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.

Engineers of Happyland

Summaries & Reviews

Engineers of Happyland, Rudolf Mrázek

         Rudolf Mrázek’s work, clothed in the language of a history of technology, was in fact not a history of technology at all. Instead, Mrázek artfully uses technology to discuss his real interest — nationalism and modernity in the colonial setting. Through the lenses of the ways that people make and do things, and the engineers who help make those decisions, the author is able to capture conceptions and expositions of nationalism, both Dutch and Indonesian. Mrázek’s definition of “technology” is quite broad in this book, including not only the more obvious examples — trains, telephones, and radios — but also cultural technologies like clothing and language. This wide definition is more conducive to an intimate study of the rapidly changing of national identities the people of the Indies underwent in the tumultuous time period Engineers of Happylimaand covers.

This wider definition of technology lends itself to a similarly broad definition of “engineer.” Mrázek’s engineers are engineers in the sense that they are well versed in the technical, and they use this knowledge and the technologies it concerns to create new ways of making and doing. They are not designers of traditional technologies like televisions and computers, however, but focus their energies on engineering society and culture. They are cultural and political leaders, speaking to and promoting what they perceived would lead the Indies in the direction of their particular modern imaginary. Mrs. J. M. T. Catenius was one such engineer, as a writer of a manners and fashion guide; she gave advice on what was culturally and socially acceptable in clothing and manners, thus engineering an aspect of society. Mrázek’s other engineers included novelists, politicians, and other leaders whose ideas about progress and modernity were followed by constituents of the Indies. They often lead others with an eye to modernity, or what they conceived of as a better way to live; shedding light on what was dark, trading ambiguity for certainty and curves for straight lines, humans for machines. These people played important roles in determining how technologies would be used and what sorts of worlds they would create.

A theme of particular importance was that of space between the Dutch and the natives. Whatever technologies the Dutch introduced in an attempt to create a New Holland abroad, a glass house as Mrázek would say, the natives continued to incorporate their own visions of modernity into them, distorting and closing the space between Dutch and native modernity. This harks back to last week and Barak’s work, which also dealt with how colonized populations used the very technology deployed to control or alter them to instead birth a new vision for themselves. Regardless of how the colonizers would have it, the Indies was not the Netherlands, and the natives were not Dutch. What to do with the space in between?

Social and cultural technologies, because they often by definition reside in the communal, proved particular points of contention for the colonizer and the colonized, and thus the space in between them. Roads and railways both required native and colonial bodies to share the same physical space, and both parties brought with them into that space the cultural practices and experiences that defined their origins. Dutch citizens would complain when native grobak carts slowed their progress on the roads; “if you can only teach him… to decently keep to the left side of the road as I am passing by on my motorcycle,” one wrote. (23) The carts’ wheels were bad for the roads, others pointed out.

Equally important in this space, and of particular interest to me, was the perceived space between the bodies of the natives and the Dutch. The native body was viewed as more tolerant of heat in the discussion of air conditioning, and on more than one occasion, was associated with dirt, disease, and feces. An object of much concern with Dutch social engineers was that of the dirtying of the roads by native bodies; their feet brought dirt, and they were prone to defecating in the road. Their ill constructed carts, situated on off-centered axles, “rode over ‘the feces of men, horses, and buffaloes, and made them into dust,’” which was then blown into the homes and businesses that lined the road. The roads, like modern man, needed to be “healed,” H. F. Tillema, a pharmacist and social commentator wrote. In a later work published by the same man, images of natives using their dirty latrines were juxtaposed with images of the clean, Dutch alternative. Natives were dirty and the Dutch were clean.

The native body, and the perceived unregulated Indies more generally, were also heavily associated with disease and contrasted with the “hygienic” practices of the Dutch. The dusty roads mentioned above were blamed for the high infant mortality of the Indies, along with “throat, nose, and lung disorders,” “Typhus,” “Pneumonia,” and other “pathogenic organisms.” The ideal modern road, by contrast, was to be “hard and antiseptic.” (25) Kampongs, low-class native living quarters, were often targeted as the source of epidemics and were contrasted with Dutch bungalows, situated above the city in healthful altitude, termed both “clean and healthy.” (69) The healthfulness of technologies for the European body were also a major selling point in debates about whether they should be implemented; in discussing the importance of air conditioning, the effect of heat on the “mental stamina” of white colonists was considered, and the exclusion of natives in the discussion implied that their bodies were fundamentally different than their native contemporaries’. In creating space between the Dutch and the natives, these commentators stressed the physiological, bodily differences inherent in the two populations. A harder, more concrete distinction can hardly be imagined.

This biological space was supplemented by other distance-inducing recommendations deployed by commentators. One such example is that found in the architecture of the period. In an attempt to maintain their glass houses in the Indies, the Dutch constructed houses higher and higher off of the ground. Even though these structures were ill-suited for the climate — heat rises — they helped to further delineate the Dutch from the native population. These attempts at creating space between colonizer and colonized gave the Dutch and their technologies a sense of “floating,” something that would increasingly contribute to growing dissonance in the eyes of the colonized, who did not use technologies to separate themselves from their colonizers. Instead, “they did not seem intent to build or dismantle any bridges, as they did not seem to be disturbed by any space in between.” (130) Their sense of modernity was not “dirtied” by Dutch interference.

The final three chapters focus on the way that the rising Indonesian nationalist movement deployed these same technologies — social, cultural, and technical — to create their own brand of modernity. Donning European-style clothes, Indonesian dandies encroached on Dutch space by adopting the regalia appropriate to their social standing, which was increasingly closer to that of the colonizer, as a new “substrata” of natives attained college degrees and were employed in office, telegraph, and railway station settings. Mrázek presents the question that most of the Dutch at the time were probably asking; “If a native became clothed as he or she wanted to, would he or she no longer be a native? Wherein, then, would the native belong?” As the colony became more fluid, less easy to categorize and define, these questions became more pressing.

My complaints about Engineers of Happyland are quite similar to the ones I voiced concerning On Barak’s On Time. The timeline is obscured, making some of Mrázek’s arguments harder to follow. His metaphorical language sometimes relied on an understanding of the timeline of Indonesian colonization and independence that I do not have. That being said, it is a fact that, along the lines of Pramoedya Ananta Toer, his strategy for understanding the complexity of the time period he covers is to “loosen time.”

He is also discussing a time of changing political boundaries, and he does very little in the vein of explaining what he means by “the Indies” and “Indonesia.” I realize, however, that the book’s intended audience is probably comprised of scholars already versed in this time period. That being said, if academics focusing on terrain normally excluded from scholarly narratives want their work to hold more importance in the discipline, would it not be advantageous to make such works more accessible to those unfamiliar with the territory?