No More Learning

48.
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30 JANUARY 1974
The problem of diagnosis in medicine and psychiatry. ^ The place of the body in psychiatric nosology: the model of general paralysis. ^ Thefate of the notion of crisis in medicine and psychiatry. ^ The test of reality in psychiatry and its forms:
1. Psychiatric questioning (Vinterrogatoire^) and confession. The ritual of clinical presentation. Note on "pathological heredity" and
degeneration. ^ 2. Drugs. Moreau de Tours and hashish. Madness and dreams. rsJ 3. Magnetism and hypnosis. The discovery of the "neurological body. "
I HAVE TRIED TO show you how and why the medical crisis, which as well as being a theoretical notion was above all a practical instrument in medicine, disappeared at the end of the eighteenth and the beginning of the nineteenth century, basically because the appearance of pathological anatomy made it possible to bring to light the reality of the disease in a localized lesion within the organism and identifiable in the body Then, on the other hand, starting with these different lesions that individualized diseases, this same pathological anatomy made it possible to constitute clusters of signs from which the differential diagnosis of diseases could be established. You can see that under these conditions--ascription of the disease to the body and the possibility of a differential diagnosis--the crisis, as the test in which disease produced its own truth, became pointless. In the realm of psychiatry the situation is completely different,
for two reasons.
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The first is that in the psychiatric order, the problem is not funda mentally, not at all in fact, one of differential diagnosis. Of course, at a certain level in psychiatric practice, diagnosis does appear to develop as the differential diagnosis of one illness as distinct from another; mania or melancholy, hysteria or schizophrenia, etcetera. But in truth, I think all this is only a superficial and secondary activity in relation to the real question posed in every diagnosis of madness, which is not whether it is this or that form of madness, but whether it is or is not madness. I think the position of psychiatry is very different from that of medicine in this respect. You will say that the prior question of whether or not one is dealing with an illness is also necessary in medicine; however, truly, it is both a relatively simple and, at bottom, marginal question; it is almost only in cases of dissimulation or hypochondnacal delirium that the problem of "illness or not" can really be posed seriously. In the domain of mental illness, however, the only real question is posed in the form of yes or no. That is to say, the differential field within which the diagno sis of madness is practiced is not constituted by the range ol nosographic species, but simply by marking the difference between what is madness and what is not: the diagnosis of madness is carried out in this binary domain, in this strictly dual field. So I would say that, except as a sec ond order and, as it were, superfluous justification, psychiatry does not require differential diagnosis. Psychiatric diagnosis does not involve a differential diagnosis but, if you like, a decision, or an absolute diagnosis. Psychiatry functions, then, in terms of the model of an absolute, and not a differential, diagnosis.
Second, psychiatry as it is being established in the nineteenth century again contrasts with medicine in that it is clearly a medicine in which the body is absent. However, we must be clear here, because it is absolutely certain that, on the one hand, from the beginnings of the development of nineteenth century psychiatry, there was a search for organic correlations, the domain of lesion, the type of organ that might be involved in an illness like madness. There was the search for this, and in some cases it was found; in 1822-1826 it was Bayle's definition ol gen- eral paralysis, and meningeal lesions as after-effects of syphilis. 1 This is true, and we can say that the body was no more absent from the psych1 atric order than it was from standard medicine. And yet there was an
? essential difference: the problem to be resolved in psychiatric activity was not so much, or was not primarily, whether a particular form of behavior, a way of speaking, a type of illusion, or a category of halluci- nation, were due to this or that form of lesion, but whether or not say ing such things, conducting oneself in such a way, hearing such voices, and suchlike, belonged to madness. And the best proof that this was the fundamental question is that in 1826 Bayle recognized that in general paralysis, which was one of the major forms in which it was thought there was an assignable relationship between mental illness and the organism, there were three major types of syndromes: the motor syn- drome of progressive paralysis; second, the psychiatric syndrome ol madness; and third, the terminal condition of dementia. 2 Now, forty years later, Baillarger said: Everything that Bayle said is more or less true, but there is a fundamental error nonetheless, which is that there is no madness at all in general paralysis, only an intrication of paralysis and dementia. 5
So, I think we can say that the liquidation of the medical crisis was acceptable to medicine thanks to pathological anatomy, but was not possible in the psychiatric domain due to absolute diagnosis and the absence of the body/ The problem psychiatry faces becomes precisely that of constituting, of establishing, the kind of test, or series of tests, that will enable it to meet this requirement of absolute diagnosis, that is to say, the kind of test that will accord reality or unreality to what is taken to be madness, to inscribe it within the field of reality or disqualify it as unreal.
In other words, we can say that the classical notion of crisis in medicine, the classical practice of the medical crisis as it was put to work for over two thousand years, basically had two nineteenth century descendants. On the one hand, through pathological anatomy, procedures of verification, in the form of the objective report and demonstration, were substituted for the classical medical crisis and its test: this was the medical offspring. The psychiatric offspring of the classical crisis was different. Since there was no field within which psychiatry could ascertain
* The manuscript clarifies: "This therefore implies a completely specific procedure for establishing the illness. "
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the truth, it had to establish and substitute something for the old classical medical crisis which was, like the old medical crisis, a test, but a test of reality rather than a test of truth. Put differently, the test of truth splits into techniques for ascertaining the truth on one side: this is standard medicine; [and, on the other), a test of reality: this is what happens in psychiatry.
To summarize, and to start studying this system, this game, this panoply of tests of reality, I think we can say the following: In psychiatry, the essential moment that punctuates, organizes, and at the same time distributes this field of disciplinary power I have been speaking about, is this test of reality, which has a double meaning.
On the one hand, it involves making the reasons given for a requested confinement, or for possible psychiatric intervention, exist as illness, or possibly non-illness. The psychiatric test is then what I will call the test of administrative medical reduplication: Can what has motivated the request be retranscribed in terms of symptoms and illness? The lirst function of the psychiatric test is to retranscnbe the request as illness, to make the grounds for the request exist as symptoms of illness.
