Riese, A History oj
Neurology
(New York: MD Publications, 1959), and F.
Foucault-Psychiatric-Power-1973-74
p.
465.
Moreau de Tours, for his part, refer ring to the "organic conditions" ol sleep, and the "lundamental phenomena of delirium," proposes that "to grasp, study, and understand well a set of phenomena as complex as that
of intellectual disorders, we must. . . group these phenomena according to the analogies,
the more or less numerous aflinities that they present" Du hashish, p. 44.
38. Moreau de Tours, ibid. Part II, ? 1: "Generalites physiologiques," pp. 32 47.
39. An allusion to the privilege that, according to J. Derrida, Descartes accords to the dream
over madness in the "First meditation: Some things that one can put in doubt," Meditations touchant la premiere philosophic (1641), in CEuvres et Lettres, pp. 268-269; English translation, "Meditations on First Philosophy" trans. John Cottingham, in The Philosophical Writings of Descartes, vol. II, pp. 13 14; See Foucault's commentaries in Histoire de lafolie, Part I, ch. 2,
pp. 56-59 (omitted Irom the English translation of Madness and Civilisation except for
one short paragraph, p. 38) and "Mon corps, ce papier, ce feu" in, Dits et Ecrits, vol. 2,
pp. 245 268; English translation, "My Body, This Paper, This Fire" trans. Geoff Bennington, in Essential Works of Foucault, 2, pp. 393 417.
40. JJ. Moreau de Tours, Du haschisch, Part III: "Therapeutique," p. 402: "One of the effects of hashish that I was most struck by ( . . . ) is that sort of maniacal excitation always
? accompanied by a sense ol cheerfulness and happiness ( . . . ) . I saw in this an ellective means for combating the fixed ideas o( melancholies (? ? ? ). Was I mistaken in my conjectures? I am led to think so. "
41. Ibid. p. 405: "Pinel, and with him all doctors ol the insane, saw mental alienation decided by bouts of agitation. " An allusion to the accounts of cures obtained following a "critical attack (acres critique)" that Pinel reports in his Traite mcdico-philosophique, section I, ? xiu: "Reasons which lead considering most bouts of mania as the healthy and favorable reaction to the cure" pp. 37-41; A Treatise on Insanity, pp. 3943. See also the article by Landre Beauvais (Pinel's assistant at Salpetriere) "Crisis" in Dictionnaire des sciences medicales, vol. VII (Paris: C. L. F. Panckoucke, 1813) pp. 370-392.
42. JJ. Moreau de Tours, Du haschisch: "A precise indication emerged that could be lormulated in this way: to preserve his primary acuity in the delirium tending to the chronic state, or to call back this acuity, to revive it when it threatens to become extinguished. The extract ol Indian hemp was, of all the medicaments known, the most eminently suited lor lullilling this indication. "
43. See above, note 21 to lecture of 12 December 1973-
44. P. Foissac, Memoire sur le magnetisme animal, adresse a messieurs les membres de VAcademie roya/e
de medecine (Paris: Didot Jeune, 1825) p. 6: "When they have tallen into a deep sleep, the magnetized display the phenomena of a new lile (. . . ) . The sphere of consciousness grows, and already that faculty appears that is so precious that the first magnetizers will call 'intu
Hive' or 'lucidity' ( . . . ) . With it, the somnambulists ( . . . ) recognize the illness Irom which they suller, the near and distant causes ol these illnesses, their seat, their prognosis and their appropriate treatment (. . . ). By placing a hand successively on the head, chest, and abdomen ol someone unknown, the somnambulists also discover their illnesses, the pains and various alterations that they occasion; in addition they indicate whether cure is possi ble, easy or dilhcult, near at hand or lar oil, and what means must be used to achieve the result. "
45- See above, notes 28 and 33 the lecture ol 23 January 1974.
46. Thus the magnetic cure carried out on 4 May 1784 by Armand Marc Jacques de Chastenet,
marquis ol Puysegur (1751 1825), on Victor Race, a peasant attached to his property at Buzancy (Soissonnais): asleep, the latter answered questions, gave an opinion ol his state, indicated a course of therapy, and gave a prognosis with the date ol his return to health,
which will be confirmed. And on Charles Francois Ame, aged 14, who when put in a magnetic sleep announced the duration and intensity of his future crises. See,
A. M. J. Chastenet de Puysegur, (1) Memoires pour servir a I'histoire et a Vetablissement du magnetisme animal, vol. I, (Pans: 1784) pp. 199 211 and pp. 96 97; (2) Detail des cures operees
a Buzancy, pres de Soissons, par le magnetisme animal, a short anonymous work published by Puysegur (Soissons: 1784); (3) see also the account of the cure ol the young Hebert, pre
ceded by a plea in favor of magnetism: Appel aux savans observateurs du dix-neuvieme siecle de
la decision porlee par leurs predecesseurs contre le magnetisme animal, et fin du traitement du jeune Hebert (Paris: Dentu, 1813). On the history ot magnetic cures one can consult: S. Mialle,
Expose par ordre alphabelique des cures operees en France par le magtietisme animal depuis Mcsmer jusqu'a nos jours (1774-1&26) (Paris: Dentu, 1826). See also, H. F. Ellenberger, "Mesmer and
Puysegur: from magnetism to hypnotism," Psychoanalytic Review, vol. 52, no. 2 (1965).
47. This is taken from the eighth session conducted on 2 November 1820 by the Baron Jules Dupotet de Sennevoy in the service of Dr. Husson, head doctor at the Hotel Dieu, on
Catherine Samson, aged 18: see, Expose des experiences publiques sur le magnetisme animalfaites
a I'Hotel-Dieu de Paris, pendant le cours des mois d'octobre, novembre et decembre 1820 ( P a n s : Bechet Jeune, 3rd edition, 1826) p. 24.
48. In 1816, Etienne Jean Georget entered Esquirol's department at Salpetriere. On 8 February 1820 he defended his thesis, "Dissertation sur les causes de la folie," then published the work on which his reputation is based: De la folie. Considerations sur cette maladie. In 1821, with Leon Rostan, he turned two patients into experimental subjects, Petronille and Manoury, the widow Brouillard, called Braguette (see above, note 43).
49. "Petronille . . . asks Georget to throw her in the water while she is having her period" C. Burdin and F. Dubois (known as Dubois d'Amiens), Histoire academique du magnetisme animal (Paris: J. -B. Bailliere, 1841) p. 262.
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50. Ibid. pp. 262 263: "Petromlle's instructions had not been carried out meticulously; Pelronille had said that she had to be plunged in the Ourcq canal, since it was in this canal that she had (alien and contracted her illness: similia similibus; such had to be the end ol the story. "
51. James Braid (1795 i 8 6 0 ) , Scottish surgeon, converted to magnetism as a result ol demonstrations o( "mesmerism" at Manchester in November 1841 by Charles Lalontame,
a disciple ol the marquis de Puysegur, and popularized his practice under the term "hypnotism. " See,J. Braid, Neurhypnology, or the Rationale of Nervous Sleep Considered in rela-
tion with Animal Magnetism. Illustrated by Numerous Cases of its Successful Application in the
Relief and Cure of Diseases (London: John Churchill, 1843); French translation, with a
preface by E. Brown Sequard, Neurhypnologic, ou Traile du sommeil nerveux considere dans ses rapports avec le magnelisme animal, el relalanl de nombreux succes dans ses applications au iraitemenl des maladies, trans. G. Simon (Paris: A. Delahaye, 1883).
52. See below, note 55-
53. During the Restoration, the increasing potential ol magnetism was seen as a threat
by institutional medicine. The conlrontation corresponds to the setting up ol olbcial commissions: the lust, appointed on 28 February 1826, started work in January 1827 and delivered its conclusions on 28 June 1831, which, being deemed too lavorable, were not published by the Academie de medecine. A second, unlavorable, was voted on 5 September I837. The death warrant lor magnetism was signed on 15June 1842 with the decision ol the Academie to no longer concern itsell with the question. See, L. Peisse, "Des sciences occultes au xixc siecle. Le magnetisme animal," Revue des deux mondes, vol. 1, March 1842, pp. 695 723.
54. Whereas mesmerism proposed to "demonstrate that the heavenly bodies act on our earth and that our human bodies are equally subject to the same dynamic action" (A. Mesmer, Dissertalio physico-medica de planetarum influxu | Vienna: Chelem: 1766 | p. 32), and that the action ol the magnetizcr consists in canalizing this fluid on the patient, James Braid invoked a subjective action founded on the physiology ol the brain: see, The Power of the Mind over the Body: An Experimental Enquirey into the Nature and Cause of the Phenomena Attributed by Baron Reichenbach and Others to a New Imponderable (London: John Churchill, 1846), lor which he was hailed by, among others, the doctor Edgar Bei illon: "It is to Braid that honor is due lor having delmitively introduced the study ol induced sleep into the scientilic domain," and lor having rendered "a great service to science by giving to the whole ol his research the generic name ol hypnotism" Histoire de I'hypnotisme experimental ( Paris: Delahaye, 1902) p. 5.
