No More Learning

32. 33. 34. 35-
J. E. D. Esquirol, "De la folie" (1816) in Des maladies mentales, vol. I, p. 126; Mental Maladies, "Insanity," p. 76.
F. Leuret, Du traitement moral de lajolie, p. 424.
Ibid. p. 434.
Ibid. p. 435.
Ibid.
Michel Foucault is alluding here to the "money-excrement" relationship, which had a great
iuture in psychoanalytic literature. Mentioned by Freud in a letter to Fliess of 22 December
1897 (French translation in La Naissance de la psychanalyse. Lettres a Wilhelm Fliess, 1887-1902, trans. A Berman [Paris: P. U. F. , 19561 p. 212; English translation, The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887-190/I, trans. J. M. Masson [Cambridge, Mass. : The Belknap Press of Harvard University Press, 1985] p. 288), this symbolic relationship
is developed in the theory of anal eroticism. See, S. Freud, "Charakter und Analerotik"
( 1 9 0 8 ) in Gesammelle Werke | hereafter, GW] (Frankfurt: S. Fischer Verlag, 1941) vol. VII,
pp. 201 209; English translation "Character and Anal Eroticism" in The Standard Edition
oj the Complete Psychological Works of Sigmund Freud | hereaiter Standard Edition], trans, under General Editorship of James Strachey (London: The Hogarth Press, 1953 1974) vol. 9; "Uber Triebumsetzung insbesondere der Analerotik" (1917) in GW (1946) vol. X,
pp. 401 410; "On Transformations of Instinct as Exemplified in Anal Eroticism," Standard Edition, vol. 17. See also, E. Borneman, Psychoanalyse des Geldes. Eine kritische Untersuchungpsy- choanalytisher Geldtheorien (Frankiurt: Suhrkamp Verlag, 1973); French translation, Psychanalyse de Vargent. Une recherche critique sur les theories psychanalytiques de I'argent, trans. D. Guerineau (Paris: P. U. F. , 1978); English translation, The Psychoanalysis of Money
(New York: Urizen Books, 1976).
G. Ferrus, Des alienes. Considerations sur I'etat des maisons qui leur sont destinees, lanl en France qu'en Anglelerre; sur le regime hygienique et moral auquel ces malades doivent etre soumis; sur quelques questions de medecine legale el de legislation relatives a leur elat civil (Pains: printed by Mme. Huzard, 1834) p. 234.
36.
37. Ibid.
38. See above, lecture of 5 December 1973, note 18.
39. The "Sainte Anne iarm" derived irom the donation made by Anne of Austria in 1651 for
the construction of an establishment for taking in the sick during epidemics. Partially con structed, the land remained under cultivation. In 1833, Guillaume Ferrus (1784-1861), head doctor at Bicetre, decided to use it to put to work convalescents and able bodied incurables irom the three sections of the asylum. A decision oi the commission set up on 27 December i860 by the prefect Haussmann to "study the improvements and reforms to be carried out in the service for the insane of the Seine department" marked the end oi the iarm. The construction of an asylum, begun in 1863 according to the plans established
? under the directive oi Girard de Cailleux, was inaugurated on 1 May 1867. See, C. Guesstel,
AsHe d'alienes de Saintc-Anne a Paris (Versailles: Aubert, 1880).
'lO. Henri Girard de Cailleux (1814 1884) iilled the posts of head doctor and director ol the
Auxerre insane asylum lrom 20 June 1840 until his appointment in i860 as Inspector General for the Seine service for the insane. The quotation comes from his article: "De la construction et de la direction des asiles d'alienes" Annales d'hygiene publique et de medecine legate, vol. 40, 1st Part, July 1848, p. 30.
