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The problem of diagnosis in medicine and psychiatry.
30 JANUARY 1974
The problem of diagnosis in medicine and psychiatry.
Foucault-Psychiatric-Power-1973-74
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. On the one hand, through pathological anatomy, procedures of verification, in the form of the objective report and demonstration, were substituted for the classical medical crisis and its test: this was the medical offspring. The psychiatric offspring of the classical crisis was different. Since there was no field within which psychiatry could ascertain
* The manuscript clarifies: "This therefore implies a completely specific procedure for establishing the illness. "
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the truth, it had to establish and substitute something for the old classical medical crisis which was, like the old medical crisis, a test, but a test of reality rather than a test of truth. Put differently, the test of truth splits into techniques for ascertaining the truth on one side: this is standard medicine; [and, on the other), a test of reality: this is what happens in psychiatry.
To summarize, and to start studying this system, this game, this panoply of tests of reality, I think we can say the following: In psychiatry, the essential moment that punctuates, organizes, and at the same time distributes this field of disciplinary power I have been speaking about, is this test of reality, which has a double meaning.
On the one hand, it involves making the reasons given for a requested confinement, or for possible psychiatric intervention, exist as illness, or possibly non-illness. The psychiatric test is then what I will call the test of administrative medical reduplication: Can what has motivated the request be retranscribed in terms of symptoms and illness? The lirst function of the psychiatric test is to retranscnbe the request as illness, to make the grounds for the request exist as symptoms of illness.
The second function is correlative to this and in a way is much more important. The test involves making the power of intervention and the dis ciphnary power of the psychiatrist exist as medical knowledge. I have tried to show you how this power operated within a disciplinary field, which had a medical stamp of course, but which lacked real medical content. Well, this disciplinary power must now be made to function as medical power, and the psychiatric test will be, on the one hand, what constitutes the request for confinement as illness, and, on the other, what makes the person given powers of decision in confinement function as a doctor.
In organic medicine, the doctor vaguely formulates the following demand: Show me your symptoms and I will tell you what your illness is. In the psychiatric test, the psychiatrist's demand is much weightier, much more surcharged, and is: With what you are, with your life, with the grounds for people's complaints, [. . . *J, with what you do, and what you say, provide me with some symptoms, not so that I know what your illness is, but so that I can stand before you as a doctor.
* (On the recording, repetition of:) with what you are
? That is to say, the psychiatric test is a double test for the official estab- lishment of an individual's life as a tissue of pathological symptoms, as well as the constant official establishment of the psychiatrist as a doctor, or of the supreme disciplinary authority as a medical authority. Consequently, we can say that the psychiatric test is an endless test of admittance into the hospital. Why is it that one cannot leave the asylum? One cannot leave the asylum, not because the exit is far away, but because the entrance is too near. One never stops entering the asylum, and every encounter, every confrontation between the doctor and the patient begins again and indefinitely repeats this founding, initial act by which madness will exist as reality and the psychiatrist will exist as doctor.
Consequently you can see how there is a very curious and complex game into which all the real games of the asylum and of the history of psychiatry and madness in the nineteenth century throw themselves. If you consider things at the level of the disciplinary functioning of the asylum, (which I analyzed in the previous sessions), then at this level there is a formidable medical surplus-power because the doctor and the disciplinary system ultimately form a single body; the hospital itself is the doctor's body. However, on the other side, there is a prodigious surplus power of the patient, since it is the patient, in terms, precisely, of the way in which he undergoes and comes out from the psychiatric test, who will or will not establish the psychiatrist as doctor, who will either refer him back to his pure and simple disciplinary role or allow him to play his doctor's role--and you understand through what opening.
You can see how the phenomena I will try to explain to you next week, the phenomena of hysteria and the game between Charcot and the hysterics, will be able to rush in here. The hysteric is precisely someone who says: It is thanks to me, but thanks only to me, that what you do to me--confine me, prescribe me drugs, and so on--really is a medical act, and I crown you doctor to the extent that I provide you with symptoms. Underneath the doctor's surplus power is the patient's surplus power.
There is, then, [a] general framework of the psychiatric test which, as I told you last week, took, I think, three principal forms in the first sixty
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years of the nineteenth century. There are, then, three techniques for this test of the realization of the illness that invests the psychiatrist with the status of doctor and makes the demand for psychiatry Junction as symptom: first, psychiatric questioning Q'interrogatoirey, second, drugs; and third, hypnosis.
First, the technique of questioning in the broad sense. Let's say: questioning, anamnesis, confession, etcetera. To what does questioning correspond? How exactly is it practiced? I have already pointed out the disciplinary aspect of questioning, insofar as it involves pinning the individual to his identity, obliging him to recognize himself in his past, in certain events of his life/' But this is only a minor, superlicial function of questioning. There are, I think, others, which are so many processes oi realizing madness. And I think questioning realizes madness in four ways, or by four processes.
