The Birth of the Clinic: An Archaeology of Medical Perception

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XVIII і медичних уявлень ХІХ ст. У XVIII ст. панує патологічна медицина із нозологічною таблицею в основі, а у ХІХ ст. - постає кланако-патологічний погляд лікаря. Змінюється уявлення про смерть, хворобу, тіло, здоров'я. І ці всі зміни у медицини постають у період і під впливом політичного зламу - Французької революції. Modern medicine has fixed its own date of birth as being in the last years of the eighteenth century. Reflecting on its situation, it identifies the origin of its positivity with a return—over and above all theory—to the modest but effecting level of the perceived. In fact, this supposed empiricism is not based on a rediscovery of the absolute values of the visible, nor on the predetermined rejection of systems and all their chimeras, but on a reorganization of that manifest and secret space that opened up when a millennial gaze paused over men’s sufferings. Nonetheless the rejuvenation of medical perception, the way colours and things came to life under the illuminating gaze of the first clinicians is no mere myth.

Yet it concerns one of those periods that mark an ineradicable chronological threshold: the period in which illness, counter-nature, death, in short, the whole dark underside of disease came to light, at the same time illuminating and eliminating itself like night, in the deep, visible, solid, enclosed, but accessible space of the human body. What was fundamentally invisible is suddenly offered to the brightness of the gaze, in a movement of appearance so simple, so immediate that it seems to be the natural consequence of a more highly developed experience. It is as if for the first time for thousands of years, doctors, free at last of theories and chimeras, agreed to approach the object of their experience with the purity of an unprejudiced gaze. But the analysis must be turned around: it is the forms of visibility that have changed; the new medical spirit to which Bichat is no doubt the first to bear witness in an absolutely coherent way cannot be ascribed to an act of psychological and epistemological purification; it is nothing more than a syntactical reorganization of disease in which the limits of the visible and invisible follow a new pattern; the abyss beneath illness, which was the illness itself, has emerged into the light of language” (p.195). In many ways this book is a structuralist analysis of the kinds of discourses that go on in medicine. There is some incredibly interesting stuff at the start where the disadvantages of putting people into hospitals prior to the French Revolution is discussed by doctors at the time because they understood illness as something needing to be explained in relation to the patient’s entire life as lived and in the hospital a person stops being a person and becomes merely an example of an illness. This shifting relationship between what one is and what one becomes due to where one is, how one is being observed, is really interesting and still relevant today. I think it is also interesting in relation to more than just medicine – also education, workplaces, the courts and so on. Towards the middle of the eighteenth century, Pomme treated and cured a hysteric by making her take ‘baths, ten or twelve hours a day, for ten whole months’. At the end of this treatment for the desiccation of the nervous system and the heat that sustained it, Pomme saw ‘membranous tissues like pieces of damp parchment ...peel away with some slight discomfort, and these were passed daily with the urine; the right ureter also peeled away and came out whole in the same way’. The same thing occurred with the intestines, which at another stage, ‘peeled off their internal tunics, which we saw emerge from the rectum. The oesophagus, the arterial trachea, and the tongue also peeled in due course; and the patient had rejected different pieces either by vomiting or by expectoration’ [1].

We must place ourselves, and remain once and for all, at the level of the fundamental spatialization and verbalization of the pathological, where the loquacious gaze with which the doctor observes the poisonous heart of things is born and communes with itself” (xii-xiii). This medical experience is therefore akin even to a lyrical experience that his language sought, from Hölderlin to Rilke. This experience, which began in the eighteenth century, and from which we have not yet escaped, is bound up with a return to the forms of finitude, of which death is no doubt the most menacing, but also the fullest. Hölderlin’s Empedocles, reaching, by voluntary steps, the very edge of Etna, is the death of the last mediator between mortals and Olympus, the end of the infinite on earth, the flame returning to its native fire, leaving as its sole remaining trace that which had precisely to be abolished by his death: the beautiful, enclosed form of individuality; after Empedocles, the world is placed under the sign of finitude, in that irreconcilable, intermediate state in which reigns the Law, the harsh law of limit; the destiny of individuality will be to appear always in the objectivity that manifests and conceals it, that denies it and yet forms its basis: ‘here, too, the subjective and the objective exchange faces.’ This period saw the attempt to model medicine on the chemical approach. In chemistry there had occurred huge breakthroughs through the method of analysis: breaking up substances in their elements and describe their relations and proportions through observation. Similarly, doctors started breaking down diseases into elements and their relations, trying to quantify these through the observation of huge amounts of patients. Medicine became statistics and observation – fitting neatly into the current trend of transforming almost everything into mathematical models.

The history of illness to which he is reduced is necessary to his fellow men because it teaches them by what ills they are threatened. Modern medicine begins for Foucault around the time of the French Revolution, at a time when the gaze newly encompasses other factors. Time and space now mattered. This clinical medicine is more open than classificatory medicine and offers a “concrete sensibility.” Doctors no longer decided whether a patient’s condition fit into this or that class; they instead assessed the probabilities of a condition fitting into this or that disease. They no longer had to “simply read the visible; [they had] to discover its secrets” (p. 120). To Foucault, this was the clinic, a place of analysis.

The locus in which knowledge is formed is no longer the pathological garden where God distributed the species, but a generalized medical consciousness, diffused in space and time, open and mobile, linked to each individual existence, as well as to the collective life of the nation… “(p. 31) This book is about space, about language, and about death; it is about the act of seeing, the gaze. Naissance de la clinique" est sans doute la moins lue et la moins commentée de toutes les monographies foucaldiennes. Publiée pour la première fois en 1963, cette "archéologie du regard médical" n'a jamais suscité le même intérêt que des ouvrages désormais classiques comme "Les Mots et les choses" (1966) ou "Surveiller et punir" (1975).

