Gazing at Death

The Birth of the Clinic is a description of the changes in the language of medicine, particularly French medicine, between 1794 and 1820. It is therefore in the first place a work of history, concerned with a specific problem during a specific period. But it is also an experiment in a new way of writing the history of science, a testing ground for a radically redefined historical epistemology and methodology. Hence the double appeal of this book, which will be read not only by those who are interested in this seminal period of medical history but also by those who are dissatisfied with the traditional procedures of intellectual history and would like to see historians of ideas re-think their objectives and their methods.

The Birth of the Clinic, published in France in 1963, came after Foucault’s Histoire de la Folie (Madness and Civilization, 1961) and preceded his Les Mots et les Choses (The Order of Things, 1966). Together these works make up a trilogy in which the author is successively a historian of psychiatry and psychopathology, of medicine, of natural history, of economics, and of grammar. This ambitious enterprise has not only yielded positive results of great value, it has also led to an important theoretical advance. Foucault’s latest book, L’Archéologie du Savoir (The Archaeology of Knowledge), may be seen as the methodological postscript to his trilogy on the history of science: in this work he sums up his position, clarifying his aims, freely criticizing certain aspects of his work, and proposing new goals for future research.

We cannot fully understand The Birth of the Clinic unless we are aware of its position in this series and take note of Foucault’s subsequent declarations, in which he puts distance between himself and his preoccupations at the time when he wrote this book. In particular we need to know that the expression “regard médical” (medical perception), which figures in this book’s subtitle and reflects much of Foucault’s argument, now no longer seems to him “very well chosen,” since it seems to “refer to the unifying or synthesizing function of a subject,” i.e., of a thinker or a thinking mind. And there are indeed passages in The Birth of the Clinic which are genuine phenomenological analyses, where a subject (the doctor, the scientist, “medical perception” itself) is seen in the act of constituting the objects of its thoughts.

Since he wrote these pages Michel Foucault has completely transferred his emphasis to what he calls the “order of discourse,” i.e., to discovering the laws that tacitly govern the intellectual discourse of a given period. He now emphasizes the “dispersion of the subject,” i.e., the ways by which all thinking, no matter how individual or “creative” it may seem, is unconsciously but systematically constrained by the rules or codes that are embedded in the discourse of the times. He would reject any recourse to psychological subjectivity of any sort, and he would prefer to leave out of The Birth of the Clinic those emotional terms which (however discreetly) suggest a psychology of scientific discovery.

Nevertheless Foucault is far from wishing to disown this book; it is an important element in the inquiry which is the basis of his current theorizing. And even here the absence of any biographies of scientists and the way he sets up impersonal schemes show very clearly an approach which is more interested in systems of thought, their appearance and disappearance, their way of organizing scientific discourse and the conditions which make them possible than in the individual destiny of their “inventors.” We could call this book a study of the styles of medical knowledge, or more precisely a study of the differences in such styles, an inquiry concerned with the mutations, discontinuities, incompatibilities, and displacements which make the medical discourse of the nineteenth century totally unlike that of preceding centuries.

What interests Foucault are first the internal rules (and the exceptions to those rules) which govern a particular corpus of documents and then those rules which govern the corpus of documents that follow at a later stage of a science. This methodology, which can broadly be described as structuralist, leads quite logically to a rejection both of the heroic role attributed to individual innovators and of the evolutionary perspective customary in the history of ideas, whereby attention is paid to the connections between “themes” and “ideas” which are transmitted by tradition, adopted, and gradually transformed.

Michel Foucault’s own style, as one might guess, is frequently polemical when he seeks to refute the old historiography. It has to be admitted that he handles his weapon well; his foil may draw blood occasionally, but at least it is not poisoned. Most of the time he simply omits to mention the previous studies on the subject as a sign of distrust for traditional scholarship. However, this polemic plays a secondary role in his book; the essential thing is his description of the different styles of medical knowledge, the social “space” in which these styles are practically deployed—at home or in a hospital for example—the objects they select or reject, the concepts they use, and the metaphors they favor. And this description is not done in the “scientific” language of contemporary linguistics or semiology; it is specifically philosophical in nature and is expressed in a splendidly literary language, full of figures, dramatic turns of phrase, metaphors, wordplay, allusions,¹ and poetic inventions, all of which introduce an element of the unexpected into the treatment of such a subject. It should be added that Michel Foucault’s prose, with all its bold playfulness and elegant originality, can be very attractive to the French reader.

