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Michel Foucault “The Birth of the Clinic”

Foucault, Michel 2008. The Birth of the Clinic: An archaeology of medical perception. London; New York: Routledge.

 

Introduction

We are doomed historically to history, to the patient construction of discourses about discourses, and to the task of hearing what has already been said. (xvii)

[…] in stating what has been said, one has to re-state what has never been said. (xviii)

[…] to comment is to admit by definition an excess of the signified over the signifier; a necessary, unformulated remainder of thought that language has left in the shade—a remainder that is the very essence of that thought, driven outside its secret—but to comment also presupposes that this unspoken element slumbers within speech (parole), and that, by a super-abundance proper to the signifier, one may, in questioning it, give voice to a content that was not explicitly signified. By opening up the possibility of commentary, this double plethora dooms us to an endless task that nothing can limit: there is always a certain amount of signified remaining that must be allowed to speak, while the signifier is always offered to us in an abundance that questions us, in spite of ourselves, as to what it ‘means’ (veut dire). (xviii)

What counts in the things said by men is not so much what they may have thought or the extent to which these things represent their thoughts, as that which systematizes them from the outset, thus making them thereafter endlessly accessible to new discourses and open to the task of transforming them. (xxii)

 

1. Spaces and classes

The first structure provided by classificatory medicine is the flat surface of perpetual simultaneity. Table and picture. (5) In a flat, homogeneous, non-measurable world, there is essential disease where there is a plethora of similarities. (6) The order of disease is simply a ‘carbon copy’ of the world of life; the same structures govern each, the same forms of division, the same ordering. The rationality of life is identical with the rationality of that which threatens it. Their relationship is not one of nature and counter-nature; but, in a natural order common to both, they fit into one another, one superimposed upon the other. In disease, one recognizes (reconnait) life because it is on the law of life that knowledge (connaissance) of the disease is also based. (6-7) In the rational space of disease, doctors and patients do not occupy a place as of right; they are tolerated as disturbances that can hardly be avoided: the paradoxical role of medicine consists, above all, in neutralizing them, in maintaining the maximum difference between them, so that, in the void that appears between them, the ideal configuration of the disease becomes a concrete, free form, totalized at last in a motionless, simultaneous picture, lacking both density and secrecy, where recognition opens of itself onto the order of essences. (8)

What classificatory medicine calls particular histories’ are the effects of multiplication caused by the qualitative variations (owing to the temperaments) of the essential qualities that characterize illnesses. The individual patient finds himself at the point at which the result of this multiplication appears. Hence his paradoxical position. If one wishes to know the illness from which he is suffering, one must subtract the individual, with his particular qualities: ‘The author of nature,’ said Zimmermann, ‘has fixed the course of most diseases through immutable laws that one soon discovers if the course of the disease is not interrupted or disturbed by the patient’; at this level the individual was merely a negative element, the accident of the disease, which, for it and in it, is most alien to its essence. But the individual now reappears as the positive, ineffaceable support of all these qualitative phenomena, which articulate upon the organism the fundamental ordering of the disease […] (15)

The patient is the rediscovered portrait of the disease; he is the disease itself, with shadow and relief, modulations, nuances, depth; and when describing the disease the doctor must strive to restore this living density: ‘One must render the patient’s own infirmities, his own pains, his own gestures, his own posture, his own terms, and his own complaints’. (Zimmerman ‘Traité de l’experience’, 1800) (16)

The natural locus of disease is the natural locus of life—the family: gentle, spontaneous care, expressive of love and a common desire for a cure, assists nature in its struggle against ,the illness, and allows the illness itself to attain its own truth. The hospital doctor sees only distorted, altered diseases, a whole teratology of the pathological; the family doctor ‘soon acquires true experience based on the natural phenomena of all species of disease’. (19)

Independently of their justifications, the thought structure of the economists and that of the classificatory doctors coincide in broad terms: the space in which disease is isolated and reaches fulfilment is an absolutely open space, without either division or a privileged, fixed figure, reduced solely to the plane of visible manifestations; a homogeneous space in which no intervention is authorized except that of a gaze which is effaced as it alights, and of assistance whose sole value is its transitory compensation—a space with no other morphology than that of the resemblances perceived from one individual to another, and of the treatment administered by private medicine to a private patient. (21)

