Frederic
Gros, English series ed.
Foucault-Psychiatric-Power-1973-74
Girard de Cailleux--the great organizer ol all the asylums built on the outskirts of Paris Irom i86022--said: "It is, of course, through a hierarchy that the impulse given by the head doctor is communicated to every part ol the service; he is its regulator, but his subordinates are the essential cogs.
"2^
All in all, I think we can say that the psychiatrist's body is the asylum itself; ultimately, the asylum machinery and the psychiatrist's organism must lorm one and the same thing. And this is what Esquirol says in his treatise Des maladies menlales: "The doctor must be, as it were, the princi- ple ol a hospital's life for the insane. It is through him that everything must be put m motion; he directs every action, called upon as he is to be
? the regulator of every thought. Everything concerning the inhabitants of the establishment must be submitted to him as the center of action. "2/|
So I think the need to give the asylum a medical stamp, the assertion that the asylum must be a medical place, signifies first of all--this is the first stratum of meaning we can draw out--that the patient must find himself faced with the doctor's omnipresent body, as it were, that ulti- mately he must be enveloped within the doctor's body But, you will say, exactly why must it be a doctor? Why could not any director play this role? Why must this individual body, which becomes the power, the body through which all reality passes, be precisely a doctor's body?
Oddly enough, the problem was both always being taken up and never debated head on. In the texts of the nineteenth century you find it repeat- edly asserted, as a principle, as an axiom, that the asylum really must be directed by a doctor and that the asylum will have no therapeutic function if the doctor does not direct it entirely. And then, at the same time, you see the difficulty of explaining this constantly recurring principle, with the revival of the worry that since it is, after all, a disciplinary establish- ment, a good administrator would suffice. In fact, for a long time there was a constant conflict between the medical director of the hospital, who had therapeutic responsibility, and the person with responsibility for sup- plies, administration ol the personnel, and management, etcetera. Pinel himself had a kind of anxiety from the start, since he said: Basically, my job is to care for the patients, but, when we come down to it, Pussm, who has been the porter, concierge, and supervisor at Bicetre for many years, knows just as much as me; and, after all, it was actually by leaning on his experience that I was able to learn what I did. 25
This will be found throughout the nineteenth century, transposed to another scale, with the problem of who, manager or doctor, ultimately must prevail in the running of the hospital. The doctors' answer--and in the end this is the solution adopted in France--is that the doctor must prevail. 26 The doctor will have the main responsibility and will ultimately be the director, with, alongside him, someone in charge of, the tasks of management and supply, but under the doctor's control and, to an extent, responsibility. So, why the doctor? Answer: because he knows. But since it is precisely not his psychiatric knowledge that is actually put to work in the asylum regime, since it is not psychiatric
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knowledge that is actually used by the doctor when he directs the regime of the insane, what is it that he knows? So, how can we say that a doctor must direct an asylum because the doctor knows? And in what respect is this knowledge necessary? I think that what is thought to be necessary in the good running of the asylum, what makes it necessary that the asylum is given a medical stamp, is the effect of the supplemen- tary power given, not by the content of a knowledge, but statutorily, by the formal stamp of knowledge. In other words, it is through the tokens of his possession of a knowledge, and only through the action of these tokens, whatever the actual content of this knowledge, that medical power, as necessarily medical power, functions within the asylum.
What are these tokens of knowledge? How are they put to work in the proto-asylum of the first years of the nineteenth century, and how will they work, moreover, for years afterwards? It is fairly easy to follow the series of formulae by which these tokens of knowledge worked in the organization and functioning of the hospital.
First, Pinel said: "When you question a patient, you should first of all inform yourself about him, you should know why he is there, what the complaint is against him, his biography; you should have questioned his family or circle, so that when you question him you know more about him than he does or, at least, you know more than he imagines you do, so that when he says something you think is untrue you will then be able to intervene and stress that you know more about it than he does, and that you attribute what he says to lying, to delirium . . . "27
Second, the technique of psychiatric questioning Q'interrogatoire^)as defined in fact, if not theoretically, and no doubt less by Pinel than by Esquirol and his successors,28 is not a way of getting information from the patient that one does not possess. Or rather, if it is true that, in a way, it really is necessary, by questioning the patient, to get information from him that one does not possess, the patient does not have to be aware that one is dependent upon him for this information. The ques- tioning must be conducted in such a way that the patient does not say what he wants, but answers questions. 29* Hence the strict advice: never
* The manuscript also refers to a form of questioning by "the doctor's silence" and illustrates it with this observation by F. Leuret: "Partial dementia with a depressive character. Auditory hallucinations" in Fragments pyschologiques sur lafolie (Paris: Crochard, 183^ ) p. 153.
? let the patient spin out an account, but interrupt him with questions which are both canonical, always the same, and also follow a certain order, for these questions must function in such a way that the patient is aware that his answers do not really inform the doctor, but merely provide a hold for his knowledge, give him the chance to explain; the patient must realize that each of his answers has meaning within a field of an already fully constituted knowledge in the doctor's mind. Questioning is a way of quietly substituting for the information wormed out of the patient the appearance of an interplay of meanings which give the doctor a hold on the patient.
Third--still with these tokens of knowledge that enable the doctor to function as a doctor--the patient must be constantly supervised, a per- manent file must be kept on him, and when dealing with him one must always be able to show that one knows what he has done, what he said the day before, what faults he committed, and what punishment he received. So, a complete system of statements and notes on the asylum patient must be organized and made available to the doctor. 30
Fourth, the double register of medication and direction must always be brought into play. When a patient has done something that one wants to curb, he must be punished, but in punishing him one must make him think that one punishes him because it is therapeutically use- ful. One must therefore be able to make the punishment function as a remedy and, conversely, when one fixes a remedy for him, one must be able to impose it knowing that it will do him good, but making him think that it is only to inconvenience and punish him. This double game of remedy and punishment is essential to how the asylum functions and can only be established provided that there is someone who presents himself as possessing the truth concerning what is remedy and what is punishment.
Finally, the last element in the asylum by which the doctor gives himself the insignia of knowledge, is the great game of the clinic that is so important in the history of psychiatry. The clinic is basically a staged presentation of the patient in which questioning the patient serves the purpose of instructing students, and in which the doctor operates on the double register ot someone who examines the patient and someone who teaches the students, so that he will be both the person who cares
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and the person who possesses the master's word; doctor and teacher at the same time. And [. . . ] this practice of the clinic is established very early on within asylum practice.
In 1817, Esquirol started the first clinics at Salpetnere,31 and from 1830 regular clinical lessons were given at Bicetre32 and Salpetnere. 33 Finally, from around 1830 to 1835, every important head of a service, even if he is not a professor, uses this system of the clinical presentation of patients, that is to say, this interplay between medical examination and professorial performance. Why is the clinic important?
We have a really fine theory of the clinic from Jean-Pierre Falret, someone who actually practiced it. Why was it necessary to use this method of the clinic?
First, the doctor must show the patient that he has around him a number of people, as many as possible, who are ready to listen to him, and that, consequently, the patient, who may possibly object to the doc tor's words, who may not pay any attention to them, nevertheless can- not fail to notice that they really are listened to, and listened to with respect by a number of people. The effect ot power of his words is thus multiplied by the presence of auditors: "The presence of a large and def- erential public imparts the greatest authority to his words. ")H
Second, the clinic is important because it allows the doctor not only to question the patient, but also, by questioning him or by commenting on his answers, to show the patient himself that he is familiar with his illness, that he knows things about his illness, that he can talk about it and give a theoretical account of it before his students. 35 In the patient's eyes, the status of the dialogue he has with the doctor will change its nature; he will understand that something like a truth that everyone accepts is being formulated in the doctor's words.
