“Frailty, Danger, and Isolation”: Turn-of-the Century America and the Pathologization of Old Age

Meredith Carroll is a rising senior at Grinnell College, where she studies history, plays flute, and braves the Iowa climate as a campus tour guide. Her interests include the history of the popularization of science and its intersections with the history of the book. She can regularly be found ensconced in Grinnell’s Burling Library, with a cup of chai in hand and the latest Doctor Who queued up on Netflix.

As baby boomers retire, their parents age, and medical technologies stretch life ever longer, aging has become a magnet for Americans’ anxieties. Nursing homes provide a barrage of services at the cost of tens of thousands of dollars. Articles about the “sandwich generation” and books about mortality give voice to mounting dread of growing old. And writers talk about the “frailty, danger, and isolation of old age” as if all three are givens.

Amid all these messages, it can be easy to forget that Americans haven’t always feared aging. We haven’t always seen old age as a medical problem that society needs to solve. In fact, we haven’t always viewed the elderly as a distinct social group. All three developments are in large part products of the past century, when industrialization, urbanization, and the professionalization of medicine all conspired to transform how people grew old in America.

The most important of these developments was the medicalization of aging — a turn-of-the-century phenomenon that historians are only just beginning to recognize. This is not for a lack of rich thematic material. The pathologization of aging interwove cultural contingencies with biological realities. Medicalizing aging may have been unique to the twentieth century, but the features of age it relied on — the wrinkles, the stiff joints, the exhaustion and the vulnerability to disease — were universal. Aging has always involved similar “symptoms.” But at least in America, it wasn’t until the early twentieth century that people began to group these symptoms together into a “disease.”

The medicalization of aging didn’t coalesce until the turn of the century; even still, it can be traced as far back as an ancient Greek theory. Human life, this theory argued, was demarcated by certain “climacterics,” or ages at which the body passed from one life stage to another. These upheavals left the body progressively more vulnerable to disease and disorder, particularly during the penultimate climacteric: age 65, when the body passed from maturity into old age.[1] Influenced by climacteric theory, nineteenth-century physicians began to treat old age as worthy of medical attention in its own right. And at least in this case, distinctness resided but a short step away from pathologization. Soon, doctors began to hypothesize that the elderly had unique medical conditions and required special treatments. Even when physicians observed symptoms in the elderly that they’d seen in younger patients, they invented old age-specific pathologies.[2] The specialty of geriatrics and the medicalization of age soon followed.

Diagnosis, however, was often as far as these doctors went. Doctors found few ways to ameliorate the pathologies of old age. To put things rather cynically, experimenting on frail patients was too risky to be worth developing treatments that would only extend life a few years anyway.[3] In short, even as geriatrics became a distinct specialty it would also remain a marginal one. Not treatment but diagnosis would remain its goal. As a result, geriatricians both fomented and cemented the pathologization of old age.

By the turn of the century, elite American physicians took climacteric theory a step further by transforming it into an age-specific condition they labeled climacteric disease. The “symptoms”? Inevitable physical, mental, and emotional decline. The effects? Twofold and decidedly ironic. On one hand, the physical dangers of aging meant that sufferers needed medical attention more than ever. On the other hand, the intransigence and childishness ascribed to the elderly meant that the very patients supposed to “act the part of needy invalids” were also thought to be “the most unpleasant and incurable patients.”[4] As so often occurs when pathologizing natural parts of life, the logic was circular. Processes natural to senescence were transmuted into pathologies. Resistance only confirmed physicians’ beliefs about their own importance.

In this way, developments in medicine were surely responsible for many turn-of-the-century changes in how Americans aged. But what about the broader social context in which these shifts took place? Some answers can be found by studying the (self-proclaimed) life-extension movement. As more Americans survived childhood and middle age, life-extension advocates began to speculate just how long human life could be extended.[5] Their reaction both built on the medicalization of age and reinforced it. A few doctors questioned the science underlying life extension campaigns. But many others noted that the chronic, progressive diseases associated with aging could only be caught by a physician’s watchful eye. Regular checkups and medical expertise, they convinced many Americans, were the only way to catch and prevent the insidious creep of the increasingly scary aging process.[6] Like climacteric disease, the life extension movement only expanded the authority of the physician.

The life extension movement made its biggest splash, however, outside the medical establishment, where it harnessed the pathologization of age to enforce social norms. As aging became a mass phenomenon, longevity evangelists hawked cures not just for death but also for the aging process. Eat the right food, do the right exercise, and hew to the right moral codes, activists proclaimed, and you might just escape senility entirely.[7] Indeed, it was during the early twentieth century that the world “senile” started to pick up the negative connotations we still affix to it today.[8]

Age-extensioners often singled out women in particular. Wear constricting clothes, they cautioned, and you might just weaken before your time. Wear too much makeup, they chided, and you might mask from your doctor and husband the warning signs of impending senility. The ostensible goal was protecting women’s health. The effects included policing women’s bodies and favoring men’s opinions about female health over the experiences of the women in question.[9]

With its close ties to eugenics, the life extension movement also singled out African Americans. Discrimination ensured (and continues to ensure) that far fewer Black Americans benefited from the otherwise astonishing rise in life expectancy. Confronted with higher mortality rates among Blacks, many life-extensioners used racism to their advantage. Exploiting existing prejudices, they asserted that Blacks didn’t live as long because they were physically lazy and morally corrupt.[10] Such arguments shored up longevity evangelists’ claims that individual willpower could extend life and quality of life. They did so by playing off existing racism — and, in the process, adding to it.

