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Theorising the medical philosophy

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.


This medical field, restored to its pristine truth, pervaded wholly by the gaze, without obstacle and without alteration, is strangely similar, in its implicit geometry, to the social space dreamt of by the Revolution, at least in its original conception: a form homogeneous in each of its regions, constituting a set of equivalent items capable of maintaining constant relations with their entirety, a space of free communication in which the relationship of the parts to the whole was always transposable and reversible.


There was thus a certain amount of tension between the requirements of a reorganization of knowledge, those of the abolition of privileges and those of an effective supervision of the nation’s health. How can the free gaze that medicine, and, through it, the government, must turn upon the citizens be equipped and competent without being embroiled in the esotericism of knowledge and the rigidity of social privilege?


The great myth of the free gaze, which, in its fidelity to discovery receives the virtue to destroy; a purified purifying gaze; which freed from darkness, dissipates darkness. The cosmological values implicit in the Aufklärung are still at work here. The medical gaze, whose powers were beginning to be recognized, had not yet been given its technological structure in the clinical organization; it was only one segment of the dialectic of the Lumières transported into the doctor’s eye.


No doubt medical experience remained open for a long time, and succeeded in striking a balance between seeing and knowing (le voir et le savoir) that protected it from error: ‘In far-off times, the art of medicine was taught in the presence of its object and young men learnt medical science at the patient’s bedside’; the patients were often accommodated in the doctor’s own house, and the pupils accompanied their masters at all hours on the rounds of their patients [5].


Tissot is in favor of making him look for it for a long time. He suggests that each patient in the clinic should be entrusted to two students; they and they alone would examine him, ‘with decency, with gentleness, and with that kindness that is so consoling for those poor unfortunates’ [27]. They would begin by questioning him as to his country of origin, the constitutions that are common there, his profession, his previous illnesses, the way in which his present illness began, the remedies already taken; they would investigate his vital functions (breathing, pulse, temperature), his natural functions (senses, faculties, sleep, pain); they would also have to ‘palpate the abdomen in order to ascertain the state of his viscera’ [28]. But what are they looking for, and what hermeneutic principle should guide them in their examination? What are the relations set up between the phenomena observed, the antecedences ascertained, the disorders and deficiencies noted? Nothing more than will enable one to name the disease. Once the designation has been carried out, it will be an easy matter to deduce the causes, the prognosis, and the indications, by ‘asking oneself: What is wrong with this patient? What is to be put right?’ [29]. Compared with later methods of examination, that recommended by Tissot is hardly less meticulous, apart from a few details. The difference between this investigation and the ‘clinical examination’ lies in the fact that in the former no inventory of a sick organism is made; one retains those elements that enable one to put one’s hand on an ideal key—a key that has four functions, since it is a mode of designation, a principle of coherence, a law of evolution, and a body of precepts. In other words, the gaze that traverses a sick body attains the truth that it seeks only by passing through the dogmatic stage of the name, in which a double truth is contained: the hidden, but already present truth of the disease and the enclosed truth that is clearly deducible from the outcome and from the means.


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.


In the article entitled ‘Abus’ in the Dictionnaire de Médecine, Vicq d’Azyr sees the organization of a system of teaching within the hospital as the universal solution for the problems of medical training; that, for him, is the major reform to be carried out: ‘Diseases and death offer great lessons in hospitals. Are we benefiting from them? Are we writing the history of the illnesses that strike so many victims in our hospitals? Do we teach in our hospitals the art of observing and treating diseases? Have we set up any chairs of clinical medicine in our hospitals?’ [1] Yet, in a very short time, this reform of the teaching system was to assume a much wider signficance; it was recognized that it could reorganize the whole of medical knowledge and establish, in the knowledge of disease itself, unknown or forgotten, but more fundamental, more decisive forms of experience: the clinic and the clinic alone was capable of ‘reviving among the moderns the temples of Apollo and Aesculapius’ [2]. A way of teaching and saying became a way of learning and seeing.


At the end of the eighteenth century, as at the beginning of the Renaissance, education was given a positive value as enlightenment: to train was a way of bringing to light, and therefore of discovering. The childhood and youth of things and men were endowed with an ambiguous power: to tell of the birth of truth; but also to put to the test the tardy truth of men, to rectify it, to bring it closer to its nudity. The child became the immediate master of the adult insofar as true education was identified with the very genesis of truth. In every child things tirelessly repeat their youth, the world resumes contact with its native form: he who looks for the first time is never an adult. When it has untied its old kinships, the eye is able to open at the unchanging, ever-present level of things; and of all the senses and all sources of knowledge (tous les savoirs), it is intelligent enough to be the most unintelligent by repeating so skilfully its distant ignorance. The ear has its preferences, the hand its lines and its folds; the eye, which is akin to light, supports only the present. What allows man to resume contact with childhood and to rediscover the permanent birth of truth is this bright, distant, open naïvety of the gaze. Hence the two great mythical experiences on which the philosophy of the eighteenth century had wished to base its beginning: the foreign spectator in an unknown country, and the man born blind restored to light. But Pestalozzi and the Bildungsromane also belong to the great theme of Childhood-Gaze. The discourse of the world passes through open eyes, eyes open at every instant as for the first time.