55. Foucault refers here to the operation performed by E. F. Folhn and Paul Broca (to whom
the works ol Braid became known through a Bordeaux surgeon, Paul Azam) on a 40 year
old woman on 4 December 1859 at the Necker hospital. The operation was the subject ol
a report to the Academie des sciences presented by A. A. L. M. Velpeau on 7 December 1859: "Note sur une nouvelle methode anesthesique," Comptes rendus hebdomadaires desseances de I'Academie des sciences, vol. 49 (Paris: Mallet Buchelier, 1859) pp. 902 911.
56. Joseph Pierre Durand, known as Durand de Gros (1826 1900), was an exile in England where he discovered Braidism, and then in the United States. He returned to France where he published under the pseudonym ofJoseph Philips, Electrodynamisme vital, ou les Relations
physiologiques de Vesprit et de la matiere, demontrees par des experiences entieremenl nouvelles (Paris: J. B. Bailliere, 1855), and then, Cours theorique el pratique de braidisme, ou Hypnotisme nerveux
considere dans ses rapports avec la psychologiie, la physiologie et la pathologic, el dans ses applications a la medecine, a la chirurgie, a la physiologie experimenlale, a la medecine legale et a ^education (Paris:J. B. Bailliere, i860).
57. Durand de Gros defines "the hypotaxic state" as "a preparatory modification of vitality, a modification which usually remains latent and the whole effect of which is to incline the organization to undergo the determinant and specific action constituting the second stage" Cours theorique et pratique, p. 29.
58. Ibid. p. 112.
59. Ibid. Chorea is a nervous disorder characterized by sweeping and jerky involuntary
movements, with a gesticulatory appearance.
? 60. Ibid. p. 87: "Braidism is a process by which we seek to determine certain physiological changes in man with the aim ol lulfilling certain indications for medical or surgical treatment, or in order to facilitate the experimental studies of biology. "
61. Between 1850 and i 8 6 0 , under the impulse ol Guillaume Benjamin Amand Duchenne de Boulogne (1806 1875), the nosology of functional disorders ol motivity was redefined and enriched by two new groups of affections. On the one hand, "progressive muscular atrophy," studied from 18-19, and the "muscular atrophies with myopathic origin," in 1853: (1) La Paralyse atrophique de I'enjance (Pans: 1855). On the other hand, "progressive locomolor atrophy," known up until then as tabesdorsalis: (2) "De l'ataxie locomotrice progressive. Recherches sur unc maladie caractensee specialement par des troubles generaux de coordination des mouvemcnts," Archives generates de medecinc, 5th series, vol. 12, December 1858, pp. 6/|1 652; vol. 13, January 1859, pp. 5-23; February 1859, pp. 158 I64; April 1859, pp. -117 yi32. In i860 he described (3) the "paralysie glosso labio laryngee," ibid. 5th series, vol. 16, i860, pp. 283 296 and pp. /|31 Vi5. On Duchenne de Boulogne, see P. Guilly, Duchenne de Boulogne (Paris: Bailliere, 1936). On the constitution ol the neurological lield, see W.
Riese, A History oj Neurology (New York: MD Publications, 1959), and F. H. Garrison, History of Neurology, edition revised and expanded by Laurence McHenry (Springfield, 111. : C. C. Thomas, 1969).
}0 January 7974 295
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6 FEBRUARY 1974
The emergence of the neurological body: Broca and Duchenne de Boulogne. ^ Illnesses of differential diagnosis and illnesses of absolute diagnosis. ^ The model of "generalparalysis" and the
neuroses. ^ The battle of hysteria: 1. The organisation of a "symptomatologLcal scenario. "nu 2. The maneuver of the "functional
mannequin" and hypnosis. The question of simulation. nu 3. Neurosis and trauma. The irruption of the sexual body.
LAST WEEK I SAID that one of the important events in the history of the consolidation of psychiatric power was, in my view, the appearance of what I called the "neurological body. "* What should we understand by "neurological body"? I would like to begin with this today.
Of course, the neurological body is still, always, the body of pathological-anatomical localization. There is no opposition between the neurological body and the body of pathological anatomy; the second is part of the first; it is, if you like, a derivative or expansion of it. And the best proof of this is that in one of his courses, in 1879, Charcot said that the constitution, progress, and, in his view, the culmination of neu- rology, was the triumph of the "spirit of localization. "1 Except that what I think is important is that the procedures for matching up anatomical localization and clinical observation in the case of neurology are not at all the same as in the case of ordinary general medicine. It seems to me
* The manuscript adds: "From 1850 to 1870, emergence of a new body. "
? 298 PSYCHIATRIC POWER
that neurology, clinical neurology, involves a quite different deployment of the body in the field of medical practice. My impression is that the encounter of the patient-body and the doctor body in neurology takes place in terms of a very different arrangement from that in general medicine. And it is the setting up of this new apparatus that seems to me to be the important episode, which is why I would like to try to identify the new apparatus set up by and through the constitution ol a neuropathology or neurological clinical medicine.
What is this apparatus, and in what does it consist? How is the sick body* captured in clinical neurology? Its capture takes place, I think, very differently trom the way the body was captured at the time ol the formation of pathological anatomy, more or less between Bichat2 and Laennec* I will give you an example straightaway by taking a text that is not by Charcot himself, but which is found in the Charcot archives at Salpetriere and was quite certainly written by one of his students-- clearly we don't know which one. It is an observation of a patient. This is how the patient is described: the patient's symptom was something very simple, the drooping of the left eyelid, called ptosis. So, the student takes the following notes for Charcot for him then to use for a lecture-- I am not giving you the description of the whole of the patient's lace, but just a quite small excerpt.
"If we tell him to open his eyelids, he raises the right one normally, the left one however, does not noticeably move, no more than the eye brow, so that the superciliary asymmetry becomes more marked. In this movement (. . . ) the skin ol the forehead wrinkles transversally on the right side, while it remains almost smooth on the left. At rest, the skin of the forehead is wrinkled neither on the right nor the left ( . . . ) . "
"Two more points should be noted: a small dimple, quite visible under a certain angle of light, eight millimeters above the left eyelid and about two centimeters to the left of the median line of the forehead; and a little projection within the dimple which seems due to the contraction of the eyelid muscle. These two points are very noticeable in comparison with the normal state of the right side. "1
* The manuscript clarifies: "body whose surlace is the bearer ol plastic values. "
? You have here a type of description which is, I think, really quite different from what is found in the anatomical-pathological procedure, m anatomical-pathological observation. ^ In a sense, this sort of descrip- tion takes us back to a sort of surlace, almost impressionistic gaze, such as could be found m eighteenth century medicine, when the patient's complexion, color, red cheeks and bloodshot eyes, etcetera, were impor tant elements for clinical diagnosis. 6 Pathological anatomy--Bichat, Laennec, if you like? infinttely reduced this impressionistic description of the surlace and codified what were ultimately a quite limited number of surlace signs intended to identify what was essential according to a well established clinical code, this being, precisely, the lesion, which then, thanks etther to a surgical operation or, especially, the autopsy, was described by the anatomical pathologist with almost as many details as, if not more than, the description I have just read to you. In other words, anatomical-pathology brought its minutely detailed description to bear on the deep and injured organ, the surface only being questioned through a grid of ultimately simple and limited signs.
Here, rather, as you can see, you have the striking reemergence of sur face values within medical discourse and knowledge. It is this surface that must be covered in all its hollows and bumps, and practically by looking only, by looking only that far. In fact, and no doubt even more than this clinical re validation of the almost impressionistic values of the surface, what is important and, I think, decisive, in this new clinical capture of the neurological patient, and in the correlative constitution of a neurological body before this gaze and apparatus of capture, is that the neurological examination is basically looking tor "responses. "
What I mean is that in the pathological anatomy of Bichat Laennec one can, of course, identify the signs straightaway, at the first glance; one can also obtain them from a stimulation: one taps, one listens, etcetera. That is to say, what is sought in classical pathological anatomy is essentially the system of stimulation-effect: one sounds the chest and listens to the noise;7 one asks the patient to cough and listens to its harshness; one palpates and sees if there is any heat. So: stimulation- effect.
In the case of the neurological examination being constituted in the mid-nineteenth century, the main part of the signs, in short what makes
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a sign a sign, is not so much that it is [deciphered asj a more or less mechanical effect, like the noise following percussion in classical patho logical anatomy, but that a sign is [deciphered) as a response. I think the substitution of the schema of stimulus-response for the schema of stimulus effect, and the organization of a whole battery of stimuli- responses, is crucial.
