Now these were bad
illnesses
for two reasons.
Foucault-Psychiatric-Power-1973-74
Bailliere, 1855), and then, Cours theorique el pratique de braidisme, ou Hypnotisme nerveux
considere dans ses rapports avec la psychologiie, la physiologie et la pathologic, el dans ses applications a la medecine, a la chirurgie, a la physiologie experimenlale, a la medecine legale et a ^education (Paris:J. B. Bailliere, i860).
57. Durand de Gros defines "the hypotaxic state" as "a preparatory modification of vitality, a modification which usually remains latent and the whole effect of which is to incline the organization to undergo the determinant and specific action constituting the second stage" Cours theorique et pratique, p. 29.
58. Ibid. p. 112.
59. Ibid. Chorea is a nervous disorder characterized by sweeping and jerky involuntary
movements, with a gesticulatory appearance.
? 60. Ibid. p. 87: "Braidism is a process by which we seek to determine certain physiological changes in man with the aim ol lulfilling certain indications for medical or surgical treatment, or in order to facilitate the experimental studies of biology. "
61. Between 1850 and i 8 6 0 , under the impulse ol Guillaume Benjamin Amand Duchenne de Boulogne (1806 1875), the nosology of functional disorders ol motivity was redefined and enriched by two new groups of affections. On the one hand, "progressive muscular atrophy," studied from 18-19, and the "muscular atrophies with myopathic origin," in 1853: (1) La Paralyse atrophique de I'enjance (Pans: 1855). On the other hand, "progressive locomolor atrophy," known up until then as tabesdorsalis: (2) "De l'ataxie locomotrice progressive. Recherches sur unc maladie caractensee specialement par des troubles generaux de coordination des mouvemcnts," Archives generates de medecinc, 5th series, vol. 12, December 1858, pp. 6/|1 652; vol. 13, January 1859, pp. 5-23; February 1859, pp. 158 I64; April 1859, pp. -117 yi32. In i860 he described (3) the "paralysie glosso labio laryngee," ibid. 5th series, vol. 16, i860, pp. 283 296 and pp. /|31 Vi5. On Duchenne de Boulogne, see P. Guilly, Duchenne de Boulogne (Paris: Bailliere, 1936). On the constitution ol the neurological lield, see W. Riese, A History oj Neurology (New York: MD Publications, 1959), and F. H. Garrison, History of Neurology, edition revised and expanded by Laurence McHenry (Springfield, 111. : C. C. Thomas, 1969).
}0 January 7974 295
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6 FEBRUARY 1974
The emergence of the neurological body: Broca and Duchenne de Boulogne. ^ Illnesses of differential diagnosis and illnesses of absolute diagnosis. ^ The model of "generalparalysis" and the
neuroses. ^ The battle of hysteria: 1. The organisation of a "symptomatologLcal scenario. "nu 2. The maneuver of the "functional
mannequin" and hypnosis. The question of simulation. nu 3. Neurosis and trauma. The irruption of the sexual body.
LAST WEEK I SAID that one of the important events in the history of the consolidation of psychiatric power was, in my view, the appearance of what I called the "neurological body. "* What should we understand by "neurological body"? I would like to begin with this today.
Of course, the neurological body is still, always, the body of pathological-anatomical localization. There is no opposition between the neurological body and the body of pathological anatomy; the second is part of the first; it is, if you like, a derivative or expansion of it. And the best proof of this is that in one of his courses, in 1879, Charcot said that the constitution, progress, and, in his view, the culmination of neu- rology, was the triumph of the "spirit of localization. "1 Except that what I think is important is that the procedures for matching up anatomical localization and clinical observation in the case of neurology are not at all the same as in the case of ordinary general medicine. It seems to me
* The manuscript adds: "From 1850 to 1870, emergence of a new body. "
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that neurology, clinical neurology, involves a quite different deployment of the body in the field of medical practice. My impression is that the encounter of the patient-body and the doctor body in neurology takes place in terms of a very different arrangement from that in general medicine. And it is the setting up of this new apparatus that seems to me to be the important episode, which is why I would like to try to identify the new apparatus set up by and through the constitution ol a neuropathology or neurological clinical medicine.
What is this apparatus, and in what does it consist? How is the sick body* captured in clinical neurology? Its capture takes place, I think, very differently trom the way the body was captured at the time ol the formation of pathological anatomy, more or less between Bichat2 and Laennec* I will give you an example straightaway by taking a text that is not by Charcot himself, but which is found in the Charcot archives at Salpetriere and was quite certainly written by one of his students-- clearly we don't know which one. It is an observation of a patient. This is how the patient is described: the patient's symptom was something very simple, the drooping of the left eyelid, called ptosis. So, the student takes the following notes for Charcot for him then to use for a lecture-- I am not giving you the description of the whole of the patient's lace, but just a quite small excerpt.
"If we tell him to open his eyelids, he raises the right one normally, the left one however, does not noticeably move, no more than the eye brow, so that the superciliary asymmetry becomes more marked. In this movement (. . . ) the skin ol the forehead wrinkles transversally on the right side, while it remains almost smooth on the left. At rest, the skin of the forehead is wrinkled neither on the right nor the left ( . . . ) . "
"Two more points should be noted: a small dimple, quite visible under a certain angle of light, eight millimeters above the left eyelid and about two centimeters to the left of the median line of the forehead; and a little projection within the dimple which seems due to the contraction of the eyelid muscle. These two points are very noticeable in comparison with the normal state of the right side. "1
* The manuscript clarifies: "body whose surlace is the bearer ol plastic values. "
? You have here a type of description which is, I think, really quite different from what is found in the anatomical-pathological procedure, m anatomical-pathological observation. ^ In a sense, this sort of descrip- tion takes us back to a sort of surlace, almost impressionistic gaze, such as could be found m eighteenth century medicine, when the patient's complexion, color, red cheeks and bloodshot eyes, etcetera, were impor tant elements for clinical diagnosis. 6 Pathological anatomy--Bichat, Laennec, if you like? infinttely reduced this impressionistic description of the surlace and codified what were ultimately a quite limited number of surlace signs intended to identify what was essential according to a well established clinical code, this being, precisely, the lesion, which then, thanks etther to a surgical operation or, especially, the autopsy, was described by the anatomical pathologist with almost as many details as, if not more than, the description I have just read to you. In other words, anatomical-pathology brought its minutely detailed description to bear on the deep and injured organ, the surface only being questioned through a grid of ultimately simple and limited signs.
Here, rather, as you can see, you have the striking reemergence of sur face values within medical discourse and knowledge. It is this surface that must be covered in all its hollows and bumps, and practically by looking only, by looking only that far. In fact, and no doubt even more than this clinical re validation of the almost impressionistic values of the surface, what is important and, I think, decisive, in this new clinical capture of the neurological patient, and in the correlative constitution of a neurological body before this gaze and apparatus of capture, is that the neurological examination is basically looking tor "responses. "
What I mean is that in the pathological anatomy of Bichat Laennec one can, of course, identify the signs straightaway, at the first glance; one can also obtain them from a stimulation: one taps, one listens, etcetera. That is to say, what is sought in classical pathological anatomy is essentially the system of stimulation-effect: one sounds the chest and listens to the noise;7 one asks the patient to cough and listens to its harshness; one palpates and sees if there is any heat. So: stimulation- effect.
In the case of the neurological examination being constituted in the mid-nineteenth century, the main part of the signs, in short what makes
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a sign a sign, is not so much that it is [deciphered asj a more or less mechanical effect, like the noise following percussion in classical patho logical anatomy, but that a sign is [deciphered) as a response. I think the substitution of the schema of stimulus-response for the schema of stimulus effect, and the organization of a whole battery of stimuli- responses, is crucial.
We have a number of examples of this staging of a battery of stimuli- responses. At the strictly elementary level, there was the founding discovery oi neuropathology in Duchenne de Boulogne's research into what he called "localized Faradization," when, by moistening two electrodes, he succeeded in getting a single muscular response, or, rather, the response of a single muscle to electrification of the surface of the skin; by moistening the surface of the skin he succeeded in limiting the effect of the charge and obtained a single response of a single muscle: this was the founding discovery of everything here. 8 Then, starting from this, there were the studies of reflexes and then, especially, the study of complex behavior involving either a gearing of diverse automatisms or a prior learning, and it is there that we find, more or less, the two great domains in which the capture, the apparatuses of neurological capture, were completely established. This was Broca's study of aphasia,9 the study of walking, and notably Duchenne de Boulogne's study of tabetics. 10
Taking the second example, Duchenne produced a description of the walking of tabetics that is presented precisely in terms of stimulus response or, rather, in terms of behavior and the sequence of episodes of behavior that constitute the action of walking. Duchenne's problem was to distinguish the disorder of balance found in tabetics, that is to say, at a certain stage and in a certain form of general paralysis, from the vertigo of alcoholic intoxication or even of certain cerebellar disorders. In 1864, in a fundamental article, Duchenne managed to give a differential description of the gait of tabetics and the rocking of vertigo. " In the case of vertigo, the subject gives way to wide swaying, whereas in the subject suffering from tabes the rocking movements are "short," "they are abrupt"--Duchenne de Boulogne says that the subject has the bearing of a tightrope walker without his balancing pole, cautiously advancing one step at a time while trying to restore his balance. 12 In the case of vertigo, there is no muscular contraction, but a general weakening of the
? musculature and tone instead, whereas [-. . *] the tabetic is always holding himself back, and if we observe what happens at the level of his calves and legs, we see, even before he loses his balance, even before he is aware of losing his balance, some small, brief spasms which flicker across the musculature ot his legs, and then, gradually, these contrac- tions become more significant, until they become voluntary when the subject becomes aware that he is losing his balance. 13 This is completely different, therefore, from the collapse in vertigo. In vertigo, the subject zigzags; that it to say, going from one point to another, he cannot keep to a straight line. The tabetic however, goes completely straight ahead; it is just his body that wobbles around this straight line. 17' And finally, in drunkenness, there is the internal sensation of vertigo, whereas the tabetic has the impression that it is not his body that lacks balance at all, but only his legs, locally as it were. 15 These are the principal themes, more or less, of Duchenne de Boulogne's analysis of the tabetic's gait.
Now, in this kind of analysis--and the same would be true for Broca's analyses of aphasia roughly at the same time, between 1859 and 1865-- what is achieved by seeking to obtain a system of signs of responses that show dysfunctions, rather than a system of signs of effects that would reveal the presence of lesions at a given point? What we obtain, of course, is the possibility of distinguishing and analyzing what neurolo- gists called, and still call today, synergies, that is to say, the different cor- relations existing between this or that muscle: What are the different muscles that must be used in order to get such and such a response? What happens when it is precisely just one of them that is put out of play? So, we get a study of synergies.
Secondly, and I think this is the important thing, it becomes possible to set out the phenomena analyzed in different levels according to an axis of the voluntary and the automatic. That is to say, on the basis of this analysis of behavior, of responses to different stimuli, we can see the functional difference, the difference of neurological and muscular imple mentation, between simple reflex behavior, automatic behavior, sponta- neous voluntary behavior, and, finally, spontaneous behavior produced
* (On the recording, repetition of:) rather
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by an order coming from outside. All of this hierarchy in the bodily implementation of the voluntary and the involuntary, of the automatic and the spontaneous, of what is required by an order or what is sponta- neously linked together within behavior, will make possible--and this is the essential point--a clinical analysis, an analysis in terms of physical ascription, of the mdividuaPs intentional attitude.