The second function is correlative to this and in a way is much more important. The test involves making the power of intervention and the dis ciphnary power of the psychiatrist exist as medical knowledge. I have tried to show you how this power operated within a disciplinary field, which had a medical stamp of course, but which lacked real medical content. Well, this disciplinary power must now be made to function as medical power, and the psychiatric test will be, on the one hand, what constitutes the request for confinement as illness, and, on the other, what makes the person given powers of decision in confinement function as a doctor.
In organic medicine, the doctor vaguely formulates the following demand: Show me your symptoms and I will tell you what your illness is. In the psychiatric test, the psychiatrist's demand is much weightier, much more surcharged, and is: With what you are, with your life, with the grounds for people's complaints, [. . . *J, with what you do, and what you say, provide me with some symptoms, not so that I know what your illness is, but so that I can stand before you as a doctor.
* (On the recording, repetition of:) with what you are
? That is to say, the psychiatric test is a double test for the official estab- lishment of an individual's life as a tissue of pathological symptoms, as well as the constant official establishment of the psychiatrist as a doctor, or of the supreme disciplinary authority as a medical authority. Consequently, we can say that the psychiatric test is an endless test of admittance into the hospital. Why is it that one cannot leave the asylum? One cannot leave the asylum, not because the exit is far away, but because the entrance is too near. One never stops entering the asylum, and every encounter, every confrontation between the doctor and the patient begins again and indefinitely repeats this founding, initial act by which madness will exist as reality and the psychiatrist will exist as doctor.
Consequently you can see how there is a very curious and complex game into which all the real games of the asylum and of the history of psychiatry and madness in the nineteenth century throw themselves. If you consider things at the level of the disciplinary functioning of the asylum, (which I analyzed in the previous sessions), then at this level there is a formidable medical surplus-power because the doctor and the disciplinary system ultimately form a single body; the hospital itself is the doctor's body. However, on the other side, there is a prodigious surplus power of the patient, since it is the patient, in terms, precisely, of the way in which he undergoes and comes out from the psychiatric test, who will or will not establish the psychiatrist as doctor, who will either refer him back to his pure and simple disciplinary role or allow him to play his doctor's role--and you understand through what opening.
You can see how the phenomena I will try to explain to you next week, the phenomena of hysteria and the game between Charcot and the hysterics, will be able to rush in here. The hysteric is precisely someone who says: It is thanks to me, but thanks only to me, that what you do to me--confine me, prescribe me drugs, and so on--really is a medical act, and I crown you doctor to the extent that I provide you with symptoms. Underneath the doctor's surplus power is the patient's surplus power.
There is, then, [a] general framework of the psychiatric test which, as I told you last week, took, I think, three principal forms in the first sixty
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years of the nineteenth century. There are, then, three techniques for this test of the realization of the illness that invests the psychiatrist with the status of doctor and makes the demand for psychiatry Junction as symptom: first, psychiatric questioning Q'interrogatoirey, second, drugs; and third, hypnosis.
First, the technique of questioning in the broad sense. Let's say: questioning, anamnesis, confession, etcetera. To what does questioning correspond? How exactly is it practiced? I have already pointed out the disciplinary aspect of questioning, insofar as it involves pinning the individual to his identity, obliging him to recognize himself in his past, in certain events of his life/' But this is only a minor, superlicial function of questioning. There are, I think, others, which are so many processes oi realizing madness. And I think questioning realizes madness in four ways, or by four processes.
First, classical psychiatric questioning, as you see it at work from around 1820 to 1830, always includes what we can call the search for a medical history. What is this search for a medical history? It is asking the patient what different illnesses his ancestors or collaterals may have had. This search is very paradoxical because, until the end ol the nineteenth century at least, it is completely anarchical and collates everything that comes up that might have been illness in the patient's ancestors and collaterals. And it is a very curious search because at the time I am considering, that is to say, at the time of its appearance around 1830 to 1840, there is neither the notion of pathological heredity,5 nor even of degeneration, which is formulated much later around 1855 to I860. 6
That is to say, we should be surprised by the sheer extent of the research undertaken in this examination of the medical history of all the patient's ancestors and collaterals, ot all the sorts of illnesses from which they may have suffered, and we should also be surprised by its early appearance and persistence still today. What basically was involved when a mental patient was asked about the illnesses in his family, and when it was carefully noted down if his father had died of apoplexy, if his mother suffered from rheumatism, if his uncle had been an idiot child, and so on? What was going on? Of course, it extended the search for certain signs, prodromes, etcetera, to a multi-individual scale, but
? I think it was above all and essentially a way of making up for the lack of pathological anatomy, for that absence of the body or distance from the body I have spoken to you about. Insofar as one cannot and does not know how to find any organic substratum of the illness in the patient, one looks for pathological events at the level of the patients family which are such that, whatever their nature, they will refer to the communication, and consequently existence, of a pathological material substratum. Heredity is a way of giving body to the illness at the very moment that this illness cannot be situated at the level ot the individual body; so one invents, one cuts out a sort of huge fantastical body of the family affected by a mass of illnesses: organic and non-organic diseases, constitutional and accidental diseases, it doesn't matter, since if they are transmitted then they have a material support, and as long as one gets back to the material support in this way then one has the organic substratum of madness, but an organic substratum that is not the individual substratum of pathological anatomy. It is a sort o( meta-organic substratum, but one which constitutes the true body of the illness. The sick body in the questioning of madness, the sick body one palpates, touches, percusses, sounds and in which one wants to try to find patho- logical signs, is in reality the body of the entire family; it is, rather, the body constituted by the family and family heredity. Trying to trace heredity therefore means substituting a different body and correlative material for the body of pathological anatomy; it constitutes a meta- individual analogon of the doctors' organism. I think this is the first aspect of medical questioning: the search for a medical history.
Second, there is the search for prodromes, signs of predisposition, an individual medical history. What are the phases through which the approach of madness is indicated before it really exists as madness? And this is another very constant aspect of psychiatric questioning: Recount your childhood memories. Tell me what happened. Give me some infor- mation about your life. Tell me what happened to you when you were ill? In fact this assumes that madness as illness always precedes itself; elements of a medical history must be found even in cases of illnesses marked by their sudden onset.
