The Simulation of Hysteria at the Limits of Medical Rationality: Foucault’s Study of an Event
In the previous chapter, we analysed the political factors which constituted psychiatry as a discipline in the late eighteenth century. We focused on the juridical components that contributed decisively to the formation of a particular diagnostic truth regime that generated psychiatric knowledge. We contrasted Foucault’s analysis with anti-psychiatry, to show how these extra-psychiatric forces comprised the external truth conditions that shaped but did not penetrate truthful discourse and made up the political coordinates, which guided but did not distort diagnosis in psychiatry. We shall now turn to the internal, ethico-epistemological conflicts and transformations, which took place in the years following the initial episode of the birth of the asylum. We shall deal extensively with the obstacles, which impeded the formulation of diagnostic truth in a way that would harmonize the newly born discipline of psychiatry with the rest of medicine. We shall focus our discussion on simulation, the major epistemological blockage of the nineteenth century, which still constitutes a central topic of debate, a crucial issue threatening the scientific validity of psychiatry as a whole. Hysteria, a special case of simulation in late nineteenth-century psychiatry, will be the reference point of our analysis. For Foucault, the phenomenon of hysteria was a groundbreaking event, which altered the course of psychiatry and the way psychiatrists approached normality. It was not a random accident, a mere dysfunction in the technology of the psychiatric institution, but an exceptional case, a singularity which introduced a new problematic for diagnosis emerging alongside the medical model, becoming itself the model for critique. As a point of rupture in the history of psychiatry, hysteria can serve as a clinical example of what constitutes an event from a historical perspective. That event disrupted the rational framework of psychiatry by creating a situation in which truth and illusion, the history of veridictions and the history of simulacra, came to coexist on the same strategic plane. Foucault’s analysis of hysteria demonstrates how his philosophy of the event does not undermine Enlightenment critique but actually enacts it by causing reason to reflect on the limits of the rational explanations that it provides.
Simulation as Crisis
Simulation has been the most important epistemological problem haunting psychiatry since the early nineteenth century. It had already constituted a problem for general medicine, forcing doctors to face the possibility that symptoms may not simply be accepted as facts of nature, but also as artificially produced and reproduced signs. While medicine, however, could hope to overcome this phenomenon by demonstrating the objective causes of real illnesses, in psychiatry this task seemed impossible. As we have shown, the truth regime of alienism had designated madness as the prototype of mental illness, on account of its appearance as a limit experience conceived by reason. It justified psychiatric intervention. On the basis of its classification as a newly constituted type of malady of the spirit, doctors could commit individuals to the asylum without requiring their consent. However, the appearance of madness as a limit experience conflicted with the need to identify it in clinical terms. It was by definition impossible to demonstrate its presence through proof and verification. The fact that the incarceration of the mad rested – according to the Kantian anthropological project – on the conception of an a priori of reason rendered the empirical identification of madness far from self-evident. Madness emerged as a conceptual entity which could not be subjected to unequivocal rational observation and interpretation, generating an inner tension for clinical practice: ‘The madman, who was the outsider par excellence, pure difference, “other” to the power of two, became in this very distance the object of rational analysis, fullness offered to knowledge and evident perception, the one precisely to the extent that he was the other.’1 Madness as an object of medical perception contained a fundamental conflict: while in the realm of logic it stood out as a clear entity, on the level of perception it was inaccessible and impenetrable: ‘The eighteenth century perceived the madman, but deduced madness.’2 The tension between the de jure, that is, in principle, exclusion of the mad as agents of unreason, and their de facto, empirical identification,3 generated the phenomenon of simulation. Delirium was expressed solely in the patient’s speech and was evaluated by the subjective judgement of the doctor: it was therefore not difficult for healthy individuals to simulate it for secondary gains. There appeared, since the time of Pinel in the early nineteenth century,4 impostors who presented the psychiatrist with typical signs of mental illness, but who turned out to be individuals who wanted to absolve themselves of responsibility for a crime or who sought to escape army recruitment. On many occasions, it was the family which provoked, modified or projected the patient’s delirium for its own benefit. Simulation displayed the epistemological singularity of proto-psychiatric thinking, especially its inherent dualism:
Whereas [general] medical knowledge functions at the point of the specification of the illness, at the point of differential diagnosis, medical knowledge in psychiatry functions at the point of the decision between madness or non-madness, the point, if you like, of reality or non-reality, reality or fiction, whether this be fiction on the part of the patient who, for one reason or another, would like to pretend to be mad, or the fiction of the family circle, which imagines, wishes, desires, or imposes the image of madness.5
In the face of simulation, characterization of illness was not feasible. There was no objective truth that would enable the psychiatrist to demonstrate illness anatomically in order to conduct evidence-based forensic analyses, statistical observations and experimental research: that is, to perform the role of a proper clinician. The psychiatrist could not produce the reality of madness, which remained, at this stage, a conceptual object with no empirical support. He could not substantiate its existence and justify its presence scientifically. He could not convince the courts that restraining the mad and diagnosing them as carriers of risk and danger could be medically grounded. He could not verify sufficiently whether a patient was in need of involuntary hospitalization or whether he was a malingerer. He could not provide valid prognosis regarding the future threats that the patient might pose. He lacked demonstrative truth:
The great problem of the history of psychiatry in the nineteenth century is not the problem of concepts, and not at all the problem of this or that illness; neither monomania nor even hysteria was the real problem, the cross psychiatry had to bear in the nineteenth century. If we accept that the question of truth is never posed in psychiatric power, then it is easy to understand that the cross nineteenth century psychiatry has to bear is quite simply the problem of simulation.6
The simulators posed the greatest challenge to the truth claims of the early medical anthropologists and were the driving force behind the formulation of valid knowledge concerning mental illness. If the definition of legal responsibility was the major external truth condition which set in motion the entire epistemological machinery of proto-psychiatry, simulation was the most important internal truth requirement for the construction of psychiatry as a serious medical practice.
