# FOUCAULT /// Episode 6: Architecture and Discipline: The Hospital

Although this title is very ambitious, the following article will only focus on Michel Foucault‘s reading of a specific architectural typology, the hospital, and even more specifically, the “physical” hospital rather than the psychiatric institution for which he also dedicated a lot of his work. In October 1974, Foucault gives a few lectures at The Institute of Social Medicine in Rio de Janeiro. The third one is transcribed under the name The Incorporation of the Hospital into Modern Technology (see text at the end of the article) and will appear in various volumes, including the very interesting Space, Knowledge and Power: Foucault and Geography edited by Jeremy W. Crampton and Stuart Elden (Ashgate 2007.)

Through this text, Foucault as an archeologist of ideas introduces a shift in the 18th century -era that marks the beginning of modernity in many texts he wrote- from a place to die to a place to be cured. He starts his text with the research accomplished respectively by John Howard and Jacques Tenon in the 1780’s which led to the careful reading of how space was influencing the recovery or the death of a patient:

They also tried to determine the relations that might exist between pathological phenomena and the state of cleanliness of each establishment. For example, Tenon investigated under what special conditions those hospitalized because of wounds were better cured and what were the most dangerous circumstances. Thus, he established a correlation between the growing rate of mortality among the wounded and the proximity to the patients with a malign fever, as it was called at that time. He also explained that the rate of mortality of those that were giving birth increased if they were located in a room situated above that of the wounded. As a consequence the wounded should not be placed below the rooms where those in labour were.

This correlation between cleanliness and health seems fairly obvious when retranscribed in our era. Nevertheless, Foucault argues that before the end of the 18th century, the hospital was separated from medicine and therefore was not the object of a careful design and organization. In his interpretation, this shift operated based on a paradigm that was not the civil hospital, but rather, the specific maritime or military hospitals. The function of these two institutions was indeed different from the more common hospital as they were both existing to maintain the life of their patients. The maritime hospital and its quarantine was more an instrument of prevention than one of curing, and the army could not afford to loose manpower in its hospital and was therefore attempting to bring its patients back to an operable status in the shortest delays.

According to Foucault, those two examples which constituted the new paradigm of a medicalized hospital also transmitted their disciplinary characteristics to the civil institution. The maritime hospital forbids its patients in quarantine to exit it while the military one applies a continuous surveillance on his to prevent them from deserting or to fake diseases. For him, discipline is indeed the new key word of this society that starts to constructs itself at the end of the 18th century and space has therefore to be thought through this filter:

Discipline is, above all, analysis of space; it is individualization through space, the placing of bodies in an individualized space that permits classification and combinations.
[...]
Discipline is a technique of power, which contains a constant and perpetual surveillance of individuals. It is not sufficient to observe them occasionally or see if they work to the rules. It is necessary to keep them under surveillance to ensure activity takes place all the time and submit them to a perpetual pyramid of surveillance.

Few years later, in the History of Sexuality, Foucault will transcribe this societal shift as the change from a society of blood, in which life has a relatively limited value and can therefore be sacrificed, to a society of sex, in which the biological and anatomical characteristics of the human body (alive) are recognized as the motor of an economy entangled with its political strategy. Hospitals, along with schools, factories and prisons, become therefore the spatial apparatuses par excellence in which disciplinary processes are operating. As often with Foucault, those processes are not necessarily driven by a sadistic class over another, but rather they are functioning within a system in which power is exercised with no particular moral intent. Hospitals are exemplary in this regard as their discipline is applied for its subjects’ the own good, namely, their health. Their design are therefore driven by this new societal envisioning of human life and its attempted perpetuation within a politico-economical system.

one also had to calculate the internal distribution of the space of the hospital as a function of certain criteria: if it was certain that an action practiced in the environment would cure diseases, it would be necessary to create about each patient a small individualized space environment, specific to them and modifiable according to the patient, the disease, and its evolution. It is necessary to obtain a functional and medical autonomy of the space for survival of the patient
[...]
All of this shows how, in a particular structure, the hospital constitutes a means of intervention on the patient. The architecture of the hospital must be the agent and instrument of cure.

The regular readers of this blog might have made the connection of this article with one I wrote about a month and half ago about the Canadian Center for Architecture’s book, The Medicalization of Architecture. Despite the clear qualities of this volume, I then pointed out the absolute lack of reference or questioning about Foucault’s work which yet seemed essential. The following text could be thus seen as an outsider appendix to this collection of articles that the CCA gathered and curated.

