What is the crisis in medical practice prior to pathological
anatomy?
Foucault-Psychiatric-Power-1973-74
, says La Vallee de I'Eure (1891), made a violent sexual assault on a young idiot girl, who, what's more, was engaged in prostitution.
"
66. Ibid. p. |/|8.
67. F. Voisin, De Vidiolie chevies enfanls, p. 83.
68. D. M. Bourneville, Assistance, Traitement et Education, p. V|5.
69. In the second hall of the nineteenth century the research ol psychiatrists concerning
instinct developed on two fronts: one, natural, of cerebral physiology, and the other, cul tural, ol the relationships between sociability and morality. See, G. Bouchardeau, "La notion d'instinct, dans la clinique psychiatrique au XIX1" Evolution psychiatrique, vol. XLIV , no. 5, July September 1979, pp. 617 6*2.
Valentin Magnan (1835 1916) established a link between the instinctive perversions ol degenerates and anatomico physiological disorders ol the cerebral spinal system, in a classihcation which connected the different perversions to processes of excitation or inhibition ol corresponding cerebral spinal structures. See his "Etude clinique sur les impulsions et les actes des alienes" (1861) in Recherches sur les centres netveux, vol. II (Pans: Masson, 1893) pp. 353 369- See also, Paul Serieux (1864 I97l7), Recherches cliniques sur les anomalies de I'instinct sexuel, Medical Thesis, Pans, no. 50,1888 (Pans: Lecrosnier and Babe, 1888 1889), and Charles Fere (1852 1907) Uinstinct sexuel. Evolution et dissolution (Paris: Alcan, 1889). Foucault returns to this point in Les Anormaux, lectures ol 5 and 12 February and 21 March 1975, pp. 120-125, pp. 127 135, and pp. 260 271; Abnormal, pp. 129 13'l, 137 Vi5, and 275 287.
70. Thus, in 1886, Joseph Jules Dejerine (187 I9 1917) reviews Darwin's work very positively in L'Heredite dans les maladies du systeme nervetix (Pans: Asselin and Houzeau, 1886). But it was V. Magnan who developed Morel's theory by introducing a relerence to the notion of evolution and of the neurological localization ol the degenerative process. See his Lecons cliniques sur les maladies mentalcs (Paris: Battaille, 1893); V. Magnan and P. Legrain, Les Degeneres (etat mental et syndromes episodiques) (Paris: Rueff, 1895); and A. Zaloszyc,
Elements d'une histoirc de la theorie des degenerescences dans la psychiatric francaise, M e d i c a l Thesis, Strasbourg, July 1975.
71. Two years before the publication of Charles Darwin's On the Origin oj the Species by means oj Natural Selection, or the Preservation oj Favoured Races in the Struggle j or Life ( L o n d o n : J. Murray, 1859), B. A. Morel published his Traite des degenerescences physique, intellectuelles el morales de I'espece humaine, et des causes qui produisent ces varietes maladives ( P a r i s :
J. B. Bailliere, 1857) in which he defines degeneration: "The clearest idea we can give our selves ol the degeneration of the human species is to think ol it as a primitive type of unhealthy deviation. This deviation, however simple we imagine it to be in its origin, nonetheless contains elements of transmissibility of such a kind that the person who car ries its germ becomes increasingly incapable of fulfilling his functions in humanity, and intellectual progress, already checked in his person, is still threatened in his descendants" (p. 5). The psychiatry that comes from Morel will only convert to evolutionism by ceasing
? . 2.
to see "perlection" as the most exact conlormity to a "original (primiti/)"
seeing it instead as the greatest possible divergence Irom that type.
Sec, I. R. Dowbiggin, Inheriting Madness: Professional Ration and Psychiatric Nineteenth-Century France (Berkeley: University ot California Press, 1991); French translation, La Folie hereditaire, ou Comment la psychialrie francaise s 'est consliluee en un coips de savoir el de pouvoir dans la seconde moitie du XIX'' siecle, trans. G. Le Gaulrey, prelace by G. Lanteri Laura (Paris: Ed. Epel, 1993).
/}. After reaching its peak in the 1880s, the theory of degeneration began to decline. Freud criticized it in 1894 in his article on "Die Abwehr Neuropsychosen" Neurologisches Zen/ralblatt, vol. 13, 1894, no. 10, pp. 362 364 and no. 11, pp. 402 409, reprinted in GW, vol. I, 1952, pp. 57 74; French translation, "Les psychonevroses de delese" trans.
J. Laplanche, in S. Freud, Nevrose, Psychose et Perversion (Paris: Presses universitaires de- France, 1973); English translation, "The Neuro Psychoses of Delence, Standard Edition, vol. 3. Also: Drei Abhandlungen %itr Sexua/theorie (Vienna: Deuticke, 1905) in GW, vol. V, 1942, pp. 27 145; French translation, Trois Essais sur la theorie de la sexualite, Irans. B. Reverchon Jouve (Paris: Gallimard, 1923); English translation, "Three Essays on the Theory of Sexuality, Standard Edition (1953 1974) vol. 7. In 1903, Gilbert Ballet (1853 1916) wrote in a Traite de pathologie mentale published under his editorship (Pans: Doin, 1903), that he saw no advantages in including the term "degeneration" in the vocab ulary ol twentieth century psychiatry ( pp. 273 275). See, G. Genii Perrin, Histoire des orig- ines el de revolution de I'idee de degenerescence en medecine mentale ( P a n s : A. Leclerc, 1913).
16 January 1974
231 type, and by
Knowledge in
? ten
23 JANUARY 1974
Psychiatric power and the question of truth: questioning and confession; magnetism and hypnosis; drugs. ^ Elements for a history of truth: 1. The truth-event and itsforms: judicial, alchemical and medical practices. r^ Transition to a technology of
demonstrative truth. Its elements: (a) procedures of inquiry; (b) institution of a subject of knowledge; (c) ruling out the crisis in medicine and psychiatry and its supports: the disciplinary space
of the asylum, recourse to pathological anatomy; relationships between madness and crime. ^ Psychiatric power and hysterical resistance.
I HAVE ANALYZED THE level at which psychiatric power appears as a power in which and by which truth is brought into play. It seems to me that, at a certain level at least, let's say the level of its disciplinary opera- tion, the function of psychiatric knowledge is by no means to found a therapeutic practice in truth, but much rather to give the psychiatrist's power a particular stamp, to give it an additional, supplementary distinc- tion; in other words, the psychiatrist's knowledge is one of the compo- nents by which the disciplinary apparatus organizes the surplus-power of reality around madness.
But this leaves out of account certain elements that are nevertheless present in this historical period of what I call proto-psychiatry, extend- ing, roughly, from the 1820s to the 1860s and 1870s, until what we can call the crisis of hysteria. In one sense the elements I have left to one side are fairly unobtrusive, dispersed, not very prominent, and they have
? 234 PSYCHIATRIC POWER
certainly not occupied a large space in the organization of psychiatric power in the operation of the disciplinary regime, and yet I think these elements were switch points in the process of the internal and external transformation of psychiatric power. These few, unobtrusive, dispersed points are those where madness was posed the question of truth despite the overall working of the disciplinary apparatus. In saying that there are three such points, I do not claim that this is an exhaustive list; it seems to me that we can say provisionally that there were three in which the question ol truth addressed to madness creeps in.
These points are, first of all, the practice or ritual of questioning and the extortion of confession, which is the most important and most constant process, and which ultimately has not changed much within psychiatric practice. Second, a different process which had a cyclical for- tune, which disappeared at one point, but which, through the havoc it wreaked in the disciplinary world of the asylum, was extremely impor- tant historically: the procedure of magnetism and hypnosis. And finally, third, a well known element about which the history of psychiatry has been significantly quiet, which is the use, I do not say the absolutely constant use, but from around 1840 to 1850 the very general use of drugs--mainly ether,1 chloroform,2 opium,3 laudanum/1 and hashish,5 a whole panoply--which for a dozen years were used on a daily basis in the asylum world of the nineteenth century, and on which the histori- ans of psychiatry have been prudently silent, although, along with hypnosis and the technique of questioning, it is probably the point on which the history of psychiatric practice and power took a sudden turn or, at any rate, was transformed.
Of course, these three techniques are ambiguous, that is to say, they function at two levels. On the one hand, they function at the disciplinary level; in this sense, questioning is really a particular way of fixing the individual to the norm of his own identity--Who are you? What is your name? Who are your parents? What about the different episodes of your madness? --of pinning the individual to his social identity and to the madness ascribed to him by his own milieu. Questioning is a disciplinary method and its effects can in fact be identified at that level.
Magnetism was introduced into the nineteenth century asylum very early on, that is to say around 1820 to 1825, at a time when its use was
? still at an empirical level and other doctors generally rejected it. It was very clearly used as an adjunct of the doctor's physical, corporal power. 6 In this space of the extension of the doctor's body organized by the asylum, in this kind of process, this game, by which the working parts of the asylum must be like the psychiatrist's own nervous system, so that the psychiatrist's body and the asylum space itself form a single body, it is clear that magnetism, with all its physical effects, was a functional component in the mechanism of discipline. Finally, drugs--mainly opium, chloroform, and ether--were, like drugs still today, an obviously disciplinary instrument lor maintaining order, calm, and keeping patients quiet.
At the same time, the use of these three perfectly decipherable ele ments whose disciplinary ellects make their insertion into the asylum quite comprehensible, and despite what was expected of them, had an effect in which they brought with them or introduced a question of truth. It may be that it was the cross examined, magnetized, hypnotized, and drugged madman himself who posed the question of truth. And, to that extent, it seems to me that these three elements really were the ele- ments of the disciplinary system's fracture, the moment at which medical knowledge, which again was only a token of power, found itself required to speak, no longer just in terms of power, but in terms of truth.
I would like to open a parenthesis here and insert a little history of truth in general. It seems to me that we could say that knowledge of the kind we call scientific basically presupposes that there is truth every- where, in every place and all the time. More precisely, this means that while there are of course moments for scientific knowledge when the truth is grasped more easily, points of view that allow it to be perceived more easily or certainly, and instruments for discovering it where it is hidden, remote or buried, nonetheless, for scientific practice in general, there is always the truth; the truth is always present, in or under every thing, and the question of truth can be posed about anything and everything. The truth may well be buried and difficult to reach, but this only directs us to our own limits and circumstances. The truth in itself
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permeates the entire world, without break. There is no black hole in the truth. This means that for a scientific type of knowledge nothing is too small, trivial, ephemeral, or occasional for the question of truth, nothing too distant or close to hand tor us to put the question: what are you in truth? The truth dwells in everything and anything, even Plato's famous nail clippings. 7 This means not only that the truth lives everywhere and that the question of truth can be posed at every [moment], but it also means that no one is exclusively qualified to state the truth, if, of course, they have the instruments required to discover it, the categories necessary to think it, and an adequate language for formulating it in propositions. Speaking even more schematically, let's say that we have here a philosophico scientilic standpoint of truth linked to a technology for the construction of truth, or for finding it in principle, a technology of demonstration. Let's say that we have a technology of demonstrative truth joined, in short, to scientific practice.