A stranger, more hidden contract of the same kind was silently being formed about the same time between the hospital, where the poor were treated, and the clinic, in which doctors were trained. Once again, the thinking of those last days of the Revolution revived, sometimes word for word, what had been formulated in the period immediately preceding it. The most important moral problem raised by the idea of the clinic was the following: by what right can one transform into an object of clinical observation a patient whose poverty has compelled him to seek assistance at the hospital? He had asked for help of which he was the absolute subject, insofar as it had been conceived specifically for him; he was now required to be the object of a gaze, indeed, a relative object, since what was being deciphered in him was seen as contributing to a better knowledge of others. Furthermore, while observing, the clinic was also carrying out research; and this search for the new exposed it to a certain amount of risk: a doctor in private practice, Aikin remarked [57], must take care of his reputation; his way must be that of safety, if not of certainty; ‘In the hospital he is not fettered in this way and his genius may express itself in a new way.’ Does not the very essence of hospital aid become altered by the following principle: ‘Hospital patients are, for several reasons, the most suitable subjects for an experimental course’? [58]


A certain balance must be kept, of course, between the interests of knowledge and those of the patient; there must be no infringement of the natural rights of the sick, or of the rights that society owes to the poor. The domain of the hospital was an ambiguous one: theoretically free, and, because of the non- contractual character of the relation between doctor and patient, open to the indifference of experiment, it bristled with obligations and moral limitations deriving from the unspoken—but present-contract binding man in general to poverty in its universal form. If, in the hospital, the doctor does not carry out theoretical experiments, free of all obligation to their human object, it is because, as soon as he sets foot in the hospital, he undergoes a decisive moral experience that circumscribes his otherwise unlimited practice by a closed system of duty. ‘It is by entering the asylums where poverty and sickness languish together that he will feel those painful emotions, that active commiseration, that burning desire to bring comfort and consolation, that intimate pleasure that springs from success, and which the sight of spreading happiness cannot but increase. It is there that he will learn to be religious, humane, compassionate’ [59].


But to look in order to know, to show in order to teach, is not this a tacit form of violence, all the more abusive for its silence, upon a sick body that demands to be comforted, not displayed? Can pain be a spectacle? Not only can it be, but it must be, by virtue of a subtle right that resides in the fact that no one is alone, the poor man less so than others, since he can obtain assistance only through the mediation of the rich. Since disease can be cured only if others intervene with their knowledge, their resources, their pity, since a patient can be cured only in society, it is just that the illnesses of some should be transformed into the experience of others; and that pain should be enabled to manifest itself: ‘The sick man does not cease to be a citizen….


These, then, were the terms of the contract by which rich and poor participated in the organization of clinical experience. In a regime of economic freedom, the hospital had found a way of interesting the rich; the clinic constitutes the progressive reversal of the other contractual part; it is the interest paid by the poor on the capital that the rich have consented to invest in the hospital; an interest that must be understood in its heavy surcharge, since it is a compensation that is of the order of objective interest for science and of vital interest for the rich. The hospital became viable for private initiative from the moment that sickness, which had come to seek a cure, was turned into a spectacle. Helping ended up by paying, thanks to the virtues of the clinical gaze.


In the medical tradition of the eighteenth century, the disease was observed in terms of symptoms and signs. These were distinguished from one another as much by their semantic value as by their morphology. The symptom-hence its uniquely privileged position-is the form in which the disease is presented: of all that is visible, it is closest to the essential; it is the first transcription of the inaccessible nature of the disease. Cough, fever, pain in the side, and difficulty in breathing are not pleurisy itself—the disease itself is never exposed to the senses, but ‘reveals itself only to reasoning’-but they form its ‘essential symptom’, since they make it possible to designate a pathological state (in contradistinction to health), a morbid essence (different, for example, from pneumonia), and an immediate cause (a discharge of serosity) [3]. The symptoms allow the invariable form of the disease-set back somewhat, visible and invisible-to show through.


