The emergence of psychiatric semiology during the Age of Revolution: evolving concepts of ‘normal’ and ‘pathological’

Introduction

Semiology (or semiotics) is the study of signs and symbols and their use or interpretation.^{1, 2} The field is closely linked to linguistics and to the words used to describe the signs and symbols of relevance. In the context of psychiatry, the signs and symbols relate to mental states and behaviour, and therefore questions as to what is ‘normal’ and what is ‘morbid’ are of fundamental importance. This article describes how psychiatric semiology formed and developed during the eighteenth and nineteenth centuries, as this has been critical for how mental states and behaviour are described in contemporary clinical practice.

Georges Lantéri-Laura, one of the most important authorities in the epistemology and history of psychiatry, emphasized the fundamental importance of semiology to psychiatry:

… semiotic knowledge in psychiatry, as in the rest of medicine, constitutes the origin of psychiatry – because without the clinic we could not locate either syndrome or disease or structure, and one would even ignore issues arranged in other areas – and yet it would remain devoid of autonomy. (Lantéri-Laura, 1991: 253)

One of the features of psychiatric semiology (or descriptive psychopathology) is that there was a spectacular increase in the number of signs, disorders and mental illnesses that came into use in the span of less than a century. Why this was so is an important question for us to address. Alongside this, we need to ask how psychiatric semiology gained its ‘scientific’ status from the concepts of ‘normal’ and ‘pathological’. What factors validate and legitimize semiology within psychiatry?

To explore these issues, I will first take a look at the time of birth of alienism and psychiatry, which tallies exactly with the historical period known as the ‘Age of Revolution’. This begins with the period before Pinel, the growth of sensualist philosophy and the common sense school, and the introduction of Dégerando’s linguistics work (eighteenth century). The second part of this era has three key aspects: the rules of rhetoric and language as essential elements that constitute pathological signs, Foucault’s vision of semiotic constitution of psychiatry from the voluntary-involuntary and the instinct, and finally, population statistics and eugenics in the nineteenth century. This article traces how the distinction between ‘normal’ and ‘pathological’ has changed from being located within the symptom itself, through being regarded as a question of conscious versus unconscious acts, to being considered as a matter of population statistics.

Symptoms and signs

First of all, what is normal and what is pathological? The difficulty of making a clear distinction between normal and pathological mental phenomena was described by the French psychiatrist, Edouard Zarifian, as follows:

There is a continuum between normal human behaviour and the pathological one. So, how and where could we set the passage from the normal to the pathological? Who should rightfully do so: the suffering subject, the doctor assigned to that subject, or society? The subject is often little aware of his status (delusion). The doctor (and increasingly the patient) is subject to various pressures to recognize from the disease, where it may not exist, what contributes to tremendously increase medical consumption. Society, i.e. the culture, is dependent on place and time, therefore varies greatly in its interests. (Zarifian, 1994: 71)

Pathological states are described by recourse to concepts of symptoms and signs. A long-established approach to the distinction of symptoms and signs follows the approach of Littré (1873–1874) and Landré-Beauvais (1818). A ‘symptom’ is related to the senses. So, especially with the emergence of psychoanalysis, ‘symptom’ has an internal meaning and a relationship with subjectivity.

In contrast, a ‘sign’ is a trace or signal that is related to a value judgement. Let us consider a bodily change, observable by a large number of people, which makes it initially a symptom. This symptom, however, quickly acquires a certain meaning and then medical observation takes over. By critical thinking, looking at both unique and shared features of the symptom, medicine transforms the symptom into a sign that locates the bodily change into the features of a disease entity. There are four types of signs: the proper signs (exclusive to a diagnosis), the common signs with other areas of medicine, the pathognomonic signs (where a single sign is sufficient for a diagnosis but it is not identical to the syndrome or disease itself), and the cardinal signs, where a group of signs is necessary (at least one proper sign) for a diagnosis.

It is noteworthy that the shape and the appearance of these signs increase with time and the evolution of the medical discipline. However, in the case of psychiatry, there have been hardly any significant biological discoveries, apart from the bacterium responsible for syphilis and some brain injuries. At the neurobiological and physiological levels there have been no fundamental insights into the aetiology of psychiatric disorders for nearly a century. A peculiarity of psychiatry is the absence of biological markers – if a biomarker of a disease is discovered, it ceases to belong to psychiatry and becomes part of another medical speciality; this happened with general paresis in syphilis, which now belongs to neurology and general medicine. In which case, it may well be asked: why do the numbers of signs and diagnoses in psychiatry continue to increase?

How can a sign become a sign?

Lantéri-Laura (1991) has emphasized one of the key features of a sign, namely that it must have identical features, even in different contexts.

