Foucault: The Birth of the Clinic

Notes, Summaries & Reviews

Foucault’s is a history (if we can call it that) of discourse — of the way people talked about the body, particularly in its diseased state, and the way they’ve understood the doctor and the patient himself in relation to the disease.

« …commenter, c’est admettre par définition un excès du signifie sur le signifiant, un reste nécessairement non formule de la pensée que le langage a laisse dans l’ombre, résidu qui en est l’essence elle-même, poussée hors de son secret; mais commenter suppose aussi que ce non-parle dort dans la parole, et que, par une surabondance propre au signifiant, on peut en l’interrogeant faire parler un contenu qui n’était pas explicitement signifie. »

To comment on something is to assume that the ultimate meaning of what you’re getting at is more important than what you’re saying — that there’s something more, something left in the shadows of your words. I think Foucault is laying the foundations for the kind of work he will do in the rest of the book here, asserting that if we can read through the way that doctors talk about the body, the patient, the disease, and themselves in relation to it, we can understand at a deeper, more complex level how they saw and understood these concepts.

This is a history of reading between the lines, of seeing what was not explicitly stated and looking underneath for larger take-aways. I’m unsure how I feel about this, because it doesn’t seem to be based in anything tangible. It feels farfetched and difficult to substantiate, problems that Foucault does resolve, in my mind, in the remainder of the text.

I think it has the potential to be very powerful, though, and I love that Foucault states he is not arguing that this epistemic change in the late 18th century was doctors/scientists suddenly waking up and seeing what had really been there all along — rather, that a new kind of science (by which I mean what was considered scientific) emerged, and through its lenses, scientists and doctors saw different things. They were looking for different things.This way of looking at things, I think, is something a lot of historians of science don’t like. It’s the ultimate critique to the progress narrative and to positivism, to viewing the history of science, technology, and medicine as the story of how scientists eventually “got it right.”

Espaces et Classes

Primary (disease), secondary (disease + individual), tertiary (disease + individual + health infrastructure, or « l’ensemble des gestes par lesquels la maladie, dans une société, est cernée, médicalement investie, isolée, repartie dans des régions privilégiées et closes, ou distribuée a travers des milieux de guérison, aménages pour être favorables »). Big changes took place in the tertiary.

Une Conscience Politique

Begins by talking about epidemics, exploring how they were understood and why the concept of contagion was largely unimportant.

« On a discute beaucoup et longuement, et maintenant encore, pour savoir si les médecins du 18ieme siècle en avaient saisi la caractère contagieux, et s’ils avaient pose le problème de l’agent de leur transmission. Oiseuse question… »

Details growing « conscience collective » of medicine, as observations around France were being collectivized and disseminated through medical infrastructure.

« Le lieu où se forme le savoir, ce n’est plus ce jardin pathologique où Dieu avait distribue les espèces, c’est une conscience médicale généralisée, diffuse dans l’espace et dans le temps, ouverte et mobile, liée à chaque existence individuelle, mais bien à la vie collective de la nation, toujours éveillée sur le domaine indéfini où le mal trahit, sous ses aspects divers, sa grande forme massive. »

Discusses change in the doctor’s role being reinstituting an individual, idiosyncratic “normal” to, in the 19th century onwards, adhering to a common, popular normal as the standard for health.

Importance of the concept of healing the state — health as something the entire nation should be concerned about.

Le  Champ Libre

Account of the debates surround the reformation of medical education during the French Revolution;

Hospitals should be abolished; they shouldn’t be needed in the ideal state, because everyone will be healthy. They end up becoming the new “natural” place for disease, though, replacing the family.

Arguments over whether education/medical field should be regulated.

The Old Age of the Clinic

“Before it became a corpus of knowledge, the clinic was a universal relationship of mankind with itself; the age of absolute happiness for medicine. And the decline began when writing and secrecy were introduced, that is, the concentration of this knowledge in a privileged group, and the dissociation of the immediate relationship, which had neither obstacle nor limits between Gaze and Speech: what was known was no longer communicated to others but put to practical use once it had passed through esotericism of knowledge.”

Theory vs. seeing — to what extent do our theories dictate what we see? (“When Hippocrates had reduced medicine to a system, observation was abandoned and philosophy was introduced into medicine.”)

I’ve felt this way about learning history a lot. If I read so much theory, it’s going to change the way I do history. It’s going to change the way I read sources, the way that I understand them, and the way that I relate them to contemporaneous and modern-day situations and ideas. Is this less pure? Or merely substituting someone else’s bias for my own?