 

2. A political consciousness

It is important to determine how and in what manner the various forms of medical knowledge pertained to the positive notions of ‘health’ and ‘normality’. Generally speaking, it might be said that up to the end of the eighteenth century medicine related much more to health than to normality; it did not begin by analysing a ‘regular’ functioning of the organism and go on to seek where it had deviated, what it was disturbed by, and how it could be brought back into normal working order; it referred, rather, to qualities of vigour, suppleness, and fluidity, which were lost in illness and which it was the task of medicine to restore. To this extent, medical practice could accord an important place to regimen and diet, in short, to a whole rule of life and nutrition that the subject imposed upon himself.  This privileged relation between medicine and health involved the possibility of being one’s own physician. Nineteenth-century medicine, on the other hand, was regulated more in accordance with normality than with health; it formed its concepts and prescribed its interventions in relation to a standard of functioning and organic structure, and physiological knowledge—once marginal and purely theoretical knowledge for the doctor—was to become established (Claude Bernard bears witness to this) at the very centre of all medical reflexion. Furthermore, the prestige of the sciences of life in the nineteenth century, their role as model, especially in the human sciences, is linked originally not with the comprehensive, transferable character of biological concepts, but, rather, with the fact that these concepts were arranged in a space whose profound structure responded to the healthy/morbid opposition. When one spoke of the life of groups and societies, of the life of the race, or even of the ‘psychological life’, one did not think first of the internal structure of  the organized being, but of the medical bipolarity of the normal and the pathological. Consciousness lives because it can be altered, maimed, diverted from its course, paralysed; societies live because there are sick, declining societies and healthy, expanding ones; the race is a living being that one can see degenerating; and  civilizations, whose deaths have so often been remarked on, are also, therefore, living beings. If the science of man appeared as an extension of the science of life, it is because it was medically, as well as biologically, based: by transference, importation, and, often, metaphor, the science of man no doubt used concepts formed by biologists; but the very subjects that it devoted itself to (man, his behaviour, his individual and social realizations) therefore opened up a field that was divided up according to the principles of the normal and the pathological. Hence the unique character of the science of man, which cannot be detached from the negative aspects in which it first appeared, but which is also linked with the positive role that it implicitly occupies as norm. (40-41)

 

3. The free field

If the family was bound to the unfortunate individual by the natural duty of compassion, the nation was bound to him by the social, collective duty to provide assistance. Hospital foundations represented an immobilization of wealth, and, by their very inertia, created poverty; these must disappear, but they must be replaced by a national, constantly available fund capable of providing help when and where required. The state must therefore ‘divert to its own use’ the wealth of the hospitals and then combine it into a ‘common fund’. (47)

The field of practical medicine was divided between a free, endlessly open domain—that of home practice—and a closed space, confined to the truths of the species that it revealed; the field of apprenticeship was divided between an enclosed domain of essential truths and a free domain in which truth speaks of itself. And the hospital played this dual role: for the doctor’s gaze it was the locus of systematic truths; for the knowledge formulated by the teacher it was the locus of free experiment. (57)

For reasons that are bound up with the history of modern man, the clinic was to remain, in the opinion of most thinkers, more closely related to the themes of light and liberty—which, in fact, had evaded it—than to the discursive structure in which, in fact, it originated. It is often thought that the clinic originated in that free garden where, by common consent, doctor and patient met, where observation took place, innocent of theories, by the unaided brightness of the gaze, where, from master to disciple, experience was transmitted beneath the level of  words.  And to the advantage of a historical view that relates the fecundity of the clinic to a scientific, political, and economic liberalism, one forgets that for years it was the ideological theme that prevented the organization of clinical medicine. (61)

 

4. The old age of the clinic

In the hospital, the patient is the subject of his disease, that is, he is a case; in the clinic, where one is dealing only with examples, the patient is the accident of his disease, the transitory object that it happens to have seized upon. (71)

In this clinical method, in which the density (épaisseur) of the perceived hides only the imperious and laconic truth that names, it is a question not of an examination, but of a deciphering. (72)

