Michel Foucault -The Birth of the Clinic-Routledge (2004)

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II. MEDICAL ADMINISTRATION AND GEOGRAPHY ....................................216 III. REFORM OF PRACTICE AND TEACHING ..............................................218 .............................................................................222 ............................................................................................223 13~~ R,,~tm Ltn~~ The Birth of the Clinic e very best of Routledg ntury or so, books that have, popular consent, become ffe.ld. Drawing on a fantastic published by Routledge and it •• •,::ctive, affordable form of the The Birth of the Clinic 'No other thinker in recent history had so dynamically influenced the fields of history, philosophy, literature and literary theory, the social sciences, even medicine.' phy in France single-handed.' The Birth of the Clinic Translated by A. M. Sheridan . ° London and New York The Birth of the Clinic 'Foucault's importance is that he has bold Theodore Zeldin, New Statesman In this remarkable book Michel Foucault, uential thinkers of uncover new layers of significance. In do es our assumptions not only about history, but also about th e nature of language and reason, even ed French thinker and activist. Philosophy/History of Medicine -415-30772-4 II I , II , II Ili II I „ II utledyeclassics.com ' S NOTE INTRODUCTION he Old A he Lesson of the Hos X Naissance de la Clinique Universitaires de France English edition first published 1973 by Tavistock Publications Limited First published 9 by Routledge First published in Routledge Classics 2003 by Routledge Routledge is an imprint of the Taylor at Francis Group Universitaires de France Transl Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall All rights reserved. No part of this bo ok may be reprinted or reproduced or utilized in any form or by any electro known or hereafter invented, includin g photocopying and recording, or in British Library Cataloguin g in Publication Data is book is available fr om the British Library ISBN 0—415—30772—4 TRANSLATOR'S NOTE One of the characteristics of Foucault s language is his repe key words. Many of these pr esent no difficulty to the translator. Others, however, have no normal equivalent. In such case single unusual word rather than a number ng of both clinical medicine and the teach-ing hospital. to the unprepared reader. INTRODUCTION out language, and about death; it is about the act of seeing, the gaze. hysteric by making her take 'baths, te n or twelve hours a day, for ten whole months . At the end of this treatment for th e desiccation of the nervous system damp parchment ... peel away with so me slight discomfort, and these were passed daily with the urine; the right ur Less than a hundred years later, this is how a doctor observ lesion of the brain and it s enveloping membranes, false membranes' frequently found on patients suffering from 'chronic meningitis:' the arachnoidian layer of the dura ((xi)) apes of 'lungs as they really are? of medical know-l edge, nor any more or less spontaneous break with imaginary Investments; 'positive medicine is not a medicine that has made ,In 'objectal all the powers of a visionary space through which doctors and patients, rational discourse? What sharp line divides a description that depicts membranes as being like damp parchment ((Xii)) membranes possess greate objectivity—in terms of scientific discou rse—than the horny sc ales described by things and their shapes? Modern medicine has fixed its own date of birth as being in the last years of the ((xiii)) reorganization of that manifest and parts of the brain had been dehydrated, which parts had been swollen, and by which dis-eases. Modern medicine has ma de hardly any use of this research. Brain pathology achieved its 'positive broad, thin end. If one appears, wrapped in viscous, veined skin which—freed at last and exposed at last to the light of day— knowledge. The antisanal skill of the br For Descartes and Malebranche, to see was to perceive (even in the most ((xv)) , but to the slowness of th them, around them, and gradually into th em, bring-ing them nothing more than of truth in the dark centre of things is linked, paradoxically, to this sovereign power of the empirical gaze that turns their now flickers around solid objects and, in so doing, establis form. Rational discourse is based less on ings, and perhaps with it alone, to authorize a knowledge of the individual of a historic or ((Xvi)) is accession to the individu al the establishment of a unique dialogue humanism, as old as man ss phenomenologies of understanding mingle the sand of their co notion; the feebly eroticized vocabulary of doctor/patient relationship itself in trying to communicate the pale powers of matrimonial fantas n-thought Clinical In order to be able to offer each of perfectly adapted to his illness and to hi Miracles are not so easy to come by: the mutation that made it possible—and which continues to do so to become a field of at of a body of knowledge and some ((xvii)) glance . Medicine made its appearance as a clinical science in cond It may well be that we belong to an age of criticism whose lack of a primary philosophy reminds us at every moment of its reign and its fatality: an age of intelligence that keeps us irremediably For Kant, the possibility and necessity of a critique were linked, through certain scientific contents, to the fact that there is such a thing as knowledge. In our But is it inevitable that we should know of no other function for speech ntary questions discourse as to what it says and intended to say; it tries to ((XVIII)) uncover that deeper meaning of speech that enables it to achieve an identity er to its essential truth; what has never been said. In this ary which tries to transm it an old, unyielding discourse seemingly silent to itself, into rary—is concealed a strange attitude towards language: to comment is to ad mit by definition an excess of the signified over the signifier; a necessary, unformulated remainder of thought that language has left in the shade—a visible, heavy world of a signifier that is itself burdened with a meaning that it translation', that it has the dangerou s privilege images have of showing tituted for itself indefinitely in the To speak about the thought of others, to try to say what they have said has, by tradition, been to anal and by others, be treated exclusively in play of signifier and signified, as a series of themes pr esent more or less implicitly to one would evade the fate of commentary by supposing no remainder, nothing in excess of what has been said, but only the fact of its historical appearance? be treated not as autonomous nuclei of multiple significations, but as even segments gradually believed), from which there has since developed a sort of of thought, the results of which can quite le ed—the nucleus of the nucleus being always its opposite. ysis of a type of discourse—that of To anyone wishing to draw up an inventor idea of the clinic would undoubtedly seem to be imbued wi th rather vague values; insipid figures would probably take shape, such as the st pathological evo- lution, the need for sharp perception (the need to be constantly alert to the to medical knowledge—old, threadba the old clinical theme appearances—an essential mutation ((xxi)) e onto the organism (the disappearance of the general morbid entiti new structure is indicated—but not, of course, exhausted—by the minute but d eenth-century dialogue deliberately both historical and critical , in that it is co ((xxii)) ility of medical experi I should like to make it plain once an written in favour of one kind of medicine as against another kind of medicine, or against medicine and in favour of an abse nce of medicine. It is a structural study disentangle the conditions of its history from the density of discourse, as do What counts in the things said by men is not so much what they may have thought or the extent to which these th ings represent their thoughts, as that Traite des affections va poreuses des deux sexes (4th edn., Lyons, doctrine des maladies mentales F. Lallemand, introduction, p. vii, n.). J.-Ch. Sournia, For us, the human body defines, by natu of origin and of laid down, in accordance wi hardly offers a coherent lexicon. Every gr d of pathology lays down a configuration for man is no more than a historical, temporary datum. Their encounter is self- nning to detach ourselves mposed, in medical ex relatively short period of time—the period But how did this supposedly natural, i mmemorial right come about? How was this locus, in which disease indicated aphic of Pinel (1798), the eory and practice: it appears as the immanent logic of morbid forms, the pr pherment, and the semantic rule of their definition: Pay no heed to those envious men who would cast the shadow of contempt over the writings of theclebrated Sauvages.... infallible rules of healthy logic. Observe with what care he defines his words, with what scrupulousness he circumscribes Before it is removed from the density of the body, disease is given an organization, species. Apparently, this is no more than a remember the proliferating domain of th genealogical tree, at a lower level than the comparison that it involves and all its imaginary themes, presuppo ses a space in which kinship is formalizable, the figure of the diseases that is neither the chain of in the human body. This organization treats localization in th e organism as a subsidiary problem, but defines a fundamental system of relations involving envelopments, subordinations, divisions, , in which the implications ar e, emerging beneath our gaze, becomes embodied in a living organism. primary configuration of disease? century identified it with opposed to philosophical, knowledge'. Know-ledge is hi pleurisy by its four phenomena: fever, difficulty in breathing, coughing, and pains in the side. Knowledge would be philosophical question the origin, tween the historical and th The historical embraces whatever, de facto or de jure, sooner or later, directly or indir ectly, may be offered to the gaze. A cause that can be seen, a symptom that is grad ually discovered, a principle that can be philosophical' knowledge, but to a very simple of defining a sort of fundamental area in which perspectives are levelled off, and in which shifts of coincides with what follows it. e broken and time abolished: a local inflammation is merely theideal juxtaposit Disease is perceived fundamentally in a space of projection without depth, of plane and one moment. The form in which truth is originally shown is the surface in which relief is both manifested and abolished—the portrait: He who writes the history of dis-eases r and natural phenomena of diseases, however uninteresting they may seem. In this he must imitate the painters who 2. It is a space in which analogies de fine essences. The pictures resemble things, but they also resemble one an other. The distance that separates one without reference to the logicotemp oral divergence of genealogy. The disappearance of voluntary movements and reduced activity in the internal or particular forms as apoplexy, syncope, or but it spares the breathing and the only a locally assignable sector of the a general effect, but it also interrupts respiratory movements. The perspective distribution, which episode, and in apoplexy an organic and functional attack, does no t exist for the classificatory gaze, which is sensitive only to surface divisions, in which vicinity is not defined by measurable distances but by formal similarities. cross the threshold of ere is no fundamental When one perceives a resemblance, one mappings ; one begins to read off the intelligible the diseases. The veil is lifted from this is the general order of nature. As ts or animals, the action of disease is fundamentally subjected to less certain laws in produc ing diseases or in maturing morhific humours, than irr growing plants and an imals.... He who observes attentively quart fever begins, the phenomena of shivering, of heat, in a word all the symptoms proper to it, will is disease is a species as he has to believe that a plant constitutes a species because it grows, flowers, and dies This botanical model has a double impo made it possible to turn the principle of ly, it allowed the perceptual attention discovers and relates- to communicate with the ontological order which organizes from the inside, prior to all manifestation—the world of disease. The order of disease is simply a of division, the same ordering. The rati onality of life is identical with the rationality of that which threatens it. Their relationsh ip is not one of nature and counter- nature; but, in a natural order common to one another, one superimposed upon the other. In di because it is on the law of life that knowledge (connaissance) of are both natural and ideal. Natural, e their essential truths; ideal insofar as unchanged and undisturbed. troduced with and by disease itself. To the pure patient adds, in the form of so many disturbances, his predispositions, his age, his way of life, and a whole relation to the essential nucleus, appear as accidents. In order to know the truth of the pathological fact, the doctor must abst a disease must take care to dis ting from those that are only accidental and liar tuitous, such as those that depend Paradoxically, in relation to that course, the doctor must know of our bodies ; but only in order to Subtract it, and to lire to the doctor nature and combination of synrptonrs, funxnuus, in relation to life, .IS a eotrntrr adorn', but the patient iii relation to the disease itself. And not only the patient; the doctor, too. I lis intervention is an act of violence the ideal order ing of mosology: The knowledge cure depends on an exact knowledge of the disease ; the doctor's gaze is directed initially nut towards untreatable. In the period of invasion, th his breath, for 'the beginnings of disease reveal its class, its genus, and its species ; when the s and patients do not occupy a place as of right; they are tolerated as disturba nces that can hardly be avoided: the paradoxical role of medicine consists , above all, in neutralizing them, in ssential space, which it proceeds to efface at each moment. Disease exists only in th at space, since that space constitutes it Disease, which can be mapped out on the picture, becomes apparent in the body. lids, movements, or functions, causes lesions that become visible under autopsy, triggers off, at one point or another, the interplay of symptoms, causes reaction s, and thus moves towards a fatal, and ing here with those complex, derived the thick, dense volume of the organism and becomes embodied within it. How can the flat, homogeneous, homologica l space of classes become visible in a geographical system of masses differentiated by their volume and distance? How can a disease, defined by its place in a family, be characterized by its seat in an organism? This is the problem that might be called the secondary spatialization of the pathological. an organ is never absolutely necessary to define a disease: this disease may tr another, reach other bodily surfaces, wh enough latitude to slide away from one another. The same, single spasmodic malady may move from the lower part of the abdomen, where it ma interruption of the menstrual or haernorrhoidal flow, towards the chest, with breathlessness, palpitations, the feeling of a lump in the throat, coughing, and finally reach the head, causing epileptic convulsions, syncopes, or sleepiness. d by symptomatic ch anges, may occur in time in a single individual; they may individuals with different link points: in ects, while in its cerebral fo among sanguine temperaments. But in any case, the essential pathological configuration is not altered. The organs ar In this corporal space in which it circulates freely, disease undergoes organism is Or, rather, threshold, not boundary. Fo madness than is thought; and they ar usality dissociates the simultaneities and intersections in order to main In this pathology, time plays a limited role. It is admitted last, and that its various episodes may appear in turn; ever since Hippocrates and known the significant e real body of the the points of localization, but, rather, the quality. In ribed before the Prussian how he observed the alteration in the brain during different diseases. When he carried out an autopsy, he removed from the brain small cubes of equal volume 6 linesiii each direction other, and with similar cubes taken from other phthisis, a disease involving exhaustion of the brain was r than in the case of apoplexy, a disease involving discharge (1 dr 3 normal subject who had died naturally th weights may vary according to the part of the brain from which the samples have been extracted: in phthisis it is, above all, the cerebellum that is light; in its specific qualities: the brains of ma niacs are light, dry, and friable because languish-ing, inert, anaemic, because phthisis belongs to the general class of the It is understandable, then, that medicine should turn away Knowing quantities and being able to measure them, being able, for example, to mathematical form, but to gauge the inte nsity of the pathological quality that constituted the disease. No measurable mech or mathematical particularities, a ical phenomenon; convulsions may be due to a dehydratio n and contraction of the nervous system _______________and this is certainly s of inter-linked qualities, articulated movements, upheavals that are triggere d off in series, no quantifiable segments. It may involve a mechanism, but it cannot belong to the Physicians must confine themselves to knowing the know their laws, and be tireless in the of disease would imply a common, homogeneous space, with organic figures and a nosological ordering. On the contrary, their shift implies a qu alitative gaze; in order to grasp the and where there is humidity, dis-charge , debility. How can one distinguish, beneath the same fever, the same coughing , the same tiredness, pleurisy of the a dry inflammation of the lungs, and there a serous discharge? How can one dist inguish, if not by their quality, the suffering from cerebral inflammation, and those of a the viscera? A subtle perception of qualities, a perception of the differe The human body is made up of vessels and fluids; . . . when the vessels and fibres have neither too much nor too littl ds have just the right consistency, when they have neither too much nor too little movement, man is in a state of health; if the movement . . . is too strong, the solids harden and the fluids thicken; if it is too weak, the fibre slackens and the blood becomes And the medical gaze, open to these fine qualities, necessarily hecomes of perception that must take account of t in what does this partic ularity consist? It is not that of an organism in which patholog Hence his paradoxical position. If one wi shes to know the illness from which he vidual, with his particular qualities: through immutable laws that one soon disc overs if the course of the disease is not interrupted or disturbed by the patient at this level the individual was vidual now reappears as the positive, ive phenomena, which articulate upon ordering of the disease; it is the local, sensible plane of kinships to the anatomic vol ume of vicinities. The patient is a descriptions, icular histories. Howe ver simple nature may be as a whole, it is nevertheless varied in its parts; consequently, we must try to know it both as a whole and in its parts The medicine of species becomes engaged in a renewed attention to the individual—an ever-more impatient the general forms of perception and the hasty inspection of essences. Every morning a certain Aesculapius has fi fty or sixty patients in his waiting nd, a