Epoché (XIV), 11. 2. 2021
A synopsis of our reading of The Normal and the Pathological by Georges Canguilhem
Part I/Ch. 4 “The Conceptions of René Leriche” (pp. 91-101)
&
Part I/Ch. 5 “Implications of a Theory” (pp. 103-112)
&
Part II “Do Sciences of the Normal and the Pathological Exist?” / Ch. 1 “Introduction to the Problem” (pp. 115-123)
Abridgment by: Sebastjan Vörös
[his outline and commentary of the whole book can be found here]
Chapter IV: The Conception of René Leriche
The discussion about the invalidity of the sick man’s judgment regarding the reality of his illness is an important theme in a recent theory of disease put forward by René Leriche. Leriche’s theory extends the preceding theory in one direction and deviates from it in others.
By C.’s lights, Leriche starts off in a very promising manner, defining “health” and “disease” thus:
“Health is life lived in the silence of the organs […while] disease is what irritates men in the normal course of their lives and work, and above all, what makes them suffer.” (91)
C. expounds on this further:
“The state of health is a state of unawareness where the subject and his body are one. Conversely, the awareness of the body consists in a feeling of limits, threats, obstacles to health. Taking these formulae in their full sense, they mean that the actual notion of the normal depends on the possibility of violating the norm. Here at last are definitions which are not empty words, where the relativity of the contrasting terms is correct. For all that the primitive term is not positive; for all that the negative term does not represent nothingness. Health is positive, but not primitive, disease is negative, but in the form of opposition (irritation), not deprivation.” (91)
However, this is not the whole story. Leriche points out that the “silence of the organs” does not imply the absence of disease, for there are, say, functional lesions which long remain imperceptible to those whose lives they endanger. This is the price we pay for the prodigality of our organism (the fact that it has too much of every tissue – e.g., lungs – that is strictly needed for carrying out a given function – e.g., breathing). Thus, in order to properly define illness, the latter must “dehumanized”; or more radically: “in disease, when all is said and done, the least important thing is man”:
“Hence it is no longer pain or functional incapacity and social infirmity which makes disease, but rather anatomical alteration or physiological disturbance. Disease plays its tricks at the tissue level, and in this sense, there can be sickness without a sick person.” (92)
Example: man who has never complained of any pain, discomfort, etc., suddenly dies in a car crash; an autopsy reveals a cancer of the kidney in his kidney unknown to its late owner; according to Leriche, one needs to conclude in favour of a disease, although no symptoms were present: “The disease which never existed in the man’s consciousness begins to exist in the physician’s science.”
C. disagrees: “We think that there is nothing in science that has not first appeared in the consciousness.” [!!!] (92-3) How so? What follows is an important passage that I quote in full:
“Doctors and surgeons have clinical information and sometimes use laboratory techniques which allow them to see ‘patients’ in people who do not feel that way. This is a fact. But a fact to be interpreted. It is only because today’s practitioners are the heirs to a medical culture transmitted to them by yesterday’s practitioners that, in terms of clinical perspicacity, they overtake and outstrip their regular or occasional clients. There has always been a moment when, all things considered, the practitioner’s attention has been drawn to certain symptoms, even solely objective ones, by men who were complaining of not being normal – that is, of not being the same as they had been in the past – or of suffering. If, today, the physician’s knowledge of disease can anticipate the sick man’s experience of it, it is because at one time this experience gave rise to, summoned up, that knowledge. Hence medicine always exists de jure, if not de facto, because there are men who feel sick, not because there are doctors to tell men of their illnesses. [!!!] The historical evolution of the relations between the physician and the sick man in clinical consultation changes nothing in the normal, permanent relationship of the sick man and disease.” (93)
This, says C., is partially confirmed by Leriche himself, who distinguishes between the static and dynamic point of view in pathology, and claims the primacy for the latter. To people who claimed that it was possible to identify disease and lesion, Leriche objected that the anatomical fact must considered “second and secondary: second, because it is produced by a primitively functional deviation in the life of the tissues; secondary, because it is only one element in the disease and not the dominant one” (93). Consequently it is the sick’s man disease which becomes again the adequate concept of disease:
“The idea must be accepted that the disease of the sick man is not the anatomical disease of the doctor. [example] A stone in an atrophic gall bladder can fail to give symptoms for years and consequently create no disease, although there is a state of pathological anatomy. […] Under the same anatomical appearances one is sick and one isn’t. […] The difficulty must no longer be conjured away by simply saying that there are silent and masked forms of disease: these are nothing but mere words. The lesion is not enough perhaps to make the clinical disease the disease of the sick man, for this disease is something other than the disease of the anatomical pathologist.” (94)
However, we need to tread carefully here. Namely, when talking of “the sick person”, what Leriche has in mind is not so much “the individual aware of his organic functions” but rather “the organism in action, in functions”. That is to say, although the sick man has ceased to be an entity for the anatomist, he remains an entity for the physiologist: “Thus, the coincidence of disease and the sick man takes place in the physiologist’s science, but not yet in the real man’s consciousness.” (94)
Drawing on Bernard, Leriche proclaims the continuity and indiscernibility of the physiological state and the pathological state.