Foucault may be difficult and occasionally irritating, but he is never obscure; he is disconcerting, but this is because his writing is so full of dazzling insights. The English translation by A. M. Sheridan Smith is both faithful and subtle; the translator teases out the meaning of Foucault’s lapidary and sometimes cryptic formulations and performs veritable tours de force in the rendering of his metaphors. The reader is given the feeling of a style which is lively, original, and constantly thought-provoking.²

Michel Foucault’s starting point is the medical science that immediately preceded the rise, at the end of the eighteenth century, of the clinic, by which he means both clinical medicine and the teaching hospital. Eighteenth-century medicine, as he describes it, was concerned principally with classifying different forms of illness and setting them out in charts like those of the botanists. In practice the doctor’s task was to recognize the species of illness of which the patient was a representative. “In order to know, he must recognize, while already being in possession of the knowledge that will lend support to his recognition.”

Such a form of medicine was wary of hospitals, where species of disease were confused and the clarity of the chart became obscured. This medicine preferred to let the ailment declare itself in its essential being and was afraid that this might be distorted by premature intervention; it therefore tended to favor biding one’s time. Foucault—and this is a constant feature of his analysis—draws important conclusions from this concerning the social space where the illness was situated and the place occupied by medical practice. According to the “medicine of species” the patient should remain at home, while the doctor should give his assistance in “the natural environment of social life—the family.”

This situation was to change radically when at the end of the eighteenth century hospitals were organized to receive a large number of patients and became the medical training ground par excellence. From then on medicine spoke a different language, creating for itself a new subject matter, basing itself on a different institutional organization, forming its concepts on the strength of new sorts of experience, and opening the way to different forms of medical practice. This change was in large part a consequence of the Revolution and the sociopolitical upheaval in French life. The two chapters which Foucault devotes to this are rich in documentary evidence and give a valuable account of the debates surrounding the setting up in 1794 of the new Ecole de Santé—which was renamed the Ecole de Médecine in 1796.

Foucault demonstrates very clearly the interconnections between medicine as a science, medical activity as a social fact, and the university’s role in transmitting “scientific learning.” He is remarkably successful here in highlighting the mutations affecting “the status, institutional position, situation and modes of insertion of the speaking and writing subject”—we see such figures as the philosopher-physician Pierre Caban-is promoting entire new schemes of medical training, treatment, credentials, in which contradictory concepts of nature and politics were often combined.

The French Revolution, as Foucault shows, reorganized the teaching of medicine, centralized it, subjected it to state control, and established new hierarchies. But before it did this, the Revolution went through a period of Utopian daydreaming: this was not the first time nor the last that people have dreamed of a just state sharing out prosperity equally among all its citizens and thus eliminating not only poverty but illness. Almshouses and hospitals thus became superfluous; they were the blemishes on the face of the old order. The new education would create nothing but healthy, virtuous people devoted to the revolutionary cause: “The first task of the doctor is therefore political: the struggle against disease must begin with a war against bad government. Man will be totally and definitively cured only if he is first liberated…. And gradually, in this young city entirely dedicated to the happiness of possessing health, the face of the doctor would fade, leaving a faint trace in men’s memories of a time of kings and wealth, in which they were impoverished, sick slaves.”

After all these daydreams and myths what actually came into being was a new pedagogical and technical organization, in which teaching hospitals, “schools of health,” and new categories of professionals were planned. The vision here was of a “transparent, undivided” medical domain that would be “exposed from top to bottom to a gaze armed nonetheless with its privileges and qualifications…: in liberty, disease was to formulate of itself an unchanging truth, offered, undisturbed, to the doctor’s gaze; and society, medically invested, instructed, and supervised, would, by that very fact, free itself from disease.”

But this vision too, according to Foucault, was itself “only one segment of the dialectic of the Lumières transported into the doctor’s eye.” In other words the revolutionary reorganization of the University was at first no more than a necessary condition for the rise of clinical medicine; while the revolutionary theme of the doctor liberating society from newly liberated disease was hardly an adequate conceptual basis for the practice of this medicine. What clinical medicine lacked and what it had to create was “a new, coherent, unitary model for the formation of medical objects, perceptions, and concepts.”

