What are the principles of this rimary configuration of disease? 1. The doctors of the eighteenth century identified it with 'historical', as opposed to philosophical, 'knowledge'. Knowledge is historical that circumscribes pleurisy by its four phenomena: fever, difficulty in breathing, coughing, and pains in the side. Knowledge would be philosophical that called into question the origin, the principle, the causes of the disease: cold, serous discharge, inflammation of the pleura. The distinction between the historical and the philosophical is not the distinction bet- ween cause and effect: Cullen based his classificatory system on the attribution of related causes [5]; nor is the distinction between principle and consequences, since Sydenham thought he was engaged in historical research when studying 'the way in which nature produces and sustains the different forms of diseases' [6]; nor even is it exactly the difference between the visible and the hidden or conjectural, for one sometimes has to track down a 'history' that is enclosed upon itself and develops in- visibly, like hectic fever in certain phthisics: 'reefs caught under water' [7]. The historical embraces whatever, de facto or de jure, sooner or later, directly or indirectly, may be offered to the gaze. A cause that can be seen, a symptom that is gradually discovered, a principle that can be deciphered from its root do not belong to the order of 'philosophical ' knowledge, but to a 'very simple' knowledge, which 'must precede all others', and which situates the original form of medical experience. It is a question of defining a sort of fundamental area in which perspectives are levelled off, and in which shifts of level are aligned: an effect has the same status as its cause, the antecedent coincides with what follows it. In this homogeneous space series are broken and time abolished: a local inflammation is merely the ideal juxtaposition of its historical elements (redness, tumour, heat, pain) without their network of reciprocal determinations or their temporal intersection being involved. Disease is perceived fundamentally in a space of projection without depth, of coincidence without development. There is only one 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 diseases must...observe attentively the clear and natural phenomena of diseases, however uninteresting they may seem. In this he must imitate the painters who when they paint a portrait are careful to mark the smallest signs and natural things that are to be found on the face of the person they are painting' [8]. The first structure provided by classificatory medicine is the flat surface of perpetual simultaneity. Table and picture. 2. It is a space in which analogies define essences. The pictures resemble things, but they also resemble one another. The distance that separates one disease from another can be measured only by the degree of their re- semblance, without reference to the logico-temporal divergence of genealogy. The disappearance of voluntary movements and reduced activity in the internal or external sense organs form the general outline that emerges beneath such particular forms as apoplexy, syncope, or paralysis. Within this great kinship, minor divergences are established: apoplexy robs one of the use of all the senses, and of all voluntary motility, but it spares the breathing and the functioning of the heart; paralysis affects only a locally assignable sector of the nervous system and motility; like apoplexy, syncope has a general effect, but it also interrupts respiratory movements [9]. The pers- pective distribution, which enables us to see in paralysis a symptom, in syncope an episode, and in apoplexy an organic and functional attack, does not 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. When they become dense enough, these similarities cross the threshold of mere kinship and accede to unity of essence. There is no fundamental difference between an apoplexy that suddenly suspends motility, and the chronic, evolutive forms that gradually invade the whole motor system: in that simultaneous space in which forms distributed by time come together and are suerimposed, kinship folds back into identity. In a flat, homogeneous, non-measurable world, there is essential disease where there is a plethora of similarities. 3. The form of the similarity uncovers the rational order of the diseases. When one perceives a resemblance, one does not simply lay down a system of convenient, relative 'mappings'; one begins to read off the intelligible ordering of the diseases. The veil is lifted from the principle of their creation; this is the general order of nature. As in the case of plants or animals, the action of disease is fundamentally specific: 'The supreme Being is not subjected to less certain laws in producing diseases or in maturing morbific humours, than in growing plants and animals....He who observes attentively the order, the time, the hour at which the attack of quart fever begins, the phenomena of shivering, of heat, in a word all the symp- toms proper to it, will have as many reasons to believe that this disease is a species as he has to believe that a plant constitutes a species because it grows, flowers, and dies always in the same way' [10]. this botanical model has a double importance for medical thought. First, it made it possible to turn the principle of the analogy of forms into the law of the production of essences; and, secondly, it allowed the perceptual at- tention of the doctor--which, here and there, 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 'carbon copy' of the world of life; the same structures govern each, the same forms of division, the same ordering. The rationality of life is identical with the rationality of that which threatens it. Their rela- tionship is not one of nature and counter-nature; but, in a natural order common to both, they fit into one another, one superimposed uon the other. In disease, one recognizes (reconnait) life because it is on the law of life that knowledge (connaissance) of the disease is also based. 4. We are dealing with species that are both natural and ideal. Natural, because it is in them that diseases state their essential truths; ideal insofar as they are never experienced unchanged and undisturbed. The first disturbance is introduced with and by disease itself. To the pure nosological essence, which fixes and exhausts its place in the order of the species without residue, the patient adds, in the form of so many disturbances, his predispositions, his age, his way of life, and a whole series of events that, in relation to the essential nucleus, appear as accidents. In order to know the truth of the pathological fact, the doctor must abstract the patient: 'He who describes a disease must take care to distinguish the symptoms that necessarily accompany it, and which are proper to ir, from those that are only accidental and fortuitous, such as those that depend on the temperament and age of the patient' [11]. Paradoxically, in relation to that which he is suffering from, the patient is only an external fact; the medical reading must take him into account only to place him in parentheses. Of course, the doctor must know 'the internal structure of our bodies'; but only in order to subtract it, and to free to the doctor's gaze 'the nature and combination of symptoms, crises, and other circumstances that accompany diseases' [12]. It is not the pathological that functions, in relation to life, as a counter-nature, but the patient in relation to the disease itself. And not only the patient; the doctor, too. His intervention is an act of violence if it is not subjected strictly to the ideal ordering of nosology: 'The knowledge of diseases is the doctor's compass; the success of the cure depends on an exact knowledge of the disease'; the doctor's gaze is directed initially not towards that concrete body, that visible whole, that positive plenitude that faces him--the patient--but towards intervals in nature, lacu- nae, distances, in which there appear, like negatives, 'the signs that dif- ferentiate one disease from another, the true from the false, the legitimate from the bastard, the malign from the benign' [13]. It is a grid that catches the real patient and holds back any theraeutic indiscretion. If, for polemical reasons, the remedy is administered too early, it contradicts and blurs the essence of the disease; it prevents the disease from acceding to its true nature, and, by making it irregular, makes it untreatable. In the period of invasion, the doctor must hold his breath, for 'the beginnings of disease reveal its class, its genus, and its species'; when the symptoms increase and become more marked, it is enough 'to diminish their violence and reduce the pains'; when the disease has settled in, one must 'follow step by step the paths followed by nature', strengthening it if it is too weak, diminishing it if it strives too vigorously to destroy what resists it' [14]. --

※ 发信站: 批踢踢实业坊(ptt.cc) ◆ From: 122.120.96.100