Example: vaso-constriction and spasms: Leriche maintains that there is no borderline between tonus and vaso-constriction, and then between vaso-constriction and spasm; thus, there is no threshold between physiology and pathology.
C. comments: there is no quantitative threshold, but there is qualitative distinction and opposition in terms of different effects of the same quantitatively variable cause.
Example: obliteration, necrosis, pain = pathological facts for which there are no physiological equivalents: (i) blocked artery = no longer an artery (from the physiological perspective), since it is an obstacle; (ii) necrotic cell = no longer a cell (there is no physiology of the cadaver); (iii) pain = no longer a physiological sensation (Leriche: “pain is not nature’s plain”) (95-6).
C. takes a closer look at pain. Pain is neither (a) an expression of a normal activity of a sense susceptible of permanent stimuli; nor (b) a detector of and diligent warning signal for events menacing organic integrity; nor (c) a reaction of salutary defense. Instead, as Leriche puts it, it is “a monstrous individual phenomenon and not a law of the species”, i.e., it is “[a] fact of disease”. That is to say, disease is no longer defined in terms of pain, but vice versa: pain is defined in terms of disease. And here, disease stands for an authentically abnormal state. Thus, the phenomenon of pain actually provides support for Leriche’s theory mentioned at the beginning of this section, i.e., a theory of the state of disease as a “physiological novelty” (96): “That which produces disease in us touches life’s ordinary resiliences so subtly that their responses are less that of a physiology gone wrong than that of a new physiology where many things, tuned in a new key, have unusual resonance.” (97)
In C.’s view, it is important that a doctor recognize in pain a “phenomenon of total reaction which makes sense, which is a sensation only at the level of concrete human individuality”. Further, it is important to state that man makes pain rather than that he receives it or submits to it, i.e., pain is dependent on the activity of the subject who experiences it (97). According to C., while the mechanicists are right in claiming that pain is far from always being a faithful and infallible warning signal, as the finalists claim, they are ultimately mistaken in that they overlook that the indifference on the part of a living being to its conditions of life is also profoundly abnormal:
“It can be admitted that pain is a vital sensation without admitting that it has a particular organ or that it has encyclopedic value as a mine of information with regard to the topographical or functional order.” (98) [!]
Further:
“The physiologist can indeed denounce the illusions of pain as the physicist does those of sight; this means that sensation is not knowledge and that its normal value is not a theoretical value, but this does not mean that it is normally without value. It seems that one must above all carefully distinguish pain of integumentary [surface] origin from pain of visceral origin. If the latter is presented as abnormal, it seems difficult to dispute the normal character of pain which arises at the surface of the organism’s separation from as well as encounter with the environment. The suppression of integumentary pain in scleroderma or syringomyelia can lead to the organism’s indifference to attacks on its integrity.” (98) [!]
What is especially significant here is that Leriche defines disease in terms of its effects. But now it was shown that, with at least one of these effects, i.e., pain, we leave the plane of abstract science for the sphere of concrete awareness. Here, we obtain the total coincidence of disease and the diseased person (entire conscious individual): thus, the “pain-disease” (Lariche’s term) turns out to be a fact at the level of behaviour[!].
So, how do Leriche’s ideas sit with Comte’s and Bernard’s?
