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

The book Incurable and Intolerable explores attitudes and policies toward chronic incurable disease in nineteenth century France, then the epicenter of Western scientific medical research and practice. The author presents various psychological, social, and institutional facets of illnesses such as cancer and tuberculosis to illuminate the evolution of current practices.

The book should be of particular interest to health care providers, administrators, and policymakers who deal with the chronically ill population. The book should also appeal to scholars and practitioners in various subfields of sociology, history, and public policy. The writing style is accessible, but the author uses, by necessity, a fair amount of specialized and sometimes archaic terminology.

Szabo employs a broad historical approach to illustrate attitudes and policies concerning the incurably ill. The author presents the subject from the perspective of physicians, patients, family, clergy, researchers, and public administrators to provide an inclusive cross-sectional analysis. The historical arc of the subject is also explored, which provides a complementary longitudinal view tracing the evolution of current conditions.

A central theme of the book is the fluid, changing definition of incurable disease. In nineteenth century France, incurable diseases included a fairly broad mix of conditions, including tuberculosis, scrofula, cancer, gout, scurvy, and rickets. These chronic diseases were generally categorized as diatheses—originating as a result of an inherent susceptibility or constitutional predisposition. Debates over prognoses included questions of environment vs. constitutional flaw, when and why conditions became incurable, and the limits of prevention and cure. Advances in pathophysiology offered hope for eventual progress. Knowledge of tumors and tubercle cells, early detection, and surgical interventions all contributed to a more optimistic outlook, although these advances offered little immediate help for sufferers.

It was commonly assumed that diatheses were heavily influenced by social degeneration, which increased the tendency to blame the patient for the disease. In one extreme example, a leading surgeon of the period stated that nuns suffering from uterine cancer most likely “masturbated themselves into an early grave.”^[p.63] Darwinian thinking tended to validate those who attributed these diseases to hereditary weaknesses, viewing chronic disease as nature’s way of culling out the weak. The advent of germ theory didn’t really change this attitude. The discovery of the tubercle bacillus only further stigmatized consumptives as being dirty and dangerous.

Romantic notions of the era also influenced how chronic illness was viewed. Literary depictions of consumptives as tragic rather than pathetic figures filtered people’s views of suffering. This romantic notion tended to abate as the disease progressed. Late-stage illness was accompanied by symptoms and behavior repulsive to family and physicians alike. A related factor contributing to marginalization was the taboo against dead or decaying bodies. It is understandable that the self-preservation instinct made caring for these patients extremely difficult.

Attitudes in the medical profession were conflicting. Most physicians subscribed to the empathetic ideal, but still felt that their valuable time and efforts were wasted on incurable patients. Other difficulties for doctors included feelings of helplessness, a mortality rate for doctors twice that of lawyers, and difficulties in serving rural patients. Research advanced slowly, partly due to the fact that researchers found chronic diseases scientifically uninteresting. All this inevitably led to feelings of abandonment in patients, with the poor suffering the worst. Like others, the wealthy suffered horribly, but at least had access to spas and other material comforts.

Choices for treatment and management strategies were limited. In general the only options available involved a combination of trial and error, morphine, and deception. Physicians had to walk a fine line between truthful prognosis and patient morale, since the raw truth about incurability could itself worsen the prognosis. Palliatives consisted of drugs, tonics, surgery, and therapeutic aids for physical comfort. Surgery became a more common option with cancer patients at the end of the century, but the intervention was at best palliative and temporary. Charlatanism was rife, especially...