Consequently, a capture of the subject's attitude, of the subject's consciousness, of the will itself within his body, becomes possible. Neuropathology showed the will invested in the body, the effects of the will or the degrees of will legible in the organization of responses to stimuli. You are familiar with all the analyses Broca initiated on the different levels ol the performance of aphasics, according to whether it is a matter ol simple mumblings, of swear words uttered automatically, of phrases triggered spontaneously in a certain situation, or of phrases which must be repeated in a certain order and on a certain injunction. 16 All of these clinical deferences of performance between different levels of behavior make possible the clinical analysis of the individual at the level of his intention, at the very level of that much vaunted will that I have tried to show you was the great correlate of discipline. It was the will, in fact, on which and to which disciplinary power had to be applied; it really was the vis avis of disciplinary power, but then it was only acces sible through the system of reward and punishment. Neuropathology now provides the clinical instrument by which it is thought the individual can be captured at the level of this will itself.
Let's consider things a bit differently and bit more precisely. We could say that, in one respect, with the neurological examination medicine will lose power m comparison with classical anatomical-pathology. That is to say, in the anatomical pathology constituted by Laennec, Bichat, and others, ultimately very little was demanded from the individual: he was asked to lie down, bend his leg, cough, breathe deeply, and so on. Consequently there was a minimum of injunctions on the doctor's part, and minimum dependence on the patient's will. On the other hand, with neuropathology, the doctor's understanding of his patient will have to pass through the latter's will, or at any rate through his cooperation. He will not just say: "Lie down! Cough! ", but will have to say to him: "Walk! Put out your leg! Hold out your hand! Speak! Read this
? sentence! Try to write this! " and so on. In short, we now have a technique of examination reliant on instruction and injunction. Consequently, since instruction and injunction necessarily have to pass through the patients will, the latter will be at the very heart of the examination and, to that extent, the doctor's authority will be at the very heart of this neurological apparatus. The doctor will give orders, he will try to impose his will, and the patient, after all, may always feign inability or unwillingness. That is to say, one really will depend on the patient's will. However, the clinical possibility of identifying voluntary and involuntary, automatic and spontaneous behavior, the possibility of clinically deciphering the levels of will in behavior that I was just telling you about, will enable one to see whether the patient really responds as he is told to, the quality and nature of his responses, and the extent to which his responses have or have not been faked by the will which comes into play; and here the doctor will recapture the power he lost by giving instructions. For example, after Broca, neurologists could easily distinguish voluntary mutism from an aphasia like anarthna: in the case of anarthna, the impossibility of speaking is always accompanied by a series of background sounds, of automatisms which accompany the attempt to speak; it is also always accompanied by correlative motor disorders, and it is also accompanied by expressive deficiencies in gestures and written expression, etcetera. 17 Someone who refuses to speak, and furthermore a hysteric who does not speak, is someone who has gestures, can write, understands, and has none of the accompanying supplementary disorders typical of anarthna.
So you can see that the individual's will can be captured at the level of his real behavior, at the level, rather, of the clinical observation of his behavior. Consequently, if it is true that, on the one hand, the game of instruction typical of the neurological examination makes the possibility of examination depend on the patient's will to a certain extent, on the other hand, with clinical observation, with the clinical decipherment now available, the patient can be circumvented and short-circuited.
To summarize this in a few words, let's say that a new clinical medical apparatus is put in place that is different in its nature, equipment, and effects from what we can call the Bichat-Laennec clinical apparatus, as well as from the psychiatric apparatus. In organic medicine, the patient
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was given a minimum of injunctions like "Lie down! Cough! " and the rest was given over entirely to the doctors examination carried out through the interplay of stimuli and effects. I have tried to show you that the essential component of capture in psychiatry was questioning, which is the substitute for the examination techniques of organic medi- cine. Questioning depends, of course, on the subjects will, and for the psychiatrist the answers are not a test of truth or the possibility of a dif- ferential decipherment of the disease, but merely a test of reality; ques- tioning simply corresponds to the question: "Is he mad? "
So, neurology is neither an examination in the sense of pathological- anatomy, nor questioning; it is a new apparatus which replaces question- ing with injunctions, and which through these injunctions seeks to get responses, but responses which are not the subjects verbal responses, as in questioning, but the responses of the subject's body; responses which can be clinically deciphered at the level of the body and which one can consequently submit to a differential examination without fear of being duped by the subject who responds. We can now differentiate between someone who does not want to speak and someone suffering from apha- sia, that is to say, we can now establish a differential diagnosis within forms of behavior for which this was hitherto not possible and which were previously questioned in terms of an absolute diagnosis. The test of reality is no longer necessary: clinical neurology, m a certain domain at least, will enable differential diagnosis to get a hold, like organic medicine, but on the basis of a completely different apparatus. Broadly speaking, the neu- rologist says: Obey my orders, but keep quiet, and your body will answer for you by giving responses that, because I am a doctor, I alone will be able to decipher and analyze in terms of truth.
"Obey my orders, keep quiet, and your body will respond": you see that it is precisely here that the hysterical crisis will quite naturally rush in. Hysteria will enter into this apparatus. I am not talking about the appearance of hysteria: in my view the question of the historical exis- tence of hysteria is a futile question. I mean that the emergence of hyste ria within the medical field, the possibility of making it an illness, and its medical manipulation are only possible when this new clinical appa- ratus, the origin of which is neurological and not psychiatric, was estab- lished; or when this new trap was set.
? "Obey, keep quiet, your body will speak. " So, you want my body to speak! My body will speak, and I really promise you that there will be much more truth than you can imagine in the answers it will give you. Not, certainly, that my body knows more about it than you, but because there is something in your injunctions that you do not formulate but which I can clearly hear; a certain silent injunction to which my body will respond. * And it is this, the effect of your silent injunctions, that you will call "hysteria in its nature. " This, more or less, is the hysteric's discourse rushing in to the trap I have just described.
Fine. So, what takes place once this trap, this new apparatus of cap ture has been set?
Broadly speaking, I think we could say that until then, in medicine, until the existence of neurology and the clinical apparatus specific to neurology, there were two great domains of illnesses: mental illnesses and the others, the true illnesses. I do not think it is enough to say that mental illnesses and all the others are opposed to each other as illnesses of the mind on the one hand, and illness of the body on the other. This would not be correct, first of all because for many psychiatrists, from 1820 to 1870-1880, illnesses of the mind are just illnesses of the body with the characteristic of having psychical symptoms or syndromes. Then, it was absolutely accepted in this period that the so-called con- vulsive illnesses--medically, clinically, no effective difference was made between epilepsy and the others18--were illnesses of the mind. So I do not think that the mind/body opposition, organic illnesses/psychical illnesses, is the real distinction that divided medicine between 1820 and 1880, whatever the theoretical discussions were, and even because of the theoretical discussions on the organic basis of illness. 19 Actually, I think that the only true difference is the one I talked about last week. That is to say, there were certain illnesses which could be evaluated in terms of differential diagnosis--and these were the good, solid illnesses with which genuine and serious doctors concern themselves--and then the illnesses on which the latter could get no hold, and which could only be
k The manuscript adds: "I will hear what you do not say, and I will obey, providing you with symptoms the truth ol which you will have to recognize, since they will respond, without your knowing, to your unspoken injunctions. "
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recognized by a test of reality--and these were the so called mental illnesses, those to which there was only a binary response: "He really is mad" or "He is not mad. "
I think this is the real division of medical practice and knowledge in the first two thirds of the nineteenth century: between illnesses integrated within a differential diagnosis and illnesses falling solely under an absolute diagnosis. Between these two categories of illnesses there were obviously a number of intermediaries, of which there were basically two that I think are important. There was the good intermedi- ary, the good illness, which was of course general paralysis. This was an epistemologically good illness and, consequently, it was morally good to the extent that, on the one hand, it included psychological syndromes- delirium according to Bayle,20 and then dementia according to Baillarger21--and motor syndromes: trembling of the tongue, progressive paralysis of the muscles, etcetera. There are the two syndromes, and in terms of pathological-anatomy both of them refer to an encephalic lesion. A good illness, consequently, exactly intermediary between those illnesses of the test of reality, which were, if you like, the so-called mental illnesses, and then the illnesses differentially allocated and referring to pathological anatomy. 22 General paralysis was an absolutely good illness, better, more complete, and giving a stronger foundation to all these phenomena in that it was not yet known that general paralysis had a syphilitic origin. 23 Consequently, one had all the epistemological benefits and none of the moral inconveniences.
On the other hand, still intermediary between illness of differential diagnosis and illness of absolute diagnosis, there was a completely different, bad and swampy region, which was at that time called "the neuroses. "21 What did the word "neurosis" mean around the 1840s? The word cov- ered illnesses with all the motor or sensory components--"disorders of relational functions" as it was said--but without any pathological anatomical lesion which would allow an etiology to be established. So, of course, these illnesses of "disorders of the relational functions" without ascribable anatomical correlates, covered convulsions, epilepsy, hysteria, hypochondria, and so forth.
Now these were bad illnesses for two reasons. They were epistemo logically bad because in these illnesses there was a kind of symptomatic
? confusion or irregularity. In the domain of convulsions, for example, one could not make a division between the different types because, precisely, the neuropathological apparatus did not enable one to make a precise analysis ol different lorms of behavior. Faced with a convulsion, one said: "This is a convulsion"; one could not make those firm bodily inter- pretations that I was talking about a moment ago, and, consequently, one was faced with a "region" of confusion and irregularity. In the first number oi the Annales medico-psychologiques, in 18^3, the editors said: We must concern ourselves with madness; we should also concern ourselves with the neuroses, but it is so difficult, "because these disorders are fleeting, varied, protean, exceptional, difficult to analyze and under stand, we banish them from observation and dismiss them as we reject troublesome memories. "25
Epistemologically bad, these disorders were also morally bad due to the ease with which they could be simulated and the fact that, in addition to this possibility, there was a constant sexual component ol behavior. Thus,Jules Falret, in an article which was reprinted m 1890 m his Etudes cliniques, said: "The life of hysterics is just a constant lie; they put on airs of pity and devotion and succeed in passing themselves off as saints, while they secretly abandon themselves to the most shameful actions, while at home with their husband and children they make the most violent scenes in which they say coarse and sometimes obscene things. "26
The emergence of the neurological body, or rather, of the system con- stituted by neurology's clinical apparatus of capture and the correlative neurological body, will make it possible to remove the disquabiication, this double epistemological and moral disqualification, to which the neuroses were subject until the 1870s. It will be possible to remove this disqualification to the extent that it will finally be possible to place these illnesses called "neuroses," that is to say, illnesses with sensory and motor components, not exactly in the domain ol neurological illnesses strictly speaking, but very close by, not so much through their causes, but basically because ol their forms. That is to say, thanks to the clinical apparatus of neurology, the blade oi diflerential diagnosis will now be able to separate neurological illnesses, such as disorders due to a cere bellar tumor, for example, from hysterical convulsions and trembling.
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This famous differential diagnosis, which one had never been able to apply to madness, which never really managed to get a grip on the men- tal illnesses, this differential diagnosis that one could never insert between an ordinary illness and madness, because madness, above all and essentially, fell under an absolute diagnosis, this differential diagnosis then, through the apparatus I have tried to describe, can now be inserted between neurological disorders with ascribable anatomical lesions, and those disorders called "neuroses. " So that what was, morally and epistemologically, the last category in the domain of mental illness--the neuroses--will suddenly be promoted to the closest proximity to genuine and serious illnesses by this new instrument of neurological analysis, of clinical neurology. That is to say, through the use of differential diagnosis the previously discredited zone of the neuroses will receive pathological consecration.