In general medicine, elements of a previous history, events indicating the onset of the illness, are discovered so as to be able to distinguish this
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or that type of illness, to find out whether it is a case of a progressive or a chronic illness, for example. The search for a medical history is quite different in the psychiatric domain. Looking for these individual med- ical histories basically means trying to show that madness existed before being constituted as illness, and, at the same time, that these signs are not yet the madness itself, but the conditions of possibility of madness. So signs must be found that are not exactly pathological--since that would mean they are signs of the illness, real elements of the illness, and not just prodromes--but which must be something different from the internal signs of the illness while at the same time having a certain relationship with the illness so that they can be given as prodromes, warning signs, marks of a predisposition to an illness--both internal and external to the illness. 7 That is to say, basically, setting madness in the individual context of what we can call abnormality.
Abnormality is the individual condition of possibility of madness; it is what must be established in order to show that what one is treating, that what one is dealing with, and what precisely one wants to show are symptoms of madness, is really of a pathological order. For the different elements constituting the object or motive for the demand for confine ment to be transformed into pathological symptoms, these elements must be set within this general web of abnormality.
I refer you, for example, to the Pierre Riviere dossier for some of the details on this. 9 When the doctors tried to determine whether or not Pierre Riviere was mentally ill, whether or not he was suffering from something that one hardly dared call "monomania"--at this time mono- mania had been defined by Esquirol as an illness that suddenly exploded and was characterized precisely by its suddenness and by its main symptom being the sudden appearance of a criminal form of conduct10--their problem was how this criminal conduct could be proven to be mad? It had to be set in a field of abnormalities constituted by a number of elements. A child cutting off the heads of cabbages while imagining himself at the head of an army destroying his enemies, for example, or crucifying a frog,11 formed a horizon of abnormalities within which the conduct in question could then be realized as madness. So, the second operation of questioning is the constitution of a horizon of abnormalities.
? The third role of questioning is to organize what could be called the junction or chiasmus between responsibility and subjectivity. My impression is that at the bottom of every psychiatric interview there is always a sort of transaction taking the following form. The psychiatrist says to the person before him: Well, here we are, you are here either of your own free will or at the behest of someone else, but you have come here because people are uneasy and complain about you; you say certain things, you have done certain things, you behave in a certain way. I am not in any way questioning you about the truth of these facts and I do not want to know the truth or falsity of the reproaches made against you, or even of the malaise you feel--I am not an investigating magistrate-- however, I am prepared to relieve you of legal or moral responsibil- ity for what you have done or for what happens to you, or for the feel- ings you experience, on the one condition that you subjectively accept the reality of all this, on condition that you give all these facts back to me as subjective symptoms of your existence, of your consciousness. I want to find all these elements again in your account and confessions, more or less transformed, no matter, as elements of your suffering, as the force of a monstrous desire, as the signs of an irrepressible impulse, in short, as symptoms. I really want to remove the weight of your legal and moral responsibility from the reasons for you being here, but I will only perform this subtraction, I will only lift these reasons from your head on condition, precisely, that you give them to me, in one form or another, as symptoms. Give me some symptoms; I will remove the fault.
I think this kind of deal, played out at the heart of psychiatric questioning, means that questioning essentially always bears in fact on the reasons why the individual finds himself before the psychiatrist. The psychiatric interview must question the reasons for the individual find- ing himself before the psychiatrist--no matter whether these are linked to voluntary conduct or given by other people--and retransform these reasons into symptoms.
The fourth function of psychiatric questioning is what I will call the organization of the central confession. That is to say, basically psychiatric questioning always has a certain end, and what's more always breaks off at a certain point. This end, this point on the horizon for psychiatric
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questioning, would be the heart of the madness, its core, a kind of focal point in the realm of madness corresponding to the center of a patho- logical lesion. * And this center of madness that questioning seeks to realize, to effectuate, is the extreme, indisputable form of the madness. The subject being questioned must not only be got to recognize the exis- tence of this delirious center, he really must actualize it within the interview.
This actualization can be obtained in two ways. Either it can be obtained in the form of confession, of the confession ritually obtained within the questioning: "Yes, I hear voices! Yes, I have hallucinations! ";12 uYes, I think I'm Napoleon! ";1* "Yes, I rave! " This is the end to which psychiatric questioning must lead. Or, if not actualization in confession, through pinning down the symptom in the first person, the crisis itselt must be actualized in the questioning; arousing the hallucination or provoking the hysterical crisis. In short, whether in the form of confes sion or in the form of actualization of the central symptom, the subject must be forced into a sort of tight corner, a point of extreme contraction at which he is constrained to say "I am mad" and really play out his madness. At that point, pinned in that extreme corner of the interroga- tion, he can no longer escape his own symptoms; he can no longer thread his way between them. He is constrained to say: Really, I am someone for whom the psychiatric hospital was built, I am someone for whom a doc- tor was needed, I am sick and, since I am sick, it is clear that you, whose major function is to confine me, are a doctor. And there we arrive at the essential point of the double establishment of the confined individual as sick and of the confining individual as doctor and psychiatrist.
One extracts an extreme confession, basically on the assumption and with the claim that if one avows the madness, one gets rid of it. In the technique of psychiatric questioning the double analogy with both reli- gious confession and medical crisis comes into play: religious confession helps the pardon; expectoration and excretion bring out the morbific substance in the medical crisis. At the point of their convergence or, if you like, in a kind of oscillation between the confession, which brings
* The manuscript adds: "A bit like the family taking the place oi the somatic substratum for madness. "
? about pardon, and the expectoration, which drives out the disease, the extreme confession of madness is--the psychiatrists of that time, and no doubt many others still today, assure us--ultimately the basis on which the individual will be able to free himsell from his madness. "I will free you from your madness on condition that you confess to me your madness," that is to say: "Give me the reasons why I confine you; really give me the reasons why I deprive you of your freedom, and, at that point, I will lree you from your madness. The action by which you will be cured of your madness is also that by which I will assure myself that what I do really is a medical act. " Such is the entanglement between the doctor's power and the extortion ol confession in the patient, which constitutes, I think, the absolutely central point ol the technique of psychiatric questioning.