We have a number of examples of this staging of a battery of stimuli- responses. At the strictly elementary level, there was the founding discovery oi neuropathology in Duchenne de Boulogne's research into what he called "localized Faradization," when, by moistening two electrodes, he succeeded in getting a single muscular response, or, rather, the response of a single muscle to electrification of the surface of the skin; by moistening the surface of the skin he succeeded in limiting the effect of the charge and obtained a single response of a single muscle: this was the founding discovery of everything here. 8 Then, starting from this, there were the studies of reflexes and then, especially, the study of complex behavior involving either a gearing of diverse automatisms or a prior learning, and it is there that we find, more or less, the two great domains in which the capture, the apparatuses of neurological capture, were completely established. This was Broca's study of aphasia,9 the study of walking, and notably Duchenne de Boulogne's study of tabetics. 10
Taking the second example, Duchenne produced a description of the walking of tabetics that is presented precisely in terms of stimulus response or, rather, in terms of behavior and the sequence of episodes of behavior that constitute the action of walking. Duchenne's problem was to distinguish the disorder of balance found in tabetics, that is to say, at a certain stage and in a certain form of general paralysis, from the vertigo of alcoholic intoxication or even of certain cerebellar disorders. In 1864, in a fundamental article, Duchenne managed to give a differential description of the gait of tabetics and the rocking of vertigo. " In the case of vertigo, the subject gives way to wide swaying, whereas in the subject suffering from tabes the rocking movements are "short," "they are abrupt"--Duchenne de Boulogne says that the subject has the bearing of a tightrope walker without his balancing pole, cautiously advancing one step at a time while trying to restore his balance. 12 In the case of vertigo, there is no muscular contraction, but a general weakening of the
? musculature and tone instead, whereas [-. . *] the tabetic is always holding himself back, and if we observe what happens at the level of his calves and legs, we see, even before he loses his balance, even before he is aware of losing his balance, some small, brief spasms which flicker across the musculature ot his legs, and then, gradually, these contrac- tions become more significant, until they become voluntary when the subject becomes aware that he is losing his balance. 13 This is completely different, therefore, from the collapse in vertigo. In vertigo, the subject zigzags; that it to say, going from one point to another, he cannot keep to a straight line. The tabetic however, goes completely straight ahead; it is just his body that wobbles around this straight line. 17' And finally, in drunkenness, there is the internal sensation of vertigo, whereas the tabetic has the impression that it is not his body that lacks balance at all, but only his legs, locally as it were. 15 These are the principal themes, more or less, of Duchenne de Boulogne's analysis of the tabetic's gait.
Now, in this kind of analysis--and the same would be true for Broca's analyses of aphasia roughly at the same time, between 1859 and 1865-- what is achieved by seeking to obtain a system of signs of responses that show dysfunctions, rather than a system of signs of effects that would reveal the presence of lesions at a given point? What we obtain, of course, is the possibility of distinguishing and analyzing what neurolo- gists called, and still call today, synergies, that is to say, the different cor- relations existing between this or that muscle: What are the different muscles that must be used in order to get such and such a response? What happens when it is precisely just one of them that is put out of play? So, we get a study of synergies.
Secondly, and I think this is the important thing, it becomes possible to set out the phenomena analyzed in different levels according to an axis of the voluntary and the automatic. That is to say, on the basis of this analysis of behavior, of responses to different stimuli, we can see the functional difference, the difference of neurological and muscular imple mentation, between simple reflex behavior, automatic behavior, sponta- neous voluntary behavior, and, finally, spontaneous behavior produced
* (On the recording, repetition of:) rather
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by an order coming from outside. All of this hierarchy in the bodily implementation of the voluntary and the involuntary, of the automatic and the spontaneous, of what is required by an order or what is sponta- neously linked together within behavior, will make possible--and this is the essential point--a clinical analysis, an analysis in terms of physical ascription, of the mdividuaPs intentional attitude.
Consequently, a capture of the subject's attitude, of the subject's consciousness, of the will itself within his body, becomes possible. Neuropathology showed the will invested in the body, the effects of the will or the degrees of will legible in the organization of responses to stimuli. You are familiar with all the analyses Broca initiated on the different levels ol the performance of aphasics, according to whether it is a matter ol simple mumblings, of swear words uttered automatically, of phrases triggered spontaneously in a certain situation, or of phrases which must be repeated in a certain order and on a certain injunction. 16 All of these clinical deferences of performance between different levels of behavior make possible the clinical analysis of the individual at the level of his intention, at the very level of that much vaunted will that I have tried to show you was the great correlate of discipline. It was the will, in fact, on which and to which disciplinary power had to be applied; it really was the vis avis of disciplinary power, but then it was only acces sible through the system of reward and punishment. Neuropathology now provides the clinical instrument by which it is thought the individual can be captured at the level of this will itself.
Let's consider things a bit differently and bit more precisely. We could say that, in one respect, with the neurological examination medicine will lose power m comparison with classical anatomical-pathology. That is to say, in the anatomical pathology constituted by Laennec, Bichat, and others, ultimately very little was demanded from the individual: he was asked to lie down, bend his leg, cough, breathe deeply, and so on. Consequently there was a minimum of injunctions on the doctor's part, and minimum dependence on the patient's will. On the other hand, with neuropathology, the doctor's understanding of his patient will have to pass through the latter's will, or at any rate through his cooperation. He will not just say: "Lie down! Cough! ", but will have to say to him: "Walk! Put out your leg! Hold out your hand! Speak! Read this
? sentence! Try to write this! " and so on. In short, we now have a technique of examination reliant on instruction and injunction. Consequently, since instruction and injunction necessarily have to pass through the patients will, the latter will be at the very heart of the examination and, to that extent, the doctor's authority will be at the very heart of this neurological apparatus. The doctor will give orders, he will try to impose his will, and the patient, after all, may always feign inability or unwillingness. That is to say, one really will depend on the patient's will. However, the clinical possibility of identifying voluntary and involuntary, automatic and spontaneous behavior, the possibility of clinically deciphering the levels of will in behavior that I was just telling you about, will enable one to see whether the patient really responds as he is told to, the quality and nature of his responses, and the extent to which his responses have or have not been faked by the will which comes into play; and here the doctor will recapture the power he lost by giving instructions. For example, after Broca, neurologists could easily distinguish voluntary mutism from an aphasia like anarthna: in the case of anarthna, the impossibility of speaking is always accompanied by a series of background sounds, of automatisms which accompany the attempt to speak; it is also always accompanied by correlative motor disorders, and it is also accompanied by expressive deficiencies in gestures and written expression, etcetera. 17 Someone who refuses to speak, and furthermore a hysteric who does not speak, is someone who has gestures, can write, understands, and has none of the accompanying supplementary disorders typical of anarthna.
So you can see that the individual's will can be captured at the level of his real behavior, at the level, rather, of the clinical observation of his behavior. Consequently, if it is true that, on the one hand, the game of instruction typical of the neurological examination makes the possibility of examination depend on the patient's will to a certain extent, on the other hand, with clinical observation, with the clinical decipherment now available, the patient can be circumvented and short-circuited.
To summarize this in a few words, let's say that a new clinical medical apparatus is put in place that is different in its nature, equipment, and effects from what we can call the Bichat-Laennec clinical apparatus, as well as from the psychiatric apparatus. In organic medicine, the patient
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was given a minimum of injunctions like "Lie down! Cough! " and the rest was given over entirely to the doctors examination carried out through the interplay of stimuli and effects. I have tried to show you that the essential component of capture in psychiatry was questioning, which is the substitute for the examination techniques of organic medi- cine. Questioning depends, of course, on the subjects will, and for the psychiatrist the answers are not a test of truth or the possibility of a dif- ferential decipherment of the disease, but merely a test of reality; ques- tioning simply corresponds to the question: "Is he mad? "
So, neurology is neither an examination in the sense of pathological- anatomy, nor questioning; it is a new apparatus which replaces question- ing with injunctions, and which through these injunctions seeks to get responses, but responses which are not the subjects verbal responses, as in questioning, but the responses of the subject's body; responses which can be clinically deciphered at the level of the body and which one can consequently submit to a differential examination without fear of being duped by the subject who responds. We can now differentiate between someone who does not want to speak and someone suffering from apha- sia, that is to say, we can now establish a differential diagnosis within forms of behavior for which this was hitherto not possible and which were previously questioned in terms of an absolute diagnosis. The test of reality is no longer necessary: clinical neurology, m a certain domain at least, will enable differential diagnosis to get a hold, like organic medicine, but on the basis of a completely different apparatus. Broadly speaking, the neu- rologist says: Obey my orders, but keep quiet, and your body will answer for you by giving responses that, because I am a doctor, I alone will be able to decipher and analyze in terms of truth.
"Obey my orders, keep quiet, and your body will respond": you see that it is precisely here that the hysterical crisis will quite naturally rush in. Hysteria will enter into this apparatus. I am not talking about the appearance of hysteria: in my view the question of the historical exis- tence of hysteria is a futile question. I mean that the emergence of hyste ria within the medical field, the possibility of making it an illness, and its medical manipulation are only possible when this new clinical appa- ratus, the origin of which is neurological and not psychiatric, was estab- lished; or when this new trap was set.
? "Obey, keep quiet, your body will speak. " So, you want my body to speak! My body will speak, and I really promise you that there will be much more truth than you can imagine in the answers it will give you. Not, certainly, that my body knows more about it than you, but because there is something in your injunctions that you do not formulate but which I can clearly hear; a certain silent injunction to which my body will respond. * And it is this, the effect of your silent injunctions, that you will call "hysteria in its nature. " This, more or less, is the hysteric's discourse rushing in to the trap I have just described.
Fine. So, what takes place once this trap, this new apparatus of cap ture has been set?
