's May Begin Early," ran the headline in the San Francisco Chronicle .[1] The possibilities for Alzheimer's swelled as the ever more contested distribution of intelligence—heretofore limited to the revived Bell Curve nature-nurture debates of the 1990s academy—could be framed as the harbinger of worse hard-wired horrors.[2] Once again, the institutionalized bodies of old women are the substrate for geriatric knowledge, but these bodies are now extended back in time to a plumbing of a youthful confession for new stigmata. Other explanations for the distribution of novitiate intelligence and for its correlation with the mental status of aged nuns were unimaginable.
From the wordplay of Mary Daly, ex-Catholic and self-proclaimed Witch: "academentia."[3] But real.