In a book--what's more, not a very good book--which a contemporary neurologist called Guillain devoted to Charcot, his predecessor, the author says, with a kind of radiant joy: "Charcot all the same rescued hysteria lrom the psychiatrists," which is to say that he really brought it into the domain ol the medicine ol differential diagnosis, which is the only medicine. 2/ Basically, I think Freud thought the same when he put Charcot alongside Pinel and said: Pinel freed the mad from their chains, that is to say, he brought about their recognition as patients. Well, in a way, Charcot too made it possible for hysterics to be seen as ill: he pathologized them. 28
If we situate Charcot's operation in this way then I think we can see how what I will call "the great maneuvers of hysteria" unfolded at Salpetnere, and how they were constituted. I will not try to analyze this in terms ol the history of hysterics any more than in terms ot psychiatric knowledge of hysterics, but rather in terms of battle, confrontation, reciprocal encirclement, of the laying of mirror traps, ol investment and counter investment, of struggles for control between doctors and hysterics. * I do not think that there was exactly an epidemic ol hysteria; I think hysteria
* The manuscript adds: "of deals also, ol lacit pacts. "
? was the set of phenomena, and phenomena of struggle, which occurred within as well as outside of the asylum, around this new medical apparatus of clinical neurology; and it was the maelstrom of this battle which in fact summoned around hysterical symptoms all those people who actually joined in the battle. Rather than an epidemic, there was a maelstrom, a kind of hysterical vortex within psychiatric power and its disciplinary sys- tem. So how was this played out? I think we can pick out certain maneu- vers in this struggle between neurology and the hysteric.
The first maneuver is what could be called the organization of the symptomatological scenario. I think we can schematize things in the fol lowing way: lor hysteria to be put on the same level as an organic illness, for it to be a genuine illness falling under a differential diagnosis, that is to say, for the doctor to be a true doctor, the hysteric must present a sta ble symptomatology. Consequently, the doctor's consecration as a neurol- ogist, unlike the psychiatrist, necessarily implies an injunction given to the patient on the quiet: "Give me some symptoms, but give me some stable, coded, regular symptoms"--something that the psychiatrist was already saying--and this regularity and stability had to have two forms. First, consistent symptoms which should be permanently legible on the patient whenever the neurological examination takes place: No more of those illnesses that appear and disappear, the only symptoms of which are the flash of a gesture or the return of fits; we want stable symptoms, and in this way we will find them whenever we ask for them. This was how what Charcot and his successors called the "stigmata" of hysteria were defined. "Stigmata" are phenomena found in every hysteric, even when not suffering an attack:29 contraction ol the visual field,30 simple or double hemianaesthesia,31 pharyngal anesthesia, contracture caused by a circular bond around a joint. 32 Moreover Charcot said: All these stigmata are typical of hysteria; they are constants in hysteria, but, despite their con- stancy, I have to acknowledge that it quite often happens that we do not find them all, or even, in extreme cases, we do not find any. 33 But the epis temological requirement was there, the injunction was there, and I would point out that all of these wonderful stigmata were clearly responses to instructions: instructions to move, to feel a rubbing or contact on the body.
And then, second, the attacks (crises) themselves had to be ordered and regular, and so develop according to a very typical scenario
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sufficiently close to an existing illness, to an existing neurological illness, so that it crosses the line ol diiferential diagnosis, and yet nonetheless sufficiently different for the diagnosis to be made; hence the codification ol the hysterical attack (crise) on the model ol epilepsy. Vl In this way the huge domain of what before Charcot was called "hystero epilepsy," the "convulsions," is divided in two. *5 You had two illnesses, one which included the famous elements of the epileptic fit, that is to say, tonic phase, clonic phase, and period of stupor; and the other, which had to have tonic and clonic phases like epilepsy, with certain minor signs, differences in the phases, and then some elements absolutely specilic to hysteria: the phase of illogical, that is to say, disor dered movements; then the phase of passionate postures, that is to say, expressive movements, movements meaning something, a phase that was also called "plastic," inasmuch as it reproduced and expressed emotions like lustfulness, terror, etcetera; and finally, the phase of delirium, which was also lound in epilepsy moreover. And there you have the two great classical pictures ol the hysteria/epilepsy opposition. i6
You can see that there is a double game in this maneuver. On the one hand, m appealing to these supposedly constant stigmata ol hysteria, and in appealing to regular attacks, the doctor thereby gets nd ol his own stigmata, that is to say, the fact that he is only a psychiatrist and obliged to demand at every moment, in each ol his questionings: "Are you mad? Show me your madness! Actualize your madness. " In appealing to the hysteric's stigmata and the regularity ol her attacks, the doctor asks her to give him the possibility ol perlorming a strictly medical act, that is to say, a diilerential diagnosis. However, at the same time--and this is the advantage lor the hysteric and why she will give a positive response to the psychiatrist's demand--the hysteric will thereby escape medical extra territorially or, more simply, she will escape asylum tern tonality. That is to say, as soon as she has been able to provide her symptoms, which, through their constancy and regularity, allow the neurologist to make a diilerential diagnosis, the hysteric will cease to be a mad person in the asylum; she will acquire citizenship within a hospital worthy ol the name, that is to say, of a hospital which will no longer be entitled to the mere status of an asylum. The hysteric acquires the right to be ill and not mad thanks to the constancy and regularity of her symptoms.
? Now what is the basis of this right acquired by the hysteric? It is founded on the situation in which the doctor ultimately finds himself dependent upon her. Because if the hysteric were to refuse to give her symptoms, then straightaway the doctor could no longer be a neurologist in relation to her; he would be consigned to the status of psychiatrist and to the obligation of making an absolute diagnosis and answering the inescapable question: "Are you or are you not mad? " Consequently, to function as a neurologist the doctor depends on the hysteric actually providing him with regular symptoms. To that extent, what the psychi atrist is offered not only ensures his own status as a neurologist, but also ensures the patient's hold over the doctor, since the patient gams a hold over him by providing him with symptoms, since she thereby sanctions his status as doctor, and no longer as psychiatrist.
You can understand the pleasure the hysterics will invest in the sup- plement of power they are given when they are asked lor regular symptoms; and we can see why they never hesitated to provide all the symptoms one wanted, and even more than one wanted, since, the more they provided the more their surplus-power was thereby asserted in relation to the doctor. And we have evidence that they provided a plentiful supply of symptoms, since one of Charcot's patients--and it is one example taken from many-- who was at la Salpetnere lor thirty four years, regularly provided the same stigmata for fifteen years: a "complete left hemianaesthesia. "37 So one got what one wanted from the point of view of duration; one also got what one wanted from the point ol view of quantity, since one of Charcot's patients had 7i506 attacks in thirteen days and, not content with this, some months later, she had 17,083 attacks in lourteen days. 38
The second maneuver is the one I will call the maneuver of the "functional mannequin. "39 It is triggered by the iirst maneuver inas much as the doctor, in calling for this proliferation of symptoms--since his status and power depend on it--finds himself both confirmed, and then losing out. Actually, this plethora, these 17,083 attacks in fourteen days, is clearly much more than he can control and more than his little neurological clinical apparatus (appareil) can record. So the doctor must provide himself with the possibility, obviously not of controlling this overabundance ol hysterical symptomatology but, at any rate--a bit like Duchenne de Boulogne whose problem was: "how to limit electrical
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stimulation so that it only acts on one muscle"--of giving himself the kind of instrument that will enable him to trigger typically and exclusively hysterical phenomena, but without getting this torrent of thousands of attacks in such a short time.
In answer to the objective of arousing these phenomena on demand, when one wants them, showing that they [are] all pathological, natu- rally pathological, to get round as it were the maneuver of exaggeration, the hysteric's exaggerated generosity, and succeed in bypassing this plethora, two techniques were established.
First, the technique ol hypnosis and suggestion, that is to say: putting the subject in a situation such that, on a precise order, one will be able to get a perfectly isolated hysterical symptom: paralysis of a muscle, inability to speak, trembling, etcetera. In short, hypnosis is used for pre- cisely this purpose, placing the patient in a situation such that he will have exactly the symptom one wants, when one wants it, and nothing else. Charcot did not use hypnosis to multiply hysterical phenomena; it was, like Duchenne's localized electrification, a way of limiting the phe- nomena of hysteria and of being able to trigger them exactly at will/'0 Now, as soon as we have triggered at will one and only one hysterical symptom, by means of hypnosis, do we not come up against a difficulty: If I induced it, if I said to a hypnotized patient, "you cannot walk," and he became paralyzed, "you cannot speak," and he became aphasic, is this really an illness? Is it not merely the effect in the patient's body of what has been forced on him? So if hypnosis is a good technique for isolating hysterical phenomena, it is also dangerous since it risks being only the effect of an instruction given: the effect, and not the response.
Consequently, precisely when and insofar as doctors put hypnosis to work, they are obliged to find some kind of correlative outside hypnosis to guarantee the natural character of hypnotically induced phenomena. Patients must be found outside all asylum culture and medical power, and so, of course, outside all hypnosis and suggestion, who display exactly the disorders that are observable on demand, under hypnosis, in hospitalized patients. In other words, a natural hysteria, without hospital, doctor, and hypnosis, is needed. In fact, it turned out that Charcot had these patients to hand, patients whose role, faced with hypnosis, was to naturalize, as it were, the effects of hypnotic intervention.
? He had them, and this requires a very short reference to a completely different history that connects up with the history of hysteria in a way that is very curious, but not without important historical effects. In 1872 Charcot takes over the hysteria-epilepsy department,,1 and he begins hyp- nosis in 1878/12 This is the time of accidents at work and on the railway, of accident and health insurance systems/1^ Not that accidents at work date from that time, but it is at this time that an absolutely new category of patients is making its appearance within medical practice--but whom, sadly, historians of medicine rarely mention--that is, patients who are neither paying nor receiving aid. In other words, in the medicine of the eighteenth and the beginning of the nineteenth century, there were basi cally only two categories of patient: those who were paying and those who were receiving aid at the hospital. Now a new category of patient appeared, the insured patient, who is neither entirely paying, nor entirely supported by aid/1'1 The appearance together of the insured patient and the neurolog- ical body, arising from completely different elements, is probably one of the important phenomena of the history of hysteria. What actually took place was that, from the end of the eighteenth century, precisely to the extent that it wanted to profit from a maximized health, society was gradually led to perfect a whole series of techniques of supervision, close control, cover, and insurance also, of illness and accidents.
However, precisely to the extent that society was obliged to divide up, control, and supervise health and to insure against accidents and illnesses in order to extract maximum profit lrom bodies, at the point when these techniques were established, and by the same process, illness became something profitable lor the person who was ill. In the eighteenth century, the only profit a patient receiving aid could draw from his illness was to stay a bit longer in hospital, and this minor problem is frequently encountered in the history of hospital institutions in the eighteenth century. With the tight control dating from the nineteenth century, and with this general cover of phenomena of illness by both medicine and insurance, illness itself, as such, can become a source of profit for the subject and, at any rate, a way of benefiting from this general system.
Illness becomes profitable precisely when it raises a problem at the general level of the profits of society. Illness is consequently intertwined with the whole economic problem of profit.