First, classical psychiatric questioning, as you see it at work from around 1820 to 1830, always includes what we can call the search for a medical history. What is this search for a medical history? It is asking the patient what different illnesses his ancestors or collaterals may have had. This search is very paradoxical because, until the end ol the nineteenth century at least, it is completely anarchical and collates everything that comes up that might have been illness in the patient's ancestors and collaterals. And it is a very curious search because at the time I am considering, that is to say, at the time of its appearance around 1830 to 1840, there is neither the notion of pathological heredity,5 nor even of degeneration, which is formulated much later around 1855 to I860. 6
That is to say, we should be surprised by the sheer extent of the research undertaken in this examination of the medical history of all the patient's ancestors and collaterals, ot all the sorts of illnesses from which they may have suffered, and we should also be surprised by its early appearance and persistence still today. What basically was involved when a mental patient was asked about the illnesses in his family, and when it was carefully noted down if his father had died of apoplexy, if his mother suffered from rheumatism, if his uncle had been an idiot child, and so on? What was going on? Of course, it extended the search for certain signs, prodromes, etcetera, to a multi-individual scale, but
? I think it was above all and essentially a way of making up for the lack of pathological anatomy, for that absence of the body or distance from the body I have spoken to you about. Insofar as one cannot and does not know how to find any organic substratum of the illness in the patient, one looks for pathological events at the level of the patients family which are such that, whatever their nature, they will refer to the communication, and consequently existence, of a pathological material substratum. Heredity is a way of giving body to the illness at the very moment that this illness cannot be situated at the level ot the individual body; so one invents, one cuts out a sort of huge fantastical body of the family affected by a mass of illnesses: organic and non-organic diseases, constitutional and accidental diseases, it doesn't matter, since if they are transmitted then they have a material support, and as long as one gets back to the material support in this way then one has the organic substratum of madness, but an organic substratum that is not the individual substratum of pathological anatomy. It is a sort o( meta-organic substratum, but one which constitutes the true body of the illness. The sick body in the questioning of madness, the sick body one palpates, touches, percusses, sounds and in which one wants to try to find patho- logical signs, is in reality the body of the entire family; it is, rather, the body constituted by the family and family heredity. Trying to trace heredity therefore means substituting a different body and correlative material for the body of pathological anatomy; it constitutes a meta- individual analogon of the doctors' organism. I think this is the first aspect of medical questioning: the search for a medical history.
Second, there is the search for prodromes, signs of predisposition, an individual medical history. What are the phases through which the approach of madness is indicated before it really exists as madness? And this is another very constant aspect of psychiatric questioning: Recount your childhood memories. Tell me what happened. Give me some infor- mation about your life. Tell me what happened to you when you were ill? In fact this assumes that madness as illness always precedes itself; elements of a medical history must be found even in cases of illnesses marked by their sudden onset.
In general medicine, elements of a previous history, events indicating the onset of the illness, are discovered so as to be able to distinguish this
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or that type of illness, to find out whether it is a case of a progressive or a chronic illness, for example. The search for a medical history is quite different in the psychiatric domain. Looking for these individual med- ical histories basically means trying to show that madness existed before being constituted as illness, and, at the same time, that these signs are not yet the madness itself, but the conditions of possibility of madness. So signs must be found that are not exactly pathological--since that would mean they are signs of the illness, real elements of the illness, and not just prodromes--but which must be something different from the internal signs of the illness while at the same time having a certain relationship with the illness so that they can be given as prodromes, warning signs, marks of a predisposition to an illness--both internal and external to the illness. 7 That is to say, basically, setting madness in the individual context of what we can call abnormality.
Abnormality is the individual condition of possibility of madness; it is what must be established in order to show that what one is treating, that what one is dealing with, and what precisely one wants to show are symptoms of madness, is really of a pathological order. For the different elements constituting the object or motive for the demand for confine ment to be transformed into pathological symptoms, these elements must be set within this general web of abnormality.
I refer you, for example, to the Pierre Riviere dossier for some of the details on this. 9 When the doctors tried to determine whether or not Pierre Riviere was mentally ill, whether or not he was suffering from something that one hardly dared call "monomania"--at this time mono- mania had been defined by Esquirol as an illness that suddenly exploded and was characterized precisely by its suddenness and by its main symptom being the sudden appearance of a criminal form of conduct10--their problem was how this criminal conduct could be proven to be mad? It had to be set in a field of abnormalities constituted by a number of elements. A child cutting off the heads of cabbages while imagining himself at the head of an army destroying his enemies, for example, or crucifying a frog,11 formed a horizon of abnormalities within which the conduct in question could then be realized as madness. So, the second operation of questioning is the constitution of a horizon of abnormalities.
? The third role of questioning is to organize what could be called the junction or chiasmus between responsibility and subjectivity. My impression is that at the bottom of every psychiatric interview there is always a sort of transaction taking the following form. The psychiatrist says to the person before him: Well, here we are, you are here either of your own free will or at the behest of someone else, but you have come here because people are uneasy and complain about you; you say certain things, you have done certain things, you behave in a certain way. I am not in any way questioning you about the truth of these facts and I do not want to know the truth or falsity of the reproaches made against you, or even of the malaise you feel--I am not an investigating magistrate-- however, I am prepared to relieve you of legal or moral responsibil- ity for what you have done or for what happens to you, or for the feel- ings you experience, on the one condition that you subjectively accept the reality of all this, on condition that you give all these facts back to me as subjective symptoms of your existence, of your consciousness. I want to find all these elements again in your account and confessions, more or less transformed, no matter, as elements of your suffering, as the force of a monstrous desire, as the signs of an irrepressible impulse, in short, as symptoms. I really want to remove the weight of your legal and moral responsibility from the reasons for you being here, but I will only perform this subtraction, I will only lift these reasons from your head on condition, precisely, that you give them to me, in one form or another, as symptoms. Give me some symptoms; I will remove the fault.