(i) What Comte and Bernard have in common is the fundamental positivist idea that a technology must be the application of science: to know in order to act. Thus, physiology must illuminate pathology so as to establish therapeutics (physiology → pathology → therapy).
(ii) Leriche, on the other hand, thinks that we often proceed in the opposite manner, i.e., from medical and surgical technology prompted by the pathological state to physiological knowledge (pathology → therapy → physiology): “Knowledge of the physiological state is obtained by retrospective abstraction from the clinical and therapeutic experience” (99).
In certain regards, Leriche is similar to Comte in that he, too, believes that pathology can tell us a lot about normal physiological processes. But whereas Comte thinks that knowledge of the normal state must normally precede the evaluation of the pathological state and could be formed without the reference to pathological state, Leriche believes that physiology is the collection of solutions to problems posed by sick men through their illnesses:
“At every moment there lie within us many more physiological possibilities than physiology would tell us about. But it takes disease to reveal them to us.” [!]
Important passage (again, I quote it at length):
“[i] Physiology is the science of the functions and ways of life, but it is life which suggests to the physiologist the ways to explore, for which he codifies the laws. Physiology cannot impose on life just those ways whose mechanism is intelligible to it. Diseases are new ways of life. Without the diseases which incessantly renew the area to be explored, physiology would mark time on well-trod ground. But the foregoing idea can also be understood in another, slightly different sense. [ii] Disease reveals normal functions to us at the precise moment when it deprives us of their exercise. Disease is the source of the speculative attention which life attaches to life by means of man. If health is life in the silence of the organs, then, strictly speaking, there is no science of health. Health is organic innocence. It must be lost, like all innocence, so that knowledge may be possible. Physiology is like all science, which, as Aristotle says, proceeds from wonder. But the truly vital wonder is the anguish caused by disease.” (100-1) [!!!] [vitalism]
This is a direct bearing on Leriche’s theory of technology, in which technology is not a docile handmaid in the hands of scientific knowledge, but rather “an advisor and animator, directing attention to concrete problems and orienting research in the direction of obstacles without presuming anything in advance of the theoretical solutions which will arise“ (101).
Chapter V: Implications of a Theory
C. starts with a quote from Sigerist:
“Medicine is the most closely linked to the whole of culture, every transformation in medical conceptions being conditioned by transformations in the ideas of the epoch.” (103)
The theory just expounded, says C., perfectly verifies Sigert’s proposition. First of all, it gives rise to the conviction of rationalist optimism that evil has no reality. In general: (i) 19th-century medicine is a resolutely monist medicine; (ii) 18th-century medicine, however, remained a dualist medicine, a medical Manichaeism (103). The denial of an ontological conception of disease is thus perhaps, at its core, the deeper refusal to confirm evil (104).
C. makes it clear that he is not trying to dismiss scientific therapeutics; it is just important how one construes it:
“It is very important not to identify disease with either sin or the devil. But it does not follow from the fact that evil is not a being, that it is a concept devoid of meaning; it does not follow that there are no negative values, even among vital values; it does not follow that the pathological state is essentially nothing other than the normal state.” (104)
In general, the theory endorsed by Comte, Bernard and, to a certain degree, Leriche conveys the conviction that man’s action on himself and on his environment must become completely one with his knowledge of man and environment, i.e., it must be only the application of a previously instituted science (104-5). In such a conception, the fact that human consciousness experiences occasions of new growth and theoretical progress in its domain of nontheoretical, pragmatic and technical activity is not appreciated:
“To deny technology a value all its own outside of the knowledge it succeeds in incorporating, is to render unintelligible the irregular way of the progress of knowledge and to miss that overtaking of science by the power which the positivists have so often stated while they deplored it. If technology’s rashness, unmindful of the obstacles to be encountered, did not constantly anticipate the prudence of codified knowledge, the number of scientific problems to resolve, which are surprises after having been setbacks, would be far fewer. Here is the truth that remains in empiricism, the philosophy of intellectual adventure, which an experimental method, rather too tempted, by reaction to rationalize itself, failed to recognize.” (105) [!]
Although Bernard was not blind to the importance of the intellectual stimulus provided to physiology by clinical practice (105), he still gave greater weight to the physiological explanation than to the pathological fact. In C’s words: “The pathological fact accepts explanation more than it stimulates it.”
