Incurable and Intolerable: Chronic Disease and Slow Death in Nineteenth-Century France

6: Medical Strategies, Social Conventions, and Palliative Medicine

VVVVVVVVVVV 113 6 Medical Strategies, Social Conventions, and Palliative Medicine Prognosis has long affected patterns of social behavior and is justly deemed a critical determinant of something now known as patients’ “illness trajectory .”1 It should come as no surprise that nineteenth-century society had weighty expectations in the setting of chronic progressive illness. Physicians ’ behavioral blueprint essentially consisted of three healing gestures: trial and error, morphine, and deception. Yet this enumeration belies the richness and complexity of the palliative encounter. Incurable illness was an intricate form of performance in which the idea of tragic predestination was omnipresent. People’s line of conduct was also subject to rigid conventions and norms. Yet for various reasons, this social encounter was marked by considerable, and generally unwelcome, improvisation. Although opiates were in many ways the cornerstone of care, other palliative practices played an equally important role in shaping this experience . Both the form and content of these customs highlight contemporaries ’ single-minded commitment to sustaining hope. A combination of tradition, “hard” science, and social consensus ensured that most saw this as a therapeutic objective worth pursuing at all costs. It is obviously tempting to view doctors’ white lies as an egregious form of medical paternalism . In fact, it reflected an intriguing, multidirectional dialectic among patients, healers, and families, each acting in accordance with perceived self-interests and within the limits of various constraints. More than anything , deception was an integral part of the culturally driven and socially acceptable language of caring. At an abstract level, fostering hope was unproblematic. Translating theory into practice proved much trickier. Like most delicate social interactions of comparable importance, palliative practices engendered almost as many 114 INCUR A BLE A ND INTOLER A BLE dilemmas as they solved. For this reason, physicians regularly complained about the shortcomings of their therapeutic culture. Among the things that troubled them most was that, in attempting to stage-manage incurable illness , the line between “good” and “bad” medicine was disquietingly fine, subjective, and easily crossed. In attempting to provide a full reckoning of nineteenth-century palliative medicine and end-of-life customs, I’ll pay particular attention to the cultural specificities of the dying phase of incurable illness. Though it was often easier said than done, everyone who moved within this social space was expected to act in accordance with some perceived greater good. Importantly , patients and families remained deeply committed to the dominant action model, mostly because it assuaged certain forms of distress without putting too much strain on social ties. Physicians, of course, also had their own reasons, noble and ignoble, for being single-mindedly committed to having things go “well,” that is to say, according to plan. The Therapeutic Ethos of Deceit When they suspected the worst, doctors choreographed the diagnostic process lest a careless word or gesture let the cat out of the bag.2 A reassuring diagnosis was thus always preferred. In an 186 lecture, the eminent physician Auguste Chomel initiated students into the art of double-speak. He was well-placed to lecture on the issue of medical decorum. Descended from an illustrious medical family, his career had been brilliant. An accomplished anatomist, he replaced the recently deceased René Laënnec at the Academy of Medicine in 1828. A fervent Orleanist, he was rewarded with a professorship in 1830 before being named consultant to King Louis-Philippe in 1832. The thrust of Chomel’s lecture was that if diagnostic acumen was critical to earning patients’ trust, it was not to come at the expense of their morale. Nowhere was this balancing act more critical than in chronic illnesses, “which pass for incurable in the minds of most people.” As he noted, “If you establish the diagnosis as you’re convinced you should, you will destroy the patient’s hopes and do irreparable harm.” It was preferable to tell consumptives they had chronic bronchitis; chronic gastritis would similarly substitute for gastric cancer.3 Any doctor inclined to second-guessing could invoke tradition to justify his behavior. The first tradition was “common sense”—common to both sickly New Englanders who liked the term chronic bronchitis and the French working class who often referred to chronic lung ailments as rhumes négligés. There was also the wisdom of the ages; centuries before, Michel de Montaigne had insisted that “a means of assuaging illness often consists of sweetening the name”5 MEDIC A...