The proto-psychiatrists followed a unique and singular method in order to deal with the problem of simulation. Normally, it would be expected that they would simply reproduce the medical process of anatomical demonstration and postmortem examination in order to refute the falsification of symptoms, but this was not what happened. They adhered to a truth modality that did not privilege global, empirical knowledge. According to their para-scientific truth regime, truth is not universal, global and timeless, but has a history and a geography: it occurs only in ruptures and breaks. It does not obey the Aristotelian desire for truth, but emerges suddenly as an event. Truth, according to this epistemological attitude, is the locus of the simultaneous emergence of subjects and objects. It surfaces not when meaning manifests itself or when causal connections are established, but whenever gaps in the universe of meaning appear and points of reversibility overturn knowledge relationships. It is a discourse which does not produce scientific knowledge, but determines truth in the form of the test, arbitration, strategy and conflict.7 This truth regime had existed in the civilizations of the Near East as well as in Archaic Greece, and it was only later that it was inserted into the philosophical system of the post-Aristotelian Greek philosophers.8 Once it was systematized and organized as a rigorous epistemological schema, particularly in the Stoics, it began to enjoy an equal apodeictic status as deductive reasoning and scientific demonstration, influencing the conjectural sciences, as Aristotle had called them: military and political strategic thought, agronomy and medicine.9
Thus, despite its marginalization in western society since the Middle Ages, this truth regime has been pervasive inside the diagnostic thinking of medical practice from Hippocrates (c. 460–c. 370 bc) and Galen (129 ad–c. 200/c. 216), up to the eighteenth century. In Hippocratic and Galenic medicine and later in the medicine of Thomas Sydenham (1624–89), it was less the anatomical localization of an illness and more its critical moments – fevers, convulsions – which were of interest. These moments of crisis, where the battle between the illness and the defences of nature reached its peak, revealed the truth of the illness, determined its course and constituted the right occasion, the kairos when medical intervention would be appropriate.10 The proto-psychiatrists applied the same logic and followed the same regime of truth; they did not rely on inquiry and examination in order to tackle the problem of unreason. Their basic diagnostic method was the test which they used in order to detect and prove, albeit negatively, the presence of madness.11 They studied madness in its crises and the sudden outbursts of its inner truth. Although their nosographic approach was formally isomorphic with the rest of medicine, it was designed in such a way as to test and make manifest the moment when the truth of madness appeared, as in crime, and they saw their ability to establish the truth of the mad as a way of gaining control over unreason. In the early asylum, biological theories or psychological interpretations were used only secondarily; it was the ruptures, unintelligible and reversible relationships that determined the presence of madness. Madness was not sought in the causal chain of a known mental pathology, but in its violent discontinuity with all prior causality. A criminal was judged and incarcerated as mad when he did not present with any motive, interest or predisposing signs.12 When a person exhibiting disruptive behaviour was sequestered, the intention was not to explore her disturbed family life or poor upbringing, but to explain her sudden rupture with an otherwise normal family milieu.13 The spatio-temporal crisis of madness, by definition foreign to meaning, etiology and causality, was the cornerstone for the decision to commit individuals, with the further aim to isolate them from their ordinary environment which could mask, trigger, muddle or exaggerate the clinical presentation of an irrational paroxysm. The space of the asylum was first and foremost the place where the crisis of delirium could be observed in its naked state as the locus of rupture and upheaval in the patient’s consciousness and behaviour.14
The implementation of the truth-crisis offered a way out of the perils of simulation, because it defied the typical rules of clinical diagnosis. Simulation is possible only to the extent that there exists a presupposed, pre-established mode of medical representation that it imitates, a basic medical reality that it pretends to embody and a system of psychological meaning which it faithfully reproduces. Proto-psychiatry, on the other hand, conscious of its confrontation with meaninglessness, managed to furnish reliable evidence of insanity by positioning it precisely at the limits of representation, where it by logical necessity manifests itself. It looked for it at the edges of representation, on the fringes of meaning and in a world of false appearances, foreign to reality. The body of the insane was not scrutinized anatomically but was subjected to restraints and a system of deprivations. The insane individual was inserted into a sub-real environment. He underwent a ritual in which he was subjected to isolation, minimal satisfaction of needs as well as a tactical process of rewards and punishments, in which he was led to the awareness of his deluded omnipotence and distance from the real world.15 This ceremony, aspects of which are still in existence in today’s mental hospitals (chemical restraints, isolation, electroconvulsive therapy) has been studied and criticized by sociologists and anti-psychiatrists as an unscientific and shameful practice of psychiatry.16 However, its cruelty, barbarity and violence can only be judged as such by the standards of the moral, all-inclusive and pacifying order of a risk-free order, an order for which madness has ceased to exist as a limit experience. Confronted with the incomprehensibility and non-negotiable truth of madness, this ‘scientifically incorrect’ practice involved a truth ordeal involving bodily interactions as the sole evidence of delirium when all that the psychiatrists had at their disposal was the patient’s discourse.17 The fact that it constitutes a truth modality foreign to scientific proof and positive demonstration is no argument against its value as a testing ground for madness.