For more on the topic, read (in French) La politique de la santé au XVIIIe siècle in his report for the CERFI, Les Machines à guérir, Aux origines de l’hôpital moderne (dossiers et documents, Paris, Institut de l’environnement, 1976)

The Incorporation of the Hospital into Modern Technology
by Michel Foucault

When did the hospital come to be considered as a therapeutic instrument, as an instrument of intervention of illness for the patient, an instrument capable either along or through its effects, of curing?
The hospital as a therapeutic instrument is a relatively modern concept, dating from the end of the eighteenth century. Around 1760 the idea that the hospital can and ought to be an instrument destined to cure the patient appears and is reflected in a new practice: the investigation and systematic and comparative observation of hospitals.
In Europe a series of investigations begin. Among these were the trips of the Englishman [John] Howard, who went to hospitals, prisons, and poor houses of the continent in the period of 1775–1780, and that of the Frenchman [Jacques] Tenon, at the request of the Academy of Sciences when the problem of the reconstruction of the ‘Hotel Dieu’ of Paris was being posed.
Those investigations had several characteristics:

1-Their purpose consisted in defining, based on the inquiry, a program of reform or reconstruction of hospitals. When in France the Academy of Sciences decided to send Tenon to different countries in Europe to do research about the situation of hospitals, he expressed an important statement: ‘It is the currently existing hospitals that enable the judging of the merits and defects of the new hospitals.’
No medical theory is sufficient by itself to define a hospital program. Moreover no abstract architectural plan can offer a formula for a good hospital. One is dealing with a complex problem of which the effect and consequences are not well known, which acts on illnesses and is capable of aggravating them, multiplying them, or by contrast attenuating them. Only an empirical investigation of that new object, the hospital, integrated and isolated in a similarly new manner, will be capable of offering a new program of construction of hospitals. The hospital then is no longer a simple architectural figure and comes to form part of a medical-hospital complex that must be studied the same way one studies climate, illness, etc.

2-These fact-finding missions afforded few details on the external aspect of the hospital and the general structure of the building. No longer were they descriptions of monuments, like those which were made by the classical travellers of the seventeenth and eighteenth centuries but functional descriptions. Howard and Tenon gave an account of the number of the patients per hospital, the number of beds, the useful space of the institution, the length and height of the rooms, the cubic units of air which each patient used, and the rate of mortality and cure.
They also tried to determine the relations that might exist between pathological phenomena and the state of cleanliness of each establishment. For example, Tenon investigated under what special conditions those hospitalized because of wounds were better cured and what were the most dangerous circumstances. Thus, he established a correlation between the growing rate of mortality among the wounded and the proximity to the patients with a malign fever, as it was called at that time. He also explained that the rate of mortality of those that were giving birth increased if they were located in a room situated above that of the wounded. As a consequence the wounded should not be placed below the rooms where those in labour were.
Tenon likewise studied journeys, dislocations and movements within the hospital, particularly in the room that the clean linen, sheets, dirty linen, rags utilized to treat the wounded, etc., were located. He tried to determine who transported that material and where it was taken, washed and distributed. According to him that route would explain several pathological facts interior to hospitals.
He analyzed why trephination, one of the operations practiced most frequently at this time, had more satisfactory results in the English hospital of Bethlehem [Bedlam] than in the Hotel Dieu of Paris. Might there be internal factors of the hospital structure and distribution of patients to explain that circumstance? The problem is posed as a function of the interrelation of the location of the room, its ventilation and the transfer of dirty linen.

