From Measuring Rods to DNA Sequencing: Assessing the Human [1st ed.] 9789811575815, 9789811575822

Table of contents :
Front Matter ....Pages i-xxi
Introduction: What Measuring Means (Ingrid Voléry)....Pages 1-27
Front Matter ....Pages 29-29
Producing Otherness Through Resemblance: Bodily Orifices and the Measuring of the Human (1800–1860) (Nicoletta Diasio)....Pages 31-64
Talking Bones: Age in Nineteenth-Century Forensic Handbooks (1813–1906) (Ingrid Voléry)....Pages 65-96
Thinking “Quality of Life”: From Measures to Categorizations of the Human Beings (Milena Maglio, Vivien García)....Pages 97-121
Front Matter ....Pages 123-123
Being Born in the Era of Genomics (Jean-Hugues Déchaux)....Pages 125-151
From “Technicized” Bodies to Body Technologies: The Human in Resuscitative Care, Between Objectivization and Subjectivization (Thomas Denise)....Pages 153-171
Front Matter ....Pages 173-173
Bone Geopolitics: Bone Age and the Racialization of Growth in UK and US Pediatrics (1940–1980) (Ingrid Voléry, Marie-Pierre Julien)....Pages 175-203
Models of Corporeality and Controversies Around Puberty (Virginie Vinel)....Pages 205-229
Everyone for Himself and All Together? Thinking “Race” Between Social Science, Epidemiology, and Medicine (Catherine Cavalin, Odile Macchi, Paul-André Rosental)....Pages 231-249
Conclusion: Measurement as an Ontological Scalpel (Ingrid Voléry)....Pages 251-282

Citation preview

HEALTH, TECHNOLOGY AND SOCIETY

From Measuring Rods to DNA Sequencing Assessing the Human Edited by Ingrid Voléry Marie-Pierre Julien

Health, Technology and Society

Series Editors Andrew Webster Department of Sociology University of York York, UK Sally Wyatt Faculty of Arts and Social Sciences Maastricht University Maastricht, The Netherlands

Medicine, health care, and the wider social meaning and management of health are undergoing major changes. In part this reflects developments in science and technology, which enable new forms of diagnosis, treatment and delivery of health care. It also reflects changes in the locus of care and the social management of health. Locating technical developments in wider socio-economic and political processes, each book in the series discusses and critiques recent developments in health technologies in specific areas, drawing on a range of analyses provided by the social sciences. Some have a more theoretical focus, some a more applied focus but all draw on recent research by the authors. The series also looks toward the medium term in anticipating the likely configurations of health in advanced industrial society and does so comparatively, through exploring the globalization and internationalization of health. More information about this series at http://www.palgrave.com/gp/series/14875

Ingrid Voléry  •  Marie-Pierre Julien Editors

From Measuring Rods to DNA Sequencing Assessing the Human

Editors Ingrid Voléry Laboratoire Lorrain de Sciences Sociales Université de Lorraine Nancy, France

Marie-Pierre Julien Laboratoire Lorrain de Sciences Sociales Université de Lorraine Nancy, France

Health, Technology and Society ISBN 978-981-15-7581-5    ISBN 978-981-15-7582-2 (eBook) https://doi.org/10.1007/978-981-15-7582-2 © The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd. 2020 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover image © shuoshu This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

We warmly thank the Laboratoire Lorrain de Sciences Sociales (Université de Lorraine, 2L2S, F-54000 Nancy, France), which contributed not only to financing this book but also, and above all, to the organization of the International Sociology Festival in Épinal (2017) where the authors of this book had the chance to meet each other. We are also grateful to Valentine Leys Legoupil and Tom Smith for translating and especially for their deep commitment to this publication project.

Series Editors’ Preface

Medicine, health care and the wider social meaning and management of health are undergoing major changes. In part this reflects developments in science and technology, which enable new forms of diagnosis, treatment and the delivery of health care. It also reflects changes in the locus of care and burden of responsibility for health. Today, genetics, informatics and imaging and integrative technologies, such as nanotechnology, are redefining our understanding of the body, health and disease; at the same time, health is no longer simply the domain of conventional medicine, nor the clinic. The ‘birth of the clinic’ heralded the process through which health and illness became increasingly subject to the surveillance of medicine. Although such surveillance is more complex, sophisticated and precise as seen in the search for ‘predictive medicine’, it is also more provisional, uncertain and risk laden. At the same time, the social management of health itself is losing its anchorage in collective social relations and shared knowledge and practice, whether at the level of the local community or through state-funded socialized medicine. This individualization of health is both culturally driven and state sponsored, as the promotion of ‘self-care’ demonstrates. The very technologies that redefine health are also the means through which this individualization can occur—through ‘e-health’, diagnostic tests and the commodification of restorative tissue, such as stem cells and cloned embryos. vii

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This Series explores these processes within and beyond the conventional domain of ‘the clinic’ and asks whether they amount to a qualitative shift in the social ordering and value of medicine and health. Locating technical developments in wider socioeconomic and political processes, each book discusses and critiques recent developments within health technologies in specific areas, drawing on a range of analyses provided by the social sciences. The Series has already published more than 20 volumes that have explored many of these issues, drawing on novel, critical and deeply informed research undertaken by their authors. In doing so, the books have shown how the boundaries between the three core dimensions that underpin the whole Series—health, technology and society—are changing in fundamental ways. The data, models and broad protocols used to measure health and the body are fundamental to past and present understanding of biological processes, disease and clinical interventions that define and treat pathologies of one form or another. A number of books in the Series have explored this issue in various contexts, such as Lynch and Farrington’s Quantified Lives and Vital Data (2018). More recently, Oudshoorn’s Resilient Cyborgs (2020) examined the ways in which medical devices and implants deploy different forms of data platforms to both measure and alert users to potential risk or promote health-seeking behavior. Measurement is itself based on different paradigms or models (as we have seen in the 2020 pandemic) based on both ontological and epistemic assumptions about what and why something needs to be measured, how it can then be classified and used as a basis for intervention. This operates not only at an individual level but more widely through, for example, the epidemiological models and statistics used to assess population health. These, in turn, become, as Foucault has argued, powerful discursive repertoires of governmentality and biosocial control. This latest book in the Series edited by Ingrid Voléry and Marie-Pierre Julien provides a very rich and analytically powerful exploration of the meaning(s) of measurement since the mid-nineteenth century to the present day. The introduction to the book provides an excellent account of the sociological, anthropological and historical literature and the different ways in which measurement has been understood and sets up the

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core themes for the more substantive chapters that follow. The book is divided into three main sections that follow the chronology of measurement according to its role in measuring the body and psyche, in objectifying the body (and resistance to this) and in producing hierarchies and inequalities in regard to gender, ethnicity and age. In her conclusion to the book, Voléry captures all these processes in her highly instructive phrase—‘measurement as an ontological scalpel’. With this, she means that measurement is never a neutral tool but always one that cuts and so defines the very nature of its object, gives it its ontological shape and meaning and so produces powerful and diverse biopolitical and cultural classifications of forms of life. In summarizing the book’s overall argument, Voléry says that measurement technologies ‘contribute to the making and reproduction of the human (the person, the subject), as well as enduring modes of division within social groups’. This is a scholarly and fascinating story that readers will find informative and of great value for both their research and teaching. York, UK Maastricht, The Netherlands 

Andrew Webster Sally Wyatt

Praise for From Measuring Rods to DNA Sequencing “This collection is more than a sum of its superb studies at various sites, ranging from bone age in nineteenth century forensic medicine to intensive care units today, of the measurement and mis-measurement of the human body. Together these studies provide a window into how we know and think about what it means, politically and ethically, to be embodied in the modern age.” —Thomas W. Laqueur, Helen Fawcett Distinguished Professor Emeritus, Department of History, University of California Berkeley, USA “From Measuring Rods to DNA Sequencing is a masterful series of explorations into the biopolitics of bodily measurement, exposing the scientific truths of patterns, curves, averages, biomarkers, probabilities, weights, and standards as templates of imperialist modernity itself. Ingrid Voléry and Marie-Pierre Julien have created an inspiring text, compelling readers to rethink the power of quantifying knowledges in the history of human governance, while pointing ahead to liberating transformations of what it means to be human.” —Professor Stephen Katz, Trent University, Canada “Why do you measure and why are you also measured? What measurement tools are used to offer a quantified vision of the body and its parts, its growth, and of human life itself? Is measurement the same thing as quantification? Based on in-depth historical investigations and case studies from the 19th century up to the present day, this book proposes enlightening answers to such questions. Combining basic insight from the ‘classics’—Foucault, Rose—on the political dimension of measurement with contextualizing epistemologies, it brilliantly shows how ontologies emerge from various social ‘assemblages’.” —Marie Gaille, Philosopher, Senior Researcher, Université de Paris-CNRS, France “This book splendidly shows to what extent the measurement of the body is a complex operation: it is part of a system of social transactions, it is shaped by situated configurations of knowledge, it organizes cognitive and technical

conditions under which bodies can be scientifically appropriated. By rooting epistemological reflection in the historicity of tools, practices and institutional and disciplinary spaces, this book powerfully enriches the field of the political, social, and intellectual history of the modes of production of the body.” —Rafael Mandressi, Historian, Senior Researcher, CNRS-EHESS, France

Contents

1 Introduction: What Measuring Means1 Ingrid Voléry Part I The Measurements of the Human Body Between the Nineteenth and the Twentieth Century: from the Flesh to the Subjectivity29 2 Producing Otherness Through Resemblance: Bodily Orifices and the Measuring of the Human (1800–1860)31 Nicoletta Diasio 3 Talking Bones: Age in Nineteenth-­Century Forensic Handbooks (1813–1906)65 Ingrid Voléry 4 Thinking “Quality of Life”: From Measures to Categorizations of the Human Beings97 Milena Maglio and Vivien García

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Part II Between Objectivization and Subjectivization: How Forensic Identification, Genomic Correction and Life Support Technologies Reshape the Frontiers Between Things, Human Person and Social Subject123 5 Being Born in the Era of Genomics125 Jean-Hugues Déchaux 6 From “Technicized” Bodies to Body Technologies: The Human in Resuscitative Care, Between Objectivization and Subjectivization153 Thomas Denise Part III Measurement and the Rise of New Hierarchies Between Human Beings173 7 Bone Geopolitics: Bone Age and the Racialization of Growth in UK and US Pediatrics (1940–1980)175 Ingrid Voléry and Marie-Pierre Julien 8 Models of Corporeality and Controversies Around Puberty205 Virginie Vinel 9 Everyone for Himself and All Together? Thinking “Race” Between Social Science, Epidemiology, and Medicine231 Catherine Cavalin, Odile Macchi, and Paul-André Rosental 10 Conclusion: Measurement as an Ontological Scalpel251 Ingrid Voléry

Notes on Contributors

Catherine  Cavalin is a Permanent fellow researcher in sociology at IRISSO (Interdisciplinary Research Institute in the Social Sciences), National Center for Scientific Research (CNRS). She works on the diversity of health statuses and social health inequalities, which include gender, labour and exposure to toxicants at work, as well as interpersonal violence. Catherine Cavalin’s research systematically encompasses a historical and sociological approach of knowledge. She particularly investigates the categories on which statistics are based, and the nosological categories that frame medical knowledge. In 2020, a book on interpersonal violence and public health based on her PhD thesis, and her book on the under-recognition of occupational diseases (coedited) are going to be published. Jean-Hugues Déchaux  is Full professor of sociology at the Université de Lyon, and a member of the Centre Max Weber (UMR 5283). As a sociologist of family and kinship, his recent researches focus on new reproductive technologies and genomics. On these topics, he recently wrote: (2017). “La parenté au crible de la génétique: l’offre de services de deux banques de sperme européennes”, Anthropologie et Santé, 15; (2018). “The Almost Perfect Baby. Genetics, Reproduction, and Eugenics”, Books and Ideas, Collège de France; (2019). “L’individualisme génétique: marché du test xv

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génétique, biotechnologies et transhumanisme”, Revue Française de Sociologie, 60(1), 103–115; (with M-C. Le Pape) (2021). Sociologie de la famille (Third Edition). Paris: La Découverte. Thomas Denise  has a PhD in sociology and is a research associate at the Center for Studies and Research on Risks and Vulnerabilities (Centre d’Etude et de Recherche sur les risques et les vulnérabilités). From sociological and anthropological approaches, he works on life-support services. His research focus is on the social categorizations that lead the care in these services characterized by technology, uncertainty and vulnerability. Nicoletta  Diasio is Full professor of sociology at the Université de Strasbourg, member of the Institut Universitaire de France and member of the research center Dynamiques européennes (UMR CNRS 7367). She is the chief editor of the Revue des Sciences sociales. She studies how societies govern the bodily transformations, time and gender, particularly during the age transitions (childhood, adolescence, “critical age”) and in the experience of chronic illness. On these topics, she wrote: (2019). “Chronic illness and the ideology of the individual: towards a critique of the concept of agency”, Salute e società, XVIII (3), 35–48; (with R. Sirota & L. Hamelin) (2019) “L’intime et le politique. Le corps de l’enfant entre recherche scientifique et action publique”, Enfances, familles, générations, 33; (with Virginie Vinel) (dir.) (2017). Corps et préadolescences. Intimes, privés, public. Rennes: PUR. Vivien García  is a contractual lecturer (A.T.E.R. position) at the Faculty of Medicine of the Université de Lorraine. He has specialized in political and moral philosophy. His research interests focus on power, normativity and technology. In 2014, he has co-authored with M. Maglio “Redéfinir la mort : Entre nécessités pratiques et discours éthiques”, Terrain, 62, 24–35. Marie-Pierre Julien  is Lecturer of Sociology and Anthropology at the Université de Lorraine. She is a member of the Laboratoire Lorrain de Sciences Sociales and her research explores the different conceptions of body, age and food practices, and the relation between practices and categorizations. She is the president of the French Association of Ethnology and Anthropology (AFEA) since 2020. She recently wrote (2020). “Clothing choices and questioning the incorporation of habitus”. In L. Douny & U. Mohan (Eds.), The Material Subject: Rethinking Subjects

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Through Objects and Praxis (pp. 61–74). Londres, New York: Bloomsbury; (with N.  Diasio) (Eds.) (2019). Family Food Practices, Constraints, Adjustments and Innovations. Bruxelles: Peter Lang; (Ed.) (2019). Food provisioning, Review of Agricultural, Food and Environmental Studies RAFES, 99-1. Odile Macchi  oversees the social sciences department at the Paris Samu Social Observatory. She works on homelessness, especially on the biographical pathways of homeless people and their survival methods, using an ethnographic approach, centered on local observations and interviews. She was previously part of a collective research team on occupational and environmental health (ERC Silicosis). She is working on a collective research project on workers' precariousness in economic growth periods in Europe and Asia (ANR Eurasemploi). Part of her research is disseminated through documentary drama performances that she directs. Milena Maglio  works as a consultant at the Clinical Ethics Center of Paris. She is also an associate researcher at SPHERE Research Unit (Université Paris-Diderot). Her research interests focus on moral philosophy and bioethics. She has specialized in the sanctity of life/quality of life debate and in definition of death and end-of-life issues. On these topics she published: (2019) “Jonathan Glover : pour une reformulation du principe de la sacralité de la vie”. Revue canadienne de bioéthique, 2(1); (with Vivien García) (2014). “Redéfinir la mort : Entre nécessités pratiques et discours éthiques”. Terrain, 62, 24–35. Paul-André Rosental  is a Full professor in modern history at Sciences Po in Paris. He studies the framing and implementation of social, demographic and health policies in Europe during the nineteenth and twentieth centuries and leads the research team ESOPP on these fields (http:// esopp.ehess.fr). He recently wrote: (2018). Population, the State, and National Grandeur. Demography as a political science in modern France. Bruxelles: Peter Lang; (2020). A Human Garden: French Policy and the Transatlantic Legacies of Eugenic Experimentation. New York: Berghahn Books. On the history of occupational diseases, he directed: (2017). Silicosis. A World History. Johns Hopkins University Press; (2015). “From

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Silicosis to Silica Hazards”. American Journal of Industrial Medicine (special issue), 58(S1). Virginie Vinel  is full professor at the Université de Bourgogne Franche-­ Comté, and director of the Laboratoire de Sociologie et Anthropologie (LaSA UBFC). Her research interests cover age, especially age transitions, health, gender and the body. She notably wrote: (with F. Zaltron) (Eds.) (2020). “Enfants. Contraintes et pouvoir d’agir”. Revue des Sciences Sociales, 63; (with V. Kushtanina) (2019). “Agency or disempowerment: Children with learning disorders in France”. Salute e Società, 3, 107–118; (2017). “Générations, genre et classes sociales”. In N. Burnay & C. Hummel (Eds.), Vieillissement et classes sociales (pp. 119-139). Bern: Peter Lang; (with D. Cozzi) (2015). “Risky, early, controversial. Puberty in medical Discourses”. Social Science & Medicine, 143, 287–296. Ingrid Voléry  is full professor of Sociology at the Université de Lorraine and a member of the Laboratoire Lorrain de Sciences Sociales. She both studies age categorizations (in relation to biomedical knowledge, public policies, gender, racialization and social class) and how they are reshaped by social groups. On these topics, she published: (with F. Balard) (2021). La médicalisation des âges en France. Nancy: PUN; (with Marie-Pierre Julien) (2019). “Mesurer les corps pour normer les temps de vie”. Recherches sociologiques et anthropologiques (Special issue), 50(1); or (2015). “Sexualisation and the transition from childhood to adulthood in France: from age-related child development control to the construction of civilisational divides”. Childhood, 23(1), 140–153.

List of Figures

Fig. 2.1 “Profile of the Apollo, of Negro and Orang-outang”, Virey, 1824, BIU Santé, Paris Fig. 2.2 “Degenerated types influenced by the genealogical constitution of the soil in the department of Meuse”, Morel 1857, BIU Santé, Paris Fig. 2.3 “Developmental arrests—hereditary degenerations”, Morel 1857, BIU Santé, Paris Fig. 2.4 “Types of cretinism”, Morel 1857, BIU Santé, Paris Fig. 9.1 The “host–agent–environment” triangle or (triad) Fig. 9.2 The exposome’s three domains, with non-exhaustive examples illustrating their respective components

40 46 48 49 234 235

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List of Tables

Table 3.1

Pagliani’s table, Sopra alcuni fattori dello sviluppo umano, Turin, 1876 (quoted by Lacassagne 1906: 125) Table 3.2 On age (Lacassagne 1906: 123) Table 10.1 The five human measurement styles

82 83 261

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1 Introduction: What Measuring Means Ingrid Voléry

Rom drawing to compasses, tracing papers, measuring rods, statistical tables, or gene sequencers: the tools used to categorize represent and quantify the human have a long history that spans across science, economics, morals, and politics. However, they were recently considered as an object of study, particularly in France where the human body was viewed as a more or less compliant vehicle for social relations of class (Memmi et al. 2009; Jacquot and Voléry 2019). This book aims to contribute to this theoretical and epistemological construction, by reviewing the main analytical frameworks through which the measurement of the human has been understood. It approaches measurement through three key dimensions: as an indicator of distinct worldviews; as a contextualized social activity involving specific tools; and as a practice that produces ontologies—whether those are social hierarchies, subjectivities, or perceptions of time.

I. Voléry (*) Laboratoire Lorrain de Sciences Sociales, Université de Lorraine, Nancy, France e-mail: [email protected] © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_1

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 etting the Measure of Things: G A Macro Approach The first perspective draws from macroscopic philosophical or socio-­ historical approaches, adopting a long-term view of models of interpretation of life in different moments and spaces. Measurement is interpreted as an indicator of particular interpretative frameworks—whether those are examined as historical forms of human cognition, as avatars of power-­ knowledge dispositifs, or as an expression of the rationalization/individualization of the world.

 easurement as an Indicator of Historical Forms M of Human Cognition In the wake of holistic and structuralist sociologies, which attempt to detect patterns in understandings of the world and to connect them to the social contexts in which they emerged (Durkheim 1968 [1912]), some of the contributions to this book focus on the types of thinking that underpin classifications of life. This approach is in line with Ian Hacking’s early studies on probabilistic thinking, although these are more related to cognitive and pragmatic sociology than to structuralist one. Hacking attempts to identify wide frameworks through which humans understand the world: Styles of scientific reasoning have developed over the course of the evolution of human cultures. Each of them has a beginning, which often only subsides in memories as a myth, and each has their own pace of development. Logic, in broadest sense of the term, is a precondition to the emergence of styles of scientific reasoning, but it is not a style in itself. What I refer to as logics includes the rudiments of deduction, induction, the hypothetical method—or what Pierce called abduction—as well as classification practices. The mathematical style, the taxonomic style and all the others have as their prerequisite this combination of cognitive capacities that we call “logics”, which they derive from. It is quite legitimate for the cognitive sciences to investigate these faculties but for the purpose of our argument,

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we will consider them as facts that belong to “the natural history of human beings” whose character tends to “escape remark because we always have them before our eyes” (Wittgenstein). In contrast, the study of styles of reasoning is the object of philosophical anthropology. (Hacking 2003: 547)

While the study of human logical aptitudes is the remit of cognitive science, the way these aptitudes arrange themselves into styles of scientific reasoning falls within the scope of philosophy. Inspired by Anglo-Saxon analytical philosophy as well as by Michel Foucault, Hacking seeks to historicize his epistemological description and analysis. Drawing from the works of historians of science such as Alistair C.  Crombie (1915–1996),1 he focuses on probabilistic thinking (Logic of Statistical Inference 1965, The Emergence of Probability 1975, The Taming of Chance 1990). Hacking identifies two understandings of probability, objective or subjective, examining particularly the necessary conceptual conditions for the emergence of a notion which, in spite of its apparent simplicity, was not established until 1650. He thus considers that the prehistory of a scientific concept is more important than its history because “the preconditions for the emergence of probability determined the space of possible theories about probability” (Hacking 1975: 9). In keeping with Foucault’s archaeological ambition, Hacking widely looks at the social conditions that caused the emergence and dissemination of ways of measuring life, as well as their effects. In particular, he examines the way in which understandings and classifications of the human world shape subjectivities (how people define themselves in relation to the categories they are targeted by), but also material conditions (e.g., diets or medical treatments associated with a person’s categorization as obese which can have bodily effects). Hacking then describes the contemporary characteristics of categories used to analyze the human. Features include the role of quantification (with quantities replacing qualities in our understanding of the human) and biologization (the search for the biological causes of human characteristics, disorders, and behaviors); the inaccessibility of classifications for the people who are classified (e.g., medical and psychiatric categorizations, which become autonomous, depriving those who are classified from the ability to understand the classifications of which they are the

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object); the weight of administrative classifications (classifications of life are an integral part of the biopower described by Foucault, and are used for administrative purposes); normalization (searching for average human features and instituting these averages into a norm); and the re-­ appropriation by certain groups of the categories assigned to them (Hacking 2005: 539). According to Hacking, scientific measurement with a small “m” provides insights into broader socio-cognitive styles whose effects reach beyond scientific spaces. A similar perspective can be found in the writings of Stephen Jay Gould and André Turmel, two major contributors to the studies on measurements of life, including the measurement of human intelligence. In The Mismeasure of Man (1981), Gould investigates the measurement of intelligence in the nineteenth and twentieth centuries: craniometry and later intelligence tests are used to measure intellectual and moral abilities and establish a hierarchy of value between persons as well as between sexes or “racial” groups. Gould highlights the scientific weaknesses of these arguments—some due to cultural biases that affect the ways in which well-meaning researchers interpret the data, others due to data manipulation strategies in particular political contexts. In addition, the author shows how measurement models (cranium volume, brain density, or IQ) and the political contexts in which they are elaborated2 and disseminated3 contribute to the construction of the entities that are measured. More recently, Turmel (2008) approaches measurement from a similar angle: the author starts from an investigation of the methods used to measure children’s intelligence, to shed light on scientific conceptions of childhood and human growth. He identifies six moments. The first moment is clinical observation, inspired by Hippocratic medicine: childhood illnesses are observed on the anatomy tables of dispensaries. The second moment sees the emergence of nineteenth-century populational surveys: children are no longer considered individually but as a populational subgroup whose height, weight, and growth are measured to tackle malnutrition and mortality issues, caused by living conditions and factory work. Comparisons are often drawn between children in urban and rural areas (Villermé, Farr, etc.). The third moment starts from the late nineteenth century, with Charles Darwin (1971 [1877]) taking interest

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in child development after observing his son during the first months of his life. Darwin thus begins to elaborate a developmentalist and biologizing vision of growth. The fourth moment starts with Pastor and the chemical analysis of the cell: childhood is increasingly biologized and is the object of state-led rationalization policies (see Hacking’s description of the weight of administrative classifications). The fifth moment begins with the implementation of systematic surveys of children’s health, leading to the production of averages and representations of the “normal” child. The sixth moment, during the interwar period, sees an increasing psychologization of childhood, with the influence of three key figures in developmental psychology: Alfred Binet (1857–1911), Jean Piaget (1896–1980), and Arnold Gesell (1880–1961). Human maturation is then understood in terms of development and punctuated by linear, standardized, and irreversible sequences. Doing so, Turmel builds bridges between Hacking’s perspective and cognitive sociology. He also extends Gould’s findings to other spaces and types of measurement, including medico-administrative expertise and public health surveys, which have their own measurement models and their distinctive uses of scientific measurements. He also opens the reflection to other “vital phenomena”, including human maturation and consequently, age—an understudied area in research on the measurements of human bodies, to which this book aims to contribute. A second approach, more inspired by Foucault, opens the perspective to embrace non-scientific spaces, focusing on the political and agonistic dimensions of these categorizations.

Measurements and Powers: Foucault’s Heritage Foucault is certainly the second most influential author in studies of the measurement of life. His work provides two major foundations for the analysis of measurement: his archaeology of thinking and epistemes developed in the 1960s, and his analysis of dispositifs of power engaged from the 1970s onward. The episteme, a term by which Foucault refers to “all phenomena formed by relations between sciences, or between diverse scientific discourses” (Foucault 1966), is the bedrock referred back to by the knowledges and thinking frameworks of a given period. As such, it

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underpins both scientific thinking and artistic production, and reflects a specific worldview. For example, Foucault uses Cervantes’ Quixote to illustrate the episteme of difference: a diligent pilgrim breaking his journey before all the marks of similitude. He is the hero of the Same. He never manages to escape from the familiar plain stretching out on all sides of the Analogue, anymore than he does from his own small province. He wanders endlessly over that plain, without ever crossing the clearly defined frontiers of difference or reaching the heart of identity. (Foucault 1966: 51)

Quijote reveals the crisis undergone by this episteme, which according to Foucault tapered off at the turn of the eighteenth century although in fact it continued to shape the nineteenth century: during this period, the world continued to fold in upon itself, and was organized by a dual principle of synchronicity (analogies and correspondences between forms) and diachronicity (searching for resemblance to situate the human within lineages and genealogies—see Diasio’s chapter in this book). The classical episteme, which according to Foucault began in the eighteenth century, is illustrated by Velázquez’s “Las Meninas”: in this painting, the world is approached through representations of representations, but where the subject of knowing is not represented: “In Classical thought, the personage for whom representation exists, and who represents himself within it, recognizing himself therein as an image or reflection, he who ties together all the interlacing threads of the ‘representation in the form of a picture or a table’—he is never to be found in that table himself ” (Foucault 1966: 336), as Velázquez made sure to hide himself in the nooks of his painting. In contrast, from the nineteenth century, the modern episteme was built around the central position of the gazing subject: the measurement of the world is entirely constructed around the human, his gaze, and categories of perception. While Foucault remains vague as to the specific historical conditions that provoked these changes and shaped the concrete deployment of these epistemes in scientific and social spaces, he nevertheless introduces two important notions: first of all, the idea of a bedrock that structures scientific thinking and possibly the models of representation of the world

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that derive from it—including metrologies; secondly, and more importantly, the role played by the measurement of human life in the modern episteme, providing the foundation for the development of life sciences and social sciences. The “zeal” deployed in classifying life in the nineteenth century, which forms the object of Nicoletta Diasio’s and Ingrid Voléry’s chapters, was driven by a quest for the world’s organizing principles, no longer based on transcendence and hermeneutics, but rather on identifying the laws of human nature—both physical and social—and on classification. In this respect, the modern episteme also fundamentally challenged understandings of practices aimed at interpreting life. As a consequence, existing life exploration technologies were imbued with new meaning: for example, dissection, formerly viewed as an instrument supporting the search for Beauty and transcendence, became a technology aimed at investigating the principles that govern the organism’s operation. In The Birth of the Clinic (1963), Foucault shows that the clinical gaze did not emerge because technological progress gave access to new regions of the body: rather, it predated this process and imbued auscultation and dissection with new values, both epistemic (instruments of true knowledge) and moral (necessary to the progress of science). Foucault’s first theoretical proposition is later complemented by his work on the analysis of powers, biopower, and biopolitics at large. In this second part of his work, the author defines a threshold of biological modernity during which the political field takes control over human bodies—considered both as singular individuals needing to be straightened up by anatomo-politics, and as a species whose maturation must be apprehended on a populational scale. Power—and specifically political power—creates regulation or insurance mechanisms aimed at controlling biological processes that affect the populations, thus assigning a political value to these mechanisms. Foucault insists on the economic and political contexts for the emergence of this new analysis of the living world: social medicine, formalized at the turn of the nineteenth century, is described as urban, labor-oriented, and state-led (Foucault 1977). As well as being an indicator of an episteme, measurement also becomes a cog in a complex dispositif of power, or even a technology of government when biopolitics is “statized”—for instance, when national health policies and public hospital networks expand their reach by controlling

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private medical practices and engaging with families who become auxiliaries of this delegated form of biopolitics (Memmi 2004). Foucault then focuses on the bodies and subjectivities generated by this biopower, highlighting the body’s place in contemporary dispositifs of power: power does not just target the body but pervades it and mobilizes it to serve the purposes of government (Discipline and Punish 1975), and even contributes to the emergence of a particular form of care of the self.4 This assertion inspired further research into the impact of categorization technologies on the ways in which those who are classified define themselves. For example, Thomas Denise (Chap. 6) shows how the measurements performed in intensive care departments are not just de-subjectivizing or re-subjectivizing technologies, but also provide ways of disciplining bodies in situations of strong physiological instability. Virginie Vinel (Chap. 8) investigates the body models that underpin categorizations and medical measurements of puberty while questioning the connection between the racialization of measurement and that of young pubescent girls. This second angle in Foucault’s thinking paves the way for a sociology of measurement that considers the political conditions and effects of this practice. This approach was developed and expanded by other scholars who opened their scope to include the economic dimension, which had overall been scarcely considered by Foucault.

Measurement, from Self-Care to Self-Management This second perspective is attentive to the representations that underpin measurement. This time, the focus is not so much on “the politics of life itself ” (Rose 2007) as on a process of individualization, which is analyzed from two angles. Considered from the angle of the cult of the self, measurement appears first as the vector of a worldview that regards the individual as the key unit from which to interpret and modify life. Although self-measurement is not addressed in this book, studies on this topic provide a good illustration of this perspective. In this field, which has been particularly active in recent years, the quantified self, analyzed as an ideology, is seen as an

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expression of the cult of narcissism (Lasch 1979) and of a culture of control in an uncertain world (Beck 2001) where instability prevails (Voléry and Tersigni 2015). This perspective can also be associated with self-­ experimentation (Kristensen and Ruckenstein 2018), pointing to the notion of care of the self as analyzed by Foucault. These approaches interpret measurement as a set of technologies that create and sustain distinctive subjectivities. Secondly, considered from the angle of self-management (Lupton 2013; Pharabod et al. 2013), measurement can appear as an avatar of a neoliberal view that expects the individual to manage and pursue a sort of “bioperfectibility” (Le Dévédec 2008). Regarded as the ultimate form of self-fulfillment (Knorr-Cetina 2005), this quest for biological excellence affects the individual who is measured—in their self-perception but also in their material existence. The “market” pervades the body (Jacquot and Voléry 2019), transforming the status of its cells, genes, or organs: pieces of the person become entities whose value depends on their marketing (Steiner 2010; Lafontaine 2014; Colomb 2019). For instance, studies on the bioeconomy and biobanks have examined the institutionalization of the market of body fragments based on sampling, preservation, and distribution technologies, but also the measurement of the value of these standardized and individualized body fragments. These studies also stress how these technological dispositifs indicate a deep transformation in the status of the body: halfway between person (non-­ marketable) and waste (a thing regarded as worthless but that can still be marketed) (Ogien 2016). Jean-Hugues Déchaux (Chap. 5) follows this perspective in his analysis of the uses and deployment of CRISPR-Cas9 gene editing, which sits at the intersection of two deep cultural shifts: on the one hand, the resurge of a probabilistic reasoning style and on the other, a quest for self-optimization involving not only moral qualities but also the organism, not only the subject but also his/her descendants. In addition to these studies considering measurement in a major key, other works examine measurement in a minor key—considering the act of measuring from diverse theoretical angles.

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 easurement Considered as a Praxis M and a Contextualized Activity This perspective looks at measurement not just as an expression of wider social processes, but as an activity that is performed in specific situations, involving socio-technical networks of professions and objects, and affecting both “measurees” and “measurers” (e.g., see the material semiotic approach conceived by M’Charek 2013).

Measurement as Assemblage Considered not as a representation but as an activity, measurement can first of all be perceived as a complex assemblage of heterogeneous dimensions that accommodate diverse objects, professions, methods, logics of use, and so forth. In his socio-history of quantification technologies examined both as cognitive forms and social practices, Alain Desrosières greatly contributed to formalizing the notion of measurement as assemblage (Desrosières 1995, 1989: 239). The author recommends distinguishing between the multiple operations and objects that form part of the measuring process. The design of classes, numbers, and figures took on diverse forms over time, it was born out of different social contexts, it fed into diverse debates and produced diverse effects. For example, the creation of classes is based on the principle of equivalence, which organizes the heterogeneous matter of the world into classes of homogeneous entities. This operation must be distinguished from quantification, a more recent phenomenon that raises different issues: the question is no longer “can life be organized into classes?” but rather “can it be described through figures?” Although quantification and measurement are often mixed up today due to the major role played by quantification in measurement systems, these two terms must be differentiated (Desrosières 2003). According to Desrosières, measurement implies that “a real thing can be measured according to a realistic metrology” that can assume different forms including cartographic drawing, sound recording, video capture, and so on. In contrast, quantification involves transforming impressions, observations, or words into numbers and “creating a specific

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language characterized by properties such as transferability, potential for standardized manipulation through calculation, and routinized systems of interpretation” (Desrosières 2003: 12). Measurement therefore involves a metrology that can function without numbers and averages (e.g., by combining qualitative measurements), whether those are hetero-­ measurements or self-measurements. Some measurements can indeed combine quantification and observation. For example, Descartes recognized the existence of an original divine force that breathes life into things and can be grasped through the observation of vital phenomena, while also endeavoring to quantify human forms, using mathematics and geometry to understand the laws of human nature (Descartes 1984 [1644]: 101–102). Similarly, while Adolphe Quételet (1835) fine-tuned the notion of average, making it into an essential tool for the description of life, he also took care to specify the range of social and vital phenomena to which his model could not apply (e.g., life expectancy): namely, all the phenomena whose observed values do not follow a “constant cause” (i.e., a Gaussian curve). Quételet believes that new metrologies need to be designed for these phenomena: while he does not embark on this task himself, he does not exclude such metrologies from his project of measuring the vitality of populations. Similarly, nineteenth-century anthropologists quantify the senses of the human body (Dias 2004) without excluding more qualitative dimensions—for example, the “cultural” habits or perceptions of the people under study. Nélia Dias mentions the case of Jean Louis Armand de Quatrefages, who measured the volume of air necessary to ventilate huts—“6 cubic meters of air per hour and per person” (Quatrefages 1884: 556), while also pointing out how cultural learning, past experience, and adaptation to the environment can directly impact his quantitative data (Dias 2016). Dias explains: “While anthropologists generally adopted the same criteria of objectivity as science, they were nevertheless attentive to physiological differences between European and non-­ European peoples, and had to question the very notion of differential sensory threshold” (Dias 2016: 55). In this context, quantification does not necessarily serve the enforcement of standards that abolish human diversity, nor does it prevent from taking human subjectivities into account.

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The composite nature of measurement dispositifs is also due to the diverse graphic systems they resort to. Although it has been understated by the sociology of quantification, the importance of these systems has been particularly highlighted by contemporary historians of science. For instance, Marianne Sommer (2016) analyzes the staging of human bodies or of these bodies’ measurements in exhibitions. Lorraine Daston and Peter Galison (2007) also study graphic representations in their socio-­ history of scientific objectivity between the eighteenth and the twentieth centuries. These philosophers of science identify the four main regimes of objectivity, showing how each of these is associated with a specific graphic style. The first regime “truth-to-nature” is concerned with capturing the quintessence of life behind variations of form: it uses estheticized drawings, in which objectivity relies as much on the scientist’s moral magnitude as on the illustrator’s art: as skeletons differ from one another, not only as to the age, sex, stature and perfection of the bones, but likewise in the marks of strength, beauty and make of the whole; I made choice of one that might discover signs both of strength and agility; … in short, all the parts of it beautiful and pleasing to the eye. For as I wanted to show an example of nature, I chose to take it from the best pattern of nature. (Bernhard Albinus 1747 quoted by Daston and Galison 2007: 73–74)

The second regime, mechanical objectivity, uses numerical surveys and tables, as its purpose is to abolish subjectivity, which is regarded as a source of error in the production chain of measurement. The mechanization of measurement relies on technical devices that are regarded as “neutral” (photography) or is performed by female data entry clerks whose subjectivity is deemed insignificant, thus avoiding any distortion of measurements. The third regime, trained judgment, breaks with this suppression of the observer-measurer. The aim is to be positioned as close as possible to the reality that is being measured, considering that objectivity stems not so much from a mechanical recording as from the technical honing of the researcher’s eye. Graphic representations (e.g., the electrocardiogram) are used to train researchers at discriminating between core measurements (typical curves) and secondary measurements (“noise” in

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the curves). The fourth regime is called structural objectivity. It focuses on regular statistical patterns, mechanization, and a standardized approach to the processing but also to the recording of data, with a preference for statistical and probabilistic graphs. Similarly, in his analysis of statistical thinking, Desrosières insists on the rupture operated in the eighteenth century by the shift from tables to topographies (e.g., diagram or probability tree) (Desrosières 1995: 16). In his study on the emergence and establishment of developmental thinking, Turmel (2008) also scrutinizes the curves used to represent “normal” cognitive maturation in children. In the aforementioned examples, measurement is understood as part of a wider socio-technical network, where one measured object can be “both identical and different, depending on the actions built upon it” (Desrosières 1995: 19). A similar perspective can be found in Voléry’s chapter on the transformations of bone measurement models. The author shows that these are shaped by the ontogenic models in circulation in a given place at a given point in time, but also by the situations in which the measurements are performed (medico-legal assessments that vary according to political and legal policies) and by the socio-technical networks in which these measurements are embedded in: whether the data comes from hygienist surveys or is produced by insurance companies, and whether it is disseminated via European medico-­ legal networks, unlike the anthropometric measurements studied by Diasio in Chap. 2. The effects of reality produced by these dispositifs can also vary. For example, tables de-singularize the data by disconnecting it from the bodies it was extracted from, whereas drawings can artificially maintain such a connection. A diagram, which assembles data in space, can create the sense of a strong logic proximity between measured entities, whereas “average” pictures, used in abacuses for the measurement of puberty or bone maturity, can transform a mathematical artifact (an average) into an “average” body. As pointed out by Daston and Galison, “Not only do images make the atlas; atlas images make the science” (Daston and Galison 2007: 23). Because measurements are regarded as social practices and not just as abstract cognitive or representational forms, they need to be considered within their broader context.

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A Contextualized Activity The contextualization of measurement activities operates on two levels, which this book investigates in detail. The first level is formed by the political context. Each in their own way, Desrosières, Foucault, and Hacking highlight the link between categorizations, metrologies, and government. Measurement is an integral part of the government process, aimed at controlling interpretations of the world. The contributions to this book document the miscellaneous political uses of the diverse measured objects, as well as the variability of their political effects. While Desrosières also demonstrated that numbers and statistics are government technologies, Jean-Pierre Beaud and Claudia Damasceno Fonseca show that they are never used in isolation. In particular, these authors show how colonial governments in eighteenth- and nineteenth-century Latin America used maps in support of numbers (Beaud and Damasceno Fonseca 2017). Pictorial representations of space—not always quantified, or sometimes quantified in a very disparate manner—were used as a model to “know”, but also to make and govern the world. In combination with census statistics from Brazil, these maps were used to unify the nation and wipe out its geophysical and populational diversity.5 This is also apparent in Voléry and Julien’s chapter on the spaces and processes that accommodated the racialization of bone maturation in British and US pediatrics in the late 1970s. Between 1950 and 1970, measurements of child growth took on a new purpose: formerly seen as a way of regulating social class relations (straightening up the bodies of indigent children, offsetting the physical traces of social inequalities through metered comparisons between the growth of children in urban/rural or poor/rich areas), they became a way of regulating the global population, against a backdrop of concerns over the demographic boom of Southern countries and its effects on the populations of Northern countries. The role of proximity was thus reassessed: the initial belief that social proximity necessarily induces ontological and metric sameness (“poor” growth rates are associated with poor neighborhoods) gave way to the idea that a combination of spatial distance and metrologic similarities indicates a hidden shared “racial” identity. If two poor children from the same area do not

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grow up identically, this is seen as an indication of an underlying identity—the racial pattern of growth. The analysis of these different political contexts runs throughout the book, and often opens up onto a geopolitical dimension: either because of the internationalization of measurement dispositifs from the eighteenth century onward or because of the geopolitical stakes of such measurements (demonstrating the strength or the “normality” of a population group, exhibiting the state’s command of sophisticated measuring devices, etc.). This book also explores scientific contexts, another particularly important dimension, showing that the sociology of measurement cannot go without a sociology of science. This point is masterfully demonstrated by Daston and Galison in their exploration of understandings and practices of scientific objectivity, based on the study of controversies but also on that of technologies for the exploration, measurement, and representation of life. In contrast with the static nature of Foucault’s paradigms and episteme, Daston and Galison stress that history is made up “of dynamic fields, in which newly introduced bodies reconfigure and reshape those already present, and vice versa” (Daston and Galison 2007: 19). Measurement can thus be analyzed as a disciplinary field composed of professionals (evidence and measurement workers) and hierarchies (e.g., between those who perform the measurements and those who process the data). And it can also be understood as an activity that does not just affect the entities measured but also the measurers who are themselves classified by the measurements they perform. These hierarchies affect the boundaries between specialisms or professions (e.g., see the role of illustration artists in truth-to-nature, or that of engineers and statistics in the structural objectivity model), but also within professional groups. The objectivity of measurement can thus act as a hierarchizing factor: this is illustrated by the controversy that unfolded between two early twentieth-century histologists about edited images of the brain and measurements of neural activity.6 In a similar perspective, Voléry and Julien also highlight how the racialization of bone measurements is the product of the competition between researchers in Northern and Southern countries. For the latter, being published in scientific journals requires using certain “measurement standards” based on abacuses designed by North European researchers for bodies close to theirs. In

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addition to the boundaries between and within professional groups, measurements also contribute to the redefinition of boundaries between disciplines, as shown by the chapter dedicated to epigenetics. Catherine Cavalin, Odile Macchi, and Paul-André Rosental show that epigenetic measurements have deeply rearranged disciplinary lines in genetics— between so-called classic genetics and epigenetics, but also between life sciences and social sciences (Dubois et al. 2018). Finally, measurement does not just involve linguistic, metric, and graphic aspects: it also produces ontologies.

Measuring to Produce Ontologies Examined in philosophy by Hacking, the links between technologies of intervention on human life and ontologies were investigated in a new light by US medical anthropologies in the 1990s as well as by gender and racial studies, but also in France thanks to the revival of the pragmatic school.

Making Others Evelyn Fox Keller (1985), Emily Martin (1989), Thomas Laqueur (1992), Marilyn Strathern (1992), Nelly Oudshoorn (1994), Anne Fausto-­ Sterling (2000), Delphine Gardey and Ilana Löwy (2000), and Hélène Rouch (2011): these various authors highlight the transformations undergone by technologies used for the measurement and representation of biological sex, and their impact on representations of sex but also on the materiality of sex itself—as measurements often go along with hormonal, surgical, and psychic interventions (e.g., see transgender studies). In addition, this prism of analysis was extended to include studies that took “race” as their object. In 2014, Nicolas Bancel et  al. studied the genesis of scientific understandings of race and their influence on the taxonomy of human collections presented in ethnographic museums and ethnic shows or exhibitions. In 2016, Amos Morris-Reich analyzed the place of photography in the scientific and social thinking of race from

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1876 to 1980. On the same year, in France, Claude-Olivier Doron (2016) studied the thinking of “race” from the eighteenth to the twentieth century, and the raciological models based on “othering” and “alteration” (in French: “altérisation” vs “altération”) made possible by this thinking. Although dispositifs for the measuring of sex or race are not always examined in depth by these scholars, they produce new abstract entities—figures and images—that affect the persons with whom these entities are associated. The chapter in this book by Cavalin, Macchi, and Rosental echoes these analyses. It shows how epigenetics leads to a reappraised vision of sex and race, now seen as an environmental and processual dimension rather than as essentialized organic attributes: epigenetic knowledge shedding light on the processes through which social relations make sex and embedding cultural notions of race into the body. Nevertheless, measurement is also associated with ontologies of existential age and time, which are examined in detail in this book.

Making Temporalities and Hierarchizing Rhythms While gender and racial studies, and more widely intersectional research, have placed the emphasis on the role played by technologies for the exploration, measurement, and representation of life in establishing boundaries and hierarchies in terms of sex and race, age remains under-­ examined by these disciplines. One notable exception is provided by David Armstrong’s work (1983), which examines the place of surveys and surveillance medicine in postwar Britain and their role in the emergence of pediatrics and geriatrics based on norms of populational maturation. Other examples can be found in Turmel’s (2008) studies of child intelligence approached through the prism of developmental thinking, or in Stephen Katz’s work on gerontology (1996). In these seminal studies, however, measurement is not always central: the focus tends to be on knowledges and powers, or on the emergence of new professions. How can the study of measurement inform the production of temporalities and ontologies of age? The studies compiled in this book show that measuring life also means taking the beat of the measure, to borrow a musical expression.

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Anthropologists and historians have, for instance, highlighted how medicine contributed not only to the standardization of human bodies but also to that of the “human life cycle”, involving standards of physical, psychological, social, and moral maturation. Ernst Haeckel (1866) observed the development of human embryos (ontogenesis) in a bid to understand the species’ past and development (phylogenesis). Although this theory of recapitulation was criticized from its very onset, it left its mark on nineteenth- and twentieth-century medical and social knowledge—in particular by aligning the cosmogonic vision of the ages of life, still very much present in the eighteenth century, with the three stages of development of the species: growth, stagnation, and decline. This ambition is also documented by Diasio’s and Voléry’s chapters. The measurement of orifices, like that of bone maturation, contributes to making time, as measured bodies are integrated into the distinctive timeline of genealogy and lineage, or into that of the developmental curve. From this point of view, techniques used for measuring transformations of the body are also social clocks. First, these measurements “embody” characteristic visions of time that form an integral part of biopolitics—although this aspect was not considered by Foucault. For instance, iterated measurements of singular bodies emphasize the asperities of growth and the discontinuities of the growing body, while the production of average measurements, performed at a given point in time on children of different ages and standardized, creates the impression of an even flow of time, like grains of sand in an hourglass. In a way, these measurement technologies imbue the body with notions of time that stem from other economic, familial, and political contexts (Voléry and Julien 2019). Not only is time spatialized into bodies but reversely, measured bodies also contribute to establishing a particular vision of time as an objective, non-random physical given, that eludes social construction—thus contributing to essentializing “age”, seen as an objective trace of the flow of time that may not be resisted. Reduced to its chronological dimension, age comes to represent “the span of time between birth and death” (Peatrik 2003: 20). Such a vision of biological age as a neutral physical coordinate strongly contributes to its naturalization—including in disciplines that had endeavored to deconstruct other biological facts. Indeed, while biological sex is

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now clearly seen as a possible field of enquiry for social science, biological age continues to be excluded from its scope. In addition, these temporal measurements contribute to the normalization of bodies. Conformity with development rhythms has become a keystone of Western medicine, which focuses on human rhythms of maturation, as shown by the proliferation of bone or stature atlases—such the growth curves in French child health booklets, which now include Body Mass index (BMI) (Rollet 2008). Reversely, these tempos contribute to the making of Others: for example, when the rhythm of puberty or bone maturation contributes to the racialization of puberty, thus turning race into a chronotype (see the chapters by Vinel and by Voléry and Julien); or when the state seeks to leave the mark of social progress on the flesh of its population—for instance, in France, public health institutions considered that the curves contained in earlier child health booklets were ill-adapted to a society that has successfully maximized its life, and needed to be recalculated.7 The time dimension in biopower is particularly emphasized in this book, with several contributions showing that measurements of the human provide a particularly fertile field of analysis to understand this dimension.

Structure of the Book For reasons of readability, this book is not structured according to the authors’ approaches or to the aspects of measurement under study, but chronologically. This choice is explained by the fact that the contributions often combine various analytical angles and sometimes echo one another chronologically—in particular when addressing the socio-history of measurements of bone maturation, which is studied over two particular spaces and periods: forensic medicine in the last third of the nineteenth century and pediatrics in the second half of the twentieth century. Furthermore, as the human body’s metrologies vary according to social, economic, and political contexts, it is quite difficult to consider extended historical and spatial dimensions. Thus, the authors decided to focus especially on Western worlds, while being aware of the globalization of measurement devices. As we can find in this volume (cf. the chapters by

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Diasio, by Voléry and Julien or by Vinel), both during the nineteenth and twentieth centuries, non-Western bodies were used to measure and “normalize” Western bodies, which are themselves multiple and changing while, since the 1970s, Western child growth standards were also partly imposed on Southern countries. The first section compiles articles documenting the heterogeneity of measurements of the body, and the ways in which these measurements spill over from the soma to the psyche. Chapter 2 by Diasio examines controversies and scientific usages associated with the measurement of orifices in the mid-nineteenth century, a period during which hierarchies between beings and the genealogy of the human species were being reassessed. Diasio shows that these measurements combine a genealogical paradigm, which she associates with the episteme of resemblance, with a mathematical paradigm. These measurements led to a reassessment of the boundaries and internal hierarchies of the human species by focusing on two extremes: the cretin and the savage. Chapter 3 is rooted in the same historical context but in a very different space: forensic medicine and the early standardizations of bone maturation. Voléry shows how bone was gradually constructed as an indicator of maturational development and subsequently paired with age. Bone thus became a sign of age, while also contributing to the redefinition of this notion. Initially viewed as an unstable qualitative state, age became a continuous and predictable quantitative variable that could be targeted by hygienist policies aimed at fortifying the population. In Chap. 4, Milena Maglio and Vivien García adopt a decentered perspective by addressing a type of measurement that focuses on psychic rather than somatic aspects in the late twentieth century. Quality of life is examined from a philosophical angle, as a practical concern that emerged with the development of resuscitation care and life support technologies, and later as a moral doctrine that conveys a particular understanding of the person and establishes new frontiers between humans and things. The second section of the book engages with contemporary debates on measurement that oppose objectivation and subjectivation—in particular, when measurement is narrowed down to the sole act of quantification and associated with the rationalization of the world against individual singularities. In contrast with these positions, the authors show that the

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technologies that measure and modify life do not go against singularities and subjectivities but shape them. Looking at the example of CRISPR-Cas9 gene editing, in Chap. 5, Déchaux demonstrates how genomic editing and remodeling technologies contributed to transforming perceptions of the embryo, of the unborn child and of the role of the parents, who are made morally responsible for the health of their unborn child and descendants. Chapter 6 shifts to intensive care services. Denise studies how contrasting forms of measurement are deployed: the person is at times standardized and hidden behind the monitoring of vital signs, but resurges at other times when the focus is placed on more qualitative clinical measurements that inform the individual’s position in a vital continuum. Such measurements can help reconstruct the patient’s social existence, by associating objects (stuffed toys, perfume, etc.) with quantitative and clinical measurements. The measuree’s status is thus reasserted in the eyes of the measurer, showing how measurement can involve a form of body work (Wolkowitz 2006), which has effects on the professionals’ subjectivity. In the third section, the focus moves to the hierarchies that derive from these measurements, depending on the gender, race, or age of measurees, but also on hierarchies between measurers. In Chap. 7, Voléry and Julien show how measurements of bone maturation were initially standardized and deployed in a clinical setting by British and US pediatricians, with the purpose of regulating the effects of class poverty on child growth. However, these measurements later contributed to the racialization of certain patterns of growth (and subsequently, to that of the groups to which these patterns were associated) and to the de-racialization of other groups. The authors also analyze how these measurements create hierarchies between measurers: pediatricians who associate with geneticists to lend more scientificity to their work and consolidate their position within the research field; population geneticists who associate with pediatricians to set themselves apart from lab-based genetics; measurers from Northern countries versus those from Southern countries, and so forth. In Chap. 8, Vinel investigates controversies on the decreasing age of puberty in Afro-American girls. This study, which echoes Chap. 7, shows the plurality of models of corporeality associated with pediatric research and clinical medicine, but also the geopolitical character of

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measurements that lead to an interpretation of European/African growth patterns according to the normal/pathological epistemic dualism. Finally, Chap. 9 questions the shifts brought about by epigenetic research in perceptions of sex and race. Against the notion that genetics brings the ontologization and essentialization of “sex” and “race” down to an infra-cellular level, Cavalin, Macchi, and Rosental show that environmental epigenetics interprets race, class, and sex as relational dimensions that are the product of an interaction between environments (characterized by social relations as studied by sociologists and politicists) and organisms. As well as reassessing medical and biological definitions of “sex” and “race”, this approach produces new readings of social relations of class, considered through the prism of lifestyles and their material traces.

Notes 1. Crombie (1994) identifies different styles in European scientific thinking: mathematical postulate and axiomatic demonstration; experimentation and measuring practices; hypothetical construction and analogical modeling; taxonomy; statistical and probabilistic analysis. 2. To differentiate their measurements, scientists go in search of bodies that are judged “different” according to particular sociopolitical standards: “Black” people, women, and many others. 3. See the use of IQ tests, which were mainstreamed by the US army in the 1950s. These tests, initially designed to organize students in France in the context of compulsory education, were then used to measure soldiers’ “intelligence” and optimize the management of military capital. 4. See particularly Foucault’s analysis of confession in History of Sexuality (1976). 5. See also the association of figures and maps in graphic representations of the genome, combining the codes of cartography with statistics—where the map indicates genetic proximity and distance between two genes, which is defined according to the genetic recombination frequency of these genes from one generation to the next. Characterized with reference to probabilistic statistics, the genome becomes a map, creating the illusion

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of an already there that could be explored with adequate equipment by the human eye. 6. Spanish researcher Santiago Ramon y Cajal claimed that each neuron had an autonomous function and development while Italian scientist Camillo Golgi supported the idea of a network of neurons. Golgi used a coloring tool that revealed the brain’s nerve cells, and Cajal accused Golgi of manipulating his images (Daston and Galison 2007: 143). 7. This particularity appears very strong in France where developmental medicine is increasingly becoming a medicine of developmental rhythms. The new abacuses published in 2018 child health booklets do not just present weight, height, or BMI thresholds to be reached at certain chronological ages, but also “growth corridors” calculated according to speed and growth trajectories. http://www.co-naitre.net/actualites/nouveau-carnetde-sante-1er-avril-2018/.

Bibliography Armstrong, D. (1983). Political Anatomy of the Body. In Medical Knowledge in Britain in the 20th Century. Cambridge: Cambridge University Press. Bancel, N., David, T., & Thomas, D. (Dir.). (2014). L’Invention de la race: Des représentations scientifiques aux exhibitions populaires. Paris: La Découverte. Beaud, J., & Damasceno Fonseca, C. (2017). Le chiffre et la carte: Pratiques statistiques et cartographiques en Amérique latine (du milieu du 18e au milieu du 20e siècle). Histoire & mesure, XXXII(1), 3–8. Beck, U. (2001). La société du risque. Sur la voie d’une autre modernité. Paris: Aubier. Colomb, F. (2019). La marchandisation du corps à l’épreuve des biobanques. La nouvelle revue du travail [Online], 14 | 2019, Online since 24 April 2019, Connection on 17 March 2020. Retrieved from http://journals.openedition. org/nrt/4886. Crombie, A. (1994). Styles of Scientific Thinking in the European Tradition: The History of Argument and Explanation Especially in the Mathematical and Biomedical Sciences and Arts. London: Gerald Duckworth & Company. Darwin, C. (1971 [1877]). A Biographical Sketch of an Infant. Developmental Medicine and Child Neurology, 13(24), 3–8. Daston, L., & Galison, P. (2007). Objectivity. New York: Zone Books.

