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Home , The Birth of the Clinic

Michel and The Birth of Modern Medicine

Kevin Jobe, SUNY Stony Brook

2012

The Birth of the Clinic: An Archaeology of Medical Perception tr., A. M. Sheridan Smith (New York: Vintage Books, 1994). ISBN: 978-0679753346

i] Introduction. "This book is about space, about language, and about death; it is about the act of seeing, the gaze." (ix) So begins The Birth of the Clinic: an Archaeology of Medical Perception by . As he often begins his histories, Foucault reminds us of an important fact about our contemporary understanding of life, death and disease: that each of these are historically contingent and are bound up with other seemingly disparate of social reality: biology, to be sure, but also economics, politics, geography, and language itself.

For Foucault, the 18th century relationship between the patient, her disease and the physician is exemplified by the question, ‘What’s the matter with you" - a question which implies a certain antiquated conception of life, death and disease. By the time of Bichat at the turn of the 19th century, this question and the conception of life, and disease it entails has been transformed into the question ‘Where does it hurt?’ It is at this moment, Foucault concludes, that we have entered the age of modern medicine. However what most interests Foucault is not the discovery of this moment itself, but rather all of the seemingly minute and invisible transformations of our discursive reality that makes this moment - and modern medicine itself - possible in the first place. It is the broader social transformation marked by this change – conceived together as the 'historical a priori' of modern medicine – which Foucault sets out to analyze in BC. Thus the task set out in BC is one of “…determining the conditions of possibility of medical experience in modern times.” (xix)

1] Spaces and Classes: One of Foucault’s major tasks in BC is to show that the question ‘Where does it hurt’, which we take as given standard medical procedure of diagnosing the diseased body, is actually part of an interpretive grid of medical perception that is contingently constituted and quite recent. An interpretive grid of medical perception involves for Foucault a very specific type of configuration of concepts, objects and statements. This is why the question ‘What’s the matter with you’ does not register quite right in the web of statements which constitute our modern medical experience. Such a question, Foucault shows, belongs to another field of medical experience altogether, that of 18th century medical experience. According to Foucault, 18th century medical experience operated, as all other kinds of classical knowledge systems, on the basis of the classificatory structure of species and classes. Classificatory medicine therefore maintained a certain spatial configuration and conceptualization of disease which operated along four fundamental principles: the table, the analogy, and similarity (6-7). More importantly, the medicine of spaces, classificatory medicine, holds that disease manifests its essence in its natural locus. Because of this, both the patient and the doctor were thought to be accidents and even barriers to learning the true essence of the disease, as both the hospital and the patients body itself distorted the true manifestation of the nature of the disease itself. Because of the primacy that 18th century medicine placed on the spatialization of disease, as opposed to what Foucault will call the secondary spatialization of disease – the individual human body - he refers to as the primary spatialization of classificatory medicine. Although classificatory medicine had a conception of secondary spatialization – the presence of disease in the human body – it held that such embodiment was not necessarily relevant to understanding the structure of the disease. Unlike modern medicine, the anatomical location and re-location of disease was not relevant to the essential nature of the disease itself. As for what he calls tertiary spatializtion, Foucault refers to the social network in which and through which disease and the management of disease operates; it is the institutional, often non-discursive space which also influences the organization and negotiation of medical knowledge. Tertiary spatialization refers to all those “…heterogeneous figures, time lags, political struggles, demands and utopias, economic constraints, social confrontations” which make up the social experience of disease. (16)

2] A Political Consciousness: This medicine of spaces, according to Foucault, begins to disappear with the emergence of a collective consciousness of disease brought on by several specific institutional changes. The first change was the collaboration of the 18th century practice of private home care with state supervision. Because the home and the family were considered the most natural locus for disease– as opposed to for example the hospital – medical assistance had to be supervised and given a certain legal status by the state. In this respect, restoring health becomes a task of the nation: “Good medicine would be given status and legal protection by the state; and it would be the task of the state ‘to make sure that a true art of curing does exist’ [40] The second and more drastic change come with the institutionalization of epidemic medicine. For Foucault, it was the founding of the Societe Royale de Medecine in 1776 and its conflict with the Faculte doctors that signals a major turn in medical consciousness. The founding of the SRM was the result of a disease that broke out in southern France which forced the Controller General of Finance to order the killing off of suspect animals, which in turn led to economic instability. As a result, it was concluded that epidemics must be made a national medical issue, an issue for the entire nation. (26) Such a medicine of epidemics, however, would require a health ‘police’ which would gather statistics and information of all kinds, down to the last detail, about the life and health of the nation. (25-26) Most significantly, this led to a new totalization of knowledge, which began as a control body for epidemics, but gradually became “…a place for the centralization of knowledge, an authority for the registration and judgment of all medical activity….it had become the official organ of a collective consciousness of pathological phenomena.” (28)

