Subjectivity in clinical practice: on the origins of psychiatric semiology in early French alienism

Introduction

It is well known that the medical and philosophical enterprise, inspired by idéologie and developed through applying Condillac’s sensualism and the analytical method, played an essential role in revitalizing medicine in the late eighteenth and early nineteenth centuries. First Bichat, then Corvisat, Bayle and Laënnec, laid the foundations for what is known as the ‘anatomo-clinical mind-set’ (Laín, 1950), a method and practice which gave rise to an entire semiology that associated symptoms with bodily injury.

The fledgling study of alienism was not at all isolated from this medical reform. However, it is easy to imagine the difficulties these early doctors of the mind must have encountered when constructing a semiology that was in keeping with the principles advocated by the group at Paris’s Charité.

The nosographic and semiological efforts – clinical practice, in short – of the first alienists were organized along these lines. The sensualist materialism of Cabanis was of the opinion that sensations are the source of ideas and that the relationship between the physical and the moral was essential to understanding human nature (Cabanis, 1805).

Jan Goldstein has maintained that this new medicine had anthropological aspirations, seeking to encompass the two domains – the physical and the moral – in its desire to verify their ‘mutual enchaînement’ (Goldstein, 1987: 51). ¹ This ongoing exchange operated in both directions: the physical condition of individuals affected their passions and ideas; and the passions and ideas in turn affected the physical condition. As a result of this conceptualization, two notions of ‘medicine’ coexisted for the idéologues. There was medicine in its older, narrow sense, which they continued to refer to as ‘medicine properly so-called’ and which denoted the art of healing sickness through the application of physical remedies; and there were the ‘new destinies’ which awaited medicine now that it had been properly philosophically construed, medicine as the ‘suprême science de l’homme vivant’ (Alibert, 1799: 4). This science of man was destined to become the ‘crown of the natural sciences’ (Arquiola and Montiel, 1993).

At its heart, this anthropological scheme for medicine entailed the emergence and acceptance of an explicitly psychiatric field – alienism – as well as a psychological conception of medical practice and the medicalization not just of madness, but of psychology itself. All of this gave rise to a specialization process with very specific characteristics with regard to not only the profile of the new experts, but also their institutionalization and the particular features of their knowledge and practices (Goldstein, 1987: 55). ²

Pinel has rightly been considered as one of the founders of clinical psychiatry, a field of clinical medicine understood as a ‘conscious and systematic path’ (Bercherie, 1980: 25) which requires Condillac’s analytical method, natural history as a research model and Hippocratic observation (Peset, 2003; Sueur and Hodgkiss, 1995) to describe and classify mental disorders. In addition, the preoccupation with autopsy findings and ultimately with the causal consideration of madness, also found in the first alienists (Sueur and Hodgkiss, 1997), confirms their efforts to liken themselves to doctors of the body as much as possible. However, both the practice of taking medical histories and examination methods were forced to take into consideration the subjective experiences of patients, with these being incorporated into the repertoire of symptoms for the new mental medicine. It is thus no surprise that the changes in psychological theories developed over the course of the eighteenth century made it possible to accept concepts such as ‘internal experience’ and ‘contents of consciousness’, making them a legitimate field of inquiry for medical practitioners (Berrios, 1996: 22).

German Berrios (1984, 1996) has skilfully explained the factors involved in the emergence of this new psychiatric semiology: the need for descriptive tools for use by the new asylum officers; the availability of psychological theories which might support stable descriptions; the changing notion of sign and symptom in medicine; the introduction of subjective symptomatology; the use of time as context; and the development of quantification. Other authors have reflected, also from a historical perspective, on the relationship between semiology and psychopathology (Lantéri-Laura, 1994, 2003; Rejón, 2012).

My aim in the following pages is to focus the analysis on one of the factors noted by Berrios: the introduction of subjective symptomatology. It is my belief that it was precisely because it placed emphasis on subjective symptomatology that the emergence of this new psychiatric semio-logy gave rise to psychopathology as the scientific and intellectual undertaking of alienism. By the first third of the nineteenth century, it is already possible to identify this subjective symptomato-logy in various spheres of alienist theory and practice. Most noteworthy among them were: clinical observation of hallucinations; the internal world of the suicide; the problems of partial madness; induced or recreated experiences and the study of the writings of the insane. We will now briefly discuss two of these: the role which the reformulation of the concept of hallucination played in the creation of this new semiology and the possibilities which the writings of the insane offered experts for exploring the subjective world of mental patients.