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Descartes, R. (1984 [1644]). Principia Philosophia. In C. Adam & P. Tannery (Dir.) (Ed.), Œuvres de Descartes (pp. 101–102). Tome IX. Paris: Vrin. Desrosières, A. (1989). Comment faire des choses qui tiennent: histoire sociale et statistique. Histoire & Mesure, 4(3–4), 225–242. Desrosières, A. (1995). Classer et mesurer: les deux faces de l’argument statistique. Réseaux, 13(71), 11–29. Desrosières, A. (2003). Pour une sociologie historique de la quantification. L’argument statistique 1. Paris: Presses des Mines. Dias, N. (2004). La mesure des sens. Les anthropologues et le corps humain au 19e siècle. Paris: Aubier. Dias, N. (2016). Les sens et la circulation des éléments au 19e siècle. Hermès, La Revue, 74(1), 50–56. Retrieved from https://www.cairn.info/revue-hermesla-revue-2016-1-page-50.htm. Doron, C.-O. (2016). L’homme altéré: races et dégénérescence (17e–19e siècles). Paris: Champ Vallon. Dubois, M., Guaspare, C., & Louvel, S. (2018). De la génétique à l’épigénétique: une révolution “post-génomique” à l’usage des sociologues. Revue française de sociologie, 59(1), 71–98. Durkheim, E. (1968 [1912]). Les formes élémentaires de la vie religieuse. Le système totémique en Australie. Paris: Presses Universitaires de France. Fausto-Sterling, A. (2000). Sexing the Body: Gender Politics and the Construction of Sexuality. New York: Basic Books. Foucault, M. (1963). Naissance de la clinique. Paris: Presses Universitaires de France. Foucault, M. (1966). Les mots et les choses. Paris: Gallimard. Foucault, M. (1975). Surveiller et punir. Paris: Gallimard. Foucault, M. (1976). Histoire de la sexualité tome 1. La volonté de savoir. Paris: Gallimard. Foucault, M. (1977). La naissance de la médecine sociale (trans: Reynié, D). In D.  Defer & F.  Ewald (Dir.) (Ed.), Dits et Ecrits II (pp.  207–228). Paris: Gallimard. Fox Keller, E. (1985). Reflections on Gender and Science. New-Haven: Yale University Press. Gardey, D., & Löwy, I. (Dir.). (2000). L’Invention du naturel. Les sciences et la fabrication du féminin et du masculin. Paris: Éditions des archives contemporaines. Gould, S. J. (1981). The Mismeasure of Man. New York: Norton & Company.

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Hacking, I. (1965). Logic of Statistical Inference. Toronto: Cambridge University Press, Macmillan of Canada. Hacking, I. (1975). The Emergence of Probability. New  York and London: Cambridge University Press. Hacking, I. (1990). The Taming of Chance. Cambridge, New  York, and Port Chester: Cambridge University Press. Hacking, I. (2003). Des Styles de raisonnement scientifique. Lecture at the Collège de France. Retrieved from https://www.college-de-france.fr/media/ian-hacking/UPL4445123752442236773_Hacking2002_2003.pdf. Hacking, I. (2005). Façonner les gens II. Cours au collège de France. Philosophie et histoire des concepts scientifiques. Retrieved from https://www.college-defrance.fr/site/ian-hacking/ouvrages-publies.htm. Haeckel, E. (1866). Generelle Morphologie der Organismen. Berlin: Reimer. Jacquot, L., & Voléry, I. (2019). Le travail dans la peau. Les figures du corps dans la sociologie du travail contemporaine. La nouvelle revue du travail [Online], 14 | 2019, Online since 30 April 2019, Connection on 17 March 2020. Retrieved from https://journals.openedition.org/nrt/4541?lang=fr. Katz, S. (1996). Disciplining Old Age: The Formation of Gerontological Knowledge. Knowledge: Disciplinarity and Beyond. Charlottesville: University Press of Virginia. Knorr-Cetina, K. (2005). The Rise of a Culture of Life. EMBO Reports, 6(I), 76–80. Kristensen, D. B., & Ruckenstein, M. (2018). Co-evolving with Self-Tracking Technologies. New Media and Society, 20, 3624–3640. Lafontaine, C. (2014). Le Corps-marché. La marchandisation de la vie humaine à l’ère de la bioéconomie. Paris: Seuil. Laqueur, T. (1992). La fabrique du sexe. Essai sur le corps et le genre en Occident. Paris: Gallimard. Lasch, C. (1979). Culture of Narcissism: American Life in an Age of Diminishing Expectations. New York: WW Norton & Co. Le Dévédec, N. (2008). De l’humanisme au post-humanisme: les mutations de la perfectibilité humaine. Revue du MAUSS permanente [en ligne]: 1–11, Connection on 25 June 2020. Retrieved from http://www.journaldumauss. net/?De-l-humanisme-au-post-humanisme. Lupton, D. (2013). Quantifying the Body: Monitoring and Measuring Health in the Age of Health Technologies. Critical Public Health, 23(4), 393–403. Martin, E. (1989). The Woman in the Body: A Cultural Analysis of Reproduction. Milton Keynes: Open University Press.

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M’Charek, A. (2013). Beyond Fact Or Fiction: On the Materiality of Race in Practice. Cultural Anthropology, 28(3), 420–442. Memmi, D. (2004). Administrer une matière sensible. Conduites raisonnables et pédagogie par corps autour de la naissance et de la mort. In D. Fassin & D.  Memmi (Dir.) (Ed.), Le gouvernement des corps (pp.  135–154). Paris: Éditions de l’EHESS. Memmi, D., Guillo, D., & Martin, O. (Dir.). (2009). La tentation du corps, corporéité et sciences sociales. Paris: Éditions de l’EHESS. Morris-Reich, A. (2016). Race and Photography. Racial Photography as Scientific Evidence. Chicago and London: University of Chicago Press. Ogien, R. (2016). La marchandisation du corps humain: un slogan confus et dangereux. Cités, 65(1), 15–32. Oudshoorn, N. (1994). Beyond the Natural Body: An Archeology of Sex Hormones. London and New York: Routledge. Peatrik, A.-M. (2003). L’océan des âges. L’Homme, 167–168, 7–23. Pharabod, A., Nikolski, V., & Granjon, F. (2013). La mise en chiffres de soi: Une approche compréhensive des mesures personnelles. Réseaux, 177(1), 97–129. de Quatrefages, J.  L. A. (1884). Hommes fossiles et hommes sauvages: études d’anthropologie. Paris: Baillière. Quételet, A. (1835). Sur l’homme et le développement de ses facultés, ou Essai de physique sociale (2 volumes). Paris: Bachelier imprimeur-libraire. Rollet, C. (2008). Les carnets de santé des enfants. Paris: La Dispute. Rose, N. (2007). The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the 21st Century. Princeton: Princeton University Press. Rouch, H. (2011). Les corps, ces objets encombrants. Contribution à la critique féministe des sciences. Donnemarie-Dontilly: Editions IX. Sommer, M. (2016). History Within: The Science, Culture, and Politics of Bones, Organisms, and Molecules. Chicago: The University of Chicago Press. Steiner, P. (2010). La transplantation d’organes: un commerce nouveau entre les êtres humains. Paris: Gallimard. Strathern, M. (1992). Reproducing the Future: Essays on Anthropology, Kinship and the New Reproductive Technologies. Manchester: Manchester University Press. Turmel, A. (2008). A Historical Sociology of Childhood: Developmental Thinking, Categorization and Graphic Visualization. Cambridge: Cambridge University Press.

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Voléry, I., & Tersigni, S. (2015). La masculinité hégémonique au crible de l’âge. Genre, sexualité & société [Online], 13, Online Since 01 June 2015, Connection on 29 February 2020. Retrieved from http://journals.openedition.org/gss/3512. Voléry, I., & Julien, M.-P. (2019). Mesurer les corps pour normer les temps. Recherches sociologiques et anthropologiques, 50(1). Retrieved from https:// journals.openedition.org/rsa/3042. Wolkowitz, C. (2006). Bodies at Work. Londres: Sage.

Part I The Measurements of the Human Body Between the Nineteenth and the Twentieth Century: from the Flesh to the Subjectivity

2 Producing Otherness Through Resemblance: Bodily Orifices and the Measuring of the Human (1800–1860) Nicoletta Diasio

In the late eighteenth and early nineteenth centuries, the question of “what makes a man” stopped being a matter of “plain common sense” (Maupertuis quoted by Pouchet 1858: 33) if it ever was. “The era of classifications” (Duvernay-Bolens 1995: 225) began, and along with it the ambition to define humanity’s diverse lineages as specifically as possible, with their respective morphologies and distinctive characters. Measuring what makes a man also meant pushing “defective humanity” (Balibar 2012: 21) out into the margins of society, as well as monitoring, assisting, and sometimes excluding these populations from the social consortium. The emergence of these questions went along with a series of epistemological liberations. As the understanding of the human became emancipated from metaphysics and theology, more value was attached to

N. Diasio (*) Dynamiques européennes, Université de Strasbourg, Institut universitaire de France, Strasbourg, France e-mail: [email protected] © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_2

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empiricism, direct observation, and experimentation. Under the egis of physicians and naturalists, the science of man had the ambition of jointly embracing the physical, social, and moral dimensions, as reflected by the scientific project of the Idéologues. With this liberation came a surge of curiosity toward the Other: at last, Montaigne’s aspiration to become the “topographer” of the human condition (1965: 303) appeared achievable. However, due to the “crisis undermining the Enlightenment’s cosmopolitanism and implicit egalitarianism” (Montaldo 2018: 89), to the intensification of colonial conquest and to the rise of biological racism as a founding principle of the nation-state (Foucault 1997), this curiosity toward the Other gradually evolved into an attempt to systematize, hierarchize, and naturalize the diversity of human types. In Europe, the nineteenth century was characterized by an extensive effort to produce populations through the study of languages, folklore, and literature as well as through political theories and historiographical debates. The nationalist liturgy was built in an attempt to organize the masses through a combination of narratives, symbols, and collective activities. The measurement of bodies played a major role in this process. Anthropological knowledge derived from natural science and medicine laid the foundations for the assignation to a “species”, “race”, “nationality”, or social group. This was made possible by the emergence of technologies designed for the quantitative or qualitative assessment of anatomies, physiologies, and pathologies. The body became a matrix for collective identities: its characteristics and alterations appeared to provide an insight into the history of populations, with their origins and intermixing. The making of populations was closely associated with a specific perception of time that attached value to the depths of the past and its geological layers, to ancient history and immemorial roots (Moravia 1982). This process is also associated with the emergence of new geopolitical spaces, under the effect of national independence movements, national unification processes, imperial crises, colonization, and the emerging role of regional identities. Developed against the Revolution’s egalitarian humanitarianism, the distinctions between peoples were also grounded in “the characteristically ‘diversitarian’ impulse of Romanticism [which] had, as A. O. Lovejoy has pointed out, an important racial potential” (Stocking 1971: 36). However, “if in the nineteenth century

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‘civilization’ was increasingly seen in racial terms, ‘race’ itself had still to be explained” (Stocking 1971: 38). “Race” provided a “cultural idiom with a social scope” (Aramini and Bovo 2018: 15),1 involving the body as well as time and space. The focus was placed on physical properties and their measurements, while developmental rhythms were assessed according to a scale of progression that was deemed universal. Bodies and time were captured within the diverse geographic and social spaces where they are deployed. Before these naturalistic discourses provided the bedrock for the racist theories of the late nineteenth century or for twentieth-century totalitarianism, they started off as tentative experiments to define what is human and which marginal beings should be controlled, amended, or excluded from full citizenship. This chapter analyzes early nineteenth-century discourses on bodily orifices as they appear, often indirectly, in a corpus of medical and anthropological texts. This angle allows us to interrogate the long-term process of scientific categorization that led to the production of a differential humanity. The objective of this analysis is to show the diverse descriptive, qualitative, and quantitative models, which were used to provide a definition of the biologized Other—whether the “savage” came from within or from outside. These paradigms, situated at the crossroads of science and politics, were far from mutually exclusive: they coexisted in tension, and consolidated each other. The period under study spans from the Bourbon Restoration to the beginning of the Second Republic and ends with the hegemony of the anthropometric model, with a general fascination with numerical data and with the emergence of the experimental approach in medicine. It begins with a sweeping effort led by the Société des Observateurs de l’Homme (1799–1805) to observe and compare customs, ideas, and bodies, combining ethnographical descriptions with physical measurements. It closes with the creation of the Société d’Anthropologie de Paris (1859), when anthropology became set on a comparatist, anatomical, and quantitative approach (Broca 1865). This period saw the coexistence of various observation and classification models, at a time when budding scientism was finding its footing and hesitating between different descriptive systems. This was also a historic moment of transition from a societal point of view: tensions between the aristocracy and the bourgeoisie gradually gave way to other class confrontations, with the rise of conflicts and claims

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from urban workers and employees. Theories on France’s ethnic dualism, developed to explain oppositions in Revolutionary France,2 were sometimes reactivated to translate recent social confrontations into instances of racial antagonism. Controversies on slavery, the beginnings of colonization in Algeria, and the dissemination of utopian theories all contributed to creating a state of social effervescence that also affected scientific theories. For example, the desire for social reform expressed through scholarly controversies produced very diverse outcomes. In addition, while this study mostly focuses on France, it is important to stress the international reach of nineteenth-century science: this contributed to the dissemination of a common Weltanschauung, which was shared all the more easily that it was legitimized and sacralized by science.

Describing or Measuring Differences This chapter examines discourses on orifices, which reflect the diversity of explanatory models. Knowledge was structured along two key paradigms: ocular and mathematical. The introduction of tools such as the numerical method, statistics, serial analysis, and anthropometrical averages was anticipated and supported by diverse observation and data collection methods, which were all based on a visual approach. The memoirs of the Société des Observateurs de l’Homme show constant interactions between medicine, the natural sciences, and the ethnographic study of so-called savage peoples. A survey handbook by Joseph-­ Marie Gérando Considerations on the diverse methods for the observation of savage peoples (1994 [1800]) draws an inventory of what was later referred to as the “techniques of the body” (sleep, walking, physical education, hygiene, nursing and weaning, pathological susceptibility, and attitude toward diseases), which are not distinguished from other ethnographical descriptions of these peoples’ “customs”. This approach is not however perceived as conflicting with the “geometric method” promoted around the same time by Cuvier. In his instructions to travelers, the anatomist warned observers against making comparisons based solely on visible characteristics (skin color, hair type), which had led famous painters in

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the past to misrepresent “the character of the Negro”, and depict him as “a soot-smudged white man” (Cuvier 1978 [1800]: 174).3 With the emerging aspiration to develop a structured operational process, and the division of scientific work between on the one hand non-­ professional “measurers”—usually colonial doctors or administrators— and, on the other, scholars based in mainland France who are tasked with processing the data (Diasio 1999), quantitative measurement was valued over “visual judgement”, which had been the predominant tool used in the early nineteenth century. Nevertheless, as shown by Claude Blanckaert (2009), the introduction of the mathematical paradigm into physical anthropology did not go without resistance. The establishment of the statistical method faced barriers such as the difficulty of accessing an enough number of bodies to document ethnic classifications, and the opacity that spoiled the collection and selection of these bodies. In addition, the use of averages tended to lessen racial differences instead of emphasizing them. For some time, the credibility of the quantitative tool was also hampered by the difficulty of identifying “pure” features in bodies that were inevitably affected by the vicissitudes of history and migratory waves: “The method of averages remained unpopular with early nineteenth century anthropologists …. Cranioscopy was largely empirical, relying on the trained eye of the doctor who knew the protuberances, cavities and expansions of the bone head” (Blanckaert 2009: 115). The prevalence of visual observation was, for instance, supported by the Société Ethnologique de Paris in 1829, under the guidance of William Frédéric Edwards who advises to train “the eye in in-situ conditions, to summarize experiences, to distinguish sets” (Blanckaert 2009: 116). The objective is to “distinguish the shapes and features that form a particular type” (Edwards 1853 [1829]: 1227). In contrast to quantitative measuring, which favors deconstruction and counting, Edward recommends identifying a “family likeness” and reconstructing sets based on the co-­ occurrence of recurring similitudes. This approach can also be found in the measurement work of Petrus Camper—which also indicates the complementarity of visual and quantitative approaches. Finally, it must be stressed that at the time, many ethnologists were formed in medicine and in the anatomical theater. Trained at observing the singular, at examining

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individual bodies on the autopsy table or on their sickbed, these scientists relied first and foremost on their eyes and gesture.

Resemblance and Genealogical Thinking The tension between the ocular and mathematical paradigms finds a resolution in the importance of resemblance as a vector of scientific knowledge. Quantitative measurement was recognized as a way of supporting sensory experience with reliable and indisputable evidence. However, analogical thinking was not entirely dismissed. In my opinion, the epistemological shift described by Foucault in The Order of Things (2002 [1966]) does not involve the dismissal of resemblance in the elaboration of knowledge. As a primordial comparison tool, it continued to provide an immediate resource for the scientists who sought to identify and measure the different human types: resemblance is the degree zero of the comparatist approach.4 Analogy, or the search for relations between things, is one of the keystones of European Romanticism. Its power lays in the ability to create chains of correspondences mutually reinforcing: “Resemblance never remains stable within itself; it can be fixed only if it refers back to another similitude, which then, in turn, refers to others; each resemblance, therefore, has value only from the accumulation of all the others” (Foucault 2002 [1966]: 34). These similitudes are mobile and polysemic: they can operate on different scales and involve details or segments, configurations, or “family likeness”. They can function on different levels: a similitude between visible forms can indicate deeper affinities or shared moral characteristics. For instance, when evoking the “immense series of organized beings”, naturalist Gama Machado states that it is possible to “establish unquestionably … that wherever identical forms, coats or colors can be found; … one encounters similar instincts, habits and customs” (1831–1858, quoted by Baridon 2004: 151). Another aspect of resemblance is on the contrary associated with versatility, transiency, combinations, and reversibility: it regards the transmission of characters along the line of filiation. This type of similitude, closely associated with heredity, provides the grounds for the

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construction of groups whose common properties are passed on from generation to generation, eventually making them into distinct entities. This notion is at the very heart of genealogical thinking which, according to Claude-Olivier Doron (2016), provided a tool to understand relations between natural beings and classify them into groups. The species is understood “as a series of individuals who are mutually connected by relations of kinship and can pass on a specific form, secondary lineages through which some characteristics are transmitted hereditarily, and which form relatively stable varieties” (Doron 2016: 11). Doron describes the emergence and the development of a form of racism built on alteration: the Other is not seen “as radically different, but instead as fundamentally identical but altered. This alteration is understood in two ways: either as a distance, deviation, degradation or degeneration from an original identity; or as a delay, archaism or arrest from a universal standard of development” (Doron 2016: 21). This line of thought draws inspiration from the theories of degeneration and is based on the transmission of pathological characteristics. However, genealogy also acts as a “positive” model: it provides a matrix of recognition and affinity that runs through the process of production of populations. The theory of resemblance cuts across medical anthropology, ethnology, and early sociology and serves a dual purpose in defining populations: finding characters that indicate a shared genealogy and the identity of a “race”, nation, or social class; and identifying what differentiates a group from the others by “othering” them.5 Looking alike is equated with belonging.6 Resemblance continues to be operative because it offers a language that is both familiar and familial. In the nineteenth century, it formed the core of a nationalist ideology that took its roots from the gender stereotypes associated with the roles of mother, father, and children of the nation (Mosse 1985, Yuval-Davis 1997, Dorlin 2009). At a time when classifications become ever more complex—to the point of introducing disorder when their expected purpose was to order human varieties—resemblance provided a fixed point. Along with descent and permanence, it provided one of the fundamental criteria for the definition of race (Blanckaert 1999). Resemblance relies on similarity rather than identity (Diasio 2010), on disparity rather than repetition: as such, it offered a tool for questioning the human in its diverse manifestations.

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The body’s orifices provide a key to apprehend and hierarchize these variations of the human.7 They can be external and visible (mouth, ears, eyes, nose); at the edge between the inside and the outside of the body (fontanel and other cranial sutures); or internal and invisible but measurable (foramen magnum, orbital cavity, olecranon fossa on the humerus). Their polysemic character enables them to accommodate diverse descriptive systems, of which we will examine four: aesthetic, sensory, clinical, and anthropometrical. Orifices constitute a peephole through which to examine the degree of humanity of diverse “characters”, who were seen as the highest point of otherness or degeneration: the “Hottentot”, regarded as the most “primitive” representative of the human species, and the cretin, seen as a diseased variety of the species. These denominations were applied to very disparate subjects.8 However, as a similitude leads to the next, diverse othered types and populations found themselves associated under the same characteristics.

From Beastly Ugliness to Fallacious Seduction The first approach established an equivalence between beauty and civilization. The human type expressed by Greek art was regarded as the highest point of perfection. This rhetoric provided a common ground between anatomists, naturalists, and doctors on the one hand, and on the other artists, philosophers, and art historians. For example, anatomist Camper, the inventor of the facial angle, took inspiration from the theories of German archeologist Joann Joachim Winckelmann according to whom “ancient Greek sculptures revealed the most harmonious geometric proportions for the human face and the standard for all conceptions of beauty” (Staum 2003: 26).9 Camper also gave lectures at the Amsterdam Drawing Academy (1770) and later at the Paris Academy of Science (1777) to teach artists the best way of depicting the features of non-­ European peoples, which reflects the intense circulation of practices and discourses between artists and scientists.10 This aesthetic model for the making of otherness provided the foundations for Georges Cuvier’s anatomic description of the corpse of Saartjie Baartman, or the “Hottentot Venus”:11

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That which our female Bushman possessed that was the most repulsive was her physiognomy: her face took in part after the Negro by the jutting out of the jaw, the obliquity of the incisor teeth, the thickness of lips … blackish, monstrously swelled … the shortness … of the chin, and in part after the Mongol by the enormity of the cheek bones, the flatness of the base of the nose, of the forehead and of the eyebrow arch, the narrow slits of the eyes …. Her ears were much like those found in many monkeys, small and weakly formed at the tragus, with an outer rim that was almost inexistent at the back. (1817: 264)

Mouth, nose, ears: this description was reused by many commenters after Cuvier, for example, by Bory de Saint Vincent (1826), who described the Hottentot as having a hideous, beastly face, as well as eating vermin and the unwashed entrails of wild animals. In 1824, Virey reused the aesthetic opposition between the brute and the ideal ancient Greek type, illustrating his claims with images showing examples of resemblance (Fig. 2.1).12 Apelike features and a hideous physiognomy were regarded as signs of radical otherness, associated with an excessive proximity to the animal world.13 At the Société Française d’Ethnologie, a controversy opposed Victor Schoelcher, who was appalled by this “anatomical hatred of the Negro” (Blanckaert 2009: 19) and proclaimed the absolute equality of all members of the human family regardless of sex, nose shape, or skin color, and Victor Courtet de l’Isle. In a diatribe published by the Bulletin de la Société Ethnologique de Paris (1847: 184), Courtet de l’Isle claimed that “the more attractive a race’s type, the more advanced its civilization; and the uglier the type, the more imperfect its civilization. My idea of relative beauty or ugliness can easily be understood by anybody, by taking as points of comparison the figure of Apollo or Minerva, and the form that most resembles the brute”. Ugliness thus indicates “an imperfect state, a form of animality” (Bulletin: 198). Similarly, the most attractive races are also the most intelligent, and the equality demanded by abolitionists is a proof of social incompetence that destroys relations of solidarity between the rich and the poor (Bulletin: 206). In these writings, harmonious and regular features are aesthetic indications of a hierarchized society where

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Fig. 2.1  “Profile of the Apollo, of Negro and Orang-outang”, Virey, 1824, BIU Santé, Paris

relations of domination and complementarity are made apparent by the distribution of pleasing or repulsive features. For example, the Hottentot brute is associated with the features of “very poor and destitute workers” (Morel 1864: 32) with their strabismus caused by asymmetrical lines, their thick lips and wide-set nostrils, reflecting “the particular decadence of the race in manufacturing countries” (Morel 1864: 32). While ugliness is not the preserve of a single sex, the question of gender is not indifferent: the description of so-called savage women is

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particularly ambivalent. While many testimonies emphasized the repulsiveness or ungracefulness of their features or body smells, others highlighted their nobility. The women’s nudity, the charm they exerted on travelers and sailors who were unaccustomed to female company and their presumed sensuality were the object of a voyeuristic gaze that oscillated between moral disapproval and aesthetic appreciation. During the same expedition, captain Dumont d’Urville considered that the women of Tanga would make good models for artists, while phrenologist and artist Dumoutier expressed his shock at their lascivious dances and sexual availability, all the while appreciating their breasts and pleasing faces.14 In spite of their wide noses, wide-set ears, and extremely thick nostril walls, Hottentot women were regarded by Desmoulins as “very fine models” (1826: 295–296). Years later, photography took interest in these “models”, thus amplifying the circulation of erotic and exotic images and representations. Finally, the question of beauty was inseparable from sexual availability and moral values. Authors like Mario Praz (2008 [1930]) or Sander Gilman (1985) have shown that in the literature of this period, women regarded as sexually available were described as presenting a devious sort of beauty, depicted as a source of corruption, like a new incarnation of the vanitates of the Baroque era: decomposed faces, sickly corpulence, grayish or dull complexion, tainted reproductive organs. This corrupted, and therefore fallacious, beauty was indicated by the abnormal conformation of the sexual orifices. Gilman shows, for instance, that gynecological treatises associated the Hottentot woman’s physical anomalies with those found in prostitutes and lesbians. The deformation of female external genitalia had already been described in travel literature and in accounts by explorers and colonial administrators. Cuvier’s description of the female Hottentot’s “tablier” (apron) as well as the dissection of her sexual parts that were preserved in the Museum’s collections provided a factual backing to the fantastical narratives by travelers, who “believed” or “pretended” to have seen similar elongated labia. The convergence of these stories with the “truth” of the autopsy report transformed “une chose absolument fabuleuse” (Cuvier 1817) into scientific fact.

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As an analogy and a similitude led to the next, this representation of savage femininity was extended until it applied to all African populations, which were envisaged as the feminine segment of humanity: Blainville’s and Cuvier’s descriptions, which center on the detailed presentation of the sexual parts of the black, dominate medical descriptions of the black during the nineteenth century. To an extent, this reflects the general nineteenth-century understanding of female sexuality as pathological. The female genitalia were of interest in examining the various pathologies that could befall them, but they were also of interest because they came to define the sum of the female for the nineteenth century. (Gilman 1985: 88)

Similarly, Julien-Joseph Virey transferred these sexual stereotypes to Black men, who were both hypersexualized and feminized. According to Virey, their “hideous” form, their “horribly flattened” nose, and the size of their sexual organs in reverse proportion to that of their brain made them unsuited to civilization and relegated them to bestiality.

 ensory Organs: Controlling Time S and the World A second descriptive system presented orifices, their shapes, and functions as an expression of the improvement of the nervous and sensory system, and of the ability to exert control in the world. In 1853, Jéhan and Migne’s anthropological dictionary presented a systematic analysis of sense organs and their respective orifices, described as indicating the “stages of development of the mind and its needs”. The eye is “the brain’s principal organ, and the brain is the principal organ of the man as spirit. The mouth is the superior center and the stomach is the principal organ of the man as animal” (Jéhan and Migne 1853: 1071). The ear is characterized by its progressive organization: it is still incomplete at birth when it has no function, and later develops under the stimulation of speech. While “the eye is the mirror of the body as that of the soul, home to an almost supernatural power through which man dominates his kind, animals and all of nature” (Jéhan and Migne 1853: 1062), the “naturals”, or

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natives, of New Holland are one-eyed (Nouvelle relation… 1815: 488). The Black man’s eyes are described as obtuse (Vogt 1864 [1858]: 247), their flattened cornea causes them to suffer from presbyopia and their primitive structure can be guessed from the “observation” of a nictitating membrane (Virey 1824, t.2: 148): “This third eyelid is normally considerably larger in mammals … in some tribes, especially among Negroes and Australians, the nictitating membrane is not smaller than in apes, so that these people exhibit an approach to the animal type” (Vogt 1864 [1858]: 129). In addition, the study of the mouth cavity shows the inadequacy of its morphology for phonation—see the cackles of the Hottentot and Bushman females according to Bory de Saint Vincent (1826). The mouth’s spiritual function is outstripped by its sole feeding function; the structure of the ear and the perfection of hearing remain incomplete: “The remarkably small, thick, projecting … ear of the Negro” (Vogt 1864 [1858]: 130), “Smell, taste or hearing do not seem highly developed” (ibid.: 188), “The grown up Negro partakes, as regards his intellectual faculties, of the nature of the child, the female and the senile White” (ibid.: 192), due to their instinctive, emotive, and lazy nature. There is therefore a sensory difference between peoples and social groups that favor sight, and those, deemed “inferior”, who are more sensitive to the touch or smell: “the discipline of the senses and its corollary, sensory control, are one of the manifestations of social control” (Dias 2004: III). These characteristics (protruding and hanging lips, flattened nose, projecting ear lobes with an auditory orifice in line with the eyebrows) all converge in depicting a body that bursts out and that is sensitive to even the most basic external stimulations. These elements revealed an obsession with “a humanity eternally leaving animality behind, and eternally threatened with falling into the grasp of animality” (Balibar 1991 [1990]: 57). The primacy of vision was theorized in 1853 by German philosopher Lorenz Oken, who classified the animal world according to the five senses: “the highest being the Eye-man, the White, the European”, and the lowest degree being “the Skin-man” (Gilman 1993: 215–216). Skin was seen as the first sensory organ, at the foundations of the primary stage of human development.15

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Sensory organs thus do not just reveal man’s susceptibility to being influenced by their external environment or their ability to control it. Their structure also translates the evolution of sensitive and intellectual faculties. Time can be measured in the body and its anatomy (Diasio 2019) and along with it, the individual’s or group’s ability to improve him or itself. The focus on the degree and pace of development triggered comparisons between the savage and the cretin, who share a common incapacity to innovate and transform themselves. For example, the premature closing of the fontanel, which was understood to have consequences on brain development and therefore on the individual’s ability to better himself, provided a similarity among Bushmen, Hottentots, and microcephalics. Even when showing partial genius at drawing, music, calculus or memory, these degenerated types “do not invent anything or perfect anything, (they) are purely instinctive” (Voisin quoted by Morel 1864: 33). There is clearly a common thread running throughout the nineteenth century, from Cuvier who blamed the “cruel law, that seems to have condemned to eternal inferiority those races with a small and compressed skull” (Cuvier 1817: 273) to Quatrefages who claimed that it was “better to be an improved ape than a degenerated Adam” (1870: 372). Pierre Broca (1873) did not dissipate this fear of a body that is frozen in time due to having been compressed too early. According to this author, the early closing of the fontanel in so-called inferior races and women blocks the brain in a rigid shell, reduces the effects of education, and, by first closing in the frontal area, halts the development of language and so-called superior functions. By establishing correspondences between the maturation of the individual body and the evolution of the population, Broca considers that the development of an individual’s intellectual life requires a certain flexibility in the frontal sutures, which are the most complex and take longer to close. This concern can also manifest itself through the opposite process, that is, incomplete ossification: when the thickness, solidity, and growing capacity of cranial bones are uneven, for example, in the case of hydrocephaly, “the brain grows in all directions and tends to dilate cranial walls” (Broca 1875: 143). Composed of islets of varying and discontinued shapes, these cranial vaults are a reminder of the importance of conforming with a

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standardized, even and universal developmental rhythm. The different forms of organization of life are set apart by the ways in which they deploy over time, through the stages of their evolution. The “savages” and diverse othered populations do not just exist in a different space: they are also situated within a different timeline and seen as the living witnesses of a long-gone era.16 Their bodies and customs are an epiphany of the past in the present. Dissemblance between humans stems from contrasting developmental rhythms, which manifest themselves in the failed or delayed growth of some organs or in their configuration. The consequence is a necessarily finalist and scalar vision of the world that sets hierarchies between orders (plants, animals, humans), between species, between “races” or societies and within those, between categories of individuals regarded as similar.

Clinical Clues: Generation Trouble In certain writings, the body appears in a state of precarious balance: an aggregate of fullness and emptiness, the product of complex compensation mechanisms that determine the spatial distribution of organs (for instance, authors insist on the negative effects of having one’s organs compressed). The distribution of body parts and their mutual relations also indicate, as mentioned earlier, the notion of a “correct” developmental timeline, both on the scale of a population and on that of the individual. Particular attention is granted to “maturation”, which is measured according to an ideal development schedule that runs from conception to senescence. This relation to time is key in another interpretative model in relation to orifices, which draws a distinction between what is normal and what is pathological. This model considers alterations introduced by diverse external influences (environment, occupation, housing, etc.) or internal ones such as family history. These qualities can be transmitted over time and modify the lineage by introducing morbid varieties. Time operates by producing deviations from the norm, thus impacting procreation and the course of generations. Examples of this notion can be found in the writings of Bénédict-Auguste Morel, although the theory of degeneration developed years before this author, as shown by Doron (2016).

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L’Anthropologie Morbide (Morbid anthropology) aimed to identify diseased varieties of the human species, both curable and incurable, and to understand their unequal distribution among social classes, as well as the causes that provoke them (intoxication, famine, industries, occupation, insalubrious housing, poverty, geography). These influences are analyzed according to a genealogical perspective, articulated around the concept of heredity. The aim is to define “degenerated” types and to reconstruct “relations of pathological kinship between individuals who are subjected to the action of similar degenerative causes” (Morel 1864: 2) (Fig. 2.2). Through these patho-histories, Morel aimed to map out the diseased varieties of the species based on their physical, intellectual, and moral characteristics. These morbid conditions determine the construction of types: the scrofulous, the rachitic, the goitrous, the deaf and dumb, the idiot, and many others. The extreme limit of humanity is reached with

Fig. 2.2  “Degenerated types influenced by the genealogical constitution of the soil in the department of Meuse”, Morel 1857, BIU Santé, Paris

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cretinous degeneration, which is at the core of this casuistry from the late nineteenth century. Orifices enable the clinician to measure “the perfectibility of the nervous system” and the “development of the sensory devices” (Morel 1857: 72). Just like the Hottentots and the apes, “cretins present a greater development of the zygomatic arches, a more flattened nose, larger lips and a more considerably developed lower jawbone” (Morel 1864: 30).17 The “vicious conformation” of the ears, also a marker of the Hottentot’s “animality”, functions once again as a sign of physical, psychic, and moral deformity. For example, the most common deformations are found in their flattened ear, which is thin as a sheet of paper. The rim of the helix more or less disappears and in some of them the auricle is excessively thin, flattened, transparent. Finally, the most extraordinary but rarest deformity is the entire disappearance of the ear, which is only represented by a rudimentary lobule. I met a very curious specimen of this type in a resident of Earlswood asylum in England, which is dedicated to the education of idiots and cretins. (Morel 1864: 36–37)

These affinities between “all the degenerated beings in the species” (Morel 1864: 9) combine to create ties of pathological kinship that are stronger and more evident than resemblance to the parents: “they look alike, they constitute types; they form races, diseased varieties of the species; they reveal their common origin through the identity of their character and nature” (Morel 1864: 2–3). The similitude within this pathological community attenuates, by comparison, the extreme diversity of population groups—so much so that “there are fewer discrepancies between the most wretched individual in the Hottentot nation and the most accomplished European in terms of the perfection of his type, than there are between this same European and the sickly degenerated being we call a cretin” (Morel 1857: 34). Furthermore, in the “cretin” for whom family ties are replaced with pathological ties, the ability to procreate is challenged. He is regarded a “eunuch”:18 a halt in genealogy. His sexual orifices are incomplete and “imperfect”: he marks an interruption in the making of a “plentiful and

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Fig. 2.3  “Developmental arrests—hereditary degenerations”, Morel 1857, BIU Santé, Paris

brilliant population”, as wished by Fodéré (1813: 3) who recommended for this purpose the implementation of a health code similar to the commercial or moral code (Figs. 2.3 and 2.4). In this clinical model, which is driven by a sense of anxious vigilance regarding the growth of the population and the need to improve the species (Foucault 1976), the ability to improve oneself is tightly connected to the ability to procreate. Cretins are regarded as children, much like the “Negroes” in whom the reduced distance between the navel and the penis (more orifices) shows, according to Serres from the Société Ethnologique de Paris, that they have remained arrested at an almost fetal stage.19 They are considered both as incapable of procreating—due to their incomplete sexual maturity—and as “lascivious”, “shameless”, and “perverse”: the complete opposite of the nineteenth century’s prevalent vision of fecund sexuality.20 Traces of this representation of cretinous degeneration can still be found in nineteenth-century clinical descriptions, for instance, in

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Fig. 2.4  “Types of cretinism”, Morel 1857, BIU Santé, Paris

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the writings of Cesare Lombroso, an admirer of Morel and morbid anthropology. The author describes the case of a twenty-five-year-old patient, the “bird-man”, through a series of emblematic signs: atrophied testicles and open cranial sutures, inability to close his mouth, ears that stick out and a foramen magnum located too far back as in anthropomorphic apes (Lombroso 1892).

Numerating the Invisible Finally, the anthropometric model provided another descriptive system. Considering that multiple characteristics could be measured, and that their respective importance varied according to the measurement method adopted, it is important to establish a scientific grounding for these quantifying activities. In 1859, the Société Française d’Anthropologie was founded under the direction of Broca in an attempt to respond to this imperative.21 While physiognomic features were assessed according to external characteristics that were pervasive in the collective imaginary, at the end of the century, they were regarded as “deceitful, fleeting, unstable” (Quatrefages 1887: 209). The fluctuations that derive from the great variety of human types and from the instability caused by the body’s transformations need to be offset: attempts were thus made to create more precise measurements to obtain numerical averages. Stephen Jay Gould (1992) showed that mathematical uncertainty has been accommodated to satisfy the ideological certainties: the measurement of bodily orifices is no exception to this phenomenon. His aim was not only to assess external orifices, measuring them and ordering them into series according to their visible similarities, but also and more importantly to measure invisible internal orifices, following a supposedly rational and numeral approach based on anthropometric observation. The very presence of these internal orifices was seen as an indicator. This is the case with the olecranon foramen on the humerus: a hole in the head of the arm bone, observed by Cuvier in the anatomy of the Hottentot Venus (1817: 270), which was said to be present in dogs, in primates and in the Guanches, an extinct population from the Canary Islands regarded as the “remains of the ancient nation of the Atlanteans” (Cuvier 1817:

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274). Once again, autopsy was used to bring truth to legend, establishing it into a scientific fact. The process was guided by the search for similarities: and later in 1871, a criminal anthropologist as Lombroso observed the common presence of the olecranon foramen in the Hottentot and in fetuses. Invisible orifices were also considered through the prism of their position and dimension. An example is provided by the debate on the foramen magnum initiated by naturalist and Doctor Louis Daubenton (1767). In his search for an indisputable criterion of humanity, Daubenton identified the location and gradient of the foramen magnum—the hole located at the junction between the spine and the cranium—as an anatomic principle that allows the human to “stand, a posture that is unique to him, to the exclusion of all other animals” (Daubenton 1795: 330). The angle of inclination of the hole indicates the way an individual carries their head and whether they are a biped. To measure the position of this orifice, Daubenton invented the notion of occipital angle, which was used to measure the discrepancy between humans and animals but not as a discriminating factor between races. However, after Daubenton, other scientists made the foramen magnum into an indicator of Black people’s proximity from apes. Initially considered a proof of humanity, the measure of the occipital angle became a marker of animality (Sömmering 1799b, Virey 1824, Vogt 1864 [1858], White 1799), and a signifier of otherness in the Hottentot, the idiot, the cretin, and the microcephalic. In addition to the geometric measuring of the occipital angle, its volume was also assessed: a larger foramen magnum allows more space for the nerves to pass through, which indicates a hypertrophy of instincts, sensations, and “animal” appetites in contrast with the development of reason and of the intellect in the encephalon.22 According to Broc, because his foramen magnum is larger and more posteriorly positioned, the Black man is forced to look to the ground instead of the sky; he has “more face and less cranium”, and the brain to nerves proportion is reversed. Like the woman, the old man, the child, and the idiot, “the Negro savage, deprived from the magnificent privilege granted to man, is unable to control nature” and his intelligence is “drowned in matter, dominated by the viscera” (Broc 1836: 77). The posterior position of the foramen magnum thus has aesthetic and sensory consequences, which

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are then described in qualitative terms: this indicates the coexistence of the various descriptive models examined earlier. Hence, in 1837, artist and anatomist Pierre-Marie-Alexandre Dumoutier, who took part as a doctor and pathology assistant in Dumont d’Urville’s expedition in Oceania and the Torres Strait, described the foramen magnum of Tasmania’s inhabitants. Dumoutier regarded the foramen’s position as the cause for these people’s rough and hideous features, reminiscent of those of Black people who were the closest to animality. The history of the measurement of the foramen magnum is retraced by Claude Blanckaert (1990), who explores its different variations and the controversies it has raised. Broca revisited Daubenton’s measurements using a new instrument, the arc goniometer, to back the theories of his predecessors who had been challenged by abolitionists, spiritualists, and philanthropists. However, statistical reality turned out to be less eloquent than expected, and the “racial averages” were the object of further controversies.23 Nevertheless, the dimension and position of the foramen magnum remained an important factor in subsequent years. In the 1940s, these measurements were still used as an indicator of immaturity in the fetus and the prehistoric man, especially in the Neanderthal variety, which was regarded as the missing link in the evolutionist paradigm.24 Comparative anatomy thus provided a theoretical framework for an understanding of development as a diversification process from elementary to complex. The measurement of time reveals hierarchical relations between beings, and the quantification associated with evolution, lays the foundations for scientific racism (Gould 1992). Even more so than the other models applied to the description of orifices, this anthropometric and recapitulative model focused on “race”, sex, age, and class. These categories mutually reinforced each other as they were based upon indisputable evidence that does not derive from visible differences—regarded as fallacious and insidious—but from precise and irrefutable “figures”.

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 onclusion: The Dangers of Analogy C in Scientific Reasoning “[Its] reversibility and [its] polyvalency endow analogy with a universal field of application. Through it, all the figures in the whole universe can be drawn together. There does exist, however, in this space, furrowed in every direction, one particularly privileged point: it is saturated with analogies …. This point is man” (Foucault 2002 [1966]: 24). While all societies produce otherness, the specificity of the “new” science of man that emerged in the nineteenth century was the illusion that it could systematize and scientifically measure the differences between human varieties, thus freeing itself from analogy. This new episteme dismissed the perception of the human body inherited from the science of the classical era, where the body is saturated with similitudes and caught in a game of magical mirrors. However, the issue is in fact more complex, as shown by this study of the qualitative and quantitative assessment of bodily orifices. These measurements were characterized by the tension between the ocular and mathematical paradigms, deployed through four models based on aesthetics, sensory improvement, morbid heredity, and anthropometry. The diversity of these descriptive models was unified by the role of resemblance in the construction of the knowledge of the Other. First, discourses on orifices reveal the plasticity of epistemological models. Scientist theories do not rely on a single paradigm: they draw from various competing models and thrive on their inconsistencies, polysemy, and approximation. The systems of description and measurement analyzed here are multifold and flexible, and mutually reinforce each other: for example, Virey’s anatomical/anthropometric model reinforces the sensory/functional model; while Broca (1871 [1861]) ignores the “evolved” orbital index detected in the Eskimo by resorting to aesthetic/ descriptive observations proving their “inferiority”. Second, the diversity of models is reinforced by the narrative and fictional character of these descriptions. Their language is vague, as are the descriptions of places and peoples. Cuvier’s anatomical report, which lay the foundations for the Hottentot legend, reads like a travel narrative. This account was then reused, quoted, and adapted in later

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writings—both scientific and non-scientific—until the original source was forgotten and these narratives became indisputable. The indeterminacy of sources and the repeated quotes produce looped narrations that are held for true once they have been repeated enough times. Yet references to science and to its methodological apparatus produce an effect that could be summed up by the saying: “there is no smoke without fire”. These theories sometimes had a tragic impact when, although they had initially been the expression of a thirst for knowledge, they echoed the social concerns of their time and were used to validate or legitimate relations of power and practices of domination. Finally, the treatment of bodily orifices shows the persistence of an analogic approach, according to which the ancient concept of similitude was applied to scientific measurement and to the numeration of reality. Analogy was not as influential then as it had been in the cosmogonic theories that prevailed until the nineteenth century: hence the often redundant and simplistic character of many of the descriptions examined earlier. However, the search for correspondences continued to be at the heart of the making of otherness. Similitudes are first and foremost visual, manifesting themselves in affinities of form, morphology, and color and reflecting analogies between the configuration of different body parts. However, what common points are there between Cuvier’s Venus, Desmoulins’ or Virey’s Hottentot, and Morel’s patients? What about anomalies, exceptions, off-frames that don’t fit into the classifications? Resemblance provides a key to develop classifications based on features, exceptions, and anomalies—by emphasizing or ignoring certain characteristics, by examining the interrelation of others, and sometimes by fragmenting the body to the point where some of its parts become unrecognizable and can be used for any purpose. Resemblance permits so many combinations that its efficiency is guaranteed. Empty orifices can be filled with any possible form or meaning: regardless of whether the ears are too small, too long, or even inexistent; whether the eyes are bulging or slit; whether the lips are too protuberant or on the contrary inexistent; whether the cranial sutures are prematurely ossified or the fontanels close too early. The mentions of harmony, regularity, and pleasantness scattered throughout these texts hint at the existence of a correct form even before any form is observed.

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The enduring power of resemblance also derives from the importance attached to visual representation. The period briefly examined in this chapter is characterized by its abundant production of images that drew from a rich material culture. The diverse human groups were made visible using drawings, moldings, etchings, waxworks, charts, display windows, resin models, body part specimens, and many others. The opening of natural history collections to the public was met with such success that concerns were expressed as to the preservation of the specimens. The public was able to access new scientific developments thanks to the emergence of new publishing technologies and to the proliferation of illustrated publications, reproduced via lithography, copper plate etchings, or wood engravings.25 At the eve of the advent of scientific photography, bodies and gazes were reorganized into a new space: to quote Monique Sicard, “there is no longer anything to stop the body from being seen” (Sicard et al. 1995: 11). This space of visibility was not yet that provided by photography, but it offered an equally naturalizing platform for bodily difference. This space also provided scope to explore diverse deviations from the norm through new technologies and representation models. The case of Saartjie Baartman shows the link between the multiplicity of visual media and the plurality of descriptive models. The drawings made in her lifetime, the exhibition of her skeleton and its casting, the sampling of her body parts for anatomical collections all indicate the blurred distinctions between a thing and a person, between a zoological and a human specimen, which are typical of the debate on racial classifications (Blanckaert 2013). These diverse systems of representation of the body also reveal the tension between the biography of an individual— whether it’s referred to as an exotic specimen or as a supernatural phenomenon, as indicated by the nickname “Hottentot Venus”—and the staging of racialized and nationalized bodies: for example, with the display of Baartman’s skeleton in natural history galleries or that of her cast at the Musée de l’Homme. In scientific illustration as in museum collections, “the world of raciological classifications tends to absorb its singular object into a mathematical series. Qualifiers thus become quantifiers: arbitrary judgement is subordinated to the rule, as is passion to reason and curiosity to science” (Patin 2013: 104).

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However, resemblance does not just involve the visual observation of similitude between forms: it also indicates the pervasiveness of genealogy as part of a wider mathematicization of life. In 1870, Quatrefages identifies the pillars of the notion of “species”: filiation (and therefore the ability to procreate) and resemblance, or the expression of specificity and unity in a being’s conformation.26 The theory of resemblance does not describe an object, but a relation of similitude or difference between individuals or elements that have been selected through cognitive choice. It implies the idea of a transmission of characteristics (physical, psychological, moral, and intellectual) along the line of descent: in this respect, it justifies the aggregation of like individuals and the exclusion of others. Resemblance thus provides a tool to capture both horizontal otherness, ordered into taxonomic classifications that cut across the diversity of places and environments—that is, the “savage”—and “in-depth” otherness as a product of heredity, history, and successive generations. It promotes an understanding of the Other as a variation from a model that is never defined or questioned. Whether they are considered as radically alien or as deviations from a self-evident prototype, the Others are connected between them by a chain of similarities that are disconnected from the socio-scientific context they stem from. The savage, the cretin, the child, the fetus, the woman, the alcoholic worker, the Jew are associated by series of indicators that vary according to the social or political context. This polysemy is also due to the fact that resemblance does not express identity but a discrepancy, a difference, “the surface of the blur” (Deleuze 1968): the Hottentot is not a cretin or a child but he is like them, and the space opened up by this “like” allows for the establishment, permutation, and transfer of multiple properties. In this profuse constellation of signs, it is always possible to find a point where bodies touch, respond to each other, and look alike. Therefore, in scientific theory, analogy, the daughter of resemblance, is so dangerous: it produces common sense and lends the obvious its “indisputable” truth. This is also why the power of resemblance is so enduring. Through the interplay of similarity and dissimilarity, social recognition opens the way for scientific knowledge.

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Notes 1. This chapter will not focus on the various meanings of the terms race, species, type, and lineage, which could provide enough material for another article on a theme that has already been widely studied. 2. The idea of an ethnic dualism cutting France in two, which underpinned the opposition between the nobility and the Tiers État, was elaborated among others by historian Augustin Thierry (1795–1856) (see Reynaud-­ Paligot 2011). 3. Le “caractère du Nègre” et “le Blanc barbouillé de suie”. 4. The analogy controversy that took over the world of natural sciences in Paris and beyond shows the scope of these tensions (Saint-Hilaire and Cuvier 1983). It opposed anatomist and physiologist Cuvier, who highlighted the role of organs in the differentiation of species, against Geoffroy de Saint-Hilaire, who believed that “nature constantly works with the same materials: it is only ingenious in varying their form” (Geoffroy de Saint-Hilaire quoted by Piveteau 1950: 346). As well as questioning the role of formal resemblance, this controversy challenged the very design of scientific reasoning and the development of life. 5. Doron distinguishes between othering (altérisation), which is based on classification, and alteration (altération), which suggests a distance from a set of original qualities. However, these two notions appear too polarized in Doron’s study, while they are often connected and associated in the texts analyzed here. 6. For example, according to Cesare Lombroso, one of the founders of criminal anthropology, a “pathological” genius is recognized by his thinness, pallor, short size, precocity, carelessness, and inconstancy and by the lack of resemblance between his parents. 7. The word orifice (orificium, 1314 < os and facere) is used here in its double anatomical meaning: “a narrow aperture in an organ” and more generally, an opening through which a cavity (natural or artificial) communicates with the outside. 8. These denominations actually cover very different populations. The Hottentot crystallizes multiple representations of the Black man, the savage, and the primitive. This word is sometimes used alternately with Bushman (Bochimane in French), Pygmy, or Bantu. The same goes with the category of the cretin, which includes, save for a few exceptions, the idiot, the microcephalic, and the deaf and dumb.

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9. German historian Christophe Meiner proposes a hierarchy of races, using beauty as a criterion of differentiation between peoples. Johann Friedrich Blumenbach identifies five main races, each of which has a beauty of their own although any deviation from the Greek ideal is regarded as a degeneration. Hegel also supports the ideal of beauty embodied by Greek art, and in particular by the Greek profile: “the facial formation in which the expression of the spirit puts the merely natural wholly into the background” (Hegel 1998: 730). 10. To demonstrate the human character of the fetus, anatomist Samuel Sömmering (1799a) summons up a vocabulary that borrows from the language of painting. 11. Baartman’s first autopsy was carried out by de Blainville. “Sur une femme de race hottentote”, Bulletin de Sciences par la société de philomathique de Paris (1816: 183–190). 12. On the influence of Cuvier’s observations among his contemporaries and successors, see Taquet (2013). 13. The development of raciology is associated with the weakening of the notion of species, and with the emergence of questions on what separates man from the animal. I explored this theme, which will not be examined in depth here, in a workshop: “Les orifices du corps. Traversées anthropologiques”, organized with Virginie Vinel in Strasbourg on the 25–26 October 2011. 14. See the descriptions of “savage” women produced by geographers in the early nineteenth century (Staum 2003: 103 sq). 15. The “Skin Man” is also insensitive to pain: a theme that acquires a political value in this context, as the anti-slavery movement organized itself around the idea of a common sensitivity to pain (Laqueur 1999). The same argument was taken on again by the movements against speciesism in the twentieth century. 16. Johannes Fabian (1983) calls this phenomenon “allochrony” and regards it as the operation through which early anthropology constructed its object of study. 17. This outpouring of the physiognomy is also described by Virey (1824), and associated with personality traits such as voracity, lubricity, a continual proneness to laugh, an inability to invent, and insensitivity to pain. 18. The cretin is set apart from the idiot and other diseased varieties by his inability to procreate, which places these individuals at the extreme margin of humanity.

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19. On Serres positions in the controversies of his time and on his influence within the Société Ethnologique de Paris, see Williams (1994: 233–241). 20. This disconnection of sexuality from reproduction is also used to describe the sexual orifices of Black men, who are characterized by the length and width of the penis and the relative smallness of the testicles and scrotum (White 1799: 61). Similarly, a Black female’s “vagina is at all times large and in proportion with the male’s often enormous member, but almost incapable of a full erection, [which means that] no other women are more prone to abortions” (Bory de Saint Vincent 1826: 32). 21. On the history of the Société d’Anthropologie de Paris, its functioning, and the controversies it gave rise to, see Blanckaert (2009). 22. In keeping with the logic of compensation, the anatomists of the time opposed the volume of the brain to that of the peripheral nervous system (nerves, spinal cord, and cerebellum): the larger the latter, the lesser the encephalon and the intellect. 23. In 1873, Broca was still surprised to find that “the Tasmanians, who belong to one of the inferior races, [rank] at an average of +2°58, which places them immediately after Europeans” (1873: 227). Broca works his way out of this impasse by claiming that the foramen magnum is more anteriorly located in Blacks than in Whites because of the atrophied frontal area of their skull, associated with lower intellectual faculties. 24. The orbital index was also the object of debates. According to this index, human populations are divided into megasemic, mesosemic, and microsemic. This index is 100 in a fresh fetus, it increases in microcephalics and is understood to remain very high in young children, women, and Negroes. According to Broca, megasemia indicates a halt in evolution. These conclusions are in line with Haeckel’s theory of recapitulation, according to which ontogenesis—or the development of an individual from embryo to complete being—recapitulates phylogenesis, or the development of the species. 25. On technological innovation in scientific and medical illustration, see Ségal et al. (2006). 26. According to Quatrefages, “there are dissimilarities, both external and anatomical, between animals belonging to the same species but to a different race” (Quatrefages 1870: 220).

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References Sources de Blainville, H. (1816). Sur une femme de la race hottentote. Bulletin des sciences par la société philomatique de Paris. Séance du 18 mars 1815, 183–190. Bory de Saint Vincent, J.-B. (1826). L’Homme. Essai zoologique sur le genre humain. Paris: Rey et Gravier. Broc, P.  P. (1836). Essai sur les races humaines considérées sous les rapports anatomiques et philosophiques. Paris: Rouvier-Le Bouvier. Broca, P. (1865). Instructions générales pour les recherches anthropologiques. Paris: Masson et fils. Broca, P. (1871 [1861]). Sur le volume et la forme du cerveau. Mémoires d’anthropologie. Tome 1, 155–220. Paris: Reinwald. Broca, P. (1873). Sur la direction du trou occipital et sur les angles occipitaux et basilaires. Revue d’Anthropologie, Tome, 2, 193–234. Broca, P. (1875). Instructions craniologiques et craniométriques de la Société d’Anthropologie de Paris. Paris: Masson. Bulletins de la Société Ethnologique de Paris, tome I, 2ème trimestre, 1847, séances du 11 et du 25 juin. Cuvier, G. (1800 [1978]). Note instructive sur les recherches à faire relativement aux différences anatomiques des différentes races d’homme (1800). In J. Copans & J. Jamin (Dir.), Aux Origines de l’anthropologie française. Les Mémoires de la Société des Observateurs de l’Homme en l’an VIII (pp. 171–176). Paris: Le Sycomore. Cuvier, G. (1817). Extrait d’observations faites sur le cadavre d’une femme connue à Paris et Londres sous le nom de Vénus Hottentote. Mémoires du Muséum d’Histoire Naturelle, Tome, 3, 259–274. Daubenton, L. (1767). Mémoire sur les différences de la situation du grand trou occipital dans l’homme et dans les animaux. In Histoire de l’académie royale des Sciences, année 1764 (pp. 568–575). Paris: Imprimerie royale. Daubenton, L. (1795). Leçons sur l’homme. Leçons professées aux Ecoles normales, 8, 313–351. Desmoulins, A. (1826). Histoire Naturelle des races humaines du nord-est de l’Europe, de l’Asie Boréale et orientale et de l’Afrique Australe. Paris: Méquignon-Mervis.