Now I think there has been a completely different standpoint of truth in our civilization. This completely different standpoint of truth, no doubt more archaic than the one I am talking about, was gradually pushed aside or covered over by the demonstrative technology of truth. This other standpoint of truth, which is, I think absolutely crucial in the history of our civilization by virtue of it being covered over and colonized by the other, is that of a truth which, precisely, will not be everywhere and at all times waiting for us whose task is to watch out for it and grasp it wherever it happens to be. It will be the standpoint of a dispersed, dis- continuous, interrupted truth which will only speak or appear from time to time, where it wishes to, in certain places; a truth which does not appear everywhere, at all times, or for everyone; a truth which is not waiting for us, because it is a truth which has its favorable moments, its propitious places, its privileged agents and bearers. It is a truth which has its geography. The oracle who speaks the truth at Delphi8 does not express it anywhere else, and does not say the same thing as the oracle in another place; the god who cures at Epidaurus,9 and who tells those who come to consult him what their illness is and what remedy they must apply, only cures and expresses the truth of the illness at Epidaurus and nowhere else. A truth, then, which has its geography, and which has its calendar as well, or, at least, its own chronology.
? Take another example. In the old Greek, Latin and medieval medicine of crises, to which I will come back, there is always a moment lor the truth of the illness to appear. This is precisely the moment of the crisis, and there is no other moment at which the truth can be grasped in this way. In alchemical practice, the truth is not lying there waiting to be grasped by us; it passes, and it passes rapidly, like lightning; it is in any case linked to the opportunity, to the kairos, and must be seized. 10
It is not only a truth with its geography and calendar, but also with its messengers or privileged and exclusive agents. The agents of this discon- tinuous truth are those who possess the secrets of times and places, those who undergo tests of qualification, those who have uttered the required words or performed ritual actions, and those again whom truth has cho- sen to sweep down on: prophets, seers, innocents, the blind, the mad, the wise, etcetera. This truth, with its geography, its calendars, and its mes- sengers or privileged agents, is not universal. Which does not mean that it is rare, but that it is a dispersed truth, a truth that occurs as an event.
So you have attested truth, the truth of demonstration, and you have the truth-event. We could call this discontinuous truth the truth thunderbolt, as opposed to the truth-sky that is universally present behind the clouds. We have, then, two series in the Western history of truth. The series of constant, constituted, demonstrated, discovered truth, and then a different series of the truth which does not belong to the order of what is, but to the order of what happens, a truth, therefore, which is not given in the form of discovery, but in the form of the event, a truth which is not found but aroused and hunted down: production rather than apophantic. It is not a truth that is given through the medi- ation of instruments, but a truth provoked by rituals, captured by ruses, seized according to occasions. This kind of truth does not call for method, but for strategy. The relationship between this truth-event and the person who is seized by it, who grasps it or is struck by it, is not a relationship of subject to object. Consequently it is not a relationship within knowledge but, rather, a relationship of a shock or clash, like that of a thunderbolt or lightning. It is also a hunting kind of relation- ship, or, at any rate, a risky, reversible, warlike relationship; it is a relationship of domination and victory, and so not a relationship of knowledge, but one of power.
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There are those who are in the habit of writing the history of truth in terms of the forgetting of Being,11 that is to say, when they assert forgetting as the basic category of the history of truth, these people place themselves straightaway within the privileges of established knowledge, that is to say, something like forgetting can only take place on the ground of the assumed knowledge relationship, laid down once and for all. Consequently, I think they only pursue the history of one of the two series I have tried to point out, the series of apophantic truth, of dis covered, established, demonstrated truth, and they place themselves within that series.
What I would like to do, what I have tried to do in the last years, is a history of truth starting with the other series,12 that is to say, I have tried to single out the technology--today, effectively dismissed, brushed aside and supplanted--of the truth-event, truth-ritual, truth-power relation ship, as opposed to the truth-discovery, truth method, truth-knowledge relationship, as opposed, therefore, to truth that is presupposed and placed within the subject-object relationship.
I would like to emphasize the truth-thunderbolt against the truth sky, that is to say, on the one hand, to show how this truth-demonstration, broadly identified in its technology with scientific practice, the present day extent, force and power of which there is absolutely no point in denying, derives in reality from the truth-ritual, truth event, truth- strategy, and how truth knowledge is basically only a region and an aspect, albeit one that has become superabundant and assumed gigantic dimensions, but still an aspect or a modality of truth as event and of the technology of this truth-event.
Showing that scientific demonstration is basically only a ritual, that the supposedly universal subject of knowledge is really only an individ- ual historically qualified according to certain modalities, and that the discovery of truth is really a certain modality of the production of truth; putting what is given as the truth of observation or demonstration back on the basis of rituals, of the qualifications of the knowing individual, of the truth-event system, is what I would call the archeology of knowledge. 13
And then there is a further move to be made, which would be to show precisely how, in the course of our history, of our civilization, and
? in an increasingly accelerated way since the Renaissance, truth- knowledge assumed its present, familiar and observable dimensions; to show how it colonized and took over the truth-event and ended up exer- cising a relationship of power over it, which may be irreversible, but which for the moment anyway is a dominant and tyrannical power, to show how this technology of demonstrative truth colonized and now exercises a relationship of power over this truth whose technology is linked to the event, to strategy, and to the hunt. We could call this the genealogy of knowledge, the indispensable historical other side to the archeology of knowledge, and which I have tried to show you, very schematically, with some dossiers, not what it might consist of, but how it might be sketched out. Opening up the dossier of judicial practice was an attempt to show how, through judicial practice, politico-juridical rules were gradually formed for establishing the truth in which we saw the technology of the truth-test ebbing away and disappearing with the advent of a certain type of political power and the establishment of the technology of a truth of certified observation, of a truth authenticated
by witnesses, etcetera.
What I would now like to do with regard to psychiatry is show how in the nineteenth century this event type of truth is gradually hidden by a different technology of truth, or at least, how, with regard to madness, there was an attempt to cover up this technology of the truth-event with a technology of demonstrative truth, of observation. We could also do this, and in the next years I will try to do it with regard to pedagogy and the dossier on childhood. 1^
It could be said that this is all very well historically, but all the same, there is little now that corresponds to the truth-test-event series in our society; we may be able to find this technology of the truth event in some old practices--say in oracular, prophetic practices, etcetera--but it is a long time since this game was played and there is no point in return ing to it. Actually, I think there really is something else here, and that in actual fact, within our civilization, this truth-event, this technology of the truth-thunderbolt, seems to me to have subsisted for a long time and has considerable historical importance.
First, with regard to the judicial forms I have talked about in previous years and to which I have just referred, a very profound and
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fundamental transformation is involved. You remember what I said to you about archaic medieval justice, of justice before the twelfth century, more or less: the medieval procedure for discovering the guilty person, or rather, for assigning individual culpability, the procedures broadly placed under the rubric of "the judgment of God," were in no way methods for discovering what really happened. There was absolutely no question of reproducing within "God's judgment" something like the analogon, the image itself of what really happened at the level of the criminal action. "God's judgment" and tests of this kind were proce- dures for governing how to determine the victor in a confrontation between two individuals in dispute. 15 Even confession was not a sign or a method for discovering a sign of culpability in medieval judicial techniques. 16 When the Inquisitors of the Middle Ages tortured some- one, they did not appeal to the kind of argument made by present day torturers, that someone's acknowledgement of guilt is the best proof, even better, closer, than that of an eye witness; the torturer of the Middle Ages did not seek to obtain this kind of proof afortiori. In fact, torturing someone in the Middle Ages involved the judge and the person accused or suspected in a real physical struggle--the rules of which, while not rigged, were of course completely unequal and with no reciprocity--to find out whether or not the suspect would stand up to it. When he gave way, this was not so much a demonstrative proof that he was guilty, as quite simply the reality of the fact that he had lost in the game, in the confrontation, and could consequently be sentenced. All this could then be inscribed, secondarily as it were, in a system of significations: God, then, has abandoned him, etcetera. But this was absolutely not the mundane sign of his culpability; it was the final phase, the final episode, the conclusion of a confrontation. 17 And finally to pass from this technique for establishing the truth in the test to the establishment of truth in the certified report, through evidence and demonstration, required the whole process by which penal justice was brought under State control. 18
We could say the same about alchemy. The basic reason why alchemy has never really been refuted by chemistry, why it cannot figure in the history of science as an error or scientific impasse, is that it does not correspond, and never has corresponded, to the technology of
? demonstrative truth; from start to finish it corresponded to the technol- ogy of the truth-event or of the truth-test.
Very roughly, summarizing its main characteristics, what is alchemical research in fact? First of all it involves the individuals initiation, that is to say, his moral or ascetic qualification; he must prepare himself for the test of truth, not so much by the accumulation of certain contents of knowledge as by the fact that he really has gone through the required ritual. 19 Moreover, in the alchemical process itself, the alchemical opus is not the final acquisition of a certain result; the opus is the ritual staging of certain events, which, according to a certain margin of luck, chance, or
blessing, may include, may possibly include, the truth, which will burst forth or pass by as an opportunity to be grasped in a ntually determined moment that is always enigmatic for the person who brings it about and that this individual will, precisely, have to grasp and understand. 20 Which means, moreover, that alchemical knowledge is always knowledge that is lost and so cannot have the same rules of accumulation as a scientific type of knowledge: alchemical knowledge must always start again from zero, that is to say, every alchemist has to start again the whole cycle of initiations; you are not borne on the shoulders of your predecessors in alchemical knowledge.
The only thing is that sometimes something like an enigmatic and indecipherable secret, which may have been overlooked or cast aside but which actually contains the essential, falls into someone's hands. And this secret, so secret that we do not even know it is a secret unless, precisely, we have undergone the ritual initiations or are prepared, or if the occasion is good, puts us on the track of something which may or may not take place. In any case, the secret will be lost again, or buried in some text or book of magic that chance, like an opportunity, like the Greek katros, will once more put into the hands of someone else, who may or may not be able to recognize it anew. 21
Good! All this belongs to a technology of truth which has nothing to do with the technology of scientific truth, and in this sense alchemy is not part of the history of science, [not] even as a sketch or possibility. However, this technology of truth-test or truth event survived for a long time within knowledge that might not be described as scientific, but which was nonetheless very close to science, lived on its borders, and
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accompanied its birth in the eighteenth century; that is to say, it survived in medicine, at the heart of medical practice.
It was at the heart of medical practice for centuries, roughly from Hippocrates22 to Sydenham,23 or even until eighteenth century medi- cine, that is to say, for 22 centuries. 2' It was not in medical theory, or in what began to take the form of anatomy or physiology in medicine, but in medical practice, in the relationship to the disease established by medicine that for 22 centuries there was something that did not fall within the sphere of demonstrative truth but within the sphere of this technology of truth-test. This is the notion of "crisis," or rather the set of medical practices organized around the notion of crisis.
What in actual fact is the crisis in medical thought since Hippocrates? What I am going to say to you is obviously very schematic since I am going to cover these 22 centuries presumptuously without considering all the modifications, sudden changes, disappearances and reappearances of the notion, etcetera, over this time.
What is the crisis in medical practice prior to pathological anatomy? It is well known that the crisis is the moment at which the evolution of the disease risks being resolved, that is to say, risks the decision of life or death, or also transition to the chronic state. 25 Is it a moment in an evolution? It is not exactly this; the crisis is quite precisely the moment of combat, the moment of the battle, or even the point at which the bat- tle is decided. The battle between Nature and Evil, the body's struggle against the morbific substance,26 or, as doctors in the eighteenth century will say, the battle between solids and humors. 27 The combat has its definite days, its moments prescribed by the calendar. However, this prescription of the days of the crisis is ambiguous in the sense that the crisis days for a disease actually mark a sort of natural rhythm that is typical ol the disease, and of this particular disease. That is to say, every disease has its own rhythm of possible crises; every patient has days when the crisis may be triggered. Hippocrates had already distinguished in this way fevers which have crises on even days from those which have them on odd days; for those with crises on even days, this may be the fourth, sixth, eighth, tenth, fourteenth, twenty-eighth, thirty-fourth, thirty eighth, fiftieth, or eightieth day. 28 For Hippocrates, and for the Hippocratic type of medicine, this gives a kind of description of the
? disease--we cannot say a symptomatological description--that charac terizes it on the basis of the, possible, necessary crisis day. It is therefore an intrinsic feature of the disease.