clyster for the third, and a change of ai This is not medicine; the same is true of hospital practice, which kills the capacity to observe. Medica l perception must be directed neither to series nor to groups; it must be structured as a look a magnifying glass, which, when applied to different parts of an object, makes one notice other parts that thus g the individual. At this point, one is d portrait of the disease; he is the modulations, nuances, depth; and when describing the disease the doctor must st rive to restore this liv-ing density: ins, his own gestures, his own posture, his own terms, and his own complaints status; in secondary spatialization, on the other hand, it required an acute group gaze and of hospital experience itse lf. Doctor and patient are caught up in reveals the way in which a group, in orde r to protect itself, practises exclusions, establishes the forms of assistance, and reacts to poverty and to the fear of death. But to a greater extent than the other forms of spatialization, it is the locus of various dialectics: In the medicine of species, disease has, as a birthright, fo )) Like civilization, the hospital is an ar tificial locus in which the transplanted ng its essential identity. It comes up against a form of complication that doctors call prison or ho spital fever: muscular asthenia, dry or coated tongue, livid face, sticky skin, diarrhoea, pale urine, difficulty in breathing, generally, contact with other diseases, in this unkempt garden where the species of the sick, from gangrenous limbs, decayed bones, contagious ulcers, and putrid fevers And, in any case, can impression that the sight many are nothing more than temples of death , will have on a sick man or woman, removed from the familiar surrou urb, with the health y reactions of the organism, the natural course of the dise ase; it would require a very skilful hospital doctor to avoid the danger of the false eems to result theartificial diseases to which he devote hospital disease is a pure disease ral locus of life—the family: gentle, d a common desire for a cure, assists nature in its struggle against the illness, an ly distorted, altered diseases, a whole based on the natural phenomen This family st nature without violating it, and wait, admitting in a ll modesty that much knowledge is still ialization for the disease, with no privileged region, no constraint im posed by hospital conditions—a sort of The criticism levelled at hospital foundations was a common-place of analysis. The funds on which they are based are, of course, ina The sick man is no doubt in capable of working, but if he becomes a double burden broth is made; and in heating his tisane, it costs no more to warm his children The chain of one disease engender-ing another, and that of the Independently of their justifications, disease is isolated and reaches fulfilment is an absolutely open space, without either division or a privileged, fixed figu manifestations; a homogeneous space in which no intervention is authorized ensation—a space with no ot her morphology than that other, and of the patient. But, by being carried to its conclusion in this way, th ) In this way a certain supervision would be exercised over the doctors themselv quacks forbidden to practise , and, by means of an orga nized, healthy, rational and avoid exposure to contagion of the patient s family. Good medicine would be given status and legal protection by the state; and it would be the task of the to make sure that a true .' The medicine of individual perception, of family assistance, of home care can be based only on a e, or on one that is integr (Neuchatel, 1772, vol. I, p. 198). Institutions de medecine pratique 5 W. Cullen, Institutions de medecine pratique 6 Th. Sydenham, Medecine pratique (Fr. trans. Jault, Paris, 1784, p. 390). 7 Ibid. 8 Th. Sydenham, quoted by Sauvages, 9 W. Cullen, op. 10 Sydenham, quoted by Sauvages, op. cit., Guide pour la conservation ('homme La nature opprimee par la medecine moderne 17 Fr. Solano de Luques, s by Nihell (Fr. trans., Ibid., Ibid., Ibid., Ibid., Ibid., . 43 2 -44) . Essai sur la saute des gens du monde (Lausanne, 177o, pp. 8-12). Memoires sur les h8pitaux (Paris, 1788, p. 451). Dupont de Nemours, Idees sur les secours d donner (Paris, 1786, Ibid. ns la medecine pratique Cf. Vicq d'Azyr, Chamousset (C.H.P.), 'Plan general pour ('administration des h8pitaux', ' , in Dupont de Nemours, ssemblee Nationale surla necessite 2. A POLITICAL CONSCIOUSNESS Compared with the medicine marginal importance But we must return to Sydenham and to the ambiguity of what he has to teach might be a historical and geographical is not an autonomous nature, bu of a more intense or weaker kind: feve rs may be violent and dry, catarrhs and serous discharges more frequent; during a long, hot summer, visceral congestion is more common and more tenacious than usual. Of London, ; but an epidemic is a finer-grained constitution, with more constant, more homogeneous phenomena. There has been, and still is, a great deal of discu ssion as to whether the doctors of the The basis of this perception is not a specific type, but nucleus of circumstances. The basis of an epidemic is not pestilence or The regularity of symptoms does not al low the wisdom of a natural order to show through as in filigree; it trea ts only the constancy of causes, the obstinacy of a factor whose total, uncea disease shows the same symptoms in all: this is because dryness or humidity, heat or cold, when prolonged, ensure th e domination of one of our constitutive principles: alkalis, salts, phlogiston; ese accidents must be the same for different subjects? form of the disease, by placing it in nosology, but the rediscovery, beneath the gene ar process, which varies idemic to another, and which weaves from the cause to the morbid form a we in 1785, there was an the bile had dried up in its passages and turned into melancholy, the blood had become imp overished, thickened, and sticky as it the abdomen had swollen and become or a sort of over-all singularity, an individual with many similar heads, wh in time and space. The specific disease is always more or less repeated, the epidemic is never quite repeated. e, the problem of contagion is of little importance. , which can be communicated through water, food, contact, the wind, or confined air, y (when, in a town or hospital, the disease caused by some other factor). But contagion is only one modality of th readily admitted that malign diseases, lik e plague, had a transmittable cause; it was more difficult to recognize the same fact in the case of the simple, epidemic diseases (whooping cough, meas phenomenon, it requires a multiple ga supplemented by constant, constricting intervention. A medi could exist only if supplemented by a police: to supervis rant, even children, would learn to health inspectors would have sent out to the provinces, placing ea depart-ment ation about the various domains physics, chemistry, natural history, topography, and astronomy, would prescr ibe the measures to be taken, and would supervise the wo It is to be hoped that the state would provide for these physicians and spare th make useful discoveries entails'.'' unique and unrepeatable may be opposed to the individual pe vealed in the multiplicity of phenomena. The analysis of a series in the one ca se, the decipherment of a type in the other; the integration of ti historical and geographical space—the demarcation of a homogeneous surface This was the origin of the Soci insuperable conflict with the Faculte (the university authorities). In 1776, the ctor in uncertainty as to the choice of treatment that should be applied; and this uncerta describe the symptoms of ation, by keeping itself idemic movements; elaborat ion, by comparing facts, zing experiments; and supervision and prescription, by informing the medical prac collision of two institutio cally supported, the other nner of reasons and principally in the in protest: it refused to exercise its functions, and its members refused to co But, above all, its role was control body for epidemics, it gradually knowledge, an authority for the regist ration and judgement of all medical activity. At the beginning of the Re above all, to Political events had a certain novelty value here, as far as basic structures were concerned. A new type of experi formed around the years 1775-1780, were with them, during the Revolution and right up to the Consulate, many these plans were ever implemented. century, Institutions, Apho risms, Nosologies, en-c losed medical knowledge within a defined space: the table draw chain linking, throughout the universe, on earth and in man, all beings, all What now constituted the was not the circle of knowledge in which it was achieved but that open, infinite, moving totality, ceaselessly displaced and enriched by time, whose course it began but would never he able to stop—by th is time a clinical recording of the infinite, variable ess, with all the information that intersects in it, growing in a complex, ever-proliferating way until it finally achieves the dimensions of a hi story, a geography, a state. In the eighteenth century, the fundamental act of medical knowledge was the drawing up of a ecific ensemble, and this ensemble in a general plan of the pathological world. In the ex carving up means of the interplay of series, which, in intersecting one another, made it under observation and with the 24 A system of coincidences then appeared that also suggested kinships or new it is work of this kind carried out over a period of fifty years, s carry out the same observa- tions in our Hotel-Dieu ." What defines the act of medical body of knowledge and a perception ; it is the systematic inter- rmation, each homogeneous but alien to each other—two series th separate events, but whose inters ection reveals, in its isolable dependence, the individual fact. A sagittal figure of knowledge. In this movement, medical consci observations; but it is taken up izes the constitutions, confronts them, and, turning back upon the spontaneous forms, dogmatically pronounces its judgement and its knowledge. It becomes cen tralized in structure. At the insti- tute the jurisprudence of addition to a Judiciary, ve that would exercise a distributes to daily experience the knowledge that it has borrowed from af ar and of which it has made itself of diffusion. incide with social space, or, rather, sness of each individual medical know-ledge is necessary and possible. And each practitioner must su pplement his supervisory activity with teaching, for the best way of avoiding the propagation of disease is to spread pathological garden where God distri buted the species, but a generalized ace and time, open and mobile, linked of the nation, ever alert to the endless domain in which illne llowing the Revolution saw the birth of two great myths with opposing th nationalized medical profession, organized like the clergy, and invested, at s bodily health, with powers si milar to those exercised by the ' s souls; and the myth as the natural heirs of the Church s two consolation of souls and the alleviation of pain. So the wealth of the Church, which has been diverted from its origin be a sort of lay carbon copy. To the ar tion of souls would correspond that of the doctors who concern themselves with the health of' bodies. way of life of individuals, diseases va ry from one period and one place to me of war and famine, the sick were relaxation of the feeling for one s country and of the obligations that such a feeling must begin with a war against had government. Man will be totally and Who, then, should denounce tyrants to mankind if not the doctors, who make man their sole study, and who, each day, in the homes of poor and rich, among ordinary citizens and among the highest in the land, in cottage and ma nsion, contemplate the human miseries that have no other origin If medicine could be nger be indispensable medically. And in a concord reigned, the doctor would have no more than a temporary role: that of giving legislator and citizen advice as to the regulation of his heart and body. There would no longer be any need for academies and 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 impoverished, sick slaves. All this was so much day-dreaming; th by an open-air mankind, in which you th would be naked and age know no winter, the familiar symbol of ancient arcadias, to which has been added the liest forms of' truth all these values were soon to fade. ined to a body e; it will also embrace a knowledge of healthy man, that is, a study of non-sick man and a definition of the model man. In the ordering of hum an existence it assumes a normative posture, which authorizes it not only to distribute advice as to healthy life, but tions of the individual and to become established (Claude Bernard ry subjects that it devoted itself to (man, his behaviour, his individual and up a field that was divided up accordin g to the principles of the normal and acter of the scien 1 Th. Sydenharr, 'Obser 3 Le Brun, Traite bistorique sur les maladies epidemiques 4 Lepecq de la Cloture, Collection d'observations sur les 7 Banan and Turben, Languedoc 8 Le Brun, op. cit., p. 66, n. 1. Description des epidemies qui ont regne depuis generalite de Paris 12 Le Brun, op. cit., pp. op. cit., Ibid., Cf. Precis historique Motif de la reclamation de la (Place and date of pu blication unknown). Recueil d'observations h6pitaux militaires op. cit. Cf. N.-L. Lespagnol, 28 J.-B. Demangeon, Des moyens de perfectionnerla (Paris, Year VII, pp. 5—9); cf. Audin Rouviere, . (Paris, Year XI, p. 38). 30 Sabarot de L'AverniPre, 33 Lanthenas, De ('influence de la Ibid., Ibid., 36 On 2 June 1793, Lanthenas, who was a list, then crossed off, Marat having described him as 'weak-headed'. Cf. La Revolution francaise 38 Lanthenas, op. cit., about the health of a populati on. This medical field, restored to its pristine truth, pervaded wholly by the gaze, without obstacle and without alteration, is relationship of the parts to the whole was always transposable and reversible. Despotism has need of darkness, but li berty, radiant with glory, can only all the light that can enli ghten men; it is during tablish itself and become naturalized among them. . . . Make other nations trib utaries not of your political authority, nor of your government, but of your tale nts and your knowledge. . . . There is a dictatorship for peoples whose yoke under it, and that is the dictatorship of genius.' that guides all structural reforms from 1789 to Thermidor Year II is that of the so uth: the majestic violence of light, which is in itself supr eme, brings to an end the bounded, dark kingdom of privileged knowledge and es tablishes the unimpeded empire of the The Comite de Mendicite de I both economists and doctors who believe possible locus for recovering from disease was the natural of the disease leading to artificial complications, spre ading of its own accord, and form of a disease of the disease was avoided. In the family, the disease was in a state of , that is, in accord with its own nature and freely exposed to gaze that is turned upon it person has the vital force of Misfortune . . . arouses by its presence beneficent compassion, brings to birth in men's hearts the pressing need to offer comfort and consolation, and the abundant spring of wealth distributed by is put into a hospital , he is deprived of ons who have no family, an communal houses for the sick must be set up that would function as family substitutes and spread, in the form of reciprocity, the gaze of compassion e poor would find who are at least not entirely strangers to them find its natural, or almost natural, locale, where it would be free to follow its own But the ideas of the Comite de Mendicit e of health is not eedom. If the family was bound to the unfortunate individual by the natural duty of compassion, the nation was bound ance. Hospital foundations represented an immobilization of wealth constantly available fund capable of providing help when and where required. 'divert to its own use the wealth of the hospitals and then combine it into a 'common fund . The first, that of the diversion of hospital funds, is political diseases. The Legislative e nationalization of hospital capital; it to entrust the administrati ral body, which, it was believed, would be too cumbersome, to disease and poverty was to sness. And in this field, as in so many others, the Legislative Assembly went back on the the essential links, keep themselves stribute the revenues; they would form a multiple tralization is associated with two ance and of repression. Tenon, in his leaving them to the me ; he would act according to the belief that the lives of the rich and an those of the poor and weak ; lastly, he would be able to refuse help to public malefactors In addition to his role as a technician of medicine, he ribution of help, and a moral, quasi- ibution; he would become the guardian of public morals and public health alike In this regional configurat of discontinuous authorities contagion, and for difficult, complex, In the projects of the Comite de of the distribution of aid, involves a continuous supervision of the social space with a system of highly medicalized regional centres; and the extra-ordinary , which is made up of discontinuous, according to the model of scientific knowledge. Disease is thus caught in a do gaze that does not distinguish it from, bu t re-absorbs it into, all the other social ills to be eliminated; and a ga ze that isolates it, with a view to circumscribing its natural truth. The Legislative Assembly left to the Co resolved: that of the ownership of hospital funds and the new problem of the d must be carried out by private subscription, but the government mu would be misled and would give little or no help'.' The abolition of the hospitals was demanded rty, who regarded them as an institutionalization of poverty and who believed that one of the tasks of the Revolution must be to make them and needy? . . . Th With the victory of the Mountain, the idea of an organization of public of a complementary abolition of the hospitals, over a fairly long period of time, was accepted. The constitution of Year II proclaims in public assistance is a sacred debt great book of national beneficence organization of a system of help throug only for help there s to he postponed of the poor and that stigma ideal state in which the human being would no longer know exhaustion from A man is made neither for a trade, nor for a hospital, nor for a poorhouse: such a prospect is too terrible II. THE LAW OF MEDICAL PRACTICE AND TEACHING 1707, regulated the practice of medicine and the training of doctors for the rest matter of struggling against charlatans, quacks, and persons practising medicine ; similarly, there had been medical faculties, which for many years had fallen into the most . It was laid down that henceforth medicine would be taught in all the universities of the kingdom that had, or had had, a faculty; instead of remain-ing vacant for an indefi nite period, would be made available as udents would receive their degree only duly verified by matriculation every four months; that would follow compulsory courses in cy, and in demonstrations of plants. In these conditions, Article 26 of th e decree enunciated the principle that no person may practise medici , even without payment, if he has not obtained ; and the text added—and this was of Medicine at the cost of their reorganization— And all religious, mendicant or non-mendicant, shall be and remain included in the prohibition laid down in the preceding article us on at least four points: charlatans continued to flourish; the canonical teaching provided by the discoveries (only theory was taught; neither mathematics nor physics was of medicine for teac out in a satisfactory manner; any