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Edwards, W. F. (1853 [1829]). Physiologie des races humaines. In L-F. Jéhan & J-P. Migne (Dir.), Dictionnaire d’Anthropologie ou Histoire Naturelle de l’Homme et des races humaines. Anatomie, Physiologie, Psychologie, Ethnologie (pp. 1171–1228). Paris: J.P. Migne. Fodéré, F.-E. (1813). Traité de médecine légale et d’hygiène publique ou de police de santé. Paris: Imprimerie de Mame. de Gérando, J.-M. (1994 [1800]). Considérations sur les diverses méthodes à suivre dans l’observation des peuples sauvages. In J. Copans & J. J amin (Dir.), Aux origines de l’anthropologie française. Les Mémoires de la Société des Observateurs de l’Homme en l’an VIII (pp. 127–169). Paris: Le Sycomore. Jéhan, L.-F., & Migne, J.-P. (1853). Dictionnaire d’Anthropologie ou Histoire Naturelle de l’Homme et des races humaines. Anatomie, Physiologie, Psychologie, Ethnologie. Paris: J.P. Migne. Lombroso, C. (1871). L’uomo bianco e l’uomo di colore. Letture sull’origine e le varietà delle razze umane. Padova: F. Sacchetto. Lombroso, C. (1892). Microcefalia e cretinismo. Torino: Bocca. Morel, B.-A. (1857). Traité des dégénérescences physiques, intellectuelles et morales de l’espèce humaine et des causes qui produisent ces variétés maladives (avec Atlas de XIII planches). Paris: Baillière. Morel, B.-A. (1864). De la formation du type dans les variétés dégénérées ou Nouveaux éléments d’anthropologie morbide pour faire suite à la théorie des dégénérescences de l’espèce humaine. Paris: Baillière et Masson. Nouvelle Relation des Découvertes faites dans la Nouvelle Hollande à l’Ouest des Montagnes Bleues (avril et mai 1815). Mémoires du Muséum National d’Histoire Naturelle, Tome 2 (pp. 479–492). Paris: Dufour. Pouchet, G. (1858). De la pluralité des races humaines. Essai anthropologique. Paris: Baillière. de Quatrefages, J.-L. A. (1870). Charles Darwin et ses précurseurs français. Etude sur le transformisme. Paris: Germer-Baillière. de Quatrefages, J.-L. A. (1887). Histoire générale des races humaines. Introduction à l’étude des races humaines. Paris: A. Hennuyer. de Saint Hilaire, G. E., & Cuvier, G. (1983). La querelle des analogues. Plan de la Tour Var: Editions d’aujourd’hui. Sömmering, S.  T. (1799a). Icones Embryonum Humanorum. Francofurti ad Moenum: Varrentrapp und Wenner. Sömmering, S. T. (1799b). On the comparative Anatomy of the Negro and the European. In C. White (Ed.), An Account of the Regular Gradations in Man and in Different Animals and Vegetables (pp. CXIL–CLXVI). London: C. Dilly.

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Virey, J. J. (1824). Histoire naturelle du genre humain. Paris: Crochard. Vogt, C. (1864 [1858]). Lessons on Man. His Place in Creation and in the History of the Earth. London: Longman, Green, Longman and Roberts. White, C. (1799). An Account of the Regular Gradations in Man and in Different Animals and Vegetables. London: C. Dilly.

Bibliography Aramini, A., & Bovo, E. (2018). Introduction. Pour une étude la pensée de la race en Italie. De l’âge romantique à la période fasciste. In A.  Aramini & E.  Bovo (Dir.), La pensée de la race en Italie. Du Romantisme au fascisme (pp. 13–22). Besançon: Presses Universitaires de Franche-Comté. Balibar, E. (1991 [1990]). Racism and Nationalism. In E.  Balibar & I.  Wallerstein. Race, Nation, Class. Ambiguous Identities (pp.  37-85). New York: Verso. Balibar, E. (2012). L’introuvable humanité du sujet moderne. L’universalité civique-bourgeoise et la question des différences anthropologiques. L’Homme, 203-204, 19–50. Baridon, L. (2004). Hybridation d’un artiste romantique. Les autoportraits en animal de J.-J. Grandville. In L. Baridon & M. Guédron (Dir.), Homme animal. Histoire d’un face à face (pp.  139–153). Strasbourg: Les Musées de Strasbourg-Adam Biro. Blanckaert, C. (1990). Le trou occipital et la “crâniotomie” comparée des races humaines (18e-19e siècle). In J.  Hainard & R.  Kaehr (Dir.), Le trou (pp. 253–299). Neuchâtel: Musée d’Ethnographie de Neuchâtel. Blanckaert, C. (1999). Contre la méthode: unité de l’homme et classification dans l’anthropologie des Lumières. In C.  Calame & M.  Kilani (Dir.), La fabrication de l’humain dans les cultures et en anthropologie (pp.  111–126). Lausanne: Payot. Blanckaert, C. (2009). De la race à l’évolution. Paul Broca et l’anthropologie française (1850–1900). Paris: L’Harmattan. Blanckaert, C. (2013). Figurée, défigurée. Les carrières de Sarah Baartman. In C. Blanckaert (Dir.), La Vénus hottentote entre Barnum et Museum (pp. 7–30). Paris: Muséum National d’histoire naturelle. Deleuze, G. (1968). Différence et répétition. Paris: Presses Universitaires de France. Dias, N. (2004). La mesure des sens. Les anthropologues et le corps humain au 19e siècle. Paris: Aubier.

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Diasio, N. (1999). La science impure. Anthropologie et médecine en France, Grande-Bretagne, Italie et Pays Bas. Paris: Presses Universitaires de France. Diasio, N. (2010). Faire corps, ou comment faire du collectif en singularisant. L’exemple des ressemblances familiales. Anthropologica. Journal de la Société Canadienne d’Anthropologie, 52(2), 323–336. Diasio, N. (2019). Une biopolitique à bas bruit. Temps, normes de croissance et intensification du corps masculin à l’aube du 20e siècle. Recherches sociologiques et anthropologiques, 50(1), 45–76. Dorlin, E. (2009). La matrice de la race. Généalogie sexuelle et coloniale de la nation française. Paris: La Découverte. Doron, C.-O. (2016). L’homme altéré. Races et dégénérescence (17e-19e siècles). Ceyzérieu: Champ Vallon. Duvernay-Bolens, J. (1995). Les Géants Patagons. Voyage aux origines de l’homme. Paris: Michalon. Fabian, J. (1983). Time and Other. How Anthropology Makes Its Objects. New York: Columbia University Press. Foucault, M. (1966 [2002]). The Order of Things: An Archaeology of the Human Sciences. London: Psychology Press. Foucault, M. (1976). La volonté de savoir. Histoire de la sexualité 1. Paris: Gallimard. Foucault, M. (1997). “Il faut défendre la société”. Cours au Collège de France. 1976. Paris: Gallimard-Seuil. Gilman, S. (1985). Difference and Pathology: Stereotypes of Sexuality, Race, and Madness. New York: Cornell University Press. Gilman, S. (1993). Touch, Sexuality and Disease. In W. F. Bynum & R. Porter (Eds.), Medicine and the Five Senses (pp. 198–224). Cambridge: Cambridge University Press. Gould, S. (1992). The Mismeasure of Man. London: Penguin Books. Hegel, F. (1998). Aesthetics. Lectures on Fine Art. Oxford: Oxford University Press. Laqueur, T. W. (1999). L’homme, l’humanitaire et la catégorie de l’humain au 18e siècle. In C. Calame & M. Kilani (Dir.), La fabrication de l’humain dans les cultures et en anthropologie (pp. 93–110). Lausanne: Payot. Montaldo, S. (2018). Le début de la pensée raciste de Lombroso (1860–1871). In A. Aramini & E. Bovo (Dir.), La pensée de la race en Italie. Du Romantisme au fascisme (pp. 87–100). Besançon: Presses Universitaires de Franche-Comté. Moravia, S. (1982). Filosofia e scienze umane nell’età dei Lumi. Firenze: Sansoni. de Montaigne, M. (1965 [1580]). Essais. Tome 1. Paris: Gallimard.

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Mosse, G.  L. (1985). Nationalism and Sexuality: Middle-Class Morality and Sexual Norms in Modern Europe. Madison: University of Wisconsin Press. Patin, C. (2013). Les vies post-mortem de Saartjie Baartman. Muséologie et économies morales. In C. Blanckaert (Dir.), La Vénus hottentote entre Barnum et Museum (pp. 65–167). Paris: Muséum National d’histoire naturelle. Piveteau, J. (1950). Le débat entre Cuvier et Geoffroy de Saint-Hilaire sur l’unité de plan et de composition. Revue d’histoire des sciences et de leurs applications, 3(4), 343–363. Praz, M. (2008 [1930]). La carne, la morte e il diavolo nella letteratura romantica. Milano: Rizzoli. Reynaud-Paligot, C. (2011). De l’identité nationale. Science, race et politique en Europe et aux Etats-Unis 19e-20e siècle. Paris: Presses Universitaires de France. Ségal, A., Samion-Contet, J., & Molitor, B. (2006). Les illustrateurs et les illustrations de la maison d’édition medico-scientifique J.-B. Baillère et fils au 19e siècle. In D. Gourevitch & J-F. Vincent (Dir.), J.-B. Baillère et fils, éditeurs de médecine (pp. 93–114). Paris: De Boccard. Sicard, M., Pujade, R., & Wallach, D. (1995). A corps et à raison. Photographies médicales 1840–1920. Paris: Marval. Mission du patrimoine photographique. Staum, M. (2003). Labeling People. French Scholars on Society, Race, and Empire 1815–1848. Montréal: McGill-Queen’s University Press. Stocking, G.  W. (1971). Race, Culture, and Evolution. Essays in the History of Anthropology. New York: The Free Press. Taquet, Ph. (2013). Les corps de Sarah Baartman et de Georges Cuvier sous le regard du 19e siècle. In C. Blanckaert (Dir.), La Vénus hottentote entre Barnum et Museum (pp. 169–193). Paris: Muséum National d’Histoire Naturelle. Williams, E. (1994). The Physical and the Moral. In Anthropology, Physiology, and the Philosophical Medicine in France, 1750–1850. Cambridge; New  York: Cambridge University Press. Yuval-Davis, N. (1997). Gender & Nation. London: Sage.

3 Talking Bones: Age in Nineteenth-­ Century Forensic Handbooks (1813–1906) Ingrid Voléry

In the nineteenth century, the measuring of humans intensified as this issue assumed diverse forms and perspectives, from anthropology to evolutionary biology and medicine, including colonial, school, military, or hygienist medicine. This chapter addresses one of these specialisms: forensic medicine. The reasons for this choice are multifold. First, forensic medicine’s contribution to the measuring of humans remains understudied. French forensic medicine is today mostly investigated by sociologists in terms of its professional organization and its relations with the judicial field (Chauvaud 2000; Rabier 2010; Porret 2010; Menenteau 2017; Goburdhun 2017; Juston 2018), more marginally from the perspective of its social reception (Bertherat 2016) or that of the technologies used to represent, identify, and explore the body (Bertherat 2013).1 Thus, few studies have considered the ontogenetic models and metric cultures conveyed by forensic medicine.

I. Voléry (*) Laboratoire Lorrain de Sciences Sociales, Université de Lorraine, Nancy, France e-mail: [email protected] © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_3

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Secondly, forensic medicine sits at the crossroads of multiple social worlds (clinical, scientific, political, legal, regulatory) and sciences (biology, anatomic pathology, toxicology, orthopedic surgery, etc.). As such, it provides a great point of entry for analyzing the intermixing and hybridization of the various ways in which humans are measured. In addition, these measurements occur in very particular situations, in close connection with legal debates and political/social controversies surrounding the crimes and offenses that require the expertise of forensic medicine.2 From this perspective, forensic medicine is quite similar to colonial one in that it allows us to observe the complex mix of scientific, political, and legal factors that underpin any action aimed at exploring and calibrating the human. But it also differs because of specific political concerns: if colonial medicine focus on the otherness of the bodies of the “colonized”, forensic one is framed by infra-national issues, seen as essential to the protection of local communities, to “social progress” or to the strengthening of the population (e.g., preserving heritage, new-born infants and children, or prophylaxis).

The Anatomic Politics of “Bone Age” The metrics of age in relation to bones has been shaped by similar concerns. We chose to examine this topic for several reasons. First of all, age has remained unexamined in scholarly research: the measuring of humans from the late eighteenth century onward has mostly been approached through the processes of genderization and racialization fueled by these practices (Gould 1981; Laqueur 1992; Hocquet 2013; Peyre 2015; Bouhallier 2015; Doron 2016; Sommer 2016). Studies addressing the measurement of age have mostly focused on the turn of the twentieth century, with the emergence of developmental thinking (Rollet 2008; Turmel 2008). These studies considered intellectual performance, height, weight, and growth, leaving aside internal parts, although these also formed part of the codification of human development. See, for instance, orifices, studied by Diasio in this book, or the bones targeted by the straightening or structural strengthening techniques deployed by school medicine in the late nineteenth century (Parayre 2010), and later by

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geriatric medicine in the late twentieth century (Armstrong 1983; Kérisit and Pennec 2001). Finally, in addition to the fact that “bone age” is currently under the spotlight in French news,3 bones are singular objects that sit at the intersection of diverse measuring systems whose interconnection is the object of this book. Their observations are underpinned by the observer’s social and moral knowledge, by technological procedures, but also by quantitative measurements based on singular specimens or, on the contrary, on standardized series. By studying doctrines on bone formation, on its transformation throughout life and on the relations between bones, the rest of the human body, and its social environment, we can gain insights into the ontogenies used by forensic pathologists and into the different conceptions of age they convey.4 How is the effect of time on the person perceived? How is the maturation of the person understood— as a member of a species, but also as an individual and a social subject? Is age at the heart or at the margins of the characterization of the person? Is it seen as a moral condition or as a variable? As an ontology or as a developmental stage? These questions are addressed by forensic pathologists in a dual context: on the one hand, the emergence of a specific field of knowledge of bones, and on the other hand, the assimilation of bone maturation processes with reified chronological stages. This chapter examines the construction of this knowledge.

F orensic Medicine Treatises: A Vantage Point to Examine Two Early and Late Nineteenth-­Century Ontogenetic Models Various methods can be used to investigate these historic systems. One possible corpus could be provided by legal cases involving age assessments, but this corpus is very fragmented and does not bring any detailed insights into the formation and accumulation of medical knowledge.5 Another method, used by Marianne Sommer (2016), consists in working from a study of the major figures of forensic medicine—at the risk of underrating the role of the social and legal contexts that facilitated the emergence of these figures and the articulation of their institutional,

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political, or professional positions. In contrast, the present article starts out from a study of forensic medicine manuals. In the nineteenth century, these manuals were the product of cross-national collaborations and were very numerous, as for example Belloc 1800, Mahon 1801, Vigné 1805, Ballard 1812, Fodéré 1813 and 1821, Poilroux 1837, Devergie 1837 and 1852, Bayard 1843, Briand and Chaudé 1846 and 1874, Orfila 1848, Casper 1862, Lacassagne 1881 and 1921, Lefort 1889, Coutagne 1896, Tourdes and Metzgier 1896, Brouardel 1899, 1881, 1895, and 1909.6 Most of the manuals listed were published between 1841 and 1919, a period during which this discipline, sitting at the crossroads of diverse segments of medical knowledge and cutting across policing, law, and medicine, became institutionalized. This institutionalization process was supported by the publication of forensic medicine treatises: these manuals served to establish this specialism but were also used to train practitioners, turning them from artists into experts in a context where objectiveness required a sharp eye, hand, and mind (Daston and Galison 2007). From this perspective, this material presents undeniable advantages as it provides insights into forms of professional legitimatization that were just being constructed at the time, and into internal controversies that are sometimes alluded to in the manuals’ long preambles. However, this corpus also shows its limitations: while the preambles contain information on the authors’ professional and ideological positions, they omit their political role as well as some major themes of nineteenth-century medicine. For instance, the theme of the origin of species, which was very prominent in the physical anthropology literature, is eclipsed by the issue of identification, which was brought to the forefront by the political and social reforms that forensic medicine manuals had to incorporate. Nevertheless, beyond these limitations, this material has a heuristic value—most importantly because it shows how forensic pathologists worked on the ground, “in shirtsleeves” (to quote Daston and Galison), to fabricate the two human metrics examined here. These systems are presented here through two manuals that are not necessarily representative of the work of all forensic physicians during the two periods at hand, but that reveal two models constructed at both ends of the nineteenth century: the works of François-Emmanuel Fodéré (1764–1835), a mix of

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Ancien Régime and contemporary knowledge (neo-humoral vision of the body and age, mentions of the figure of the holistic doctor, or “médecin total” in French); and those of Alexandre Lacassagne (1843–1924) who promoted expertise in medicine and a biochemical reading of the body, while seeking to calibrate its maturation. Comparing these two authors, who come from very different social backgrounds, does not amount to claiming that forensic medicine has undergone a linear evolution. Nor does it mean that one should ignore the diverse movements that emerged during this period of intense anthropo-technological production. On the contrary, this article seeks to highlight the contrasts between two measuring systems that were born from distinct historical contexts7 and that should not be seen as successive moments but, on the contrary, as capable of being mobilized jointly, as we will see in the second part of this chapter.

 ge as a Marker of Singularity A at the Beginnings of Forensic Medicine in the Early Nineteenth Century The early vision of age and the body appears remarkably clearly in the Treatise of Forensic Medicine and Public Hygiene or Health Policy, Updated According to the Codes of the French Empire and to State-ofthe-Art Knowledge by François-Emmanuel Fodéré (1813). Regarded as the founder of forensic positivism, the author was an institutional figure in the field of forensic medicine, but also in the politics of his time. An opponent of the hygienist doctors of the Conseil de salubrité de Paris (“Paris Health Council”) whom he considered too liberal (Jorland 2010), Fodéré insisted that medicine was a holistic science embracing physical, moral, and social health. An expert in miasma theory, he was also heavily inspired by the neo-Hippocratist theory of climate8 (Fressoz 2009; Gaille 2018), which left a deep imprint on his understanding of the human and of the “correct” ways of measuring it.

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 he “Médecin Total” and the Art of the Forensic T Pathologist According to Fodéré According to Fodéré, a forensic pathologist is both a forensic medicine official and an advocate of public hygiene:9 two roles that can be found later, but envisaged separately, in Lacassagne’s thinking. In Fodéré’s treatise, the doctor’s knowledge is expected to shed light on bodily matters as well as on the soul and on society. A doctor must be able to see through his contemporaries’ subjectivities, but also to put his own subjectivity at the service of the production of scholarly knowledge. Like Vigné (1805), who associated the doctor’s healing skills with his sense of observation but also with his keen knowledge of the human mind, Fodéré considered that subjectivity was an essential basis for “good medical knowledge”— because it provides the setting for the physician’s unique experience (see the use of terms like the “seasoned eye” or “experienced eye”), but also because of the importance of their fortitude and probity. This theme can later be found in the writings of other physicians who assumed the role of the expert (Devergie 1837). In Fodéré’s writings, however, a good physician should not just be a person of integrity. He must also be able to detect the fluctuations of human passions from the observation of bodies and situations. From this angle, Fodéré began to articulate the investigative method that will characterize the experimental approach of the late nineteenth century, with a model of objectivity based on “trained judgement”.10 Fodéré thus recommended using a notebook and recording the facts as near as possible to the crime scene or post-mortem site. These techniques were later popularized by Claude Bernard, who was quoted as a major influence by Lacassagne (1906: 289) and by twentieth-century handbooks (Planques 1967 [1959]). Nevertheless, Fodéré had a particular understanding of observation, which he presented as a process aimed at revealing the quintessence under appearances and at establishing “truth to nature”.11 And yet, to capture the quintessence hidden under the visible, one must consider the visible surface that is the body—understood as organism—in a particular manner. The body becomes a key element of the observation process, but this process does not stop there: the body is

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first and foremost a place on which one can read an individual’s environment, lifestyle, and morality.

The Body: A Tangle of Passions, Lifestyles, and Organs In line with the Hippocratic tradition, Fodéré believed that the boundaries between the body and its environment were porous. While it is no longer a mirror for the cosmos or transcendence, the body remains part of a specific environment—whether geographic (influence of the climate and heat on the body’s physiological maturation and on age), social (influence of profession and lifestyles), or moral (influence of passions and moral depravity)—which can profoundly shape it. For instance, Fodéré distinguishes between girls in Southern regions who become nubile at an earlier age (menstruation at 12 or even 9–10  years old) because of the heat that ripens them like it does fruit and vegetables (Fodéré 1813: 39), and children of modest origin living in sun-­ deprived places: On the contrary, everything that diminishes plethora such as poverty, sorrows, abstinence, unflavorsome foods, an exceedingly laborious life or a hard bed can delay the onset of puberty because in this case, nutrition is difficult to obtain. (ibid.: 45)

When writing about bones,12 Fodéré once again referred to humoral theory. For instance, wet and soft qualities can indicate either the temperament of a specific sex (the “softness of the flesh, the lesser density of bones” in females) (ibid.: 29) or a “soft” and unstable age. The softness of the fontanel bones, a characteristic of early infancy, is opposed to the rigidity of older bodies, marked by the curving of the spine (ibid.: 28), the solidification and drying of the bone structure (ibid.: 26) and eventually the crumbling of cartilage in old age. Fodéré thus considered that over time, gelatinous cartilage (a soft matter that is not genuinely equated with bone) dried out and eventually transformed into bone. This idea of a continuity between cartilage and bone can be found later in twentieth-­ century theories of osteogenesis. But Fodéré’s understanding was quite

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different: he considered this evolution as an ontological shift rather than a gradation in density or a mineralization process on which chemical analyses will later focus. From this point of view, Fodéré echoed a particular vision of the human life cycle: he believed that the body did not change gradually with age but rather renewed itself, with a fundamental transformation of its structure occurring every seven years, tied to intense moral, social, and relational changes. This understanding of the effects of time on the person led him to adopt a distinctive approach to age. As he or she grows older, a person changes rather than developing—which can have the effect of blurring their identity.

 ge: An Equivocal Criterion and the Mark of a Unique A Biographical Experience Fodéré’s vision of age remained imbued with humoral notions, which were deemed obscurantist by Lacassagne seventy years later. This is evident in the title of his 161-page-long section dedicated to the “Different ages of human life” (“Différens âges de la vie humaine”), as well as in his use of terms such as “virile age” (“âge de la virilité”) or “age of decline” (“âge de retour”).13 A matter of morals as much as physiology, age was intimately connected with the individual’s sex and temperament and, just like these characteristics, was affected by plethora and living conditions.14 For instance, a child was characterized by its confusion and ability to blush. When considering cases of marriage, abduction, or seduction, Fodéré assessed a subject’s childhood based on their behavioral reactions: “confused ideas, a blushing that drives one to think that the subject has not yet reached the age of discernment” (ibid.: 66). A moral condition rather than an organic one, age was only equivocal in that it was affected by multiple dimensions, and it did not guarantee the continuity of the person. Under its influence, people could change to the point where they could become unidentifiable by their close relatives, as had been illustrated by the case of Martin Guerre (1560). As well as being deceptive for the community that contribute to identify a person, age was also misleading for early nineteenth-century forensic pathologists, as they were not required to judge the normal development

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of a body-as-species (a question considered by physicians in the late nineteenth and early twentieth century) but rather on a person’s alleged identity. In the first treatises, the issue of the measurement of age appeared in relation to situations where a forensic pathologist was called upon to identify a living individual—often adult men or women who had returned to claim their assets or family status after a long absence that had disconnected them from their close community, in the absence of reliable administrative documents. For instance, the practical applications listed on page 61 include cases where a person who had lost their identity documents needed to be identified. Such cases were common in this period of “political troubles”, when the state’s industrialization and urbanization policies increased population movements and when civil registries were being restructured (Chauvaud 2003; Ilsen and Vincent 2010). Situations involving children appear to have been less frequent,15 and usually served a dual purpose. As with adults, the question was often an individual’s belonging in a community (i.e. a family) from which they could draw their subsistence and entitlement. A forensic pathologist could be called upon to ascertain or establish filiation, an exercise made more complex by the context, where children were very mobile, traveling across the national territory as well as within their family (e.g., see private fostering, apprenticeship, or aristocratic fostering practices as described by Jablonka 2005 and Fine 2008). In addition, due to the transformation of children’s social status in the early nineteenth century, physicians could also be required to assess their discernment, specifically when it came to the rights that regulated marriage with respect to inheritance and sexuality (determining a marriage’s validity or nullity, assessing virginity, etc.). In such cases, the forensic measurement of the body had nothing to do with a search for signs of bio-geographic belonging, or with the use of the body as proof of an individual’s alleged age (see Chap. 7 in this book). Nor was the objective to appreciate an individual’s vulnerability and whether it might require public protection. Measurements were mostly carried out for the purpose of controlling the circulation of property through filiation or marriage: according to Fodéré, “identity questions are therefore similar to filiation questions, and vice-versa” (1813: 80). Fodéré thus stressed that the forensic pathologist’s mission was to support civil courts in protecting citizens against identity theft and miscarriages of justice caused by

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resemblance. For this purpose, the courts could use public registers, an individual’s continuous use of a first name and surname, testimonies, or “bodily signs such as spots, growths, mutilations, family resemblance or the voice of blood” (ibid.: 85). Bones were therefore used to identify singularity and age only indicated the individual’s place in a trajectory that had in some cases left marks (disease, accident) examined by the forensic pathologist. As a biographic experience that deeply transformed the body, age was used to distinguish between social subjects, based not only on organic dispositions stemming from their social heredity or bloodline, but also on the fact that living conditions and biographic events contributed to building a subject who was singularized from the outside, and not just atypical on the inside.16

Measuring Singularity While the aging process was seen first and foremost as a transformation of souls and characters, it also involved physical changes. Fodéré examined the body’s fluctuations using a detailed method of observation that consisted in collating and comparing corpses of diverse ages, in order to analyze their changes of state.17 However, while Fodéré did take measurements, his focus remained on detail and particularity, in contrast with the generalization of averages applied by Devergie (1837), for instance. According to Fodéré, since the Martin Guerre affair and other cases involving lost children whose identity had been established thanks to “smallpox” marks that had been observed and archived by doctors, no human was identical to another in form or smell, or in the bodily marks resulting from their history. As with lifestyles, diseases or accidents of life, age altered semblance to the point of making it difficult for an individual to be recognized:18 We follow the same order as Zacchias [with reference to Quest med. Legal. Consilium LXI] to present the reasons for the alteration of semblance, beginning with age. Regarding this cause, no-one ignores how dissimilar puberty is from childhood …; how much young age differs from adolescence, virile age from young age, etc. …; so much so, that one has difficulty

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recognizing the same man whom one had seen as a child after they have reached puberty. (Fodéré 1813: 111)

According to Fodéré, growing up amounted to transforming oneself. An example could be found in children who underwent a radical change in their substance, such as “these fair children who grow up to become ugly” (ibid.: 114). Fodéré also quoted the example of Chinese people who look pretty as children due to their “naturally small heads and features” but become ugly as they grow older as they have “a small head on a larger torso” (ibid.: 113). The notion of a “good” aging process involved both an aesthetic appreciation and an assessment of anatomic conformity (brightness of the complexion, intensity of the eyes, and bodily proportions). In contrast with Lacassagne who measured age by assessing the individual’s conformity to developmental stages and rhythms, Fodéré mixed up moral, aesthetic, social, and medical criteria to understand the “walk of ages”. For him, growing up involved the deployment of forms until they reach plenitude (adult age),19 and the person’s transformation under the effect of time—changing from pretty to ugly, intensity of the eyes, changes in hair and eye color, but also in the arterial and venous systems (ibid.: 113–114). Seen as a characteristic of the self rather than an objective mark of the passing of time on bodies, age was singular and eminently variable depending on lifestyle and on the movements of the soul (passion, for instance, could age a person’s features).20 Age was therefore deceitful, and as such not trustworthy as an identification criterion—particularly in adults, who accounted for the majority of cases where a forensic pathologist was consulted. More widely, Fodéré believed that a “good” measurement was necessarily informed by experience and required work in close proximity with situations and communities, the knowledge of which was essential for reading bodily marks. A “good” measurement should be an encounter between the researcher’s singularity and those of the observee ’s that has to be approached through his body rather than through quantification, standardization, and mechanization. However, in the last third of the nineteenth century, changes were introduced in forensic technologies and literature (collections of fetuses and comparison between skeletons at different stages of gestation), in the professional status of forensic medicine

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(which became structured around technical expertise) and in the legal frameworks regulating forensic activities. These changes transformed the vision of age in relation to bones, especially with Lacassagne’s contributions.

 ge as a Development Marker Used A in Association with Chronological Thresholds in Late Nineteenth-Century Medical Expertise Lacassagne’s work sits at the crossroads of diverse medical, doctrinal, and technological movements. It articulates a different way of measuring the human, based on a biologization of age that was deployed differently depending on its use: for the purposes of hygienism (see Lacassagne’s 1879 treatise on private and social hygiene) or for forensic medicine (see his 1906 treatise). Lacassagne draws a clear distinction between the forensic pathologist’s different positions, depending on whether these applied to populational technologies as formalized in hygiene treatises, or to forensic assessments that established a clear delineation between the biological realm (of which bone age forms part) and the social realm.21 After examining the biochemical shift that characterizes his work, we will see how, through his measuring of human and populational development, Lacassagne entirely revisits the status of bone matter and his vision of the transformation of the human over the course of life.

 rfila or the Experimental Biochemical Shift O in Forensic Science While Lacassagne does not fully align himself with Orfila’s legacy, he does, however, refer to a large extent to two of the disruptions that the latter introduced: first of all, the shift from an art to a mathematically regulated action; secondly, a reading of the human body that departs from environmental etiology (looking for instance at the influence of climate on the organism) to adopt a biochemical perspective, used by Orfila to codify the laws of ontogenesis and bone maturation based on

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the observation of fetuses.22 Of course, the observation of fetuses was not new. For instance, Fodéré had also used this technique, but his purpose was to examine the gestating body and to distinguish between different qualities of pregnancy (intra-uterine vs. extra-uterine). In contrast, in Orfila’s writings, fetuses acquire a specific status. This is due first to the politico-legal context: a distinction was introduced at the time between penalties applied to infanticides and abortions, while mothers and the protection of infants and children were the object of increased surveillance. But it was also due to the scientific context: a separation was established between the fetus’ body and that of the gestating woman, and the fetus became a vantage point from which to observe the species as a whole (Duden 1996). Nevertheless, in his forensic pathology assignments, Orfila (1848) did not study fetuses to analyze the history of the species, but rather to decipher human development in terms of bio-chronological sequences and thresholds, working from bones as a starting point. For instance, he explains that the embryo forms between the 10th and 20th day. From day 30 to day 45, the fetus looks like a “big ant”. Between four weeks and two months, the ossification process begins, and this process is used to detect stages of maturation, which are associated with specific chronological periods. “The ossification of the apophyseal processes in the upper cervical vertebrae” is followed by the “ossification of the limbs, the distinction of the face between 2 and 3 months, the structuring of the brain as an organ between 3 and 5 months, the increase in length, the ossification of the sternum and teeth [here dentine is considered as bone] from 6 to 7 months” (Orfila 1848: 68). Orfila then focused on the ossification of the different parts of the skull (occipital-frontal bones at 11–11.5  months; mental, frontal-mental, and biparietal bones at 9–9.5  months; temporal bone at 7–8  months), before mentioning the closing of the fontanel that becomes “less flared”: “the bones that form the skull, although mobile, [are in contact] via their membranous edges” (ibid.: 71). The study then opens up in scope to embrace the totality of human life. Orfila defines five stages which, although they appear to reproduce categories borrowed from humoral theory (virile age, age of decline, etc.), are now defined by bio-chronological milestones that are established independently from the environment or the movements of the soul: early childhood (“première enfance”) from birth to 7 years old;

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second childhood (“deuxième enfance”) from 8 to 12 for girls and from 8 to 15 for boys; adolescence from 12/15 to 25; adult age from 25 to 60; and old age from 60 onward. Of course, bone was not the only physiological sign that contributes to this metric of human development: all organs were considered, taking precedence over the social and moral indicators used by Fodéré to determine age.23 However, Orfila was one of the first specialists to fully introduce bone matter into the measuring of human development and to change its status. Formerly seen by Fodéré as a marker of biographic singularity, bone was now considered as the marker of a developmental continuum24 that could be used to assess age: “As shown by the advanced stage of ossification, he was over 25 years old and had not yet reached the age of 50” (ibid.: 94). In addition, bone was associated with a distinctive system of knowledge characterized by two historic disruptions. First, the standard was no longer set by what was typical but by the average of observations, which secondly formed a knowledge base that could be used to determine age in future postmortems: Since these observations were made on healthy individuals whose size was neither too large nor too short with respect to the age at which they were examined, it would be preferable if they could be extended to a large enough number of individuals in order to provide average proportions which would be particularly useful in determining age. (ibid.: 104)

With Orfila, the measuring process henceforth understood as static became rhythmical and based on average chronological evolution milestones. Consequently, the abnormal also acquired a different status: no longer a distance from a given state (monster or malformed individual) but a distance from a given maturation stage (delayed, early, or atypical development). This change in the interpretation of bone also brought about a fundamental shift in the understanding of human maturation. Development was no longer seen as a drying process (Fodéré’s description of soft bones becoming harder), or as the revelation of the plenitude of forms contained in an individual from birth. Rather, it involved a shift from the formless to the formed—hence the importance of ossification points. Young age then became a key concern for political and medical

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action aimed at producing strong and healthy adults. This was all the more crucial in that the acquisition of a form was now seen as less influenced by external modifiers (to quote the expression later used by Lacassagne) than by internal laws, which forensic pathologists were required to know. With Orfila, age became rooted in an organic given, which was subsequently used by Lacassagne and the second hygienist movement as a basis on which to fortify the population.25

L acassagne and the Hygienist Movement: Age as an Organic State, an Individual Modifier, and a Lever for the Fortification of the Population Lacassagne was deeply involved in the second hygienist movement, which was more concerned with alterities than with alterations (Lacassagne 1912), and aspired to perfect the human: “Making people healthier means improving them; it means enabling them to use their intelligence and action to perform their role in human society” (Lacassagne 1879: 1). Strengthening society and the population was the main objective of this movement, which targeted not so much lifestyle or circumstances but the organisms themselves, using diverse alimentary and prophylactic technologies that were designed according to the age of the subject and acted as “individual or biological modifiers” (“modificateurs biologiques ou individuels”) (ibid.: 553). The ages of life were seen as “periods of life during which the organism experiences certain changes that bring about particular physiological or pathological modifications corresponding to each of these periods” (ibid.: 555). Formerly considered as a position in the course of life, to which corresponded a certain moral and physical experience (age as bios), age was now seen as a programmed state depending on the place occupied by the subject within a continuum regulated by universal internal organic laws (age as zoe). The effort initiated by Orfila in his work with fetuses was applied to the rest of the human life cycle— with long developments setting out the various thresholds of maturation of the body-as-organism, while the question of age-related identification lost prominence.

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Lacassagne drew a distinction between the first age of fetal life, characterized by a number of organic and functional dispositions and by congenital diseases (ibid.: 556), and the period from birth to two years old, marked by adaptation to extra-uterine life and by the transformation of diseases, which is also the period during which the child’s nutrition becomes a collective and political issue: “The hygiene of infants is, from a social perspective, one of the most important questions, and is of a major concern to hygienists and economists” (ibid.: 558). During early childhood (two to eight months), the focus was on nutrition; in second childhood (eight months to two years old), the emphasis was placed on weaning, on the appearance of teeth, and on new risks of disease, particularly the fear of rickets. The question of feeding the population appears to have driven the creation of new sub-ages within early infancy, with a focus on growth conditions. Third childhood, from two to seven years old, saw the introduction of meat into the diet and the appearance of childhood diseases affecting the body’s vigor (rickets) or its vital functions (whooping cough). Adolescence (7 to 15 years old) was characterized by the growth of teeth, the body, and the nervous system, and by the development of intelligence, which called for the learning of intellectual disciplines. Puberty (15 to 20 years old) was characterized by the growth of the genitals. Adult age (20 to 30) saw the “comprehensive development of the organism, with rheumatic diseases”. The “virile age” (30 to 40), for men and women, was associated with the “plenitude of nutrition”, reproduction and passions. The “age of decline” (40 to 60) marked the beginning of the decline for the hair, teeth, muscles, and genitals, the end of menstruation in women and the onset of chronic diseases. Finally, old age was characterized by the upsurge of selfish feelings and the weakening of nutritional, respiratory, and circulatory functions. While references to bone are key to the description of fetal maturation, they are almost absent from this typology. They only appear marginally in the description of old age, referred to as the phase of the “resorption of bones” (ibid.: 569), but not in that of puberty (15–20  years old), which is mostly referred to through the development of the genitals, the halt in growth, the onset of menstruation and the risk of anemia in women.26 This knowledge was deeply marked by the social circumstances that presided over its production. Hygienists were not only expected to treat living bodies, they were

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also responsible for their fortification. As a biological attribute that fell outside the scope of medical intervention, bone was not seen, like diet, as a lever for strengthening the population.27 In contrast, in Lacassagne’s 1906 writings on forensics, bone development is presented as a fully operant marker for the measurement of age. This treatment illustrates the fact that within a given profession, an individual practitioner can assign very different values to age depending on whether their purpose is to set out hygienist policies aimed at facilitating growth, or to carry out an identification within a forensic context, which may require assessment of the age of a victim.

 he Progress of Ossification and the Measuring of Age T in Lacassagne’s Forensic Medicine In his 1906 forensic medicine handbook, Lacassagne reused the same classification presented in his first hygiene handbook published 40 years earlier, but with a different scope. His aim was no longer to measure the moral and dietary issues affecting each age of life to better promote the fortification of the population. Instead, Lacassagne aimed to identify people based on the criteria of age—a “sure” criteria according to Orfila’s method of observation of the progress of ossification. Lacassagne compiled a sum of all the knowledge and measurements accumulated throughout the nineteenth century around Europe. He quotes Magitot, a dental surgeon and the founder of stomatology (Lacassagne 1906: 119), on determining the age of the embryo based on their dental system in forensic assessments where the pathologist is called upon to distinguish between in or ex utero death. From Italian public health expert Pagliani, Lacassagne borrowed a table of weight/height ratios in subjects between 10 and 19 years of age, observed in 1876 in Turin (ibid.: 125). He also reproduced Orfila’s tables presenting measurements carried out on 74,162 men who had applied for life insurance in 1817 (ibid.: 126).28 Sex, race, and age became fixed attributes that might influence height, according to Pagliani, and bone maturity according to Lacassagne, independently of social variations. The rhythm of growth was the only factor that Lacassagne

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Table 3.1  Pagliani’s table, Sopra alcuni fattori dello sviluppo umano, Turin, 1876 (quoted by Lacassagne 1906: 125) Average weight, height (1), and so forth in subjects aged between 10 and 19 Age

Weight

Height

Ribcage circumference

Lung capacity

Muscular strength

10 years… 11–… 12–… 13–… 14–… 15–… 16–… 17–… 18–… 19–…

24.51 26.18 28.38 31.75 33.06 39.36 41.47 43.2 44.55 46.05

126.3 128.1 132.1 137.5 140 148.6 151.2 151.3 154.3 156

61 61.2 62.8 65.2 66.4 69.5 70.3 71.6 72.6 74.2

1660 1700 1800 2045 2100 2445 2485 2660 3115 3125

66.5 68.5 79 95 105 118.5 121 136 142 150

(1) must distinguish between growth and height—The latter depends almost exclusively on sex and race. The progress of growth is especially affected when individuals are most diverted from their definitive development by conditions such as their environment, food, exercise, climate, and professions In healthy 20-year-old individuals, the ribcage circumference exceeds the halfheight by 20 centimeters

considered as being subject to social variations, as shown by the comments in Table 3.1 (ibid.: 125). Finally, Lacassagne used the classification of bone system maturation established by Orfila in 1848, considering the bones’ size, the shape of their “articular heads”, their “degree of ossification”, as well as their “volume”, weight, and chemical composition. The emphasis was placed on the connection between the epiphysis and the shaft of the bone, which reflects a vision of development as a process of assuming form (ibid.: 123) (Table 3.2). As shown by this extract, the “progress of ossification” (la “marche de l’ossification”) runs throughout the ages of life, along with the ossification of the skull and long bones in babies and infants, and that of the metacarpals and metatarsals from 3 months to 18 years old. This latter milestone is not examined in detail because the forensic and legal concerns of

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Table 3.2  On age (Lacassagne 1906: 123) Femur

Tibia

Fibula Metacarpal and metatarsal bones

Diaphyseal point by month 2 of fetal life, lower epiphyseal point (also referred to as Bichow’s) at birth, secondary points in years 2 to 8; complete ossification circa 25 years old Diaphyseal point by day 40 of fetal life, upper epiphyseal point at birth, lower epiphyseal point by 2 years old, additional point (anterior tuberosity) by about 12 years old; complete ossification circa 24 years old Diaphyseal point by day 40 of fetal life, epiphyseal points in years 2 to 4; complete ossification circa 20 years old Diaphyseal points by month 3 of fetal life, epiphyseal point (digital for the last four, metacarpal and metatarsal for the first); complete ossification circa 18 years old

the time were more focused on in-utero ossification (Lacassagne 1906: 123). As for the period between 15 and 18 years old, it is characterized by the “fusing of the sacral vertebrae and of the femur’s three epiphyses”. In Lacassagne’s treatise, the spine serves as a developmental calendar where each fused vertebra marks a successive stage (ibid.: 121). Whenever a regular pattern is observed with respect to these stages, it is turned into a reified quantitative norm. Measurements are systematically presented in a table or a list, disconnected from social context and with no mention of the photographs used elsewhere by Lacassagne when he addresses the facial recognition of criminals (see photographs of earlobes) (ibid.: 179).29 In keeping with Orfila’s theories, Lacassagne used bone to identify the maturation of the body-as-species rather than the singular age of an individual. Identity was dissociated from age, which became an independent quantitative variable. In this perspective, this text reveals the emergence of the notion of “bone age”, based on two postulates articulated by Lacassagne: first, the idea that physiological age is structured by sequences of evolution and involution, by a standardizable continuum of development governed by internal organic rules; and second, the strict pairing of chronological age with physiological development milestones, which were later fine-tuned by developmental medicine (including pediatrics and endocrinology) in the twentieth century.

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Conclusion To conclude, drawing a socio-history of the study of “age in relation to bone” in forensic medicine—considering not only this field’s key figures, but also the knowledge they produced—shows firstly the benefit, when analyzing historical periods, of considering the situations of expertise in which and for which this knowledge was elaborated. When, on the one hand, Lacassagne contributed to hygienist policies, he supported a vision of age influenced by humoral theory and focusing on living conditions, where age was biologized and bones were not considered. But in parallel, when seeking to legitimize forensic experts’ capacity to inform judiciary decision-­making in the short term, and the use of bone as a marker to assess the age of the body-as-species, the author contributed to the standardization and reification of bone maturation. As noted by Bernard Lahire (2015: 16), drawing up a genealogy of human measurements requires one to be attentive to the authors’ social characteristics, but also to those of the contexts in which they operated, producing texts that exceeded their control and survived their lifetime. In addition, this line of enquiry shows that science, just like doctrine or practice, cannot be examined in isolation from its political and moral context. Forensic medicine provides an archetypal illustration of this idea, due to its porosity to the “political issues” of its time: the fetus in the mid-nineteenth century, early infancy as a key moment of growth and the making of a strong body, adult alcoholism and juvenile delinquency in 1950s handbooks, or the age of adulthood today. Secondly, this research shows the place occupied by forensic medicine in a process of medicalization, but also of biologization of age. Previously seen as an unmeasurable social and individual criterion, age became an evolutive but standardizable biological state that could be assessed, “all else being equal”. This biologization through standardization explains why the number of pages formally dedicated to age in treatises diminished over time. For example, the number drops from 161 pages dedicated to the “Differens âges de la vie humaine” by Fodéré to 31 pages on “L’histoire des âges” in Orfila’s 1848 forensic medicine treatise, and later to 13 pages on the “progress of ossification” (“la marche de l’ossification”) in

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Lacassagne’s 1906 treatise. At the turn of the twentieth century (for instance in Thoinot’s 1913 study), age was not even assigned a dedicated section. Only ten scattered mentions refer to the specificities of muscle development that need to be considered in expert assessments of injuries (Thoinot 1913: 87). This does not however imply that age was no longer studied: rather, this dilution reveals a change in its ontology. Age was no longer a qualitative variable that the forensic pathologist deciphered by considering the individual’s social background and biography. Instead, it became an immutable quantitative variable that could be studied in physics and biology. This shift was influenced by the contribution of pediatricians and psychologists, but also by that of military doctors (Diasio 2019) and of forensic pathologists in the nineteenth and early twentieth century—and their input remains understudied to this day. The analysis of forensic medicine manuals does, however, show the essential role that the links between law, biology, chemistry, and medicine played in this codification of ages, and the way these links contributed, beyond the study of age, to conveying new understandings of human ontology. It would be interesting to further investigate the bodily fragments used to mark the person’s individual and collective dimension—what singularizes them and what connects them to the species. Just like smell, which is used today to singularize the patient (see Denise’s contribution to this book Chap. 6), bone was in some instances used as a vector for the individualization of the person, before it acquired a new status in forensic medicine practices at the turn of the twentieth century. This topic could provide a new area of deployment for the anthropologies of the person, which have often focused exclusively on the social treatment of mortal remains in remote countries (Bloch 1993). Thirdly, this chapter shows that it can be productive to carefully consider the practical and conceptual articulations between medicalization and biologization, as well as the different forms of biologization that can be observed. Indeed, medicalization, or the appropriation by forensic pathologists of the issues associated with the assessment of age, does not necessarily involve the biologization of age—as illustrated clearly by Fodéré’s writings. Similarly, diverse forms of biologization can be found in handbooks (Lemerle 2016). Some physicians focus on the uniqueness of situations and on the singularity of bodies, while others favor

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standardization. Some use this standardization to serve practical purposes (organizing information or responding to urgent judiciary requests), while others institute the average as a scientific and moral doctrine. Finally, some establish norms that govern organic states, while others focus on the conformity of developmental patterns (the “good” progress of ossification). Fourthly, from this angle, our analysis shows how the strict pairing of chronological age with degrees of development-maturation brought about a shift in medical normativity: bodies were no longer considered at a given point in time, but situated within a “growth corridor”, to quote the terms used in contemporary French health records (Rollet 2008). These “growth corridors” have facilitated the development of predictive disciplines, while at the same time altering bodies based on their development rhythms: this tendency is apparent in current debates in French forensic science about the variations in bone maturation rhythms between men and women, or between “African” and “Caucasian” children. At the turn of the twentieth century, the biomedical and political measuring of human bodies became rhythmical: the temporal dimension of biopower was thus reinforced in European public health policies (Voléry and Julien 2019). This change was echoed by new social divisions based on alterations, defined as a deviation from developmental standards and from physiological growth corridors. Finally, this normativity overturned the understandings of age. From a fuzzy and equivocal criterion, it became trustworthy, easily measurable, a-historical, a-social, and a-political: no longer the expression of relations of power, but a physical measure, disconnected from context, whose “recording” requires no specific precautions. From a sociological object, it became a matter of physics and biology and the strong connections, which existed between sociologists and forensic pathologists and during the later nineteenth century disappeared (see the dialogue between Tarde and Lacassagne). This is probably one of the reasons why, unlike the categories of “sex” and “race”, “biological” age remains marginally analyzed by contemporary social sciences (Peatrik 2003).

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Notes 1. It should be mentioned however that the English-language literature offers more diverse angles of approach: examples include the transformations introduced by DNA testing (Lynch 2013), the epistemic culture of forensic medicine (Cole 2013), the normalization of the past in the treatment of unresolved cases (Innes and Clarke 2009), or the medical treatment of bodily fragments and the changes in their ontologies (Fonseca and Garrido 2019). 2. Debates include the legal distinction between abortion (involving a fetus) and infanticide (involving a new-born child), respectively, punishable by prison and death (articles 317 and 302 of the French 1810 Code Pénal); the emergence of the legal notion of responsibility, which led to assessments of discernment—including on behalf of children (article 64 of the 1810 Code Pénal); regulations on nubile age and marriage (art. 144 of the 1804 Code Civil which brought nubile age to 15 for girls and 18 for boys); or the laws regulating child labor in 1841–1892 and compulsory education (1822). 3. See debates on the “medical assessments” of the age of unaccompanied foreign minors based on wrist bone radiographs. In France, forensic pathologists are caught up in controversies surrounding the contradictions between migration policies regulating population flows based on rules that do not consider age, and policies that impose the protection of vulnerable minors that do not have a legal representative with them. Determining an individual’s adulthood has become a key issue, on which forensic pathologists are usually consulted by the legal system. 4. Crossland (2009: 76) highlighted the links established throughout the nineteenth century by forensic medicine between bones and individuals, while recent research (Fonseca and Garrido 2019: 15) shows the specific status that bones still hold in forensic medicine laboratories, particularly for identification procedures. 5. This corpus is nevertheless very relevant for anyone interested in the emergence of forensics expertise (in the various senses that this term was assigned throughout the eighteenth and nineteenth centuries) and in the relations between medicine and justice. 6. This list of manuals was compiled through a documentary search on Gallica using the keywords “manuels” (manuals), “précis” (handbooks), “traités” (treatises), “hygiène” (hygiene), and “médecine légale” (forensic

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medicine). For the purposes of comparison, we also consulted some twentieth-­century handbooks (Vibert 1911; Thoinot 1913; Planques 1967; Beauthier 2007). 7. These include the political (the shift from the issue of industrialization to that of the strengthening of the national population), institutional (from a historical legitimization to a rational-legal legitimization of forensic medicine, from the médecin total to the expert doctor), and scientific context (from the medicine of miasma to the medicine of organisms). These criteria explain why the periods defined in this article do not entirely correspond with those used by other studies, for example, on hygienism. See Jorland (2010), who opens his study in 1770, when Lavoisier opposed the old climatic vision of neo-Hippocratic medicine, and finishes it in 1902 when hygienists entered the political arena. 8. In addition to his forensic medicine treatise, Fodéré also worked on phthisis (1795), smallpox (1826), diseases encountered in mountains (1794 and 1799), and the poverty of nations and abandoned children (1825). 9. The two disciplines only became distinct in 1903, when forensic medicine became institutionally autonomous and split into two branches: scientific police (Bertillon, Balthazard, Locard) and occupational medicine. 10. According to Daston and Galison (2007), the scientific model of the “trained judgement” consists in recording life’s singularities in all their diversity, remaining as close as possible to the circumstances of measurement, with a distinctive understanding of the connection between the eye and the gaze. Within this model, the quality of observation depends on the physician’s technical experience rather than on their moral qualities. 11. Within the “truth-to-nature” model, objective knowledge involves as much the technical qualities and knowledge as the moral values and design skills of the individual who observes and reproduces their observations (for instance, an illustrator of anatomical charts). This knowledge also requires the capture of a general type under the diversity of life as observed: the organism or plant represented must be typical but not necessarily observed as such in nature (Daston and Galison 2007). 12. In contrast with later handbooks (Orfila, Lacassagne), which reflect the construction of a dedicated area of knowledge, bones are mentioned here alongside miscellaneous attributes including temperaments, phenotypic,

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and aesthetic signs (brightness of eyes and complexion, hair, gait, stature), as well as organic (viscera, bladder), functional (stubborn constipation in old age), and moral characteristics (control over one’s modesty and passions, etc.). 13. Théré (2015) shows how in the nineteenth century humoral theory was used to construct a new gender regimen, which can be detected in the genderization of the notion of “age of decline”, a term that had in the past been used to differentiate between ages and that became specifically applied to women. 14. The distinction between ages was gendered and associated with puberty. They were not so much approached from the perspective of bones as through references to women’s soft and wet character. Age was intimately interwoven with sex, not because of a distinction between male and female maturation (which was only established in the mid-twentieth century), but because of the association between “soft” ages and the “soft” sex, comparing women to children. At the time, the regimen of age (with organic and moral qualities assigned to each age) was not distinct from that of gender, both of which were governed by plethora. 15. Cases involving children are more present in Fodéré’s Leçons sur les Epidémies et l’hygiène publique (vol. 1, 1822). 16. If some (Mediterranean) children were indeed othered, this judgment was based not so much on internal processes (their specific development rhythm, which is today stressed by forensic medicine articles on the bone maturation of “African” or “Asian” children) (Mora et al. 2001; CCNE 2004: 2) as it was on external factors (Mediterranean girls ripened by the sun). 17. This illustrates how metrics elaborated from corpses (or forms of potential life like fetuses) were historically used to normalize the maturation of living beings. 18. Particularly in women who, while living in a constant environment, are literally transformed by their entering and exiting procreative life (puberty and menopause). 19. This perception of evolution as the deployment of a form and a potentiality that are revealed over the course of an individual’s life under the effect of environmental conditions runs throughout the nineteenth century. It can also be found in the writings of American paleoanthropologist Henry Fairfield Osborn, or in those of O’Toole: “in line with Osborn’s orthogenesis, O’Toole believed that the creator had endowed

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original stocks (classes) with certain potentialities that remained latent until called for by the necessities of the environment during phylogenesis” (Sommer 2016: 58). 20. There was little distinction between changes caused by age or by the passions of the soul. For instance, white hair was not associated with aging as systematically as it was in later handbooks, while “certain foods and the passions of the soul” could make it turn white (Fodéré 1813: 116). 21. Lacassagne expressed his disagreement with Léonce Manouvrier during the 1889 Congress of Criminal Anthropology: he thus stated his ambition to move beyond a vision of a science of man as totality, asserting on the contrary his grounding in medical science and this field’s superiority over legal knowledge. As for Manouvrier (1894: 33), he suggested that forensic medicine should become an anthropotechnology, drawing on the knowledge produced by anthropology beyond the genealogy of races (Buffon, Quatrefages, etc.) and craniometry. 22. The founder of French toxicology, Orfila (1787–1853) was a trained chemist and a passionate advocate for the expertise of forensic medicine (Chauvaud 2006). He believed that this discipline was a source of fundamental knowledge on life—among other reasons, because it provided access to precious organic material (e.g., the fetuses he worked on to develop a measurement of human bone maturation). Unlike other forensic pathologists of his time, Orfila also considered that corpses provided material for science and that they should be observed beyond the autopsy and archived in collections and museums (see, for instance, his archive of bone measurements performed to assess the size of a dead or living subject, his collections of fetuses and his advocacy in favor of the opening of a museum of anatomo-pathology in 1835). 23. The choice of these signs remained closely linked to contemporary judicial issues. For instance, Orfila used the drying up and falling off of the umbilical cord, which occurs on average on the third day of life, because these signs could be used to rule out the hypothesis of a stillbirth, and to estimate the length of life prior to an accidental death or infanticide (1848: 81). Similarly, the author worked from the observation of teeth and bones, which could be used to determine the age of a living individual between the ages of three and seven in the absence of a radiograph. However, he left this element aside when studying adolescence, for which the emphasis was placed on determining a person’s nubility (focusing on sperm, menstruation, breaking of the voice), and in the

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adult age when teeth and bones were regarded as too affected by “external factors”. Bones were then considered again during old age (ibid.: 89). 24. It should be noted that bone singularities continue to be used to identify individuals (e.g., traces left by falls or diseases) (Orfila 1848: 91). However, this use of bone lost prominence with the introduction of other bodily markers of identity (e.g., fingerprints, introduced by Galton in the late nineteenth century). 25. The second hygienist movement was also marked by a change in the political context. Concerns about the dangers posed by the working class in industrial cities gave way to fears regarding the “others”: the internal “others”, or the criminals who threatened to corrupt the population’s moral vigor, and the external “others” who could corrupt the population’s physical vigor. See, for example, the fear of the “racial” mix, which, in the documents we examined, went beyond national borders and continued to be of geographic and climatic origin (Lacassagne 1879: 572). 26. In contrast, from the 1960s, bone maturation assumed a major role in determining the phases of pre-puberty, puberty, and post-puberty in the writings of pediatricians (see Chap. 8 in this book). 27. Classified as a chemical modifier, food was considered to transform bones, teeth, and blood globules: Lacassagne insists on the importance of serving roasted meat to convalescents, growing children, and menstruating women. 28. At the end of the century, Quételet complemented these tables, establishing a correspondence between weight and height to create growth tables, which were reproduced in handbooks until the turn of the twentieth century (Planques 1967 [1959]: 60). 29. Bruno Bertherat shows that the use of photography and later of radiography by forensic science started at the very end of the nineteenth century, under the influence of Paul Brouardel. These images mostly represented fragments of corpses, with the aim of objectivizing the circumstances of the crime and the nature of the lesions, which could have been altered by hand drawing (Bertherat 2013: 103). Photography was not really intended to restore the singularity of the person.