We must focus on the importance of the extrinsic elements and the qualities of nonverbal and verbal contact; however, psychiatric semiology only exists if identical invariants are extracted whatever the conditions of the context and the singularities of the contact are. That is, we would not know about signs in psychiatry if some identical elements did not appear in the interview, whether it is a subject that comes willingly to counselling for disorders that he confides to us in a situation of great contact or in unaccepted judicial expertise where the hostile detainee employs digressions and avoids the subject. Psychiatric symptomatology as such cannot be fulfilled if one has no signs that share identical features despite changes of the context in which they appear and the particularities of the contact. (Lantéri-Laura, 1991: 207)

Using obsessions as an example of a clinical sign, Lantéri-Laura (1991) suggests two requirements to make them legitimate clinical signs in psychiatry. First, many alienists and clinicians have previously characterized, identified and described obsessions in their many varieties by introducing them into a thesaurus semioticus; and second, obsessions are clinical signs because they are different aspects of the current norm (p. 209). Lantéri-Laura proposes three benchmarks for accepting obsessions (for example) as clinical signs. First, they cause suffering to the patient on multiple occasions, so it is not a transient uniqueness but a repeated iteration of the same trouble with the same characteristics on each occasion. Second, obsessions are consistent from one patient to the other; if they are not exactly the same at least they have the same formal features that allow easy recognition. Third, obsessions must be distinguished from other equally typical alterations of inner experience, for instance in that it is an obsession and not a phobia or a flight of ideas (p. 210). The sign acquires its designative power, linking it to the underlying concept, by its differences from other signs.

For Lantéri-Laura (1991) obsessions are not isolated in psychiatric symptomatology, but have a unique and distinct place within a fairly homogeneous group of conditions of lived experiences. There is a logic that determines whether something is regarded as a clinical sign. However, he argues that certain elements do not deserve the label of clinical signs despite being recognized by many clinicians as such; for example, suicide or suicide attempts, or even behaviour disorders. For him, suicide is not a psychiatric sign because many suicides are related to personal issues and social values   that have nothing to do with mental illness, and second, it is a fairly complex set (of behavioural elements) that does not facilitate its treatment as a semiotic unit. These elements are too complex, too general and too involved in multiple networks to be considered as semiotic units (Lantéri-Laura, 1991). However, suicide or suicide attempts may appear or be determined by a mental condition, for example psychosis, or it may be the stage of an altruistic delirium in melancholia. Furthermore, Lantéri-Laura (1998) makes it clear in another text that a particular form of behaviour is not sufficient to determine a diagnosis.

Psychiatry also needs to consider social contexts in determining what is or is not a sign of pathology. For example, psychoanalyst Pierre-Henri Castel (2009: 120) argues that if

X sign of madness has no social meaning that does not mean that X is directly biological, nor does it mean that if that X is not biological and is devoid of social meaning, that same X is not real. It is difficult to treat these signs or madness as a natural reality without witnessing at the same time the type of culture and its conception of moral or mental suffering which pervades us.

For Germán Berrios, historical research of psychiatric semiology depends on the way the clinician determines the object of his inquiry. From this starting point, it is possible to map out how a sign and a symptom have emerged and been defined, and how they have then evolved. The research inquiry will be determined by the nature of the ‘invariant’ the clinician chooses to postulate (Berrios, 1996: 11). ‘An invariant is an entity (e.g. brain lesion or population of receptors) or a concept (e.g. the unconscious) which acts as the “referent” to a particular symptom and is robust enough (i.e. has sufficient ontology) to provide trans-epistemic continuity’ (p. 11). A symptom may be catalogued as such if it has appeared with the same behavioural and semiotic characteristics throughout time and throughout historical descriptions. Descriptive psychopathology (also called ‘psychiatric semiology’ within Continental countries) is the application of names to speech and action coming from abnormal behaviour; in order to do so a relevant lexicon and segments (symptoms and referents) must be ‘outlined’ or ‘constructed’ (p. 15).

An important feature of semiology, as with other languages, is that it builds on past usage and evolves continually. Semiology is, above all, a cumulative and an inherited knowledge, so for example, what constitutes flight of ideas as a sign is that when it is correctly identified the diagnosis of mania can be quickly established. As highlighted by Lantéri-Laura (1991: 211), what makes a sign like the deep despondency or ‘moral pain’ (douleur morale) a legitimate sign of the diagnosis of melancholia is the fact that already in the past others have recognized it as such.

Normal signs and pathological signs: the ‘science’ behind it

The problem of what is normal and what is pathological in medicine has been widely discussed by many theorists and historians. However, the work of physician Georges Canguilhem (1991) provides one of the most thorough discussions of this subject. His perspective has to be contrasted with Foucault’s views on psychiatry as a ‘normative power’ and normalization in psychiatry. For Foucault, psychiatry seeks its object from ‘outside’ and ‘above’ to discipline it; thus, it is in prison and in the asylum that the norm applies and prevails in all its rawness and nakedness (Castel, 2009: 220–9), seeking no other reason than self-satisfaction. In Foucault’s critical writings, psychiatric institutions and psychiatrists are all blinded by normalization (Foucault, 1988, 2006).

In contrast to Foucault (Castel, 2009), Canguilhem uses concepts of the norm and of health that are derived from medicine and biology. For him, health is the ability to derive enjoyment from the existing norms; thus, health results from these existing norms of the body. On the other hand, disease pushes the body to invent new ways of operating – new norms. Canguilhem (1991: 240) therefore defines the norm and the normal:

The norm by devaluating everything that the reference to it prohibits from being considered normal creates on its own the possibility of an inversion of terms. A norm offers itself as a possible mode of unifying diversity, resolving a difference, settling a disagreement. But to offer oneself is not to impose oneself. Unlike a law of nature, a law does not necessitate its effect. That is to say, a law has no significance as norm pure and simple. Because we are dealing with possibility only, that possibility of reference and regulation which the norm offers leaves room for another possibility, which can only be its opposite. A norm is in effect a possibility of a reference only when it has been established or chosen as the expression of a preference or as the instrument of a will to substitute a satisfying state of affairs for a disappointing one.

