Madness and Civilzation ( A History of Madness)

by Foucault, Michel -

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  rum, as do the other fluids which the latter provides. . . . In this way, it becomes probable that the so-called immate­rial hysterical affection and hypochondriacal disease derive from the dispositions of the particular state of the fibers." It is to this sensibility, this mobility, that we must attribute the sufferings, the spasms, the singular pains so readily suffered by "young girls of pale complexion, and individu­als too much given to study and meditation." Hysteria is indiscriminately mobile or immobile, fluid or dense, given to unstable vibrations or clogged by stagnant humors. No one has managed to discover the actual nature of its move­ments.

  We receive the same impression in the realm of chemical analogies: for Lange, hysteria is a product of fermentation, quite precisely of the fermentation "of salts, sent into different parts of the body," with "the humors that are located there." For others, it is of an alkaline nature. Mi­chael Ettmuller, on the contrary, considers that diseases of this kind belong to a chain of acid reactions, "the immedi­ate cause being the acid rawness of the stomach; the chyle being acid, the quality of the blood is corrupted; it no longer furnishes spirits; the lymph is acid, the bile without strength; the nervous system suffers irritation, the digestive leaven, spoiled, is less volatile and too acid." Viridet under­takes to reconstitute, apropos of "vapors which we experi­ence," a dialectic of alkalis and acids whose movements and violent collisions, in the brain and the nerves, provoke the signs of hysteria and hypochondria. Certain particularly volatile animal spirits are alkaline salts that move with great speed and transform themselves into vapors when they be­come too tenuous; but there are other vapors that are vol­atilized acids; the ether gives these latter enough movement to carry them to the brain and the nerves where, "encoun­tering the alkalis, they cause infinite ills."

  Strange, the qualitative instability of these hysterical and

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  hypochondriacal illnesses; strange, the confusion of their dynamic properties and the secret nature of their chem­istry! To the very degree that the diagnosis of mania and melancholia seemed simple in the context of qualities, so the decipherment of these illnesses seemed hesitant. No doubt, this imaginary landscape of qualities which was decisive for the constitution of the melancholia-mania couple remained secondary in the history of hysteria and hypochondria, where it probably played no more than the role of continu­ally shifted scenery. The progress of hysteria did not lead, as did that of mania, through the world's obscure qualities reflected in a medical imagery. The space in which it as­sumed its dimensions was of another kind: that of the body, in the coherence of its organic values and its moral values.

  It is customary to credit Charles le Pois and Willis with liberating hysteria from the old myths of uterine displace­ment. Jean Liebault, translating or rather adapting Marinello's book to seventeenth-century standards, still ac­cepted, despite some restrictions, the idea of a spontaneous movement of the womb; if it shifted position "it was to be more at ease; not that this was done out of prudence, be­hest, or animal stimulus, but to preserve health and to ex­perience the enjoyment of something delectable." No doubt, it was no longer deemed possible for the womb to change place or to course through the body somersaulting as it went, for it was "strictly attached" by its neck, by ligaments, by vessels, and finally by the tunic of the peri­toneum; yet it could change position: "And so the womb, though it be so strictly attached to the parts we have de­scribed that it may not change place, yet often changes position, and makes curious and so to speak petulant move­ments in the woman's body. These movements are various:

  to wit, ascending, descending, convulsive, vagrant, pro-

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  lapsed. The womb rises to the liver, spleen, diaphragm, stomach, breast, heart, lung, gullet, and head." The physi­cians of the classical period were almost unanimous in refusing to accept such an explanation.

