Michel Foucault and the Birth of Modern Medicine

[This is a post from Kevin Jobe, friend of Law Ware and the podcast.  It is part of a longer paper which PEL Citizens can download here.]
i] Introduction. “This book is about space, about language, and about death; it is about the act of seeing, the gaze.” (ix) So begins The Birth of the Clinic: an Archaeology of Medical Perception by Michel Foucault. As he often begins his histories, Foucault reminds us of an important fact about our contemporary understanding of life, death and disease: that each of these are historically contingent and are bound up with other seemingly disparate discourses of social reality: biology, to be sure, but also economics, politics,  geography, and language itself.

For Foucault, the 18th century relationship between the patient, her disease and the physician is exemplified by the question, ‘What’s the matter with you” – a question which implies a certain antiquated conception of life, death and disease. By the time of Bichat at the turn of the 19th century, this question and the conception of life, and disease it entails has been transformed into the question ‘Where does it hurt?’ It is at this moment, Foucault concludes, that we have entered the age of modern medicine. However what most interests Foucault is not the discovery of this moment itself, but rather all of the seemingly minute and invisible transformations of our discursive reality that makes this moment – and modern medicine itself – possible in the first place. It is the broader social transformation marked by this change – conceived together as the ‘historical a priori’ of modern medicine – which Foucault sets out to analyze in BC.  Thus the task set out in BC is one of “…determining the conditions of possibility of medical experience in modern times.” (xix)

 1] Spaces and Classes: One of Foucault’s major tasks in BC is to show that the question ‘Where does it hurt’, which we take as given standard medical procedure of diagnosing the diseased body, is actually part of an interpretive grid of medical perception that is contingently constituted and quite recent. An interpretive grid of medical perception involves for Foucault a very specific type of configuration of concepts, objects and statements. This is why the question ‘What’s the matter with you’ does not register quite right in the web of statements which constitute our modern medical experience. Such a question, Foucault shows, belongs to another field of medical experience altogether, that of 18^th century medical experience. According to Foucault, 18^th century medical experience operated, as all other kinds of classical knowledge systems, on the basis of the classificatory structure of species and classes. Classificatory medicine therefore maintained a certain spatial configuration and conceptualization of disease which operated along four fundamental principles: the table, the analogy, and similarity (6-7). More importantly, the medicine of spaces, classificatory medicine, holds that disease manifests its essence in its natural locus. Because of this, both the patient and the doctor were thought to be accidents and even barriers to learning the true essence of the disease, as both the hospital and the patients body itself distorted the true manifestation of the nature of the disease itself. Because of the primacy that 18^th century medicine placed on the spatialization of disease, as opposed to what Foucault will call the secondary spatialization of disease – the individual human body – he refers to as the primary spatialization of classificatory medicine. Although classificatory medicine had a conception of secondary spatialization – the presence of disease in the human body – it held that such embodiment was not necessarily relevant to understanding the structure of the disease. Unlike modern medicine, the anatomical location and re-location of disease was not relevant to the essential nature of the disease itself. As for what he calls tertiary spatializtion, Foucault refers to the social network in which and through which disease and the management of disease operates; it is the institutional, often non-discursive space which also influences the organization and negotiation of medical knowledge. Tertiary spatialization refers to all those “…heterogeneous figures, time lags, political struggles, demands and utopias, economic constraints, social confrontations” which make up the social experience of disease. (16)

2] A Political Consciousness:  This medicine of spaces, according to Foucault, begins to disappear with the emergence of a collective consciousness of disease brought on by several specific institutional changes. The first change was the collaboration of the 18^th century practice of private home care with state supervision. Because the home and the family were considered the most natural locus for disease– as opposed to for example the hospital – medical assistance had to be supervised and given a certain legal status by the state. In this respect, restoring health becomes a task of the nation: “Good medicine would be given status and legal protection by the state; and it would be the task of the state ‘to make sure that a true art of curing does exist’ [40] The second and more drastic change come with the institutionalization of epidemic medicine. For Foucault, it was the founding of the Societe Royale de Medecine in 1776 and its conflict with the Faculte doctors that signals a major turn in medical consciousness. The founding of the SRM was the result of a disease that broke out in southern France which forced the Controller General of Finance to order the killing off of suspect animals, which in turn led to economic instability. As a result, it was concluded that epidemics must be made a national medical issue, an issue for the entire nation. (26) Such a medicine of epidemics, however, would require a health ‘police’ which would gather statistics and information of all kinds, down to the last detail, about the life and health of the nation. (25-26) Most significantly, this led to a new totalization of knowledge, which began as a control body for epidemics, but gradually became “…a place for the centralization of knowledge, an authority for the registration and judgment of all medical activity….it had become the official organ of a collective consciousness of pathological phenomena.” (28)

