L’art du diagnostic : sémiologie et clinique à l’âge de la psychiatrie classique

Abstract

ObjectiveBecause of the particular nature of its object, the clinical examination performed by an alienist is in no way similar to that of a medical physician. What are the characteristics of the semiological examination of the mentally ill? How reproducible are the findings of an examination? How were delusion and hallucination viewed in the 19th century? How far do the attitude of the physician and the weight of prejudice affect clinical observations? This research sets out to study the different modes of clinical examination in the area of alienation, and to analyse the epistemological and anthropological challenges involved. MethodThis research is restricted to a historical period of around 70 years, known as the period of “classical psychiatry”, corresponding to the second paradigm (1854–1926) according to Lantéri-Laura. It is based on a wide review of the psychiatric literature of the time, with particular attention to manuals produced by teachers. This research does not address the question of the physical examination of the insane, and focuses only on the psychic domain. ResultsClinical practice is first of all a skill taught at the patient's bedside, accompanied by “teachers”. It became organised and normalised in the second half of the 19th century, in particular under the influence of the teachings of J. Guislain and J.-P. Falret. It contributed to the professionalisation of the alienist corporation, and to a clarification of their particular methods. Clinicians had several problems to solve: the person of the doctor himself can be an obstacle to the expression of symptoms, since the observable signs have no lesional basis, and the word of the insane person on the subject of his alienation is often viewed as a distorting prism. DiscussionThe clinical methodology implemented by practitioners forms a unified and coherent ensemble with few variations. The establishment of these rules for clinical diagnosis has contributed to defining a profession and to defining the mental illness paradigm (in the meaning of T. Kuhn). These rules are based in particular on the predominance of a mental semiology and on a form of objectivity derived from questioning of the patient's entourage, and constant examination and surveillance. ConclusionThe signs used in classical psychiatry continue to be used today in contemporary psychiatry. Confidence in their descriptive powers should not obscure the conception of clinical practice and of relationships from which these signs are derived.