Broadly speaking, I think we could say that until then, in medicine, until the existence of neurology and the clinical apparatus specific to neurology, there were two great domains of illnesses: mental illnesses and the others, the true illnesses. I do not think it is enough to say that mental illnesses and all the others are opposed to each other as illnesses of the mind on the one hand, and illness of the body on the other. This would not be correct, first of all because for many psychiatrists, from 1820 to 1870-1880, illnesses of the mind are just illnesses of the body with the characteristic of having psychical symptoms or syndromes. Then, it was absolutely accepted in this period that the so-called con- vulsive illnesses--medically, clinically, no effective difference was made between epilepsy and the others18--were illnesses of the mind. So I do not think that the mind/body opposition, organic illnesses/psychical illnesses, is the real distinction that divided medicine between 1820 and 1880, whatever the theoretical discussions were, and even because of the theoretical discussions on the organic basis of illness. 19 Actually, I think that the only true difference is the one I talked about last week. That is to say, there were certain illnesses which could be evaluated in terms of differential diagnosis--and these were the good, solid illnesses with which genuine and serious doctors concern themselves--and then the illnesses on which the latter could get no hold, and which could only be
k The manuscript adds: "I will hear what you do not say, and I will obey, providing you with symptoms the truth ol which you will have to recognize, since they will respond, without your knowing, to your unspoken injunctions. "
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recognized by a test of reality--and these were the so called mental illnesses, those to which there was only a binary response: "He really is mad" or "He is not mad. "
I think this is the real division of medical practice and knowledge in the first two thirds of the nineteenth century: between illnesses integrated within a differential diagnosis and illnesses falling solely under an absolute diagnosis. Between these two categories of illnesses there were obviously a number of intermediaries, of which there were basically two that I think are important. There was the good intermedi- ary, the good illness, which was of course general paralysis. This was an epistemologically good illness and, consequently, it was morally good to the extent that, on the one hand, it included psychological syndromes- delirium according to Bayle,20 and then dementia according to Baillarger21--and motor syndromes: trembling of the tongue, progressive paralysis of the muscles, etcetera. There are the two syndromes, and in terms of pathological-anatomy both of them refer to an encephalic lesion. A good illness, consequently, exactly intermediary between those illnesses of the test of reality, which were, if you like, the so-called mental illnesses, and then the illnesses differentially allocated and referring to pathological anatomy. 22 General paralysis was an absolutely good illness, better, more complete, and giving a stronger foundation to all these phenomena in that it was not yet known that general paralysis had a syphilitic origin. 23 Consequently, one had all the epistemological benefits and none of the moral inconveniences.
On the other hand, still intermediary between illness of differential diagnosis and illness of absolute diagnosis, there was a completely different, bad and swampy region, which was at that time called "the neuroses. "21 What did the word "neurosis" mean around the 1840s? The word cov- ered illnesses with all the motor or sensory components--"disorders of relational functions" as it was said--but without any pathological anatomical lesion which would allow an etiology to be established. So, of course, these illnesses of "disorders of the relational functions" without ascribable anatomical correlates, covered convulsions, epilepsy, hysteria, hypochondria, and so forth.
Now these were bad illnesses for two reasons. They were epistemo logically bad because in these illnesses there was a kind of symptomatic
? confusion or irregularity. In the domain of convulsions, for example, one could not make a division between the different types because, precisely, the neuropathological apparatus did not enable one to make a precise analysis ol different lorms of behavior. Faced with a convulsion, one said: "This is a convulsion"; one could not make those firm bodily inter- pretations that I was talking about a moment ago, and, consequently, one was faced with a "region" of confusion and irregularity. In the first number oi the Annales medico-psychologiques, in 18^3, the editors said: We must concern ourselves with madness; we should also concern ourselves with the neuroses, but it is so difficult, "because these disorders are fleeting, varied, protean, exceptional, difficult to analyze and under stand, we banish them from observation and dismiss them as we reject troublesome memories. "25
Epistemologically bad, these disorders were also morally bad due to the ease with which they could be simulated and the fact that, in addition to this possibility, there was a constant sexual component ol behavior. Thus,Jules Falret, in an article which was reprinted m 1890 m his Etudes cliniques, said: "The life of hysterics is just a constant lie; they put on airs of pity and devotion and succeed in passing themselves off as saints, while they secretly abandon themselves to the most shameful actions, while at home with their husband and children they make the most violent scenes in which they say coarse and sometimes obscene things. "26
The emergence of the neurological body, or rather, of the system con- stituted by neurology's clinical apparatus of capture and the correlative neurological body, will make it possible to remove the disquabiication, this double epistemological and moral disqualification, to which the neuroses were subject until the 1870s. It will be possible to remove this disqualification to the extent that it will finally be possible to place these illnesses called "neuroses," that is to say, illnesses with sensory and motor components, not exactly in the domain ol neurological illnesses strictly speaking, but very close by, not so much through their causes, but basically because ol their forms. That is to say, thanks to the clinical apparatus of neurology, the blade oi diflerential diagnosis will now be able to separate neurological illnesses, such as disorders due to a cere bellar tumor, for example, from hysterical convulsions and trembling.
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This famous differential diagnosis, which one had never been able to apply to madness, which never really managed to get a grip on the men- tal illnesses, this differential diagnosis that one could never insert between an ordinary illness and madness, because madness, above all and essentially, fell under an absolute diagnosis, this differential diagnosis then, through the apparatus I have tried to describe, can now be inserted between neurological disorders with ascribable anatomical lesions, and those disorders called "neuroses. " So that what was, morally and epistemologically, the last category in the domain of mental illness--the neuroses--will suddenly be promoted to the closest proximity to genuine and serious illnesses by this new instrument of neurological analysis, of clinical neurology. That is to say, through the use of differential diagnosis the previously discredited zone of the neuroses will receive pathological consecration.
In a book--what's more, not a very good book--which a contemporary neurologist called Guillain devoted to Charcot, his predecessor, the author says, with a kind of radiant joy: "Charcot all the same rescued hysteria lrom the psychiatrists," which is to say that he really brought it into the domain ol the medicine ol differential diagnosis, which is the only medicine. 2/ Basically, I think Freud thought the same when he put Charcot alongside Pinel and said: Pinel freed the mad from their chains, that is to say, he brought about their recognition as patients. Well, in a way, Charcot too made it possible for hysterics to be seen as ill: he pathologized them. 28
If we situate Charcot's operation in this way then I think we can see how what I will call "the great maneuvers of hysteria" unfolded at Salpetnere, and how they were constituted. I will not try to analyze this in terms ol the history of hysterics any more than in terms ot psychiatric knowledge of hysterics, but rather in terms of battle, confrontation, reciprocal encirclement, of the laying of mirror traps, ol investment and counter investment, of struggles for control between doctors and hysterics. * I do not think that there was exactly an epidemic ol hysteria; I think hysteria
* The manuscript adds: "of deals also, ol lacit pacts. "
? was the set of phenomena, and phenomena of struggle, which occurred within as well as outside of the asylum, around this new medical apparatus of clinical neurology; and it was the maelstrom of this battle which in fact summoned around hysterical symptoms all those people who actually joined in the battle. Rather than an epidemic, there was a maelstrom, a kind of hysterical vortex within psychiatric power and its disciplinary sys- tem. So how was this played out? I think we can pick out certain maneu- vers in this struggle between neurology and the hysteric.
The first maneuver is what could be called the organization of the symptomatological scenario. I think we can schematize things in the fol lowing way: lor hysteria to be put on the same level as an organic illness, for it to be a genuine illness falling under a differential diagnosis, that is to say, for the doctor to be a true doctor, the hysteric must present a sta ble symptomatology. Consequently, the doctor's consecration as a neurol- ogist, unlike the psychiatrist, necessarily implies an injunction given to the patient on the quiet: "Give me some symptoms, but give me some stable, coded, regular symptoms"--something that the psychiatrist was already saying--and this regularity and stability had to have two forms. First, consistent symptoms which should be permanently legible on the patient whenever the neurological examination takes place: No more of those illnesses that appear and disappear, the only symptoms of which are the flash of a gesture or the return of fits; we want stable symptoms, and in this way we will find them whenever we ask for them. This was how what Charcot and his successors called the "stigmata" of hysteria were defined. "Stigmata" are phenomena found in every hysteric, even when not suffering an attack:29 contraction ol the visual field,30 simple or double hemianaesthesia,31 pharyngal anesthesia, contracture caused by a circular bond around a joint. 32 Moreover Charcot said: All these stigmata are typical of hysteria; they are constants in hysteria, but, despite their con- stancy, I have to acknowledge that it quite often happens that we do not find them all, or even, in extreme cases, we do not find any. 33 But the epis temological requirement was there, the injunction was there, and I would point out that all of these wonderful stigmata were clearly responses to instructions: instructions to move, to feel a rubbing or contact on the body.
And then, second, the attacks (crises) themselves had to be ordered and regular, and so develop according to a very typical scenario
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sufficiently close to an existing illness, to an existing neurological illness, so that it crosses the line ol diiferential diagnosis, and yet nonetheless sufficiently different for the diagnosis to be made; hence the codification ol the hysterical attack (crise) on the model ol epilepsy. Vl In this way the huge domain of what before Charcot was called "hystero epilepsy," the "convulsions," is divided in two. *5 You had two illnesses, one which included the famous elements of the epileptic fit, that is to say, tonic phase, clonic phase, and period of stupor; and the other, which had to have tonic and clonic phases like epilepsy, with certain minor signs, differences in the phases, and then some elements absolutely specilic to hysteria: the phase of illogical, that is to say, disor dered movements; then the phase of passionate postures, that is to say, expressive movements, movements meaning something, a phase that was also called "plastic," inasmuch as it reproduced and expressed emotions like lustfulness, terror, etcetera; and finally, the phase of delirium, which was also lound in epilepsy moreover.
of intellectual disorders, we must. . . group these phenomena according to the analogies,
the more or less numerous aflinities that they present" Du hashish, p. 44.