Details how the clinic is different from a hospital, one being that, while in a hospital, “one is dealing with individuals who might suffer from one disease or another,” in the clinic, “one is dealing with diseases that happen to be afflicting this or that patient: what is present is the disease itself, in the body that is appropriate to it, which is not that of the patient, but that of its truth.”

The Lesson of the Hospitals

Clinical hospitals became a space where “truth teaches itself… offers itself to the gaze of both the experienced observer and the naive apprentice; for both there is only one language…”

They made possible “the immediate communication of teaching within the concrete field of experience… effac[ing] dogmatic language as an essential stage in the transmission of truth.” (68)

Interesting, although I’d still argue there was a lot going on with medical language at this time. Someone didn’t just walk in and know how to talk about the body. The body still wasn’t speaking for itself.

“What makes medicine, thus understood, a corpus of knowledge of use to all citizens is its immediate relationship with nature; instead of being, like the old Faculty, the locus of an esoteric, bookish corpus of knowledge, the new school would be ‘the temple of nature’; there one would learn not what the old masters thought they knew, but that form of truth open to all that is manifested in everyday practice…” (70)

Signs and Cases

Begins by discussing similarities and differences between natural history and this new brand of medicine; continuing conversation distinguishing classificatory medicine and clinical medicine. Instead of just classifying everything by their differences and similarities, clinical medicine embodied “a gaze… not bound by the narrow grid of structure (form, arrangement, number, size), but that could and should grasp colors, variations, tiny anomalies… it must make it possible to outline chance sand risks; it was calculating.” (89)

Discusses signs and symptoms — actually kind of defines something for once — and the changing amount of space between what was a signifier and what was signified. Symptoms, instead of being a sign of something, become themselves part of the whole of the disease.

Fascinating discussion of the rising importance of statistics in medicine (WISH THERE WAS MORE SUBSTANTIAL EVIDENCE), which “gave the clinical field a new structure in which the individual in question was not so much a sick person as the endlessly reproducible pathological fact to be found in all patients suffering in a similar way; in which the plurality of observations was no longer simply a contradiction or confirmation, but a progressive, theoretically endless convergence…” (97) “The only normative observer is the totality of observers…’Several observers never see the same fact in an identical way, unless nature has really presented it to them in the same way.’” (102)

Seeing and Knowing

Difference between experimentation and observation

“The observing gaze manifests its virtues only in a double silence: the relative silence of theories, imaginings, and whatever serves as an obstacle to the sensible immediate; and the absolute silence of all language that is anterior to that of the visible.” (108)

The setting of the hospital is important, permitting “pathological events to be reduced to the homogenous; the hospital domain is no doubt not pure transparency to truth, but the refraction that is proper to make possible, through its constancy, the analysis of truth.” (110)

“…by saying what one sees, one integrates it spontaneously into knowledge…” (114)

This is a really important point for Foucault, I think. He’s writing about discourse as a way of knowing. How we put into language what we see is how we construct knowledge.

Long-winded analogy between disease and languages:

“Disease, like the word, is deprived of being, but, like the word, it is endowed with a configuration.” (119) – nominalistic (denies the existence of universals and abstract objects, but affirms the existence of general or abstract terms and predicates)

Open Up a Few Corpses

Argues that the histories of anatomy that posit dissection was not common until the mid-19th century are false, constructed to explain why pathological anatomy (the correlation of lesions with symptoms) wasn’t a thing earlier.

Historical narratives constructed as “retrospective justifications.”

The patient’s narrative & hospital medicine

Notes, Summaries & Reviews, Thesis Research

Mary Fissell, “The disappearance of the patient’s narrative and the invention of hospital medicine,” in British medicine in an age of reform, eds. Roger French and Andrew Wear (London: Routledge, 1991).

In this piece, author Mary Fissell traces the changing nature of the doctor-patient relationship in the 18th century through the narratives doctors and patients used to understand illnesses. As the century wore on, physicians’ notebooks contained fewer patient voices. Where once lay vocabulary, only slightly filtered through the doctor, had been the source for both parties’ understanding of an ailment, a new, professional language emerged and began to eclipse that of the patient. The hospital facilitated this development, changing the landscape in which the patient and doctor interacted from one where the patient retained interpretive authority to one where he or she came to be examined. In this new setting, his or her physical characteristics spoke to the authoritative doctor trained to interpret them. “The body, the disease,” Fissell argues, “became the focus of the medical gaze, not the patient’s version of illness.” (100)

The testimonial is a difficult source to include for the historian because of its proclivity for exaggeration and potential issues with its authenticity. Fissell uses testimonials to discuss patient narratives, and her strategy for mitigating these issues is, I think, both elucidative and adequately tempered. “The veracity of some of these puffs is open to question; but whether ‘genuine’ lived experience or not, these tales followed similar narrative conventions about illness.” (97) She traces the commonalities between the content of the testimonials, concluding that all used a hot/cold, wet/dry framework for understanding the cause and cure of ailments. This gave patients some command over the what would otherwise seem to be random and uncontrollable health problems they encountered.

