it is the disease itself that fear attacks and suppresses. It has, in fact, the property of petrifying the operations of the nervous system, somehow congealing its too mobile fibers, controlling all their disordered movements; "fear being a passion that diminishes the excitation of the brain, it can consequently calm its excesses, and especially the irascible excitation of maniacs."13
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If the fear-anger antithesis is efficacious against manic irritation, it can be used inversely against the unmotivated fears of melancholics, hypochondriacs, and all those who have a lymphatic temperament. Tissot, reviving the traditional idea that anger is a discharge of bile, considers that it is useful for dissolving the phlegms amassed in the stomach and in the blood. By subjecting the nervous fibers to a stronger tension, anger gives them more vigor, thus restoring their lost elasticity and permitting fear to disappear. The cure by passion is based on a constant metaphor of qualities and movements; it always implies that they are immediately transferable in their own modality from the body to the soul, and vice versa. It must be used, says Scheidenmantel in the treatise he devotes to this form of cure, "when the cure necessitates in the body changes identical to those which this passion produces." And it is in this sense that it can be the universal substitute for all other physical therapeutics; it is only another way to produce the same sequence of effects. Between a cure by the passions and a cure by the prescriptions of the pharmacopoeia, there is no difference in nature; but only a diversity in the mode of access to those mechanisms which are common to the body and to the soul. "The passions must be utilized, if the sufferer cannot be led by reason to do what is necessary for the restoration of his health."
It is thus not possible to use as a valid or at least meaningful distinction for the classical period the difference—immediately apparent to us—between physical medications and psychological or moral medications. The difference only begins to exist in all its profundity the day when fear is no longer used as a method for arresting movement, but as a punishment; when joy does not signify organic expansion, but reward; when anger is nothing more than a response to concerted humiliation; in short, when the nine-
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teenth century, by inventing its famous "moral methods," has brought madness and its cure into the domain of guilt. The distinction between the physical and the moral becomes a practical concept in the medicine of the mind only when the problematics of madness shifts to an interrogation of the subject responsible. The purely moral space, which is then denned, gives the exact measurements of that psychological inwardness where modem man seeks both his depth and his truth. Physical therapeutics tends to become, in the first half of the nineteenth century, a cure devised by an innocent determinism, and moral treatment a cure wrought by a culpable freedom. Psychology, as a means of curing, is henceforth organized around punishment. Before seeking to relieve, it inflicts suffering within the rigor of a moral necessity. "Do not employ consolations, they are useless; have no recourse to reasoning, it does not persuade; do not be sad with melancholics, your sadness sustains theirs; do not assume an air of gaiety with them, they are only hurt by it. What is required is great sang-froid, and when necessary, severity. Let your reason be their rule of conduct. A single string still vibrates in them, that of pain; have courage enough to pluck it."14
The heterogeneity of the physical and the moral in medical thought is not a result of Descartes's definition of substances; a century and a half of post-Cartesian medicine did not succeed in assimilating that separation on the level of problems and methods, nor in understanding the distinction of substances as an opposition of organic to psychological. Cartesian or anti-Cartesian, classical medicine never introduced Descartes's metaphysical dualism into anthropology. And when the separation did occur, it was not by a renewed loyalty to the Meditations, but by a new privilege accorded to transgression. Only the use of punishment distinguished, in treating the mad, the medications of the body from those of the soul. A purely psychological medi-
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cine was made possible only when madness was alienated in guilt.
Of this, however, a whole aspect of medical practice during the classical period might stand as a long denial. The psychological element, in its purity, seems to have its place among the techniques. How else explain the importance attached to exhortation, to persuasion, to reasoning, to that whole dialogue in which the classical physician engages with his patient, independently of the cure by bodily remedies? How explain that Sauvages can write, in agreement with all his contemporaries: "One must be a philosopher to be able to cure the diseases of the soul. For as the origin of these diseases is nothing more than a violent desire for a thing which the sufferer envisages as a good, it is part of the physician's duty to prove to him by solid reasons that what he desires so ardently is an apparent good but a real evil, in order to make him renounce his error."
In fact this approach to madness is neither more nor less psychological than any of those we have already discussed. Language, the formulations of truth or morality, are in direct contact with the body; and it is Bienville again, in his treatise on Nymphomania, who shows how the adoption or the rejection of an ethical principle can directly modify the course of organic processes. However, there is a difference in nature between those techniques which consist in modifying the qualities common to body and soul, and those which consist in treating madness by discourse. In the first case, the technique is one of metaphors, at the level of a disease that is a deterioration of nature; in the second, the technique is one of language, at the level of a madness perceived as reason's debate with itself. The technique, in this last form, functions in a domain where madness is "treated" —in all the senses of the word—in terms of truth and error. In short, there always existed, throughout the classical
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period, a juxtaposition of two technical universes in the therapeutics of madness. One, which is based on an implicit mechanics of qualities, and which addresses madness as essentially passion—that is, a certain compound (movement-quality) belonging to both body and soul; the other, which is based on the discursive movement of reason reasoning with itself, and which addresses madness as error, as double inanity of language and image, as delirium. The structural cycle of passion and of delirium which constitutes the classical experience of madness reappears here in the world of techniques—but in a syncopated form. Its unity is expressed only distantly. What is immediately visible, in capital letters, is the duality, almost the opposition, in the medicine of madness, of the methods of suppressing the disease, and of the forms of treating unreason. These latter can be reduced to three essential configurations.
