Latham (London: The Sydenham Society,
mdcccxlvm)
vol.
Foucault-Psychiatric-Power-1973-74
Basically, when M.
Dupre was taken to see Pans, it was not so much in order that his perception revealed to him that Paris really was there, and that it was Pans.
This is not what was asked of him; we know full well that so far as he will perceive anything, he will perceive Paris as the imitation of Paris.
What is asked of him--and this is how the statement of the truth becomes effective--is that he avow it.
It does not have to be perceived, it has to be said, even if it is said under the constraint of the shower.
The fact alone of saying something that is the truth has a func- tion in itself; a confession, even when constrained, is more effective in the therapy than a correct idea, or an idea with exact perception, which remains silent.
So, the statement of the truth has a performative charac ter in the game of the cure.
Second, I think we should note that the essential point of the truth, what Leuret is especially attached to, is in part, of course, that Paris is Paris, but what he wants above all is that his patient pin himself to his own history. What is required is that the patient recognizes himself in a kind of identity constituted by certain episodes in his life. In other words, it is in this recognition of certain biographical episodes that the patient must firstly state the truth; the most effective statement of the truth will not bear on things, but rather on the patient himself.
Finally, third, I think we should notice that this biographical truth which is asked of the patient, and the confession of which is so effective in the therapy, is not so much the truth that he could say about himself, at the level of his actual experience, but a truth imposed on him in a canon ical form: cross examination of identity, the recall of certain episodes already known to the doctor, acknowledgement that he really was at Charenton at a given moment, that he really was ill between certain dates, etcetera? 1 A biographical corpus is established from the outside through the system of family, employment, civil status, and medical observation. Ultimately the patient must own to this entire corpus of identity, and it has to be one of the most fruitful moments of the therapy when he does so; it is when this does not take place that we must despair of the illness.
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I will quote, just for the beauty of the dialogue, from another of Leuret's cases. It is the story of a woman whom he said he would never be able to cure. And the fact that he could never cure this woman is attributed precisely to her inability to own to this biographical schema that carries her identity. Here is the dialogue that, according to Leuret, reveals her incurability: "How are you madam? --The person of myself is not a Mrs. (une dame), please call me Miss. --I do not know your name; would you like to tell me? --The person of myself does not have a name: she wishes that you do not write. --I would however really like to know what to call you, or rather what your name was formerly. --I understand what you mean. It was Catherine X, one must speak no more of what took place. The person of myself has lost her name, she gave it on enter ing Salpetriere. --How old are you? --The person of myself has no age. -- But this Catherine X you were talking about, how old is she? --I do not know (. . . )--II you are not the person about whom you speak, perhaps you are two people in one? --No, the person of myself does not know the one who was born in 1799- Maybe it is that lady whom you see there (. . . )--What have you done, and what has happened to you since you have been the person of yourself? --The person of myself has lived in the clinic for ( . . . ) . Physical and metaphysical experiments have been made on her and are still being made on her (. . . ) . There is an invisible who comes down, she wants to mix her voice with mine. The person of myself does not want this, she sends her away gently. --What are they like, these invisibles of which you speak? --They are small, impalpable, barely formed. --How are they dressed? --In a coat. --What language do they speak? --They speak French; if they spoke another language the person of myself would not understand them. --Are you certain that you see them? --Certainly, the person of myself sees them, but metaphysi- cally, in invisibility, never materially, because then they would no longer be invisible (. . . )--Do you sometimes feel the invisibles on your body? --The person of myself feels, and is very angry at it; they have done all sorts of indecent things to her (. . . )--How are you finding it at Salpetriere? --The person of myself finds it very well; she is treated very kindly by M. Pariset. She never asks anything from the maids (. . . )-- What do you think of the ladies with you here in this ward? --The person of myself thinks they have lost their reason. '02
? In a sense this is the most marvelous description of asylum existence lo be found. Once the name has been given on entering Salpetriere, once I his administrative, medical individuality has been constituted, all that remains is "the person of myself," who only speaks in the third person. In such a case, in which confession is not possible and with the endless statement in the third person of this someone who only expresses her self in the form of the person who is not anyone, Leuret clearly sees that lhe therapeutic processes organized around the statement of the truth were no longer possible. As soon as one has left one's name on entering Salpetriere and one is no more than "the person oi myself" in the asy lum, when, consequently, one can no longer recount one's childhood memories and recognize oneself in this statutory identity, then one is definitely good for the asylum.
We could say that at bottom the asylum machine owes its effectiveness to a number of things: uninterrupted disciplinary training; the dissym- metry of power inherent in this; the game of need, money, and work; statutory pinning to an administrative identity in which one must recognize oneself through a language of truth. However, you can see that this truth is not the truth of madness speaking in its own name but l he truth of a madness agreeing to first person recognition of itself in a particular administrative and medical reality constituted by asylum power. The operation of truth is accomplished when the patient has rec ognized himself in this identity. Consequently, the operation of truth lakes place in the form of charging discourse with the task oi this insti- tution of individual reality. The truth is never at issue between doctor and patient. What is given at the start, established once and for all, is the biographical reality with which the patient must identify if he wants to he cured.
There remains a final, supplementary episode in this Dupre affair. When Leuret has got this true account, but true precisely in terms of a biographical canon constituted in advance, he does something astonishing: he releases Dupre while telling him that he is still ill but no longer in need of the asylum at this time. What was Leuret doing in releasing his patient? In a way, certainly, it was a matter of continuing that kind of intensification of reality for which the asylum had been responsible.
That is to say, we will see Leuret again plotting exactly the same kind of
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maneuvers around his patient, now living in freedom, as those I have been talking about. He is trapped with problems of truth; when he claims to know Arabic he is placed in a situation in which he is iorced to confess that he does not know it. s* He is caught in the same con straints of language as those in which he was held in the asylum. The job Leuret found for his patient to lead him to the cure, that is to say, so that reality has a total grip on him, was as a printer's corrector,57' so that he is effectively inserted into that constraining order of language which, again, is not that of language as the bearer of truth, in its dialectical use, but of language in its imperative use. What he reads must actually con iorm to statutory and school orthography.
