Against Utopia Issue #3: The Epistemology of Depression Part 3 - How We "See" Depression
Hello, and welcome to Against Utopia, a newsletter that lifts the veil of authoritarian utopianism in science, technology, politics, culture, and medicine, and explores anti-authoritarian alternatives. This is Issue Three, published May 30th, 2018.
At the end of the last issue, I said we’d talk about “The Medical Epistemology of Drug Development for Antidepressants”, which I thought would dovetail nicely from what we learned about depression and serotonin in mammals and humans. However, in order for us to now get an understanding of how medical knowledge works in drug development, we first need to explore how the Western medical apparatus sees—specifically, how medical perception was shaped by the sociopolitical climate of the West in the 1800s through to 1950s. So for now, I’m going to take a detour through how this warped perception continues to shape how we think about the body, disease, death, and medicine today, in 2018.
To recap, in Issue #1 we learned what being “against utopia” means; how modern medicine is utopian in vision and execution; how utopianism is authoritarian in that it values some knowledges at the expense of marginalizing or erasing others; and how utopian visions structure sociological and political constructs that inevitably lead to authoritarian outcomes.
In Issue #2, we applied this utopian vision analysis to serotonin and conventional models of depression. We showed how biological knowledge was excluded in this study of depression by heroic simplification. As a result, the mammalian and insect evidence demonstrating the physiology of how serotonin actually works has been neglected.
So in Issue #3, I want to run with this idea of “vision,” but more literally. I want to explore the dilemma of perception in science. I want to help you, reader, see that there are multiple ways of seeing what we call Depression.
Put simply, depression is more than a disease. Culture surrounds the depressive person and gives meaning to the suffering, meaning that changes with context and history. How depression is diagnosed and treated in any society, too, is dependent on cultural conditions. Doctors are not free to practice medicine how they wish but must at least attempt to abide by best practices and standards that they themselves do not establish, but that are established by a common language, discourse, and ways of perceiving. For these reasons, it's critical for us as we think about Depression to examine it in its proper context. How a doctor uses the various human faculties to procure knowledge, generate models, and make sense of what’s going on in a healthy body, a pathological body, and a dead body, and how these all relate to each other, are not objective - they all occur in a culture that shapes their perception, available choices, and actions, at every level of interaction (interpersonal, communal, nation-state).
Let’s get into it.
In The Birth of the Clinic (1963), Michel Foucault follows the reorganization of medical knowledge through the 18th century, resulting in the institutionalization of the modern clinic of post-revolutionary France. Foucault centers his analysis around what he calls the “medical gaze.” The “medical gaze” simultaneously describes three phenomena: 1) the material structure that makes possible a physical analysis of the body via the sensory faculties, 2) the epistemic structure that enables physicians share best practices and a collective history of knowledge of various pathologies, and 3) a taxonomy regarding normative health that enables doctors to diagnose, classify and define illnesses. We’ll call these three historical components of the medical gaze the classificatory gaze (genealogy), the nosological gaze (diagnosis, histories), and the anatomico-clinical gaze (experience derived from material structure).
The classificatory gaze describes how Western medicine worked before the end of the 18th century. Inspired by animal taxonomy, it was a theory of medicine that sought to group diseases hierarchically within families, genera, and species. Causal and temporal evolutions were normalized to the present only, and the perception of a given disease was as a state without depth in time or space. A given disease was distinguished by its key symptoms and features, and it was believed to be closed, systemic, and self-contained. It’s evolution in time filled in gaps in knowledge, but even this was problematic as time evolution of disease did not matter as much as holding the features static for classification. In fact, the patient’s own experience would only hamper classification, as every individual’s signs of progression muddled classification.
For example, phthisis, what we now just call tuberculosis, was understood as a vast space of wasting diseases accompanied with fever and inflammation. Phthises were grouped into phthises of the eye, the kidney, and more, and the specific disease of phthisis became classified as one of wasting, and not of inflammatory lung disease caused by an infection of Mycobacterium tuberculosis. Physicians of this period merely classified diseases by their common symptoms but did not have a theory of causation until much later (which we’ll examine when we look at the To call tuberculosis a bacterial disease was not possible, no matter what empirical methodology one chose, simply because it could not be conceptualized in any other way; its species classification demanded that it be nested within the species of phthisis. This becomes more clear when you realize that the analogy was key to the classificatory gaze. Practicing doctors of the 18th century compared numerous cases and constructed ontologies of disease that would give them complete pictures of disease, so that physicians could structure and communicate about the world of disease.
Foucault believed that the basis of our knowledge is the set of language. Language is what allows us to articulate experience but it also constrains how we can express ourselves. In this way, language shapes our knowledge and what can be named by language implicitly obscures other possibilities of interpretation. Thus, the shape of discourse in turn shapes medical knowledge, and phthisis offers a perfect example of this. To decry phthisis as unscientific, and correctly point out that tuberculosis bacterium is the ultimate cause of consumption, this would not have done much to alter the actual practice of medicine in the 18th century. Doctors of the 18th century would not know what to do with the empirical reality of bacterial infection. They would not have an appreciation for how the body’s immune system processes bacterial infection. They would not have the language to talk about it. The classificatory gaze itself, the way we see, shapes the discourse of tuberculosis, and also stands in the way of other possibilities.