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Sources Medicine and Forensic Medicine Beauthier, J.-P. (2007). Traité de médecine légale (2e édition). Bruxelles: De Boeck Editions. CCNE. (2004). Avis n° 88 Sur les méthodes de détermination de l’âge à des fins juridiques. Devergie, A. (1837). Médecine légale, théorique et pratique: avec le texte et l’interprétation des lois relatives à la médecine légale. T. 1. Bruxelles: Dumont-Libraire-Editeur. Fodéré, F.-E. (1794). Mémoire sur une affection des gencives et de l’intérieur de la bouche endémique parmi une troupe de l’armée des Alpes. Embrun: Imprimerie Louis Moyse. Fodéré, F.-E. (1795). Essai sur la phtisie pulmonaire. Marseille: Imprimerie de Jouve et Compagnie. Fodéré, F.-E. (1799). Traité du goître et du crétinisme, précédé d’un Discours sur l’influence de l’air humide sur l’entendement humain. Paris: Chez Bernard. Fodéré, F.-E. (1813). Traité de Médecine Légale et d’hygiène publique ou de police de santé adapté aux codes de l’empire français et aux connaissances actuelles. Tome 1. Paris: Imprimerie de Mame. Fodéré, F.-E. (1822). Leçons sur les épidémies et l’hygiène publique. Paris: Levrault. Fodéré, F.-E. (1825). Essai historique et moral sur la pauvreté des nations: la population, la mendicité, les hôpitaux et les enfans trouvés. Paris: chez Madame Huzard Libraire. Fodéré, F.-E. (1826). Mémoire sur la petite vérole vraie et fausse et sur la vaccine. Strasbourg et Paris: Heitz et Servier. Lacassagne, A. (1879). Précis d’hygiène privée et sociale (2e édition revue et augmentée). Paris: Masson Editeurs. Lacassagne, A. (1906). Précis de Médecine légale. Paris: Masson et éditeurs. Lacassagne, A. (1912). La signification des tatouages chez les peuples primitifs et dans les civilisations méditerranéennes. Lyon: Imprimerie A. Rey. Manouvrier, P. (1894). L’anthropologie et le droit. Paris: V. Giard et E. Brière. Orfila, M. (1848). Traité de médecine légale. Tome 1 contenant en entier le traité des exhumations juridiques (4e édition). Paris: Labé Editeurs. Planques, J. (1967 [1959]). La Médecine légale judiciaire. Paris: PUF. Thoinot, J.-L. (1913). Précis de médecine légale. Tome 1. Paris: Octave Douin et Fils Editeurs.

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Vibert, C. (1911). Précis de médecine légale (8e édition, revue et corrigée). Paris: Baillière et fils. Vigné, J.-B. (1805). De la médecine légale. Rouen: Imprimerie des Arts.

Bibliography Armstrong, D. (1983). Political anatomy of the body. Medical Knowledge in Britain in the 20th Century. Cambridge: Cambridge University Press. Bertherat, B. (2013). La dame au chapeau. La photographie des femmes mortes en France à l’époque de Bertillon. Corps, 11(1), 97–106. Bertherat, B. (2016). Visiter les morts: La Morgue (Paris, 19e siècle). Hypothèses, 19(1), 377–390. Bloch, M. (1993). La mort et la conception de la personne. Terrain [En ligne], 20 | mis en ligne le 15 juin 2007, consulté le 06 juillet 2019. Retrieved from http://journals.openedition.org/terrain/3055. Bouhallier, J. (2015). Le bassin osseux: splendeurs et misères de la clé de voûte du corps humain. In E. Peyre & J. Wiels (Dir.), Sur le genre, dialogue entre biologie et sciences sociales (pp. 120–142). Paris: La Découverte. Chauvaud, F. (2000). Les experts du crime: la médecine légale au 19e siècle. Paris: Aubier. Chauvaud, F. (2003). Le sacre de la preuve indiciale. De la preuve orale à la preuve scientifique (19e-milieu du 20e siècle). In B. Lemesle (Dir.), La Preuve en justice (pp. 221–239). Rennes: Presses Universitaires de Rennes. Chauvaud, F. (2006). ‘Cet homme si multiple et si divers’: Orfila et la chimie du crime au 19e siècle. Sociétés et Représentations, 2(22), 171–187. Cole, S. A. (2013). Forensic culture as epistemic culture: The sociology of forensic science. Studies in History and Philosophy of Biological and Biomedical Sciences, 44(1), 36–46. Crossland, Z. (2009). Of clues and signs: The dead body and its evidential traces. American Anthropologist, 111(1), 69–80. Daston, L., & Galison, P. (2007). Objectivity. New York: Zone Books. Diasio, N. (2019). Une biopolitique à bas bruit. Recherches sociologiques et anthropologiques, 50(1), 45–76. Doron, C.-O. (2016). L’homme altéré: races et dégénérescence (17e–19e siècles). Paris: Champ Vallon. Duden, B. (1996). L’invention du fœtus. Le corps féminin comme lieu public. Paris: Descartes et Cie.

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Fine, A. (2008). Regard anthropologique et historique sur l’adoption: Des sociétés lointaines aux formes contemporaines. Informations sociales, 146(2), 8–19. Connection on 25 June 2020. Retrieved from https://www.cairn.info/revueinformations-sociales-2008-2-page-8.htm. Fonseca, C., & Garrido, R. (2019). Discarding used organic samples in a forensic lab: The manifold materiality of human remains. Human Remains Violence, 5(1), 3–17. Fressoz, J. (2009). Circonvenir les circumfusa. La chimie, l’hygiénisme et la libéralisation des ‘choses environnantes’: France, 1750–1850. Revue d’histoire moderne & contemporaine, 56–54(4), 39–76. Gaille, M. (2018). Santé et environnement. Paris: PUF. Goburdhun, M. (2017). La naissance des experts “médico-légaux”. Naples, 17e siècle. Déviance et Société, 41(3), 371–385. Gould, S. J. (1981). The Mismeasure of Man. New York: Norton & Company. Hocquet, T. (2013). Le sexe biologique. Anthologie historique et critique. Paris: Hermann Editeurs. Ilsen, A., & Vincent, D. (2010). Histoire de l’identification des personnes. Paris: La Découverte. Innes, M., & Clarke, A. (2009). Policing the past: Cold case studies, forensic evidence and retroactive social control. British Journal of Sociology, 60(3), 543–563. Jablonka, I. (2005). Les Abandonnés de la République. L’enfance et le devenir des pupilles de l’Assistance publique de la Seine placés en famille d’accueil (1874–1939). Revue d’histoire du 19e siècle [En ligne], 30 | mis en ligne le 01 avril 2008, consulté le 06 juillet 2019. Retrieved from http://journals. openedition.org/rh19/2402. Jorland, G. (2010). Une société à soigner. Hygiène et salubrité publiques en France au 19e siècle. Paris: Gallimard. Juston, R. (2018). Devenir expert, rester médecin? Les effets de la spécialité médicale sur l’exercice de la médecine légale. Sociologie du travail [En ligne], 60(3) | Juillet-Septembre 2018, mis en ligne le 06 septembre 2018, consulté le 04 juillet 2019. Retrieved from http://journals.openedition.org/sdt/2668. Kérisit, M., & Pennec, S. (2001). La ‘mise en science’ de la ménopause. Cahiers du Genre, 31(2), 129–148. Lahire, B. (2015). Comportements individuels, comportements collectifs: dispositions, contextes d’action et échelles d’observation. In P.  Laborie & Fr. Marcot (Dir.), Les comportements collectifs en France et dans l’Europe allemande (pp. 15–23). Rennes: Presses Universitaires de Rennes.

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Laqueur, T. (1992). Making Sex  – Body & Gender from the Greeks to Freud. Harvard: Harvard University Press. Lemerle, S. (2016). Trois formes contemporaines de biologisation du social. Socio [En ligne], 6 | mis en ligne le 29 mars 2017, consulté le 06 juillet 2019. Retrieved from http://journals.openedition.org/socio/2329. Lynch, M. (2013). Science, truth, and forensic cultures: The exceptional legal status of DNA evidence. Studies in History and Philosophy of Biological and Biomedical Sciences, 44(1), 60–70. Menenteau, S. (2017). ‘L’édifice de l’expertise restera […] comme bâti sur le sable’. Enjeux et obstacles à la professionnalisation de la médecine légale dans la France du 19e siècle. Déviance et Société, 41(3), 343–369. Mora, S., Boechat, M., Pietka, E., Huang, H. K., & Gilsanz, V. (2001). Skeletal age determinations in children of European and African descent: Applicability of the Greulich and Pyle standards. Pediatric Research, 50(5), 624–628. Parayre, S. (2010). L’entrée de l’éducation à la santé à l’école par la prévention (18e–19e siècles). Recherches & éducations [En ligne], 3 | mis en ligne le 01 janvier 2012, consulté le 05 juillet 2019. Retrieved from http://journals. openedition.org/rechercheseducations/554. Peatrik, A.-M. (2003). L’océan des âges. L’Homme [En ligne], 167–168 | mis en ligne le 01 janvier 2005, consulté le 06 juillet 2019. Retrieved from http:// journals.openedition.org/lhomme/21476. Peyre, E. (2015). Le squelette a-t-il un sexe?. In E. Peyre & J. Wiels (Dir.), Sur le genre, dialogue entre biologie et sciences sociales (pp.  105–120). Paris: La Découverte. Porret, M. (2010). La médecine légale entre doctrines et pratiques. Revue d’Histoire des Sciences Humaines, 22(1), 3–15. Rabier, C. (2010). La disparition du barbier chirurgien: analyse d’une mutation professionnelle au 18e siècle. Annales. Histoire, Sciences Sociales, 65(3), 679–711. Retrieved from https://www.cairn.info/revue-annales-2010-3page-679.htm. Rollet, C. (2008). Les carnets de santé des enfants. Paris: La Dispute. Sommer, M. (2016). History within: The science, culture, and politics of bones, organisms, and molecules. Chicago: University Of Chicago Press. Théré, C. (2015). Âge de retour et retour d’âge: l’asymétrie entre les sexes dans les discours médicaux en France (1770–1836). Clio. Femmes, Genre, Histoire, 42(2), 53–77. Retrieved from https://www.cairn.info/revue-clio-femmesgenre-histoire-2015-2-page-53.htm.

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4 Thinking “Quality of Life”: From Measures to Categorizations of the Human Beings Milena Maglio and Vivien García

Since the 1970s, in the United States, “quality of life” has emerged as a matter of concern within a political and a social context characterized by an improvement of material conditions which started to be perceived as insufficient although necessary. Quality of life was no longer understood in collective terms: it was also expecs so-called quality of life measures. Similar indicators also gradually appeared in the medical field. Their evolution was in part the result of technological breakthroughs that made it possible to act upon fundamental biological processes. The apparently obvious distinction between life and death was challenged. In this context, as observed by Thomas Denise in his contribution to this book, “resuscitation compels us to rethink life, its definition and its transformation” (Denise, Chap. 6). The definition of brain death in 1968 was an

M. Maglio (*) SPHERE Research Unit, Université Paris-Diderot, Paris, France V. García APEMAC Research Unit, Faculty of Medicine, Université de Lorraine, Nancy, France © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_4

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essential milestone in this process (García and Maglio 2014). The term “quality of life” became common currency in cases involving a “separation between the body and the person” (Denise, Chap. 6). This notion was used as an argument to justify withholding and withdrawing medical treatment and, for some authors, to legitimize euthanasia. Nevertheless, in the absence of any serious reflection on human life and its value, quality of life remained an opaque notion. Bioethics tackled the question through debates on the diverse ways in which human beings can be categorized. The attempts to measure quality of life led to the introduction of distinctions or boundaries (and subsequently, of hierarchies) between persons and nonpersons resonating with political, medical, and religious debates. The measures examined in this chapter do not assess an individual’s singularity or their affiliation to a social group, based on certain corporeal markers or on the normality of their maturation. Rather, they (re)activate a conflict between categories that touch on the boundaries and limits of human life. This conflict is far from purely theoretical: it derives from specific practices and knowledges, and reversely feeds back into them. The first section of this contribution will focus on the emergence of the notion of quality of life, on its integration into medicine, and on its uses in this context. We will examine how terminological and conceptual issues in bioethics arose from certain gaps in the definitions that had so far been deemed sufficient in the quality of life measures. The second section describes the main categorizations that were proposed in bioethics. The last section introduces some elements that could provide starting points for a critical reflection on these categories to question a persistent unthought in bioethical discourses on quality of life.

 easuring Quality of Life: A Political, Social, M Medical, and Ethical Priority From the 1960s onward, the expression “quality of life” became “a routinely invoked concept” in the United States (Rapley 2003: XIII). It functioned equally as a political slogan, an everyday language expression,

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and a category used in social science. It soon became a criterion for medical practice, as well as a key notion in ethical1 and bioethical discourses. In these diverse contexts, the notion of quality of life became inseparable from that of “measure”, especially in the field of healthcare. Over time, quality of life measures took on various functions and opened up scope for reflection, which had so far been neglected, on the very notion of quality of life, which contains at its core a new understanding of the notion of progress.

“ Quality of Life”: From the Social Indicators Movement to Ethics In the field of public policy, with the improvement of material conditions, the focus shifted from the individual’s survival needs to the conditions that can ensure a life of well-being, or a good quality of life. Material wealth and economic growth were no longer perceived as sufficient in defining a country’s progress or development: collateral social costs, such as poverty, exploitation or growing inequality also had to be considered. Economic indicators were therefore complemented with “social indicators” to produce quantitative data relevant to social, political, and technological issues2 (Land 1975; Noll 2000). These indicators were “equated with ‘direct measures of welfare’ or the ‘quality of life’ experienced by people or social groups” (Schneider 1976: 299). This terminology and the issues it raised soon made their way onto the political stage. In 1964, US President Lyndon B.  Johnson proclaimed that quality of life was the ingredient that could make the United States a “great society”: We are rich, and we are powerful, but that is not enough …. The Great Society … can be a society of success without squalor, beauty without barrenness, works of genius without the wretchedness of poverty …. These goals cannot be measured by the size of our bank balance. They can only be measured in the quality of the lives that our people lead. (Johnson 1964)

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A few years later, this vocabulary broke into the field of medicine and medical ethics. This change in the understanding of progress gave rise to an alternative vision of life and the body that goes beyond basic biological survival and requires to take into account their qualities. Political discourse, and the novel possibility of acting upon natural processes and creating previously unseen situations, modified ethical discourse.3 This is apparent in a 1970 editorial in California Medicine that advocates for quality of life to become “A New Ethic for Medicine and Society” (California Medicine 1970), which would replace traditional Western ethics. This traditional ethics, which bears the legacy of the “Judeo-­ Christian” tradition, would tend to consider all human lives as equally valuable, regardless of their condition. According to the authors, this perspective compels physicians “to try to preserve, protect, repair, prolong and enhance every human life which comes under their surveillance”. But factors such as demographic growth, the sparsity of resources, and more importantly, “a new social emphasis on something which is beginning to be called the quality of life, a something which becomes possible for the first time in human history because of scientific and technologic development” all indicate the need for a new ethic, which should assign “relative rather than absolute values on such things as human lives”. Hierarchies, and the measures that derive from them, should depend upon how quality of life is defined: The criteria upon which these relative values are to be based will depend upon whatever concept of the quality of life or living is developed. This may be expected to reflect the extent that quality of life is considered to be a function of personal fulfillment; of individual responsibility for the common welfare, the preservation of the environment, the betterment of the species. (California Medicine 1970)

However, this claim was far from uncontroversial. Internal tensions arose within the medical field, based on scientific, legal, ethical, and religious considerations, concerning the way in which this quality was to be defined. These conflicting positions were later to form the basis for the diverse definitions of the human and the person that were elaborated in subsequent years. But at the time, liberal Catholic philosopher Daniel

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Callahan, one of the first critics of quality of life and a partisan of sanctity of life seen as the ultimate consensual principle (Callahan 1969), regarded the California Medicine editorial as an attempt to turn quality of life into “a new standard of ethical measurement” (Callahan 1971: 9), or into a quantitative standard of moral judgment. According to him, this was the worst possible outcome. Callahan professes that human beings can never feel safe in a society where the value of their lives is regarded as relative. He considers that the notion of “quality of life” (i.e., a concept that can vary according to its measures and be subjected to particular interpretations) should not form a starting point for the decision of who should live or die. From this perspective, quality of life equates to an assessment of “social status” (Callahan 1971: 15). Nevertheless, moral or ethical judgment should not be based on measures. In addition, “quality of life” measures poses countless terminological, epistemological, and theoretical issues. How can one assess something that is unquantifiable, and for which no units of measure are available (Gaille 2010: 140–141)? From the seventies, the healthcare sector saw a boom of studies aimed at defining quality of life measures, which we will now examine.

 he Evolution of Quality of Life Measures T in Healthcare In healthcare, the initial objective of quality of life measures has been, in the wake of the social indicators movement, to evaluate the impact of medical treatments and technologies on individuals’ quality of life and by extension, on the state of society as a whole. From this perspective, there is a close connection between “well-being” and “welfare”: the underlying idea is that if individuals are “feeling good”, then society will too. This quest for knowledge was initially pursued through the elaboration of “objective criteria”, with the creation of measures that are independent from the assessment of the patient: survival, medical complications, social background, education, environment, and so on (Najman and Levine 1981). However, quality of life measures were gradually accused of being a hypocritical tool serving the governments’ economic and political

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interests, without truly taking any consideration in the individuals’ true preferences (Benamouzig 2010). Critics stressed that interest in welfare was taking prevalence over interest in well-being. These judgments form part of the wider criticism of medical practices expressed at the time and directed at: (1) their mostly paternalistic attitude, seen as contrary to the ideal of equality and as ignoring the patient’s point of view; (2) the exclusive control of medical technologies by physicians and healthcare administrators, placing them in a position to decide who should live or die (e.g., in 1968, a doctor could decide which patients could benefit from a dialysis); (3) the focus on the growth of life expectancy, which meant disregarding the iatrogenic effects of modern medicine (i.e., the persistent vegetative state, which is a condition provoked by resuscitation measures). These critiques brought about changes in the way decisions were made in healthcare, which, in turn, had an impact on the evaluation methods used for the measurement of quality of life. For example, “a tutelar and hierarchical perspective that places the emphasis on the data’s objective character gave way to a more democratic perception, more likely to factor subjective elements into the evaluation” (Benamouzig 2010: 155). The patient’s perspective is increasingly considered. In the early 1980s, the “objective criteria” that had prevailed around 1975–1979 were complemented by the introduction of “subjective criteria” (Najman and Levine 1981). These involved a qualitative assessment by the patient of their satisfaction in their own life, happiness, and overall well-being, or on the gap between their expectations and their perceptions (Hollandsworth 1988). The integration of quality of life measures into clinical research (especially cancer research) brought the patient’s point of view to the forefront. More interest was given to the impact the quality of healthcare could have on individuals and their well-being. Physicians began to be more attentive to extra-medical and subjective aspects—which contributed, for example, to the development of support care in cancer treatments. These issues were still very much considered in terms of public health and welfare. However, the emergence of “subjective data” brought a new contribution to the analysis of key topics such as healthcare expenditure. This data was soon integrated by health economists to evaluate the efficiency of healthcare strategies. Measures combining individual preferences with cost-benefits calculations were elaborated: QALY

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(quality-adjusted life year), HYEs (Health Years Equivalent), and DALYs (Disability Adjusted Life Years). In other words, quality of life was used to provide recommendations aimed at a better allocation of resources. Presented as a means of objectivizing individual experiences, quality of life measures responded to both economic and political concerns. However, while quality of life measures introduced a greater focus on the individual, the criteria used to assess it still posed several issues. Personal values remained secondary, and it was still down to physicians, politicians, and economists to determine, through diverse measures, what constituted the quality of life of individual patients. In parallel, the notion of quality of life also began to be used to justify the decision of interrupting a patient’s life support treatment in the event of a disconnection between the body and the person, for example, in the context of resuscitation care. This gave rise to new debates as to the definition of the human being, the person, and their connection to or disconnection from their body. From a tool used to structure political decisions and deliver management recommendations, quality of life gradually became a moral standard that introduced degrees of (human) life.

A New Understanding of Quality of Life Up to this point, the question of whether to continue or withdraw and withhold a medical treatment and the duty to preserve life had mostly been discussed in light of the distinction, invented by Catholic theology but gradually adopted by the medical world, between ordinary treatment means (always compulsory) and extraordinary ones (optional). However, the growing availability and evolution of life support techniques with the potential to reverse the dying process led to the questioning of this model. For instance, following the Karen Quinlan case,4 Catholic theologian Richard McCormick declared: The tragic case of Karen Ann Quinlan sent moral theologians and ethicists back to their traditions to reevaluate the formulations that attempted to

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spell out and mediate traditional value judgments in an increasingly complex world. Conceptualization has always been very important to moral theology. Because times, circumstances, and perspectives change, sometimes dramatically, the viability of some of our most treasured value judgments depends on the accuracy of their formulation in our time. (McCormick 1978: 30)

Quality of life thus found itself once more under the spotlight of moral discourse. However, in this context, quality of life measures were only of limited help; something remained unthought. Consequently, some researchers began to express the need to interrogate the meaning of the very terms that make up the expression “quality of life”. This expression undeniably contains an element of vagueness, which in fact serves a specific purpose. Despite the interest sparked off by quality of life measures, the very existence of such measures immediately created a sense of discomfort among the medical community. Efforts were made to avoid associating them in any way with the assessment of human life or the hierarchization of its forms (Shaw 1990 [1977]). The literature of this period reveals the implicit assumption that it is possible to carry out research on quality of life without engaging in a philosophical discussion on the definition of well-being, quality or human life, or on the latter’s value (see Najman and Levine’s literature review 1981). And yet, quality of life measures are far from being plain medical statements that are axiologically neutral and objective. The use of such measures to evaluate a treatment’s efficiency necessarily implies an ethical judgment—more or less implicit and definite—which cannot be regarded as plain medical indications. It is indeed one thing to state whether a given medical treatment has achieved a certain result (a simple medical description), and another to judge that this treatment is “futile” because it does not deliver a sufficient quantity/quality of life ratio, or because the sole benefit it can bring is the prolonging of life. As contended by Peter Singer and Helga Kuhse (although these authors do not explicitly refer to quality of life measures): this “is not a value-neutral medical judgment. Rather, it is an ethical judgment about the undesirability of prolonging the patient’s life because of what the life is like” (Kuhse and Singer 1989: 206). Without an attempt at understanding the concept of quality of life,

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it is impossible to adequately solve the issues addressed using quality of life measures. Beyond the variability of indicators, quality of life measures rely on an implicit ethical assumption: the belief that life is not a good that must be prolonged at any cost, independently from any other consideration. While many authors concurred on this point (including the Catholic hierarchies5), disagreements arose when quality of life became a criterion that presided over decisions of life or death. Nevertheless, any normative judgment to withhold or withdraw a treatment (including the distinction between ordinary and extraordinary means of treatment) entails a judgment on the value of human life, which is based on a distinctive definition of the human. To quote Protestant theologian Joseph Fletcher: Yet it is this question, how we are to define the humanum, which lies at the base of all serious talk about the quality of life. We cannot appraise quality or enumerate human values if we cannot first say what a human being is. (Fletcher 1974)

This issue turned out to assume a key role in the history of the development of bioethics, where discussions on measures gave way to a categorial debate about the human. As we saw, this debate stemmed from a new perception of progress in which quality of life was a crucial element. This notion shaped ethical discourses and became inseparable from the idea of measurement. Quality of life measures were thus developed in a medical context. However, as well as making it possible to consider the patient’s condition, these measures raised questions as to the definition of the human being.

F rom Measures to Categories: Quality of Life in Bioethics To envisage the meaning of quality of life, it is necessary to clarify the meaning of the terms that make up this expression. While the concept of human life is often mentioned, it is hardly ever explained or defined. The biological sense of the term had appeared sufficient so far, but the ability

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to artificially prolong human life, to replace vital organs and to modify biological processes changed the game. In the past, a human being was defined by their “biological limits”, which appeared consensual until these limits were disputed. The definition of a “human being” had to be interrogated to assess the moral legitimacy of certain practices. Bioethicists undertook to define the human based on what became referred to as “indicators of humanity”. Faced with the difficulty of defining such indicators, some bioethicists were led to focus not on the definition of human life, but on what gives it value or worth. Others introduced a distinction between “human being” and “person”.

Indicators of Humanity Joseph Fletcher was one of the first bioethicists who engaged in an attempt to define human life. In a short 1972 article, Fletcher sketches out a “profile of man”. Not without reminding “social indicators”, he identifies “indicators of humanhood” (20 in total) that permit to define a human, a man, or a person—three terms that Fletcher uses as synonyms. The key indicator, the one absolute criterion, is the neocortical function. Without it, “the person is non-existent”. Individuals that lack this function “are objects but not subjects” (Fletcher 1972: 3). Fletcher’s thinking is inspired by the definition of “brain death” set out by the Harvard Medical School committee (Beecher et al. 1968). According to Fletcher, the equivalence between irreversible coma and the death of a human being is justified by the irreversible loss of personal life—which is marked biologically by the loss of the neocortical function.6 The advantage of this indicator is that it can be determined medically and admits no exception, which means that this judgment does not rely on an arbitrary choice. In addition, this indicator considers the individual’s biological dimension while maintaining a distinction between biological (or physical) life and personal life. The loss of the neocortical function justifies withholding or withdrawing medical treatment. Humanhood is thus defined by an objective biological criterion—which is chosen because the cerebral cortex is regarded as home to rationality.

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Based on this criterion and considering the question of euthanasia (of which he is a supporter), Fletcher suggests, in line with the California Medicine editorial, that the traditional sanctity of (human) life ethics should be replaced with the quality of life ethics. He defines this rationale as a “doctrine of man” that “puts the homo and ratio before the vita. It holds that being human is more ‘valuable’ than being alive …. It is personal function that counts, not biological function. Humanness is understood as primarily rational, not physiological” (Fletcher 1973: 671). However, Fletcher’s attempt to define human life was not met with unanimous agreement. Over the following years, several other bioethicists tackled the same questions (Fletcher 1974). Some thinkers refused to state the problem in these terms and preferred to only consider the criterion of biological affiliation to the Homo Sapiens species (without however explicitly defining what characterizes this species); the ultimate aim of this theoretical approach is to dismiss any action that puts an end to any form of human life (May 1974). Others such as Catholic theologian Leonard Weber (one of Fletcher’s main adversaries) tried to avoid establishing any distinction between biological (or physical) life and personal life. Weber believes that the person (or human being) is a combination of inseparable elements. It is therefore impossible to distinguish between the body and the person. Causing harm to the body means negating the person’s integrity. Basing decisions on the notion of quality of life means negating equality between human lives, and asserting that because of their condition, one person has more or less value than another. This means perpetuating the idea that being human is not a sufficient condition to grant respect. According to Weber, taking the life of a dying person, even when they asked for it, amounts to a violation of their body and their person, because a human is always more than their present intention or desire. The author therefore recommends standing by the Pope’s distinction between ordinary and extraordinary means of treatment (Weber 1973). As mentioned earlier, this opinion was not shared by Richard McCormick. According to this author, it is “the kind of, the quality of, the life thus saved (painful, poverty-stricken, and deprived, away from home and friends, oppressive) that establishes the means as extraordinary. That type of life would be an excessive hardship for the individual”

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(McCormick 1990 [1974]: 31). While refuting, like Weber, that the word “life” could have a double meaning (life of the body vs. life of the person), McCormick believes that “life is … a basic and precious good, but a good to be preserved precisely as the condition of other values”. And it is precisely “these other values and possibilities that found the duty to preserve physical life and also dictate the limits of this duty” (McCormick 1990 [1974]: 30). In other words, biological (or physical) life is only an instrumental good, and the duty to preserve it is also limited with respect to these “other values”. However, McCormick’s reflection does not stop there: “If we must face the frightening task of making quality-of-life judgments—and we must—then we must face the difficult task of building criteria for these judgments” (McCormick 1990 [1974]: 30). According to McCormick, quality of life depends on one’s ability to maintain human relations—as suggested by the Christian message of loving God and one’ neighbor. The question of whether a means of treatment is extraordinary or ordinary can therefore only be assessed on human relationship (potential) capability. Unlike Fletcher, McCormick believes that there is only one indicator of humanity, and that this criterion is subjective: the individual’s actual or potential relational capability. When lacking, it can justify withholding or withdrawing medical treatment because physical (or bodily) life is only a good to be pursued when it makes it possible to achieve superior goods. Philosopher Michael Tooley also identifies a single subjective indicator of humanity: subjectivity or self-awareness (the author refers to “the self-­ consciousness requirement”). The mandatory condition granting an organism the right to live resides in self-awareness, which Tooley defines as “the concept of self as a continuing subject of experiences and other mental states” (Tooley 1972: 44). Tooley refers to any individual who meets this criterion as a “person”. These diverse propositions and the difficulty of identifying indicators of humanity they reflect contribute to highlighting a crucial theoretical question: “Do we value ‘life’ even if unconscious, or do we value life only as a vehicle for consciousness?” (Glover 1984 [1977]: 45, see also Maglio 2019). Over time, this question led most bioethicists to distinguish between “human being” and “person”, in line with Michael Tooley. This

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distinction became determinant in the opposition between a sanctity of life ethics and a quality of life ethics.

From Human Life to Person In this context, while philosopher Hugo Tristram Engelhardt maintained that different categorizations of human life are possible, he renounced to identify indicators of humanity (Engelhardt 1973). According to this author, the question of the definition of brain death or irreversible coma reveals disagreements between the multiple understandings of “human life”. These conflicting opinions can ultimately be boiled down to the categorial opposition between “biological human life” and “personal human life”. In the first case, human life is associated with its biological or metabolic process. In the second, the focus is on the possession of certain functions or qualities that go beyond the biological. According to Engelhardt, “personal human life” can be defined by three general criteria: brain function, self-consciousness, and the relational or social dimension. While biological (or physical) human death necessary implies personal human death, reversely personal human death does not imply biological (or physical) human death. Examples of this include cases of persistent vegetative state or irreversible coma (Engelhardt 2000 [1978]). The philosopher believes that the mere fact of being alive (biological human life) has no intrinsic value. His thinking finds its theoretical grounding in Kant’s distinction between things and persons.7 Engelhardt considers that only “persons”—understood as rational, self-conscious, and self-­ determining entities—can demand respect and must be treated as ends-­ in-­themselves. They have an intrinsic dignity and worth. Things, in contrast, only have a value in relation to persons—and this value is therefore relative. Engelhardt sees this distinction as the theoretical foundation for the difference between “personal human life” and “biological human life”. In addition, it can provide a direction for medical practice, which has the duty to preserve personal human life but not biological human life. According to this philosopher, this distinction already exists: for

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example, human cell cultivation is not perceived the same as the treatment of patients. Philosopher Peter Singer pushes this logic further. According to him, the difference between biological human life and personal human life translates into a distinction between “human beings” and “persons” (Singer 1995). By discarding the word “life”, Singer introduces a distinction between two terms that had in the past appeared as variations of the same notion. As observed by Canadian lawyer Edward Keyserlingk, “from the ethical/ontological as well as the medical standpoints, the real and crucial question in decision-making is not whether the patients or newborns are human (they are) but whether they are any longer, or can ever be, ‘persons’” (Keyserlingk 1979: 61). For Singer, the term “human being” only refers to an individual’s affiliation to the Homo Sapiens species: a characteristic that can be determined scientifically by examining cells and chromosomes. In contrast, the word “person”, in line with Locke’s definition,8 refers to a “rational and self-aware being” (Singer 2011a [1980]: 75). From this, Singer derives that not all human beings are persons (fetus, individual in a vegetative state…), and that not all persons are human beings (e.g., great apes). It is therefore not always morally reprehensible to end the life of individuals who are mere human, while it is generally morally reprehensible to kill persons.

The Concept of “Person” and Its Ambiguities As noted by Engelhardt (2000 [1978]), the concept of person is not univocal. It is possible to distinguish between what this author calls “the moral concept of person” and “the social concept of person”. The former only applies to persons in the narrowest sense—that is, moral, rational, and self-conscious entities—while the latter refers to individuals who, while unconscious, are still recognized by their relations as persons because of the role they occupy within a given social structure. While some human beings cannot be regarded as persons in the narrow moral sense, the (relative) value they hold for different persons must be considered.

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In contrast, Singer believes that a different principle must prevail, based on the equal consideration of interests: similar cases must be treated in a similar way. Human beings and nonhuman animals have a common interest, which is to avoid pain. To avoid committing discrimination on the grounds of an individual’s affiliation to the human species (a form of discrimination Singer refers to as “specism”), we must change our attitude toward both nonhuman animals and human beings. As a consequence, it becomes possible to include nonhuman animals into the sphere of our moral concerns, and to stop treating them exclusively as means to our ends (consuming their flesh or products deriving from their exploitation); but it also becomes possible to kill human beings (and not just allow them to die) when their life is one of unbearable suffering, as is commonly done with animals. Such conceptual distinctions can justify certain practices—such as abortion or withholding and withdrawing treatment for individuals in a state of irreversible coma—that appeared as unacceptable according to traditional medical ethics. They also contributed, in the 1970s and early 1980s, to shifting the focus onto autonomy and informed consent, in a context where medical paternalism still prevailed. By taking on the major task of clarifying concepts associated with human life, bioethicists have opened some essential areas for reflection, thus dissipating the fuzziness that had so far characterized the notion of quality of life. They questioned the meaning of the word (human) life, and what gives it value. New distinctions, such as that between “human being” and “person” were introduced—but this thinking opened new ambiguities and blind spots, which we will now examine.

Questioning the Person The distinction between “person” and “human being” is often regarded as one of the major contributions made by bioethics in the 1970s and 1980s. But the context in which these semantic distinctions were elaborated has been little investigated, although some bioethical debates—for instance, between sanctity of life ethics and quality of life ethics—had a significant impact on certain aspects of political life. After examining this

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debate and the forms it assumed in various places and periods, it is important to consider the notion of “person” and its diverse biopolitical implications.

From Ethics to Politics In the 1980s, the bioethical debates examined earlier crystallized into an opposition between the sanctity of life and quality of life. The distinction between “human being” and “person” was established by supporters of the latter standpoint. In general, refusing this distinction amounted to defending the ethics of the sanctity of life. However, this conflict did not remain confined to the limited sphere of controversies between experts of medicine and ethicists. It permeated a growing number of political discourses, which took sides in favor of one camp or the other and demanded for public policies to be set accordingly. The opposition between conservatives and liberals resonated in this bioethical debate, as well as the opposition between sanctity of life and quality of life. This brings us back, in a recursive movement, to the fields in which we saw the notion of quality of life emerging. Remember that in 1964, it had been identified by President Johnson as an objective to pursue. However, while the same words reappeared in the mouth of Ronald Reagan in 1983, they were used in a dramatically different perspective. This time, the President of the United States urged the nation to defend the sanctity of life ethic. Reagan firmly opposed the idea that it is necessary for an individual to have certain qualities for them to be considered a person. His speech implicitly referenced ideas such as those defended by Fletcher and Singer. According to Reagan, what had been predicted 13 years earlier in the editorial of California Medicine was well and truly happening. The President talked about “defiance of the long-held Western ethic of intrinsic and equal value for every human life regardless of its stage, condition, or status” (Reagan 1983). He exhorted the nation to make a choice: Every legislator, every doctor, and every citizen needs to recognize that the real issue is whether to affirm and protect the sanctity of all human life, or

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to embrace a social ethic where some human lives are valued and others are not. As a nation, we must choose between the sanctity of life ethic and the “quality of life” ethic. (Reagan 1983)

This resurgence of ethical categories in political discourses did not only occur in the United States. It was also present in several other English-­ speaking countries and, following a process of translation, in some Latin American countries, and in Italy. This latter country is interesting in many respects: there, the ethical debate was articulated in similar terms, but it opposed “catholic bioethics” that defended the sanctity of life, to “secular bioethics” in favor of the notion of quality of life (Fornero 2005; Lo Sapio 2017). This new variation on the opposition described earlier is even more interesting that, against a backdrop of medical ethics, it highlights the issue of secularism, and therefore the confrontation between theology and politics. In other terms, it incites to rethink the political dimension of the debate between sanctity of life and quality of life outside the sole stage of state politics, and opens up scope for theoretical considerations that had not been considered by North American bioethicists.

A New Focus on the Person In his book on political theology, Two: The Machine of Political Theology and the Place of Thought (2013), Italian philosopher Roberto Esposito stresses the fundamental role played by the person as a category in the history of Western thinking. Esposito sees this notion as the core of any relation between theology and politics. Along with Giorgio Agamben, Esposito is a major figure of the so-called Italian theory, which provided a renewed reading of Foucault’s biopolitics (1997). According to Esposito, the “dispositif” of the person sits at the heart of a “theologico-political machine” characterized by a mechanism that includes what it excludes and excludes what it includes, by subjecting it to the other’s domination. In other words, Esposito notes the duplicity of the notion of person, which produces a mechanism of “exclusion-captivation”.

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If we return to the developments of bioethics in the United States, it appears that the distinction between “person” and “human being” reflects this dual movement. While bioethics often presents itself as an accomplished form of moral philosophy, as opposed to the bioethics of the sanctity of life, which often lags behind technical and scientific progress, the understanding of the person it develops does not just draw its roots from modern moral philosophy. On the contrary, it often reestablishes, sometimes explicitly, the ius personarum and the divisions between men and persons established by the archaic Roman law. The status of person “becomes the operator of a depersonalization that classifies a certain type of men under the regime of things” (Esposito 2013: 9). Just as in Rome, relations between persons and things are determined by fluid boundaries. Esposito notes, for instance, that several intermediate states exist between the two extremes formed by the person and the nonperson, which facilitate exclusion–inclusion: Of course, between the two categories, taken in their typological purity … lies a series of intermediate degrees, which go from one to the other according to increasing or decreasing thresholds of personality that depend on the point of observation. In any case, whether you start from the beginning or from the end of life, what really qualifies as “person” only occupies the central section: that of adult, healthy individuals. Before and after this lies the no man’s land of the non-person (the fetus), the quasi-person (the infant), the semi-person (the elderly, no longer mentally or physically able), the no-longer-person (the patient in a vegetative state), and, finally, the anti-person (the fool, whom Singer puts in the same relation to the intelligent human being as obtains between the animal and the normal human being—albeit with a clear preference for the animal). To this categorization of the different classes of living beings, which we might characterize as “static,” he then adds a dynamic one, defined by the transition from one status to another. (Esposito 2012 [2007]: 97–98)

For instance, labeling a patient as disabled or terminally ill means moving them from an intermediate state to another, thus classifying certain actions affecting them as legitimate or illegitimate. The comparison between human beings and nonhuman animals also forms part of this “including–excluding” mechanism. While Singer (2011b [1981]) sees his

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categorization as an expansion of the circle of moral concern (see the title of his book, The Expanding Circle), it can also be described according to a very different perspective. Enhancing the status of certain nonhuman animals also implies lowering the status of certain human beings below that of certain nonhuman animals: “The boundary between human being and animal is erased for the benefit a new boundary within the human species, which is just as excluding” (Esposito 2013: 146). Nonpersons are thus “at the disposal” of persons who care for them and decide over their fate—just like in Rome, sons were at the disposal of their patres who had a power of life or death over them. However, the notion of person is eminently paradoxical because the role of assessing “humanity indicators”—or selecting qualities that can determine that an individual belongs to the category of person—can only befall a person. Esposito emphasizes the characteristic situation of the persons who arbitrate on which/who are the de-personalized human beings. We are thus faced once again with the same issues that were posed by quality of life measures and which bioethics had attempted to resolve, without considering the biopolitical dimension associated with this endeavor.

Conclusion In the United States, the notion of quality of life emerged against the backdrop of the social indicators’ movement, before permeating medicine through diverse measures. At first, it accommodated a certain level of conceptual vagueness to avoid being associated with the evaluation and hierarchization of human lives. But when this notion became used to discuss the continuation or the withdraw and withhold of certain treatments, its unavoidably axiological dimension became apparent, and was eventually fully accepted with the development of a coherent ethical discourse on quality of life. Bioethics thus took on the task of defining human life by identifying and challenging indicators of humanity (or by debating such indicators). The notion of humanity was thus devaluated and became secondary to that of person, while the definition of the person was broadened to refer

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to life beyond its biological and bodily dimension. However, this approach was once again built upon on a blind spot. In their categorial work, bioethicists used the notion of person while ignoring (or pretending to ignore) the notion’s theological and political load. While insisting on its inclusive dimension, they also reactivated its excluding dimension and its disconnectedness from the multiple social practices that exist around the de-personalized body, beyond measurement and ontological categorization (Denise in Chap. 6). While medical power has been criticized for its paternalism, in particular, by bioethicists who were concerned with autonomy, these same thinkers—who spoke on behalf of de-personalized beings and emitted categorial judgments from a place of pure moral expertise—have nonetheless recreated partly comparable power configurations. The objective of this chapter is not so much to dispute the positions of ethicists on diverse ethical issues, but rather to highlight the foundations from which these positions have emerged, and which often tend to minimize or marginalize the collective dimension wherever the thresholds of life are considered.

Notes 1. The words “ethics” and “morals” are used here as synonyms. In the context of 1970s US bioethics, the distinction between these two terms is less significant than elsewhere—in France, for instance (see Cassin 2004). 2. A 1962 NASA-commissioned study by the American Academy of Arts and Science pointed at the insufficiency of economic indicators. The objective of this research was to forecast the effects of the space program on US society. Two years later, the National Commission on Technology, Automation, and Economic Progress was created for this purpose. Its objective was to investigate the current effects and future impacts of technological change on society and the economy, and to deliver recommendations based on its findings. Both bodies noted the absence of methodologies that could enable them to achieve their objectives. Economic indicators, which had so far been regarded as essential, are incapable of documenting various aspects of society. A priority was set to devise “social indicators” to analyze the overall social, economic, techni-

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cal, and political conditions. This movement was referred to as “the social indicators movement”. 3. This perception of progress, the discourses that articulated it, and the various bioethical considerations at play in the opposition between the sanctity of life and quality of life had at their core “the boundary between nature and culture [that] marks the dividing line between scientist and humanist and often defines the battle-line between liberal and conservative” (Daston 2002: 394). As accurately noted by Lorraine Daston, and as we will see in the third section of this chapter, “a whole metaphysics underpins the distinction” (ibid.). 4. Karen Ann Quinlan was 22 when she entered coma in 1975. Two months later, her (Catholic) parents, faced with an irreversible situation, signed the disclaimers required for their daughter to be disconnected from the mechanical ventilator. However, it took a year before the New Jersey Supreme Court authorized this interruption. Quinlan had started breathing autonomously again, but without regaining her conscious functions. She spent nine years in a persistent vegetative state. 5. Pope John Paul II articulates this idea in the Encyclical letter Evangelium vitæ: “Another welcome sign is the growing attention being paid to the quality of life and to ecology, especially in more developed societies, where people’s expectations are no longer concentrated so much on problems of survival as on the search for an overall improvement of living conditions”. However, a few lines above, he writes: “The so-called ‘quality of life’ is interpreted primarily or exclusively as economic efficiency, inordinate consumerism, physical beauty and pleasure, to the neglect of the more profound dimensions—interpersonal, spiritual and religious—of existence” (John Paul II 1995). 6. At the time, there was no theoretical justification for the equivalence between irreversible coma and death: this was only articulated in 1981 with Defining Death. But contrary to Fletcher’s wishes, the US President’s Commission that issued this document justified the equivalence between brain death and the death of a human being by the irreversible functional arrest of the organism, and not by the irreversible loss of conscious abilities and of the neocortical function (President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research 1981; see also García and Maglio 2014). 7. This interpretation is not shared by all. For instance, Marie Gaille holds that “according to Kant, human life may not be assessed because it holds

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a dignity that is peculiar to all moral beings”. Nevertheless, Gaille is aware that Kant’s argument is not without ambiguities. In a footnote, she states that “one could try to conclude … that patients who have lost their reasoning capabilities must be excluded from the realm of moral subjects, and that their life could therefore be assessed”. This is exactly Engelhardt’s perspective. Against this thesis, Gaille opposes that “it cannot be that simple to assume that this was Kant’s opinion because nothing testifies, at least from an exegetical perspective, that he might have adopted this stance if faced with the questions posed by the decision of keeping patients who have ‘lost their mind’ alive” (Gaille 2010: 130–131). 8. “A thinking intelligent being, that has reason and reflection, and can consider itself as itself, the same thinking thing, in different times and places; which it does only by that consciousness which is inseparable from thinking, and, as it seems to me, essential to it: it being impossible for any one to perceive without perceiving that he does perceive” (Locke 1690: ch. XXVII).

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Land, K. (1975). Théories, modèles et indicateurs de changement social. Revue internationale des sciences sociales, 27(1), 7–40. Lo Sapio, L. (2017). Bioetica Cattolica e Bioetica Laica nell’era di Papa Francesco. Milan: UTET. Locke, J. (1690). An Essay Concerning Humane Understanding I. Retrieved from h t t p : / / w w w. g u t e n b e r g . o r g / f i l e s / 1 0 6 1 5 / 1 0 6 1 5 - h / 1 0 6 1 5 - h . htm#link2HCH0030. Maglio, M. (2019). Jonathan Glover: pour une reformulation du principe de la sacralité de la vie. Canadian Journal of Bioethics, 2(1), 37–46. May, W.  E. (1974). The Morality of Abortion. The Linacre Quarterly, 41(1), 66–78. McCormick, R. (1978). The Quality of Life, The Sanctity of Life. The Hastings Center Report, 8(1), 30–36. McCormick, R. (1990 [1974]). To Save or Let Die. In J. J. Walter & T. A. Shannon (Eds.), Quality of Life: The New Medical Dilemma (pp. 26–34). New York: Paulist Press. Najman, J. M., & Levine, S. (1981). Evaluating the Impact of Medical Care and Technologies on the Quality of Life: A Review and Critique. Social Science & Medicine, 15(2), 107–115. Noll, H.-H. (2000). Social Indicators and Social Reporting: The International Experience. Retrieved from https://www.gesis.org/fileadmin/upload/institut/ wiss_arbeitsbereiche/soz_indikatoren/Publikationen/isscnoll.pdf. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. (1981). Defining Death: A Report on the Medical, Legal and Ethical Issues in the Determination of Death. Washington, DC.  Retrieved from https://repository.library.georgetown.edu/bitstream/ handle/10822/559345/defining_death.pdf?sequence=1&isAllowed=y. Rapley, M. (2003). Quality of Life Research: A Critical Introduction. London and Thousand Oaks: SAGE. Reagan, R. (1983). Abortion and the Conscience of the Nation. The Human Life Review. Retrieved from http://www.humanlifereview.com. Schneider, M. (1976). The ‘Quality of Life’ and Social Indicators Research. Public Administration Review, 36(3), 297–305. Shaw, A. (1990 [1977]). Defining the Quality of Life. In J.  J. Walter & T.  A. Shannon (Eds.), Quality of Life: The New Medical Dilemma (pp. 91–92). New York: Paulist Press. Singer, P. (1995). Rethinking Life & Death: The Collapse of Our Traditional Ethics. Oxford: Oxford University Press.

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Singer, P. (2011a [1980]). Practical Ethics. New York: Cambridge University Press. Singer, P. (2011b [1981]). The Expanding Circle. Ethics, Evolution and Moral Progress. Princeton: Princeton University Press. Tooley, M. (1972). Abortion and Infanticide. Philosophy & Public Affairs, 2(1), 37–65. Weber, L. J. (1973). Ethics and Euthanasia: Another View. The American Journal of Nursing, 73(7), 1228–1231.

Part II Between Objectivization and Subjectivization: How Forensic Identification, Genomic Correction and Life Support Technologies Reshape the Frontiers Between Things, Human Person and Social Subject

5 Being Born in the Era of Genomics Jean-Hugues Déchaux

After the full sequencing of the human genome in 2003, the meteoric progress accomplished by genetics is now showing its effects in the field of reproductive medicine. This is only the beginning of a shift in the conditions of the transmission of life. This change is characterized by the growing role of genetic engineering in the care and monitoring of pregnant women. Beyond the media coverage received by cases of “medically assisted reproduction”, which only account for a minor proportion of all births (3.4% in France in 2018),1 this shift is affecting human reproduction as a whole and could have a major impact in years to come. Genetics came to the forefront as the sequencing of portions of the embryo’s genome2 from the early stages of pregnancy became common practice. Sequencing is now easy: the procedure requires no invasive medical examination; DNA reading devices have become more affordable. Furthermore, the contextual data needed for the fine-scale analysis of the sequences is now widely available from biobanks thanks to the

J.-H. Déchaux (*) Centre Max Weber, Université de Lyon, Lyon, France e-mail: [email protected] © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_5

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mainstreaming of genetic tests and can be processed by bioinformatics. The results of the sequencing make it possible to calculate scenarios for the unborn child’s life, forecasting the risks they will be exposed to depending on mutations that may have been detected in their genome. Based on this information, the parents can, with advice from medical professionals, decide on the embryo’s future life and potentially act on the genome itself through an operation referred to as gene editing,3 in order to suppress risk or select a given phenotypic characteristic, thus modifying the child’s future. This chapter analyzes the consequences of genetically assisted reproduction by focusing on the nature of the data generated through sequencing. How can this data inform, motivate or justify decisions made by the parents with respect to the embryo’s life and to the child’s future? The analysis is based on different materials. Concerning the first part of this chapter, we offer a synthesis of recent scientific publications on genetics and social sciences. Then we discuss controversies and public statements by scientists, ethics committees and medical corporations on genetic screening issue and the editing of the germline genome in Western Europe (mainly France and the United Kingdom) and in the United States. In the second and in the third part of the text, the analysis is based on specialized press from 2015 to January 2019.4 This corpus shows that the growing influence of genetic information can be encapsulated in three verbs that refer to three distinct stages in the reproductive process: predicting, choosing and correcting. For each of these stages, we will examine the importance of genetic measuring and the role of medical and technological expertise. This analysis does, of course, have an anticipatory character: the processes described here are only in their early days and can only be partially foreseen, in particular where prenatal gene editing is concerned as this technology has not had any clinical applications to this day.5

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Predicting The first question posed by genetically assisted reproduction is that of prediction: what can be predicted, and on what grounds? During early pregnancy, genetic monitoring is already present in the form of tests which pregnant women are invited to take. These tests, including for instance, non-invasive prenatal testing (NIPT)6 which has been used for a few years to screen for trisomies, are likely to replace ultrasound and biochemical tests7 which are currently used in obstetric care. NIPT is a screening tool: if the result of the test is positive, it must then be confirmed with a fetal karyotype test8 which will form the basis for the diagnosis. The tests consider the fetus’s DNA, which is present in the mother’s blood from the early stages of pregnancy along with small fragments of genetic material,9 to screen for a relative predisposition to the three trisomies (21, 18 and 13) and to anomalies in the X chromosome (Turner syndrome) or Y chromosome (Klinefelter syndrome). Other prenatal genetic tests are available: for example, the sequencing of the fetus’s exome, available in some hospitals in the United States for cases where fetal anomalies have been detected by the ultrasound scan. The systematic use of the preimplantation genetic diagnosis after in vitro fertilization (IVF) and before the embryo is transferred into the uterus is increasingly recommended as a form of prenatal testing to detect any risk of chromosomal alterations.10 These various genetic tests are based on sequencing techniques that can detect polymorphisms, or variations in the DNA sequence, which are associated with risks affecting a person’s phenotype—for instance, the probability that they might be affected by a given condition in the future. To understand these practices, it is important to analyze the notion of “genetic variation”. Variation, also referred to as “mutation”, is a statistical concept. On a formal level, it can be defined as a variation from a norm. It is calculated in relation to a reference genome, based on bioinformatic data drawn from large human population samples and obtained thanks to the increasingly common use of high throughput sequencing. Strictly speaking, a variation is therefore a deviation from the most widespread genomic configuration in a given environment. It translates as “an

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incongruity between an individual’s genetic endowment and his or her environment”, to quote geneticist Siddhartha Mukherjee (2016: 264). The question of its interpretation is wide open: these incongruities or disharmonies can have diverse phenotypic effects—some heavy and associated with severe conditions or handicaps, and others benign, or even functional in certain circumstances. The nature of the disharmony, that is, the likelihood that it will cause a pathology, depends on multiple factors, both genetic (involving other parts of the genome) and environmental (diet, lifestyle, stress, etc.), which interact according to a probabilistic model. The object of the measurement is therefore the individual’s predisposition, calculated as a “relative risk”11 in relation to a reference genome. However, a predisposition is a probability and not a biological reality. This probabilistic reasoning is particularly difficult to comprehend for the individual who is taking the test—and in this instance, for the parents who take a prenatal test, but also for the health professionals who are not used to working with biostatistical data. On medical tests, Pascal Ducournau (2018) notes that the calculation of genetic risk is not so much to do with “foresight” as it is with “probabilistic prediction” (ibid.: 144). It derives from a rational model based on the statistical processing of a sample of individuals selected according to diverse phenotypic parameters, including mostly etiological ones.12 Although this model is applied to an individual or to their offspring (in the case of antenatal tests), it bears no relation to their past or present subjective experience and can never account for an individual’s singular life. Ducournau rightly points out the gap between the spontaneously deterministic nature of prevision—from the point of view of the person who takes the test to find out whether their unborn child runs the risk of having a given condition—and on the other, the probabilistic nature of statistical thinking which only measures propensity, “possibilities of existence”13 in relation to collective reference entities, which remain abstract from the individual’s point of view. The difference of scale (individual life vs. collective entity) and the epistemological gap (determinism vs. probabilism) concur to make the reception and the interpretation of the results particularly complex and challenging.