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As a result, we see the appearance of new patients, that is to say, insured patients with what are called post-traumatic disorders such as paralysis, anesthesia, spasms, pains, convulsions, etcetera, without any assignable anatomical basis. And the problem at this time, still in terms of profit, is whether they should be considered as patients, and so covered by insurance, or as malingerers (simulateurs)/^ There is a huge literature on the results of railroad accidents--and also on accidents at work, but to a lesser degree and a bit later, almost at the end ol the century--which covers, I think, an enormous problem that in a way sup- ported the development of neurological techniques, of the techniques oi examination I have been talking about. "16
The insured patient, who joins up with the neurological body, who is the bearer of a neurological body that can be captured by the clinical apparatus of neuropathology, is the other figure lacing the hysteric, pre- cisely the person one is looking for, so that one can be played off against the other. On one side are these patients who are not yet hospitalized, not yet medicalized, and who are not therefore under hypnosis, under medical power, and who display certain natural phenomena if they are not stimulated. And then, on the other side, are the hysterics within the hospital system, under medical power, on whom artificial illnesses have been imposed by means of hypnosis. So, when compared with the trauma, the hysteric will make it possible to recognize whether or not the traumatized person is a simulator, a malingerer. There are two possibilities in fact: either the traumatized person displays the same symptoms as the hysteric--obviously I am talking about someone trau matized who has no trace ol a lesion--and, as a result, we can say: "he has the same illness as the hysteric," since the first maneuver consisted in showing that the hysteric was ill, and so the hysteric will authenticate the traumatized person's illness; or the traumatized person will not have the same illness, will not display the same symptoms as the hysteric, and as a result will fall outside the field of pathology and one will be able to ascribe his symptoms to simulation.
On the other hand, with regard to hysteria, comparison will lead to the lollowmg result: if someone who is not hypnotized can be found with symptoms similar to those obtained in a hysteric by means of hypnosis, then this really will be the sign that the hypnotic phenomena
? obtained in hysterics are indeed natural phenomena. So, the hysteric is naturalized by means oi the traumatized person, and the traumatized person's possible simulation is revealed by means of the hysteric.
Hence Charcot's grand stagecralt. It is olten said that this consisted in getting a hysteric and saying to his students: "See what illness she is afiected by," and, effectively, dictating symptoms to the patient. This is true, it corresponds to the first maneuver I was telling you about, but I think the major and most subtle and perverse of Charcot's maneuvers, was precisely displaying these two hgures together. When traumatized people from outside the hospital appeared at his private oflice--the vic- tims o) different kinds ol accidents with no visible traces of lesions and sulfering from paralysis, coxalgia, anesthesia--Charcot called for a hysteric, hypnotized him and said: "You can no longer walk," and looked to see whether the hysteric's paralysis really was similar to that of the person traumatized. A famous case of this kind was one ol post-traumatic coxalgia in a railroad employee. Charcot was almost sure that the coxalgia was not caused by a lesion; he had a feeling however that it was not a pure and simple simulation. He called for two hysterics, hypnotized them, and gave them instructions through which he managed to reconstitute the employee's coxalgia on the kind ol lunctional mannequin that the hysteric had become, and so the coxalgia had to be considered hysterical? '
Everyone benefits. In the first place, the insurance companies, of course, and the people who had to pay, and, also the patient to a certain extent, since, if he is not a simulator, a malingerer, Charcot said, we can not deny him something, albeit, obviously, not of the same order as ll he had a real injury. So the cake was cut in two. However, clearly this is not the important problem: the doctor also benelits since, thanks to the use of the hysteric as a lunctional mannequin, the doctor could make a dif lerential diagnosis that will now be brought to bear on the simulator. One will now be able to master the iamous panic dread of the simulator that so obsessed doctors in the first half of the nineteenth century, since one will have these hysterics who, traitors to their own lie, as it were, will make it possible to denounce the lie of others, and, as a result, the doctor will hnally have the upper hand over simulation. '8
Finally, ol course, the hysterics beneht, since il they serve as functional mannequins in this way, authenticating the functional or, as
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it was said at this time, "dynamic" illness without lesion, if the hysteric is there to authenticate this illness, then she inevitably escapes all suspicion of simulation, since she is the basis on which the simulation of others can be denounced. As a result, it is once again thanks to the hysteric that the doctor will be able to ensure his power; if he escapes the simulator's trap it is because he has the hysteric who makes possible the double, organic/dynamic/simulation, differential diagnosis. And con- sequently, the hysteric has the upper hand over the doctor a second time, since by obeying the instructions he gives her under hypnosis, she gets to be the authority of verification, as it were, the authority adjudicating truth between illness and lie. The second triumph of the hysteric. You understand that here too the hysterics do not hesitate to reconstitute, on demand, the coxalgia and anesthesia, etcetera that they are asked for under hypnosis.
Hence the third maneuver of redistribution around the trauma. At the end of the second maneuver, the doctor is therefore once again newly dependent on the hysteric, because if the disorders reproduced on order by the hysteric, and so generously, so profusely, with such obedience and, at the same time, with such a thirst for power, will not this be proof after all that it is all fabricated, as Bernheim was already beginning to say? H9 In the end, is not the appearance of this great hysterical symp- tomatology at la Salpetriere all due to the set of medical powers being exercised within the hospital?
If the doctor is not to be entirely dependent on this hysterical behav- ior which could well be said to be fabricated, if he is to renew his power over all this phenomena and take it back under his control, he will have to include within a strict pathological schema both the fact that some one can be hypnotized and the fact that he reproduces pathological types of phenomena under hypnosis, and, at the same time, that those well known lunctional disorders, which Charcot had shown were so close to hysterical phenomena, can be placed in this pathological frame- work. A pathological framework is needed which simultaneously envelops hypnosis, the hysterical symptoms produced under hypnosis, and the event which brings about the functional disorders oi patients who are not hypnotized. Since the body cannot speak because there is no lesion, this search for a pathological framework leads Charcot to look for
? an assignable cause. One will have to look at the etiological level for something on which to pin all these phenomena and thereby attach them to a rigorous pathology, that is to say, what one will have to discover is an event.
This was how Charcot developed the concept ol trauma. 50
What is a trauma for Charcot? It is something--a violent event, a blow, a (all, a (ear, a spectacle, etcetera--which provokes a sort of dis- crete, localized hypnotic state, but which sometimes lasts for a long time, so that, following the trauma, a certain idea enters the individual's head, inscribes itself in his cortex, and acts like a sort of permanent injunction.
An example of a trauma: a child is knocked down by a vehicle; he faints. In the moment before fainting he has the feeling that the wheels ol the vehicle run over his body. He comes to and, after a time, realizes that he is paralyzed; and if he is paralyzed it is because he thinks the wheels ran over his body. 51 Now this belief is inscribed and continues to (unction within a set ol micro hypnotic states, within a localized hyp- notic state concerning this beliel. What provokes paralysis o( the legs is, as it were, this idea that has become a hypnotic injunction? 2 We see here how the notion of trauma, which will be so important in the iuture, is established and, at the same time, the link between this notion and the old conception of delirium. Since if he is paralyzed, it is because he believes that the wheels of the van ran over him--you can see how this is linked with the old conception of madness always concealing a delirium. 5* So, a trauma is something that provokes a localized and permanent hypnotic state on just this point.
As for hypnotism, what is it? Well, it will also be a trauma, but in the form ol a complete, brief, transitory shock, which will be suspended solely by the doctor's will, but which will envelop the individual's general behavior, so that within this state of hypnosis, which is a sort oi generalized and provisional trauma, the doctor's will, his words, will be able to implant ideas and images in the subject which thus have the same role, the same Iunction, and the same eilect of injunction as the injunction I was talking about with regard to natural, non-hypnotic traumas. Thus, between hysterical phenomena produced under hypno- sis and hysterical phenomena following an event, there is a convergence
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which points towards this fundamental notion of trauma. Trauma is what provokes hypnosis, and hypnosis is a sort of general reactivation o( the trauma through the doctor's will.
Hence the need in Charcot's practice to go in search of the trauma itself.
That is to say, to be sure that the hysteric really is a hysteric and that all her symptoms, whether under hypnosis or outside ol hypnosis, really are pathological, one will have to discover the etiology, to find the trauma, the kind of invisible and pathological lesion which makes all of this a well and truly morbid whole. * Hence the necessity for hysterics, whether or not they are under hypnosis, to recount their childhood, their life, so as to lind again that kind of fundamental and essential event that will persist and is always present in the hysterical syndrome, and of which the latter is in some way the permanent actual izati on. Vl'
However--and here we find the hysteric again and her counter- maneuver--what will the patients do with this injunction to find the trauma that persists in the symptom? Into the breach opened by this injunction they will push their lile, their real, everyday life, that is to say, their sexual hie. It is precisely this sexual life that they will recount, that they will connect up with the hospital and endlessly reactualize in the hospital. Unfortunately, we cannot trust Charcot's text for prool of this counter-investment of the search for the trauma by the story of sexual life, because Charcot does not talk about it. However, when we look at his students' observations, we see what is involved throughout these anamneses, what was at stake, what was talked about, and also what was really involved m the famous attacks with a pseudo-epileptic lorm. I will take just one example, a case recorded by Bourneville.
This is how the patient recounted her life. From age six to thirteen she was a boarder in a religious convent "at La Ferte sous Jouarre where she enjoyed a degree ol lreedom, wandered in the countryside, willingly let herself be kissed for sweets. " This is the protocol produced by one ol Charcot's students on the basis of the patient's own accounts. "She often
* The manuscript clarifies: "Hence the double search: (a) lor the nervous diathesis which causes susceptibility to trauma; search for heredity. And then (b) for the trauma itsell. "
t The manuscript adds: "Hence the violence ol the opposition to Bernheim: if everyone could be hypnotized the edifice would collapse. "
? visited the wife ol a workman, Jules, a painter. The latter was in the habit of getting drunk, and when this happened there were violent arguments in the household; he beat his wife, dragged her or tied her up by the hair. Louise [the patient; M. F. ] sometimes witnessed these scenes. One day,Jules would have tried to kiss her, even rape her, which gave her a great fright. During the holidays [she was aged between six and thirteen years; M. F. |, she came to Paris and spent the days with her brother, Antonio, one year younger than her, who seems to have been very precocious and taught her many things she should not have known. He mocked her naivety, which led her to accept the explanation he gave to her of, amongst other things, how children are made. During the hoi idays, in the house where her parents were in service, she had the opportunity to see a Mr. C [the master of the house; M. F. ], who was her mother's lover. Her mother obliged Louise to kiss this man and wanted her to call him her father. On her permanent return to Pans, Louise was placed [after her period of boarding, so she was 13; M. F. ] in C's home on the pretext of learning to sing and sew, etcetera. She slept in a little isolated room. C, whose relationship with his wife was a bit strained, took advantage of her absences to try to have relations with Louise, aged thirteen and a half. The first time, he failed; he wanted her to go to bed in front of him. A second attempt ended in some incomplete approaches, due to her resistance. A third time, C, after dangling all sorts of promises before her eyes, hne gowns, etcetera, seeing that she did not want to give in, threatened her with a razor; taking advantage of her fear, he got her to drink a liqueur, undressed her, threw her down on his bed, and had full sexual intercourse with her. The following day Louise was suffering, etcetera. "^
The lives of hysterics recounted by Charcot's patients are in fact often of this order and level. And, if we look at the observations taken for Charcot by his students, what really happened in those famous attacks that Charcot said were strangely similar to epileptic fits and very diffi- cult to distinguish from epileptic fits if you were not a good neurologist?