Next time I read through a set of testimonials, I plan on looking for narrative patterns — similarities and differences between what patients and doctors understood to be the reason for the springs’ efficacy. Did this change over time, as the claims in other parts of the ads become more scientifically oriented?

Fissell also discusses the use of what I have seen termed as “heroic therapies” — “an anti-phlogistic regimen that featured bleeding, purging, blisters, and a bland diet” — in silencing the patient’s narrative. In these regimens, it was the body’s response to treatment that aided in diagnosis and the evaluation of therapeutic efficacy. A fast pulse and red complexion called for bleeding, while a “languid” one indicated that the patient was “contraindicated.” (105)

I have seen in many of the works I have read on hydrotherapy that a major reason it became so popular was due to the fact that people were becoming increasingly skeptical about and weary of allopathic therapeutics. Obviously patients were growing tired of draining (literally) and ineffective treatments; I think, after reading this, they were probably also exasperated by the lack of agency they had in their relationships with their doctors. If their bodies always spoke for them, what control did they have over their health? Add to that the evidence (and it was piling up) that these kinds of treatments were ineffectual, and you have a scientifically-informed populace that is looking for an understandable health system in which they have a voice. A big part of the hydrotherapeutic movement was its emphasis on the importance of the doctor-patient relationship, the sharing of experiences between patients, the social outings, dances, clubs… You went to resorts to heal, but it was a communicative, socially stimulating practice as well. Where an allopathic physician had little interest in communication with his patient, hydrotherapeutic regimens and resorts were constructed with the importance of communication in mind.

Malignant

Summaries & Reviews

Malignant: How Cancer Becomes Us, S. Lochlann Jain

            Part memoir part cultural analysis, Malignant tries to untangle the complicated relationship between cancer, institutional America, and people within and without the disease’s enigmatic aura. Using evidence from popular culture (ad campaigns, cartoons, and artwork), Jain elucidates how cancer is (mis)understood; the way that American medical and governmental institutions have attempted to grapple with cancer, Jain argues, is fundamentally flawed in many ways due to the prevalence and long-term nature of the disease. In various chapters, she cites statistical analysis, trials, the survivor mentality, prognoses, fundraisers (like the pink ribbon campaign), prosthetics, tort law, carcinogen regulation, doctor-patient relations, screening, and the use of fear as aspects of a bigger problem — that the ways we try to understand and deal with cancer are problematic, and that we need a change. Jain argues that we should not see cancer as “a disease awaiting a cure,” but instead “as a constitutive aspect of American social life, economic and science.”[1]

I admittedly had a little trouble initially relating this to other readings because of the style’s unfamiliarity. I wonder if this book is indicative of how medical anthropologists write — by inserting themselves and their experiences into the narrative and argument. As someone trained in history, I recoiled at first, but the message of the book was made all the more powerful by the protagonist’s insight — insight that could only be garnered from having been a part of the system she critiques. The images she presents, and her analysis of them, reminded me of Dangerous Pregnancies. Both authors took posters produced by various institutions and analyzed their usage of disease and the sick body to promote different agendas. The images of the mentally handicapped child and of the supermodel dying of cancer were both presented in the service of warning the public against certain activities, lest they end up in a similar situation. I think analyses of these kinds of images are extremely valuable in determining a society’s understanding of disease and the kind of moral behavior seen as counter to the depravity of illness.

I found Jain’s linking of the doctor-patient relationship to a separation of knowledge, and, by extension, a separation of roles has great potential for analyzing the changing dynamics in doctor-patient relations in the medical field in the late nineteenth and early twentieth centuries. In my research for my undergraduate thesis, I found that up until the 1870s and 1880s, what Roy Porter called a “lively medical pluralism” dominated. Patients had the authority to choose between different types of practitioners in times before government-sponsored medical regulation was the norm. Contrasting that with the experiences of cancer patients in Jain’s narrative, it is evident that a major change took place with the rise of medical authority. Patients, it seems, have lost their voice in many ways now that they do not have access to the privileged knowledge of trained practitioners. This separation of expertise has wide-ranging effects, as elucidated in part by Jain’s presentation of the powerless, relatively uninformed cancer patient. I wonder if a research project has been undertaken to try and understand how this structure — the doctor-patient relationship in which all of the power lies with the former — emerged from the quite different doctor-patient dynamic characteristic of nineteenth-century medical practice.

[1] S. Lochlann Jain, Malignant, 4.