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The difficulty resides in applying to oneself, or more precisely to one’s unborn child, the perspective of probabilistic prediction—that is, to think of oneself as an average individual and not as a singular person. This is a major challenge as no individual can spontaneously think of themselves in such terms, based on figures and percentages that do not say anything about them individually. Because the calculation is based on biomarkers that were obtained from the sequencing of vast population samples, this produces a standardization effect that suppresses the subject’s singularity. Reversely, to compensate for this suppression, parents are tempted to “re-subjectivize” the results, moving from probabilistic prediction to individual prevision and thus lending the genetic test a normative and moral value. Statistical normality (whatever is widespread in a given environment is considered “normal”) thus becomes invested with qualitative and moral value (whatever is normal in a given environment is considered “good”, and therefore desirable): this shift is all the easier to operate that it is cognitively very challenging—both for a layperson and for a healthcare professional who has to respond to a patient’s concerns—to consider the environment and large-scale abstract entities. This tendency is amplified when people are required to project themselves into an indeterminate future, in particular in the case of germline editing:14 a process that involves modifying an individual’s germinal lineage, which can by definition be transmitted to their entire line of descent over several generations. The parents thus find themselves in the position of laypeople who do not have the knowledge required to interpret test results. They must therefore rely on biomedical experts: the medical teams in maternity hospitals, the commercial complex formed by the testing and sequencing industry and birth-related public health policies. Depending on the relation of power between these various entities and on general policy orientations, the parents’ decision-making autonomy is more or less effective. For example, looking at the prenatal screening of Down syndrome, a recent international study comparing England, the Netherlands and France revealed sharp discrepancies in the recourse to ultrasounds and biochemical screening. In France, these tests are taken by almost all pregnant women (84%), against just over half in England (61%) and a quarter in the Netherlands (26%). This field study15 also shows that French

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doctors are much more prescriptive than their English or Dutch counterparts: most of them consider parental consent, which they are obliged to obtain by law, as granted, and only spend minimal time explaining what the screening is and what it is for. There is no comparable data available to this day concerning new generation genetic tests like the NIPT, but almost all French doctors who have spoken out about this procedure praise its reliability and recommend its use as part of standard pregnancy follow-up. This has been the case in France since December 2018:16 NIPT screening for trisomy 21 is now one of the medical procedures that are reimbursed by the national health insurance service, but only for women who present a higher risk than average according to their first prenatal screening results. With the progress of genetically assisted reproduction, the prenatal phase is increasingly informed and calibrated by biogenetic measurement. While the medical monitoring of pregnancies is not a novelty—it emerged in France with the creation of the Agency for the Protection of Mothers and Infants (PMI) in 1945, it took on a genetic turn from the 1970s and later a genetic one with the screening of genetic anomalies like trisomy 21. The current period and the years to come have two main characteristics: first of all, time boundaries are expanding backward with the development of embryogenesis monitoring and forward with the forecasting of likely effects on the unborn child’s and potentially his or her descendants’ health and life. Secondly, probabilistic calculation highlights the crucial role of the cellular scale in our understanding of life: this shift is referred to as the “molecularization” (Lock 2006) of measurement. While this shift brought about a higher level of scientificity, it is in practice raising some complex interpretative issues. Before the child is even born, the parents are required to project themselves into the future of this child or even into that of their entire line of descent—which is all the more abstract and difficult to imagine considering the long timescales involved—in order to decide whether or not to take the pregnancy forward and if so, under which conditions. As part of this projection process, the parents are asked to think rationally and to base their decision on the results of genetic tests. The child’s or the descendants’ future is broken down into probabilities, each of them associated with abstract phenotypic entities that form a reference genome,

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according to which predispositions are calculated. The initial phase of the reproductive process is thus marked by an ever-growing level of abstraction and standardization. When a probabilistic prediction is, explicitly or not, interpreted as a prevision or a diagnosis, biomedical experts find themselves in a position where they can imbue a technical test with moral value17 and deliver a judgment on the quality of the existences at stake. During this preliminary stage, parenthood is considered as a technology, or more precisely as a technologically assisted project where statistical and moral normality tend to merge, since the reasons to bring a child into the world can only rationally be grounded in statistical prediction. An alternative scenario is that of the moral dilemma that arises when the parents, for any given motive or intention, oppose different reasons (e.g. their strong desire for a child) to the statistical arguments of the biomedical experts and persist in wanting to give birth although probabilistic prediction would recommend not to do so considering the risk. The value attached to prenatal prediction reflects a strong concern with controlling and managing of human lives, dismissing those who decide to leave things in the hands of the “genetic lottery” as irrational or reckless. On the contrary, the “geneticization” of birth (i.e. the abstractification and standardization of reproduction) can have a paradoxical effect: contemporary genetics and embryology have shown that, from gamete stage, the transmission and production of life are irremediably affected by random combinations that cannot entirely be controlled.18

Choosing The predictions calculated through genetic tests are expected to enable parents to make an informed choice. The second question after prediction is therefore that of choice: how does one decide, and according to which criteria? In addition to this question comes the normative issue of responsibility for this decision: what must a “good parent”—that is, a responsible parent—do? Biogenetical considerations, both factual and predictive, thus become entangled with moral considerations, involving the notion of what is right and fair in terms of parenting and parenthood (what one passes on to their descendants).

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Through the act of choosing—whether to take a pregnancy to term and give birth, whether to correct any mutations associated with risks that are considered significant, and so on—and of making this choice according to certain criteria, whether those are explicit or not, one accepts the programming and standardization of reproduction: with their decision, the parents select elements in their unborn child’s phenotype. This can be a negative choice, when the parents decide not to run the risk of giving birth considering the genetic predispositions that have been identified; it can also be a positive one in the case of germline editing, where the objective is to modify a targeted section of the embryo’s DNA that will be transmittable to their descent. In any case, on a conceptual level, parental choice goes against chance: choosing means not leaving things in the hands of fate, not relying on the “genetic lottery”. Quite logically, if random chance is no longer a factor, then the parents who have become designers can be held fully accountable for their child’s phenotypic profile. The hypothesis of the eradication of chance is not realistic due to the random genetic combinations involved in the reproductive process. However, any shift toward more control through selective choice brings about greater responsibilities for the decision-makers—and in this instance, for the parents. Prenatal choice thus presents a dual nature, which constitutes the two sides of the same coin: one the one hand, it is associated with “reproductive freedom”,19 meaning that the aspiring parents refuse to remain passively subjected to random factors; on the other hand, it necessarily involves an element of responsibility, since the parents intervene voluntarily and deliberately in the unborn child’s gene pool. From an ethical perspective, the first aspect—freedom of choice—is not problematic as and of itself, or at least not for the mainstream public opinion in liberal Western societies: it forms part of the history of the freedom claimed and gradually conquered by women in terms of reproduction, including contraceptive rights, the right to abortion, the right to medically assisted reproduction and more generally all aspects of birth control. Although feminist critique denounces biomedical control over the reproductive process as a form of control and instrumentalization of women (Tain 2005), prenatal selection appears as the continuation of a liberal evolution that is already underway. In contrast, the second issue—parental

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responsibility—is more complex to examine from an ethical standpoint. It questions the “right reasons” for prenatal choice (what should a “good parent” do considering the genetic information provided to them?): parental responsibility will be deemed legitimate or not depending on one’s understanding of what is good and fair. The ethical controversies that surround this issue reflect the moral pluralism of western societies.20 In this context, it is not surprising to observe the gradual emergence in the public opinion of discourses advocating for selective choice and considering that this choice forms part of the parents’ legitimate, and perhaps morally binding, responsibility. These discourses, theoreticized by bioethical literature, are reworded in a more basic form by many doctors and geneticists. Their main characteristic is their tendency to mix up two distinct levels: on the one hand, biomedical expertise, which grounded in the genetic measurement of risk and its interpretation in terms of suffering and death; on the other, standards of parenting and parenthood that are based on a moral standpoint, whether explicitly or not, and convey an image of what a good, “genetically responsible” parent should act like. The distinction between these two levels is not clear-cut. The mere fact that notions like suffering and the obligation to relieve it are injected into the interpretation of genetic predispositions points to an overlap between the positive field of measurement and the normative field of assessment and judgment. These arguments, which always place the emphasis on therapeutic or preventative purposes, are based on one key reason: saving human lives. By discarding genetic mutations that can cause severe incurable or lethal conditions, prenatal selection can enable many people and their descendants (in the case of germline editing) to live in good conditions, that is without suffering, or to not die. For example, in a 2015 article for The Guardian, Cambridge bioethics professor John Harris writes that it is a true tragedy that 6% of babies are born worldwide every year with a genetic condition and condemned to die.21 In this perspective, ethical concerns with the threat of eugenics or arguments for the sacrosanctity of the human genome do not carry much weight: prenatal selection, and in particular germinal editing which forms the object of Harris’s column, is a moral obligation to alleviate suffering and avoid deaths. This type of opinion is far from unusual, especially in English language countries

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(Déchaux 2017b), and forms part of an intellectual tradition that goes back to the mid-2000s. In an influential article often quoted by the supporters of prenatal choice, philosopher and Oxford professor Julian Savulescu (2001) introduces the concept of “procreative beneficence” according to which parents have the moral obligation to select the best genes for their children in order to offer them “the best life”, based on the information available to them. In the early 2000s, long before the development of non-invasive prenatal testing or gene editing technologies, Savulescu stated that the selection of embryos based on a PGD was preferable to abortion due to its lower “psychological cost”. Since then, he has regularly commented on innovations in the field of reproductive genetics wherever those offered greater control over the individual’s genetic destiny. For example, Savulescu co-authored an ethical statement in favor of germline editing in a genetics journal (Savulescu et  al. 2015) and later in the Journal of Applied Philosophy (Gyngell et al. 2017): he asserts that germline editing is preferable to the selection of embryos through PGD because when this technique has been sufficiently improved to be applied to human reproduction, it will destroy much fewer embryos than PGD and will be more efficient medically because it will not rely on the parents’ genotype due to the possibility of inserting DNA sequences. This argument justifies the necessity of performing the selection at the earliest stage possible. The key principle underpinning this argument is freedom of choice, which is seen as the prerogative of the individual: decision-making depends on nobody but the parents, and the role of the state is to provide the right conditions for the exercise of procreative freedom. Nevertheless, both Harris and Savulescu22 draw a portrait of the “good parent” in terms of prenatal choice: a responsible parent is one who sorts between “good” and “bad” genes, based on the results of the tests. This attitude is analyzed as a double responsibility for the parents: first, as highlighted by Savulescu, toward the child, to whom the best possible life must be offered; and second, according to Harris, toward society or humanity, with the objective of alleviating suffering and death. This discourse is based on a utilitarian vision of responsibility to others. The options the parent must choose between are ordered according to their expected consequences,

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which can be appreciated on the grounds of the individual’s genetic predispositions as observed and calculated using probabilistic prediction: how much is the risk of a pathology reduced? To which extent are the casualties or the suffering avoided? How can the child be given the best possible life? The space allowed for free choice is thus reclaimed by moral reasoning, according to which the duty to select is the best possible choice. This utilitarianism, which presents itself as altruism, is illustrated by the recurring use of the word “best” (“best children”, “best life”, “best interests”, “best assets”, etc.), thus implicitly establishing a hierarchy between the lives that are worth living. Biogenetic and moral considerations are conflated within this utilitarian discourse, which is designed to integrate both. Prenatal choice becomes a parenting decision, involving the act of caring for a child (or a future child in this instance). In this respect, Harris and Savulescu consider that the genetic sorting of embryos and the targeted modification of the germinal genome are not fundamentally different in their effects from many of the educational choices made by the parents which have an early impact on the child’s existence.23 But beyond parenting, prenatal choice also affects parenthood, or more precisely filiation, through the cross-generational transmission of a certain genotype which has been selected or modified. Although this idea is not present in the discourses mentioned earlier, which place the emphasis on parenting or responsibility toward society or humanity, one could imagine that it forms part of the category of “reproduction strategies” (Bourdieu 1994) deployed by parents: the aim is to pass on a “good” gene pool in order to produce a “good” germinal lineage. When defined in genetic terms—sorting between genes—parental responsibility becomes an anticipated responsibility that requires of the parents that they project themselves in a future that can be relatively near (the life of the child) or on the contrary very remote (when the entire line of descent is affected by the decision), on the grounds of a reasoning whose epistemological premises remain probabilistic. As well as expanding into the future, the timescale of parental responsibility can also spread well ahead of procreation, when a reproductive partner is selected based on expected consequences on the unborn child’s genotype. For example, some sperm banks offer genomic pairing services to help find the donor

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whose genotype is best matched with the female client’s genotype, that is, least likely to transmit a deleterious mutation once fertilization has occurred.24 There are also genetic “pre-conception” tests aimed at this same purpose, for couples who want to rationalize their reproductive project.25 While the prediction phase is characterized by the abstraction and standardization of reproduction, the choosing phase highlights another aspect: projection and anticipation, in a context where reproduction is envisaged as part of a much wider time sequence that is understood in normative terms. This new temporal space, informed by probabilistic thinking, provides the setting for the construction of a definition of what forms a good, genetically responsible parent. By analogy with the prediction phase, we could talk about the “molecularization” of decision-­making criteria and parental responsibility. The decision is expected to involve the sorting of genes according to a moral hierarchy opposing “good” and “bad” biomarkers, depending on their level of “susceptibility”, that is of involvement with diverse pathologies.

Correcting During this third stage, the focus is on germline editing: this time, the purpose is to correct the unborn child’s genotype. This is where the true specificity of germline editing lies with respect to procreation. The other two stages (predicting and choosing) are already a reality in many couples’ reproductive trajectories and are likely to become more widespread in the future with the genetic monitoring of pregnancies. This is not yet the case with germline editing. However, is prenatal genomic editing only a science-fiction scenario? Clearly not, as the first “genetically modified” babies already exist.26 Lulu and Nana are a pair of twin girls born in China in late 2018. This information has been revealed on 25 November, two days before the opening of the Second International Summit on Human Genome Editing in Hong Kong: a Chinese researcher, He Jiankui, claimed—at first in videos and later during his talk at the Hong Kong summit—that twins had been born and explained what his work had entailed.27 The modification

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carried out in their genome aimed to deactivate a gene (CCR5) by provoking a mutation (CCR5∆32), which made the individual HIV-­ resistant. This was performed at an early stage of the embryo’s life, five days after its fecundation. In conditions that remain obscure to this day, He Jiankui claims to have recruited seven Chinese couples each made up of an HIV-positive man and an HIV-negative woman. After deactivating the CCR5 gene in 16 embryos out of 22, 11 were re-implanted, producing one pregnancy that gave birth to Lulu and Nana. Technically speaking, this germline editing operation was obtained by using the tool CRISPR-Cas9 which is today considered the most efficient for editing.28 The genetic modification affects the reproductive cells and can therefore be passed on to the twins’ line of descent. Only one of the twins had both copies of the gene modified. According to subsequent information (21 January 2019), a second woman who took part in the same program in Shenzhen hospital became pregnant with a baby whose CCR5 gene was modified. However, no further birth has been confirmed. While the “affair of the Chinese twins” was soon condemned almost unanimously by the international community (Meyer 2018), a Russian researcher running a gene editing laboratory in a private Moscow clinic, Denis Rebrikov, also stated his ambition to give birth to children with a modified CCR5 gene.29 In an interview with Science on 13 June 2019, Rebrikov announced his intention to continue He Jiankui’s work by improving his experimental protocol to make it safer and to obtain more precise results.30 The key question raised by germline editing is not only that of knowing how DNA can be modified and what the effects of this modification would be, but also that of whether it should be done at all. Even before the birth of the Chinese twins, ever since the discovery of CRISPR-­ Cas9 in 2012, research on human gene editing, including on the germinal genome (Déchaux 2017a), has proliferated. The first experiments involving germinal cells were performed in China in 2015 in great secrecy, using supernumerary embryos from IVF treatments. Other programs soon followed in the United States and Sweden and were the object of intense international competition. These experiments were developed for research purposes: engineering the germinal genome to cure unborn children from incurable pathologies. Once the experiments were completed, the embryos were destroyed. However, the very possibility of such

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experiments should not be taken for granted. Should geneticists be allowed to engineer the germinal genome at will? Should research projects aimed at editing germinal lineage by introducing targeted mutations be supported, when these mutations are irreversibly transmittable? There were debates between geneticists and bioethicists,31 specially at the First International Summit on Human Gene Editing which took place in December 2015 in Washington. Some people called for a moratorium on research. Others opposed this idea in the name of scientific freedom. Three years later, the birth of the Chinese twins revived this debate. It appears that the scenario involving the editing of unborn children’s genome is highly controversial, even more so than questions to do with genetic prediction and prenatal selection. Faced with the hostility of professional genetics organizations and with that of national and international regulatory bodies—including in China, where the authorities claim to have been unaware of the researcher’s activities and opened an investigation—He Jiankui had to issue an apology and promise to interrupt his research.32 However, this apparent unanimity in fact conceals significantly different positions on the refusal of prenatal gene editing. Two levels of discussion can be identified, depending on the way germline editing is apprehended: the first focuses on technical aspects associated with the use of editing tools, while the second highlights the ethical question of the very legitimacy of editing. The technical argument revolves around the issue of the reliability of editing biotechnologies—in this case, the tool CRISPR-Cas9, which is regarded as the most effective considering the current state of knowledge and genetic engineering. This debate mostly involves geneticists (specially professional associations) as well as some national regulatory or consultation bodies. The supporters of this approach consider that the CRISPR-­ Cas9 editing tool is not at present sufficiently reliable and precise, and that there is a risk of side effects that could provoke unwanted genetic modifications: their priority is therefore to define criteria for “responsible” germline editing. He Jiankui’s initiative is denounced as irresponsible because it is premature considering the risks taken. The final communiqué of the Second International Summit in Hong Kong, issued on 29 November 2019, illustrates this position.33 The question raised is that of the “specificity” of the editing tool. The use of CRISPR-Cas9 can have

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two kinds of detrimental effects, which are addressed by numerous biotechnology research studies aimed at reducing these impacts: the “off-­ target” effect when a modification occurs in a different location in the genome than that which was targeted by the modification of the DNA; and the “mosaic effect” when some cells in the organism are modified while others are not. Until both effects are under control, there is a real risk that the editing process may not produce the desired genomic modification, or that it may inadvertently introduce another—thus posing a severe threat to the life of the child and its line of descent.34 These objections are of a technical nature: the opportunity of using germline editing for reproductive purposes is evaluated according to a risk versus benefits approach. Current editing tools still lack accuracy and safety: in other words, they lack specificity, and the severity of risk outbalances the benefits expected from this operation. This rejection of germline editing is therefore not grounded in principle: on the contrary, the idea is in term to establish the technological and medical conditions under which this operation could become responsible and acceptable. For this purpose, research in genetic engineering should be encouraged to improve the specificity of editing tools; in addition, research should focus on severe pathologies for which there is currently no reasonable alternative to germline editing.35 This take on the issue of prenatal gene editing was already supported, even before the birth of the Chinese twins, by a number of national regulation and consultation bodies on bioethics, which thus took a different stance from the international consensus against clinical applications for procreative purposes that had been expressed at the first Washington International Summit in December 2015 (Déchaux 2018). In the United States, in a February 2017 report, the National Academy of Sciences (NAS) recommended prudence but not prohibition, envisaging that gene editing in embryos could be permitted in the near future in well-defined conditions and under strict medical surveillance.36 In July 2018, in the United Kingdom, the Nuffield Council on Bioethics (NCB) cautiously concluded that editing the germinal genome of a human being could be permissible, on the condition that this intervention was not detrimental to the well-being of the child or to society (by increasing the risk of division or discrimination), and that the objective was first and foremost to prevent a specific genetic

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disorder from being passed on.37 Lastly, and more surprisingly considering Germany’s recent bioethical positions on genetics, the Deutscher Ethikrat stated in a March 2019 report that the human genome was not inviolable and that a distinction should be established between the principle of editing, deemed acceptable from an ethical standpoint, and the technical considerations that invite us to exert caution in the current state of research, considering the severity of the risks involved.38 There is a deep coherence between this focus on the technical aspects of prenatal gene engineering through the question of the specificity of the editing tool, the approach that favors a pragmatic assessment of risk and benefits, and the factorial and determinist reasoning that underpins this way of considering the specific effect of a specific genetic alteration in isolation. This thinking follows the same epistemological orientation as the process of abstraction, standardization and anticipation of reproduction made possible by the growing prominence of genetic prediction and prenatal choice. The moral issues raised by genetically assisted reproduction are minimized because they are reduced to technical parameters that are expected to bring a solution to these issues. The outcome seems already known: gene editing is presented as an ineluctable scenario, and the only points that are open to debate are the timelines and modalities of its implementation.39 This approach sees prenatal correction as an issue of relevance to scientists, but not to society as a whole. The second level of discussion is based on an ethical standpoint: this time, the question at stake is the legitimacy of editing the genome during the prenatal stage and, beyond the genotype of the unborn child, of modifying the germline’s gene pool. Five types of issues are raised in this context. The first is to do with parent/child asymmetry: what is the value of the life of a person whose phenotypic profile has been (at least in part) created by their parents? How likely is this person to feel free and equal to others if this original subjection cannot be erased?40 All these questions derive from the impossibility of initial consent, since gene editing takes place during the embryonic period before the person exists as a subject. The “de-subjectivation” that had already been observed about the extension of probabilistic prediction is undeniable—all the more so when the modification was not introduced for therapeutic or preventative purposes, but with the objective of modifying the child’s appearance or

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human characteristics. The child appears as the product of a series of technical operations aimed at calibrating him or her, based on a determinist vision according to which the genotype configures the phenotype. The second issue is the risk of inequality, traditionally prefigured by dystopian literature representing cloning or eugenics: if germline edition becomes common practice, will society not run the risk of seeing a growing gap between those whose genome has been modified (“gene-rich”) and the others (“gene-poor”)? The former, individuals who have been genetically engineered to be more resistant to certain pathologies or to perform better in certain activities, would benefit from a “better life” from the moment of their birth and throughout their existence. This injustice would breach the principle of the equal dignity of all human lives, creating the conditions for discriminatory treatment across society and humanity as a whole.41 The third issue lies in the purposes of prenatal gene editing: should germline editing be dedicated to a strictly medical use, or should other purposes be envisaged like selecting cognitive traits in an unborn child? Is it possible to draw a line between these two purposes—therapeutic or meliorative? When discarding genes that carry pathogenic mutations, the question remains of where pathology begins, considering that the link between a genetic variation and its phenotypic expression is of a probabilistic nature. Consequently, everything depends on the interpretation of the predisposition associated with a distinctive mutation, and of the protection that gene editing is supposed to provide. For example, one could consider that the Chinese twin girls only ran a very minimal risk of contracting HIV, since their mother was HIV-­ negative. The objective was not to cure them of an existing or highly predictable pathology, but to protect them from a disease that they were very unlikely to contract. This use of germline editing can therefore be considered meliorative rather than therapeutic.42 The fourth issue concerns timescales, since germline editing not only impacts the unborn child but also, in the longer term, their entire line of descent: how can the effect of this heritability be anticipated in a future environment that will become all the more unknown and unpredictable in the longer term? The particularity of a genetic variation lies in its rarity in each environment and consequently its ill-adaptation to this environment. If the environment changes (e.g. climate, diet or lifestyle), this variation may cease to

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be ill-adapted and even become a selective advantage.43 In this context, how can we be certain of the long-term effects of a genomic modification that has been performed in a specific environment, considering that the germinal edits are irreversible while the environment is subjected to permanent and contingent changes? Finally, the last issue lies with moral responsibility. Do we have the right to edit the human genome? The answer depends on another question: who does the genome belong to? If one considers that the “human genome” is only an abstraction and that there are only singular genomes that differ between individuals, then the view that each person can edit their own genome can be defended. This focus on individual freedom justifies the right for the parents to choose the best option for their unborn child. However, one can also adapt the opposite view: nobody owns their own genes. The genome, understood as an initial and partly random determinant that forms the foundations of each life, must remain intangible to guarantee the equality of all human lives, regardless of their genetic profile. This view sees the human genome as a common good, and even as the “heritage of humanity”.44 The ethical perspective raises the issue of the role played by technical expertise. It contends the fact that the issues raised by prenatal editing can be solved by genetic and biotechnological arguments on the measurement of predictions or the specificity of editing tools. The supporters of this perspective present it as a counter-fire against the growing abstraction and standardization of reproduction, while calling for people to engage with the strictly normative aspects associated with birth seen as the human act of transmitting life. Against technological questions, which can be solved by innovations of a similar nature, it opposes questions of principle that must be addressed by moral reflection and cannot be the sole preserve of scientists and experts. The discussion on genetically assisted reproduction is thus shifted to the public sphere. It places the standards of what is good and fair at the heart of the debate by challenging societies to open an inclusive deliberation process to build up regulatory and legal frameworks under the leadership of legal bodies.45 This approach is supported by international political bodies—UNESCO, Council of Europe46—as well as by associations that embrace a specific bioethical philosophy,47 rather than by professional bodies from life

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sciences disciplines (genetics, medicine, biotechnology) who are reluctant to have legislators set restrictions on their activities.

Conclusion A new paradigm is emerging with the growing role of genetics in reproductive medicine. Before characterizing it, it should be noted that it is still too early to know if it will impose itself and will become widespread in societies where its first manifestations were observed (the United States and Western Europe). It is even more to state that in other societies. However, the growing presence of genetic engineering in human procreation is a process which largely ignores national borders, both in the field of research (with the key role played by China) and in clinical applications. Thus, the first birth by mitochondrial replacement, called “in vitro fertilization with three parents” in the media, took place in January 2016 in Mexico and was carried out by a US team led by a doctor of Chinese origins. The first babies who were born following a germline edition were Chinese, but some of the trusted researchers who worked with He Jiankui were North American. That being said, this new paradigm primarily affects birth but also parenting, filiation and even, to some extent, the human person. Birth, or the act of giving life, becomes increasingly abstract and standardized due to the pervasiveness of genetic measurement, which is a product of gene sequencing. This process is understood in terms of probabilistic prediction, thus excluding the individual’s subjective experience. This projective dimension has come to span an increasingly long period of time, as decisions can affect the individual’s entire germline. In addition, normative considerations regarding prenatal choice contribute to defining a standard of what a “good parent” is, in particular when it comes to choosing the right genes in the best interest of the unborn child. Beyond the reproductive process, this shift also affects parenting—that is, the process through which parents care for a child—and filiation—that is, the cross-­ generational transmission of resources within a lineage. This impact now plays out further ahead of the child’s birth with prenatal choice and potentially gene editing. These diverse aspects increasingly shift the focus

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onto the prenatal period, which ranges from fertilization to birth (or its interruption), placing the parents in a situation of objective dependence on biomedical experts. Even when they claim to adopt a non-directive approach and to respect the parents’ decision-making autonomy, experts are the only ones able to produce an interpretation of genetic measures that can be understood by a layperson. Many of the debates on prenatal gene editing today examine the role of the experts, and more specifically scientific and medical arguments examining the accuracy of measurement and the precision of gene editing operations. This new vision also conveys a genocentric representation of the human person. The genome appears as the person’s infrastructure, a secret map of their life which is deciphered, analyzed and interpreted through gene engineering. The individual’s future is summed up into a series of probabilities that often gets translated by laypersons, who are unfamiliar with statistical reasoning and concerned with their future or that of their child, into singular previsions. This focus on the genome, especially during the embryonic phase, has a curious effect on the embryo’s ontological status. Depending on the biomedical practices adopted, depending on the scientific or familial context where they are applied and on the moral discourses that go along with them, the embryo can be seen—if we only consider the two ends of the spectrum—either as experimental material or on the contrary, as a potential person, a “preborn child” (Cromer 2018: 382)48 who is associated with very sensitive moral and political questions. Paradoxically, this corpus of representations where the genome is seen as the foundation of the person produces reductionist and deterministic discourses, based on the notion of a “genetic program”, which is today being gradually left behind by modern medicine. In contrast, “post-genomic” medicine (Perbal 2011) is adopting a more systemic approach and reassessing the role of chance, while epigenetics encourages us to rediscover the complex role of the environment in gene expression.49 This hiatus suggests that genocentricity is in fact a discourse on the social reception of genetics, promoted by those who use this knowledge for professional purposes—for instance, health professionals—and by those to whom these notions are applied for the elaboration of a diagnosis—for instance, expecting parents. In both cases, the content of genetics is inflected by the purpose it is used for: by medical professionals, for

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monitoring pregnancies; by parents, out of their concern to do whatever is necessary to give birth to a healthy child with a beneficial life ahead of them. Similarly, the notion of personal infrastructure must be understood in a specific manner, which serves practical purposes to reconcile determinism with the control of one’s destiny: a person’s genome is seen as a transformable infrastructure that can be modified and controlled. Genetically assisted reproduction thus creates a paradigm that simultaneously implies the sense of an all-powerful determinism and gives the individual the pleasing impression—which is also probably an illusion, considering the complexity of genome regulation mechanisms—that the genome can be manipulated to serve their objectives.

Notes 1. Figures provided by INED (De La Rochebrochard 2018, https://doi. org/10.3917/popsoc.556.0001). 2. The sequencing process usually analyzes the exome, that is, the coding portion, which amounts for an estimated 1% of the genome. The sequencing of a fetus’s full exome is less common. 3. In French, this operation is also referred to as “targeted modifications of the genome”. 4. The British news site Bionews (https://www.bionews.org.uk/) is the main source of information. It is published by the Progress Educational Trust (PET), an organization which is presented as independent and promoting informed debate on research in biology. Time milestones (from 2015 to January 2019) correspond to the first clinical applications of genome editing on human embryos (2015) until the first birth of babies whose genome was modified (November 2018). 5. Only a single birth resulting from this process has been reported to this day—see further. 6. Non-invasive prenatal testing for trisomy 21 is considered very reliable. 7. Measurement of nuchal translucency and sampling of maternal serum markers. 8. A karyotype of the embryo’s chromosomes is obtained via amniocentesis. 9. This screening analyzes circulating cell-free fetal DNA, which is present in maternal serum from the fifth week of amenorrhea. The tests are car-

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ried out from the tenth week of amenorrhea, when the proportion of fetal DNA is deemed sufficient to be analyzed. The sequencing is performed exclusively on circulating cell-free fetal DNA. 10. In France, the use of the preimplantation genetic diagnosis (PGD) is strictly controlled and remains exceptional (under 600 PGDs per year). It is restricted to cases where at least one of the parents has a “severe and incurable” genetic condition. A collective of doctors recommends providing wider access to “the genetic screening of the embryo”, as is the case in other European countries (Frydman 2017). 11. The relative risk is the relation between two probabilities: the ratio of the probability of being affected by a given pathology associated with the observed mutation (e.g. 10%) to the probability of this pathology occurring in a reference population (e.g. 25%). A high relative risk can be low in absolute value if the probability in the denominator is very low (e.g. 10:0.25=40). See Jordan (2000). 12. For example, the presence of a given condition, for which associated genetic variations are identified in comparison with a sample of healthy individuals. 13. According to Martin (2011), “probability does not refer to an observable and controllable existence; rather, it signifies a possible existence”. A “possible existence” is an abstract notion that can be difficult to grasp from a cognitive standpoint. 14. The germinal genome is the genome of reproductive cells (gametes, early-stage embryos). 15. Interviews with medical teams and female patients, observations performed in medical practices in the three countries (Vassy et al. 2014). 16. Ruling of 1 December 2018 setting good practice guidelines in terms of prenatal screening and diagnosis; ruling of 19 April 2018 by the National Union of Health Insurance bodies published on 27 December 2018. 17. “Genetic texts … are also moral tests”: Mukherjee (2016: 438) quotes an oral comment by genetician Eric Topol. 18. On this point, see Testart (2014) and Mukherjee (2016). 19. The notion of “reproductive freedom” is key in the discourses of the philosophers and ethicists who support the expansion of prenatal selection from a normative perspective. 20. Moral pluralism refers here to diversification and divergence between standards of what is good and fair in liberal tradition societies.

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21. “Why human gene editing must not be stopped”, The Guardian, 2 December 2015. https://www.theguardian.com/science/2015/dec/02/ why-human-gene-editing-must-not-be-stopped. Harris supported these arguments as early as 2007 in Enhancing evolution. The ethical case for making better people. 22. And many others in their wake: see, for instance, Christopher Gyngell and Russell Blackford in Australia, Ronald M. Green, Steven Pinker or Silvia Camporesi in North America. These authors adopt a utilitarian perspective to support the moral imperative of prenatal choice (Camporesi uses the term eligogenics, from the Latin eligere for choosing, sorting) seen as the parent’s duty. In France, Laurent Alexandre expresses a similar point of view in “Distorsion morale sur la correction du génome”, Le Monde, 20 May 2015. 23. This argument is also presenting in discourses advocating in favor of prenatal selection: see, for example, Blackford (2014) and Camporesi (2014). 24. This service is offered by the Manhattan Cryobank. http://www.manhattancryobank.com/. 25. In Japan and the United States, a test screening for a broad spectrum of pathologies and calculating the future parents’ degree of genetic compatibility is available on the market (the-japan-news.com, 21 May 2017: “New services to predict genetic disorders in children”). In Belgium, in a March 2017 ruling, the Superior Council of Health recommended to offer free pre-conception tests to all future parents who have undergone a fertility treatment or are diagnosed as carriers of a recessive genetic condition. https://health.belgium.be/fr/avis-9240-depistage-genetique. 26. This sensationalist expression used by the media was rejected by many geneticists. 27. https://www.bionews.org.uk/page_140038. 28. On CRISPR-Cas9, see Tremblay (2015). 29. https://www.bionews.org.uk/page_143364. 30. https://www.sciencemag.org/news/2019/06/russian-geneticist-answerschallenges-his-plan-make-gene-edited-babies. 31. A total of 61 reports or statements on germline editing from about 50 countries or organizations were found for the period 2015–2018 (Brokowski 2018). 32. Le Monde, 28 November 2018.

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33. http://www8.nationalacademies.org/onpinews/newsitem.aspx? RecordID=11282018b. 34. Based on the genomic data he has had access to, geneticist Sean P. Ryder refutes that He Jiankui could have provoked the CCR5∆32 mutation in the twins because of the evidence of an off-target and mosaic effect (Ryder 2018). 35. Savulescu and his team support a similar position: they believe that germline editing can be justified morally if a monogenic mutation with a “catastrophic” effect is detected in an embryo (Savulescu quotes the example of the Tay-Sachs disease). This is not the case with the editing performed on the Chinese twins, which is for this reason considered nonethical (Savulescu and Singer 2019; Gyngell et al. 2019). 36. http://nationalacademies.org/cs/groups/genesite/documents/webpage/ gene_177260.pdf. 37. http://nuffieldbioethics.org/wp-content/uploads/Genome-editing-andhuman-reproduction-FINAL-website.pdf. 38. https://www.ethikrat.org/en/press-releases/2019/ethics-councilgermline-interventions-currently-too-risky-but-not-ethically-out-ofthe-question/. 39. In Europe, this opinion is also that of ARRIGE (Association for Responsible Research and Innovation in Genome Editing) (Montoliu et al. 2018). 40. The problem had already been mentioned by Jürgen Habermas in the early 2000s before genome editing was perfected, in Future of Human Nature (2003 [2001]). 41. The argument of inequality is key according to Marcy Darnovsky, director of the Center for Genetics and Society, which opposes the opinions of NAS in the United States or NCB in the United Kingdom. Her multiple publications include: “Genetically modifying future children isn’t just wrong. It would harm all of us”, The Guardian, 17 July 2018. https:// www.theguardian.com/commentisfree/2018/jul/17/geneticallymodifying-future-children-embryos-nuffield-council-bioethics. 42. This is the opinion of French doctor and ethicist Axel Khan on the birth of the Chinese twins: “The aim is not to eradicate diseases: in this case, this is about creating augmented men or women” (atlantico.fr, 27 November 2018). 43. On this question, see Morange (2017) and Mukherjee (2016).

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44. These words can be found in Article 1 of the UNESCO’s Universal Declaration on the Genome and Human Rights (1997). It was reasserted in October 2015  in the report of this body’s International Committee on Bioethics. https://unesdoc.unesco.org/ark:/48223/ pf0000233258. 45. See recent statements on this topic by philosopher Françoise Baylis (2019) and geneticist J.  Benjamin Hurlbut in an opinion column in Nature, 10 January 2019. https://www.nature.com/articles/d41586018-07881-1. 46. Based on the Oviedo Convention (1997), the Parliamentary Assembly of the Council of Europe voted a recommendation on 12 October 2017, stating that “deliberate germ-line editing in human beings would cross a line viewed as ethically inviolable”. http://assembly.coe.int/nw/xml/ XRef/Xref-XML2HTML-EN.asp?fileid=24228&lang=en. 47. The spectrum of ideological orientations is broad: for example, in the United States, the Center for Genetics and Society claims to adhere to secular humanism; in France, Alliance Vita and the Jérôme Lejeune Foundation (which publish information website Généthique), both are Catholic-leaning pro-life associations. 48. This point confirms the conclusions of Anne-Sophie Giraud (2014) on representations of the embryo in medically assisted reproduction. 49. This new approach is based on “stochastic gene expression”: the notion of a genetic program that could reveal the “secrets of life” is dismissed as a “legend of genes” (Lambert 2006). The role played by the genes is not negated but relativized, and re-situated within a network of interactions that go beyond the unilateral gene-cell relation (Kupiec et al. 2011).

Bibliography Baylis, F. (2019). Human Genome Editing: Our Future Belongs to All of Us. Issues in Science and Technology, 35(3), 42–44. Blackford, R. (2014). Humanity Enhanced: Genetic Choice and the Challenge for Liberal Democracy. Cambridge: MIT Press. Bourdieu, P. (1994). Stratégies de reproduction et modes de domination. Actes de la Recherche en Sciences Sociales, 105, 3–12. Brokowski, C. (2018). Do CRISPR Germline Ethics Statements Cut It? The CRISPR Journal, 1(2), 115–125.

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Camporesi, S. (2014). From Bench to Bedside, to Track and to Field: The Context of Enhancement and Its Ethical Relevance. San Francisco: University of California Medical Humanities. Cromer, R. (2018). Saving Embryos in Stem Cell Science and Embryo Adoption. News Genetics and Society, 37(4), 362–386. De La Rochebrochard, E. (2018). 1 enfant sur 30 conçus par assistance médicale à la procréation en France. Population et Sociétés, 556, 1–4. Déchaux, J.-H. (2017a). La procréation à l’ère de la révolution génomique. Esprit, 438, 114–129. Déchaux, J.-H. (2017b). L’hypothèse du ‘bébé sur mesure’. Revue française des affaires sociales, 3, 192–212. Déchaux, J.-H. (2018). L’édition du génome humain: discussions et controverses. In C. Jourdan & G. Gachelin (Dir.), La Science au présent 2019. Une année d’actualité scientifique et technique (pp.  110–119). Encyclopædia Universalis France. Ducournau, P. (2018). S’entreprendre avec ses gènes. Enquête sur l’auto-­génétisation. Rennes: Presses Universitaires de Rennes. Frydman, R. (2017). Le droit de choisir. Manifeste des médecins et biologistes de la procréation médicale assistée. Paris: Seuil. Giraud, A.-S. (2014). L’embryon humain en AMP, éléments pour une approche relationnelle. Enfance Famille Génération, 21, 48–69. Gyngell, C., Douglas, T., & Savulescu, J. (2017). The Ethics of Germline Editing. Journal of Applied Philosophy, 34(4), 498–513. Gyngell, C., Bowman-Smart, H., & Savulescu, J. (2019). Moral Reasons to Edit Human Genome: Picking Up from the Nuffield Report. Journal of Medical Ethics, First Published Online: 24 January 2019. Retrieved from https://jme. bmj.com/content/medethics/45/8/514.full.pdf. Habermas, J. (2003 [2001]). The Future of Human Nature. Cambridge: Polity Press. Harris, J. (2007). Enhancing Evolution. The Ethical Case for Making Better People. Princeton: University Press. Jordan, B. (2000). Les imposteurs de la génétique. Paris: Seuil. Kupiec, J.-J., Grandillon, O., Morange, M., & Silberstein, M. (Eds.). (2011). Le hasard au cœur de la cellule. Paris: Edition Matériologiques. Lambert, G. (2006). La légende des gènes. Anatomie d’un mythe moderne (2e édition). Paris: Dunod. Lock, M. (2006). La ‘molécularisation’ de l’esprit et la recherche sur la démence naissante. Sciences Sociales et Santé, 24(1), 21–56.

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Martin, T. (2011). De la diversité des probabilités. In J.-J. Kupiec, O. Grandillon, M.  Morange, & M.  Silberstein (Eds.), Le hasard au cœur de la cellule (pp. 60–80). Paris: Edition Matériologiques. Meyer, M. (2018). Irresponsible Research? Dis/qualifying the Gene Editing of Human Embryos. hal-01958508. Retrieved from https://hal-mines-paristech. archives-ouvertes.fr/hal-01958508. Montoliu, L., Merchant, J., Hirsch, F., Abecassis, M., Jouannet, P., Baertschi, B., Sarrauste de Menthière, C., & Chneiweiss, H. (2018). ARRIGE Arrives: Toward the Responsible Use of Genome Editing. The CRISPR Journal, 1(2), 128–130. Morange, M. (2017). Une histoire de la biologie (2e édition). Paris: Seuil. Mukherjee, S. (2016). The Gene: An Intimate History. New  York: Simon and Schuster. Perbal, L. (2011). Gènes et comportements à l’ère post-génomique. Paris: Vrin. Ryder, S. P. (2018). CRISPR Babies: Notes on a Scandal. The CRISPR Journal, 1(6), 355–357. Savulescu, J. (2001). Procreative Beneficence: Why We Should Select the Best Children. Bioethics, 15(5–6), 413–426. Savulescu, J., & Singer, P. (2019). An Ethical Pathway for Gene Editing. Bioethics, 33(2), 221–222. Savulescu, J., Pugh, J., Douglas, T., & Gyngell, C. (2015). The Moral Imperative to Continue Gene Editing Research on Human Embryos. Protein Cell, 6(7), 476–479. Tain, L. (2005). Refus des médecins, abandon des couples: quel contrôle pour la pratique de procréation assistée? Sciences Sociales et Santé, 23(3), 5–30. Testart, J. (2014). Faire des enfants demain. Révolutions dans la procréation. Paris: Seuil. Tremblay, J. P. (2015). CRISPR, un système qui permet de corriger ou de modifier l’expression de gènes responsables de maladies héréditaires. Médecine / Sciences, 31(11), 1014–1022. Vassy, C., Rosman, S., & Rousseau, B. (2014). From Policy Making to Service Use: Down’s Syndrome Antenatal Screening in England, France and the Netherlands. Social Science and Medicine, 1(6), 67–74.

6 From “Technicized” Bodies to Body Technologies: The Human in Resuscitative Care, Between Objectivization and Subjectivization Thomas Denise

In The Birth of the Clinic,1 Michel Foucault analyzes the historical structures of medical perceptions and associated mechanisms of power and knowledge (Foucault 2002 [1963]). Foucault shows how a shift in perspective and the introduction of what he calls “dividing practices” (“la découpe des choses”) produced new forms of knowledge of the body, which he refers to as “clinical”, “objectivized”, and “objectivizing” knowledges. This process is associated with a new articulation between history and life through the notion of biopower, characterized by “this dual position of life that placed it at the same time outside history, in its biological environment, and inside human historicity, penetrated by the latter’s techniques of knowledge and power” (Foucault 1978 [1976]: 143). In line with Foucault’s approach (2002 [1963], 1978 [1976]), this chapter investigates the treatment, production, and definition of the body in life-threatening emergency situations. Working from a study of three adult intensive care units,2 I address the ways in which bodies are T. Denise (*) Team CERREV, Université de Caen, Caen, France © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_6

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conditioned by the medical support technologies used to treat patients whose lives are threatened in the short to medium term. As a field where life or death is at stake (Pouchelle 2003), medical resuscitation provides an opportunity to reconsider the treatment of the body from an ethical, moral, and clinical perspective. Many studies have been published on this topic in recent years, addressing, for instance, death in intensive care (Kentish-Barnes 2007), decisions to interrupt treatment (Paillet 2007), the legal definition of death (Iacub 1999) and its productivization (Steiner 2006), as well as the experiences of the friends and families of hospitalized patients (Legrand 2010). However, the question of the production of the person in intensive care—as a human and social person, and as a subject singularized by their biography—remains under-examined. The care of patients in states of “crepuscular consciousness” (Pouchelle 2003: 67) poses several questions: How are their bodies processed, preserved, or transformed? How are technological aspects interwoven with moral, symbolic, or cultural dimensions, which are particularly pregnant in departments where a struggle against disease and death is at play? What happens to the person and their biographic singularity? Is it only approached through a combination of clinical knowledges in which life and death are redefined according to a quantitative continuum of vital signs? In other words, are bodies only approached as a product of the clinic and of objectivized measurement? Analysis of the practices and discourses of medical professionals reveals that the care of “technicized” patients3 cannot be reduced to the sole medicalization of bodies, or in other words to the sole implementation of artificial life-support technologies. This process is also characterized by the coexistence of practices and intervention methods that simultaneously objectivize and subjectivize the human person. Far from being opposed, these two types of approaches are articulated throughout time sequences that are codified by professionals, from the patient’s admission into intensive care to the prognosis phase, and to periods of latency during which medical uncertainty is at its strongest (Fox 1988). The analysis of medical practices shows that the various ways in which bodies are managed in intensive care are not just indicators enabling us to analyze representations of the human: they also contribute to the production of

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the body, through a combination of biomedical life support technologies and singularizing technologies aimed at preventing the “technicized” patient’s social death (Sudnow 1970).

 esuscitative Care in France: Ethical Questions R and Legal Evolutions Although for years intensive care units remained closed to the public for hygiene reasons (Pouchelle 2003), they are today—along with palliative care services (see among others Castra 2003, 2010; Schepens 2013)—the focus of ethical reflections on making medical care and end-of-life support more humane. Recent evolutions in patients’ rights, the introduction of support services for their families, or the development of collegial decision-making processes reflect a new outlook on the relation to the patient, which interrogates the regime of production of the human in a medical environment.

Moral Interrogations Intensive care units admit “patients who present or are likely to present serious multiple organ failure, that directly threatens their life”:4 brain, heart, kidney, or lung pathologies, or extreme multiple traumas (domestic accident, traffic accident, etc.). Most patients are in a state of coma, which is either vegetative (“natural”) or artificially induced. As such, they are the object of many uncertainties as to the evolution of their condition. The average length of stay in hospital generally oscillates between three days and several weeks (ANAP 2011), and the death rate, which occurs on average after eight days in hospital (Lalande and Veber 2009), is in the region of 25% in intensive care units (or almost 50% of all deaths in hospital) (Kentish-­ Barnes 2007). In these situations of emergency and uncertainty, patients are “monitored” from the moment of their admission and maintained on life support until they pass away or are moved on into a follow-up unit or a post-resuscitation support and reeducation unit. However, the prospect

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of emergency care and artificial life-support immediately raises issues as to the criteria of admission, practices, and therapeutic choices: to which extent should a patient be revived? Until which point should active therapies be maintained (ventilator, intubation, drug infusions)? What will be their consequences on the patient’s future quality of life? When should treatments be interrupted? The dilemmas facing medical and paramedical teams are not new: in 1957, Pope Pius XII issued an address entitled: “three questions on medical morals treating the subject known as ‘resuscitation’” (Pius XII 1957). However, the question has become more complex in recent years due to the evolution of medical knowledge and technologies, which has pushed back the limits of artificial life support—at what cost?5—but also to the emergence of new interlocutors (Abbott 1988)—users, friends and families, associations, institutions—in debates about end-of-life care. Caught between the medical culture of survival (Paillet 2007) and the rise of ethical reflections on end-of-life care, decisions as to the continuation or interruption of treatments are now based on a dual interpretative framework that can be regarded as both cognitive and normative, as noted by Nancy Kentish-Barnes and Julien Valy (2013): on the one hand, decisions are informed by tools and protocols that measure physiological activity (magnetic resonance imaging, electroencephalogram, electrocardiogram, etc.) according to the standards of evidence-based medicine that aim to ensure a certain level of “clinical objectivity”; on the other hand, they rely on subjective judgments that consider the patient’s singularities (biography, beliefs, values, etc.), “implicitly referring to the question of human dignity” (Kentish-Barnes and Valy 2013: 21). While most decisions are motivated by the “ethics of audacity” (Pouchelle 2003), according to which the battle against disease prevails over any premature interruption of treatment (Paillet 2007), the decision of whether to continue or interrupt treatment is increasingly swayed by a new end-of-life paradigm, backed by recent legal evolutions in patients’ rights.

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Legal Frameworks and Practices Since the 2000s, the French public authorities have worked to consolidate the patient’s place in the medical process, with the adoption of the law on patients’ rights on 4 March 2002.6 In a medical context characterized by a relative absence of information and therapeutic autonomy, these measures were regarded as innovative both in terms of their production, with user associations taking an active part in drafting the law, and because of the way they redefine the patients’ involvement in care pathways. The law introduces ethical principles such as informed consent and access to one’s medical record. It asserts the right for the patient to understand and consent to medical decisions in full knowledge of the facts, which implies the obligation for the doctor to be aware of or to actively obtain the consent of the patient or their family. Any person can access their own medical record (lab test results, degree of severity, benign or critical condition) and use this information to exercise the right to consent to or refuse a treatment: failure to respect this choice engages the doctor’s civil liability. The “Leonetti” law, adopted in 2005 and supplemented in 2016 (when it became the “Claeys-Leonetti” law), also reinforced patients’ rights by envisaging end-of-life decisions and the support of the dying through a new normative framework based on the notion of human dignity. This law comprises two main angles: through the concepts of “advance directives” (“directives anticipées”) and “trusted person” (“personne de confiance”), it guarantees a greater recognition of patients’ rights and autonomy; through the concepts of “collegiality” (“collégialité”) and “unreasonable obstinacy” (“obstination déraisonnable” or futile medical care), it sets a legal framework for end-of-life care, while also improving the legal protection of the medical teams who make the decision to interrupt treatment. The patient and their family become active parties in decisions regarding resuscitation or treatment interruption. The patient can communicate his or her wishes, either through a dedicated institution or through a trusted person they have designated in advance. The subjective perspective on end-of-life thus became more prevalent as new factors were

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considered: family, biography, or personal beliefs. In addition, decisions regarding the interruption or continuation of treatment are now made in consultation with the family, the patient’s physician, and the medical team. In the last instance, when a decision is made to interrupt treatment, palliative technologies are implemented to relieve pain and support the patient’s family through the end of their life. Although these legal evolutions in terms of end-of-life care are quite recent, they reflect a new representation of the human person in intensive care: as hospital units are reorganized, the person is apprehended simultaneously through the cognitive framework of medical measurement and assessment (clinical score, severity scales, measurement of vital signs, etc.), and through the increasingly prevalent ethical standards aimed at preserving the “technicized” patient’s dignity and singularity to the extent possible.

“ Technicized” Bodies: Objectivization and Therapeutic Efficacy Built on the legacy of the clinic (Foucault 2002 [1963]), intensive care produces its own singular ontology, marked by the diverse range of biomedical knowledges and technologies used in the care of patients on life support. Looking into more depth, it appears that the objectivization of the human person derives from categories produced by medical professionals throughout the course of the patient’s condition (Strauss et  al. 1985) to guarantee the “efficacy” of their treatment, sometimes independently of significant evolutions in the patient’s clinical condition.

Metric Objectivization and the Clinical Legacy Intensive care medicine is the product of the encounter between anatomo-­ clinical medicine—also referred to as the “Paris school” of medicine (Adam and Herzlich 1994)—and Claude Bernard’s experimental physiology (1947 [1858]). This practice has its roots in the investigation of bodies and in the emergence of a new outlook on patients and disease.

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Intensive care initially emerged from the clinical tradition as a specialism and a new medical paradigm aimed at “controlling the mechanics of life through medicine” (Barras and Panese 2006: 37). The observation, measurement, and assessment of bodies are used to evaluate the severity of a life-threatening emergency, by combining the measurement of homeostasis (internal organic environment, blood concentration, blood pressure, temperature) with the monitoring of vital organs (heart, brain, and lungs, referred to by Bichat as “the vital tripod”). This measuring work, inspired by clinical medicine, comprises two different types of observations that aim to produce the “objective” indicators needed to establish a diagnosis. The first involves the use of exploration technologies based on a corpus of standardized measurements, while the second relies on “trained judgement” (Daston and Galison 2007), involving the observation of the patient’s epidermis, smell, or stereotypical gestures (as in the case of presumedly brain-injured patients) and draws from a culture of measurement that predates the standards of evidence-based medicine. Whether it is associated with the field of biomedical standards or with the fine interpretation of signs of disease, the observation of bodies in resuscitation care serves the same objective: to make the bodies “speak” and thus integrate them into the medical realm. The body is the place where practice, discourse, and medical knowledge come into play through sight and touch, as noted by Foucault who describes the “glance” (coup d’oeil) and the “touch” (tact) applied to the object: The glance is of the non-verbal order of contact, a purely ideal contact perhaps, but in fact a more striking contact, since it traverses more easily, and goes further beneath things. The clinical eye discovers a kinship with a new sense that prescribes its norm and epistemological structure; this is no longer the ear straining to catch a language, but the index finger palpating the depths. Hence that metaphor of “touch” by which doctors will ceaselessly define their glance. (Foucault 2002 [1963]: 150)

In resuscitation units, this “touch” is deployed through the diverse physiological measurements and biological samples performed daily: monitoring, diuresis, weighing, observation of epidermis, blood gases, and so on. Physiological and biological results, which are discussed

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during medical staff meetings and patient visits (in presence of the chief doctor), are all the more “telling” from a clinical point of view that patients are most of the time in a situation of vegetative or artificial coma. The body is therefore regarded by resuscitation medicine as its main interlocutor, while its language is the measurement of vital signs. Medical observation seeks to make bodies speak through technologies that measure vital signs, scales designed to assess the patient’s degree of consciousness (e.g., the “Glasgow scale”) or “severity scores” evaluating the probability of a future event (morbidity, mortality, post-resuscitation complications) to measure the coma’s reversibility. In doing so, it reduces the body to an artifact upon which action can be taken regardless of the person’s biographic singularities.

“De-suscitation” and Therapeutic Efficacy Because of the predominance of biomedical technology and of the symbolic need for isolating both the patient and the disease, resuscitation tends to separate the body, perceived as living matter, from the individual subject with their personal history. This is manifest in the layout of intensive care units that comprise a maximum of ten individual rooms with their doors left ajar and glass walls, where silence is at all times broken by alarm signals connected to CCTV screens located in strategic points (nurses’ station, break room, reception desk). As for the rooms, they are characterized by the omnipresence of medical devices, packed around the patients who are sedated, strapped (for safety reasons) and “technicized”: ventilator, monitoring devices, feeding tubes, pulse oximeter, catheters, and many others take up the majority of the space, to the extent that nursing staff often have to remind the newcomers that “behind the machines, there is a patient”. The architecture of intensive care units supports the symbolic structure of resuscitation. According to Foucault, architecture “is especially thought of as a plunge into a field of social relations, in which it brings about some specific effects” (Foucault 1984 [1982]: 253). By separating patients from their usual social space (family, friends, environment, activities, habits), the layout of the units both reflects and contributes to producing

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a form of de-suscitation—or in other words, a way of “healing the bodies without taking the persons’ history into account” (Pouchelle 2003: 96). Inside this architecture, the use of resuscitation technologies is guided by the search for therapeutic efficacy and most technological procedures (setting up tubes, feeding, tracheal suctioning,7 bandage redressing, etc.) are performed regardless of social markers such as age, gender, profession, or social class. As is the case with surgery (Zolesio 2012), the most technical procedures involve a form of separation and detachment: for instance, when a tracheal intubation is performed, the patient’s face is hidden outside the operative field to ensure that medical staff are able to efficiently “focus” on the tracheal incision. Depending on the technicity of the intervention, the body thus becomes the object of the procedure: the social and singular individual gradually fades away for the benefit of therapeutic efficacy, as stressed by nursing staff in interviews: Whenever you’re doing something that’s a bit invasive, well, you try not to think too much that there is a patient there, but sometimes that’s not easy. You can see it when they’re uncomfortable and you’re suctioning or washing them …. In fact, I find it easier when the patient is sedated because then you don’t need to worry about that so much, even though you still need to be attentive. (Nurse)

Similarly, when discussing clinical observation and life support, an intensive care physician declared: Our job is first and foremost to resuscitate people. That means taking on patients who are in a state of distress and trying to keep them alive. Some cases are more complicated than others, but our job is about knowing how to assess what is going on from a physiological point of view, restoring vital signs wherever possible and saving patients whenever that can be done. (Intensive care physician)

The distinction between human and nonhuman, justified by the context of vital emergency (as in the case of the tracheotomy mentioned above), goes along with a rhetoric of scientific objectivization that can be found in the first instance in medical professionals. This is the case, for

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example, in cases of life-threatening emergency, when the necessity of a clinical intervention strictly prevails over any other aspect of medical care; but also when medical staff are talking with family members and stress the indispensability of the technical devices set up around the patients. Family visits are times when the focus is on risk prevention, but also when families have the chance to familiarize themselves with the technicization of bodies as well as with medical uncertainty. For instance, in situations where some gestures—such as abnormal posturing in brain-­ damaged patients—can be misinterpreted by non-experts and induce false hopes, nursing staff respond with discourses that recommend observation and restraint: “We can never be sure of anything”. These discourses delivered by nursing staff imbue the patient’s condition with a temporal structure and bring meaning to the uncertainty of their evolution—for instance, in cases where a patient does not wake up, or when the lack of prognosis indicators is compensated by a certain level of trust in life-­ support devices. This objectivizing rhetoric is very similar to what Renée Fox identified as “scientific magic” (Fox 1959: 64), in reference to Malinowski’s writings (1948): it is a rhetoric aimed at adopting and perpetuating “essentially magical ways of behaving that stimulate medical scientific attitudes and behaviors … and that help physicians and nurses to face problems of uncertainty, therapeutic limitation and meaning” (Fox 1988 [1979]: 581). The objectivized representation of the body thus finds itself at the center of a complex interaction between the clinical gaze, medical uncertainty, and the doctor–patient relationship: In our work, personal interaction and all those things are no real use to the patient, I think that’s rather secondary. They’re no real use to the patient because when we take them in, they need to be resuscitated. You see, the patient’s dead and you’re having to bring them back to life. Personal interaction is not what’s going to save their life! It’s true that there’s all these machines, but they perform all the functions that the patient is unable to handle by him or herself, so we can’t do without them. (Nurse)

This testimony shows that resuscitation produces a specific type of ontology, characterized on the one hand by the possibility of the patient’s

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impending death and the absence of any future prospects, and on the other hand by the persistence of a career–patient relationship, which, although it is “no real use to the patient”, is still present in resuscitation care. The representation of the body can thus provide a glimpse into the existence of time sequences that articulate various modalities of intervention upon the human, both clinical and “relational”.

