Epoché (XII), 21. 1. 2021

A synopsis of our reading of The Normal and the Pathological by Georges Canguilhem

“Foreword” (p. 25)

&

“Preface to the Second Edition (1950)” (pp. 29-32)

&

“Introduction” (pp. 33-35)

&

Part I “Is the Pathological State Merely a Quantitative Modification of the Normal State?” / Ch. 1 “Introduction to the Problem” (pp. 39-46)

Abridgment by: Sebastjan Vörös
[his outline and commentary of the whole book can be found here]

Preface to the Second Edition

The second edition directly reproduces the text of the first (published in 1943). C. points out that, already in 1943, he could have drawn on Pradines’ Traité de psychologie générale and Merleau-Ponty’s Structure du comportment (the latter was only mentioned, as it was discovered when C’s manuscript was already in press) (29). However, he adds that he is not too sorry about having overlooked them, “as I much rather prefer a convergence whose fortuitous character better emphasizes the value of intellectual necessity to an acquiescence, even fully sincere, in the view of others” (29-30).

Further, C. says that, if he were to rewrite his essay, he would devote a great deal of space to Hans Selye’s work (on stress or – as he calls it – “the state of organic alarm”):

“Selye established that the failures or irregularities of behaviour as well as the emotions and fatigue they generate, produce through their frequent repetition, a structural modification of the adrenal cortex analogous to that determined by the introduction of hormonal substances […] or toxic substances into the internal environment. […] Moreover, these structural reactions […] involve the thyroid or hypophysis as well as the adrenal gland. But these normal (that is biologically favourable) reactions end up wearing out the organism in the case of abnormal (that is statistically frequent) repetitions of situations which generate the alarm reaction. In certain individuals, then, disadaptation diseases are set up.”

In C’s view, Selye’s work is important as it could “mediate between Leriche’s and Goldstein’s theses”:

“If these facts are interpreted from Goldstein’s point of view, disease will be seen in catastrophic behavior; if they are interpreted from Leriche’s point of view, disease will be seen in the determination of histological anomaly by physiological disorder. These two points of view are not mutually exclusive, far from it.” (30)

C. also says that he would pay more attention to Etienne Wolff’s work in the field of teratogenesis, and that he would address some of his more acute critics (e.g., Louis Bounoure). He concludes the preface with the following words:

“In concluding I want to add that certain readers were surprised at the brevity of my conclusions and at the fact that they leave the philosophical door open. I must say that this was intentional. I had wanted to lay the groundwork for a future thesis in philosophy. I was aware of having sacrificed enough, if not too much, to the philosophical demon in a thesis in medicine. And so I deliberately gave my conclusions the appearance of propositions which were simply and moderately methodological.” [!]

Introduction

The problem of pathological structures and behaviours (e.g., a congenital clubfoot, a sexual inversion, a diabetic, a schizophrenic, etc.,) is enormous, as it raises numerous questions concerning anatomical, embryological, physiological and psychological research. C. attempts address this problem by combining medical research and philosophical reflection. As to the latter he says the following:

“Philosophy is a reflection for which all unknown material is good, and we would gladly say, for which all good material must be unknown.” (33)

The reason why C. took up the study of medicine is because it seemed “to provide precisely an introduction to concrete human problems”; since medicine, in C’s view, is more like a technique or art at the crossroads of several sciences than one of the sciences, it seemed to be very useful with regards to two central issues that C. was concerned with: (a) the relations between science and technology, and (b) the relations between norms and the normal. Specifically, despite the numerous attempts of rationalizing medicine, C. believes that the essential still lay “in the clinic and therapeutics” (34).

So, what is the aim and structure of his book? He points out three things:

1. Integration of medicine into philosophy (aim: renewal of certain methodological concepts)

“The present work is thus an effort to integrate some of the methods and attainments of medicine into philosophical speculation. It is necessary to state that it is not a question of teaching a lesson, or of bringing a normative judgment to bear upon medical activity. If medicine is to be renovated, it is up to physicians to do so at their risk and to their credit. But we want to contribute to the renewal of certain methodological concepts by adjusting their comprehension through contact with medical information.” (34)

2. Emphasis on nosology:

“In the present exposition we want to limit ourselves very strictly to the problem of somatic nosology or pathological physiology, without, however, refraining from borrowing from teratology or pathological psychology this datum, that notion or solution, which would seem to us particularly suited to clarify the investigation or confirm some result.” (35)

3. Examination of a normal-pathological continuity thesis:

“We have also tried to set forth our conceptions in connection with the critical examination of a thesis, generally adopted in the nineteenth century, concerning the relations between the normal and the pathological. This is the thesis according to which pathological phenomena are identical to corresponding normal phenomena save for quantitative variations. With this procedure we are yielding to a demand of philosophical thought to reopen rather than close problems. Leon Brunschvicg said of philosophy that it is the science of solved problems. We are making this simple and profound definition our own.”

Part One: Is the Pathological State Merely a Quantitative Modification of the Normal State?