11. H. Belloc, Les Asiles d'alienes transformed en centres d'exploitation rurale, moyen d'exonerer en tout ou en partie les departements des depenses c/u'ils font pour leurs alienes en augmentant le bien-etre de ces maladcs, et en les rapprochant des conditions d'existence de Vhomme en societe (Pans: Bechet, 1862) p. 15.
|2. Foucault is alluding here to several earlier propositions: (a) In the lecture of 7 November 1973 he argues that the doctor's therapeutic process does not require "any discourse ol truth" (above, p. 10); ( b ) in that of 14 November Foucault claims that the "game ol truth, within delirium and of delirium, will be completely suppressed in the psychiatric practice that commences at the start oi the nineteenth century" (above, p. 35); and (c) in the lec- ture of 12 December 1973 he concludes that in psychiatric power the question of truth is never posed (above, p. 134).
15. F. Leu ret, Du traitement moral de lajolie, p. 423 and pp. 435 436.
14. Ibid.
15. Ibid. 16. Ibid. 17. Ibid. 18. Ibid. 19. Ibid.
50. Ibid.
51. Ibid,
p. 438.
p. 439.
p. 440.
pp. 440 442. p. 444.
pp. 444 445.
pp. 441 442.
52. F. Leuret, Fragments psychologiques sur lajolie, pp. 121-124.
53. T. Leuret, Du traitement moral de la /olie, pp. 449450.
54. Ibid. p. 449.
55. Ibid. p. 451.
56. Ibid. p. 425: "He does not dream of leaving the hospital and no longer fears the treatments with which he is threatened or that he has been made to undergo. "
57. Ibid. p. 426: "A red hot iron was applied once to the top of his head, and twice to the nape of his neck. "
58. Ibid. p. 429: "He then asks me ii it is a question oi his treatment; in which case he will resign himself to whatever I would like to do. "
59. Ibid. p. 430.
6 0 . Ibid. p. 453: "In a very short letter he let pass a dozen spelling mistakes, and it would have
been better if he had not aspired for a job of this kind. "
61. Ibid. p. 454: "I let the struggle get under way; M. Dupre detended himseli the best
he could, then, when he was too greatly pressed, I came to his aid, taking the role oi
conciliator. "
62. Ibid. p. 461.
19 December 1973 171
? eight
9 JANUARY 1974
Psychiatric power and the practice of "direction ". ^ The game of "reality" in the asylum. ^ The asylum, a medically demarcated
space and the question of its medical or administrative direction. ^ The tokens of psychiatric knowledge: (a) the technique of questioning; (b) the interplay of medication and punishment; (c) the clinical presentation. ^ Asylum "microphysics ofpower. " ^ Emergence of the Psyfunction and of neuropathology. ^ The triple destiny of psychiatric power.
I HAVE SHOWN THAT psychiatric power in its both archaic and elementary form, as it functioned in the proto-psychiatry of the first thirty or forty years of the nineteenth century, essentially operated as a supplement of power given to reality.
This means, first of all, that psychiatric power is above all a certain way of managing, of administering, before being a cure or therapeutic intervention: it is a regime. Or rather, it is because and to the extent that it is a regime of isolation, regularity, the use of time, a system of measured deprivations, and the obligation to work, etcetera, that certain therapeutic effects are expected from it.
Psychiatric power is a regime, but at the same time--and I have stressed this aspect--it seems to me that in the nineteenth century it is a struggle against madness conceived as a will in revolt, as an unbounded will, whatever nosographic analysis or description may ultimately be given of its phenomena. Even in a case of delirium, it is the will to
? 17xl PSYCHIATRIC POWER
believe in that delirium, the will to assert that delirium, the will at the heart of that assertion of the delirium, which is the target ol the strug gle that runs through and drives the psychiatric regime throughout its development.