In the same way, Leuret explains that he created needs by taking him to the Opera so that he acquire the desire to go to performances. Hence the need for him to earn some money. It is still the same |enterprise] ol the renewal ol or identification with reality through a disciplinary game, now extended rather than concentrated and intense as in the asylum: "I increased his enjoyments so as to extend his needs and thus gain many means lor directing him. ,,vs
However, there is a much stronger, more subtle and interesting reason. This is that, in fact, Leuret identilied something in his patient that had three forms: the pleasure of the asylum,""6 the pleasure of being ill, and the pleasure of having symptoms. This triple pleasure is the underlying basis ol the omnipotence of madness.
When we go back over the whole development of the treatment, we see that from the start Leuret tried to attack this pleasure of the illness that he had detected in his patient. He uses the famous shower, the straitjacket, and deprivation of food right from the start, and these repressions have a double, physiological and moral, justification. The moral justification cor- responds to two objectives. On the one hand, it involves, of course, making the reality of the doctor's power felt against the omnipotence of madness. But it is also a matter of taking the pleasure out ot madness, that is to say, wiping out the pleasure of the symptom through the displeasure of the cure. Here again I think Leuret reproduces techniques that were employed by the psychiatrists of his time without being reflected or theorized.
However, what is particular about Leuret--and here he takes things further--is that in Dupre he found a special case. He had a patient who,
? when under the shower, and even when cauterized on the skin of his head,5' hardly protested and found that it was completely bearable so long as it was part of his treatment. ^8 Now it is here that Leuret no doubt goes further than most of the psychiatrists ol the time who--as sign, moreover, of their omnipotence lacing the patient--basically required the patient to accept treatment without a word. In this case he has a patient who accepts the treatment, and whose acceptance is, in a way, part of the illness.
Leuret identifies this acceptance as a bad sign lor his therapy; treatment is being incorporated within the delirium. When given a shower, Dupre says: "A woman is insulting me! "w Things must there- lore be arranged so that treatment and delirium are disconnected, so that treatment is confiscated from the delirium constantly invading it. It is thus necessary to give an especially painlul edge to the treatment, so that reality will establish its hold on the illness through the treatment.
We find some fundamental ideas in this technique: madness is linked to a pleasure; through pleasure, treatment may be integrated into the madness itself; the impact of reality may be neutralized by a mechanism ol pleasure intrinsic to the treatment; and, consequently, the cure must not only work at the level of reality, but also at the level of pleasure, and not only at the level of the pleasure the patient takes in his madness, but at the level of the pleasure the patient takes in his own treatment/
Hence, when Leuret realized that Dupre lound a whole series of pleasures in the asylum--in the asylum he could be delirious at ease, he could integrate his treatment in his delirium, and all the punishments inflicted on him were reinvested in his illness--then, at that point, Leuret concluded that he had to get his patient out ol the asylum and to deprive him of the pleasure of the illness, the hospital, and of the cure. As a result, he put him back into circulation, consequently taking the pleasure out ol the treatment and making it function in an absolutely non medical mode.
In this way Leuret is entirely resorbed as a medical personage. He has ceased playing his aggressive and imperious role, and in its place he brings a number of accomplices into play in order to construct the
* The manuscript adds: "There is both power and pleasure in every symptom. "
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following kind o( scenarios. Despite his job as a corrector at a printing house, M. Dupre continued to make systematic spelling mistakes, since in his delirium he wanted to simphiy the spelling system. A pseudo- letter of appointment was sent to him for a job that would have brought him a lot of money. M. Dupre drafts a letter oi acceptance of this new, well remunerated situation, but he lets by one or two spelling mistakes, so that Leuret's accomplice can send him a letter in which he says: "I would have employed you, if you had not made dreadful spelling mistakes. "60
So you see that all the mechanisms here, which are of the same type as those in the asylum, are now demedicalized. The medical personage, as Leuret says himself, must become instead a benign personage who tries to arrange things, who acts as an intermediary between harsh real ity and the patient. 61 However, as a result of this, the patient will no longer be able to take pleasure either in his illness, which causes so many unfortunate consequences, or in the asylum, since he is no longer there, or even in his doctor, since the doctor will have disappeared as such. M. Dupre's cure was wholly successful; it ended in the Spring of 1839 with a complete recovery. However, Leuret noted that at Paques in 1840 some unfortunate signs proved that a new illness was overcoming "the patient. "62
In summary, we can say that in the way that it functions through this kind of treatment, the asylum is a curing apparatus in which the doctor's action is part and parcel of the institution, the regulations, and the build ings. Basically, it is a question of a sort of great single body in which the walls, the wards, the instruments, the nurses, the supervisors, and the doctor are elements which have, of course, different functions to perform, but the essential function of which is to bring about a collective effect. And, according to different psychiatrists, the main accent, the most power, will sometimes be fixed on the general system of supervision, sometimes on the doctor, and sometimes on spatial isolation itself.
The second thing I would like to emphasize is that the asylum has been a site for the formation of several series of discourse. It was
? possible to construct a nosography, a classification of illnesses, on the basis of these observations. Also, on the basis of the free disposal of the corpses of the mad, it was possible to outline a pathological anatomy of mental illness. However, you can see that none of these discourses, nei- i her nosography nor pathological anatomy, served as a guide in the for ination of psychiatric practice. In actual fact, although we have had some protocols of this practice, we can say that it remained silent in that for years and years psychiatric practice did not produce an autonomous dis course other than the protocol of what was said and done. There have been no real theories of the cure, nor even attempts to explain it; the cure has been a corpus of maneuvers, tactics, and gestures to be made, actions and reactions to be activated, the tradition of which has been carried on through asylum life, in medical teaching, and with just some ol those cases, the longest of which I have quoted, as surfaces of emergence. All we can say about the way in which the mad were treated amounts to a body of tactics, a strategic ensemble.
Third, I think we should talk of an asylum tautology, in the sense that, through the asylum apparatus itself, the doctor is given a number of i instruments whose basic function is to impose reality, to intensify it, and add to it the supplement of power that will enable the doctor to get a grip on madness and reduce it, and therefore, to direct and govern it. These supplements of power added to reality by the asylum are discipli nary asymmetry, the imperative use of language, the management of lack and needs, the imposition of a statutory identity in which the patient must recognize himself, and the removal of pleasure from madness. These are the supplements oi power by which, thanks to the asylum and its processes, reality will be able to fix its grip on madness. But, you see-- and it is in this sense that there is a tautology--that all of this--the dis symmetry of power, the imperative use of language, etcetera--is not merely a supplement of power added to reality, but the real form of real- ity itself. To be adapted to the real, \. . . *] to want to leave the condition
of madness, is just precisely to accept a power that one recognizes is insurmountable and to relinquish the omnipotence of madness. To stop being mad is to agree to be obedient, to be able to earn one's living, to
' (Recording:) to relinquish the omnipotence ol madness,
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recognize onesell in the biographical identity that has been Iormed ol you, and to stop taking pleasure in madness. So as you can see, the instru- ment by which madness is reduced, the supplement of power added to reality so that it masters madness, is at the same time the criterion of the cure, or again, the criterion ol the cure is the instrument by which one cures. So, we can say that there is a great asylum tautology in that the asy lum is that which must give a supplementary intensity to reality and, at the same time, the asylum is reality in its naked power, it is reality med- ically intensified, it is medical action, medical power-knowledge, which has no other function than to be the agent of reality itseH.