Simulation and Hyperreality – The Neurological Body
Nevertheless, it is a historical fact that the ritualistic and juridical mode of truth production of the test was soon deemed unacceptable for a psychiatry aspiring to become a medical specialism continuous not just with the form but mainly with the content of medical discourse.18 So long as madness could not be demonstrated anatomically, psychiatry could never become a branch of medicine. Nineteenth-century psychiatry, therefore, strove to incorporate the regime of truth-demonstration and truth-observation already prevalent in medicine. It sought to dispense with the para-scientific truth-test, not only because it was irreconcilable with a proper medical discourse, but also because it allowed the crises of madness to run their course, posing social and individual danger.
Psychiatry thus set for itself the task of combating simulation without having to resort to the truth-test. This endeavour was supported by a new form of extra-medical rationality, which set new standards for the epistemological threshold of medicine. It was the regime of security, which, since the middle of the nineteenth century, replaced the law of the sovereign and the norm of discipline with a new concept destined to alter radically the social and political role of psychiatry: the concept of reality. The logic of security and management of the population set up an ensemble of mechanisms for the protection of society from the uncontrollable elements of nature, whether present or future ones. It was centred on the effort to intervene at the level of variables, unforeseeable elements of the environment and potential accidents, in order to ensure the safety of the population and secure the forecasting and prevention of risks, dangers and crises. The processes of the external world were studied, plotted on statistical graphs, manipulated in order to be put in check, nullified and regulated, even or mainly before they occurred. Contrary to, and in juxtaposition to, the disciplinary logic which opposes reality to the imaginary, security tried ‘to work within reality, by getting the components of reality to work in relation to each other, thanks to and through a series of analyses and specific arrangements’.19 Reality was not established as a negative supplement to a set of prescriptions and norms, but as a continuum between the actual and the virtual. It encompassed every possible anomaly that was no longer considered as a future actuality to be prevented, but as a potentiality intrinsic to the present processes which science must correct. Reality became so strong a principle of action and domain of intervention, that it soon ceased to be a self-sufficient notion and became an all-encompassing, all-inclusive force engulfing the virtual. It became ‘hyperreal’.20 Otherness, negativity and simulation ceased to be arguments against it, but began to function as its necessary correlates. Any real event which threatened security could be measured against its preconceived statistical existence and its simulation models and conversely any simulated event could be refuted by recourse to scientific proof of actual processes. Armed with the power of the real, security-targeted simulation as a general political issue, a new problematic in the distinction between truth and falsity, which gave science the task of policing the global milieu by applying its precise system of diagnosis and establishing accurate predictions based on that diagnosis.21
In the context of this governmental logic of security and hyperreality, a new truth regime enhanced and expanded the role of science. In discipline, there was a vast taxonomic discourse – the Taxinomia universalis analysed in Chapter 3 – which laid out the norm, classification and order against which things could be measured and made intelligible. In the logic of security, on the other hand, the measurement of natural processes should be made in vivo, in their point of simulated reality, their genesis, their development and mutation. Truth therefore was no longer a norm, a law to which phenomena should conform, but was part of these phenomena: it was inscribed in the elements of reality. There was a total identification of truth and reality, a coincidence between statements and processes, signs and things, an exact and measurable correspondence of truth with its object of study. A ‘truth’ now existed, ‘that [was] of the same order as the object’.22 This is the birth of positivism. In positivism, truth has no gaps, no black holes and no crises. On the contrary, its objective is to prevent crises from occurring. Positivist truth is considered to be everywhere, at every time and every moment. It cannot and must not come forth in the form of unexpected events. It should be controllable, programmable and graspable through investigation using instruments of technology and knowledge of technique. Positivism extended the inquiry of the classical age and the examination of disciplinary systems to an in-depth colonization of things, bodies and actions, where universal truth could be discovered and measured by qualified individuals who possessed academic knowledge and had access to laboratories, universities and canonical teaching.23 This truth regime could free research from the speculative approach of philosophy, the abstract theories of historians, and of the dilemmas of anthropology regarding the finitude of man. It could make feasible the study of man in terms of given truths derived from physics and mathematics, the rules of logic and the laws governing human perception. It assigned to the body the locus where truth could be recognized and made manifest, granting the human sciences the fully constituted privilege of reflecting on man and replacing the philosophical concerns of the eighteenth century.24
The hyperreality of this network of security and the prevalence of positivism brought about the ‘somatocracy’ of the nineteenth century.25 The body satisfied both requirements of the new political technology; that is, the new government of individuals and the exact coincidence of truth and reality. In the developing logic of security and bio-power, the body appeared as a biological entity connecting the individual with the population, generating the notion of the man-as-species. In somatocracy the health of the body and the protection of public hygiene became crucial political targets, rendering medicine a new scientific power central to the government of the population. The body itself became hyperreal: it was no longer the docile and useful body which had to be disciplined, manipulated and controlled so as to function as a model of normality. It was a set of natural processes, the ‘metabody’ of genetics, which contained the real domain of forces where disease took shape and burst forth, but also the locus of simulated illness, the reservoir of potential ailments.26 At the same time, the body became the site of truth. Insofar as the body was both the foundation of perceived reality and the object of this reality as a set of biological processes, truth and reality were grounded in the body, the unequivocal source of a knowledge, which from now on, should be not only diagnostic but also prognostic. Combining these new governmental and positivist aspirations, medicine, the human science of the body par excellence, could thus serve as a perfect model for a positive, both true and real, science of man. Medicine became immune to simulation from the moment pathological anatomy as an empirical and accurate knowledge provided diagnostic truth with the power of rigorous demonstration; pathological anatomy effectively confounded the classification and organization of illnesses in such a way that their anatomical seat could be revealed and their localization inside the body would be discovered and predicted. If it could be applied to psychiatry, it would extend its demonstrative powers to the discovery of the ontology of madness.