The nosological gaze was the another perception mechanism of the antebellum period. Now, it was already understood that the primary space of disease was its locus within the genealogy - its classification. It’s secondary spatialization, how it was embodied in the organs and tissues, was underutilized because it lacked coherence. It was only tied together by clinical experience, and clinical experience was seen as faulty, prone to error, and ahistorical (seen as impossible to tie together). Early 19th century nosology defined clinical experience further with symptoms and signs, and this was when doctors began to make progress beyond classification.
Symptoms were understood as visible presentations of pathological essence regardless of the individual patient. They were universally accessible. Signs implied the fate of the individual patient, and were tied to the course of the disease, and outcomes. As the clinic began to take hold as the primary way to teach medical histories, essences of disease were left behind: the direct experience of the clinician took precedence over any classification, and temporal phenomenon began to be integrated more tightly into the practice of medicine, as a result of direct experience. The primary spatialization, as we said above, was the disease place in the family; the body and organs embodied the disease, but merely as a secondary spatialization outside of the classification. With the nosological gaze born of the clinic, this spatialization took more and more precedence, and the space of thought moved from the imaginary of classifications to the embodiment of disease in a person.
There was a problem here of course - the path of disease is usually uncertain, non-linear and unpredictable. How did we know that a cough with fever with no sputum was not tuberculosis, when a cough with blood would occasionally clear up with no intervention? What was to be done to address these cases?
In the early 19th century, mathematician Pierre-Simon Laplace presented a new methodology for resolving this problem: statistics. The grand project of taxonomizing disease was abandoned for the application of empirical measure, the probability of signs, symptoms, and ultimately disease. The false binary of health and illness was dissolved. . How would statistics come into play?
One way to study disease would be to cut a person open and directly gaze at the lesions in their body to monitor the course of disease. This was of course unethical, but vivisecting and examining corpses was not. By studying the dead in the 19th century, researchers began to be able to define health in opposition to pathological states observed among the sick and the dead. But because health was so broadly defined in this way, it was at this point that Foucault observed the discrepancy between genealogies (classificatory gaze) and experience (nosological gaze) could begin to be bridged in the discourse of doctors. Probability gave doctors a gradient from which to walk from the observed lesions and seat of disease in a dead body, to the pathological states of normative health observed in a still living person. One could look at the lesions in the liver left behind from cirrhosis in a chronic alcoholic, and surmise that a sore liver coupled with yellowed eyes and skin indicate a particular progression and probability of morbidity vs. someone with a blocked bile duct who was otherwise fine. A gradation could be formed in the discourse that helped to finally migrate from a static ontology of classifiable diseases, to the lived experience and probabilistic progression of observed disease. This set the stage for the anatomico-clinical gaze.
As the 19th century practice of medicine developed, the anatomico-clinical gaze began to take shape. Surely, there had been many people before the 18th century who cut a person open to see what was inside, but it was not until the 19th century that we would see researchers using systemic knowledge derived from the scientific examination of thousands of dead bodies to bridge this gap and inform healthy states of being. The theory of a medicine of species had become increasingly inadequate as theories and classification were not often enough, yet practice was found wanting and did not equal theory in application. The two, theory and practice, were linked by the experienced anatomico-clinical gaze. In a language of probability for instance, this gaze was trying to bridge between the uncertainty of what was hidden beneath the surface and could only be observed via symptoms and signs, with the total certainty of death as examined by autopsy. A physiologically-based nosology becomes possible with this linkage, and the temporality of symptoms and disease can be mapped on the spatiality of the tissues, with probability used to fill in the gaps in course.
That brings us to the 20th century and how medical researchers “do” science today. If statistics helped researchers resolve previous empirical error it seems that by the 20th century, researchers have doubled down on statistical objectification as an ideological commitment. Contemporary medicinal research has developed a jargon and concomitant gaze deeply entrenched in the symbol system of mathematics and probability. I’m going to call this the statistical-inferential medical gaze.
You’ve probably experienced the statistical-inferential medical gaze if you’ve ever asked your doctor for an opinion on a potential operation. If it is an iffy situation, either likely to result in potentially bad outcomes, or even better, uncertain outcomes , in between hems and haws your doctor will likely say something along the lines of:
“50% of the time the operation is a success, but that should be weighed against the costs of surgery, financial and otherwise”
“These types of cysts generally have a very low likelihood of becoming malignant, therefore not operating is probably the best option, but they can get ugly, so if cosmetic reasons matter to you operation is valid”
“1 in 5 patients experience improved symptoms on <anti-depressant drug> within 90 days, 1 in 20 experience suicidal thoughts, and 2 out of 5 do not respond. It has a low likelihood of working for you because of <potential complication>, so let’s try <more aggressive or expensive drug>”
Now we have a firm understanding of how contemporary doctors “see” disease and treatment through the hegemonic lenswork of probability. From here, we can now examine how the modern language of the doctor shapes their knowledge of our bodies. We can use the statistical-inferential medical gaze to construct our own history of what normal and pathological mental states are, how depression emerges and is quantified in this gaze, and what experiences these power structures exclude, at great cost to us. We’ll cover that next by looking at the statistical-inferential medical gaze in the mid 20th century, the classification of depression, and the development of the first SSRIs in the pharmaceutical-industrial complex model. Thanks for reading.
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Foucault, Michel. The Birth of the Clinic: An Archaeology of Medical Perception. London: Routledge, 2010. Print.
Montgonery, K. How Doctors Think. Oxford: Oxford UP, 2006. Print.
Dumit, Joseph. Drugs for Life: How Pharmaceutical Companies Define Our Health. Duke University Press, 2012.