38. Moreau de Tours, ibid. Part II, ? 1: "Generalites physiologiques," pp. 32 47.
39. An allusion to the privilege that, according to J. Derrida, Descartes accords to the dream
over madness in the "First meditation: Some things that one can put in doubt," Meditations touchant la premiere philosophic (1641), in CEuvres et Lettres, pp. 268-269; English translation, "Meditations on First Philosophy" trans. John Cottingham, in The Philosophical Writings of Descartes, vol. II, pp. 13 14; See Foucault's commentaries in Histoire de lafolie, Part I, ch. 2,
pp. 56-59 (omitted Irom the English translation of Madness and Civilisation except for
one short paragraph, p. 38) and "Mon corps, ce papier, ce feu" in, Dits et Ecrits, vol. 2,
pp. 245 268; English translation, "My Body, This Paper, This Fire" trans. Geoff Bennington, in Essential Works of Foucault, 2, pp. 393 417.
40. JJ. Moreau de Tours, Du haschisch, Part III: "Therapeutique," p. 402: "One of the effects of hashish that I was most struck by ( . . . ) is that sort of maniacal excitation always
? accompanied by a sense ol cheerfulness and happiness ( . . . ) . I saw in this an ellective means for combating the fixed ideas o( melancholies (? ? ? ). Was I mistaken in my conjectures? I am led to think so. "
41. Ibid. p. 405: "Pinel, and with him all doctors ol the insane, saw mental alienation decided by bouts of agitation. " An allusion to the accounts of cures obtained following a "critical attack (acres critique)" that Pinel reports in his Traite mcdico-philosophique, section I, ? xiu: "Reasons which lead considering most bouts of mania as the healthy and favorable reaction to the cure" pp. 37-41; A Treatise on Insanity, pp. 3943. See also the article by Landre Beauvais (Pinel's assistant at Salpetriere) "Crisis" in Dictionnaire des sciences medicales, vol. VII (Paris: C. L. F. Panckoucke, 1813) pp. 370-392.
42. JJ. Moreau de Tours, Du haschisch: "A precise indication emerged that could be lormulated in this way: to preserve his primary acuity in the delirium tending to the chronic state, or to call back this acuity, to revive it when it threatens to become extinguished. The extract ol Indian hemp was, of all the medicaments known, the most eminently suited lor lullilling this indication. "
43. See above, note 21 to lecture of 12 December 1973-
44. P. Foissac, Memoire sur le magnetisme animal, adresse a messieurs les membres de VAcademie roya/e
de medecine (Paris: Didot Jeune, 1825) p. 6: "When they have tallen into a deep sleep, the magnetized display the phenomena of a new lile (. . . ) . The sphere of consciousness grows, and already that faculty appears that is so precious that the first magnetizers will call 'intu
Hive' or 'lucidity' ( . . . ) . With it, the somnambulists ( . . . ) recognize the illness Irom which they suller, the near and distant causes ol these illnesses, their seat, their prognosis and their appropriate treatment (. . . ). By placing a hand successively on the head, chest, and abdomen ol someone unknown, the somnambulists also discover their illnesses, the pains and various alterations that they occasion; in addition they indicate whether cure is possi ble, easy or dilhcult, near at hand or lar oil, and what means must be used to achieve the result. "
45- See above, notes 28 and 33 the lecture ol 23 January 1974.
46. Thus the magnetic cure carried out on 4 May 1784 by Armand Marc Jacques de Chastenet,
marquis ol Puysegur (1751 1825), on Victor Race, a peasant attached to his property at Buzancy (Soissonnais): asleep, the latter answered questions, gave an opinion ol his state, indicated a course of therapy, and gave a prognosis with the date ol his return to health,
which will be confirmed. And on Charles Francois Ame, aged 14, who when put in a magnetic sleep announced the duration and intensity of his future crises. See,
A. M. J. Chastenet de Puysegur, (1) Memoires pour servir a I'histoire et a Vetablissement du magnetisme animal, vol. I, (Pans: 1784) pp. 199 211 and pp. 96 97; (2) Detail des cures operees
a Buzancy, pres de Soissons, par le magnetisme animal, a short anonymous work published by Puysegur (Soissons: 1784); (3) see also the account of the cure ol the young Hebert, pre
ceded by a plea in favor of magnetism: Appel aux savans observateurs du dix-neuvieme siecle de
la decision porlee par leurs predecesseurs contre le magnetisme animal, et fin du traitement du jeune Hebert (Paris: Dentu, 1813). On the history ot magnetic cures one can consult: S. Mialle,
Expose par ordre alphabelique des cures operees en France par le magtietisme animal depuis Mcsmer jusqu'a nos jours (1774-1&26) (Paris: Dentu, 1826). See also, H. F. Ellenberger, "Mesmer and
Puysegur: from magnetism to hypnotism," Psychoanalytic Review, vol. 52, no. 2 (1965).
47. This is taken from the eighth session conducted on 2 November 1820 by the Baron Jules Dupotet de Sennevoy in the service of Dr. Husson, head doctor at the Hotel Dieu, on
Catherine Samson, aged 18: see, Expose des experiences publiques sur le magnetisme animalfaites
a I'Hotel-Dieu de Paris, pendant le cours des mois d'octobre, novembre et decembre 1820 ( P a n s : Bechet Jeune, 3rd edition, 1826) p. 24.
48. In 1816, Etienne Jean Georget entered Esquirol's department at Salpetriere. On 8 February 1820 he defended his thesis, "Dissertation sur les causes de la folie," then published the work on which his reputation is based: De la folie. Considerations sur cette maladie. In 1821, with Leon Rostan, he turned two patients into experimental subjects, Petronille and Manoury, the widow Brouillard, called Braguette (see above, note 43).
49. "Petronille . . . asks Georget to throw her in the water while she is having her period" C. Burdin and F. Dubois (known as Dubois d'Amiens), Histoire academique du magnetisme animal (Paris: J. -B. Bailliere, 1841) p. 262.
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50. Ibid. pp. 262 263: "Petromlle's instructions had not been carried out meticulously; Pelronille had said that she had to be plunged in the Ourcq canal, since it was in this canal that she had (alien and contracted her illness: similia similibus; such had to be the end ol the story. "
51. James Braid (1795 i 8 6 0 ) , Scottish surgeon, converted to magnetism as a result ol demonstrations o( "mesmerism" at Manchester in November 1841 by Charles Lalontame,
a disciple ol the marquis de Puysegur, and popularized his practice under the term "hypnotism. " See,J. Braid, Neurhypnology, or the Rationale of Nervous Sleep Considered in rela-
tion with Animal Magnetism. Illustrated by Numerous Cases of its Successful Application in the
Relief and Cure of Diseases (London: John Churchill, 1843); French translation, with a
preface by E. Brown Sequard, Neurhypnologic, ou Traile du sommeil nerveux considere dans ses rapports avec le magnelisme animal, el relalanl de nombreux succes dans ses applications au iraitemenl des maladies, trans. G. Simon (Paris: A. Delahaye, 1883).
52. See below, note 55-
53. During the Restoration, the increasing potential ol magnetism was seen as a threat
by institutional medicine. The conlrontation corresponds to the setting up ol olbcial commissions: the lust, appointed on 28 February 1826, started work in January 1827 and delivered its conclusions on 28 June 1831, which, being deemed too lavorable, were not published by the Academie de medecine. A second, unlavorable, was voted on 5 September I837. The death warrant lor magnetism was signed on 15June 1842 with the decision ol the Academie to no longer concern itsell with the question. See, L. Peisse, "Des sciences occultes au xixc siecle. Le magnetisme animal," Revue des deux mondes, vol. 1, March 1842, pp. 695 723.
54. Whereas mesmerism proposed to "demonstrate that the heavenly bodies act on our earth and that our human bodies are equally subject to the same dynamic action" (A. Mesmer, Dissertalio physico-medica de planetarum influxu | Vienna: Chelem: 1766 | p. 32), and that the action ol the magnetizcr consists in canalizing this fluid on the patient, James Braid invoked a subjective action founded on the physiology ol the brain: see, The Power of the Mind over the Body: An Experimental Enquirey into the Nature and Cause of the Phenomena Attributed by Baron Reichenbach and Others to a New Imponderable (London: John Churchill, 1846), lor which he was hailed by, among others, the doctor Edgar Bei illon: "It is to Braid that honor is due lor having delmitively introduced the study ol induced sleep into the scientilic domain," and lor having rendered "a great service to science by giving to the whole ol his research the generic name ol hypnotism" Histoire de I'hypnotisme experimental ( Paris: Delahaye, 1902) p. 5.
55. Foucault refers here to the operation performed by E. F. Folhn and Paul Broca (to whom
the works ol Braid became known through a Bordeaux surgeon, Paul Azam) on a 40 year
old woman on 4 December 1859 at the Necker hospital. The operation was the subject ol
a report to the Academie des sciences presented by A. A. L. M. Velpeau on 7 December 1859: "Note sur une nouvelle methode anesthesique," Comptes rendus hebdomadaires desseances de I'Academie des sciences, vol. 49 (Paris: Mallet Buchelier, 1859) pp. 902 911.