3-The authors of these functional descriptions of the medico-spatial organizations of the hospital were, however, not architects. Tenon was a doctor, and it was as such that the Academy of Sciences instructed him to visit hospitals; Howard was not a doctor, but rather a precursor of philanthropists and possessed an almost sociomedical competency.
There thus arises a new way of viewing the hospital, considered as a mechanism to cure, and of which the pathological affects it causes must be corrected. One might suggest that this is not new, since hospitals dedicated to curing patients have existed for millennia; that the only thing which perhaps may be affirmed is that in the seventeenth century it was discovered that hospitals do not cure as much as they ought; and that it is merely a question of refining the classically formulated requirements of the hospital as instrument.
I should like to express a series of objections to that hypothesis. The hospital which functioned in Europe from the Middle Ages on was not by any means a means of cure nor had it been conceived as such.
In the history of the care of the patient in the West, there were two distinct categories which did not overlap, which were sometimes paired but differed fundamentally: medicine and the hospital.
The hospital, as an important and even essential institution for urban life in the
West from the Middle Ages on, is not a medical institution. At this time medicine is not a hospital profession. It is necessary to keep this situation in mind to understand the innovation that the introduction of hospital-medicine, or the medical-therapeutic hospital, represents in the eighteenth century. I shall try to show the divergences of those two categories in order to situate this innovation.
Before the eighteenth century the hospital was essentially the institution of assistance of the poor. It was at the same time an institution of separation and exclusion. The poor, as such, required assistance and as a patient, he was the carrier of disease and risked spreading them. In sum, he was dangerous. Hence the necessity of the existence of the hospital, as much to keep him apart as to protect others from the dangers he represented. Until the eighteenth century the ideal person of the hospital was not the patient, there to be cured, but the poor person on the point of death. It is a question of a person who needs help, material and spiritual, who has to receive final care and the last rites. This was the essential function of the hospital.
One used to say in those times – and with reason – that the hospital was the place where one went to die. The hospital personnel were not attempting the cure of the sick, but rather of attaining their salvation. It was the charitable personnel (comprised of religious or lay people) who were to perform works or mercy which would guarantee that person eternal salvation. As a consequence the institution served to save the
soul of the poor in the moment of death and also save the soul of the staff members taking caring of him. He exercised a function in the transition of life to death, in the spiritual salvation more than the material one, all within the function of separating out the dangerous individual for the general health of the population.
For the study of the general significance of a hospital in the Middle Ages and
Renaissance one must consider the text entitled The Book of Active Life of the Hotel Dieu written by a parliamentarian who was an administrator of the Hotel Dieu in a language full or metaphors – a type of Roman de la Rose of hospitalization – which reflects clearly the mixture of functions of assistance and spiritual transformation which were incumbent upon the hospital.
These were the characteristics of the hospital until the beginning of the eighteenth century. The General Hospital, a place of internment where the sick, the mad, prostitutes, etc., are jumbled and mixed up is still a place of the seventeenth century, a type of diverse instrument of exclusion, assistance, and spiritual transformation from which the medical function is absent.
As far as medical practice is concerned, none of the elements that it integrated and served as its scientific justification predestined it to be a hospital medicine.
Medieval medicine and that of the seventeenth and eighteenth centuries were profoundly individualistic. Individualist on the part of the doctor who recognized this condition after an initiation guaranteed by the medical corporation itself, which comprised knowledge of texts and the more or less secret transmission of remedies.
The hospital experience was not included in the ritual training of the doctor at that time. What authorized him was the transmission of remedies rather the experiences he would have assimilated and integrated.
The intervention of the doctor in the disease turned around the concept of ‘crisis’.
The doctor was to observe the patient and the disease from the appearance of the first symptoms to determine the moment at which the crisis was to occur. The crisis represented the moment in which the patient and disease confronted each other; the doctor was to observe the signs, to predict the evolution and to support, as far as possible, the triumph of health and nature over the disease. In the cure, nature, the disease and the doctor came into play. In this struggle, the doctor fulfilled a function of prediction, arbitrator and ally of nature against the disease. The type of battle whose cure took this form could only proceed through an individual relation between the doctor and the patient. The idea of a vast series of observations, collected within a hospital, which would have made it possible to raise the general characteristics of a disease and its particular elements, etc., did not form part of the medical practice.
