Ackerknecht, La Medecine
hospilaliere
a Paris (UW-lcfyS) p p .
Foucault-Psychiatric-Power-1973-74
Flaceliere, Devins et Oracles grecs; and ed.
J. P. Vernant, Divination et Rationalite (Paris: Le Seuil, I974).
30. Hippocrates "considers an important part ol the art of medicine" to be the ability "to
observe the order of the critical days and to extract the elements ol prognosis from it. When we know these things, we know too when and how to give nourishment to the patient" Hippocrates, Epidemies, III, 3ul section, ? 16, in CEuvres completes, vol. Ill; English translation, Hippocrates, Epidemics, 3, trans. W. H. S. Jones, Hippocrates, vol. I, Loeb Classical Library (Cambridge, Mass: Harvard University Press, 1923).
31. Hippocrates, Pronostic, ? 1: "The best doctor seems to me to be one who can know in advance . . . He will treat best those diseases whose future course he can loresee with the help of the present condition" CEuvres completes, vol. II, p. 111; Prognosis ? 1, in Hippocratic Writings: "It seems to be highly desirable that a physician should pay much attention to
? prognosis. . . . he will be better able to effect a cure if he can loretell, trom the present
symptoms, the future course of the disease. " p. 170.
}2. In Hippocrates's own terms, the doctor's task is to "combat (avrayoviaaBai) each of the
accidents through his art. " Or again, "if we know the cause of the disease, we will be in a position to administer what is useful to the body, starting from contraries to counter (SK TOV evavTtov ermao[tEVo<;) the disease" Des Vents, I, in Guvres completes, vol. VI, p. 93 (translation amended by J. L. |; English translation, Airs, I, in Hippocrates, vol. I, Locb Classical Library (1923).
33. Taken from juridical language, the term krisis means "judgment," "decision," before desig nating in medicine the crucial moment at which "the disease judges | KpiveTcu] lor death
or life "Des Affections internes,21 220, 9, in GLuvres completes, vol. VII, p. 217; "Internal Affections," trans. Paul Potter, Hippocrates, vol. VI, Loeb Classical Library (1988). Or again there is this expression in Epidemies, I, 2IK section, ? 4: "In some ( . . . ) the illness is decided by a crisis" in GLuvres completes, vol. II, p. 627; EpiJemies, Book One, (11), ? 8, p. 92. As for the doctor, he is judged on his sense of opportunity and his interventions; see, Des maladies, I, 5. pp. 147 151; Diseases, I, trans. Paul Potter, Hippocrates, vol. V, Loeb Classical Library (1988).
34. See the medical scenes in the plays by Mohere (1622 1673): (1) VAmour medecin (performed
on 14 September, 1665), Act II, scene 2, in which four doctors are involved, and scenes 3-4 of
the consultation, in Guvres completes, ed. M. Rat (Paris: Galhmard, 1947) vol. II, pp. 14 25; (2) Monsieur de Pourceaugnac ( 6 October 1669) in Act I, scenes 7 8, ol which, two doctors and an apothecary are involved, Guvres completes, vol. II, pp. 141-120; and (3) Le Malade imaginaire (10 February 1673), posthumous work ( 1682), Act II, scenes 5 6, and Act III, scene 5, Guvres com- pletes, vol. II , pp. 845-857 and pp. 871 873. See, F. Millepierres, La Vie quotidienne des medecins au temps de Moliere (Paris: Hachette, 1964).
}5. This refers to an episode that took place during Galen's (b. Peigamum 129 A. D. ) first stay in Rome from the autumn of 162 until the summer ol 166, before coming back to settle there from 169 until his death around 200. Sec, De Praecognitione ? 1$ in Opera Omnia, vol. XIV, ed. and Latin trans. C. G. Kiihn (Lipsiae: in officina, C! Cnoblochii, 1827) pp. 666 668; English translation, On Prognosis: Corpus Medicomm Graecorum, V, 8, 1, trans. Vivian Hutton (Berlin: Akademie Verlag, 1979) pp. 135-137. On Galen's relations with the Roman medical world, see J. Walsh, "Galen clashes with the medical sects at Rome (163 A. D. )," Medical Life, vol. 35,1928, pp. 408-444. On his practice, see,J. Ilberg, "Aus Galens Praxis. Ein Kulturbild aus der Kaiserzeit," Neue Jahrbiicher fur das klassische Allerlum (Leipzig: Teubner, vol. 15, 1905, pp. 276 312; and, V. Nutton, "The chronology ol Galen's early career," The Classical Quarterly, vol. 23, 1973, pp. 158 171.
36. This passage echoes a number of treatments by Foucault of "the inquiry": (1) The 1971- 1972 lectures at the College de France, the first part of which deals with the inquiry and its development in the Middle Ages; see the course summary, "Theories et Institutions penales" Dits et Ecrits, vol. 2, pp. 390 391; "Penal Theories and Institutions," trans. Robert Hurley, Essential Works of Foucault, 1, pp. 17 19; (2) The College de France lectures ol 1972 1973, "The Punitive Society," in which, in the lecture of 28 March 1973, Foucault returns to the constitution of an "inquiry knowledge"; (3) The third lecture (23 May 1973) on "La Verite et les formes jundiques" pp. 581 588; "Truth and Juridical Forms" pp. 44 52. Foucault returns to the process of the colonization of a "truth test" in the form of the event by a "truth-findings" in the lorm ol a body of knowledge in 1975 in "La Maison des lous" Dits et Ecrits, vol. 2, pp. 6 9 6 697.
37. In the second half ol the eighteenth century, since Fnedrich Hoffmann, who still believed in the theory of crises, albeit with reservations about the notion of critical days, died in 1742. See, C. Daremberg, Histoire des sciences medicates, vol. II, p. 929.
38. This grid, which dates from the organization of administrative health correspondence by the Intendants in order to collect lnlormation on epidemics and endemic diseases, found institutional expression with the creation on 29 April 1776, on Turgot's initiative, of the "Societe Royale de Medecine" responsible for studying epidemics and epizootic diseases, before disappearing in 1794. See, C. Hannaway, "The Societe Royale de Medecine and epi demies in the Ancient Regime," Bulletin of the History of Medicine, vol. 46, no. 3, 1972, pp.
