Medical Equipment

Still at the desk, although I have been to my office in KCL to recuperate various books I thought useful. This time I am looking at the ‘Medical equipment’ section of Chapter 4, which has entailed reading around Foucault’s Histoire de la folie and Naissance de la Clinique.

Les équipments médicaux

1963 Publication of Foucault’s Naissance de la Clinique: une archéologie du regard médical in the collection ‘Galien’, ‘Histoire et philosophie de la biologie et de la médecine’, PUF, directed by Georges Canguilhem. Revised edition 1ere trimestre 1972. Published simultaneously with Raymond Roussel, coll. ‘Le Chemin’, Gallimard, nrf, directed by Georges Lambrichs. The preface points to the influence of Canguilhem (on the normal and the pathological) and Merleau-Ponty (in the visible and the invisible), while the division between spatialisation and verbalisation, seeing and saying, echoes the terms of Raymond Roussel.

David Macey draws attention to the importance of ‘le regard’ in the subtitle, evoking Sartre, but the term ‘archaeology’ has more valency, prefiguring the later ‘archaeology of knowledge’, and the reference to the archive, whence the voluminous bibliography. The 1972 revisions to the 1963 edition replace some of the appeals to ‘structure’ with ‘history’, e.g. ‘Ici, comme ailleurs, il s’agit d’une étude structurale qui essaie de déchiffrer dans l’épaisseur de l’historique les conditions de son histoire elle-même’ becomes: ‘Ici, comme ailleurs, il s’agit d’une étude qui essaie de dégager dans l’épaisseur du discours les conditions de son histoire’. Elden has a brief blog post on the subject, and points, as does Macey, to Bernauer’s study of the revisions in Michel Foucault’s Force of Flight. The key question for us is which edition do the R13 group refer to. The bibliography says 1963, though the footnotes (e.g. p. 148) says 1972.

Reading the chapter ‘Les Équipments médicaux’ in R13…

Emergence of the couple normal/pathological in the 19thc. From two postulations: 1. illness is an essence, or a specific entity; thought in terms of botanic species (e.g by Kraepelin on schizophrenia) 2. Illness is a deviation in relation to nature. The references here are to Durkheim (statistical norm) and Ruth Benedict (‘pattern’). Neither are footnoted or in the bibliography. [Benedict, Patterns of Culture, 1934; Échantillons de civilisation, 1950].

Focus on ‘équipement sanitaire’ thus instances of conformity in relation the norm of health, but the notion of the hospital as a site of care only developed slowly through ruptures and displacements; the idea of ‘normal man’ thought as anterior to any illness is a ‘creation of the 19th century’; in order to understand how illness became a mode of deviation and the ill person a deviant, we need to undertake a genealogy not of illness itself but of what constituted it, i.e ‘hospital equipment’ [‘l’équipment hospitalier’]

Care as such is a recent invention; it had to be dissociated from poverty. It is from the fracture of indigence and illness that the modern hospital was born as a site of care.

The norm of health had to be distinguished from the norm of work. The early hospital as a site of enclosure (enfermement). Beggars (nomads) were excluded from the city and interned. Thus the idea of the ‘hosp-ital’. The reference here is to Gaston Roupnel, La ville et la campagne au XVIIe siècle. Etude sur les populations du pays dijonnais, 1955. This work is in the bibliography, published by SEVPEN (Service d'Edition et de Vente des Publications de l'Education Nationale). Roupnel, b. 1871, d. 1946, friend of Gaston Bachelard. It is not cited by Foucault in Naissance de la clinique, but is by Braudel in La Méditerrannée and Civilization et capitalisme.

Move (glissement) whereby the place of internment takes on an ethical vocation. The hospital as a place of correction to bring the nomadic and poor back within the realm of productivity. Reference here to Foucault’s Histoire de la folie, on the hospital in the pre-modern period as a ‘forteresse de l’ordre moral’, in the chapter on ‘Le Grand enfermement’ where Foucault is discussing the workhouses of protestant Europe of the 17thC.

But suddenly internment encounters limits. 1749 – arrest of all beggars; 1765 – creation of centres for beggars (depôts de mendicité) [discussed by Foucault in Histoire de la folie chapter on ‘Le Nouveau partage’]. The idea of the hospital as a place of ‘assistance’ and repression of unemployment is put in question. The moral question of poverty etc becomes an economic question, insofar as rather than being put out of circulation in spaces of internment, the poor become a cheap labour resource.