Psychiatric power is therefore mastery, an endeavor to subjugate, and my impression is that the word that best corresponds to this function ing of psychiatric power, and which is found in all the texts Irom Pinel to Leuret,1 the term that recurs most frequently and appears to me to be entirely typical of this enterprise of both regime and mastery, of regu- larity and struggle, is the notion of "direction" (direction)* The history of this notion should be studied, because it did not originate in psychiatry--lar lrom it. In the nineteenth century this notion still carries a whole set of connotations arising lrom religious practice. For three or four centuries before the nineteenth century, "spiritual direction" (direction de conscience) defined a general field of techniques and objects. 2 At a certain point, some of these techniques and objects, along with this practice of direction, were imported into the psychiatric iield. It would be a history worth doing. Anyway, there's a track here: the psychiatrist is someone who directs the operations of the hospital and who directs individuals.
Just to indicate not only its existence, but also the clear awareness of this practice on the part of psychiatrists themselves, I will quote a text from 1861 which comes from the director of the Saint-Yon asylum: "In the asylum I direct, I praise, reward, reprimand, command, constrain, threaten, and punish every day; and for why? Am I not then a madman myself? And everything I do, my colleagues all do likewise; all, without exception, because it derives from the nature of things. "3
What is the aim of this "direction"? This is the point I got to last week. I think it is basically to give reality a constraining power. This means two things.
First of all it means making this reality inevitable and, as it were, commanding, making it function like power, giving it that supplement
* Nineteenth century English psychiatrists, and English translations of French psychiatrists, such as Pinel, generally use "management," or "moral treatment" etcetera, where the French use "direction," although the latter is occasionally used as well. Since Foucault explicitly draws attention to the term and its history I have left it as direction in English.
? oi vigor which will enable it to match up to madness, or to give it that extra reach which will enable it to get through to those individuals who are mad who flee it or turn away from it. So it is a supplement given to reality.
But at the same time, and this is the other aspect of psychiatric power, its aim is to validate the power exercised within the asylum as being quite simply the power of reality itself. What does this intra-asylum power claim to bring about by the way it functions within this planned space, and in the name of what does it justify itself as power? It justifies itself as power in the name of reality itself. Thus you find both the principle that the asylum must function as a closed milieu, absolutely independent ol pressures like those exerted by the family, etcetera--an absolute power therefore--and, at the same time, the principle that this asylum, in itseH, entirely cut off, must be the reproduction of reality itself. Its buildings must be as similar as possible to ordinary dwellings; relationships between those within the asylum must be like those between citizens; the general obligation to work must be represented within the asylum, and the system of needs and the economy must be reactivated.
So, there is the reduplication of the system of reality within the asylum.
So, giving power to reality and founding power on reality is the asylum tautology.
But in fact, and more exactly, what is actually introduced within the asylum in the name of reality? What is given power? What is it exactly that is made to function as reality? What is given the supplement of power, and on what type of reality is asylum power lounded? This is the problem, and it was in an attempt to disentangle it a little that last week I quoted the long account of a cure that appeared to me to be absolutely exemplary of how psychiatric treatment functions.
I think we can identify precisely how the game of reality within the asylum is introduced and how it functions. I would like to summarize schematically what emerges from it quite naturally. What basically can we identify as reality in "moral treatment" in general, and in the case we have been considering in particular?
I think it is, first of all, the other's will. The reality the patient must con- front, the reality to which his attention--distracted by his insubordinate
9 January 1974 175
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will--must submit and by which he must be subjugated, is first of all the other as a center of will, as a source of power, the other inasmuch as he has, and will always have, greater power than the mad person. The greater part of power is on the other's side: the other is always the holder of a greater part of power in relation to the mad person's power. This is the first yoke of reality to which the mad person must be subjected.
Second, we found another type, or another yoke of reality to which the mad person is subjected. This was shown by the apprenticeship of the name, of the past, the obligation of anamnesis--you remember [the way in which] Leuret required and got his patient to recount his life, under the threat of eight pails of water. ^ So: name, identity, the biogra phy recited in the first person, and recognized consequently in the rit- ual of something close to confession. This is the reality imposed on the mad person.
