The Archeology of Knowledge Michel Foucault contents part I introduction 3

4. THE FORMATION OF
ENUNCIATIVE MODALITIES

Qualitative descriptions, biographical accounts, the location, interpret­ation, and cross-checking of signs, reasonings by analogy, deduction, statistical calculations, experimental verifications, and many other forms of statement are to be found in the discourse of nineteenth-century doctors. What is it that links them together? What necessity binds them together? Why these and not others? Before attempting an answer to such questions, we must first discover the law operating behind all these diverse statements, and the place from which they come.
(a) First question: who is speaking? Who, among the totality of speaking individuals, is accorded the right to use this sort of language (langage)? Who is qualified to do so? Who derives from it his own special quality, his prestige, and from whom, in return, does he receive if not the assurance, at least the presumption that what he says is true? What is the status of the individuals who — alone — have the right, sanctioned by law or tradition., juridically defined or spontan­eously accepted, to proffer such a discourse? The status of doctor involves criteria of competence and knowledge; institutions, systems,

((56))

pedagogic norms; legal conditions that give the right — though not without laying down certain limitations — to practise and to extend one^'s knowledge. It also involves a system of differentiation and relations (the division of attributions, hierarchical subordination, functional complementarity, the request for and the provision and exchange of information) with other individuals or other groups that also possess their own status (with the state and its representatives, with the judiciary, with different professional bodies, with religious groups and, at times, with priests). It also involves a number of charac­teristics that define its functioning in relation to society as a whole (the role that is attributed to the doctor according to whether he is con­sulted by a private person or summoned, more or less under compul­sion, by society, according to whether he practises a profession or carries out a function; the right to intervene or make decisions that is accorded him in these different cases; what is required of him as the supervisor, guardian, and guarantor of the health of a population, a group, a family, an individual; the payment that he receives from the community or from individuals; the form of contract, explicit or implicit, that he negotiates either with the group in which he practises, or with the authority that entrusts him with a task, or with the patient who requests advice, treatment, or cure). This status of the doctor is generally a rather special one in all forms of society and civilization: he is hardly ever an undifferentiated or interchangeable person. Medical statements cannot come from anybody; their value, efficacy, even their therapeutic powers, and, generally speaking, their existence as medical statements cannot be dissociated from the statutorily defined person who has the right to make them, and to claim for them the power to overcome suffering and death. But we also know that this status in western civilization was profoundly modified at the end of the eight­eenth century when the health of the population became one of the economic norms required by industrial societies.
(b) We must also describe the institutional sites from which the doctor makes his discourse, and from which this discourse derives its legitimate source and point of application (its specific objects and instruments of verification). In our societies, these sites are: the hospital, a place of constant, coded, systematic observation, run by a

((57))

differentiated and hierarchized medical staff, thus constituting a quan­tifiable field of frequencies; private practice, which offers a field of less systematic, less complete, and far less numerous observations, but which sometimes facilitates observations that are more far-reaching in their effects, with a better knowledge of the background and environ­ment; the laboratory, an autonomous place, long distinct from the hospital, where certain truths of a general kind, concerning the human body, life, disease, lesions, etc., which provide certain elements of the diagnosis, certain signs of the developing condition, certain criteria of cure, and which makes therapeutic experiment possible; lastly, what might be called the ^'library^' or documentary field, which includes not only the hooks and treatises traditionally recognized as valid, but also all the observations and case-histories published and transmitted, and the mass of statistical information (concerning the social environment, climate, epidemics, mortality rates, the incidence of diseases, the centres of contagion, occupational diseases) that can be supplied to the doctor by public bodies, by other doctors, by sociologists, and by geographers. In this respect, too, these various ^'sites^' of medical dis-course were profoundly modified in the nineteenth century: the importance of the document continues to increase (proportionately diminishing the authority of the book or tradition); the hospital, which had been merely a subsidiary site for discourse on diseases, and which took second place in importance and value to private practice (in which diseases left in their natural environment were, in the eight­eenth century, to reveal themselves in their vegetal truth), then becomes the site of systematic, homogeneous observations, large-scale confrontations, the establishment of frequencies and probabilities, the annulation of individual variants, in short, the site of the appearance of disease, not as a particular species, deploying its essential features beneath the doctor^'s gaze, but as an average process, with its significant guide-lines, boundaries, and potential development. Similarly, it was in the nineteenth century that daily medical practice integrated the laboratory as the site of a discourse that has the same experimental norms as physics, chemistry, or biology.
(c) The positions of the subject are also defined by the situation that it is possible for him to occupy in relation to the various domains or