I think this kind of deal, played out at the heart of psychiatric questioning, means that questioning essentially always bears in fact on the reasons why the individual finds himself before the psychiatrist. The psychiatric interview must question the reasons for the individual find- ing himself before the psychiatrist--no matter whether these are linked to voluntary conduct or given by other people--and retransform these reasons into symptoms.
The fourth function of psychiatric questioning is what I will call the organization of the central confession. That is to say, basically psychiatric questioning always has a certain end, and what's more always breaks off at a certain point. This end, this point on the horizon for psychiatric
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questioning, would be the heart of the madness, its core, a kind of focal point in the realm of madness corresponding to the center of a patho- logical lesion. * And this center of madness that questioning seeks to realize, to effectuate, is the extreme, indisputable form of the madness. The subject being questioned must not only be got to recognize the exis- tence of this delirious center, he really must actualize it within the interview.
This actualization can be obtained in two ways. Either it can be obtained in the form of confession, of the confession ritually obtained within the questioning: "Yes, I hear voices! Yes, I have hallucinations! ";12 uYes, I think I'm Napoleon! ";1* "Yes, I rave! " This is the end to which psychiatric questioning must lead. Or, if not actualization in confession, through pinning down the symptom in the first person, the crisis itselt must be actualized in the questioning; arousing the hallucination or provoking the hysterical crisis. In short, whether in the form of confes sion or in the form of actualization of the central symptom, the subject must be forced into a sort of tight corner, a point of extreme contraction at which he is constrained to say "I am mad" and really play out his madness. At that point, pinned in that extreme corner of the interroga- tion, he can no longer escape his own symptoms; he can no longer thread his way between them. He is constrained to say: Really, I am someone for whom the psychiatric hospital was built, I am someone for whom a doc- tor was needed, I am sick and, since I am sick, it is clear that you, whose major function is to confine me, are a doctor. And there we arrive at the essential point of the double establishment of the confined individual as sick and of the confining individual as doctor and psychiatrist.
One extracts an extreme confession, basically on the assumption and with the claim that if one avows the madness, one gets rid of it. In the technique of psychiatric questioning the double analogy with both reli- gious confession and medical crisis comes into play: religious confession helps the pardon; expectoration and excretion bring out the morbific substance in the medical crisis. At the point of their convergence or, if you like, in a kind of oscillation between the confession, which brings
* The manuscript adds: "A bit like the family taking the place oi the somatic substratum for madness. "
? about pardon, and the expectoration, which drives out the disease, the extreme confession of madness is--the psychiatrists of that time, and no doubt many others still today, assure us--ultimately the basis on which the individual will be able to free himsell from his madness. "I will free you from your madness on condition that you confess to me your madness," that is to say: "Give me the reasons why I confine you; really give me the reasons why I deprive you of your freedom, and, at that point, I will lree you from your madness. The action by which you will be cured of your madness is also that by which I will assure myself that what I do really is a medical act. " Such is the entanglement between the doctor's power and the extortion ol confession in the patient, which constitutes, I think, the absolutely central point ol the technique of psychiatric questioning.
I think this questioning, the principal moments of which I have tried to indicate, can be deciphered at three levels. Let's leave the first, the dis- ciplinary level about which I have already spoken;17' the other two levels are, I think, essential. The first level involves constituting a medical mimesis in psychiatric questioning, the analogon of a medical schema given by pathological anatomy: first, psychiatric questioning constitutes a body through the system of ascriptions ol heredity, it gives body to an illness which did not have one; second, around this illness, and in order to pick it out as illness, it constitutes a field of abnormalities; third, it fabricates symptoms from a demand lor confinement; and finally, fourth, it isolates, delimits, and defines a pathological source that it shows and actualizes in the confession or in the realization of this major and nuclear symptom.
So questioning in nineteenth century psychiatry is a certain way of reconstituting exactly those elements that characterize the activity of differential diagnosis in organic medicine. It is a way of reconstituting, alongside and parallel to organic medicine, something that functions in the same way, but in the order of mimesis and analogon. The other strata in the interview is the level at which, through the play of sleights of hand, exchanges, promises, gifts and counter-gifts between psychiatrist and patient there is the triple realization of conduct as madness, of madness as illness, and finally, of the mad person's guardian as doctor.
You can see that under these conditions the kind of questioning involving these elements is the completely renovated ritual of absolute
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diagnosis. What is the psychiatrists activity in a model hospital of the nineteenth century? You know that there are two and only two. First, the visit; second, questioning. The visit is the action by which the doctor brings about the daily mutation of discipline into therapy by passing through the different departments of his hospital: I will pass through the entire asylum machinery, I will see all the mechanisms of the disciplinary system in order to transform them, simply by my presence, into a therapeutic apparatus (^appareit)}^
The second activity, questioning, is precisely this: Give me some symptoms, make some symptoms from your life for me, and you will make me a doctor.
The two rites, of the visit and questioning, are, as you can see, the elements by which the disciplinary field I have spoken about functions. You also see why this great rite of questioning needs to be reinvigorated from time to time. Just as alongside Low Mass there is solemn High Mass, so the clinical presentation to students is to private questioning ol the patient what the sung Mass is to Low Mass. And why is it that psychiatry is thrown so soon, so quickly, into this Missa so/lemnis, into this rite of almost public presentation, of anyway the clinical presentation ol patients to students? I have already said why in a couple of words,16 but I think you now find here the possibility of grasping a different level of the working of this clinical presentation.