The development of this generalized medical consciousness, which implied the centralization of and dispersion of the medical gaze, were supported by two great myths around the time of the Revolution: a) a nationalized medical profession of doctors as priests of men’s bodies, and b) the total alleviation of disease throughout a completely healthy social body. These myths reinforced the collective consciousness of the medico-administrator as one who advises not only bodies, but souls and even cities or nations: “The first task of the doctor is therefore political: the struggle against disease must begin with a war against bad government.” (33) The myth of the free gaze developed during the Revolution envisioned the institutionalization of the medico-administrator making obsolete the academies and hospitals, and the abolition of disease created by tyranny and slavery, and extremes of wealth and poverty. (33) These myths played an important role: they linked conceptually the function of medicine and medical knowledge to the functioning of the state. Instead of retaining a role of negative restoration of health, medicine was given the task “…of establishing in men’s lives the positive role of health, virtue and happiness.” Its goal was heretofore “…to ensure that the life and activity of the nation was based on the only lasting condition of happiness, namely, their benefit to the state. [37]” (34) Thus we eventually at the transition from a medicine of health in the 18th century to a medicine of normality in the nineteenth century. From this point, life is measured according to the bipolarity of the normal and the pathological. The race, the population, and the nation “…is a living being that one can see degenerating” (35) Medicine, from this point on, functions according to the norm (eventually for Foucault, that around which bio-power and disciplinary power revolve in a normalizing society). The science of life (medicine) thus provides the theoretical basis for the sciences of man that develop in the 19th century (biology, economics, linguistics) which Foucault treats in Les Mots et Les Choses (1966)

3. ] The Free Field: In the late 18th century, the medicine of spaces and classes (classificatory) and the medicine of social normality converge upon a common demand and goal: the abolition of all institutions and barriers which stand in the way of the new generalized medical gaze. In other words, the medical technology of the old classificatory medicine and the political technology of the normalizing medicine begin to demand the removal of barriers that stand in the way of the sovereign liberty of the gaze. Hospitals must go, because they distort the natural environment of the disease (and thus the laws of its manifestation); they must go also because they are a liability to society in terms of funding and labor. Likewise the guilds and associations of doctors must go because they prevent the formation of a centralized medical consciousness; and the university Faculties must go for they regard medical knowledge as a social privilege for themselves. These are opposed to the generalized medical gaze of this era because it the medical gaze is the light of liberty which “…which to an end the unbounded, dark kingdom of privileged knowledge and establishes the unimpeded empire of the gaze.” (39) These structural reforms begin, for Foucault, from 1789 to the reactionary period of Thermidor Year II (around 1794).

After a certain decentralization due to logistic barriers, the rationalities of the medicine of spaces and normality converge upon the local hospital which serves several functions originally. First, as a space of protection. Second, as a space of training and distribution, whereby each hospital devoted itself to a certain category of patients, families or diseases and admitted patients on that basis. Thus the hospital becomes the new family, the locus for the natural manifestation of disease in its essence, in its truth. Here in the hospital, the truth of the disease can be isolated and learnt. In the teaching hospital therefore, there is a double gaze: one that sees disease as part of a general social disorder, and one that isolates it, “with a view to circumscribing its natural truth.” (43) It is eventually in the hospital that modern medicine finds for itself the principle for the articulation of a medical gaze which transforms the experience of seeing and saying in clinical practice.

