The Birth of the Clinic is a description of the changes in the language of medicine, particularly French medicine, between 1794 and 1820. It is therefore in the first place a work of history, concerned with a specific problem during a specific period. But it is also an experiment in a new way of writing the history of science, a testing ground for a radically redefined historical epistemology and methodology. Hence the double appeal of this book, which will be read not only by those who are interested in this seminal period of medical history but also by those who are dissatisfied with the traditional procedures of intellectual history and would like to see historians of ideas re-think their objectives and their methods.
The Birth of the Clinic, published in France in 1963, came after Foucault’s Histoire de la Folie (Madness and Civilization, 1961) and preceded his Les Mots et les Choses (The Order of Things, 1966). Together these works make up a trilogy in which the author is successively a historian of psychiatry and psychopathology, of medicine, of natural history, of economics, and of grammar. This ambitious enterprise has not only yielded positive results of great value, it has also led to an important theoretical advance. Foucault’s latest book, L’Archéologie du Savoir (The Archaeology of Knowledge), may be seen as the methodological postscript to his trilogy on the history of science: in this work he sums up his position, clarifying his aims, freely criticizing certain aspects of his work, and proposing new goals for future research.
We cannot fully understand The Birth of the Clinic unless we are aware of its position in this series and take note of Foucault’s subsequent declarations, in which he puts distance between himself and his preoccupations at the time when he wrote this book. In particular we need to know that the expression “regard médical” (medical perception), which figures in this book’s subtitle and reflects much of Foucault’s argument, now no longer seems to him “very well chosen,” since it seems to “refer to the unifying or synthesizing function of a subject,” i.e., of a thinker or a thinking mind. And there are indeed passages in The Birth of the Clinic which are genuine phenomenological analyses, where a subject (the doctor, the scientist, “medical perception” itself) is seen in the act of constituting the objects of its thoughts.
Since he wrote these pages Michel Foucault has completely transferred his emphasis to what he calls the “order of discourse,” i.e., to discovering the laws that tacitly govern the intellectual discourse of a given period. He now emphasizes the “dispersion of the subject,” i.e., the ways by which all thinking, no matter how individual or “creative” it may seem, is unconsciously but systematically constrained by the rules or codes that are embedded in the discourse of the times. He would reject any recourse to psychological subjectivity of any sort, and he would prefer to leave out of The Birth of the Clinic those emotional terms which (however discreetly) suggest a psychology of scientific discovery.
Nevertheless Foucault is far from wishing to disown this book; it is an important element in the inquiry which is the basis of his current theorizing. And even here the absence of any biographies of scientists and the way he sets up impersonal schemes show very clearly an approach which is more interested in systems of thought, their appearance and disappearance, their way of organizing scientific discourse and the conditions which make them possible than in the individual destiny of their “inventors.” We could call this book a study of the styles of medical knowledge, or more precisely a study of the differences in such styles, an inquiry concerned with the mutations, discontinuities, incompatibilities, and displacements which make the medical discourse of the nineteenth century totally unlike that of preceding centuries.
What interests Foucault are first the internal rules (and the exceptions to those rules) which govern a particular corpus of documents and then those rules which govern the corpus of documents that follow at a later stage of a science. This methodology, which can broadly be described as structuralist, leads quite logically to a rejection both of the heroic role attributed to individual innovators and of the evolutionary perspective customary in the history of ideas, whereby attention is paid to the connections between “themes” and “ideas” which are transmitted by tradition, adopted, and gradually transformed.
Michel Foucault’s own style, as one might guess, is frequently polemical when he seeks to refute the old historiography. It has to be admitted that he handles his weapon well; his foil may draw blood occasionally, but at least it is not poisoned. Most of the time he simply omits to mention the previous studies on the subject as a sign of distrust for traditional scholarship. However, this polemic plays a secondary role in his book; the essential thing is his description of the different styles of medical knowledge, the social “space” in which these styles are practically deployed—at home or in a hospital for example—the objects they select or reject, the concepts they use, and the metaphors they favor. And this description is not done in the “scientific” language of contemporary linguistics or semiology; it is specifically philosophical in nature and is expressed in a splendidly literary language, full of figures, dramatic turns of phrase, metaphors, wordplay, allusions,1 and poetic inventions, all of which introduce an element of the unexpected into the treatment of such a subject. It should be added that Michel Foucault’s prose, with all its bold playfulness and elegant originality, can be very attractive to the French reader.
Foucault may be difficult and occasionally irritating, but he is never obscure; he is disconcerting, but this is because his writing is so full of dazzling insights. The English translation by A. M. Sheridan Smith is both faithful and subtle; the translator teases out the meaning of Foucault’s lapidary and sometimes cryptic formulations and performs veritable tours de force in the rendering of his metaphors. The reader is given the feeling of a style which is lively, original, and constantly thought-provoking.2
Michel Foucault’s starting point is the medical science that immediately preceded the rise, at the end of the eighteenth century, of the clinic, by which he means both clinical medicine and the teaching hospital. Eighteenth-century medicine, as he describes it, was concerned principally with classifying different forms of illness and setting them out in charts like those of the botanists. In practice the doctor’s task was to recognize the species of illness of which the patient was a representative. “In order to know, he must recognize, while already being in possession of the knowledge that will lend support to his recognition.”
Such a form of medicine was wary of hospitals, where species of disease were confused and the clarity of the chart became obscured. This medicine preferred to let the ailment declare itself in its essential being and was afraid that this might be distorted by premature intervention; it therefore tended to favor biding one’s time. Foucault—and this is a constant feature of his analysis—draws important conclusions from this concerning the social space where the illness was situated and the place occupied by medical practice. According to the “medicine of species” the patient should remain at home, while the doctor should give his assistance in “the natural environment of social life—the family.”
