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

In an era of increasingly heroic medicine, certain chronic diseases presented an intractable problem for the nineteenth-century medical profession. How did doctors respond to the limits of their ability to treat disease? As Jason Szabo demonstrates in his nuanced and humane account of chronic illness in nineteenth-century France, it was with a mixture of compassion, frustration, pessimism, defensiveness, and professional jealousy. The book explores the development of palliative care in the context of emerging disease models, particularly the tensions between individual manifestations and experience of illness and the construction of universal disease categories. Szabo, a Montréal-based clinician and historian, usefully draws out resonances with contemporary issues relating to the care of chronic and terminal illness.

In Incurable and Intolerable, Szabo examines the construction of “incurable” as a category used to describe a constellation of conditions, most notably phthisis and cancer, that were resistant to positive therapeutic interventions. He argues that chronic illness and incurable disease have been neglected in the analysis of nineteenth-century medicine and public health. A historiographic focus on acute and infectious disease has meant that the incidence, impact, and cultural concern surrounding chronic illness in nineteenth-century France have been underrepresented.

Szabo explores how the profession reacted to those diseases—and patients—they could not treat, and the religious, social, and political implications of dealing with a population of people suffering incurable illnesses. Although the emphasis of the book is on medical responses to the specter of incurable disease, rather than firsthand accounts, the figure of the patient is in no way sidelined. Szabo gives us a sense of patient suffering, both physical and emotional, as their demands, pain, physical disintegration, and even smell alienated and frustrated physicians and family alike. He emphasizes the social role demanded of the incurably ill and the stress placed on a “good death,” which followed a redemptive narrative arc.

In separate chapters, Szabo examines the linguistic contortions of practitioners faced with patients they knew they could not cure, the tenacity of therapeutic optimism in the face of incurability, the ambivalence of the profession toward patient suffering, the role of the medical marketplace as suffering patients and those around them sought new treatments and therapeutic possibilities, tensions between state and private charitable models of support, and the slow institutional and political responses to the needs of the chronically ill.

A particular strength of the book is Szabo’s ability to tease out the apparently contradictory representations of chronic disease. Hence the tubercular patient was frequently represented as displaying signs of degeneracy or inherited weakness—a potential addict, but also a potential martyr, able to transcend suffering. Suffering in particular was a category freighted with immense social and religious significance, although Szabo convincingly argues that the role of Catholic conceptions of suffering in medical interventions have perhaps been overemphasized in previous accounts. In particular, he demonstrates that Catholicism was not the overriding frame in which the use of opiates was debated and discussed.

Overall, the book presents a compelling account of an underexplored aspect of medical care. It will be of equal interest to medical and French historians, as well as clinicians, and to any readers with an interest in how the experience of illness is shaped by the sociopolitical world in which clinicians and patients move.