At the level of the discourse, this is what Louise said: "Tell me! . . . You must tell me! Peasant! You must be vile. So you believe this boy more than me. . . I swear to you that this boy has never laid a hand on me. . . I did not respond to his caresses, we were in a held . . . I assure you that I did not
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want it. . . Call them (Commanding physiognomy). Well? (She suddenly looks to her right) . .
considere dans ses rapports avec la psychologiie, la physiologie et la pathologic, el dans ses applications a la medecine, a la chirurgie, a la physiologie experimenlale, a la medecine legale et a ^education (Paris:J. B. Bailliere, i860).
57. Durand de Gros defines "the hypotaxic state" as "a preparatory modification of vitality, a modification which usually remains latent and the whole effect of which is to incline the organization to undergo the determinant and specific action constituting the second stage" Cours theorique et pratique, p. 29.
58. Ibid. p. 112.
59. Ibid. Chorea is a nervous disorder characterized by sweeping and jerky involuntary
movements, with a gesticulatory appearance.
? 60. Ibid. p. 87: "Braidism is a process by which we seek to determine certain physiological changes in man with the aim ol lulfilling certain indications for medical or surgical treatment, or in order to facilitate the experimental studies of biology. "
61. Between 1850 and i 8 6 0 , under the impulse ol Guillaume Benjamin Amand Duchenne de Boulogne (1806 1875), the nosology of functional disorders ol motivity was redefined and enriched by two new groups of affections. On the one hand, "progressive muscular atrophy," studied from 18-19, and the "muscular atrophies with myopathic origin," in 1853: (1) La Paralyse atrophique de I'enjance (Pans: 1855). On the other hand, "progressive locomolor atrophy," known up until then as tabesdorsalis: (2) "De l'ataxie locomotrice progressive. Recherches sur unc maladie caractensee specialement par des troubles generaux de coordination des mouvemcnts," Archives generates de medecinc, 5th series, vol. 12, December 1858, pp. 6/|1 652; vol. 13, January 1859, pp. 5-23; February 1859, pp. 158 I64; April 1859, pp. -117 yi32. In i860 he described (3) the "paralysie glosso labio laryngee," ibid. 5th series, vol. 16, i860, pp. 283 296 and pp. /|31 Vi5. On Duchenne de Boulogne, see P. Guilly, Duchenne de Boulogne (Paris: Bailliere, 1936). On the constitution ol the neurological lield, see W. Riese, A History oj Neurology (New York: MD Publications, 1959), and F. H. Garrison, History of Neurology, edition revised and expanded by Laurence McHenry (Springfield, 111. : C. C. Thomas, 1969).
}0 January 7974 295
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The emergence of the neurological body: Broca and Duchenne de Boulogne. ^ Illnesses of differential diagnosis and illnesses of absolute diagnosis. ^ The model of "generalparalysis" and the
neuroses. ^ The battle of hysteria: 1. The organisation of a "symptomatologLcal scenario. "nu 2. The maneuver of the "functional
mannequin" and hypnosis. The question of simulation. nu 3. Neurosis and trauma. The irruption of the sexual body.
LAST WEEK I SAID that one of the important events in the history of the consolidation of psychiatric power was, in my view, the appearance of what I called the "neurological body. "* What should we understand by "neurological body"? I would like to begin with this today.
Of course, the neurological body is still, always, the body of pathological-anatomical localization. There is no opposition between the neurological body and the body of pathological anatomy; the second is part of the first; it is, if you like, a derivative or expansion of it. And the best proof of this is that in one of his courses, in 1879, Charcot said that the constitution, progress, and, in his view, the culmination of neu- rology, was the triumph of the "spirit of localization. "1 Except that what I think is important is that the procedures for matching up anatomical localization and clinical observation in the case of neurology are not at all the same as in the case of ordinary general medicine. It seems to me
* The manuscript adds: "From 1850 to 1870, emergence of a new body. "
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that neurology, clinical neurology, involves a quite different deployment of the body in the field of medical practice. My impression is that the encounter of the patient-body and the doctor body in neurology takes place in terms of a very different arrangement from that in general medicine. And it is the setting up of this new apparatus that seems to me to be the important episode, which is why I would like to try to identify the new apparatus set up by and through the constitution ol a neuropathology or neurological clinical medicine.
What is this apparatus, and in what does it consist? How is the sick body* captured in clinical neurology? Its capture takes place, I think, very differently trom the way the body was captured at the time ol the formation of pathological anatomy, more or less between Bichat2 and Laennec* I will give you an example straightaway by taking a text that is not by Charcot himself, but which is found in the Charcot archives at Salpetriere and was quite certainly written by one of his students-- clearly we don't know which one. It is an observation of a patient. This is how the patient is described: the patient's symptom was something very simple, the drooping of the left eyelid, called ptosis. So, the student takes the following notes for Charcot for him then to use for a lecture-- I am not giving you the description of the whole of the patient's lace, but just a quite small excerpt.
"If we tell him to open his eyelids, he raises the right one normally, the left one however, does not noticeably move, no more than the eye brow, so that the superciliary asymmetry becomes more marked. In this movement (. . . ) the skin ol the forehead wrinkles transversally on the right side, while it remains almost smooth on the left. At rest, the skin of the forehead is wrinkled neither on the right nor the left ( . . . ) . "
"Two more points should be noted: a small dimple, quite visible under a certain angle of light, eight millimeters above the left eyelid and about two centimeters to the left of the median line of the forehead; and a little projection within the dimple which seems due to the contraction of the eyelid muscle. These two points are very noticeable in comparison with the normal state of the right side. "1
* The manuscript clarifies: "body whose surlace is the bearer ol plastic values. "
? You have here a type of description which is, I think, really quite different from what is found in the anatomical-pathological procedure, m anatomical-pathological observation. ^ In a sense, this sort of descrip- tion takes us back to a sort of surlace, almost impressionistic gaze, such as could be found m eighteenth century medicine, when the patient's complexion, color, red cheeks and bloodshot eyes, etcetera, were impor tant elements for clinical diagnosis. 6 Pathological anatomy--Bichat, Laennec, if you like? infinttely reduced this impressionistic description of the surlace and codified what were ultimately a quite limited number of surlace signs intended to identify what was essential according to a well established clinical code, this being, precisely, the lesion, which then, thanks etther to a surgical operation or, especially, the autopsy, was described by the anatomical pathologist with almost as many details as, if not more than, the description I have just read to you. In other words, anatomical-pathology brought its minutely detailed description to bear on the deep and injured organ, the surface only being questioned through a grid of ultimately simple and limited signs.
Here, rather, as you can see, you have the striking reemergence of sur face values within medical discourse and knowledge. It is this surface that must be covered in all its hollows and bumps, and practically by looking only, by looking only that far. In fact, and no doubt even more than this clinical re validation of the almost impressionistic values of the surface, what is important and, I think, decisive, in this new clinical capture of the neurological patient, and in the correlative constitution of a neurological body before this gaze and apparatus of capture, is that the neurological examination is basically looking tor "responses. "
What I mean is that in the pathological anatomy of Bichat Laennec one can, of course, identify the signs straightaway, at the first glance; one can also obtain them from a stimulation: one taps, one listens, etcetera. That is to say, what is sought in classical pathological anatomy is essentially the system of stimulation-effect: one sounds the chest and listens to the noise;7 one asks the patient to cough and listens to its harshness; one palpates and sees if there is any heat. So: stimulation- effect.
In the case of the neurological examination being constituted in the mid-nineteenth century, the main part of the signs, in short what makes
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a sign a sign, is not so much that it is [deciphered asj a more or less mechanical effect, like the noise following percussion in classical patho logical anatomy, but that a sign is [deciphered) as a response. I think the substitution of the schema of stimulus-response for the schema of stimulus effect, and the organization of a whole battery of stimuli- responses, is crucial.
We have a number of examples of this staging of a battery of stimuli- responses. At the strictly elementary level, there was the founding discovery oi neuropathology in Duchenne de Boulogne's research into what he called "localized Faradization," when, by moistening two electrodes, he succeeded in getting a single muscular response, or, rather, the response of a single muscle to electrification of the surface of the skin; by moistening the surface of the skin he succeeded in limiting the effect of the charge and obtained a single response of a single muscle: this was the founding discovery of everything here. 8 Then, starting from this, there were the studies of reflexes and then, especially, the study of complex behavior involving either a gearing of diverse automatisms or a prior learning, and it is there that we find, more or less, the two great domains in which the capture, the apparatuses of neurological capture, were completely established. This was Broca's study of aphasia,9 the study of walking, and notably Duchenne de Boulogne's study of tabetics. 10
Taking the second example, Duchenne produced a description of the walking of tabetics that is presented precisely in terms of stimulus response or, rather, in terms of behavior and the sequence of episodes of behavior that constitute the action of walking. Duchenne's problem was to distinguish the disorder of balance found in tabetics, that is to say, at a certain stage and in a certain form of general paralysis, from the vertigo of alcoholic intoxication or even of certain cerebellar disorders. In 1864, in a fundamental article, Duchenne managed to give a differential description of the gait of tabetics and the rocking of vertigo. " In the case of vertigo, the subject gives way to wide swaying, whereas in the subject suffering from tabes the rocking movements are "short," "they are abrupt"--Duchenne de Boulogne says that the subject has the bearing of a tightrope walker without his balancing pole, cautiously advancing one step at a time while trying to restore his balance. 12 In the case of vertigo, there is no muscular contraction, but a general weakening of the
? musculature and tone instead, whereas [-. . *] the tabetic is always holding himself back, and if we observe what happens at the level of his calves and legs, we see, even before he loses his balance, even before he is aware of losing his balance, some small, brief spasms which flicker across the musculature ot his legs, and then, gradually, these contrac- tions become more significant, until they become voluntary when the subject becomes aware that he is losing his balance. 13 This is completely different, therefore, from the collapse in vertigo. In vertigo, the subject zigzags; that it to say, going from one point to another, he cannot keep to a straight line. The tabetic however, goes completely straight ahead; it is just his body that wobbles around this straight line. 17' And finally, in drunkenness, there is the internal sensation of vertigo, whereas the tabetic has the impression that it is not his body that lacks balance at all, but only his legs, locally as it were. 15 These are the principal themes, more or less, of Duchenne de Boulogne's analysis of the tabetic's gait.
Now, in this kind of analysis--and the same would be true for Broca's analyses of aphasia roughly at the same time, between 1859 and 1865-- what is achieved by seeking to obtain a system of signs of responses that show dysfunctions, rather than a system of signs of effects that would reveal the presence of lesions at a given point? What we obtain, of course, is the possibility of distinguishing and analyzing what neurolo- gists called, and still call today, synergies, that is to say, the different cor- relations existing between this or that muscle: What are the different muscles that must be used in order to get such and such a response? What happens when it is precisely just one of them that is put out of play? So, we get a study of synergies.
Secondly, and I think this is the important thing, it becomes possible to set out the phenomena analyzed in different levels according to an axis of the voluntary and the automatic. That is to say, on the basis of this analysis of behavior, of responses to different stimuli, we can see the functional difference, the difference of neurological and muscular imple mentation, between simple reflex behavior, automatic behavior, sponta- neous voluntary behavior, and, finally, spontaneous behavior produced
* (On the recording, repetition of:) rather
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by an order coming from outside. All of this hierarchy in the bodily implementation of the voluntary and the involuntary, of the automatic and the spontaneous, of what is required by an order or what is sponta- neously linked together within behavior, will make possible--and this is the essential point--a clinical analysis, an analysis in terms of physical ascription, of the mdividuaPs intentional attitude.