However, this is problematic:
“[The identity-view:] For whoever knows physiology, diseases verify the physiology he knows, but essentially they teach him nothing; phenomena are the same in the pathological state, save for conditions. [C.’s objections:] As if one could determine a phenomenon’s essence apart from its conditions! As if conditions were a mask or frame which changed neither the face nor the picture!” (106)
At this point C. mentions Dr. Victor Prus, a rather obscure physician, who – at the beginning of the 19th century – challenged Broussais’ views. After having challenged the idea that physiology by itself constitutes the natural foundation of medicine, Prus adds:
“If we want to exhaust the question dealt with in this article we would have to show that physiology, far from being the foundation of pathology, could only arise in opposition to it. It is through the changes which the disease of an organ and sometimes the complete suspension of its activity transmit to its functions that we learn the organ’s use and importance […] Thus pathology, aided by pathological anatomy, has created physiology: every day pathology clears up physiology’s former errors and aids its progress.” (107)
Comte and Bernard both claim that the efficacious action is the same as science, which in turn is also identical with the discovery of the laws of phenomena (so: science = (i) efficacious action and (ii) discovery of the laws of phenomena) (107). In this regard, both accept the “universal validity of the determinist postulate”:
“Science rejects the indeterminate [!], and in medicine, when opinions are based on medical palpation, inspiration, or a more or less vague intuition about things, we are outside of science and are given the example of this medicine of fantasy, capable of presenting the gravest perils as it delivers the health and lives of sick men to the whims of an inspired ignoramus.” (108)
That is to say, during the time when pathology was still permeated with prescientific notions, a newly emerging physicochemical physiology, which seemed to meet the demands of scientific knowledge, offered a potential model for the construction of an effective, rational pathology (108).
However, as C. points out, just because of the two (i.e., pathology and physiology) only the latter involved laws and postulated the determinism of its object, this does not necessarily imply that the laws and determinism of pathological facts are the same laws and determinism of physiological facts.
[a] One thing that is problematic here is the idea, adopted by Bernard from Laplace, the father of determinism, that physical determinism is not only a methodological requirement, but is the reality itself (complete and incorrigible). This “closed” version of determinism does not – unlike its “open” (methodological?) counterpart – leave room for corrections of its formulas and laws. This is why, in Bernard’s view, the collaboration between pathology and physiology is not likely to modify and rectify physiological (and on this view, unchangeable) concepts. However, such ahistorical/atemporal understanding of physics is highly dubious, as revealed by Whitehead’s dictum:
“Every special science has to assume results from other sciences. For example, biology presupposes physics. It will usually be the case that these loans really belong to the state of science thirty or forty years earlier. The presuppositions of the physics of my boyhood are today powerful influences in the mentality of physiologists.” (109)
[b] The second thing that is problematic is the reduction of quality to quantity, which is implied in the identity of physiology and pathology (109). Reducing the difference between, say, (example) a healthy man and a diabetic to quantitative difference of the amount of glucose in the body, means “obeying the spirit of the physical sciences which, in buttressing phenomena with laws, can explain them only in terms of their reduction to a common measure” (109-10). However, C. raises the following objection:
“But it should be remembered that, though scientific knowledge invalidates qualities, which it makes appear illusory, for all that it does not annul them. Quantity is quality denied, but not quality suppressed. [Example:] The qualitative variety of simple lights, perceived as colors by the human eye, is reduced by science to the quantitative difference of wavelengths, but the qualitative variety still persists in the form of quantitative differences in the calculation of wavelengths. Hegel maintains that, by its growth or diminution, quantity changes into quality. This would be perfectly inconceivable if a relation to quality did not still persist in the negated quality which is called quantity.” (110) [!!!]
This has direct implications for the relationship between pathology and physiology:
“From this point of view it is completely illegitimate to maintain that the pathological state is really and simply a greater or lesser variation of the physiological state. [a] Either this physiological state is conceived as having one quality and value for the living man, and so it is absurd to extend that value, identical to itself in its variations, to a state called pathological whose value and quantity are to be differentiated from and essentially contrasted with the first. [b] Or what is understood as the physiological state is a simple summary of quantities, without biological value, a simple fact or system of physical and chemical facts, but as this state has no vital quality, it cannot be called healthy or normal or physiological. Normal and pathological have no meaning on a scale where the biological object is reduced to colloidal equilibria and ionized solutions.” [!!!] (110)
The quality of a given state is (at least tacitly) assumed by the working physiologist:
“In studying a state which he describes as physiological, the physiologist qualifies it as such, even unconsciously; he considers this state as positively qualified by and for the living being. Now this qualified physiological state is not, as such, what is extended, identically to itself, to another state capable of assuming, inexplicably, the quality of morbidity.” (110-1) [!!!]