Given the characteristic double absence of the body and the cure in psychiatric practice, how could one bring about the real investiture ol the doctor as a real doctor, and how could the processes of the trans mutation of the demand for conhnement into symptoms, of Hie events into abnormalities, and of heredity into a body, etcetera, be really effec tuated if, in addition to the daily working of the asylum, there were not this kind of rite solemnly marking what happens in psychiatric questioning? Well, precisely, a space is organized in which the alienist is marked out as doctor solely by the fact that there are students around him as spectators and listeners. So the medical character of his role will in no way be actualized by the success of his cure, by his discovery of the true etiology, since, precisely, it is not a question of this. The medical character of his role and the processes of transmutation I have talked about are possible inasmuch as the doctor is surrounded by the chorus
? and body ot the students. Since the patients body is lacking, it really will be necessary for there to be this kind ot institutional corporeality which will be the crown of students around the master, listening to the patient's answers. As soon as this listening is coded in this way and institutionalized as students listening to what the psychiatrist says as master, and as master of medical knowledge, from that point on, all the processes I have talked about really will play their part, with a renewed intensity and vigor, in this medical transmutation of madness into illness, ot the demand for confinement into symptom, and so on.
In other words, I think the professorial dimension of speech, which, in the doctor's case, is merely additive, if you like, a way of increasing his prestige and making what he says a little more true, is much more essential and much more inherent in the case of the psychiatrist; the professorial dimension ot the psychiatrist's words is constitutive of his medical power. In order tor this speech really to carry out the medical transmutations I have spoken about, it must, trom time to time at least, be ritually and institutionally marked as professorial by the rite of the clinical presentation of the patient to students.
That's what I wanted to say to you about questioning. Obviously all this needs to be refined inasmuch as the forms of questioning have varied. In someone like Leuret it takes much more subtle torms. Leuret invented questioning by silence, for example, in which one says nothing to the patient, waits tor him to speak, and lets him say what he wants, because, according to Leuret, this is the only way, or at any rate the best way to arrive at precisely that focal confession of madness. 17 Again in Leuret, there is the kind ot game in which another demand is recognized behind a symptom, and this is what the questioning must analyze. Anyway, all ot these are supplementary with regard to the central rite of psychiatric questioning.
Alongside questioning and, to tell the truth, here again in a secondary form, but with much more of a future than Leuret's techniques, there are the two other major agents of medicalization, of the realization ot madness as illness: drugs and hypnosis.
Drugs tirst. Here again, I have drawn your attention to the discipli- nary use of certain drugs, which goes back to the eighteenth century: laudanum,18 opiates, and so forth. 19 At the end of the eighteenth century
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you see the new phenomenon ol the medico legal use of drugs. At the end of the eighteenth century, an Italian doctor had the idea of using massive doses of opium in order to determine whether a subject really is or is not a mental patient, of using opium as an authority for deciding between madness and its simulation. 20
This was the start, and then we find, we can say for the first eighty years of the nineteenth century, an enormous use of drugs in psychiatric hospitals, the main ones being opium, amyl nitrate,21 chloroform,22 and ether:23 in 1864 an important text by Morel appeared in the Archives
generates de medecine on etherisation of patients in psychiatric hospitals. 2' However, I think the | major] episode in all this was obviously the book Du haschisch et de Valienation menlale, and the practice, of Moreau de Tours in 1845. 25 In his book on hashish, which I think was very impor tant historically, Moreau de Tours recounts that he has "himself"--and we will see |the meaning]* of this "himself"--tested hashish, and that, alter having taken a lairly considerable amount of it in jam, he was able to pick out a number ol phases in hashish intoxication, which were the following: first, "feeling of well being"; second, "excitement, dissocia- tion of ideas"; third, "errors of time and space"; fourth, "development of sensibility, both visual and auditory: exaggeration of sensations when listening to music, etcetera"; fifth, "fixed ideas, delirious convictions"; sixth, alteration or, as he says, "lesion of the affections," exaggeration of lears, excitability, and amorous passion, etcetera; seventh, "irresistible drives"; eighth and last, "illusions, hallucinations. "26 I think there are a number ol reasons for considering Moreau de Tours's experiment and the use he made of it.
First--and I won't be able to give you an explanation, or even an analysis, here--is the lact that, in this experiment, Moreau de Tours immediately, straightaway [. . . '] refers the drug's effects to the processes of mental illness/ When he describes the dillerent stages I have just men- tioned, from the second stage, the feeling of well being having passed-- and yet we will see that he succeeds in recuperating it--we are very
* (Recording:) the importance
' (On the recording, repeat ol:) immediately
Section m the manuscript entitled: "Idea that the phenomena deriving from the absorption ol hashish are identical to those ol madness. "
? quickly in the realm of mental illness: dissociation of ideas, errors of time and space, etcetera. I think this psychiatric appropriation of the effects of the drug within the system of mental illness raises an important prob lem, but to tell the truth I think it should be analyzed within a history of drugs rather than within a history of mental illness. Anyway, with regard to the history of mental illness, according to Moreau de Tours this use of the drug, and the immediate assimilation of the effects of the drug and symptoms of mental illness, provide the doctor with a possible reproduction of madness, a reproduction which is both artificial, since intoxication is needed to produce the phenomena, and natural, because none oi the symptoms he lists are foreign, either m their content or suc- cessive sequence, to the course of madness as a spontaneous and natural illness. So, we have an induced but authentic reproduction of the illness.