The third reality is the reality of the illness itself or, rather, the ambiguous, contradictory, vertiginous reality of the madness, since, on the one hand, in a moral cure it is always a question of showing the mad person that his madness is madness and that he really is ill, thus forcing him to abandon any possible denial of his own madness and subjecting him to the inflexibility of his real illness. And then, at the same time, he is shown that at the heart of his madness is not illness but fault, wicked- ness, lack of attention, presumption. At every moment--you remember M. Dupre's cure--Leuret requires his patient to acknowledge that, in the past, he was at Charenton and not in his chateau of Saint-Maur,5 that he really is ill, and that his status is that of a patient. This is the truth to which the subject must be subjected.
However, at the same time, when he is subjecting him to a shower, Leuret actually says to M. Dupre: But I am not doing this in order to care for you, because you are ill; I am doing this because you are bad, because you harbor an unacceptable desire. 6 And you know how far Leuret pushed the tactic, since he goes so far as to force his patient to leave so that he does not enjoy his illness within the asylum, and so that he does not shelter the symptoms of his illness in the surrounds of the asylum. Consequently, in order to deny illness its status as illness, the bad desire within it and sustaining it, must be driven out. So it is
? necessary both to impose the reality of the illness and also to impose on the consciousness of the illness the reality of a desire that is not ill, which sustains and is the very root of the illness. Leuret's tactic broadly revolves around this reality and unreality of the illness, this reality and unreality of madness, and this constitutes the third yoke of reality to which, generally speaking, patients are subjected in moral treatment.
Finally, the fourth form of reality is everything corresponding to the techniques concerning money, need, the necessity to work, the whole system of exchanges and services, and the obligation to provide for his needs.
These four elements--the other's will and the surplus power situated definitively on the side of the other; the yoke of identity, of the name and biography; the non-real reality of madness and the reality of the desire which constitutes the reality of madness and nullifies it as madness; and the reality of need, exchange, and work--are, I think, the kind of nervures of reality which penetrate the asylum and constitute the points within the asylum on which its system is articulated and on the basis of which tactics are formed in the asylum struggle. Asylum power is really the power exerted to assert these realities as reality itself.
It seems to me that the existence of these four elements of reality, or the filtering that asylum power carries out in reality in order to let these four elements penetrate the asylum, is important for several reasons.
The first is that these four elements introduce a number of questions into psychiatric practice that stubbornly recur throughout the history of psychiatry. First, they introduce the question of dependence on and sub- mission to the doctor as someone who, for the patient, holds an inescapable power. Second, they also introduce the question, or practice rather, of confession, anamnesis, of the account and recognition of one- self. This also introduces into asylum practice the procedure by which all madness is posed the question of the secret and unacceptable desire that really makes it exist as madness. And finally, fourth, they intro duce, of course, the problem of money, of financial compensation; the problem of how to provide for oneself when one is mad and how to establish the system of exchange within madness which will enable the mad person's existence to be financed. You see all of this taking shape, already fairly clearly, in these techniques of proto-psychiatry.
9 January 1974 177
? 178 PSYCHIATRIC POWER
I think these elements are equally important, not only through these techniques, through these problems deposited in the history of psychia- try, in the corpus of its practices, [but also]* because through these elements we see the definition of the cured individual. What is a cured individual if not precisely someone who will accept these four yokes of dependence, of confession, of the unacceptability of desire, and of money? The cure is the process of daily, immediate physical subjection carried out in the asylum that constitutes the cured individual as the bearer of a fourfold reality. And this fourfold reality ol which the indi- vidual must be the bearer, that is to say, the receiver, is the law of the other, self-identity, the unacceptability of desire, and the insertion of need in an economic system. These are the four elements which, when they have been effectively taken on by the individual treated, will qua! ify him as a cured individual. The fourfold system of adjustment,1 which cures by itself, through its effectuation, restores the individual.
I would now like to deal with another set of consequences that I would like to develop further and which will be the object of my remarks. This fourfold subjection is brought about therefore in a disci- plinary space, and thanks to this disciplinary space. To that extent, and until now, what I have been able to tell you about the asylum does not differ that much from what we could have said about barracks, schools, orphanages, and prisons for example. Nevertheless, there is a funda- mental difference between these establishments or institutions and the asylum. The difference is, of course, that the asylum has a medical stamp.