The asylum tautology is this action of the supplement ol power accorded to reality, which consists in nothing other than the reproduc tion ol this reality itself within the asylum. And you can see why the doctors ol the time could say both that the asylum had to be something absolutely cut oil from the outside world, that the asylum world of mad ness had to be an absolutely specialized world entirely in the hands of a medical power delined by the pure competence of knowledge--confiscation, therelore, of the asylum space for the benefit of medical knowledge-- and, on the other hand, that the same doctors said that the general forms of the asylum had to recall everyday life as much as possible, that the asylums had to be similar to the colonies, workshops, colleges, and prisons, that is to say, that the specificity of the asylum is to be exactly homogeneous to that from which it is differentiated, by virtue of the line separating madness and non-madness.
Finally, the last point on which I will stop, and about which I will talk later, is that when we follow a cure like Leuret's in some detail-- with, of course, the qualification that this is the most sophisticated of all the cures for which we have an account--simply quoting the different episodes, without adding, I think, to what Leuret said, and by taking into account the fact that Leuret did not in any way theorize what he meant, you see a number of notions appearing: the doctor's power, language, money, need, identity, pleasure, reality, childhood memory. All of this is completely inscribed within the asylum strategy, but not yet constituting anything more than points of support for this asylum strat egy. Later, you know what their future will be; you will find them again m a completely extra-asylum discourse, or at any rate in a discourse that will
? present itself as extra-psychiatric. * However, before taking on this sta- tus of object or concept, in the kind of slow-motion which M. Dupre's cure offers us, we see them at work as tactical points of support, strate- gic elements, maneuvers, plans, and nodes in the relationships between I he patient and the asylum structure ltseli.
Later, we will see how they are detached from it in order to enter another type of discourse.
A The manuscript adds: "it is there that Freud will look lor them. "
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1. Opiates, preparations with an opium base, renowned lor suspending attacks ol lury and restoring order between ideas, were recommended, in preference to purgatives and bleedings, by Jean Baptiste Van Helmont (1577-1644) and Thomas Sydenham (1624 1689). Their use in treating "maniacal" or "furious" torms ol madness developed in the eighteenth century. See, Philippe Hecquet (1661 1737) Reflexions sur /'usage cle /'opium, des calmants el des narcoliques pour la guerison des maladies (Paris: G. Cavalier, 1726) p. 11;
J. Guislain, Traile sur Valienation meniale et sur les hospices des alienes, vol. I, book IV: "Moyens diriges sur le systeme nerveux central. Opium," pp. 345 353. See also the pages devoted to
this substance by M. Foucaull, in Hisloire de lajolie, pp. 516 319 (omitted Irom the English translation).
In the nineteenth century, Joseph Jacques Moreau de Tours ( 1804-1884) recommended
the use ol opiates in the treatment ol mania: "In the opiates (opium, datura, belladonna, henbane, aconite, etcetera) we can still find an excellent means ol calming the usual agita-
tion of maniacs and the passing Iits ol rage of monomaniacs. " "Lettres medicales sur la colome d'alienes de Gheel" Annales medko-psychologiques, vol. V, March 1845, p- 271. See,
C. Michea, De I'emploi des opiaces dans le trailement d'alienalion meniale (Pans: Malteste, 1849), and Rechcrches experimentales sur I'emploi des principaux agents de medication slupefianle dam le trailement de I'alienation meniale (Paris: Labe, 1857); H. Legrand du Saulle, "Recherches chnic|ues sur le mode d'administration de l'opium dans la manic" Annales medico-psychologiques, 3U series, vol. V, January 1857, pp. 1 27; H. Brochin, "Maladies nerveuses. ? Narcoliques" in Diclionnaire encyclopedique des sciences medicales, 2 series, vol. XII (Paris: Masson/Asselin, 1877), pp. 375 376; and, J. B. Fonssagrives, "Opium" ibid.
2,ul series, vol. XVI, 1881, pp. 146 240.
2. Laudanum, a preparation in which opium was combined with other ingredients, ol which
the most widely used was the liquid laudanum ol Sydenham, or "*>/>/ d'opium compose," was recommended lor digestive disorders, the treatment ol nervous illnesses and hysteria; see,
T. Sydenham, "Observaliones Medicae" (1680) in Opera Omnia (London: W. Greenhill, 1844) p. 113; English translation, "Medical Observations" in The Works of Thomas Sydenham, trans. R. G.
Latham (London: The Sydenham Society, mdcccxlvm) vol. 1, p. 173. See Diclionnaire encyclopediaue des sciences medicales, 2 series, vol. II (Pans: Masson/Asselin, 1876) pp. 17 25.
3. Since Pinel, who asserted "the absolute necessity lor an invariable order ol work" (Traile medico-philosophique, section V: "Police generale et ordre journaher du service dans les hospices d'alienes" p. 212; A Treatise on Insanity, "General police and daily distribution ol services in lunatic asylums," p. 206) the alienists constantly stressed the importance ol regulations. Thus,J. P. Falret, "Du traitement generale des alienes" Des maladies menlales et des asiles d'alienes, p. 690: "What do we see in modern asylums? We see a strictly observed positive regulation, which fixes the use ol every hour ol the day and forces every patient to react against the irregularity of his tendencies by submitting to the general law. He is obliged to place himsell in the hands ol a loreign will and to make a constant ellort on himsell so as not to incur the punishments attached to inlnngemenls ol the rule. "
4. The problem of the dietary regime occupied a privileged place, both as a component of the daily organization of asylum time, and as a contribution to treatment. Thus, Francois Fodere states that "lood is the lirst medicine" Traite du delire, vol. II, p. 292. See, J. Daquin, La Philosophic de la jolie, republished with a presentation by C. Quetel (Paris: Editions Frenesie, 1987) pp. 95 97; and, J. Guislain, Traile sur I'alienation meniale, vol. II, book 16: "Regime alimentaire a observer dans I'alienation mentale" pp. 139 152.