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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PSYCHIATRIC POWER
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. On the one hand, through pathological anatomy, procedures of verification, in the form of the objective report and demonstration, were substituted for the classical medical crisis and its test: this was the medical offspring. The psychiatric offspring of the classical crisis was different. Since there was no field within which psychiatry could ascertain
* The manuscript clarifies: "This therefore implies a completely specific procedure for establishing the illness. "
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the truth, it had to establish and substitute something for the old classical medical crisis which was, like the old medical crisis, a test, but a test of reality rather than a test of truth. Put differently, the test of truth splits into techniques for ascertaining the truth on one side: this is standard medicine; [and, on the other), a test of reality: this is what happens in psychiatry.
To summarize, and to start studying this system, this game, this panoply of tests of reality, I think we can say the following: In psychiatry, the essential moment that punctuates, organizes, and at the same time distributes this field of disciplinary power I have been speaking about, is this test of reality, which has a double meaning.
On the one hand, it involves making the reasons given for a requested confinement, or for possible psychiatric intervention, exist as illness, or possibly non-illness. The psychiatric test is then what I will call the test of administrative medical reduplication: Can what has motivated the request be retranscribed in terms of symptoms and illness? The lirst function of the psychiatric test is to retranscnbe the request as illness, to make the grounds for the request exist as symptoms of illness.
The second function is correlative to this and in a way is much more important. The test involves making the power of intervention and the dis ciphnary power of the psychiatrist exist as medical knowledge. I have tried to show you how this power operated within a disciplinary field, which had a medical stamp of course, but which lacked real medical content. Well, this disciplinary power must now be made to function as medical power, and the psychiatric test will be, on the one hand, what constitutes the request for confinement as illness, and, on the other, what makes the person given powers of decision in confinement function as a doctor.
In organic medicine, the doctor vaguely formulates the following demand: Show me your symptoms and I will tell you what your illness is. In the psychiatric test, the psychiatrist's demand is much weightier, much more surcharged, and is: With what you are, with your life, with the grounds for people's complaints, [. . . *J, with what you do, and what you say, provide me with some symptoms, not so that I know what your illness is, but so that I can stand before you as a doctor.
* (On the recording, repetition of:) with what you are
? That is to say, the psychiatric test is a double test for the official estab- lishment of an individual's life as a tissue of pathological symptoms, as well as the constant official establishment of the psychiatrist as a doctor, or of the supreme disciplinary authority as a medical authority. Consequently, we can say that the psychiatric test is an endless test of admittance into the hospital. Why is it that one cannot leave the asylum? One cannot leave the asylum, not because the exit is far away, but because the entrance is too near. One never stops entering the asylum, and every encounter, every confrontation between the doctor and the patient begins again and indefinitely repeats this founding, initial act by which madness will exist as reality and the psychiatrist will exist as doctor.
Consequently you can see how there is a very curious and complex game into which all the real games of the asylum and of the history of psychiatry and madness in the nineteenth century throw themselves. If you consider things at the level of the disciplinary functioning of the asylum, (which I analyzed in the previous sessions), then at this level there is a formidable medical surplus-power because the doctor and the disciplinary system ultimately form a single body; the hospital itself is the doctor's body. However, on the other side, there is a prodigious surplus power of the patient, since it is the patient, in terms, precisely, of the way in which he undergoes and comes out from the psychiatric test, who will or will not establish the psychiatrist as doctor, who will either refer him back to his pure and simple disciplinary role or allow him to play his doctor's role--and you understand through what opening.
You can see how the phenomena I will try to explain to you next week, the phenomena of hysteria and the game between Charcot and the hysterics, will be able to rush in here. The hysteric is precisely someone who says: It is thanks to me, but thanks only to me, that what you do to me--confine me, prescribe me drugs, and so on--really is a medical act, and I crown you doctor to the extent that I provide you with symptoms. Underneath the doctor's surplus power is the patient's surplus power.
There is, then, [a] general framework of the psychiatric test which, as I told you last week, took, I think, three principal forms in the first sixty
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years of the nineteenth century. There are, then, three techniques for this test of the realization of the illness that invests the psychiatrist with the status of doctor and makes the demand for psychiatry Junction as symptom: first, psychiatric questioning Q'interrogatoirey, second, drugs; and third, hypnosis.
First, the technique of questioning in the broad sense. Let's say: questioning, anamnesis, confession, etcetera. To what does questioning correspond? How exactly is it practiced? I have already pointed out the disciplinary aspect of questioning, insofar as it involves pinning the individual to his identity, obliging him to recognize himself in his past, in certain events of his life/' But this is only a minor, superlicial function of questioning. There are, I think, others, which are so many processes oi realizing madness. And I think questioning realizes madness in four ways, or by four processes.