I think this questioning, the principal moments of which I have tried to indicate, can be deciphered at three levels. Let's leave the first, the dis- ciplinary level about which I have already spoken;17' the other two levels are, I think, essential. The first level involves constituting a medical mimesis in psychiatric questioning, the analogon of a medical schema given by pathological anatomy: first, psychiatric questioning constitutes a body through the system of ascriptions ol heredity, it gives body to an illness which did not have one; second, around this illness, and in order to pick it out as illness, it constitutes a field of abnormalities; third, it fabricates symptoms from a demand lor confinement; and finally, fourth, it isolates, delimits, and defines a pathological source that it shows and actualizes in the confession or in the realization of this major and nuclear symptom.
So questioning in nineteenth century psychiatry is a certain way of reconstituting exactly those elements that characterize the activity of differential diagnosis in organic medicine. It is a way of reconstituting, alongside and parallel to organic medicine, something that functions in the same way, but in the order of mimesis and analogon. The other strata in the interview is the level at which, through the play of sleights of hand, exchanges, promises, gifts and counter-gifts between psychiatrist and patient there is the triple realization of conduct as madness, of madness as illness, and finally, of the mad person's guardian as doctor.
You can see that under these conditions the kind of questioning involving these elements is the completely renovated ritual of absolute
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diagnosis. What is the psychiatrists activity in a model hospital of the nineteenth century? You know that there are two and only two. First, the visit; second, questioning. The visit is the action by which the doctor brings about the daily mutation of discipline into therapy by passing through the different departments of his hospital: I will pass through the entire asylum machinery, I will see all the mechanisms of the disciplinary system in order to transform them, simply by my presence, into a therapeutic apparatus (^appareit)}^
The second activity, questioning, is precisely this: Give me some symptoms, make some symptoms from your life for me, and you will make me a doctor.
The two rites, of the visit and questioning, are, as you can see, the elements by which the disciplinary field I have spoken about functions. You also see why this great rite of questioning needs to be reinvigorated from time to time. Just as alongside Low Mass there is solemn High Mass, so the clinical presentation to students is to private questioning ol the patient what the sung Mass is to Low Mass. And why is it that psychiatry is thrown so soon, so quickly, into this Missa so/lemnis, into this rite of almost public presentation, of anyway the clinical presentation ol patients to students? I have already said why in a couple of words,16 but I think you now find here the possibility of grasping a different level of the working of this clinical presentation.
Given the characteristic double absence of the body and the cure in psychiatric practice, how could one bring about the real investiture ol the doctor as a real doctor, and how could the processes of the trans mutation of the demand for conhnement into symptoms, of Hie events into abnormalities, and of heredity into a body, etcetera, be really effec tuated if, in addition to the daily working of the asylum, there were not this kind of rite solemnly marking what happens in psychiatric questioning? Well, precisely, a space is organized in which the alienist is marked out as doctor solely by the fact that there are students around him as spectators and listeners. So the medical character of his role will in no way be actualized by the success of his cure, by his discovery of the true etiology, since, precisely, it is not a question of this. The medical character of his role and the processes of transmutation I have talked about are possible inasmuch as the doctor is surrounded by the chorus
? and body ot the students. Since the patients body is lacking, it really will be necessary for there to be this kind ot institutional corporeality which will be the crown of students around the master, listening to the patient's answers. As soon as this listening is coded in this way and institutionalized as students listening to what the psychiatrist says as master, and as master of medical knowledge, from that point on, all the processes I have talked about really will play their part, with a renewed intensity and vigor, in this medical transmutation of madness into illness, ot the demand for confinement into symptom, and so on.
In other words, I think the professorial dimension of speech, which, in the doctor's case, is merely additive, if you like, a way of increasing his prestige and making what he says a little more true, is much more essential and much more inherent in the case of the psychiatrist; the professorial dimension ot the psychiatrist's words is constitutive of his medical power. In order tor this speech really to carry out the medical transmutations I have spoken about, it must, trom time to time at least, be ritually and institutionally marked as professorial by the rite of the clinical presentation of the patient to students.
That's what I wanted to say to you about questioning. Obviously all this needs to be refined inasmuch as the forms of questioning have varied. In someone like Leuret it takes much more subtle torms. Leuret invented questioning by silence, for example, in which one says nothing to the patient, waits tor him to speak, and lets him say what he wants, because, according to Leuret, this is the only way, or at any rate the best way to arrive at precisely that focal confession of madness. 17 Again in Leuret, there is the kind ot game in which another demand is recognized behind a symptom, and this is what the questioning must analyze. Anyway, all ot these are supplementary with regard to the central rite of psychiatric questioning.
Alongside questioning and, to tell the truth, here again in a secondary form, but with much more of a future than Leuret's techniques, there are the two other major agents of medicalization, of the realization ot madness as illness: drugs and hypnosis.
Drugs tirst. Here again, I have drawn your attention to the discipli- nary use of certain drugs, which goes back to the eighteenth century: laudanum,18 opiates, and so forth. 19 At the end of the eighteenth century
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you see the new phenomenon ol the medico legal use of drugs. At the end of the eighteenth century, an Italian doctor had the idea of using massive doses of opium in order to determine whether a subject really is or is not a mental patient, of using opium as an authority for deciding between madness and its simulation. 20
This was the start, and then we find, we can say for the first eighty years of the nineteenth century, an enormous use of drugs in psychiatric hospitals, the main ones being opium, amyl nitrate,21 chloroform,22 and ether:23 in 1864 an important text by Morel appeared in the Archives
generates de medecine on etherisation of patients in psychiatric hospitals. 2' However, I think the | major] episode in all this was obviously the book Du haschisch et de Valienation menlale, and the practice, of Moreau de Tours in 1845. 25 In his book on hashish, which I think was very impor tant historically, Moreau de Tours recounts that he has "himself"--and we will see |the meaning]* of this "himself"--tested hashish, and that, alter having taken a lairly considerable amount of it in jam, he was able to pick out a number ol phases in hashish intoxication, which were the following: first, "feeling of well being"; second, "excitement, dissocia- tion of ideas"; third, "errors of time and space"; fourth, "development of sensibility, both visual and auditory: exaggeration of sensations when listening to music, etcetera"; fifth, "fixed ideas, delirious convictions"; sixth, alteration or, as he says, "lesion of the affections," exaggeration of lears, excitability, and amorous passion, etcetera; seventh, "irresistible drives"; eighth and last, "illusions, hallucinations. "26 I think there are a number ol reasons for considering Moreau de Tours's experiment and the use he made of it.