Despite the importance of physiology for medicine and human biology, the concept of norm is not reducible to an objective concept determined by scientific methods. What is considered to be the norm is often a matter of agreements and negotiations. Therefore, it is an issue beyond the fields of biology, medicine or statistics. Instead, norms can be viewed from social and anthropological fieldwork, and contain strong subjective elements.

According to Canguilhem, there is no biological science of the normal, but there is a science that describes normal biological conditions. This branch of the life sciences is concerned with the regulatory activity of life and thus contributes to establishing what is seen as normal (Canguilhem, 1991). Canguilhem follows a vitalist point of view where life, in order to continue, creates and regulates its own norms: vital regulations. This science is physiology.

But how can this be applied to the field of psychopathology? Is physiology equivalent in its precepts and its foundations with psychopathology and the psyche? Do biological and somatic norms apply equally at the mental and psychological level? For some authors, like Castel (2009), psychiatry and psychopathology (regardless of the approach: psychoanalytic, neuroscientific, cognitive-behavioural, etc.) can determine an objective norm of insanity. This is because they have no preconceived ideal of normalcy to attain. Instead they have to weigh the evidence in favour of or against certain parameters to diagnose insanity or mental illness (Castel, 2009: 246). This viewpoint also regards returning the subject to the norm as being the healing role of the physician or, in this case, the psychiatrist. Bringing the person back to the norm comprises a return to the common social representation, that of time and context, of what is health and/or sanity. Hence someone like Lantéri-Laura uses the notion of ‘current norm’ to indicate how the sign is dependent on its temporal and social context.

However, some authors take a different view on psychopathology and mental disorders. For Freud (1937: 389), normality is an ‘ideal fiction’, and between neurosis and normality exist ‘gradual transitions’. Thus, between neurosis (a term redefined by Freud and Janet) and normalcy there is continuity, and each can acquire shades of the other. The boundaries between normal and abnormal are established by an agreed conventional value, without necessarily regarding the abnormal as being pathological. The same forces that act in normal life do so in the pathological state. This is an interesting and important matter: the idea of psychiatry as able to provide treatment for ‘normal’ people is an issue that began in the late nineteenth century with Beard’s concept of neurasthenia and the birth of psychoanalysis.

Sensations and reason in the period before Pinel: the question of the faculties

From the time of the ancient Greeks until the late eighteenth century, madness was essentially simply divided between mania and melancholia. The Savoyard physician Joseph Daquin, who worked at the hospice of Chambéry, is regarded by some as the true father of French alienism. In his 1792 essay on the philosophy of madness (La Philosophie de la folie), he described various types of madmen: the raving lunatic, the quiet crazy, the extravagant, the insane, the moron and the demented. According to Daquin the common feature of all these forms of insanity, besides displaying different degrees of alienation, is the failure of reason. For Daquin, reason is directly related to the mind and the intellect. It is the main faculty of the human mind, unlike in other animals. Reason is the means by which the true is revealed, whereas folly is the deprivation of this knowledge. In each form of madness (raving, furious, quiet, extravagant, etc.), the intellectual faculty is altered or affected in one way or another (Daquin, 1792). The impairment of reason in turn affects the other senses.

Daquin (1792) based his classification of the six varieties of insanity on a whole series of typical behaviours. Examples of each type of insanity vary in the character of their speech, the form and type of the ideas they outline, and their use of language. All of these features thus serve as semiotic guidelines. Other authorities, such as Francis Bacon and Descartes, based on Plato’s three faculties of the soul, proposed that the mind had three key faculties: memory, imagination and reason. For Daquin, reason takes the highest place: it is how we able to understand the operations of the soul. Sensations are subordinate and they play an important role in driving the brain. According to William Cullen (1781), if the sensation only stimulates part of the brain, then false perceptions and false associations will arise. In moronic states and dementia, neither memory nor imagination operate properly, and reason even less so. In madness, memory and imagination are exacerbated but this nonetheless also leads to impaired reason. However, Daquin’s writing is quite contradictory concerning the ability to think and to reason in madness; sometimes he says they are affected in a mad person, but at other times he implies that this is less so. Daquin, however, is not usually regarded as the true founder of alienism in Europe, ³ perhaps because his work does not extend to a full system of classification and therapeutics.

Another seminal contribution is that of the English physician William Battie. His book, A Treatise on Madness (Battie, 1758), sets out his views of madness: ‘Madness, or false perception, being then a preternatural state or disorder of Sensation; before we attempt to discover its causes effects and cure, it will be necessary for us to investigate the seat, the causes and the effects of natural Sensation’ (Battie, 1758: 6). Both Daquin and Battie emphasize the active role played by the nervous system and the brain in the formation of madness. Both of these authors regarded madness as a disease of the nerves where one or more forms of sensation are corrupted by some internal disorder. For Battie (1758), clinical signs of madness (Original or Consequent) are located in the manifestations of classical mania: spasms, frenzy (at the same time a form of insanity), delusions, stupidity, etc. All these manifestations are associated with other medical signs, including fever, seizures and headaches; or, in times of calm or tranquillity, low pulse, weakness or cooling.