First, classical psychiatric questioning, as you see it at work from around 1820 to 1830, always includes what we can call the search for a medical history. What is this search for a medical history? It is asking the patient what different illnesses his ancestors or collaterals may have had. This search is very paradoxical because, until the end ol the nineteenth century at least, it is completely anarchical and collates everything that comes up that might have been illness in the patient's ancestors and collaterals. And it is a very curious search because at the time I am considering, that is to say, at the time of its appearance around 1830 to 1840, there is neither the notion of pathological heredity,5 nor even of degeneration, which is formulated much later around 1855 to I860. 6
That is to say, we should be surprised by the sheer extent of the research undertaken in this examination of the medical history of all the patient's ancestors and collaterals, ot all the sorts of illnesses from which they may have suffered, and we should also be surprised by its early appearance and persistence still today. What basically was involved when a mental patient was asked about the illnesses in his family, and when it was carefully noted down if his father had died of apoplexy, if his mother suffered from rheumatism, if his uncle had been an idiot child, and so on? What was going on? Of course, it extended the search for certain signs, prodromes, etcetera, to a multi-individual scale, but
? I think it was above all and essentially a way of making up for the lack of pathological anatomy, for that absence of the body or distance from the body I have spoken to you about. Insofar as one cannot and does not know how to find any organic substratum of the illness in the patient, one looks for pathological events at the level of the patients family which are such that, whatever their nature, they will refer to the communication, and consequently existence, of a pathological material substratum. Heredity is a way of giving body to the illness at the very moment that this illness cannot be situated at the level ot the individual body; so one invents, one cuts out a sort of huge fantastical body of the family affected by a mass of illnesses: organic and non-organic diseases, constitutional and accidental diseases, it doesn't matter, since if they are transmitted then they have a material support, and as long as one gets back to the material support in this way then one has the organic substratum of madness, but an organic substratum that is not the individual substratum of pathological anatomy. It is a sort o( meta-organic substratum, but one which constitutes the true body of the illness. The sick body in the questioning of madness, the sick body one palpates, touches, percusses, sounds and in which one wants to try to find patho- logical signs, is in reality the body of the entire family; it is, rather, the body constituted by the family and family heredity. Trying to trace heredity therefore means substituting a different body and correlative material for the body of pathological anatomy; it constitutes a meta- individual analogon of the doctors' organism. I think this is the first aspect of medical questioning: the search for a medical history.
Second, there is the search for prodromes, signs of predisposition, an individual medical history. What are the phases through which the approach of madness is indicated before it really exists as madness? And this is another very constant aspect of psychiatric questioning: Recount your childhood memories. Tell me what happened. Give me some infor- mation about your life. Tell me what happened to you when you were ill? In fact this assumes that madness as illness always precedes itself; elements of a medical history must be found even in cases of illnesses marked by their sudden onset.
In general medicine, elements of a previous history, events indicating the onset of the illness, are discovered so as to be able to distinguish this
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or that type of illness, to find out whether it is a case of a progressive or a chronic illness, for example. The search for a medical history is quite different in the psychiatric domain. Looking for these individual med- ical histories basically means trying to show that madness existed before being constituted as illness, and, at the same time, that these signs are not yet the madness itself, but the conditions of possibility of madness. So signs must be found that are not exactly pathological--since that would mean they are signs of the illness, real elements of the illness, and not just prodromes--but which must be something different from the internal signs of the illness while at the same time having a certain relationship with the illness so that they can be given as prodromes, warning signs, marks of a predisposition to an illness--both internal and external to the illness. 7 That is to say, basically, setting madness in the individual context of what we can call abnormality.
Abnormality is the individual condition of possibility of madness; it is what must be established in order to show that what one is treating, that what one is dealing with, and what precisely one wants to show are symptoms of madness, is really of a pathological order. For the different elements constituting the object or motive for the demand for confine ment to be transformed into pathological symptoms, these elements must be set within this general web of abnormality.
I refer you, for example, to the Pierre Riviere dossier for some of the details on this. 9 When the doctors tried to determine whether or not Pierre Riviere was mentally ill, whether or not he was suffering from something that one hardly dared call "monomania"--at this time mono- mania had been defined by Esquirol as an illness that suddenly exploded and was characterized precisely by its suddenness and by its main symptom being the sudden appearance of a criminal form of conduct10--their problem was how this criminal conduct could be proven to be mad? It had to be set in a field of abnormalities constituted by a number of elements. A child cutting off the heads of cabbages while imagining himself at the head of an army destroying his enemies, for example, or crucifying a frog,11 formed a horizon of abnormalities within which the conduct in question could then be realized as madness. So, the second operation of questioning is the constitution of a horizon of abnormalities.
? The third role of questioning is to organize what could be called the junction or chiasmus between responsibility and subjectivity. My impression is that at the bottom of every psychiatric interview there is always a sort of transaction taking the following form. The psychiatrist says to the person before him: Well, here we are, you are here either of your own free will or at the behest of someone else, but you have come here because people are uneasy and complain about you; you say certain things, you have done certain things, you behave in a certain way. I am not in any way questioning you about the truth of these facts and I do not want to know the truth or falsity of the reproaches made against you, or even of the malaise you feel--I am not an investigating magistrate-- however, I am prepared to relieve you of legal or moral responsibil- ity for what you have done or for what happens to you, or for the feel- ings you experience, on the one condition that you subjectively accept the reality of all this, on condition that you give all these facts back to me as subjective symptoms of your existence, of your consciousness. I want to find all these elements again in your account and confessions, more or less transformed, no matter, as elements of your suffering, as the force of a monstrous desire, as the signs of an irrepressible impulse, in short, as symptoms. I really want to remove the weight of your legal and moral responsibility from the reasons for you being here, but I will only perform this subtraction, I will only lift these reasons from your head on condition, precisely, that you give them to me, in one form or another, as symptoms. Give me some symptoms; I will remove the fault.