One of the war cries of the Revolution was ‘No more alms, no more hospitals.’ It was the goal of the Revolution to make these institutions unnecessary. Since hospitals represented the institutionalization of poverty and the sickness of the nation, they must be abolished. (43) Thus the idea of public medical assistance by the state (through home care) and abolition of the hospitals was accepted. The Girondists, for example, demanded total freedom in medical teaching: In this regime of economic liberalism and competition, education returned, in a sense, to the freedom of the ancient Greeks: knowledge is spontaneously transmitted by the Word, and the Word that contains most truth prevails…Fourcroy proposed that after twenty-five years of teaching, the masters should, like so many Socrates recognized at last by a better Athens, be housed and fed throughout their long old age. (49)

However, the dream of the free field of medical practice (government assisted practitioners competitively spreading the light of medical knowledge for everyone) came up against several (familiar) obstacles: quality control, abolition of the guilds, the disappearance of the society of medicine and the closing of the universities. Less radical reformist solutions, however, eventually prevailed. These solutions entailed the reorganization of the Schools of Medicine, compulsory practical medical training regulated by a Royal Institute, a residential medical school, and organized medical field work. (47) Bouquier, a member of the Committee of Public Instruction, proposed a compromise by introducing the medical Insituteurs and proposing the eventual nationalization of the hospital funds as well as closing the the University Faculties and Schools of Medicine.

Throughout this entire period, Foucault notes, the entire reorganization of medicine failed on account of two things: first, medical knowledge still obeyed two types of regularity: individual medical perception mapped out in accordance with the classificatory system of diseases, and the generalized and centralized statistical gathering of qualitative information on climates and places. (51) Because medical knowledge was essentially still operating within the same interpretive grid of seeing and saying, visible and invisible, the subject of medicine remained the same. It had reorganized already-constituted elements of the same knowledge-grid. (51) Medicine still operated on the basis of the same set of concepts, rules, and ways of knowing/perceiving. It would take the structural reorganization of basic medical practice (savoir) and perception (regard) to lay the foundations for a new kind of medical experience. For Foucault, that reorganization would occur in the turn of the century clinics, whose lesson would be the hospital.

4.] The Old Age of the Clinic/5.]The Lesson of the Hospital:

The ‘clinic’ of most the 18th century was primarily a teaching clinic which served as a learning space of the classes of diseases. It was not concerned with discovery of the ‘facts’ of disease or the pathology of individual cases. (59) This is different from the hospital, where the individual is a ‘case’, and the truth of the disease lies within the individual. Not so in the clinic, where the concern is with instruction, not true medical experience. Since the essence of the disease is distorted through the accident of the body and thus remained hidden and obscure, the relation of the visible to the invisible entails that the descriptive language of the visible will always fall short of getting at the invisible, the essence of disease. This is because the classical medical gaze attends primarily to the signifiers of whatever specific class of disease (the signs and symptoms) as perhaps indicating the signified, but not necessarily representing it. Therefore a classical medicine based on seeing is not possible, nor rational for understanding the essence of the nature of the disease. Thus, Foucault says, the clinic of the 18th century could not provide the basis for a scientific empirical language of disease. Medical knowledge in the 18th century teaching clinic was said, not discovered. The significant reorganization of medical knowledge thus begins with the recognition (by Vicq d’Azyr) that the solution to the problems of medical training lie in the hospital. There, “ ‘diseases and death offer great lessons’ ”. (64) It is in the hospital that “A way of teaching and saying became a way of learning and seeing.” (ibid) This transformation was for Foucault to forever change the structure of the clinic.

It is the convergence of hospital and clinic, brought about by the abolition of the old hospital structures and the university, which made possible the “…immediate communication of teaching within the concrete field of experience.” (68) The new clinics, one of which Foucault cites as the teaching clinic of Saint-Eloi under Baumes in 1794, made possible “a language without words, possessing an entirely new syntax, to be formed: a language that did not owe its truth to speech but to the gaze alone. In this hasty recourse to the clinic, another clinic, with an entirely new configuration, was born.” (69) Thermidor and the Directoire took this new clinical structure as their paradigm of restructuring the institution of medicine as a reaction to the radical Revolutionary experiments of ‘liberty in medicine’. (69). However a further compromise had to be made between the residue of the revolutionary ideals of liberalism (the abolition of hospitals, alms-houses, etc) and the demand of social protection (the poor from the rich and vica-versa). (82) Since the hospitals were on the chopping block, and the structure of the old clinics offered a decentralized but controlled space to practice medicine and relieve the nation’s sick and poor, the new clinics offered a solution.