1. Awakening. Since delirium is the dream of waking persons, those who are delirious must be torn from this quasi-sleep, recalled from their waking dream and its images to an authentic awakening, where the dream disappears before the images of perception. Descartes sought this absolute awakening, which dismisses one by one all the forms of illusion, at the beginning of his Meditations, and found it, paradoxically, in the very awareness of the dream, in the consciousness of deluded consciousness. But in madmen, it is medicine which must effect the awakening, transforming the solitude of Cartesian courage into an authoritarian intervention, by the man awake and certain of his wakefulness, into the illusion of the man who sleeps waking: a short cut that dogmatically reduces Descartes's long road. What Descartes discovers at the end of his resolution and in the doubling of a consciousness that never separates from itself and does not split, medicine imposes from outside, and in the dissociation of doctor and patient. The physician, in relation to the madman, reproduces the mo-
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ment of the Cogito in relation to the time of the dream, of illusion, and of madness. A completely exterior Cogito, alien to cogitation itself, and which can be imposed upon it only in the form of an invasion.
This structure of invasion by wakefulness is one of
the most constant forms among the therapeutics of madness. It often assumes the simplest aspects, simultaneously those most highly charged with images and those most credited with immediate powers. It is asserted that a gun discharged near her cured a young girl of convulsions contracted as the result of severe grief. Without going so far as this iconographic representation of the methods of awakening, sudden and strong emotions achieve the same result. It is in this spirit that Boerhaave performed his famous cure of convulsives at Haarlem. In the city hospital, an epidemic of convulsions had broken out. Antispasmodics, administered in strong doses, did no good. Boerhaave ordered "that stoves filled with burning coals be brought, and that iron hooks of a certain form be heated in them; thereupon, he said in a loud voice that since all the means hitherto employed in attempting to cure the convulsions had been useless, he knew of only one other remedy, which was to bum to the bone, with red-hot irons, a certain spot on the arm of any person, male or female, who suffered an attack of a convulsive illness."15
Slower, but also more certain of the truth it confronts, is the awakening that proceeds from wisdom itself and from its insistent, imperative progress through the landscapes of madness. From this wisdom, in its various forms, Willis sought the cure of the various madnesses. For imbeciles, a pedagogical wisdom; an "attentive and devoted master must educate them completely"; they must be taught, little by little and very slowly, what children are taught in school. For melancholics, a wisdom that takes as its model the most rigorous and most evident forms of truth: what is
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imaginary in their delirium will disappear in the light of an incontestable truth; this is why "mathematical and chemical" studies are strongly recommended. For the others, the wisdom of a well-ordered life will reduce their delirium;
there is no need to impose upon them any other truth than that of their everyday life; remaining in their homes, "they must continue to manage their affairs, direct their families, order and cultivate their estates, their gardens, their orchards, their fields." It is, on the contrary, the exactitude of a social order, imposed from without and, if necessary, by force, that can gradually restore the minds of maniacs to the light of truth: "For this, the insane person, placed in a special house, will be treated, either by the doctor or by trained assistants, in such a way that he may be always maintained in his duty, in his appearance and habits, by warnings, by remonstrances, and by punishments immediately inflicted."16
Little by little during the classical period, this authoritarian awakening of madness would lose its original meaning and limit itself to being no more than recollection of moral law, return to the good, fidelity to the law. What Willis still intended as a reintroduction to truth would no longer be entirely understood by Sauvages, who speaks of lucidity in the recognition of the good: "Thus, one can recall to reason those whom false principles of moral philosophy have caused to lose their own, as long as they are willing to examine with us what is truly good, and what things are to be preferred to others." Already it is no longer as awakener that the physician is to function, but as moralist. Against madness, Tissot considers that "a pure conscience, without reproach, is an excellent preservative." And soon comes Pinel, for whom the awakening to truth no longer has a meaning in the cure, but only obedience and blind submission: "A fundamental principle for the cure of mania in a great number of cases is to resort first of
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all to an energetic repression, and to proceed subsequently to methods of benevolence."