((58))

groups of objects: according to a certain grid of explicit or implicit interrogations, he is the questioning subject and, according to a certain programme of information, he is the listening subject; according to a table of characteristic features, he is the seeing subject, and, according to a descriptive type, the observing subject; he is situated at an optimal perceptual distance whose boundaries delimit the wheat of relevant information; he uses instrumental intermediaries that modify the scale of the information, shift the subject in relation to the average or immediate perceptual level, ensure his movement from a superficial to a deep level, make him circulate in the interior space of the body — from manifest symptoms to the organs, from the organs to the tissues, and finally from the tissues to the cells. To these perceptual situations should be added the positions that the subject can occupy in the infor­mation networks (in theoretical teaching or in hospital training; in the system of oral communication or of written document: as emitter and receiver of observations, case-histories, statistical data, general theor­etical propositions, projects, and decisions). The various situations that the subject of medical discourse may occupy were redefined at the beginning of the nineteenth century with the organization of a quite different perceptual field (arranged in depth, manifested by successive recourse to instruments, deployed by surgical techniques or methods of autopsy, centred upon lesional sites), and with the establishment of new systems of registration, notation, description, classification, inte­gration in numerical series and in statistics, with the introduction of new forms of teaching, the circulation of information, relations with other theoretical domains (sciences or philosophy) and with other institutions (whether administrative, political, or economic).
If, in clinical discourse, the doctor is in turn the sovereign, direct questioner, the observing eye, the touching finger, the organ that deciphers signs, the point at which previously formulated descriptions are integrated, the laboratory technician, it is because a whole group of relations is involved. Relations between the hospital space as a place of assistance, of purified, systematic observation, and of partially proved, partially experimental therapeutics, and a whole group of perceptual codes of the human body — as it is defined by morbid anatomy; rela­tions between the field of immediate observations and the domain

((59))

of acquired information; relations between the doctor^'s therapeutic role, his pedagogic role, his role as an intermediary in the diffusion of medical knowledge, and his role as a responsible representative of public health in the social space. Understood as a renewal of points of view, contents, the forms and even the style of description, the use of inductive or probabilistic reasoning, types of attribution of causality, i.n short, as a renewal of the modalities of enunciation, clinical medicine must not be regarded as the result of a new technique of observation — that of autopsy, which was practised long before the advent of the nineteenth century; nor as the result of the search for pathogenic causes in the depths of the organism — Morgagni was engaged in such a search in the middle of the eighteenth century; nor as the effect of that new institution, the teaching hospital — such institutions had already been in existence for some decades in Austria and Italy; nor as the result of the introduction of the concept of tissue in Bichat^'s Traite des membranes. But as the establishment of a relation, in medical discourse, between a number of distinct elements, some of which concerned the status of doctors, others the institutional and technical. site form which they spoke, others their position as subjects perceiving, observing, describing, teaching, etc. It can be said that this relation between dif­ferent elements (some of which are new, while others were already in existence) is effected by clinical discourse: it is this, as a practice, that establishes between them all. a system of relations that is not ^`really^' given. or constituted a priori; and if there is a unity, if the modalities of enunciation that it uses, or to which it gives place, are not simply juxtaposed by a series of historical contingencies, it is because it makes constant use of this group of relations.

One further remark. Having noted the disparity of the types of enunciation in clinical discourse, I have not tried. to reduce it by uncovering the formal structures, categories, modes of logical succes­sion, types of reasoning and induction, forms of analysis and synthesis that may have operated in a discourse; I did not wish. to reveal the rational organization that may provide statements like those of medi­cine with their element of intrinsic necessity. Nor did I wish to reduce to a single founding act, or to a founding consciousness the general horizon of rationality against which the progress of medicine grad­ually emerged, its efforts to model itself upon the exact sciences, the

((60))

contraction of its methods of observation, the slow, difficult expulsion of the images or fantasies that inhabit it, the purification of its system of reasoning. Lastly, I have not tried to describe the empirical genesis, nor the various component elements of the medical mentality: how this shift of interest on the part of the doctors came about, by what theoretical or experimental model they were influenced, what phil­osophy or moral thematics defined the climate of their reflexion, to what questions, to what demands, they had to reply, what efforts were required of them to free themselves from traditional prejudices, by what ways they were led towards a unification and coherence that were never achieved, never reached, by their knowledge. In short, I do not refer the various enunciative modalities to the unity of the subject — whether it concerns the subject regarded as the pure founding author­ity of rationality, or the subject regarded as an empirical function of synthesis. Neither the ^'knowing^' (le ^'connaitre^'), nor the ^'knowledge^' (les ^'connaissances^').

In the proposed analysis, instead of referring back to the synthesis or the unifying function of a subject, the various enunciative modalities manifest his dispersion.^' To the various statuses, the various sites, the various sites, the various positions that he can occupy or be given when making a discourse. To th.e discontinuity of the planes from which he speaks. And if these planes are linked by a system of relations, this system is not established by the synthetic activity of a consciousness identical with itself, dumb and anterior to all speech, but by the speci­ficity of a discursive practice. I shall abandon any attempt, therefore, to see discourse as a phenomenon of expression — the verbal translation of a previously established synthesis; instead, I shall look for a field of regularity for various positions of subjectivity. Thus conceived, dis-course is not the majestically unfolding manifestation of a thinking, knowing, speaking subject, but, on the contrary, a totality, in which the dispersion of the subject and his discontinuity with himself may be determined. It is a space of exteriority in which a network of dis­tinct sites is deployed. I showed earlier that it was neither by ^'words^' nor by ^'things^' that the regulation of the objects proper to a discursive

((footnote))

In this respect, the term 'regard medical' used in my Naissance de In Clinique was not a very happy one.

((61))

formation should be defined; similarly, it must now be recognized that it is neither by recourse to a transcendental subject nor by recourse to a psychological subjectivity that the regulation of its enunciations should be defined.
((62))