Third, the clinic is important because it consists not only in ques tioning the patient, but also in making the general anamnesis of the case before the students. The whole of the patient's life will be summarized before [them,]* he will be got to recount it, or, if he does not want to recount it, the doctor will do so in his place; the questioning will carry on and, in the end--with his assistance if he wants to speak, or even
* (Recording:) the students
? without it if he shuts himsell up in silence--the patient will see his own life unfolding before him, which will have the reality of illness, since it is actually presented as illness before students who are medical students. *6
And, lmally, by playing this role, by accepting to come to the front of the stage, on display with the doctor, exposing his own illness, answering his questions, the patient, says Falret, will take note that he is giving pleasure to the doctor and that, to some extent, he is paying him for the trouble he is taking. *'
You can see that in the clinic we find again the four elements of reality I spoke about earlier: power of the other, the law of identity, confession ol the nature of the madness in its secret desire, and remuneration, the game ol exchanges, the economic system controlled by money. In the clinic, the doctor's words appear with a greater power than those ol any- one else. In the clinic, the law of identity weighs on the patient, who is obliged to recognize himself in everything said about him, and in the entire anamnesis of his life. By answering the doctor's questions in pub- lic, in having the final confession ol his madness dragged from him, the patient recognizes and accepts the reality ol the mad desire at the root ol his madness. Finally, he enters in a particular way into the systems of satisfactions and compensations, and so on.
As a result, you see that the great support of psychiatric power, or rather the great amplifier of the psychiatric power woven into the daily hie ol the asylum, will be this famous ritual ol the clinical presentation of the patient. The enormous institutional importance of the clinic in the daily life of psychiatric hospitals lrom the 1830s until today is due to the fact that the doctor constituted himself as a master of truth through the clinic. The technique of confession and of the account becomes an institutional obligation, the patient's realization that his madness is illness becomes a necessary episode, and the patient enters in turn into the system of profits and satisfactions given to the person who looks after him.
You can see how the tokens of knowledge are magnified in the clinic, and how, in the end, they function. The tokens of knowledge, and not the content of a science, allow the alienist to function as a doctor within the asylum. These insignia of knowledge enable him to exercise an
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absolute surplus power in the asylum, and ultimately to identify himself with the asylum body. These tokens of knowledge allow him to constitute the asylum as a sort of medical body that cures through its eyes, ears, words, gestures, and machinery. And, finally, these tokens of knowledge will enable psychiatric power to play its real role of the intensification of reality. You see how it is not so much contents of knowledge as tokens oi knowledge that are put to work in this clinical scene. Through these tokens of knowledge, you see the emergence and work of the four tentacles of reality I have been talking about: the surplus power of the doctor, the law of identity, the unacceptable desire of madness, and the law of money.
I think we could say that through this identification of the psychiatrist's body and the asylum, through this game ol the tokens of knowledge and the four forms of reality which pass through them, we can identify the formation of a medical figure who is at the opposite pole to another medical figure taking on a completely new form at this time--the surgeon. The surgical pole began to take shape in the medical world of the nineteenth century with the development of pathological anatomy, broadly speaking, let's say with Bichat. *8 On the basis of a real content of knowledge, it involved the doctor identifying a reality ol the illness in the patient's body, and the use of his own hands, of his own body, to nullify the disease.
At the other end of this field is the psychiatric pole, which operates in a completely dilferent way. On the basis, then, not ol the content of knowledge, but of tokens of knowledge qualifying the medical figure, the psychiatric pole involves making the asylum space function as a body which cures by its own presence, its own gestures, its own will, and, through this body, it involves giving a supplement of power to the lourfold form of reality.
In conclusion, I would like to say that, as you can see, we arrive at this paradox of the completely specific constitution of a space ol discipline, of an apparatus of discipline, which differs from all the others because it has a medical stamp. But this medical stamp, which distinguishes the asylum space from all the other disciplinary spaces, does not function by putting a theoretically lormulated psychiatric knowledge to work within the asylum. This medical distinction is in reality the establishment of a
? game between the mad person's subjected body and the psychiatrist's institutionalized body, the psychiatrist's body extended to the dimen sions of an institution. We should think of the asylum as the psychia- trist's body; the asylum institution is nothing other than the set of regulations that this body effectuates in relation to the body of the subjected mad person in the asylum.
In this, I think we can identiiy one of the fundamental features of what I will call the microphysics of asylum power: this game between the mad person's body and the psychiatrist's body above it, dominating it, standing over it and, at the same time, absorbing it. This, with all the specific effects of such a game, seems to me to be the typical leature of the microphysics of psychiatric power.
We can pick out three phenomena from this that I will try to analyze a bit more precisely in the lollowing lectures. The first is that from around 1850 to i860 this proto psychiatric power that I have tried to define in this way will, ol course, be considerably transformed as the result ol certain phenomena that I will try to point out to you. Nonetheless, it lives on, surcharged and modified, not only in asylums, but also outside. That is to say, around ^8/\0 to i 8 6 0 , there was a sort of diffusion, a migration of this psychiatric power, which spread into other institutions, into other disciplinary regimes that it doubled, as it were. In other words, I think psychiatric power spread as a tactic for the subjection of the body in a physics of power, as power ol the intensifica- tion of reality, as constitution of individuals as both receivers and bearers of reality.
I think we find it under what I will call the Psy functions: pathological, criminological, and so on. Psychiatric power, that is to say, the function of the intensification of reality, is found wherever it is necessary to make reality function as power. If psychologists turn up in the school, the fac tory, in prisons, in the army, and elsewhere, it is because they entered precisely at the point when each of these institutions was obliged to make reality function as power, or again, when they had to assert the power exercised within them as reality. The school, for example, calls on
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a psychologist when it has to assert that the knowledge it provides and distributes is reality, when it ceases to appear to be real to those to whom it is offered. The school has to call in the psychologist when the power exercised at school ceases to be a real power, and becomes a both mythical and Iragile power, the reality of which must consequently be intensified. It is under this double condition that one needs the educa tional psychologist who reveals the differential abilities of individuals on the basis oi which they will be placed at a certain level in a held of knowledge, as if this was a real field, as il it was a field which had m itself its power of constraint, since one has to remain where one is in this held of knowledge defined by the institution. In this way knowledge functions as power, and this power of knowledge presents itself as real- ity within which the individual is placed. And, at the end ol the educa- tional psychologist's treatment, the individual actually is the bearer of a double reality: the reality of his abilities on the one hand, and the real- ity of the contents of knowledge he is capable of acquiring on the other. It is at the point of articulation of these two "realities" defined by the educational psychologist that the individual appears as an individual. We could undertake the same kind of analysis of prisons, the factory, and so forth.
The fundamental role of the psychological function, which historically is entirely derived from the dissemination of psychiatric power in other directions beyond the asylum, is to intensify reality as power and to intensify power by asserting it as reality. 1 think this is, if you like, the first point to be stressed.
Now, how did this kind of dissemination come about? How was it that this psychiatric power, which seemed to be so firmly tied up with the specific space of the asylum, began to drift? At any rate, what were the intermediaries? I think the intermediary is easily found and is basi- cally the psychiatrization of abnormal children, and more precisely the psychiatrization of idiots. It is when the mad were separated from idiots within the asylum that a kind of institution began to take shape in which psychiatric power was put to work in the archaic form I have just been describing. 39 For years, we can say for almost a century, this archaic form remained what it was at the beginning. I think it is on the basis of this mixed form, between psychiatry and pedagogy, on the basis of this
? psychlatrization of the abnormal, of the feeble minded, mentally defective, etcetera, that the system of dissemination took place that allowed psychol- ogy to become that kind of permanent doubling of the functioning of every institution. So, next week I would like to say something about this organization and establishment of the psychiatrization of idiots.
Then I would also like to pick out other phenomena based on this proto-psychiatry. The other series of phenomena is this: whereas in the psychiatrization of idiots the psychiatric power I have described contin- ues to advance within the asylum almost without change, on the other hand, a number of utterly fundamental and essential things take place, a double process in which (as in every battle) it is very difficult to know who started it, who takes the initiative and even who gams the upper hand in the end. What were these two twin processes?
First, the appearance of neurology, or more precisely, of neuropathol ogy, was a fundamental event in the history of medicine, that is to say, when certain disorders began to be dissociated from madness and it became possible to assign them a neurological seat and neuropathologi- cal etiology that made it possible to distinguish those who were really ill at the level of their body from those for whom one could assign no eti ology at the level of organic lesions. ,0 This raised the question of the seriousness, of the authenticity, of mental illness, which generated the suspicion that, after all, should a mental illness without any anatomical correlation really be taken seriously?