2. Theatrical Representation. In appearance at least, this is a technique rigorously opposed to that of awakening. There, delirium, in all its immediate vivacity, was confronted by the patient work of reason. Either in the form of a slow pedagogy, or the form of an authoritarian invasion, reason was imposed, as if by the weight of its own being. The non-being of madness, the inanity of error, was forced to yield, finally, to this pressure of the truth. Here, the therapeutic operation functions entirely in the space of the imagination; we are dealing with a complicity of the unreal with itself; the imagination must play its own game, voluntarily propose new images, espouse delirium for delirium's sake, and without opposition or confrontation, without even a visible dialectic, must, paradoxically, cure. Health must lay siege to madness and conquer it in the very nothingness in which the disease is imprisoned. When the imagination "is sick, it can be cured only by the effect of a healthy and active imagination. ... It is all one whether the invalid's imagination is cured by fear, by a strong and painful impression upon the senses, or by an illusion."17 Illusion can cure the illusory—while reason alone can free from the unreasonable. What then is this dark power of the imaginary?
Insofar as it is of the essence of the image to be taken for reality, it is reciprocally characteristic of reality that it can mime the image, pretend to the same substance, the same significance. Without a break, without a jolt, perception can continue the dream, fill in its gaps, confirm what is precarious about it, and lead it to its fulfillment. If illusion can appear as true as perception, perception in its turn can become the visible, unchallengeable truth of illusion. Such is the first step of the cure by "theatrical representation":
to integrate the unreality of the image into perceived truth,
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without the latter seeming to contradict or even contest the former. Thus Zacatus Lusitanus describes the cure of a melancholic who believed himself damned while still on earth because of the enormity of the sins he had committed. In the impossibility of convincing him by reasonable arguments that he could be saved, his physicians accepted his delirium and caused an "angel" dressed in white, with a sword in its hand, to appear to him, and after a severe exhortation this delusive vision announced that his sins had been remitted.
From this very example, we see the next step: representation within the image is not enough; it is also necessary to continue the delirious discourse. For in the patient's insane words there is a voice that speaks; it obeys its own grammar, it articulates a meaning. Grammar and meaning must be maintained in such a way that the representation of the hallucination in reality does not seem like the transition from one register to another, like a translation into a new language, with an altered meaning. The same language must continue to make itself understood, merely bringing a new deductive element to the rigor of its discourse. Yet this element is not indifferent; the problem is not to pursue the delirium, but by continuing it to bring it to an end. It must be led to a state of paroxysm and crisis in which, without any addition of a foreign element, it is confronted by itself and forced to argue against the demands of its own truth. The real and perceptual discourse that prolongs the delirious language of the images must therefore, without escaping the latter's laws, without departing from its sovereignty, exercise a positive function in relation to it; it tightens that language around its essential element; if it represents it at the risk of confirming it, it is in order to dramatize it. The case is cited of a sufferer who thought that he was dead, and was really dying from not eating; "a group of people who had made themselves pale and were
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dressed like the dead, entered his room, set up a table, brought food, and began to eat and drink before the bed. The starving 'dead man' looked at them; they were astonished that he stayed in bed; they persuaded him that dead people eat at least as much as living ones. He readily accommodated himself to this idea."18 It is within a continuous discourse that the elements of delirium, coming into contradiction, bring on the crisis. A crisis which is, in a very ambiguous manner, both medical and theatrical; a whole tradition of Western medicine dating from Hippocrates here intersects, suddenly and for only a few years, with one of the major forms of theatrical experience. Before us appears the great theme of a crisis that confronts the madman with his own meaning, reason with unreason, man's lucid ruse with the blindness of the lunatic—a crisis which marks the point at which illusion, turned back upon itself, will open to the dazzlemen
t of truth.
This opening is imminent in the crisis; in fact it is this opening, with its immediate proximity, that constitutes the essential element of the crisis. But the opening does not result from the crisis itself. In order for the crisis to be medical and not simply dramatic, in order for it to be not an annihilation of the man, but simply a suppression of the disease; in short, in order for the dramatic representation of the delirium to have an effect of comic purification, a ruse must be introduced at a given moment. A ruse, or at least an element which surreptitiously alters the autonomous operation of the delirium, and which, ceaselessly confirming it, does not bind it to its own truth without at the same time linking it to the necessity for its own suppression. The simplest example of this method is the ruse employed with delirious patients who imagine they perceive within their bodies an object or an extraordinary animal: "When an invalid believes that he has a living animal shut up within his body, one must pretend to have withdrawn it; if it is in
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the stomach, one may, by means of a powerful purge, produce this effect, throwing such an animal into the basin without the patient's noticing."19 The theatrical device represents the object of the delirium but cannot do so without externalizing it, and if it gives the invalid a perceptual confirmation of his illusion, it does so only while ridding him of it by force. The artificial reconstitution of delirium constitutes the real distance in which the sufferer recovers his liberty.
Madness and Civilzation ( A History of Madness) Page 20