The Birth of the Clinic: An Archaeology of Medical Perception

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By what right can one transform into an object of clinical observation a pacient whose poverty has compelled him to seek assistance at the hospital? This book is about space, about language, and about death; it is about the act of seeing, the gaze. Ik miste wel de laatste vertaalslag naar de hedendaagse geneeskunde, de geneeskunde van de microbiologie, genetica, farmacologie. We eindigen op een punt waar de geneeskunde de chemie nog afwees - wat veranderde er eigenlijk zodat de geneeskunde echt een soort van verlengstuk van de biologie werd?

Wat een prachtig boek, zoveel wijsheid! Het vergt echt een boel inspanning om het te begrijpen maar het is het meer dan waard. Foucault gebruikt het halve boek om de tegenstelling te schetsen tussen hoe de geneeskunde was en hoe de geneeskunde nu is. Dat is nog best een lastig onderscheid, maar dat het zo moeilijk te begrijpen is, toont ook hoe normaal de huidige manier van denken is. Stap voor stap ontleedt en reconstrueert Foucault de klinische blik, de vanzelfsprekendheid waarmee je als arts je patiënt tegemoet treedt. Dat is ontzettend waardevol, want de blinde vlekken worden zo ook duidelijk. En kritische reflectie op het hoe en waarom kan ook nooit kwaad. Dit boek is een absolute aanrader voor iedereen die zich wel eens afvraagt waarom we de dingen in de kliniek op een bepaalde manier doen. In many ways this book is a structuralist analysis of the kinds of discourses that go on in medicine. There is some incredibly interesting stuff at the start where the disadvantages of putting people into hospitals prior to the French Revolution is discussed by doctors at the time because they understood illness as something needing to be explained in relation to the patient’s entire life as lived and in the hospital a person stops being a person and becomes merely an example of an illness. This shifting relationship between what one is and what one becomes due to where one is, how one is being observed, is really interesting and still relevant today. I think it is also interesting in relation to more than just medicine – also education, workplaces, the courts and so on. 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). 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. Pathological anatomy took the medical gaze deeper through “a path that had not so far been opened to it: vertically from the symptomatic surface to the tissual surface” (p. 135). The gaze could now account for more than just surface observations and signs and symptoms, and became three dimensional as a result. Even the term “gaze” took on added meaning. Where it once referred to what was seen, pathological anatomy added touch and hearing as sensorial elements. Altered anatomy and various lesions, such as “deformations, figures, and accidents and of displaced, destroyed, or modified elements” could be linked to observations” (p. 136).the development of hospitals, the whole philosophy around hospital and disease (before that step, people were treated at home, and after that step, the rich were still treated at home and the hospital was just a mean of treating / isolating the poor)

Bangsa yang hidup tanpa peperangan dan keganasan tidak akan mengalami perkara-perkara di atas. Begitu juga bangsa yang kaya. Sebaliknya, rakyat marhaen pula akan menjadi mangsa despotik kuasawan. Mereka dihimpit dengan cukai yang menyebabkan mereka mengemis, kemiskinan yang hanya menguntungkan golongan atasan dan penginapan yang tidak kondusif (malahan gelandangan) yang hanya memaksa mereka untuk tidak mendirikan keluarga atau hidup dalam rupa bentuk yang sangat mengerikan! This book is a philosophical compendium of the progression of medical history and ethical discourses, language development, aesthetical theories and medical system of thoughts that led to the development of the clinical gaze, a non-language beyond languages that physicians have been deploying to read the human body, instead of the former Aristotelean way of simply classifying symptoms and illnesses. This clinical medicine is more open than classificatory medicine and offers a “concrete sensibility.” Doctors no longer decided whether a patient’s condition fit into this or that class; they instead assessed the probabilities of a condition fitting into this or that disease. They no longer had to “simply read the visible; [they had] to discover its secrets” (p. 120). To Foucault, this was the clinic, a place of analysis.