Chapter I: Introduction to the Problem

A. Ontological theory of disease:

“To act, it is necessary at least to localize. For example, how do we take action against an earthquake or hurricane? The impetus behind every ontological theory of disease undoubtedly derives from therapeutic need. When we see in every sick man someone whose being has been augmented or diminished, we/are somewhat reassured, for what a man has lost can be restored to him, and what has entered him can also leave. […] Disease enters and leaves man as through a door.” (39)

There is what C. refers to as “a vulgar hierarchy of diseases”, which still exists today and which is based “on the extent to which symptoms can – or cannot – be readily localized”. For this reason, Parkinson’s disease is more of a disease than, say, thoracic shingles (39). One of the reasons for the success of Pasteur’s “germ theory of contagious disease” was definitely the fact that “it embodies an ontological representation of sickness”:  after all, a germ can be seen, while a miasma cannot: “To see an entity is already to foresee an action.” (39-40)

In this conception, then, “we delegate the task of restoring the diseased organism to the desired [vital] norm to the technical means, either magical or matter of fact”; the reason for this is that “we expect nothing good from nature itself” (40).

B. Dynamic theory of disease:

This conception appears in Greek medicine (Hippocratic writings). It is no longer “localizationist”, but “totalizing”:

“Nature (physis), within man as well as without, is harmony and equilibrium. The disturbance of this harmony, of this equilibrium, is called disease. In this case, disease is not somewhere in man, it is everywhere in him; it is the whole man. External circumstances are the occasion but not the causes. [..four humour theory…] But disease is not simply disequilibrium or discordance; it is, and perhaps most important, an effort on the part of nature to effect a new equilibrium in man. Disease is a generalized reaction designed to bring about a cure; the organism develops a disease in order to get well.” (40-1)

This, of course, has direct impact on therapeutic practices:

“Therapy must first tolerate and if necessary, reinforce these hedonic and spontaneously therapeutic reactions. Medical technique imitates natural medicinal action (vis medicatrix naturae). […]  Of course, such a conception is also optimistic, but here the optimism concerns the way of nature and not the effect of human technique.” (41)

According to C., medical thought has been perpetually oscillating between these two conceptions of disease,  always finding some good reason to endorse one or the other:

@A: ontological theory is favoured by deficiency and infectious diseases;

@B: dynamic theory is favoured by endocrine disturbances (and all diseases beginning with “dys”)

1. Qualitative approach (that which unites A and B)

However, (A) & (B) have one point in common: in the experience of being sick they envision a “polemical situation”, either (ad 1) a battle between the organism and a foreign substance, or (ad 2) an internal struggle between opposing forces. Crucially, there is a “heterogeneity of normal and pathological states” – i.e., disease differs qualitativelyfrom a state of health -, which still persists today in the naturalist conception (41).

2. Quantitative approach

However, it proved difficult to maintain this view in a conception, developed particularly during the time of scientific revolution, which “expects, man to be able to compel nature and bend it to his normative desires”. To “govern disease” would, in this conception, mean “to become acquainted with its relations to the normal state, which the living man – loving life – wants to regain”; in short, a theoretical need emerged for establishing scientific pathology by linking to physiology, i.e., to make it “a natural extension of physiology” (41-2):

“The end result of this evolutionary process is the formation of a theory of the relations between the normal and the pathological, according to which the pathological phenomena found in living organisms are nothing more than quantitative variations, greater or lesser according to corresponding physiological phenomena. Semantically, the pathological is designated as departing from the normal not so much by a- or dys- as by hyper- or hypo-. While retaining the ontological theory’s soothing confidence in the possibility of technical conquest of disease, this approach is far from considering health and sickness as qualitatively opposed, or as forces joined in battle. The need to reestablish continuity in order to gain more knowledge for more effective action is such that the concept of disease would finally vanish. The conviction that one can scientifically restore the norm is such that in the end it annuls the pathological. Disease is no longer the object of anguish for the healthy man; it has become instead the object of study for the theorist of health. It is in pathology, writ large, that we can unravel the teachings of health, rather as Plato sought in the institutions of the State the larger and more easily readable equivalent of the virtues and vices of the individual soul.” (42-3)

The quantitative approach received an additional boost in the 19th century, when the “real identity of normal and pathological vital phenomena” became a “kind of scientifically guaranteed dogma”. This dogma, says C., was expounded in France by two figures: Auguste Comte and Claude Bernard, each working under different circumstances and following different intentions:

(a) Comte: he based his doctrine on the work of Broussais, and moved in the direction: pathological → normal; here, the identity remains purely conceptual;

(b) Bernard: he based his doctrine on a lifetime of experimentation, and moved in the direction: normal → pathological; here, the identity is presented in quantitative, numerical terms (43-4).

By calling the theory in question a dogma, C. says, he does “not mean at all to disparage it, but rather to stress its scope and repercussions” (44). He then goes on to provide, in a few brief and general strokes, a portrayal of the dissemination of Comte’s (44-5) and Bernard’s ideas (45), respectively. What is crucial here is the following:

“These summary indications must suffice to show that the thesis whose meaning and importance we are trying to define has not been invented for the sake of the cause. The history of ideas cannot be superimposed perforce on the history of science. But as scientists lead their lives as men in an environment and social setting that is not exclusively scientific, the history of science cannot neglect the history of ideas. In following a thesis to its logical conclusion, it could be said that the modifications it undergoes in its cultural milieu can reveal its essential meaning.” (46)

The reason why he chose to focus on Comte and Bernard is because they played the role of “standard bearers”. To their ideas he will also add those of Leriche’s, which are much discussed in medicine and physiology.

Discussion

Presenter: Izak Hudnik