C. drives the final nail in the coffin:
“Of course this is not to say that an analysis of the conditions or products of pathological functions will not give the chemist or physiologist numerical results comparable to those obtained in a way consistent with the terms of the same analyses concerning the corresponding, so-called physiological functions. But it is arguable [objection 1] as to whether the terms more and less, once they enter the definition of the pathological as a quantitative variation of the normal, have a purely quantitative meaning. Also arguable [objection 2] is the logical coherence of Bernard’s principle: ‘The disturbance of a normal mechanism, consisting in a quantitative variation, an exaggeration, or an attenuation, constitutes the pathological state.’ As has been pointed out in connection with Broussais’s ideas, in the order of physiological functions and needs, one speaks of more and less in relation to a norm. For example, the hydration of tissues is a fact which can be expressed in terms of more and less; so is the percentage of calcium in blood. These quantitatively different results would have no quality, no value in a laboratory, if the laboratory had no relationship with a hospital or clinic where the results take on the value or not of uremia, the value or not of tetanus. Because physiology stands at the crossroads of the laboratory and the clinic, two points of view about biological phenomena are adopted there, but this does not mean that they can be interchanged. The substitution of quantitative progression for qualitative contrast in no way annuls this opposition. It always remains at the back of the mind of those who have chosen to adopt the theoretical and metrical point of view. When we say that health and disease are linked by all the intermediaries, and when this continuity is converted into homogeneity, we forget that the difference continues to manifest itself at the extreme, without which the intermediaries could in no way play their mediating role; no doubt unconsciously, but wrongly, we confuse the abstract calculation of identities and the concrete appreciation of differences.” (111-2) [!!!]
Part Two: Do Sciences of the Normal and the Pathological Exist?
Chapter I: Introduction to the Problem
C. notes that, unlike physicians and physiologists, contemporary psychiatrists (Claude Blondel, Daniel Lagache, Eugene Minkowski) have brought about a rectification and restatement of the concepts of normal and pathological. Perhaps the reason for this lies in the closer ties between psychiatry and philosophy via psychology (115).
Here’s a short summary. According to Blondel, there are cases of insanity where the doctor has the impression of dealing with another mental structure. The issue is that, when sick men try to express their experiences, they are forced to use ordinary concepts, which are not suitable for what they are experiencing, i.e., the patient is deprived of appropriate concepts (116).
Lagache is less radical in this regard, claiming that, when it comes to abnormal consciousness, there exit “variations of nature” – cases when the patient’s personality is heterogeneous with his former personality (incomprehensible psychoses) – and “variations of degree” – cases where the patient’s personality remains homogenous with his former personality (comprehensible psychoses). Thus, psychosis can be used to shed light on normal consciousness (116). However, one needs to tread carefully here, since pathological symptoms cannot be compared with elements of normal consciousness, for the simple reason that a symptom has a pathological significance only in the context of the global disturbance (example: a verbal hallucination is involved in delirium, which is an alteration of the personality). Thus, although pathological data can be useful for general psychology, the originality of the pathological needs to be recognized: morbid disorganization is not the symmetrical inverse of normal organization, for there are pathological phenomena that have no equivalent in the normal state, and yet by which general psychology is enriched (117).
Minkowski agrees with the idea that there is a radical alterity in the experience of madness. The madman is not so much deviant as (radically) different, and is detached “from everything which forms men and life” (117). In Minkowski’s views, insanity has its one unique characteristics, which are not contained in the (general) concept of disease. For him, mental illness is a more directly vital category than disease: somatic disease does not rupture the harmony between fellow creatures, while the physically abnormal person has no consciousness of his state (118).