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257273. Concerning these inquiries, see, J. Meyer, "Une enquete de 1'Academie de medecine sur les epidemics (1774 1794)" Annales ESC, 21st year, no. 4, August 1966, pp. 729 749; H. Dupin and L. Masse, uUne enquete epidemiologique a peripeties multiple: I'etude de la pellagre," Revue d'epidemiologie, medecine sociale el sanle publique, vol. XIX, no. 8, 1971, pp. 743 76();J. P. Peter, (1) "Une enquete de la Societe Royale de Medecine. Malades et maladies a la fin du xvmc siecle," Annales ESC, 22,ul year, no. 4, July August 1967, pp. 711 751; ( 2 ) "Les mots et les objets de la maladie. Remarques sur les epidemies et la medecine dans la societe Iran^aise de la lin du xvni' siecle," Revue hisloriijue, no. 499, 1971,pp. 13 38;J. P. Desaive, P. Goubert, E. Le Roy Ladurie, Medecins, climals et epidemies a fin du xviii . siecle (Paris: Mouton, 1972). See also the pages devoted to this in M. Foucault, Naissance de la clinicjue, ch. 2, "Une conscience politique," pp. 21 36; Birl/i of the Clinic, ch. 2, "A Political Consciousness," pp. 22 37.
39. On the development of hospital lacilities and the advent ol a medical police, see, G. Rosen, (1) "Hospitals, medical care and social policy in the French Revolution," Bulletin of the Histoty of Medicine, vol. 30, no. I, 1956, pp. 124 I49, reprinted in G. Rosen, From Medical Police to Social Medicine: Essays on the History of Health Care ( N e w York: Science History Publications, 1974) pp. 220 245; (2) A History of Public Health (New York: MD Publications, 1958); ( 3 ) "Mercantilism and health policy in eighteenth century French thought," Medical History, vol. Ill, October 1959, pp. 259 277, reprinted in From Medical Police, pp. 201 219; M. Joeger, (1) "Les enquetes hospitalieres au xviii' siecle," Bulletin de la Societe francaise d'histoire des hopitaux, no. 31,1975, pp. 51 6(); ( 2 ) "La structure hospital lere de la France sous I'Ancien Regime," Annales ESC, 32m year, no. 5, September October 1977, pp. 1025 1051; M. J. Imbault Huart, "L'hopital, centre d'une nouvelle medecine (1780 1820)," in Zusammentrang Festschrift fur Marilene Pulscher, vol. II (Cologne: Wienand, 1984) pp. 581 603. Foucault takes up this question in a number ol places: ( 1) Naissance de la clinique, ch. v, "La lecon des hopitaux," pp. 63 86; Birth oj the Clinic, ch. 5, "The lesson of the Hospitals" pp. 64 87; "La politique de la sante au XVIII1' siecle," in Michel Foucault, Blandine Barret Kriegel, Anne Thalamy, Francois Beguin, and Bruno Fortier, Les Machines a guerir. Aux origines de l'hopital moderne. Dossiers et documents (Paris: Institut de I'Environnement, 1976) pp. 11 21, reprinted in Dits et Ecrits, vol. 3, pp. 13 27; English translation, "The politics ol health in the eighteenth century," trans. Colin Gordon, Essential Works oj Foucault, 3, pp. 9 0 105; (3) he relers to it in his hrst lecture on the his tory ol medicine in Rio de Janeiro in October 1974: "Crise de la medecine 011 crise de 1'an- timedecine? " Dits et Ecrits, vol. 3, pp. 50 54, and in the third "L'incorporation de l'hopital dans la technologic moderne," Dits et Ecrits, vol. 3, pp. 5 0 8 521.
40. See M. Foucault, Naissance de la clinique, ch. vui, "Ouvrez quelques cadavres," pp. 125 149; Birth of the Clinic, ch. 8, "Open Up a Few Corpses," pp. 124 148. E. H.
Ackerknecht, La Medecine hospilaliere a Paris (UW-lcfyS) p p . 2 0 9 214.
41. Foucault takes up this point in his second lecture at Rio de Janeiro, "La naissance de la medecine sociale," Dits et Ecrits, vol. 3, pp. 212-215; English translation "The Birth ol Social Medicine," trans. Robert Hurley, Essential Works of Foucault, 3. See G. Rosen, "Problems in
the application ol statistical knowledge analysis to questions of health (1711 1 8 8 0 ) " Bulletin of the History of Medicine, vol. 29, no. 1, 1955, pp. 27 45; M. Greenwood, Medical Statistics from Graunt to Farr (Cambridge: Cambridge University Press, 1948).
42. Thus, Georget states as "1bl principle: never direct the minds of the insane towards their delir- ium" in chapter 5, "Traitement de la lolie," of his work: De lafolie. Considerations sur cette mal- adie, p. 280. Leuret states that "one must impose silence on the patient with regard to his delirium, and occupy them with something else" Du traitement moral de lajolie, p. 120. On this "principle of distraction" see above, note 6 to the lecture of 5 December 1973.
43. Recourse to the research of pathological anatomy was recommended by Jean Pierre Falret in the introduction (September 1853) to his Des maladies mentales, p. v: "Against the doc- trines of our teachers, we yielded, like the others, to that anatomical direction of the sci
ence that at that time was thought to be the true basis of medicine ( . . . ) . We quickly convinced ourselves that only pathological anatomy could give the primary cause ol the phenomena observed in the insane. " Thus, research into pathological anatomy was pursued at Charenton and gave rise to various publications: Jean Baptiste Delaye (1789 1879), attached to Esquirol's department, defended his thesis on 20 November 1824, Consideration
? sur une cspke de paralysic qui ajjecte parliculierement les alienes, Medical Thesis, Paris, No. 224 (Paris: Didot, 1824); Louis Florenlin Calmeil (1798-1895), intern in the department of Royer Collard, chief doctor at Charenton from 1805 until his death in 1825, published: De la paralysie consideree chevies alienes. Recherchesfaites dans le service dejeu M. Royer-Collard et de M. Esquirol (Paris: J. B. Bailliere, 1826); Antoine Laurent Jesse Bayle, arrived at the same department in 1817 where he pursued anatomical research resulting in his thesis of 1822: Recherches sur les maladies mentales. Recherches sur {'arachnitis chronique, la gastrite, la gas- tro-enterite et la goutte considerees comme causes de {'alienation mentale, Medical Thesis, Paris, no. 147 (Pans: Didot, 1822) as well as his work of 1826: Traite des maladies du cerveau et de ses membranes. See J. E. D. Escjuirol, "Memoire historique et statistique sur la Maison Royale de Charenton" (1835) in Des maladies mentales, vol. II, ? "Ouvertures de corps," pp. 698 700. The results of Jean Pierre Falret's research at Salpetriere were presented on 6 December 1823 at the Athence de Medecine: Inductions tirees de Vouverture du corps des alienes pour servir au diagnostic el au trailement des maladies mentales (Paris: Bibhotheque Medicale, 1824); Eli enne Georget presents the results ol around 3 0 0 ouvertures des corps ol insane persons at the Salpetriere hospital in chapter 5, "Recherches cadavenques. Etudes de l'anatomie pathologique" in his De lajolie, pp. 423 431. A. [de| Foville pursued anatomical research resulting in his thesis: Observations cliniques propres a eclairer certaines questions relatives a lfal- ienation mentale, Medical Thesis, Paris, no. 138 (Paris: Didot Jeune, 1824). Felix Voisin undertook anatomical work lor his, Des causes morales et physiques des maladies mentales, et de quelques autres affections lelles que I'hysterie, le nymphomanie et le satyriasis.