Disease is perceived fundamentally in a space of projection without depth, of coincidence without development. There is only one plane and one moment. The form in which truth is originally shown is the surface in which relief is both manifested and abolished—the portrait: ‘He who writes the history of diseases must… observe attentively the clear and natural phenomena of diseases, however uninteresting they may seem. In this he must imitate the painters who when they paint a portrait are careful to mark the smallest signs and natural things that are to be found on the face of the person they are painting.' the becoming of the clinical medicine, the whole narrative around "the gaze" made me realize again how important this step was in the development of modern medicine. By what right can one transform into an object of clinical observation a pacient whose poverty has compelled him to seek assistance at the hospital? Access-restricted-item true Addeddate 2023-01-23 15:27:59 Autocrop_version 0.0.14_books-20220331-0.2 Boxid IA40821218 Camera Sony Alpha-A6300 (Control) Collection_set printdisabled External-identifierBut this experience [of the epidemic –ZJB] could achieve full significance only if it was supplemented by constant, constricting intervention. A medicine of epidemics could exist only if supplemented by a police: to supervise the location of mines and cemeteries, to get as many corpses as possible cremated instead of buried, to control the sale of bread, wine, and meat, to supervise the running of abattoirs and dye works, and to prohibit unhealthy housing; after a detailed study of the whole country, a set of health regulations would have to be drawn up that would be read ‘at service or mass, every Sunday and holy day’, and which would explain how one should feed and dress oneself, how to avoid illness, and how to prevent or cure prevailing diseases: These precepts would become like prayers that even the most ignorant, even children, would learn to recite.’ Lastly, a body of health inspectors would have to be set up that could be ‘sent out to the provinces, placing each one in charge of a particular department’; there he would collect information about the various domains related to medicine, as well as about physics, chemistry, natural history, topography, and astronomy, would prescribe the measures to be taken, and would supervise the work of the doctor. ‘It is to be hoped that the state would provide for these physicians and spare them the expense that an inclination to make useful discoveries entails’” (25-6). The Birth Company in Alderley Edge, Cheshire was last inspected by the Care Quality Commission in April 2021. The CQC rated The Birth Company as Good for being a caring and responsive service.

Foucault jumps in during the mid-eighteenth-century period of “classificatory medicine,” when “…disease is given an organization, hierarchized into families, genera, and species,” (p. 4) akin to botanical classifications, offering doctors “a gardener’s gaze” (p. 119). Diseases were accorded their own existence independent of the individual body, and so knowledge of particular bodies only interfered with discerning true diseases. Botanical classification; 227 figures of plant anatomical segments with descriptive text. Colour process print. Wellcome Collection. Public Domain Mark He further notes that there is no significance to whether these signs and symptoms progress over time within a single person, suggesting some sort of pathological relationship, or whether one or more occur separately across several individuals, suggesting differentiating pathologies; they still get placed in the same class: “single spasmodic malady.” Nevertheless, there are also very interesting parts, which, as a doctor for human medicine, i appreciated a lot. At the beginning of the nineteenth century, doctors described what for centuries had remained below the threshold of the visible and the expressible, but this did not mean that, after over-indulging in speculation, they had begun to perceive once again, or that they listened to reason rather than to imagination; it meant that the relation between the visible and invisible—which is necessary to all concrete knowledge—changed its structure, revealing through gaze and language what had previously been below and beyond their domain. A new alliance was forged between words and things, enabling one to see and to say. Sometimes, indeed, the discourse was so completely ‘naive’ that it seems to belong to a more archaic level of rationality, as if it involved a return to the clear, innocent gaze of some earlier, golden age” (p.xii).In the genealogy of medicine—knowledge about the human body—the term Le regard médical (The medical gaze) identifies the doctor’s practice of objectifying the body of the patient, as separate and apart from his or her personal identity. In the treatment of illness, the intellectual and material structures of la clinique, the teaching hospital, made possible the inspection, examination, and analysis of the human body, yet the clinic was part of the socio-economic interests of power. Therefore, when the patient’s body entered the field of medicine, it also entered the field of power where the patient can be manipulated by the professional authority of the medical gaze. [2] T]he solidity, the obscurity, the density of things closed in upon themselves, have powers of truth that they owe not to light, but to the slowness of the gaze that passes over them, around them, and gradually into them, bringing them nothing more than its own light. The residence of truth in the dark centre of things is linked, paradoxically, to this sovereign power of the empirical gaze that turns their darkness into light” (xiii-xiv). Bangsa yang hidup tanpa peperangan dan keganasan tidak akan mengalami perkara-perkara di atas. Begitu juga bangsa yang kaya. Sebaliknya, rakyat marhaen pula akan menjadi mangsa despotik kuasawan. Mereka dihimpit dengan cukai yang menyebabkan mereka mengemis, kemiskinan yang hanya menguntungkan golongan atasan dan penginapan yang tidak kondusif (malahan gelandangan) yang hanya memaksa mereka untuk tidak mendirikan keluarga atau hidup dalam rupa bentuk yang sangat mengerikan! The Birth Company are proud of the high-quality service provided to their patrons and welcome a re-inspection by the CQC. Ik miste wel de laatste vertaalslag naar de hedendaagse geneeskunde, de geneeskunde van de microbiologie, genetica, farmacologie. We eindigen op een punt waar de geneeskunde de chemie nog afwees - wat veranderde er eigenlijk zodat de geneeskunde echt een soort van verlengstuk van de biologie werd?