Thus there was nothing in the medical practice of this period that permitted the organization of hospital knowledge, nor did the organization of the hospital permit the intervention of medicine. In consequence, up until the middle of the eighteenth century the hospital and medicine continued being two separated domains. How did the transformation occur, that is, how did the hospital become medicalized and how was hospital medicine achieved?
The principal factor in the transformation was not the search for a positive action of the hospital on the patient or the illness but simply the annulment of the negative effects of the hospital. It was not first a question of medicalizing the hospital but purifying it of its harmful effects, of the disorder that it created. And in this case one understands by disorder the illnesses which that institution might create in the interned people and propagate in the city in which it was located. It was thus that the hospital was a perpetual focal point of the economic and social disorder.
This hypothesis of the medicalization of the hospital through the elimination of disorder it produced is confirmed by the fact that the first great hospital organization of Europe is found in the seventeenth century, essentially in maritime and military hospitals. The point of departure of the hospital reform was not the civil hospital but the maritime one, which was a place of economic disorder. Through it one trafficked merchandise, precious objects, rare materials, spices, etc., proceeding from the colonies. The trafficker feigned illness and when he disembarked they would take him to the hospital. There he could distribute these goods avoiding the economic control of customs. The great hospitals of London, Marseilles and La Rochelle thus became places of an enormous traffic, against which the fiscal authorities protested.
Thus then the first regulation of the hospital that appears in the seventeenth century refers to the inspection of the coffers which the sailors, doctors and apothecaries retained in the hospital. From that moment on one could inspect the coffers and record their contents; if they found merchandise destined to be contraband their owners would be punished. Thus in this regulation appears an initial economic inquiry.
Moreover, another problem appears in these maritime and military hospitals: that of quarantine, that is to say the epidemic illnesses that can be carried by people disembarking ships. The lazarettos established in Marseilles and La Rochelle constitute a kind of perfect hospital. But it is essentially a type of hospitalization which does not conceive of the hospital as an instrument of cure, but rather as a means of preventing its constituting a focus of economic and medical disorder.
If military and maritime hospitals became a model as a point of departure for hospital reorganization, it is because with mercantilism economic regulations became stricter. But it is also because the value of a man increased more and more. It was in effect precisely in that period that the training of the individual, his capability and his aptitude began to have a value for society.
Let us examine the example of the army. Until the second half of the seventeenth century there was no difficulty in recruiting soldiers; it was sufficient to have financial means. Throughout the whole of Europe there were unemployed people, vagabonds, wretches ready to enter the army of any power, nationality or religion. At the end of the seventeenth century with the introduction of the rifle the army becomes more technical, subtle, and costly. To learn to wield a rifle exercise, manoeuvres, and training are required. This is how the price of a soldier exceeded that of a simple labourer and the cost of an army is converted into a budget entry for every country.
Once trained, a soldier could not be permitted to die. If he dies, it has to be in a battle, as a soldier, not because of an illness. One must not forget that in the seventeenth century the index of mortality of a soldier was very high. For example, an Austrian army that left Vienna for Italy lost five sixths of the men before arriving at the field of combat. The losses because of illnesses, epidemic or desertion constituted relatively common phenomena. From this technical transformation of the army on, the military hospital became an important technical and military matter. (1) It was necessary to oversee [surveiller] men in the military hospital so they did not desert because they had been trained at a considerable cost. (2) It was necessary to cure them so they did not die from illness. (3) It was necessary to ensure that having recovered they did not still pretend to be ill and remain in bed.
In consequence, an administrative and political reorganization, a new control of authority in the environs of the military hospital. And the same thing occurs in the maritime hospital, from the moment when the maritime technique become more complex and where similarly the person trained at a considerable cost also may not be lost.
How did this reorganization come to be carried out? The reorganization of the maritime and military hospitals did not stem from a medical technique but essentially from a technology which might be called political, namely discipline.
Discipline is a technique of exercising power, which was not so much invented but rather elaborated in its fundamental principles during the seventeenth century.
It had existed throughout history, for example in the Middle Ages, and even in antiquity. For example, the monasteries constitute an example of a place of power of which a disciplinary system was at the heart. Slavery and the great slave companies existing in the Spanish, English, French, and Dutch colonies were also models of disciplinary mechanisms. We can go back to the Roman legion and in it we would similarly find an example of discipline.