But it is also an opportunity to be seized, somewhat like the favor- able date in Greek manticism. 29 Just as there were days on which one could not engage the enemy in battle, so there are days when there should not be a crisis; and just as there were bad generals who did not join battle on a propitious day, so there were patients or diseases which produced their crisis on a day that was not propitious, so that on those occasions one had bad crises, that is to say, crises which necessarily led to an unfavorable development, a kind of supplementary complication, but without this meaning that crises occurring at a propitious moment always have lavorable outcomes. You can see the role of this crisis, which is both the intrinsic feature and, at the same time, the obligatory oppor- tunity, the ritual rhythm, to which events should conform.
Now when the crisis occurs, the disease breaks out in its truth; that is to say, it is not only a discontinuous moment but also the moment at which the illness, I won't say "reveals" a hidden truth, but appears m its own truth, its intrinsic truth. Belore the crisis the disease is one thing or another; it is nothing in truth. The crisis is the reality of the disease becoming truth, as it were. And it is precisely then that the doctor must intervene.
What is the doctor's role in the technique of the crisis? He must consider the crisis as the way, practically the only way, through which he can get a hold on the disease. With its variables of time, intensity, and types of resolution, etcetera, the crisis defines the way in which the doctor must intervene. 30 On the one hand, the doctor must first foresee the crisis, identify when it will occur,31 wait for the exact day on which it will take place, and then, at that point, engage in battle to defeat the disease,32 in short, so that nature triumphs over the disease. That is to say, in a sense the doctor's role is to reinforce the energy of nature. But we must be careful when reinforcing nature's energy, because what happens if we reinforce it too much when struggling against the disease? The result is that being, as it were, exhausted, and lacking strength, the disease will not join in the combat and the crisis will not take place, and if the crisis does not take place, then the harmful condition will persist.
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So a proper balance must be maintained. Similarly, if we reinforce nature too much, if nature becomes too vigorous and too strong, then the movement by which it tries to expel the disease will be too violent, and there will be the danger of the patient dying from the violence of nature's efforts against the disease. So we must neither weaken the ill ness too much, which risks avoiding the crisis, as it were, nor reinforce nature too much, because then there is the danger of the crisis being too violent. So you can see that in this technology of the crisis the doctor is much more the manager and arbitrator of the crisis than the agent of a therapeutic intervention. * The doctor must foresee the crisis, know the opposing forces, imagine its outcome, and arrange things so that it occurs at the right time; he must see how and with what force it approaches, and he must introduce only those necessary adjustments to each side of the balance so that the crisis takes its proper course.
And you can see that in its general form the technique of the crisis in Greek medicine is no different from the technique of a judge or arbitra- tor in a judicial dispute. In this technique of the test you have a sort of model, a jundico political matrix, which is applied both to the con- tentious battle in a case of penal law and to medical practice. Moreover, in medical practice there is a sort of supplementary complexity that is found again in judicial practice. This is that, as you can see, the doctor does not cure, and it cannot even be said that he directly confronts the disease, since it is nature that confronts the disease; he foresees the crisis, he gauges the contending forces, and he succeeds if he manages nature's success. And, to come back to this word crisis, which after all means "to judge,"B just as the disease comes up for judgment on the day of the crisis, so the doctor, in this role as a kind of arbitrator, is judged in turn by how he presides over the combat, and he may come out as victor or vanquished in relation to the disease.
In relation to the combat of nature and the disease, the doctor's is a second order combat, from which he will come out victor or vanquished in relation to these internal laws, but equally in relation to other doctors. And here again we come back to the juridical model. You know
* The manuscript adds: "more the role of observance of rules than of the observation ol phenomena. "
? that judges could be disqualified when they judged badly, in turn having to undergo a trial from which they will come out either victors or vanquished. And this kind of joust between the adversaries and between the laws of combat and then the judge had a sort of public character. This double combat always had public features. Now medical consultation, as you see it at work from Hippocrates up to Moliere's famous doctors--on the meaning and status of which we should nonetheless reflect a little--always involved several people. ^ That is to say, it involved at once a joust of nature against the disease, of the doctor with regard to this struggle of nature against the disease, and of the doctor with other doctors.
They were all present, each confronting the others, each making his own prediction about when the crisis must occur, what its nature would be, and what would be the outcome. However self-justifymg it may be, it seems to me that the famous scene Galen describes to explain how he made his lortune in Rome is an entirely typical scene of this kind of enthronement of the doctor. The story recounts how the young Galen, an unknown doctor coming to Rome from Asia Minor, participates in a kind of medical joust around a patient. When the doctors were predict mg this or that, Galen says, looking at the ill young man: There will be a crisis shortly; this crisis will be a nosebleed, and he will bleed from the right nostril. This is in fact what happens, and, Galen says, one by one all the doctors around me were quietly overshadowed. 35 The joust was also a joust between the doctors.
The doctor's appropriation of a patient, the recognition of the family doctor, the doctor patient discourse, are all the effect of a whole series oi economic, sociological and epistemological transformations of medi cine. However, in this medicine of the test, in which the crisis was the main component, the joust between doctors was as essential as the joust between nature and the disease. So you can see, this technology of truth test, of truth-event, persists for a long time in medicine, m medical practice, which, once again, like alchemy, was not utterly foreign to the developments of the scientific knowledge which adjoined, cut across, and were tangled up with it.
A word more on this subject. With the example ol medicine you can see, of course, that the extension of the other series, of the demonstrative
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technology of truth, was not brought about at a stroke, like a kind ol overall reversal, and it certainly does not take place in the same way in astronomy as in medicine, or in judicial practice the same way as m botany. However, broadly speaking, I think we can say that two processes have supported this transformation in the technology of truth, at least in what concerns empirical knowledge.
I think the transition from a technology of truth-event to truth demonstration is linked, on the one hand, to the extension of political procedures of the inquiry. The inquiry, the report, the evidence ol several people, the cross checking of information, the circulation of knowledge from the center of power to the points where it ends up and back again, as well as all the agencies ol parallel verification, progres sively, over a long history, gradually constituted the instrument of the political and economic power of industrial society; hence the refine- ment, the increasingly fine grid of these techniques of inquiry within the elements where they were usually applied. Broadly speaking, the refinement by which we passed from a basically fiscal kind of inquiry in the Middle Ages--knowing who collects what, who possesses what, so that the necessary deductions are made--to a police kind of investiga tion into peopled behavior, into how they live, think, make love, etcetera, this transition from fiscal inquiry to police investigation, the constitution of a police individuality starting from fiscal individuality, which was the only individuality known by power in the Middle Ages, reveals the tightening of the technique of inquiry in our kind of society. 36
Moreover, there was not only a local tightening, but also a planetary extension to the entire surface of the globe. There is a double movement of colonization: colonization in depth, which fed on the actions, bodies, and thoughts of individuals, and then colonization at the level of territories and surfaces. We can say that from the end of the Middle Ages we have seen the entire surface of the Earth, down to the finest grain of things, bodies, and actions, subjected to generalized investigation: a sort of grand inquisitorial parasitism. That is to say, at any time, at any place, and with regard to anything in the world, the question of truth can and must be posed. Truth is everywhere and awaits us everywhere, at any place and at any time. This, very schematically, is the great process that led to this move from a technology of the truth-event to a technology of truth findings.
? The other process was a sort of opposite process, f. . . *] establishing the rarity of this truth of anywhere and anytime. This rarefaction is not brought to bear on the emergence or production of truth however, but precisely on who can discover it. In one sense, this universal truth of anywhere and anytime, which any inquiry can and must track down and discover with regard to no matter what, is accessible to anyone; anyone can have access to it, since it is there, everywhere and all the time. However, the necessary circumstances are still required, and we must acquire the forms of thought and techniques that will give us access to this truth that is everywhere, but always deep down, buried, and diffi cult to reach.
So we will have, of course, a universal subject of this universal truth, but it will be an abstract subject because, concretely, the universal sub- ject able to grasp this truth is rare, since it must be a subject qualified by procedures of pedagogy and selection. Universities, learned societies, canonical teaching, schools, laboratories, the interplay of specialization and professional qualification, are all ways of organizing the rarity of those who can have access to a truth that science posits as universal. It will be the abstract right of every individual to be a universal subject, if you like, but to be one in fact, concretely, will necessarily entail rare individuals being qualified to perform the function of universal subject. In the history of the West since the eighteenth century, the appearance of philosophers, men of science, intellectuals, professors, laboratories, etcetera, is directly correlated with this extension of the standpoint of scientilic truth and corresponds precisely to the rarelaction of those who can know a truth that is now present everywhere and at every moment. Fine. That's the little history I wanted to present. What is its relation- ship to madness? We're just coming to it.
In the medicine in general that I have been talking about, the notion of crisis disappears at the end of the eighteenth century. It not only
* (Recording:) we could call it
23 January 1974 1\1
? 248 PSYCHIA TRIC POWER
disappears as a notion, after Hoffmann*7 say, but also as an organizing principle of medical technique. Why did it disappear? Well, I think it disappeared for the reasons I have just given in a general schema, that is to say, with regard to disease, as with regard to everything henceforth, there is the organization of a sort of inquisitorial space or grid. 38 The construction of what we can broadly call hospital and medical facilities in Europe in the eighteenth century basically ensures the general sur- veillance of populations, making it possible, in principle, to investigate the health of every individual. 39 The hospital also makes possible the integration of the living individual's body, and especially his dead body, into the disease. ^0 That is to say, at the end of the eighteenth century we will have both a general surveillance of populations and the concrete possibility of establishing a relationship between a disease and a body on which an autopsy has been carried out. The birth of pathological anatomy and, at the same time, the appearance of a statistical medicine, of a medicine of large numbersH1--both the ascription of precise causal- ity by the projection of the illness on a dead body and the possibility of inspecting a set of populations--provide the two major epistemological tools of nineteenth century medicine. And it is quite clear that hence forth a technology of observation and demonstration will progressively make the technique of crisis unnecessary.
What happens in psychiatry then? Well, I think something very strange takes place. On the one hand, it is clear that the psychiatric hospital, like the hospital of general medicine, cannot but tend to make the crisis disappear. The psychiatric hospital, like any other hospital, is a space of inquiry and inspection, a sort of inquisitorial site, and there is no need at all for that test of truth. I have also tried to show you that not only is there no need for the test of truth, but there is no need for truth at all, whether arrived at by the technique of the test or by that of demonstration. Furthermore, not only is there no need for it, but to tell the truth the crisis as an event in the madman's madness and behavior is ruled out. Why is it ruled out? Essentially for three reasons I think.
First, it is ruled out precisely by the fact that the hospital functions as a disciplinary system, that is to say, as a system subject to rules, expecting a certain order, imposing a certain regime that excludes any thing like the raging and raving outburst of the crisis ol madness.
? Moreover, the main instruction, the main technique of this asylum discipline, is: Don't think about it. Don't think about it; think about something else; read, work, go into the fields, but anyway, don't think about your madness/'2 Cultivate, not your own garden, but the director's. Do woodwork, earn your keep, but don't think about your illness. The disciplinary space of the asylum cannot permit the crisis of madness.
Second, constant recourse to pathological anatomy in asylum practice, from about around 1825, played the role of theoretical rejection of the crisis/3 Actually, nothing, apart from what took place with general paral- ysis, permitted the assumption, or anyway the ascription, of a physical cause to mental illness. Now, the practice of autopsy was, at least in a great many hospitals, a sort of regular practice the basic meaning of which was, I think, the following: if there is a truth of madness, it is cer- tainly not in what the mad say; it can only reside in their nerves and their brain. To that extent, the crisis as the moment of truth, as the moment at which the truth of madness burst forth, was ruled out epistemologically by recourse to pathological anatomy, or rather, I think that pathological anatomy was the epistemological cover behind which the existence of the crisis could always be rejected, denied, or suppressed: We can strap you to your armchair, we can refuse to listen to what you say, since we will seek the truth of madness from pathological anatomy, when you are dead.
Finally, the third reason for rejecting the crisis was a process I have not considered until now: the relationship between madness and crime. In fact, from around 1820-1825 we see a very strange process in the courts in which doctors--who were not called on by the prosecutor or by the president of the court, and often not even by lawyers--gave their opinion on a crime and, as it were, tried to claim the crime for mental illness itself. v' Faced with any crime, the doctors raised the question: Could not this be a sign of illness? And it was in this way that they con- structed the very curious notion of monomania which, schematically, means this: when someone commits a crime which has no raison d'etre, no justification at the level of his interest, wouldn't the fact alone of committing the crime be the symptom of an illness, the essence of which would basically be the crime itself? Monomania was a sort of single symptom illness with just one symptom occurring only once in the individual's life, but a symptom that was, precisely, the crime? ''5
23, January 1974 249
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One wonders why psychiatrists take this interest in crime, and why they insist so strongly and, in a way, so violently on the potential identity of crime and mental illness. There are, of course, a number of reasons, but I think one of them is the attempt to demonstrate not so much that every criminal may be mad, but to demonstrate something that is much more serious, and also much more important for psychi- atric power, namely, that every mad person is a possible criminal. The determination to pin madness on a crime, even on every crime, was a way of founding psychiatric power, not in terms of truth, since precisely it is not a question of truth, but in terms of danger: Mve are here to protect society, since at the heart of every madness there is the possibil ity of crime. In my view, pinning something like a madness on a crime is, for social reasons of course, a way of getting the individual out of trouble, but, as a general rule, at the level of the general operation of this ascription of madness to crime, there is the psychiatrists' wish to base their practice on something like social defense, since they cannot base it in truth. So, we can say that the effect of the disciplinary system of psychiatry is basically to get rid of the crisis. Not only is it not needed, it is not wanted, since the crisis could be dangerous, since the madman's crisis could well be another person's death. There is no need for it, pathological anatomy dispenses with it, and the regime of order and discipline means that the crisis is not desirable.
However, at the same time as this is taking place, there is a movement in the opposite direction, for the explanation and justification of which there are two reasons. On the one hand, the crisis is needed because, in the end, neither the disciplinary regime, nor the obligatory calm imposed on the mad, nor pathological anatomy, enabled psychiatric knowledge to be founded as truth. So that this knowledge, which I have tried to show you operated as a supplement of power, was for a long time running on empty, and obviously it could not rail to seek to pro- vide itself with a content of truth according to the same norms of the medical technology of the time, that is to say, the technology of reported findings. But since this was not possible, the crisis was resorted to for another, positive reason.
The real point at which psychiatric knowledge is exercised is not ini- tially or essentially what enables the illness to be specified, described,
? and explained. In other words, whereas the doctor, given his position, is basically obliged to respond to the patient's symptoms and complaints with an activity of specification and characterization--hence the bet that differential diagnosis has been the major medical activity since the nineteenth century--the psychiatrist is not required, or called in at the patient's request, to give the latter's symptoms a status, character, and speciiication. The psychiatrist is needed at an earlier stage, at a lower level, where it has to be decided whether or not there is an illness. For the psychiatrist it is a matter of answering the question: Is this individ- ual mad or not? The question is put to him by the Iamily in cases ol voluntary admission, or by the administration in cases ol compulsory admission--although the administration only puts the question on the quiet, since it reserves the right to disregard what the psychiatrist says--
but, in any case, the psychiatrist is situated at this level.
Whereas (general] medical knowledge functions at the point ol the specification ol the illness, at the point of differential diagnosis, medical knowledge in psychiatry functions at the point of the decision between madness or non madness, the point, if you like, ol reality or non reality, reality or fiction, whether this be liction on the part of the patient who, for one reason or another, would like to pretend to be mad, or the fiction of the Iamily circle, which imagines, wishes, desires, or imposes the image of madness. This is the point at which the psychiatrist's
knowledge, and also his power, functions. '6
Now what tools does the psychiatrist possess that enable him to
function at this level and decide on the reality ol madness? It is precisely here that we encounter the paradox of nineteenth century psychiatric knowledge once again. On the one hand, psychiatric knowledge really tried to construct itsell on the model ol medicine observation, of inquiry and demonstration; it really tried to constitute a symptomato- logical type of knowledge for itself; a description of different illnesses was actually constituted, etcetera, but, to tell the truth, this was only the cover and justification for an activity situated elsewhere, and this activity was precisely that of deciding between reality or lie, reality or simulation. The activity of psychiatric knowledge is really situated at the point of simulation, at the point of fiction, not at the point of characterization.
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There are, I think, a number of consequences of this. The first is that in order to resolve this problem the psychiatric hospital literally invented a new medical crisis. This was no longer that old crisis of truth played out between the forces of the disease and the forces of nature that was typical of the medical crisis put to work in the eighteenth century, but a crisis that I will call a crisis of reality, which is played out between the mad person and the power that confines him, the doctor's power knowledge. The doctor must be able to arbitrate on the question of the reality or non-reality of the madness.
So, as you can see, unlike the hospital of general medicine, the psychiatric hospital's function is not to be the place where an "illness" exhibits its specific and differential characteristics in comparison with other illnesses. The psychiatric hospital has a much simpler, more elementary, more lundamental function. Its function is, precisely, to give madness reality, to open up a space of realization for madness. The psychiatric hospital exists so that madness becomes real, whereas the hospital's function tout court is both knowing what the illness is and eliminating it. The psychiatric hospital's function, following the psychi atric decision concerning the reality of the madness, is to make it exist as reality.
Here we encounter an institutional type of criticism of the psychi atric hospital, which charges it, precisely, with fabricating the mad out of the people it claims to cure. This institutional type of criticism thus poses the question: What kind oi institution could work in such a way that the mad could be cured and not pushed deeper into illness? How could the [asylum] institution work like any hospital? " However, in the end I think this criticism is quite inadequate because it lacks the essential. That is to say, it lacks an analysis of the distribution of psychiatric power that makes it possible to show that the fact that the psychiatric hospital is a place for the realization of madness is not an accident or due to a deviation of the institution, but that the very func tion of psychiatric power is to have before it, and for the patient, a space of realization for the illness (that, when it comes to it, may or may not be in the hospital). We can say then that the function of psychiatric power is to realize madness in an institution where the function of dis- cipline is precisely to get rid of all the violence, crises, and, if necessary,
? all the symptoms of madness. The real function and effect of the asylum institution in itself, of this institution of discipline--and it is in this respect that my analysis differs from institutional analyses--is to sup- press, I do not say madness, but the symptoms of madness, at the same time as the function of psychiatric power, which is exercised within and lixes individuals to the asylum, is to realize madness.
All in all, there is an ideal for this double lunctioning of psychiatric power, which realizes madness, and of the disciplinary institution, which refuses to listen to madness, which flattens out its symptoms and planes down all its manifestations: this is dementia. What is a demented person? He is someone who is nothing other than the reality of his madness; he is the person in whom the multiplicity of symptoms or, rather, their flattening out, is such that it is no longer possible to ascribe to him a specific symptomatology by which he could be characterized. The demented person is therefore someone who corresponds exactly to the working of the asylum institution, since, by means of discipline, all the symptoms in their specificity have been smoothed out: there are no longer any outward signs, externalizations, or crises. And, at the same time, someone who is demented answers to what psychiatric power wants, since he actually realizes madness as an individual reality within the asylum.
The famous development of dementia, which nineteenth century psy- chiatrists could observe as a natural phenomenon in madness, is noth- ing other than the series of intertwined effects of an asylum discipline that smoothes away outward signs and symptoms, and medical power's appeal to the patient to be a madman, to realize madness. The demented person is actually what was fabricated by this double game of power and discipline.
As for the hysterics, those famous, dear hysterics, I would say that they were precisely the front of resistance to this gradient of dementia that involved the double game of psychiatric power and asylum discipline. They were the front of resistance, because, what is a hysteric? A hysteric is someone who is so seduced by the best and most clearly specified symptoms--those, precisely, offered by the organically ill--that he or she adopts them. The hysteric constitutes herself as the blazon of genuine illnesses; she models herself as a body and site bearing genuine
2^ January 1974 253
? 254 PSYCHIATRIC POWF,R
symptoms. To the ascription ol and propensity towards the subsidence ol symptoms in dementia, the hysteric responds with the exacerbation of the most precise and well determined symptoms; and while doing this, she pursues a game such that when one wants to lix her illness in reality, one can never manage to do so, since, when her symptom should refer to an organic substratum, she shows that there is no substratum, so that she cannot be fixed at the level of the reality of her illness at the very moment she displays the most spectacular symptoms. Hysteria was the effective way ol defending onesell Irom dementia; the only way not to be demented in a nineteenth century hospital was to be a hysteric, that is to say, to counter the pressure that annihilated symptoms, that obliterated them, by building up the visible, plastic edifice of a whole panoply of symptoms, and, by means of simulation, resisting madness being fixed in reality. The hysteric has magnificent symptoms, but at the same time she sidesteps the reality of her illness; she goes against the current of the asylum game and, to that extent, we salute the hysterics as the true militants ol antipsychiatry. ^
? 1. Discovered in the sixteenth century, the use oi ether spread in the nineteenth century in the treatment ol neuroses and for screening simulated illnesses, on account of its "stupefying" property. See above, note 18 to lecture of 9'11 January 1974.
2. Discovered simultaneously in 1831 by Justus Liebig in Germany and by Soubeiran in France, the use of chloroform as an anesthetic began in 1847. See, E. Soubeiran, "Recherches sur quelques combinaisons de chlore" Annales de chimie et de physique, vol. XLIII, October 1831, pp. 113-157; H. Bayard, "L'utihsation de l'ether et le diagnostic des maladies men tales"; H. Brochin, "Maladies nerveuses", ? "Anesthesiques: ether et chloroforme"; and, Lailler (pharmacist of the Quatre Mares asylum) "Les nouveaux hypnotiques et leur emploi en medecine mentale" Annales medico-psychologiques, 7lh series, vol. IV,July 1886, pp. 64-90.
}. See above, note 1 to lecture ol 19 December 1973.
4. See above, note 2 to lecture of 19 December 1973.
5. J. J. Moreau de Tours discovered the effects ol hashish on his journey in the East from 1837
6.
to 1840 and he subsequently devoted his research to it, loreseeing possibilities of experi ment to clanly the relations between its ellects and dreams and delirium. See, Du haschkh
et d'alienation mentale. Etudes psychologiques (Paris: Fortin, 1845).
Experiments in "animal magnetism" took place in hospitals under the Restoration.
66. Ibid. p. |/|8.
67. F. Voisin, De Vidiolie chevies enfanls, p. 83.
68. D. M. Bourneville, Assistance, Traitement et Education, p. V|5.
69. In the second hall of the nineteenth century the research ol psychiatrists concerning
instinct developed on two fronts: one, natural, of cerebral physiology, and the other, cul tural, ol the relationships between sociability and morality. See, G. Bouchardeau, "La notion d'instinct, dans la clinique psychiatrique au XIX1" Evolution psychiatrique, vol. XLIV , no. 5, July September 1979, pp. 617 6*2.
Valentin Magnan (1835 1916) established a link between the instinctive perversions ol degenerates and anatomico physiological disorders ol the cerebral spinal system, in a classihcation which connected the different perversions to processes of excitation or inhibition ol corresponding cerebral spinal structures. See his "Etude clinique sur les impulsions et les actes des alienes" (1861) in Recherches sur les centres netveux, vol. II (Pans: Masson, 1893) pp. 353 369- See also, Paul Serieux (1864 I97l7), Recherches cliniques sur les anomalies de I'instinct sexuel, Medical Thesis, Pans, no. 50,1888 (Pans: Lecrosnier and Babe, 1888 1889), and Charles Fere (1852 1907) Uinstinct sexuel. Evolution et dissolution (Paris: Alcan, 1889). Foucault returns to this point in Les Anormaux, lectures ol 5 and 12 February and 21 March 1975, pp. 120-125, pp. 127 135, and pp. 260 271; Abnormal, pp. 129 13'l, 137 Vi5, and 275 287.
70. Thus, in 1886, Joseph Jules Dejerine (187 I9 1917) reviews Darwin's work very positively in L'Heredite dans les maladies du systeme nervetix (Pans: Asselin and Houzeau, 1886). But it was V. Magnan who developed Morel's theory by introducing a relerence to the notion of evolution and of the neurological localization ol the degenerative process. See his Lecons cliniques sur les maladies mentalcs (Paris: Battaille, 1893); V. Magnan and P. Legrain, Les Degeneres (etat mental et syndromes episodiques) (Paris: Rueff, 1895); and A. Zaloszyc,
Elements d'une histoirc de la theorie des degenerescences dans la psychiatric francaise, M e d i c a l Thesis, Strasbourg, July 1975.
71. Two years before the publication of Charles Darwin's On the Origin oj the Species by means oj Natural Selection, or the Preservation oj Favoured Races in the Struggle j or Life ( L o n d o n : J. Murray, 1859), B. A. Morel published his Traite des degenerescences physique, intellectuelles el morales de I'espece humaine, et des causes qui produisent ces varietes maladives ( P a r i s :
J. B. Bailliere, 1857) in which he defines degeneration: "The clearest idea we can give our selves ol the degeneration of the human species is to think ol it as a primitive type of unhealthy deviation. This deviation, however simple we imagine it to be in its origin, nonetheless contains elements of transmissibility of such a kind that the person who car ries its germ becomes increasingly incapable of fulfilling his functions in humanity, and intellectual progress, already checked in his person, is still threatened in his descendants" (p. 5). The psychiatry that comes from Morel will only convert to evolutionism by ceasing
? . 2.
to see "perlection" as the most exact conlormity to a "original (primiti/)"
seeing it instead as the greatest possible divergence Irom that type.
Sec, I. R. Dowbiggin, Inheriting Madness: Professional Ration and Psychiatric Nineteenth-Century France (Berkeley: University ot California Press, 1991); French translation, La Folie hereditaire, ou Comment la psychialrie francaise s 'est consliluee en un coips de savoir el de pouvoir dans la seconde moitie du XIX'' siecle, trans. G. Le Gaulrey, prelace by G. Lanteri Laura (Paris: Ed. Epel, 1993).
/}. After reaching its peak in the 1880s, the theory of degeneration began to decline. Freud criticized it in 1894 in his article on "Die Abwehr Neuropsychosen" Neurologisches Zen/ralblatt, vol. 13, 1894, no. 10, pp. 362 364 and no. 11, pp. 402 409, reprinted in GW, vol. I, 1952, pp. 57 74; French translation, "Les psychonevroses de delese" trans.
J. Laplanche, in S. Freud, Nevrose, Psychose et Perversion (Paris: Presses universitaires de- France, 1973); English translation, "The Neuro Psychoses of Delence, Standard Edition, vol. 3. Also: Drei Abhandlungen %itr Sexua/theorie (Vienna: Deuticke, 1905) in GW, vol. V, 1942, pp. 27 145; French translation, Trois Essais sur la theorie de la sexualite, Irans. B. Reverchon Jouve (Paris: Gallimard, 1923); English translation, "Three Essays on the Theory of Sexuality, Standard Edition (1953 1974) vol. 7. In 1903, Gilbert Ballet (1853 1916) wrote in a Traite de pathologie mentale published under his editorship (Pans: Doin, 1903), that he saw no advantages in including the term "degeneration" in the vocab ulary ol twentieth century psychiatry ( pp. 273 275). See, G. Genii Perrin, Histoire des orig- ines el de revolution de I'idee de degenerescence en medecine mentale ( P a n s : A. Leclerc, 1913).
16 January 1974
231 type, and by
Knowledge in
? ten
23 JANUARY 1974
Psychiatric power and the question of truth: questioning and confession; magnetism and hypnosis; drugs. ^ Elements for a history of truth: 1. The truth-event and itsforms: judicial, alchemical and medical practices. r^ Transition to a technology of
demonstrative truth. Its elements: (a) procedures of inquiry; (b) institution of a subject of knowledge; (c) ruling out the crisis in medicine and psychiatry and its supports: the disciplinary space
of the asylum, recourse to pathological anatomy; relationships between madness and crime. ^ Psychiatric power and hysterical resistance.
I HAVE ANALYZED THE level at which psychiatric power appears as a power in which and by which truth is brought into play. It seems to me that, at a certain level at least, let's say the level of its disciplinary opera- tion, the function of psychiatric knowledge is by no means to found a therapeutic practice in truth, but much rather to give the psychiatrist's power a particular stamp, to give it an additional, supplementary distinc- tion; in other words, the psychiatrist's knowledge is one of the compo- nents by which the disciplinary apparatus organizes the surplus-power of reality around madness.
But this leaves out of account certain elements that are nevertheless present in this historical period of what I call proto-psychiatry, extend- ing, roughly, from the 1820s to the 1860s and 1870s, until what we can call the crisis of hysteria. In one sense the elements I have left to one side are fairly unobtrusive, dispersed, not very prominent, and they have
? 234 PSYCHIATRIC POWER
certainly not occupied a large space in the organization of psychiatric power in the operation of the disciplinary regime, and yet I think these elements were switch points in the process of the internal and external transformation of psychiatric power. These few, unobtrusive, dispersed points are those where madness was posed the question of truth despite the overall working of the disciplinary apparatus. In saying that there are three such points, I do not claim that this is an exhaustive list; it seems to me that we can say provisionally that there were three in which the question ol truth addressed to madness creeps in.
These points are, first of all, the practice or ritual of questioning and the extortion of confession, which is the most important and most constant process, and which ultimately has not changed much within psychiatric practice. Second, a different process which had a cyclical for- tune, which disappeared at one point, but which, through the havoc it wreaked in the disciplinary world of the asylum, was extremely impor- tant historically: the procedure of magnetism and hypnosis. And finally, third, a well known element about which the history of psychiatry has been significantly quiet, which is the use, I do not say the absolutely constant use, but from around 1840 to 1850 the very general use of drugs--mainly ether,1 chloroform,2 opium,3 laudanum/1 and hashish,5 a whole panoply--which for a dozen years were used on a daily basis in the asylum world of the nineteenth century, and on which the histori- ans of psychiatry have been prudently silent, although, along with hypnosis and the technique of questioning, it is probably the point on which the history of psychiatric practice and power took a sudden turn or, at any rate, was transformed.
Of course, these three techniques are ambiguous, that is to say, they function at two levels. On the one hand, they function at the disciplinary level; in this sense, questioning is really a particular way of fixing the individual to the norm of his own identity--Who are you? What is your name? Who are your parents? What about the different episodes of your madness? --of pinning the individual to his social identity and to the madness ascribed to him by his own milieu. Questioning is a disciplinary method and its effects can in fact be identified at that level.
Magnetism was introduced into the nineteenth century asylum very early on, that is to say around 1820 to 1825, at a time when its use was
? still at an empirical level and other doctors generally rejected it. It was very clearly used as an adjunct of the doctor's physical, corporal power. 6 In this space of the extension of the doctor's body organized by the asylum, in this kind of process, this game, by which the working parts of the asylum must be like the psychiatrist's own nervous system, so that the psychiatrist's body and the asylum space itself form a single body, it is clear that magnetism, with all its physical effects, was a functional component in the mechanism of discipline. Finally, drugs--mainly opium, chloroform, and ether--were, like drugs still today, an obviously disciplinary instrument lor maintaining order, calm, and keeping patients quiet.
At the same time, the use of these three perfectly decipherable ele ments whose disciplinary ellects make their insertion into the asylum quite comprehensible, and despite what was expected of them, had an effect in which they brought with them or introduced a question of truth. It may be that it was the cross examined, magnetized, hypnotized, and drugged madman himself who posed the question of truth. And, to that extent, it seems to me that these three elements really were the ele- ments of the disciplinary system's fracture, the moment at which medical knowledge, which again was only a token of power, found itself required to speak, no longer just in terms of power, but in terms of truth.
I would like to open a parenthesis here and insert a little history of truth in general. It seems to me that we could say that knowledge of the kind we call scientific basically presupposes that there is truth every- where, in every place and all the time. More precisely, this means that while there are of course moments for scientific knowledge when the truth is grasped more easily, points of view that allow it to be perceived more easily or certainly, and instruments for discovering it where it is hidden, remote or buried, nonetheless, for scientific practice in general, there is always the truth; the truth is always present, in or under every thing, and the question of truth can be posed about anything and everything. The truth may well be buried and difficult to reach, but this only directs us to our own limits and circumstances. The truth in itself
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permeates the entire world, without break. There is no black hole in the truth. This means that for a scientific type of knowledge nothing is too small, trivial, ephemeral, or occasional for the question of truth, nothing too distant or close to hand tor us to put the question: what are you in truth? The truth dwells in everything and anything, even Plato's famous nail clippings. 7 This means not only that the truth lives everywhere and that the question of truth can be posed at every [moment], but it also means that no one is exclusively qualified to state the truth, if, of course, they have the instruments required to discover it, the categories necessary to think it, and an adequate language for formulating it in propositions. Speaking even more schematically, let's say that we have here a philosophico scientilic standpoint of truth linked to a technology for the construction of truth, or for finding it in principle, a technology of demonstration. Let's say that we have a technology of demonstrative truth joined, in short, to scientific practice.