44. C. C. H. Marc, for example, took up the case of the wile ol a journalist ol Selestat--who, in July 1817, killed her fifteen month old child, and cut oil his right thigh, cooked it, and then partly ate it--and analyzed the medico legal report ol Dr. F. D. Reisseisen, "Examen d'un cas extraordinaire d'infanticide" (originally published in German in Jahrbuch der Staatsarlheilkund, J. H. Kopp, ed. , vol. XI, 1817) in his De lajolie consideree dans ses rapports avec les questions medico-judiciaires, vol. II (Pans:J. -B. Bailliere, 1840) pp. 130 146. Etienne Georget, in particular, considers several criminal cases: (1) Examen medical des proces crim- inels de Leger, Feldman, Lecouffe, Jean-Pierre, Papavoine, dans lesquels Valienation mentale a ete alleguee comme moyen de defense, suivi de quelques considerations medico-legales sur la liberte morale (Pans: Migneret, 1825); (2) Nouvelles discussions medico-legales sur la folie ou alienation men- tale, suivies de Vexamen de plusieurs proces criminels dans lesquels celle maladie a ete alleguee comme moyen de defense (Paris: Migneret, 1826). On these medical strategies we can turn to, R. Castel, "Les medecins et les juges," in Michel Foucault, ed. Moi, Pierre Rivihe, ayant egorge ma mere, ma soeur et monfrere. Un cas de parricide au xix1 siecle (Paris: Gallimard, 1973) pp. 315-331; English translation, "The Doctors and Judges," J, Pierre Riviere, having slaughtered my mother, my sister and my brother. . . , trans. F. Jellinek ( N e w York: Pantheon, 1975 and Harmondsworth: Penguin, 1984) pp. 250 268. P. Devernoix, Les Alienes et I'expertise medico-legate. Du pouvoir discretionnaire des juges en matiere criminelle, et des inconvenients qui en resultent (Toulouse: C. Dirion, 1905). Michel Foucault returns to these cases in his course, Les Anormaux, lectures ol 29 January and 5 February 1975, pp. 94 100 and pp. 101-126;
Abnormal, pp. 102-104 and 109 134.
45. In a note to chapter 4, "De I'impulsion insolite a une action determinee," section III ol J. Hoffbauer's treatise, Medecine legate relative aux alienes et aux sourds-muets, ou les his appliquees aux desordrcs de {'intelligence, trans. A. M. Chambeyron, with notes by Itard and Esquirol (Paris: J. B. Bailliere, 1827), Esquirol gives the following delinition of monoma- nia: "There is a kind of homicidal monomania in which one can observe no intellectual or
moral disorder; the murderer is driven by an irresistible power, by a force he cannot over come, by a blind impulse, by a thoughtless determination, without interest, without motive, without distraction, to an atrocious action" (reprinted in Des maladies mentales, vol. II, p. 804). On the history ol the concept, see, R. Fontanille, Alienation mentale et Criminialite (Historique, expertise medico-legale) (Grenoble: Allier Freres, 1902); P. Dubuisson and A. Vigouroux, Responsibilite penale et Folie. Etude medico-legate (Paris: Alcan, 1911); and A. Fontana, "Les intermittences de la raison," in Moi, Pierre Riviere. . . , pp. 333 350; "The Intermittences of Rationality," /, Pierre Riviere,. . . , pp. 269 288.
46. Thus, C. C. Marc states that "one ol the most serious and delicate functions that can be devolved on the expert in forensic medicine is that of determining whether the mental
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47.
alienation is real or feigned" in "Matenaux pour l'histoire medico-legale de 1'ahenation mentale," Annales d'hygiene publique el de medecine legate, vol. II, 2 part (Paris: Gabon, 1829) p. 353.