Thus disciplinary mechanisms date from ancient times but in an isolated, fragmented manner, until the seventeenth and eighteenth centuries, when disciplinary power is perfected in a new technique with the management of men. We frequently speak of the technical inventions of the seventeenth century – chemical, metallurgical technology – yet we do not mention the technical invention of this new form of governing man, controlling his multiplicity, utilizing him to the maximum, and improving the useful products of his labour, of his activities thanks to a system of power which permits controlling them. In the great workshops which begin to appear, in the army, in schools, when we see throughout Europe great progress in literacy there also appear these new techniques of power which constitute the great inventions of the seventeenth century.
On the basis of the example of the army and school, what is it that arises in this period? An art of spatial distribution of individuals. In the army of the seventeenth century individuals were herded together forming a conglomeration, with the stronger and most capable at the front. And those who did not know how to fight, the more cowardly or those who desired to flee, were at the flanks and at the middle.
The power of a military body was rooted in the effect of the density of this human mass. In the eighteenth century, on the contrary, beginning at the moment when a soldier receives a rifle, it is necessary to study the distribution of individuals and place them as they ought to be so their efficacy might reach the maximum. Military discipline begins at the moment when one teaches the soldier to locate himself and be at the place that is required.
In the same way, in the schools of the seventeenth century the students were grouped together. The teacher used to call one of them and for a few minutes gave him some instruction and then sent him back to his seat continuing the same operation with another, and so on in succession. Collective teaching works with all students and simultaneously demands a spatial distribution of the class.
Discipline is, above all, analysis of space; it is individualization through space, the placing of bodies in an individualized space that permits classification and combinations.
Discipline does not exercise its control on the results of an action but on its development. In the workshops of the corporate type of the seventeenth century what was required of the worker or master was the fabrication of a product of a determined quality. The mode of fabrication depended upon what was transmitted from one generation to another. The control did not affect the mode of production. In the same way one taught the soldier how to fight, to be stronger than the adversary in the individual fight or on the battlefield.
Beginning in the eighteenth century an art of the human body developed.
Movements that are made begin to be observed, in order to determine which are the most efficacious, rapid and best adjusted. Thus the famous and sinister character of the supervisor or foreman appears in workshops, charged not with observing if the work was being done but how it would be done more quickly and with betteradapted movements. In the army appears the non-commissioned officer and with him the army exercises, manoeuvres and the breaking down of movements in time.
The famous regulation of infantry that assured the victories of Frederick of Prussia comprises a series of mechanisms of the direction of the movement of the body.
Discipline is a technique of power, which contains a constant and perpetual surveillance of individuals. It is not sufficient to observe them occasionally or see if they work to the rules. It is necessary to keep them under surveillance to ensure activity takes place all the time and submit them to a perpetual pyramid of surveillance. There thus emerge a series of ranks in the army that go, without interruption, from the commander-in-chief to the simple soldier, as well as systems of inspection, reviews, parades, marches, etc., which permit each individual to be observed in a permanent manner.
Discipline supposes a continuous registration: annotations of the individual, relation of events, disciplinary elements, and communication of the information to the higher ranks, so that no detail escapes the top of the hierarchy.
In the classical system the exercise of power was confused and global and discontinuous. It was a question of the power of the sovereign over groups, integrated by families, cities, and parishes, that is by global units, not by the power which acted continuously on the individual.
Discipline is the collection of techniques by virtue of which systems of power have as their objective and result the singularization of individuals. It is the power of individualization whose basic instrument rests in the examination. The examination is permanent, classificatory surveillance, which permits the distribution of individuals, judging them, measuring or evaluating them and placing them so they can be utilized to the maximum. Through the examination, the individual is converted into an element for the exercise of power.
The introduction of the disciplinary mechanisms into the disorganized space of the hospital allowed its medicalization. Everything which has been set out, explains why the hospital is disciplined. Economic reasons, the value attributed to the individual, the desire to avoid the propagation of epidemics explains the disciplinary control to which the hospitals are subjected. But if this discipline acquires a medical character, if this disciplinary power is entrusted to the doctor, it is due to a transformation of medical knowledge. The formation of a hospital medicine has to be attributed, on one hand, to the introduction of discipline into hospital space, and on the other hand, to the transformation that the practice of medicine in that period was undergoing.