The development of this generalized medical consciousness, which implied the centralization of and dispersion of the medical gaze, were supported by two great myths around the time of the Revolution: a) a nationalized medical profession of doctors as priests of men’s bodies, and b) the total alleviation of disease throughout a completely healthy social body. These myths reinforced the collective consciousness of the medico-administrator as one who advises not only bodies, but souls and even cities or nations: “The first task of the doctor is therefore political: the struggle against disease must begin with a war against bad government.” (33) The myth of the free gaze developed during the Revolution envisioned the institutionalization of the medico-administrator making obsolete the  academies and hospitals, and the abolition of disease created by tyranny and slavery, and extremes of wealth and poverty. (33) These myths played an important role: they linked conceptually the function of medicine and medical knowledge to the functioning of the state. Instead of retaining a role of negative restoration of health, medicine was given the task “…of establishing in men’s lives the positive role of health, virtue and happiness.” Its goal was heretofore “…to ensure that the life and activity of the nation was based on the only lasting condition of happiness, namely, their benefit to the state. [37]” (34) Thus we eventually at the transition from a medicine of health in the 18^th century to a medicine of normality in the nineteenth century. From this point, life is measured according to the bipolarity of the normal and the pathological. The race, the population, and the nation “…is a living being that one can see degenerating” (35) Medicine, from this point on, functions according to the norm (eventually for Foucault, that around which bio-power and disciplinary power revolve in a normalizing society). The science of life (medicine) thus provides the theoretical basis for the sciences of man that develop in the 19^th century (biology, economics, linguistics) which Foucault treats in Les Mots et Les Choses (1966)

3. ] The Free Field:  In the late 18^th century, the medicine of spaces and classes (classificatory) and the medicine of social normality converge upon a common demand and goal: the abolition of all institutions and barriers which stand in the way of the new generalized medical gaze. In other words, the medical technology of the old classificatory medicine and the political technology of the normalizing medicine begin to demand the removal of barriers that stand in the way of the sovereign liberty of the gaze. Hospitals must go, because they distort the natural environment of the disease (and thus the laws of its manifestation); they must go also because they are a liability to society in terms of funding and labor. Likewise the guilds and associations of doctors must go because they prevent the formation of a centralized medical consciousness; and the university Faculties must go for they regard medical knowledge as a social privilege for themselves. These are opposed to the generalized medical gaze of this era because it the medical gaze is the light of liberty which “…which to an end the unbounded, dark kingdom of privileged knowledge and establishes the unimpeded empire of the gaze.” (39) These structural reforms begin, for Foucault, from 1789 to the reactionary period of Thermidor Year II (around 1794).

After a certain decentralization due to logistic barriers, the rationalities of the medicine of spaces and normality converge upon the local hospital which serves several functions originally. First, as a space of protection. Second, as a space of training and distribution, whereby each hospital devoted itself to a certain category of patients, families or diseases and admitted patients on that basis. Thus the hospital becomes the new family, the locus for the natural manifestation of disease in its essence, in its truth. Here in the hospital, the truth of the disease can be isolated and learnt. In the teaching hospital therefore, there is a double gaze: one that sees disease as part of a general social disorder, and one that isolates it, “with a view to circumscribing its natural truth.” (43) It is eventually in the hospital that modern medicine finds for itself the principle for the articulation of a medical gaze which transforms the experience of seeing and saying in clinical practice.

One of the war cries of the Revolution was ‘No more alms, no more hospitals.’ It was the goal of the Revolution to make these institutions unnecessary. Since hospitals represented the institutionalization of poverty and the sickness of the nation, they must be abolished.  (43) Thus the idea of public medical assistance by the state (through home care) and abolition of the hospitals was accepted. The Girondists, for example, demanded total freedom in medical teaching:

In this regime of economic liberalism and competition, education returned, in a sense, to the freedom of the ancient Greeks: knowledge is spontaneously transmitted by the Word, and the Word that contains most truth prevails…Fourcroy proposed that after twenty-five years of teaching, the masters should, like so many Socrates recognized at last by a better Athens, be housed and fed throughout their long old age. (49)

However, the dream of the free field of medical practice (government assisted practitioners competitively spreading the light of medical knowledge for everyone) came up against several (familiar) obstacles: quality control, abolition of the guilds, the disappearance of the society of medicine and the closing of the universities. Less radical reformist solutions, however, eventually prevailed. These solutions entailed the reorganization of the Schools of Medicine, compulsory practical medical training regulated by a Royal Institute, a residential medical school, and organized medical field work. (47) Bouquier, a member of the Committee of Public Instruction, proposed a compromise by introducing the medical Insituteurs and proposing the eventual nationalization of the hospital funds as well as closing the the University Faculties and Schools of Medicine.

Throughout this entire period, Foucault notes, the entire reorganization of medicine failed on account of two things: first, medical knowledge still obeyed two types of regularity: individual medical perception mapped out in accordance with the classificatory system of diseases, and the generalized and centralized statistical gathering of qualitative information on climates and places. (51) Because medical knowledge was essentially still operating within the same interpretive grid of seeing and saying, visible and invisible, the subject of medicine remained the same. It had reorganized already-constituted elements of the same knowledge-grid. (51) Medicine still operated on the basis of the same set of concepts, rules, and ways of knowing/perceiving. It would take the structural reorganization of basic medical practice (savoir) and perception (regard) to lay the foundations for a new kind of medical experience. For Foucault, that reorganization would occur in the turn of the century clinics, whose lesson would be the hospital.

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