It is extremely difficult to tell someone that their illness is incurable and that they are going to die. I know only too well, because I have had to do it often. I have spent my professional life treating chronically ill patients, most of whom were infected with the human immunodeficiency virus (HIV). Before the advent of effective antiretroviral drugs, a diagnosis of AIDS was essentially a death sentence. With little to offer them, I watched hundreds of people go on to die a slow and agonizing death. Most of them were my age, or slightly older. None of them...

When patients nowadays go to a physician, the questions uppermost in their minds are usually “What’s going on?” and “Is it serious?” In responding to the latter, physicians have increasingly relied on prognostic templates that presuppose that each disease has a distinct natural history. These outcome models, in turn, decisively shape doctors’ attitudes and management strategies. With self-limited or comparably benign diseases, the information exchange tends to be straightforward; physicians offer reassurance, encouragement, and suggestions for hastening recovery. When they suspect a progressive and incurable illness, physicians find “being in the know” extremely problematic.

While incurable illnesses have always had...

Despite their dismal track record treating cancer, physicians in the 1860s were again questioning whether the disease was inherently and inevitably incurable.¹ Reluctant to admit defeat, they embraced the spirit of a colleague’s earnest reminder that “when old age and death alone will remain untreatable, then medicine will have attained [its] goal.”² Three decades later, despite growing worries about humanity’s progressive physical degeneration, physicians were increasingly optimistic. Much of the medical elite embraced an outwardly paradoxical worldview: modern medicine was winning the battle against humanity’s greatest scourges even as France (and the rest of Europe) was believed to be regressing...

During the nineteenth century, the science of chronic disease was intimately tied up with questions surrounding the meaning of life. If Sir Thomas Sydneham’s centuries-old suggestion that mankind brought such sicknesses upon itself still represented the dominant conceit, Sir James Paget put his finger on something equally decisive.¹ In struggling to explain terminal illness, naturalism gave way to metaphysics. Addressing the Royal College of Surgeons in 1853, Paget acknowledged that malignant tumors and tubercles were singularly disturbing because “we trace no fulfilment of design for the well being of the body: they seem all purposeless or hurtful.” Only Divine Will,...

Ritual and narrative have long been sources of solace in the struggle with adversity. In the Christian tradition, illness represented the price of original sin, a symbol of the transitoriness of earthly existence, and a foretaste of hell’s torments. Most importantly, however, disease was a vehicle of spiritual awakening and growth and a divine reminder that earthly life should be spent preparing for the hereafter. Such chastisement was particularly important for the wealthy; it was a precious corrective for the deadliest of sins, vanity.¹ To this day, spiritual reflections on sickness remain an important strand of devotional literature. Yet beginning...

Shortly before Christmas 1866, Auguste Runeau de Saint-Georges had his physician and his confessor join him for a sumptuous meal. He ate nothing. His condition, worrisome in September, had steadily worsened since. Beyond wanting to make a show of good graces, he had presumably invited his physical and spiritual doctors to thank them for their efforts at assuaging the “atrocious pains of a long illness.” The final course completed, a toast to the priest served as the prelude for a touching farewell to his grandchildren. There’s little doubt that, whatever the official prognosis might have been, de Saint-Georges had few...

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...

Opiates have inspired several distinct literary traditions. Physicians and poets have celebrated their medicinal virtues for millennia, while (non) fictional accounts of their pleasures and pains have proliferated since the nineteenth century. Long intrigued by famous habitués, historians have progressively broadened the scope of their reflections. A range of studies, spanning countries and eras, explore concepts such as intoxication and addiction, criminality and repression. The sheer number of works devoted to “drug problems” and “problem drugs” speak to their interest as historical objects. Few other social artifacts, in fact, give such purchase on important aspects of human culture and social...

Dr. Georges Daremberg’s 1905 study of tuberculosis included an intriguing ethnography of chronic illness laced with value judgments. His interest in illness behaviors had complex roots. His father, Dr. Charles Daremberg, was a leading medical historian of the nineteenth century, an interest that his literary-minded son also shared. In addition to years of clinical practice, Georges’s hard-won insights reflected his own decades-long struggle with tuberculosis, a struggle that ended tragically two years after the book’s publication. Ironically, Daremberg’s analysis began with the premise that “good” patients followed orders and got better. In the world of chronic illness, successful outcomes were...

Soon after the unanimous passage of landmark pension legislation in 1905, one of the law’s framers observed, “It is grounded on the idea that assistance to the elderly, the infirm, and to incurables is not merely a good turn offered up by the collective, but a legal obligation.”¹ Coming twelve years after a better-known statute guaranteeing free medical care for the indigent, the legislation of July 1905 confirmed the importance of health concerns within the emerging welfare state. Although a comparable social compact was one of the utopian dreams of 1789, authorities did little in practice to assuage the elderly,...

During the second half of the nineteenth century, various private charitable initiatives began providing assistance to the incurably ill. For a start, they benefited from a growing number of focused charitable offerings. Of course, the therapeutic limitations of contemporary medicine meant that tremendous unmet needs remained. The elderly, infirm, and incurable were also still sorely neglected by the public welfare system. This slowly began to change after 1870, as political upheaval, humanitarian sentiment, and public health concerns progressively moved incurables closer to the top of the sociomedical agenda. Over time, modest and tentative steps were taken to deal with the...

Today we speak of chronic and/or degenerative diseases, and sufferers previously classified as incurable are now considered disabled, chronic, or terminally ill. There are no longer any Homes for Incurables in Boston, Philadelphia, and Brooklyn; “reputedly incurable” is also a forgotten notion. Yet despite changes in vocabulary, the related issues of prognosis and disease trajectory are as significant today as they were a century and a half ago. Importantly, many of the developments that make “being incurable” what it is today trace their origins to the nineteenth century.

During that period, physicians wielded new forms of knowledge, new technologies, and...