In the epistemological systems of eighteenth century, the great marvel of the intelligibility of illnesses is botany, the classification of [Carl von] Linne. This means the necessity of understanding illnesses as a natural phenomenon. As in plants, in diseases there will be different species, observable characteristics, and courses of evolution. Disease is nature, but a nature due to a particular action of the environment on the individual. The healthy person, when he has submitted to certain actions of the environment, serves as a support to the disease, a phenomenon limited by nature. Water, air, food, and the general regimen constitute the bases on which the different types of diseases are developed in individuals.
In this perspective the cure is directed by a medical intervention which is no longer directed toward the disease itself, as in the medicine of crises, but precisely to the intersection of the disease and the organism, as it is in the surrounding environment: air, water, temperature, the regimen, food, etc. It is a medicine of the environment, which is being constituted, to the extent to which the disease can be conceived as a natural phenomenon that obeys natural laws.
In consequence it is in the articulation of those two processes – the displacing of medical intervention and the application of discipline to the space of the hospital – that one finds the origin of the medical hospital. Those two phenomena, of different origin, were going to be adjusted to the hospital discipline whose function would consist in guaranteeing the inquiry, surveillance, and application of disciplines into the disorganized world of the patients and of illness and in transforming the conditions of the environment which surrounds the patients. Likewise patients would be individualized and distributed in a space where one could oversee them and record the events that took place; one could also modify the air they breathed, the temperature of the environment, the water to drink, the regimen, so that the hospital panorama imposed by the introduction of discipline had a therapeutic function. If one accepts the hypothesis that the hospital is born from techniques of disciplinary power and from the medicine of interventions on the environment, we can understand several characteristics possessed by that institution. The localization of the hospital and the internal distribution of space. The question of the hospital at the end of the eighteenth century was fundamentally a question of space. In the first place it is a matter of knowing where to situate a  hospital so that it does not continue to be a dark, obscure and confused place in the heart of the city where a person would arrive at the hour of death and spread dangerous miasma, contaminated air, dirty water, etc. It was necessary that the place in which the hospital was located conformed to the sanitary control of the city. The location of the hospital had to be determined within the overall medicine of urban space.
In the second place, one also had to calculate the internal distribution of the space of the hospital as a function of certain criteria: if it was certain that an action practiced in the environment would cure diseases, it would be necessary to create about each patient a small individualized space environment, specific to them and modifiable according to the patient, the disease, and its evolution. It is necessary to obtain a functional and medical autonomy of the space for survival of the patient. In this way the principle that beds should not be occupied by more than one patient is established, and thus ends the bed dormitory that at times would be filled by up to six people.
It would also be necessary to create around the patient a manageable environment, to allow the temperature to be increased, to cool the air, and to direct it toward a single patient. Because of this studies on the individualization of living space and the respiration of the patients would be undertaken, including in the collective wards.
Thus for example, there was a project of isolating the bed of each patient employing screens at the sides and on the top that would permit the circulation of air but would block the propagation of miasmas.
All of this shows how, in a particular structure, the hospital constitutes a means of intervention on the patient. The architecture of the hospital must be the agent and instrument of cure. The hospital where patients were sent to die must cease to exist.
Hospital architecture becomes an instrument of cure in the same category as a dietary regime, bleeding or other medical actions. The space of the hospital is medicalized in its purpose and its effects. This is the first characteristic of the transformation of the hospital at the end of the eighteenth century.
Transformation of a system of power in the heart of the hospital. Up to the middle of the seventeenth century religious personnel exercised power and rarely lay people. They were in charge of the daily life of the hospital, the salvation, and the feeding of interned persons. One called the doctor to attend to the most seriously ill, and rather than real action it was a question of a guarantee, a justification. The medical visit was a very irregular ritual, in principle it was performed once a day and for hundreds of patients. In addition, the doctor depended administratively on the religious personnel, who could even dismiss the doctor. From the moment when the hospital was conceived as an instrument of cure and the distribution of space becomes a therapeutic means, the doctor assumes the main responsibility for the hospital organization. He is consulted as to how the hospital should be constructed and organized; for this reason Tenon realized the previously mentioned mission. Laws prohibited the cloister form of a religious community which had been employed to organize the hospital up to this point. Moreover, if thefood regime, the ventilation, the frequency of beverages, were to be instruments of cure, the doctor, upon controlling the regime of the patient, takes charge to a certain point of the economic functioning the hospital, which up to then had been a privilege of the religious order.