These descriptions, however, raise a series of questions. Where exactly do these signs come from? How do the faculties of the mind begin to slowly turn into indications of a psychiatric diagnosis? For this we need to understand the similarities between the semiotics of psychiatry and those of general medicine. In this respect, the nosological classification of Pinel is quite close to those of other physicians, such as William Cullen (Scottish) and François Boissier de Sauvages (French). Pinel’s classification of vésanies in his Nosographie Philosophique (1807) follows Cullen’s system of classification. Pinel classifies them as a sub-order of neurosis, considered initially as an inflammation or nerve injury without a structural injury.

However, another important influence upon Pinel and the first alienists in their efforts to characterize psychiatric signs and diagnoses is the sensualist philosophy initiated by John Locke and Étienne Bonnot de Condillac. This is based on the idea that all knowledge and all ideas come from the senses. For Locke, knowledge in Man appears by the confluence of simple and complex ideas. Simple ideas are those that cannot be communicated or transmitted but are acquired through experience, such as the sensation of warmth, cold, etc., and it is thus impossible to engender a new simple idea (Bréhier, 2004). Simple ideas comprise those of sensation (cold, pain, strength, bitterness, etc.) and of reflection (which are the faculties of the mind: will, memory, attention, etc.).

Complex ideas result from the combination of simple ideas, and are divided into two groups: a few simple ideas which are combined in a single idea (e.g. the idea of gold or the idea of man), and the combination of the ideas that represent different things that are unique (e.g. the idea of parenthood or filiation). For Locke, what constitutes true and objective knowledge is the perception of a relationship between ideas. On the other hand, Condillac (1798) suggested that sensations can engender faculties. The use of signs to name and make abstraction of sensations expands them at the same time; thus, language is the essence and the basis of all forms of analysis (Bréhier, 2004). Scientific knowledge is the result of observation of phenomena as delivered to us by the sensations. In this philosophy, objective observations should be classified and named, and we must create concepts that ‘acquire a structure that can be enunciated’ (Bercherie, 1980: 27).

The psychology of the faculties, derived from the Scottish School of Common Sense, has also contributed relevant items to consider in psychiatric semiology. For this school, ‘common sense’ designates the ‘fundamental laws’ of belief; the essential and immediate, necessary and universal rules. Condillac and Locke regarded perception as separated from judgement while the sense was merely a receptive faculty; however, in the everyday language favoured by the Scottish School, the term sense necessarily involves judgement (good sense, senseless, sensation) (Bréhier, 2004). Thomas Reid was the great thinker who proposed and categorized a series of descriptive psychological faculties to account for knowledge and reason (Bréhier, 2004). The philosopher Christian Wolff also described how certain capacities such as paying attention or perceiving things in the environment can be used to define mental powers as faculties (Klein, 1970; see also Rullier, 1815). Reid spoke of the faculties of memory, learning, intelligence, perception and will. However, Pinel was particularly influenced by another member of this school, Dugald Stewart, because of his work on intellectual and moral faculties, signalling the lesions altering the personality ⁴ of the insane (Lantéri-Laura, 1991: 56). Consequently, morbid alterations in psychological faculties, such as thinking, mood and affective life, consciousness, perception or critical thinking, have been regarded as the essential elements when capturing, naming, classifying and configuring a sign.

Pinel’s inheritance

According to some authors, such as Bercherie, Pinel brought research and observation of madness into the medical and scientific domain. He is therefore the founder of psychiatry as an idea of science or pre-science, as an ideology, in its epistemological sense (Bercherie, 1980). ‘One may naturally wonder about this little naive epistemology, but one fact remains: with it, Pinel opened the systematic exploration of a field and the organization of phenomena that constitute it’ (Bercherie, 1980: 27). The growth of botanical classification and the methods of naturalists such as Carl von Linné and the Count of Buffon allowed the pursuit of psychiatric knowledge in an organized and methodical manner. There had been treatises relating to taxonomy since the time of the Roman Empire, notably that of Aretaeus of Cappadocia (1834), a Greek physician from the first century AD, which provided one of the first descriptions of the clinical signs and therapeutics of mania, melancholy and epilepsy. These disorders were related to the four humours: for example, melancholia was an acute disease of the black bile causing some signs such as irritability, sadness or a profound dejection to prevail. However, the rise of botanical taxonomy was crucial for the new science of mental conditions.

Pinel was certainly influenced by various authors from classical Greece and Rome. For example, his views on mania and melancholia in the two versions of his Traité médico-philosophique sur l’aliénation mentale (Pinel, 1800, 1809) are close to the particular semiological approach of Aretaeus of Cappadocia, in that each takes the issue from the concept of partial or general delirium, or the subject of deep despondency and despair. Another influence on Pinel’s semiotics was the Greek physician Soranus of Ephesus (translated into Latin by Caelius Aurelianus in the fifth century AD). Hippocrates’ work allowed Pinel to observe how the disease is ‘a regular set of characteristic symptoms and a succession of periods, with a tendency of nature, most often favourable and sometimes fatal’ (Pinel, 1807: viij). Thus, he uses Hippocrates’ work as a general model for the description of the disease coming from individual cases and generating a medical theory; a model that is reflected in the analytical method of Locke and Condillac (Pigeaud, 2000). However, the great step made by Pinel (ahead of classical writers like Aretaeus of Cappadocia and his contemporaries such as Daquin and Battie) is that he was able distinguish madness, in its social and cultural meaning, from insanity in the medical sense, by creating a unique and defined concept: mental alienation.