Consequently, a capture of the subject's attitude, of the subject's consciousness, of the will itself within his body, becomes possible. Neuropathology showed the will invested in the body, the effects of the will or the degrees of will legible in the organization of responses to stimuli. You are familiar with all the analyses Broca initiated on the different levels ol the performance of aphasics, according to whether it is a matter ol simple mumblings, of swear words uttered automatically, of phrases triggered spontaneously in a certain situation, or of phrases which must be repeated in a certain order and on a certain injunction. 16 All of these clinical deferences of performance between different levels of behavior make possible the clinical analysis of the individual at the level of his intention, at the very level of that much vaunted will that I have tried to show you was the great correlate of discipline. It was the will, in fact, on which and to which disciplinary power had to be applied; it really was the vis avis of disciplinary power, but then it was only acces sible through the system of reward and punishment. Neuropathology now provides the clinical instrument by which it is thought the individual can be captured at the level of this will itself.
Let's consider things a bit differently and bit more precisely. We could say that, in one respect, with the neurological examination medicine will lose power m comparison with classical anatomical-pathology. That is to say, in the anatomical pathology constituted by Laennec, Bichat, and others, ultimately very little was demanded from the individual: he was asked to lie down, bend his leg, cough, breathe deeply, and so on. Consequently there was a minimum of injunctions on the doctor's part, and minimum dependence on the patient's will. On the other hand, with neuropathology, the doctor's understanding of his patient will have to pass through the latter's will, or at any rate through his cooperation. He will not just say: "Lie down! Cough! ", but will have to say to him: "Walk! Put out your leg! Hold out your hand! Speak! Read this
? sentence! Try to write this! " and so on. In short, we now have a technique of examination reliant on instruction and injunction. Consequently, since instruction and injunction necessarily have to pass through the patients will, the latter will be at the very heart of the examination and, to that extent, the doctor's authority will be at the very heart of this neurological apparatus. The doctor will give orders, he will try to impose his will, and the patient, after all, may always feign inability or unwillingness. That is to say, one really will depend on the patient's will. However, the clinical possibility of identifying voluntary and involuntary, automatic and spontaneous behavior, the possibility of clinically deciphering the levels of will in behavior that I was just telling you about, will enable one to see whether the patient really responds as he is told to, the quality and nature of his responses, and the extent to which his responses have or have not been faked by the will which comes into play; and here the doctor will recapture the power he lost by giving instructions. For example, after Broca, neurologists could easily distinguish voluntary mutism from an aphasia like anarthna: in the case of anarthna, the impossibility of speaking is always accompanied by a series of background sounds, of automatisms which accompany the attempt to speak; it is also always accompanied by correlative motor disorders, and it is also accompanied by expressive deficiencies in gestures and written expression, etcetera. 17 Someone who refuses to speak, and furthermore a hysteric who does not speak, is someone who has gestures, can write, understands, and has none of the accompanying supplementary disorders typical of anarthna.
So you can see that the individual's will can be captured at the level of his real behavior, at the level, rather, of the clinical observation of his behavior. Consequently, if it is true that, on the one hand, the game of instruction typical of the neurological examination makes the possibility of examination depend on the patient's will to a certain extent, on the other hand, with clinical observation, with the clinical decipherment now available, the patient can be circumvented and short-circuited.
To summarize this in a few words, let's say that a new clinical medical apparatus is put in place that is different in its nature, equipment, and effects from what we can call the Bichat-Laennec clinical apparatus, as well as from the psychiatric apparatus. In organic medicine, the patient
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was given a minimum of injunctions like "Lie down! Cough! " and the rest was given over entirely to the doctors examination carried out through the interplay of stimuli and effects. I have tried to show you that the essential component of capture in psychiatry was questioning, which is the substitute for the examination techniques of organic medi- cine. Questioning depends, of course, on the subjects will, and for the psychiatrist the answers are not a test of truth or the possibility of a dif- ferential decipherment of the disease, but merely a test of reality; ques- tioning simply corresponds to the question: "Is he mad? "
So, neurology is neither an examination in the sense of pathological- anatomy, nor questioning; it is a new apparatus which replaces question- ing with injunctions, and which through these injunctions seeks to get responses, but responses which are not the subjects verbal responses, as in questioning, but the responses of the subject's body; responses which can be clinically deciphered at the level of the body and which one can consequently submit to a differential examination without fear of being duped by the subject who responds. We can now differentiate between someone who does not want to speak and someone suffering from apha- sia, that is to say, we can now establish a differential diagnosis within forms of behavior for which this was hitherto not possible and which were previously questioned in terms of an absolute diagnosis. The test of reality is no longer necessary: clinical neurology, m a certain domain at least, will enable differential diagnosis to get a hold, like organic medicine, but on the basis of a completely different apparatus. Broadly speaking, the neu- rologist says: Obey my orders, but keep quiet, and your body will answer for you by giving responses that, because I am a doctor, I alone will be able to decipher and analyze in terms of truth.
"Obey my orders, keep quiet, and your body will respond": you see that it is precisely here that the hysterical crisis will quite naturally rush in. Hysteria will enter into this apparatus. I am not talking about the appearance of hysteria: in my view the question of the historical exis- tence of hysteria is a futile question. I mean that the emergence of hyste ria within the medical field, the possibility of making it an illness, and its medical manipulation are only possible when this new clinical appa- ratus, the origin of which is neurological and not psychiatric, was estab- lished; or when this new trap was set.
? "Obey, keep quiet, your body will speak. " So, you want my body to speak! My body will speak, and I really promise you that there will be much more truth than you can imagine in the answers it will give you. Not, certainly, that my body knows more about it than you, but because there is something in your injunctions that you do not formulate but which I can clearly hear; a certain silent injunction to which my body will respond. * And it is this, the effect of your silent injunctions, that you will call "hysteria in its nature. " This, more or less, is the hysteric's discourse rushing in to the trap I have just described.
Fine. So, what takes place once this trap, this new apparatus of cap ture has been set?
Broadly speaking, I think we could say that until then, in medicine, until the existence of neurology and the clinical apparatus specific to neurology, there were two great domains of illnesses: mental illnesses and the others, the true illnesses. I do not think it is enough to say that mental illnesses and all the others are opposed to each other as illnesses of the mind on the one hand, and illness of the body on the other. This would not be correct, first of all because for many psychiatrists, from 1820 to 1870-1880, illnesses of the mind are just illnesses of the body with the characteristic of having psychical symptoms or syndromes. Then, it was absolutely accepted in this period that the so-called con- vulsive illnesses--medically, clinically, no effective difference was made between epilepsy and the others18--were illnesses of the mind. So I do not think that the mind/body opposition, organic illnesses/psychical illnesses, is the real distinction that divided medicine between 1820 and 1880, whatever the theoretical discussions were, and even because of the theoretical discussions on the organic basis of illness. 19 Actually, I think that the only true difference is the one I talked about last week. That is to say, there were certain illnesses which could be evaluated in terms of differential diagnosis--and these were the good, solid illnesses with which genuine and serious doctors concern themselves--and then the illnesses on which the latter could get no hold, and which could only be
k The manuscript adds: "I will hear what you do not say, and I will obey, providing you with symptoms the truth ol which you will have to recognize, since they will respond, without your knowing, to your unspoken injunctions. "
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recognized by a test of reality--and these were the so called mental illnesses, those to which there was only a binary response: "He really is mad" or "He is not mad. "
I think this is the real division of medical practice and knowledge in the first two thirds of the nineteenth century: between illnesses integrated within a differential diagnosis and illnesses falling solely under an absolute diagnosis. Between these two categories of illnesses there were obviously a number of intermediaries, of which there were basically two that I think are important. There was the good intermedi- ary, the good illness, which was of course general paralysis. This was an epistemologically good illness and, consequently, it was morally good to the extent that, on the one hand, it included psychological syndromes- delirium according to Bayle,20 and then dementia according to Baillarger21--and motor syndromes: trembling of the tongue, progressive paralysis of the muscles, etcetera. There are the two syndromes, and in terms of pathological-anatomy both of them refer to an encephalic lesion. A good illness, consequently, exactly intermediary between those illnesses of the test of reality, which were, if you like, the so-called mental illnesses, and then the illnesses differentially allocated and referring to pathological anatomy. 22 General paralysis was an absolutely good illness, better, more complete, and giving a stronger foundation to all these phenomena in that it was not yet known that general paralysis had a syphilitic origin. 23 Consequently, one had all the epistemological benefits and none of the moral inconveniences.
On the other hand, still intermediary between illness of differential diagnosis and illness of absolute diagnosis, there was a completely different, bad and swampy region, which was at that time called "the neuroses. "21 What did the word "neurosis" mean around the 1840s? The word cov- ered illnesses with all the motor or sensory components--"disorders of relational functions" as it was said--but without any pathological anatomical lesion which would allow an etiology to be established. So, of course, these illnesses of "disorders of the relational functions" without ascribable anatomical correlates, covered convulsions, epilepsy, hysteria, hypochondria, and so forth.
Now these were bad illnesses for two reasons. They were epistemo logically bad because in these illnesses there was a kind of symptomatic
? confusion or irregularity. In the domain of convulsions, for example, one could not make a division between the different types because, precisely, the neuropathological apparatus did not enable one to make a precise analysis ol different lorms of behavior. Faced with a convulsion, one said: "This is a convulsion"; one could not make those firm bodily inter- pretations that I was talking about a moment ago, and, consequently, one was faced with a "region" of confusion and irregularity. In the first number oi the Annales medico-psychologiques, in 18^3, the editors said: We must concern ourselves with madness; we should also concern ourselves with the neuroses, but it is so difficult, "because these disorders are fleeting, varied, protean, exceptional, difficult to analyze and under stand, we banish them from observation and dismiss them as we reject troublesome memories. "25
Epistemologically bad, these disorders were also morally bad due to the ease with which they could be simulated and the fact that, in addition to this possibility, there was a constant sexual component ol behavior. Thus,Jules Falret, in an article which was reprinted m 1890 m his Etudes cliniques, said: "The life of hysterics is just a constant lie; they put on airs of pity and devotion and succeed in passing themselves off as saints, while they secretly abandon themselves to the most shameful actions, while at home with their husband and children they make the most violent scenes in which they say coarse and sometimes obscene things. "26
The emergence of the neurological body, or rather, of the system con- stituted by neurology's clinical apparatus of capture and the correlative neurological body, will make it possible to remove the disquabiication, this double epistemological and moral disqualification, to which the neuroses were subject until the 1870s. It will be possible to remove this disqualification to the extent that it will finally be possible to place these illnesses called "neuroses," that is to say, illnesses with sensory and motor components, not exactly in the domain ol neurological illnesses strictly speaking, but very close by, not so much through their causes, but basically because ol their forms. That is to say, thanks to the clinical apparatus of neurology, the blade oi diflerential diagnosis will now be able to separate neurological illnesses, such as disorders due to a cere bellar tumor, for example, from hysterical convulsions and trembling.
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This famous differential diagnosis, which one had never been able to apply to madness, which never really managed to get a grip on the men- tal illnesses, this differential diagnosis that one could never insert between an ordinary illness and madness, because madness, above all and essentially, fell under an absolute diagnosis, this differential diagnosis then, through the apparatus I have tried to describe, can now be inserted between neurological disorders with ascribable anatomical lesions, and those disorders called "neuroses. " So that what was, morally and epistemologically, the last category in the domain of mental illness--the neuroses--will suddenly be promoted to the closest proximity to genuine and serious illnesses by this new instrument of neurological analysis, of clinical neurology. That is to say, through the use of differential diagnosis the previously discredited zone of the neuroses will receive pathological consecration.