And, opposite this--correlative to this kind oi suspicion that neurol- ogy began to cast over the whole world of mental illness--there was the game of patients who never ceased to respond to psychiatric power in terms of truth and falsehood. To psychiatric power, which said "I am only a power, and you must accept my knowledge solely at the level of its tokens, without ever seeing the effects ol its content," patients responded with the game of simulation. When, with neuropathology, doctors finally introduced a new content of knowledge, patients responded with another type of simulation, which was, broadly speak ing, the hysterics' great simulation of nervous illnesses like epilepsy, paralysis, and so on. And the game, the kind of endless pursuit between patients, who constantly trapped medical knowledge in the name of a certain truth and in a game of lies, and doctors, who endlessly tried to
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recapture patients in the trap of a neurological knowledge of pathological signs, of a serious medical knowledge, finally permeated the whole history of nineteenth century psychiatry as a real struggle between doctors and patients.
Finally, the last point is how the principal elements we saw taking shape within psychiatric power, and which were its main supports, were taken up outside the asylum institution. That is to say, how were those elements of reality--the law of the power of the other, the prestige given to the doctor's words, the law of identity, the obligation of anamnesis, the attempt to drive out the mad desire that constitutes the reality of madness, and the problem of money, etcetera--brought into play within a practice like psychoanalysis that claims it is not psychiatric, and yet in which one sees how its different elements were inscribed within the game of psychiatric power that isolated them and brought them out? '1
So, if you like, psychiatric power will have a triple destiny. We will find it persisting for a long time in its archaic form, after the period 18/|0 to i 8 6 0 , in the pedagogy of mental deficiency. You will find it being re-elaborated and transformed in the asylum through the inter play of neurology and simulation. And then, a third destiny will be its take up within a practice that puts itself forward however as a practice that is not exactly psychiatric.
? I. Apart from the many occurrences of the term "direction" (diriger) in his Traile medico-philosophique (pp. xlv, 46, 50, 52, 194, 195, and 200), Pinel devotes two passages to the direction of the insane: section II, ? vi: "Advantages of the art of directing (diriger) the insane in order to promote the effect of medicines" pp. 57-58; and ? xxii: "Skill in direct mg (diriger) the insane by seeming to go along with their imaginary ideas" pp. 92-95;
A Treatise on Insanity, pp. 59 60 and pp. 95 98 (the English translation generally renders diriger as "management"; G. B. ). For his part, Esquirol defines moral treatment as "the art of directing (diriger) the intelligence and passions of the insane" Des maladies mentales, vol. I, p. 134; Mental Maladies, p. 79. Leuret states that "it is necessary to direct (diriger) the intel ligence of the insane and to excite passions in them which can divert their delirium" Du traitement moral de lajolie, p. 185-
2. The practice of "direction" or "conduct" was instituted on the basis of the pastoral ol Carlo Borromeo (1538 1584), Pastoruminstructions ad concionandum, conjessionisque el eucharistiae sacramenta ministrandum utilissimae (Antwerp: C. Plantini, 1586), and in connection with Catholic reform and the development ol "retreats. " Among those who laid down its rules,
we can reler to (a) Ignace de Loyola, Exercilia spirititalia (Rome: A. Bladum, 1548); English translation, Ignatius Loyola, The Spiritual Exercises of Si. Ignatius Loyola, trans. Elisabeth Meier Tetlow (Lanham and London: University Press of America, 1987). See, P. Dudon, Saint Ignace de Loyola(Paris: Beauchesne, 1934); P. Doncceur, "Saint Ignace et la direction des ames" in La Vie Spirituelle, vol. 48, Paris, 1936, pp. 48 54; M. Olphe Galliard, "Direction spirituelle," III: "Penode moderne" in Dictionnaire de spiritualite ascetique et mystique. Doctrine et histoirc, vol. Ill (Paris: Beauchesne, 1957) col. 1115-1117. ( b ) Francois de Sales (1567 1622) Introduction a la vie devote ( 1 6 0 8 ) , of which chapter 4 became the direc tors' bible: "De la necessile d'un directeur pour entrer et lair progres en la devotion" in (Euvres, vol. Ill (Annecy: Nierat, 1893) pp. 22 25; English translation, St. Francis de Sales, Introductionto the Devout Life, trans. Michael Day (Wheathampstead: Anthony Clarke, 1990), "The necessity ol a guide," pp. 12 15. See F. Vincent, Francois de Sales, directeur d'dmes. L'education de la volonte (Paris: Beauchesne, 1923). And (c) Jean Jacques Olier (1608 1657), founder ol the Saint-Sulpice seminary, "L'esprit d'un directeur des ames" in (Euvres completes (Paris: J. -P . Migne, 1856) col. 1183-1240.
On "direction" we can refer to the following works: E. M. Caro, "Les direction des ames
au XVIIC siecle" in Nouvelles Etudes morales sur le temps present (Paris: Hachette, 1869) pp. 145 203; H. Huvelin, Quelques directeurs d'dmes au XVII' siecle: saint Francois de Sales, M. Olier, saint Vincent de Paul, Vabbe de Ranee (Paris: Gabalda, 1911 )? Foucault returns to the notion o( "direction" in his lectures at the College de France o( 1974 1975, Les Anormaux, lectures of 19 February and 26 February 1975, pp. 170 171 and pp. 187 189; Abnormal, pp. 182-184 and pp. 201-204; of 1977-1978, Securite, Territoire, Population, ed. Michel Senellart (Paris: Gallimard/Seuil, 2 0 0 4 ) lecture of 28 February 1978; and 1981-1982, L'Hermeneutique du sujet, ed. F. Gros (Paris: Gallimard/Seuil, 2001) lectures ol
3 and 10 March, pp. 315-393; English translation, The Hermeneutics of the Subject. Lectures at the College de France 1981-82, ed.
Frederic Gros, English series ed. Arnold I. Davidson, trans. Graham Burchell (New York: Palgrave Macmillan, 2005) pp. 331-412; and in his lecture at the University of Stanford, 10 October 1979, " 'Omnes et singulatim': Towards a Critique of Political Reason" in The Essential Works of Michel Foucault 195/\-198/\, vol. } : Power, ed. James D. Faubion, trans. Robert Hurley and others (New York: New Press,
2 0 0 0 ) pp. 310 311; French translation, "'Omnes et singulatim': vers une critique de la raison politique" trans. P. E. Dauzat, Dits et Ecrits, vol. 4, pp. 146 147.
3. H. Belloc, "De la responsabilite morale chez les alienes," Annales medico-psychologiques, 3rd series, vol. Ill, July 1861, p. 422.
4. F. Leuret, Du traitement moral de lafolie, pp. 444-446. 5. Ibid. p. 441, p. 443, and p. 445.
6. Ibid. p. 431: "I direct a jet of water on his face and body, and when he seems disposed to bear everything/or his treatment, I am very careful to tell him that it is not a question of treating him, but of offending and punishing him" (Leuret's emphasis).
7. Constructed in 1634 with the view to being an asylum for poor nobility and wounded soldiers, the Bicetre chateau was incorporated in the Hopital general created by the edict
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PSYCHIATRIC POWER
of 27 April 1656, ordering that "the able bodied and disabled mendicant poor, of both sexes, be confined in a hospital to be employed in works, manulacture, and other work according to their ability. " It was in the "Saint Prix employment" [special quarters for the ill;J. L. J, created in 1660 to take in the insane, that Pinel took up the post ol "infirmary doctor" on 11 September 1793; he occupied this post until 19 April 1795- See, P. Bru, Histoire de Bicetre (hospice, prison, asi/e), d'apres des documents historiques (Paris: Ed. du Progres medical, 1890); F. Funck-Brentano and G. Marindaz, L'Hopilaf generalde Bicetre (Lyon: Laboratoires Ciba, 1938); and J. M. Surzur, "L'Hopital hospice de Bicetre. Historique, fonclions sociales jusqu'a la Revolution Irancaise," Medical Thesis, Paris, 1969, no. 9/l3 (Paris: 1969).
8. La Salpetriere owed its name to the saltpeter factory erected on the spot under Louis XIII. The edict of 27 April 1656 incorporated it in the Hopilal generale for the "confinement of
the mendicant poor" ol the town and inner suburbs of Paris, lor "incorrigible women," and
for some "mad persons. " On the suppression ol its carceral lunction in 1793, the home became the "Maison nationale des femmes," until 1823. The General Council lor hospitals and homes of the Seine, founded in 1801 by Jean Antoine Chaptal (1756 1832) by a decree
of 27 March 1802, ordered the transler to Salpetriere ol mad women hospitalized at the Hotel Dieu. See, L. Boucher, La Salpetriere. Son hisloire de 1656 a 1790. Ses origines et son fonctionnement au XVIII' siecle (Pans, Ed. du Progres medical, 1883); G. Guillain and
P. Mathieu, La Salpetriere (Lyon: Laboratoires Ciba, 1939); J. Couteaux, "L'histoire de la Salpetriere" Revue hospitaliere de France, vol. 9, 1944, pp. 106 127 and 215 242. Since then a well-documented study has become available: N. Simon and J. Franchi, La Pitie-Salpetriere (Saint Bcnoit la Forel: Ed. de PArbre a images, 1986).