Exploring hallucinatory symptoms

Perhaps one of the most notable examples to illustrate the appearance of a strictly psychiatric semiology can be found in Esquirol’s reformulation of the concept of hallucination (Huertas, 2008; Lantéri-Laura, 2001). The novel approach to the problem of hallucinations enabled Esquirol to arrive at a spectacular redefinition of Cabanis’s (1802) notion of ‘internal sensitivity’ and adapt it to the new theoretical premises. This concept was used almost exclusively to ascertain the causes of madness. From Esquirol onwards, hallucinations and illusions would succeed in supplanting the old visceral aetiologies in the alienists’ area of interest (Azouvi, 1984).

Cabanis’s (1802) criteria, a mixture of old and new theories, led to two ways of interpreting madness. On the one hand, the internal sensations of a visceral origin were invoked by some alienists to support their idea of mental disorders originating in the abdomen. On the other hand, this same thesis was updated. What was understood in eighteenth-century medicine as the conveyance to the brain of animal spirits or humours was now interpreted as pathogenic sensations which elude the consciousness. With Esquirol, however, ‘cerebral sensations’ were the object of a far more fecund and innovative approach. Now termed hallucinations, these sensations would not be considered exclusively as causes of madness, but would begin to appear as one of its most salient symptoms.

It is obvious that the well-known distinction between hallucinations and delusions must be attributed to that established by Cabanis (1802) in distinguishing between ‘visceral sensations’ and ‘cerebral impressions’. However, as I have indicated, this distinction no longer served to establish an aetiology, but merely a symptomatology (Huertas, 2008).

But how to identify a hallucinatory symptom? How to explore the subjectivity of a hallucinating patient? The very definition proposed by Esquirol contains the basic elements of the clinical diagnosis: ‘A man with the intimate conviction of a perceived sensation, even in the absence of an external object causing him this sensation, is at the mercy of his senses, in a state of hallucination: he is a visionary’ (Esquirol, 1838, I: 159, original italics). This definition has a clear sensualist and sensory dimension. From a semiological perspective, the most noteworthy phenomena are listed: the ‘intimate conviction’, the ‘absence of an object to be perceived’ – the famous ‘perception without object’ – and the importance which Esquirol places on the ‘visual’ dimension of the hallucinations.

Drawing on Esquirol’s contributions, the interest in hallucinations increased (Lantéri-Laura, 1991). However, what I find most interesting to highlight at this time is the distinction which Jules Baillarger makes between psycho-sensory hallucinations and psychic hallucinations, because there is a displacement of the visual dimension of hallucinations towards hearing and language. This author’s keen clinical observation is quite evident when he writes:

There are in fact some who, in their own words, do not experience anything like an auditory sensation: they hear thought. For them, the phenomenon is not at all sensory. The voice which speaks to them is a secret, interior voice, and completely different from what is perceived with the ears. However, there are other hallucinating patients who assert that the voices that come to them are loud, resonant and entirely resemble ordinary voices. In some cases, the patient has even experienced the two different kinds of phenomena in succession and can distinguish between the perfectly. (Baillarger, 1846: 368–9, original italics)

In a later work, he would end up systemizing two types of hallucinations:

It is possible to distinguish two types of hallucinations. The first are complete, composed of two elements, and they are the result of the action of both the imagination and the sense organs: these are psycho-sensory hallucinations. The others, due entirely to the involuntary exercise of the memory and the imagination, are completely foreign to the sense organs. They lack the sensory element, and for this reason are incomplete: they are psychic hallucinations. (Baillarger, 1890, I: 379, original italics)

Thus the author’s general approach tends to consider psychic hallucinations essentially to concern the ear, while psycho-sensory ones involve all the senses. This displacement of the visual element of hallucinations, as they were initially described by Esquirol, towards an auditory register, introduces a link to language which would be an essential part of future conceptions of psychopatho-logy, as in the work of Séglas (1892), for example. ³ Nor should we fail to point out the relationship which Baillarger established between dreams and hallucinations, before other authors such as Maury (1848), ⁴ Griesinger (1871) and Freud (1900) took an interest in this field of research.

While Baillarger (1846: 385) naturally insisted that his proposals were based on ‘direct observation of the insane’, I believe however that it is important to highlight that this ‘observation’ was not limited to a clinical ‘gaze’. The existence of clinical ‘listening’ is already evident in this early alienism: ‘there are hallucinating patients who affirm …’; ‘in their own words …’. By just listening to the mad, the doctor would be able to learn exactly what the patients’ sensations and experiences were. This was the only way they would be able to elucidate that ‘intimate conviction’, that ‘experience of certainty’ which by definition accompanies the hallucinatory phenomenon. Introspection thus became an outstanding semiological method.