5. Work, an essential component ol moral treatment, was conceived ol in the double perspec live of therapy (isolation) and discipline (order). See, P. Pinel, Traile medico-philosophique, section V, ? xxi: "L01 fondamentale de tout hospice d'alienes, celle d'un travail mecanique": "Constant work changes the vicious circle ol ideas, clanhes the laculties ol understanding by exercising them, alone keeps order wherever the insane are assembled, and dispenses with a host ol detailed and often pointless rules in order to maintain inter
nal police" p. 225; A Treatise on Insanity, "Mechanical employment essential to the success
ful management of lunatic hospitals" p. 217. Cf. , C. Bouchct, "Du travail applique aux alienes" Annales medico-psychologiques, vol. XII, November 1848, pp. 301-302. In Hisloire de
? lajolie, pp. 505 506; Madness and Civilisation, pp. 247 249, Foucault refers to a study by Jean Calvet, from 1952, on the historical origins ol the work ol patients in insane asylums. 6. P. Pinel lends his authority to the shower by making it an instrument of both treatment and conditioning. See the second, revised and expanded edition of his Traitemedico-
philosophique sur {'alienation mentale (Paris: Caille et Ravier, 1809) pp. 205-206. See also, H. Girard de Cailleux, "Considerations sur le traitement des maladies mentales" Annales medico-psychologiques, vol. IV, November, 1844, pp. 330-331; H. Rech (de Montpellier), "De la douche et des affusions d'eau Iroide sur la tete dans le traitement des alienations men- tales" ibid. vol. IX, January 1847, pp. 124 125. It is Francois Leuret especially who makes use of it in Traitement moral de lafolie, ch. 3, ? "Douches et affusions froides" pp. 158-162. See Foucault's discussion of M. Dupre's cure in this and the following lecture (above, French p. 143 sq. and below, French p. 173 sq). Foucault devotes several pages to this cure in: Maladie mentale et Psychologic (Paris: P. U. F. , 1962) pp. 85-86; English translation, Mental Illness and Psychology, trans. Alan Sheridan (Now York: Harper and Row, 1976) p. 72; Histoire de lajolie, p. 338 and pp. 520-521; Madness and Civilisation, p. 172 and pp. 266 267; and "L'eau et la iolie" Dils et Ecrits, vol. 1, pp. 268-272. He returns to it in "Sexuality and Solitude" London Review of Books, 21 May 5 June 1981, p. 3 and pp. 5 6, reprinted in The Essential Works oj Foucault, 1954-19$/l, vol. 1: Ethics: subjectivity and truth, ed. Paul Rabinow, trans. Robert Hurley and others (New York: The New Press, 1997) pp. 175 176; French translation, "Sexualite et solitude," trans. F. Durand Bogaert, Dits el Ecrits, vol. 4. , pp. 168 169.
7. The rotary swing was perfected by the English doctor Erasmus Darwin (1731-1802) and used to treat madness by Mason Cox, who praised its eilectiveness: "I think it can be put
to both a moral and a physical use, and be employed with success both as a means of rebel
and as a means oi discipline, in order to make the patient more adaptable and docile" Observations sur la demence, p. 58. | It has not been possible to consult the first, 1804, edi tion of Practical Observations on Insanity, on which the French translation is based, and the passage quoted here does not appear in the second, 1806, edition. However, reierence is made to the rotary swing elsewhere in the 1806 edition, e. g. , p. 137; G. B. ] See, L. Amard, Traite analytique de la folie et des moyens de la guerir (Lyon: printed by Ballanche, 1807)
pp. 80 93; J. Guislain, Traite sur Valienation mentale, vol. I, book IV, and, Moyens diriges sur le systeme nerveux cerebral. De la rotation (Amsterdam: Van der Hey, 1826) p. 374 and p. 404; C. Buvat Pochon, Les Traitemenls de choc d'autrejois en psychiatric Leurs liens avec les therapeu- tiques modernes, Medical thesis, Paris, no. 1262 (Paris: Le Francois, 1939). See Histoire de la
Jolie, pp. 341 342; Madness and Civilisation, pp. 176-177.
8. While he was alive, Leuret had to defend himself from critics who condemned his practice
as, in his own words, "retrograde and dangerous" (DM traitement moral de lafolie, p. 68). His main opponent was E. S. Blanche, in his paper to the royal Academy of medicine, Du dan-
ger des rigueurs corporelles dans le traitement de lajolie (Paris: Gardembas, 1839), as well as in his short work, De Fetal actuel du traitement de lajolie en France (Paris: Gardembas, 1840). These polemics were echoed in Leuret's obituary notices: U. Trelat, "Notice sur Leuret" Annales d'hygiene publique et de medecine legale, vol. 45, 1851, pp. 241-262; and A. Brierre de Boismont, "Notice biographique sur M. F. Leuret" Annales medico-psychologiques, 2nd series, vol. III,July 1851, pp. 512 527.
9. It is Observation XXII: "Bearers ol imaginary titles and ranks" Du traitement moral de la folie, pp. 418-462.
10. 11. 12.
Ibid. pp. 421-424.
Ibid. p. 429.
P. Pinel, Traile medico-philosophique, op. cit. , section II, ? ix: "Intimider Pahene, mais ne point se permettre aucun acte de violence" p. 61; A Treatise on Insanity, "Intimidation too often associated with violence" pp. 64-65.
13. J. E. D. Esquirol, "De la folie" (1816) in Des maladies mentales vol. 1, p. 126; Mental Maladies, "Insanity," p. 76.
14. See above note 3. Already, for J. Guislain, this was one ol the advantages of "isolation in the treatment oi insanity": "Based on a leeling of dependence that he makes the insane person feel ( . . . ) lorced to conform to a loreign will" Traile sur I'alienation mentale, vol. I, p. 409.
