by Antoine Lentacker
For all their concern with the nature of medical authority, historians of medicine have paid remarkably little attention to the history of the medical script, the main medium in and through which the doctor’s authority is enacted. This essay analyzes the medical prescription as an instance of a written performative. While focusing on the changing uses of one particular documentary genre in turn-of-the-twentieth-century France, it seeks to outline a broader theory of graphic performativity, or of the conditions under which the symbolic power of the oral performance is transferred and transformed as it is transcribed on paper.
Although a somewhat stern personality, Paul Brouardel, dean of the Paris School of Medicine, enjoyed an occasional night out at the theater. On one such night in the late 1890s he had found himself particularly entertained by a vaudeville scene that had some relevance to his line of work, so he decided to relate it to his students. That scene, in his summary, involved an on-duty physician at a fictive theater who, longing for a night off, left his seat to a friend who was a stranger to the medical arts. By a stroke of fate, a young lady in attendance that night finds herself unwell, and all eyes turn toward the man occupying the on-call doctor’s seat. Put on the spot, the doctor’s friend quickly realizes he has no way out, so he rushes to the patient’s side, unlaces her corset, and, for good measure, pretends to write up a prescription, scribbling a few words without rhyme or reason on a slip of paper and signing it as illegibly as he could. While the ink is still drying, the script is snatched out of his hands and an usher is dispatched with it to the nearest pharmacy. Thankfully, the potion he returns with has the effect everyone counts on, and the indisposed spectator promptly recovers her health.
How are we to interpret such a scene? Is it that the prescription is useless? If a cure can be effected with a prescription that is senseless, illegible, and apocryphal—hence flawed in all the ways that seem to matter—what added value, we might ask, is there in the proper prescriptions of licensed and qualified physicians? Or is it on the contrary that the prescription does it all? That the accuracy of the diagnosis and the nature of the drug prescribed matter less in achieving the desired effect than the ritual of the prescription itself? Brouardel did not tell his students. Instead, he deemed the story “very fitting in a comedy, but not so in practice” and proceeded to lecture his audience on the need to write prescriptions clearly and legibly. Only later, in an article of 1905, did he appear to ponder what might have been the implicit lesson of the comedy he had delighted in ten years earlier:
The first source of the efficacy of the physician’s action is the trust that the sick place in him. The patient complies with and fulfills prescriptions in whole only if he surrenders completely to the authority of his physician. Trust sustains his moral fortitude; moral fortitude acts upon physiological processes; hope restores strength and resilience in the struggle against disease. The lack of trust has the opposite effect. Prescriptions fail to be fully observed; despair takes hold of the patient and recovery is compromised.
This essay follows Brouardel’s lead in accounting for the double nature of the prescription as both a drug to be consumed and an order to be trusted and obeyed. While suspending judgment on his psychophysiological speculations, it also sees the efficacy of the prescription as residing in an alchemy of words and gestures as much as in a chemistry of substances, and it sets out to describe what this symbolic efficacy owes to the form and medium in which the prescription is administered.
To name and analyze the symbolic powers of the medical script, I shall argue, we need a concept of graphic performativity. In elaborating this concept, two main pitfalls ought to be eschewed. The first mistake would be to locate the powers of performative speech in speech itself rather than in the relations of power between speakers and their addressees. Instead, we need to understand performativity as John Austin originally did—namely, as a theory of ritual whose efficacy is linked to a number of sociohistorical, as well as linguistic, conditions. Of the “conditions of felicity” of performative speech, the first to be mentioned in How to Do Things with Words is the “position of the speaker”: to produce its effect, ritual speech must be delivered by the “person appointed” to do so. Socially efficacious speech, in other words, is inseparable from the casts of socially codified roles in which speech is produced. In this sense, a theory of the performative speaks to the vaudeville scene Brouardel related to his students. The prescription in that instance worked its magic only because its author was, quite literally, in the doctor’s place, and also of course because he was a man of a certain age and poise, the sort of man who could claim doctors among his friends. Furthermore, it speaks to a rich historiography on the changing roles of doctors, patients, and (to a lesser degree) pharmacists in nineteenth-century medicine, a body of work in which few subjects have been as thoroughly investigated as has the struggle of an institutionalized medical profession for the exclusive authority to diagnose and to prescribe.
The opposite pitfall, however, would be to view the script as merely registering or reflecting relations of power constituted elsewhere and by other means. Authority is relational, and so it ought to be examined through its media as well as through its figures or possessors. On this the historiography has less to offer. For all their interest in the deployment of professional authority, medical historians have left the prescription, the main medium in and through which the doctor’s authority is expressed and enacted, virtually unattended. And so does Austin, whose performatives are typically oral performances engaging a kind of spectacle of the speech act. While there is no doubt that prescribing is a performative in Austin’s sense, a speech act whose proper performance endows words with a certain binding force and validity, it is an act deposited in a graphic artifact and mediated by it. Once the patient walks away from the stage of the medical consultation, the performance is over and only a script remains. Hence the specific question here is: How to do things with written words? As a general rule, writing frees the powers of speech from the body of the speaker, even as it threatens to undermine these powers by severing the link to the performance and performer from which they emanate. This means that there are specific conditions of felicity to the written performative—and specific ways it can go wrong.
By graphic performativity, then, I refer to the ways in which the graphic artifact captures and transforms the powers of the oral performance as it is transcribed on paper. My argument takes aim throughout at what might be termed a fetishism of the document. Documents do not attest, authorize, or document on their own, but only within shifting scriptural usages, practices, and institutions. To illustrate this point, I focus on one specific moment in the history of the medical script and examine it from the viewpoint of the three main figures involved in acting it out—physicians, pharmacists, and patients. The special attention the genre attracted in fin de siècle France resulted from the rise of a vast proprietary drug industry whose products were advertised in newspapers and available over the counter. France was not unique in this, but, for reasons explained in the first section of the essay, it was exemplary. French physicians during this period registered with unique acuity the erosive effects of printed medical advice on the authority of the script. Their conversations on the subject generated the trove of sources on which this essay relies. The next two sections consider the matter from the perspective of the pharmacist who judges the validity of the doctor’s note. This allows for a description of some of the concrete ways in which the script creates or loses a connection to the original scene of its production. The final section returns to the effect of the prescription on the patient. Its goal is to reveal the script as a medium in which the subject positions of physician and patient were not merely mirrored but also at once made, maintained, and destabilized. Continue reading …
ANTOINE LENTACKER is Assistant Professor of History at the University of California, Riverside. His work is broadly dedicated to investigating the effects of changing communication technologies on the governing of people and things in Europe since 1800.