other post: the professors charged fo for them), which when qualified, the new doctor still had to gain practical experience by accompanying some well-known practitioner on his visits, for which privilege he stricter limitation of the right to practi se and a stricter organization of the university cursus. But both went agains t the whole movement of reforms that culminated in the abolition of guilds There was thus a certain amount of te profession that is protected by no ion of practice, no privilege of qualification? Can the as spontaneous as its civic or moral on the ground that they should be understood not in the sense of privilege but of medical body is to be distinguished from po litical bodies in that it does not seek to limit the liberty of others or to impo se laws and obligations upon the citizens; its imperative applies only to itself; its jurisdiction is concentrated but it is also to be distinguished from other professional bodies rights and obscure traditions but to confront and to communicate knowledge: without an established organ, enlightenment would be extinguished at birth and individual all. In forming themselves into a body, doctors make th e following implicit oath: We wish to enlighten our minds by fo rtifying ourselves knowledge; the weakness of some of our number is corrected by the superiority al of the Girondists, dreamt of freeing up to a free regime of uncontrolled the reorganization of the Schools of Medicine. They fall into two gr oups, the first presupposing the survival of university structures and the second taking into ' reformists ' one constantly en-cou and public opinion would thus favour the development of a body of medical know-ledge and a medical consciousness that would at last be adequate to the nation s needs. Thiery thought that four preferred two, with a number of special schools for a less-advanced course of training. Moreover, the duration of studies would have to be longer: seven years accord-ing to Gallot, ten according to Cantin; this was because it was now A practical training curiously independen In a rather paradoxical way, this acqu isition of practical train-ing, which is ss, was left almost entirely to private initiative, with the state controlling li s studies: for some, two year s would be enough; other, these lessons would have to be paid fo r by the students, and the professors This reformist thinking has a curious an d complex structure. Assistance was to be left to individual initiative, and th e hospital establishments were to be privileged medicine; by a kind of position of teaching was inverted. It foll owed an obligatory, public course to the university, to become, at the hospital stag nded total freedom, and they were supported by all those who had benefitted from the old in the absence of any organization, thought that they might get hack, if not their Catholics like Durand Maillane, former Oratorian fathers like Daunou or Si aching arts and sciences. For them, certificate of integrity and good citizenship: and those closest to Robespierre, who an that of the Girondists and less rigid than that of Le Pelletier and Romme. He made e hospital funds were nati been thoroughly discussed, and the wide problems; and, above all, since the Legislative Assembly had laid down in principle what, from Thermidor to the Consulate, was to be rediscovered as the solution. structure that might have given unity to a form of experience already defined by individual observation, th e everyday practice of diseases, and a form of teac hing that everyone knew ou the hospital rather than in the Faculty, changes that had come about in the ined the same, the position of knowing the same, and concepts were formed , medical know-ledge as a whole obeyed The entire pedagogical and technical reor account of a central lacuna: the absence of a new, coherent, unitary model for scientific unity of the medical institution im plied, for its realization, this mutation in depth. But, for the re volution, this unity was manded a unity of knowledge and of l place for it; but they were also the principal obstacle to its realization. The idea of a transparent, undivided domain, exposed from top to bottom to a gaze ar qualifications, dissipated its own difficulties in the powers accorded to liberty: in liberty, disease was to formulate of it self an unchanging truth, offered, undisturbed, to the doctor up with the history of mo dern man, the clinic was y related to the themes of light and liberty—which, in fact, had evad ed it—than to the discursive structure in which, in fact, it originated. It is ofte n thought that the clinic originated in that Adresse 6 la Convention pluvi6se an ii. Guillaume, d'instruction publique de la Convention 2 Bloch and Tutey, Ibid., Asylums in which beggars, the poor, the work less, prostitutes, political agitators, tual or potential agents of disorder were interned. Quoted in Imbert, 1954, p. 52). 6 Cabanis, Du degre de certitude de la medecine (3rd edn., Paris, 1819, p. 135 9 Tenon, (Paris, 1788, p. 359). Ibid., 11 J.-B. Duvergier, Le droit Ibid., Law of 19 March 1793. 15 Saint-Just in Buchez and Roux, 16 Articles 1, 6, 9, 10, 14, and 22. (Neuchatel, 1772, Vol. II, pp. 58-118). Thiery, Voeux d'un patriote sur la to have been written til the Estates General. er Nos Seigneurs de I'Assemblee Nationale above, p. 29. cit.; J.-P. stauration de ('art de 26 Cabanis, (Paris, 1790, pp. 32-3). 27 Durand Maillane, J. Guillaume, de la Convention, Rapport sur I'enseignement libr 29 Ibid., p. 2. 30 Ibid., p. 8. 31 Sainte-Foy, Journal de Montagne, 32 Fourcroy, op. cit. 4. THE OLD AGE OF THE CLINIC patient does not date from the end of the revolutions in medicine have been carried through in the name nt norm. But what was constantly according to which this experience was given, was found a discursive formulation. Not only ping of systems were not the same; but the fundamental perceptual codes that were applied to patients bodies, the field of objects to which observation addressed itself, the surfaces and depths ientation of this gaze also recount its own history as if the patient s bedside had always been a d systems, which had been in perpetual ccounts by which, at the end of the passed from father to children rpus of knowledge (un savoir), the clinic was a unive rsal relationship of mankind with itself: the age of absolute happiness for medicine. And this knowledge in a privi- leged group, and the dissociation of th e immediate relationship, which had en for a long time, and succeeded in Hippocrates seems to be both the last witness and the most ambiguous representative of this balan eek medicine would seem to be no more than th Such is the occultation that has made the multiplicity of differ from time only its destructive mark. Bu t beneath that destructive history lies another history, one more faithful to time original truth. Into this history is imperceptibl of the clinic. It remains keeping medical practi ce in contact with the world of perception, and opening it up the help of that analysis that comes so natur-ally to the human mind, Immobile, but always close to things, the clinic gives medicine its true historical movement, it effaces systems, while the experience h. Thus a fruitful continuity is found that guarantees to pathology the uninterrupted uniformity of that science Over and against systems, which belong to negating time, the clinic is the posi tive time of knowledge. It is not to be invented, therefore, but to be rediscovered: it wa medicine; it has constituted its full plenitud which denies it, to destroy it is nothingness—that is, would then he on a level with its truth. und so frequently word; and, therefore, it authorized all su bsequent simplifications whereby clinical In order to understand the meaning and utions in which its organizational effort has been manifested. Up to the last years tury, this history, the hospital at Leyden; he published the resulting observat ions under the title of Collegium The most illustrious of his successors was Boerhaave. It is also medicine at Padua sixteenth century. In any case, it was at Leyden that the practice began, with affairs whereby practical teaching was given individually, privately, and with more celebrated consultants. It was in the military hospitals that clinical teaching was first organized; the Reglement pour le its article XIII that each year of study must include clinical medicine of the principal diseas es to be found among the troops in the And Cabanis quotes as an ex the naval hospital at Brest founded by Du breil under the auspi To conclude, one might mention the der to understand their meaning and disentangle the problems that they pose , one must first reexamine a number of minish their import on the other? Can it be a 1.This proto-clin a special kind. It was not the direct expression of the hospital, since a principle of choice serves as a selective limit what is present is the disease itself, in th e body that is appropriate to it, which is that of its truth. It is ' the different diseases that serve as the text ' : ' the patient is only that through wh therefore, only in its sy this investigation and the clinical examination lies in the fact th no inventory of a sick organism is made (epaisseur) of the perceived hides only the imperious and laconic truth that names, it is a question not of an examination, but of a deciphering. ic should have had only one direction— from top to bottom, from constituted know ledge to ignorance. century, there were only teac hing clinics, though only in a limited form, since it ctor should be able by this method at any moment posited in the illne ss. The clinic was struction, in the narrow sense of the word, that is objects must be observed in order to be In no sense was the clinic to discover by means of the gaze; it merely duplicated the art of demonstrating (demontrer) by t understood the lessons of clinical brought analysed its features, out-lined the action that was to be taken, c arried out the necessary operations, essence as it may he, accepted in spite of everything the judgement and risk of experience, but it was experience at least in the sense that it was a test—a test of knowledge that time must confirm, a test of prescriptions that will be proved right or wrong by the outcome, before th students: there is a sort of con-test, before witnesses, with say, and which, despite the dogmatic sp own language. Thus the lesson given by against him, and provide, despite his vain language, a lesson that belongs to nature itself. Cahanis makes a mistake, his failures are soon unmasked by nature .. . whose language can be neither stifled nor altered. They re ineffective images which might otherwise have made only a slight impression on them. ';' fails, therefore, and when time has prove d its worthlessness, that the movement of nature is recognized for itself: the language of knowledge nesty, for it was linked to its proper newed daily. At the Edinburgh clinic the diagnosis made, of the state of the patient at every visit, and of the medicines taken during the day. Tissot, eping of a diary, adds in his report to Count l clinic, that these diaries should be ion must provide a last In the eighteenth century, then, the clinic was already a much more complex form than a mere knowledge of cases. An But in a few years, the last years of p. 8). 2 Ibid. , P . 7) . Ibid., ns la medecine pratique (Fr. trans., Strasbourg, Year VII, p. 13). Histoire de la medecine clinique (Paris, Year XII, . 3 2 3)- . de la medecine (Paris , 1828, vol. I), article 'Clinique', pp. 830-7. 10 J.-B. Regnault, Considerations 11 P.-A.-O. Mahon, op. cit., Ibid., 15 J. Aikin, 16 A. Storck, Instituta Facultatis mediae Vivobonensis op. cit. 22 J.-B. Demangeon, ce, at the HSpital General, the eighteenth century an apprentice surgeon live op. cit. 25 Tissot, 'M6-noire pour la construc l clinique', op. AGEOFTHECLINIC op. cit., Ibid., Ibid., op. cit., op. cit., p. 95. Tissot, op. cit. ibid., Azyr sees the organization of a system of teaching with in the hospital as the universal solution for the problems of medical training; that , for him, is the major reform to be ns in hospitals. Are we bene- victims in our hospitals? Do we teach in our hospitals the art of observing and education was given a positive value as enlightenment: to train was a way of bringing to light, and therefore of discove ring. The childhood and youth of things and men were endowed with an ambiguous power: to tell of the birth of truth; ctify it, to bring it closer to the adult insofar as true the very genesis of truth. In every child things tirelessly repeat their youth, the world re sumes contact with its native form: he ult. When it has untied its old kinships, ous les savoirs), it is intelligent enough to be the most unintelligent by repeating so skilfully it s distant ignorance. The ear s folds; the eye, which is akin to light, What allows man to resu me contact with childhood I'oissonniere section, was still denouncin g doctors trained by the Faculty as vulgar against whom the people wished to be defended. But this fear soon took on a different shape, and the danger was seen to come from the real charlatans who were not doctors: ill-taught individuals who, on no othe to limit this dangerous liberty: '0 representative citizens, the nation is making its material cries heard and the urgency: the delay of a single da y may mean the death of' several Inadequately trained doctors and the hospitalization of the poor and sick became increasingly difficult. The nationalization training and experi the Comite de Salut Public had asked the Comite d Instruction Publique to draft a officers of health can be trained armies of the Republic';'' but the situation had been too urgent, all volunteers had and apart from the first-grade officers of health, who had to show proof of pr evious training, they had no further knowledge of medicine than what they ha d just been taught. these ill-trained practitioners had been cr iticized for their numerous mistakes. ong the civilian population officer of health in the Creuse who killed his patients by administering purges of From all sides demands flowed in fo r proper control and supervision and With how many ignorant murd erers will you inundate France if you authorize second- and third-class physicians, surgeons, and chemists ... to out a new examination; ... it is, above against this state of affairs. Some of the more precariously based were popular in origin. If certain of the more hful to the axiom of the Mountain—'No more indigents, no more hospitals —and continued to demand the distribution of individual aid, to benefit the si others, including penury and the difficulty the privileges that would be able to prot ect both the social order and individual 'affrighted by the ills that they had e silence of the law , did not wait until the decided to establish their own control over those who claimed to practise medici Montpellier provided what was no doubt officers of health; but since no teaching had been organized, the medical students appealed to the This may be a privileged example, but it is no less significant for that. By a spontaneous convergence of pressures and demands proceeding from social different kinds, an experience was beginni ng to he formed by a kind of ortho- reviving, as the only possible way of had been developed in the eighteenth dogmatic language as an essential stag e in the transmission of truth. The professorial chair made it possible, bene ath the old language, in the obscurity of a partly blind practice, driven this way and that by circumstances, for a language with-out words, possessing to be formed: a language entirely new configuration, was born. an entirely new medicine, based upon the clinic, swept away the theme of a been dominant righ reactionary ), nor progress (although medicine, as a practice and as a science, benefitted in several ways) ; wh medicine in liberty : in a liberated domain, the necessity of the truth that communicated itself to the gaze was to define its own institutiona l and scientific structures . It was not only out of ure fidelity to coherences that no twisting in events could defl opposed any project aimed at restoring the Gothic universiti and in Year III demanded that the temporary closure of the Faculties should be used to brin g about their 'reform and improvement 'murderous quackery and ambitious ignorance must not he allowed to lay their the very practice of the art, the observat ion of patients in their beds essential part of the new medicine. re took the clinic as institutional reorganization of medicine: for them, it was a means of putting an end to the I. THE MEASURES OF 14 FRIMAIRE, YEAR III s. The justifications that he offered are worth noting, especially in vi were taken up virtually in e law that was in fact passed, though he departs more is helping the people to feel the benefits of truth. As rather awkwardly puts it, It is to give veral channels that , thus understood, a corpus of knowledge of use to all citize nature: instead of being, like the old Faculty, the locus of an esoteric, bookish e new school would be the temple of nature would learn not what the old masters thou open to all that is manife and political purity of the new medical organization. It represents the truth of th at organization in guaranteed liberty. Humanite, the Unite, and the Hopital de 1 Ecole), the clinical teaching should be entrusted to professors who would be suffic iently well paid to be able to devote The public would be freely admitted to the new school of health: in this way, it was ho there should be only special schools. The deputies from the south of France objected, and insisted that Montpellier lt that the law of 14 Frimai re Year III provided for medical chemistry during the first semester, and materia medica, botany, and physics during the second; throughout the year the students would visit hospitals broader theoretical teac hing. Once one defined a by which the new Paris school commented on the law of 14 Frimaire required entary structure of the inanimate omena of the organism and life strive to show the relationships that revealing the inseparablenes s of the human being with istence, it would show how ; and it would represent efore, a medicine concerned only with the first degree of empiricism, r short of solving a ll the problems that de Sante to the public, it was hoped that inadequately trained officers of heal th would be attracted, and that by free Moreover, the teaching provided by th criticism. The programme was far too broad and too By demanding too much, Finally, taking full advantage of all thes the law of 14 Frirnaire. The first of on precepts for which experience alone can pro-vide observers. For this reason, several ion of the learned so the law supervises those professions concerned wi ted. This is not the place to give a detailed account s centered mainly around the question The first plan of reform had been draw n up by Daunou, one of the authors of the Constitution of the Year III, who, in the Convention, had had Girondist sympathies. He did not wish to alter substantially the Frimaire laws, but he wanted to see, in addition, the establishment of in twenty-three provincial hospitals; and it would then be possible for local authorities to require pr oper qualifications for the practice of out having attended a school, but you will demand a solemn guarantee of the kn owledge of every candidate: in this those of public use of its fidelity to the principles of s project was unanimously crit icized: Baraillon called it .'A few weeks later, the Commission ted another report, drawn up this time by Cales. itten in a quite different spirit: in order to win doctors, which was implicit in his project, he opposed th e distinction whereby physicians were , and th the treatment of children. In the five andardized