I think this kind of deal, played out at the heart of psychiatric questioning, means that questioning essentially always bears in fact on the reasons why the individual finds himself before the psychiatrist. The psychiatric interview must question the reasons for the individual find- ing himself before the psychiatrist--no matter whether these are linked to voluntary conduct or given by other people--and retransform these reasons into symptoms.
The fourth function of psychiatric questioning is what I will call the organization of the central confession. That is to say, basically psychiatric questioning always has a certain end, and what's more always breaks off at a certain point. This end, this point on the horizon for psychiatric
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questioning, would be the heart of the madness, its core, a kind of focal point in the realm of madness corresponding to the center of a patho- logical lesion. * And this center of madness that questioning seeks to realize, to effectuate, is the extreme, indisputable form of the madness. The subject being questioned must not only be got to recognize the exis- tence of this delirious center, he really must actualize it within the interview.
This actualization can be obtained in two ways. Either it can be obtained in the form of confession, of the confession ritually obtained within the questioning: "Yes, I hear voices! Yes, I have hallucinations! ";12 uYes, I think I'm Napoleon! ";1* "Yes, I rave! " This is the end to which psychiatric questioning must lead. Or, if not actualization in confession, through pinning down the symptom in the first person, the crisis itselt must be actualized in the questioning; arousing the hallucination or provoking the hysterical crisis. In short, whether in the form of confes sion or in the form of actualization of the central symptom, the subject must be forced into a sort of tight corner, a point of extreme contraction at which he is constrained to say "I am mad" and really play out his madness. At that point, pinned in that extreme corner of the interroga- tion, he can no longer escape his own symptoms; he can no longer thread his way between them. He is constrained to say: Really, I am someone for whom the psychiatric hospital was built, I am someone for whom a doc- tor was needed, I am sick and, since I am sick, it is clear that you, whose major function is to confine me, are a doctor. And there we arrive at the essential point of the double establishment of the confined individual as sick and of the confining individual as doctor and psychiatrist.
One extracts an extreme confession, basically on the assumption and with the claim that if one avows the madness, one gets rid of it. In the technique of psychiatric questioning the double analogy with both reli- gious confession and medical crisis comes into play: religious confession helps the pardon; expectoration and excretion bring out the morbific substance in the medical crisis. At the point of their convergence or, if you like, in a kind of oscillation between the confession, which brings
* The manuscript adds: "A bit like the family taking the place oi the somatic substratum for madness. "
? about pardon, and the expectoration, which drives out the disease, the extreme confession of madness is--the psychiatrists of that time, and no doubt many others still today, assure us--ultimately the basis on which the individual will be able to free himsell from his madness. "I will free you from your madness on condition that you confess to me your madness," that is to say: "Give me the reasons why I confine you; really give me the reasons why I deprive you of your freedom, and, at that point, I will lree you from your madness. The action by which you will be cured of your madness is also that by which I will assure myself that what I do really is a medical act. " Such is the entanglement between the doctor's power and the extortion ol confession in the patient, which constitutes, I think, the absolutely central point ol the technique of psychiatric questioning.
I think this questioning, the principal moments of which I have tried to indicate, can be deciphered at three levels. Let's leave the first, the dis- ciplinary level about which I have already spoken;17' the other two levels are, I think, essential. The first level involves constituting a medical mimesis in psychiatric questioning, the analogon of a medical schema given by pathological anatomy: first, psychiatric questioning constitutes a body through the system of ascriptions ol heredity, it gives body to an illness which did not have one; second, around this illness, and in order to pick it out as illness, it constitutes a field of abnormalities; third, it fabricates symptoms from a demand lor confinement; and finally, fourth, it isolates, delimits, and defines a pathological source that it shows and actualizes in the confession or in the realization of this major and nuclear symptom.
So questioning in nineteenth century psychiatry is a certain way of reconstituting exactly those elements that characterize the activity of differential diagnosis in organic medicine. It is a way of reconstituting, alongside and parallel to organic medicine, something that functions in the same way, but in the order of mimesis and analogon. The other strata in the interview is the level at which, through the play of sleights of hand, exchanges, promises, gifts and counter-gifts between psychiatrist and patient there is the triple realization of conduct as madness, of madness as illness, and finally, of the mad person's guardian as doctor.
You can see that under these conditions the kind of questioning involving these elements is the completely renovated ritual of absolute
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diagnosis. What is the psychiatrists activity in a model hospital of the nineteenth century? You know that there are two and only two. First, the visit; second, questioning. The visit is the action by which the doctor brings about the daily mutation of discipline into therapy by passing through the different departments of his hospital: I will pass through the entire asylum machinery, I will see all the mechanisms of the disciplinary system in order to transform them, simply by my presence, into a therapeutic apparatus (^appareit)}^
The second activity, questioning, is precisely this: Give me some symptoms, make some symptoms from your life for me, and you will make me a doctor.
The two rites, of the visit and questioning, are, as you can see, the elements by which the disciplinary field I have spoken about functions. You also see why this great rite of questioning needs to be reinvigorated from time to time. Just as alongside Low Mass there is solemn High Mass, so the clinical presentation to students is to private questioning ol the patient what the sung Mass is to Low Mass. And why is it that psychiatry is thrown so soon, so quickly, into this Missa so/lemnis, into this rite of almost public presentation, of anyway the clinical presentation ol patients to students? I have already said why in a couple of words,16 but I think you now find here the possibility of grasping a different level of the working of this clinical presentation.