Sign, signum, in the work of Dégerando and Landré-Beauvais: the creation of a language

Joseph-Marie Baron Dégerando or De Gérando, linguist, educator and philosopher, one of the fathers of modern anthropology and ethnology, spoke in his famous treatise on the influence of language and the sign as a means by which the immediate perceptions are supplied to the mind (Dégerando, 1799–1800: 29). For Dégerando, the sign, signum, mainly expresses something sensitive that is intended to show, point out or highlight other things that were not perceived, and it is also an event which presents to our senses other events that were not noticeable before. A sign ‘is the union of the sensation which composes it together with the ideas that this very sensation excites in the mind’ (Dégerando, 1799–1800: 64). He uses the same definition of a sign as that proposed by Condillac. Dégerando explored the relationship between signs and thoughts relating this concept alongside the idea of sensation and perception conveyed by Condillac (1798). This proposes that sensation is fundamental to all human faculties (reason, comparison, judgement, etc.) as it is present in all of them, and because changes in sensation lead to changes in the other faculties (Bréhier, 2004: 1063; Condillac, 1798). For Condillac the faculties precede the signs – they are in a lower stage – but it is through the existence of signs that the faculties can be further developed and integrated with each other (Bréhier, 2004: 1063).

Augustin-Jacob Landré-Beauvais was a surgeon and a disciple of Pinel. His famous treatise on medical semiology (Landré-Beauvais, 1818: 2) was one of the first treatises to be written from the perspective of a semiology of disease (Berrios, 1996: 131) in the way that it brings together mental symptoms with general medicine. Landré-Beauvais described the phenomenon as ‘any change in the body, either healthy or sick, which is perceptible to the senses’; therefore it is any effect that appears as a novelty for the senses, and it is a neutral term that refers to the states of both health and disease. The symptom is defined as a ‘change, alteration of parts of the body or of some of its functions, produced by a morbid cause and perceptible to the senses’ (Landré-Beauvais, 1818: 3). He sees the sign as ‘every phenomenon, every symptom, whereby it comes to knowledge the most hidden effects’ (p. 3). His definition of sign is closely linked to Dégerando and Condillac, ‘the sign belonging more to the judgement and the symptom to the sense’. Thus, only people endowed with a knowledge of medicine can manage to find signs within the symptoms that are visible for everyone.

Landré-Beauvais (1818: 4) clearly explains how the sign becomes a signifier linked to the signified phenomenon, generating a meaning, which can be translated into a diagnosis. This should be done, according to him, through clinical and physiological observations and pathological anatomy. Landré-Beauvais borrows from Dégerando and Condillac the idea that all scientific terms should be derived from sensory experiences (Charland, 2010: 52), but he is also inspired in most of his work by Pinel (see Rigoli, 2001: 145); for instance, the description Landré-Beauvais (1818: 145) gives of mania is taken almost verbatim from Pinel (1800: 27). The work of these two thinkers had a strong influence on the development of psychiatric symptomatology and semiological texts in the years to come. Thus, the sensualist philosophy of Condillac strongly influenced the development of definitions of sign and symptom, and how a phenomenon turns into a sign with a place in the thesaurus semioticus.

Rhetoric and psychiatric symptomatology: the inner passions and the external signs

A movement that has strongly influenced the classification of diseases and psychiatric symptomatology from the early years of alienism was the Rhetoric. Juan Rigoli, Professor of French Literature at Fribourg (Switzerland), showed in his great doctoral thesis (Rigoli, 2001; see also Alvarez et al., 2004) how many of the clinical conditions encountered in the late eighteenth and early nineteenth centuries were described following the guidelines and conventions of Rhetoric. Signs taken up from the rhetorical level keep a reference to it by the notion of a credible and an acceptable (Alvarez et al., 2004: 605).

Scholars such as Pinel, Esquirol and Leuret were greatly influenced from their youth by philosophy, the art of rhetoric and the belles-lettres These influences included especially the treaty of Charles Rollin, De la manière d’enseigner et d’étudier les belles-lettres, par rapport à l’esprit et au coeur (1726–28), and also the lessons of ancient and modern literature, such as the Gradus ad Parnassum and many classic texts, for example the Leçons de litterature et moral by Noël and Deplace (Rigoli, 2001: 135). Everything concerning the language of the ‘passions’ (from the Greek pathos, ‘suffering’, ‘disease’: defined in Cicero’s Tusculan Disputations as ‘that which disturbs or alters the mood’) placed the accent on the eloquence and instincts of the orator. For Aristotle, in the arts of rhetoric persuasion, pathos was the means by which one should touch the sensitivity and emotion of the listener, unlike the ethos which derives its power of persuasion from the integrity of the speaker. Passion (pathos) was an element of great importance for rhetoric and later in linguistics, but it also played an important role in the fields of medicine and alienism.

