543992

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HPY0010.1177/0957154X14543992History of PsychiatryHuertas

Article

History of Psychiatry
2014, Vol. 25(4) 459­–467
Subjectivity in clinical practice: © The Author(s) 2014
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on the origins of psychiatric sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0957154X14543992
semiology in early French alienism hpy.sagepub.com

Rafael Huertas
Spanish Council for Scientific Research

Abstract
The aim of this article is to contribute to the analysis of the origins of psychiatric semiology, which by
emphasizing subjectivity in clinical practice, gave birth to psychopathology as the scientific and intellectual
enterprise of alienism. In other words, beyond simple anatomical and clinical observation, there was an effort
to ‘listen to’ and ‘read’ the patient’s delirium. In essence, the basic thesis which this short paper seeks to
defend is that, despite a growing anatomical and clinical mind-set and a clear interest in physically locating
mental illness within the body, during the Romantic period, psychiatry was able to construct a semiology
largely based on the experience of the ego, on the inner world of the individual. This makes it possible to
establish, from a clinical perspective, that the birth of alienism – of psychiatry – must be situated within the
framework of a modernity in which the culture of subjectivity was one of its most characteristic features.

Keywords
French alienism, hallucinations, semiology, subjectivity, 19th century

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 associ-
ated 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 con-
structing a semiology that was in keeping with the principles advocated by the group at Paris’s
Charité.

Corresponding author:
Rafael Huertas, Department of History of Science, Institute of History, Spanish Council for Scientific Research, C/
Albasanz, 26–28, 28037 Madrid, Spain.
Email: rafael.huertas@cchs.csic.es
460 History of Psychiatry 25(4)

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 sensa-
tions 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 prac-
tice 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 conscious-
ness’, 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
Huertas 461

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 semi-
ology 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 alien-
ists 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 con-
sidered 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 diag-
nosis: ‘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 with-
out 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)
462 History of Psychiatry 25(4)

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, intro-
duces 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 observa-
tion 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 alien-
ism: ‘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 ‘expe-
rience 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
Huertas 463

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 Marcé6 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 con-
sidered 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 ‘subjec-
tivity’ 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
464 History of Psychiatry 25(4)

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 relin-
quished. There are also descriptions of the patients, their temperament, their physical characteris-
tics, 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 concep-
tion, 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 pres-
ence 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 men-
tal illness. If it could not be read in the inside of their body, the alienists strove, not always success-
fully, 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.
Huertas 465

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 act-
ing 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.

Notes
1. See also Williams, 1994; for Spain: Novella, 2010.
2. However, for later periods, see also: Dowbiggin, 1991; Huertas, 2002.
3. See also Fuentenebro and Berrios, 2000.
4. Regarding this author, see Dowbiggin, 1990.
5. The explanatory model proposed by this author and its importance to psychiatric historiography have
been the object of recent studies: Moyn, 2009; Weymans, 2009.
6. This author’s contributions to the psychopathology of eating disorders have been studied by Blewett and
Bottéro, 1995.
7. The quotes from Brierre de Boismont are taken from the report which the French alienist prepared con-
cerning the case of Juana Sagrera, a patient whose confinement gave rise to a great debate in Spanish
medical institutions; Huertas and Novella, 2011. Regarding the influence of Brierre de Boismont on
Spanish psychiatry, see Novella and Huertas, 2011.

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