9. Saint Lazare, lounded in the ninth century by the hospitaller friars of Saint Lazare for the care of lepers, was transformed by Saint Vincent de Paul on 7 January 1632 to take in "persons detained by order ol His Majesty" and the "insane poor. " In 1794 it became a prison lor streetwalkers. See, E. Pottet, Hisloire de Saint-Lazare, 1122-1912 (Paris: Societe franchise d'lmpnmeric et de libraine, 1912);J. Vie, Les Alienes et les correctionnaires a Saint- Lazare au XVII et au XVIII siecle (Paris: F. Alcan, 1930). Foucault refers to it in Histoire de lajolie, p. 62 and p. 136; Madness and Civilisation, p. 42 (page 136 of the French edition
is omitted from the English translation).
10. The Charenton home was the result of a foundation ol the King's counsellor, Sebaslien
Leblanc, in September 1641. In February 1644 it was handed over to the St Jean-de Dieu order ol hospitallers, created in 1537 by the Portuguese Jean Cindad for the service of the poor and sick. See, J. Monval, Les Freres hospitaliers de Saint-Jean-de-Dieu en France (Paris: Bernard Grasset, 1936); A. Chagny, L'Ordre hospitaller de Saint-Jean-de-Dieu, two volumes (Lyon: Lescuyer el fils, 1953). See also, P. Sevestre, "La maison de Charenton, de la londa tion a la reconstruction: 1641 1838" Histoire des sciences medicales, vol. 25,1991, pp. 61 71.
Closed in July 1795, the home was reopened and nationalized under the Directory, on
15 June 1797, to replace the quarters lor the insane at the Hotel Dieu. Its direction was then entrusted to an old member ol the regular order ol Premonstralensians, Francois de Coulmiers, and Joseph Gastaldy was appointed head doctor. See, C. F. S. Giraudy, Memoire
sur la Maison nationale de Charenton, exclusivement detinee au traitement des alienes (Pans: Imprimene de la Societe de Medecine, 1804); J. E. D. Esquirol, "Memoire historique et statislique sur la Maison Royale de Charenton" (1835) in Des maladiesmentales considerees sous les rapports medical, hygicnique et medico-legale, vol. II, 1838, pp. 539 736; and, C. Strauss, La maison nationale de Charenton (Paris: Imprimene nationale, 1900).
11. F. Leuret, Du traitement moral de la Jolie, p. 185: "In an establishment lor the insane that I could name, the number ol patients is such that in the course of a whole year the head doctor can give only thirty seven minutes to each patient, and in another, where the n-um
ber ol patients is even greater ( . . . ) each patient has the right to see the head doctor for only eighteen minutes a year. "
12. Foucault refers here to the distinction established by Esquirol in the field of madness defined as a "usually chronic cerebral affection, without fever, characterized by disorders of sensibility, intelligence, and the will" J. E. D. Esquirol, "De la lolie" (1816) in Des maladies mentales, vol. I, p. 5; Mental Maladies, p. 21. Within the field marked out by this tripartite division of psychological laculties will be inserted the clinical varieties differing
? Irom each other in terms ol ( a ) the nature ol the disorder allecling the laculties; ( b ) the extension ol the disorder; (c) the quality of the humor which allects it. Thus, whereas mania is characterized by "disturbance and over excitement ol the sensibility, intelligence, and will" ("De la manie" [1818J, ibid. vol. II, p. 132; English, ibid. p. 378), in lypemania - a neologism created by Leuret in 1815 on the basis ol Greek root, XVTTTJ, sadness, affliction--"sensibility is painfully excited or injured; the sad, oppressive passions modily the intelligence and will" ("De la lypemanie ou melancoli" |1820|, ibid. pp. 398 481; English, ibid. pp. 199 233).
13. The criterion for the distinction between mania and monomania was the extension ol the disorder, general or partial, that is to say, localized in a facility (intellectual or instinctive monomania, etcetera), an object (erotomania), or a theme (religious or homicidal mono mania). Thus mania is characterized by the fact that "the delirium is general, all the lacul ties of the understanding are over excited and disrupted," whereas in monomania "the sad or gay, concentrated or expansive delirium is partial and circumscribed to a small number of ideas and affections" ibid. vol. II, "De la manie" p. 133; English, ibid. "Mania" p. 378.
V\. In contrast with mania characterized by "over excitement ol the laculties," the group ol dementias--with "acute," "chronic" and "senile" varieties--are distinguished by their negative aspects: "Dementia is a usually chronic cerebral allection without lever, charac tenzed by deterioration ol the sensibility, intelligence and will" ibid. "De la demence" (1814); p. 219; English, ibid. "Dementia" p. 417.
15. Cauterization or "actual cautery" consisted in the application ol an iron heated 111 the lire or in boiling water to the top of the head or the nape ol the neck. See, L. Valentin, "Memoire el observations concernant les bons ellets du cautere actuel, applique sur la tele dans plusieurs maladies," Nancy, 1815. Esquirol recommended the use ol the moxa and "red hot iron applied to the nape ol the neck in mania complicated by lury" D o maladies mentales, vol. I, "De la folie" (1816) p. 154; Mental Maladies, p. 87: "I have many limes applied the iron at a red heat to the neck, in mania complicated with lury," and ibid. , vol. II, "De la manie" p. 191 and 217; English, ibid. "Mania" pp. 400 401 and p. 411. See,
J. Guislain, Trade sur lfalienation menlale et sur les hospices des alienes, vol. II, ch. vi, "Moxa et cautere actuel" pp. 52-55.
16. "Moxas" are cylinders made Irom a material the progressive combustion ol which was supposed to excite the nervous system and have a Junction ol sensory arousal through the pain it caused. See, A. E. M. Bernardin, Dissertation sur les avantages (/u'on pent retenir de rap- plication du moxa (Paris: Lefebvre, 1803); EJ. Georget, De lafolie, p. 247: Georget recom mended its use in lorms ol insanity involving stupor and insensibility;J. Guislain, Traile sur les phrenopalhies, section IV, p. 458: "This powerful irritant acts on the physical sensibility through pain and the destruction ol living parts, but it also has a moral action through the fear it inspires. "
17.
18.
Ugo Cerletti (1877 1963), dissatisfied with the cardiazol shock used by the Milanese psychiatrist Laszlo von Meduna since 1935, perlected electroshock therapy with Lucio Bmi. On 15 April 1938, a schizophrenic was subjected to this therapy for the first time. See, U. Cerletti, "L'elettroshock" Rivista sperimentale difrenialria, Reggio Emilia, vol. XVIII, 1940, pp. 2 0 9 310; "Electroshock therapy," in A. M. Sackler and others, The Great Physiodynamic Therapies in Psychiatry: An Historical Appraisal (New York: Harper, 1956) pp. 92 94.
From the second hall ol the nineteenth century, the use of ether developed in psychiatry for both therapeutic purposes--notably for calming "states ol nervous excitement" (see, W. Griesinger, Die Pathologie und Therapie derpsychischen Krankheiten [Stuttgart: A. Krabbe, 18451 p. 544; English translation, Mental Pathology and Therapeutics, trans. C. Lockhart Robertson and James Rutherford |New York and London: Halner, 1965] p. 478)--and lor diagnosis. See, H. Bayard, "L'utilisation de Tether et le diagnostic des maladies mentales" Annales d'hygiene publique et medicate, vol. 42, no. 83,July 1849, pp. 201-214; B. A. Morel, "De l'elhcnsation dans la lolie du point de vue du diagnostic et de la medecine legale" Archives
generates de medecine, 51'1 series, vol. 3, 1, February 1854, p. 135: "In certain definite circum stances, etherisation is a precious means for modifying the unhealthy condition and for enlightening the doctor as to the real neuropathic character ol the affection"; and, H. Brochim, "Maladies nerveuses," ? "Anesthesiques: ether et chlorolorme" in Dictionnaire encyclopedujue des sciences medicates, 2mi series, vol. XII, 1877, pp. 376 377.