In the light of these transformations, however, psychiatry was still unable to eliminate simulation. It lacked the conditions necessary to achieve medical truth and positive knowledge, despite its insertion in the logic of security and its second enthronement as a royal science engaged in the discourse par excellence of reality. In terms of defining reality, psychiatry was once again queen. Inasmuch as it was able to formulate what counts as real in scientific terms, psychiatry acquired the legitimacy and authority to diagnose, cure and correct those who stand outside reality. The once sub-real asylum became the exemplary site of hyperreality; it became a space where power and reality were mutually reinforced. In the asylum, power was exercised as an agent of reality and reality was capable of operating as the sole element of power: ‘Giving power to reality and founding power on reality is the asylum tautology.’27 This tautology, however, still relied on crises and tests rather than demonstrative truth. The reality of madness could emerge only on condition that the patient was carefully isolated from his environment. The patient began to confront the reality of the asylum from the moment he faced the doctor’s will, the regulations of the institution and his own morbid desires. Only crises and conflicts could resolve the fundamental dilemma between truth and lie, reality and fiction: ‘The activity of psychiatric knowledge is really situated at the point of simulation, at the point of fiction, not at the point of characterization.’28
The psychiatrist was obliged to produce a new, positive type of knowledge that would sidestep the problem of simulation in the same way that the rest of medicine had managed to limit it through objective investigation of bodily illnesses. For this reason, the psychiatrist of the mid-nineteenth-century asylum pursued a form of research beyond the diagnostic thinking of the proto-psychiatrists, a type of scientific endeavour that would discover aetiology and localization. It was an enormous effort, which sought to bridge the gap between the otherness of madness and the same of knowledge, to cancel crisis before its emergence and to eliminate the distance between disease and its symptoms. It was in one type of body that this dream could be realized: the corpse. The corpse was the body of reference, the ideal limit of the body for the emerging system of clinical medicine. In the corpse, the immobile truth of death could provide identity and absolute, indisputable knowledge. The corpse offered itself to pathological anatomy and postmortem examination, making it possible to obtain unequivocal demonstration of madness without the precarious mediation of worlds, signs and gestures:
If there is a truth of madness, it is certainly not in what the mad say; it can only reside in their nerves and their brain. To that extent, the crisis as the moment of truth, as the moment at which the truth of madness burst forth, was ruled out epistemologically by recourse to pathological anatomy, or rather, I think that pathological anatomy was the epistemological cover behind which the existence of the crisis could always be rejected, denied, or suppressed: we can strap you to your armchair, we can refuse to listen to what you have to say, since we will seek the truth of madness from pathological anatomy, when you are dead.29
Pathological anatomy, however, almost immediately proved to be practically useless. Psychiatry could not gain access to the total identification of symptoms and anatomical seats, the thorough penetration and transparency of the body, which only the corpse could provide, in order to connect the surface of clinical signs with the depth of the underlying bodily pathology. This is why psychiatry lacked the ability to lay hold on the patient’s body and adopt the diagnostic truth regime of medical discourse and its methodology. In the nineteenth century, psychiatry, for both clinical and pathologo-anatomical reasons, was a medicine without a body.30 The model of syphilis gave only an approximate anatomical account of madness, failing to provide reliability.31 The neuroses, mental disorders with clear bodily manifestations such as hypochondriasis and hysteria, were too atypical and irregular in their presentation, lacking ascribable anatomical correlations and were vulnerable to simulation.32 The psychiatrist had to substitute for this absence of the body through confessional techniques that provided the family body and the body of heredity and the use of drugs which offered an elementary understanding of irrationality.33 Psychiatry remained an imitation, an analogon of medicine rather than a specialism of it. The demonstrative power of the psychiatrists was limited and it was left to their de jure judgement to incarcerate the mad. Insanity still constituted an ideal object, a transcendence, a disembodied illness with no empirical justification.
Psychiatry resorted to a truth regime which was derivative of pathological anatomy, but was more appropriate for valid psychiatric research: the neurological body. As we discussed in the previous chapter, it was observed that in epilepsy and other neurological conditions there was automatism and lack of will, an irrational and even dangerous behaviour that imitated delirium. It was also observed that such behaviour could be traced in its origins, in the personality and past conduct of the individual. Neurological abnormalities could be extracted from the patient’s individual history and pathological instincts could be spotted in the childhood, development and family life of criminals such as Pierre Rivière.34 Neurology could now provide a host of predisposing factors, diagnostic evidence and prognostic indicators for the manifestation of madness, its future course and the perils that it carried. Psychiatry could study, analyse and investigate abnormal instincts objectively, like the rest of medicine. The notion of degeneration was born. The symptomatological field exploded and psychiatry could now intervene medically in all aspects of human conduct.35 This increase in psychiatric power in the field of abnormalities was due to its firm establishment within the rules of medical discourse:
The appearance of neurology, or more precisely, of neuropathology, was a fundamental event in the history of medicine, that is to say, when certain disorders began to be dissociated from madness and it became possible to assign them a neurological seat and neuropathological etiology that made it possible to distinguish those who were really ill at the level of their body from those for whom one could assign no etiology at the level of organic lesions.36
Psychiatry escaped for the first time from the old dilemma ‘mad or not mad’ and sanctioned a game of truth and falsity so as never to be called into question. Neurology offered both the form and the content of mental illness, both its truth and its reality. Differential diagnosis and organic aetiology were finally achieved and psychiatry could form a part of medicine:
This famous differential diagnosis, which one had never been able to apply to madness, which never really managed to get a grip on the mental illnesses, this differential diagnosis that one could never insert between an ordinary illness and madness, because madness, above all and essentially, fell under 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’.37
Psychiatry became a royal science for one more reason. Aside from its role as an agent of reality, its expertise in the definition and distribution of abnormalities, and its scientific intervention at the level of all types of human conduct, it managed to be enthroned as a medical specialism capable of articulating truthful discourse:
In crude terms, psychiatric power says: […] I am the possessor, if not of truth in its content, at least of all the criteria of truth. Furthermore, because, as scientific knowledge, I thereby possess the criteria of verification and truth, I can attach myself to reality and its power and impose on these demented and disturbed bodies the surplus-power that I give to reality. I am the surplus-power of reality inasmuch as I possess, by myself and definitively, something that is the truth in relation to madness.38