Foucault is alluding here to the movements oi institutional criticism which developed alter
the 2nd World War and which denounced an asylum, the medicalized heir to the "hopitaux generaux" of the "great confinement," which had become a pathogenic institution through
the conditions of life it provided for the patients; see the Report presented by Lucien Bonnafe, Louis Le Guillant and Henri Mignont, "Problemes poses par la chronicite sur le plan des institutions psychiatricjues," in XII' congres de Psychiatrie et de Neurologie de langue
francaise, Marseilles, 7-12 September 1964 (Paris: Masson, 1964). The question then was
one of knowing whether "the aim pursued by the institution (. . . ) truly conforms to the aim that we can agree to formulate as: psychiatric therapy" (L. Bonnafe, "Le milieu hospi- taller vu du point de vue therapeutique, ou theone et pratique de Phopital psychiatrique,"
La Raison, no. 17, 1958, p. 26) and it was a matter ol promoting "the use of the hospital milieu itself as treatment and social readaptation" (ibid. p. 8). The following articles con
tain detailed bibliographies on the problem: G. Daumezon, P. Paumelle, F. Tosquelles, "Organisation therapeutique de Phopital psychiatrique. I: Le fonctionncment therapeu tique," in Encylopedie medico<hirurgicale. Psychiatrie, vol. I, February 1955, 37 930, A-10, pp. 1 8; G. Daumezon and L. Bonnafe, "Perspectives de reforme psychiatrique en France depuis la Liberation. " See also, below, "Course context. "
This qualification of "militants ol antipsychiatry" derives irom the definition Foucault put forward in his contribution, "Histoire de la folie et antipsychiatrie," during the Montreal colloquium organized by H. F. Ellenberger in May 1973, "Faut il interner le psychiatres? ":
"I call antipsychiatry everything which challenges and calls into question the role ol a psy chiatrist formerly called upon to produce the truth of the illness in the hospital space. " Hysterics are the "militants" oi this in that, providing their crises on demand, they gave birth to "the suspicion that the great master oi madness, the person who made it appear and disappear, Charcot, was the person who did not produce the truth of the illness, but rather its artifice" (typed manuscript, pp. 12 13). See also, below, "Course summary. " In this Foucault was inspired by the analyses T. Szasz devoted to Charcot in the first chapter
oi The Myth of Mental Illness: Foundations of a Theory oj Personal Conduct (New York: Harper and Row, 1974) ch. 1, "Charcot and the problem ol hysteria"; French translation Le Mythe
de la maladie mentale, trans. D. Berger (Paris: Payot, 1975). This is confirmed by an inter- view on this text: "there is a chapter which seems to me exemplary: hysteria is taken apart as a product oi psychiatric power, but also as the counter attack on it and the trap into which it ialls" "Sorcellene et iolie" Dits el Ecrits, vol. 3, p. 91. Foucault saw in "the explo sions of hysteria which broke out in psychiatric hospitals in the second half of the nine- teenth century (. . . ) an after-effect oi the exercise of psychiatric power" "Les rapports de pouvoir passent a l'interieur du corps" ibid. p. 231.
48.
? eleven
30 JANUARY 1974
The problem of diagnosis in medicine and psychiatry. ^ The place of the body in psychiatric nosology: the model of general paralysis. ^ Thefate of the notion of crisis in medicine and psychiatry. ^ The test of reality in psychiatry and its forms:
1. Psychiatric questioning (Vinterrogatoire^) and confession. The ritual of clinical presentation. Note on "pathological heredity" and
degeneration. ^ 2. Drugs. Moreau de Tours and hashish. Madness and dreams. rsJ 3. Magnetism and hypnosis. The discovery of the "neurological body. "
I HAVE TRIED TO show you how and why the medical crisis, which as well as being a theoretical notion was above all a practical instrument in medicine, disappeared at the end of the eighteenth and the beginning of the nineteenth century, basically because the appearance of pathological anatomy made it possible to bring to light the reality of the disease in a localized lesion within the organism and identifiable in the body Then, on the other hand, starting with these different lesions that individualized diseases, this same pathological anatomy made it possible to constitute clusters of signs from which the differential diagnosis of diseases could be established. You can see that under these conditions--ascription of the disease to the body and the possibility of a differential diagnosis--the crisis, as the test in which disease produced its own truth, became pointless. In the realm of psychiatry the situation is completely different,
for two reasons.
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The first is that in the psychiatric order, the problem is not funda mentally, not at all in fact, one of differential diagnosis. Of course, at a certain level in psychiatric practice, diagnosis does appear to develop as the differential diagnosis of one illness as distinct from another; mania or melancholy, hysteria or schizophrenia, etcetera. But in truth, I think all this is only a superficial and secondary activity in relation to the real question posed in every diagnosis of madness, which is not whether it is this or that form of madness, but whether it is or is not madness. I think the position of psychiatry is very different from that of medicine in this respect. You will say that the prior question of whether or not one is dealing with an illness is also necessary in medicine; however, truly, it is both a relatively simple and, at bottom, marginal question; it is almost only in cases of dissimulation or hypochondnacal delirium that the problem of "illness or not" can really be posed seriously. In the domain of mental illness, however, the only real question is posed in the form of yes or no. That is to say, the differential field within which the diagno sis of madness is practiced is not constituted by the range ol nosographic species, but simply by marking the difference between what is madness and what is not: the diagnosis of madness is carried out in this binary domain, in this strictly dual field. So I would say that, except as a sec ond order and, as it were, superfluous justification, psychiatry does not require differential diagnosis. Psychiatric diagnosis does not involve a differential diagnosis but, if you like, a decision, or an absolute diagnosis. Psychiatry functions, then, in terms of the model of an absolute, and not a differential, diagnosis.
Second, psychiatry as it is being established in the nineteenth century again contrasts with medicine in that it is clearly a medicine in which the body is absent. However, we must be clear here, because it is absolutely certain that, on the one hand, from the beginnings of the development of nineteenth century psychiatry, there was a search for organic correlations, the domain of lesion, the type of organ that might be involved in an illness like madness. There was the search for this, and in some cases it was found; in 1822-1826 it was Bayle's definition ol gen- eral paralysis, and meningeal lesions as after-effects of syphilis. 1 This is true, and we can say that the body was no more absent from the psych1 atric order than it was from standard medicine. And yet there was an
? essential difference: the problem to be resolved in psychiatric activity was not so much, or was not primarily, whether a particular form of behavior, a way of speaking, a type of illusion, or a category of halluci- nation, were due to this or that form of lesion, but whether or not say ing such things, conducting oneself in such a way, hearing such voices, and suchlike, belonged to madness. And the best proof that this was the fundamental question is that in 1826 Bayle recognized that in general paralysis, which was one of the major forms in which it was thought there was an assignable relationship between mental illness and the organism, there were three major types of syndromes: the motor syn- drome of progressive paralysis; second, the psychiatric syndrome ol madness; and third, the terminal condition of dementia. 2 Now, forty years later, Baillarger said: Everything that Bayle said is more or less true, but there is a fundamental error nonetheless, which is that there is no madness at all in general paralysis, only an intrication of paralysis and dementia. 5
So, I think we can say that the liquidation of the medical crisis was acceptable to medicine thanks to pathological anatomy, but was not possible in the psychiatric domain due to absolute diagnosis and the absence of the body/ The problem psychiatry faces becomes precisely that of constituting, of establishing, the kind of test, or series of tests, that will enable it to meet this requirement of absolute diagnosis, that is to say, the kind of test that will accord reality or unreality to what is taken to be madness, to inscribe it within the field of reality or disqualify it as unreal.
