Chronic Disease in the Twentieth Century: A History

10. Maladies chroniques in France

When I first began researching chronic disease in France, I encountered two difficulties. First, French historians and sociologists had no idea what I was talking about. It was not that they did not understand the literal meaning of the words; these simply had little relevance to healthcare, as they understood it. Nor was the term used very much. Ngram graphs that show a significant rise throughout the twentieth century in the use of terms chronic illness and chronic disease in the large numbers of English-language books that Google has digitalized show in contrast a flat line for maladies chroniques or any related terms in French works during the century. A second and related problem is that there is an almost complete lack of historical writing on this subject. With the exception of a small number of French and North American works that I cite in this chapter, I was forced to rely on research on more-or-less related subjects. This situation is particularly astonishing given the many books and articles on chronic disease published in France during the nineteenth century. This chapter analyzes the institutional logic that made the term increasingly irrelevant for healthcare policy in the twentieth century. Indigence and Chronicity As was the case in Britain, chronicity in nineteenth-century France was associated with indigence, particularly and increasingly among elderly people, and was most frequently used as shorthand to designate those who should not be in hospitals because medicine could do little for their conditions. Three conditions in particular fell into this category: old age, infirmity, and incurability. These rendered the very poor eligible for public assistance or charity since they made work and economic self-sufficiency impossible and were not associated with moral failings . (Foundlings were another important group whose blameless helplessness chapter ten Maladies chroniques in France Maladies chroniques in France 205 made them eligible for assistance, but they are not relevant to this discussion.) While these conditions permitted “assistance”—food, lodging, small subsidies, and the like—they frequently excluded sufferers from the medical care that the indigent in many localities had a right to as consequence of a law passed in 1851. Since space was limited in hospitals that provided medical care, it was thought proper and appropriate to reserve them for those who would respond to treatment : the sick, or les malades, in the parlance of the period. Those not considered malades could, however, be lodged in nonmedical institutions, hospices, which generally fell under the same municipal administration as hospitals (in Paris what became the Assistance Publique ([AP] in 1849 and in Lyon the Hospice de Lyon). Only a few localities could support two separate kinds of institutions and the majority had mixed institutions called hospital-hospices. Although categories were not always clear-cut, official statistics in 1851 indicated that in all of France there were 337 hospitals, 199 hospices, and 734 hospitalhospices . This translated into 63,237 hospital beds and 55,052 hospice beds. In Paris, general hospitals contained 3,783 beds; specialist hospitals (for sick children , venereal diseases, and the like), 3,429; and hospices and retirement homes, 10,691. There were several huge hospices in Paris that had mixed vocations. Bicêtre and Salpêtrière, each with more than 3,000 beds, were predominantly hospices for elderly men and women respectively. Each also had a section for mental illness, comprising about one-quarter of all beds. In both institutions there were also small numbers of younger incurably ill patients, primarily sufferers from tuberculosis, cancer, and what we would now call disabilities. Two other large Parisian hospices , one for men and one for women, were devoted to “incurables” and together held a little more than 1,200 beds. Despite the large number of beds in hospices, the lengthy stays of many patients meant that annually about 12,000 elderly, infirm, and incurable patients were housed in Paris while about 99,000 malades were in hospitals. Nationally, at midcentury, there were about 650,000 malades annually in hospitals and about 100,000 individuals in hospices.1 The latter moreover could be of several different sorts. Bordeaux, for instance, had two hospices, one for elderly and another for incurable patients.2 These complex categories give some idea of how unstandardized the system was, a feature intensified by local variations. Although reserved officially for the indigent, both hospitals and hospices contained small numbers of paying patients throughout the nineteenth century. Even the basic distinction—malades in hospitals and “elderly, incurable, and infirm...