The positivism of the body, the dissection of the body through the blade of differential diagnosis and neurological knowledge, replaced the need to trace delirium, error and illusion, with the pathology of automatism, involuntary behaviour and biological dysfunction. A continuum going from medicine and organic disorder to the disturbance of conduct was possible from the moment the body became the space where the transcendence of delirium could find its empirical correlate and its positive manifestation. Psychiatry – or neuropsychiatry – became ‘hyperreal’ in both its clinical and social roles. From now on simulation could no longer constitute an enemy to its epistemological armature, insofar as the malingerer could be refuted through careful differential diagnostic procedures and proof of organic aetiology. His behaviour could be submitted to the law of the voluntary and the involuntary, to the investigation of his instincts and psychological motives. Moreover, it became possible for psychiatry to expand its role into the very core of social reality as its scientific point of reference. Inasmuch as political issues, art criticism and military technology began to revolve around debates regarding reality, perception and simulation, psychiatry acquired a royal status and inevitably began to play a political and cultural role.39 It inaugurated and increased its normalizing function, the ‘psy-function’, which has arisen as an institutional discipline infiltrating the family, the school, the army and the workshop.40 Throughout the nineteenth century psychiatry extended its powers to medicine, pedagogy, psychology and philosophy, augmenting the logic of integration, treatment and socialization.41
Hysteria and the Subversion of the Neurological Body
It is at this historical point that hysteria emerged as a singularity within the heart of the asylum system. Although hysteria existed from the ancient times, in the nineteenth century it appeared as simulacrum. Jean-Martin Charcot (1825–93) and his pupils picked out hysteria from the large crowd of simulators who populated the asylum space, but it soon turned out that it was not a typical case of simulation; simulators were random malingerers, healthy individuals who feigned madness by faithfully adopting all the known symptoms of mental illness for personal gain. The hysterics, by contrast, were asylum patients already designated as ill, who did not pose a problem concerning the reality of madness, but played effectively the truth game promoted by psychiatric power. They did not confuse the distinction between truth and falsity and they did not simply make sanity imitate madness. On the contrary, they responded positively to Charcot’s efforts in differentiating real illness from simulation. They confirmed the truth game of neurological diagnosis, while at the same time emerging from another order, outside the field of cognition opened up by the neurological model.42 They did not represent the way sanity simulates madness, but ‘the way hysteria simulates hysteria’, ‘madness simulating madness’. Through them:
madness replied: If you claim to possess the truth once and for all in terms of an already fully constituted knowledge, well, for my part, I will install falsehood in myself. And so, when you handle my symptoms, when you are dealing with what you call illness, you will find yourself caught in a trap, for at the heart of my symptoms there will be this small kernel of night, falsehood, through which I will confront you with the question of truth. Consequently, I won’t deceive you when your knowledge is limited — that would be pure and simple simulation — but rather, if one day you want really to have a hold on me, you will have to accept the game of truth and falsehood that I offer you.43
Hysteria had unique characteristics. It displayed clear neurological symptoms and signs – tonic-clonic seizures, anaesthesias, paralyses – which, however, showed no indications of a definite anatomical seat, as they displayed no correspondence to identifiable areas of the central or peripheral nervous system. These symptoms were not clear simulation either, as they did not imitate real illness exactly. Thus, the hysterical symptoms were close to an existing neurological illness and yet sufficiently different for the diagnosis of genuine illness to be made.44 But they were so atypical and unstable that they could hardly be considered as signs of a genuine illness in its own right. It was very difficult to identify an authentic clinical syndrome behind the versatility of the hysterical patterns and forms of presentation (hemianaesthesia alternating between left and right, thousands of fits in the course of a few days). There was no clear psychological content, no delirium, but also no rational interest or secondary gain beneath the theatrical, dramatic or catatonic postures, the indifference to symptoms. Neurological examination was not only unable to fathom the diversity and ambiguity of symptoms, but actually enhanced them, as it merely displayed the suspicious ease with which the hysterics complied with the dictates of the neurologist. This is why Charcot resorted to quite unorthodox methods in order to isolate hysteria: he set up a photographic studio inside the Salpêtrière, where he took numerous pictures of his hysterical patients during their spontaneous or artificially provoked crises. Using the photographic image as a mirror that would stabilize the clinical picture of hysteria, he sought to immobilize the numerous fits, conversions, postures and gestures of the hysterics, as proof of its autonomous existence as a clinical entity, free from the suspicion of simulation. Juxtaposing the photographs of various hysterics at various stages of their clinical presentation, he managed to show the internal pattern and rhythm of hysteria, the unique repetition of its spontaneous posturing, its screams and disturbances of consciousness.45 Moreover, in order to limit the instability and irregularity of the symptoms of hysteria, Charcot used hypnosis which had the demonstrative value of reproducing the patient’s pseudo-neurological symptoms at will, thus ruling out malingering. Hypnosis required the patient’s suggestibility in order to freeze her clinical picture, a phenomenon that did not occur when a healthy patient simply pretended to be ill. Moreover, the hysteric reproduced exactly the simulator’s symptomatology at Charcot’s command, exposing the falsity and artificiality of malingering. Through hypnotic suggestibility, therefore, hysteria became the touchstone for distinguishing between real neurological illness and simulation.46
Thus, through hysteria Charcot was sanctioned as a neurologist, a real doctor who could finally win the battle against simulation and restore the medical status of psychiatry. Charcot owed much of his renown as an astute clinician to the hysterics; they provided him with the diagnostic rigour that neurology lacked. But the trap for psychiatric power and Charcot lay in his total dependence on hysteria for the verification of his clinical observations. In his very effort to dispense with madness, Charcot was obliged to rely on it. Photography and hypnosis were not neurological practices but quasi-artistic, theatrical and ritualistic ways of mastering the problematic manifestation of blindness, pseudo-paralysis or convulsion.47 Their implementation inevitably reinserted the coexistence of observation and testing, of truth-demonstration and truth-crisis.48 Charcot unknowingly became an alienist, putting forth a unique clinical scene where the madness of hysteria staged its own dramatic disappearance. The photographic image and the ritual of hypnosis were the perfect media for this violent absence, recording the false appearance of hysteria that concealed its own identity. Testing the presence of hysteria, Charcot’s efforts to offer a neurological model for the explanation of madness were at the same time undermined. His hyperrealism and expressionism, which sought to bring forth the reality of illness, generated the surrealism of the hysterics who brought truth, the discourse of diagnosis, into conflict with that of reality.49 Hysteria became the protagonist in one of the most important reversals in the history of psychiatry, a moment when the will to medicalize insanity was suspended, and has become problematic ever since.
As simulacrum, as singularity at the heart of the asylum system, hysteria represents the actual involvement of the mad in the struggle over truth and the strategies inherent in the structure of the asylum. Hysteria appeared as a body that resisted neurological organization and disrupted the distribution of signs and symptoms. It was an incomprehensible body, a body erratic in its responses, which exacerbated symptoms, producing them in an unstable manner and yet complying with the dictates of the clinician; it was a wholly unpredictable and unmanageable body:
the explosions of hysteria manifested in psychiatric hospitals in the second half of the 19th century were indeed a backlash, a repercussion of the very exercise of psychiatric power: the psychiatrists got their patients’ hysterical body full in the face (I mean in full knowledge and in full ignorance) without wanting it, without even knowing how it happened.50
The body of the hysteric emitted confused and ambivalent signs. It was a ‘body without organs’,51 a locus of phantasms which surfaced in its meaninglessness and enigmatic significations at a time when psychiatry made its first attempt to provide recognition of the asylum patient in terms of a coherent discourse of truth and knowledge. The hysterics illustrate clearly that ‘nothing in man — not even his body — is sufficiently stable to serve as the basis for self-recognition or for understanding other men’.52 Hysteria shows how the body is a specific locus and target of forms of rationality which inscribe in the body true and false statements that strategically demarcate it, describe it, dissect it and define it, in order to turn it into an object of recognition. It shows that the body does not resist by confronting the artificial constraints of power with its supposed naturalness, but by becoming actively engaged in this politics of truth, by both submitting to external inscriptions and subverting the truth that purports to circumscribe it and essentialize it.53 It is not surprising, Foucault notes, that the body of hysteria appeared exactly at the historical moment when medicine attempted to construct the mad subject as a fully constituted and recognizable type through neurology.54 With the emergence of hysteria, the neurological body was abandoned; the process of medicalizing madness came to a standstill as its truth regime was called into question. The introduction of the sexual and psychotropic body was under way. The hysterics were discharged from the asylum, gaining a rightful place in the general hospital; psychopharmacology and psychoanalysis were born, the deinstitutionalization that prevailed in the twentieth century was initiated.55
Hysteria was the major impact of a small group of asylum patients on the rationality and practice of psychiatry near the end of the nineteenth century.56 With hysteria madness was once again problematized. Silenced through integration and medicalization, madness reappeared as a problem, raising its incomprehensible voice only to confuse the clarity of medical discourse. It disrupted the calm, settled, but illusory positivism of medical rationality and opened the possibility for renewal and transformation for medical truth in a way far more radical than any liberal, anarchic or leftist anti-psychiatric discourse: ‘Anti-psychiatry demolishes the medicalization of madness within the institution and the conscience of doctors. But from this very fact, the question of madness comes back to us after this long colonization by medicine and psychiatry. What can we make of it?’57
Hysteria and the History of the Simulacrum
It is now possible to appreciate the value of Foucault’s history of the simulacrum since it clearly illustrates, in a condensed form, the central problematic which tacitly permeates his work. Foucault does not seek to refute scientific knowledge by exposing its limitations. He does not concern himself with simulation, which confuses the distinction between the true and the false. The evil genius of the simulacrum deceives by introducing a split, a duality, inside the truth of diagnosis. Hysteria provoked a crisis by ironically forcing neurologists to encounter madness from within their positivist model of truth which was designed precisely with the intention of depsychiatrizing madness.58 The hysterics did not introduce the truth of madness against the truth of reason, but a division, a caesura inside rationality itself, inside the regime of global acceptance and limitless expansion which was made to recognize the necessity of a marginalized, binary diagnostic discourse of limits and boundaries. Hysteria ‘reproblematized’ madness59 and reintroduced it as a question in the form of an illusion, when all medical answers appeared settled and fixed, and positivism figured as an all-encompassing solution.
Hysteria was the ‘minimal difference’, as psychoanalysis will later argue,60 the infinitesimal difference inside the differential system of clinical diagnosis, opening a gap, a void of absolute and irreducible difference between the empirical determination of illness and the transcendental character of insanity. Or, in phenomenological terms, it was the set of clinical signs presiding simultaneously over the appearance of medical meaning and its disappearance. The hysterics manipulated the truth regime of neurology in a crude and cynical way. They were ‘visible statues’ of a paradoxical truth which at once sanctioned diagnosis and made it unacceptable.61 The hysterics clearly did not represent the truth of madness: on the contrary, they suspended madness not only as an essence, but also as a universal, as a transcendence. Hysteria was a curious case of madness, a madness with no ascription to anatomy; it was the living embodiment of clear symptomatology and its existence was linked to moments of crisis and nothing else, at the time when the ideal end goal of psychiatry was to demonstrate the pure reality of madness, the neurological expression of degeneration in its terminal stage (dementia), without the need for signs, symptoms and crises.62 But at the same time hysteria was a madness ‘with absolutely no delirium or error’, a madness with no private truth but capable of playing effectively the game of truth and falsity with the psychiatrists.63 It was not ‘the absence of an œuvre’,64 but a form of madness fully engaged in ‘the dance of masks, the cries of bodies, and the gesturing of hands and fingers’.65 By willingly accepting all clinical attributions, the hysterics showed how madness cannot be approached in its reality without a prior and fundamental investigation of its truth. Madness can only be posed in terms of truth and it is its truth that conditions every effort to grasp its ontology. This is why the effect of hysteria on the production of psychiatric knowledge is not one of intrinsic limitation or epistemological blockage. As in the case of the human monster in forensic psychiatry, hysteria led differential knowledge in psychiatry to a deadlock, illustrating the indispensability of absolute diagnosis, of the basic duality between madness and non-madness, which is at the heart of the psychiatric endeavour.
It was for these reasons that hysteria caused the collapse of the neurological model. Charcot’s experiment succeeded on a clinical level, but the hysterics who aided his effort at the same time marked its limits. They manipulated Charcot himself, who had to face the question of whether the symptoms induced in the hysterics actually belonged to the nature of hysteria or were a product of his own intervention.66 Charcot was obliged to seek recourse to dubious clinical methods such as hypnosis, which belied his own attempt to insert rigour into his diagnosis. His desire to prove the reality of madness, through the verification and demonstration of neurological truth, came up against the paradox of imposing the truth of the test and of suggestion, allowing madness to control the game of truth and falsity. From the ambitious positivist who would depsychiatrize madness for the first time, Charcot became the ‘miracle worker of hysteria’ and the fabricator of simulation inherent to madness itself.67
Simulation as Epistemological Crisis
The case of hysteria can alter the way an epistemological crisis can be interpreted. An epistemological crisis does not emerge from the temporary impasses and shortcomings of an immature theoretical model. It does not even arise from simulation, from the provisional inability of a diagnostic truth regime to elucidate the distinction between truth and falsity, which is expected to be overcome once a clearer positivist model of explanation becomes accepted. A crisis which threatens the rationality and institutional framework of a discipline manifests itself in the coexistence of simultaneous truth regimes in the same diagnostic discourse. We saw in the previous chapter that penal psychiatry follows its own normative structure, although it claims to be an extension of psychiatric knowledge. The psychiatrist who represents his discipline in the courtroom articulates a discourse that is not consistent with the established, positive knowledge of psychiatry. In the same way, Charcot’s efforts to stabilize the clinical picture of hysteria and to produce it in terms of neurological differential diagnosis, introduced a method foreign to neurology itself (hypnosis), raising systematically for the first time the anti-psychiatric suspicion that the alleged epistemological achievements of psychiatry mask procedures, rituals and tests external to the rules of medicine.68
For Foucault, the coexistence of heterogeneous truth regimes inside the same diagnostic model is not an argument against the validity of psychiatry, but a domain that needs to be analysed and brought to the fore. For him, the insidious intrusion of para-scientific modes of truth telling into the otherwise solid scientific structure, which rests on proof and demonstration, is not an accident, an undesirable mishap. On the contrary, Foucault argues that verification and positivism have excluded, set aside and subordinated other modes of truth production, which still subsist and continue to have great historical importance. In psychiatry, such a marginalized type of truth lies beneath the calm positivism of the analysis of bodies, and concerns the unexpected and singular crises in which truth is reconsidered. Foucault, however, does not privilege this type of truth over psychiatric positivism. He does not look for the moments of crisis, which will reveal the inner truth of madness against the blindness of the psychiatrist who denies it. He foregrounds the role of this forgotten and dismissed form of truth as a limitation to the pretentions and claims to universality that a regime of truth-demonstration puts forward. The absolute diagnosis between madness and non-madness, the modality of the truth-test, which preoccupies both the everyday judicial decision of whether a person is genuinely mad and in need of compulsory incarceration, precedes and determines the specification of illnesses and their characterization. In psychiatry, these two types of truth are indispensable to one another and their mutual superimposition generates events and crises which touch the roots of psychiatric rationality:
For a long time, medicine, psychiatry, penal justice, and criminology, remained, and to a large extent remain still today, on the borders of a manifestation of truth in accordance with the norms of knowledge and of a production of truth in the form of the test, the latter always tending to hide behind and get its justification from the former. The current crisis of these ‘disciplines’ does not merely call into question their limits or uncertainties with the field of knowledge, it calls into question knowledge itself, the form of knowledge, the ‘subject-object’ norm. It puts in question the relationships between our society’s economic and political structures and knowledge (not its true or false contents, but in its power-knowledge functions). It is, then, a historico-political crisis.69
The limitation that the truth-test imposes on the psychiatrist does not demonstrate the infancy or primitive state of his knowledge. On the contrary, it is the frontier of objective knowledge, a protective barrier against the self-delusion of possessing too much knowledge and too great a grasp on the reality of madness. It is a truth-boundary to the surplus power of reality inside the psychiatric institution that creates the false image of a universal truth, a timeless objectivity, and a universal subject who is in a position to possess it. The truth-event or the truth-crisis creates gaps and empty spaces inside the positivist field, which is saturated with meaning and information. This is why it requires specific subjects to trace it and make it manifest, not everywhere and at all times, but in exceptional, singular instances. Hysteria would never have provoked such a stir in the psychiatric world were it not for its manifestation in a precise geography (the Salpêtrière in the nineteenth century), in a precise historical moment (the unique confrontation between Charcot and his simulators) and by specific agents (without Charcot and his clinical tests and hypotheses, hysteria would still be nothing more than mere simulation for the abstract subject of neurology). Insofar as the truth-event is not susceptible to research and proof and it is not amenable to repeated analysis and verification, it has a peripheral role to play in relation to scientific knowledge. Critique, however, traces its confrontation with positivism, and gives it theoretical force in order to make it more intense and pronounced, so that psychiatric truth can be questioned, not at its weakest moments, but at the high points of its rigour.
