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.