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15- F. Leuret, Du irailemenl moral de lajolie, p. 422: "Dupre is a name oi convenience, a name oi disguise; his true name, as we well know, is Napoleon. "
16. Ibid. p. 423: "The distinctive sign of his Halcyon status is his constant ability to enjoy the pleasures of love. "
17. Ibid. p. 423: "Only he in the home is a man; all the others are women. "
18. EJ. Georgct, De lafolie. Considerations sur cette maladie, p. 284.
19. F. Leuret, Du traitement moral de lafolie, p. 429.
20. Ibid. p. 430. 21. Ibid. p. 430. 22. Ibid. p. 422. 23. Ibid. p. 431.
Second, I think we should note that the essential point of the truth, what Leuret is especially attached to, is in part, of course, that Paris is Paris, but what he wants above all is that his patient pin himself to his own history. What is required is that the patient recognizes himself in a kind of identity constituted by certain episodes in his life. In other words, it is in this recognition of certain biographical episodes that the patient must firstly state the truth; the most effective statement of the truth will not bear on things, but rather on the patient himself.
Finally, third, I think we should notice that this biographical truth which is asked of the patient, and the confession of which is so effective in the therapy, is not so much the truth that he could say about himself, at the level of his actual experience, but a truth imposed on him in a canon ical form: cross examination of identity, the recall of certain episodes already known to the doctor, acknowledgement that he really was at Charenton at a given moment, that he really was ill between certain dates, etcetera? 1 A biographical corpus is established from the outside through the system of family, employment, civil status, and medical observation. Ultimately the patient must own to this entire corpus of identity, and it has to be one of the most fruitful moments of the therapy when he does so; it is when this does not take place that we must despair of the illness.
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I will quote, just for the beauty of the dialogue, from another of Leuret's cases. It is the story of a woman whom he said he would never be able to cure. And the fact that he could never cure this woman is attributed precisely to her inability to own to this biographical schema that carries her identity. Here is the dialogue that, according to Leuret, reveals her incurability: "How are you madam? --The person of myself is not a Mrs. (une dame), please call me Miss. --I do not know your name; would you like to tell me? --The person of myself does not have a name: she wishes that you do not write. --I would however really like to know what to call you, or rather what your name was formerly. --I understand what you mean. It was Catherine X, one must speak no more of what took place. The person of myself has lost her name, she gave it on enter ing Salpetriere. --How old are you? --The person of myself has no age. -- But this Catherine X you were talking about, how old is she? --I do not know (. . . )--II you are not the person about whom you speak, perhaps you are two people in one? --No, the person of myself does not know the one who was born in 1799- Maybe it is that lady whom you see there (. . . )--What have you done, and what has happened to you since you have been the person of yourself? --The person of myself has lived in the clinic for ( . . . ) . Physical and metaphysical experiments have been made on her and are still being made on her (. . . ) . There is an invisible who comes down, she wants to mix her voice with mine. The person of myself does not want this, she sends her away gently. --What are they like, these invisibles of which you speak? --They are small, impalpable, barely formed. --How are they dressed? --In a coat. --What language do they speak? --They speak French; if they spoke another language the person of myself would not understand them. --Are you certain that you see them? --Certainly, the person of myself sees them, but metaphysi- cally, in invisibility, never materially, because then they would no longer be invisible (. . . )--Do you sometimes feel the invisibles on your body? --The person of myself feels, and is very angry at it; they have done all sorts of indecent things to her (. . . )--How are you finding it at Salpetriere? --The person of myself finds it very well; she is treated very kindly by M. Pariset. She never asks anything from the maids (. . . )-- What do you think of the ladies with you here in this ward? --The person of myself thinks they have lost their reason. '02
? In a sense this is the most marvelous description of asylum existence lo be found. Once the name has been given on entering Salpetriere, once I his administrative, medical individuality has been constituted, all that remains is "the person of myself," who only speaks in the third person. In such a case, in which confession is not possible and with the endless statement in the third person of this someone who only expresses her self in the form of the person who is not anyone, Leuret clearly sees that lhe therapeutic processes organized around the statement of the truth were no longer possible. As soon as one has left one's name on entering Salpetriere and one is no more than "the person oi myself" in the asy lum, when, consequently, one can no longer recount one's childhood memories and recognize oneself in this statutory identity, then one is definitely good for the asylum.
We could say that at bottom the asylum machine owes its effectiveness to a number of things: uninterrupted disciplinary training; the dissym- metry of power inherent in this; the game of need, money, and work; statutory pinning to an administrative identity in which one must recognize oneself through a language of truth. However, you can see that this truth is not the truth of madness speaking in its own name but l he truth of a madness agreeing to first person recognition of itself in a particular administrative and medical reality constituted by asylum power. The operation of truth is accomplished when the patient has rec ognized himself in this identity. Consequently, the operation of truth lakes place in the form of charging discourse with the task oi this insti- tution of individual reality. The truth is never at issue between doctor and patient. What is given at the start, established once and for all, is the biographical reality with which the patient must identify if he wants to he cured.
There remains a final, supplementary episode in this Dupre affair. When Leuret has got this true account, but true precisely in terms of a biographical canon constituted in advance, he does something astonishing: he releases Dupre while telling him that he is still ill but no longer in need of the asylum at this time. What was Leuret doing in releasing his patient? In a way, certainly, it was a matter of continuing that kind of intensification of reality for which the asylum had been responsible.
That is to say, we will see Leuret again plotting exactly the same kind of
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maneuvers around his patient, now living in freedom, as those I have been talking about. He is trapped with problems of truth; when he claims to know Arabic he is placed in a situation in which he is iorced to confess that he does not know it. s* He is caught in the same con straints of language as those in which he was held in the asylum. The job Leuret found for his patient to lead him to the cure, that is to say, so that reality has a total grip on him, was as a printer's corrector,57' so that he is effectively inserted into that constraining order of language which, again, is not that of language as the bearer of truth, in its dialectical use, but of language in its imperative use. What he reads must actually con iorm to statutory and school orthography.
In the same way, Leuret explains that he created needs by taking him to the Opera so that he acquire the desire to go to performances. Hence the need for him to earn some money. It is still the same |enterprise] ol the renewal ol or identification with reality through a disciplinary game, now extended rather than concentrated and intense as in the asylum: "I increased his enjoyments so as to extend his needs and thus gain many means lor directing him. ,,vs
However, there is a much stronger, more subtle and interesting reason. This is that, in fact, Leuret identilied something in his patient that had three forms: the pleasure of the asylum,""6 the pleasure of being ill, and the pleasure of having symptoms. This triple pleasure is the underlying basis ol the omnipotence of madness.