 

5. The lesson of hospitals

[…] it was hoped that there would be an increase in home treatment [55]. However, the time was past when such treatment was regarded as universally valid and when people dreamt of a society without alms-houses and hospitals: poverty was too widespread—there were over 60,000 paupers in Paris in the Year II [56] and their number was increasing; popular movements were too feared, and too much suspicion surrounded the political use to which individual assistance might be put, to allow the whole system of assistance to be left to them. A structure had to be found, for the preservation of both the hospitals and the privileges of medicine, that was compatible with the principles of liberalism and the need for social protection—the latter understood somewhat ambiguously as the protection of the poor by the rich and the protection of the rich against the poor. (100)

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. (103)

The doctor’s gaze is a very small saving in the calculated exchanges of a liberal world … (104)

 

6. Signs and cases

The old dream of Boissier de Sauvages of being the Linnaeus of diseases was not entirely forgotten in the nineteenth century: doctors long continued to botanize in the field of the pathological. But the medical gaze was also organized in a new way. First, it was no longer the gaze of any observer, but that of a doctor supported and justified by an institution, that of a doctor endowed with the power of decision and intervention. Moreover, it was a gaze that was not bound by the narrow grid of structure (form, arrangement, number, size), but that could and should grasp colours, variations, tiny anomalies, always receptive to the deviant. Finally, it was a gaze that was not content to observe what was self-evident; it must make it possible to outline chances and risks; it was calculating. (109)

It is no longer a question of giving that by which the disease can be recognized, but of restoring, at the level of words, a history that covers its total being. To the exhaustive presence of the disease in its symptoms corresponds the unobstructed transparency of the pathological being with the syntax of a descriptive language: a fundamental isomorphism of the structure of the disease and of the verbal form that circumscribes it. The descriptive act is, by right, a ‘seizure of being’  (une prise d’e• tre),  and, inversely, being does not appear in symptomatic and therefore essential manifestations without offering itself to the mastery of a language that is the very speech of things. In the medicine of species, the nature of a disease and its description could not correspond without an intermediate stage that formed the ‘picture’ with its two dimensions; in clinical medicine, to be seen and to be spoken immediately communicate in the manifest truth of the disease of which it is precisely the whole being. There is disease only in the element of the visible and therefore statable. (116)

As an isomorph of ideology, clinical experience offers it an immediate domain of application.  Not that medicine, as Condillac supposed, had returned to an empirical respect for the thing perceived; but in the clinic, as in analysis, the armature of the real is designed on the model of language. The clinician’s gaze and the philosopher’s reflexion have similar powers, because they both presuppose a structure of identical objectivity, in which the totality of being is exhausted in manifestations that are its signifier-signified, in which the visible and the manifest come together in at least a virtual identity, in which the perceived and the perceptible may be wholly restored in a language whose rigorous form declares its origin. The doctor’s discursive, reflective perception and the philosopher’s discursive reflexion on perception come together in a figure of exact superposition, since the world is for them the analogue of language. (117)

 

7. Seeing and knowing

The clinical gaze has the paradoxical ability to hear a language as soon as it perceives a spectacle. (132)

It is in this exhaustive and complete passage from the totality of the visible to the over-all structure of the expressible (structure d’ensemble de l’énonçable)  that is fulfilled at last that significative analysis of the perceived that the naïvely geometric architecture of the picture failed to provide. It is description, or, rather, the implicit labour of language in description, that authorizes the transformation of symptom into sign and the passage from patient to disease and from the individual to the conceptual. And it is there that is forged, by the spontaneous virtues of description, the link between the random field of pathological events and the pedagogical domain in which they formulate the order of their truth. To describe is to follow the ordering of the manifestations, but it is also to follow the intelligible sequence of their genesis; it is to see and to know at the same time, because by saying what one sees, one integrates it spontaneously into knowledge; it is also to learn to see, because it means giving the key of a language that masters the visible. (140)

This speaking eye would be the servant of things and the master of truth. (141)