In the work of Esquirol (1805) and Pinel the concept of passion is central to the origin of insanity and its causes. Passions influence both the art of rhetoric and that of alienism. The medical signs will manifest themselves as the outward expression of the inner passions of the soul. Hence many treatises of medical semiology from the eighteenth and nineteenth centuries discussed the external effects of the passions of the soul. Psychiatrists, such as Guislain, placed great emphasis on facial expressions which betray the emotions and passions that dominate the alienated (Rigoli, 2001: 112). But for many other alienists it was language, voice, speech and writing that truly reveal these deadly passions of the soul. In the famous Dictionnaire des sciences médicales, par une société de médecins et de chirurgiens (Fodéré, 1821), the author used the notion of ‘sign’ and its ‘effects’ and its relationship to the aesthetics of rhetoric and its main elements (dispositio, elocutio, pronuntiatio) to show how these contributed to medical semiology.

The manner of the voice and speech is an outward sign of madness. In examining the language used in the writings of the insane, psychiatrists undertake a rhetorical assessment to the point at which the clinical lexicon and literary topic overlap. As one is reminded by Rigoli (2001: 149–50), it

is the emotional expressiveness of language, linked to the myth of the affective origin of languages, that the rhetoric of the passions passes through and reorients the discourse of alienists. That ‘spoken language will have its natural foundation in sensory feelings and expressions’ is one of the least reported convictions, but one of the strongest of alienism. Medical representations of the exalted word of the alienated, driven by this passion that is fuelled madness, curiously take away from the expression of the mad at that point of origin designated by Rousseau where omnipotent passion precedes and generates the language: ‘the illusory image offered by passion firstly shown, meets its answer in the language that for that purpose was also firstly invented’. The alienated therefore becomes the one who opposing reason follows an inverse path that the original myth, perfectly assimilated to the rhetoric, assigns to language: ‘In all successive changes of language all along the progress of civilization, good sense has gained supremacy over imagination’.

In order to identify these characteristic morbid signs of madness, it is necessary to observe certain rhetorical and oratory devices, for example discursive flaws, dispersion and rupture. These features can be helpful when locating delusions and disorders of language; and these devices are already described in the treatises of rhetoric by Bernard Lamy and Pierre Fontanier, from the seventeenth and nineteenth centuries, respectively. Ellipsis, interruption, abrupt transitions, sudden reversals, even hesitation, for example, allow us to distinguish some of those inner passions manifested in language, but also in the discourse of the insane (Rigoli, 2001). Moreover, figures of excess and emphasis in rhetoric, such as hyperbole, question, exclamation or recurrence, can indicate those areas of thought that are vulnerable to passions.

Epithets obey an alienist principle of a demagogy of madness over passion, and that is also in perfect agreement with the distinction rhetoric operates between a ‘change of order’, which is proper to the ‘figures of speech’, and the ‘real disorder’… Because the mad [person] not only transgresses the rules, but what separates them; he is the one whose discourse, taken in the movement that overruns the passion, and through it, the rhetoric, tends to get away in what is only a loss of the very foundations of speech …. (Rigoli, 2001: 227)

Abnormal psychiatry: Foucault and the ‘instinct’

Les Anormaux is the title of the lectures that Foucault delivered at the Collège de France between 1974 and 1975 (Foucault, 2003). Foucault is of course well known as a philosopher and representative of the anti-psychiatric movement of the 1960s and 1970s, and his work ranged over medico-legal issues and the involvement of psychiatry and alienism within this area. For him, much of the semiology of psychiatric symptomatology arose from the problem of the concept of ‘instinct’. According to this notion, psychiatry conceptualizes the term ‘instinct’ starting from the infamous case of Henriette Cornier who in 1825 beheaded a small girl without any reason. ⁵ The murderer did not show a state of strong delusion, nor was she incoherent or visibly insane, and she gave no clear reasons for the crime. This led psychiatry to a transformation of the so-called ‘partial insanities’ (folies partielles), but also psychiatry was pushed to promote the instinct as the engine of alienation, even if only partial, within its own discursive operations. Hence, Foucault (2003: 132) says:

On the basis of the instincts and around what was previously the problem of madness, it becomes possible to organize the whole problematic of the abnormal at the level of the most elementary and everyday conduct. This transition to the minuscule, the great drift from the cannibalistic monster of the beginning of the nineteenth century, is finally converted into the form of all the little perverse monsters who have been constantly proliferating since the end of the nineteenth century. This transition from the great monster to the little pervert could only have been accomplished by means of this notion of instinct and its use and functioning in the knowledge and operations of psychiatric power.

For Foucault, instinct does not play its main role at the psychiatric epistemological level, but instead at the legal and political level (in the context of vindications, distributions and redistributions of power in the nineteenth century). According to Foucault (2003), this concept of instinct became so powerful in all psychiatric activity, without experts even noticing it, because of three key factors that affect the integration of psychiatry into the mechanisms of power (power external to it).