The compromise that was found in the new clinics, however faced a new dilemma: “…by what right can one transform into an object of clinical observation a patient whose poverty has compelled him to seek assistance at the hospital?” (83) The poor were now transformed in the new clinics as objects of a precarious gaze, since now the observation of individuals was instrumental for the health of the population, the people, the nation. To observe in order to know, to show and dissect in order to teach, becomes the necessary violence of the new contract between the rich and poor of the liberal state; the pain and disease of the poor and sick, since it can only be cured through the mediation of the rich, can and must become a spectacle – a sacrifice of observation for the good of the population. If the sick man refuses to offer himself to clinical observation, “…the patient would be guilty of ingratitude, because ‘he would have enjoyed the advantages resulting from sociability, without paying the tribute of gratitude’ [60]”. (84) In return, the rich gains utility in that by funding the clinics, he is “…making possible a geater knowledge of the illnesses with which he himself may be affected.” (84) Benevolence to the poor is simultaneously transformed into knowledge beneficial to the rich. Foucault ends the chapter on the Lesson of the Hospitals with the following important quote:

These, then, were the terms of the contract by which rich and poor participated in the organization of clinical experience. In a regime of economic freedom, the hospital had found a way of interesting the rich; the clinic constitutes the progressive reversal of the other contractual part; it is the interest paid by the poor on the capital that the rich have consented to invest in the hospital; an interest that must be understood in its heavy surcharge, since it is a compensation that is of the order of objective interest for science and of vital interest for the rich. The hospital became viable for private initiative from the moment that sickness, which had come to seek a cure, was turned into a spectacle. Helping ended up by paying, thanks to the virtues of the clinical gaze. (85) For Foucault, the new contract of modern medicine between rich and poor also came with a specific agreement between the physician and the poor, 'unclean' patient forced to subject himself to clinical observation. The clinical gaze for Foucault begins by turning the suffering of the ‘sick poor’ body into a spectacle for the health and well-being of the nation. And because the truth of the individual case comes only through visibility, the bodies of the poor must be made objects of a precarious gaze. However, it is not the ‘moral shame’ of poverty which prevents the actual contact of the physician with the body of the sick poor. Rather, most importantly, contact with the body of the sick poor will be made possible precisely by the ‘contract’ which exchanges the spectacle of their ‘dirt and poverty’ for medical assistance; it is precisely the objectification of the ‘unclean body’ - making their dirt and poverty a spectacle - which makes physical contact permissible and legitimate. The ‘distance’ that would otherwise be made between the shame of poverty and the rich is nullified by the spectacle of the unclean body itself. (163)

In other words, modern medicine, for Foucault, can be marked from the moment when the physical distance of the physician from the patient is no longer constituted by the ‘moral prohibition’ of Enlightenment sensibilities, that sense of shame in revealing one’s nakedness – for example the case of the woman’s breast in a heart exam. Modern medicine, for Foucault, can be signaled from the moment in which the distance from physician to patient is measured no longer by the moral prohibition, but by the ‘uncleanliness’ of the body due to ‘dirt and poverty’. The ‘contact’ between physician and patient, for Foucault, is from this point made possible by the distance the physician can take from the ‘unclean’ body, which in the case of the ‘unclean’ body of the woman meant the invention of the stethoscope, which allowed a ‘safe’ and ‘sanitary’ distance from the exposed breast of the ‘unclean’ woman. With the invention of the stethoscope, Foucault writes these words: “What one cannot see is shown in the distance from what one must not see.” (164) What ‘cannot’ be seen is the ‘invisible visibility’ of disease transmitted through the stethoscope concerning the patient’s heartbeat. However this communication is only made possible in the distance from what ‘must not’ be seen, that is the ‘unclean’ body of the woman. The gaze of the physician, therefore, extracts knowledge of the individual case only at the expense of objectifying the ‘unclean’ body of the woman through a ‘safe’ distance. Therefore the knowledge of the individual case is predicated upon the imposed visibility of the objectified body: the woman’s body as 'unclean' or the poor body as 'dirty'.