F rom “Technicized” Bodies to “Body Technologies” Drawing from nonspecialist forms of knowledge (in comparison with formalized medical knowledge), nursing staff in intensive care units combine several relational technologies that are shared outside of a medical setting. Contrary to clinical medicine, these practices reintegrate “technicized” patients into their own social and singular dimension, through the emergence of a ritual dimension and a moral economy (Fassin and Eideliman 2012) in intensive care.

Body Technologies and Relational Care In addition to “technological” procedures (that respond to a medical prescription), nursing staff also perform hygiene and comfort procedures on a daily basis, most of which can be referred to as “body technologies” (Mauss 1950 [1936]): washing, oral hygiene, grooming (hair, skin, nails, etc.), changing diapers, making beds, cleaning the patient’s environment, or checking their temperature. These operations, which sit halfway between the predominance of clinical medicine and the institutional reality of the handling of bodies (Juan 2015), take on a particular dimension in intensive care, at the boundary between everyday care (routine hygiene) and extra-ordinary operations (hospital treatment). For instance, “oral health” procedures are performed both for reasons of oral hygiene and to prevent any complications caused by the permanent presence of a ventilation tube such as lung disease, infections, or mucous membrane lesions. When nursing

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staff use a transfer board to maintain a patient in a lateral position when changing their diaper, or use an intracranial pressure monitor (with a sensor attached to the cranial epidermis) when washing a patient’s hair, they are borrowing both from medical technologies (protocols, procedures, and technical sheets) and body technologies—thus reminding us that “man’s first and greatest technical object as well his main technical means is his body” (Mauss 1950 [1936] 372). While these operations are performed according to formalized protocols or procedures that describe the nature and implementation of each action, they also differ from technical operations in that they also rely on a social evaluation of the patient (Arborio 1996), based on a number of bodily indicators (weight, condition of hair and skin, color of nails, callousness of hands, etc.) or biographical indications (discussions with the patient’s family, friends, physician, etc.). Some of these actions, delivered in compliance with the categorizations of nursing, are performed with particular care, like, for instance, grooming the patient’s hair (washing, combing, cutting) and beard (trimming, combing, moisturizing). Other practices have an even more direct impact on the individual, in particular when nursing staff have access to the patient’s personal products, such as cosmetics, perfume, and moisturizer. These singularization technologies contribute to restoring the person’s biographic singularity— for instance, the perfume acts as a reminder of the person’s particular smell, in a context where the dominant smells are those of disinfectant or drugs. A nurse commented: Some families bring moisturizer. Or sometimes it’s deodorant, or perfume. All of that helps recreate a sense of the everyday. You see, perfume is very personal. It’s their smell, you know. Smells bring back memories, things that are kept deep inside. We also take care of those things. (Nurse)

“Recreating a sense of the everyday” is the main objective of body technologies in resuscitation units, beyond hygiene and comfort. Marked by domestic know-how (Arborio 1996), these body technologies are a way of caring for the human person when personal hygiene tasks are performed as part of the therapeutic process, but also for the social person (as shown by the social categorization of patients by nursing staff) and for

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the individual (characterized by elements of their biography). These practices aim to maintain the body’s social uses, which are momentarily interrupted by disease due to the patient’s pathological state (vegetative or artificial coma) but also due to their “technicization” (life-support and monitoring) and to the isolation measures imposed to them in the name of therapeutic efficacy. These situations thus require the use of other techniques to preserve the human person.

Unnecessary Technologies and Ritual Imperatives In addition to the body technologies that aim to restore both the social person and the individual, another type of social technology contributes to preserving the human person. At a time when patients could be reduced to their sole “technical” dimension—that of living matter— observations show that nursing staff perform a number of “technically unnecessary” processes, or “unnecessary technologies” aimed at preserving “humane standards”: Persons are almost always considered to be ends in themselves, as reflected in the broad moral principles of a total institutions’ environing society. Almost always, then, we find that some technically unnecessary standards of handling must be maintained with human materials. This maintenance of what we call humane standards comes to be defined as one part of the “responsibility” of the institution and presumably is one of the things the institution guarantees the inmate in exchange for his liberty. (Goffman 1968 [1961]: 123)

In a context where patients have no autonomy (sedation, isolation, immobilization, curarization), intensive care units have recently been the object of policies aimed at making medical care more human8 and at safeguarding human dignity.9 Nevertheless, some practices, most of which are implicit, are also implemented independently of these new measures: hiding the bodies’ nudity, protecting the patients’ privacy, introducing oneself to the unconscious patient, verbally announcing the actions to be performed, etc. These practices, which were introduced before any “Good practice charters” or “Intensive care handbooks” were

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formalized, are performed with reference to moral standards which, although they have been established outside of an intensive care context, are also present in these units. Three main categories of implicit moral rules contribute to the patients’ subjectivization. The first type is prospective. It manifests itself in the form of “avoidance rituals” (Goffman 1974 [1967]: 62) that “refer to those forms of deference which lead the actor to keep at a distance from the recipient and not violate what Simmel has called the ‘ideal sphere’ that lies around the recipient” (Goffman 1974 [1967]: 62). Actions such as closing the door when performing a care operation and using a sheet to hide the patient’s nudity when washing them, in situations where the patients are concretely “laid bare”, are gestures of avoidance, and as such actions of deference toward the person and the self. The second category is prescriptive. It takes on the form of “presentational rituals” and “encompasses acts through which the individual makes specific attestations to recipients concerning … how he will treat them in the on-coming interaction” (Goffman 1974 [1967]: 71). In intensive care units, for instance, professionals often introduce themselves to the patients and talk to them although they are most of the time in a state of vegetative or artificial coma, and as such incapable of responding or even of being in a state of consciousness. When a patient spends a longer period in hospital, it is not unusual to observe nursing staff who talk to them (about current news, hobbies, etc.), or to use metonymic expressions to refer to “their” patients with a certain familiarity—which also reflects the temporal dimension attached to the subjectivization of “technicized” patients. The third category has a ritual and symbolic function associated with death rites, which are “supposed to guide the defunct into their post-­ mortem destiny, and chiefly aim to transcend the survivors’ anxiety of death” (Thomas 1988: 91). This way of approaching the human, perceived as a defunct rather than a corpse, is perhaps the most concrete illustration of the use of subjectivization techniques in resuscitation and their temporality. Indeed, while the individual initially disappears in favor of the “technicized” body when the patient is admitted and hospitalized (emergency stage), he/she later re-emerges as a social person through singularization technologies (during the period of uncertainty

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represented by the prognosis stage), and later as a human person when he/she is engaged in the dying process (end-of-life stage). This is the case for instance when nursing staff perceive the first signs of impending death and work in close proximity with the future defunct’s family, and during the interruption of treatment, when the patient is “de-technicized”, that is, unplugged from the medical devices that were keeping him/her alive. The defunct is then “brought to life” (Kentish-Barnes and Valy 2013: 24) according to rules and techniques of preparation of the body that are reminiscent of funeral rites: they are washed, shaven, combed, dressed up, and sometimes adorned with personal objects—one such example included a young girl who had passed away during the night, and around whom personal objects, cards, photographs, and toys had been laid out. With the prospect of impending death, both the environment and the medical staff’s relation to the person are transformed: the medical devices are removed, the physiological and therapeutic monitors are taken away, the light is softened, the patient’s personal objects are displayed. The corpse thus becomes a defunct, and the patient becomes a person. The end of life is the last time period in intensive care that articulates medical technologies (sedation and pain relief ) with singularization and subjectivization techniques that contribute to reinjecting humanity into hospital units that are mostly marked by technology.

Conclusion Interventions on the body in resuscitation, with their implications in terms of knowledges and powers (Foucault 1978 [1976]), are multifaceted and heterogeneous. “Technicized”, suffering, and vulnerable bodies are modeled according to two repertoires of intervention: objectivization and subjectivization, both of which complement, overlap, or succeed one another over consecutive time sequences that are codified by medical professionals. At first, objectivization technologies prevail for the purposes of therapeutic efficiency, when there is still hope of resuscitating the patient and future prospects are still open. As the patient’s condition declines, increasingly specific subjectivizing technologies are deployed (Ménoret 1999). The patient is then no longer a “technicized” body (it is

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“de-technicized”), perceived solely as a receptacle for life, within a vital continuum that finishes with the interruption of vital signs: instead, resuscitation technologies contribute to producing a representations of the person as a human, social, and singular being. As observed by Ingrid Voléry and Cherry Schrecker in their study of home-based end-of-life care, intensive care combines an array of “spatial, relational, corporeal and temporal technologies that form the basis for the governing of the dying process” (Voléry and Schrecker 2018: 15). As a consequence, even in the institutional context of a hospital intensive care unit, the human appears to never be reduced to a mere “technicized” object: it is also the product of an interplay between culture and nature, where “the process of objectivization contributes to the production [of health] and as such becomes inseparable from an operation of subjectivization” (Fassin 2000: 101). When medical professionals are faced with the limitations of medical knowledge and technology, as is the case in situations of “brain death”,10 they draw from a repertoire of intervention on the human that leads to a change in ontology. Ultimately, the shift from biopower to thanatopower reveals that intensive care produces a particular ontology marked by an in-betweenness—to quote Louis-Vincent Thomas, “between states of apparent death and states of apparent life, between the living who are almost dead and the dead who appear to still be alive” (Thomas 2006: 16)—which could not be resolved by the clinical alone.

Notes 1. When Foucault speaks of “la clinique”, he is thinking of both clinical medicine and the teaching hospital. So if one wishes to retain the unity of the concept, one is obliged to use the rather odd-looking “clinic” (“Translators’ note”, Foucault 1963: vii). 2. This study was conducted as part of a sociology PhD thesis. The survey took place between 2012 and 2013, with three periods of participant observation (n = 560 hours) in three medical and surgical resuscitation units, complemented by 37 ethnographic interviews and a review of specialist literature.

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3. “Technicized” is directly transcribed from the French “techniqué”, which is used by medical staff in France to refer to patients who are kept alive thanks to life-support technologies. In this chapter, the term is used both in this sense and as a conceptual category that refers to the process through which patients are objectivized. 4. Article R6123–33 of the Public Health Code (Code de la Santé Publique). 5. Intensive care units are among the most expensive departments of a hospital, with a day’s hospitalization estimated at an average €1425 (Garrigues 2010). 6. Law n° 2002–303 of 4 March 2002 on patients’ rights and quality in healthcare. 7. Tracheal suctioning is a means of clearing the upper respiratory tract of secretions or mucus through the application of negative pressure via a suction catheter. 8. Law n° 2002–303 of 4 March 2002 on patients’ rights and quality in healthcare. 9. Law n° 2005–370 of 22 April 2005 on patients’ rights and end of life. Modified by Law n° 2016–87 of 2 February 2016 introducing new rights for patients and persons at the end of life. 10. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition on Brain Death (1968).

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Castra, M. (2003). Bien mourir. Paris: Presses Universitaires de France. Castra, M. (2010). L’émergence d’une nouvelle conception du “bien mourir”. Les soins palliatifs comme médicalisation et professionnalisation de la fin de vie. Revue internationale de soins palliatifs, 25, 14–17. Daston, L., & Galison, P. (2007). Objectivité. Bruxelles: Les presses du réel. Fassin, D. (2000). Entre politiques du vivant et politiques de la vie: pour une anthropologie de la santé. Anthropologie et Sociétés, 241, 95–116. Fassin, D., & Eideliman, J-S. (Dir.). (2012). Économies morales contemporaines. Paris: La Découverte. Foucault, M. (1963). Naissance de la clinique. Une archéologie du regard médical. Paris: Presses Universitaires de France. Foucault, M. (1978 [1976]). La volonté de savoir. History of Sexuality (R. Hurley, Trans.). New York: Pantheon Books. Foucault, M. (1984 [1982]). Space, Knowledge and Power, Interview for Skyline (March 1982). In P.  Rabinow (Ed.), The Foucault Reader (pp.  239–263). New York: Pantheon Books. Foucault, M. (2002 [1963]). The Birth of the Clinic: An Archaeology of Medical Perception. New York: Routledge. Fox, R. (1959). Experiment Perilous: Physicians and Patients Facing the Unknown. Glencoe, IL: The Free Press. Fox, R. (1988). L’incertitude médicale. Paris: L’Harmattan. Garrigues, B. (2010). Étude CRRéa: Évaluation médico-économique du Coût Réel d’une journée en Réanimation. Séminaire ENC 2—09 et 10 décembre. Goffman, E. (1967). Interaction Ritual: Essays in Face-to-Face Behavior. New Brunswick: Transaction Publishers. English Edition: Goffman, E. (1974). Les rites d’interaction. Paris: Les Éditions de Minuit. French Edition. Goffman, E. (1968 [1961]). Asiles. Études sur la condition sociale des malades mentaux. Paris: Les Éditions de Minuit. Iacub, M. (1999). La construction de la mort en droit français. Enquête [En ligne], 7. Retrieved from https://journals.openedition.org/enquete/1564. Juan, S. (2015). L’École française de socioanthropologie. Auxerre: Éditions Sciences Humaines. Kentish-Barnes, N. (2007). “Mourir à l’heure du médecin”. Décisions de fin de vie en réanimation. Revue française de sociologie, 48(3), 449–475. Kentish-Barnes, N., & Valy, J. (2016 [2013]). Les soignants et la mort en réanimation. In F. Schepens (Dir.), Les soignants et la mort (pp. 17–31). Toulouse: Éditions Érès.

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Lalande, F., & Veber, O. (2009). La mort à l’hôpital. Tome I. Paris: Rapport de l’Inspection générale des affaires sociales. Legrand, É. (2010). Quand la réanimation échoue: l’expérience des familles. Sciences sociales et santé, 28(1), 43–70. Malinowski, B. (1948). Magic, Science and Religion, and Other Essays. Selected, and with an Introduction by Robert Redfield. Boston: Glencoe, Beacon Press, The Free Press. Mauss, M. (1950 [1936]). Les techniques du corps. Communication présentée à la Société de Psychologie le 17 mai 1934. Sociologie et anthropologie. Paris: Presses Universitaires de France/Quadrige. Ménoret, M. (1999). Les temps du cancer. Paris: Éditions du CNRS. Paillet, A. (2007). Sauver la vie, donner la mort. Une sociologie de l’éthique en réanimation néonatale. Paris: La Dispute. Pie XII. (1957). En réponse à trois questions de morale médicale sur la réanimation. Discours prononcé le 24 novembre 1957. Documentation Catholique, 1267, col. 1607. Pouchelle, M.-C. (2003). L’hôpital corps et âmes. Essais d’anthropologie hospitalière. Paris: Séli Arslan. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition on Brain Death. (1968). A Definition of “Irreversible Coma”. Journal of the American Medical Association, 205, 337–340. Schepens, F. (2013). Les soignants et la mort. Toulouse: ERES. Steiner, P. (2006). La “productivisation” de la mort: mort encéphalique et transplantation d’organes. Quaderni, 62, 69–80. Strauss, A., Fagerhaugh, S., Suczek, B., & Wiener, C. (1985). Social Organization of Medical Work. Chicago: University of Chicago Press. Sudnow, D. (1970). Dying in a public hospital. In G. B. Orville, H. E. Freeman, S. Levine, & A. N. Scotch (Eds.), The dying patient (pp. 1–15). New York: Russel Sage Foundation. Thomas, L.-V. (1988). La mort. Paris: Presses Universitaires de France. Thomas, L.-V. (2006). En hommage à Louis-Vincent Thomas. Le cadavre. Études sur la mort, 129(1), 11–22. Voléry, I., & Schrecker, C. (2018). Quand la mort revient au domicile. Familles, patients et soignants face à la fin de vie en hospitalisation à domicile (HAD). Anthropologie & Santé [En ligne], 17. Connection on 25 june 2020. Retrieved from https://journals.openedition.org/anthropologiesante/3681. Zolesio, E. (2012). La relation chirurgien-patient: “J’ai pas fait parleuse”. Sciences sociales et santé, 30(4), 75–98.

Part III Measurement and the Rise of New Hierarchies Between Human Beings

7 Bone Geopolitics: Bone Age and the Racialization of Growth in UK and US Pediatrics (1940–1980) Ingrid Voléry and Marie-Pierre Julien

In recent years, European migration policies have brought under the attention of the media a type of measurement at the intersection of anthropometry, radiography, biology, pediatrics, and forensic medicine: bone age assessment. Practiced in several European countries (France, Italy, the United Kingdom) to evaluate whether unaccompanied foreign youths were minors or adults, this type of measurement resorts to abacuses that have been elaborated in the mid-twentieth century in a very different context and for very different purposes. Intense debates were raised by these measurements of age: critics pointed at their symbolic violence, at disparities in their implementation, at their unreliability, and at the unequal socio-administrative treatment of children that can derive from them. In particular, issues were raised as to the applicability of abacuses that have been elaborated on “Caucasian” children to “immigrant adolescents of Moroccan origin”, whose chronological age, when measured according to Greulich and Pyle’s atlas (1959), was overestimated by

I. Voléry • M.-P. Julien (*) Laboratoire Lorrain de Sciences Sociales, Université de Lorraine, Nancy, France e-mail: [email protected]; [email protected] © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_7

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up to three years (Jacques 2009; Chariot 2019: 4). From an “indicator of development” constructed in the late nineteenth century by hygienist medicine (see Chap. 3 of this book), bone age has become a tool for “measuring” the age of adolescents, characterized according to fuzzy ethno-national or racial categories (“of Moroccan origin”, “Caucasian”, etc.). In what historical contexts and social spaces did this shift occur? What children was it applied to, and what controversies did it raise? At what point did “Caucasian” come to being used as a category? What does this category refer to? Does it indicate a “racialization” of bone age, overwriting the “ageization” of bone that had been introduced at the turn of the twentieth century?

 thnicity, Race, and Bone Age in Research E and Reports on Child Growth This chapter follows a sociohistorical perspective on the categorizations and measurements of human bodies, whose foundations were set by major figures of philosophy, sociology, and history of science (Foucault 1966; Knorr-Cetina 1999; Hacking 2005; Doron 2016). However, instead of postulating the existence of major epistemes or reasoning styles underpinning the measurement of bone age, we chose to go down a pragmatic route: we consider that the actions based upon measurement activities, but also the context in which these activities are implemented and used, can dramatically alter their meaning and effects (Desrosières 1995; Hartigan 2009). From this perspective, to quote Doron and Lallemand-­ Stempak’s approach on race (2014), we will attempt to examine “the whole complex task of defining objects and aligning categories used with other pre-existing categories; the task of designing software and technologies involved, and highlighting the hypotheses they include and their limitations; and the task of enshrining values and ethico-political choices, which determine the researchers’ interests and method of presenting their results” (Doron and Lallemand-Stempak 2014). To analyze these alignments and discontinuities, we conducted a study of generalist and specialist databases (Scholar, PubMed, and Medline), using as keywords

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“racial”, “ethnical”, “skeletal age”, “bone age”, “children”, “adolescent”, and “forensics”, and working our way back to the 1940s when the abacuses used today for the measurement of bone maturity in children and young migrants were designed (Todd 1937; Greulich and Pyle 1959). In analyzing this corpus,1 we paid specific attention to the types of publications and to the disciplinary affiliations of their authors. While earlier articles were published in journals on child health and human development (Child Development, American Journal of Diseases of Children, Human Growth, Human Biology), the most recent appeared in international publications on pediatrics (Pediatrics international), radiology (Radiology) or forensic medicine, in connection with current events involving “unaccompanied foreign minors” and politico-legal procedures that placed forensic medicine at the heart of public debates. For each article identified, we then considered the way in which children are referred to (with reference to their city of origin, nationality, regional, or social origin? In terms of “White” vs. “Caucasian”? As “Afro-American” or “negro”?), as well as the arguments upon which these classifications are based, and the ways in which biological and social determinants are formalized (in terms of ethnicity, race, “gene pools”, “growth patterns”, etc.). In addition, we studied the ways in which the climatic, geographic, socioeconomic, and biological dimensions are articulated in the authors’ arguments. Our analysis also focused on the devices used to measure and establish comparisons: who are these children compared to? How are measurements performed, and to which end? Is the purpose to produce a set of standards of human growth? Is it to detect diseases? Is it to test the applicability of an abacus? Or, is it to characterize pre-determined “racial” groups”? Finally, in what political contexts did these measurements and classifications emerge? We complemented the first corpus, comprising journals, with an in-depth study of books reflecting discontinuities in the categorizations and uses of bone age measurement standards. We thus identified three distinct periods. Initially used in the aftermath of World War II to explore class differences in the United States and the United Kingdom, bone age assessment shifted from the field of clinical and social pediatrics, and was integrated into a large-scale project aimed at standardizing knowledge on human maturation—nationally at first, and later internationally. In this particular new context, under the

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influence of international pediatrics, population genetics, and international medical aid, bone measurement came to be used to reveal geneticized development patterns, which went along with the de-racialization of European populations and the racialization of African populations.

 he 1960s: Honing the Measurement T of Human Growth and Capturing Class Variations While the notion of bone age appeared in forensic medicine in the late nineteenth century (see Voléry Chap. 3), the first abacuses for its measurement were not formalized until the mid-twentieth century: in 1937, British orthodontist Thomas Wingate Todd conducted a first study on the skeletal age of Cleveland children for the Brush Foundation; in 1959, in Boston, Greulich and Pyle (anatomy professor and research assistant) complemented their measurements with a radiographic tool for additional measurement and data figuration. They performed 30 standard radiographs for each sex, each representing a particular bone age, based on a relatively small number of well-off Euro-American children born in the 1930s, and associated an “average” X-ray with each chronological age for each sex.2 Recent meta-analyses of the applicability of Greulich and Pyle’s abacuses to “ethnicized” populations (Alshamrani et  al. 2019) categorize these 1950s studies as conducted on “White” subjects. However, these early studies were more interested with in social background of children and the degree of industrialization of the city where they were surveyed. The populations studied were then not defined according to “ethnic” criteria. In Philadelphia, Cleveland, Boston, and London, pediatricians, dentists, and anatomists measured degrees of bone maturation in children who were healthy but exposed to varying socioeconomic conditions: all these studies considered first and foremost the effects of living environments on child development and aimed to capture growth delays caused by poverty.

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Conducted in community health centers or school medicine settings, these researches formed part of what David Armstrong refers to as a new regime of truth deployed after the war due to the dissemination of the survey method: “The survey was part of a ‘new regime of truth’ which, in its focus on the social rather than the individual body, introduced a new direction and imperative in medical investigation” (Armstrong 1983: 76). The child’s body is no longer considered in isolation, but in relation to other bodies in its community: “Pre-war, the child was essentially constituted by analysis of discrete bodies and problems were located within the child; post-war, the child was increasingly constituted by its social mapping in the community and its problems were located around the child” (Armstrong 1983: 59). Concurrently, normality itself was redefined: it no longer referred to a discrete condition but rather to a space within the “range of normal variation” or the “continuous distribution curve of health” (Armstrong 1983: 90). Research into child diseases gave way to investigations of the normal child (Illingworth 1953): “The break with the panoptic vision of clinico-pathological medicine was to replace the question: ‘Has this patient a disease?’ with: ‘Is the child growing normally?’”(Armstrong 1983: 59). Normality and abnormality were thus derived from the spatial and temporal variations of child growth and maturation in the space of the community.3 In this context, social pediatrics set averages as well as standardized indicators to monitor child growth, and in particular growth delays caused by poverty, which were targeted by US and UK governments postwar and in the 1960s (see the “Great Society” program launched in 1964 by Lyndon Johnson in the United States, or the policies engaged by Wilson’s Labour government around the same period in the United Kingdom).

Setting Growth Scores James M. Tanner is one of the key medical figures who contributed to the elaboration of growth scores. This London pediatrician studied three fundamental indicators of child growth: pubertal maturation in the 1950s (see Vinel Chap. 8 of this book); bone maturation, in collaboration with Whitehouse in 1959; and dental calcification with Demirjian in the

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1970s. Tanner researched the growth of middle-class children, working from the medical center where he practiced (Child Health Center in London). In contrast with Greulich and Pyle’s protocol elaborated around the radiography of a single ossification point, Tanner and Whitehouse established a more complex procedure “based on a large random sample of not very well-off British children”, considering 20 hand and wrist bones examined separately to standardize eight or nine development stages (Tanner 1975). Like Greulich and Pyle, these pediatricians establish a necessary difference of sex between their scales but do not mention any “ethnic” or “racial” dimensions. While Tanner is very critical of the possibility of using skeletal age to extrapolate an individual’s chronological age (Eveleth and Tanner 1976: 14),4 he does also regard that skeletal age as a good indicator of maturation, due to its statistical connection with the menarche and chronological age. Skeletal age thus becomes a benchmark: it even provides a conceptual and metrological framework for other development standards formalized throughout the 1970s. The method for the measurement of calcification elaborate to assess bone age is later transposed to teeth, which also go through a calcification process that can be captured using similar radiographic tools (Demirjian et al. 1973). It is then applied to the measurement of pubertary development, to which bone age is eventually integrated. In each of these cases, measurement readings are used to calculate averages by age group, to which X-rays are associated to support the pediatrician’s observations. Tanner’s early works thus form part of a broader movement of elaboration of maturation indicators, at the intersection of research and community health. These universal indexes, easily reproducible in school medicine settings and child health centers, were regarded as tools that could be used to map out bodies within social space, thus opening up a new topographic approach to disease and development: “The survey had shown certain forms of illness to be intimately related to the social body” (Armstrong 1983: 81). This perspective based on close and continual monitoring soon raised practical issues, involving, for instance, the ergonomics of measuring tools and the speed of execution of metrological readings in medical practices.

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Standardizing Scores and Rectifying Variations In the late 1950s, abacuses were no longer used solely to document the living world. They equipped the eye and judgment of professionals operating in new institutional and political spaces (Daston and Galison 2007) where growth assessment was mainstreamed on a finer topographical scale, looking not just at cities but also at their districts. The scores thus obtained needed to be standardized. First, this standardization required canceling out the “noise” in the data—that is, variations observed between individuals. An excellent example is provided by US anthropologist Johnston, who is frequently cited in pediatrics. In 1963, Johnston conducted surveys on the skeletal age of 120 white children in Philadelphia, characterized according to their sex (62 girls, 58 boys) and living environments. All of them were assessed as clinically normal and monitored throughout their education by the Philadelphia Center for Research in Child Growth where Johnston worked. In addition to weight measurements from the ages of 7 to 17, Johnston had access to 976 radiographs, which he interpreted according to Greulich and Pyle’s standards (Johnston 1963: 193). Then, the measurement of skeletal age was compared to chronological age, and the discrepancies were interpreted in terms of precocity or delay with respect to a standard chronological age. At the age of seven, boys from Philadelphia were thus described as late developers in comparison with the Cleveland boys studied by Todd (Johnston 1963: 201); they grew faster until ten when they became more precocious. Johnston then compared Philadelphia children with Boston children (studied by Greulich and Pyle) whose skeletal age and chronological age were equal in both sexes (Johnston 1963: 201). From this comparison between cities and social backgrounds, Johnston drew three structuring conclusions. First of all, he observed a gap between children born in the 1920s and 1930s as studied by Todd and Greulich and Pyle, and those born in the 1950s and 1960s. According to him, better living conditions (food, access to healthcare) are a cause of faster growth. However, while Johnston observed the influence of the socioeconomic environment on maturation, he does not acknowledge the flexibility of bone age, which is on the

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contrary regarded as a linear maturational standard: “The concept of skeletal age has become an accepted technique in the assessment of the maturational status of children, whether considered individually or collectively. The assignment of a development age … permits the rapid placement of a given child along a graduated scale, the end points of which are fixed biological entities” (Johnston 1963: 192). Secondly, former studies highlighted a great variability in the age at which ossification points appear (in 1937, Todd even mentioned the possibility of changing these thresholds depending on the group of children being studied). In contrast, Johnston used his measurements to support the hypothesis that constant sequences could be observed in normal individuals, making it possible to calculate growth curves with a margin of error only due to the samples used for the calculation of the initial growth rates. Initially regarded as flexible and susceptible to social conditions of existence (hence the comparisons between cities and districts), bone age was gradually reified in the early 1970s. This seems to be due to the practical demands of public health policies (reproducibility of results, speed of execution, etc.): the priority was no longer to explore the statistical variations of the living world, but to create stabilized metrologies and convert them into public health monitoring technologies. Finally, while some references to skin color (“white”) can be found in earlier studies as a complement to other information on socioeconomic conditions of existence,5 Johnson’s work reveals a change of perspective by introducing the hypothesis of ethnic background, in keeping with the approaches of biological anthropology: “It is felt that Philadelphia and Cleveland children may, in general, be equated environmentally. However, the Brush series probably represents a somewhat higher socioeconomic level. Ethnic backgrounds are similar, both being largely north-central European. The groups do not represent breeding isolates which would tend to limit genetic differences at population levels” (Johnston 1963: 198–199). The ethnic dimension is used here to refer to “genetic” differences, which are distinguished from social background and divide the national space into subgroups (the north-central European background in Philadelphia and Cleveland). However, in contrast with later studies, ethnicity is not used as a pre-established criterion of classification: rather, it is a control variable that can help interpret stature discrepancies within

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a given social class. In a way, this variable introduces difference within difference. Furthermore, these “ethnic” divisions do not reproduce the raciological classifications inherited from late eighteenth-century biological anthropology. For example, the term “north-central European” is preferred to “Caucasian”, which came into prominence in the 1990s, in particular in contemporary medico-legal spaces where the influence of physical anthropology is greater than in pediatrics, where biology and endocrinology are more influential. We will now examine the contexts in which this research into social class-related bone maturation discrepancies was gradually reorganized around new categories based on ethno-national and later bio-racial specificities.

F rom Class to Nation: The Dissemination of US and UK Standards and Bottom-Up Ethnicization A second use of bone age appeared at the turn of the 1970s: no longer used to document social inequalities in child growth, it became a standard expressing a fictional national body (the American child) to which other countries could compare themselves. This marks a first phase in “bone geopolitics”, and more widely in the measurement of child growth.

 onitoring Public Health or Positioning Countries M Within an International Metrologic Space In the 1970s, child growth standards were disseminated beyond their countries of origins. These indicators and abacuses were used in Northern European countries and beyond. Their purpose was no longer necessarily clinical or public health-related: the aim became that of engaging with an increasingly international field of knowledge production on human growth, from which researchers derived their international scientific rankings. Of course, anthropometric data had been circulating for decades, and most intensely in the seventeenth and eighteenth centuries

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(Bancel et al. 2014). Merchants were trading data collected in faraway colonies, which was then processed by European savants for the purpose of describing the plurality of humanity or othering alien bodies (see Chap. 2 of this book). However, the political and institutional context of the production of science—and in particular, the importance of knowledge on human growth—changed dramatically in the early 1970s. First of all, there was a transformation in the political use of data on human growth: the search for variety in faraway countries gave way to an exploration of the variability of what is near—first by considering social conditions of existence, and later by embracing global demographic and economic concerns. While Foucault associates these measurements of the human with the emergence of biopolitics from the eighteenth to the twentieth century, this specific form of biopolitics went through contrasting historical moments. In the early 1970s, the gaze of powerful countries in the North turned to social health inequalities. Their objective was to maximize their population’s health, but also to imprint modernity, social progress, and national greatness in their children’s bodies. Funding was channeled into the alleviation of these social health inequalities while a market developed for expertise and intervention, nationally at first and later internationally. This benefited the researchers who worked on human growth: see, for example, the Bolton-Brush Growth Study Center founded by Todd in 1926 to investigate normal human mental and physical growth and development by collecting “the world’s most extensive source of longitudinal human growth data”.6 Secondly, the very organization of the scientific world was transformed: measurement was revalued and placed at the heart of the production of research findings. In the pediatric spaces that form the object of this study, “measurers” were required to display medical knowledge and to be trained in performing measurements. Tanner explains at length his method for measuring height, with the subject sitting down and standing up, with photographs showing correct postures and instruments (Eveleth and Tanner 1976: 9). He is also highly reflexive as to the biases induced by these methods (associated with different ways of measuring, standardizing data, etc.). In 1975, US pediatrician Alexander F. Roche who specialized in community health backed his research with a major training program for his “assessors”, in order to control intra- and inter-measurer

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variations. As pointed out by Daston and Galison (2007) concerning “trained judgement”, a particularly prominent model in clinical research, the objectivity of pediatric science is closely associated with measurement practices: a good researcher must conduct his measurements him or herself. This can also be explained by the fact that a scientific niche was being built at the time around human metrologies—with dedicated journals, disciplinary specialisms, specific professional applications, potential fields of expertise associated with these metrologies, and the development of collections whose economic and scientific exchange value depends on measurement methods. Finally, science as an institutional field also underwent major changes: the dissemination of knowledge became concentrated and standardized, partly because of the structuring of reference journals whose boards are based in certain Western countries, and which impose a number of normalized methodological standards for submissions to be accepted in their pages (Merton 1973 [1942]). In this context, the use of internationalized measurement scales became a structuring condition for accessing legitimate publications, which gave rise to specific geopolitical scientific issues, such as being able to demonstrate that the abacus can be applied to a given population.

“Nationalizing” Abacuses: Bottom-Up Ethnicization The question of whether human maturation measurement standards can be applied to local populations became crucial for scientists, as well as for medical practitioners who used these standards in their clinical or medico-­ legal practice. This question arose as scientists attempted to produce research data that could be assessed as adequate, that is, that could be compared with other available data and resorted to existing metrologies. It also emerged in a context where the measurement of the living world became a priority in medical and political agendas. These factors brought the question of the applicability of abacuses to the forefront—a question that today forms the object of a large proportion of publications on bone age assessment in children.

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For example, in 1971, biological anthropologist E. Andersen (1971) applied both Greulich and Pyle’s (GP) and Tanner and Whitehouse’s (TW) methods to Danish children between the ages of 7 and 18 and concluded that the latter was more reliable, but more susceptible to variations in measurement, less user-friendly and less adaptable to older children. Andersen also recommended some adjustments that could be brought to both methods (by six months for GP and two months for TW), thus focusing on these studies’ essentially practical aspects. In doing so, Andersen also argued that there was such a thing as “Danish” measurements—in contrast with earlier studies which investigated potential growth delays caused by poverty in the 1940s–1950s and captured variations on the finer topographical scale of a socioeconomic space (city/ district), rather than that of a nation.7 From the early 1990s onward, multiple studies have addressed the applicability of abacuses in forensic medicine, radiology, orthodontics, and human biology.8 After Denmark, researchers investigated standards in Austria (Wenzel et al. 1984), Sweden (Kullman 1995), the Netherlands (Van Rijn et  al. 2001), Morocco (Garamendi et al. 2005), Germany (Schmidt et al. 2007), Italy (Santoro et al. 2012), Scotland (Hackman and Black 2013), and France (Zabet et  al. 2015). Turkey was the object of five studies from 2007 to 2015 (Büken et al. 2007; Büken et al. 2009; Gungor et al. 2015; Öztürk et al. 2016), China of four studies between 1990 and 2007 (So and Yen 1990; So 1991; Chiang et al. 2005; Griffith and Cheng 2007), and India of five studies between 2012 and 2015 (Patil et al. 2012; Shilpa et al. 2013; Rai et al. 2014; Mohammed et al. 2015; Patel et al. 2015). Other researchers investigated the perspectives opened up by Johnston by focusing on subnational groups, often characterized in an inconsistent and inexplicit manner: some studies refer to skin color—for instance, Dembetembe and Morris (2012) refer to South-Africans of African biological origin as “Blacks”—while others like Roche et al. (1975) resort to the notion of racial geographic area, combining social (nutrition, access to healthcare), environmental (climate), and biopolitical factors (the “white” vs. “negro” opposition in American society). These various studies all highlighted the practical implications of using measurement tools that had been built between the 1950s and 1970s, pointing at discrepancies, convergences, and statistical corrections, or at

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necessary interpretative precautions. However, there was no attempt to explain these “ethnical” variations. Doing so, measurement was ethnicized “from the bottom up” according to practical considerations rather than theoretical ones,9 as shown by the fluctuating uses of the term “Caucasian”, or by the multiple connections established between nationalities and ethnicities. For instance, Turks, classified as “Caucasians”, are described by some authors as perfectly aligned with Western abacuses (Cantekin et al. 2012), while others describe them as non-aligned due to geographic and socioeconomic specificities (Öztürk et al. 2016). Similarly, Italians are categorized as “Caucasian”—although they present “ethnic differences” from European Americans (Santoro et  al. 2012)—because the Greulich and Pyle abacus is rated as “reliable for the sample analyzed”. This ethnicization of bone age and child growth standards reflects the rising “nationalization” of measurement. The social space where bodies are interpreted is no longer associated with class but gradually reconfigured along the borders of the nation-states—this shift is mostly unnoticed by Armstrong in his analysis of the changes introduced by the survey method in pediatrics, psychiatry, general medicine, and geriatrics. However, this nationalization of measurement is not so much related to the rise of raciological or nationalist doctrines—manipulating growth data to support the notion of a national people—but rather to the global scientific agenda, organized around North American and British standards. Ethnicity is thus constructed by default: it fills the gaps between measurement instruments and measured bodies, in conjunction with social factors that were still considered at the time. The third type of use of bone age emerged around the same period (mid-1970s) in a different branch of pediatrics and followed a very different perspective.

 one Age and Development Patterns B in Mid-­1970s International Pediatrics In the mid-1970s, a third use of bone age was formalized outside of social pediatrics, in a branch of pediatrics influenced by genetics and by the increasingly globalized biopolitical context. No longer practiced in school

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medicine settings only, research was encouraged by global health and development institutions. During this period, the differential measurement of health in children of different classes and the practical interrogations as to the applicability of abacuses gave way to a measurement of growth according to a global perspective.

 he Internationalization of Biopolitics T and the Geneticization of Pediatrics The emergence of a global perspective on growth measurement can be explained by a twofold context. From a geopolitical point of view, this period saw the constitution of major international aid and development agencies. In addition, global demographic growth and the need to regulate it became an issue of interest in Northern countries, as shown by the influence of the Club of Rome and the dissemination of its views in medical, activist, economic, and environmentalist circles (Randers and Meadows 1972). During the same period, pediatrics underwent institutional and scientific transformations. The foundations that supported research into growth and social class changed their strategies and focused on data collection to map growth on a global scale. In addition, some foundations supported the creation of the first “ethnicized” databases, looking at specific pathologies at first and later at wider issues (Epstein 2007; Braun 2014).10 Concurrently, clinical and social pediatrics were losing their prestige: as the medical field reorganized, research was increasingly separated from clinical activities11 while biological and genetic knowledge acquired a growing influence (on these topics, see Déchaux Chap. 5 in this book). Along with geriatrics (Faya-Robles 2018), pediatrics was symbolically rehabilitated by its alliance with genetics and in particular population genetics, which was establishing itself as a distinct field from lab-based genetics (Rabinow 2000). This particular context fostered the geneticization of bone age and its parallel use as a marker of racialization.

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 orldwide Variation in Human Growth: Mapping W Genetic Growth Patterns to Tailor Global Development Policies This context finds an illustration in the research program “Worldwide Variation in Human Growth”, led in 1976 by Phyllis B. Eveleth (a biological anthropologist who supported a genetic and ethnic interpretation of growth) in collaboration with Tanner, an eminent figure in early pediatric studies on growth and social inequality. The project “Worldwide Variation in Human Growth” was developed under the “human adaptability” topic, as part of the International Biological Program launched in 1964 by the World Health Organization (WHO), UNICEF, and the International Council of Scientific Unions. In a context of strong population growth that required, according to the NGOs involved, to rethink the management of natural resources,12 this program aimed to collect data on child growth and physical maturation from a medical and anthropological angle, by comparing European populations (which continued to be held up as a standard) with others. The program draws from two theoretical perspectives. The first is the notion of human ecology as developed by Tanner. The environment is integrated into the study in a very particular manner: the purpose is not just to investigate variations in human biology under environmental pressure but also to prove that geographic proximity induces biological proximity. Tanner applies the very spatialized approach of social pediatrics that associates living places, living conditions, and maturational status. The second perspective, championed by Eveleth, is influenced by Cavalli-Sforza’s genetic geography (Cavalli-Sforza and Bodmer 1971).13 Phyllis Eveleth follows a similar analytical framework: against nutritional interpretations of growth, she supports the idea that genetic factors are determinant (Eveleth 1975, Eveleth and Tanner 1976: 214). Both Tanner and Eveleth do not just interpret the body according to a social space, understood as statistical distance from other bodies that form part of a given class or national community. The body is also interpreted in relation to a physical space, according to which genetic similarities and differences are postulated and integrated into the analysis (Rajagopalan and

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Fujimura 2011). In particular, one of the authors’ objectives is to determine the respective impacts on growth of heredity and the environment, in order to assess the “possibilities for improvement in growth in large areas of the world”. The study concludes that all populations do not have the same potential for growth, due to pure heredity or to this factor’s interplay with the social environment (in particular nutrition and healthcare): genetic patterns of growth can therefore be detected. The monitoring of child development (measured through child mortality and growth rates) is associated with the objective of determining the genetic potential of “bioethnies”, to which public health policies must be tailored.

 econsidering Global Child Growth Data Through R the Ethnical Background Hypothesis For this purpose, the program proposes to collate existing studies conducted according to diverse research approaches. Eveleth and Tanner use measurements collected through 340 studies conducted in 42 countries on different scales. They choose to aggregate this data into five groups: Sub-Saharan African populations and their descendants in the Americas; Asian populations including Chinese, Japanese, Amerindians, and Southeast Asians to the exclusion of Indians and Bengalis (although these populations were categorized as Asians in mid-1970s British statistics); Australian Aborigines and Pacific island peoples; and Indo-Mediterranean peoples of the Near East, North Africa, and India. When considering African populations, the authors also introduce sparse data on “tribal groups”—the data in question was collected in rural villages in Africa, where Eveleth and Tanner postulate that genetical patterns have been preserved due to lower migration14 and to a greater distance from Western lifestyle and consumption standards. African populations are thus subdivided into “ethnic groups” (Eveleth and Tanner 1976: 75): Nilotes and Nilo-Hamites, Bantu, Sudanese, Khoisan, and related peoples (Bushmen, Hottentots) and Pygmies. These groups are characterized using secondhand data, which had originally been produced by country and living place (rural vs. urban), and not by ethnicity: these studies cover Jamaica

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(rural areas vs. Kingston), the poor city of Santo Domingo, California, the city of Dakar in Senegal, and the village of Imesi in Nigeria. From this angle, “Worldwide Variation in Growth” is an example of a re-­ interpretation process through which these maturational data are not just interpreted differently but undergo a deep transformation. First of all, the measurements are converted: while they occupied a secondary place in their initial studies, they are now used as criteria for the stratification of populations.15 The data figuration models are also transformed. The tables showing measurements, previously sorted by country, place, or living standard, are replaced by tables organized according to particular “bio-ethnic” subgroups. Eveleth and Tanner encounter great difficulties in defining clearly delimited subgroups, except for the European group, which they regard as genetically homogeneous. However, the authors do not consider this as an indication of the fragility of their interpretative model, but rather as the consequence of social variations that blur the underlying genetic substrates they are seeking to uncover. The ethnic factor is not regarded as a variable among others, within a multi-modal analysis that takes in socioeconomic and environmental data, as Johnston and Roche did in 1971 and 1975, respectively. Instead, it becomes a principle of categorization that presides over the initial breakdown of measured bodies and of the data on growth thus produced. From a statistical variable, ethnic categories become a homogeneous biological entity. Eveleth and Tanner even back these categories with specific measurements selected to highlight their distinctive qualities: they examine the selected populations’ genetic makeup, physical shape, nutritional status, tolerance to climate, physical makeup, growth and development measured through weight-to-height ratio, skinfold thickness, limb circumference, and skeletal diameters, as well as maturational status defined through the triptych (bones, teeth, puberty) established by Tanner in the 1960s United Kingdom and used very differently in this case. In addition to the geneticization of growth, this project thus introduces new divides and hierarchies (Fujimura 2018), chiefly of which the racialization of African populations and the de-racialization of Europeans to whom the others are perpetually compared.

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 eneath Social Class: The Racial Growth Pattern B of African Populations For instance, Chap. 4 (Eveleth and Tanner 1976: 104), is dedicated to Africans in Africa and America. While the authors observe size discrepancies to do with living conditions, in particular in children for whom the genome is not regarded as fully expressive, Eveleth and Tanner note other phenotypical particularities that they regard as genomic markers, in particular when they persist into adulthood. Those include muscles, skin folds, and leg length:16 “The triceps skinfolds of Africans are less than those of Europeans due to ethnic rather than to nutritional influences” (ibid.: 112) or “the longer legs of African groups is believed to be a genetic characteristic” (ibid.: 111). Furthermore, skeletal age occupies a crucial place in this process of racialization as it is used to extrapolate different genetic patterns (ibid.: 199–206) even if the racialization of skeletal development is based on incomplete data (7 ossification centers out of 30, for which selection criteria remain undisclosed) and deducted from proximities in measurements of Africans in America and Europe, who are exposed to presumptively similar living and healthcare conditions (ibid.: 204): “African children under good nutritional and environmental circumstances are more advanced than Europeans in skeletal development from birth to adolescence” (ibid.: 206). The skeletal development speed of African children placed in Western living conditions supports the argument of a genetic specificity, proving the existence of a “racial” tempo of growth—which remains dormant in Africa when children are subjected to difficult living conditions, but is activated in the West. Difference thus moves in beyond the barrier of the skin. A profound otherness is constructed both in growth tempos than in nature: “There may also be differences between different parts of the hand skeleton” (ibid.: 206). The bones of African skeletons are thus described as denser than the bones of Europeans (ibid.: 236). Similarly, when observing teeth, Tanner chooses to only consider permanent teeth to reinforce the differences between “ethnic groups”, which are not as apparent during prime infancy: “whereas there are no clear differences between ethnic groups in the age of eruption of deciduous teeth” (ibid.: 210).

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Finally, the causal role of social determinants is underplayed in African populations17 and restricted to specific bodily features—head circumference, for example (ibid.: 110). While highlighting the specificities of the social conditions of existence experienced by these groups (malnutrition, measles, pertussis, vulnerable living conditions of mothers), the authors support the idea of a shared genetic heritage, which becomes apparent when comparing Africans in North America with well-fed European children and “tribal Africans”, because “the combination of the effects of malnutrition and diseases masks the underlying genetic growth pattern” (ibid.: 75). Far from nuancing the genetic interpretation of growth, the comparison between social classes serves an argument that defines race as something people share in common beyond social class. Concurrently, African children are systematically compared to European children who are on the contrary de-racialized.

 ariations Between Social Classes: The De-racialization V of Europeans The second chapter of the book, dedicated to Europeans in Europe, characterizes tempos of growth by using available growth data. In this section, shoulder and hip widths, chest, arm and calf circumferences, skinfold thickness, and head circumference are used to measure child development, and not as a marker of race (contrary to Diasio’s findings concerning the mid-nineteenth century, see Chap. 2). In addition, the authors stress the heterogeneity of available data—as much in the construction of samples of children as in measurement methods, in the standardization of measurements (Eveleth and Tanner 1976: 19) and in the geographical areas surveyed. Therefore, they refuse to calculate a national average for these groups, highlighting the variable degrees of maturation observed per “occupational category” (ibid.: 34). The focus is placed on socioeconomic variations of growth and on the assertion of this group’s genetic and auxologic homogeneity—in spite of significant variations in the measurements: “Europe also has the advantage that the population is relatively homogeneous from a genetical point of view” (ibid.: 15). Finally, when Europeans are compared with other African and Asian

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populations, this is done with the purpose of deducting universal standards of growth or medical risk,18 or that of identifying racial patterns of growth. For example, leg length is mentioned in this section when the authors stress that European populations meet certain standards in their conformation (like the African’s, the European’s leg is about half the total height of their body), whereas in the chapter dedicated to the characterization of an African growth pattern, longer legs and arms are described as specific biological traits found in populations of African descent. This third period in the interpretation of bone age is thus marked by a racialized medical reading of human growth, which stems from a distinctive type of genetic knowledge. Otherness is denoted not so much by conformation or by the measurement of orifices (see Chap. 2) as by maturation tempos. As it transforms into a chronological process, race paradoxically becomes a more rigid notion. It is not understood as an encounter between an organism situated within a given maturational phase and a particular socioeconomic environment at a given point in time. Instead, it is regarded as a degree of expressiveness of an initial “genetic map”, a program whose deployment can be attenuated or optimized under certain living conditions at certain ages: childhood is seen as a phase of plasticity, puberty as the awakening of a pattern, adult age as the period of its full expression. This view, which was formalized in the late 1970s, occupies a key place in pediatric and endocrino-pediatric research (Mora et al. 2001), as studied in the Chap. 8, and even converges with the mainstreaming of genetic bio-ancestry measurement tests (Guo et al. 2014; Doron 2016).

Conclusion This chapter shows how bone age, initially regarded as a marker of age, became an ethno-national and later a racial marker: the study of models used for the categorization of age can thus shed light on previously undetected processes of racialization. Our study also highlighted the emergence of a new form of racialization based on chronology, which seems to have appeared in a particular branch of late 1970s pediatrics, and which is also addressed by Vinel in her study of the menarche (Chap. 8). Genetics

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occupies a complex role in this process. Whereas in certain spaces, this discipline contributed to the deconstruction of race, in others on the contrary (human biology and “inter-cultural” pediatrics), it reconstructed this notion by paradoxically tapping into social data.19 Race thus becomes what cannot be explained by class conditions: this redefinition shows that considering the social environment does not necessarily imply a deracialized interpretation of human measurement. This study of the very particular case of the racialization of bone measurements also reveals a transformation of the medical gaze as noted by Armstrong (1983), and more specifically of the medical field’s spatial economy and associated categorizations. This shift modified the scale of the communities produced by researchers, and the interpretations of the reference groups thus constructed (M’charek et al. 2014). In the wake of World War II, the community of reference was a local social space defined by shared social living conditions, with people living on the poor or wealthy side of town. In contrast, from the 1970s onward, the interpretation of standards of growth spans across more distant spaces: “national” differences, immutable “tribal groups” versus “mixed”, or “homogeneous but non-tribal” groups (e.g., European populations according to Eveleth and Tanner). This social space is used no longer to situate bodies within a metered continuum, but rather to infer their sameness based on presumedly shared genes. Regardless of social distance, physical proximity becomes an indicator of ontological kinship—another occurrence of the episteme of resemblance described by Diasio in her study of the nineteenth century (Chap. 2).

Notes 1. The corpus initially comprised 5889 entries. By reading the abstracts, we were able to filter out papers addressing bone maturation in children with specific pathologies and restrict ourselves to studies aimed at determining age in relation to “ethnicity” or “race”. Working from this narrower ­second corpus (191 entries), we carried out a double analysis—first by considering each document individually, then by comparing them. We were thus able to extract the three main categories of uses of bone age

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presented in this article. We then selected a number of “typical” contributions, which formed the focus of our argument. The selection was based on these contributions’ line of argument and on the understanding of bone age they conveyed, but also on the position occupied by their authors in the field of bone maturation studies. This perspective, which places the emphasis on authors rather than on lexemes, allowed us to reveal shifts in the positioning of major figures in this field, thus highlighting the weight of historical, scientific, and political contexts on these changes. For instance, Tanner “exported” his vision, initially developed in the context of social pediatrics, into late 1970s genetics-inspired pediatrics. 2. An analysis of the sexualization of bone and of the construction of bone maturation measurement tables establishing a rigid distinction between sex groups remains to be conducted—according to the same model followed by anthropologists who studied how bone was gradually constructed as a marker of sex. On this question, see, for instance, Evelyne Peyre (2015) and Judith Bouhallier (2015). This question exceeds the scope of our study, which focuses on the ethno-nationalization and racialization of bone. 3. The notion of community in Armstrong’s works is close to that of population in Foucault’s. It does not imply a subjective identification or a type of tie but refers to the collective in which children’s bodies are aggregated (for instance, a city), and based on which deviations from the norm are assessed: “The new body is not a disciplined object constituted by a medical gaze which traverses it, but a body fabricated by a gaze which surrounds it: the new body is one held in constant juxtaposition to other bodies, a body constituted by its social relationships and relative mental functioning, a body, of necessity, of a subject rather than an object” (Armstrong 1983: 102). 4. In particular when is missing a random control survey comprising children with contrasting health statuses and whose measurements would be likely to meet normal standards. This is an important condition that allows the use of the abacus (this precaution is taken by Quételet when using averages). Here, Tanner refers to families who falsify their children’s age in Southern countries with a “male predominant culture” in order to have boys in education at an earlier age and girls at a later age. For these ages, Tanner suggests using primary teeth, which are less susceptible to the environment, to determine children of school age (five to

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six years old). Very different markers were later used in France to determine whether unaccompanied foreign minors were 18 or more. This reflects the impact of social issues on the selection of relevant biological markers as shown by Voléry (Chap. 3). 5. This term appears to have been misunderstood in French translations of Greulich and Pyle where the authors are often presumed to support the notion of a “white race” (Jacques 2009). In these early works, skin color does not express the author’s belief in the existence of a biologically distinct group but rather a quite fuzzy dimension: this phenotype is politically associated with class position, as individuals who are “labeled” as Black find themselves circumscribed in disqualified social spaces. 6. In 1970, the foundation expanded its collection of international maturation measurements with over 200,000 radiographs of the head (lateral and frontal views) and the main joints of the body (shoulder, elbow, wrist/hand, pelvis, knee, and ankle/foot). This website actively promotes these collections, which clearly act as a marker of the foundation’s position in the field and market of medical measurements. https://case.edu/ dental/departments-programs/bolton-brush-growth-study-center. 7. This, in spite of the fact that these studies were conducted on sometimes narrow samples—from 190 (Zabet et  al. 2015) to 1009 individuals (Andersen 1971)—with a particular social profile: students described as “healthy”, living in “average” sanitary conditions. 8. It should be stressed that most forensic medicine studies cover Northern countries or strategically placed neighboring countries located along migratory routes (between Morocco and Italy for example)—that is, places in which forensic assessments of bone age or postmortem identification can involve a guesswork estimation of age. 9. See, for instance, Braun’s study (2014) on the introduction of racial standards into spirometers. 10. This trend was widely supported by public health institutes: see, for instance, the surveys conducted by the NCHS and the University of Texas School of Public Health under whose impulse the first ethnicized database were introduced, in particular on cardiovascular diseases (in Louisiana, Philadelphia and Pennsylvania). This “racialization” was present well before 2000 and the introduction of the BiDil as studied by Khan (2013): see Jones’ study (2013) of pharmacogenetics in the 1950s. 11. This shift goes along with the transformation of the role of measurement in the symbolic economy of research tasks (clinical measurers vs. model-

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ers from research institutions) and methodologies (where individual clinical studies were discredited in favor of statistics, deemed to provide a higher level of proof ). 12. This biology, based on the diversity of humanity, seeks to measure its potential of change under environmental pressure. It is supported by the World Health Organization and the International Biological Program— see J. S. Weiner, international convener of the Human Adaptability program, in the acknowledgments (Eveleth and Tanner 1976: XIV). 13. See in particular the Human Genome Diversity Project (HGDP), launched in parallel with the Human Genome Project to identify and preserve intra-human genetic biodiversity by drawing samples from isolated populations with common geographic, cultural, and linguistic features. 14. This perspective underestimates the intensity of internal migrations within the African continent and Southern countries. 15. Studies on Afro-Americans in the United States did not include blood tests to compare genomic and stature measurement. The authors used the presence of a particular blood factor that was absent in “tribal groups” but present in “American Africans” to deduct their “mix” and support the idea that one-fifth to one-fourth of US Afro-Americans were descendants of Europeans. For a critique of these methods, see Doron (2016). 16. The menarche, whose racialization is studied by Vinel in this book, has a particular status in this study. The “precocious” menarche in girls is mentioned, but it does not function as a factor of racialization. Instead, it marks the beginning of a phase in which variations between measurements intensify, requiring additional methodological precautions. It is also described as subjected to major environmental influences—diet, but also the influence of the tropical climate (Eveleth and Tanner 1976: 219)—and is rarely associated with clear genetic determinants that could make it possible to distinguish between populations. This explains why this factor takes on a secondary role in Eveleth and Tanner’s study. 17. The analysis follows a different perspective regarding “Asiatics in Asia and America”, for whom nutritional differences and measurement biases are more widely considered: “There is great diversity in adult Asiatic populations, reflected in the growth of the children” (Eveleth and Tanner 1976: 118) due to “differences in nutritional or racial background, or possibly even to some unknown differences in measuring techniques” (ibid.: 153).