First--and I won't be able to give you an explanation, or even an analysis, here--is the lact that, in this experiment, Moreau de Tours immediately, straightaway [. . . '] refers the drug's effects to the processes of mental illness/ When he describes the dillerent stages I have just men- tioned, from the second stage, the feeling of well being having passed-- and yet we will see that he succeeds in recuperating it--we are very
* (Recording:) the importance
' (On the recording, repeat ol:) immediately
Section m the manuscript entitled: "Idea that the phenomena deriving from the absorption ol hashish are identical to those ol madness. "
? quickly in the realm of mental illness: dissociation of ideas, errors of time and space, etcetera.
I think this psychiatric appropriation of the effects of the drug within the system of mental illness raises an important prob lem, but to tell the truth I think it should be analyzed within a history of drugs rather than within a history of mental illness. Anyway, with regard to the history of mental illness, according to Moreau de Tours this use of the drug, and the immediate assimilation of the effects of the drug and symptoms of mental illness, provide the doctor with a possible reproduction of madness, a reproduction which is both artificial, since intoxication is needed to produce the phenomena, and natural, because none oi the symptoms he lists are foreign, either m their content or suc- cessive sequence, to the course of madness as a spontaneous and natural illness. So, we have an induced but authentic reproduction of the illness. This is in 187I5 when a series of works of experimental physiology are under way. This is the Claude Bernard oi madness; it is the liver's glyco genie function transposed by Moreau de Tours. 2/
Another important thing is that we not only have the idea, and so the instrument it seems, of a concerted, intentional experiment on madness, but in addition we have this idea that the different phenomena typical of hashish intoxication constitute a natural, necessary succession, a spontaneous sequence, a homogeneous series. That is to say, since these phenomena and those of madness are homogeneous, we arrive at the idea that the different symptoms of madness, which nosographers might distribute on this or that level, or attribute to this or that form of illness, basically all belong to the same series. Whereas PmePs, and espe cially EsquiroPs type of psychiatry tried to see what faculty was injured in this or that mental illness,28 here we have instead the idea that there is basically only one madness that evolves throughout the individual's life, which may, of course, be halted, blocked, and fixed at a particular stage, just like hashish intoxication, but which in any case is the same madness found everywhere and throughout its evolution. So, hashish will enable the psychiatrist to discover what he had sought for so long, that is to say, precisely the kind of single "core" from which all the symptoms of madness can spread. Through the hashish experiment we will obtain this center, the famous center that pathological-anatomists had the opportunity to grasp and fix in a point of the body, since we
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will have the nucleus itself from which all madness unfurls. And this fundamental nucleus that Moreau de Tours thought he had found is what, in 1845, he called the "original intellectual modification"29 and that, in 1869, he will call "the primordial modification. "30 This is how he describes this original modification: "Every form, every accident of delirium or madness strictly speaking--fixed ideas, hallucinations, irre- sistibility of drives [you see these are all the symptoms we come across in hashish intoxication; M. F. ]--owe their origin to an original intellec- tual modification, always identical to itself, which is evidently the essen- tial condition of their existence. This is maniacal excitation. "31 This expression is not quite right, for it is a matter of a "simple and complex state of, at one and the same time, vagueness, uncertainty, oscillation and mobility of ideas, which are often expressed in a profound incoherence. It is a disaggregation, a veritable dissolution of the intellectual composite that we call the moral faculties. "32
So, the major symptom, or rather, the very center from which the dif- ferent symptoms of madness spread out, is located thanks to hashish. Through hashish we can then reproduce, reconstitute, and truly actualize that essential "core" of all madness. But you can see, and this is what is important, that we reproduce this essential "core" through hashish, and in whom do we reproduce it? In anyone and, as it happens, in the doctor. That is to say, the hashish experiment gives the doctor the pos- sibility of communicating directly with madness through something other than the external observation of visible symptoms; it will be pos- sible to communicate with madness through the doctor's subjective experience of the effects of hashish intoxication. For the famous organic body that the pathological anatomists have before them, and which the alienist lacked, for that body, ground of evidence, and level of experi- mental verification the psychiatrist lacked, the psychiatrist could substi- tute his own experience. Hence it becomes possible to pin the psychiatrist's experience on to the mad person's experience and so gain access to something like the zero point between moral psychology and pathological psychology. And, especially for the psychiatrist, in the name of his normality and of his experiences as a normal, but intoxi- cated psychiatrist, it becomes possible to see, express, and lay down the law to madness.
? Prior to the Moreau de Tours's experiment it was, of course, the psychiatrist who, as a normal individual, laid down the law to madness, but he did so in the form of exclusion: You are mad because you do not think like me; I recognize you are mad insofar as what you do is impen- etrable to the reasons valid for me. It was as a normal individual that the psychiatrist had dictated the law to the mad in the form of this exclu sion, of this alternative. Now however, with the hashish experiment, the psychiatrist will be able to say: I know the law of your madness, I recog- nize it precisely because I can reconstitute it in myself; under the condi tion of modifications like hashish intoxication, I can follow and reconstitute the typical thread of events and processes of madness in myself. I can understand what happens; I can grasp and reconstitute the authentic and autonomous movement of your madness and conse- quently grasp it from within.
