From a religious view of madness to religious mania: the Encyclopédie,Pinel,Esquirol

Traditional elements

Traditionally, as Pigeaud (2002) usefully reminds us, madness comes from two areas. ‘Frenzy’ and ‘dementia’ fully belong to medicine – in that they are often grouped with certain known organic diseases, like fever. Non-frenetic forms of madness, such as melancholy or the set of symptoms that came to be viewed as mania in the eighteenth century, pertain to moral philosophy – since one finds in them neither a substrate nor a physical cause; and in this sense, the most appropriate help one can give to the patient is of a philosophical nature. ² An essential part of madness – the one that most clearly goes against ordinary medicine – thus pertains rather to a moral tradition than to medicine. This distinction goes back to Greek Antiquity, to Celsus and Areteus, and essentially does not contain religious elements.

The religious meaning appears when we bring in the idea that (human) nature is corrupted. When corruption is the norm, then all that is uncorrupted – namely, God’s will, common sense, etc. – will appear as abnormal and thereby as a sort of scandal, hence as madness, for madness means exception from the norm.

Christ’s teaching and life are a scandal; for worldly beings, the life suggested by Christ is madness: in this sense, the Christian experience confers an essential relativity to the very definition of madness. ‘The cross: scandal and madness for some, salvation for others’, wrote the famous theologian Lemaistre de Sacy (1838: 291) in his translation of the New Testament, in the summary of Corinthians 1:1. There is a specifically Christian dialectic for madness, which Pascal summarized best in the following way: ‘Men are so necessarily mad that it would be another kind of madness not to be mad’ (Pascal, 1962: 412).

But I am not trying to portray a ‘Christian’ perception of madness, and an allusion to Pascal would certainly be insufficient if such were my intention. I am simply pointing out a contribution that the Christian experience made to the many angles of the experience of madness that have been lumped together since the beginning of ancient Greek morals and medicine. This contribution consists in looking at madness in light of the Christic scandal, from which two radical consequences can be drawn: madness is widespread (‘all humans are mad’), and madness is consubstantial with Truth (‘the wise man is mad’), as Pascal meant in the Pensée quoted above. These are certainly two radical positions which cannot both be upheld – and this is why there is not a Christian ‘conception’ of madness, but rather a dimension, or a tonality. Christian by nature, this tonality tainted the discourses surrounding madness for a long time, in a manner that was massive enough for it to be present in the background of the use of the term throughout the classical age.

Of course, we must not over-interpret Pascal here. The idea of a madness so consubstantial with human nature that it ultimately affects those who would seem farthest away from it appears to be found, in a different manner, in Chamfort shortly afterwards: ‘There are more madmen than wise; and even within the wise man, there is more folly than wisdom’ (Chamfort, 1795/1923: Maxim n. 149). One could see in these reflections a resurgence of ancient scepticism rather than a Christian perception. Human beings are mad, in the sense that they prefer the short term to the long term, do not make use of their reason, believe they know things when they do not know how to assess the elements that would be able to justify their knowledge, etc. As the philosopher Vauvenargues said in the same period, someone who is familiar with madness in human nature will have the tendency to put its most startling forms into perspective, because each human being ultimately succumbs to madness at her own scale: ‘Caligula’s follies hardly surprise me; I have known, I believe, many men who would have made their horses consuls if they had been Roman emperors’ (Vauvenargues, 1857: Posthumous maxims, n. 383).

I am not, however, claiming that this scepticism constitutes the background for Pascal’s assertion. Indeed, as for the sceptic, the madness of men is de facto, so the wise man can and must remove himself from it. He must measure his statements against empirical evidence, just as on the moral level he must set goals that meet what he hopes for and he can accomplish: an ideal of generalized commensurability guides the steps of the wise man, and separates him from human folly. But nothing here calls to mind the element of ‘scandal’ (hence, the consubstantiality of madness and truth). ‘Madness’ in the sceptic understanding is not a reversible state; it indicates a condition that is de facto widely shared, but in a stable manner – and this condition is surmountable.

Thus, in the quote from Pascal, the words ‘necessarily mad’ refer to our corrupted nature; in contrast, the wisdom of the Ancients – or even of Montaigne who Pascal rightly and often paraphrases, mentions or caricatures – would have certainly been able to complain about how the majority of men are mad, but their statement would not have had the value of a necessary natural fact. Rather, Pascal echoes a saying in Corinthians (1: 20): ‘Has not God made foolish the wisdom of the world?’ This is how he gestures towards a religious idea of madness.

I have lingered on this point because such ‘reversibility’ and ‘generality’ of madness seem, by contrast, to be excluded from the modern medical understanding of madness: if madness is essentially considered as an ‘abnormality’, its difference from non-madness is unequivocal, and the state of madness cannot be generalized (as long as the norm always bears a statistical connotation of ‘majority’). However, if we look at texts that predate the birth of psychiatry by only a few decades, we still find traces of this Christian dimension of madness. I turn now to the texts from the Encyclopédie.

Moral and medical insanity in the Encyclopédie

The articles by D’Aumont in the Encyclopédie include two entries on madness. The first, ‘Folie (morale)’, essentially examines the type of madness that is relevant to philosophers and moralists, according to the classic bipartition we have already discussed; the second, ‘Folie (médecine)’, examines the other kind of madness (D’Aumont, 1765c). Granted, the text is ambiguous and the duality can mean either a duality of possible viewpoints on madness, or a duality of the types of madness. