To silence, to recognition in the mirror, to perpetual judgment, we must add a fourth structure peculiar to the world of the asylum as it was constituted at the end of the eighteenth century: this is the apotheosis of the medical personage. Of them all, it is doubtless the most important, since it would authorize not only new contacts between doctor and patient, but a new relation between insanity and medical thought, and ultimately command the whole modem experience of madness. Hitherto, we find in the asy-
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lums only the same structures of confinement, but displaced and deformed. With the new status of the medical personage, the deepest meaning of confinement is abolished: mental disease, with the meanings we now give it, is made possible.
The work of Tuke and of Pinel, whose spirit and values are so different, meet in this transformation of the medical personage. The physician, as we have seen, played no part in the life of confinement. Now he becomes the essential figure of the asylum. He is in charge of entry. The ruling at the Retreat is precise: "On the admission of patients, the committee should, in general, require a certificate signed by a medical person. ... It should also be stated whether the patient is afflicted with any complaint independent of insanity. It is also desirable that some account should be sent, how long the patient has been disordered; whether any, or what sort of medical means have been used."17 From the end of the eighteenth century, the medical certificate becomes almost obligatory for the confinement of madmen. But within the asylum itself, the doctor takes a preponderant place, insofar as he converts it into a medical space. However, and this is the essential point, the doctor's intervention is not made by virtue of a medical skill or power that he possesses in himself and that would be justified by a body of objective knowledge. It is not as a scientist that homo medicus has authority in the asylum, but as a wise man. If the medical profession is required, it is as a juridical and moral guarantee, not in the name of science. A man of great probity, of utter virtue and scruple, who had had long experience in the asylum would do as well. For the medical enterprise is only a part of an enormous moral task that must be accomplished at the asylum, and which alone can ensure the cure of the insane: "Must it not be an inviolable law in the administration of any establishment for the insane, whether public or private, to grant the maniac all the
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liberty that the safety of his person and of that of others permits, and to proportion his repression to the greater or lesser seriousness of danger of his deviations ... , to gather all the facts that can serve to enlighten the physician in treatment, to study with care the particular varieties of behavior and temperament, and accordingly to use gentleness or firmness, conciliatory terms or the tone of authority and an inflexible severity?"18 According to Samuel Tuke, the first doctor appointed at the Retreat was recommended by his "indefatigable perseverance"; doubtless he had no particular knowledge of mental illnesses when he entered the asylum, but "he entered on his office with the anxiety and ardor of a feeling mind, upon the exertion of whose skill, depended the dearest interest of many of his fellow-creatures." He tried the various remedies that his own common sense and the experience of his predecessors suggested. But he was soon disappointed, not because the results were bad, or that the number of cures was minimal: "Yet the medical means were so imperfectly connected with the progress of recovery, that he could not avoid suspecting them, to be rather concomitants than causes." He then realized that there was little to be done using the medical methods known up to that time. The concern for humanity prevailed within him, and he decided to use no medicament that would be too disagreeable to the patient. But it must not be thought that the doctor's role had little importance at the Retreat: by the visits he paid regularly to the patients, by the authority he exercised in the house over all the staff, "the physician . . . sometimes possesses more influence over the patients' minds, than the other attendants."
It is thought that Tuke and Pinel opened the asylum to medical knowledge. They did not introduce science, but a personality, whose powers borrowed from science only their disguise, or at most their justification. These powers,
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by their nature, were of a moral and social order; they took root in the madman's minority status, in the insanity of his person, not of his mind. If the medical personage could isolate madness, it was not because he knew it, but because he mastered it; and what for positivism would be an image of objectivity was only the other side of this domination. "It is a very important object to win the confidence of these sufferers, and to arouse in them feelings of respect and obedience, which can only be the fruit of superior discernment, distinguished education, and dignity of tone and manner. Stupidity, ignorance, and the lack of principles, sustained by a tyrannical harshness, may incite fear, but always inspire distrust. The keeper of madmen who has obtained domination over them directs and rules their conduct as he pleases; he must be endowed with a firm character, and on occasion display an imposing strength. He must threaten little but carry out his threats, and if he is disobeyed, punishment must immediately ensue."19 The physician could exercise his absolute authority in the world of the asylum only insofar as, from the beginning, he was Father and Judge, Family and Law—his medical practice being for a long time no more than a complement to the old rites of Order, Authority, and Punishment. And Pinel was well aware that the doctor cures when, exclusive of modem therapeutics, he brings into play these immemorial figures.