C. disagrees with M. on this last point – the purported difference between insanity and somatic disease -, and thinks that it is in opposition with M’s general take on life, construing it – in line with Bergson’s philosophy – as “a dynamic force of transcendence”). For if such a construal is taken seriously, one is forced to treat somatic and psychic anomaly in the same way (118-9).
C. quotes Ey, who, apparently, sympathizes with Minkowski’s views:
“The normal man is not a mean correlative to a social concept, it is not a judgment of reality but rather a judgment of value; it is a limiting notion which defines a being’s maximum psychic [physical, cf. below] capacity. There is no upper limit to normality.”
He proposes that we should simply replace “psychic” with “physical” to obtain what he feels is a very correct definition of the concept of the normal regularly used in the physiology and medicine of organic diseases (119).
Further, there are good reasons for adopting such a definition, for, in the final analysis, it is the patients who usually decide whether they are no longer normal or whether they have returned to normality:
“For [example] a man whose future is almost always imagined starting from past experience, becoming normal again means taking up an interrupted activity or at least an activity deemed equivalent by individual tastes or the social values of the milieu. Even if this activity is reduced, even if the possible behaviors are less varied, less supple than before, the individual is not always so particular as all that. The essential thing is to be raised from an abyss of impotence or suffering where the sick man almost died; the essential thing is to have had a narrow escape.” (119)
Example: young man whose arm was arm was severely injured; after the injury, the movement in that arm is severy limited; and in comparison with the other (normal) arm, the range of motions and movements will be significantly impaired; but on the whole, the man can take up the trade again, on which he places a reason for living; socially, he will continue to be appreciated according to former norms (he will still be a cartwright, etc.), even if his output is a bit lower or if he needs to adopt different behavioural strategies to achieve his end goal; the sick man loses sight of the fact that, on account of injury, he will from now on lack various neuromuscular adaptations and improvisations; and for the most part, the practicing physician is often happy to agree with his patients in defining the normal and abnormal according to their individual norms – except in the cases where there is blatant ignorance on the part of the patient of the minimal anatomical and physiological conditions of life (119-121).
Jaspers, says C., was well aware of the difficulties that bedevil this medical determination of the normal and health:
“It is the physician who searches the least for the meaning of the words ‘health and disease.’ He is concerned with vital phenomena from the scientific point of view. More than the physician’s judgment, it is the patients’ appraisal and the dominant ideas of the social context, which determine what is called ‘disease’.” (121)
One common point in contemporary and past conceptions of disease is that they form a judgement of virtual value. (a) “Disease is a general concept of non-value which includes all possible negative values.” To be sick is to be harmful, undesirable, socially devalued, etc. (b) On the other hand, we find desirable values, such as “life, a long life, the capacity for reproduction and physical work, strength, resistance to fatigue, the absence of pain, etc.” The real task of medical science is to determine what are the vital phenomena with regard to which men call themselves sick: what are their origins, their laws of evolution, the actions which alter them:
“The general concept of value is specified in a multitude of concepts of existence. But despite the apparent disappearance of any value judgment in these empirical concepts, the physician persists in talking of diseases, because medical activity, through clinical questioning and therapeutics, has a relationship with the patient and his value judgments.
It is perfectly understandable, then, that physicians are not interested
in a concept which seems to them to be too vulgar or too metaphysical. What interests them is diagnosis and cure. In principle, curing means restoring a function or an organism to the norm from which they have deviated. The physician usually takes the norm from [1] his knowledge of physiology – called the science of the normal man – from [2] his actual experience of organic functions, and from [3] the common representation of the norm in a social milieu at a given moment. Of the three authorities, physiology carries him furthest. Modern physiology is presented as a canonical collection of functional constants related to the hormonal and nervous functions of regulation. These constants are termed normal insofar as [a] they designate average characteristics, which are most frequently practically observable. But they are also termed normal because [b] they enter ideally into that normative activity called therapeutics. Physiological constants are thus normal in [a] the statistical sense, which is a descriptive sense, and in [b] the therapeutic sense, which is a normative sense.” (122)
The crucial dilemma here is the following:
(1) whether (a) the descriptive sense determines (b) the normative sense (i.e., whether medicine converts purely descriptive concepts into biological ideals);
(2) whether (b) the normative sense determines (a) the descriptive sense (i.e., whether medicine, in adopting constants from physiology, is not taking back what it itself had given) (123).