Given the characteristic double absence of the body and the cure in psychiatric practice, how could one bring about the real investiture ol the doctor as a real doctor, and how could the processes of the trans mutation of the demand for conhnement into symptoms, of Hie events into abnormalities, and of heredity into a body, etcetera, be really effec tuated if, in addition to the daily working of the asylum, there were not this kind of rite solemnly marking what happens in psychiatric questioning? Well, precisely, a space is organized in which the alienist is marked out as doctor solely by the fact that there are students around him as spectators and listeners. So the medical character of his role will in no way be actualized by the success of his cure, by his discovery of the true etiology, since, precisely, it is not a question of this. The medical character of his role and the processes of transmutation I have talked about are possible inasmuch as the doctor is surrounded by the chorus
? and body ot the students. Since the patients body is lacking, it really will be necessary for there to be this kind ot institutional corporeality which will be the crown of students around the master, listening to the patient's answers. As soon as this listening is coded in this way and institutionalized as students listening to what the psychiatrist says as master, and as master of medical knowledge, from that point on, all the processes I have talked about really will play their part, with a renewed intensity and vigor, in this medical transmutation of madness into illness, ot the demand for confinement into symptom, and so on.
In other words, I think the professorial dimension of speech, which, in the doctor's case, is merely additive, if you like, a way of increasing his prestige and making what he says a little more true, is much more essential and much more inherent in the case of the psychiatrist; the professorial dimension ot the psychiatrist's words is constitutive of his medical power. In order tor this speech really to carry out the medical transmutations I have spoken about, it must, trom time to time at least, be ritually and institutionally marked as professorial by the rite of the clinical presentation of the patient to students.
That's what I wanted to say to you about questioning. Obviously all this needs to be refined inasmuch as the forms of questioning have varied. In someone like Leuret it takes much more subtle torms. Leuret invented questioning by silence, for example, in which one says nothing to the patient, waits tor him to speak, and lets him say what he wants, because, according to Leuret, this is the only way, or at any rate the best way to arrive at precisely that focal confession of madness. 17 Again in Leuret, there is the kind ot game in which another demand is recognized behind a symptom, and this is what the questioning must analyze. Anyway, all ot these are supplementary with regard to the central rite of psychiatric questioning.
Alongside questioning and, to tell the truth, here again in a secondary form, but with much more of a future than Leuret's techniques, there are the two other major agents of medicalization, of the realization ot madness as illness: drugs and hypnosis.
Drugs tirst. Here again, I have drawn your attention to the discipli- nary use of certain drugs, which goes back to the eighteenth century: laudanum,18 opiates, and so forth. 19 At the end of the eighteenth century
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you see the new phenomenon ol the medico legal use of drugs. At the end of the eighteenth century, an Italian doctor had the idea of using massive doses of opium in order to determine whether a subject really is or is not a mental patient, of using opium as an authority for deciding between madness and its simulation. 20
This was the start, and then we find, we can say for the first eighty years of the nineteenth century, an enormous use of drugs in psychiatric hospitals, the main ones being opium, amyl nitrate,21 chloroform,22 and ether:23 in 1864 an important text by Morel appeared in the Archives
generates de medecine on etherisation of patients in psychiatric hospitals. 2' However, I think the | major] episode in all this was obviously the book Du haschisch et de Valienation menlale, and the practice, of Moreau de Tours in 1845. 25 In his book on hashish, which I think was very impor tant historically, Moreau de Tours recounts that he has "himself"--and we will see |the meaning]* of this "himself"--tested hashish, and that, alter having taken a lairly considerable amount of it in jam, he was able to pick out a number ol phases in hashish intoxication, which were the following: first, "feeling of well being"; second, "excitement, dissocia- tion of ideas"; third, "errors of time and space"; fourth, "development of sensibility, both visual and auditory: exaggeration of sensations when listening to music, etcetera"; fifth, "fixed ideas, delirious convictions"; sixth, alteration or, as he says, "lesion of the affections," exaggeration of lears, excitability, and amorous passion, etcetera; seventh, "irresistible drives"; eighth and last, "illusions, hallucinations. "26 I think there are a number ol reasons for considering Moreau de Tours's experiment and the use he made of it.
First--and I won't be able to give you an explanation, or even an analysis, here--is the lact that, in this experiment, Moreau de Tours immediately, straightaway [. . . '] refers the drug's effects to the processes of mental illness/ When he describes the dillerent stages I have just men- tioned, from the second stage, the feeling of well being having passed-- and yet we will see that he succeeds in recuperating it--we are very
* (Recording:) the importance
' (On the recording, repeat ol:) immediately
Section m the manuscript entitled: "Idea that the phenomena deriving from the absorption ol hashish are identical to those ol madness. "
? quickly in the realm of mental illness: dissociation of ideas, errors of time and space, etcetera. I think this psychiatric appropriation of the effects of the drug within the system of mental illness raises an important prob lem, but to tell the truth I think it should be analyzed within a history of drugs rather than within a history of mental illness. Anyway, with regard to the history of mental illness, according to Moreau de Tours this use of the drug, and the immediate assimilation of the effects of the drug and symptoms of mental illness, provide the doctor with a possible reproduction of madness, a reproduction which is both artificial, since intoxication is needed to produce the phenomena, and natural, because none oi the symptoms he lists are foreign, either m their content or suc- cessive sequence, to the course of madness as a spontaneous and natural illness. So, we have an induced but authentic reproduction of the illness.