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This means that the clinical gaze moves from the literally superficial – the doctor can look at your skin or in your mouth and so on – to a gaze in the broadest sense, one where the doctor can listen to your breathing or feel your temperature or pulse, and from this ‘gaze’ interpret what is going on under the surface to tissue there. The shift to a classification system of tissues is essential for this movement and such a shift fundamentally changes how medicine will be carried out.

Thus, the medical—classificatory—gaze during this period was confined to signs and symptoms such that “paradoxically, in relation to that which he is suffering from, the patient is only an external fact; the medical reading must take him into account only to place him in parentheses” (p. 8). As a result, judgments about a patient’s condition could draw only from similarities and differences among sets of signs and symptoms laid out in pre-determined patterns—this sign goes here, that symptom goes there. Time and space have no role; never first this, then that, or here this, there that. The Shifting Gaze Learned [and] rewarding... The Birth of the Clinic continues [Focault's] brilliant history, not of ideas as such, but of the structures of perception."-- The New York Times Book Review Less than a hundred years later, this is how a doctor observed an anatomical lesion of the brain and its enveloping membranes, die so-called ‘false membranes’ frequently found on patients suffering from ‘chronic meningitis:’ Patient attributes and environmental factors became relevant considerations in discerning diseases. Furthermore, political changes stemming from the French Revolution ceded power over health matters to the new government, which it promptly transferred to the doctors. Society would now have a point of view on what constitutes health, a view the gaze could not escape. This gaze focused on health as it concerned a “benefit to the state.” Not until later yet in the nineteenth-century would the gaze shift towards deviations from established norms of health, when, in other words, the gaze was redirected from what Foucault calls the social space to the pathological space. This particular shift for him marked a transformation of classificatory medicine to clinical medicine. Foucault jumps in during the mid-eighteenth-century period of “classificatory medicine,” when “…disease is given an organization, hierarchized into families, genera, and species,” (p. 4) akin to botanical classifications, offering doctors “a gardener’s gaze” (p. 119). Diseases were accorded their own existence independent of the individual body, and so knowledge of particular bodies only interfered with discerning true diseases. Botanical classification; 227 figures of plant anatomical segments with descriptive text. Colour process print. Wellcome Collection. Public Domain MarkIn the 18th century, the professional authority of the doctor was based upon his command of the organised medical knowledge of his time; in the 19th century, a doctor's authority derived from his command of the new, verifiable clinical medicine. An 18th-century doctor would examine a diseased organ as would a 19th-century doctor, yet, because of their different medical cultures, these doctors would reach different conclusions about the cause and treatment of the disease. Despite their perceptual differences of diagnosis, each medical report would be "true", because each doctor diagnosed according to a generally accepted way of thinking (an episteme) in which their respective forms of organised medical knowledge were considered factual. Hence, despite their medical researches having occurred thirty years apart, the father of anatomical pathology, Giovanni Battista Morgagni (1682–1771), and the father of histology, Xavier Bichat (1771–1802), did not practise the same human anatomy. [8] See also [ edit ] Naissance de la clinique" est sans doute la moins lue et la moins commentée de toutes les monographies foucaldiennes. Publiée pour la première fois en 1963, cette "archéologie du regard médical" n'a jamais suscité le même intérêt que des ouvrages désormais classiques comme "Les Mots et les choses" (1966) ou "Surveiller et punir" (1975).

Interestingly, I found out more about the contributions of Bichat, Morgagni, Dupuytren and so on, names that nowadays only depict some syndromes, diseases or anatomical parts (Bichat's Bullae, Morgagni tubercles, Dupuytren contracture).MRI scan; brain cancer (glioma). Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0) The clinic—constantly praised for its empiricism, the modesty of its attention, and the care with which it silently lets things surface to the observing [medical] gaze without disturbing them with discourse—owes its real importance to the fact that it is a reorganization-in-depth, not only of medical discourse, but of the very possibility of a discourse about disease. [5] The Doctor by Sir Luke Fildes (1891)