  At the beginning of the seventeenth century, Le Pois could write, speaking of hysterical convulsions: "Of all these one source is the father, and this not through sym­pathy but through idiopathy." More precisely, their origin is in an accumulation of fluids toward the posterior part of the skull: "Just as a river results from the confluence of a quantity of smaller vessels which join to form it, so the sinuses that are on the surface of the brain and terminate in the posterior part of the head amass the liquid because of the head's inclined position. The heat of the parts then causes the liquid to warm and affect the origin of the nerves." Willis, in his turn, makes a minute critique of the uterine explanation: it is especially from affections of the brain and the nervous system "that all the derangements and irregularities which obtain in the movement of the blood during this illness derive." And yet all these analyses did not thereby abolish the idea of an essential link between hysteria and the womb. But the link is differently con­ceived: it is no longer regarded as the trajectory of a real displacement through the body, but as a sort of secret prop­agation through the pathways of the organism and through functional proximities. We cannot say that the seat of the disease had become the brain, nor that Willis had made possible a psychological analysis of hysteria. But the brain now played the part of a relay station and the distributor of a disease whose origin was visceral: the womb occasioned it along with all the other viscera. Until the end of the eigh­teenth century, until Pinel, the uterus and the womb re­mained present in the pathology of hysteria, but as the result of a privileged diffusion by the humors and nerves, and not by a special prestige of their nature.

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  Stahl justifies the parallelism of hysteria and hypochon­dria by a curious comparison of menstrual flow and hemor­rhoids. He explains, in his analysis of spasmodic move­ments, that the hysterical affection is a violent pain, "ac­companied by tension and compression, which makes itself principally felt below the hypochondriac regions." It is called a hypochondriacal disease when it attacks men "in whom nature makes an effort to be rid of excess blood by vomiting or hemorrhoids"; it is called a hysterical affection when it attacks women "the course of whose periods is not as it should be. However, there is no essential difference between these two affections." Hoffman's opinion is quite similar, in spite of many theoretical differences. The cause of hysteria is in the womb—loosening and weakening—but the seat of the disease is to be sought, as in the case of hypochondria, in the stomach and the intestines; the blood and the vital humors begin to stagnate "in the membranous and nervous tunics of the intestines"; gastric disturbances result, which spread thence throughout the whole body. At the very center of the organism, the stomach serves as a relay station and diffuses the maladies that come from the interior and subterranean cavities of the body: "It is not to be doubted that the spasmodic affections experienced by hypochondriacs and hysterics have their seat in the nervous parts, and especially in the membranes of the stomach and the intestines, from which they are communicated by the intercostal nerve to the head, to the chest, to the kidneys, to the liver, and to all the principal organs of the body."

  The role Hoffmann assigns to the intestines, the stomach, and the intercostal nerve is indicative of the manner in which the problem was presented in the classical period. It was not so much a question of escaping the old localization in the uterus, but of discovering the principle and the path­ways of a diverse, polymorphous disease dispersed throughout the entire body. A disease was to be accounted

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  for that could attack the head as well as the legs, express itself in a paralysis or in frenzied movements, that could bring on catalepsy or insomnia: in short, a disease that traversed corporeal space so rapidly and so ingeniously that it was virtually present throughout the entire body.

  It is futile to insist on the change of medical horizons that occurred from Marinello to Hoffmann. Nothing subsists of that famous mobility ascribed to the uterus, which had constantly figured in the Hippocradc tradition. Nothing, except perhaps a certain theme which appeared more clearly now that it was no longer confined to a single med
­ical theory, but persisted unchanged through the succession of speculative concepts and explanatory schemas. This was the theme of a dynamic upheaval of corporeal space, of a tide of the lower powers, which, too long constrained and, as it were, congested, began to seethe and ultimately spread their disorder—with or without the brain's mediation-through the entire body. This theme remained almost sta­tionary until the beginning of the eighteenth century, de­spite the complete reorganization of physiological con­cepts. And strangely enough, it was during the eighteenth century, when no theoretical or experimental innovation in pathology had occurred, that the theme was suddenly mod­ified, changed direction—that a dynamics of corporeal space was replaced by a morality of sensibility. It was then, and only then, that the ideas of hysteria and hypochondria were to veer, and definitively enter the world of madness.

  We must try now to reconstitute the evolution of the theme, in each of its three stages:

  1. a dynamics of organic and moral penetration;

  2. a physiology of corporeal continuity;

  3. an ethic of nervous sensibility.