All in all, I think we can say that the psychiatrist's body is the asylum itself; ultimately, the asylum machinery and the psychiatrist's organism must lorm one and the same thing. And this is what Esquirol says in his treatise Des maladies menlales: "The doctor must be, as it were, the princi- ple ol a hospital's life for the insane. It is through him that everything must be put m motion; he directs every action, called upon as he is to be
? the regulator of every thought. Everything concerning the inhabitants of the establishment must be submitted to him as the center of action. "2/|
So I think the need to give the asylum a medical stamp, the assertion that the asylum must be a medical place, signifies first of all--this is the first stratum of meaning we can draw out--that the patient must find himself faced with the doctor's omnipresent body, as it were, that ulti- mately he must be enveloped within the doctor's body But, you will say, exactly why must it be a doctor? Why could not any director play this role? Why must this individual body, which becomes the power, the body through which all reality passes, be precisely a doctor's body?
Oddly enough, the problem was both always being taken up and never debated head on. In the texts of the nineteenth century you find it repeat- edly asserted, as a principle, as an axiom, that the asylum really must be directed by a doctor and that the asylum will have no therapeutic function if the doctor does not direct it entirely. And then, at the same time, you see the difficulty of explaining this constantly recurring principle, with the revival of the worry that since it is, after all, a disciplinary establish- ment, a good administrator would suffice. In fact, for a long time there was a constant conflict between the medical director of the hospital, who had therapeutic responsibility, and the person with responsibility for sup- plies, administration ol the personnel, and management, etcetera. Pinel himself had a kind of anxiety from the start, since he said: Basically, my job is to care for the patients, but, when we come down to it, Pussm, who has been the porter, concierge, and supervisor at Bicetre for many years, knows just as much as me; and, after all, it was actually by leaning on his experience that I was able to learn what I did. 25
This will be found throughout the nineteenth century, transposed to another scale, with the problem of who, manager or doctor, ultimately must prevail in the running of the hospital. The doctors' answer--and in the end this is the solution adopted in France--is that the doctor must prevail. 26 The doctor will have the main responsibility and will ultimately be the director, with, alongside him, someone in charge of, the tasks of management and supply, but under the doctor's control and, to an extent, responsibility. So, why the doctor? Answer: because he knows. But since it is precisely not his psychiatric knowledge that is actually put to work in the asylum regime, since it is not psychiatric
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knowledge that is actually used by the doctor when he directs the regime of the insane, what is it that he knows? So, how can we say that a doctor must direct an asylum because the doctor knows? And in what respect is this knowledge necessary? I think that what is thought to be necessary in the good running of the asylum, what makes it necessary that the asylum is given a medical stamp, is the effect of the supplemen- tary power given, not by the content of a knowledge, but statutorily, by the formal stamp of knowledge. In other words, it is through the tokens of his possession of a knowledge, and only through the action of these tokens, whatever the actual content of this knowledge, that medical power, as necessarily medical power, functions within the asylum.
What are these tokens of knowledge? How are they put to work in the proto-asylum of the first years of the nineteenth century, and how will they work, moreover, for years afterwards? It is fairly easy to follow the series of formulae by which these tokens of knowledge worked in the organization and functioning of the hospital.
First, Pinel said: "When you question a patient, you should first of all inform yourself about him, you should know why he is there, what the complaint is against him, his biography; you should have questioned his family or circle, so that when you question him you know more about him than he does or, at least, you know more than he imagines you do, so that when he says something you think is untrue you will then be able to intervene and stress that you know more about it than he does, and that you attribute what he says to lying, to delirium . . . "27
Second, the technique of psychiatric questioning Q'interrogatoire^)as defined in fact, if not theoretically, and no doubt less by Pinel than by Esquirol and his successors,28 is not a way of getting information from the patient that one does not possess. Or rather, if it is true that, in a way, it really is necessary, by questioning the patient, to get information from him that one does not possess, the patient does not have to be aware that one is dependent upon him for this information. The ques- tioning must be conducted in such a way that the patient does not say what he wants, but answers questions. 29* Hence the strict advice: never
* The manuscript also refers to a form of questioning by "the doctor's silence" and illustrates it with this observation by F. Leuret: "Partial dementia with a depressive character. Auditory hallucinations" in Fragments pyschologiques sur lafolie (Paris: Crochard, 183^ ) p. 153.
? let the patient spin out an account, but interrupt him with questions which are both canonical, always the same, and also follow a certain order, for these questions must function in such a way that the patient is aware that his answers do not really inform the doctor, but merely provide a hold for his knowledge, give him the chance to explain; the patient must realize that each of his answers has meaning within a field of an already fully constituted knowledge in the doctor's mind. Questioning is a way of quietly substituting for the information wormed out of the patient the appearance of an interplay of meanings which give the doctor a hold on the patient.
Third--still with these tokens of knowledge that enable the doctor to function as a doctor--the patient must be constantly supervised, a per- manent file must be kept on him, and when dealing with him one must always be able to show that one knows what he has done, what he said the day before, what faults he committed, and what punishment he received. So, a complete system of statements and notes on the asylum patient must be organized and made available to the doctor. 30
Fourth, the double register of medication and direction must always be brought into play. When a patient has done something that one wants to curb, he must be punished, but in punishing him one must make him think that one punishes him because it is therapeutically use- ful. One must therefore be able to make the punishment function as a remedy and, conversely, when one fixes a remedy for him, one must be able to impose it knowing that it will do him good, but making him think that it is only to inconvenience and punish him. This double game of remedy and punishment is essential to how the asylum functions and can only be established provided that there is someone who presents himself as possessing the truth concerning what is remedy and what is punishment.
Finally, the last element in the asylum by which the doctor gives himself the insignia of knowledge, is the great game of the clinic that is so important in the history of psychiatry. The clinic is basically a staged presentation of the patient in which questioning the patient serves the purpose of instructing students, and in which the doctor operates on the double register ot someone who examines the patient and someone who teaches the students, so that he will be both the person who cares
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and the person who possesses the master's word; doctor and teacher at the same time. And [. . . ] this practice of the clinic is established very early on within asylum practice.
In 1817, Esquirol started the first clinics at Salpetnere,31 and from 1830 regular clinical lessons were given at Bicetre32 and Salpetnere. 33 Finally, from around 1830 to 1835, every important head of a service, even if he is not a professor, uses this system of the clinical presentation of patients, that is to say, this interplay between medical examination and professorial performance. Why is the clinic important?
We have a really fine theory of the clinic from Jean-Pierre Falret, someone who actually practiced it. Why was it necessary to use this method of the clinic?
First, the doctor must show the patient that he has around him a number of people, as many as possible, who are ready to listen to him, and that, consequently, the patient, who may possibly object to the doc tor's words, who may not pay any attention to them, nevertheless can- not fail to notice that they really are listened to, and listened to with respect by a number of people. The effect ot power of his words is thus multiplied by the presence of auditors: "The presence of a large and def- erential public imparts the greatest authority to his words. ")H
Second, the clinic is important because it allows the doctor not only to question the patient, but also, by questioning him or by commenting on his answers, to show the patient himself that he is familiar with his illness, that he knows things about his illness, that he can talk about it and give a theoretical account of it before his students. 35 In the patient's eyes, the status of the dialogue he has with the doctor will change its nature; he will understand that something like a truth that everyone accepts is being formulated in the doctor's words.
Third, the clinic is important because it consists not only in ques tioning the patient, but also in making the general anamnesis of the case before the students. The whole of the patient's life will be summarized before [them,]* he will be got to recount it, or, if he does not want to recount it, the doctor will do so in his place; the questioning will carry on and, in the end--with his assistance if he wants to speak, or even
* (Recording:) the students
? without it if he shuts himsell up in silence--the patient will see his own life unfolding before him, which will have the reality of illness, since it is actually presented as illness before students who are medical students. *6
And, lmally, by playing this role, by accepting to come to the front of the stage, on display with the doctor, exposing his own illness, answering his questions, the patient, says Falret, will take note that he is giving pleasure to the doctor and that, to some extent, he is paying him for the trouble he is taking. *'
You can see that in the clinic we find again the four elements of reality I spoke about earlier: power of the other, the law of identity, confession ol the nature of the madness in its secret desire, and remuneration, the game ol exchanges, the economic system controlled by money. In the clinic, the doctor's words appear with a greater power than those ol any- one else. In the clinic, the law of identity weighs on the patient, who is obliged to recognize himself in everything said about him, and in the entire anamnesis of his life. By answering the doctor's questions in pub- lic, in having the final confession ol his madness dragged from him, the patient recognizes and accepts the reality ol the mad desire at the root ol his madness. Finally, he enters in a particular way into the systems of satisfactions and compensations, and so on.