At this point, writing of the same events, other historians bring in a series of factors whose combined effect they see as playing a determining role in the birth of clinical medicine. According to them, its rise depended on the decline of dogmatic causal interpretation and the rejection of Galenic, Cartesian, and other preconceptions which had provided a speculative foundation for a nonverifiable physiology and pathology.³ It depended too on the primacy accorded to unprejudiced observation, for under the patronage of Hippocrates, now considered as the model of the undogmatic observer, such observation had taken the place, and acquired the authority, of the scholastic tradition. And finally it depended on the suppression of the old hierarchies and privileges, which made it possible for the Revolution to unify the domain of medical science and bring together medicine and surgery, enabling them to share their experience and their methods.

For some time surgeons had been used to paying close attention to the particular unhealthy organ or affected part. It is not insignificant that M. F. X. Bichat, the great French anatomist, who first named and classified the human tissues into twenty-one types, had started as the pupil of the surgeon Desault, who practiced systematic autopsies on the bodies of deceased patients. Desault “demonstrated on the lifeless body the alterations that had rendered further exercise of art useless.” The pathological anatomy of clinicians came directly from that of the surgeons.

This connection has recently been mentioned in a very well documented study by E. H. Ackerknecht, whose way of quoting fellow-scholars is exactly contrary to Foucault’s autistic and self-sufficient manner:

The Leipzig clinician C. A. Wunderlich, who knew Paris medicine very well from his own experience, wrote, “Actually the whole new trend of French medicine has come out of the surgical school.” Temkin substantiated this idea…in his essay “The Role of Surgery in the Rise of Modern Medical Thought.” Pinel, Bichat, Broussais, Laënnec, and Bouillaud all expressly stated that they handled the data of internal medicine like surgeons…. Due to the Academy of Surgery, France was the first country in which surgery had started its triumphal social and scientific comeback in the eighteenth century…. Surgeons are by definition localists and anatomists. Anatomists turn easily to the study of pathological anatomy.⁴

There is a further factor: clinical observation, comparison of cases, and statistical evaluation would have been impossible if the hospital population had not grown considerably. And this growth, by way of the administrative reorganization of the Paris hospitals, reflects the increased population of Paris (and of the other capitals of Europe), which was largely due to the Industrial Revolution. Ackerknecht, following the lead given by H. E. Sigerist, speaks of

the tremendous influx of uprooted and penniless boys and girls from the country…. Pariset (1845), in his purple prose, called the hospitals the “observatories” of the new medicine; in a certain sense, he might also have called them its factories.

As we see from these accounts, “traditional” history thus invokes causal relations, none of which is presented as a sufficient cause, but all of which together make up a sociocultural pattern; in this way it defines the sum of conditions which made possible the rise of the new medicine. All of these facts are fleetingly mentioned by Foucault, but none of them is used to provide a causal explanation. He shows the same distrust of socioeconomic “causal attributions” as of expressive or psychological ones. He is as unwilling to admit a Freudian explanation of “scientific genius” as he is a Marxist interpretation of science as a superstructure. Instead, Foucault offers a theory of “formation systems,” which he develops more elaborately in The Archaeology of Knowledge. Although they are produced by men, the “formation systems” constitute a world of their own. “These,” he writes,

are not constraints originating in men’s thoughts or in the free play of their concepts; nor are they determinations which are formed at the level of institutions or social or economic relations and subsequently impose themselves on the surface of human discourse itself…. By formation system we must therefore understand a complex network of relationships which perform the function of rules.

Having discarded all genetic interpretations, Foucault is determined to analyze what takes place “at the surface of discourse.” To bring in the Industrial Revolution, the reunification of surgery and medicine, the surgical training of many clinicians as army doctors in the Napoleonic wars would for him be to get sidetracked into developments that teach us nothing about the specific characteristics of the new medical discourse. Foucault, in a more radical and more abstract way, is pointing to the same “revolutionary” phenomenon in science that has been described by T. S. Kuhn. He wants to deal with the appearance in medicine of (to use Kuhn’s terms) “new paradigms”; the “rules” he again and again refers to could best be defined as the patterns of thought which prevail in each dominant paradigm. Having rejected any belief in cumulative progress in medicine, Foucault’s view of “scientific revolution” insists that the principal changes are, in the broadest sense, of a stylistic nature.

In chapter 9—“The Visible Invisible”—Foucault sums up the main rules which the new clinical medicine began to follow. They consist in a predominant role attributed to gaze (“le regard“) and in adopting “the point of view of death”—i.e., the point of view of a knowledge essentially based on what can be discovered through opening and observing corpses.

Paradoxically, the presence of the corpse enables us to perceive it living—living with a life that is no longer that of either old sympathies or the combinative laws of complications, but one that has its own roles and its own laws.

