The Death of the Clinic

This book explores such experiments through five clinics: the Institute for Sexual Sciences in Weimar Berlin; the Peckham Experiment in human biology of interwar London; the psychiatric clinic of La Borde in post-war France; Le Dispensaire des Femmes at the heart of Geneva’s women’s liberation movement; and the Community Research Initiative at the height of New York’s AIDS crisis. Much like yours, these clinics emerged from private initiatives on the margins, outside conventional hospital structures and against conservative orthodoxies. Despite their distinct contexts, they are bound by a shared political struggle for access and solidarity – by a commitment to an expansive vision of care that unsettles preconceived notions of  health. I see a little bit of you in each one of them: in their protagonists’ political activism, their horizontal modes of  being, their shared desire to bridge medicine and philosophy.

Together, these clinics outline a tradition rooted in resistance, pushing back against the dominant models of modern care that took shape in the West. As Foucault famously observed in The Birth of the Clinic (1963), it was towards the end of the eighteenth century that medicine underwent a profound transformation marked by centralization and isolation. In the wake of the French Revolution, the nationalization of medical knowledge, echoing the paradigm of the modern state, became associated with the eradication of disease. The war on illness required a defined territory, enveloping both the nation and the patient. Its weapon was the empiricism of the medical gaze, reducing bodies to specimens. Priests had been the guardians of the soul – now, doctors were the priests of  bodies. Where they had once considered the patient as a whole, asking ‘What is wrong with you?’, in the nineteenth century, they asked: ‘Where does it hurt?’

Clinical medicine, of course, pre-dates the eighteenth century. The word ‘clinic’ refers to a relationship to the sick. It comes from the French clinique, which in turn derives from the Latin clīnicus (a bed-ridden person) and Ancient Greek klīnikós (pertaining to the bedside). In the fifth century B.C., Hippocrates and his followers defended the ‘art of medicine’, where ‘art’ (deriving from the Greek technē) referred to the creative and practical application of  knowledge to craftsmanship. The art of medicine relied equally on skills and knowledge, which accrued through observation. Accordingly, the Hippocratics kept detailed notes of their clinical observations. They sampled their patients’ sweat and urine to describe their flavour, temperature, and texture: is it hot or cold, sweet or bitter, clear or cloudy? A diagnosis meant identifying an excess of one of the four humours – blood, phlegm, yellow bile or black bile – and a treatment aimed to restore the adequate balance between them. The art of medicine, they wrote, ‘is to do away with the sufferings of the sick, to lessen the violence of their diseases’.

By contrast, Galenic medicine – which dominated from the Roman era until the Renaissance – still followed humoral theory but favoured abstract reasoning, relegating clinical observation to a secondary role. ‘For he was grounded in astronomy,’ Chaucer says of the doctor in The Canterbury Tales. ‘He knew the best hours for the sick, / By the power of  his natural magic.’ Stars, in the middles ages, had more to say about disease than our own bodies.

By the eighteenth century, metaphysical epistemology slowly gave way to empiricism, reviving ancient observational methods. Contrary to Hippocratic medicine, however, the modern clinic was organized as a body of  knowledge, combining practical experience, analytical method and structured teaching. Indebted to imperial expansion and Linnaean taxonomy – grouping and naming living things hierarchically – the clinic would become a vehicle of classification. ‘Before being a meeting of patient and doctor, a truth to be deciphered and an ignorance,’ Foucault notes, ‘the clinic must form, constitutionally, a structured nosological field.’ The clinic was no longer merely about the care of the sick – about the methods and manners of the bedside – it became a site of  knowledge that, through evidence and verifiability, gained authority and governing legitimacy. In other words, the clinic developed into a normative and regulatory power – one that speaks without naming itself – establishing its jurisdiction over the bodies and morals of the nation.

The nineteenth century was the golden age of the clinic: an age of great scientific discoveries and growing specialization. Thanks to such figures as the Scottish anatomist John Hunter, the tradition of the medieval barber-surgeon – once equally responsible for cutting hair, pulling teeth, and amputating limbs – gradually gave way to the highly trained surgical profession we know today. This transition required a steady supply of cadavers as training material. Death was in vogue and so were resurrectionists, snatching up bodies like there’s no tomorrow. Corpses were the coal of the clinical revolution: raw material to be mined, exploited and commodified.

Capitalizing on this development, the rise of pathological anatomy – the study of organs and tissues to determine the causes and effects of disease – forever changed the interplay between life and death. ‘Open up a few corpses,’ the French pathologist Xavier Bichat instructed his students in the early 1800s, ‘you will dissipate at once the darkness that observation alone could not dissipate.’ If the medical gaze had once merely scanned the surface of the body, looking for signs of disease like defects on a painting, it now penetrated the layers of death to uncover the knowledge of  life. It is hardly a coincidence that one of the most popular novels of the time, Mary Shelley’s Frankenstein (1818), tells the story of a scientist who creates life by piecing together parts from dead bodies – a vitalist fantasy with a timely ethical dimension.

From the 1830s onwards, anatomy acts and other policies designed to regulate the use of  human bodies were introduced to address shortages and curb body snatching. But other problems arose. Namely, the study of dead bodies was limiting, pushing many physiologists to turn to animals, more readily available and unburdened by ethical conventions. Vivisection offered the opportunity to observe living organisms in real time – to see blood pumping through the heart and muscles softening after nerves were severed. On his morning commute to the Collège de France, Claude Bernard – the father of experimental medicine – routinely picked up stray dogs for his laboratory experiments. On one occasion, he accidentally abducted the beloved pet of the local police superintendent, who did not appreciate having it returned in pieces. A hefty fine did little to deter Bernard – his curiosity was insatiable. So much so that his wife Fanny eventually left him after walking in on him dissecting the family dog on their kitchen table. (She went on to become a prominent animal rights activist.)

As the modern paradigm of the clinic took shape, so too did the role of the doctor as a state custodian of  health and morality. ‘As a public and supervised activity,’ Foucault notes, ‘medicine would become a copy of the Church.’ It is telling that Dr Benassis, the protagonist of Balzac’s novel The Country Doctor (1833), hesitated between becoming a priest, a judge or a doctor: ‘the men of the black robe,’ he says – ‘The first heals the wounds of the soul, the second those of the purse, and the third those of the body. They represent the three principal elements necessary to the existence of society – conscience, property, and health.’ This alignment – upon which ‘the progress of civilization and the well-being of the masses depends’ – reflects the emergence of modern biopolitics: a form of power exercised not only through law, but through the regulation, management and optimization of  life. (…)