Listening to the mad, reading the madness

The ‘dialogue with the insane’, to borrow the expression used by Gladys Swain (1994), ⁵ has been highlighted in recent works on the practices of French alienism in the first half of the nineteenth century. Juan Rigolí (2001) very clearly explained the desire of the first alienists to construct a psychic semiology based on familiarity with the words and writings of the insane. This is, at least in part, somewhat a rereading of alienism (Tardits, 2002), which provides us with relevant keys to understanding not only the importance of the ‘discourse’ of madness, but also the need for the new experts to make use of non-medical knowledge and culture. Philosophy, aesthetics, linguistics, rhetoric, etc., unquestionably show themselves to be useful for constructing and disseminating a semiology of subjectivity. The approach is not new. In fact, some years ago Marcel Gauchet (1994: xxxii) already warned that ‘we often tend to forget that behind a certain clinical positivism, behind the medicalization of passions and injustice which is the aim of alienism, there is an attempt to explore the subjective sphere’. Nonetheless, a detailed investigation of this subjectivity made it necessary to take into account an entire narrative filled with impressions, perceptions, feelings and sensations that only the patient was able to convey. Reading the delirium (lire le delire), knowing how to interpret what the mad express, became a priority for alienism.

This interest in what the mad are capable of communicating about themselves is a constant feature in the thought and practices of the alienists. Once again, Esquirol makes an appearance as the initiator and advocate of this concern. A number of observation logs have been found in the clinical archives at Charenton, in which Esquirol commented on the patients’ capacity for communication, warning that silence in an insane person was a sign of a bad prognosis or a worsening of their mental state (Mesmin d’Estienne, 2010). Esquirol’s disciples continued such practices. We have seen the importance which Baillarger placed on the information obtained from what the patient told him, but this was a semiological task taken on and accepted by most French alienists. For example, François Leuret, in his Fragmens psychologiques sur la folie, noted that in order to:

gain a clear idea of the hallucinations, it is important to question the patients and carefully note down their answers, and even more so to read what they write. In their letters, in fact, it is possible to obtain all of their thoughts, and the observer is certain not to incorporate their own. (Leuret, 1834: 186)

Questioning, listening, noting down … but also reading their writings. The semiological value assigned to the written statements of patients, which far exceeds that of their oral expression, is repeatedly asserted in alienist literature, at least from the 1830s. Thus, for Scipion Pinel (1836: 284) ‘the facts of mental alienation, verified by an inquiry and by writings, have much more value than data obtained through verbal answers’. These writings could have great forensic significance, as through them it might be possible to obtain a diagnosis, especially in cases of monomania or partial madness. In the words of Marc (1840, I: 7): ‘there are those among the insane whose actions and words are filled with reason, and who only rave in their writings’.

Years later, Brierre de Boismont’s contributions in this area are possibly the best known and most significant. Based on his pioneering work on the last wishes written by suicides (Brierre de Boismont, 1851) and other works (Brierre de Boismont, 1864a, 1864b), there was a veritable explosion of discourse regarding the writings of the insane, in both the clinical and the forensic spheres. Louis-Victor Marcé ⁶ is probably the author who expresses most clearly and specifically the semiological role which patients’ writings should play in exploring subjectivity:

… examination of written documents acquires considerable semiological value each time questioning the subjects leaves some doubt as to their mental state … provided that they remain calm, they can weigh their words, their gestures, their actions and rarely give an idea of their mental state. On the other hand, when they take up the pen, they give in to a need for indiscreet expansiveness, and believing themselves safe from surveillance, let escape, whether covertly or openly, sentences which reveal their deepest thoughts. In fact, it is only through careful reading of these secrets that it is possible to gain a good idea of the mental state of these patients. (Marcé, 1864: 383)

Writings of this type were used as legal evidence (Artières, 2000; Campos, 2010) and were also considered exercises which produced, sometimes simultaneously, both the expression of the madness and the therapy itself, making it possible to identify correspondences between uses of the lexicon, specific rhetoric, the spelling of signs, etc., and certain forms of mental disorder (Artières, 1998).

It should not, however, be forgotten that patients’ writings can have other interpretations, other historiographical approaches (Huertas, 2013). Some years ago now, Roy Porter (1987: 12) warned that: ‘The writings of the mad can be read not just as symptoms of diseases or syndromes, but as coherent communications in their own right.’ These communications can provide information about the living conditions inside institutions (Beveridge, 1998), but they also make it possible to observe the existence of a ‘pact’ between doctor and patient, between the reader and the writer. In the majority of cases, the writer writes to expound their ‘truth’ and the reader reads to confirm their diagnosis or as an ‘archivist’ who identifies and classifies the signs of mental illness. The ‘subjectivity’ of the inmate stands against the supposed ‘objectivity’ of the expert. However, in reality, this ‘pact’ – which is certainly unequal as it hinges on elements of authority, submission or resistance – can also be understood as a clash of subjectivities (Molinari, 2005).