studies and examinations. s project, supported by doctors like obtained a double tactical advantage: he , at the scientific those who had more or less taught themselves medicine since 1792, and, st teaching was, he suggested that instea maintained. This amounted quite But meanwhile, on the very day before th e uprising that was to reveal him as one of the leaders of the Royalist plot an All those who had taken up medicine during bjected to examination by juries trained again be able to control their own as a body capable of defining their own made its application difficult; by demanding that they be reduced still further, Prieur thought that he would ma A positive law should compel anyone who claims to practise one of the professions of the art of healing to un dergo long studies and examination by a series of four examinations to be held on fixed dates . The only real innovation was the requirement of a clinical test: will expound at the Thus, for the first time, the criteria of theoretical knowledge and those of a practice that can be linked only to und together in a single project did not permit the integration or gradual assimilation into official practised since 1792; but it ' CABANIS'S INTERVENTION Chronologically speaking, Cabanis presented his report on medical the polemics contemporary with it. Although it attempted to define the conditions fo r a practical solution, it sought, above all, to provide the outline of a theory of the medical profession. At the immediate, practical level, Cahani no difficulties they could be allowed to practise , how-ever, would have to undergo an em; it would he confined to the fundamental skills of the art, partic ularly those relating to its practice . Ordinary medical studies, however, would have to he controlled by an examination, including a written test, an oral test, an internal and external clinical medicine medical profession. domain, reserved to it alone, without rporative structures of Taking industry in the wide sense of wishing to impose a truth upon it from the outside; real va In a well-regulated social state, the ject and value do not depend upon er these objects are among those that serve to in the same way that goldsmiths industry who do not produce wealth, but who treat that which meas That is why physicians, surgeons, and pharmacist s must be subject to stringent abilities, and their moral habits. . . . ded or the liberty of the individual ' of 19 Ventose Year XI concerning the practice of s themes and, in a more general way, provided for a two-tier hier doctors iii medicine and surgery who had qualified in one of the six schools, and the officers of health, form those whom Cabanis had wished to reintegrate on a provisiona l footing. After four ex aminations (anatomy and physiology; pathology and nosography; medicine), doctors would take a test in clinical medicine, internal or external, This whole movement of ideas, project . In defining the closed character of on, one managed to avoid both the old corporative model and that control over medical acts economic liberalism. The principle of referred to by who has per-formed it is worth; his intrinsic value is a function of the socially recognized quality of the beralism patently inspired by Adam liberal 2.In this world of aptitudes, ho , and on the other object is manifested, but of a diffe s reflected in institutions: but it in the objective domain of their activity; it was now displaced towa rds the qualitative index of this 3.This distinction had an objective would treat 'the industrious and active people century, it was accepted that the labo uring classes, especially those in the country, led a more simple, moral, and healthy li fe than others, 4. On what was the distinction based among those practising the art of healing? The most important part of the tr aining of an officer of health was his years of practice, which might be as many as six; the doctor, on the other hand, time knowledge, a gaze that exists, that was master of its truth, and free of all ex ample, even if at times it had made use of health, hut the doctors would reserve the initiation in e clinic was bound up with At first, both Thermidor and the Directoire the Legislature on I I Thermidor Year III, Del ecloy attacked the law providing fin- the nationalization of hospital funds alone, instead of' placing it general commiseration and under the gu However, the time was past when such treatment was regarded as universally valid the Thermidorian suspend, on 2 w to nationalize hospital funds. On the basis of a new report submitted by Delecloy on 12 Vendemiaire Year IV, the law of' 23 Messidor was definitively revoked: the funds that had been sold would be replaced by national funds, and the gove rnment would thereby he discharged of all obligation. The hospitals would recover their civil character; their organization and management were entrusted to the municipal administrations, which would appoint a five-member executive committ om any necessity of providi ng assistance and left the burden of'identifying themselv es with the poor to fairly s own poverty and for the way in which it protected itself from it. The system of obligation and co A stranger, more hidden contract of the same kind was silently s his otherwise unlimited practice by a closed system of duty. It is by entering the asylums where poverty ccess, and which the sight of' spreading happiness cannot but increase. It is ther e that he will learn to be religious, humane, compassionate , to show in order to teach, is not this a tacit form ive for its silence, upon a sick body that demands to be comforted, not displayed? Can pain he must he, 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 others intervene with 103)) Beneficent gifts will assuag from which enlightenment will result for the preservation of the rich. Yes, rich benefactors, generous g in the bed that you ha ve subscribed is now experiencing the disease that will be attacking you ere long; he will be his fate may enlighten your physician and save your life. These, then, were the terms of or participated in the organization of d a way of' interesting the rich; the clinic constitutes the progressive reversal the interest paid by the p invest in the hospital; an interest that must be understood in its heavy sur- �fir science and of' vitIIl interest for cure, was turned into a spectacle. Helpin g ended up by paying, thanks to the virtues of the clinical gaze. stic of pre-Revolutionary thinking, and which found frequent expression ln 'l re the Revolution, were given new meaning and immediate application in Explaining in the Year Vfl how the mate rnity clinic at Copenhagen functioned, dangerous class may he of the greatest possible use to honourable families; mora lity will find its reward in that which flouts it, fig the women not being in a state to ribute to the training of good doctors and repay their benefactors with interest exchanges of a liberal world .. . i Vicq d'Azyr, Oeuvres 2 Demangeon, Du moyen de perfectionner la medecine, p. 29. Les charlatans devoiles (Paris, Year VIII, preface, unpaged). quoted by A. Seboul, (Paris, n. 12 Nivose Year VI, quoted by Ba raillon in his Germinal Year VI. 8 Message of 24 Nivose Year VI. Vol. II, p. 200. to Guillaume, Proces-verbaux du Comite d'Instruction publique de la Convention, Rapport au Conseil des Cinq-Cents, the scandal of amputations. Ibid. Opinion de Porcher au 14 By the section of Lombards, cf. Soboul, 15 'Adresse de la section de publique sur un mode pr Essai sur I'esprit de la Montpellier Rapport d la Convention au nom des Comites de Ibid., 23 Ibid., p. 9. Ibid., 12-13. 26 Plan general de I'enseignement (Paris, Year III, p. 1,). . op. cit., Plan general de I'enseignement da Opinion de j.-Fr. Baraillon, the first number of the Ibid., I, p. Ibid., From March 1798, Cabanis sat in the Assemblee des Cinq-Cents, as a P.-C.-F. Daunou, Rapport d I'Assemblee des Cinq-C ents sur ('organisation des Ibid. Rapport au Conseil des Anciens, 6 Ibid., Motion d'ordre de C.A. Prieur relative mblce des Cinq-Cents, 24 Nivose Year VI. r la partie de la police qui tient d la medecine, 6 Opinion sur le mode provisoire d'ex 49 Cabanis, sur un mode provisoire de police 4 Messidor Year VI, pp. 12-18. Ibid., pp. 6-7. Ibid. ce by J.-C.-F. Caron, slatif le 79 Vent6se an XI, Le droit hospitalier sous Ibid., (Paris, 1958). 57 J. Aikin, Ibid., 6o Chambon de Montaux, Moyen de rendre les h6pitaux plus utiles b la nation 61 Du Laurens, 62 J.-B. Demangeon, Ibid., And here we have the unbounded Unravel the principle and cause of an obscurity of the symptoms; know its nature, its forms, its complications; distinguish at first glance all its charac teristics and differences; by means of a prompt and delicate analysis separate it from all that is foreign to it; foresee This solemn, prolix text yields it s meaning in the light of another through its sheer brevity can be possible, make science ocular powers, from the slow illumination of obscurities, the ever-prudent reading of the essential, the calculation of ti mes and risks, to the mastery of the paternal authority, are just so many gaze gradually esta blishes itself the eye that knows and decides, the eye that governs. The clinic was probably the first attemp t to order a science on the exercise natural history had set out to analyse and classify natural beings according of' knowledge that antiquity and the Middle Ages had accumulated an plants, the powers of animals, secr l history. As much, and to a certain extent, the same entical and those that are different, to regroup them, to classify them by species or families. The naturalist model, to active. The old dream of Boissier de Sauv ages of being the Linnaeus of diseases te eighteenth-century clinical medicine g subject reorganizes himself, changes himself, and begins to function in a changed first and later the way in which it was the aleatory struct ure of the case. e were distinguished from one another semantic value as tomhence its uniquely privi- leged positionis the form in wh pain in the side, and difficulty in breathing are not pleurisy itselfthe disease itself hut 'reveals itself only to reasoning'--hut they form its 'essential symptom since they make it possible to de signate a pathological state (ill rent, for example, from pneumonia), and an immediate cause (a discharge of serosity). The ic sign, what will happen; the anamnestic sign, what has happened; the diagnostic sign, what is now is an unfailing announcement of death, or the crises of the fourth day, in intestinal fevers, promise recovery. Thro the sign indicates that which is further away death, time, not that immobile truth, that given, hidden truth that the ry transcribed the double reality, natural and dramatic, of disease, establishing the truth of a corpus of knowledge and the possibility of its applicatio n. A happy, calm structure, in which a balance was a fact of nature to which medical perception adapted it self, hut which it did not constitute. ER AND SIGNIFIED the disease is itself a phenomenon; in th at respect, the syniptonts play a simple role, primary in nature: `Their collectio n forms what is known as the disease more than a t uth wholly given to the gaze; their link and status ce, but indicate a natural totality that has only its or less regular forms of duration: s role of sovereign indicator, the law of appearance; it is on the same level as This complexity in the stru be found in all philosophy of the natural sign; clinical thought mere ly transposes, into often more con-fused vocabulary of prac latitude, to Condillac. In the general equilibrium of clinical thou ght, the symptom plays more or less the role of the language of action: like it, it is caught up in the general movement of nature; primitive, as naturally given as the that bears this initial form of language; it is the disease in its animation that prolongs it, maintains it , and turns it back into an external form, which is of the same nature as its internal truth. But it is conceptually impossible that this immediate language should take on meaning for another another place: an act of which Condillac availed himself, in advan ce, by conferring consciousness upon and whose singular, sovereign natu re he has hidden by inserting it When he posits the language of action as the origin of II. IT IS THE SOVEREIGNTY OF CO NSCIOUSNESS THAT TRANSFORMS THE d say the same thing, the only difference being material reality, the with the symptom itself; the symptom is the indispensable morphological support no sign without a a sign belongs not to that originates elsewhere. by right, but not every sign is in the sense that the to tality of symptoms will never be able to exhaust the real ity of the sign. How does this sforms the symptom into a gnifies the disease as precisely By an operation that makes visibl its stages, and dissipates all its opaque structures: by comparing organisms: tumour, redness, heat, pain, throbbing, tension as a sign of phlegmon, because one hand is compar one individual with another; and of their imminent destruction an operation that registers th or succession: What relation is th scrutinizes the body and discovers at the autopsy a visible sudden interruption of pain and the gradual weakening of ecomes a !,i}fin —a spontaneously differential operation, devoted to totality ,,nd to memory, and calculating as well; a single movement, the element and the than Condillac s analysis put into practice in medi cal Iierception. Here and there is it not simply a question of 'composing and decomposing our ideas in order to make different comparisons with them, an d in order to discover by this means t selves, and the new ideas t h a t they may produce'?'' Analysis and the clinical gaze also have this feature in common order to reveal an ordering that is the natural order itself: their Artifice is to ENTIRELY STATED IN ITS TRUTH External signs taken from the pulse, heat, breathing, hearing, alteration in facial features, nervous or spasmo dic affections, and impairment of the ng that by which the disease can be l of words, a history that covers its corresponds the unobstructed transparen cy of the pathological being with the syntax of a descriptive language : a fundamental isomorphism of the d of the verbal form th at circumscribes it. The descriptive act is, by right, a seizure of being' (une prise d titre), and, inversely, being does not appear in manifestations without offering itself to nguage that is the and its description could not correspond with its two dimensions; in c and to he spoken immediately communica te in the manifest truth of the for Condillac, was the fun-damental language restores them in their most original articulation: To analyse is simply to observe in a of an object with a view to ascribing to them the simultaneous order in which they exist.... But what is this order? Nature herself .° The order of truth does only time to its necessary and statable, that is, discursive form. The history of diseases, to which Sauvages gave an obscurely spatial meaning, now assumes its chronological dimension. cture of this new knowledge the role in nger to know these silent species, As an isomorph of ideology, clinical ex of application. Not that medicine, as Condillac supposed, had returned to an in analysis, the armature of the real is designed on the model of lang uage. The clinician s gaze and the philosopher s reflexion have similar powers, manifestations that are its signifier- signified, in which the visible and the Medicine as an uncertain kind of kn ive. It was to be found, reinforced s elements always to give to th.e immense combinations of which it is capable the uniformi certainty that characterize the ph An xity concerning the object and of years, made a positive element of knowledge. In the period of within a similar movement of thought, medicine discovered that uncertainty may he treated, analytically, as the sum of a certain number of isolatable of rigorous calculation. Thus, this confused, negative con cept, whose meaning derived from a traditional opposition to mathematical knowledge, ncept and offered to the pe tion was decisive: it open ed up to investigation a But at this period this schema was neither radicalized, thought out, nor even drawn up in an absolutely coherent way. It was not so much an over-all this did not lie in the probabilities, but in the conditions that could make it applicable: the enumeration of physiological or pathological facts like that of a population or a series of astronomical events was no t technically possible at a time when the hospital field was still so much on th e fringe of medical experience that it often seemed to act as its caricature or distorting mi mastery of probability in medicine imp lied the validation of a hospital domain which, in turn, could be recognized as ce only by already probabilistic thinking. Hence the imperf ect, precarious, and partial character e fact that it sought for itself a confused basis that was op nological meaning. Thus Cabanis tried to justify the instruments of the clinic, which were then still in the process of being formed, with the aid of a concept whose technical and i. Complexity of combination such that, however confus simplicity is not to be foun d in the essential generality but at the primary level of the given, in the small numbe ents. It is not the class of fevers which, owing to the inadequate principle of intelligibility, but the small ght think that we were pr cases could no longer he attributed fications that disturb essential truths, and force us gnition that neglects and abstracts; it may be gasped and recognized in itself, in combination, that is, if one defines all th that knowledge of life divine understanding, the progress of knowledge now had the same origin and found itself caught up in the same empirical ogression of life: 'Nature wanted the source of our know-ledge to be the same as that of life; we must receive receive impressions in order to know t is the law of combination of these ed analogous forms fy symptoms and diseases. The medicine of species and classes also made use of th nt of pathological ance of their reproductive or from one plant to another. But these anal ogies related only to inert morphological data: it was a question of perceived fo rms whose general lines could be super- an inactive, constant state of bodi es, a state foreign to the present nature of the function linical gaze rested in order to recognize, in different patients, sign s and symptoms are of a different order; function-ing or a dysfunctioning. Thus difficulty in breath in phthisis, asthma, hear t disease, pleurisy, and scurvy: but it would be misleading and dangerous to attach too much import-a nce to such a resemblance. The fruitful analogy that identifi es a symptom is in relation to other functions weakness (which is found in dropsy), a livid complexion (similar to that found in obstructions) , spots on the tartar), form a constellation in which th e co-existence of elements designates a functional interaction peculiar to scurvy. It is the analogy of Furthermore, within the same disease and analogy may make it possible to define th e singularity of the disease as a whole. complication , which always enabled them to find a pathological essence by simply extracting from the manifest symptoms whatever and these elements were then labelled , headaches, thirst, nce when accompanied by prostration, rmittent pulse rate, difficulty in by an adynamic fever. rigorous use of analogy was to make it possible to avoid such arbitrariness in distinctions and groupings. From one pathological entity, a certa in analogy could be found in their relations with external or internal ca Thus many nosographers saw bilious pleuropneumonia as a complicated volv pains in the pit of the stomach) and i rritation of the pulmonary organs, which sectors, apparently deriving from dist , make it possible 3. Perception of frequencies Medical knowledge will gain lation to the number of By its multiplicity, the series b ng of blood) among the rs—a distinction in accord with the challenge. But if the phthisis-haemoptys is complex (despite many distinctions cases, circumstances, stages) achieves a certain qualitative density in the total series , their connexion w ill become, over and above any encounter or any gap, outsid It is by studying the most frequent s and their regular s the bases of the general laws of nature Individual variations are spontaneou only by a positive operation: in order ty of essence, it was first necessary to possess it, sively rich content of experience; it was to distinguish what is constant from what is variable in it, the essential from the purely accidental In clinical experience, ideal, transcendent Spectator whose genius and patience might he approached produced by their individual points of view are distributed possesses its own powers of indication. Their very divergences reveal, in this nucleus in which, after all, they inters in an identical way, unless nature has really presented it to them in the same way. Notions circulate, in obscurity and in n of error, the gap, the bo the visibility of the medical field assumes rceptual field not a garden events. But nothing has b In principle, this failure was due not to but to the organization of the field. 