6.] Signs and Cases: For Foucault, the discursive structures which underlie the (properly scientific) transformation of the new clinics can be described by reference to two different ‘codes of knowledge’. These structures are what provide the grid of intelligibility for the medical concepts, objects and statements that make up this new clinical experience. First, he points to the linguistic transformation of the symptom and the sign from Classical to contemporary understandings of disease. For Classical medicine, as we recall, the essence of the disease was never fully manifest in the body of the individual. One result of this, as Foucault points outs, is that any language which seeks to describe the disease empirically will always leave a gap between what is a signifier (signs and symptoms) and what is signified (the disease). Furthermore, for 18th century medicine, the symptom is what allows the disease to ‘show through’ whereas the sign merely indicates events or stages of the diseases temporal life. In nineteenth century medicine, however, this distinction collapses, such that any signifier (sign or symptom) is at once the signified. Since there is no longer a hidden essence behind the symptoms of disease, all symptoms and signs must necessarily be transparent to that which they signify. Foucault identifies this development with the impetus of modern medicine to create a descriptively exhaustive language of pathological phenomena – the idea that disease exists only in the visible, and thus statable domain. The second code of knowledge which makes up the discursive structure of the new clinic is the ‘aleatory’ or probabilistic structure of medical cases which emerges at relatively the same period. Under this view developed by Laplace, uncertainty of medical cases could be treated as degrees of certainty capable of finer and finer calculation. This development involved four stages: complexity of combination, unitary analogy, perception of frequencies, and finally a method for calculation of probabilities. (97-104)

7.] Seeing and Saying: These codes of knowledge, taken by themselves, however, fall short of providing an entirely coherent body of knowledge from which one can make intelligible statements. In the case of clinical medicine, this required the organization of these codes of knowledge into a coherent whole that connected empirical cases, the clinical experience of seeing, to the linguistic structure of medical signs, the saying. This project culminated, according to Foucault, in the notion of an ideally exhaustive description of phenomena which entails perception which omits nothing and language that expresses all that is perceived. (Condillac’s convertability of perception and language thesis). In the wake of attempting to ‘cover over’ the failed attempt to uphold such a thesis, there arose two ‘myths’ as inimical to the third great moment in the transformation of medical experience. The first is the ‘chemical metaphor’ of medical disease: the clinical analysis of diseases into their constitutive elements. For Foucault, this is significant because it provides the grounds for the transition to the anatamo-clinical gaze, which reverts back to the notion of ‘implicit structure’ or ‘essence’ of the disease. Secondly, there is the myth of the medical perception as a fine ‘sensibility’ which transformed the gaze into the ‘penetrating glance’. These two myths represent a fundamental change in the clinical experience for Foucault because of their depth and penetration into their objects of observation that was not present in even the new clinics of the early nineteenth century. (118-122) This paved the way for the work of Bichat who was to utilize the new codes of knowledge in order to found clinical medicine on the new ground of pathological anatomy:

Clinical experience sees a new space opening up before it: the tangible space of the body, which at the same time is that opaque mass in which secrets, invisible lesions, and the very mystery of origins lie hidden. The medicine of symptoms will gradually recede, until it finally disappears before the medicine of organs, sites, causes, before a clinic wholly ordered in accordance with pathological anatomy. The age of Bichat has arrived. (122)

8.] Open up a Few Corpses/9.] The Visible Invisible/10.] Crisis in Fevers: Foucault considers the work of Bichat one of the great transformative moments in the history of medicine because he fundamentally changed the orientation of the ‘surface gaze’ of the new clinics. Building upon the myths of the clinical chemist’s gaze that breaks down disease to reveal its true structure, Bichat went beyond surface observation and description into a domain of hidden causes of disease. One important feature of Bichat’s work was the practice of comparing healthy bodies to dead bodies in order to make identifications of different anatomical lesions and their development. According to Foucault, this changed the concept of disease in a significant way. Rather than being a collection of pathological phenomena, the body was now the site of disease itself. This amounts to a reversal of the classical spatialization of disease, such that secondary spatialization is now seen as primary spatialization – the site and hidden structure of disease now lies in the individual body, not in its natural locus. The medicine of symptoms has been replaced by the medicine of the bodily lesion; the priority of the seat of disease has replaced the species of disease.