In other words, we can say that the classical notion of crisis in medicine, the classical practice of the medical crisis as it was put to work for over two thousand years, basically had two nineteenth century descendants.
J. P. Vernant, Divination et Rationalite (Paris: Le Seuil, I974).
30. Hippocrates "considers an important part ol the art of medicine" to be the ability "to
observe the order of the critical days and to extract the elements ol prognosis from it. When we know these things, we know too when and how to give nourishment to the patient" Hippocrates, Epidemies, III, 3ul section, ? 16, in CEuvres completes, vol. Ill; English translation, Hippocrates, Epidemics, 3, trans. W. H. S. Jones, Hippocrates, vol. I, Loeb Classical Library (Cambridge, Mass: Harvard University Press, 1923).
31. Hippocrates, Pronostic, ? 1: "The best doctor seems to me to be one who can know in advance . . . He will treat best those diseases whose future course he can loresee with the help of the present condition" CEuvres completes, vol. II, p. 111; Prognosis ? 1, in Hippocratic Writings: "It seems to be highly desirable that a physician should pay much attention to
? prognosis. . . . he will be better able to effect a cure if he can loretell, trom the present
symptoms, the future course of the disease. " p. 170.
}2. In Hippocrates's own terms, the doctor's task is to "combat (avrayoviaaBai) each of the
accidents through his art. " Or again, "if we know the cause of the disease, we will be in a position to administer what is useful to the body, starting from contraries to counter (SK TOV evavTtov ermao[tEVo<;) the disease" Des Vents, I, in Guvres completes, vol. VI, p. 93 (translation amended by J. L. |; English translation, Airs, I, in Hippocrates, vol. I, Locb Classical Library (1923).
33. Taken from juridical language, the term krisis means "judgment," "decision," before desig nating in medicine the crucial moment at which "the disease judges | KpiveTcu] lor death
or life "Des Affections internes,21 220, 9, in GLuvres completes, vol. VII, p. 217; "Internal Affections," trans. Paul Potter, Hippocrates, vol. VI, Loeb Classical Library (1988). Or again there is this expression in Epidemies, I, 2IK section, ? 4: "In some ( . . . ) the illness is decided by a crisis" in GLuvres completes, vol. II, p. 627; EpiJemies, Book One, (11), ? 8, p. 92. As for the doctor, he is judged on his sense of opportunity and his interventions; see, Des maladies, I, 5. pp. 147 151; Diseases, I, trans. Paul Potter, Hippocrates, vol. V, Loeb Classical Library (1988).
34. See the medical scenes in the plays by Mohere (1622 1673): (1) VAmour medecin (performed
on 14 September, 1665), Act II, scene 2, in which four doctors are involved, and scenes 3-4 of
the consultation, in Guvres completes, ed. M. Rat (Paris: Galhmard, 1947) vol. II, pp. 14 25; (2) Monsieur de Pourceaugnac ( 6 October 1669) in Act I, scenes 7 8, ol which, two doctors and an apothecary are involved, Guvres completes, vol. II, pp. 141-120; and (3) Le Malade imaginaire (10 February 1673), posthumous work ( 1682), Act II, scenes 5 6, and Act III, scene 5, Guvres com- pletes, vol. II , pp. 845-857 and pp. 871 873. See, F. Millepierres, La Vie quotidienne des medecins au temps de Moliere (Paris: Hachette, 1964).
}5. This refers to an episode that took place during Galen's (b. Peigamum 129 A. D. ) first stay in Rome from the autumn of 162 until the summer ol 166, before coming back to settle there from 169 until his death around 200. Sec, De Praecognitione ? 1$ in Opera Omnia, vol. XIV, ed. and Latin trans. C. G. Kiihn (Lipsiae: in officina, C! Cnoblochii, 1827) pp. 666 668; English translation, On Prognosis: Corpus Medicomm Graecorum, V, 8, 1, trans. Vivian Hutton (Berlin: Akademie Verlag, 1979) pp. 135-137. On Galen's relations with the Roman medical world, see J. Walsh, "Galen clashes with the medical sects at Rome (163 A. D. )," Medical Life, vol. 35,1928, pp. 408-444. On his practice, see,J. Ilberg, "Aus Galens Praxis. Ein Kulturbild aus der Kaiserzeit," Neue Jahrbiicher fur das klassische Allerlum (Leipzig: Teubner, vol. 15, 1905, pp. 276 312; and, V. Nutton, "The chronology ol Galen's early career," The Classical Quarterly, vol. 23, 1973, pp. 158 171.
36. This passage echoes a number of treatments by Foucault of "the inquiry": (1) The 1971- 1972 lectures at the College de France, the first part of which deals with the inquiry and its development in the Middle Ages; see the course summary, "Theories et Institutions penales" Dits et Ecrits, vol. 2, pp. 390 391; "Penal Theories and Institutions," trans. Robert Hurley, Essential Works of Foucault, 1, pp. 17 19; (2) The College de France lectures ol 1972 1973, "The Punitive Society," in which, in the lecture of 28 March 1973, Foucault returns to the constitution of an "inquiry knowledge"; (3) The third lecture (23 May 1973) on "La Verite et les formes jundiques" pp. 581 588; "Truth and Juridical Forms" pp. 44 52. Foucault returns to the process of the colonization of a "truth test" in the form of the event by a "truth-findings" in the lorm ol a body of knowledge in 1975 in "La Maison des lous" Dits et Ecrits, vol. 2, pp. 6 9 6 697.
37. In the second half ol the eighteenth century, since Fnedrich Hoffmann, who still believed in the theory of crises, albeit with reservations about the notion of critical days, died in 1742. See, C. Daremberg, Histoire des sciences medicates, vol. II, p. 929.
38. This grid, which dates from the organization of administrative health correspondence by the Intendants in order to collect lnlormation on epidemics and endemic diseases, found institutional expression with the creation on 29 April 1776, on Turgot's initiative, of the "Societe Royale de Medecine" responsible for studying epidemics and epizootic diseases, before disappearing in 1794. See, C. Hannaway, "The Societe Royale de Medecine and epi demies in the Ancient Regime," Bulletin of the History of Medicine, vol. 46, no. 3, 1972, pp.