When we go back over the whole development of the treatment, we see that from the start Leuret tried to attack this pleasure of the illness that he had detected in his patient. He uses the famous shower, the straitjacket, and deprivation of food right from the start, and these repressions have a double, physiological and moral, justification. The moral justification cor- responds to two objectives. On the one hand, it involves, of course, making the reality of the doctor's power felt against the omnipotence of madness. But it is also a matter of taking the pleasure out ot madness, that is to say, wiping out the pleasure of the symptom through the displeasure of the cure. Here again I think Leuret reproduces techniques that were employed by the psychiatrists of his time without being reflected or theorized.
However, what is particular about Leuret--and here he takes things further--is that in Dupre he found a special case. He had a patient who,
? when under the shower, and even when cauterized on the skin of his head,5' hardly protested and found that it was completely bearable so long as it was part of his treatment. ^8 Now it is here that Leuret no doubt goes further than most of the psychiatrists ol the time who--as sign, moreover, of their omnipotence lacing the patient--basically required the patient to accept treatment without a word. In this case he has a patient who accepts the treatment, and whose acceptance is, in a way, part of the illness.
Leuret identifies this acceptance as a bad sign lor his therapy; treatment is being incorporated within the delirium. When given a shower, Dupre says: "A woman is insulting me! "w Things must there- lore be arranged so that treatment and delirium are disconnected, so that treatment is confiscated from the delirium constantly invading it. It is thus necessary to give an especially painlul edge to the treatment, so that reality will establish its hold on the illness through the treatment.
We find some fundamental ideas in this technique: madness is linked to a pleasure; through pleasure, treatment may be integrated into the madness itself; the impact of reality may be neutralized by a mechanism ol pleasure intrinsic to the treatment; and, consequently, the cure must not only work at the level of reality, but also at the level of pleasure, and not only at the level of the pleasure the patient takes in his madness, but at the level of the pleasure the patient takes in his own treatment/
Hence, when Leuret realized that Dupre lound a whole series of pleasures in the asylum--in the asylum he could be delirious at ease, he could integrate his treatment in his delirium, and all the punishments inflicted on him were reinvested in his illness--then, at that point, Leuret concluded that he had to get his patient out ol the asylum and to deprive him of the pleasure of the illness, the hospital, and of the cure. As a result, he put him back into circulation, consequently taking the pleasure out ol the treatment and making it function in an absolutely non medical mode.
In this way Leuret is entirely resorbed as a medical personage. He has ceased playing his aggressive and imperious role, and in its place he brings a number of accomplices into play in order to construct the
* The manuscript adds: "There is both power and pleasure in every symptom. "
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following kind o( scenarios. Despite his job as a corrector at a printing house, M. Dupre continued to make systematic spelling mistakes, since in his delirium he wanted to simphiy the spelling system. A pseudo- letter of appointment was sent to him for a job that would have brought him a lot of money. M. Dupre drafts a letter oi acceptance of this new, well remunerated situation, but he lets by one or two spelling mistakes, so that Leuret's accomplice can send him a letter in which he says: "I would have employed you, if you had not made dreadful spelling mistakes. "60
So you see that all the mechanisms here, which are of the same type as those in the asylum, are now demedicalized. The medical personage, as Leuret says himself, must become instead a benign personage who tries to arrange things, who acts as an intermediary between harsh real ity and the patient. 61 However, as a result of this, the patient will no longer be able to take pleasure either in his illness, which causes so many unfortunate consequences, or in the asylum, since he is no longer there, or even in his doctor, since the doctor will have disappeared as such. M. Dupre's cure was wholly successful; it ended in the Spring of 1839 with a complete recovery. However, Leuret noted that at Paques in 1840 some unfortunate signs proved that a new illness was overcoming "the patient. "62
In summary, we can say that in the way that it functions through this kind of treatment, the asylum is a curing apparatus in which the doctor's action is part and parcel of the institution, the regulations, and the build ings. Basically, it is a question of a sort of great single body in which the walls, the wards, the instruments, the nurses, the supervisors, and the doctor are elements which have, of course, different functions to perform, but the essential function of which is to bring about a collective effect. And, according to different psychiatrists, the main accent, the most power, will sometimes be fixed on the general system of supervision, sometimes on the doctor, and sometimes on spatial isolation itself.
The second thing I would like to emphasize is that the asylum has been a site for the formation of several series of discourse. It was
? possible to construct a nosography, a classification of illnesses, on the basis of these observations. Also, on the basis of the free disposal of the corpses of the mad, it was possible to outline a pathological anatomy of mental illness. However, you can see that none of these discourses, nei- i her nosography nor pathological anatomy, served as a guide in the for ination of psychiatric practice. In actual fact, although we have had some protocols of this practice, we can say that it remained silent in that for years and years psychiatric practice did not produce an autonomous dis course other than the protocol of what was said and done. There have been no real theories of the cure, nor even attempts to explain it; the cure has been a corpus of maneuvers, tactics, and gestures to be made, actions and reactions to be activated, the tradition of which has been carried on through asylum life, in medical teaching, and with just some ol those cases, the longest of which I have quoted, as surfaces of emergence. All we can say about the way in which the mad were treated amounts to a body of tactics, a strategic ensemble.
Third, I think we should talk of an asylum tautology, in the sense that, through the asylum apparatus itself, the doctor is given a number of i instruments whose basic function is to impose reality, to intensify it, and add to it the supplement of power that will enable the doctor to get a grip on madness and reduce it, and therefore, to direct and govern it. These supplements of power added to reality by the asylum are discipli nary asymmetry, the imperative use of language, the management of lack and needs, the imposition of a statutory identity in which the patient must recognize himself, and the removal of pleasure from madness. These are the supplements oi power by which, thanks to the asylum and its processes, reality will be able to fix its grip on madness. But, you see-- and it is in this sense that there is a tautology--that all of this--the dis symmetry of power, the imperative use of language, etcetera--is not merely a supplement of power added to reality, but the real form of real- ity itself. To be adapted to the real, \. . . *] to want to leave the condition
of madness, is just precisely to accept a power that one recognizes is insurmountable and to relinquish the omnipotence of madness. To stop being mad is to agree to be obedient, to be able to earn one's living, to
' (Recording:) to relinquish the omnipotence ol madness,
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recognize onesell in the biographical identity that has been Iormed ol you, and to stop taking pleasure in madness. So as you can see, the instru- ment by which madness is reduced, the supplement of power added to reality so that it masters madness, is at the same time the criterion of the cure, or again, the criterion ol the cure is the instrument by which one cures. So, we can say that there is a great asylum tautology in that the asy lum is that which must give a supplementary intensity to reality and, at the same time, the asylum is reality in its naked power, it is reality med- ically intensified, it is medical action, medical power-knowledge, which has no other function than to be the agent of reality itseH.