4. The calculation of the degrees of certainty If one day one discovers in the calculatio frequences; it is offered, in an ambigu A simple example will enable us to grasp the natu e of this fundamental confusion. Brulley recalls the principle fo rmulated by Jacques Bernoulli in his Ars regarded as a whole divisible into as many probabilities as one wishes Thus the certainty of pregnancy in a woman may he divided into eight degrees: the disappearance of menstruation; nausea and vomiting in the first mont month; a much greater in crease of the II womb pubic bones; the gion in the fifth month; and the ; beyond that probability begins. sex; he is of a bilious . The subject would not hear of this It was hoped by an arithmetic of rinthine ways to the sanctuary of truth'." defined according to the epistemological model of mathematic ideology. As an instrument, it served to define the system of implications in its complex totality: less so, with their various re lations; one rises to the most simple idea ' ; but like its mathematical model, this analysis was used to s bedside , and that, as such, it was identical with .' The clinic was much more than a revival But are not this domain itself and that which, fundamentally, makes it visible doubly in accord? Are they not based on over-lapping forms that nevertheless l, acclimatized in the analysis of signs, remains implicit and enveloped with of the forms of intelligibility. The mathematical model is always explicit and invoked; it is present lminates outside itself: it is a question of the contribution of themes of formalization. But this fundamenta l contradiction was not felt to he such. And the gaze that re sted on this apparently liberated domain seemed, for a time, a happy gaze. . 3 Cf. Zimmermann, 5 Audibert-Caille, Memoire sur I'utilite de (Montpellier, 7 Condillac, 'Essai sur I'origine des connaissances humaines', 10 A.-J. Landre-Beauvais, (Paris, n Ibid. 13 Landr6-Beauvais, op. Ibid., op. cit., Ibid. 18 Ph. Pinel, La medecine clinique 19 Condillac, quoted by Pinel, Nosographie philosophique (Paris, Year VI, de la science de I'homme (Montpellier, Year XII, pp. 27-8). Du degrr de certitude de la rnedecine (3rd 76-7. 24 Audibert-Caille, Brulley, op. cit., Audibert-Caille, op. cit., Double, Semeiologie generale vol. I, p. 146. op. cit., vol. I, p. Ibid., Ibid., Roucher-Deratte, Le¢ons sur fart d'observer (Paris, , p. 53) 6 37 3 8 39 0 Hippocrates applied himself only to observation and only by following in his footsteps that rvation were much more by tradition and of a quite different privileges of a pure gaze, prior to all intervention and faithful to ok up without modifying it, whole logical armature, which exorcised The observing gaze refrains from interv ening: it is silent and gestureless. Observation leaves things as they are; th ere is nothing hidden to it in what is given. The correlative of vation is never the invisible, but always the d the obstacles erected to reason by theories and to the senses by th e imagination. In the clinician purity of the gaze is bound up nables him to listen. The prolix discourses ` and the suggestions of the imagination—which anticipate what one perceives, find illusory relations, and give voice to wh at is inaccessible to the senses—must How rare is the accomplished observer who knows how to await, in the silence of the imagination, in the calm of the mind, and before forming his judgement, the relation of access to the truth of in silence, if everything keeps silent around what it cal ability to hear a language as soon as it perceives a spectacle. In the clinic, what is manifested is originally what an unsupersedable (indepassable) origin that the Double expresses in terms of causality: with experience; the latter is e means or cause; observation leads double silence: the relative silence of theories, imaginings, and whatever serves as an obstacle to the sensible immediate; and the ab all language that is anterior to that of the visible. Above the density of this solely by virtue of the fact that they are seen. This gaze, then, which refrains from all possible intervention, and from all experimental decision, and which does not modify, shows th bound up with the strength of its arma-ture. To be what it must be, it is not enough for it to exercise prudence or scepticism; the immediate on which it opens states the truth only if it is at the same time its origin, that is, its starting point, its principle and law of compositio n; and the gaze must restore as truth what was produced in accordance with reproduce in its own operations what ha s been given in the very movement of composition. It is precisely in this sense that it is d the art of observing seems to be particularly, teach their operations and usages. In a word, it us, and of deriving inductions from th em that are their correct consequences. Logic is ... the basis of th art might be regarded as one of the parts of Logi dependent on meanings.' ation, define this clinical gaze as a logic of operations; it is an the genesis of composition; but it is pure of all intervention in is only the syntax of the language spoke n by things themselves in an original things it perceives the same Logos, which, in the latter, is a genesis of totalities and, in the former, Clinical observation involves two necessar and the teaching domain. The hospital domain is that in which . Not long ago the family still formed the natural locus in which truth resided unaltered. Now its double power of' illusion has been discovered: there is a risk that disease may be masked by treatment, by a regime, by va rious actions tending to disturb it; and it is caught up in the singularity of phys ical conditions that make it incomparable with others. As soon as medical knowledge is defined in terms of frequency, one no longer needs a natural environmen t; what one now needs is a neutral domain, one that is homogeneous in all possible and open to any form of pathol no principle of in everything must he possible, and possible in the same way. What a source of instruction is provi patients each! ... What a varied spectacle of fevers or phlegmasias, malign or pathological disorders and disorderings of pathological forms is neither dismissed nor ignored. but rigourously annulled, sin therefore, to isolate them by analysis a degree of foresight and precision landscape in which diseases appear of th but the refraction that is proper to it makes possible, nstancy, the analysis of truth. l experience, the collective char- acter of the hospital field—the clinic seen infinite. If the clinical domain is open only to the tasks of language or to the demands of' the gaze, it will ha ve no limits and, therefore, no organization. There is boundary, form, and meaning only if interrogation and examination are conn 1. The alternation of spoken stag es and perceived stages in an 2. The effort to define a statutory ents that the disease offers to perception; but in the x axis, he indicates the significant values that these symptoms may assume. In an acute fever, a painful sensitivity in the pit of the stomach, a headache, and hand, prostration and abdominal tension ha ve an adynamic meaning; lastly, pain in the limbs, a dry tongue, rapid breathing, a paroxysm, especially one segment assumes a significant value, analytical function in clin ical knowledge. But it is ob vious that the analytical structure is nei-I her produ ure itself; the analytical makes nothing known; at most, it makes possible recognition. 3. The ideal of an exhaustive description namely, the continuous correlation of an entirely—that is, doubly faithful description; in relation to its object it must he, in effect, wi thout any gap; and in language describing the object it must allow no deviation. Descriptive rigour will he the result of precision in the statemen t and of regularity in the designation: By virtue of this dual function, the work of description ensures in rising to general views without lending reality to abstract terms a simple, regular distribution, invariably based on the relations of structure or the organic functions of the parts certain internal measure-ment consisting of fidelity and fixity, of primary and absolute openness to things and rigour in the The art of describing fa in medicine: everything pales before it e part of clinical thought to 14 It is understandable that, after the revol utionary dream of an absolutely open science and practice, a certain medical esotericism could be revived around form of the manifestation of things in th initiation into the truth of things. It was this e as a self-evident banality some forty years later: The medical clinic may be regarded either as a science or .22 A hearing gaze and a speaking gaze: clin There is a simple historical reason for this: Condillac s logic did not allow a scribable were caught up in a total adequation. Condillac s philosophy gradually shifte original impression to an operational logi this logic to the constitution of a knowledge that would be both language and calculation: used th different meanings, the notion of element sustained throughout this refl ure. Condillac never derived a universal This ambiguity had its effect on clinic ulation to the primacy of genesis; after e with the expressible by a lculability, it gave that post exhaustive description. The essential op eration was no longer combinative but a g is more typical of this movement— which takes up again, in the opposite direction, Condillac s whole approach—than s thought, and this is particularly a analysis. Brulley wished probabilities as one may wish . 'A probability is therefore a degree, a part of certainty must thus be obtained by a co mbination of probabilities; after laying y declares that he will go no further, task of elucidating this subject _______________a task that he would out.' in all probability, it was Cabanis to whom he referred. For in Les Revolutions but by an organization whose values ar e essentially expressive; it is not a question of drawing up a calculation to room for the calculation of probabilities in the construction of medicine, it is only construction of scientific discourse. l of La Longue des calculs; although cturally on a footing with the Essai sur It might be thought—and all the clinicia ns of that generation thought so—that things would rest there and that an un problematic equilibrium was possible at But this generalized form of transpar language that must be its foundation, its justification, and its delicate instrument. number of epistemological myths that are in new spatial figures, in which visibility thickens and becomes cloudy, in which the gaze is confronted by obscure masses, by i. The first of these epistemological myths concerns the Particular, isolated observations are to The order in which they appear, their im enough to give birth to nalist reduction on the essence of pathological phenomena a reduction of a chemical type teenth century th e gaze of the no sogra-)hers was a gardener ' s gaze; one had to recognize the sp The notion of analysis clinic, we have already recognized signification: it will have e bodies and the de combinations. One has passed from the th syntax and finally to And, by reciprocity, the clinician tional equivalent of rough it that the essential purity of hs. And just as in this paradoxical act of consuming. The reality, whose language it spontaneou sly reads in order to restore it as it ght be supposed: its truth is given in a decomposition that is much more than of an implicit structure. ic no longer has simply to read the visible; it ha The clinical gaze is not that of an inte unalterable purity of essences beneat erudition and such solid instruction, if not the result 'I'lius this sensory knowle dge—which nevertheless implies the conjunction of a hospital domain and a pedagogic domain, eld of probability and a linguistic structure of tI ie real is reduced to praise of the immediate sensibility. The whole dimension of analysis is deployed only at the level )I At this level, all structures are dissolv ed, or, rather, those that constituted the and in apparent disorder, replaced by those that are to constitute gaze implies an open field, and its essential activity is of the successive order of reading; it records and totalizes; it gradually reconstitutes immanent d that is already the world of language, hearing and speech; it forms, as it tion of two fundamental aspects of saying (what is e other hand, does not scan a field: it strikes at one point, which is central or decisive; the gaze is endlessly modulated, the glance goes straight to instantly distinguishes the essential; it th erefore goes beyond what it sees; it is not misled by the immediate forms of the sensible, for it knows how to traverse them; it is essentially demystifying. If it strikes in its violent rectitude, it is in order to shatter, to lift, to release appe abuses of language. The glance is sile nt, like a finger pointing, denouncing. contact perhaps, but in fact a more striking contact, since it traverses more easily, and goes discovers a kinship with a new sense that prescribes its norm and epistemological structure; this is no long er the ear straining to catch a language, And by that very fact, clinical experi ence sees a new space opening up before the same time is that opaque mass in ch translation of Auenbrugger, viii. 4 Roucher-Deratte, Lecons sur fart d'observ vol. I, p. 80. 7 Ph. Pinel, 91 Maygrier, Ibid., Ibid., pp. 5 and 3. Ibid., Essai d'un nouveau plan d'observations medicales (Fr. trans., op. cit., Nosographie philosophique, Ibid., 8 Cf. above, Chapter 6. l. I, p. 64). Ibid., Philosophie medicale 23 Condillac, Ibid., Ibid. 27 Cabanis, Coup 28 Double, op. cit., p. 79. 29 Cabanis, Du degre de certitude (3rd edn., Paris, 1819, p. 86). Ibid., Ibid., Cf. above, Chapter 6. op. cit., Roucher-Deratte, Corvisart, op. 6 37 3 8 39 8. OPEN UP A FEW CORPSES At a very early stage historians linked h seemed to define it in its essentials, to bear it and overlap it, to form both its most vi An entirely new period for medicine has just begun in France ...; analysis applied to the study of physiological phenomena, an enlightened taste for the writings of Antiquity, the union of medi d the organization of the clinical schools have brought ab out an astonishing revolution that is pathological anatomy.' Pathological anatomy was given the curious privilege of bring-ing to knowledge, at its final stage, the first principles of its positivity. Why this chronological inversion? Why did time deposit at he end of its course ments, once the vile prey of worms, A fine transmutation of the d condemned it to putrefaction, to the e that violated only to reveal, to bring to the light the figures of truth. Knowledge Morgagni had no difficulty in the middle in carrying out his autopsies; nor did Hunter, some character and indicate no opposition on principle. From 1754 the Vienna clinic had had a dissection room; so had the clinic that Tissot had organized at to demonstrate on the body deprived of life the alterati One has only In the history of medicine, this illusion has a precise meaning; it functions as a church militant and suffering, whose hidden spirit made the clinical possible be authorized, diurnal practice of auto psy, was imagined out of nothing. But chronology is not so pliable: Morgagni publishe in the great line derived from Valsalva; Lieutaud wrote a summary of the book in the medical field, and this was unchallenged by But for Bichat, the re-reading of Morgagni did not involve a break with the The major discovery of the Traite des membranes, later systematized in the Anatomic generate, is a principle of deci phering corporal spa intra-organic, inter-organic, and tran omical element has of spatialization and to command, by a relation of proximity, the ways of physiological or pathological communication; it is now no more than a secondary form of a primary space, which, by a process of winding ro und, super-position, and thickening, constitutes it. This fundamental space is entirely defined by the thinness of fe, arteries, veins, the tissue of the exhaling vessels, that of the absorbents, bones, medullary tissue, muscles, mucous membrane, se glands, the derma, the epidermis, was not dis-hi nguished, or of the lung without isolating the pleura; the peri toneum and the gastric organs were ganic masses into tissular surfaces can and must be made if one is to unders of function and alteration: the hollow organs are provi a fluid that usually moistens their free surface and that is supplied by small pleura, the peritoneum, and the arachnoid are serous membranes is separated by exhalation from the volume of blood ter, and the aponeuroses are made up of membranes and that 'are composed lar to the tendons On the basis of tissues alone, nature but they traverse them, relate them different ways some few general principles external conformation of Two very different structural perception s were involved: Morgagni wished to gans whose varied entity in which secondary modification would find thei r fundamental kinships. In his Traite des membranes, ading of the body carried out according to expanses the organs, envelop them, divide them, , and, at the same time, bind them s soon acquired is due, paradoxically, Morgagni, and places it in the line of' is to which it brings, ho wever, additional meaning. a surface gaze. The tissual area is no space to which one can relate the phenomena of the disease. Thanks to Bichat, superficiality now becomes embodied in th e real surfaces of membranes. Tissual of the surface gaze that defined the onlooker, had become a figu re of the one observed. was ordinal before it was localizing. Yet it gave to analysis a new, decisi ve value, showing, unl ike the clinicians, ect to which it must be applied only insofar as it is already, of itself, the acti ve subject that exercises it pitilessly upon to be analysed, it is beca use it is itself analysis; t hat is engaged in a series of real phen omena, and acting in such a way as to ical simplicities; it frees elements that the discovery of pathological anatomy: it was not that they rediscovered Morgagni beyond Pinel or Cabanis; they re discovered analysis in the body itself; they revealed, in depth, the order of th ; they de-fined for ple of generalization of perception of real analyses. And, quite the beginning of Astonishment has often been expressed that Bichat should have cited a text