In a book--what's more, not a very good book--which a contemporary neurologist called Guillain devoted to Charcot, his predecessor, the author says, with a kind of radiant joy: "Charcot all the same rescued hysteria lrom the psychiatrists," which is to say that he really brought it into the domain ol the medicine ol differential diagnosis, which is the only medicine. 2/ Basically, I think Freud thought the same when he put Charcot alongside Pinel and said: Pinel freed the mad from their chains, that is to say, he brought about their recognition as patients. Well, in a way, Charcot too made it possible for hysterics to be seen as ill: he pathologized them. 28
If we situate Charcot's operation in this way then I think we can see how what I will call "the great maneuvers of hysteria" unfolded at Salpetnere, and how they were constituted. I will not try to analyze this in terms ol the history of hysterics any more than in terms ot psychiatric knowledge of hysterics, but rather in terms of battle, confrontation, reciprocal encirclement, of the laying of mirror traps, ol investment and counter investment, of struggles for control between doctors and hysterics. * I do not think that there was exactly an epidemic ol hysteria; I think hysteria
* The manuscript adds: "of deals also, ol lacit pacts. "
? was the set of phenomena, and phenomena of struggle, which occurred within as well as outside of the asylum, around this new medical apparatus of clinical neurology; and it was the maelstrom of this battle which in fact summoned around hysterical symptoms all those people who actually joined in the battle. Rather than an epidemic, there was a maelstrom, a kind of hysterical vortex within psychiatric power and its disciplinary sys- tem. So how was this played out? I think we can pick out certain maneu- vers in this struggle between neurology and the hysteric.
The first maneuver is what could be called the organization of the symptomatological scenario. I think we can schematize things in the fol lowing way: lor hysteria to be put on the same level as an organic illness, for it to be a genuine illness falling under a differential diagnosis, that is to say, for the doctor to be a true doctor, the hysteric must present a sta ble symptomatology. Consequently, the doctor's consecration as a neurol- ogist, unlike the psychiatrist, necessarily implies an injunction given to the patient on the quiet: "Give me some symptoms, but give me some stable, coded, regular symptoms"--something that the psychiatrist was already saying--and this regularity and stability had to have two forms. First, consistent symptoms which should be permanently legible on the patient whenever the neurological examination takes place: No more of those illnesses that appear and disappear, the only symptoms of which are the flash of a gesture or the return of fits; we want stable symptoms, and in this way we will find them whenever we ask for them. This was how what Charcot and his successors called the "stigmata" of hysteria were defined. "Stigmata" are phenomena found in every hysteric, even when not suffering an attack:29 contraction ol the visual field,30 simple or double hemianaesthesia,31 pharyngal anesthesia, contracture caused by a circular bond around a joint. 32 Moreover Charcot said: All these stigmata are typical of hysteria; they are constants in hysteria, but, despite their con- stancy, I have to acknowledge that it quite often happens that we do not find them all, or even, in extreme cases, we do not find any. 33 But the epis temological requirement was there, the injunction was there, and I would point out that all of these wonderful stigmata were clearly responses to instructions: instructions to move, to feel a rubbing or contact on the body.
And then, second, the attacks (crises) themselves had to be ordered and regular, and so develop according to a very typical scenario
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sufficiently close to an existing illness, to an existing neurological illness, so that it crosses the line ol diiferential diagnosis, and yet nonetheless sufficiently different for the diagnosis to be made; hence the codification ol the hysterical attack (crise) on the model ol epilepsy. Vl In this way the huge domain of what before Charcot was called "hystero epilepsy," the "convulsions," is divided in two. *5 You had two illnesses, one which included the famous elements of the epileptic fit, that is to say, tonic phase, clonic phase, and period of stupor; and the other, which had to have tonic and clonic phases like epilepsy, with certain minor signs, differences in the phases, and then some elements absolutely specilic to hysteria: the phase of illogical, that is to say, disor dered movements; then the phase of passionate postures, that is to say, expressive movements, movements meaning something, a phase that was also called "plastic," inasmuch as it reproduced and expressed emotions like lustfulness, terror, etcetera; and finally, the phase of delirium, which was also lound in epilepsy moreover. And there you have the two great classical pictures ol the hysteria/epilepsy opposition. i6
You can see that there is a double game in this maneuver. On the one hand, m appealing to these supposedly constant stigmata ol hysteria, and in appealing to regular attacks, the doctor thereby gets nd ol his own stigmata, that is to say, the fact that he is only a psychiatrist and obliged to demand at every moment, in each ol his questionings: "Are you mad? Show me your madness! Actualize your madness. " In appealing to the hysteric's stigmata and the regularity ol her attacks, the doctor asks her to give him the possibility ol perlorming a strictly medical act, that is to say, a diilerential diagnosis. However, at the same time--and this is the advantage lor the hysteric and why she will give a positive response to the psychiatrist's demand--the hysteric will thereby escape medical extra territorially or, more simply, she will escape asylum tern tonality. That is to say, as soon as she has been able to provide her symptoms, which, through their constancy and regularity, allow the neurologist to make a diilerential diagnosis, the hysteric will cease to be a mad person in the asylum; she will acquire citizenship within a hospital worthy ol the name, that is to say, of a hospital which will no longer be entitled to the mere status of an asylum. The hysteric acquires the right to be ill and not mad thanks to the constancy and regularity of her symptoms.
? Now what is the basis of this right acquired by the hysteric? It is founded on the situation in which the doctor ultimately finds himself dependent upon her. Because if the hysteric were to refuse to give her symptoms, then straightaway the doctor could no longer be a neurologist in relation to her; he would be consigned to the status of psychiatrist and to the obligation of making an absolute diagnosis and answering the inescapable question: "Are you or are you not mad? " Consequently, to function as a neurologist the doctor depends on the hysteric actually providing him with regular symptoms. To that extent, what the psychi atrist is offered not only ensures his own status as a neurologist, but also ensures the patient's hold over the doctor, since the patient gams a hold over him by providing him with symptoms, since she thereby sanctions his status as doctor, and no longer as psychiatrist.
You can understand the pleasure the hysterics will invest in the sup- plement of power they are given when they are asked lor regular symptoms; and we can see why they never hesitated to provide all the symptoms one wanted, and even more than one wanted, since, the more they provided the more their surplus-power was thereby asserted in relation to the doctor. And we have evidence that they provided a plentiful supply of symptoms, since one of Charcot's patients--and it is one example taken from many-- who was at la Salpetnere lor thirty four years, regularly provided the same stigmata for fifteen years: a "complete left hemianaesthesia. "37 So one got what one wanted from the point of view of duration; one also got what one wanted from the point ol view of quantity, since one of Charcot's patients had 7i506 attacks in thirteen days and, not content with this, some months later, she had 17,083 attacks in lourteen days. 38
The second maneuver is the one I will call the maneuver of the "functional mannequin. "39 It is triggered by the iirst maneuver inas much as the doctor, in calling for this proliferation of symptoms--since his status and power depend on it--finds himself both confirmed, and then losing out. Actually, this plethora, these 17,083 attacks in fourteen days, is clearly much more than he can control and more than his little neurological clinical apparatus (appareil) can record. So the doctor must provide himself with the possibility, obviously not of controlling this overabundance ol hysterical symptomatology but, at any rate--a bit like Duchenne de Boulogne whose problem was: "how to limit electrical
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stimulation so that it only acts on one muscle"--of giving himself the kind of instrument that will enable him to trigger typically and exclusively hysterical phenomena, but without getting this torrent of thousands of attacks in such a short time.
In answer to the objective of arousing these phenomena on demand, when one wants them, showing that they [are] all pathological, natu- rally pathological, to get round as it were the maneuver of exaggeration, the hysteric's exaggerated generosity, and succeed in bypassing this plethora, two techniques were established.
First, the technique ol hypnosis and suggestion, that is to say: putting the subject in a situation such that, on a precise order, one will be able to get a perfectly isolated hysterical symptom: paralysis of a muscle, inability to speak, trembling, etcetera. In short, hypnosis is used for pre- cisely this purpose, placing the patient in a situation such that he will have exactly the symptom one wants, when one wants it, and nothing else. Charcot did not use hypnosis to multiply hysterical phenomena; it was, like Duchenne's localized electrification, a way of limiting the phe- nomena of hysteria and of being able to trigger them exactly at will/'0 Now, as soon as we have triggered at will one and only one hysterical symptom, by means of hypnosis, do we not come up against a difficulty: If I induced it, if I said to a hypnotized patient, "you cannot walk," and he became paralyzed, "you cannot speak," and he became aphasic, is this really an illness? Is it not merely the effect in the patient's body of what has been forced on him? So if hypnosis is a good technique for isolating hysterical phenomena, it is also dangerous since it risks being only the effect of an instruction given: the effect, and not the response.
Consequently, precisely when and insofar as doctors put hypnosis to work, they are obliged to find some kind of correlative outside hypnosis to guarantee the natural character of hypnotically induced phenomena. Patients must be found outside all asylum culture and medical power, and so, of course, outside all hypnosis and suggestion, who display exactly the disorders that are observable on demand, under hypnosis, in hospitalized patients. In other words, a natural hysteria, without hospital, doctor, and hypnosis, is needed. In fact, it turned out that Charcot had these patients to hand, patients whose role, faced with hypnosis, was to naturalize, as it were, the effects of hypnotic intervention.
? He had them, and this requires a very short reference to a completely different history that connects up with the history of hysteria in a way that is very curious, but not without important historical effects. In 1872 Charcot takes over the hysteria-epilepsy department,,1 and he begins hyp- nosis in 1878/12 This is the time of accidents at work and on the railway, of accident and health insurance systems/1^ Not that accidents at work date from that time, but it is at this time that an absolutely new category of patients is making its appearance within medical practice--but whom, sadly, historians of medicine rarely mention--that is, patients who are neither paying nor receiving aid. In other words, in the medicine of the eighteenth and the beginning of the nineteenth century, there were basi cally only two categories of patient: those who were paying and those who were receiving aid at the hospital. Now a new category of patient appeared, the insured patient, who is neither entirely paying, nor entirely supported by aid/1'1 The appearance together of the insured patient and the neurolog- ical body, arising from completely different elements, is probably one of the important phenomena of the history of hysteria. What actually took place was that, from the end of the eighteenth century, precisely to the extent that it wanted to profit from a maximized health, society was gradually led to perfect a whole series of techniques of supervision, close control, cover, and insurance also, of illness and accidents.
However, precisely to the extent that society was obliged to divide up, control, and supervise health and to insure against accidents and illnesses in order to extract maximum profit lrom bodies, at the point when these techniques were established, and by the same process, illness became something profitable lor the person who was ill. In the eighteenth century, the only profit a patient receiving aid could draw from his illness was to stay a bit longer in hospital, and this minor problem is frequently encountered in the history of hospital institutions in the eighteenth century. With the tight control dating from the nineteenth century, and with this general cover of phenomena of illness by both medicine and insurance, illness itself, as such, can become a source of profit for the subject and, at any rate, a way of benefiting from this general system.
Illness becomes profitable precisely when it raises a problem at the general level of the profits of society. Illness is consequently intertwined with the whole economic problem of profit.
