For a fish, one of the most difficult things to notice is the fact that it spends every moment of every day in water. Water is such a ubiquitous and ever-present feature of its experience that it goes through its days unaware of this utterly pervasive feature of its daily life. Something similar can happen to human beings, for whom constant features of daily experience can prove difficult to recognize and therefore difficult to understand with any degree of depth. The 18th-century philosopher Immanuel Kant famously suggested that space and time represent two such underappreciated facets of experience .
Radiology and radiologists are in a similar boat, at least when it comes to the role of “seeing” in the contemporary practice of medicine. Anyone who knows anything about radiology recognizes that it is an inherently visual field. The role of vision in the field is so central that to speak of a blind radiologist would be oxymoronic. Throughout each workday, the radiologist uses the power of vision to inspect images of the interior of the human body, attempting to detect and characterize the telltale signs of health and disease.
But built into this approach to medical diagnosis is a wealth of assumptions that many radiologists have barely paused long enough to recognize, let alone ponder or critically inspect. To see these assumptions for what they are, it is necessary to look at medicine through the lens of history. There was a time when our current way of thinking about health and disease was radically new. To understand this paradigm in depth, we need to see it anew, by gaining some insights into both the paradigm it replaced and the nature of the replacement it represented.
In his book, The Birth of the Clinic , French historian Michel Foucault argues that a radical transformation took place in medicine in the late 18th century . This shift involved a change in medical perception, as indicated by the book’s subtitle, An Archaeology of Medical Perception . The central concept here is what Foucault calls the “medical gaze,” which refers to the way the physician observes the patient, including the various features of disease that the sick person may demonstrate . According to Foucault, in the 18th century, physicians began to see patients very differently .
One crucial assumption here is that perception is not a strictly physiological or even psychological phenomenon. The cornea, lens, and retina, optic nerve, and visual cortex all play a vital role in enabling us to see, but what we in fact see is also affected by how we look and what we expect to find. The spirit of this point of view is well captured in the adage, “You only find what you look for.” Foucault believes that our vision is shaped by historical and cultural factors, and that physicians in the 17th and 19th century literally perceived their patients in radically different ways .
What, precisely, was the nature of this shift? This question is best answered with respect to the questions physicians put to their patients. At the beginning of the 18th century, physicians tended to ask their patients, “What is the matter with you?” . The expectation was that the patient would describe some disruption or alteration in their daily experience, such as difficulty breathing or walking. The idea was that disease involved the whole person, and that to understand what was ailing a patient, it was necessary to take the whole person into account.
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Disease is no longer a bundle of characters disseminated here and there over the surface of the body and linked together by statistically observable concomitances and successions; it is a set of forms and deformations, figures, and accidents and of displaced, destroyed, or modified elements bound together in sequence according to a geography that can be followed step by step. It is no longer a pathological species inserting itself into the body wherever possible; it is the body itself that has become ill.
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References
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