by e of his discovery Pinel, who until the end of his life deaf to the essential lessons of pathologic al anatomy. In the first edition of the Nosographie, Bichat read like a revelation to him: eura, and the peritoneum reside in different regions of the body, since thes e membranes have general conformities the state of phlegmasia?' inciple of analogy applied to tissual pathology; but Bichat s debt to Pinel is still greater, since he found in ts, formulated though not satisfied, that this prin- general ordering of the nosological picture. In the classification of diseases Bichat general form only to inflammations and scirrhi; other alterations are regional, and must he studied organ by organ. ; Laennec believed that geography of the organs, to which one disorders of form and position (disloca- tions, hernias) and nutritional disorders (atrophies, hyper-trophies); perhaps one day one might regard as belonging to the same pathological family the hypertrophies of the heart and those of the brain. On the other hand, Laennec analyses, without regional boundaries, fore texture, which have the same typology in all the tissual groupings: they are continuity (sores, frac tures), accumulations or extravasations of natural liquids (fatty pneumonia or gastritis, or accidental de the case of scirrhi and tubercle. re modeled on chemistry: designate the general forms of alteration (gastroses, designate irritations of the tissues, those omical perception to the reading of definition, entirely anterior to it? From Sauvages to Double, the very idea of an atomical basis for pathology had had its disease. How in a complex lesional grouping can one distinguish the essential order the body of a pleurisy patient one of the ph delineating the original and the very good indicator of the intensity of the morbid would not suppose that a minuscule tumour on the brain could lead to death. By never relating anything other than stract form of its spatial coexistence, anatomy cannot say that which is connexio n, pro-cess, and legible text in the order of time. A clinic of symptoms seeks the living body of the disease; anatomy provides it only with the corpse. A doubly misleading corpse, too, since to the phenomena interrupted by death are added those caused by it and deposited on the organs in accordance with its or putrid fever; on the other hand, tions dis-appears very quickly after the this interruption of natu ral movements (heartbeats, brain and the rapid softening that follows th of circulation interrupted by death? Last ly, we should perhaps take into account , which triggers off the cessation of life without belonging to the disease on which it nevertheless depends. of chronic disease diminution of sensibility and conductibilit y) have more to do with a certain Two series of questions confront a path ological anatomy that wishes to be objections, there did not seem to be any need to modify the structure of the clinical gaze itself : was it not enough simply to observe the dead as one observes the living and to apply to corpses the diacritical principle of medical observat ion: the only pathological fact is a In their application of this ccessors found themselves each of them present in its lesion ' . ' ` ' But the peculiarity of anatomo-clinical ch more complex and problematic dimension: that in which the recognizable forms of pathologic Pathological anatomy is a science whos dge of the visible alterations produced on the organs corpses is the means of acquiring this knowledge; but in order for it to become of direct use . . . it must be joined to observation of the symptoms or alterations of functi ons that coincide wi alteration in the organs.'' ong a path that had not so fin- been opened to it: vertically from the sympto tissual surface; in depth, plunging from the manifest to th e hidden; and in both directions, as it must continuously travel if third dimension. In this way, anatomo- ill be defined. The gaze plunges into the sp In its primary form, the c linical reading implied an the basis of and beyond that which it spelt out, ordered an d defined kinships. In anatomo-clinic fore it, horizontally be thought that this cons This amounts to no more ble data, abandonment of theories and genuinely scientific empiri cism. And behind all this, But this is surely a project on histor y, an old theory of' know-ledge whose ng been known. A more pr justment beyond these adjustments: it knowledge (savoir), on the po occupy in order to map them, on the instrumental mediations th at enables it to grasp them, on the modalities of registration and memory that qualify it as a subject of legitimate knowledge. What is modified in giving place to anatomo-clinical level of epistemic knowledge (savoir) itse lf, and not at the level of accumulated, knowledge (connaissances). physical effort, quick, diffic ult breathing, waking up with a feeling of pressure and constriction in the precordial region and of heaviness ing signs of heart diseases in which only anatomy can distinguish pericarditis (which affects the investing membrane), or contractions and hardening (in which The coincidence, or at least the regular succession, of catarrh and ph aphers, since autopsy shows her an alteration of the parenchyma, possibly to the po But, inversely, two diseases like tuberculosis symptomatology like that of Sauvages failed to find a sufficient link of fr In other words, medical ex perience will substitute the localization of the fixed point for the reco pulmonary phthisis include coughing, di fficulty in breathing, marasmus, hectic Attached to that fixed poin in the form of secondary phenomena, according to the ramification of the is peculiar to it. Studying the strange and th dark-red stains and is swollen on the inside, and the glands of the corresp dark-red and bluish in colour, and deeply inflamed and congested. If the dis-ease has lasted a long time, there is ulceration and destruct ion of t he intestinal tissue. It can be The analysis of the anatomo-clinical references (those of localization, site, and origin) that modify the essentially temporal reading of the clinic. The organic iom in medicine it is certain ly the proposition that there have to admit that there existed functi ons without organs, which is a palpable uth ful-filled, and by the same br d became a thing of te into the corpse, then no evidence Pathological anatomy, the technique of the corpse, had to gi ve this notion. a al status. This conceptual mastery of death was first acquired, at a very elementary level, by the organization of clinics. rediscovers nosographical time, as the scalpel does organic space. Death is now thin line that joins, in dividing them, On the other hand, Bic hat, taking up various suggestions made by Hunter, tried to distinguish between two types of phenomena that Morgagni's anatomy had confused: manifestations contemporary death. In fact, an alteration need not refer to the disease . process, partly autonomous, partly death. Thus muscular flaccidity belongs to the semiology of certain paralyses that which would not have taken place withou t the disease, is not, however, the its duration with an evol ution that indicates not a figure of the pathological, but the proxim ity of death; it designates, beneath the ciated, but different process of 'mortification gn referred to a possible outcome, by anticipation in time; and it indicated either d in time: it is not that absolute, me stops and moves hack; like ganic life ceases, at least in its major forms, since long after the death of th e individual, minuscule, partial deaths activity, the weakening of locomotion, ri gidity of the muscles and diminution of their contractility, quasi-paralysis of the To this chronological picture of successive death must be added the ee main relays: heart, lungs, and brain. It may he The processes of death, which can be id entified neither with those of life nor with those of disease, are nevertheless of a nature to illuminate organic bances. The slow, natural ent of' lile in the child, in the embryo, natural death annihilates er, and even to that of the h the mediation of muscular paralysis, interruption in breathing, or circulatory dis-orders.' Thus fixed in its own d the variable manifestations of death are known an d mastered, one may reconstitute, by means of this opening onto time, the e volution of a whole morbid series. For phthisis, these are, first of all, firm, ho mogeneous, whitish tubercles; then softer leus of purulent matter that changes colour; finally, a state of suppuration destruction of the pulmonary parenchyma. thod, Laennec was able to logical type but a possible phase of evol ution. The time of death may slide along rbid evolution; and as th by virtue of its effect of temporal interruption, the instrume nt by which the duration integrated with the immobile al trinity. The a triangular figure the summit of which is defined by death. It is from the height pathological sequences. Instead of being wh which life disappeared, in ecomes blurred, it is now ation that dominates and reveals both and the time of the diseas e. The privilege of its intemporality, which is no doubt as old as the consciousness of its imminence, is to a technical instrument that provides a grasp on the truth of life and the nature of its illness. Death is the great analyst that shows them, and bursts open th n: and the word decomposition must he allowed to . Analysis, the philo sophy of elements t he said about Bichat vitalism . It is true that in trying to circumscribe th linked to its specificity the risk of diseas e: a simply physical body cannot deviate from its natural type. ct that the analysis of the e point of view of death---of the death which life, by definition, resists. Bichat relativized the concept of death, bringing it down from that absolute in which it appeared as an indivisible, decisive, irrecoverable event: he volatilized it, distri buted it throughout life in the form of separate, partial, progressive deaths, deat hs that are so slow in occurring that from this fact he b Tined an essential and perception: that to wh ich life is opposed and to which it is exposed; that in relation to wh ich it is living opposition, and there-fore life; that in relation to which it is analytically exposed, and n before him, went to the crux of the problem, but as biologists, wh ches physiologiques opens: idea, since to die signifies in every language to cease to live, and so the supposed definition is redu ced to the following vicious circle: Life is the totality of functions that as an anatomo-pathologist that d since that relatively recent moment when Cabanis assigned to the knowledge of life the same origin and foundati of our knowledge shall be the s in order to know; and since ly proportional to their action upon us, it follows that our means of instruction are always proportionate to our needs. that was already familiar in the Re ving, since it, too, is no more the living, or of its (mechanical) models and (Immoral, chemical) constituents; vitalism and anti- vitalism both sprang from this fundamental anteriority of life in the knowledge of life finds it origin s extreme opposite; it is at death that disease and life speak their truth: a otected from all assimilations to t Ile inorganic by the circle of death that designates them for nis, who thrust life back so far into the depths of' origin s, was naturally more mechanistic than century, the knowledge of life was caught up in the circle g itself; from Bichat onwards it is in relation to life, and separated which it observes itself. It was no doubt a very difficult and pa s fear turned the could only be a matter of restoring it. Behind the doctor the great dark threat in which his knowle dge and skill were abolished; it was the risk not only of life and disease but of knowledge that questioned them. With Bichat, the medical gaze pivots on itself and demands of death an account of life and disease, of' its definitive immobility of their time and movements. Was it not ld circumvent its oldest ca that which must found its truth? But Bichat did more than free medicine of' the fear of death. He integrated that death into a technical and conceptual totality n which it assumed its specific characteristics and its fundamental value great break in the history of Western me dicine dates precisely from the moment anatomo-clinical gaze. Pinel analysis seem to triumph in ment of symptomatic totalities. But a year before, Bichat had relegated them to history: t, you have taken notes at patients' is confusion for you in the symptoms which, refusing to yield up their meaning, offer you a succession of inco not dissipate. The living night is dissipated in the brightness of death. NOTES 1 P. Rayer, Sommaire dune histoire abregee de I'anatomie pathologique oduction, p. v). , de pronostic, d'indications Nosologie naturelle (Paris, 1817, Cf. the account of the autopsy of the giant in D. Ottley, . 1 o8. 6 Cf. Gilibert, L'Anarchie medicinale by Magendie), p. 6. Ibid., Ibid., Ibid., Anatomie pathologique Anatomie generate (Paris, 18o1, vol. I, avant-propos, p. xcvii). Anatomie pathologique, Anatomie pathologique, 17 Quoted in Lallemand, pathologiques sur Anatomie generate 1 3 2 33 34 35 3 6 37 8 39 4 1 4 2 43 44 45 4 6 47 4 8 49 Nosographie philosophique, R. Laennec, pathologique', II, p.49. op. cit., pathological anatomy in Marandel, Andral. Se me iologie ge ne rale, vol. I, pp. 56—7. Ibid., 26 J. Hunter, iences medicales, Ibid., Laennec, op. cit. thisie pulmonaire (Paris, 1810). X. Bichat, Anatomic pathologique pp. 8—9. Anatomic generale, vol. I, p. Recherches physiologiques Anatomic pathologique, p. 7. Ibid., Ibid., Ibid., Ibid., La connaissance de la vie De la division la plus naturelle des phesnomenrs physiologiques ie, n. 1, p. 2 of his edition 50 Cabanis, Du degre de certitude de la medecine Anatomie generale, avant-propos, p. xcix. 9. THE VISIBLE INVISIBLE From the point of view of death, disease has a land, a mappable territory, a s kinships and its consequences are enables us to perceive it living—living with roles and its own laws. I. PRINCIPLE OF TISSUAL COMMUNICATION d morbus mucosus as an inflammation that may affect both the internal and the external surface of the alimentary canal Bichat generalized this ob identity. Each type of membrane has its own pathological modalities: Since from others in relation to these properties, it is evident that it must also differ in its diseases The arachnoid II. PRINCIPLE OF TISSUAL IMPERMEABILITY inciple. Extending in areas, the morbid estion, this principle limi mology by the rules of re gional influences, and the rule of impermeability by admit-ting form may last sufficiently long to impregnate su bjacent or neighbouring tissues: this is d, in the end, are 'confused in a common mass not by impregnation or by contact but by a double movement from one tissue to function. The alteration of one me mbrane may, without affecting the neighbouring membrane, prevent more or OF THE MODE OF ATTACK ON THE ck but on their own nature. Bichat did not go very far in the description of thes tissual localization, Dupuytren noted that alteration: for example, polyps on th It was by applying this principle that Bayle was able to follow the evolution of' phth isis from beginning to end, recognize the unity of its stinguish it from affections whose syinptoniatology may be sim ilar but which belong to an absolutely different type of alteration. Phthisis is characteri zed by a 'progressive disorganization of the lung, which may assume a tuberculous, melanotic, or cancerous form; and it must he con-fused neither with irritation of itself, but in the form of inflammation, namely, chronic V. PRINCIPLE OF ALTERATION OF ALTERATION cludes the diagonal affections that intersect various modes of' attack and use them in turn. However, there are effects of facilitation that link differen Chronicity, or at least the persis tence of an attack over a period e pathological cursus and describe in it must follow. They fi sprouting, its own ways of taki ng root, and its organism in accordance with their own : disease is hooked onto life itself, feeding on it, and sharing in that ything is connected with everything Is this, at last, a non-chaotic, ordere d development of disease? But it had already been a long-acquired fact; bo clinical forms had brought order to the world of illness long before the advent of the new anatomy. It was not the fact of ordering that lace in a general structure of rationalit and t i n order of things. From Bichat onwards, the path ological ph(' nomenon was perceived against the background of life, thus find ing itself linke It did so, no doubt, in a very consid ort. Paradoxically, clinical `nominalism left floating at the limit of the medical ilosophy? It is true Bordeu or Barthez was familiar to Bichat. Bu t if vitalism is a schema of specific of the living only in order to place life at a deeper, more concealed ontological series of natural figures but assumed so le responsibility for the role of the absolute, con-sidered basis that the eigh teenth century accorded to nature, the very idea of vitalism lost its signification life, and pathological life, so fundamenta the vitalist and other related problems. Hence the feeling, which bore up the At this epistemological level, life is to be distinguished from the inorganic only its consequences. It is profoundly bound up with death, as to that which positively threatens to destroy its living force. In was both nature and counter-nature, since it sease/death rela tion, another, fe and death, and so frees, besides, the Earlier, death appeared as the cond ition of the gaze that gathered rbid fact, is ~~~ based of the order of life, but ol a life that moves towards death. med with the appearance pathological anatomy degeneration'. It was already an old notion: Buffon applied it to individuals or series of individuals that diverged natural robust humanity that life in soci the singular points of pathological ph time it is the principle governing the readin was open to controversy. In a report on organic diseases, Martin degeneration , wished to reserve it for that tivity of the no parallel in the state of health; such tissues, which usually present According to Laennec, one may speak of degeneration in two precise cases: when one ti ssue changes into another that exists in a different form and localization in the organism (o sseous degeneration of the cartilages, fatty degeneration of the liver); an configuration that has no pre-existing model (tuberculous degeneration of the lymphatic glands or of the pulmonary pa renchyma; scirrhous degeneration of the ovaries or testicles). eak of degeneration in the case of a pathological superposition of tissues. An apparent thickening of the dura mater is not always an ossification; d by three indices. It is not simply a as in the construction of beings Organic legality is not, there-fore, simply a precarious, delicate process; it is a reversible the phenomena of life follow laws, even in their alterations ." A direction indicated by figures whose level of organization becomes weak becomes blurred (irregular ossifications); then intra- organic difli•ren tiations occur (cirrhosis, hepatization of the lung); finally, the s: when it is inflamed, the cellular allows itself to he cut like lard liver may be pulled away with no effort. This disorganization may even se of tuberculous parenchyma but of the tubercles themselv of life, the necessity of death that is life, and the most general possibility of disease. link with the anatomo- a triangle whose summit culminated in asp life and disease iii a sing le unity only insofar as it invested death in its own gaze. An duration and disease as a possibility of deviation find their origin in the possible its real form by anticipation. sought a mode of articulation that In the depths of its being, disease