  If corporeal space is perceived as a solid and continuous whole, the disordered movement of hysteria and of hypo-

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  chondria could result only from an element whose extreme tenuousness and incessant mobility permitted it to penetrate into the place occupied by the solids themselves. As Na­thaniel Highmore put it, the animal spirits, "because of their igneous tenuity, can penetrate even the densest, the most compact bodies . . . , and because of their activity, can penetrate the entire microcosm in a single instant." The spirits, if their mobility increased, if penetration occurred, chaotically and in an untimely manner, in all the parts of the body to which they were unsuited, provoked a thou­sand diverse signs of disturbance. Hysteria, for Highmore as for Willis, his adversary, and for Sydenham as well, was the disease of a body indiscriminately penetrable to all the efforts of the spirits, so that the internal order of organs gave way to the incoherent space of masses passively sub­ject to the chaotic movement of the spirits. These latter "move impetuously and in excessive quantity upon such or such a part, there causing spasms or even pain . . . and disturbing the function of the organs, both those which they abandon and those toward which they move, neither being able to avoid serious damage from this unequal dis­tribution of spirits, which is entirely contrary to the laws of animal economy."13 The hysterical body was thus given over to that disorder of the spirits which, outside of all organic laws and any functional necessity, could succes­sively seize upon all the available spaces of the body.

  The effects varied according to the regions affected, and the disease, undifferentiated in the pure source of its move­ment, assumed various configurations depending on the spaces it traversed and the surfaces where it appeared:

  "Having accumulated in the stomach, they rush in a host and with impetuosity upon the muscles of the larynx and the pharynx, producing spasms throughout the entire area they traverse, and causing in the stomach a swelling which resembles a large ball." A little higher, the hysterical affec-

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  tion, "seizing upon the colon and upon the region which is below the heart cavity, causes there an insupportable pain which resembles the iliac affection." Should it rise still higher, the disease attacks "the vital parts and causes so violent a palpitation of the heart that the sick person does not doubt that his attendants must be able to hear the sound his heart makes as it beats against his ribs." Finally, if it attacks "the exterior part of the head, between the cranium and the pericranium, and there remains fixed in a single spot, it causes an extreme pain that is accompanied by violent fits of vomiting."14 Each part of the body de­termines in its own right and by its own nature the form of the symptom produced. Hysteria thus appears as the most real and the most deceptive of diseases; real because it is based upon a movement of the animal spirits; illusory as well, because it generates symptoms that seem provoked by a disorder inherent in the organs, whereas they are only the formation, at the level of these organs, of a central or rather general disorder; it is the derangement of internal mobility that assumes the appearance, on the body's sur­face, of a local symptom. Actually suffering from the dis­ordered and excessive movement of spirits, the organ imi­tates its own illness; starring from a defect in the movement within internal space, it imitates a disorder that strictly be­longs to itself; in this manner, hysteria "imitates almost all the maladies to which human flesh is subject, for in what­ever part of the body it lodges, it immediately produces the symptoms that are proper to that part, and if the physician does not have great wisdom and experience, he will easily be deceived and will attribute to an illness essential and proper to such and such a part, symptoms that are entirely the result of hysterical affection":15 stratagems of a disease that, traversing corporeal space in the homogenous form of movement, manifests itself in specific aspects; but the type, here, is not essence; it is a ruse of the body.