And this is how that famous and absolutely novel grasp of madness by psychiatry m the form of understanding was founded. The relation ship of interiority established by the psychiatrist through hashish will enable him to say: This is madness, for, as a normal individual, I myself can really understand the movement by which this phenomenon occurs. We find the original source here of understanding as the normal psychi atrist's law on the intrinsic movement of madness. Whereas previously madness was precisely what could not be reconstituted by normal thought, it is now what must be reconstituted by and on the basis of the psychiatrist's understanding. Consequently, this internal grasp gives additional power.
But what is this primordial "core" that the psychiatrist can reconsti- tute by means of hashish and which is therefore not madness--since hashish is not madness--but which is nonetheless madness--since we find it again in madness in the pure and spontaneous state? What is this primordial core, homogeneous with madness,* which however is not madness, and which is found in both the psychiatrist and the mad per- son? Of course, Moreau de Tours names this element. You know it already: it is the dream. The hashish experience opens up the dream as the mechanism that can be found in the normal individual and that will
* The manuscript adds: "so as to be both the basis and model. "
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serve precisely as the principle of intelligibility of madness. "It seems that man has been granted two modes of moral existence, two lives. The first arises from our relations with the external world, with the great whole that we call the universe; it is common to us and to beings like us. The second is only the reflection of the first, only feeds, as it were, on material provided by the first, but is nevertheless perfectly distinct from it. Sleep is like a barrier set up between the two, the physiological point where external life ends and internal life begins. "33
What is madness exactly? Well, madness, like hashish intoxication, is that particular state of our nervous system in which the barriers of sleep or the barriers of wakefulness, or the double barrier constituted by sleep and wakefulness, are broken or, at any rate, breached at a number of places. The irruption of dream mechanisms in the waking state will induce madness if the mechanism is, as it were, endogenous, and it will induce the hallucinatory experience of someone who is intoxicated if the breach is induced by the absorption of a foreign body. The dream is therefore fixed as the law common to normal life and pathological life; it is the point from which the psychiatrist's understanding will be able to impose its law on the phenomena of madness.
Of course, the expression, "the mad are waking dreamers,"Vl is not new; you find it already clearly [stated]* in Esquirol;55 and after all there is a whole psychiatric tradition in which we find this expression. 36 However, what I think is absolutely new and crucial in Moreau de Tours and his book on hashish is not just a comparison between madness and the dream, but a principle of analysis. 3' Furthermore, when Esquirol and all the psychiatrists who said at this time, or even before, "the mad are dreamers," the analogy was between the phenomena of madness and dreaming, whereas Moreau de Tours establishes a relationship between the phenomena of dreaming and, at one and the same time, the phenomena of normal wakefulness and the phenomena of madness. 38 It is the dream's position between wakefulness and madness that Moreau de Tours pointed out and established, and it is this that makes him the absolutely founding point in the history of psychiatry and the history of
* (Recording:) formulated
? psychoanalysis. In other words, the founding point was not Descartes, who said that the dream goes beyond madness and includes il,*9 but Moreau de Tours, who put the dream in a position such that it envelops madness, includes it, and enables it to be understood. And following Moreau de Tours, the psychiatrist says, and the psychoanalyst basically never stops repeating: I can well understand what madness is, because I can dream. With my dream, and with what I can grasp ol my dream, I will end up understanding what is going on in someone who is mad. This is in Moreau de Tours and his book on hashish.
So, the drug is the dream injected into the waking state; it is wakefulness intoxicated, as it were, by the dream. It is the real effectua tion ol madness. Hence the idea that by giving hashish to a patient who is already ill, one will quite simply exaggerate his madness. That is to say, giving hashish to a normal individual will make him mad, but giving hashish to a patient will make his madness more visible; it will hasten its progress. That is how Moreau de Tours introduced therapy with hashish into his services. As he says himself, he began with a mis take: he gave hashish to some melancholies, thinking that the "maniacal excitation," that kind ol agitation that is at one and the same time the primordial lact ol madness and the characteristic ol the dream, would compensate lor the sad, frozen and immobile features of the melan cholics; his idea was to compensate lor melancholic fixity with the maniacal agitation of hashish. 10 He very quickly saw that it did not work, and then he had the idea ol reactualizing the old technique ol the medical crisis.
He said to himself: since mania consists in a kind ol excitation, and since in the classical medical tradition, still lound in Pine! moreover,'1 the crisis is precisely the point at which the phenomena of a disease become speeded up and intensified, let's make the maniacs a bit more maniacal; give them some hashish, and thanks to that we will cure them. '2 In the manuals ol this time we find a considerable number of cures, but obviously with no analysis of possible cases of the recurrence ol illness, since it was understood that, once established, a cure was a cure, even if it was called into question some days later.
You can see that alongside questioning, and having nothing to do with questioning, there is a kind ol reconstitution ol precisely those
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mechanisms we saw coming into play in questioning. Hashish is a sort of automatic questioning, and if the doctor loses power, inasmuch as he allows the drug to act, the patient finds himself caught in the automa tism of the drug and cannot oppose his power to the doctor's, and what the doctor may lose as power he regains through having an internal understanding of madness.
The third system of tests in the psychiatric practice of the (irst two- thirds of the nineteenth century is magnetism and hypnosis. To start with magnetism was basically used as a sort of displacement of the crisis. In magnetic practice at the end of the eighteenth century, the magnetizer was basically someone who imposed his will on the magne- tized, and so when psychiatrists had the idea of using magnetism within psychiatric hospitals--around 1820 to 1825 at Salpetriere--it was pre cisely to reinforce further the effect of power that the doctor wanted to attach to himseli. 43 But there was something more: the effect of the use of magnetism at the end of the eighteenth and the beginning of the nineteenth century, was to give doctors a hold, and a total, absolute hold, over the patient, but it was also to give the patient a supplemen- tary lucidity, what mesmerists called "mtuitiveness," a supplementary "intuitiveness" thanks to which the subject will be able to know his own body, his own illness, and, possibly the illness of others. ^ At the end of the eighteenth century, magnetism was basically a way of entrusting the patient himself with what had been the doctor's task in the classical crisis. In the classical crisis, it was the doctor who had to foresee what the illness was, to divine in what it consisted, and to adjust it in the course of the crisis/'5 Now, within the magnetism practiced by orthodox mesmerists, the patient is put in a state in which he can really know the nature, process and term of his illness. '6
So, in the experiments conducted at Salpetriere from 1820-1825, we tind the first tests ol this type of magnetism. A male or female patient is put to sleep and asked what their illness is, how long they have been affected by it, for what reasons and how must they get over it? There is a whole series of reports of this.