Now I think there has been a completely different standpoint of truth in our civilization. This completely different standpoint of truth, no doubt more archaic than the one I am talking about, was gradually pushed aside or covered over by the demonstrative technology of truth. This other standpoint of truth, which is, I think absolutely crucial in the history of our civilization by virtue of it being covered over and colonized by the other, is that of a truth which, precisely, will not be everywhere and at all times waiting for us whose task is to watch out for it and grasp it wherever it happens to be. It will be the standpoint of a dispersed, dis- continuous, interrupted truth which will only speak or appear from time to time, where it wishes to, in certain places; a truth which does not appear everywhere, at all times, or for everyone; a truth which is not waiting for us, because it is a truth which has its favorable moments, its propitious places, its privileged agents and bearers. It is a truth which has its geography. The oracle who speaks the truth at Delphi8 does not express it anywhere else, and does not say the same thing as the oracle in another place; the god who cures at Epidaurus,9 and who tells those who come to consult him what their illness is and what remedy they must apply, only cures and expresses the truth of the illness at Epidaurus and nowhere else. A truth, then, which has its geography, and which has its calendar as well, or, at least, its own chronology.
? Take another example. In the old Greek, Latin and medieval medicine of crises, to which I will come back, there is always a moment lor the truth of the illness to appear. This is precisely the moment of the crisis, and there is no other moment at which the truth can be grasped in this way. In alchemical practice, the truth is not lying there waiting to be grasped by us; it passes, and it passes rapidly, like lightning; it is in any case linked to the opportunity, to the kairos, and must be seized. 10
It is not only a truth with its geography and calendar, but also with its messengers or privileged and exclusive agents. The agents of this discon- tinuous truth are those who possess the secrets of times and places, those who undergo tests of qualification, those who have uttered the required words or performed ritual actions, and those again whom truth has cho- sen to sweep down on: prophets, seers, innocents, the blind, the mad, the wise, etcetera. This truth, with its geography, its calendars, and its mes- sengers or privileged agents, is not universal. Which does not mean that it is rare, but that it is a dispersed truth, a truth that occurs as an event.
So you have attested truth, the truth of demonstration, and you have the truth-event. We could call this discontinuous truth the truth thunderbolt, as opposed to the truth-sky that is universally present behind the clouds. We have, then, two series in the Western history of truth. The series of constant, constituted, demonstrated, discovered truth, and then a different series of the truth which does not belong to the order of what is, but to the order of what happens, a truth, therefore, which is not given in the form of discovery, but in the form of the event, a truth which is not found but aroused and hunted down: production rather than apophantic. It is not a truth that is given through the medi- ation of instruments, but a truth provoked by rituals, captured by ruses, seized according to occasions. This kind of truth does not call for method, but for strategy. The relationship between this truth-event and the person who is seized by it, who grasps it or is struck by it, is not a relationship of subject to object. Consequently it is not a relationship within knowledge but, rather, a relationship of a shock or clash, like that of a thunderbolt or lightning. It is also a hunting kind of relation- ship, or, at any rate, a risky, reversible, warlike relationship; it is a relationship of domination and victory, and so not a relationship of knowledge, but one of power.
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There are those who are in the habit of writing the history of truth in terms of the forgetting of Being,11 that is to say, when they assert forgetting as the basic category of the history of truth, these people place themselves straightaway within the privileges of established knowledge, that is to say, something like forgetting can only take place on the ground of the assumed knowledge relationship, laid down once and for all. Consequently, I think they only pursue the history of one of the two series I have tried to point out, the series of apophantic truth, of dis covered, established, demonstrated truth, and they place themselves within that series.
What I would like to do, what I have tried to do in the last years, is a history of truth starting with the other series,12 that is to say, I have tried to single out the technology--today, effectively dismissed, brushed aside and supplanted--of the truth-event, truth-ritual, truth-power relation ship, as opposed to the truth-discovery, truth method, truth-knowledge relationship, as opposed, therefore, to truth that is presupposed and placed within the subject-object relationship.
I would like to emphasize the truth-thunderbolt against the truth sky, that is to say, on the one hand, to show how this truth-demonstration, broadly identified in its technology with scientific practice, the present day extent, force and power of which there is absolutely no point in denying, derives in reality from the truth-ritual, truth event, truth- strategy, and how truth knowledge is basically only a region and an aspect, albeit one that has become superabundant and assumed gigantic dimensions, but still an aspect or a modality of truth as event and of the technology of this truth-event.
Showing that scientific demonstration is basically only a ritual, that the supposedly universal subject of knowledge is really only an individ- ual historically qualified according to certain modalities, and that the discovery of truth is really a certain modality of the production of truth; putting what is given as the truth of observation or demonstration back on the basis of rituals, of the qualifications of the knowing individual, of the truth-event system, is what I would call the archeology of knowledge. 13
And then there is a further move to be made, which would be to show precisely how, in the course of our history, of our civilization, and
? in an increasingly accelerated way since the Renaissance, truth- knowledge assumed its present, familiar and observable dimensions; to show how it colonized and took over the truth-event and ended up exer- cising a relationship of power over it, which may be irreversible, but which for the moment anyway is a dominant and tyrannical power, to show how this technology of demonstrative truth colonized and now exercises a relationship of power over this truth whose technology is linked to the event, to strategy, and to the hunt. We could call this the genealogy of knowledge, the indispensable historical other side to the archeology of knowledge, and which I have tried to show you, very schematically, with some dossiers, not what it might consist of, but how it might be sketched out. Opening up the dossier of judicial practice was an attempt to show how, through judicial practice, politico-juridical rules were gradually formed for establishing the truth in which we saw the technology of the truth-test ebbing away and disappearing with the advent of a certain type of political power and the establishment of the technology of a truth of certified observation, of a truth authenticated
by witnesses, etcetera.
What I would now like to do with regard to psychiatry is show how in the nineteenth century this event type of truth is gradually hidden by a different technology of truth, or at least, how, with regard to madness, there was an attempt to cover up this technology of the truth-event with a technology of demonstrative truth, of observation. We could also do this, and in the next years I will try to do it with regard to pedagogy and the dossier on childhood. 1^
It could be said that this is all very well historically, but all the same, there is little now that corresponds to the truth-test-event series in our society; we may be able to find this technology of the truth event in some old practices--say in oracular, prophetic practices, etcetera--but it is a long time since this game was played and there is no point in return ing to it. Actually, I think there really is something else here, and that in actual fact, within our civilization, this truth-event, this technology of the truth-thunderbolt, seems to me to have subsisted for a long time and has considerable historical importance.
First, with regard to the judicial forms I have talked about in previous years and to which I have just referred, a very profound and
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fundamental transformation is involved. You remember what I said to you about archaic medieval justice, of justice before the twelfth century, more or less: the medieval procedure for discovering the guilty person, or rather, for assigning individual culpability, the procedures broadly placed under the rubric of "the judgment of God," were in no way methods for discovering what really happened. There was absolutely no question of reproducing within "God's judgment" something like the analogon, the image itself of what really happened at the level of the criminal action. "God's judgment" and tests of this kind were proce- dures for governing how to determine the victor in a confrontation between two individuals in dispute. 15 Even confession was not a sign or a method for discovering a sign of culpability in medieval judicial techniques. 16 When the Inquisitors of the Middle Ages tortured some- one, they did not appeal to the kind of argument made by present day torturers, that someone's acknowledgement of guilt is the best proof, even better, closer, than that of an eye witness; the torturer of the Middle Ages did not seek to obtain this kind of proof afortiori. In fact, torturing someone in the Middle Ages involved the judge and the person accused or suspected in a real physical struggle--the rules of which, while not rigged, were of course completely unequal and with no reciprocity--to find out whether or not the suspect would stand up to it. When he gave way, this was not so much a demonstrative proof that he was guilty, as quite simply the reality of the fact that he had lost in the game, in the confrontation, and could consequently be sentenced. All this could then be inscribed, secondarily as it were, in a system of significations: God, then, has abandoned him, etcetera. But this was absolutely not the mundane sign of his culpability; it was the final phase, the final episode, the conclusion of a confrontation. 17 And finally to pass from this technique for establishing the truth in the test to the establishment of truth in the certified report, through evidence and demonstration, required the whole process by which penal justice was brought under State control. 18
We could say the same about alchemy. The basic reason why alchemy has never really been refuted by chemistry, why it cannot figure in the history of science as an error or scientific impasse, is that it does not correspond, and never has corresponded, to the technology of
? demonstrative truth; from start to finish it corresponded to the technol- ogy of the truth-event or of the truth-test.
Very roughly, summarizing its main characteristics, what is alchemical research in fact? First of all it involves the individuals initiation, that is to say, his moral or ascetic qualification; he must prepare himself for the test of truth, not so much by the accumulation of certain contents of knowledge as by the fact that he really has gone through the required ritual. 19 Moreover, in the alchemical process itself, the alchemical opus is not the final acquisition of a certain result; the opus is the ritual staging of certain events, which, according to a certain margin of luck, chance, or
blessing, may include, may possibly include, the truth, which will burst forth or pass by as an opportunity to be grasped in a ntually determined moment that is always enigmatic for the person who brings it about and that this individual will, precisely, have to grasp and understand. 20 Which means, moreover, that alchemical knowledge is always knowledge that is lost and so cannot have the same rules of accumulation as a scientific type of knowledge: alchemical knowledge must always start again from zero, that is to say, every alchemist has to start again the whole cycle of initiations; you are not borne on the shoulders of your predecessors in alchemical knowledge.
The only thing is that sometimes something like an enigmatic and indecipherable secret, which may have been overlooked or cast aside but which actually contains the essential, falls into someone's hands. And this secret, so secret that we do not even know it is a secret unless, precisely, we have undergone the ritual initiations or are prepared, or if the occasion is good, puts us on the track of something which may or may not take place. In any case, the secret will be lost again, or buried in some text or book of magic that chance, like an opportunity, like the Greek katros, will once more put into the hands of someone else, who may or may not be able to recognize it anew. 21
Good! All this belongs to a technology of truth which has nothing to do with the technology of scientific truth, and in this sense alchemy is not part of the history of science, [not] even as a sketch or possibility. However, this technology of truth-test or truth event survived for a long time within knowledge that might not be described as scientific, but which was nonetheless very close to science, lived on its borders, and
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accompanied its birth in the eighteenth century; that is to say, it survived in medicine, at the heart of medical practice.
It was at the heart of medical practice for centuries, roughly from Hippocrates22 to Sydenham,23 or even until eighteenth century medi- cine, that is to say, for 22 centuries. 2' It was not in medical theory, or in what began to take the form of anatomy or physiology in medicine, but in medical practice, in the relationship to the disease established by medicine that for 22 centuries there was something that did not fall within the sphere of demonstrative truth but within the sphere of this technology of truth-test. This is the notion of "crisis," or rather the set of medical practices organized around the notion of crisis.
What in actual fact is the crisis in medical thought since Hippocrates? What I am going to say to you is obviously very schematic since I am going to cover these 22 centuries presumptuously without considering all the modifications, sudden changes, disappearances and reappearances of the notion, etcetera, over this time.
What is the crisis in medical practice prior to pathological anatomy? It is well known that the crisis is the moment at which the evolution of the disease risks being resolved, that is to say, risks the decision of life or death, or also transition to the chronic state. 25 Is it a moment in an evolution? It is not exactly this; the crisis is quite precisely the moment of combat, the moment of the battle, or even the point at which the bat- tle is decided. The battle between Nature and Evil, the body's struggle against the morbific substance,26 or, as doctors in the eighteenth century will say, the battle between solids and humors. 27 The combat has its definite days, its moments prescribed by the calendar. However, this prescription of the days of the crisis is ambiguous in the sense that the crisis days for a disease actually mark a sort of natural rhythm that is typical ol the disease, and of this particular disease. That is to say, every disease has its own rhythm of possible crises; every patient has days when the crisis may be triggered. Hippocrates had already distinguished in this way fevers which have crises on even days from those which have them on odd days; for those with crises on even days, this may be the fourth, sixth, eighth, tenth, fourteenth, twenty-eighth, thirty-fourth, thirty eighth, fiftieth, or eightieth day. 28 For Hippocrates, and for the Hippocratic type of medicine, this gives a kind of description of the
? disease--we cannot say a symptomatological description--that charac terizes it on the basis of the, possible, necessary crisis day. It is therefore an intrinsic feature of the disease.