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18. See the focus on the increase of body fat in children in developed countries, where obesity is presented as a medical and social hazard (Eveleth and Tanner 1976). 19. Bliss (2012) refers to this thinking as “the sociogenomic paradigm of race” in contemporary genetics research.

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Santoro, V., Roca, R., & De Donno, A. (2012). Applicability of Greulich and Pyle and Demirjian Aging Methods to a Sample of Italian Population. Forensic Science International, 221(1–3), 153.e1–153.e5. Schmidt, S., Koch, B., Schulz, R., Reisinger, W., & Schmeling, A. (2007). Comparative Analysis of the Applicability of the Skeletal Age Determination Methods of Greulich–Pyle and Thiemann–Nitz for Forensic Age Estimation in Living Subjects. International Journal of Legal Medicine, 121(4), 293–296. Shilpa, P. H., Sunil, R. S., Sapna, K., & Kumar, N. C. (2013). Estimation and Comparison of Dental, Skeletal and Chronologic Age in Bangalore South School Going children. Journal of the Indian Society of Pedodontics and Preventive Dentistry, 31(2), 63–68. So, L.  L. (1991). Correlation of Skeletal Maturation with Stature and Body Weight of Southern Chinese Girls in Hong Kong. Zeitschrift für Morphologie und Anthropologie, 78(3), 307–312. So, L. L., & Yen, P. K. (1990). Secular Trend in Skeletal Maturation in Southern Chinese Girls in Hong Kong. Zeitschrift für Morphologie und Anthropologie, 78(2), 145–153. Tanner, J. M. (1975). Growth and Endocrinology of the Adolescent. In L. Gardner (Ed.), Endocrine and Genetic Diseases of Childhood (2nd ed., pp. 14–63). Philadelphia: W. B. Saunders. Todd, T.-W. (1937). Atlas of Skeleton Maturation. Saint Louis: The C.V. Mosby Company. Van Rijn, R.  R., Lequin, M.  H., Robben, S.  G., Hop, W.  C., & Van Kuijk, C. (2001). Is the Greulich and Pyle Atlas Still Valid for Dutch Caucasian Children Today? Pediatric Radiology, 31(10), 748–752. Wenzel, A., Droschl, H., & Melsen, B. (1984). Skeletal Maturity in Austrian Children Assessed by the GP and the TW-2 Methods. Annals of Human Biology, 11(2), 173–177. Zabet, D., Rérolle, C., Pucheux, J., Telmon, N., & Saint-Martin, P. (2015). Can the Greulich and Pyle Method be Used on French Contemporary Individuals? International Journal of Legal Medicine, 129(1), 171–177.

8 Models of Corporeality and Controversies Around Puberty Virginie Vinel

The descriptions of puberty in medical literature shed light on the construction of diverse ontologies—regarding childhood, transition from childhood to adulthood and maturation, as well as on expectations regarding body, gender, age, and the articulation between these three elements. These descriptions also provide insights into the scope of action that contemporary medicine assigns itself and into the tensions between the epistemologies that underpin different medical specializations.1 During the twentieth century, as the study of puberty developed, various descriptive and measurement instruments were created to capture the body transformations. These measurements aimed not only to better understand the pubertal process but also to define what constitutes a deviation from its “normal” course, thus calling for a medical intervention (Engelhardt 1975). The question of the normality of puberty came under the spotlight in the United States in the late 1990s, with the

V. Vinel (*) Laboratoire de Sociologie et d’Anthropologie (LaSA UBFC), Université de Bourgogne Franche-Comté, Besançon, France e-mail: [email protected] © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_8

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outbreak of a controversy on the precocious onset of puberty, especially among Afro-American girls. This chapter investigates the models put forward by the twentieth-­ century medicine to represent the body between childhood and adolescence, particularly in the context of this controversy, and the instruments used to observe it. A discrepancy appears between, on the one hand, an anatomo-clinical conception of medicine according to which the individual body is observed via the doctor’s senses (gaze, touch) and, on the other hand, endocrinological medicine, which uses biochemical measurements (Büttner 1980). What is the role played by quantification, technoscience, and information technologies (Clarke et  al. 2000) in this controversy? What is the impact of images on knowledge of the pubescent body? The analysis of this literature reveals not only the types of changing bodies but also the types of children and adolescents that are depicted and produced by contemporary medicine.

Methodology This review and documentary analysis of medical literature on puberty, the earlier onset of puberty and precocious puberty was completed in three stages. A first literature review was conducted, analyzing 110 medical papers and reports in French, English, and Italian spanning from 1969—the year of the publication of Marshall and Tanner’s reference article on pubertal stages in girls (Marshall and Tanner 1969)—to 2010 (Vinel 2014; Cozzi and Vinel 2015). In addition, the sweeping controversy in the United States on the exceptional advance in the age of puberty onset led me to study articles published between 1997 and 2013. These papers discuss the decreasing age of puberty and its medical consequences: first of all, in the journal Pediatrics where the findings that sparked off the debate were published (Kaplowitz et  al. 1999; Herman-Giddens et  al. 1997, 2001; Kaplowitz 2004); then, in a corpus of reactions and articles discussing this publication. A total of 49 documents were thus identified. I also selected or reviewed international papers in other journals,2 which were cross-referenced with bibliographies from review papers (Parent et al. 2003; Herman-Giddens et al. 2004; Euling et al. 2008). The third

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phase consisted in an exploration of French medical literature since Paul Godin (1903) to investigate the corporal and medical models used throughout the twentieth century as a basis for distinguishing “normal” from “pathological” puberties. The materials (almost 180 documents in total) were the object of a qualitative investigation, with questions including the following: What is the authors’ medical specialization? What investigation methodologies are used by this piece of medical writing? What measuring instruments are used? What type of description is delivered? What age, gender, ethnic, or racial categories are used? How do these articles define puberty and its pathologies, including the case of precocious puberty? Before retracing the controversy on advanced puberty and highlighting its stakes in the final section, we will first examine the different models of corporeality used in the twentieth-century medical literature to describe puberty.

 edical Models of the Body M in Pubertal Transition Puberty was initially approached by medicine as a global phenomenon that impacts the entire body, intellect, and psyche. Under the influence of new methods of investigation of the body, puberty was diffracted into diverse ontologies that overlap, complement, and sometimes contradict one other.

Puberty as a Global Physical and Psychic Phenomenon In French medical theses and manuals of the first half of the twentieth century, puberty appears as a global phenomenon that encompasses statural and ponderal growth as well as the growth of the muscles, internal and external organs, pubic and underarm hairs, but also head hair as well as the deepening of the voice—the development of the genital organs being only one aspect among others. For example, Godin (1903), a military doctor whose work remained for a long time a key reference in France, conducted a study of a cohort of 13–18-year-old boys at the

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military preparatory school of Saint Hyppolyte du Fort in the southwest of France, starting from 1896. Godin recorded information concerning the boys’ parents and their “ethnicity”, as well as on the boys’ and their parents’ health condition. He and his team compiled no less than 129 measurements per individual (bones, muscles, thorax, pelvis, thighs, cranium, face, ears, etc.) every six months over five years, along with observations on their pilosity, genitals, skin color and thickness, teeth, heart, vascularization as well as on their physical, intellectual, and artistic aptitudes (Godin 1903: 13–26). As a laureate of both the Académie de Médecine and the Société d’Anthropologie de Paris, Godin used a combination of methods and descriptions that borrowed from traditional nineteenth-­ century anthropometric measurement, anatomo-pathological clinical medicine and Claude Bernard’s medical quantification system (Grmek 1999), to serve both scientific and educational purposes (Diasio 2019). This global vision of puberty is still present in the medical theses of the 1940s. Puberty is portrayed though the growth of weight and height and the development of sexual characteristics but also through the development of the muscles, larynx and vocal cords, heart, arterial pressure (vagotonia), neurovegetative system, digestive organs, nervous system, and brain weight, with consequences in terms of intellectual and psychic development (Abd-Allah 1940: 24–31). The cases are described in great detail—in the style of naturalist writing—and compared with those contained in medical literature, keeping with the tradition of clinical anatomo-pathology (Foucault 2002 [1963]). This transition, understood as a “metamorphosis”, is characterized by uncertainty, variation, and fluidity. The global human being is observed in his or her transformation, using a range of instruments that include questions (on the subject’s background, personal information, place of birth, parents), observations, and the use of stethoscope, measuring rod, tape measure, compass, and intelligence tests. The descriptions are individual, specific, detailed, and based on the clinical method of clues (Ginzburg 2013 [1989]) and symptoms (Foucault 2002 [1963]). In Godin’s research (but not always in those of other authors’), these cases are presented through figures and tables in relation to age, respecting the developmentalist theory that was flourishing at the time (Turmel 2008).

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A Plurality of Corporeal Models Other body measurement instruments appeared in the 1940s and 1950s, deeply transforming the way puberty was represented and defined. In his 1946 thesis, Oelsnitz (1946) presented an in-depth description of a case of precocious puberty in a girl he followed every three to six months in a hospital, from the age of three and a half to five and a half years old. In addition to clinical observations, height and weight measurements, auscultations, and questioning, Oelsnitz documented this case with photographs and radiographs, as well as biochemical, hormonal, and cellular measurements. Here, the definition of puberty is restricted to its more sexual dimensions and the age ranges are more loosely indicated. For instance, Oelsnitz writes: “Puberty considered as a period of transition lasts for approximately three years. It is characterized by three key elements: the maturation of primary sexual characters, the apparition of secondary sexual characters and the onset of menstruation” (Oelsnitz 1946: 24). Both the anatomo-pathologic model based on a clinical description of the visible body and the anthropometric model underpinned with statural measurements are still present in this approach. These descriptions are complemented with photographs of the child’s naked body in front view and side view at different ages, anonymized by a white band over her eyes. In this body-as-image, the focus is drawn to the sexual organs, breasts, and pubis as well as to the body’s overall shape (belly, waist, hips, thighs), presented in relation to the child’s age. The reader is made to see the striking image of the body of flesh, frozen and exposed in its nudity. The body, which had so far been depicted in detailed case studies, is displayed to the eyes of the viewer. The imagery also includes radiographs of the girl’s hands, which make the body appear transparent. Compared with those of a “normal girl” (Oelsnitz 1946: 14), the radiographs provide visual evidence of a deviation from “normality”. Oelsnitz’s study also refers to the biochemical model of the body, although this model is still in its infancy. Five different models of corporeality are thus used by the author to describe the girl’s case: the anatomo-pathological body as observed by clinical medicine, the body-as-image captured by photographs, the

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fragmented body captured by radiographs, the hormonal body, as well as the cellular body. In the 1950s and 1960s, the medical literature made different uses of these diverse models of corporeality. During this period, puberty appears as increasingly fragmented, but it is still regarded as a process that affects the whole human being. “It is an ambiguous period during which the human being’s bisexual potentialities manifest themselves more or less clearly, a period of fragility and one of physic and psychic instability”, writes Simonnet (1956: 1).

 apturing the Progress of Puberty C Through Photography The works of Tanner (1955) and Marshall and Tanner (1969, 1970) marked a turning point and have since become both an international reference in the medical literature, and a standard for practitioners (Piccand 2015). Between 1949 and 1971, Tanner and his assistants, Whitehouse and Marshall, studied 710 children in an orphanage in Harpenden near London. Their methods included anthropometric measurement, photography, and statistics. The children were photographed in full height in different positions (Roberts 2015) but only the chest and lower abdomen of girls, and the lower abdomen of boys were included in the articles. The photographs, taken at an interval of three months, were examined and compared by Marshall. They constructed five stages of pubertal development based on these comparisons (stages B1 to B5 for breasts, PH1 to PH5 for pubic hair, G1 to G5 for boys’ genitalia). The data (relation between ages and stages, intervals between stages, intervals between the first stage and the following ones) was organized into statistical tables and graphs. In parallel, the growth measurements were also presented in curves and standardized (Marshall and Tanner 1969). These articles showed wide statistical variations in age at the development of each indicator, in intervals between stages and in age at each stage. And although the authors observed a few cases of stagnation and regression (1969: 293) as well as discrepancies between the development of the various organs (1969: 296),3 only the averages were integrated in

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the discussion and the abstract and were then taken on board by medical professionals. More importantly, these articles reveal a radical shift in the model of corporeality associated with puberty (Marshall and Tanner 1969, 1970). Only the body’s external elements, or “secondary sexual characters” (breasts, testicles, penis, and pubic hair), are considered along with statural growth, at the detriment of all the other indicators that had been examined so far, as described earlier. Due to their wide dissemination and adoption, Tanner’s studies introduced and imposed a fragmentation of the bodies of children, and a focus on discontinuous and sexualized elements as the sole definition of puberty. In addition, the body-as-image4 produced by photography enhances the perception of the relation between the child’s body, age, and gender. The direct gaze over the body promoted by clinical medicine is gone, as is the auscultation of the flesh and of the density of the skin and tissues: the body is reduced through a comparison between flat and frozen black and white images of sexual organs. Laura Piccand (2013) notes how photography as an artifact promotes idealized representations of the male and the female body and educates doctors to identify these gendered bodies. Puberty is reduced to reified and gendered stages, to body fragments stereotypically presented by photography. Indeed, unlike the written word, “photographed images do not seem to be statements about the world so much as pieces of it, miniatures of reality that anyone can make or acquire” (Sontag 1977: 4). They are pieces of “evidence” that, although they appear to “capture reality, not just interpret it”, do show what a girl’s or a boy’s body is expected to look like at a given age. The history of clinical anatomo-pathological medicine and medical photography, which both focus on specific organs in relation with certain pathologies (Roberts 2015; Grmek 1997), explains in part the emphasis placed by Tanner and his team on body fragments. This focus on the genitals and breasts—at the detriment of the growth of all other organs— can be interpreted through two basic shifts in scientific thinking from the eighteenth century onward. It consists in biological science’s ambition of demonstrating in the most accurate manner possible the differences between male and female bodies (Laqueur 1992), and the proliferation of studies on sexuality (Foucault 1978 [1976]), as we will see further. The worldwide impact of Tanner’s work on medicine was certainly facilitated

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by these bodies-as-images that became regarded as documents that carried a discourse of truth (Foucault 1978 [1976]).5 Although Tanner did not intend to create a standard (Roberts 2015), his stages have contributed to stabilizing, segmenting, and standardizing a process traditionally regarded as fluid and variable, which medicine was struggling to integrate into its ontology (Cozzi and Vinel 2015).

The Counter-Models of Endocrinology and Psychology Tanner’s researches were not immediately disseminated in France. In the 1950s to 1970s, researchers continued to present composite models of corporeality where the endocrinological and psychological models played a prominent role. For example, in 1956, the second edition of a book by Laroche La puberté, Etude clinique et physiopathologique (1st edition: 1938) appears to mark a turning point where the anatomo-clinical model declined, giving way to the hormonal body. The first chapter examines “the mechanics of puberty”, looking into the hormonal drivers of puberty and at the organs that produce and receive hormones. Working from a yet unstabilized body of technical knowledge, the authors attempt to explain how hormones trigger puberty. The mechanistic model of the body, apparent in the authors’ vocabulary, is typical of the writings of endocrinologists. For instance, one article reads: “the triggering of puberty has a central origin in the hypothalamus”, “when put into circulation, sexual hormones act on the receptors”, this mechanism is presented as a “pattern” (Simonnet 1956: 81–82). Auxological chapters on growth and the skeleton (“Skeletal development and puberty”, “Growth and state of nutrition”) show the authors’ kinship with Godin’s writing as well as their convergence with Tanner’s work. The book also tackles some medical issues that emerged in the context of postwar deprivation in France—the high incidence of goiters in the center of the country, the spread of infectious diseases like tuberculosis—and their impact on puberty. However, while two chapters are dedicated to forms of infantilism and delayed puberty among both males and females, precocious puberty only occupies a few pages in the book.

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This lack of interest in precociousness may stem from its rarity in a world still plighted by undernutrition, which is one of the delaying factors of puberty. It could also be explained by the lack of anxiety concerning the precocity of children, the “end of childhood” (Postman 1983), and the sexualization of girls, which would resurge in the 1980s and the 1990s.6 Radiography is also included in this approach but photography is not, which reflects the absence of any new auxological study in France. Furthermore, while puberty is still described as an uncertain phenomenon that affects the entire body, the book opens up on psychological and psychopathological questions that will later colonize all medical discourses on puberty. The psyche of the child during puberty was discussed in nineteenth-­ century and early twentieth-century writings, but only as a part of the overall transformation experienced by children of this age, seen as a physiological and psychic crisis (Di Spurio 2014). In the late 1970s and the early 1980s in France, the focus is on the psychic well-being of the child during puberty, which becomes the main motive for a medical intervention—in addition to the child’s adult height—in cases of pubertal delays or precociousness. The bio-psycho-social model of health, which aims to unify mental and physical health (Ankeny 2014), becomes prevalent. In an attempt to move beyond the boundary between health and disease, this model suggests taking physical, physiological, and social factors into account by working on a case-by-case basis (Nye 2003). Particularly present in pediatrics and adolescent medicine (Cozzi 2013), this model approaches treatment individually, thus promoting a holistic conception of medical intervention aimed at ensuring the child’s well-being. This notion is defined as the child’s integration with his/her environment and peers. It includes the normalization of a gendered and aged body conceived as innocent and non-sexualized. Medicine begins to offer the possibility of acting upon puberty by delaying or accelerating it, in order to normalize bodies that differ from those of their peers. It thus ensures the child’s presumed well-being. This approach marks a dramatic departure form Oelsnitz (1946: 144), who recommended to “merely help the child and their parents in a difficult period”. In Europe today, hormones are prescribed almost systematically to block the progress of puberty for girls under nine, with the objective of “reversing or stabilizing signs of

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pubertal development, from both a physical and a psychic and behavioral standpoint. This is particularly important when puberty occurs very early, creating a major discrepancy between the child and his/her peers in their maturation process” (Carel et al. 2002: 237–239). Puberty thus mobilizes different types of corporeality and medical knowledge throughout the twentieth century. Over the course of the century, the literature reflects the gradual fragmentation of the body, as well as the standardization of the elements that are regarded as relevant— sexual and sexualized organs—and of their maturation. Endocrinology provides a biochemical and mechanical model of the body while the bio-­ psycho-­social view gradually provides a legitimation for medical intervention. What role did these different models of the body and the child play in the controversy of precocious puberty in the late 1990s? Let us first examine the components of this controversy.

 Controversy About the Drop A of the “Normal” Age of Puberty In 1997, a team from the Department of Maternal and Child Health at the School of Public Health of University of North Carolina, in association with the pediatrics departments from University of Vermont and the biostatistics department of North Carolina University (Herman-Giddens et al. 1997),7 published the findings of a large-scale study conducted by a network of pediatricians (Pediatric Research in Office Settings—PROS) under the umbrella of the American Academy of Pediatrics, formed in 1986 (Wasserman et al. 1998, 2011). A total of 65 volunteer pediatricians from the network performed a visual examination of 17,077 girls aged between 3 and 12, from July 1992 to September 1993, following Marshall and Tanner’s observation methods and stages (1969).

The Early Growth of Hairs and Breasts The findings present statistics and graphs showing the percentages of “White” and “African-American” girls who have reached each puberty

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stage, based on an observation of their breasts (B2 to B5) and pubic hair (PH2 to PH5): At age 7, 27.2% of African- American girls and 6.7% of white girls had evidence of breast and/or [The italics here are my own] pubic hair development with the proportions increasing to 48.3% and 14.7% respectively, by age 8. … The mean age for onset of breast development was 8.87 years for African-American girls and 9.96 years for white girls. The mean age for the onset of pubic hair development was 8.78 years for African-American girls and 10.51 years for White girls. (Herman-Giddens et al. 1997: 507–509)

The averages for each stage were 2 years under Marshall and Tanner’s averages for African-American girls and 1 year for white girls. The menarche remained stable with respect to more recent studies: “AfricanAmerican girls began menses on the average at 12.16 years. White girls were almost three-fourths of a year older, beginning at 12.88  years” (ibid.). Herman-Giddens and her team (2001) analyzed male puberty a few years later, working from another study—NHANES III—based on data collected from girls and boys, of whom 781 were “Mexican American”, 536 “White” and 797 “African-American”. A total of 2114 boys aged 8 to 19 were examined by “primary physicians”. Their scrotum, testicles, and pubic hair were measured using the visual method, also referred to as the “Marshall and Tanner” method (1970). Facial hair, gynecomasty, the deepening of the voice and testicular ectopia (undescended testicle) were not reported on. At the age of 9, 4.3% of white boys, 21% of African-Americans, and 3.3% of Mexicans had developed pubic hair, and, respectively, 35.7%, 58.2%, and 31.6% had started genital development. These findings thus show an advance of two years in comparison with Marshall and Tanner’s study (1970). The publication on girls (Herman-Giddens et al. 1997) was worldwide disseminated, both in specialist journals and in the media, ringing the alarm on the significantly earlier onset of female puberty (Vinel 2014; Cozzi and Vinel 2015; Roberts 2015; Pinto and Macleod 2019). The decreasing age of puberty in boys did not raise any interest from the media, nor did it provoke any medical controversy (Cozzi and Vinel 2015).8 This discrepancy in the treatment of boys’ and girls’ puberties

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derives from eighteenth-century science, where the ambition was to document differences rather than resemblance between male and female bodies. The female body became “the sex” to be studied whereas the male sex was still neutral (Laqueur 1992). The alarm focused on Afro-American girls particularly, as 48% of the girls in the sample showed signs of breast or hair development. The sample selected for the PROS project was criticized, as it contained a low percentage of Afro-American girls (10% out of 17,077 girls), which made its generalization problematic (Parent et al. 2003). Furthermore, the very definition of ethno-racial groups, although it is current practice in the United States and is in principle based on voluntary self-declaration, was challenged: first, because these groups were imprecisely characterized; secondly because self-declared socio-­ ethnic or racial groups are not necessarily genetically related (Tishkoff and Kidd 2004). The dissemination of these findings in France was problematic in that it generalized the pubertal precocity of Afro-American girls to “girls of African origin” (Pienkowski and Grandjean 2008). It reinforced colonial representations of “Black” girls as sexually precocious (Vinel 2014). Roberts (2015) stresses the irrelevance of comparing data from Afro-American girls with data from the Harpenden cohort, which pertained to an exclusively “White” population sample living in a London orphanage in the 1950s (Marshall and Tanner 1969). She suggests that the lack of any earlier data on ethno-racial (or national) discrepancies discredits the controversy on the decreasing age of puberty; more importantly, the absence of any nutritional data or investigation into the socioeconomic background of the children examined as part of these studies also needs to be pointed out (Vinel 2014; Roberts 2015). Sociology thus shows how this widely disseminated research on the so-called spectacular pubertal precocity of American girls was inflected by gender biases and by a tendency toward racialization. However, these two factors remained unexamined in the controversy that unfolded in the medical sphere.

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The Boundaries of Normality and Medical Intervention The dispute in Pediatrics and a few other US journals specifically regarded the recommendations delivered by Kaplowitz et al.9 (1999)—both pediatric endocrinologists in a public hospital in Washington, DC—as to the attitude to adopt toward girls who present signs of puberty. Based on the article by Herman-Giddens et al. (1997), Kaplowitz, Oberfield and the Pediatric Endocrinology Society (PES) suggest revising the guidelines concerning the treatment of girls and to only consider puberty as precocious in “White” girls under seven and “Afro-American” girls under six, instead of the conventional eight years old threshold. The authors thus recommend that puberty should be de-medicalized before the age of eight, arguing that this transition now occurred earlier in certain groups, in particular “African-Americans”, than it had done in the 1960s. The authors asserted that there was a low risk for girls whose pubertal progress is “moderate” to be too short in adult age—which was the main reason legitimating medical intervention, along with psychological well-being. In addition, the authors claimed that it was not proven that hormonal treatment (gonadotrophin) produced a significant improvement in adult height. This article thus challenged the accepted line between what is regarded as normal or pathological in North America and Europe. Many of professionals opposed10 the idea of changing the conventional ages of the onset of puberty (Rosenfield et al. 2000; Midyett et al. 2003; Jacobson et al. 2005). According to Midyett et al. (2003) and Jacobson et  al. (2005) from the Children’s Mercy Hospital, Department of Pediatrics, University of Missouri-Kansas City School of Medicine, entering puberty at the age of six should not be regarded as benign: first of all, the PROS study may not be generalized to the entire American population; second, loosening the definition of the normal age of puberty would lead to an underdiagnosing of hidden pathologies. This argument is backed by a study of 223 girls—who visited six pediatric endocrinologists in their department—for whom the development of the breasts (visual examination and palpation) and pubic hair, growth peak, and radiograph of wrist bones were observed. The authors claim that their method is

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more efficient than that used for the PROS study in assessing cases of “true precocious puberty” and detecting potential pathologies. In 2004, Kaplowitz restated his recommendation by presenting additional arguments drawn from his clinical experience, claiming that hormonal measurements and wrist radiographs should be discarded as they were too invasive (Kaplowitz 2004: 3649). The controversy therefore concerned both the definition of the normal age of pubertal onset, and the instrumental investigation means that are necessary to determine this age. Research on the age of “true precocious puberty” is still ongoing: in 2008, a longitudinal study conducted over ten years, including girls who were self-declared (by themselves and their parents) as “White” and “Black”, and examining anthropometric and hormonal measures as well as a visual assessment of the breasts (areola) and pubic hair, concluded that the growth of pubic hair without breast development (pubarche) could be regarded as “true pubertal development” (Biro and Wang 2008). In the same year, 11 years after Herman-Giddens’ article, the US Environmental Protection Agency (Euling et al. 2008) published, again in Pediatrics, a review document authored by several specialists engaged in the debate. This nuanced article concludes that the majority of specialists agree with the validity of advancing the normal age of pubertal onset, particularly for “African-American girls”, while a minority refuse to do so due to the methodological invalidity of comparing past and recent studies. However, all specialists agree as to the existence of “ethnic” and “racial” differences. The categorization of children/adolescents into “races” or “ethnicities” (both terms appear as interchangeable in the different texts), sexes, and age groups is never questioned. These three categories are entirely naturalized; furthermore, the teenagers’ socioeconomic conditions are never discussed. At this point, it appears interesting to examine the methods used to measure the body and medical models of corporeality that come into conflict in this controversy.

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 isibility and Fragmentation of the Sexual V Body Versus Fluidity and Mechanicality of the Hormonal Body The articles authored by Herman-Giddens’ team are based on the assessment of a small number of external and sexualized parts of the body, the “secondary sexual characters” (breasts, testicles, penis, pubic hair), observed by a pediatrician in their clinic and compared with Marshall and Tanner’s stages, which were themselves constructed from photographs (see above). The fragmentation of the body and its reduction to a few discrete segments, which had been initiated in Tanner’s work, is amplified. The focus at this point is only on pubic hair and breasts. No other body transformation associated with puberty is considered. The changes undergone by the adolescent body are frozen, reduced to a few organs and captured by clinical observation, which is most of the time conducted surreptitiously.11 For example, female internal organs are not photographed or assessed, and male sexual organs are not measured.12 The first phase of these investigations starts from a clinical approach based on a perception of the singular body: it derives from the anatomo-­ clinical model, but diverges from the global vision of the body encountered in the early twentieth century to focus on the exclusively visual observation of disconnected elements. In the 1950s, Simonnet (1956: 1) writes that “the most spectacular signs are armpit and pubic hairs as well as the development of genital organs in both sexes, breast development and uterine hemorrhage in girls, and erection and ejaculation in boys”. Out of these “spectacular” signs, in the absence of any research into erections and ejaculation among boys, medicine only considers those that are the most visible through a clinical pediatric auscultation. According to Roberts (2015), the reproductive organs are selected for this purpose because concerns surrounding puberty tend to focus on the individual’s future reproduction and on gender troubles. In addition, the breasts are now more visible than they had been in previous decades due to tighter and more feminized clothes, and the focus on the girls’ appearance reveals a fear of sexualization assimilated with child sexuality, apparent in various

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government reports from the United Kingdom or France (Bailey 2011; Jouanno 2012). These clinical observations were then examined in relation to Marshall and Tanner’s standards. We could question the distortion that exists between on the one hand black and white photographs of children and teenagers from disadvantaged socioeconomic backgrounds brought up in a British orphanage in the 1950s and, on the other, the gaze of 1990s pediatricians on a population of contemporary American children. A number of biases could be pointed out including the differences in the bodies of these cohorts of children (weight, body fat, height, shape of organs, skin color) as well as in the gaze of physicians who were trained and lived 40 years apart, but also the issues posed by comparing photographs with bodies of flesh in all their diversity. In addition, Marshall and Tanner’s stages were generally simplified in drawings, which introduced even greater potential for distortion between bodies of flesh and typified drawings. The detractors of the PROS study also incriminate the absence of palpation of the mammary glands, which can induce confusion between adipose tissue and breasts (Parent et al. 2003). The breasts photographed by Marshall and Tanner (1969) appear to be stereotypical— round, with straight nipples—and to belong to a particularly thin girl. They could considerably differ from the breasts of an American girl in the 1990s, whether she is Afro-American, Latin, or White,13 whose socioeconomic background, activities (sport, games, etc.), and nutrition are obviously very different from those of the children who appeared in Marshall and Tanner’s study. The singular body is thus obscured by statistics, as body fragments are quantified and broken down into tables, curves, and charts. As noted by Alain Desrosières (1995) in the field of social and economic statistics, the objective is first and foremost to qualify and classify a phenomenon—in this case, children’s bodies—by reducing it to a few discrete units, and then to suppress the singularity of these body parts to draw an equivalence between them in order to count them (Desrosières 1995: 15). Finally, the operation consists in recording the distribution of these quantified elements according to naturalized variables, such as age, sex, and “race” in the United States. The body of flesh and even the body-as-image is eclipsed in favor of this fragmented, abstract, and numerical body.

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Endocrinologists focus on hormonal measurements that make it possible to assess whether the hypothalamo-hypophyseal system has entered maturity and is secreting the hormones that activate the development of the hairs and breasts, but also the activation of the uterus, ovaries, and spermatozoids. According to endocrinologists, puberty is a complex hormonal phenomenon whose triggers are not completely known to this day (Villanueva and Le Roux 2014). According to Parent et al. (2003), the development of breasts can occur independently from the maturation of the hypothalamo-hypophyseal system and from the menarche. The apparition of breasts—stage B2, considered by Marshall, Tanner, and the authors of the Pediatrics study as marking the onset of puberty—does not necessarily indicate “true” puberty because the reproductive organs are not always activated (Lebrethon and Bourguignon 2002). It can also be caused by serious pathologies such as tumors or hypothalamic lesions that need to be detected and treated. The growth of breasts and pubic hair can thus, according to endocrinologists, indicate a “fake puberty”. In order to evaluate puberty, endocrinologists perform hormonal measurements using blood or urine samples. They work on body fluids—in an approach reminiscent of the Hippocratic humoral model—but also on molecular biochemistry. For example, in a recent book (Bouvattier and Pienkowski 2015), puberty is described using a flowchart made up of colored rectangles, circles, and triangles with the following caption: Puberty: a transition from an inhibited state of the gonadotropic axis to an activated state, which depends directly on kisspeptin (Kp). The gonadotropic axis is inhibited during childhood by the action of GABA and other inhibitors (blue). Under the complex cellular mechanism of effect (red) causing the increase of neurotransmitters or neuropeptides other or peripheral hormones (green) the synthesis of kisspeptins increases, thereby increasing the secretion of GnRH. (Villanueva and Le Roux 2014: 33)

The pubescent body is thus represented by endocrinologists as a biochemical, hormonal, and molecular body, animated by invisible mechanics and revealed by highly elaborate instrumental processes. It is understood through a molecular paradigm, which, according to Clarke et al. (2000), is associated with the era of biomedicalization: as with the

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medical definition of menopause (Charlap 2019) or prostate cancer (Braverman 2018), the measurement of biomarkers in the blood replaces clinical signs to characterize the person’s physiological stage. The clinical markers on which the data of pediatricians or general physicians are based are not considered as puberty’s defining factors: they are the consequences of hormonal changes. Pediatric endocrinologists who engaged in the controversy suggested further indicators such as bones, assessed through radiographies of the wrist that reveal the apparition of the sesamoid bone, another invisible sign of the onset of puberty (Tauber 2002; Midyett et al. 2003). Considering the conflict between these diverse models of the body with associated observation and measuring methods, it is not surprising that the age of the onset of puberty has been an object of debate between the different medical professions depending on the model they refer to. The very ontology of puberty is at stake: Is it marked by the development of the visible sexual and sexualized organs (breasts, hairs)? Or by the inception of a complex hormonal mechanism in the sexual glands and reproductive system, which remains invisible to the eye and can be detected through a biochemical investigation of the blood? The clear divergence between these two models suffices to explain the disagreements between the specialists of each field. The shock value of the fragmented body, the evocative power of the development of breasts—a sexualized organ, surrounded by images and representations of precocious sexualization—can also explain why Herman-Giddens’ article was disseminated more widely than the complex arguments and abstract modelized data presented by endocrinologists. These controversies continue to be fueled by the idea that girls should be preserved from sexuality and sexualization.

Conclusion Different models of the body can be detected in twentieth-century medical writings on puberty: the anatomo-pathological body as observed by clinical medicine, the body-as-image as photographed—first in full height and later fragmented, the fragmented body as captured by

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radiography, the hormonal body, the body made of discrete quantified units, as well as the bio-psycho-social model that considers adolescent’s well-being as a whole. While in the early twentieth century, puberty was addressed as a global phenomenon that engaged all organs but required little intervention, these various models were gradually dissociated in the literature, and medical intervention stated being as necessary. Marshall and Tanner’s work (1969, 1970) contributed to crystalizing the stages of male and female puberty, to turn them into images and to reduce puberty to the sole development of visible sexualized organs (breasts, pubic and armpit hairs, penis, and testicles). Photography became “evidence” showing body fragments and introducing standardized organ types, over a timeline associated with a specific form, age, gender, and body type. In parallel, endocrinology developed a biochemical and mechanistic model of the pubescent body that made the body of flesh all the more remote and abstract, while making the determinants of puberty more invisible and questioning the nature of “true puberty”. Pediatricians in the tradition of Tanner and US endocrinologists came into sharp conflict in the 1990s and the 2000s regarding the normal age of pubertal onset—primarily because the two groups mobilized two different models of corporeality (visible sexualized organs for the former and hormonal markers for the latter); and secondly because in their quest for the truth, these forms of medical reductionism (Gordon 1988) have been seeking to define the onset of puberty from a stable ontology that seems incompatible with the transitions undergone by the body during puberty. The alarm on the decreasing age of puberty triggered by the American Academy of Pediatrics made a widespread impact, because of the correlation created through the production of images between sexualized organs (breasts, pubis, hips, and penis), ages, gender, and racialized assignation: unsurprisingly, these images of the body of an eight-year-old girl with generous breasts generated strong reactions. This controversy is a source of sociological insights into the essentialization of the categories used by medicine (gender binarism, chronological age, “ethno-racial” groups, “true” puberty). The controversies surrounding children’s bodies are constructed upon representations that sexualize girls, and more particularly racialized girls. However, the main issue at stake between medical specialists remains the boundary between

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the normal and the pathological, and the factors that can legitimate an intervention. In the 1970s, medical intervention was stated as necessary when the discrepancy between the bodies of girls who had entered puberty “too early” and the averages for bodies in the same age range were judged as presenting too much of a social and psychic risk. The bio-­ psycho-­social model thus justified attempts to regulate girls’ bodies, to make them conform with socially and historically situated expectations.

Notes 1. Many thanks to Veronika Kushtanina for her proofreading of the English version of the text. 2. Endocrinology and Metabolism, Pediatric and Adolescent Gynecology, The Journal of Clinical Endocrinology & Metabolism. 3. Tanner detailed these variations in a subsequent article (Tanner 1981). 4. Roberts (2015) delivered a sharp critique of the way in which these photographs and measurements had been collected from a captive population of children in an orphanage, whose consent had never been requested. 5. Piccand (2015) also shows that Tanner was already well integrated into research networks, both in Europe and in the United States, which also explains the dissemination and the impact of his work. 6. Di Spurio (2014) shows that this anxiety appears in the early twentieth century in the first publications within psychology and education studies. 7. Marcia E. Herman-Giddens PA., Dr. PH. Eric J. Slora, PhD‡, Richard C.  Wasserman, MD, MPH, Carlos J.  Bourdony, MDi, Manju V.  Bhapkar, MS, Gary G.  Koch, PhD, and Cynthia M.  Hasemeier, BS. Department of Maternal and Child Health, School of Public Health and the Office of Chief Medical Examiner, University of North Carolina, Chapel Hill, North Carolina, Pediatric Research in Office Settings, Department of Research, American Academy of Pediatrics, Elk Grove Village, Illinois, the Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont, the Department of Pediatrics, University of Puerto Rico School of Medicine, San Juan, Puerto Rico, and the Department of Biostatistics, School of Public Health, University of North Carolina, Chapel Hill, North Carolina.

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8. In Europe, the study was met with mixed reactions including a sense of alarm, a perception of the urgent need of conducting European ­longitudinal studies, and the assertion that the findings were to do with an American specificity that could not entirely be transposed to Europe (Vinel 2014; Cozzi and Vinel 2015). 9. And the Drug and Therapeutics and Executive Committees of the Lawson Wilkins Pediatric Endocrine Society. 10. The PROS study was also criticized for the age of the girls in the sample (3 to 12), for its use of averages and for its excessive focus on the age at the time of appearance of secondary sexual characters (breasts, hairs) at the detriment of the age of menarche, which had remained stable (e.g., see Parent et al. 2003). The study is also criticized because a single profession conducted it: private pediatricians. 11. Pediatricians often have to resort to ruse to clinically observe the genitals of adolescents, see Vinel (2015). 12. Oudshoorn and Morel (1998) demonstrated the importance of available data and of inequalities between data from women and men in the scientific output on male and female bodies. This example shows how the pubertal bodies of boys are underexplored in comparison with girls’ bodies, for reasons that include the lack of sample data. 13. The absence of non-White children was also criticized in Marshall and Tanner’s scale. The course of puberty can be very different from one country to another due to socioeconomic, nutritional, and genetic differences (INSERM 2007; Roberts 2015).

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9 Everyone for Himself and All Together? Thinking “Race” Between Social Science, Epidemiology, and Medicine Catherine Cavalin, Odile Macchi, and Paul-André Rosental This chapter investigates the new insights that the social sciences can bring to the question of racial categorizations by examining the etiology of complex diseases, which are thought to be triggered or exacerbated by an individual’s life path and exposure to a “high-risk environment”. The authors aim to contribute to an ongoing debate in life science and in particular epigenetics, with some scholars recommending to “molecularize the biography” and the environment (Niewöhner 2011). These discussions interrogate the boundaries between disciplines (and their respective taboos), without, however, implying that these boundaries could easily be abolished (Dubois et al. 2018).

C. Cavalin (*) IRISSO, Université de Paris-Dauphine, PSL, Paris, France e-mail: [email protected] O. Macchi Social Sciences Department, Paris Samu Social Observatory, Paris, France P.-A. Rosental Sciences Po, Paris, France © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_9

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This contribution draws from the authors’ experiences as social scientists who share a record of collaborations with the biomedical sciences, developed to serve the aims of both disciplines. This project, entitled SILICOSIS, re-examines the historical reasons that, during the twentieth century, caused the pathogenic effects deriving from the inhalation of particles of crystalline silica to be exclusively understood through the prism of silicosis. Several physicians challenged this reductionist approach, mostly because in the past 20 years, medicine has taken on a more joined­up perspective when considering the combination of a person’s exposure to these particles and the onset and symptomatology of various chronic diseases—systemic lupus, systemic sclerosis, and other connective tissue diseases, rheumatoid arthritis, sarcoidosis, vasculitis, idiopathic pulmonary fibrosis, and others—which share in common their systemic or inflammatory or autoimmune character, as well as their “unknown etiology”. While many of these are “rare diseases” (with a prevalence of under 1 in 2000 people), they affect a total of over a million people in France. These diseases are also characterized by their higher prevalence in populations identified in epidemiological literature as “Black” (of the Caribbean, Afro-American, and sub-Saharan origin) than in “White” (or “Caucasian”) populations. In addition, the former group tends to be affected by pathological varieties that are recognized as more severe and evolutionary.1 Working from two field studies conducted as part of the SILICOSIS project, this chapter will illustrate the relevance of the social sciences in understanding the differentiation between these diseases’ manifestations according to “race”. These observations do not aim to invalidate the genetic approach but rather to point at its limitations, which arise from this discipline’s self-sufficiency. In terms of methodology, we will see how, while race can be used as an instrumental category by both biomedical and social science, the latter never treats race as a statistical risk factor per se but rather uses it as a starting point for an analysis that can inform the notion’s social content. It should be noted that the very same questions could be transposed to the category of gender—which we will address in future publications. Several of the diseases considered here are also characterized by their very uneven distribution between men and women (80% of systemic lupus and sclerosis patients are female, as are 70% of rheumatoid arthritis patients), which raises

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similar issues as to the ways in which life sciences tend to naturalize a number of characteristics or treat them as “black boxes” (Shim 2002) (which actually amounts to the same), although their biological and social characteristics would call for a more thorough discussion.

“A Single Cell” Is Not Enough Biomedical research seeks to explain the extreme complexity of phenomena observed on the scale of a population through the prism of the cell. Molecular biology was eventually entrusted with the causal keys of life. However, when considering discrepancies in terms of health between “Blacks” and “Caucasians”, this reduction of biology enters in conflict with the perspective of a social history of diseases but also, paradoxically, with epidemiology’s commonplace beliefs of the past 50 years.

 oving Away from Pasteur’s “Monocausal” Paradigm M and from the Notion of Exposome: Why Epidemiology and Biomedical Science Must Reach Out to the Social Sciences? Since the 1970s, epidemiology and biomedical science have looked for the causes of chronic and noninfectious diseases, and in particular for the mechanics of carcinogenesis, beyond purely physiological factors, by developing multifactorial causalistic scenarios (Parascandola 2004, 2011). This approach is closely connected to the notion of the epidemiological transition. This highly disputed notion, introduced by Abdel Omran (1971), suggests that infectious diseases, understood through Pasteur’s so-called monocausal model (Mendelsohn 2002) according to which “one germ determines one disease”, have for the most part been contained by public health policies thanks to a combination of hygienist measures and medical progress. At least in the old industrialized countries,2 the control of diseases such as tuberculosis, measles, or smallpox has opened the way for the emergence of new morbidity and mortality factors characterized as

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Agent

Host

Environment

Fig. 9.1  The “host–agent–environment” triangle or (triad)

noninfectious, multiple, and complex in their presumed interactions. Many assessments, some of them alarmist (Surgeon General 1979), have stressed the importance of considering “environmental” and “behavioral” factors to curb the growing prevalence of noninfectious diseases (cancer, obesity, autoimmune diseases) through targeted policies. This global epidemiological paradigm goes along with a representation that also became commonplace in contemporary epidemiology: the host–agent–environment triangle (Fig. 9.1).3 This triad illustrates the fact that when searching for new explanatory scenarios, epidemiology should not ignore the biological dimension (host-specific physiological mechanisms) and replace it with the social dimension (social characteristics of the host and their environmental and social conditions of “exposure” to external “agents”). Both approaches should instead be combined, by looking for the determinants of health in interactions and interdependencies between the individual and their environment. There is a contradiction between on the one hand an almost awestruck insistence on the ability for “a single cell” (Ainsworth 2017) to shed light on the physiological differences between men and women, and on the other hand epidemiology’s ambition to consider both biological (chromosome X and Y) and social factors (e.g., highlighting the occupational causes of certain cancers). The notion of exposome coined by Christopher P.  Wild (2005) to complement the notion of genome serves this very purpose (Fig. 9.2). This notion presents two main aspects. On the one hand, this notion stems from the broad principles of the dominant epidemiological paradigm, based on the perspectives of the epidemiological transition and of

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General external Social capital, education, financial status, stress, urbanrural environment, climate, etc.

Internal Metabolism, endogenous hormones, body morphology, physical, activity, gut microflora, inflammation, lipid peroxidation, oxidative stress, ageing etc

Specific external Radiation, infectious agents, chemical contaminants pollutants. diet, lifestyle factors (tobacco, alcohol), occupation medical interventions etc

Fig. 9.2  The exposome’s three domains, with non-exhaustive examples illustrating their respective components4

the host–agent–environment triangle. It implies that there are a number of “non-genetic factors, including environmental and behavioral ones, that can impact human health throughout life” (Véran et al. 2015). In this sense, the notion of exposome is no novelty: it reinforces the epidemiological “thought collective” (Fleck 1979) that regards the environmental factors causing chronic diseases as crucial. However, on an implicit level, the notion of exposome is also innovative in that it abolishes the boundary between the inside and the outside of the human body. In this case, the “environment” includes not only “specific external” agents (potentially toxic physical or chemical agents) and “general external” agents that function as sociocultural, socioeconomic, and social-environmental determinants of health (including education, financial status, etc.) but also an internal dimension comprising physicochemical elements (hormones, microbiote bacteria, etc.) as well as the mechanisms that control their secretion and regulation (metabolism, oxidative stress, etc.) (see Fig. 9.2). In this context, it appears obvious that epidemiology and biomedical science cannot function without the social sciences. And yet, the biomedical literature on the exposome, although it is already well-developed,

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seems restricted to a “traditional” (i.e. individualizing) epidemiological approach to risk factors (Peretti-Watel 2004). The EXPOsOMICS project, involving Christopher P. Wild himself, is no exception (Vineis et al. 2016). This gap between life sciences and social sciences appears to stem in part from the wider challenges posed by the operationalization of the theoretical notion of exposome (Rappaport and Smith 2010; Rappaport 2011; Wild 2012).

 he Medical Definition of a Disease Is Always T a Social One From the externalist point of view of the social construction of diseases, reducing key determinants of health to “a single cell” appears just as irrelevant. Let us look, for example, at the 1930 definition that led to the nosological foundations of silicosis. To this day, there is still no consensus as to the very existence of this respiratory disease provoked by the inhalation of crystalline silica (the main mineral component of the earth’s crust), although it can be tracked down to the Antiquity. In its acute form (lethal in the short term) as in its chronic form (evolutional, crippling, and also potentially lethal), it is an incurable disease. In the early twentieth century, under the effect of the industrial revolution and the development of the mining industry, it affected millions of workers, in particular, in deposits where rocks had a particularly high silica content such as the Witwatersrand gold mines. A pioneer in matters of legislation (as early as 1912, vs. 1945  in France), medical care, and social insurance, South Africa (or rather, its mining industry) hosted a major international conference in Johannesburg in 1930, in partnership with the International Labour Office (ILO). After two weeks of debates, the international experts gathered at the conference literally voted a definition of the disease, which has since then become part of established medical knowledge. The disease was broken down into three stages, the first of which was defined by breathing difficulties, shortness of breath during effort, and radiographic opacities. This could seem like the most factually medical definition possible. However, it should be reminded that silicosis is the deadliest

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occupational disease in history and that this definition was dictated by the concern, expressed by South African mining corporations and social insurance institutions, with minimizing financial compensation claims. The “medical” definition of silicosis, which was disseminated widely after 1930, is therefore a transposition of medico-legal insurance frameworks set by South African social security. The three “medical” stages of silicosis that were eventually adopted literally eclipsed the earlier stages of the disease that had been identified so far (Rosental 2017) and which could (or should) have, from a medical perspective, been maintained as part of a purely nosological approach. This so-called medical definition was also racialized. Under diverse forms depending on the country, the industry operated a dual segregation of the workforce between “exposed and relatively protected” workers, and “exposed and poorly protected” workers. Silicosis was defined in the 1930s as a chronic disease that results from long-term and medium-­ intensity exposure to crystalline silica: this definition was based on the average working conditions that applied to white workers in the Transvaal. But this definition left out the working conditions of Black workers, who were literally made invisible in the 1930 conference. These workers’ exposure to silica was very different in nature—both more intense and shorter—and its medical consequences were less monitored. Black workers were more mobile, working under short-term contracts and relegated into substandard housing. They were also massively affected by tuberculosis, which in conjunction with silicosis has severe deleterious effects on respiratory health. While the utilitarianism, not to say the cynicism, that presided over the construction of this restrictive definition of silicosis is reminiscent of the “agnotological” mechanisms described by Robert N.  Proctor  and Londa Schiebinger, this shouldn’t provide a ground for systematic historical paranoia (Jas 2015; Girel 2013, 2017). Ignorance (in this case, the invisibilization of Black mining workers and their health) is not always, or not only, the product of deliberate strategies. However, this example provides a striking illustration of the need for a social history and a sociology of knowledge. Implicitly constructed as a “white” disease, silicosis (along with the other forms of pneumoconiosis that were deliberately left out of the Johannesburg conference) confirms the idea that race is neither

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a biological given—which is obvious—nor a pure construct. As suggested by Magali Bessone (2017: 134), “deconstructing the naturalistic illusion and stating that racial categories are meaningless fictions are … two different acts. The fact that races are not natural kinds does not necessary mean that they do not exist”. Based on these premises, what research tools can the social sciences bring to a collaboration with biomedical science, and for what purposes?

 hat Epistemology and Methods Should W the Social Sciences Follow? Over the past few decades, biomedical science has unraveled the biologizing construction of race, previously established by those that Magali Bessone refers to as “toxic naturalists”. Bessone reminds us that in 1972, Richard Lewontin demonstrated that two human individuals selected at random shared 99.9% of their gene pool and that out of the remaining 0.1%, 6.3% were caused by the diversity between traditional racial groups (phenotypical and geographic criteria) while 85.4% concerned differences between individuals belonging to one same continental population group. As a consequence, “there is no convergence of properties shared in common between members of one race and not the others; a logistician can always distinguish the class of ‘negroes’ from that of ‘white men’ but the naturalist is unable to identify a system of independent and uniform differences that could be associated with difference in color in a significant manner, and which could not be explained by a few (primary) genetic differences” (Bessone 2017: 126). Lewontin concluded that “racial classification has virtually no genetic or taxonomic significance”. Today, while these findings are widely known, it is surprising to notice the lack of reflexivity in biomedical research when using categories such as “Caucasian” or “Black”. Although medical science has invalidated long-rooted naturalizing prejudice, this very discipline continues to use racial categories as if they were “things”. In contrast, while social science has taken on board the scientific delegitimization of race, it is questioning the usefulness of this notion to

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decipher social experiences, and in particular experiences of discrimination. Pap Ndiaye is not very far from Magali Bessone when he suggests to distinguish between race as an object, which is meaningless, and race as a notion, which is useful to capture certain social experiences (Ndiaye 2009: 39). In this context, how can the social sciences work with biomedical science? Is it possible for these disciplines to both use the word “race” (the same could apply to “sex”), while imbuing the term with compatible meanings? We will attempt to answer this question by resorting to an approach that is both instrumental and constructionist. We have been working with several hospital teams who are experts in autoimmune or systemic diseases (national reference centers or skill hubs), where we elaborated survey tools borrowing from the usual methods of biomedical science, including the main aspects of the statistical protocols established by both epidemiologists and biostatisticians, such as case-control studies. As is the case in medicine, our survey treats race (or sex) as a “thing”, a variable that is not questioned. However, some aspects of our survey methods and protocols also derive from a constructionist approach that is more familiar to social scientists. First, the questionnaire used with patients (and controls) to assess their exposure to crystalline silica and other inorganic particles was in most cases conducted (either face-to-face or by phone) by a sociologist, and not a physician. The physicians who conducted the survey were trained beforehand in interview methods, including on how to get the respondent to expand on their statement, or to rephrase a question that has been misunderstood. These interview conditions can make a considerable difference to the responses collected, as shown by this simple observation: when junior doctors tested the questionnaire on their own, they reported that interviews lasted for an average of 15 minutes; but when the interviews were completed by a sociologist, their average duration was 45 minutes. In the second case, the section of the questionnaire dedicated to close-ended questions was not only administered in a more interactive manner but also complemented with additional, more open questions on the person’s professional and residential record, to encourage them to remember potentially brief or forgotten episodes that could be associated with their

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exposure to inorganic particles (for instance, living for several months near a construction site that generated a lot of dust). The questionnaires implemented in the SILICOSIS fieldworks differ in three ways from those used in medical surveys: (1) Respondents are asked  about their (potentially toxic) exposure, their health status, living conditions, and income. Such elements are unusual in medicine where the focus, aside from “biological” instrumental variables such as sex or age, is mostly on variables that are regarded as descriptive or significant in terms of diagnosis (e.g. antibody levels). (2) Medical surveys usually attempt to code the respondent’s profession as far as possible, using pre-existing aggregated categories such as the French socioeconomic categories (“professions et catégories socioprofessionnelles”5). “Expology”,6 which has been developing in relation with epidemiology, tends to look beyond this approach by considering more concrete and descriptive aspects, documenting a person’s exposure to potentially toxic products. The SILICOSIS project takes this approach to a more systematic level, with multiple questions on gestures, products, or potential protections, using a language that is both lay and technical, to encourage respondents to remember and identify situations they may have experienced. The questionnaire uses the contribution made by the sociology of work to the definition of “activity” (Friedmann and Naville 1961), to screen for exposure factors in a way that epidemiologists would refer to as “sensitive” (but not too much) and “specific” (as much as possible). The aim is to avoid under-detecting (sensitivity) the exposure factors that we are seeking to objectivize, while targeting precisely (specificity) the relevant factors for the study. (3) Finally, the SILICOSIS surveys address exposure to inorganic particles in an occupational as well as an extra-occupational environment, which involves adopting a “gender” perspective on the “sex” variable. To our knowledge, this aspect of the project has no equivalent in existing research.7 This questionnaire opens up new perspectives by breaking down the boundaries between environmental health and occupational health. This opposition dates back to the advent of

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occupational health as a medico-legal category in industrialized countries around 1900. Investigations conducted on the issue of asbestos have shown the limitations of this approach by revealing the existence of a domestic contamination affecting the wives and children of exposed workers, for instance, when the man’s work clothes were shaken, washed and ironed at home (Gibbs et al. 1990; Bignon et al. 1989).

Cross-Disciplinary Findings While asking epidemiologic and medical questions, our social science approach presents a number of specificities, both in its methods and in its findings. This is illustrated by one of the studies conducted as part of the SILICOSIS project. The PEDIASARC study addresses pediatric sarcoidosis. Delivered in collaboration with the Centre de Référence des Maladies Respiratoires Rares, it studied the cohort of RespiRare patients. Out of 10,000–20,000 patients affected by sarcoidosis in France, RespiRare lists only about 50 whose condition began in their childhood or teenage years (Valeyre et al. 2014). As social scientists, we immediately considered that these statistically unlikely patients amounted to what Grendi describes as the “normal exception” (Grendi 1977) and that in this specific instance, these cases were likely to magnify some of the more general traits of this particularly complex pathology. A total of 31 interviews were conducted with the children who were available. Our first observation was that Black patients accounted for the vast majority of this group, if by “Black” we refer to individuals born (in France or Africa) from parents who originate from sub-Saharan Africa or the Caribbean: only two were born from French-born French parents; and three had one French-born parent and one parent born in North Africa. The parents of the other 25 were born abroad or in a French territory of the Caribbean, and out of these, 21 had at least one parent who was born in sub-Saharan Africa or the Caribbean.