As a result, you see that the great support of psychiatric power, or rather the great amplifier of the psychiatric power woven into the daily hie ol the asylum, will be this famous ritual ol the clinical presentation of the patient. The enormous institutional importance of the clinic in the daily life of psychiatric hospitals lrom the 1830s until today is due to the fact that the doctor constituted himself as a master of truth through the clinic. The technique of confession and of the account becomes an institutional obligation, the patient's realization that his madness is illness becomes a necessary episode, and the patient enters in turn into the system of profits and satisfactions given to the person who looks after him.
You can see how the tokens of knowledge are magnified in the clinic, and how, in the end, they function. The tokens of knowledge, and not the content of a science, allow the alienist to function as a doctor within the asylum. These insignia of knowledge enable him to exercise an
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absolute surplus power in the asylum, and ultimately to identify himself with the asylum body. These tokens of knowledge allow him to constitute the asylum as a sort of medical body that cures through its eyes, ears, words, gestures, and machinery. And, finally, these tokens of knowledge will enable psychiatric power to play its real role of the intensification of reality. You see how it is not so much contents of knowledge as tokens oi knowledge that are put to work in this clinical scene. Through these tokens of knowledge, you see the emergence and work of the four tentacles of reality I have been talking about: the surplus power of the doctor, the law of identity, the unacceptable desire of madness, and the law of money.
I think we could say that through this identification of the psychiatrist's body and the asylum, through this game ol the tokens of knowledge and the four forms of reality which pass through them, we can identify the formation of a medical figure who is at the opposite pole to another medical figure taking on a completely new form at this time--the surgeon. The surgical pole began to take shape in the medical world of the nineteenth century with the development of pathological anatomy, broadly speaking, let's say with Bichat. *8 On the basis of a real content of knowledge, it involved the doctor identifying a reality ol the illness in the patient's body, and the use of his own hands, of his own body, to nullify the disease.
At the other end of this field is the psychiatric pole, which operates in a completely dilferent way. On the basis, then, not ol the content of knowledge, but of tokens of knowledge qualifying the medical figure, the psychiatric pole involves making the asylum space function as a body which cures by its own presence, its own gestures, its own will, and, through this body, it involves giving a supplement of power to the lourfold form of reality.
In conclusion, I would like to say that, as you can see, we arrive at this paradox of the completely specific constitution of a space ol discipline, of an apparatus of discipline, which differs from all the others because it has a medical stamp. But this medical stamp, which distinguishes the asylum space from all the other disciplinary spaces, does not function by putting a theoretically lormulated psychiatric knowledge to work within the asylum. This medical distinction is in reality the establishment of a
? game between the mad person's subjected body and the psychiatrist's institutionalized body, the psychiatrist's body extended to the dimen sions of an institution. We should think of the asylum as the psychia- trist's body; the asylum institution is nothing other than the set of regulations that this body effectuates in relation to the body of the subjected mad person in the asylum.
In this, I think we can identiiy one of the fundamental features of what I will call the microphysics of asylum power: this game between the mad person's body and the psychiatrist's body above it, dominating it, standing over it and, at the same time, absorbing it. This, with all the specific effects of such a game, seems to me to be the typical leature of the microphysics of psychiatric power.
We can pick out three phenomena from this that I will try to analyze a bit more precisely in the lollowing lectures. The first is that from around 1850 to i860 this proto psychiatric power that I have tried to define in this way will, ol course, be considerably transformed as the result ol certain phenomena that I will try to point out to you. Nonetheless, it lives on, surcharged and modified, not only in asylums, but also outside. That is to say, around ^8/\0 to i 8 6 0 , there was a sort of diffusion, a migration of this psychiatric power, which spread into other institutions, into other disciplinary regimes that it doubled, as it were. In other words, I think psychiatric power spread as a tactic for the subjection of the body in a physics of power, as power ol the intensifica- tion of reality, as constitution of individuals as both receivers and bearers of reality.
I think we find it under what I will call the Psy functions: pathological, criminological, and so on. Psychiatric power, that is to say, the function of the intensification of reality, is found wherever it is necessary to make reality function as power. If psychologists turn up in the school, the fac tory, in prisons, in the army, and elsewhere, it is because they entered precisely at the point when each of these institutions was obliged to make reality function as power, or again, when they had to assert the power exercised within them as reality. The school, for example, calls on
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a psychologist when it has to assert that the knowledge it provides and distributes is reality, when it ceases to appear to be real to those to whom it is offered. The school has to call in the psychologist when the power exercised at school ceases to be a real power, and becomes a both mythical and Iragile power, the reality of which must consequently be intensified. It is under this double condition that one needs the educa tional psychologist who reveals the differential abilities of individuals on the basis oi which they will be placed at a certain level in a held of knowledge, as if this was a real field, as il it was a field which had m itself its power of constraint, since one has to remain where one is in this held of knowledge defined by the institution. In this way knowledge functions as power, and this power of knowledge presents itself as real- ity within which the individual is placed. And, at the end ol the educa- tional psychologist's treatment, the individual actually is the bearer of a double reality: the reality of his abilities on the one hand, and the real- ity of the contents of knowledge he is capable of acquiring on the other. It is at the point of articulation of these two "realities" defined by the educational psychologist that the individual appears as an individual. We could undertake the same kind of analysis of prisons, the factory, and so forth.
The fundamental role of the psychological function, which historically is entirely derived from the dissemination of psychiatric power in other directions beyond the asylum, is to intensify reality as power and to intensify power by asserting it as reality. 1 think this is, if you like, the first point to be stressed.
Now, how did this kind of dissemination come about? How was it that this psychiatric power, which seemed to be so firmly tied up with the specific space of the asylum, began to drift? At any rate, what were the intermediaries? I think the intermediary is easily found and is basi- cally the psychiatrization of abnormal children, and more precisely the psychiatrization of idiots. It is when the mad were separated from idiots within the asylum that a kind of institution began to take shape in which psychiatric power was put to work in the archaic form I have just been describing. 39 For years, we can say for almost a century, this archaic form remained what it was at the beginning. I think it is on the basis of this mixed form, between psychiatry and pedagogy, on the basis of this
? psychlatrization of the abnormal, of the feeble minded, mentally defective, etcetera, that the system of dissemination took place that allowed psychol- ogy to become that kind of permanent doubling of the functioning of every institution. So, next week I would like to say something about this organization and establishment of the psychiatrization of idiots.
Then I would also like to pick out other phenomena based on this proto-psychiatry. The other series of phenomena is this: whereas in the psychiatrization of idiots the psychiatric power I have described contin- ues to advance within the asylum almost without change, on the other hand, a number of utterly fundamental and essential things take place, a double process in which (as in every battle) it is very difficult to know who started it, who takes the initiative and even who gams the upper hand in the end. What were these two twin processes?
First, the appearance of neurology, or more precisely, of neuropathol ogy, was a fundamental event in the history of medicine, that is to say, when certain disorders began to be dissociated from madness and it became possible to assign them a neurological seat and neuropathologi- cal etiology that made it possible to distinguish those who were really ill at the level of their body from those for whom one could assign no eti ology at the level of organic lesions. ,0 This raised the question of the seriousness, of the authenticity, of mental illness, which generated the suspicion that, after all, should a mental illness without any anatomical correlation really be taken seriously?
And, opposite this--correlative to this kind oi suspicion that neurol- ogy began to cast over the whole world of mental illness--there was the game of patients who never ceased to respond to psychiatric power in terms of truth and falsehood. To psychiatric power, which said "I am only a power, and you must accept my knowledge solely at the level of its tokens, without ever seeing the effects ol its content," patients responded with the game of simulation. When, with neuropathology, doctors finally introduced a new content of knowledge, patients responded with another type of simulation, which was, broadly speak ing, the hysterics' great simulation of nervous illnesses like epilepsy, paralysis, and so on. And the game, the kind of endless pursuit between patients, who constantly trapped medical knowledge in the name of a certain truth and in a game of lies, and doctors, who endlessly tried to
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recapture patients in the trap of a neurological knowledge of pathological signs, of a serious medical knowledge, finally permeated the whole history of nineteenth century psychiatry as a real struggle between doctors and patients.