Here is a case of mesmerism from around 1825 1826. A patient is presented to the magnetizer who asks him: "Who put you to sleep? --It was you. --Why did you vomit yesterday? --Because they gave me cold
? bouillon. --At what time did you vomit? --At four-o clock. --Did you eat afterwards? --Yes, monsieur, and I did not vomit what I had eaten. -- What accident made you ill for the first time? --Because I was cold. -- Was it a long time ago? --One year ago. --Didn't you have a fall? --Yes monsieur. --In this fall, did you fall on your stomach? --No, I fell backwards, etcetera. "7'7 Medical diagnosis is carried out therefore in the opening, as it were, contrived by magnetic practice.
And this is how one of the most serious alienists of the time, Georget, magnetized two patients, one ol whom was called "Petronille" and the other "Braguette. "'8 Questioned by Georget under magnetism, Petronille said: "What made me ill was that I fell in the water, and if you want to cure me you too must throw me in the water. ',/i9 Georget does this, but the cure does not take place because actually the patient had made it clear that she had fallen in the Ourcq canal, and Georget had simply made her fall in a pool? 0 Petronille was really demanding the repetition of the trauma. Afterwards she was thought to be a simulator and Georget the innocent and naive victim of her maneuvers, but this is not important, I just wanted to stress the above to show you how magnetism in this period, that is to say, still around 1825, functioned as a supple ment, an extension of the classical crisis: knowing, testing the illness in its truth.
In actual fact, the real insertion of magnetism and hypnosis into psychiatric practice takes place much later, after Braid, that is to say, after the appearance of Neurkypno/ogy, or the Rationale of Nervous Sleep in 1843,51 and especially, in France, after the introduction of Braid's practices, around Broca in 1858-1859. 52
Why was Braidism accepted, whereas the old mesmerism was aban doned around 1830? 53 If it was abandoned it was precisely because the magnetizers naively wanted to entrust patients, and their "lucidity," with the medical power and knowledge which, in the actual working ol the institution, could only fall to the doctor; hence the barrier erected by the Academie de medecine and by doctors against the first practices of hypnosis. On the other hand, from the 1860s, Braidism was accepted and penetrated asylum and psychiatric practice quite easily. Why? On the one hand, of course, because Braidism, let's just say hypnosis, aban- dons the old theory of the material basis of magnetism. 5^ That is to say,
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in Braid's definition of hypnotism, all its ellects are due solely to the doctor's will. That is to say, only the doctor's assertion, only his prestige, only the power he exercises over the patient without any inter mediary, without any material basis or the passage of fluid, will succeed in producing the specific ellects of hypnosis.
The second reason is that Braidism deprived the patient ot the abil- ity to produce the medical truth that he was still being asked to provide in 1825 or 1830. In Braidism, hypnosis constitutes the element within which medical knowledge can be deployed. What seduced the doctors and got them to accept what they rejected in 1830 is that, thanks to Braid's technique, one could completely neutralize the patient's will, as it were, and leave the field absolutely open to the doctor's pure will. What officially reinstalled hypnosis in France was the operation performed by Broca (Broca's performance of a surgical operation on someone in a hypnotic state). 5:> At that point, in fact, hypnosis appeared as the opening through which medical power knowledge was able to lorce its way in and take hold of the patient.
This neutralization of the patient by hypnosis, the (act that the hypnotized patient is no longer required to know his illness but is given instead the task of being like a neutral surface on which the doctor's will is registered, will be very important because it will enable hypnotic action to be defined. This is what was done by Braid, and after Braid, especially in France, by someone whose books bore the name Philips, but whose real name was Durand de Gros, who had emigrated in 1852 and then returned to France alter some years, living and publishing under the name ol Philips. Around i 8 6 0 to 1864, Philips defined the processes and different phases of hypnotic action. ^6 He shows how hypnosis is important first of all because it has a disciplinary eflect; it is, precisely, sedative, just like questioning, drugs. I won't return to this. But above all, the subject's state when he has begun to be hypnotized-- what Philips calls "the hypotaxic state"57--enables the doctor to get the patient to do what he wants. First ol all it allows him to direct behav ior; by giving the patient an order he will be able to prevent him from conducting himsell in this or that way, or he will be able to constrain him to do something. So, there is the possibility ol what Durand de Gros calls "orthopedics": "Braidism," he says, "gives us the basis for an
? intellectual and moral orthopedics which one day will surely be intro duced into educational and penitentiary establishments. "58 So, hypnosis makes it possible to fashion, to train behavior.
It also makes possible a nullification of symptoms. With hypnosis one must be able to prevent the appearance of a symptom; Durand de Gros claims that the shaking of chorea can be completely quashed by giving an order to the patient. 59
Finally, third, the hypnotist can get a hold on the patient's body at the level of the analysis and modification of functions: he can produce a muscular contraction or paralysis; he can excite or nullify sensibility on the body's surface; he can weaken or arouse the intellectual or moral faculties; he can even modify automatic functions like circulation and breathing. 60
So, in the hypnosis that is now accepted, you see the patient's famous body, previously absent from psychiatric practice, being defined, or appearing rather. Hypnosis will enable action on the body, not just at the disciplinary level ol manifest behavior, but also at the level of mus- cles, nerves, and basic functions. Hypnosis is consequently a new, much more sophisticated and intensive way than questioning lor the psychia trist to obtain a real hold on the patient's body; or rather, it is the first time that the patient's body is finally available to the psychiatrist in, as it were, its functional detail. Psychiatric power will finally get a hold on the body that had eluded it since it became known that pathological anatomy could never account lor the functioning and mechanisms of madness. *
So, with these different instruments, these different techniques for realizing the illness, I think we have the elements from which the great central episode in the history of nineteenth century psychiatry and madness will develop. There are, then, three instruments: questioning, hypnosis, and drugs. Questioning, hypnosis and drugs are really three
* The manuscript adds: "With hypnosis wc have then a type of test of the illness--which draws close to drugs through the effect of discipline and through the elfect ol the reproduction of the pathological reality.
hut it is distinct Irom and, in a sense, privileged with regard to drugs,
because it is entirely suited to the doctor's will: doing what one wants with the patient.