A hearing gaze and a speaking gaze: clinical experience represents a moment of balance between speech and spectacle.  A precarious balance, for it rests on a formidable postulate: that all that is visible is expressible, and that it is wholly visible because it is wholly expressible. A postulate of such scope could permit a coherent science only if it was developed in a logic that was its rigorous outcome. But the reversibility, without residue, of the visible in the expressible remained in the clinic a requirement and a limit rather than an original principle. Total description is a present and ever-withdrawing horizon; it is much more the dream of a thought than a basic conceptual structure. (142)

But this generalized form of transparence leaves opaque the status of the language that must be its foundation, its justification, and its delicate instrument. Such a deficiency, which also occurs in Condillac’s logic, opens up the field to a number of epistemological myths that are destined to mask it. But these myths are already engaging the clinic in new spatial figures, in which visibility thickens and becomes cloudy, in which the gaze is confronted by obscure masses, by impenetrable shapes, by the black stone of the body. (144)

Until the end of the eighteenth century the gaze of the nosographers was a gardener’s gaze; one had to recognize the specific essence in the variety of appearances. At the beginning of the nineteenth century another model emerged: that of the chemical operation, which, by isolating the component elements, made it possible to define the composition, to establish common points, resemblances, and differences with other totalities, and thus to found a classification that was no longer based on specific types but on forms of relations: ‘Instead of following the example of the botanists, should not the nosologists have, rather, taken as their model the systems of the chemist-mineralogists, that is, be content to classify the elements of diseases and their more frequent combinations?’  [32] The notion of analysis in which, applied to the clinic, we have already recognized a quasi-linguistic sense and a  quasimathematical sense [33] will now move towards a chemical signification: it will have as its horizon the isolation of pure bodies and the depiction of their combinations. One has passed from the theme of the combinative to that of syntax and finally to that of combination. (147)

The reality, whose language it spontaneously reads in order to restore it as it is, is not as adequate to itself as might be supposed: its truth is given in a decomposition that is much more than a reading since it involves the freeing of an implicit structure. One can now see that the clinic no longer has simply to read the visible; it has to discover its secrets. (148)

At this level, all structures are dissolved, or, rather, those that constituted the essence of the clinical gaze are gradually, and in apparent disorder, replaced by those that are to constitute the glance. And they are very different. In fact, the gaze implies an open field, and its essential activity is of the successive order of reading; it records and totalizes; it gradually reconstitutes immanent organizations; it spreads out over a world that is already the world of language, and that is why it is spontaneously related to hearing and speech; it forms, as it were, the privileged articulation of two fundamental aspects of saying (what is said and what one says). The glance, on the other hand, does not scan a field: it strikes at one point, which is central or decisive; the gaze is endlessly modulated, the glance goes straight to its object. The glance chooses a line that instantly distinguishes the essential; it therefore goes beyond what it sees; it is not misled by the immediate forms of the sensible, for it knows how to traverse them; it is essentially demystifying.  If it strikes in its violent rectitude, it is in order to shatter, to lift, to release appearance. It is not burdened with all the abuses of language. The glance is silent, like a finger pointing, denouncing. There is no statement in this denunciation. The glance is of the non-verbal order of contact, a purely ideal contact perhaps, but in fact a more striking contact, since it traverses more easily, and goes further beneath things. The clinical eye discovers a kinship with a new sense that prescribes its norm and epistemological structure; this is no longer the ear straining to catch a language, but the index finger palpating the depths. Hence that metaphor of ‘touch’  (le tact) by which doctors will ceaselessly define their glance. (149-150)

 

7. Open up a few corpses

With the coming of the Enlightenment, death, too, was entitled to the clear light of reason, and became for the philosophical mind an object and source of knowledge: ‘When philosophy brought its torch into the midst of civilized peoples, it was at last permitted to cast one’s searching gaze upon the inanimate remains of the human body, and these fragments, once the vile prey of worms, became the fruitful source of the most useful truths’. (153 – Alibert, Nosologie Naturelle, 1817)