The first factor was administrative reform, for instance the law of 1838 in France. This gave psychiatry the legitimate authority to intern subjects and keep them in nursing homes and hospitals, accompanied by prefectural and judicial evaluations and decisions. In addition, psychiatry was accorded the authority that it had the expertise to establish whether or not madness is present at the time of a crime and to determine legal liability. These changes promoted the consecration of psychiatry as a branch of medicine and as a discipline of full rights. Second, the legal framework set out the process for managing mental illness within families. With the 1838 amendment, the family or the entourage could request that the ill family member be interned, but the process required the psychiatrist to give approval through the issue of a medical certificate. The family must specify the elements that require the internment, and the relatives of the patient ask the psychiatrist to stipulate the threat he poses to those around him, not his actual disability. Finally, the third factor that comes into play is an invitation to psychiatry to comment on differences between individuals and groups in relation to political ends. In this process, academia is asked to provide a psychiatric-political discriminant among individuals, or a psychiatric discriminant with political effects between individuals, between groups, between ideologies, and between historical processes. Foucault suggests the idea of the emergence of a new legal discourse on political regimes, which unintentionally created a series of discriminants between good and bad regimes. Examples of this included Cesare Lombroso, founder of positivist criminology, who created the psychiatric, psychological, anatomical and physiognomic discriminants to distinguish clearly between good and bad characters that participate in regimes or political ideologies (Foucault, 2003: 139–54). A more extreme example was the former Soviet Union, where opponents of the regime were labelled as schizophrenic by psychiatry, and thereby were denied their political rights and were subjected to inappropriate incarceration and treatment.

Foucault’s view was that between 1845 and 1850, there was a major shift: from the alienism of Esquirol and Pinel to the appearance of what we now recognize as psychiatry. For Esquirol and Pinel, the notion of truth plays a central role, whereas the psychiatry of 1845–50 and beyond is based on what actions are seen as voluntary and involuntary. Thus, there is a change as to how we conceive of mad people. In this new sense, a madman is a person whose hierarchy between voluntary and involuntary behaviour is disturbed; neither delusions nor frenzy, nor even dementia is needed for this new discipline that is psychiatry. It is not necessarily the mental faculties, mainly moral and reason, which have to be affected in order to dictate insanity or a form of madness; now it is the spontaneity of behaviour, the axis between voluntary and involuntary behaviour that will be paramount. The subject’s relationship with the apprehension of the truth does not matter. What matters, from 1845 to 1850, are the involuntary exercises of the faculties, the instinctive and the automatic – the loss of oneself as one’s agent of action – as the new axis of incorporation into psychiatric symptomatology (Foucault, 2003: 157–60).

The early alienists apprehended a behaviour or a phenomenon as morbid because there was some element of delirium within it. However, for mid-nineteenth-century psychiatrists, especially Baillarger in France and Griesinger in Germany, what made a conduct become a clinical sign was, first of all, its gap or deviation from the norm, the rules for which were defined from an administrative, family and political background as discussed earlier; and second, a behaviour would be a sign depending on how it was placed in the involuntary-voluntary axis. The deviation from the norm and the collapse in the instinctive automatism are the two factors, according to Foucault, that cause new psychiatric symptomatology and behaviours to be identified as morbid. The interesting thing to note here (Foucault, 2003: 161–2) is the alignment of mental disorders with organic disorders affecting voluntary behaviour, essentially neurological ones. Neurology forms an important bridge between psychiatry and medicine; for example, epilepsy has been an essential element for both disciplines. Foucault has referred to the process of psychiatry starting to include all the disorders of voluntary behaviour as an ‘explosion’ of the field of symptomatology, making it directly linked to neurology in its semiotic repertoire.

Statistics, the norm and the norm deviation: Quetelet, the ‘average man’ and the eugenics of Galton

The final perspective on the boundaries of ‘normal’ and ‘pathological’ arises from the science of population statistics and the work of scientists such as Galton and Quetelet. Together with advances in genetics, this formed the basis of eugenics. Eugenics was a social doctrine formed in the late nineteenth century in the predominantly Anglo-Saxon countries (particularly the USA and Great Britain) that promoted the then fashionable idea of improving the inheritance of human factors and of all the biological, intellectual and physiological traits. Francis Galton was the father of eugenics: for years he systematized the idea of   an ‘artificial selection’ or ‘rational selection’ as opposed to Darwin’s ‘natural selection’. Through biometric and statistical studies, Galton founded biometrics, or biostatistics, and moulded the elements of modern statistics to examine the possibilities of a biological improvement of the human species. Many of these ideas were influential morally and intellectually in early twentieth-century thought. Their application in some states in the USA led to the compulsory sterilization of the mentally retarded, the epileptic, the mentally ill and sex offenders, and prohibition of marriage for such affected individuals (Hochmann, 2009).

The dogma of progress was very expensive during the times of this author. If humanity progresses because of the fittest, and also the works and discoveries of the geniuses, a way to ensure progress would be not to trust the process of natural selection, but to carry out a process of rational ‘scientific’ choice; that is, what Galton would call the ‘science of human eugenics’. This science needed adequate techniques; his project was to determine objectively who the fittest were, who excelled to establish a functional hierarchy among men, to identify those who were able to ‘succeed’ in the ability to resolve certain situations (Benedito, 2006: 189).

Unlike the astronomer and mathematician Alphonse Quetelet, Galton was not looking for the common man or the average man (homme moyen); he sought the differences and particularities of each individual, their natural abilities. Quetelet was interested in the average man as a core value around which the measure of a human characteristic is grouped according to a normal curve. Galton was also interested in the relative distribution of average men, and believed, as Quetelet did, that certain human attributes were distributed in a curve around a normal value (Desrosières, 2000: 140–1). However, Galton did not seek a norm or an average man in general, but he was more interested in the individuals who deviate from that norm. From this he derived the laws of deviation from an average, which forms the basis of modern statistics.