Responses to aging thus varied depending on the class, gender, and race of the elder in question. Nevertheless, aging was indisputably a national issue — and a political and economic one as well. By the 1920s, Americans were beginning to call for larger-scale solutions to the “problem” of aging. Not only physicians but also psychologists, popular writers, efficiency experts, and social reformers implored the government to address poverty and ill health among the elderly. Like doctors and longevity evangelists before them, these activists reinforced the idea that old age was a distinct stage of life, with distinct treatments needed to ameliorate it.[11] Campaigners for old age pensions in particular defined the “problem of old age” as a “problem of poverty”: a problem they demanded that the government address on a national scale.[12]

Indeed, changing economic circumstances made a difference. For at least some elderly Americans, poverty was a real problem. For at least some of the impoverished elderly, political and economic reforms made a difference. But along the way, the push for social reform further pathologized old age — this time in socioeconomic as well as in medical terms.

In fact, the final step in the pathologization of aging occurred not at the level of economy or policy but within the family itself. Traditionally, many scholars assumed that industrialization forced the frail, unproductive elderly to depend on their family for economic support. Yet other evidence suggests that many elders were economically secure throughout American history — before, during, and after industrialization. Again, this isn’t to say that poverty wasn’t (or isn’t) a real problem. Throughout American history, unmarried women, African Americans, and ethnic minorities proved disproportionately vulnerable to poverty as they entered old age.[13] But industrialization alone didn’t isolate the elderly or force them into dependence. As late as 1910, many elders lived with kin and even headed households.[14] Instead, the isolation of the elderly, begun when physicians started treating them as a separate class of people, was only complete when nursing homes — once the province of the impoverished — sprung up to house elders of all social classes.[15]

Institutionalization, therefore, closed the circle opened by medicalizing physicians over half a century earlier. Aging had evolved from a loosely defined constellation of symptoms to a diagnosis to be feared to a public policy problem for doctors, governments, and families alike to solve. By the 1920s, the pathologization of aging had spilled over from medicine into culture, public policy, the economy, and even the most intimate of social relations. A sweeping claim? Perhaps. And I don’t want to draw a straight line from the doctors who medicalized aging in the 1850s to the glut of institutions that have since sprung up to solve the “problem of aging.” But a glance at modern-day preoccupations with the elderly reveals how far anxieties about aging can spread. The underlying “frailty” may remain a universal, biological experience. But the “danger” and “isolation”? These seem to be products of distinctly modern anxieties about what remains a natural stage of human life.

And even with all that said, a question still remains. What about aging patients themselves? Here, the historical record seems to have fallen silent where voices are needed most. We know how turn-of-the-century doctors treated the “problem of aging.” We know how policymakers, the economy, and even families reacted to it. But until we attend to how America’s elderly experienced the pathologization of their stage of life, a major part of the story remains unheard.

[1] Carole Haber, “Medical Models of Growing Old,” in Beyond Sixty-Five: The Dilemma of Old Age in America’s Past (Cambridge University Press: Cambridge, 1983), 47-49.
[2] Ibid., 61.
[3] Ibid., 63, 51.
[4] Carole Haber, “Treating the Postclimacteric Stage,” in Beyond Sixty-Five, 79.
[5] Helen Zoe Veit, “‘Why Do People Die?’: Rising Life Expectancy, Aging, and Personal Responsibility,” Journal of Social History 45, no. 4 (2012): 1029.
[6] Ibid., 1030.
[7] Ibid., 1031
[8] Haber, “Treating the Postclimacteric Stage,” 74.
[9] Veit, “‘Why Do People Die?’”, 1034-1036.
[10] Ibid., 1037.
[11] Tamara K. Hareven, ““The Last Stage: Historical Adulthood and Old Age,” Daedalus 105, no. 4 (1976), 14.
[12] David Hackett Fischer, “Transition: Old Age Becomes a Social Problem, 1909-1970,” in Growing Old in America (New York: Oxford University Press, 1977), 162.
[13] Carole Haber and Brian Gratton, Old Age and the Search for Security: An American Social History (Bloomington: Indiana University Press, 1994).
[14] Cheryl Elman, “Old Age, Economic Activity, and Living Arrangements,” Social Science History 20, no. 3 (1996), 439-468.
[15] Carole Haber, “Institutionalizing the Elderly,” in Beyond Sixty-Five, 83, 106-107.

Further Reading
Gawande, Atul. Being Mortal: Medicine and What Matters in the End. New York: Metropolitan Books, 2014.
Haber, Carole. Beyond Sixty-Five: The Dilemma of Old Age in America’s Past. Cambridge: Cambridge University Press, 1983.
Veit, Helen Zoe. “‘Why Do People Die?’: Rising Life Expectancy, Aging, and Personal Responsibility.” Journal of Social History 45, no. 4 (2012): 1026-1048.