Finally, the last point is how the principal elements we saw taking shape within psychiatric power, and which were its main supports, were taken up outside the asylum institution. That is to say, how were those elements of reality--the law of the power of the other, the prestige given to the doctor's words, the law of identity, the obligation of anamnesis, the attempt to drive out the mad desire that constitutes the reality of madness, and the problem of money, etcetera--brought into play within a practice like psychoanalysis that claims it is not psychiatric, and yet in which one sees how its different elements were inscribed within the game of psychiatric power that isolated them and brought them out? '1
So, if you like, psychiatric power will have a triple destiny. We will find it persisting for a long time in its archaic form, after the period 18/|0 to i 8 6 0 , in the pedagogy of mental deficiency. You will find it being re-elaborated and transformed in the asylum through the inter play of neurology and simulation. And then, a third destiny will be its take up within a practice that puts itself forward however as a practice that is not exactly psychiatric.
? I. Apart from the many occurrences of the term "direction" (diriger) in his Traile medico-philosophique (pp. xlv, 46, 50, 52, 194, 195, and 200), Pinel devotes two passages to the direction of the insane: section II, ? vi: "Advantages of the art of directing (diriger) the insane in order to promote the effect of medicines" pp. 57-58; and ? xxii: "Skill in direct mg (diriger) the insane by seeming to go along with their imaginary ideas" pp. 92-95;
A Treatise on Insanity, pp. 59 60 and pp. 95 98 (the English translation generally renders diriger as "management"; G. B. ). For his part, Esquirol defines moral treatment as "the art of directing (diriger) the intelligence and passions of the insane" Des maladies mentales, vol. I, p. 134; Mental Maladies, p. 79. Leuret states that "it is necessary to direct (diriger) the intel ligence of the insane and to excite passions in them which can divert their delirium" Du traitement moral de lajolie, p. 185-
2. The practice of "direction" or "conduct" was instituted on the basis of the pastoral ol Carlo Borromeo (1538 1584), Pastoruminstructions ad concionandum, conjessionisque el eucharistiae sacramenta ministrandum utilissimae (Antwerp: C. Plantini, 1586), and in connection with Catholic reform and the development ol "retreats. " Among those who laid down its rules,
we can reler to (a) Ignace de Loyola, Exercilia spirititalia (Rome: A. Bladum, 1548); English translation, Ignatius Loyola, The Spiritual Exercises of Si. Ignatius Loyola, trans. Elisabeth Meier Tetlow (Lanham and London: University Press of America, 1987). See, P. Dudon, Saint Ignace de Loyola(Paris: Beauchesne, 1934); P. Doncceur, "Saint Ignace et la direction des ames" in La Vie Spirituelle, vol. 48, Paris, 1936, pp. 48 54; M. Olphe Galliard, "Direction spirituelle," III: "Penode moderne" in Dictionnaire de spiritualite ascetique et mystique. Doctrine et histoirc, vol. Ill (Paris: Beauchesne, 1957) col. 1115-1117. ( b ) Francois de Sales (1567 1622) Introduction a la vie devote ( 1 6 0 8 ) , of which chapter 4 became the direc tors' bible: "De la necessile d'un directeur pour entrer et lair progres en la devotion" in (Euvres, vol. Ill (Annecy: Nierat, 1893) pp. 22 25; English translation, St. Francis de Sales, Introductionto the Devout Life, trans. Michael Day (Wheathampstead: Anthony Clarke, 1990), "The necessity ol a guide," pp. 12 15. See F. Vincent, Francois de Sales, directeur d'dmes. L'education de la volonte (Paris: Beauchesne, 1923). And (c) Jean Jacques Olier (1608 1657), founder ol the Saint-Sulpice seminary, "L'esprit d'un directeur des ames" in (Euvres completes (Paris: J. -P . Migne, 1856) col. 1183-1240.
On "direction" we can refer to the following works: E. M. Caro, "Les direction des ames
au XVIIC siecle" in Nouvelles Etudes morales sur le temps present (Paris: Hachette, 1869) pp. 145 203; H. Huvelin, Quelques directeurs d'dmes au XVII' siecle: saint Francois de Sales, M. Olier, saint Vincent de Paul, Vabbe de Ranee (Paris: Gabalda, 1911 )? Foucault returns to the notion o( "direction" in his lectures at the College de France o( 1974 1975, Les Anormaux, lectures of 19 February and 26 February 1975, pp. 170 171 and pp. 187 189; Abnormal, pp. 182-184 and pp. 201-204; of 1977-1978, Securite, Territoire, Population, ed. Michel Senellart (Paris: Gallimard/Seuil, 2 0 0 4 ) lecture of 28 February 1978; and 1981-1982, L'Hermeneutique du sujet, ed. F. Gros (Paris: Gallimard/Seuil, 2001) lectures ol
3 and 10 March, pp. 315-393; English translation, The Hermeneutics of the Subject. Lectures at the College de France 1981-82, ed.
Frederic Gros, English series ed. Arnold I. Davidson, trans. Graham Burchell (New York: Palgrave Macmillan, 2005) pp. 331-412; and in his lecture at the University of Stanford, 10 October 1979, " 'Omnes et singulatim': Towards a Critique of Political Reason" in The Essential Works of Michel Foucault 195/\-198/\, vol. } : Power, ed. James D. Faubion, trans. Robert Hurley and others (New York: New Press,
2 0 0 0 ) pp. 310 311; French translation, "'Omnes et singulatim': vers une critique de la raison politique" trans. P. E. Dauzat, Dits et Ecrits, vol. 4, pp. 146 147.
3. H. Belloc, "De la responsabilite morale chez les alienes," Annales medico-psychologiques, 3rd series, vol. Ill, July 1861, p. 422.
4. F. Leuret, Du traitement moral de lafolie, pp. 444-446. 5. Ibid. p. 441, p. 443, and p. 445.
6. Ibid. p. 431: "I direct a jet of water on his face and body, and when he seems disposed to bear everything/or his treatment, I am very careful to tell him that it is not a question of treating him, but of offending and punishing him" (Leuret's emphasis).
7. Constructed in 1634 with the view to being an asylum for poor nobility and wounded soldiers, the Bicetre chateau was incorporated in the Hopital general created by the edict
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of 27 April 1656, ordering that "the able bodied and disabled mendicant poor, of both sexes, be confined in a hospital to be employed in works, manulacture, and other work according to their ability. " It was in the "Saint Prix employment" [special quarters for the ill;J. L. J, created in 1660 to take in the insane, that Pinel took up the post ol "infirmary doctor" on 11 September 1793; he occupied this post until 19 April 1795- See, P. Bru, Histoire de Bicetre (hospice, prison, asi/e), d'apres des documents historiques (Paris: Ed. du Progres medical, 1890); F. Funck-Brentano and G. Marindaz, L'Hopilaf generalde Bicetre (Lyon: Laboratoires Ciba, 1938); and J. M. Surzur, "L'Hopital hospice de Bicetre. Historique, fonclions sociales jusqu'a la Revolution Irancaise," Medical Thesis, Paris, 1969, no. 9/l3 (Paris: 1969).
8. La Salpetriere owed its name to the saltpeter factory erected on the spot under Louis XIII. The edict of 27 April 1656 incorporated it in the Hopilal generale for the "confinement of
the mendicant poor" ol the town and inner suburbs of Paris, lor "incorrigible women," and
for some "mad persons. " On the suppression ol its carceral lunction in 1793, the home became the "Maison nationale des femmes," until 1823. The General Council lor hospitals and homes of the Seine, founded in 1801 by Jean Antoine Chaptal (1756 1832) by a decree
of 27 March 1802, ordered the transler to Salpetriere ol mad women hospitalized at the Hotel Dieu. See, L. Boucher, La Salpetriere. Son hisloire de 1656 a 1790. Ses origines et son fonctionnement au XVIII' siecle (Pans, Ed. du Progres medical, 1883); G. Guillain and
P. Mathieu, La Salpetriere (Lyon: Laboratoires Ciba, 1939); J. Couteaux, "L'histoire de la Salpetriere" Revue hospitaliere de France, vol. 9, 1944, pp. 106 127 and 215 242. Since then a well-documented study has become available: N. Simon and J. Franchi, La Pitie-Salpetriere (Saint Bcnoit la Forel: Ed. de PArbre a images, 1986).