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257273. Concerning these inquiries, see, J. Meyer, "Une enquete de 1'Academie de medecine sur les epidemics (1774 1794)" Annales ESC, 21st year, no. 4, August 1966, pp. 729 749; H. Dupin and L. Masse, uUne enquete epidemiologique a peripeties multiple: I'etude de la pellagre," Revue d'epidemiologie, medecine sociale el sanle publique, vol. XIX, no. 8, 1971, pp. 743 76();J. P. Peter, (1) "Une enquete de la Societe Royale de Medecine. Malades et maladies a la fin du xvmc siecle," Annales ESC, 22,ul year, no. 4, July August 1967, pp. 711 751; ( 2 ) "Les mots et les objets de la maladie. Remarques sur les epidemies et la medecine dans la societe Iran^aise de la lin du xvni' siecle," Revue hisloriijue, no. 499, 1971,pp. 13 38;J. P. Desaive, P. Goubert, E. Le Roy Ladurie, Medecins, climals et epidemies a fin du xviii . siecle (Paris: Mouton, 1972). See also the pages devoted to this in M. Foucault, Naissance de la clinicjue, ch. 2, "Une conscience politique," pp. 21 36; Birl/i of the Clinic, ch. 2, "A Political Consciousness," pp. 22 37.
39. On the development of hospital lacilities and the advent ol a medical police, see, G. Rosen, (1) "Hospitals, medical care and social policy in the French Revolution," Bulletin of the Histoty of Medicine, vol. 30, no. I, 1956, pp. 124 I49, reprinted in G. Rosen, From Medical Police to Social Medicine: Essays on the History of Health Care ( N e w York: Science History Publications, 1974) pp. 220 245; (2) A History of Public Health (New York: MD Publications, 1958); ( 3 ) "Mercantilism and health policy in eighteenth century French thought," Medical History, vol. Ill, October 1959, pp. 259 277, reprinted in From Medical Police, pp. 201 219; M. Joeger, (1) "Les enquetes hospitalieres au xviii' siecle," Bulletin de la Societe francaise d'histoire des hopitaux, no. 31,1975, pp. 51 6(); ( 2 ) "La structure hospital lere de la France sous I'Ancien Regime," Annales ESC, 32m year, no. 5, September October 1977, pp. 1025 1051; M. J. Imbault Huart, "L'hopital, centre d'une nouvelle medecine (1780 1820)," in Zusammentrang Festschrift fur Marilene Pulscher, vol. II (Cologne: Wienand, 1984) pp. 581 603. Foucault takes up this question in a number ol places: ( 1) Naissance de la clinique, ch. v, "La lecon des hopitaux," pp. 63 86; Birth oj the Clinic, ch. 5, "The lesson of the Hospitals" pp. 64 87; "La politique de la sante au XVIII1' siecle," in Michel Foucault, Blandine Barret Kriegel, Anne Thalamy, Francois Beguin, and Bruno Fortier, Les Machines a guerir. Aux origines de l'hopital moderne. Dossiers et documents (Paris: Institut de I'Environnement, 1976) pp. 11 21, reprinted in Dits et Ecrits, vol. 3, pp. 13 27; English translation, "The politics ol health in the eighteenth century," trans. Colin Gordon, Essential Works oj Foucault, 3, pp. 9 0 105; (3) he relers to it in his hrst lecture on the his tory ol medicine in Rio de Janeiro in October 1974: "Crise de la medecine 011 crise de 1'an- timedecine? " Dits et Ecrits, vol. 3, pp. 50 54, and in the third "L'incorporation de l'hopital dans la technologic moderne," Dits et Ecrits, vol. 3, pp. 5 0 8 521.
40. See M. Foucault, Naissance de la clinique, ch. vui, "Ouvrez quelques cadavres," pp. 125 149; Birth of the Clinic, ch. 8, "Open Up a Few Corpses," pp. 124 148. E. H.
Ackerknecht, La Medecine hospilaliere a Paris (UW-lcfyS) p p . 2 0 9 214.
41. Foucault takes up this point in his second lecture at Rio de Janeiro, "La naissance de la medecine sociale," Dits et Ecrits, vol. 3, pp. 212-215; English translation "The Birth ol Social Medicine," trans. Robert Hurley, Essential Works of Foucault, 3. See G. Rosen, "Problems in
the application ol statistical knowledge analysis to questions of health (1711 1 8 8 0 ) " Bulletin of the History of Medicine, vol. 29, no. 1, 1955, pp. 27 45; M. Greenwood, Medical Statistics from Graunt to Farr (Cambridge: Cambridge University Press, 1948).
42. Thus, Georget states as "1bl principle: never direct the minds of the insane towards their delir- ium" in chapter 5, "Traitement de la lolie," of his work: De lafolie. Considerations sur cette mal- adie, p. 280. Leuret states that "one must impose silence on the patient with regard to his delirium, and occupy them with something else" Du traitement moral de lajolie, p. 120. On this "principle of distraction" see above, note 6 to the lecture of 5 December 1973.
43. Recourse to the research of pathological anatomy was recommended by Jean Pierre Falret in the introduction (September 1853) to his Des maladies mentales, p. v: "Against the doc- trines of our teachers, we yielded, like the others, to that anatomical direction of the sci
ence that at that time was thought to be the true basis of medicine ( . . . ) . We quickly convinced ourselves that only pathological anatomy could give the primary cause ol the phenomena observed in the insane. " Thus, research into pathological anatomy was pursued at Charenton and gave rise to various publications: Jean Baptiste Delaye (1789 1879), attached to Esquirol's department, defended his thesis on 20 November 1824, Consideration
? sur une cspke de paralysic qui ajjecte parliculierement les alienes, Medical Thesis, Paris, No. 224 (Paris: Didot, 1824); Louis Florenlin Calmeil (1798-1895), intern in the department of Royer Collard, chief doctor at Charenton from 1805 until his death in 1825, published: De la paralysie consideree chevies alienes. Recherchesfaites dans le service dejeu M. Royer-Collard et de M. Esquirol (Paris: J. B. Bailliere, 1826); Antoine Laurent Jesse Bayle, arrived at the same department in 1817 where he pursued anatomical research resulting in his thesis of 1822: Recherches sur les maladies mentales. Recherches sur {'arachnitis chronique, la gastrite, la gas- tro-enterite et la goutte considerees comme causes de {'alienation mentale, Medical Thesis, Paris, no. 147 (Pans: Didot, 1822) as well as his work of 1826: Traite des maladies du cerveau et de ses membranes. See J. E. D. Escjuirol, "Memoire historique et statistique sur la Maison Royale de Charenton" (1835) in Des maladies mentales, vol. II, ? "Ouvertures de corps," pp. 698 700. The results of Jean Pierre Falret's research at Salpetriere were presented on 6 December 1823 at the Athence de Medecine: Inductions tirees de Vouverture du corps des alienes pour servir au diagnostic el au trailement des maladies mentales (Paris: Bibhotheque Medicale, 1824); Eli enne Georget presents the results ol around 3 0 0 ouvertures des corps ol insane persons at the Salpetriere hospital in chapter 5, "Recherches cadavenques. Etudes de l'anatomie pathologique" in his De lajolie, pp. 423 431. A. [de| Foville pursued anatomical research resulting in his thesis: Observations cliniques propres a eclairer certaines questions relatives a lfal- ienation mentale, Medical Thesis, Paris, no. 138 (Paris: Didot Jeune, 1824). Felix Voisin undertook anatomical work lor his, Des causes morales et physiques des maladies mentales, et de quelques autres affections lelles que I'hysterie, le nymphomanie et le satyriasis.