Pinel cites the case of a girl of seventeen who had been raised by her parents with "extreme indulgence"; she had fallen into a "giddy, mad delirium without any cause that could be determined"; at the hospital she was treated with great gentleness, but she always showed a certain "haughtiness" which could not be tolerated at the asylum; she spoke "of her parents with nothing but bitterness." It was decided to subject her to a regime of strict authority; "the keeper, in order to tame this inflexible character, seized the moment of the bath and expressed himself forcibly concerning cer-
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tain unnatural persons who dared oppose their parents and disdain their authority. He warned the girl she would henceforth be treated with all the severity she deserved, for she herself was opposed to her cure and dissimulated with insurmountable obstinacy the basic cause of her illness." Through this new rigor and these threats, the sick girl felt "profoundly moved . . . she ended by acknowledging her wrongs and making a frank confession that she had suffered a loss of reason as the result of a forbidden romantic attachment, naming the person who had been its object." After this first confession, the cure became easy: "a most favorable alteration occurred . . . she was henceforth soothed and could not sufficiently express her gratitude toward the keeper who had brought an end to her continual agitation, and had restored tranquillity and calm to her heart." There is not a moment of the story that could not be transcribed in psychoanalytical terms. To such a degree was it true that the medical personage, according to Pinel, had to act not as the result of an objective definition of the disease or a specific classifying diagnosis, but by relying upon that prestige which envelops the secrets of the Family, of Authority, of Punishment, and of Love; it is by bringing such powers into play, by wearing the mask of Father and of Judge, that the physician, by one of those abrupt short cuts that leave aside mere medical competence, became the almost magic perpetrator of the cure, and assumed the aspect of a Thaumaturge; it was enough that he observed and spoke, to cause secret faults to appear, insane presumptions to vanish, and madness at last to yield to reason. His presence and his words were gifted with that power of disalienation, which at one blow revealed the transgression and restored the order of morality.
It is a curious paradox to see medical practice enter the uncertain domain of the quasi-miraculous at the very moment when the knowledge of mental illness tries to assume
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a positive meaning. On the one hand, madness puts itself at a distance in an objective field
where the threats of unreason disappear; but at this same moment, the madman tends to form with the doctor, in an unbroken unity, a "couple" whose complicity dates back to very old links. Life in the asylum as Tuke and Pinel constituted it permitted the birth of that delicate structure which would become the essential nucleus of madness—a structure that formed a kind of microcosm in which were symbolized the massive structures of bourgeois society and its values: Family-Child relations, centered on the theme of paternal authority; Transgression-Punishment relations, centered on the theme of immediate justice; Madness-Disorder relations, centered on the theme of social and moral order. It is from these that the physician derives his power to cure; and it is to the degree that the patient finds himself, by so many old links, already alienated in the doctor, within the doctor-patient couple, that the doctor has the almost miraculous power to cure him.
In the time of Pinel and Tuke, this power had nothing extraordinary about it; it was explained and demonstrated in the efficacity, simply, of moral behavior; it was no more mysterious than the power of the eighteenth-century doctor when he diluted fluids or relaxed fibers. But very soon the meaning of this moral practice escaped the physician, to the very extent that he enclosed his knowledge in the norms of positivism: from the beginning of the nineteenth century, the psychiatrist no longer quite knew what was the nature of the power he had inherited from the great reformers, and whose efficacity seemed so foreign to his idea of mental illness and to the practice of all other doctors.
This psychiatric practice, mysterious even to those who used it, is very important in the situation of the madman within the medical world. First because medicine of the
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mind for the first time in the history of Western science was to assume almost complete autonomy: from the time of the Greeks, it had been no more than a chapter of medicine, and we have seen Willis study madness under the rubric "diseases of the head"; after Pinel and Tuke, psychiatry would become a medicine of a particular style: those most eager to discover the origin of madness in organic causes or in hereditary dispositions would not be able to avoid this style. They would be all the more unable to avoid it in that this particular style—bringing into play increasingly obscure moral powers—would originally be a sort of bad conscience; they would increasingly confine themselves in positivism, the more they felt their practice slipping out of it.
As positivism imposes itself upon medicine and psychiatry, this practice becomes more and more obscure, the psychiatrist's power more and more miraculous, and the doctor-patient couple sinks deeper into a strange world. In the patient's eyes, the doctor becomes a thaumaturge; the authority he has borrowed from order, morality, and the family now seems to derive from himself; it is because he is a doctor that he is believed to possess these powers, and while Pinel, with Tuke, strongly asserted that his moral action was not necessarily linked to any scientific competence, it was thought, and by the patient first of all, that it was in the esotericism of his knowledge, in some almost daemonic secret of knowledge, that the doctor had found the power to unravel insanity; and increasingly the patient would accept this self-surrender to a doctor both divine and satanic, beyond human measure in any case; increasingly he would alienate himself in the physician, accepting entirely and in advance all his prestige, submitting from the very first to a will he experienced as magic, and to a science he regarded as prescience and divination, thus becoming the ideal and perfect correlative of those powers he
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projected upon the doctor, pure object without any resistance except his own inertia, quite ready to become precisely that hysteric in whom Charcot exalted the doctor's marvelous powers. If we wanted to analyze the profound structures of objectivity in the knowledge and practice of nineteenth-century psychiatry from Pinel to Freud,20 we should have to show in fact that such objectivity was from the start a reification of a magical nature, which could only be accomplished with the complicity of the patient himself, and beginning from a transparent and clear moral practice, gradually forgotten as positivism imposed its myths of scientific objectivity; a practice forgotten in its origins and its meaning, but always used and always present. What we call psychiatric practice is a certain moral tactic contemporary with the end of the eighteenth century, preserved in the rites of asylum life, and overlaid by the myths of positivism.