The asylum tautology is this action of the supplement ol power accorded to reality, which consists in nothing other than the reproduc tion ol this reality itself within the asylum. And you can see why the doctors ol the time could say both that the asylum had to be something absolutely cut oil from the outside world, that the asylum world of mad ness had to be an absolutely specialized world entirely in the hands of a medical power delined by the pure competence of knowledge--confiscation, therelore, of the asylum space for the benefit of medical knowledge-- and, on the other hand, that the same doctors said that the general forms of the asylum had to recall everyday life as much as possible, that the asylums had to be similar to the colonies, workshops, colleges, and prisons, that is to say, that the specificity of the asylum is to be exactly homogeneous to that from which it is differentiated, by virtue of the line separating madness and non-madness.
Finally, the last point on which I will stop, and about which I will talk later, is that when we follow a cure like Leuret's in some detail-- with, of course, the qualification that this is the most sophisticated of all the cures for which we have an account--simply quoting the different episodes, without adding, I think, to what Leuret said, and by taking into account the fact that Leuret did not in any way theorize what he meant, you see a number of notions appearing: the doctor's power, language, money, need, identity, pleasure, reality, childhood memory. All of this is completely inscribed within the asylum strategy, but not yet constituting anything more than points of support for this asylum strat egy. Later, you know what their future will be; you will find them again m a completely extra-asylum discourse, or at any rate in a discourse that will
? present itself as extra-psychiatric. * However, before taking on this sta- tus of object or concept, in the kind of slow-motion which M. Dupre's cure offers us, we see them at work as tactical points of support, strate- gic elements, maneuvers, plans, and nodes in the relationships between I he patient and the asylum structure ltseli.
Later, we will see how they are detached from it in order to enter another type of discourse.
A The manuscript adds: "it is there that Freud will look lor them. "
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1. Opiates, preparations with an opium base, renowned lor suspending attacks ol lury and restoring order between ideas, were recommended, in preference to purgatives and bleedings, by Jean Baptiste Van Helmont (1577-1644) and Thomas Sydenham (1624 1689). Their use in treating "maniacal" or "furious" torms ol madness developed in the eighteenth century. See, Philippe Hecquet (1661 1737) Reflexions sur /'usage cle /'opium, des calmants el des narcoliques pour la guerison des maladies (Paris: G. Cavalier, 1726) p. 11;
J. Guislain, Traile sur Valienation meniale et sur les hospices des alienes, vol. I, book IV: "Moyens diriges sur le systeme nerveux central. Opium," pp. 345 353. See also the pages devoted to
this substance by M. Foucaull, in Hisloire de lajolie, pp. 516 319 (omitted Irom the English translation).
In the nineteenth century, Joseph Jacques Moreau de Tours ( 1804-1884) recommended
the use ol opiates in the treatment ol mania: "In the opiates (opium, datura, belladonna, henbane, aconite, etcetera) we can still find an excellent means ol calming the usual agita-
tion of maniacs and the passing Iits ol rage of monomaniacs. " "Lettres medicales sur la colome d'alienes de Gheel" Annales medko-psychologiques, vol. V, March 1845, p- 271. See,
C. Michea, De I'emploi des opiaces dans le trailement d'alienalion meniale (Pans: Malteste, 1849), and Rechcrches experimentales sur I'emploi des principaux agents de medication slupefianle dam le trailement de I'alienation meniale (Paris: Labe, 1857); H. Legrand du Saulle, "Recherches chnic|ues sur le mode d'administration de l'opium dans la manic" Annales medico-psychologiques, 3U series, vol. V, January 1857, pp. 1 27; H. Brochin, "Maladies nerveuses. ? Narcoliques" in Diclionnaire encyclopedique des sciences medicales, 2 series, vol. XII (Paris: Masson/Asselin, 1877), pp. 375 376; and, J. B. Fonssagrives, "Opium" ibid.
2,ul series, vol. XVI, 1881, pp. 146 240.
2. Laudanum, a preparation in which opium was combined with other ingredients, ol which
the most widely used was the liquid laudanum ol Sydenham, or "*>/>/ d'opium compose," was recommended lor digestive disorders, the treatment ol nervous illnesses and hysteria; see,
T. Sydenham, "Observaliones Medicae" (1680) in Opera Omnia (London: W. Greenhill, 1844) p. 113; English translation, "Medical Observations" in The Works of Thomas Sydenham, trans. R. G.
Latham (London: The Sydenham Society, mdcccxlvm) vol. 1, p. 173. See Diclionnaire encyclopediaue des sciences medicales, 2 series, vol. II (Pans: Masson/Asselin, 1876) pp. 17 25.
3. Since Pinel, who asserted "the absolute necessity lor an invariable order ol work" (Traile medico-philosophique, section V: "Police generale et ordre journaher du service dans les hospices d'alienes" p. 212; A Treatise on Insanity, "General police and daily distribution ol services in lunatic asylums," p. 206) the alienists constantly stressed the importance ol regulations. Thus,J. P. Falret, "Du traitement generale des alienes" Des maladies menlales et des asiles d'alienes, p. 690: "What do we see in modern asylums? We see a strictly observed positive regulation, which fixes the use ol every hour ol the day and forces every patient to react against the irregularity of his tendencies by submitting to the general law. He is obliged to place himsell in the hands ol a loreign will and to make a constant ellort on himsell so as not to incur the punishments attached to inlnngemenls ol the rule. "
4. The problem of the dietary regime occupied a privileged place, both as a component of the daily organization of asylum time, and as a contribution to treatment. Thus, Francois Fodere states that "lood is the lirst medicine" Traite du delire, vol. II, p. 292. See, J. Daquin, La Philosophic de la jolie, republished with a presentation by C. Quetel (Paris: Editions Frenesie, 1987) pp. 95 97; and, J. Guislain, Traile sur I'alienation meniale, vol. II, book 16: "Regime alimentaire a observer dans I'alienation mentale" pp. 139 152.