The sociologist Alain Desrosières (2000: 141) has described how Galton went on to create measures for a series of objects or notions that seemed hitherto incommensurable: human skills. Quetelet’s aim was limited to quantifying fairly simple variables, such as height. But Galton went further and attempted to deduce from statistical measures the origin of gifted geniuses. For instance, he studied the ancestry of people like Bach, Bernoulli and Darwin to test the hypothesis of an inheritance in the direct line of genius.

Galton regarded social and environmental factors, such as education or nurture, as relatively unimportant. For example, he used sociological research on poverty in London and the position of households in the social and economic scale   as a means to strengthen his hypotheses. This research was performed to count and compare the categories of poverty in the boroughs of London, but Galton interpreted the data as an indicator of natural abilities, from a naturalistic and essentialist perspective, assimilating ‘civic values’ with natural ‘genetic values’ (Desrosières, 2000: 142–4). According to Galton, civic values would already be inscribed in the body and would be part of their essence; they would be transmitted from father to son, and from generation to generation. This research on poverty categories proposed a glimpse on these socio-economic skills, which could be distributed on a bell curve and which would allow calibrating the scale of the ‘genetic values’ for these categories (Desrosières, 2000). What is important to note is that Galton viewed these social data on a par with more obvious biological attributes, such as height or physiognomy. For Quetelet, knowing the average height could enable him to infer the nature of the average man, but for Galton, the distributions of socio-economic data led him to draw conclusions about inherited natural attributes (Desrosières, 2000: 146).

The work of Galton has thus enabled us to identify a whole range of different skills (intelligence, emotions, personality, etc.) to be measured and objectified. From this, they can be turned into numbers and key concepts to measure their frequency and for diagnostic purposes and probabilistic laws of aetiology or treatments. More importantly for the purposes of this article, measuring human attributes in this way offers a new way of establishing signs. This process causes us to reconceptualize the elements of signs and provides us with ways of measuring them. This appears to be more ‘scientific’ and ‘objective’, though whether this is truly so is of course an assumption. In order to allow such quantification, a series of abstract mental concepts must be reduced so that they can be parameterized with rules to enable us to judge, to clearly distinguish between the ‘normal’ behaviour and the ‘abnormal’ one.

Eugenics has had a greater impact upon psychiatric semiology than is generally acknowledged. It both opened a door and generated an unprecedented rupture in the annals of psychopathology. This was not so much because of the notion that all human skills or human types (genius, criminal, retarded, mentally ill, etc.) are inherited, as this idea already existed in psychiatry. Where it has made a seismic change is in the fact that these attributes can be measured and turned into numbers in order to make decisions and justify theories.

Conclusion

This article is not exhaustive, and it has not discussed other schools and disciplines that also contributed to the development of a thesaurus semioticus, such as anatomical pathology, behaviourism, psychoanalysis, phenomenology (as a philosophical current) or cognitive sciences, among others. These approaches all bring their own diverse features to this complex field, and also allow recognition of the different skills inherent to the subject of psychiatry. However, this study has concentrated on how the evolution of psychiatric semiology has been associated with different ways of looking at the distinction between what is normal and what is not. These varying approaches have had, and continue to exert, considerable influence on psychiatric practice and outcomes for patients.

From the characterization of these differences begins the semiotics whose development passes from the one to the many, from the coarse to the subtle, from the great phenomena to the small signs, from the generic to the basics, as it can be clearly seen in the studies about hallucinations ranging from Clérambault to Esquirol, passing through Baillarger and Séglas. (Alvarez et al., 2012: xx)

Many of the signs coming from these approaches are polysemous (i.e. having multiple meanings) and using them in combination tries to establish monosemy, in other words a clear diagnosis (Lantéri-Laura, 2005). As well as this, there is an extensive literature on signs and language, thanks to Dégerando and Landré-Beauvais, ‘which serves as a reference to pieces of speech and action, creating a cognitive and descriptive system that serves to represent aspects of abnormal behaviour’ (Huertas, 2012: 127).

Semiology is an inherited and a cumulative system. Certain signs considered morbid that have been legitimated in some way are transmitted from generation to generation. As well as the tradition of clinical observation, philosophy has also contributed to semiology: first, through perception and sensation and second, through the faculties. Faculty psychology has been especially important in aiding the clinician-observer to get to grips with the subject of psychiatry: ‘the beginning or origin of the phenomena’ (Rullier, 1815). These phenomena that lead to the construction of signs are an important matter of arrangement and debate within psychiatry. As a clinical science, it needs to study and maintain a serious epistemological tradition. It also has to have some means of bestowing legitimacy when considering new signs or having to discard them, with the possibility that this may require an internal debate before a consistent decision can be reached.

The disciplines of rhetoric and oratory have been important in determining the characteristics of a ‘language of the alienated’ or the object of the rising alienism. This enables decisions to be made about when language is departing from the norm and informs the psychiatrist about variations that may be observed in the language of the mad. In another vein, as described by Foucault, instincts (passions) and motor aspects traced the division between normal and pathological signs through its merger with neurology and the observance of voluntary and involuntary acts. This affected the semiology of alienism, leading it towards an inclusion of neurology as a new source of signs and the potential of treating people who were not manifestly insane. Finally, the development of statistics, the ability to quantify human mental attributes and measure them with rating scales, provided not only the diagnosis, but also a new and potentially more objective means of looking at elements and signs. This has led us into an age of objectification and reification of human skills in a particular socio-cultural context, and has provided another means of demarcating between normal and pathological, normal and abnormal.