How did the things I have been talking about--the general regime of the asylum, the technique of struggle, and the extra power given to real ity in this intra asylum struggle--concern medicine, and why was a doc- tor needed? What is the meaning of the hospital's medical status? What is the meaning of the fact that, at a certain moment, and precisely at the start of the nineteenth century, the mad had to be put not only in a dis- ciplinary place, but, what's more, in one that was medical? In other words, why was a doctor needed to convey this supplementary power of reality?
* (Recording:) it is equally important
' The manuscript has "subjection" rather than "adjustment. "
? Concretely, again, you know that until the end oi the eighteenth century the places in which the mad were put, the places which served lo disciplinanze their mad existence, were not medical places: neither Bicetre,7 nor Salpetnere,8 nor Samt-Lazare9 were medical institutions, nor even, when it comes to it, was Charenton,10 even though, unlike the other establishments, it was specifically intended for the cure of the mad. None of these were really medical places. Certainly, there were doctors, but what doctors there were had the responsibilities and role of an ordinary doctor, that is to say, providing the care entailed by the condition of the individuals confined and by the treatment itself. The cure of the mad was not demanded irom the doctor as doctor; the Iramework ensured by religious personnel, the discipline imposed on individuals, did not need a medical guarantee for one to expect them to provide what was considered to be a cure.
All this, which is very clear until the end of the eighteenth century, suddenly changes in the last years | of thej century, and in the nineteenth century we find, then, on the one hand, an absolutely general asser- tion that the mad need to be directed, that they need a regime, and, on the other hand, the paradoxical assertion, which up to a point is not entailed by the first assertion, that this direction must be in the hands ol medical personnel. Why is there this requirement ol medicalization at the moment that the discipline I have been talking about is redefined? What is the meaning of the fact that henceforth the hospital must be the place where a medical knowledge is put to work? Does it mean that the direction of the mad must be organized on the basis of a knowledge, of an analysis, nosography, and etiology of mental illness?
I don't think so. I think we must absolutely insist on the fact that in the nineteenth century there was, on the one hand, a development of nosographies, of etiologies ol mental illness, of the research of patholog ical anatomy on the possible organic correlations of mental illness, and then, on the other hand, the set of these tactical phenomena of direc- tion. This gap, this discrepancy, between what could be called a medical theory and what was the actual practice of direction, is revealed in many ways.
First, in a hospital the relationship that was possible between con- fined individuals and a doctor as someone with a particular knowledge
9 January 1974 179
? 180 PSYCHIATRIC POWER
that he can apply to the patient was infinitely slight or, if you like, com pletely random. Leuret, who conducted lengthy and difficulty therapies, of which I have given you one example, said that we should never forget that in an ordinary hospital a head doctor could devote roughly thirty seven minutes a year to each of his patients, and he cited one hospital, probably Bicetre, in which the head doctor could devote a maximum of eighteen minutes a year to each patient. 11 You can see that the relation ship between the asylum population and medical technique strictly speaking was completely random.
We find another, no doubt more serious proof of this discrepancy in the fact that if we look at how patients were actually distributed within asylums at this time, we see that it had strictly nothing to do with the nosographic division of mental illnesses found in theoretical texts. In the actual organization of asylums you see no trace or effect of the distinction between mania and lypemania,12 between mania and mono- mania,13 and the series of manias and dementias. 1' However, the dwi sions you do see being established concretely in the hospitals are completely different: these are the differences between the curable and the incurable, between calm and agitated patients, obedient and insub ordinate patients, patients able to work and those unable to work, those punished and those unpunished, and patients to be placed under constant surveillance and those under surveillance from time to time or not at all. This is the distribution that effectively measured out the intra asylum space, and not the nosographic frameworks being constructed in theoretical treatises.