5. Work, an essential component ol moral treatment, was conceived ol in the double perspec live of therapy (isolation) and discipline (order). See, P. Pinel, Traile medico-philosophique, section V, ? xxi: "L01 fondamentale de tout hospice d'alienes, celle d'un travail mecanique": "Constant work changes the vicious circle ol ideas, clanhes the laculties ol understanding by exercising them, alone keeps order wherever the insane are assembled, and dispenses with a host ol detailed and often pointless rules in order to maintain inter
nal police" p. 225; A Treatise on Insanity, "Mechanical employment essential to the success
ful management of lunatic hospitals" p. 217. Cf. , C. Bouchct, "Du travail applique aux alienes" Annales medico-psychologiques, vol. XII, November 1848, pp. 301-302. In Hisloire de
? lajolie, pp. 505 506; Madness and Civilisation, pp. 247 249, Foucault refers to a study by Jean Calvet, from 1952, on the historical origins ol the work ol patients in insane asylums. 6. P. Pinel lends his authority to the shower by making it an instrument of both treatment and conditioning. See the second, revised and expanded edition of his Traitemedico-
philosophique sur {'alienation mentale (Paris: Caille et Ravier, 1809) pp. 205-206. See also, H. Girard de Cailleux, "Considerations sur le traitement des maladies mentales" Annales medico-psychologiques, vol. IV, November, 1844, pp. 330-331; H. Rech (de Montpellier), "De la douche et des affusions d'eau Iroide sur la tete dans le traitement des alienations men- tales" ibid. vol. IX, January 1847, pp. 124 125. It is Francois Leuret especially who makes use of it in Traitement moral de lafolie, ch. 3, ? "Douches et affusions froides" pp. 158-162. See Foucault's discussion of M. Dupre's cure in this and the following lecture (above, French p. 143 sq. and below, French p. 173 sq). Foucault devotes several pages to this cure in: Maladie mentale et Psychologic (Paris: P. U. F. , 1962) pp. 85-86; English translation, Mental Illness and Psychology, trans. Alan Sheridan (Now York: Harper and Row, 1976) p. 72; Histoire de lajolie, p. 338 and pp. 520-521; Madness and Civilisation, p. 172 and pp. 266 267; and "L'eau et la iolie" Dils et Ecrits, vol. 1, pp. 268-272. He returns to it in "Sexuality and Solitude" London Review of Books, 21 May 5 June 1981, p. 3 and pp. 5 6, reprinted in The Essential Works oj Foucault, 1954-19$/l, vol. 1: Ethics: subjectivity and truth, ed. Paul Rabinow, trans. Robert Hurley and others (New York: The New Press, 1997) pp. 175 176; French translation, "Sexualite et solitude," trans. F. Durand Bogaert, Dits el Ecrits, vol. 4. , pp. 168 169.
7. The rotary swing was perfected by the English doctor Erasmus Darwin (1731-1802) and used to treat madness by Mason Cox, who praised its eilectiveness: "I think it can be put
to both a moral and a physical use, and be employed with success both as a means of rebel
and as a means oi discipline, in order to make the patient more adaptable and docile" Observations sur la demence, p. 58. | It has not been possible to consult the first, 1804, edi tion of Practical Observations on Insanity, on which the French translation is based, and the passage quoted here does not appear in the second, 1806, edition. However, reierence is made to the rotary swing elsewhere in the 1806 edition, e. g. , p. 137; G. B. ] See, L. Amard, Traite analytique de la folie et des moyens de la guerir (Lyon: printed by Ballanche, 1807)
pp. 80 93; J. Guislain, Traite sur Valienation mentale, vol. I, book IV, and, Moyens diriges sur le systeme nerveux cerebral. De la rotation (Amsterdam: Van der Hey, 1826) p. 374 and p. 404; C. Buvat Pochon, Les Traitemenls de choc d'autrejois en psychiatric Leurs liens avec les therapeu- tiques modernes, Medical thesis, Paris, no. 1262 (Paris: Le Francois, 1939). See Histoire de la
Jolie, pp. 341 342; Madness and Civilisation, pp. 176-177.
8. While he was alive, Leuret had to defend himself from critics who condemned his practice
as, in his own words, "retrograde and dangerous" (DM traitement moral de lafolie, p. 68). His main opponent was E. S. Blanche, in his paper to the royal Academy of medicine, Du dan-
ger des rigueurs corporelles dans le traitement de lajolie (Paris: Gardembas, 1839), as well as in his short work, De Fetal actuel du traitement de lajolie en France (Paris: Gardembas, 1840). These polemics were echoed in Leuret's obituary notices: U. Trelat, "Notice sur Leuret" Annales d'hygiene publique et de medecine legale, vol. 45, 1851, pp. 241-262; and A. Brierre de Boismont, "Notice biographique sur M. F. Leuret" Annales medico-psychologiques, 2nd series, vol. III,July 1851, pp. 512 527.
9. It is Observation XXII: "Bearers ol imaginary titles and ranks" Du traitement moral de la folie, pp. 418-462.
10. 11. 12.
Ibid. pp. 421-424.
Ibid. p. 429.
P. Pinel, Traile medico-philosophique, op. cit. , section II, ? ix: "Intimider Pahene, mais ne point se permettre aucun acte de violence" p. 61; A Treatise on Insanity, "Intimidation too often associated with violence" pp. 64-65.
13. J. E. D. Esquirol, "De la folie" (1816) in Des maladies mentales vol. 1, p. 126; Mental Maladies, "Insanity," p. 76.
14. See above note 3. Already, for J. Guislain, this was one ol the advantages of "isolation in the treatment oi insanity": "Based on a leeling of dependence that he makes the insane person feel ( . . . ) lorced to conform to a loreign will" Traile sur I'alienation mentale, vol. I, p. 409.
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15- F. Leuret, Du irailemenl moral de lajolie, p. 422: "Dupre is a name oi convenience, a name oi disguise; his true name, as we well know, is Napoleon. "
16. Ibid. p. 423: "The distinctive sign of his Halcyon status is his constant ability to enjoy the pleasures of love. "
17. Ibid. p. 423: "Only he in the home is a man; all the others are women. "
18. EJ. Georgct, De lafolie. Considerations sur cette maladie, p. 284.
19. F. Leuret, Du traitement moral de lafolie, p. 429.
20. Ibid. p. 430. 21. Ibid. p. 430. 22. Ibid. p. 422. 23. Ibid. p. 431.