These changes implied a very crucial shift in the concept of disease, and by implication, death and life. Because of the central importance and vast wealth of knowledge which the autopsy served for Bichat’s understanding of disease, death was no longer considered outside of the domain of medicine: death, and its processes is now not just medically relevant – it is necessary to medical practice and knowledge. Whereas in the classical conception, knowledge of life was found in the life of the living, modern medicine after Bichat proceeded the other way around : knowledge of life is found in the destruction and degeneration of life. Seen in this light, death is the condition of possibility of disease. Therefore, if we wish to understand disease, we must understand death and its destructive processes: “(K)nowledge of life finds its origins in the destruction of life.” (145) For Foucault, Bichat not only freed medicine from the fear of death, but he “…integrated that death into a technical and conceptual totality in which it assumed its specific characteristics and its fundamental value as experience.” (146) Death, therefore, left the ‘old tragic’ heavens of the Renaissance and became the lyrical core of man: “his invisible truth, his visible secret.” (172) Culminating in the work of Broussais, then, the space of localization for modern medicine overlaps precisely with its primary spatialization: the bodily lesion. Furthermore, it is the pathological tissue which is the seat and origin of the disease, and in which lies the essence of the pathological. (189) Therefore the real visibility, the true visibility, lies within the body; behind the surface. Thus, the medical perception begun by Bichat and completed by Broussais is a medical perception of the “invisible visibility”. (165)

Conclusion: Like many (or most) of Foucault's books, The Birth of the Clinic contains a hidden thesis. For Foucault, modern medicine gave us the birth of the clinic, but it also gave us the birth of the 'individual': "The old Aristotelian law, which prohibited the application of scientific to the individual, was lifted when, in language, death found the locus of its concept: space opened ip to the gaze the differentiated form of the individual." (170) For Foucault, modern medicine, in its scientific gaze which brings to light the invisible mystery of death as a scientific truth within the body of the patient, makes each patient an individual case, an individual with a secret inward truth. Modern medicine, seeking the truth of death within the body, objectifies an 'invisible visibility' within each person, a veritable soul which must be interrogated and brought to light by the medical gaze. Unlike the the Renaissance, where death represented to all a sort of homogeneous realm of mysterious fate and fortune, death in the 19th century begins to constitute the 'singularity' of individual existences, marking out individual differences according to the truth of their own bodies, and their own souls: "it is in that perception of death that the individual finds himself, escaping from a monotonous, average life; in the slow, half-subterannean, but already visible approach of death, the dull, common life becomes an individuality at last; a black border isolates it and gives it the style of its own truth." (171) Death, once and for all, "left its old tragic heaven and became the lyrical core of man: his invisible truth, his visible secret." (172)

The important consequence of this development - that death is now "embodied in the living bodies of individuals" (196) - is that modern medicine begins to pave the way for a scientific discourse not only of the individual, but of the scientific discourse of 'man'. The importance of modern medicine is not only methodological, Foucault says, but "ontological, in that it concerns man's being as object of positive knowledge." (197) Prefiguring his archaeology of the human sciences in , Foucault claims that modern medicine paves the way for the organization of the scientific discourses of biology, economics and linguistics, thus finally making man both the subject and object of knowledge: man becomes both the subject of inquiry, and the object of inquiry.

For Foucault, this subject-object relationship of man to himself is not just a scientific endeavor. It is a philosophical, theological and spiritual endeavor to confront and reveal the status of man and his finitude. For modern medicine, man becomes aware that he conquered by death, but he also is aware that he also the potential conqueror of death, the conqueror of his own finitude. In the 'architecture' of the human sciences, medicine is the discipline that sustains them all in their endeavor to grasp scientifically the limits of "man" and his finitude: "This is because medicine offers modern man the obstinate, yet reassuring face of his finitude; in it, death is endlessly repeated, but it is also exorcized." (198) In other words, for Foucault, modern medicine represents man's philosophical and theological attempt to master his own finitude. Just as man attempts to master nature, he also attempts to master himself by penetrating the depths of disease with the scepter of knowledge and light. For modern man, Foucault says, "health replaces salvation". (198) For Foucault, this philosophical-theological origin of modern medicine - and with it the human sciences - is a specific kind of relationship to ourselves that we have inherited from European culture, and which we are "only just beginning to disentangle". It is this task - unraveling the 'dark web of our experience' as modern individual subjects and objects of truth - that Foucault will set out to map in his next book, The Order of Things: an Archaeology of the Human Sciences.