56. Joseph Pierre Durand, known as Durand de Gros (1826 1900), was an exile in England where he discovered Braidism, and then in the United States. He returned to France where he published under the pseudonym ofJoseph Philips, Electrodynamisme vital, ou les Relations
physiologiques de Vesprit et de la matiere, demontrees par des experiences entieremenl nouvelles (Paris: J. B. Bailliere, 1855), and then, Cours theorique el pratique de braidisme, ou Hypnotisme nerveux
considere dans ses rapports avec la psychologiie, la physiologie et la pathologic, el dans ses applications a la medecine, a la chirurgie, a la physiologie experimenlale, a la medecine legale et a ^education (Paris:J. B. Bailliere, i860).
57. Durand de Gros defines "the hypotaxic state" as "a preparatory modification of vitality, a modification which usually remains latent and the whole effect of which is to incline the organization to undergo the determinant and specific action constituting the second stage" Cours theorique et pratique, p. 29.
58. Ibid. p. 112.
59. Ibid. Chorea is a nervous disorder characterized by sweeping and jerky involuntary
movements, with a gesticulatory appearance.
? 60. Ibid. p. 87: "Braidism is a process by which we seek to determine certain physiological changes in man with the aim ol lulfilling certain indications for medical or surgical treatment, or in order to facilitate the experimental studies of biology. "
61. Between 1850 and i 8 6 0 , under the impulse ol Guillaume Benjamin Amand Duchenne de Boulogne (1806 1875), the nosology of functional disorders ol motivity was redefined and enriched by two new groups of affections. On the one hand, "progressive muscular atrophy," studied from 18-19, and the "muscular atrophies with myopathic origin," in 1853: (1) La Paralyse atrophique de I'enjance (Pans: 1855). On the other hand, "progressive locomolor atrophy," known up until then as tabesdorsalis: (2) "De l'ataxie locomotrice progressive. Recherches sur unc maladie caractensee specialement par des troubles generaux de coordination des mouvemcnts," Archives generates de medecinc, 5th series, vol. 12, December 1858, pp. 6/|1 652; vol. 13, January 1859, pp. 5-23; February 1859, pp. 158 I64; April 1859, pp. -117 yi32. In i860 he described (3) the "paralysie glosso labio laryngee," ibid. 5th series, vol. 16, i860, pp. 283 296 and pp. /|31 Vi5. On Duchenne de Boulogne, see P. Guilly, Duchenne de Boulogne (Paris: Bailliere, 1936). On the constitution ol the neurological lield, see W.
Riese, A History oj Neurology (New York: MD Publications, 1959), and F. H. Garrison, History of Neurology, edition revised and expanded by Laurence McHenry (Springfield, 111. : C. C. Thomas, 1969).
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The emergence of the neurological body: Broca and Duchenne de Boulogne. ^ Illnesses of differential diagnosis and illnesses of absolute diagnosis. ^ The model of "generalparalysis" and the
neuroses. ^ The battle of hysteria: 1. The organisation of a "symptomatologLcal scenario. "nu 2. The maneuver of the "functional
mannequin" and hypnosis. The question of simulation. nu 3. Neurosis and trauma. The irruption of the sexual body.
LAST WEEK I SAID that one of the important events in the history of the consolidation of psychiatric power was, in my view, the appearance of what I called the "neurological body. "* What should we understand by "neurological body"? I would like to begin with this today.
Of course, the neurological body is still, always, the body of pathological-anatomical localization. There is no opposition between the neurological body and the body of pathological anatomy; the second is part of the first; it is, if you like, a derivative or expansion of it. And the best proof of this is that in one of his courses, in 1879, Charcot said that the constitution, progress, and, in his view, the culmination of neu- rology, was the triumph of the "spirit of localization. "1 Except that what I think is important is that the procedures for matching up anatomical localization and clinical observation in the case of neurology are not at all the same as in the case of ordinary general medicine. It seems to me
* The manuscript adds: "From 1850 to 1870, emergence of a new body. "
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that neurology, clinical neurology, involves a quite different deployment of the body in the field of medical practice. My impression is that the encounter of the patient-body and the doctor body in neurology takes place in terms of a very different arrangement from that in general medicine. And it is the setting up of this new apparatus that seems to me to be the important episode, which is why I would like to try to identify the new apparatus set up by and through the constitution ol a neuropathology or neurological clinical medicine.
What is this apparatus, and in what does it consist? How is the sick body* captured in clinical neurology? Its capture takes place, I think, very differently trom the way the body was captured at the time ol the formation of pathological anatomy, more or less between Bichat2 and Laennec* I will give you an example straightaway by taking a text that is not by Charcot himself, but which is found in the Charcot archives at Salpetriere and was quite certainly written by one of his students-- clearly we don't know which one. It is an observation of a patient. This is how the patient is described: the patient's symptom was something very simple, the drooping of the left eyelid, called ptosis. So, the student takes the following notes for Charcot for him then to use for a lecture-- I am not giving you the description of the whole of the patient's lace, but just a quite small excerpt.
"If we tell him to open his eyelids, he raises the right one normally, the left one however, does not noticeably move, no more than the eye brow, so that the superciliary asymmetry becomes more marked. In this movement (. . . ) the skin ol the forehead wrinkles transversally on the right side, while it remains almost smooth on the left. At rest, the skin of the forehead is wrinkled neither on the right nor the left ( . . . ) . "
"Two more points should be noted: a small dimple, quite visible under a certain angle of light, eight millimeters above the left eyelid and about two centimeters to the left of the median line of the forehead; and a little projection within the dimple which seems due to the contraction of the eyelid muscle. These two points are very noticeable in comparison with the normal state of the right side. "1
* The manuscript clarifies: "body whose surlace is the bearer ol plastic values. "
? You have here a type of description which is, I think, really quite different from what is found in the anatomical-pathological procedure, m anatomical-pathological observation. ^ In a sense, this sort of descrip- tion takes us back to a sort of surlace, almost impressionistic gaze, such as could be found m eighteenth century medicine, when the patient's complexion, color, red cheeks and bloodshot eyes, etcetera, were impor tant elements for clinical diagnosis. 6 Pathological anatomy--Bichat, Laennec, if you like? infinttely reduced this impressionistic description of the surlace and codified what were ultimately a quite limited number of surlace signs intended to identify what was essential according to a well established clinical code, this being, precisely, the lesion, which then, thanks etther to a surgical operation or, especially, the autopsy, was described by the anatomical pathologist with almost as many details as, if not more than, the description I have just read to you. In other words, anatomical-pathology brought its minutely detailed description to bear on the deep and injured organ, the surface only being questioned through a grid of ultimately simple and limited signs.
Here, rather, as you can see, you have the striking reemergence of sur face values within medical discourse and knowledge. It is this surface that must be covered in all its hollows and bumps, and practically by looking only, by looking only that far. In fact, and no doubt even more than this clinical re validation of the almost impressionistic values of the surface, what is important and, I think, decisive, in this new clinical capture of the neurological patient, and in the correlative constitution of a neurological body before this gaze and apparatus of capture, is that the neurological examination is basically looking tor "responses. "
What I mean is that in the pathological anatomy of Bichat Laennec one can, of course, identify the signs straightaway, at the first glance; one can also obtain them from a stimulation: one taps, one listens, etcetera. That is to say, what is sought in classical pathological anatomy is essentially the system of stimulation-effect: one sounds the chest and listens to the noise;7 one asks the patient to cough and listens to its harshness; one palpates and sees if there is any heat. So: stimulation- effect.
In the case of the neurological examination being constituted in the mid-nineteenth century, the main part of the signs, in short what makes
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a sign a sign, is not so much that it is [deciphered asj a more or less mechanical effect, like the noise following percussion in classical patho logical anatomy, but that a sign is [deciphered) as a response. I think the substitution of the schema of stimulus-response for the schema of stimulus effect, and the organization of a whole battery of stimuli- responses, is crucial.