Thus, the concepts of eighteenth-century medicine—the “old sympathies,” the “combinative laws of complications”—were discarded, not to speak of Galenic speculations about the mixture and corruption of humors.

Foucault then goes on to specify the rules themselves in five “principles” which he discerns in all the descriptions of organic lesions written by clinicians. There is first the “principle of tissual communication” by which each type of membrane had its own peculiar properties, and each therefore differed in its diseases. For example, the arachnoid membrane in the brain “may be affected by the same forms of dropsy as the pleura of the lung or the peritoneum, since there are serous membranes present in each case.” The other principles Foucault finds in the clinical writings—e.g., “tissual impermeability” and “penetration by boring”—often complement or extend or modify the first, describing in advance the networks of possible paths that disease may follow.

These principles, of course, were not explicitly professed by the French clinicians: they are made explicit by Foucault, in a kind of phenomenological synthesis. The same can be said for the role of gaze, which had never been fully formulated as a theory by the clinicians themselves. It takes Foucault’s virtuosity and verbal skill to describe its characteristics:

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.

Bichat and his successors declared their interest in the structure of tissues, the configuration of diseased organs, and the visible aspect of morbid conditions. Michel Foucault in turn states his intention of describing the structure of the descriptive systems of Bichat and the other Parisian clinicians and anatomical pathologists of the beginning of the nineteenth century.

The resemblance is perhaps not purely coincidental. Bichat, Laënnec, and Broussais wanted to set themselves free from the causal interpretation which tradition and even their immediate predecessors had imposed upon them. As we have seen, Foucault too is impatient with the various causalist forms of historiography, such as existentialism, which looks for the “original project” behind a particular event, or Marxism, which tries to show the interests or relations of production underlying “ideological” discourse. There is a striking parallel between what Foucault develops as his own method and the method he ascribes to, say, Bichat: in The Archaeology of Knowledge, Foucault does not want us to shift our attention from what takes place on the “surface of discourse.” In The Birth of the Clinic he shows us that “Bichat’s eye is a clinician’s eye, because he gives an absolute epistemological privilege to the surface gaze” (author’s italics).

In spite of the distance which makes it possible to expose the mythical elements in a scientific system of the past, it is as if Foucault recognized in Bichat something of himself and his own attitude. What is more, when Foucault shows how Bichat and Laënnec derive medical knowledge from the scrutiny of corpses, and give priority to the lessons learned from the dead, is he not describing the position of his own archaeology of knowledge, analyzing as it does vanished systems which are separated from us by one or more “breaks”? Does not his epistemology presuppose the isolation and death of the systems whose rules he studies?

Foucault’s book contains some beautiful lyrical passages where Bichat and Laënnec’s system of verifying their findings in autopsies is compared to a series of Romantic attitudes of such artists as Sade, Goya, Géricault, Delacroix, Baudelaire:

Is not Bichat, in fact, the contemporary of the man who suddenly, in the most discursive of languages, introduced eroticism and its most inevitable point, death? Once more, knowledge and eroticism denounce, in this coincidence, their profound kinship. Throughout the latter years of the eighteenth century, this kinship opened up death to the task, to the infinitely repeated attempts of language.

The nineteenth century will speak obstinately of death: the savage, castrated death of Goya, the visible, muscular, sculptural death offered by Géricault, the voluptuous death by fire in Delacroix, the Lamartinian death of aquatic effusions, Baudelaire’s death. To know life is given only to that derisory, reductive, and already infernal knowledge that only wishes it dead. The Gaze that envelops, caresses, details, atomizes the most individual flesh and enumerates its secret bites is that fixed, attentive, rather dilated gaze which, from the height of death, has already condemned life.

One may perhaps doubt whether Bichat and Laënnec themselves ever shared this dramatic and well-nigh metaphysical vision of death. But when Foucault declares that with them and their “superficial gaze” death became “the lyrical core of man,” and when one feels the truly lyrical appeal of so many pages of his book, one wonders whether the parallels may not go beyond Géricault and Baudelaire to Foucault himself. When he describes the break which separates the new clinical science from all preceding scientific discourse, Foucault is perhaps depicting in emblematic form his own undertaking, his own break with traditional intellectual history. Not the least of his book’s attractions is that it repeatedly allows us to glimpse the face, the personal and distinctive features of a philosopher-historian whose declared aim is nevertheless to get rid of the subject and subjectivity, to disappear in his own discourse (perhaps to disappear from his discourse), and to leave the way open for a formulation of the anonymous rules which govern human knowledge and behavior.

—translated by Peter France