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This characteristic exacerbates one relevant trait for adult sarcoidosis, which is by far the most frequent form of the disease. Black people are described by medical literature as forming a majority of patients, but not in such overwhelming proportions. Social sciences invite us to question this discrepancy: rather than (or in addition to) being the product of specific physiological mechanisms, is it not the product of specific socio-­ environmental contexts, which the study of the “extreme” population group of young patients could help objectify? This question is compatible with a hypothesis that is currently discussed in medical literature: the “epidemic” of sarcoidosis or sarcoid-like pathologies in 9/11 search and rescue forces in Manhattan have been raising questions as to the possible role of inorganic particles (the emissions of which they were massively subjected to) in the onset of this idiopathic disease (Jordan et al. 2011; Crowley et al. 2011; Newman and Newman 2012). The study comprised two parts: a questionnaire retracing the young patients’ exposure from their birth to the discovery of their condition, by recalling their successive homes, their exposure to risk, and the activities (both occupational and extra-occupational) practiced by their close relatives; in parallel, a longer and more open-ended interview which could help the respondents remember their individual and family life story and addressed the history of their condition. The sources of exposure screened for in this questionnaire include chiefly silica but also other inorganic and organic particles such as wood, diesel particles, or mold, which are mentioned in epidemiologic literature in relation to a potential “cocktail effect”, in association with other particles. The first finding of the PEDIASARC study is that this population, described by physicians as comprising a majority of Black individuals, appeared to the sociologists (who wherever possible conducted the interviews in the patients’ homes) as living and having lived in conditions of high, not to say extreme, socioeconomic deprivation. Cramped and substandard accommodation, often located near a large roadway (highway or urban ring road), often overcrowded due to a polygamous family structure, and others, constitutes some of the striking recurring features in the interviews. As well as providing a new perspective on the young patients’ Caribbean or sub-Saharan origins, this finding, which results from observations completed outside of a hospital setting, away from the doctors’ eyes, challenges the

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presumably “genetic” nature of the factors of sarcoidosis, which is described as more frequent in sibling groups. These sociological findings are medically relevant. And yet, no social characterization of the populations affected by sarcoidosis and other systemic diseases was ever conducted, save for a few rare exceptions (Arnaud et al. 2014; Jamilloux et al. 2016). An unsettling parallel could be drawn with the social epidemiology of lead poisoning (Fassin 2003, 2005). One of the young adults surveyed as part of the PEDIASARC study did actually report that in addition to sarcoidosis, he had also suffered from lead poisoning for having “eaten the wall” (i.e. the peeling paint that was accessible from his cot). Pediatric sarcoidosis could thus be referred to as a “Black condition”, to quote the words of Pap Ndiaye (2009)—where “condition” signifies both an illness and a person’s social background. This observation points at a specific social experience that arises out of social (socio-environmental) inequalities between “races”, whose definition could in this case highlight inequalities in accessing decent housing. The second key finding of the PEDIASARC study is that it reveals notable forms of exposure to inorganic particles: breathing in talcum powder or cleaning powder, ingesting chalk or soil, living near a dusty construction site or a large roadway or extreme life events (clandestine migration on an overcrowded boat in poor hygiene conditions, the deathly collapse of a house, etc.). These factors are combined with the fact that the patient’s parents have throughout their careers been themselves exposed to inorganic or toxic particles (industrial cleaning, packaging and cardboard wrapping in warehouses, etc.). This qualitative observation of cumulated exposure factors calls for an important comment, from both a methodological and an epistemological point of view. Our hypothesis is that we are highlighting a social dimension of sarcoidosis, so far bypassed by literature. This opens up onto a wider critique of social inequalities in terms of health, similar to those observed in the United States since the 1980s by popular epidemiology and environmental justice studies (Brown 1997; Hoover et al. 2015; Wylie 2018; Allen et al. 2019). However, for lack of a source that could enable us to establish a statistical study of the forms of exposure to inorganic particles with a population-based survey of children and teenagers, we are forced to test this hypothesis by using comparative quantitative elements.

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In this context, we can say that our research uses “racial” characteristics as instrumental, while at the same time opposing the instrumentalization that these characteristics are subjected to in epidemiology. These categories are instrumental, just like they could be in an epidemiology study (case-control study), in the sense that we actively recruit “controls” (matched on sex, age, and “race”) to evaluate the extent to which the young patients’ exposure levels (1) are abnormally high; (2) can be quantitatively associated to their being “Black”. This process is also critical in itself and opposes the instrumentalization operated in a “standard” epidemiological study, since its objective is to produce a—heuristic—translation of “race” in terms of inequalities in socioeconomic living conditions.

Conclusion: Toward New Social Classifications The object of our approach is not to invalidate the hypothesis, which stems from population biology, of the etiological relevance of “racial origin” as a variable. Rather, we seek to determine to which extent the empirical findings, in which this variable manifests itself, can be interpreted a priori. The point where biomedical science “draws conclusions”, or rather, stops its progress, by considering that the study is complete as soon as risk factors have been identified, is the point where social science picks up the work: this field refuses to simply regard “race” (or “sex”) as an explanatory “black box”. Instead, social science must strive to establish new social classifications. Pap Ndiaye (2009) imagines a faraway future when skin color will no longer be more discriminating than eye or hair color. We can only hope that one day, socio-environmental classifications will replace the reification of social categories that form the ground for discriminatory social relations. In recent years, research has been conducted into the development of integrated indicators of social health inequalities (Rey et  al. 2009). In the United States, the development of environmental justice issues (Laurent 2017) also suggests that new empirical materials will in the future contribute to this purpose, while remaining consistent with the social foundations of epidemiological investigation (Winslow 1920). A possible way forward can be found for processing these materials if the

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social sciences, biomedical sciences, and epidemiology work together, pooling their methods and findings.

Notes 1. These two traits do not necessarily overlap. For instance, systemic lupus is more prevalent in Black populations and females, while sarcoidosis is only more prevalent in the former (Valeyre et al. 2014). 2. The notion of epidemiological transition has been criticized for its evolutionism, which contrasts with the great diversity (and even, the divergence) of today’s epidemiological configurations. See Vallin and Meslé (2013). 3. For a presentation of this triangle, see: https://cursos.campusvirtualsp. org/mod/tab/view.php?id=23154. 4. This chart can be found at https://www.encyclopedie-environnement.org/ societe/exposome-sciences-sociales-rencontre/. It is inspired by Wild (2012). 5. French equivalent of the UK NRS social grade, for example. 6. Exposure assessment is a discipline per se, built on the foundations of industrial hygienism, very preeminent in the work of national health agencies, and represented by numerous journals. 7. Other questionnaires designed to screen for exposure (to crystalline silica in particular) such as the Australian OccIDEAS questionnaire used with the AWES cohort (Darcey et  al. 2016) only consider occupational exposure.

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Arnaud, L., Fagot, J.-P., Mathian, A., Paita, M., Fagot-Campagna, A., & Amoura, Z. (2014). Prevalence and Incidence of Systemic Lupus Erythematosus in France: A 2010 Nation-Wide Population-Based Study. Autoimmunity Reviews, 13, 1082–1089. Bessone, M. (2017). Quel genre de groupe sont les races ? Naturalisme, constructivisme et justice sociale. Raisons politiques, 66, 121–142. Bignon, J., Peto, J., & Saracci, R. (1989). Non-Occupational Exposure to Mineral Fibres. Geneva: IARC (WHO). Brown, P. (1997). Popular Epidemiology Revisited. Current Sociology, 45(3), 137–156. Crowley, L.  E., Herbert, R., Moline, J.  M., Wallenstein, S., Shukla, G., Schechter, C., & Skloot, G.  S. (2011). Sarcoid Like’ Granulomatous Pulmonary Disease in World Trade Center Disaster Responders. American Journal of Industrial Medicine, 54, 175–184. Darcey, E., Carey, R., Reid, A., & Fristchi, L. (2016). The Australian Work Exposure Study (AWES): Carcinogen Exposure in the Agriculture Industry. Canberra: Safe Work Australia. Dubois, M., Guaspare, C., & Louvel, S. (2018). De la génétique à l’épigénétique: une révolution ‘post-génomique’ à l’usage des sociologues. Revue française de sociologie, 59(1), 71–98. Fassin, D. (2003). Naissance de la santé publique. Deux descriptions de saturnisme infantile à Paris (1987–1989). Genèses, 53, 139–153. Fassin, D. (2005). Le sens de la santé. Anthropologie des politiques de la vie. In F. Saillant & S. Genest (Dir.), Anthropologie médicale. Avantages locaux, défis globaux (pp. 383–399). Québec/Paris: Presses de l’Université de Laval. Fleck, L. (1979). Genesis and Development of a Scientific Fact. Chicago: The University of Chicago Press. Friedmann, G., & Naville, P. (1961). Traité de sociologie du travail. Paris: Armand Colin. Gibbs, A. R., Griffiths, D. M., Polley, F. D., & Jones, J. S. P. (1990). Comparison of Fiber Types and Size Distributions in Lung Tissues of Paraoccupational and Occupational Cases of Malignant Mesothelioma. British Journal of Industrial Medicine, 47, 621–626. Girel, M. (2013). Agnotologie: Mode d’emploi. Critique, 799, 964–977. Girel, M. (2017). Science et territoires de l’ignorance. Versailles: Quae. Grendi, E. (1977). Microanalisi e storia sociale. Quaderni Storici, 12(35), 506–520.

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Hoover, E., Renauld, M., Edelstein, R. M., & Brown, P. (2015). Social Science Collaboration with Environmental Health. Environmental Health Perspectives, 123(11), 1100–1105. Jamilloux, Y., Maucort-Boulch, D., Kerever, S., Gerfaud-Valentin, M., Broussolle, C., Eb, M., Valeyre, D., & Sève, P. (2016). Sarcoidosis-Related Mortality in France: A Multiple-Cause-of-Death Analysis. European Respiratory Journal Express, 1(10). Jas, N. (2015). Agnotologie. In C.  Gilbert, E.  Henry, J.-N.  Jouzel, & P.  Marichalar (Dir.), Dictionnaire critique de l’expertise (pp.  33–40). Paris: Presses de Sciences Po. Jordan, H. T., Stellman, S. D., Prezant, D., Teirstein, A., Osahan, S. S., & Cone, J. E. (2011). Sarcoidosis Diagnosed After September 11 2001 Among Adults Exposed to the World Trade Center Disaster. Journal of Occupational and Environmental Medicine, 53(9), 966–974. Laurent, É. (2017). Reconnaître, en France, l’inégalité et la justice environnementales. Actuel Marx, 61, 64–78. Lewontin, R. C. (1972). The Apportionment of Human Diversity. Evolutionary Biology, 6, 381–398. Mendelsohn, A. (2002). “Like All That Lives”: Biology, Medicine and Bacteria in the Age of Pasteur and Koch. History and Philosophy of the Life Sciences, 24(1), 3–36. Ndiaye, P. (2009). La condition noire. Essai sur une minorité française. Paris: Gallimard. Newman, K. L., & Newman, L. S. (2012). Occupational Causes of Sarcoidosis. Current Opinion in Allergy and Clinical Immunology, 12, 145–150. Niewöhner, J. (2011). Epigenetics: Embedded Bodies and the Molecularisation of Biography and Milieu. BioSocieties, 6(3), 279–298. Omran, A.  R. (1971). The Epidemiologic Transition: A Theory of the Epidemiology of Population Change. The Milbank Memorial Fund Quarterly, 49(4 Pt. 1), 509–538. Parascandola, M. (2004). Two Approaches to Etiology: The Debate Over Smoking and Lung Cancer in the 1950s. Endeavour, 28(2), 81–86. Parascandola, M. (2011). The Epidemiologic Transition and Changing Concepts of Causation and Causal Inference. Revue d’histoire des sciences, 64(2), 243–262. Peretti-Watel, P. (2004). Du recours au paradigme épidémiologique pour l’étude des conduites à risque. Revue française de sociologie, 45(1), 103–132.

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10 Conclusion: Measurement as an Ontological Scalpel Ingrid Voléry

The contributions to this book identify different measurement styles that vary according to the socio-historical context and to the situations of interaction or expertise in which they are deployed. Far from being immutable and homogeneously shared practices, these styles can be regarded as so many ways of “seeing” and “doing” with the world, constantly tested by different groups that aggregate or disaggregate around these measurements, thus producing new ontologies. New parts of the body and new life forms (pre-fertilization, post-death) acquire social density from the moment that they are observed and standardized. The cases examined through the contributions illustrate that metrologies are indivisible from ontogenies, which this conclusion will explore in more depth.

I. Voléry (*) Laboratoire Lorrain de Sciences Sociales, Université de Lorraine, Nancy, France e-mail: [email protected] © The Author(s) 2020 I. Voléry, M.-P. Julien (eds.), From Measuring Rods to DNA Sequencing, Health, Technology and Society, https://doi.org/10.1007/978-981-15-7582-2_10

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Metrologies and Ontogenies Five measurement styles can be distinguished from the contributions— although this list is not exhaustive.

 arly Nineteenth Century: The Revelation of Forms, E Comparative Anatomy and the Quest for Origins The first style of measurement, studied in Voléry and Diasio’s contributions, is based on the observation and comparison of human bodies perceived as a “whole”.1 It focuses on the bodies’ singularities—whether those stem from their physical and moral characteristics, their physical environment or the social situations in which they are observed. This exploratory model was deployed in a specific context. From a scientific point of view, this measurement style developed in a context marked by the prevalence of a humoralist and environmentalist vision of the human body, the influence of preformationism and the development of comparative anatomy. The first chapters of this book show how the eighteenth century and the first two-thirds of the nineteenth century were marked by a vision of the body that amalgamates the somatic and the moral. The human body was considered as embedded in its environment. The perspective was at first cosmogonic in Hippocrates’ and Galen’s writings (symbolic relations between the body and the cosmos), then geophysical in the eighteenth century (when the focus is placed on climate, winds and the diet) and biochemical in the late eighteenth century. For instance, according to Buffon, “the color of the flesh proceeds from that of the blood, and other humors of the body, of which the quality is necessarily influenced by the nature of the nourishment” (Buffon 1749a: 481). In parallel, the eighteenth century was still suffused with preformationist theories which, in contrast with epigenetic thinking, saw each living being as the product of an original creation (whether divine or not). Buffon, for instance, predicates the existence of an “internal mold” (“moule intérieur”), which explains the continuity of form in species, and sets the foundations for genealogical thinking, examined in Diasio’s

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contribution. The human species is approached through the search for a shared foundation and for resemblances in form, from which relations of kinship can be deduced (Buffon 1749b: 35). Ultimately, this quest for resemblance and dissemblance converged with the methods promoted by comparative anatomy, whose methods were fine-tuned over the first half of the nineteenth century. The observation of skulls, faces, orifices and stature was complemented by the measuring of organs, bones and tissues, facilitated by the dissemination and social normalization of dissection practices.2 The “internal mold” was then examined internally, looking at the size, texture and color of organs. The serialization of these forms required the anatomist’s moral superiority and trained eye. From a political and social perspective, comparative anatomy developed in the particular context of a quest for the origins of humanity, scrutinizing the past for the causes of natural and social laws. For example, in Chap. 2, Diasio studies how anthropometric measurement and observation intensified at a time when the “scale of beings” was jeopardized by uncertainties regarding the origins of humanity. Sommer (2016) shows that in the late nineteenth century, the invention of the “MOA” (regarded as the species’ missing link) found its significance in a context where the urbanization of North American society raised fears of a disconnection from the wilderness and of a loss of vitality in modern man. How can human beings be characterized and distinguished from animals? How can their alterations be approached? The eighteenth century and first two halves of the nineteenth century were thus pervaded by issues surrounding identification: identifying species (see Diasio Chap. 2 in this book), but also identifying individuals in a context of political tensions and growing population mobility, as shown by Voléry (Chap. 3 in this book) in the case of forensic medicine. By looking to the past for the meaning of forms, this style of thinking carries a particular understanding of ontogenesis: it is seen as the expression of laws contained in the human from the moment of its conception, and whose nature can be transformed by its social, moral and geographic environment. This particular vision guides the observation of certain aspects of the human body (seen as fragments that can provide access to the past of the species: skull, orbital cavities, etc.) and is associated with a particular perception of time’s deleterious effects on organisms. Time can cause the degeneracy or

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alteration of an ideal original form (Doron 2016a) or be a vector of perversion, as the physical and moral aspects of the human are tightly articulated, and connected to the environment and lifestyle.

 he Deployment of Forms: Straightening T and Fortifying The last third of the nineteenth century saw the emergence of a second measurement style, whose focus shifted from the revelation of forms (which preexist from birth or from the origins of humanity) to the deployment of forms through which a living organism becomes human. This led to a change in the gaze projected upon the human body, which can be detected, for example, in the transformation of the embryo’s biomedical status. Perceived from this point as matter that assumes form over the course of gestation, the embryo became invested with different medical, legal and social values, as shown by Voléry in Chap. 3. The emphasis shifted from identification (of the species or the individual) to development. This perspective also went along with new processes for the exploration of the living world, involving new observation methods and quantification systems. Anatomical observation, thus far used to detect past kinship, then aimed to identify developmental stages and standardize them by using measurement. Form, no longer a pre-existing given, was considered in its deployment. Human maturation and its connection to the environment were reassessed: as the idea that the living world is governed by autonomous laws became more prevalent, the action of the environment was increasingly regarded as indirect and less decisive. Contributions to this book identify two distinct models that preside over the mathematicization of life.

 traightening Up the Body: The Direct Mechanical Action S of the Environment A first environmentalist perspective, which emerged in the late nineteenth century, considers that the body is mechanically shaped by its

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environment. In the writings of late nineteenth-century forensic pathologists and hygienists, living places and lifestyles are approached as technologies that can be used to fortify the population (Voléry, Chap. 3). Voléry’s analysis of forensic medicine treatises converges with Parayre’s research (2011) on school medicine during the same period (1882–1900): the emphasis is placed on spatial organization, which has the potential to influence children’s physical and moral aptitudes, in a period concerned with the vigor of future generations. For instance, Jules Uffelmann’s “Manual of the Domestic Hygiene of the Child” (1889) tackles issues such as school furniture, which causes children to hunch down, thus deforming their spine and provoking the “schoolboy’s goiter”, or heating in classrooms, a source of physical and moral languidness. On the contrary, Uffelmann recommends an education based on physical and moral rectitude and inspired by military practices: the objective is to build up the children’s character and “sense of beauty, to sharpen their senses, to hone their judgement and to rectify any vicious tendencies” (Uffelmann 1889: 9), but also to fortify their muscles to “straighten up their bodies, increase their thoracic capacity and improve the organism’s overall resistance” (Uffelmann 1889: 453). This focus on the deployment of form and on the straightening of the body also explains the importance given to bone development, which is regarded as irreversibly imprinted by the postures taken on during prime infancy: The shape of the spine at birth is by no means the same as in later years. The back becomes doubly curved by the weight and posture of the body over the course of life. … The curve of the cervical portion of the spine, when the child in the third month tries to lift up its head … while the permanent curve of the lumbar portion of the spine results from the efforts of the child to stretch its legs. … Mechanical factors, therefore, always play a part; muscular exertion, weight of the head upon the spinal column; the change in the spinal column is one forced upon it, not actively assumed by it. The hygienist’s task is to ensure that this change is effected physiologically and does not go beyond the limits assigned to it. (Uffelmann 1889: 438)

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In school medicine as in forensic medicine, the spine becomes a “developmental calendar”, used by forensic medicine to deduct the body’s chronological age and by school medicine to straighten up bodies and minds. In this perspective, if shaped by a human intervention, the environment can act upon the body in a direct, singular and non-­probabilistic manner. As demonstrated by Foucault in his study of anatomo-politics (1975), bodies are straightened up through targeted interventions, of a mechanical rather than a chemical nature. This process engages the bones, muscles and nerves and involves measurement tables and descriptive statistics rather than probabilities. It is an irreversible process: once a shape has been imprinted, it persists—in contrast with the measurement styles associated with contemporary epigenetics, which depicts the body as plastic and the effect of the environment as reversible. The passive subject is put through straightening measures and while some statistical knowledge is necessary to determine the average curvature of the spine, the straightening process itself is singular. During the same period, another model based on biochemistry begins to emerge.

 ortifying the Population: The Probabilistic Chemical Action F of the Environment This distinct measurement model observes the body on a different scale. The body as a “whole”, made of organs, tissues and bones connected by mechanical bonds, is now approached through cellular “fragments” connected by chemical processes. In Claude Bernard’s writings, the human body is compared to a “hydraulic” machine, governed by homeostatic principles (the equilibrium of the “milieu intérieur”). Vital phenomena are first and foremost approached as chemical activity. This approach reconfigures the relations between the disciplines that form part of life science—with chemistry taking precedence over other medical specialisms—and transforms the appreciation of observation methods. For example, Bernard’s vision of experimental medicine, centered on laboratory-­based vivisection, contrasts from contemporary practices:

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In leaving the hospital, a physician … must go into his laboratory; and there, by experiments on animals, he will seek to account for what he has observed in his patients, whether about the action of drugs or about the origin of morbid lesions in organs or tissues. There, in a word, he will achieve true medical science. (Bernard 1957 [1865]: 146–147)

Human development involves autonomous vital processes, both chemical and tissular: the observer’s gaze and subjectivity are no longer seen as levers that facilitate the understanding of the living world, but on the contrary as useless and potentially harmful information. The influence of the environment is regarded as limited, indirect and probabilistic. In his analysis of Darwin’s rupture from evolutionary biology’s environmentalist theories, Méloni (2017) notes that in the second half of the nineteenth century, the physical and social environment was seen at most as a regulating force whose effects are fluctuating and unpredictable: probability and statistics replaced measurement tables. The controversies of the late 1990s around precocious puberty (Vinel, Chap. 8) still bear the trace of this vision. The body, no longer a “whole”, is perceived as fragmented and driven by the universal laws of biochemical development. It is observed through probability-based standards that are disconnected from the social contexts and body types that were initially used to produce them. Whether based on mechanical or chemical principles, this understanding of development blossomed in a particular political context, where the effort to understand the human and societies was no longer turned to the past but to the future, with a strong belief in scientific and social progress and in an upward developmental curve. This political vision of the evolution of societies was projected on human bodies: the ambition was to measure the development stages reached by the body while either straightening it up (mechanical action) or fortifying it (chemical action), to ensure that it met the statistical standards of organic maturation. Identification, which had played an essential part in the first measurement style based on the revelation of forms, gave way to fortification and to the search for universal development standards, which can be applied to the somatic and later to the psychic (Armstrong 1983). This tendency can be observed in the measurement of discernment by forensic medicine

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and the psychiatric assessments of the early twentieth century, but also in the measurement of subjectivity during puberty in the 1980s (Vinel, Chap. 8), or during the “end of life” (Maglio and García, Chap. 4). Organic measurement then becomes closely intermingled with political and temporal norms, involving a particular vision of human existence and social time.

 enetic Mapping in the 1970s: Molecularized Bodies, G Fixed Laws of Life and Individual Responsibility The third metrology that emerges from the contributions to this book introduces an additional level of detail by zooming in from the tissular to the cellular and later the genomic scale (Duster 2005; Fullwiley 2007). Built on the foundations of early genetics,3 this thinking style “molecularizes” the body, in line with the thesis of the autonomy of life, first introduced by biochemistry in the late nineteenth century. A person’s genome, governed by laws of its own, is definitively determined at birth. With its representation of the organism as unsusceptible to the social and physical context, early genetics paved the way for fixist taxonomies. This third thinking style however involves two major shifts. First of all, as shown by Armstrong (1983), genomic measurement forms part of the body of disciplines referred to as survey, which developed after World War II. Not only did these disciplines redefine normality in probabilistic term,4 but they also changed the interpretative framework for vital phenomena: these were no longer approached through their pathological singularity, but instead in comparison with other vital phenomena measured in other bodies belonging to a given community. In the mid-twentieth century, the environment thus became represented as a likely social space (the normality of growth or morbidity rates is defined with relation to a social control group constructed by the researcher). Secondly, this measurement style inflects the moral outlook on the person who, with their DNA deciphered, is expected to anticipate any detected vulnerabilities or future pathologies. This shift introduces a moral economy of risk and prevention. In Chap. 5, Déchaux analyzes the perception by patients, their families and some health professionals of

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populational probabilities as individual certainty. A new mathematicization of life comes into play: as with the maturation charts of the early twentieth century, the aim is to standardize the probable, whose control becomes an individual moral responsibility. Armed with the knowledge of the main milestones of their future health, individuals are now expected to become actively involved in the control and improvement of their own life—particularly with the introduction of the first genome editing technologies. With tools such as CRISPR-Cas9 gene editing, the genome, initially viewed as a fixed and irreversible body to be deciphered, becomes an organism that can be manipulated. This vision of the human body as plastic is at the core of the fourth thinking style identified around the notion of epigenetics (Cavalin et al., Chap. 9).

The Body as Flux and the Plasticity of Human Life The “post-genomic genome” that forms the basis of epigenetics is essentially plastic (Landecker and Lappé 2015; Méloni 2017): it is subjected to reversible changes and is more susceptible to its social and physical “environment”. According to this measurement style, the body is made up of fluxes of proteins transferred under the effect of the environment, which can be responsible for the methylation of DNA and is itself considered from a molecular perspective. The human body is thus re-singularized: it is understood as the product of a unique encounter between the biochemical characteristics of a given organism, which can be more or less receptive depending on “windows of exposure”, and those of a specific environment. This perspective also explains why this second wave of genetics partly diverges from database-driven probabilistic and computational analysis. Instead, it draws upon methods that derive from experimental medicine such as research on animal models or organic material handled in test-tubes, or the longitudinal monitoring of cohorts to verify the alteration of the epigenome or the potential genetic transmission of these alterations.5 Beyond this reassessment of the boundaries between the environment and the human body, another aspect is the transformation of the understanding of the body’s maturation. The developmental curve is no longer

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punctuated by thresholds whose passing is irreversible. It becomes a succession of windows of exposure during which gene-environment interactions can dramatically modify the epigenome, so much so that some of these changes can be passed on to the next generations. Epigenetics introduces new biological, institutional and biographic timelines (the pre-/ post-embryonic phases were brought onto the scientific and political agenda by research on the DOHaD hypothesis6) and create new hierarchies of the living world. As well as transforming the medical codification of time, this post-genomic measurement style also promotes a different vision of the person’s social identifications, as shown by Cavalin et  al. (Chap. 9). Sex, race, class and age become consequences of the relations between genes and the environment, rather than in-built resources or propensities—which can, in turn, encourage sociologists to draw their attention to lifestyles rather than to social propensities of the families where humans are raised. Finally, this post-genomic style involves a change in the relations of power constructed upon these categorizations. For instance, it brings about a new way of making mothers and fathers aware of their responsibilities: not so much by controlling the potential effects of an immutable genome, but by acting on lifestyles that can impact its expression. In Germany, in the field of obesity prevention, Jorg Niewöhner (2011) observes, for example, the emergence of “prevention pariahs”: for these groups, awareness campaigns have been replaced by active lifestyle supervision. While “activable” groups are targeted through nutritional education, those deemed incapable of activating themselves have their fridges locked up. While the first genetic metrology introduced standards of somatic responsibility, the second wave of genetics structures another form of social inequality: one the one hand, those who have access to the activation dispositifs of contemporary biopolitics; on the other, those who fall under the disciplinary policies of the places where they live (Table 10.1). The emergence and deployment of these five styles give rise to two comments. First of all, although over the second half of the twentieth century, statistical tests were considerably fine-tuned thanks to computational technologies, which have mechanized statistical calculation, the quantification of life is an ancient and complex practice. The question that arises

Understanding of human maturation

Analysis of organism-­ environment relations

Epigenome, shaped by living conditions, determines developmental windows of exposure Developmentalist Developmentalist thinking thinking Search for universal Search for universal characters of characters of human human development development Quantification of Quantification of deviations from the deviations from the norm in a population norm in a group population group in a specific environment

Deployment of forms

Genetic map determining developmental patterns

Indirect, weak, probabilistic biochemical action

Singular, direct, non-probabilistic mechanical action

(continued)

Strong, direct, singular, reversible biochemical action

Molecularized body and environment

Molecularized body

Disjunction of body and environment

Late twentieth century

Mid-twentieth century

Late nineteenth century

Genealogical thinking Developmentalist thinking Search for kinship or Search for universal characters of human development filiation Quantification of the singular Deciphering of resemblances

Symbolic relations between body and environment Body and environment mutually reflect each other Revelation of forms (original creation)

Early nineteenth century

Table 10.1  The five human measurement styles

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Disciplines

Anatomy Social hygiene

Scientific context Comparative anatomy—searching for internal resemblances/ dissimilarity in conformation, inside the barrier of the skin Political context Quest for origins in reaction to challenging of the scale of species Controlling the identification of humans and persons Issues regarding the identification of space and individuals

Early nineteenth century

Table 10.1 (continued)

Detecting windows of exposure Probability Capturing the spectrum of deviations from the norm Molecular/genetic biology Computational science Pediatrics Geriatrics Public health

Comparative anatomy Anthropometry Social hygiene School medicine Forensic medicine

Experimental medicine Biochemical analysis

Epigenetics Computational science

Identifying spatiotemporal contexts for individual genetic fortification

Identifying individual genetic capitals Managing vitality on an individual scale

Mathematicizing life and sequencing its development Standardizing measurement and its management

Measuring vital phenomena Characterizing biosocial context

Measuring vital phenomena Discounting social context in favor of bioenvironmental dimensions

Measuring subjects Measuring vital in their context phenomena Straightening up in their individuals context Straightening up populations Targeting the human through growth policies/fortifying bodies Controlling the population’s vitality

Late twentieth century

Mid-twentieth century

Late nineteenth century

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is therefore how this multiform quantification is articulated with diverse measurement apparatuses. These systems vary according to the type of bodily measurement performed (Camper’s cranium drawings using a fixed grid, the values on Godin’s measuring rod, Quéthelet’s averages of measurement series, etc.), to the type of body fragments quantified, or the ways in which the data thus collected is processed and the findings are disseminated. The first thinking style combines the individual measurement of global stature with the observation of forms, textures, odors or social attitudes with Fodéré (Voléry, Chap. 3) or later Godin (Diasio 2019). The second style translates average measurements of tissues and growth rhythms into tables of figures and growth curves, or into images that emphasize the effect of truth of the “average” bodies thus fabricated (see Voléry and Julien, Chap. 7, and Vinel, Chap. 8). The genomic and post-genomic thinking styles respectively perform synchronic statistical measurements of the ties between genes which are then presented as maps (DNA mapping), or diachronic statistical and individual measurements of epigenomic alterations. However, for all the styles listed, the social and political effects of measurement do not derive so much from the act of quantification itself and its presumed tendency to commoditize or desubjectivize the human: instead, they stem from the metric or graphic assemblages of which this quantification forms part. Secondly, although this conclusion artificially outlines different metric styles, these styles cannot be regarded as consecutive episteme (Foucault 1966). For this reason, this book will not attempt to identify milestones, which would be impossible to pinpoint. Instead, it appears more relevant to discuss the heterogeneity of the social groups who contributed to the social construction of these measurement systems, and the varying uses that were made of these systems in different contexts (M’Charek 2008; M’Charek et al. 2014).

 ultiple Measurers and Social Contexts M of Measurement The contributions to this book reveal several points of discontinuity: the rise of comparative anatomy—a first attempt at mathematicizing life— with the support of anthropometry, the emergence of experimental

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medicine, on the foundations set by the biochemical analysis of the living world, the emergence of molecular biology and genetics in the late twentieth century, the alliance between systemic biology, molecular chemistry and computational science in the early twenty-first century. While these hiatuses were truly operative if we consider the approaches that were regarded as legitimate and objective by scientific, political and social institutions at a given point in time, this should not detract from the permanence of certain ways of measuring human bodies.

 easurement at the Meeting Point of Science, M Business and Art This book highlights the diversity of medical specialisms and social groups involved in the measurement of human bodies. Hygienist medicine, physical anthropology, comparative anatomy, biochemistry, forensic/colonial/school medicine, pediatrics, public health, genetics and epigenetics: very diverse corpora of knowledge, doctrines and practices have contributed in diverse capacities to the measurement of the human. However, we can also observe the existence of interrelations between the specialisms studied in each contribution7 as well as across social spaces— and in particular between the economic, political, military and artistic fields. For example, the case studies presented here show how much economic players (insurance companies, traders in exotic curiosities, etc.), the arts and the performing arts (Bancel et al. 2014) also took an active part in the standardization and representation of the human. Rose (2007) defines the era of genomics in the twentieth century through the rise of the vitality economy. However, the bioeconomy is much older and has followed diverse paths. For instance, some companies calculate insurance risk according to averages reflecting certain vital phenomena—growth, and later pathological risk, thus producing measurement tables that influenced forensic medicine manuals by Pagliani and later Lacassagne (Voléry, Chap. 3). In the late twentieth century, vital processes and economic systems were structured around the cell and the genome, with the creation of biobanks storing embryos, tumors and genes, as well as the

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industrialization of genome analysis, screening and even enhancement technologies. The molecularization of the body gave rise to new forms of commodification and sampling targeting organic matter rather than individual specimens: data banks thus replaced collections of cases. Finally, these measurement systems were disseminated not only through commercial networks (on the nineteenth century, see Bancel 2014: 315–330) but also through public policies and institutions promoting the bioeconomy (Steiner 2010; Lafontaine 2014; Colomb 2019). Once again, rather than outlining sequences of innovation that typify the specificity of each period, it appears more relevant to interrogate the transformations operated by this commodification of life itself. First of all, from a commercial and economic perspective, the various contributors to this book observe the institutionalization of relations between economic forces and producers of knowledge on human life. This institutionalization transforms the ontological status of the materials that are traded on the market. In the curiosity trade, scholars and merchants joined forces to commercialize bodies that exemplified spatial boundaries (faraway societies for which the objects that circulated with the bodies acted as reminders: for instance, the reconstructed African villages where the bodies were displayed) or human boundaries (when these bodies were displayed alongside animals who were regarded as closest to them). In the contemporary bioeconomy, scholars and industrials join forces to produce and disseminate organic materials whose value stems from the production chains that break down dead bodies into tumors, biomarkers or proteins, disconnecting them from the social groups and biographical subjects that produced them. The specimens, displayed in the Universal Exhibitions of the nineteenth century, are now replaced by organic materials, whose value no longer stems from their original social context but from the socio-technical processes used to produce them. For instance, Déchaux’s contribution (Chap. 5) shows how the value of a human embryo varies according to the type of technology used to produce it, and to the meaning of this production within a global process: is the embryo invested with meaning by professionals in support of a procreative project? Or is it regarded as material for experimental processes? In this perspective, the French draft bill on bioethics (n°2187, 24 July 2019) proposes to distinguish between the embryo and embryonic stem

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cells (Article 14) and to terminate the preservation of the cells that are not the object of a research protocol or a procreative project (Article 16): these cells are then relegated to the status of mere materials that can be used by the bioindustries. In addition to the role of the market economy, contributions to this book also show that measurement can be closely associated with aesthetic considerations. These can come into play further down the line to legitimate scientific practices or knowledges—for example, Vesale (1514–1564) referred to the codes of Greek statuary to normalize the practice of dissection, which had so far been banned. Such considerations can also be used upstream of the measurement process, as a prism through which to observe and objectivize reality. This is the case when Camper’s facial angle, which had initially been designed to capture the face’s mechanical adaptation to the weight of the cranium, was later used to assign value to “average” angles, which were deemed more adapted biologically and therefore more pleasing aesthetically (Meijer 2014). In Chaps 2 and 8, Diasio and Vinel also show how art and artistic techniques play a part in the display of data—through drawings, waxworks, photography, radiography or digital images today. Finally, artistic techniques can be used to produce scientific data—specially when they bring visibility to entities that fall outside the spectrum of human vision. This is the case with the observation of cells under a microscope (Hacking 1981), but also with Daston and Galison’s representations of “structural objectivity” as nodes in networks (Daston and Galison 2007), or with facial (re)construction as studied by M’Charek (2013). Artistic mediation was acknowledged in the seventeenth and eighteenth centuries when artists signed their drawings, and their eye was as important as a scientist’s. But it became secondary (without however disappearing entirely) in the era of experimental medicine when the focus shifted from the reproduction of an observed organic form to the mechanical recording of data and measurements (Guédron 2014). This mediation resurged in the late twentieth century, when images of the “average body” were used to back scientific “evidence” and disseminate scientific findings, as shown by the use of photography as scientific evidence in nineteenth-century anthropology and history (Sontag 1977; Morris-Reich 2016) and in twentieth-century developmental medicine. Artistic techniques were then introduced into the

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scientific field. One objective was to transcribe and disseminate scientific knowledges in a competitive environment, with examples such as the cabinets of curiosities and exotic exhibitions (Boëtsch and Blanchard 2014), or the “Hall of Man” in natural history museums (Sommer 2016).8 But the objective was also to produce scientific knowledge on entities that could not be grasped by the human eye. In such contexts, art is not seen as a mode of reproduction but rather of production. For example, the graphic visualization of the genome has become a major aspect of the genome, which cannot otherwise be seen. The history of the measurement of the human thus reflects the porosity of boundaries between science, economy and technologies.

 ombined Metrologies and Varying Measures C for Diverse Contexts While hygienism, forensic medicine and biochemistry do not deploy similar metric styles, each discipline and each observer can successively or simultaneously borrow from diverse metrologic repertoires, depending on the context and on the body type or fragment they measure. As M’Charek, Schramm and Skinner quote: “Thus, differences ascribed to specific bodies that are deemed to belong to targeted groups are made visible and readable in specific sociopolitical contexts through specific scientific and technological practices” (2014: 471). In Chap. 2, Diasio shows that the “ocular” and “mathematical” paradigms (respectively measurement styles 1 and 2) are combined when measuring the orifices of marginal bodies (Hottentot Venus or microcephales). Although measurement can lead to the questioning of resemblance, it can also support a quest for kinship (even when remote) and lend acceptability to the divisions between humans introduced by society. The choice of a metric style also depends on the situation of expertise at stake (M’Charek 2013). This is apparent in Voléry’s study of late nineteenth-­century forensic medicine manuals (Chap. 3) where a forensic physician can resort to different styles depending on the scene of intervention (forensic assessment or hygiene treatise). This is also apparent in contemporary intensive care units, where multiple micro-settings

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can be observed depending on relationships (between colleagues, with the patients’ families) or on the presumed moment in the patient’s trajectory (Denise, Chap. 6). As Mol quotes (1998, 2002), the body can be quantified and reduced to a flux of vital signs monitored and communicated by professionals, as the patient is integrated into a biopolitical system aimed at ensuring survival and restoring life. However, when it lapses into the regime of thanatopolitics governed by different moral standards, the body is observed and singularized by the nurses. As soon as the patient enters the end-of-life phase, he or she is re-subjectivized through the display of intimate objects associated with his or her biography. This last example shows that measurement is not only a technology that exists independently of the measured entity. It also produces ontologies that exceed the mathematical or graphic artifacts through which the person is represented.

Measurement as an “Ontological Scalpel” The metric styles considered in this book are associated with particular ontologies. Upstream of the measuring process, these metric styles are based on a specific understanding of the nature of the entities that are being measured or observed. However, downstream of the process, measurement also contributes to transforming these entities or to producing new ones. The contributions to this book also show how observation and measurement dispositifs can contribute to redefining the body parts targeted by these mechanisms. What had been invisible becomes visible. What had been silent acquires a voice—at least for those who perform the measurements in order to make the individual or species “speak out” or “testify” about their past or their likely or desirable future. This requalification literally transforms the ontological status of body fragments: formerly seen as “waste”, they become “experimental materials” and even “potential humans” in the case of the embryos as studied by Déchaux (Chap. 5). This phenomenon is also highlighted by Voléry’s study of the status of fetuses, which became autonomous from the mother’s body in a distinctive political and scientific context (Chap. 3). The emergence of biochemical analysis brought about a new vision, politically bolstered by

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the rise of natalist concerns and the increasing criminalization of infanticide and abortion. Formerly seen as a fragment of the maternal matrix, the fetus becomes an entity in its own right, endowed with a political weight. Death also underwent major transformations with the emergence of contemporary biopower. In the wake of studies on “neo-death” (Agamben 1998; Iacub 1999; Rémy and Winance 2010), Denise retraces the ontological changes driven by the devices that monitor, measure and regulate vital signs (Chap. 6). The surviving patient can become “neo-­ dead” in communications among medical professionals when his or her vital signs are declining, and then become a social subject again when professionals communicate with the patient’s family, who act as a reminder of their social status (background, career, family status, etc.) or their existence as a “human person”, a concept defined by the moral economy over the course of the twentieth century. Finally, in Chap. 4, Maglio and García show that the controversies surrounding the measurement of quality of life in highly medicalized situations have contributed to the representational and material making of “low-quality” lives, or lives “without qualities”, according to regulations on palliative care. For example, in France, biomedical measurements of the end-of-life phase (clinical and biochemical signs, decreasing score on the Palliative Performance Scale) have given rise to “terminal stage” as a category, to which the 2016 law associated the possibility of deploying continual and progressive sedation until death, or the reduction and termination of active therapeutics, including artificial feeding and hydration (Voléry and Schrecker 2018). In both cases—beginning and end of life—measurement technologies produce specific human temporalities and ontologies, which demonstrates how the measurement of life produces both temporal and human entities.

 ime, Spaces and Bodies: Producing Otherness T and Differences As suggested by Fabian (2006), the measurement styles studied in this book do not just contribute to the making of the human. They also define

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milestones, frontiers and boundaries through a dual movement of identification and othering. Identification and othering go together with the coding of time: scrutinizing the human body for traces of the evolution of the species; detecting universal development milestones within which the body can be shaped; or matching physical, social or moral qualities with the successive phases of the body’s maturation. Time plays a major part in the construction of biomedical standards, and that of social and political expectations regarding the diverse phases of human life. It also determines one of the key criteria that define the human person: its temporal continuity. Voléry’s contribution shows the major shift introduced by forensic medicine’s bone observation methods in the nineteenth century (Chap. 3). Experimental medicine and biochemical analysis deeply renewed perceptions of human maturation, of the effects of time on the person and consequently of age. While age was initially seen as a social state that individuals pass through, deeply renewing themselves with each age transition, it gradually became a physical criterion and an indicator of the individual’s position in the continuum of maturation. The measurement of the maturation of living things forms part of an overarching physiological and political vision of the person, seen as continuous and thinking physical and moral matter. This vision can be associated with the moral philosophy of the person which was very influential in France, but also with the power of “age group policing” in the West.9 Beyond age, Déchaux, Denise and Vinel (Chaps. 5, 6 and 8) show that the measurement of time, and in particular the creation of specific maturation timelines or tempos, has contributed to creating “new” bodies, along with specific rights and moral obligations. Measuring tempos forces us to consider the temporal dimension of contemporary biopolitics (Voléry and Julien 2019) and to consider the epistemic and institutional transformations that have affected philosophical and physical representations of time. The measurement of space, as well as time, is also an essential dimension in the construction of identity, sameness, difference and singularity: alien bodies exemplify the corporeal margins of humanity in nineteenth-­ century physical anthropology (Diasio, Chap. 2); bodies are altered by climates, environments or lifestyles that cause a problematic methylation

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of the DNA (Cavalin et al., Chap. 9). Bodies and spaces are also closely connected in Voléry and Julien’s contribution (Chap. 7): the abacuses used to measure bone maturation are not just political technologies, used in the context of the management of human growth or migratory fluxes. They also pose geopolitical issues of a scientific nature. This is the case when the objectivity of certain biomedical measurements is challenged because they were performed using abacuses, built from “Caucasian” bodies in the 1930s–1950s, that may not be suited to “other” populations. This example reveals a dual aspect of the geopolitics of bone. On the one hand, scientific practices contribute to creating an average “political” body defined according to its deviation from Western standards, regarded as the universal standards of human maturation, and played a key role in the construction of Western nation-states (Brownlie 2001; Wade 2007; About and Denis 2010; Voléry 2015; Jarty and Fournier 2019). On the other hand, knowledges of marginal bodies—that is, those that resist the abacuses or require mathematical adjustments—become particularized, while the researchers who produce these knowledges are relegated to subaltern positions in the international field of knowledge production on vital processes. Knowledges on human bodies thus generate political hierarchies that affect both “measurees” and “measurers”: (Western) researchers who have access to “universal” bodies (i.e., bodies that meet the standards developed in the nineteenth and twentieth centuries) are seen as producing “general” knowledge, which is assigned a higher value in the international scientific field, whereas researchers who have access to “particular” bodies are relegated to the field of “specialist” knowledges.

 nimals and Things: Toward a Shift in the Making A of Otherness? Metrologies of the human body also challenge the boundaries of the person, because they disrupt the lines of comparison with nonhumans— whether those are animals, often mentioned to define the boundaries of the human in the nineteenth century, or things in the contemporary period.

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The metrologies studied in this book examine the boundaries that separate humans from animals—in particular in the eighteenth and nineteenth centuries, with the introduction of the human into classifications of the animal kingdom and the increasing “classificatory zeal” described by Diasio in Chap. 2. The observation and measurement of orifices contributed to structuring the “scale of living beings” with the purpose of distinguishing between humans and animals, and between humans themselves. While animals are still present in the new spaces opened up by biotechnologies for the treatment or the exploration of human bodies,10 they seem to disappear from interrogations of the contemporary metrologies of the human. Human identity is no longer endangered by the animals’ vicinity. In contrast, when exploring the boundary between humans and things, metrologies of the human body become technologies that assess the degree of humanity and set hierarchies between “qualities” of human life. In Chap. 4, Maglio and García remind us how the rigid dichotomy between humans and things that forms the foundation of Western law is today considerably challenged by measurements of the human. The status of the person is now negotiated in close relation with “things”: as an ultimate consequence, the person “becomes the operator of a de-­ personalization that classifies a certain type of men under the regime of things” (Esposito 2013: 9). In debates around the measurement of quality of life in patients whose biological life is heavily medicalized, “relations between persons and things are determined by fluid boundaries. … several intermediate states exist between the two extremes formed by the person and the nonperson, which facilitate exclusion–inclusion” (Maglio and García Chap. 4: 114). This evolution reveals a shift in the modes of making otherness, in a period when anxieties no longer focus on the difficulty of distinguishing the human from the animal, but rather on the difficulty of distinguishing “human matter” from “thing matter”. This distinction becomes key with the rise of the vitality economy, which transforms the human (tissues, organs, cells, genes) into a resource that can be injected into economic processes to treat or improve other humans (Lafontaine 2014; Déchaux, Chap. 5). What distinguishes “human matter” from “organic waste” or “cellular matter” that can be marketed? Does this depend on symbolic

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status? For instance, placenta is regarded as a corporal fragment that can be removed and sold on the pharmaceutical market, without damaging the integrity of the person it comes from. Or does it depend on the technologies used to process the body, and on the contexts in which they are used? For example, “thing matter” can be produced using “industrialized” and heavily “routinized” technologies, through operations aimed at producing large amounts of organic matter (e.g., the production of embryos in fertility clinics). Is matter classified as “thing” when it is not assigned any meaning by the person who measures and handles it—for instance, is an embryo regarded as supernumerary when it does not serve any scientific or clinical purposes? Or on the contrary, does this status stem from the absence of meaning from the part of the person who is measured (through lack of reflexive awareness and relational skills)? What degrees or thresholds are elaborated by human societies in the gray area between “thing” and “person”? And how does human matter move from one ontological status to another? These are a few examples of the issues raised by biomedical technologies, which we attempted to address in this book. Finally, the measurement styles studied here do not just touch on the question of the human. They also contribute to the construction of the “person”, considered both as a social subject (i.e., a person situated according to their social status, age, sex, etc.) and as a singular subject (i.e., an individual singularized by their biography, tastes, corporal asperities, etc.). The contributions to this book show that measurement does not necessarily have a de-singularizing or de-subjectivizing effect, even when it relies upon quantification and statistics: these tools can also contribute to the making of particular singularities and subjectivities.

Measuring to Produce Singularities and Subjectivities The contributions by Diasio (Chap. 2), Voléry and Julien (Chap. 7) and Vinel (Chap. 8) reveal contexts and situations in which quantification can have a singularizing effect. This is the case when instruments fail to measure certain “specimens” and must be adapted: for example, when the position of a measuring rod needs to be amended, to adjust it to the asperities of bodies that defeat standardization; or when some abacuses

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measuring bone maturation “singularize” and “other” certain individuals and social groups; or when clinical measurements of puberty emphasize the diversity of signs and of their expressions. Singularization can also stem from the type of measurement performed. This phenomenon can, for instance, be observed in the case of human growth. When growth is measured diachronically via quantitative measurements of the same subjects at short intervals, it varies profoundly from one subject to the other and is subject to multiple micro-variations. Each subject has a unique way of growing. When assessed synchronically using measurements of distinct bodies of the same chronological age from which averages are drawn, growth becomes a uniform and standardized curve, which neutralizes the diversity of human vital phenomena. The paradoxical consequence is that the intensification of measurement (in repetition and granularity) enhances the singularity of measured entities (M’Charek 2000). Finally, the way the data is handled and processed can also be a vector of singularization or de-singularization: this depends on whether the collection focuses on determining averages or on standard deviation; or on whether the data is represented by an “average” image (as with bone or puberty abacuses), or using value ranges that allow for variations within given statistical boundaries. This granularity has a major impact on the way the measurees are represented by the measurers, as well as on the way the measurees perceive themselves. From the point of view of the “measurers”, Daston and Galison (2007) have demonstrated the link between “objectivation” and the “subjectivity” of the beholder. Every regime of objectivity promoted by physical and biological science is associated with a particular understanding of the researcher’s subjectivity—which can either be valued (no objectivity is possible without training and engaging the measurer’s subjectivity) or dismissed (as in the regime of “structural objectivity” where the researcher’s gaze disappears behind the mechanized recording and processing of data). In forensic medicine, Voléry (Chap. 3) shows how the measurement of the fetus has changed the physicians’ gaze, as the fetus was gradually perceived as an entity going through a process of formation and “solidification”. In their study of bioethical spaces, Maglio and García (Chap. 4) demonstrate that the reflection on indicators of humanity has deeply affected the understanding of human life and its “qualities” held

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by ethicists, philosophers, physicians and later politicians. Finally, in the field of procreative medicine, Déchaux (Chap. 5) shows indirectly that the large-scale, mechanized production of embryonic matter in fertility clinics partly explains the fact that physicians perceive embryos as experimental material. In keeping with a pragmatic approach, this book adopts a slightly oblique perspective by considering that measurement is not just the product of pre-existing systems of norms and representations, but that it also contributes to transforming these systems. From the point of view of the “measurees”, Ian Hacking (2002) shows that this group can be affected in two ways: on a macro-sociological scale, measured subjects can be impacted by wider social representations that derive from past measurements, or measurements of other subjects than themselves. Additionally, on a micro-sociological scale, these metrics can modify the status and social treatment of the subject’s body. This is the case, for instance, as noted by Maglio and García (Chap. 4) or Denise (Chap. 6), when the measurement of a patient’s “quality of life” or “vital signs” justifies placing them on continuous and profound sedation until they pass away or interrupting their resuscitation and life support systems. The effect of these metrologies can also be observed in hygienist medicine, where Lacassagne’s measurements inspired a range of techniques aimed at straightening diets and lifestyles (Voléry, Chap. 3); or in general medicine and endocrinology where the interpretation of deviations from average puberty can trigger therapeutic protocols aimed at correcting the pubertal process (Vinel, Chap. 8). This is also the case today when contemporary forensic medicine is applied to migration: in some French départements, non-conformity with the degrees of bone maturation displayed by the abacuses can be a motive for contesting a child’s minority and excluding them from child protection schemes (Perrot 2019). Finally, in genetics, several researches show how the measurement of bioancestry has affected the way in which people categorize themselves, thus reviving some groups’ identification with a new form of “whiteness” (Frank 2014; Doron 2016b). Vinel’s contribution on the racialization of studies on precocious puberty evokes similar issues: if a girl finds that, according to measurements, her puberty is that of an Afro-­ American, which group will she identify as?

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Measurement thus plays an important role in the making of singularities and subjectivities. This role can however take on diverse aspects, as it is deeply connected to the social, political and material contexts in which these metrologies are deployed. Not only can one given measurement style have de-singularizing or re-singularizing effects depending on the setting and on the professionals involved, but one given measurer can also often resort to various measuring styles. This is manifest in Denise’s study of intensive care units (Chap. 6). The monitoring of quantified vital signs is combined with clinical observation, considering the patient’s social profile. Similarly, in their practice, nursing professionals alternate between periods when they focus on the patient’s charts to communicate their health status to their family, and other periods when these measurements are eclipsed by singular measurements or objects that act as a reminder for the patient’s status (class, age, etc.) or biography (perfume, toys, etc.). The sociologies of measurement should therefore not just consider the properties of the instruments and measurers (socialization, representations, etc.) but also investigate the social properties of the contexts in which these metrics are deployed—examining whether those are institutional or professional metrics, or “ordinary” metrics implemented in everyday domestic spaces, which remain to be studied in more depth. This book, intended as a contribution to the socio-history of categorizations of the human in the tradition of UK/US scholarship, had set itself two objectives, which we hope to have reached at least partially. The first was to introduce English-language readers to a sociology of measurement that goes beyond quantification and breaks free from determinist perspectives to adopt new pragmatic approaches. Measurement is not just envisaged as a translation of a class or state doxa: it is embodied and finds its meaning in diverse contexts where groups and their beliefs are tested. Developed from field studies that explore the boundaries of the human (Rémy and Winance 2010; M’Charek et al. 2014; Maffi and Papadaniel 2017; Voléry and Julien 2019), this sociology comes across interrogations that had so far been the preserve of other fields (gender or racial studies) and other disciplines (in particular the anthropology of the person, a very developed field in France). In this new perspective, measurements do not just provide field studies for the sociology of science and a tool to analyze the successive paradigms at play in life science. They are also technologies

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that contribute to the making and reproduction of the human (the person, the subject), as well as enduring modes of division within social groups (divisions based on gender, medical and administrative status, “race”, gender, age). Beyond the lessons learned in terms of measurement science and quantification, this book intends to contribute to a broader project: de-naturalizing the human and elucidating the practices though which social groups trace boundaries between nature and nurture. This scientific endeavor appears more essential today, when the protection of human nature is brandished as an argument in many political and social controversies. It is our hope that this book will provide citizens with food for thought and inspire future researches on other worlds not studied in this book, such as the Eastern or Southern countries.

Notes 1. Comparative anatomy, introduced to wider audiences by Georges Cuvier (1769–1832), compares the anatomies of different species (animals, plants, fungi, etc.) to understand their phylogeny and adaptation to their environment. 2. This was the result of various trends, including the normalization of formerly reproved practices; changes in the types of dissected bodies and their supply channels (corpses were uncovered as they became a material for the teaching of medicine), and the emergence of new uses for the products of dissection (no longer disposed of after the demonstration but preserved in organ collections, while the findings deriving from these dissections were assembled to form an organized knowledge base). 3. See Rabinow’s socio-history of this phenomenon in France (2000). 4. See the notion of “deviation from the norm” highlighted by Voléry and Julien (Chap. 7). 5. The social world of genetics is indeed diverse and even fragmented. For instance, Calvert and Fujimura (2009) studied the tensions between systems biologists and molecular biology. The former support a holistic and systemic approach, in reaction against the latter’s molecular reductionism. Furthermore, among systems biologists, different methods come into conflict. Some researchers value lab-based experimental research

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while others favor mathematical and computational methods made possible by collaborations with bio-engineering (McCarthy 2004). 6. See, for example, the transposition of this hypothesis in pregnancy follow-­up or health and diet programs, including the “1000 Days” program. 7. In particular in the early nineteenth century when the boundaries between newly formed medical specialisms were more porous—especially with specialisms such as anthropology or forensic medicine between 1890 and 1930. 8. Boëtsch and Blanchard (2014) show how, from the fifteenth to the nineteenth century, cabinets of curiosities provided an outlet for the “marvel of abnormality”: the period saw an appetite for collections of curious, rare, exotic or monstrous cases, as well as a search for the missing link with the Hottentot Venus in early nineteenth-century Europe. Artistic mise-en-­scène supports the making of otherness but also contributes to disseminating scientific research, thus acting as a means of doing and funding science (Sommer 2016). 9. In particular in France where age was used as a criterion to organize drafts, regulate access to civil and social rights, but also produce synchronic and diachronic differences in status (Rémond and Percheron 1991). 10. See Rémy’s studies (2009) on animal xenotransplants where, beyond the question of the animalization of the human, the author discusses the humanization of animals whose are biologically closest to the human— with pigs recently replacing monkeys. See also contemporary debates on the robustness of scientific knowledge deriving from animal models— for instance, in the case of Alzheimer’s research (Balard 2019).

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