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As a result, we see the appearance of new patients, that is to say, insured patients with what are called post-traumatic disorders such as paralysis, anesthesia, spasms, pains, convulsions, etcetera, without any assignable anatomical basis. And the problem at this time, still in terms of profit, is whether they should be considered as patients, and so covered by insurance, or as malingerers (simulateurs)/^ There is a huge literature on the results of railroad accidents--and also on accidents at work, but to a lesser degree and a bit later, almost at the end ol the century--which covers, I think, an enormous problem that in a way sup- ported the development of neurological techniques, of the techniques oi examination I have been talking about. "16
The insured patient, who joins up with the neurological body, who is the bearer of a neurological body that can be captured by the clinical apparatus of neuropathology, is the other figure lacing the hysteric, pre- cisely the person one is looking for, so that one can be played off against the other. On one side are these patients who are not yet hospitalized, not yet medicalized, and who are not therefore under hypnosis, under medical power, and who display certain natural phenomena if they are not stimulated. And then, on the other side, are the hysterics within the hospital system, under medical power, on whom artificial illnesses have been imposed by means of hypnosis. So, when compared with the trauma, the hysteric will make it possible to recognize whether or not the traumatized person is a simulator, a malingerer. There are two possibilities in fact: either the traumatized person displays the same symptoms as the hysteric--obviously I am talking about someone trau matized who has no trace ol a lesion--and, as a result, we can say: "he has the same illness as the hysteric," since the first maneuver consisted in showing that the hysteric was ill, and so the hysteric will authenticate the traumatized person's illness; or the traumatized person will not have the same illness, will not display the same symptoms as the hysteric, and as a result will fall outside the field of pathology and one will be able to ascribe his symptoms to simulation.
On the other hand, with regard to hysteria, comparison will lead to the lollowmg result: if someone who is not hypnotized can be found with symptoms similar to those obtained in a hysteric by means of hypnosis, then this really will be the sign that the hypnotic phenomena
? obtained in hysterics are indeed natural phenomena. So, the hysteric is naturalized by means oi the traumatized person, and the traumatized person's possible simulation is revealed by means of the hysteric.
Hence Charcot's grand stagecralt. It is olten said that this consisted in getting a hysteric and saying to his students: "See what illness she is afiected by," and, effectively, dictating symptoms to the patient. This is true, it corresponds to the first maneuver I was telling you about, but I think the major and most subtle and perverse of Charcot's maneuvers, was precisely displaying these two hgures together. When traumatized people from outside the hospital appeared at his private oflice--the vic- tims o) different kinds ol accidents with no visible traces of lesions and sulfering from paralysis, coxalgia, anesthesia--Charcot called for a hysteric, hypnotized him and said: "You can no longer walk," and looked to see whether the hysteric's paralysis really was similar to that of the person traumatized. A famous case of this kind was one ol post-traumatic coxalgia in a railroad employee. Charcot was almost sure that the coxalgia was not caused by a lesion; he had a feeling however that it was not a pure and simple simulation. He called for two hysterics, hypnotized them, and gave them instructions through which he managed to reconstitute the employee's coxalgia on the kind ol lunctional mannequin that the hysteric had become, and so the coxalgia had to be considered hysterical? '
Everyone benefits. In the first place, the insurance companies, of course, and the people who had to pay, and, also the patient to a certain extent, since, if he is not a simulator, a malingerer, Charcot said, we can not deny him something, albeit, obviously, not of the same order as ll he had a real injury. So the cake was cut in two. However, clearly this is not the important problem: the doctor also benelits since, thanks to the use of the hysteric as a lunctional mannequin, the doctor could make a dif lerential diagnosis that will now be brought to bear on the simulator. One will now be able to master the iamous panic dread of the simulator that so obsessed doctors in the first half of the nineteenth century, since one will have these hysterics who, traitors to their own lie, as it were, will make it possible to denounce the lie of others, and, as a result, the doctor will hnally have the upper hand over simulation. '8
Finally, ol course, the hysterics beneht, since il they serve as functional mannequins in this way, authenticating the functional or, as
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it was said at this time, "dynamic" illness without lesion, if the hysteric is there to authenticate this illness, then she inevitably escapes all suspicion of simulation, since she is the basis on which the simulation of others can be denounced. As a result, it is once again thanks to the hysteric that the doctor will be able to ensure his power; if he escapes the simulator's trap it is because he has the hysteric who makes possible the double, organic/dynamic/simulation, differential diagnosis. And con- sequently, the hysteric has the upper hand over the doctor a second time, since by obeying the instructions he gives her under hypnosis, she gets to be the authority of verification, as it were, the authority adjudicating truth between illness and lie. The second triumph of the hysteric. You understand that here too the hysterics do not hesitate to reconstitute, on demand, the coxalgia and anesthesia, etcetera that they are asked for under hypnosis.
Hence the third maneuver of redistribution around the trauma. At the end of the second maneuver, the doctor is therefore once again newly dependent on the hysteric, because if the disorders reproduced on order by the hysteric, and so generously, so profusely, with such obedience and, at the same time, with such a thirst for power, will not this be proof after all that it is all fabricated, as Bernheim was already beginning to say? H9 In the end, is not the appearance of this great hysterical symp- tomatology at la Salpetriere all due to the set of medical powers being exercised within the hospital?
If the doctor is not to be entirely dependent on this hysterical behav- ior which could well be said to be fabricated, if he is to renew his power over all this phenomena and take it back under his control, he will have to include within a strict pathological schema both the fact that some one can be hypnotized and the fact that he reproduces pathological types of phenomena under hypnosis, and, at the same time, that those well known lunctional disorders, which Charcot had shown were so close to hysterical phenomena, can be placed in this pathological frame- work. A pathological framework is needed which simultaneously envelops hypnosis, the hysterical symptoms produced under hypnosis, and the event which brings about the functional disorders oi patients who are not hypnotized. Since the body cannot speak because there is no lesion, this search for a pathological framework leads Charcot to look for
? an assignable cause. One will have to look at the etiological level for something on which to pin all these phenomena and thereby attach them to a rigorous pathology, that is to say, what one will have to discover is an event.
This was how Charcot developed the concept ol trauma. 50
What is a trauma for Charcot? It is something--a violent event, a blow, a (all, a (ear, a spectacle, etcetera--which provokes a sort of dis- crete, localized hypnotic state, but which sometimes lasts for a long time, so that, following the trauma, a certain idea enters the individual's head, inscribes itself in his cortex, and acts like a sort of permanent injunction.
An example of a trauma: a child is knocked down by a vehicle; he faints. In the moment before fainting he has the feeling that the wheels ol the vehicle run over his body. He comes to and, after a time, realizes that he is paralyzed; and if he is paralyzed it is because he thinks the wheels ran over his body. 51 Now this belief is inscribed and continues to (unction within a set ol micro hypnotic states, within a localized hyp- notic state concerning this beliel. What provokes paralysis o( the legs is, as it were, this idea that has become a hypnotic injunction? 2 We see here how the notion of trauma, which will be so important in the iuture, is established and, at the same time, the link between this notion and the old conception of delirium. Since if he is paralyzed, it is because he believes that the wheels of the van ran over him--you can see how this is linked with the old conception of madness always concealing a delirium. 5* So, a trauma is something that provokes a localized and permanent hypnotic state on just this point.
As for hypnotism, what is it? Well, it will also be a trauma, but in the form ol a complete, brief, transitory shock, which will be suspended solely by the doctor's will, but which will envelop the individual's general behavior, so that within this state of hypnosis, which is a sort oi generalized and provisional trauma, the doctor's will, his words, will be able to implant ideas and images in the subject which thus have the same role, the same Iunction, and the same eilect of injunction as the injunction I was talking about with regard to natural, non-hypnotic traumas. Thus, between hysterical phenomena produced under hypno- sis and hysterical phenomena following an event, there is a convergence
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which points towards this fundamental notion of trauma. Trauma is what provokes hypnosis, and hypnosis is a sort of general reactivation o( the trauma through the doctor's will.
Hence the need in Charcot's practice to go in search of the trauma itself.
That is to say, to be sure that the hysteric really is a hysteric and that all her symptoms, whether under hypnosis or outside ol hypnosis, really are pathological, one will have to discover the etiology, to find the trauma, the kind of invisible and pathological lesion which makes all of this a well and truly morbid whole. * Hence the necessity for hysterics, whether or not they are under hypnosis, to recount their childhood, their life, so as to lind again that kind of fundamental and essential event that will persist and is always present in the hysterical syndrome, and of which the latter is in some way the permanent actual izati on. Vl'
However--and here we find the hysteric again and her counter- maneuver--what will the patients do with this injunction to find the trauma that persists in the symptom? Into the breach opened by this injunction they will push their lile, their real, everyday life, that is to say, their sexual hie. It is precisely this sexual life that they will recount, that they will connect up with the hospital and endlessly reactualize in the hospital. Unfortunately, we cannot trust Charcot's text for prool of this counter-investment of the search for the trauma by the story of sexual life, because Charcot does not talk about it. However, when we look at his students' observations, we see what is involved throughout these anamneses, what was at stake, what was talked about, and also what was really involved m the famous attacks with a pseudo-epileptic lorm. I will take just one example, a case recorded by Bourneville.
This is how the patient recounted her life. From age six to thirteen she was a boarder in a religious convent "at La Ferte sous Jouarre where she enjoyed a degree ol lreedom, wandered in the countryside, willingly let herself be kissed for sweets. " This is the protocol produced by one ol Charcot's students on the basis of the patient's own accounts. "She often
* The manuscript clarifies: "Hence the double search: (a) lor the nervous diathesis which causes susceptibility to trauma; search for heredity. And then (b) for the trauma itsell. "
t The manuscript adds: "Hence the violence ol the opposition to Bernheim: if everyone could be hypnotized the edifice would collapse. "
? visited the wife ol a workman, Jules, a painter. The latter was in the habit of getting drunk, and when this happened there were violent arguments in the household; he beat his wife, dragged her or tied her up by the hair. Louise [the patient; M. F. ] sometimes witnessed these scenes. One day,Jules would have tried to kiss her, even rape her, which gave her a great fright. During the holidays [she was aged between six and thirteen years; M. F. |, she came to Paris and spent the days with her brother, Antonio, one year younger than her, who seems to have been very precocious and taught her many things she should not have known. He mocked her naivety, which led her to accept the explanation he gave to her of, amongst other things, how children are made. During the hoi idays, in the house where her parents were in service, she had the opportunity to see a Mr. C [the master of the house; M. F. ], who was her mother's lover. Her mother obliged Louise to kiss this man and wanted her to call him her father. On her permanent return to Pans, Louise was placed [after her period of boarding, so she was 13; M. F. ] in C's home on the pretext of learning to sing and sew, etcetera. She slept in a little isolated room. C, whose relationship with his wife was a bit strained, took advantage of her absences to try to have relations with Louise, aged thirteen and a half. The first time, he failed; he wanted her to go to bed in front of him. A second attempt ended in some incomplete approaches, due to her resistance. A third time, C, after dangling all sorts of promises before her eyes, hne gowns, etcetera, seeing that she did not want to give in, threatened her with a razor; taking advantage of her fear, he got her to drink a liqueur, undressed her, threw her down on his bed, and had full sexual intercourse with her. The following day Louise was suffering, etcetera. "^
The lives of hysterics recounted by Charcot's patients are in fact often of this order and level. And, if we look at the observations taken for Charcot by his students, what really happened in those famous attacks that Charcot said were strangely similar to epileptic fits and very diffi- cult to distinguish from epileptic fits if you were not a good neurologist?
At the level of the discourse, this is what Louise said: "Tell me! . . . You must tell me! Peasant! You must be vile. So you believe this boy more than me. . . I swear to you that this boy has never laid a hand on me. . . I did not respond to his caresses, we were in a held . . . I assure you that I did not
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want it. . . Call them (Commanding physiognomy). Well? (She suddenly looks to her right) . .