Anatomy could become pathological only insofar as the pathological spontaneously anatomizes. Disease is an autopsy in the darkness of the body, dissection alive. This explains the enthusiasm that Bichat and his disciples immediately felt for the discovery of pathological anatomy: it was not that they rediscovered Morgagni beyond Pinel or Cabanis; they  rediscovered analysis in the body itself; they revealed, in depth, the order of the surfaces of things; they defined for disease a system of analytical classes in which the element of pathological decomposition was the principle of generalization of morbid species. One passed from an analytical perception to the perception of real analyses. And, quite naturally, Bichat recognized in his discovery an event symmetrical with Lavoisier’s: ‘Chemistry has its simple bodies which form by the various combinations of which they are susceptible composite bodies…. Similarly, anatomy has its simple tissues which…by their combinations form organs’ [18]. The method of the new anatomy is analysis, just as it is in chemistry, but an analysis detached from its linguistic support and defining the spatial divisibility of things rather than the verbal syntax of events and phenomena. Hence the paradoxical reactivation of classificatory thought at the beginning of the nineteenth century. Pathological anatomy, which was to be proved right some years later, far from dissipating the old nosological project, gave it new vigour, insofar as it seemed to provide it with a solid basis: real analysis according to perceptible surfaces. (161)

Disease is no longer a bundle of characters disseminated here and there over the surface of the body and linked together by statistically observable concomitances and successions; it is a set of forms and deformations, figures, and accidents and of displaced, destroyed, or modified elements bound together in sequence according to a geography that can be followed step by step. It is no longer a pathological species inserting itself into the body wherever possible; it is the body itself that has become ill. (167)

What is modified in giving place to anatomo-clinical medicine is not, therefore, the mere surface of contact between the knowing subject and the known object; it is the more general arrangement of knowledge that determines the reciprocal positions and the connexion between the one who must know and that which is to be known.  The access of the medical gaze into the sick body was not the continuation of a movement of approach that had been developing in a more or less regular fashion since the day when the first doctor cast his somewhat unskilled gaze from afar on the body of the first patient; it was the result of a recasting at the level of epistemic knowledge (savoir) itself, and not at the level of accumulated, refined, deepened, adjusted knowledge (connaissances). (168-169)

to localize was to fix only a spatial and temporal starting point. For Morgagni, the seat was the point of insertion in the organism of the chain of causalities; it was identified with its ultimate link. For Bichat and his successors, the notion of seat is freed from the causal problematic (and in this respect, they are the heirs of the clinicians) ; it is directed towards the future of the disease rather than to its past; the seat is the point from which the pathological organization radiates. Not the final cause, but the original site. It is in this sense that the fixation onto a corpse of a segment of immobile space may resolve the problems presented by the temporal developments of a disease. (172)

Death is therefore multiple, and dispersed in time: it is not that absolute, privileged point at which time stops and moves back; like disease itself, it has a teeming presence that analysis may divide into time and space; gradually, here and there, each of the knots breaks, until organic life ceases, at least in its major forms, since long after the death of the individual, minuscule, partial deaths continue to dissociate the islets of life that still subsist. (174)

Life, disease, and death now form a technical and conceptual trinity. The continuity of the age-old beliefs that placed the threat of disease in life and of the approaching presence of death in disease is broken; in its place is articulated a triangular figure the summit of which is defined by death. It is from the height of death that one can see and analyse organic dependences and pathological sequences. Instead of being what it had so long been, the night in which life disappeared, in which even the disease becomes blurred, it is now endowed with that great power of elucidation that dominates and reveals both the space of the organism and the time of the disease. The privilege of its intemporality, which is no doubt as old as the consciousness of its imminence, is turned for the first time into a technical instrument that provides a grasp on the truth of life and the nature of its illness. Death is the great analyst that shows the connexions by unfolding them, and bursts open the wonders of genesis in the rigour of decomposition: and the word decomposition must be allowed to stagger under the weight of its meaning.  Analysis, the philosophy of elements and their laws, meets its death in what it had vainly sought in mathematics, chemistry, and even language: an unsupersedable model, prescribed by nature; it is on this great example that the medical gaze will now rest. It is no longer that of a living eye, but the gaze of an eye that has seen death—a great white eye that unties the knot of life. (176-177)

The living night is dissipated in the brightness of death. (180)

 

9. The visible invisible

[…] the idea of a disease attacking life must be replaced by the much denser notion of pathological life. (188)