Recounting the subjectivity of the mad

The work of ‘archiving’ the statements of the insane made possible important new developments in how clinical observations were prepared. This was reflected not only in the case histories preserved at institutions, but also in the transmission of psychiatric knowledge. Opting to quote certain expressions or sentences used by patients is extremely common in observations which illustrate and make sense of a developing psychopathology. In describing hallucinations, quoting what the insane say (or write) proves to be particularly effective. Sometimes this is done literally: ‘… I saw, several times, in the sky, St John the Baptist on a chariot with seven horses where, I believe, he was with the angels preparing for the arrival of Christ. I beg you to believe that my visions are true’ (Esquirol, 1838, I: 85); ‘I have a voice speaking to me in my ear that tells me go on, kill yourself; what I am suffering from is a terrible sickness’ (Brierre de Boismont, 1963: 384, original italics). However, on other occasions, the patient’s subjective experience is recounted by the doctor: ‘God appears to him frequently. On the last occasion, He spoke to him, He revealed the future to him; He took the form of a venerable old man, dressed in a long white tunic’ (Esquirol, 1838, I: 90); ‘her convulsive nervous attacks; the ghosts, the horrible objects, the hanged men she saw, even when awake and in the middle of the day, but especially at night’ (Brierre de Boismont, 1863: 389–90). ⁷

These clinical observations are replete with the ‘clinical gaze’, which the alienists never relinquished. There are also descriptions of the patients, their temperament, their physical characteristics, their behaviour and even their autopsy protocol in the event of death; and along with what can be ‘observed’, they incorporate words, read or written. Both seek to demonstrate, represent and offer an image of madness and, in particular, its most characteristic symptoms. Identifying these symptoms was impossible with the examination methods of internal medicine.

All considered, one of the major new developments of the late eighteenth and early nineteenth centuries was introduced by Laín Entralgo (1982: 153 and ff.). It is known as ‘the introduction of the subject into medicine’. Already found in Freud, this was continued by what was known as the ‘Vienna Medical Circle’, and later, although with somewhat different approaches, by the ‘Heidelberg School’ (Janzarik, Viviani and Berrios, 1998) and in particular, according to Laín (1950: 583), in the anthropological medicine of Viktor von Weizsäcker (Wiedebach, 2009). According to this conception, incorporating subjectivity required the doctor to include precise descriptions of the patient’s behaviours and attitudes in case histories, as well as a generous amount of verbal expressions, quoted literally. Needless to say, the language of the patient – and consequently, literal analysis of their verbal expression – had the utmost value for psychoanalysis as well.

However, I do not believe we need to wait for Freud or von Weizsäcker to find subjectivity in clinical practice. Another issue is the new meaning which psychoanalysis and other psychological trends gave to it, but the historiographical viewpoint that puts the ‘clinical gaze’ up against ‘clinical listening’ may be excessively schematic and generalizing if not explained sufficiently. The presence of subjectivity in clinical practice, beginning with the very origins of psychiatric semiology, seems unquestionable to me.

In short, although the alienists persisted in seeking the causes of madness in autopsy rooms, many cadavers of the insane remained silent, creating problems for that anatomo-clinical gaze through which ‘la nuit vivante se dissipe à la clarté de la mort’ (Foucault, 1963: 149). In a certain sense, if the cadavers of the insane could not speak, they could not demonstrate the nature of mental illness. If it could not be read in the inside of their body, the alienists strove, not always successfully, to ‘read their thoughts’ (Esquirol, 1838, I: 275) with the aim of achieving clinical clarity, an ‘objectification’ of the altered ‘subjectivity’. As I have indicated, this required a dialogue with the mad, a highly detailed medical history which would include both their sensations and their psychic experiences, obtained through their words.

There is not, not in the least – there cannot be – any relinquishment of understanding mental alienation as a physical illness. The semiology of subjectivity – an inherent part of the birth of alienism – thus emerges not in contrast, but intimately related, to anatomo-clinical medicine. Yet this took place within a Romantic – pre-positivist – culture which fostered the introspection and reflectiveness of the ego that characterize modernity (Sass, 1992; Staeuble, 1991; Taylor, 1989) and which was supremely important in a new conception of madness and the manner of acting with regard to it (Kaufmann, 1995; Novella, 2013). It is within this historical and cultural context that we must also understand the efforts of the alienists to develop methods for medical and psychological examination which would take account of the subject’s inner self, their experiences, will and thought.