The sign announces: the prognostic sign, what will happen; the anamnestic sign, what has happened; the diagnostic sign, what is now taking place. Between it and the disease is a distance that it cannot cross without accentuating it, for it often appears obliquely and unexpectedly. It does not offer anything to knowledge; at most it provides a basis for recognition—a recognition that gradually gropes its way into the dimensions of the hidden: the pulse betrays the invisible strength and rhythm of the circulation; or, again, the sign discloses time, just as the blueing of the nails is an unfailing announcement of death, or the crises of the fourth day, in intestinal fevers, promise recovery. Through the invisible, the sign indicates that which is further away, below, later. It concerns the outcome, life and death, time, not that immobile truth, that given, hidden truth that the symptoms restore to their transparency as phenomena.


The formation of the clinical method was bound up with the emergence of the doctor’s gaze into the field of signs and symptoms. The recognition of its constituent rights involved the effacement of their absolute distinction and the postulate that henceforth the signifier (sign and symptom) would be entirely transparent for the signified, which would appear, without concealment or residue, in its most pristine reality, and that the essence of the signified-the heart of the disease-would be entirely exhausted in the intelligible syntax of the signifier.


Yet not entirely so: something, in the immediacy of the symptom, signifies the pathological, which distinguishes it from a phenomenon belonging purely and simply to organic life. ‘By phenomenon I mean any notable change in the healthy or sick body; hence the division into those that belong to health and those that designate disease: the latter are easily confused with the symptoms or sensible appearance of the disease’ [6]. By this simple opposition to the forms of health, the symptom abandons its passivity as a natural phenomenon and becomes a signifier of the disease, that is, of itself taken as a whole, since the disease is simply a collection of symptoms. There is a strange ambiguity here, since in its signifying function the symptom refers both to the relation between phenomena themselves—to what constitutes their totality and the form of their coexistence—and to the absolute difference that separates health from disease; it signifies, therefore, by tautology, the totality of what it is and, by its emergence, the exclusion of what it is not. In its existence as pure phenomenon, it is indissociably the only nature of the disease, and the disease constitutes its only nature as a specific phenomenon.


Analysis and the clinical gaze also have this feature in common that they compose and decompose only in order to reveal an ordering that is the natural order itself: their artifice is to operate only in the restitutive act of the original. This analysis is the true secret of discoveries because it makes us go back to the origin of things’ [16]. For the clinic, this origin is the natural order of symptoms, the form of their succession or of their reciprocal determination. Between sign and symptom there is a decisive difference that assumes value only against the background of an essential identity; the sign is the symptom itself, but in its original truth. At last, there emerges on the horizon of clinical experience the possibility of an exhaustive, clear, and complete reading: for a doctor whose skills would be carried to the highest degree of perfection, all symptoms would become signs’ [17], all pathological manifestations would speak a clear, ordered language.


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.


The clinician’s description, like the philosopher’s analysis, proffers what is given by the natural relation between the operation of consciousness and the sign.

Medicine as an uncertain kind of knowledge is an old theme to which the eighteenth century was especially sensitive. It was to be found, reinforced by recent history, in the traditional opposition between the art of medicine and the knowledge of inert things: ‘The science of man is concerned with too complicated an object, it embraces a multitude of too varied facts, it operates on too subtle and too numerous elements always to give to the immense combinations of which it is capable the uniformity, evidence, and certainty that characterize the physical sciences and mathematics’ [20]. An uncertainty that was a sign of complexity concerning the object and of imperfection concerning science: no objective foundation was given to the conjectural character of medicine outside the relation between that extreme scantiness and that excessive richness.


Medical certainty is based not on the completely observed individuality but on the completely scanned multiplicity of individual facts.


In clinical experience, variations are not set aside, they separate of their own accord; they cancel each other out in the general configuration, because they are integrated into the domain of probability; they never fall outside the boundaries, however ‘unexpected’ or ‘extraordinary’ they may be; the abnormal is still a form of regularity: The study of monsters or of the monstrosities of the human species gives us an idea of nature’s teeming resources and of the gaps to which she can lend herself [32].


The problem is, in fact, that late-eighteenth-century medicine never knew whether it was concerned with a series of facts whose laws of appearance and convergence were to be determined simply by the study of repetitions, or whether it was concerned with a set of signs, symptoms, and manifestations whose coherence was to be sought in a natural structure. It never ceased to hesitate between a pathology of phenomena and a pathology of cases. That is why the calculation of degrees of probability was immediately confused with the analysis of symptomatic elements: in a very strange way, it was the sign, as an element in a constellation, that was attributed, as a sort of natural right, with a coefficient of probability.


This arithmetic of implication is valid for both curative indications and for diagnostic signs.


Selle said of the clinic that it was scarcely more than ‘the very practice of medicine at the patient’s bedside’, and that, as such, it was identical with ‘practical medicine in the strict sense’ [40].

Extracted from the book, The Birth of the Clinic – Michel Foucault