- because it allows, or at least one expects from it, nullification of the symptoms, one by one,
and because it makes possible a direct hold on the body. "
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ways of actually realizing the illness, but, of course, in questioning, this realization only takes place in language and has above all the double defect of, firstly, not putting the psychiatrist in internal communication with the mechanisms of madness other than through the game of questions and answers, and, secondly, not giving a hold on the detail of the patient's body.
With drugs, rather, there is the possibility of this internal hold, this kind of supplement of power given to the psychiatrist by the fact that he thinks he can understand the phenomena of madness; an internal hold therefore. And hypnosis will be the instrument by which the psychia- trist will get a hold on the very functioning of the patient's body.
You see that we have here the elements from which it will be possi- ble to constitute, or rather, the elements which are in place and which, quite suddenly, around i860 to 1880, will assume extreme importance and intensity when, precisely within classical organic medicine, a new definition, or rather, a new reality of the body will appear, that is to say, when a body is discovered which is not just a body with organs and tis- sues, but a body with functions, performances, and behavior--in short, when, around Duchenne de Boulogne, between 1850 and i 8 6 0 , the neurological body is discovered. 61
At this point, by connecting up through the techniques of hypnosis and drugs with this new body discovered by medicine, it will finally be possible to try to inscribe the mechanisms of madness in a system of dif- ferential knowledge, in a medicine basically founded on pathological anatomy or pathological physiology; the major phenomenon will now be this inscription, this attempt to inscribe madness withm a general medical symptomatology, which the absence of the body and of differ- ential diagnosis had always marginalized. The failure of this attempt by Charcot, the fact that the neurological body, like the body of pathologi- cal anatomy, will elude the psychiatrist, will leave psychiatric power with the three instruments of power established in the first half of the nineteenth century. That is to say, after the disappearance of the great neurological hope, we will find again only the three elements: questioning--language--hypnosis, and drugs, that is to say, the three elements with which psychiatric power, within or outside the asylum space, still operates today.
? 1. In fact, it was not until 1879 that the works of Alfred Fournier (1832-1914) revealed general paralysis as a frequent complication of tertiary syphilis: see his Syphilis du cerveau (Paris: Masson, 1879). Before being accepted, this relationship gave rise to many debates at the Societe medico-psychologique, from April to June 1879 and from February to November 1898. On 27 March 1893, Le Filliatre, in a communication, "Des antecedents syphilitiques chez quelques paralytiques generaux," presented syphilis as "a major predis- posing cause," and met with hardly any opposition; see, Annales medico-psychologiques, 7th series, vol. XVII, July 1893, p. 436. As the general secretary oi the Societe medico- psychologiques later recalled, "in 1893, the exclusive partisans of the specific origin of general praralysis were still rare among us" A. Ritti, "Histoire des travaux de la Societe medico-psychologiques (1852 1902)" Annales medico-psychologiques, 8th series, vol. XVI, July 1902, p. 58. Its specific etiology will only become imperative in 1913 with the discov ery by Noguchi and Moore of pale treponema in the brains ol general paralytics.
2. A. LJ. Bayle, Traite des maladies du cerveau et de ses membranes, pp. 536 537: "Among the many symptoms with which this ailment is accompanied, we can reduce to two those which basically serve to characterize it ( . . . ) : 1. derangement of the intellectual laculties, or delir- ium; 2. incomplete paralysis. 1. Delirium: Mental alienation ( . . . ) , partial to start with and consisting in a sort of monomania with enfeeblement of the laculties, then becomes general and maniacal with over excitement (. . . ); it then degenerates into a condition oi dementia (. . . ); 2. Paralysis: The paralysis which, together with delirium, establishes the diagnosis of chronic meningitis, is a diminution and an enleeblement which, very slightly
at first, and conlined to a single organ, increases progressively and gradually extends to a greater number of parts, and ends by invading the entire locomotive system, in such a way that the name which seems the most suitable to us ( . . . ) is that oi general and incomplete paralysis. " See above, note 17 to the lecture of 12 December 1973, and see also J. Christian and A. Ritti, "Paralysie generale," in Dictionnaire encyclopedique des sciences medicales, 2nd series, vol. XX (Paris: Masson/Asselin, 1884).
3. Jules Baillarger (1809 1890) states that "it is impossible to go along with Bayle in considering madness as a constant and essential symptom of general paralysis. There are therefore no grounds for accepting the two orders ol symptoms essential for the character ization ol general paralysis: the symptoms of dementia and paralysis" in the Appendix to Doumic's French translation of the 2nd, revised and expanded edition of Wilhelm Gnesinger's Die Pathologie und Therapie depsychischen Krakheiten (Traite des maladies mentales. Pathologie et therapeutique), preceded by a work on general paralysis by Dr. Baillarger: Des symptomes de la paralysie generale et des rapports de cette maladie avec lafolie (Paris: A. Delahaye, 1865) p. 612. Baillarger returns to this problem on several occasions: (1) "Des rapports de
la paralysie generale e dal lolie" Annales medico-psychologiques, 2nd series, vol. V, January 1853, pp. 158-166; (2) "De la folie avec predominance du delire des grandeurs dans ses rapports avec la paralysie generale," ibid.