44. C. C. H. Marc, for example, took up the case of the wile ol a journalist ol Selestat--who, in July 1817, killed her fifteen month old child, and cut oil his right thigh, cooked it, and then partly ate it--and analyzed the medico legal report ol Dr. F. D. Reisseisen, "Examen d'un cas extraordinaire d'infanticide" (originally published in German in Jahrbuch der Staatsarlheilkund, J. H. Kopp, ed. , vol. XI, 1817) in his De lajolie consideree dans ses rapports avec les questions medico-judiciaires, vol. II (Pans:J. -B. Bailliere, 1840) pp. 130 146. Etienne Georget, in particular, considers several criminal cases: (1) Examen medical des proces crim- inels de Leger, Feldman, Lecouffe, Jean-Pierre, Papavoine, dans lesquels Valienation mentale a ete alleguee comme moyen de defense, suivi de quelques considerations medico-legales sur la liberte morale (Pans: Migneret, 1825); (2) Nouvelles discussions medico-legales sur la folie ou alienation men- tale, suivies de Vexamen de plusieurs proces criminels dans lesquels celle maladie a ete alleguee comme moyen de defense (Paris: Migneret, 1826). On these medical strategies we can turn to, R. Castel, "Les medecins et les juges," in Michel Foucault, ed. Moi, Pierre Rivihe, ayant egorge ma mere, ma soeur et monfrere. Un cas de parricide au xix1 siecle (Paris: Gallimard, 1973) pp. 315-331; English translation, "The Doctors and Judges," J, Pierre Riviere, having slaughtered my mother, my sister and my brother. . . , trans. F. Jellinek ( N e w York: Pantheon, 1975 and Harmondsworth: Penguin, 1984) pp. 250 268. P. Devernoix, Les Alienes et I'expertise medico-legate. Du pouvoir discretionnaire des juges en matiere criminelle, et des inconvenients qui en resultent (Toulouse: C. Dirion, 1905). Michel Foucault returns to these cases in his course, Les Anormaux, lectures ol 29 January and 5 February 1975, pp. 94 100 and pp. 101-126;
Abnormal, pp. 102-104 and 109 134.
45. In a note to chapter 4, "De I'impulsion insolite a une action determinee," section III ol J. Hoffbauer's treatise, Medecine legate relative aux alienes et aux sourds-muets, ou les his appliquees aux desordrcs de {'intelligence, trans. A. M. Chambeyron, with notes by Itard and Esquirol (Paris: J. B. Bailliere, 1827), Esquirol gives the following delinition of monoma- nia: "There is a kind of homicidal monomania in which one can observe no intellectual or
moral disorder; the murderer is driven by an irresistible power, by a force he cannot over come, by a blind impulse, by a thoughtless determination, without interest, without motive, without distraction, to an atrocious action" (reprinted in Des maladies mentales, vol. II, p. 804). On the history ol the concept, see, R. Fontanille, Alienation mentale et Criminialite (Historique, expertise medico-legale) (Grenoble: Allier Freres, 1902); P. Dubuisson and A. Vigouroux, Responsibilite penale et Folie. Etude medico-legate (Paris: Alcan, 1911); and A. Fontana, "Les intermittences de la raison," in Moi, Pierre Riviere. . . , pp. 333 350; "The Intermittences of Rationality," /, Pierre Riviere,. . . , pp. 269 288.
46. Thus, C. C. Marc states that "one ol the most serious and delicate functions that can be devolved on the expert in forensic medicine is that of determining whether the mental
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47.
alienation is real or feigned" in "Matenaux pour l'histoire medico-legale de 1'ahenation mentale," Annales d'hygiene publique el de medecine legate, vol. II, 2 part (Paris: Gabon, 1829) p. 353.