But if the doctor soon became a thaumaturge for the patient, he could not be one in his own positivist doctor's eyes. That obscure power whose origin he no longer knew, in which he could not decipher the patient's complicity, and in which he would not consent to acknowledge the ancient powers which constituted it, nevertheless had to be given some status; and since nothing in positivist understanding could justify such a transfer of will or similar remote-control operations, the moment would soon come when madness itself would be held responsible for such anomalies. These cures without basis, which must be recognized as not being false cures, would soon become the true cures of false illnesses. Madness was not what one believed, nor what it believed itself to be; it was infinitely less than itself: a combination of persuasion and mystification. We can see here the genesis of Babinski's pithiatism. And by a strange reversal, thought leaped back almost two centuries to the era when between madness, false madness, and
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the simulation of madness, the limit was indistinct—identical symptoms confused to the point where transgression replaced unity; further still, medical thought finally effected an identification over which all Western thought since Greek medicine had hesitated: the identification of madness with madness—that is, of the medical concept with the critical concept of madness. At the end of the nineteenth century, and in the thought of Babinski's contemporaries, we find that prodigious postulate, which no medicine had yet dared formulate: that madness, after all, was only madness.
Thus while the victim of mental illness is entirely alienated in the real person of his doctor, the doctor dissipates the reality of the mental illness in the critical concept of madness. So that there remains, beyond the empty forms of positivist thought, only a single concrete reality: the doctor-patient couple in which all alienations are summarized, linked, and loosened. And it is to this degree that all nineteenth-century psychiatry really converges on Freud, the first man to accept in all its seriousness the reality of the physician-patient couple, the first to consent not to look away nor to investigate elsewhere, the first not to attempt to hide it in a psychiatric theory that more or less harmonized with the rest of medical knowledge; the first to follow its consequences with absolute rigor. Freud demystified all the other asylum structures: he abolished silence and observation, he eliminated madness's recognition of itself in the mirror of its own spectacle, he silenced the instances of condemnation. But on the other hand he exploited the structure that enveloped the medical personage; he amplified its thaumaturgical virtues, preparing for its omnipotence a quasi-divine status. He focussed upon this single presence—concealed behind the patient and above him, in an absence that is also a total presence—all the powers that had been distributed in the collective existence of the asy-
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him; he transformed this into an absolute Observation, a pure and circumspect Silence, a Judge who punishes and rewards in a judgment that does not even condescend to language; he made it the Mirror in which madness, in an almost motionless movement, clings to and casts off itself.
To the doctor, Freud transferred all the structures Pinel and Tuke had set up within confinement. He did deliver the patient from the existence of the asylum within which his "liberators" had alienated him; but he did not deliver him from what was essential in this existence; he regrouped its powers, extended them to the maximum by uniting them in the doctor's hands; he created the psychoanalytical situation where, by an inspired short-circuit, alienation becomes disalienating because, in the doctor, it becomes a subject.
The doctor, as an alienating figure, re
mains the key to psychoanalysis. It is perhaps because it did not suppress this ultimate structure, and because it referred all the others to it, that psychoanalysis has not been able, will not be able, to hear the voices of unreason, nor to decipher in themselves the signs of the madman. Psychoanalysis can unravel some of the forms of madness; it remains a stranger to the sovereign enterprise of unreason. It can neither liberate nor transcribe, nor most certainly explain, what is essential in this enterprise.
Since the end of the eighteenth century, the life of unreason no longer manifests itself except in the lightning-flash of works such as those of Holderlin, of Nerval, of Nietzsche, or of Artaud— forever irreducible to those alienations that can be cured, resisting by their own strength that gigantic moral imprisonment which we are in the habit of calling, doubtless by antiphrasis, the liberation of the insane by Pinel and Tuke.
CONCLUSION
the Goya who painted The Madhouse must have experienced before that grovel of flesh in the void, that nakedness among bare walls, something related to a contemporary pathos: the symbolic tinsel that crowned the insane kings left in full view suppliant bodies, bodies vulnerable to chains and whips, which contradicted the delirium of the faces, less by the poverty of these trappings than by the human truth which radiated from all that unprofaned flesh. The man in the tricorne is not mad because he has stuck an old hat upon his nakedness; but within this madman in a hat rises—by the inarticulate power of his muscular body, of his savage and marvelously unconstricted youth—a human presence already liberated and somehow free since the beginning of time, by his birthright. The Madhouse is less concerned with madness and those strange faces one finds elsewhere in the Caprichos, moreover, than with the vast monotony of these new bodies, shown in all their vigor, and whose gestures, if they invoke their dreams, celebrate especially their dark freedom: its language is close to the world of Pinel.
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