But it is also an opportunity to be seized, somewhat like the favor- able date in Greek manticism. 29 Just as there were days on which one could not engage the enemy in battle, so there are days when there should not be a crisis; and just as there were bad generals who did not join battle on a propitious day, so there were patients or diseases which produced their crisis on a day that was not propitious, so that on those occasions one had bad crises, that is to say, crises which necessarily led to an unfavorable development, a kind of supplementary complication, but without this meaning that crises occurring at a propitious moment always have lavorable outcomes. You can see the role of this crisis, which is both the intrinsic feature and, at the same time, the obligatory oppor- tunity, the ritual rhythm, to which events should conform.
Now when the crisis occurs, the disease breaks out in its truth; that is to say, it is not only a discontinuous moment but also the moment at which the illness, I won't say "reveals" a hidden truth, but appears m its own truth, its intrinsic truth. Belore the crisis the disease is one thing or another; it is nothing in truth. The crisis is the reality of the disease becoming truth, as it were. And it is precisely then that the doctor must intervene.
What is the doctor's role in the technique of the crisis? He must consider the crisis as the way, practically the only way, through which he can get a hold on the disease. With its variables of time, intensity, and types of resolution, etcetera, the crisis defines the way in which the doctor must intervene. 30 On the one hand, the doctor must first foresee the crisis, identify when it will occur,31 wait for the exact day on which it will take place, and then, at that point, engage in battle to defeat the disease,32 in short, so that nature triumphs over the disease. That is to say, in a sense the doctor's role is to reinforce the energy of nature. But we must be careful when reinforcing nature's energy, because what happens if we reinforce it too much when struggling against the disease? The result is that being, as it were, exhausted, and lacking strength, the disease will not join in the combat and the crisis will not take place, and if the crisis does not take place, then the harmful condition will persist.
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So a proper balance must be maintained. Similarly, if we reinforce nature too much, if nature becomes too vigorous and too strong, then the movement by which it tries to expel the disease will be too violent, and there will be the danger of the patient dying from the violence of nature's efforts against the disease. So we must neither weaken the ill ness too much, which risks avoiding the crisis, as it were, nor reinforce nature too much, because then there is the danger of the crisis being too violent. So you can see that in this technology of the crisis the doctor is much more the manager and arbitrator of the crisis than the agent of a therapeutic intervention. * The doctor must foresee the crisis, know the opposing forces, imagine its outcome, and arrange things so that it occurs at the right time; he must see how and with what force it approaches, and he must introduce only those necessary adjustments to each side of the balance so that the crisis takes its proper course.
And you can see that in its general form the technique of the crisis in Greek medicine is no different from the technique of a judge or arbitra- tor in a judicial dispute. In this technique of the test you have a sort of model, a jundico political matrix, which is applied both to the con- tentious battle in a case of penal law and to medical practice. Moreover, in medical practice there is a sort of supplementary complexity that is found again in judicial practice. This is that, as you can see, the doctor does not cure, and it cannot even be said that he directly confronts the disease, since it is nature that confronts the disease; he foresees the crisis, he gauges the contending forces, and he succeeds if he manages nature's success. And, to come back to this word crisis, which after all means "to judge,"B just as the disease comes up for judgment on the day of the crisis, so the doctor, in this role as a kind of arbitrator, is judged in turn by how he presides over the combat, and he may come out as victor or vanquished in relation to the disease.
In relation to the combat of nature and the disease, the doctor's is a second order combat, from which he will come out victor or vanquished in relation to these internal laws, but equally in relation to other doctors. And here again we come back to the juridical model. You know
* The manuscript adds: "more the role of observance of rules than of the observation ol phenomena. "
? that judges could be disqualified when they judged badly, in turn having to undergo a trial from which they will come out either victors or vanquished. And this kind of joust between the adversaries and between the laws of combat and then the judge had a sort of public character. This double combat always had public features. Now medical consultation, as you see it at work from Hippocrates up to Moliere's famous doctors--on the meaning and status of which we should nonetheless reflect a little--always involved several people. ^ That is to say, it involved at once a joust of nature against the disease, of the doctor with regard to this struggle of nature against the disease, and of the doctor with other doctors.
They were all present, each confronting the others, each making his own prediction about when the crisis must occur, what its nature would be, and what would be the outcome. However self-justifymg it may be, it seems to me that the famous scene Galen describes to explain how he made his lortune in Rome is an entirely typical scene of this kind of enthronement of the doctor. The story recounts how the young Galen, an unknown doctor coming to Rome from Asia Minor, participates in a kind of medical joust around a patient. When the doctors were predict mg this or that, Galen says, looking at the ill young man: There will be a crisis shortly; this crisis will be a nosebleed, and he will bleed from the right nostril. This is in fact what happens, and, Galen says, one by one all the doctors around me were quietly overshadowed. 35 The joust was also a joust between the doctors.
The doctor's appropriation of a patient, the recognition of the family doctor, the doctor patient discourse, are all the effect of a whole series oi economic, sociological and epistemological transformations of medi cine. However, in this medicine of the test, in which the crisis was the main component, the joust between doctors was as essential as the joust between nature and the disease. So you can see, this technology of truth test, of truth-event, persists for a long time in medicine, m medical practice, which, once again, like alchemy, was not utterly foreign to the developments of the scientific knowledge which adjoined, cut across, and were tangled up with it.
A word more on this subject. With the example ol medicine you can see, of course, that the extension of the other series, of the demonstrative
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technology of truth, was not brought about at a stroke, like a kind ol overall reversal, and it certainly does not take place in the same way in astronomy as in medicine, or in judicial practice the same way as m botany. However, broadly speaking, I think we can say that two processes have supported this transformation in the technology of truth, at least in what concerns empirical knowledge.
I think the transition from a technology of truth-event to truth demonstration is linked, on the one hand, to the extension of political procedures of the inquiry. The inquiry, the report, the evidence ol several people, the cross checking of information, the circulation of knowledge from the center of power to the points where it ends up and back again, as well as all the agencies ol parallel verification, progres sively, over a long history, gradually constituted the instrument of the political and economic power of industrial society; hence the refine- ment, the increasingly fine grid of these techniques of inquiry within the elements where they were usually applied. Broadly speaking, the refinement by which we passed from a basically fiscal kind of inquiry in the Middle Ages--knowing who collects what, who possesses what, so that the necessary deductions are made--to a police kind of investiga tion into peopled behavior, into how they live, think, make love, etcetera, this transition from fiscal inquiry to police investigation, the constitution of a police individuality starting from fiscal individuality, which was the only individuality known by power in the Middle Ages, reveals the tightening of the technique of inquiry in our kind of society. 36
Moreover, there was not only a local tightening, but also a planetary extension to the entire surface of the globe. There is a double movement of colonization: colonization in depth, which fed on the actions, bodies, and thoughts of individuals, and then colonization at the level of territories and surfaces. We can say that from the end of the Middle Ages we have seen the entire surface of the Earth, down to the finest grain of things, bodies, and actions, subjected to generalized investigation: a sort of grand inquisitorial parasitism. That is to say, at any time, at any place, and with regard to anything in the world, the question of truth can and must be posed. Truth is everywhere and awaits us everywhere, at any place and at any time. This, very schematically, is the great process that led to this move from a technology of the truth-event to a technology of truth findings.
? The other process was a sort of opposite process, f. . . *] establishing the rarity of this truth of anywhere and anytime. This rarefaction is not brought to bear on the emergence or production of truth however, but precisely on who can discover it. In one sense, this universal truth of anywhere and anytime, which any inquiry can and must track down and discover with regard to no matter what, is accessible to anyone; anyone can have access to it, since it is there, everywhere and all the time. However, the necessary circumstances are still required, and we must acquire the forms of thought and techniques that will give us access to this truth that is everywhere, but always deep down, buried, and diffi cult to reach.
So we will have, of course, a universal subject of this universal truth, but it will be an abstract subject because, concretely, the universal sub- ject able to grasp this truth is rare, since it must be a subject qualified by procedures of pedagogy and selection. Universities, learned societies, canonical teaching, schools, laboratories, the interplay of specialization and professional qualification, are all ways of organizing the rarity of those who can have access to a truth that science posits as universal. It will be the abstract right of every individual to be a universal subject, if you like, but to be one in fact, concretely, will necessarily entail rare individuals being qualified to perform the function of universal subject. In the history of the West since the eighteenth century, the appearance of philosophers, men of science, intellectuals, professors, laboratories, etcetera, is directly correlated with this extension of the standpoint of scientilic truth and corresponds precisely to the rarelaction of those who can know a truth that is now present everywhere and at every moment. Fine. That's the little history I wanted to present. What is its relation- ship to madness? We're just coming to it.
In the medicine in general that I have been talking about, the notion of crisis disappears at the end of the eighteenth century. It not only
* (Recording:) we could call it
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disappears as a notion, after Hoffmann*7 say, but also as an organizing principle of medical technique. Why did it disappear? Well, I think it disappeared for the reasons I have just given in a general schema, that is to say, with regard to disease, as with regard to everything henceforth, there is the organization of a sort of inquisitorial space or grid. 38 The construction of what we can broadly call hospital and medical facilities in Europe in the eighteenth century basically ensures the general sur- veillance of populations, making it possible, in principle, to investigate the health of every individual. 39 The hospital also makes possible the integration of the living individual's body, and especially his dead body, into the disease. ^0 That is to say, at the end of the eighteenth century we will have both a general surveillance of populations and the concrete possibility of establishing a relationship between a disease and a body on which an autopsy has been carried out. The birth of pathological anatomy and, at the same time, the appearance of a statistical medicine, of a medicine of large numbersH1--both the ascription of precise causal- ity by the projection of the illness on a dead body and the possibility of inspecting a set of populations--provide the two major epistemological tools of nineteenth century medicine. And it is quite clear that hence forth a technology of observation and demonstration will progressively make the technique of crisis unnecessary.
What happens in psychiatry then? Well, I think something very strange takes place. On the one hand, it is clear that the psychiatric hospital, like the hospital of general medicine, cannot but tend to make the crisis disappear. The psychiatric hospital, like any other hospital, is a space of inquiry and inspection, a sort of inquisitorial site, and there is no need at all for that test of truth. I have also tried to show you that not only is there no need for the test of truth, but there is no need for truth at all, whether arrived at by the technique of the test or by that of demonstration. Furthermore, not only is there no need for it, but to tell the truth the crisis as an event in the madman's madness and behavior is ruled out. Why is it ruled out? Essentially for three reasons I think.
First, it is ruled out precisely by the fact that the hospital functions as a disciplinary system, that is to say, as a system subject to rules, expecting a certain order, imposing a certain regime that excludes any thing like the raging and raving outburst of the crisis ol madness.
? Moreover, the main instruction, the main technique of this asylum discipline, is: Don't think about it. Don't think about it; think about something else; read, work, go into the fields, but anyway, don't think about your madness/'2 Cultivate, not your own garden, but the director's. Do woodwork, earn your keep, but don't think about your illness. The disciplinary space of the asylum cannot permit the crisis of madness.