foll ows the obscure, but necessary ways of chronological totality of the illness. Ever y symptom was a potential sign, and the sign was simply a read sy mptom. Now, in an and the significant nucleus with which one believed it to be armed prove to be non-existent. What visible symptom can indicate pulmonary phthisis with certainty in breathing, which may be found in a case of chronic catarrh, and not be found in a tubercular patient; nor coughing, which also belong s to neuropneumonia but not always to phthisis; nor hectic fever, which is freq uent in pleurisy, but which often appears only in the latter stage of phthisis. from a fairly similar phenomenon to be risy patients: the est, but it was more than naturally in and quavering. as the only certain pathognomo nic sign of pulmonary phthisis, s perception, the sign was all the more eloquent, all the more certain, the more sur-face it disease: thus fever was the major symptom, and consequently the most certain sign, and the one closest to th e essential, by which the series of gn is no longer related to symptomatic extension; its marginal, restricted, almost impercep diagonally as it were, the visible body of the disease (composed of' general s nature at a stroke. By that very l structure that it possessed in pure clinical perception: in order for it to produce certainty, a sign had to belong to a convergent series, and it was th e random configuration of the whole ptysis make phthisis more and more probable, but, quite certain; pectoriloquy alone designates it without any possibility of error. sign referred to the disease itself, the anatomo-clinical sign to the lesion; and although cer tain tissue alterations are common to several diseases, the sign that reveals them can say nothing about the nature serve hepatization of the lung, but the sign that indicates it will not say what diseas e is responsible for that condition. The sign, then, can refer only to a lesional occurrence, never to a pathological essence. cturally different in the world of the clinical as it existed in its first form, lating in permanent nm tractions; intermittent, irregular at intervals in perceptible in hardenings, ossifications, softenings; rapid, frequent, disordered, and almost convulsive in cases of the rupture of one or several bunches of fleshy It is no longer a question of a scie Being, conforming to the laws of natura the formulation of a certain number of per the natural language of and value only within the questions pose d by medical investigation. There is licited and almost fabricated by medical investigation. It is no longer that whic ignore a technique that made a sign appear artificially where there had been no symptom, and solicited a resp did not speak: a clinic anatomy compels the clinic in its organic density, and to bring to given only in deep capable of surprising a lesion becomes once again a scientifically based idea tural, is to project upon the living body For thousands of years, after a ll, doctors had tested patients began to touch, tap, listen. Was this e raising of moral prohibitions by the Enlightenment? If such was the case, it would be difficult to rvisart should have reintroduced Laennec should have put his ear, for d; scientific necessity revealed the prohibition for what it was: ulted by a young person wh whom the application of the hand and percussion yielded poor results on account of her plump ness examination of which I have just spoken (the application of the ear to the precordial region), I happened to ar very distinctly a pin dropped on to the other end. Thus armed, the medical gaze embraces more than is said by the word 'gaze alone. It contains within a single st sight/touch/hearing trinity defines a pe rceptual configuration in which the rkers, gauged in depth, drawn to the th a view to a spatial assignation st important function; what can sight cover other than the tissue of the skin and th e beginning of the membranes Through touch we can locate visceral tu mours, scirrhous masses, swellings of the ovary, and dilations of the heart; while with the crepitation of fragments of bone, the rumbling of aneurism, the more or less and the abdomen when sounded gaze that touches, hears, and, moreover, not by e the essential. The tactile and auditory dimensions were not simply added to the domain of vision. The sensorial triangulation indispensabl e to anatomoclinical perception remains under the dominant sign of th sensorial perception is merely a way of anticipating the triumph of the gaze that is represented by the autopsy; and ear and hand are merely temporary, substi-tute organs until su ch time as death brings to truth the luminous presence of the visible; it is a question of a mapping in life, that is, in night, in or der to indicate how things would be in the white brightness of death. And above all, the alterations discovered by anatomy concern 'the shape, the si ze, the position, and the direction of organs or of their tissues: that is, spatial data that belong by right of of alterations of structure, it is perceptible to a delicate touch, but of solutions of continuity, accumulations of liquids, abnormal in In any case, the absolute limit and the depth of perceptual expl oration are always outlined by the clear plane of an at least potential vi sibility. 'They are painting a picture rather than learning things. They must see rather than meditate When Corvisart hears a heart that functions Thus, from the discovery of patholog ical anatomy, the medical gaze is ribed gaze, the borderline gaze of touch and hearing, which covers only which operates on little more than th an absolute, absolutely integrating gaze that dominates and founds all unity that which belongs to a lower level of the eye, another eye is directed upon the fundamen tal visibility of things, and, through the rticular senses are forced to work, he to the bright so that commands clinical anatomy, and all medicine that derives from it, is that of invisible visibility. Truth, which, by right of nature, is made for surreptitiously revealed by that which tr ies to evade it. Knowledge develops in form and rhythm of the hidden content, which means that, like a veil, it is ttained when the opaque envelopes more for their practised ey th death by means of the great myth Now, rigorous form of the gaze. However, this projection of illness onto the plane of absolute visibility gives nd which it can no longer go. That which is not on the scale of the gaze falls outside the domain of possible n of a number of scientif e rejection of chemistry. Analysis, as practised by logical model for the new anatomy, but it did not function as a technical extension of his gaze. In eighteen ed to know what inflammatory fever consisted of, one ca rried out blood anal was compared with that of separates from it ; distillations were made, and me asurements were taken of the earth to be found in a patient and in a mmatory fever would or would not reveal visible alterations. is usually enough to descri be its physical or perceptible characteristics, and to s development and in its terminations ; at most, only if they are very simple and intended to 'reveal certain physical characteristics ; thus one may heat a liver, or field of possible know-ledge; the composition at the level of invisible structures is rejected. Analysis is not carried out in the sense of an inde finite descent towards the fi ately to those of the inorganic; in that comes up against the absolute limit laid down for it by the gaze, and from there, taking the perpendicular, it slides sideways towa qualities. On the line on which the visi ble is ready to be resolved into the arance, singularities come into play. A discourse on the individual is once more possible, or, rather, necessary, because it is the only way in which the gaze can avoid renouncing itself, effacing itself in would be disarmed. The principle of visibility has its correlative in th fferent from clinical experience in its individualities. In the anatomic method, in dividual perception is given at the term of a spatial quadrilateral of which it constitutes the finest, most differentiated ory. LaFnnec observes a woman who affection: pale, puffy face, purple lips, inability to lie down. The op ening up of the corpse with concretionary cavities, and tuberc les yellowish at the centre, grey and e heart was in an almost natural state e, which was very distended). But the left lung p of the lung presented fairly broad, This particular kind of tube impeded, rather suffocated, breathing and rdiac appearance. For the first time, the cal language. It is no longer a question, by means of a bi-univocal placing in correspondence, of promoting the visible to the legible, and of turning it into the significative by means of the universality of t, on the contrary, of opening words to a certain qualitat its volume, was, as it were, es; its external surface, slightly mammillated and emptied, was a yellowish oval in shape, varying in size from The figure of the visible invisible organizes anatomopathological ance with a reversible structure. It is a question of the visible that the living individuality, the intersection of symptoms, the organic depth, in fact , and for a time, render invisible, much a question of this invisible of the individual modulations, whose extrication seemed impossible even and eroding language offers at last to common light what is visible for all. Language and death have operated and in accordance with its whole density, only to offer at last to sc ientific perception what, for it, had sible—the forbidden, most acute form in which life is presented. It was given at last to knowledge only at the end of a long movement of spatialization whose d use of language and a di of death. Bergson is stri ctly in error when he s eeks in time and i against the internal, in a mad ridt ality, the conditions with which it is possible to conceive of the living individuality. Bi The old Aristotelian law, discourse to the individual, was lifte d when, in language, death found the form of the individual. According to the order of historical correspondences, this introduction of death into knowledge goes very far: th aissance. To see death in h in life does not have the same function in the carried with it reductive significations: differences of fate, for tune, conditions were effaced by its universal gesture; it drew each irrevocably to all; the dances st; a black border isolates it and gives it the style of 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 mor-bid 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 it s absolute rarity. The privilege of the Death left its old tragic heaven and core of man: his Tractatus de morbo mucoso Anatomie gent=rale, avant-propos, vol. I, p. Ixxxv. X. Bichat, Traitd ie, pp. 122-3. Ibid., p. 1o1. Anatomie generate, vol. I, avant-propos, p. xci. xcii. gros vaisseaux. phtisie pulmonaire, 9 Cf. above, 10 Article 'Anatomie pathologique', in Ibid., 13 F. Lallemand, Anatomie generale, vol. IV, p. 591. Ibid., I, avant-propos, p. vii. 16 F.-J. Broussais, 17 Cf., for example, Pinel, Nosographie philosophique, introduction, p. xi, or C.-L. Montpellier 18 Buffon, 'Histoire naturelle', 19 Corvisart, op. Ibid., Anatomie pathologique 23 R. Laennec, articl Dictionnaire des Sciences medicates, 1814, vol. VIII, pp. 201—7. 24 R. Laennec, Introduction and first chapter pathologique, Dissertation inaugurale sur quelques points d'anatomie, 26 Lallemand, op. cit., discours, preliminaire, p. xvii. op. cit., pp. 5-14. 31 Laennec, Traite de ('auscultation mediate (Paris, 1819, vol. I). Elements de pathologie generate I, pp. 30—1). op. cit., Auenbrugger, G. Zimmermann, Double, Semeiologie generale. Laennec, op. cit., vol. I, pp. Elements de pathologie generale 30-1). Ch. X. Bichat, essay on Desault, Oeuvres chirurgicales de Desault, and 11. Laennec, pathologique', p. I, p. 11. e beginning of the far from it; in its general outline, it dominated the forms of knowledge and eroticism in Europe from the mid-ei onwards, and it Bichat, op. Cf., still at the end of th like that of Hufeland, Makrobiotik oder der Kunst dos Leben zu verlOngern Cf. above, Chapter and Tabor, cited by Sauvages, R. Laennec, Introduction and first chapter, Traite inedit d'anatomie pathologique De ('auscultation mediate, vol. I, pp. Ibid., Ibid., Cf. above. 10. CRISIS I N FEVERS nal process by which anatomo-clinical its equilibrium. If we a an understanding when one was in agreement as to th arguments that had little or nothing to do with pathology indicate an essential confrontation, the last (and the most vi disease and its relation to lesional perforated lung, is what one sees pleurisy , cirrhosis, or phthisis themselves, in all their pathological depth? Is the lesion the original, tri-dimensional form of the or must it be situated beyond, in the region of proximate causes, or immediat ely prior to it, as the first visible hidden? It is clear enough—after the gic of anatomo-clinical perception: for those who practised this perception for th e first time in the history of medicine, disease, it would seem that the disease it the intimacy of an There is another series of questions: correlative? Is the possibility of assignin g a seat to them a general principle of And if the latter, is it possible to begin the study of diseases with a nosographical anic disorders/non-organic di the domain of pathological anatomy? Bichat had made room for non-lesional diseases hut lie did little more th anied by a lesion present in one or dy an alteration that is constant and to which an origin may be attribut ed: these are what are commonly called nervous diseases. superimposed upon another, as in phthisis. Cruveilhier was soon to take up in a ra ally organic and secondarily vital lesions (haemorrhages) ; originally vital affect ions combined with organic lesions, However much it was said that a vital disease could be proved to be so only negatively, and by a failure to s entire work owes its strength to ea Laennec, on the other hand, found no difficulty in envelo the that which must characterize or specify them ; by providing it the last resort, to serve the cause of nosology. was discussed, but his medicine wa s given no radical revaluation. oussais published his Examen de la Doctrine generalement admise, in which he expressed in a more radical form the phlegmasies chroniques. In an unexpected way, this explicitly physiological diseases. For over fifteen years, fevers, on the other hand, were at the very finalized reaction of the organism defending itself against a pathogenic atta ck or substance; the fever that appears current; it is a sign not of the disease, value: it shows that the organism Against this background of finality, it was easy enough to analyse the movement of the fever and its mechan ism. The succession of the symptoms indicates its different phases: the shiver ion of the blood in the capillaries close dicates that the heart is reacting by making as much blood as possible flow out towards the limbs: the heat shows d that all the functions are impression of langour and the atony of th sweating indicates for example, or, in a general form, he at and movement through-out the whole the most tenuous parts of the blood separate from the heavier, which remain in the capillaries, where the lymph will : hence the suppurations respiratory or intestinal system in cases of generalized inflammation, or abscesses in cases of local fever. But if there is a functional identity Finally, the phenomenon of heat is fa febrile movement; it is no more than it the impurities that it absorbs that occur indicate what the essent ial ainst physical instriituu•nt.. that these differences are the least important in practice; ... the doctor must apply himself, above all, to distinguis hing in feverish heat qualities that practised touch, and which elude ere is, for example, that acrid, irritating quality of feverish heat , and that points to a putrid fever. Below the homogeneous phenom enon of heat, fever has, substantial, differentiated solidity that makes it possible to divide it up accord accordingly, to pass naturally and unproblematically from The shift in meaning and epistemological le homogeneous, coherent conception of to adopt a considerable number of twelve, to which he added new and unknown by the circulatory mechanism that ver analysed by J.-P. Franck, and traditionally designated as synochus), or inflammation occurred (Baglivi according to the quality fevers he had found The re-ordering brought about by Pine] was not only in line with his own the suspension of But the diversity of the symptoms also makes possible the read ing of different species: an inflammatory or angiotonic fi Sri i irritation or tensio n of tIn blood vessels (it is frequent at puberty, at the onset of I r 'g nancy, and after alcoholic excesses); a meningo-gastric (Orin with nervous symptoms, but also with ot her, more primitive ones that appear to correspond with the epigastric region and that, in any case, follow stomach disorders; an adeno-meningic form, whose symptoms indicate an an adynamic form `that is manifested extreme debility and a general atonia of the muscles . It is probably due to humidity, uncleanliness, visits to hospit als, prisons, and amphitheatres, to had food, and to the abuse of the venereal pleasures. Lastly, ataxic or malign the strangest nervous anomalies fication that the paradox resides. In its general form, fever is characterized only by its effects; it from any organic substratum; and Pinel does not even mention heat as an question of dividing up this essence, th e function of division is operated by a principle that belongs not to the logica organic spatiality of' the body: the bloo mucous membrane, the muscular or ner the formless diversity of the symptoms. And if they can be organized in such a way as to form species, it is not principle of the essentiality of the fevers In these conditions, it is unders tandable that Pinel should have symptomatological analysis of fevers the shown that mucous fever rnal and external inflammation in the s autopsies, which showed obvious in testinal lesions; but it is also understandable why he coul for him, the lesional localization occurred of itself, but as a secondary phenomenon, within a symptomatology in which. the local sign the seat of the He did not limit himself to classifying objects: materializing in some sense a assigning to each one a particular se at, making the bilious and pituitous fevers, for example, consist of others in the special i rritation of certain parts e diseases, but the signs: and the local vested did not indicate a regional origin, an original locus from which the disease derived both birth and form; it simply made it possible to recognize a disease that gave itself this signal as a characteristic being the case, the causal and tern poral chain to disease to the lesion, as to its con se quence and perhaps privileged expression. was still being faithful to the Nosograp hie when he analysed the intestinal : do they not occur relatively late (on the tenth day of the No doubt this incompatibility, which be longed logically within the anatonio- diseases that were to he so crucial to group, indicating that 'fevers of this orde r are rarely essential diseases; they may n of the brain such as phlegmasia, or a Ior all the fevers was, without the slightes t doubt, the diversity and, at the same Having been trained just before th problems proper to hospital medicine and which introduced him to pathological anatomy, Broussais resu med his military career and followed the army from Utrecht to Mainz, and from Bo hemia to Dalmatia, practising like his ain the experience of others, but who . Our Schools of Medicine, which have succeeded in freeing them-selves from ion of the new, have, for some years ence to the still-tottering step of the curing art. Living