In the spirit of the day I’m including text on epidemic consciousness, medical fields, the medical gaze, death and the human. Below are more or less chapter by chapter reading-notes cribbing directly from the primary text, Foucault’s The Birth of the Clinic. From friend and colleague Gail Hamner I’ve learned to read (early) Foucault not as a “structuralist” but in and against the phenomenological tradition. He’s writing in the wake of Merleau-Ponty with whom he studied. The familiar Foucaldian themes are all here in his analysis of the clinic: spatialization and regimes of knowing and social control. I’m sure it has been noted in the Foucault scholarship, but I’m noting this here, for me, for the first time. The  Order of Things ends with dissolution of the human, of “man,” whereas The Birth of the Cllinic ends with his first formation, or, in a more religious vein, its “creation” in the clinics of the classical 18th C. Phenomenological is the attention to observation and seeing, the invisible and visible, the bringing to light out of a dark recess the morbid body as a clear and distinct perceptual object.

Preface

“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).

“For Descartes and Malebranche, to see was to perceive (even in the most concrete kinds of experience, such as Descartes’s practice of anatomy, or Malebranche’s microscopic observations); but, without stripping perception of its sensitive body, it was a matter of rendering it transparent for the exercise of the mind: light, anterior to every gaze, was the element of ideality—the unassignable place of origin where things were adequate to their essence—and the form by which things reached it through the geometry of bodies; according to them, the act of seeing, having attained perfection, was absorbed back into the unbending, unending figure of light.

[…]

[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).

“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.

[…]

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).

Epidemic Political Consciousness

“But 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).

“But we are concerned here not simply with medicine and the way in which, in a few years, the particular knowledge of the individual patient was structured. For clinical experience to become possible as a form of knowledge, a reorganization of the hospital field, a new definition of the status of the patient in society, and the establishment of a certain relationship between public assistance and medical experience, between help and knowledge, became necessary; the patient has to be enveloped in a collective, homogeneous space. It was also necessary to open up language to a whole new domain: that of a perpetual and objectively based correlation of the visible and the expressible. An absolutely new use of scientific discourse was then defined: a use involving fidelity and unconditional subservience to the coloured content of experience—to say what one sees; but also a use involving the foundation and constitution of experience—showing by saying what one sees.” (p.196)

Free (Medical) Field

“In fact, an entirely free field of medical experiment had to be constituted, so that the natural needs of the species might emerge unblurred and without trace; it also had to be sufficiently present in its totality and concentrated in its content to allow the formation of an accurate, exhaustive, permanent corpus of knowledge about the health of a population. 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 is, therefore, a spontaneous and deeply rooted convergence between the requirements of political ideology and those of medical technology. In a concerted effort, doctors and statesmen demand, in a different vocabulary but for essentially identical reasons, the suppression of every obstacle to the constitution of this new space: the hospitals, which alter the specific laws governing disease, and which disturb those no less rigorous laws that define the relations between property and wealth, poverty and work; the association of doctors which prevents the formation of a centralized medical consciousness, and the free play of an experience that is allowed to reach the universal without imposed limitations; and, lastly, the Faculties, which recognize that which is true only in theoretical structures and turn knowledge into a social privilege. Liberty is the vital, unfettered force of truth. It must, therefore, have a world in which the gaze, free of all obstacle, is no longer subjected to the immediate law of truth: the gaze is not faithful to truth, nor subject to it, without asserting, at the same time, a supreme mastery: the gaze that sees is a gaze that dominates; and although it also knows how to subject itself, it dominates its master” (38).

Medical Gaze

“Thus armed, the medical gaze embraces more than is said by the word ‘gaze’ alone. It contains within a single structure different sensorial fields. The sight/touch/hearing trinity defines a perceptual configuration in which the inaccessible illness is tracked down by markers, gauged in depth, drawn to the surface, and projected virtually on the dispersed organs of the corpse. The ‘glance’ has become a complex organization with a view to a spatial assignation of the invisible. Each sense organ receives a partial instrumental function. And the eye certainly does not have the most important function; what can sight cover other than ‘the tissue of the skin and the beginning of the membranes’? Through touch we can locate visceral tumours, scirrhous masses, swellings of the ovary, and dilations of the heart; while with the ear we can perceive ‘the crepitation of fragments of bone, the rumbling of aneurism, the more or less clear sounds of the thorax and the abdomen when sounded.’ The medical gaze is now endowed with a plurisensorial structure. A gaze that touches, hears, and, moreover, not by essence or necessity, sees” (p.164)

“Thus, from the discovery of pathological anatomy, the medical gaze is duplicated: there is a local, circumscribed gaze, the borderline gaze of touch and hearing, which covers only one of the sensorial fields, and which operates on little more than the visible surfaces. But there is also an absolute, absolutely integrating gaze that dominates and founds all perceptual experiences. It is this gaze that structures into a sovereign unity that which belongs to a lower level of the eye, the ear, and the sense of touch. When the doctor observes, with all his senses open, another eye is directed upon the fundamental visibility of things, and, through the transparent datum of life with which the particular senses are forced to work, he addresses himself fairly and squarely to the bright solidity of death (p.165).

Death & Man

But the perception of death in life does not have the same function in the nineteenth century as at the Renaissance. Then it carried with it reductive significations: differences of fate, fortune, conditions were effaced by its universal gesture; it drew each irrevocably to all; the dances of skeletons depicted, on the underside of life, a sort of egalitarian saturnalia; 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” (pp.171-2).

Conclusion

“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).

“But the absolute eye of knowledge has already confiscated, and re-absorbed into its geometry of lines, surfaces, and volumes, raucous or shrill voices, whistlings, palpitations, rough, tender skin, cries—a suzerainty of the visible, and one all the more imperious in that it associates with it power and death. 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” (p.166)

The Human/Man

“The importance of Bichat, Jackson, and Freud in European culture does not prove that they were philosophers as well as doctors, but that, in this culture, medical thought is fully engaged in the philosophical status of man.

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.’

In what at first sight might seem a very strange way, the movement that sustained lyricism in the nineteenth century was one and the same as that by which man obtained positive knowledge of himself; but is it surprising that the figures of knowledge and those of language should obey the same profound law, and that the irruption of finitude should dominate, in the same way, this relation of man to death, which, in the first case, authorizes a scientific discourse in a rational form, and, in the second, opens up the source of a language that unfolds endlessly in the void left by the absence of the gods?” (197).