Between Sydenham and Pinel disease assumed a source and a face in a general structure of rationality concerning nature and the order of things. From Bichat onwards, the pathological phenomenon was perceived against the background of life, thus finding itself linked to the concrete, obligatory forms that it assumed in an organic individuality. Life, with its finite, defined margins of variation, was to play the same role in pathological anatomy as the broad notion of nature played in nosology: it was the inexhaustible, but closed basis in which disease finds the ordered resources of its disorders. A distant, theoretical change that, in the long term, modified a philosophical horizon; but can it be said that it affected at once a world of perception and the gaze that a doctor turns upon a patient? (188-189)

From Bichat onwards, disease was to play the same dual role, but between life and death. Let us be clear about this: an experience devoid of both age and memory knew, well before the advent of pathological anatomy, the way that led from health to disease, and from disease to death. But this relationship had never been scientifically conceived or structured in medical perception; at the beginning of the nineteenth century it acquired a figure that can be analysed at two levels. That which we know already: death as the absolute point of view over life and opening (in all senses of the term, even the most technical) on its truth. But death is also that against which life, in daily practice, comes up against; in it, the living being resolves itself naturally: and disease loses its old status as an accident, and takes on the internal, constant, mobile dimension of the relation between life and death. It is not because he falls ill that man dies; fundamentally, it is because he may die that man may fall ill. And beneath the  chronological life/disease/death relation, another, earlier, deeper figure is traced: that which links life and death, and so frees, besides, the signs of disease. (191)

Deviation in life is of the order of life, but of a life that moves towards death. (191)

Degeneration is not, therefore, a return to the inorganic; or, rather, it is such a return only insofar as it is infallibly orientated towards death. The disorganization that characterizes it is not that of the non-organic, it is that of the non-living, of life caught up in the process of self-destruction: ‘we must call pulmonary phthisis any lesion of the lung which, left to itself, produces a progressive disorganization of that organ as a result of which occur its alteration and, finally, death’. (194)

[…] life with its real duration and disease as a possibility of deviation find their origin in the deeply buried point of death; it commands their existence from below. Death, which, in the anatomical gaze, spoke retroactively the truth of disease, makes possible its real form by anticipation. (195)

The moral obstacle [to opening up corpses] was experience only when the epistemological need had emerged; scientific necessity revealed the prohibition for what it was: Knowledge invents Secret. (200-201)

That which hides and envelops, the curtain of night over truth, is, paradoxically, life; and death, on the contrary, opens up to the light of day the black coffer of the body: obscure life, limpid death, the oldest imaginary values of the Western world are crossed here in a strange misconstruction that is the very meaning of pathological anatomy if one agrees to treat it as a fact of civilization of the same order as—and why not?—the transformation from an incinerating to an inhuming culture. Nineteenth-century medicine was haunted by that absolute eye that cadaverizes life and rediscovers in the corpse the frail, broken nervure of life. (204)

This figure is not a deviation added to the pathological deviation; the disease is itself a perpetual deviation within its essentially deviant nature. Only individual illnesses exist: not because the individual reacts upon his own illness, but because the action of the illness rightly unfolds in the form of individuality. (207)

The individual is not the initial, most acute form in which life is presented.  It was given at last to knowledge only at the end of a long movement of spatialization whose decisive instruments were a certain use of language and a difficult conceptualization of death. Bergson is strictly in error when he seeks in time and against space, in a silent grasp of the internal, in a mad ride towards immortality, the conditions with which it is possible to conceive of the living individuality. Bichat, a century earlier, gave a more severe lesson. The old Aristotelian law, which prohibited the application of scientific discourse to the individual, was lifted when, in language, death found the locus of its concept: space then opened up to the gaze the differentiated form of the individual. (209-210)

death unfailingly compensated for fortune. Now, on the contrary, it is constitutive of singularity; it is in that perception of death that the individual finds himself, escaping from a monotonous, average life; in the slow, half-subterranean, 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. Hence the importance of the Morbid. The macabre implied a homogeneous perception of death, once its threshold had been crossed. The morbid authorizes a subtle perception of the way in which life finds in death its most differentiated figure. The morbid is the rarefied form of life, exhausted, working itself into the void of death; but also in another sense, that in death it takes on its peculiar volume, irreducible to conformities and customs, to received necessities; a singular volume defined by its absolute rarity. The privilege of the consumptive: in earlier times, one contracted leprosy against a background of great waves of collective punishment; in the nineteenth century, a man, in becoming tubercular, in the fever that hastens things and betrays them, fulfills his incommunicable secret. That is why chest diseases are of exactly the same nature as diseases of love: they are the Passion, a life to which death gives a face that cannot be exchanged. Death left its old tragic heaven and became the lyrical core of man: his invisible truth, his visible secret. (211)