This situation was to change radically when at the end of the eighteenth century hospitals were organized to receive a large number of patients and became the medical training ground par excellence. From then on medicine spoke a different language, creating for itself a new subject matter, basing itself on a different institutional organization, forming its concepts on the strength of new sorts of experience, and opening the way to different forms of medical practice. This change was in large part a consequence of the Revolution and the sociopolitical upheaval in French life. The two chapters which Foucault devotes to this are rich in documentary evidence and give a valuable account of the debates surrounding the setting up in 1794 of the new Ecole de Santé—which was renamed the Ecole de Médecine in 1796.
Foucault demonstrates very clearly the interconnections between medicine as a science, medical activity as a social fact, and the university’s role in transmitting “scientific learning.” He is remarkably successful here in highlighting the mutations affecting “the status, institutional position, situation and modes of insertion of the speaking and writing subject”—we see such figures as the philosopher-physician Pierre Caban-is promoting entire new schemes of medical training, treatment, credentials, in which contradictory concepts of nature and politics were often combined.
The French Revolution, as Foucault shows, reorganized the teaching of medicine, centralized it, subjected it to state control, and established new hierarchies. But before it did this, the Revolution went through a period of Utopian daydreaming: this was not the first time nor the last that people have dreamed of a just state sharing out prosperity equally among all its citizens and thus eliminating not only poverty but illness. Almshouses and hospitals thus became superfluous; they were the blemishes on the face of the old order. The new education would create nothing but healthy, virtuous people devoted to the revolutionary cause: “The first task of the doctor is therefore political: the struggle against disease must begin with a war against bad government. Man will be totally and definitively cured only if he is first liberated…. And gradually, in this young city entirely dedicated to the happiness of possessing health, the face of the doctor would fade, leaving a faint trace in men’s memories of a time of kings and wealth, in which they were impoverished, sick slaves.”
After all these daydreams and myths what actually came into being was a new pedagogical and technical organization, in which teaching hospitals, “schools of health,” and new categories of professionals were planned. The vision here was of a “transparent, undivided” medical domain that would be “exposed from top to bottom to a gaze armed nonetheless with its privileges and qualifications…: in liberty, disease was to formulate of itself an unchanging truth, offered, undisturbed, to the doctor’s gaze; and society, medically invested, instructed, and supervised, would, by that very fact, free itself from disease.”
But this vision too, according to Foucault, was itself “only one segment of the dialectic of the Lumières transported into the doctor’s eye.” In other words the revolutionary reorganization of the University was at first no more than a necessary condition for the rise of clinical medicine; while the revolutionary theme of the doctor liberating society from newly liberated disease was hardly an adequate conceptual basis for the practice of this medicine. What clinical medicine lacked and what it had to create was “a new, coherent, unitary model for the formation of medical objects, perceptions, and concepts.”
Thus, when Foucault writes: "Knowledge spins where once larva was formed" (p. 125), the French reader recognizes a paraphrase of Valéry's line "La larve file où se formaient des pleurs" ("Le Cimetière Marin").↩
One wonders whether the translator has deliberately toned down Foucault's calculated insolence; where the original reads: "Une fois n'est pas coutume; je citerai un historien de la médecine," the translation leaves out the mockery and simply gives us the banal: "Let me quote a historian of medicine" (p. 164). An excessively faithful rendering has its drawbacks too; the infrequent misprints of the French edition are preserved in the translation. On page 139 of the French edition we find: "Mais c'est là projet [sic] sur l'histoire une vieille théorie de la connaissance." This should of course read "projeter," to project. Deference to the original has made the translation unintelligible: "But this is surely a project on history, an old theory of knowledge" (p. 137).
Similarly on page 121 of the French text we find: "C'est dans l'acte de voix [sic] et la vive clarté qu'il répand sur les phénomènes que la vérité se révèle." This is a passage devoted to visual perception and "voix" should read "voir," but the translator has kept "act of voice," thus producing what in this context is a baffling enigma. "Médecine des espèces" is correctly rendered as "medicine of species." Why then on page 20 do we find a quite unwarranted "medicine of spaces"?↩
Thus, when Foucault writes: “Knowledge spins where once larva was formed” (p. 125), the French reader recognizes a paraphrase of Valéry’s line “La larve file où se formaient des pleurs” (“Le Cimetière Marin“).↩
One wonders whether the translator has deliberately toned down Foucault’s calculated insolence; where the original reads: “Une fois n’est pas coutume; je citerai un historien de la médecine,” the translation leaves out the mockery and simply gives us the banal: “Let me quote a historian of medicine” (p. 164). An excessively faithful rendering has its drawbacks too; the infrequent misprints of the French edition are preserved in the translation. On page 139 of the French edition we find: “Mais c’est là projet [sic] sur l’histoire une vieille théorie de la connaissance.” This should of course read “projeter,” to project. Deference to the original has made the translation unintelligible: “But this is surely a project on history, an old theory of knowledge” (p. 137).
Similarly on page 121 of the French text we find: “C’est dans l’acte de voix [sic] et la vive clarté qu’il répand sur les phénomènes que la vérité se révèle.” This is a passage devoted to visual perception and “voix” should read “voir,” but the translator has kept “act of voice,” thus producing what in this context is a baffling enigma. “Médecine des espèces” is correctly rendered as “medicine of species.” Why then on page 20 do we find a quite unwarranted “medicine of spaces”?↩