At the same time, the presence of the doctor in the hospital is reaffirmed and intensified. The visits increase in an ever more accelerated rhythm during the eighteenth century. In 1680 at the Hotel Dieu of Paris the doctor would visit once a day; on the other hand in the eighteenth century several rules were established, which specify successively that there must be another visit at night for the more serious patients; that each visit should last two hours; and finally in about 1770, that a doctor must reside in the hospital to whom one could go at any hour of the day or night if necessary.
Thus appears the character of the doctor that did not exist before. Until the seventeenth century the great doctors did not appear in the hospital, there were doctors for private consultation that had acquired prestige thanks to a number of spectacular cures. The doctors to whom the religious community resorted for visits to the hospital were generally the worst ones in the profession. The great hospital doctor, the most competent with the greatest experience in those institutions is an invention of the end of the eighteenth century. Tenon, for example, was a hospital doctor, and the work achieved by [Philippe] Pinel at Bicetre was possible thanks to his practice in the hospital.
This inversion of the hierarchical order of the hospital with the exercise of power by the doctor is reflected in the ritual of the visit: the almost religious procession headed by the doctor, of the whole hierarchy of the hospital: assistants, students, nurses, etc., at the foot of the bed of each patient. This codified ritual of the visit, which signals the place of medical power, is found in the regulations of hospitals in the eighteenth century. It indicates the location of each person, and that the presence of the doctor must be announced by a bell, that the nurse must be at the door with a notebook in hand and accompany the doctor when he enters the room, etc.
The organization of a permanent and as far as possible complete records system, which registers whatever occurs. In the first place we must refer to the methods of identification of the patient. A small label will be tied to the wrist of each patient that will allow them to be distinguished if they live, but also if they die. In the upper part of the bed one will place an index card with the name of the patient and what they suffer from. Likewise one begins to utilize a series of records which gather together and transmit information: the general records of admissions and discharges in which the name of the patient is written, the diagnosis of the doctor who admitted them, the ward in which they are located, and if they died or were given a discharge; the registry of each room prepared by the head nurse; the registry of the pharmacy in which are stated the prescriptions and for what patients they were issued; the records of what the doctor ordered during the visit, the prescriptions and the treatment prescribed, the diagnosis, etc.
Finally, it implanted the obligation of the doctor to confront their experiments and their records – at least once a month, in accord with the regulation of the Hotel
Dieu in 1785 – to determine the different treatments administered, those that have turned out most satisfactory, the doctors that have the most success, or if epidemic illnesses are passing from one room to another, etc. Thus a collection of documents is formed in the heart of the hospital, and thus is constituted not only a place of cure but also a place of record and the acquisition of knowledge. Medical knowledge, which up until the eighteenth century was located in books, a type of medical jurisprudence concentrated in the great classical treatises of medicine, therefore begins to occupy a place which is not a text, but a hospital. It is no longer what was written and printed, but what every day was recorded in living, active and current actions which the hospital represents.
It is for these reasons that it can be asserted that the normative formation of the doctor in the hospital occurs in the period of 1780–1790. This institution, besides being a place of cure, is a place of medical training. The clinic appears as an essential dimension of the hospital. I understand by ‘clinic’ [la clinique] the organization of the hospital as a place of formation and transmission of knowledge [savoir]. But it happens also that, with an introduction of the discipline of the hospital space, it permits curing as well as the recording, capacitating and accumulating of knowledge [connaissance]. Medicine offers an immense field as an object of observation, limited on one side by the individual themselves and on the other by the population as a whole.
With the application of the discipline of medical space, and by the fact that it is possible to isolate each individual, install him in a bed, prescribe for him a regimen, etc., one is led toward an individualizing medicine. In effect it is the individual who will be observed, surveyed, known and cured. The individual thus appears as an object of medical knowledge and practice.
At the same time, through the same system of disciplined hospital space, one can observe a great number of individuals. The records obtained daily, when compared among hospitals and in diverse regions, permit the study of pathological phenomena common to the whole population.
Thanks to hospital technology, the individual and the population present themselves at the same time as objects of knowledge and medical intervention. The redistribution of those two medicines will be a phenomenon of the nineteenth century.
The medicine that is formed in the course of the eighteenth century is simultaneously a medicine of the individual and the population.