The inherent contradiction of the mixed economy in the hospital thus needed to be dissociated; indigence and illness needed to be distinguished; the poor and ill was the negative element par excellence; needing ‘assistance totale’; illness separated from poverty;

But illness was immediately separated from the hospital; the hospital seen as the creator of illness and the family as the site of cure (this is familiar from the first few chapters of Naissance de la Clinique, chapter on ‘Le Champ libre’, pp. 38); illness should disappear in the natural milieu of the family.

The hospital as recompense for the family, and symbolically constituted in relation to it. The doctor as father and judge, on the model of the Father; hospital as microcosm of bourgeois social structures.

The Revolution: sought to abolish the charitable function of hospitals and make them attain a ‘social duty’. The general hospital as having a social function. Ref. to Foucault Naissance de la clinique on the ‘contractual’ relation between the poor whose treatment is paid for and right for whom this knowledge may be useful (p. 85, chapter ‘La Leçon des hopitaux’). Ref. to Maurice Rochaix, L’évolution des institutions hospitalières de l’ancien regime à nos jours, ed. Federation hospitalière, 1959. Not in Naissance de la clinique. Rochaix was president and founder of the society for the history of hospitals and was himself a hospital director.

Doctors nevertheless have a specific knowledge independent of hospitals ‘savoir noséographique’; epidemics as a salient issue; power decides to take medicine in hand faced with the ravages of epidemics’; create a knowledge turned towards the population in the form of prescriptions; ‘constitution d’un sur-savoir retourné en pouvoir’. Creation of Royal Society of Medicine in 1776.

This broadly follows the narrative of Naissance de la clinique.

The revolution: turned this power into collective equipments accessible to all, collective equipment without State apparatus’ (‘un equipment collectif sans appareil d’Etat’); because medical space coincides with social space; the medicine of classes = free circulation = homogenous social space – ‘rêve démocratique’.

Hospital structures put into question – nationalisation of hospitals – social assistance and repression (of illness) are dissociated (ref. to Naissance de la clinique). But social assistance is medicalised in its turn and takes on a new function – prévoyance – (prevention) – creation of Caisses de Retraite and Caisse Nationale de Prevoyance. Replacement of centres for beggars;

Para. p. 152 follows Foucault exactly in linking the enunciatory power arising from the medical ‘regard’ to police surveillance of the population, doctors-police-prison; linked to the Charter of Athens;

Reaction (post revolution) attempts to reinstitute the charitable order but comes up against a new power which is that of medical knowleldge – practice and teaching and giving the doctor the power of enunciation.

Still following Naissance de la clinique and citing its references, but adding Haroun Jamous’ contribution to a University (Paris 7) collective publication on medical sociology.

Reduced role of the State, except as police… social assistance reduced. The hospital increasingly a space of return to work…

Important reference to J. C. Polack, La Médecine du Capital, Maspero, 1972, Cahiers libres 222-23.

The conclusion to the chapter summarises and interprets: the ‘equipment of health’ is an instance of conformity to a norm, the genealogy of this collective equipment involves an account of the nature of this norm and how the equipments realise it. The norm of health and thus the collective equipment of health must be linked to the social power or norm and the realm of work and production; those who don’t work must be fixed, territorialised. There is a substantial quotation here from Jean-Claude Polack’s 1972 book La Médécine du capital, published in Maspero’s Cahiers libre collection in 1972.

[Cahiers libre was a collection with an important radical standing and legacy, having published Nizan, Fanon, Guevara, the Mouvement du 22 mars, Macchiocchi, Castells, Cathy Bernheim on ‘droit à l’avortement’; connections to CERFI include Roger Gentis, Les Murs de l’asile, 1972]. Indeed Gentis ran a new psychiatry collection, so ordained by Maspero. Guattari’s Psychanalyse et transversalité was one of its first publications. Maspero’s publishing series and bookshop was a key site for the ferment of militant leftist groups around 1968 and after].

Medical knowledge cannot be dissociated from its equipment, that is the organised field of its usage. Is medicine defined by its equipment? Non-medical treatments and equipment are rejected outside the ‘concrete’ (le béton). It remains a servant of the State.