We have a number of examples of this staging of a battery of stimuli- responses. At the strictly elementary level, there was the founding discovery oi neuropathology in Duchenne de Boulogne's research into what he called "localized Faradization," when, by moistening two electrodes, he succeeded in getting a single muscular response, or, rather, the response of a single muscle to electrification of the surface of the skin; by moistening the surface of the skin he succeeded in limiting the effect of the charge and obtained a single response of a single muscle: this was the founding discovery of everything here. 8 Then, starting from this, there were the studies of reflexes and then, especially, the study of complex behavior involving either a gearing of diverse automatisms or a prior learning, and it is there that we find, more or less, the two great domains in which the capture, the apparatuses of neurological capture, were completely established. This was Broca's study of aphasia,9 the study of walking, and notably Duchenne de Boulogne's study of tabetics. 10
Taking the second example, Duchenne produced a description of the walking of tabetics that is presented precisely in terms of stimulus response or, rather, in terms of behavior and the sequence of episodes of behavior that constitute the action of walking. Duchenne's problem was to distinguish the disorder of balance found in tabetics, that is to say, at a certain stage and in a certain form of general paralysis, from the vertigo of alcoholic intoxication or even of certain cerebellar disorders. In 1864, in a fundamental article, Duchenne managed to give a differential description of the gait of tabetics and the rocking of vertigo. " In the case of vertigo, the subject gives way to wide swaying, whereas in the subject suffering from tabes the rocking movements are "short," "they are abrupt"--Duchenne de Boulogne says that the subject has the bearing of a tightrope walker without his balancing pole, cautiously advancing one step at a time while trying to restore his balance. 12 In the case of vertigo, there is no muscular contraction, but a general weakening of the
? musculature and tone instead, whereas [-. . *] the tabetic is always holding himself back, and if we observe what happens at the level of his calves and legs, we see, even before he loses his balance, even before he is aware of losing his balance, some small, brief spasms which flicker across the musculature ot his legs, and then, gradually, these contrac- tions become more significant, until they become voluntary when the subject becomes aware that he is losing his balance. 13 This is completely different, therefore, from the collapse in vertigo. In vertigo, the subject zigzags; that it to say, going from one point to another, he cannot keep to a straight line. The tabetic however, goes completely straight ahead; it is just his body that wobbles around this straight line. 17' And finally, in drunkenness, there is the internal sensation of vertigo, whereas the tabetic has the impression that it is not his body that lacks balance at all, but only his legs, locally as it were. 15 These are the principal themes, more or less, of Duchenne de Boulogne's analysis of the tabetic's gait.
Now, in this kind of analysis--and the same would be true for Broca's analyses of aphasia roughly at the same time, between 1859 and 1865-- what is achieved by seeking to obtain a system of signs of responses that show dysfunctions, rather than a system of signs of effects that would reveal the presence of lesions at a given point? What we obtain, of course, is the possibility of distinguishing and analyzing what neurolo- gists called, and still call today, synergies, that is to say, the different cor- relations existing between this or that muscle: What are the different muscles that must be used in order to get such and such a response? What happens when it is precisely just one of them that is put out of play? So, we get a study of synergies.
Secondly, and I think this is the important thing, it becomes possible to set out the phenomena analyzed in different levels according to an axis of the voluntary and the automatic. That is to say, on the basis of this analysis of behavior, of responses to different stimuli, we can see the functional difference, the difference of neurological and muscular imple mentation, between simple reflex behavior, automatic behavior, sponta- neous voluntary behavior, and, finally, spontaneous behavior produced
* (On the recording, repetition of:) rather
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by an order coming from outside. All of this hierarchy in the bodily implementation of the voluntary and the involuntary, of the automatic and the spontaneous, of what is required by an order or what is sponta- neously linked together within behavior, will make possible--and this is the essential point--a clinical analysis, an analysis in terms of physical ascription, of the mdividuaPs intentional attitude.
Consequently, a capture of the subject's attitude, of the subject's consciousness, of the will itself within his body, becomes possible. Neuropathology showed the will invested in the body, the effects of the will or the degrees of will legible in the organization of responses to stimuli. You are familiar with all the analyses Broca initiated on the different levels ol the performance of aphasics, according to whether it is a matter ol simple mumblings, of swear words uttered automatically, of phrases triggered spontaneously in a certain situation, or of phrases which must be repeated in a certain order and on a certain injunction. 16 All of these clinical deferences of performance between different levels of behavior make possible the clinical analysis of the individual at the level of his intention, at the very level of that much vaunted will that I have tried to show you was the great correlate of discipline. It was the will, in fact, on which and to which disciplinary power had to be applied; it really was the vis avis of disciplinary power, but then it was only acces sible through the system of reward and punishment. Neuropathology now provides the clinical instrument by which it is thought the individual can be captured at the level of this will itself.
Let's consider things a bit differently and bit more precisely. We could say that, in one respect, with the neurological examination medicine will lose power m comparison with classical anatomical-pathology. That is to say, in the anatomical pathology constituted by Laennec, Bichat, and others, ultimately very little was demanded from the individual: he was asked to lie down, bend his leg, cough, breathe deeply, and so on. Consequently there was a minimum of injunctions on the doctor's part, and minimum dependence on the patient's will. On the other hand, with neuropathology, the doctor's understanding of his patient will have to pass through the latter's will, or at any rate through his cooperation. He will not just say: "Lie down! Cough! ", but will have to say to him: "Walk! Put out your leg! Hold out your hand! Speak! Read this
? sentence! Try to write this! " and so on. In short, we now have a technique of examination reliant on instruction and injunction. Consequently, since instruction and injunction necessarily have to pass through the patients will, the latter will be at the very heart of the examination and, to that extent, the doctor's authority will be at the very heart of this neurological apparatus. The doctor will give orders, he will try to impose his will, and the patient, after all, may always feign inability or unwillingness. That is to say, one really will depend on the patient's will. However, the clinical possibility of identifying voluntary and involuntary, automatic and spontaneous behavior, the possibility of clinically deciphering the levels of will in behavior that I was just telling you about, will enable one to see whether the patient really responds as he is told to, the quality and nature of his responses, and the extent to which his responses have or have not been faked by the will which comes into play; and here the doctor will recapture the power he lost by giving instructions. For example, after Broca, neurologists could easily distinguish voluntary mutism from an aphasia like anarthna: in the case of anarthna, the impossibility of speaking is always accompanied by a series of background sounds, of automatisms which accompany the attempt to speak; it is also always accompanied by correlative motor disorders, and it is also accompanied by expressive deficiencies in gestures and written expression, etcetera. 17 Someone who refuses to speak, and furthermore a hysteric who does not speak, is someone who has gestures, can write, understands, and has none of the accompanying supplementary disorders typical of anarthna.
So you can see that the individual's will can be captured at the level of his real behavior, at the level, rather, of the clinical observation of his behavior. Consequently, if it is true that, on the one hand, the game of instruction typical of the neurological examination makes the possibility of examination depend on the patient's will to a certain extent, on the other hand, with clinical observation, with the clinical decipherment now available, the patient can be circumvented and short-circuited.
To summarize this in a few words, let's say that a new clinical medical apparatus is put in place that is different in its nature, equipment, and effects from what we can call the Bichat-Laennec clinical apparatus, as well as from the psychiatric apparatus. In organic medicine, the patient
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was given a minimum of injunctions like "Lie down! Cough! " and the rest was given over entirely to the doctors examination carried out through the interplay of stimuli and effects. I have tried to show you that the essential component of capture in psychiatry was questioning, which is the substitute for the examination techniques of organic medi- cine. Questioning depends, of course, on the subjects will, and for the psychiatrist the answers are not a test of truth or the possibility of a dif- ferential decipherment of the disease, but merely a test of reality; ques- tioning simply corresponds to the question: "Is he mad? "
So, neurology is neither an examination in the sense of pathological- anatomy, nor questioning; it is a new apparatus which replaces question- ing with injunctions, and which through these injunctions seeks to get responses, but responses which are not the subjects verbal responses, as in questioning, but the responses of the subject's body; responses which can be clinically deciphered at the level of the body and which one can consequently submit to a differential examination without fear of being duped by the subject who responds. We can now differentiate between someone who does not want to speak and someone suffering from apha- sia, that is to say, we can now establish a differential diagnosis within forms of behavior for which this was hitherto not possible and which were previously questioned in terms of an absolute diagnosis. The test of reality is no longer necessary: clinical neurology, m a certain domain at least, will enable differential diagnosis to get a hold, like organic medicine, but on the basis of a completely different apparatus. Broadly speaking, the neu- rologist says: Obey my orders, but keep quiet, and your body will answer for you by giving responses that, because I am a doctor, I alone will be able to decipher and analyze in terms of truth.
"Obey my orders, keep quiet, and your body will respond": you see that it is precisely here that the hysterical crisis will quite naturally rush in. Hysteria will enter into this apparatus. I am not talking about the appearance of hysteria: in my view the question of the historical exis- tence of hysteria is a futile question. I mean that the emergence of hyste ria within the medical field, the possibility of making it an illness, and its medical manipulation are only possible when this new clinical appa- ratus, the origin of which is neurological and not psychiatric, was estab- lished; or when this new trap was set.
? "Obey, keep quiet, your body will speak. " So, you want my body to speak! My body will speak, and I really promise you that there will be much more truth than you can imagine in the answers it will give you. Not, certainly, that my body knows more about it than you, but because there is something in your injunctions that you do not formulate but which I can clearly hear; a certain silent injunction to which my body will respond. * And it is this, the effect of your silent injunctions, that you will call "hysteria in its nature. " This, more or less, is the hysteric's discourse rushing in to the trap I have just described.
Fine. So, what takes place once this trap, this new apparatus of cap ture has been set?