Michel Foucault, The Incorporation of the Hospital into Modern, trans: Edgard Knowlton Jr., William J. King, and Stuart Elden in Jeremy W. Crampton & Stuart Elden, Space, Knowledge and Power: Foucault and Geography, London: Ashgate, 2007.

4 Comments on “# FOUCAULT /// Episode 6: Architecture and Discipline: The Hospital

  1. Pingback: The Funambulist on Foucault | Progressive Geographies

  2. Pingback: Foucault, cartography, architecture, power « Foucault News

  3. With regards to the space of the hospital, it is worth looking at ‘The Birth of the Clinic’. The following piece from an essay of mine provides a glimpse. He describes 3 spatialisations in tracing the history of pathological anatomy. The third spatialisation involves practices, institutions, political and economic confrontations and struggles:

    “To reveal the singularity of pathological anatomy, which involves a certain economy of language, Foucault begins by tracing three inter-related spatialisations of medicine. Philo, noting that despite frequent and explicit references to geography and spatial features, the text has been disregarded by medical geographers (2000: 11-19), has helpfully teased out these three formations, but they do not fully exhaust the spatial reach of the book or encompass the profound points that Foucault makes regarding death and the significance of Bichat. Philo explains that there is no simple progression from one formulation to another, but rather there develops a series of reconfigurations. Classificatory medicine, historically just before anatomo-clinical period, is outlined as the primary or ‘free spatialisation’. Here the localisation of a disease is a minor concern. It is about ‘system of relations involving envelopments, subordinations, divisions, resemblances’ (Foucault, 1973: 4). Disease is pictured without depth, along one plane, without any sense of progression. As with Roussel’s work there is no privileged point of reference (see Philo, 1992: 145). It is a spatialisation of resemblances, where ‘analogies define essences’. Differences and similarities are measured within a table of class, genus and species. It is an idealised space separate or dislodged from the patient’s body and the intervention of the doctor. In a sense, disease only exists in that space; it is defined by its place within a family rather than a specific organ. Elden tellingly describes this as ‘imaginary’ space (2000: 140-142). Although this primary spatialisation is identified outside any social context and unaffected by any institutional environment, practices or techniques, such a configuration of disease nevertheless coincides with economic imperatives. The patient tends to be left within the care of families and friends, as this is both inexpensive and avoided spreading the sickness. Hospitals are perceived as a breeding ground for illness, an enclosed space that protects and nourishes disease rather than the patient.

    In contrast, the secondary space of ‘localisation’ involves perception, a subtle qualitative gaze that attempts to assess differences between cases. The individual patient is given a positive status within a close relationship with an individual doctor. Here the eye governs. It is the gaze of a ‘doctor supported and justified by an institution, that of a doctor endowed with the power of decision and intervention’ (1973: 89). This restructuring of disease, echoing in a different context Roussel’s torturous experiments, brings a profound visibility or a new relationship between space, perception and language. Foucault traces in painstaking detail the different attempts to bind and match language to this visibility of the gaze, but finds the shift towards pathological anatomy arrives when touch and sensation replace the labours of description, along with a paradoxical return to some of the basics of the primary classificatory spatialisation. What alter are the objects that are allowed significance, that are literally brought to light: the redistribution of the body through a relationship to a positive gaze. Here imaginary and real spatialisations reinforce each other. Foucault shows how the restructuring of the environment of the clinic towards the final years of the eighteenth century brought this new visibility and closeness to the actual body. The medical gaze within the clinic is as demanding and thorough as that of natural history. It is the gaze of an expert, a doctor, supported by an institution and provided with new tools to intervene and calculate.

    The third spatialisation involves practices, institutions, political and economic confrontations and struggles. Although underdeveloped in this book, Foucault does mention briefly institutional methods of dealing with epidemics at the end of the eighteenth century and a concern with overall health, involving regulations of housing, abattoirs, and cemeteries (explored later in his lectures on governmentality – see Elden 2007: 67-81). All this requires general policing, involving supervision and constraints, including the appointment of health inspectors and a wide-ranging concern with ‘healthy living’. Foucault also looks in some detail at the political ideology of the revolutionary reformers that in many ways prevents the development of hospitals and the introduction of clinical medicine. Ideals evolve around decentralising assistance rather than providing a privileged location. Revolutionary dreams of equality include ‘restoring medicine to liberty’ and the wholesale ‘dehospitalisation of illness’ (1973: 66). However, Foucault traces how all three spatialisations are superimposed to produce what we know as pathological anatomy or the ‘technique of the corpse’ (141). This is crucial to his study. He undermines attempts to write a historical narrative around the gradual development of enlightened thought that finally banishes old beliefs. Rather it is about conflicts and compromises between different forms of spatialisation or modes of knowledge (126). With again some possible mirroring of Roussel, this is particularly apparent in his analysis of Bichat’s reconfiguration of anatomy. Moreover, as Deleuze argues (1988: 93-95), Bichat’s imaginary spatialisation fascinatingly reflects Foucault’s own spatial techniques and:

    ….imposes a diagonal reading of the body carried out according to expanses of anatomical resemblances that transverse the organs, envelop them, divide them, compose and decompose them, analyse them, and at the same time, bind them together’. (Foucault 1973: 129 – emphasis in original)”.
    Peter
    http://www.heterotopiastudies.com/

  4. Pingback: Foucault: cartografia, arquitectura y poder « Filosofía Contemporanea

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