Epistemology has sought to uncover the irreducible core of scentificity inside psychiatric knowledge. Anti-psychiatry, on the other hand, seeks to expose the non-scientific elements of psychiatry in order to illustrate its low epistemological level. Foucault takes neither of these two sides. His main concern is to show how, not unlike for other sciences, in psychiatry scientific truth cannot claim exclusivity over other modalities of truth. ‘I believe too much in the truth not to assume that there are different truths and different ways of saying it.’70 There is an anthropological truth, a truth of finitude and absolute diagnosis which cuts across and disrupts the official regime of truth guiding scientific thought. This philosophical truth exists on the fringes of Western rationality and it is its effects which Foucault analyses with his ‘ethno-epistemology’.71 It is not, however, a prophetic truth: it does not speak the truth of madness as the hidden destiny returning as the repressed dark side of western science. It is not an eschatological truth-studying crises intrinsic to science through which the truth of otherness bursts forth in an apocalyptic form at the ‘point where human finitude and the structure of time are conjoined’.72 Marxist and Freudian eschatology have claimed to play this role and, as in the case of positivism and phenomenology, they have functioned as the tribunal and dialectical synthesis of the anthropology.73 For Foucault, on the other hand, anthropological truth is not the truth of madness but the truth regime which tests madness and detects its presence. Crises emerge when this truth regime becomes interchangeable, superimposed and confused with scientific truth. When the truth-test and the truth of science struggle for hegemony, modes of subjectivity and relationships of knowledge are reversed. Hysteria was such a critical moment, for it was the point when, for the first time in the history of positivist medicine, psychiatric power lost its scientific sovereignty, turning the hysterics into masters of the game of truth. Charcot became an ubu-esque, derisory figure exactly at the time when his efforts to pathologize madness crowned him as a doctor.74 At the same time, madness withdrew into the unknown at the very moment when medicine invested it with the greatest possible transparency. It retreated further behind the elusive appearance of hysteria, becoming more mysterious and enigmatic. Hysteria was an event because it disrupted rational accounts, principles of unity, peace and order, constituting itself the locus of a confrontation between heterogeneous regimes of truth, which questioned psychiatric rationality, reversed accepted roles and established novel distinctions.75
Examining the case of hysteria, Foucault uses the language of anthropology, of crisis and the event, in order to describe the asylum struggles between the neurologists and the hysterics, without choosing sides. If Foucault were to speak in the name of the patients, he would not have foregrounded the singularity of hysteria, but would have reduced it to a vague episode in the history of the patients’ struggle for liberation. In his analyses he shows instead that hysteria was not a revolutionary event: the mentally ill were not liberated as a result of hysteria; only the hysterics benefited by securing their discharge from the asylum and acquiring a medical status.76 If, on the other hand, Foucault were to describe hysteria from the standpoint of psychiatric rationality and knowledge, he would have reduced the event of hysteria to a mere epistemological blind spot, an error to be eliminated. This is precisely what psychiatric rationality attempted to do: it strove to annul the impact of hysteria through the endless expansion of differential diagnosis and its reduction to a causal chain. Shortly after the crisis of hysteria, psychiatric rationality sought to transform it into a concrete reality, to de-eventalize it, to turn it into a non-event.77 Charcot himself was soon forced to thematize the notion of trauma in order to build a pathological framework for hysteria.78 The neurologists who followed, named hysteria pithiatism, relegating it to the level of a fake illness, an illness of suggestion and persuasion.79 Sigmund Freud (1856–1939) came to the scene, replacing the neurological body with the sexual body, incorporating hysteria into a new system of differential diagnosis and medical rationality.80 Foucault, alternatively, describes hysteria as simulacrum, an unstable entity, an ‘extrabeing’,81 which constituted the trace of the strategic opposition between presence and absence. Hysteria ‘affirmed non-positively’ the presence of an absent other; it surfaced as an unfamiliar object dismantling the smooth continuity between same and other, and their dialectical sublation.82 It therefore cannot be located as a singular entity by the logic of positivism which seeks to dissipate contradiction or nonsense.83 Its detection requires a logic which is disjunctive, paradoxical and strategic.84 Only the logic of limits, only reason itself, can conceive hysteria as a subversive force and not as another mental illness or mere simulation in the field of medical rationality. Only reason can reflect on the limits of possibility to render intelligible the singular effects of hysteria, which constituted a fracture and a break on account of its detachment from all prior causality.85