Yet another proof of this discrepancy between medical theory and asylum practice was, if you like, the fact that everything medical theory defined through symptomatological analysis or pathological-anatomy as possible medication for mental illness was constantly and very quickly reused, not with a therapeutic aim, but within a technique of direction. What I mean is that medication like the shower or even cauterization,15 moxas,16 etcetera, were indeed initially prescribed in terms of a conception of the etiology of mental illness or of its organic correlations--like the need to facilitate the circulation of blood, for example, or to relieve con- gestion in a part of the body--but insofar as such methods were unpleas- ant for the patient they were very quickly taken up for use within the
? specific regime ol direction, that is to say, as punishment. You know that this is still going on, and that the way in which electroshock therapy is used is exactly this kind of thing. 1/
Even more precisely, the use oi medication itself was generally the extension of asylum discipline to the surface of the body, or into the body. What was bathing a patient really about? At one level, in theory, it really was a matter of improving the circulation of the blood. What was the reason for using laudanum or ether,18 as was frequently the case in asylums around 1840-1860? Apparently it was to calm the patient's nervous system, but it was, in fact, quite simply the extension of the asylum regime, the regime of discipline, inside the patient's body. The current use ol tranquilizers is still the same kind of practice. So, in asylum practice, you very quickly had this kind of reversion to the use ol what medical theory defined as possible medication as a component of the disciplinary regime. So I don't think we can say that the doctor iunctioned within the asylum on the basis of his psychiatric knowledge. At every moment, what was given as psychiatric knowledge, and tormu lated in the theoretical texts ot psychiatry, was converted into something else in real practice, and we can say that this theoretical knowledge never had a real hold on asylum life strictly speaking. Once again, this is true ol the first years of this proto psychiatry, and it is no doubt true, to a considerable extent, for the whole history of psychiatry up to the pre sent. So how did the doctor function, and why was he necessary, if the frameworks he established, the descriptions he gave, and the medication he defined on the basis of this knowledge, are not put to work, and are not even put to work by him?
What does it mean to stamp this asylum power as medical? Why must asylum power be exercised by a doctor? It seems to me that the interior of the asylum is given a medical stamp by the physical presence of the doctor: it is through his omnipresence, the assimilation, il you like, of asylum space to the psychiatrist's body. The asylum is the psychiatrist's body, stretched and distended to the dimensions of an establishment, extended to the point that his power is exerted as if every part of the asylum is a part of his own body, controlled by his own nerves. More precisely, I would say that this assimilation, psychiatrist's body asylum space, is revealed in different ways.
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First of all, the first reality the patient must encounter, and which is, in a way, the reality through which all the other elements ol reality will have to pass, is the psychiatrist's body itself. You recall those scenes I talked about to start with: every therapy begins with the sudden appearance of the psychiatrist in person, in flesh and blood, looming up in front of his patient, either on the day of his arrival or when his treat- ment begins, and with the prestige ol this body ol which it was indeed said that it must be without defect, that it must impose itself through its own stature and weight. This body must impress itself on the patient as reality, or as that through which the reality ol every other reality will have to pass; this is the body to which the patient must be subjected.
Second, the psychiatrist's body must be present everywhere. Asylum architecture--as defined in the 1830s and 1840s by Esquirol,19 Parchappe,20 Girard de Cailleux,21 and others--was always calculated so that the psychiatrist could be present virtually everywhere. He must be able to take in everything in a glance, and by taking a stroll, inspect the sit uation ol each ol his patients; at any moment he must be able to see and make a complete survey of the establishment, patients and personnel; he must see everything and everything must be reported to him: what he does not see himself, he must be informed about by supervisors completely sub- servient to him, so that he is always present, at every moment, in the asy lum. The entire asylum space is covered with his eyes, ears, and actions.
What's more, the psychiatrist's body must communicate directly with every part of the asylum administration: supervisors are basically the cogs ol the machine, the hands, at any rate the instruments, directly under the psychiatrist's control. 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.