 

10. Crises in fevers

And so—and this was the great discovery of 1816—the being of the disease disappears. As an organic reaction to an irritating agent, the pathological phenomenon can no longer belong to a world in which the disease, in its particular structure, would exist in conformity with a dominant type that preceded it, and in which it was fulfilled, once individual variations and non-essential accidents had been set aside; it is caught up in an organic web in which the structures are spatial, the determinations causal, the phenomena anatomical and physiological. Disease is now no more than a certain complex movement of tissues in reaction to an irritating cause: it is in this that the whole essence of the pathological lies, for there are no longer either essential diseases or essences of diseases. ‘All classifications that tend to make us regard diseases as particular beings are defective, and a judicious mind is constantly, almost in spite of itself, drawn towards a search for sick organs’. (233)

In the critique of medical ‘ontology’, the notion of organic ‘sickness’ goes further and more deeply perhaps than that of irritation. Irritation still involved an abstract structure: the universality that enabled it to explain everything formed for the gaze directed upon the organism a final screen of abstraction. The notion of a Sickness’ of the organs involved only the idea of a relationship of the organ with an agent or an environment, that of a reaction to attack, that of an abnormal functioning, and, finally, that of the disturbing influence of the element attacked upon the other organs. Henceforth the medical gaze will be directed only upon a space filled with the forms of composition of the organs. The space of the disease is, without remainder or shift, the very space of the organism. The medicine of diseases has come to an end; there now begins a medicine of pathological reactions, a structure of experience that dominated the nineteenth century, and, to a certain extent, the twentieth, since the medicine of pathogenic agents was to be contained within it, though not without certain methodological modifications. (235)

 

Conclusion

This structure, in which space, language, and death are articulated—what is known, in fact, as the anatomoclinical method—constitutes the historical condition of a medicine that is given and accepted as positive. Positive here should be taken in the strong sense. Disease breaks away from the metaphysic of evil, to which it had been related for centuries; and it finds in the visibility of death the full form in which its content appears in positive terms. Conceived in relation to nature, disease was the non-assignable negative of which the causes, forms, and manifestations were offered only indirectly and against an ever-receding background; seen in relation to death, disease becomes exhaustively legible, open without remainder to the sovereign dissection of language and of the gaze. It is when death became the concrete a priori of medical experience that death could detach itself from counter-nature and become embodied in the living bodies of individuals. (243)

[…] from the experience of Unreason was born psychology, the very possibility of psychology; from the integration of death into medical thought is born a medicine that is given as a science of the individual. And, generally speaking, the experience of individuality in modern culture is bound up with that of death: from Hölderlin’s Empedocles to Nietzsche’s Zarathustra, and on to Freudian man, an obstinate relation to death prescribes to the universal its singular face, and lends to each individual the power of being heard forever; the individual owes to death a meaning that does not cease with him. (243)

The possibility for the individual of being both subject and object of his own knowledge implies an inversion in the structure of finitude. For classical thought, finitude had no other content than the negation of the infinite, while the thought that was formed at the end of the eighteenth century gave it the powers of the positive: the anthropological structure that then appeared played both the critical role of limit and the founding role of origin. It was this reversal that served as the philosophical condition for the organization of a positive medicine; inversely, this positive medicine marked, at the empirical level, the beginning of that fundamental relation that binds modern man to his original finitude. Hence the fundamental place of medicine in the over-all architecture of the human sciences: it is closer than any of them to the anthropological structure that sustains them all. Hence, too, its prestige in the concrete forms of existence: health replaces salvation, said Guardia. (244)

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