Foucault is alluding here to the movements oi institutional criticism which developed alter
the 2nd World War and which denounced an asylum, the medicalized heir to the "hopitaux generaux" of the "great confinement," which had become a pathogenic institution through
the conditions of life it provided for the patients; see the Report presented by Lucien Bonnafe, Louis Le Guillant and Henri Mignont, "Problemes poses par la chronicite sur le plan des institutions psychiatricjues," in XII' congres de Psychiatrie et de Neurologie de langue
francaise, Marseilles, 7-12 September 1964 (Paris: Masson, 1964). The question then was
one of knowing whether "the aim pursued by the institution (. . . ) truly conforms to the aim that we can agree to formulate as: psychiatric therapy" (L. Bonnafe, "Le milieu hospi- taller vu du point de vue therapeutique, ou theone et pratique de Phopital psychiatrique,"
La Raison, no. 17, 1958, p. 26) and it was a matter ol promoting "the use of the hospital milieu itself as treatment and social readaptation" (ibid. p. 8). The following articles con
tain detailed bibliographies on the problem: G. Daumezon, P. Paumelle, F. Tosquelles, "Organisation therapeutique de Phopital psychiatrique. I: Le fonctionncment therapeu tique," in Encylopedie medico<hirurgicale. Psychiatrie, vol. I, February 1955, 37 930, A-10, pp. 1 8; G. Daumezon and L. Bonnafe, "Perspectives de reforme psychiatrique en France depuis la Liberation. " See also, below, "Course context. "
This qualification of "militants ol antipsychiatry" derives irom the definition Foucault put forward in his contribution, "Histoire de la folie et antipsychiatrie," during the Montreal colloquium organized by H. F. Ellenberger in May 1973, "Faut il interner le psychiatres? ":
"I call antipsychiatry everything which challenges and calls into question the role ol a psy chiatrist formerly called upon to produce the truth of the illness in the hospital space. " Hysterics are the "militants" oi this in that, providing their crises on demand, they gave birth to "the suspicion that the great master oi madness, the person who made it appear and disappear, Charcot, was the person who did not produce the truth of the illness, but rather its artifice" (typed manuscript, pp. 12 13). See also, below, "Course summary. " In this Foucault was inspired by the analyses T. Szasz devoted to Charcot in the first chapter
oi The Myth of Mental Illness: Foundations of a Theory oj Personal Conduct (New York: Harper and Row, 1974) ch. 1, "Charcot and the problem ol hysteria"; French translation Le Mythe
de la maladie mentale, trans. D. Berger (Paris: Payot, 1975). This is confirmed by an inter- view on this text: "there is a chapter which seems to me exemplary: hysteria is taken apart as a product oi psychiatric power, but also as the counter attack on it and the trap into which it ialls" "Sorcellene et iolie" Dits el Ecrits, vol. 3, p. 91. Foucault saw in "the explo sions of hysteria which broke out in psychiatric hospitals in the second half of the nine- teenth century (. . . ) an after-effect oi the exercise of psychiatric power" "Les rapports de pouvoir passent a l'interieur du corps" ibid. p. 231.
48.
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30 JANUARY 1974
The problem of diagnosis in medicine and psychiatry. ^ The place of the body in psychiatric nosology: the model of general paralysis. ^ Thefate of the notion of crisis in medicine and psychiatry. ^ The test of reality in psychiatry and its forms:
1. Psychiatric questioning (Vinterrogatoire^) and confession. The ritual of clinical presentation. Note on "pathological heredity" and
degeneration. ^ 2. Drugs. Moreau de Tours and hashish. Madness and dreams. rsJ 3. Magnetism and hypnosis. The discovery of the "neurological body. "
I HAVE TRIED TO show you how and why the medical crisis, which as well as being a theoretical notion was above all a practical instrument in medicine, disappeared at the end of the eighteenth and the beginning of the nineteenth century, basically because the appearance of pathological anatomy made it possible to bring to light the reality of the disease in a localized lesion within the organism and identifiable in the body Then, on the other hand, starting with these different lesions that individualized diseases, this same pathological anatomy made it possible to constitute clusters of signs from which the differential diagnosis of diseases could be established. You can see that under these conditions--ascription of the disease to the body and the possibility of a differential diagnosis--the crisis, as the test in which disease produced its own truth, became pointless. In the realm of psychiatry the situation is completely different,
for two reasons.
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The first is that in the psychiatric order, the problem is not funda mentally, not at all in fact, one of differential diagnosis. Of course, at a certain level in psychiatric practice, diagnosis does appear to develop as the differential diagnosis of one illness as distinct from another; mania or melancholy, hysteria or schizophrenia, etcetera. But in truth, I think all this is only a superficial and secondary activity in relation to the real question posed in every diagnosis of madness, which is not whether it is this or that form of madness, but whether it is or is not madness. I think the position of psychiatry is very different from that of medicine in this respect. You will say that the prior question of whether or not one is dealing with an illness is also necessary in medicine; however, truly, it is both a relatively simple and, at bottom, marginal question; it is almost only in cases of dissimulation or hypochondnacal delirium that the problem of "illness or not" can really be posed seriously. In the domain of mental illness, however, the only real question is posed in the form of yes or no. That is to say, the differential field within which the diagno sis of madness is practiced is not constituted by the range ol nosographic species, but simply by marking the difference between what is madness and what is not: the diagnosis of madness is carried out in this binary domain, in this strictly dual field. So I would say that, except as a sec ond order and, as it were, superfluous justification, psychiatry does not require differential diagnosis. Psychiatric diagnosis does not involve a differential diagnosis but, if you like, a decision, or an absolute diagnosis. Psychiatry functions, then, in terms of the model of an absolute, and not a differential, diagnosis.
Second, psychiatry as it is being established in the nineteenth century again contrasts with medicine in that it is clearly a medicine in which the body is absent. However, we must be clear here, because it is absolutely certain that, on the one hand, from the beginnings of the development of nineteenth century psychiatry, there was a search for organic correlations, the domain of lesion, the type of organ that might be involved in an illness like madness. There was the search for this, and in some cases it was found; in 1822-1826 it was Bayle's definition ol gen- eral paralysis, and meningeal lesions as after-effects of syphilis. 1 This is true, and we can say that the body was no more absent from the psych1 atric order than it was from standard medicine. And yet there was an
? essential difference: the problem to be resolved in psychiatric activity was not so much, or was not primarily, whether a particular form of behavior, a way of speaking, a type of illusion, or a category of halluci- nation, were due to this or that form of lesion, but whether or not say ing such things, conducting oneself in such a way, hearing such voices, and suchlike, belonged to madness. And the best proof that this was the fundamental question is that in 1826 Bayle recognized that in general paralysis, which was one of the major forms in which it was thought there was an assignable relationship between mental illness and the organism, there were three major types of syndromes: the motor syn- drome of progressive paralysis; second, the psychiatric syndrome ol madness; and third, the terminal condition of dementia. 2 Now, forty years later, Baillarger said: Everything that Bayle said is more or less true, but there is a fundamental error nonetheless, which is that there is no madness at all in general paralysis, only an intrication of paralysis and dementia. 5
So, I think we can say that the liquidation of the medical crisis was acceptable to medicine thanks to pathological anatomy, but was not possible in the psychiatric domain due to absolute diagnosis and the absence of the body/ The problem psychiatry faces becomes precisely that of constituting, of establishing, the kind of test, or series of tests, that will enable it to meet this requirement of absolute diagnosis, that is to say, the kind of test that will accord reality or unreality to what is taken to be madness, to inscribe it within the field of reality or disqualify it as unreal.
In other words, we can say that the classical notion of crisis in medicine, the classical practice of the medical crisis as it was put to work for over two thousand years, basically had two nineteenth century descendants.