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  The more easily penetrable the internal space becomes, the more frequent is hysteria and the more various its as­pects; but if the body is firm and resistant, if internal space is dense, organized, and solidly heterogeneous in its differ­ent regions, the symptoms of hysteria are rare and its effects will remain simple. Is this not exactly what separates female hysteria from the male variety, or, if you will, hys­teria from hypochondria? Neither symptoms, in fact, nor even causes form the principle of separation between the diseases, but only the spatial solidarity of the body, and so to speak the density of the interior landscape: "Beyond what we may call the exterior man, who is composed of parts which are visible to the senses, there is an interior man formed of a system of animal spirits, a man who can be seen only with the eyes of the mind. This latter man, closely joined and so to speak united with the corporeal constitu­tion, is more or less deranged from his state to the degree that the principles which form the machine have a natural firmness. That is why this disease attacks women more than men, because they have a more delicate, less firm constitu­tion, because they lead a softer life, and because they are accustomed to the luxuries and commodities of life and not to suffering." And already, in the lines of this text, this spatial density yields one of its meanings: it is also a moral density; the resistance of the organs to the disordered pene­tration of the spirits is perhaps one and the same thing as that strength of soul which keeps the thoughts and the desires in order. This internal space which has become permeable and porous is perhaps only the laxity of the heart. Which explains why so few women are hysterical when they are accustomed to a hard and laborious life, yet strongly incline to become so when they lead a soft, idle, luxurious, and lax existence; or if some sorrow manages to conquer their resolution: "When women consult me about some complaint whose nature I cannot determine, I ask if

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  the malady from which they are suffering attacks them only when they have some sorrow . . . : if they admit as much, I am fully assured that their complaint is an hyster­ical affection."16

  Thus we have a new formulation of the old moral intui­tion that from the time of Hippocrates and Plato had made the womb a living and perpetually mobile animal, and dis­tributed the spatial ordering of its movements; this intuition perceived in hysteria the incoercible agitation of desires in those who had neither the possibility of satisfying them nor the strength to master them; the image of the female organ rising to the breast and to the head gave a mythical expres­sion to an upheaval in the great Platonic tripartition and in the hierarchy that was intended to assure its immobility. For Sydenham, for the disciples of Descartes, the moral intuition is identical; but the spatial landscape in which it is expressed has changed; Plato's vertical and hieratic order is replaced by a volume which is traversed by incessant mo­tion whose disorder is no longer a revolution of the depths to the heights but a lawless whirlwind in a chaotic space. This "interior body" which Sydenham tried to penetrate with "the eyes of the mind" was not the objective b
ody available to the dull gaze of a neutralized observation; it was the site where a certain manner of imagining the body and of deciphering its internal movements combined with a certain manner of investing it with moral values. The development is completed, the work done on the level of this ethical perception. In this perception the ever pliant images of medical theory are inflected and altered; in it, too, the great moral themes are formulated and gradually alter their initial aspect.

  This penetrable body must, however, be a continuous body. The dispersion of the disease through the organs is only the reverse of a movement of propagation which per-

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  mits it to pass from one to another and to affect them all in succession. If the body of the hypochondriac or the hys­teric is a porous body, separated from itself, distended by the invasion of disease, this invasion can be effected only by means of a certain spatial continuity. The body in which the disease circulates must have other properties than the body in which the sufferer's dispersed symptoms appear.

  The problem haunted eighteenth-century medicine, and was to make hypochondria and hysteria diseases of the "nervous type"; that is, idiopathic diseases of the general agency of all the sympathies.

  The nervous fiber is endowed with remarkable proper­ties, which permit it to integrate the most heterogeneous elements. Is it not astonishing that, responsible for trans­mitting the most diverse impressions, the nerves should be of the same nature everywhere, and in every organ? "The nerve whose expansion at the back of the eye makes it possible to receive the impression of so subtle a matter as light; the nerve which, in the organ of hearing, becomes sensitive to the vibrations of sonorous bodies, differs no whit in nature from those which serve the grosser sensa­tions such as touch, taste, and odor." This identity of na­ture, in different functions, assures the possibility of com­munication between the most distant organs, and those most dissimilar physiologically: "This homogeneity in the nerves of the animal, combined with the numerous com­munications that all maintain with each other . . . estab­lishes among the organs a harmony that often makes one or several parts participate in the affections of those which are injured."17 But what is still more admirable, a nervous fiber can transmit simultaneously the stimulus of a volun­tary movement and the impression left on the organ by the senses. Simon-Andre Tissot conceived this double function of one and the same fiber as the combination of an undulatory movement for voluntary stimulus ("this is the move-