Second, constant recourse to pathological anatomy in asylum practice, from about around 1825, played the role of theoretical rejection of the crisis/3 Actually, nothing, apart from what took place with general paral- ysis, permitted the assumption, or anyway the ascription, of a physical cause to mental illness. Now, the practice of autopsy was, at least in a great many hospitals, a sort of regular practice the basic meaning of which was, I think, the following: if there is a truth of madness, it is cer- tainly not in what the mad say; it can only reside in their nerves and their brain. To that extent, the crisis as the moment of truth, as the moment at which the truth of madness burst forth, was ruled out epistemologically by recourse to pathological anatomy, or rather, I think that pathological anatomy was the epistemological cover behind which the existence of the crisis could always be rejected, denied, or suppressed: We can strap you to your armchair, we can refuse to listen to what you say, since we will seek the truth of madness from pathological anatomy, when you are dead.
Finally, the third reason for rejecting the crisis was a process I have not considered until now: the relationship between madness and crime. In fact, from around 1820-1825 we see a very strange process in the courts in which doctors--who were not called on by the prosecutor or by the president of the court, and often not even by lawyers--gave their opinion on a crime and, as it were, tried to claim the crime for mental illness itself. v' Faced with any crime, the doctors raised the question: Could not this be a sign of illness? And it was in this way that they con- structed the very curious notion of monomania which, schematically, means this: when someone commits a crime which has no raison d'etre, no justification at the level of his interest, wouldn't the fact alone of committing the crime be the symptom of an illness, the essence of which would basically be the crime itself? Monomania was a sort of single symptom illness with just one symptom occurring only once in the individual's life, but a symptom that was, precisely, the crime? ''5
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One wonders why psychiatrists take this interest in crime, and why they insist so strongly and, in a way, so violently on the potential identity of crime and mental illness. There are, of course, a number of reasons, but I think one of them is the attempt to demonstrate not so much that every criminal may be mad, but to demonstrate something that is much more serious, and also much more important for psychi- atric power, namely, that every mad person is a possible criminal. The determination to pin madness on a crime, even on every crime, was a way of founding psychiatric power, not in terms of truth, since precisely it is not a question of truth, but in terms of danger: Mve are here to protect society, since at the heart of every madness there is the possibil ity of crime. In my view, pinning something like a madness on a crime is, for social reasons of course, a way of getting the individual out of trouble, but, as a general rule, at the level of the general operation of this ascription of madness to crime, there is the psychiatrists' wish to base their practice on something like social defense, since they cannot base it in truth. So, we can say that the effect of the disciplinary system of psychiatry is basically to get rid of the crisis. Not only is it not needed, it is not wanted, since the crisis could be dangerous, since the madman's crisis could well be another person's death. There is no need for it, pathological anatomy dispenses with it, and the regime of order and discipline means that the crisis is not desirable.
However, at the same time as this is taking place, there is a movement in the opposite direction, for the explanation and justification of which there are two reasons. On the one hand, the crisis is needed because, in the end, neither the disciplinary regime, nor the obligatory calm imposed on the mad, nor pathological anatomy, enabled psychiatric knowledge to be founded as truth. So that this knowledge, which I have tried to show you operated as a supplement of power, was for a long time running on empty, and obviously it could not rail to seek to pro- vide itself with a content of truth according to the same norms of the medical technology of the time, that is to say, the technology of reported findings. But since this was not possible, the crisis was resorted to for another, positive reason.
The real point at which psychiatric knowledge is exercised is not ini- tially or essentially what enables the illness to be specified, described,
? and explained. In other words, whereas the doctor, given his position, is basically obliged to respond to the patient's symptoms and complaints with an activity of specification and characterization--hence the bet that differential diagnosis has been the major medical activity since the nineteenth century--the psychiatrist is not required, or called in at the patient's request, to give the latter's symptoms a status, character, and speciiication. The psychiatrist is needed at an earlier stage, at a lower level, where it has to be decided whether or not there is an illness. For the psychiatrist it is a matter of answering the question: Is this individ- ual mad or not? The question is put to him by the Iamily in cases ol voluntary admission, or by the administration in cases ol compulsory admission--although the administration only puts the question on the quiet, since it reserves the right to disregard what the psychiatrist says--
but, in any case, the psychiatrist is situated at this level.
Whereas (general] medical knowledge functions at the point ol the specification ol the illness, at the point of differential diagnosis, medical knowledge in psychiatry functions at the point of the decision between madness or non madness, the point, if you like, ol reality or non reality, reality or fiction, whether this be liction on the part of the patient who, for one reason or another, would like to pretend to be mad, or the fiction of the Iamily circle, which imagines, wishes, desires, or imposes the image of madness. This is the point at which the psychiatrist's
knowledge, and also his power, functions. '6
Now what tools does the psychiatrist possess that enable him to
function at this level and decide on the reality ol madness? It is precisely here that we encounter the paradox of nineteenth century psychiatric knowledge once again. On the one hand, psychiatric knowledge really tried to construct itsell on the model ol medicine observation, of inquiry and demonstration; it really tried to constitute a symptomato- logical type of knowledge for itself; a description of different illnesses was actually constituted, etcetera, but, to tell the truth, this was only the cover and justification for an activity situated elsewhere, and this activity was precisely that of deciding between reality or lie, reality or simulation. The activity of psychiatric knowledge is really situated at the point of simulation, at the point of fiction, not at the point of characterization.
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There are, I think, a number of consequences of this. The first is that in order to resolve this problem the psychiatric hospital literally invented a new medical crisis. This was no longer that old crisis of truth played out between the forces of the disease and the forces of nature that was typical of the medical crisis put to work in the eighteenth century, but a crisis that I will call a crisis of reality, which is played out between the mad person and the power that confines him, the doctor's power knowledge. The doctor must be able to arbitrate on the question of the reality or non-reality of the madness.
So, as you can see, unlike the hospital of general medicine, the psychiatric hospital's function is not to be the place where an "illness" exhibits its specific and differential characteristics in comparison with other illnesses. The psychiatric hospital has a much simpler, more elementary, more lundamental function. Its function is, precisely, to give madness reality, to open up a space of realization for madness. The psychiatric hospital exists so that madness becomes real, whereas the hospital's function tout court is both knowing what the illness is and eliminating it. The psychiatric hospital's function, following the psychi atric decision concerning the reality of the madness, is to make it exist as reality.
Here we encounter an institutional type of criticism of the psychi atric hospital, which charges it, precisely, with fabricating the mad out of the people it claims to cure. This institutional type of criticism thus poses the question: What kind oi institution could work in such a way that the mad could be cured and not pushed deeper into illness? How could the [asylum] institution work like any hospital? " However, in the end I think this criticism is quite inadequate because it lacks the essential. That is to say, it lacks an analysis of the distribution of psychiatric power that makes it possible to show that the fact that the psychiatric hospital is a place for the realization of madness is not an accident or due to a deviation of the institution, but that the very func tion of psychiatric power is to have before it, and for the patient, a space of realization for the illness (that, when it comes to it, may or may not be in the hospital). We can say then that the function of psychiatric power is to realize madness in an institution where the function of dis- cipline is precisely to get rid of all the violence, crises, and, if necessary,
? all the symptoms of madness. The real function and effect of the asylum institution in itself, of this institution of discipline--and it is in this respect that my analysis differs from institutional analyses--is to sup- press, I do not say madness, but the symptoms of madness, at the same time as the function of psychiatric power, which is exercised within and lixes individuals to the asylum, is to realize madness.
All in all, there is an ideal for this double lunctioning of psychiatric power, which realizes madness, and of the disciplinary institution, which refuses to listen to madness, which flattens out its symptoms and planes down all its manifestations: this is dementia. What is a demented person? He is someone who is nothing other than the reality of his madness; he is the person in whom the multiplicity of symptoms or, rather, their flattening out, is such that it is no longer possible to ascribe to him a specific symptomatology by which he could be characterized. The demented person is therefore someone who corresponds exactly to the working of the asylum institution, since, by means of discipline, all the symptoms in their specificity have been smoothed out: there are no longer any outward signs, externalizations, or crises. And, at the same time, someone who is demented answers to what psychiatric power wants, since he actually realizes madness as an individual reality within the asylum.
The famous development of dementia, which nineteenth century psy- chiatrists could observe as a natural phenomenon in madness, is noth- ing other than the series of intertwined effects of an asylum discipline that smoothes away outward signs and symptoms, and medical power's appeal to the patient to be a madman, to realize madness. The demented person is actually what was fabricated by this double game of power and discipline.
As for the hysterics, those famous, dear hysterics, I would say that they were precisely the front of resistance to this gradient of dementia that involved the double game of psychiatric power and asylum discipline. They were the front of resistance, because, what is a hysteric? A hysteric is someone who is so seduced by the best and most clearly specified symptoms--those, precisely, offered by the organically ill--that he or she adopts them. The hysteric constitutes herself as the blazon of genuine illnesses; she models herself as a body and site bearing genuine
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symptoms. To the ascription ol and propensity towards the subsidence ol symptoms in dementia, the hysteric responds with the exacerbation of the most precise and well determined symptoms; and while doing this, she pursues a game such that when one wants to lix her illness in reality, one can never manage to do so, since, when her symptom should refer to an organic substratum, she shows that there is no substratum, so that she cannot be fixed at the level of the reality of her illness at the very moment she displays the most spectacular symptoms. Hysteria was the effective way ol defending onesell Irom dementia; the only way not to be demented in a nineteenth century hospital was to be a hysteric, that is to say, to counter the pressure that annihilated symptoms, that obliterated them, by building up the visible, plastic edifice of a whole panoply of symptoms, and, by means of simulation, resisting madness being fixed in reality. The hysteric has magnificent symptoms, but at the same time she sidesteps the reality of her illness; she goes against the current of the asylum game and, to that extent, we salute the hysterics as the true militants ol antipsychiatry. ^
? 1. Discovered in the sixteenth century, the use oi ether spread in the nineteenth century in the treatment ol neuroses and for screening simulated illnesses, on account of its "stupefying" property. See above, note 18 to lecture of 9'11 January 1974.
2. Discovered simultaneously in 1831 by Justus Liebig in Germany and by Soubeiran in France, the use of chloroform as an anesthetic began in 1847. See, E. Soubeiran, "Recherches sur quelques combinaisons de chlore" Annales de chimie et de physique, vol. XLIII, October 1831, pp. 113-157; H. Bayard, "L'utihsation de l'ether et le diagnostic des maladies men tales"; H. Brochin, "Maladies nerveuses", ? "Anesthesiques: ether et chloroforme"; and, Lailler (pharmacist of the Quatre Mares asylum) "Les nouveaux hypnotiques et leur emploi en medecine mentale" Annales medico-psychologiques, 7lh series, vol. IV,July 1886, pp. 64-90.
}. See above, note 1 to lecture ol 19 December 1973.
4. See above, note 2 to lecture of 19 December 1973.
5. J. J. Moreau de Tours discovered the effects ol hashish on his journey in the East from 1837
6.
to 1840 and he subsequently devoted his research to it, loreseeing possibilities of experi ment to clanly the relations between its ellects and dreams and delirium. See, Du haschkh
et d'alienation mentale. Etudes psychologiques (Paris: Fortin, 1845).
Experiments in "animal magnetism" took place in hospitals under the Restoration.