among th eir fellow-citizens or scattered afar in our armies, they observe and meditate. . . . One day, perhaps, they will make Against the background of ssing specification, which is very in the lung only those phlegmasias that correspond rrh and pleuropneumonia), those deriving an inflammation of the lymphatic vessels (tubercular phthisis). e digestive system, (gastritis) or in the intestine (enteritis, manner, according to the logi when an inflammation of the blood persists, it always reache s the lymphatic vessels; that is why all culminate in pulmonary phthisis while intestinal inflammations usually te nd to ulcerations of the peritoneum. Homogeneous in origin, and converge phlegmasias proliferate in multiple symp s method had soreness, heat, pain—which does not corresp ond to the fortes that it assumes in the tissues; the inflammation of a membrane in nor heat, still t a constellation of signs: it is a process that develops within a tissue: any local agitation of the organic e harmony of the functions, and to disorganize the tissue in which it is fi xed, must be regarded as inflammation g two pathological layers at different levels and with different chronologies: firs attack on the texture. Inflammation ysiological medicine, observing life, not the life of the organs, and in the organs, in pathological anatomy, conceived as a mere examination of lifeless bodies, is its own limit, while ever the role and sympathies of all the organs are far from being perfectly known'. This represents a new organization of the medical gaze iii relation to Bichat: ple of visibility had been an absolute inverted; it is because disease, in its nature , is local that it is visible. Broussais, above all in the Histoire des phlegmasies, admits (and in doing so he goes further than Bichat, for whom the vital diseases need not necessarily leave a trace) that every pathological affection implies to the phenomenon that restores our bodies to the laws of inorganic matter medicine, and pose the question of the origin of inflammation. Inflammation being a local excitation of' organic movements, it presupposes in the tissues a certain ent is irritability, a faculty that tissues possess of moving when brought into contact with a foreign body. . . . Haller attributed this now agreed that it is common to all the It must not be confused with sensitivity, which is an awareness of the movements caused by foreign bodies , and forms only an additional, secondary phenomenon in relation to irritability at had dominated medicine, with few defining the cause of diseases. From this point of view, osology from Sauvages to Pi nel had been like a figure confined within this abandonment to caus And so—and this was the great discove g of the disease an irritating agent, the pathological belong to a world in which the disease, in its particular structure, would exist in confor mity with a dominant type that preceded individual variations and non-essential fever has to he deprived of its status as a general in favour of physio-pathological processes that This dissolution of' the onto the idea of' a medical (anatomical and, 1.Decide which organ is sick, which can be done on the basis of the long as one knows all the organs, all the tissues that make up the means of communication by which these organs are linked , by means of an essential fact that irrita lion may cause hyperactivity or, on the contrary, func tional asthenia, and that 'these two 3. 'Indicate what is to be done for the illness to cease : that is, eliminate not pneumonia), but also the effects that do not always disappear when the cause has ceased to operate (congestion of the blood ontology , the notion of organic goes further and more deeply perhaps than that of irritation. Irritati on still involved an final screen of' abstraction. The notion of a 'sickness' of the organs involved only the idea of a relationship of the organ with an agent or an enviro nment, that of a reaction abnormal functioning, and, finally, that of the disturbing infl attacked upon the other organs�. Hencefi rth the medical gaze will be directed illed with the fbrnis of composition of the organs. The space of the disease is, without remainder or shift, the very space of the organism. end; there now begins a medicine of pathological reactions, a structure of So necessary was Broussais s attempt in the development and balancing of leave aside the endless discussions Everything was justified in the frenzied attacks that Broussais physiological medicine that they owed this ,uiatomo-clinical lity and ,ipable of se which hey were right and he definitive form of balance. Everything in Broussais ran counter to his time, but he see. Since 1816, the confront a sick organism. The historical and rely brought about a series of rehabilitations. But since there are still doctors, and others, who think they are raphies and hand out praise and blame, publication of the Examen de la doctrine medicale events that will be long remembered in the annals of' medicine.... The medical revolution of which M. Brou ssais laid the foundation in 1816 is undoubtedly the has undergone in modern times ments de pathologie generale Anatomie gr nerale, vol. I, p. natomie pathologique', 5 Bayle, 2nd article on 'Anatomie pathologique', Essai sur I'anatomie pathologique 7 Cf. above, Chapter 1, p. 14. 8 Cf. above, Chapter 7, p. 117. owed Corvisart and Pinel 'inflamm alterations of the internal membrane of which they were pointed out to them to pass through their hands without opening up th ) . Anatomie descriptive, vol. I, p.19. 11 Laennec, Traite de I'auscultation, 12 In a dissertation that was awarded a prize, Martin criticizes the over-simple use that is made of the term 'disease ', which he would like to confine to affections resulting from a nutriti own histrionics ... a vain, loud-mouthed charlatan ... his tric ks, his impudence, his verbose argumentativity, his high-sound ing errors . . . his illusionist's self- Aphorisme. 15 Stahl, quoted in historique de la fievre 17 Apart from a few variations, this schema is to be found in Boerhaave (Aphorismes, (Fundamenta Medico), (Aphorismes sur la connaissance 18 Huxham, Essai sur les fievres (Fr. 19 Stoll, 'Aphorisme sur la connaissa . 21 Bouillaud provides a very clear analysis of this in Nosographie philosophique, 5th edn., 1813, I, p. 320. Ibid., pp. 9—10 and pp. 3 De morbo mucoso Histoire de la chirurgie (Paris, 1825, p. 250). (Paris, 182o, pp. 10— 30 P.-A. Dan de La Vautrie, Dissertation sur I'apople F.-J.-V. Broussais, Histoire des phlegrnasies chroniques, 2 33 14 35 Ibid., vol. I, Ibid., Ibid., vol. I, p. 6. Sur ('influence que les travaux Examen des doctrines Ibid., de la medecine (Paris, 1832, . 14-15). Histoire des phlegmasies, Ibid., Examen de la Ibid., (Paris, 1824, Examen des doctrines, to Fodera ('Histoire de vol. Examen de la doctrine, 5. In the text on L'influence des medecins physiologistes, 1832, Broussa is adds, between the 2nd and 3rd s fievres essentielles Recherches anatomo-pathol ogiques sur I'encephale Traite clinique ou experimental des fievres dites essentielles 56 Andral, Clinique medicale (Paris, 1823-1827, 4 vols.). According to one 0 4 1 2 43 44 45 tion of fevers from the last edition of but was prevented from doing so by his publisher. Its historical support is limited sin it is the forms of visibility that have ess in an absolutely coherent way cannot be ascribed to an act of psychological and epistemological pu nothing more than a syntactical reorganiza tion of disease in which the limits of pattern; the abyss beneath illness, which doubt, that illuminates the 120 Journees th medicine and the way in which, in a few years, the particular knowledge of the individual pati possible as a form of knowledge, a reorganization of the hospital field, a new definition of the st atus of' the patient language of description should rest upon the stable, visible, legible basis of This structure, in which space, langua ge, and death are articulated—what is known, in fact, as the anatomo-clinic It will no doubt remain a decisive fact about our culture that its first scientific to pass through this stage of death. Western man could constitute him-self in his own eyes as an object of science, he grasped himself within his language, and gave himself, in himself and by eated by his own ason was born psycho-logy, the very possibility of' psychology; from the integr ation of death into medical thought is ience of the individual. And, generally modern culture is hound up with that of death: from Holderlin and the finitude whose mark it imposes link, paradoxically, the universality of language and the precarious, irreplacea ble form of the individual. The sense- perceptible, which cannot be exhausted by description, and which so many pate, finds at last in deat It is understandable, then, that medicine should have had su constitution of the scie nces of man—an import The possibility for the individual of bein g both subject and object of his own knowledge implies an inversio de. For classical thought, finitude had no other content than the ne gation of the infinite, while the thought positive: the anthropological structure that then appeared played both the critical role of limit and the founding role of origin. It was this reversal that served as the philosophical condition for the organization of a positive medicine; inversely, this positive medicine marked, at the empi rical level, the beginning of that fundamental relation that binds modern man to his original finitude. Hence the it is closer than any of th em to the anthropological st ructure that sustains them , full form of his finitude. At that point in time, medical gestures, words, gazes took on a philosophical density that had formerly belonged only to mathematical thought. The importance of Bichat, Jackson, and Freud in European cult ure does not prove that they were philosophers as well as doctors, but that , in this culture, medical thought is fully engaged in the philoso in even to a lyri his language sought, from Holderlin to the eighteenth century, and from which menacing, but also the fullest. Hfilderlin 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 infi positive knowledge of himself; but is it surprising that the figures of knowledge and those of language should obey the same profound law, and de 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, op a language that unfolds endlessly in th e void left by the absence of the gods'? anges in the fundamental stru is obvious that these changes go well be yond what might be made out from a cursory reading of positivism. But when on e carries out a vertical investigation of the emergence of a whole series of figures—hidden by it, but also indispensable to its birth - that will be released later, and, paradoxically, used against it. In partic ular, that with which phenomenology was original powers of the perceived and its co rrelation with language in the original nization of objectivity on the basis of sign values, t All works by the Marquis de Sade. I. NOSOLOGY Capuron, J., Ch ..., J.-J., (Paris, 1816). peuvent itre profitables a la connaissance des maladies? (Bordeaux, nomenclature de la Nosogra- phie philosophique du Latour, F.-D., Nosographie synoptique Linnaeus, C., (Fr. trans., Sauvages, Nosographie philosophique Sagar, J. B. M., Voulonne, Audin-Rouvidre, J.-M., Memoires sur les epid emies du Languedoc Bienville, J.-D.-T., (The Hague, Colombier, J., ___, Code de medecine militaire G., Ordre du service des h6pi taux militaires (Paris, 1785). ___, ___, Centuries medicales du XIX` ___, System einer vollstandigen medizinischen Polizei 1779-1790). Ganne, A., Guindant, T., La nature opprimee par Guyton-Morveau, L.-B., Traite des moyens de Hautesierck, F.-M., Recueil d'observations de medecine des hopitaux militaires Hilden brand, J.-V., Du typhus contagieux (Fr. trans., Paris, 1811). Home, D. R. de, particulierement la salubrite de la ville de Paris dans le hopitaux militaires De la Sante Lafon, J.-B., Lanthenas, F., De l'influence de la li Laugier, E.-M., Lebegue de Presle, Le conservateur de Sante Lebrun, Traite theorique sur le s maladies epidemiques Lepecq de La Cloture, L., Lioult, P.-J., Les charlatans devoiles (Paris, Year Vlll). Medecine militaire ou Traite des maladi les militaires sont exposes pend ant la paix ou la guerre (6 vols., Paris, ___, -topographique de Paris (Paris, 1786). Murat, J.-A., Topographie medicale de la ville de Montpellier Memoires sur les maladies epid emiques qui ont regne dans la province de Dauphine Memoire sur les maladies contagieuses Quatroux, Fr., Traite de la peste Razoux, J., Les lois de la nature applicab (2 vols., Paris, 1788). Rochard, C.-C.-T., Programme de cours sur les maladies epidemiques bourg, Year XIII). Boulogne (Boulogne, Year II). Tallavignes, J.-A., Dissertation sur la medecine ou I'on prouve que I'homme Baraillon, J.-F., Rapport surla partie de police qu i tient 6 la medecine, 8 germ. an Discours sur la necessite des sc iences dans une nation libre (Montpellier, Year III). LEuvres (2 vols., Paris, 1956). ___, Chambon de Montaux, Moyens de rendre les h6pitaux Colon de Divol, Demangeon, J.-B., ___, Des moyens de perfectionner la medecine Duchanoy, Du Laurens, J., Dupont de Nemours, P., nner aux pauvres malades dans une grande ville Ehrmann, J.-F., Essai sur la reformation de la __, __, Rapport sur les Ecoles de Medecine, frimaire an III (Paris, Year III). __, Gallot, J.-G., Vues generates surla restaura tion de Part de guerir Guillaume, J., Proces-verbaux du Comite d'Instruction publique Le droit hospitalierde la Lefevre, J., Marquais, J.-Th., de La Feutrie). nner 1'enseignement de la medecine en France __, Plan de travail presente d la Societe de Medecine de Paris Plan general d'enseignement dans 1'Eco Opinion sur la resolution du 79 fructidor an V, i6 vendemiaire (Paris, Precis historique de I'etablissement de Cote-d'Or, C.-A., Motion relative aux Ecoles de Sonte (Paris, Programme de la Societe royale Programme des cours d'enseigneme nt dans I'Ecole de Sante de Montpellier Prunelle, Cl.-V., Des Ecoles de Medecine, de le 1820). Rdgnault, J.-B., Considerations sur I'etat depuis la Revolution jusqu'a nos fours (Paris, 1819). Royer, P.-F., Bienfaisance medi Sabarot de L'Averniere, Vue de legislation medi Tissot, S.-A.-D., Vicq d'Azyr, Amard, L.-V.-F., (2 vols., Paris, 1821). la medecine des Arabes Audibert-Caille, J.-M., Memoire sur I'utilite de (Montpellier, 1814). Auenbrugger, Bouillaud, J., Dissertation sur les generalites de la clinique Brulley, C.-A., (Paris, Year X). Brute, Chomel, J.-B.-L., Essai historique surla medecine en France (Paris, 1762). Clos (Montpellier, Year V). Corvisart, J.-N., Dardonville, H., ers des systernes en medecine Double, F.-J., Semeiologie generale ou Traite des Traite du diagnostic medical pes de fart de guerir Essai d'un nouveau plan d'observations medicales Ratio institute clinici Vicinensis Les theories medico/es mode Essai sur ('esprit de la clin ique medicale de Montpellier (Montpellier, Goulin, J., re de la medecine (Paris, 1779). Dictionnaire de diagnostic ou fa (Paris, Hildenbrand, J., Medecine pratique 824, 2 vols.). Landre- Beauvais, A.-J., Semeiotique ou traite des signes des maladies Leroux, J.-J., ___, Lordat, J., ___, Histoire de la medecine clinique (Paris, Year XII). ns la medecine pratique (Strasbourg, Tableau indiquant la maniere d'exam Rostan, L., , de pronostic, d'indications (6 vols., Paris, 1826). Roucher-Deratte, CI., Le¢ons sur fart d'observer Selle, Ch.-G., Senebier, J., ecine (Fr. trans., Paris, 1774, 3 vols.). Baillie, M., Anatomie pathologique des organes les plus importants du corps humain phtisie pulmonaire X., Anatomie generale appliques A la ___, Anatomie pathologique Elements de pathologie generale Essai sur I'anatomie pathologique en general s en anatomie pathologique Guillaume, A., De ('influence de I'anatomie path ologique sur les progres de la Laennec, R., Traite de ('auscultation mediate (2 vols., Paris, 1819). Morgagni, J.-B., Cours d'anatomie medicale (5 vols., Paris, Year XI I). Sommaire dune histoire abregee de I'anatomie pathologique De I'anatomie pathologique consid (Paris, 1825). De l'influence de I'anatomie pathologique ues sur la medecine pratique VI. FEVERS Barbier, J.-B.-G., Bompart, A., Description de la fievre adynamique Bouillaud, J., Traite clinique ou experimental des fievres dites essentielles Catechisme de medecine physiologique Examen des doctrines medicales inflammations chroniques Le¢ons surla phlegmasie gastrique M6-noire sur ('influence que les trav aux des medecins physiologistes ont de reponse å un ouvrage de M. Broussais (Paris, 1818). Refutation de la nouvelle doctrine medicale de M. le Dr. Broussais Chambon de Montaux, Chauffard, H., Collineau, J.-C., Dagoumer, Th., Precis historique de la fievre Dardonville, H., Ducamp, Th., (Paris, 1821). Fodera, M., Histoire de quelques doctrines me Fournier, M., Giannini, fievre Grimaud, M. de, Cours Hoffmann, F., (Fr. trans., Berlin, (Fr. trans., Paris, 1746). Larroque, J.-B. de, doctrine (Paris, 1818). Leroux, F.-M., Opposition aux erreurs de la science medicale Lesage, L.-A., Monfalcon, J.-B., Essai pour servir d I'histoire (Lyons, Essai sur les irritations intermittentes (2 vols., Paris, 1821). Tableau synoptique du diagno stic des fievres essentielles Quitard-Piorry, H.-H., Traite sur la non-existen Refutation des objections faites d la nouvelle doctrine des fievres Tractatus de morbo mucoso Traite des fievres adynarniques Selle, Ch.-G., Tissot, S.-A.-D., Dissertation sur les fievres bilieuses Foucault, Michel (2003) The Birth of the Clinic. London: Routledge A large bibliography is also present, divided in three parts, at the end of Page numbers are at the top of the page ....................1 Notes on layout: ............................................................................................1 .........................................................................1 .................................................................................6 .....................................................................................................16 ..............................................................................17 .....................................................................................................33 .....................................................................................................49 ......................................................................................51 .....................................................................................................65 ...................................................................67 ..............................................................77 .....................................................................................................98 .................................................................................101 ...................................................................................................119 ...................................................................................................137 8. OPEN UP A FEW CORPSES ......................................................................139 ...................................................................................................186 ...............................................................................188 ...................................................................................................208 ............................................................................................211 BIBLIOGRAPHY ..........................................................................................215 .........................................................................................215

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