9. Saint Lazare, lounded in the ninth century by the hospitaller friars of Saint Lazare for the care of lepers, was transformed by Saint Vincent de Paul on 7 January 1632 to take in "persons detained by order ol His Majesty" and the "insane poor. " In 1794 it became a prison lor streetwalkers. See, E. Pottet, Hisloire de Saint-Lazare, 1122-1912 (Paris: Societe franchise d'lmpnmeric et de libraine, 1912);J. Vie, Les Alienes et les correctionnaires a Saint- Lazare au XVII et au XVIII siecle (Paris: F. Alcan, 1930). Foucault refers to it in Histoire de lajolie, p. 62 and p. 136; Madness and Civilisation, p. 42 (page 136 of the French edition
is omitted from the English translation).
10. The Charenton home was the result of a foundation ol the King's counsellor, Sebaslien
Leblanc, in September 1641. In February 1644 it was handed over to the St Jean-de Dieu order ol hospitallers, created in 1537 by the Portuguese Jean Cindad for the service of the poor and sick. See, J. Monval, Les Freres hospitaliers de Saint-Jean-de-Dieu en France (Paris: Bernard Grasset, 1936); A. Chagny, L'Ordre hospitaller de Saint-Jean-de-Dieu, two volumes (Lyon: Lescuyer el fils, 1953). See also, P. Sevestre, "La maison de Charenton, de la londa tion a la reconstruction: 1641 1838" Histoire des sciences medicales, vol. 25,1991, pp. 61 71.
Closed in July 1795, the home was reopened and nationalized under the Directory, on
15 June 1797, to replace the quarters lor the insane at the Hotel Dieu. Its direction was then entrusted to an old member ol the regular order ol Premonstralensians, Francois de Coulmiers, and Joseph Gastaldy was appointed head doctor. See, C. F. S. Giraudy, Memoire
sur la Maison nationale de Charenton, exclusivement detinee au traitement des alienes (Pans: Imprimene de la Societe de Medecine, 1804); J. E. D. Esquirol, "Memoire historique et statislique sur la Maison Royale de Charenton" (1835) in Des maladiesmentales considerees sous les rapports medical, hygicnique et medico-legale, vol. II, 1838, pp. 539 736; and, C. Strauss, La maison nationale de Charenton (Paris: Imprimene nationale, 1900).
11. F. Leuret, Du traitement moral de la Jolie, p. 185: "In an establishment lor the insane that I could name, the number ol patients is such that in the course of a whole year the head doctor can give only thirty seven minutes to each patient, and in another, where the n-um
ber ol patients is even greater ( . . . ) each patient has the right to see the head doctor for only eighteen minutes a year. "
12. Foucault refers here to the distinction established by Esquirol in the field of madness defined as a "usually chronic cerebral affection, without fever, characterized by disorders of sensibility, intelligence, and the will" J. E. D. Esquirol, "De la lolie" (1816) in Des maladies mentales, vol. I, p. 5; Mental Maladies, p. 21. Within the field marked out by this tripartite division of psychological laculties will be inserted the clinical varieties differing
? Irom each other in terms ol ( a ) the nature ol the disorder allecling the laculties; ( b ) the extension ol the disorder; (c) the quality of the humor which allects it. Thus, whereas mania is characterized by "disturbance and over excitement ol the sensibility, intelligence, and will" ("De la manie" [1818J, ibid. vol. II, p. 132; English, ibid. p. 378), in lypemania - a neologism created by Leuret in 1815 on the basis ol Greek root, XVTTTJ, sadness, affliction--"sensibility is painfully excited or injured; the sad, oppressive passions modily the intelligence and will" ("De la lypemanie ou melancoli" |1820|, ibid. pp. 398 481; English, ibid. pp. 199 233).
13. The criterion for the distinction between mania and monomania was the extension ol the disorder, general or partial, that is to say, localized in a facility (intellectual or instinctive monomania, etcetera), an object (erotomania), or a theme (religious or homicidal mono mania). Thus mania is characterized by the fact that "the delirium is general, all the lacul ties of the understanding are over excited and disrupted," whereas in monomania "the sad or gay, concentrated or expansive delirium is partial and circumscribed to a small number of ideas and affections" ibid. vol. II, "De la manie" p. 133; English, ibid. "Mania" p. 378.
V\. In contrast with mania characterized by "over excitement ol the laculties," the group ol dementias--with "acute," "chronic" and "senile" varieties--are distinguished by their negative aspects: "Dementia is a usually chronic cerebral allection without lever, charac tenzed by deterioration ol the sensibility, intelligence and will" ibid. "De la demence" (1814); p. 219; English, ibid. "Dementia" p. 417.
15. Cauterization or "actual cautery" consisted in the application ol an iron heated 111 the lire or in boiling water to the top of the head or the nape ol the neck. See, L. Valentin, "Memoire el observations concernant les bons ellets du cautere actuel, applique sur la tele dans plusieurs maladies," Nancy, 1815. Esquirol recommended the use ol the moxa and "red hot iron applied to the nape ol the neck in mania complicated by lury" D o maladies mentales, vol. I, "De la folie" (1816) p. 154; Mental Maladies, p. 87: "I have many limes applied the iron at a red heat to the neck, in mania complicated with lury," and ibid. , vol. II, "De la manie" p. 191 and 217; English, ibid. "Mania" pp. 400 401 and p. 411. See,
J. Guislain, Trade sur lfalienation menlale et sur les hospices des alienes, vol. II, ch. vi, "Moxa et cautere actuel" pp. 52-55.
16. "Moxas" are cylinders made Irom a material the progressive combustion ol which was supposed to excite the nervous system and have a Junction ol sensory arousal through the pain it caused. See, A. E. M. Bernardin, Dissertation sur les avantages (/u'on pent retenir de rap- plication du moxa (Paris: Lefebvre, 1803); EJ. Georget, De lafolie, p. 247: Georget recom mended its use in lorms ol insanity involving stupor and insensibility;J. Guislain, Traile sur les phrenopalhies, section IV, p. 458: "This powerful irritant acts on the physical sensibility through pain and the destruction ol living parts, but it also has a moral action through the fear it inspires. "
17.
18.
Ugo Cerletti (1877 1963), dissatisfied with the cardiazol shock used by the Milanese psychiatrist Laszlo von Meduna since 1935, perlected electroshock therapy with Lucio Bmi. On 15 April 1938, a schizophrenic was subjected to this therapy for the first time. See, U. Cerletti, "L'elettroshock" Rivista sperimentale difrenialria, Reggio Emilia, vol. XVIII, 1940, pp. 2 0 9 310; "Electroshock therapy," in A. M. Sackler and others, The Great Physiodynamic Therapies in Psychiatry: An Historical Appraisal (New York: Harper, 1956) pp. 92 94.
From the second hall ol the nineteenth century, the use of ether developed in psychiatry for both therapeutic purposes--notably for calming "states ol nervous excitement" (see, W. Griesinger, Die Pathologie und Therapie derpsychischen Krankheiten [Stuttgart: A. Krabbe, 18451 p. 544; English translation, Mental Pathology and Therapeutics, trans. C. Lockhart Robertson and James Rutherford |New York and London: Halner, 1965] p. 478)--and lor diagnosis. See, H. Bayard, "L'utilisation de Tether et le diagnostic des maladies mentales" Annales d'hygiene publique et medicate, vol. 42, no. 83,July 1849, pp. 201-214; B. A. Morel, "De l'elhcnsation dans la lolie du point de vue du diagnostic et de la medecine legale" Archives
generates de medecine, 51'1 series, vol. 3, 1, February 1854, p. 135: "In certain definite circum stances, etherisation is a precious means for modifying the unhealthy condition and for enlightening the doctor as to the real neuropathic character ol the affection"; and, H. Brochim, "Maladies nerveuses," ? "Anesthesiques: ether et chlorolorme" in Dictionnaire encyclopedujue des sciences medicates, 2mi series, vol. XII, 1877, pp. 376 377.