Broadly speaking, I think we could say that until then, in medicine, until the existence of neurology and the clinical apparatus specific to neurology, there were two great domains of illnesses: mental illnesses and the others, the true illnesses. I do not think it is enough to say that mental illnesses and all the others are opposed to each other as illnesses of the mind on the one hand, and illness of the body on the other. This would not be correct, first of all because for many psychiatrists, from 1820 to 1870-1880, illnesses of the mind are just illnesses of the body with the characteristic of having psychical symptoms or syndromes. Then, it was absolutely accepted in this period that the so-called con- vulsive illnesses--medically, clinically, no effective difference was made between epilepsy and the others18--were illnesses of the mind. So I do not think that the mind/body opposition, organic illnesses/psychical illnesses, is the real distinction that divided medicine between 1820 and 1880, whatever the theoretical discussions were, and even because of the theoretical discussions on the organic basis of illness. 19 Actually, I think that the only true difference is the one I talked about last week. That is to say, there were certain illnesses which could be evaluated in terms of differential diagnosis--and these were the good, solid illnesses with which genuine and serious doctors concern themselves--and then the illnesses on which the latter could get no hold, and which could only be
k The manuscript adds: "I will hear what you do not say, and I will obey, providing you with symptoms the truth ol which you will have to recognize, since they will respond, without your knowing, to your unspoken injunctions. "
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recognized by a test of reality--and these were the so called mental illnesses, those to which there was only a binary response: "He really is mad" or "He is not mad. "
I think this is the real division of medical practice and knowledge in the first two thirds of the nineteenth century: between illnesses integrated within a differential diagnosis and illnesses falling solely under an absolute diagnosis. Between these two categories of illnesses there were obviously a number of intermediaries, of which there were basically two that I think are important. There was the good intermedi- ary, the good illness, which was of course general paralysis. This was an epistemologically good illness and, consequently, it was morally good to the extent that, on the one hand, it included psychological syndromes- delirium according to Bayle,20 and then dementia according to Baillarger21--and motor syndromes: trembling of the tongue, progressive paralysis of the muscles, etcetera. There are the two syndromes, and in terms of pathological-anatomy both of them refer to an encephalic lesion. A good illness, consequently, exactly intermediary between those illnesses of the test of reality, which were, if you like, the so-called mental illnesses, and then the illnesses differentially allocated and referring to pathological anatomy. 22 General paralysis was an absolutely good illness, better, more complete, and giving a stronger foundation to all these phenomena in that it was not yet known that general paralysis had a syphilitic origin. 23 Consequently, one had all the epistemological benefits and none of the moral inconveniences.
On the other hand, still intermediary between illness of differential diagnosis and illness of absolute diagnosis, there was a completely different, bad and swampy region, which was at that time called "the neuroses. "21 What did the word "neurosis" mean around the 1840s? The word cov- ered illnesses with all the motor or sensory components--"disorders of relational functions" as it was said--but without any pathological anatomical lesion which would allow an etiology to be established. So, of course, these illnesses of "disorders of the relational functions" without ascribable anatomical correlates, covered convulsions, epilepsy, hysteria, hypochondria, and so forth.
Now these were bad illnesses for two reasons. They were epistemo logically bad because in these illnesses there was a kind of symptomatic
? confusion or irregularity. In the domain of convulsions, for example, one could not make a division between the different types because, precisely, the neuropathological apparatus did not enable one to make a precise analysis ol different lorms of behavior. Faced with a convulsion, one said: "This is a convulsion"; one could not make those firm bodily inter- pretations that I was talking about a moment ago, and, consequently, one was faced with a "region" of confusion and irregularity. In the first number oi the Annales medico-psychologiques, in 18^3, the editors said: We must concern ourselves with madness; we should also concern ourselves with the neuroses, but it is so difficult, "because these disorders are fleeting, varied, protean, exceptional, difficult to analyze and under stand, we banish them from observation and dismiss them as we reject troublesome memories. "25
Epistemologically bad, these disorders were also morally bad due to the ease with which they could be simulated and the fact that, in addition to this possibility, there was a constant sexual component ol behavior. Thus,Jules Falret, in an article which was reprinted m 1890 m his Etudes cliniques, said: "The life of hysterics is just a constant lie; they put on airs of pity and devotion and succeed in passing themselves off as saints, while they secretly abandon themselves to the most shameful actions, while at home with their husband and children they make the most violent scenes in which they say coarse and sometimes obscene things. "26
The emergence of the neurological body, or rather, of the system con- stituted by neurology's clinical apparatus of capture and the correlative neurological body, will make it possible to remove the disquabiication, this double epistemological and moral disqualification, to which the neuroses were subject until the 1870s. It will be possible to remove this disqualification to the extent that it will finally be possible to place these illnesses called "neuroses," that is to say, illnesses with sensory and motor components, not exactly in the domain ol neurological illnesses strictly speaking, but very close by, not so much through their causes, but basically because ol their forms. That is to say, thanks to the clinical apparatus of neurology, the blade oi diflerential diagnosis will now be able to separate neurological illnesses, such as disorders due to a cere bellar tumor, for example, from hysterical convulsions and trembling.
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This famous differential diagnosis, which one had never been able to apply to madness, which never really managed to get a grip on the men- tal illnesses, this differential diagnosis that one could never insert between an ordinary illness and madness, because madness, above all and essentially, fell under an absolute diagnosis, this differential diagnosis then, through the apparatus I have tried to describe, can now be inserted between neurological disorders with ascribable anatomical lesions, and those disorders called "neuroses. " So that what was, morally and epistemologically, the last category in the domain of mental illness--the neuroses--will suddenly be promoted to the closest proximity to genuine and serious illnesses by this new instrument of neurological analysis, of clinical neurology. That is to say, through the use of differential diagnosis the previously discredited zone of the neuroses will receive pathological consecration.
In a book--what's more, not a very good book--which a contemporary neurologist called Guillain devoted to Charcot, his predecessor, the author says, with a kind of radiant joy: "Charcot all the same rescued hysteria lrom the psychiatrists," which is to say that he really brought it into the domain ol the medicine ol differential diagnosis, which is the only medicine. 2/ Basically, I think Freud thought the same when he put Charcot alongside Pinel and said: Pinel freed the mad from their chains, that is to say, he brought about their recognition as patients. Well, in a way, Charcot too made it possible for hysterics to be seen as ill: he pathologized them. 28
If we situate Charcot's operation in this way then I think we can see how what I will call "the great maneuvers of hysteria" unfolded at Salpetnere, and how they were constituted. I will not try to analyze this in terms ol the history of hysterics any more than in terms ot psychiatric knowledge of hysterics, but rather in terms of battle, confrontation, reciprocal encirclement, of the laying of mirror traps, ol investment and counter investment, of struggles for control between doctors and hysterics. * I do not think that there was exactly an epidemic ol hysteria; I think hysteria
* The manuscript adds: "of deals also, ol lacit pacts. "
? was the set of phenomena, and phenomena of struggle, which occurred within as well as outside of the asylum, around this new medical apparatus of clinical neurology; and it was the maelstrom of this battle which in fact summoned around hysterical symptoms all those people who actually joined in the battle. Rather than an epidemic, there was a maelstrom, a kind of hysterical vortex within psychiatric power and its disciplinary sys- tem. So how was this played out? I think we can pick out certain maneu- vers in this struggle between neurology and the hysteric.
The first maneuver is what could be called the organization of the symptomatological scenario. I think we can schematize things in the fol lowing way: lor hysteria to be put on the same level as an organic illness, for it to be a genuine illness falling under a differential diagnosis, that is to say, for the doctor to be a true doctor, the hysteric must present a sta ble symptomatology. Consequently, the doctor's consecration as a neurol- ogist, unlike the psychiatrist, necessarily implies an injunction given to the patient on the quiet: "Give me some symptoms, but give me some stable, coded, regular symptoms"--something that the psychiatrist was already saying--and this regularity and stability had to have two forms. First, consistent symptoms which should be permanently legible on the patient whenever the neurological examination takes place: No more of those illnesses that appear and disappear, the only symptoms of which are the flash of a gesture or the return of fits; we want stable symptoms, and in this way we will find them whenever we ask for them. This was how what Charcot and his successors called the "stigmata" of hysteria were defined. "Stigmata" are phenomena found in every hysteric, even when not suffering an attack:29 contraction ol the visual field,30 simple or double hemianaesthesia,31 pharyngal anesthesia, contracture caused by a circular bond around a joint. 32 Moreover Charcot said: All these stigmata are typical of hysteria; they are constants in hysteria, but, despite their con- stancy, I have to acknowledge that it quite often happens that we do not find them all, or even, in extreme cases, we do not find any. 33 But the epis temological requirement was there, the injunction was there, and I would point out that all of these wonderful stigmata were clearly responses to instructions: instructions to move, to feel a rubbing or contact on the body.
And then, second, the attacks (crises) themselves had to be ordered and regular, and so develop according to a very typical scenario
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sufficiently close to an existing illness, to an existing neurological illness, so that it crosses the line ol diiferential diagnosis, and yet nonetheless sufficiently different for the diagnosis to be made; hence the codification ol the hysterical attack (crise) on the model ol epilepsy. Vl In this way the huge domain of what before Charcot was called "hystero epilepsy," the "convulsions," is divided in two. *5 You had two illnesses, one which included the famous elements of the epileptic fit, that is to say, tonic phase, clonic phase, and period of stupor; and the other, which had to have tonic and clonic phases like epilepsy, with certain minor signs, differences in the phases, and then some elements absolutely specilic to hysteria: the phase of illogical, that is to say, disor dered movements; then the phase of passionate postures, that is to say, expressive movements, movements meaning something, a phase that was also called "plastic," inasmuch as it reproduced and expressed emotions like lustfulness, terror, etcetera; and finally, the phase of delirium, which was also lound in epilepsy moreover.
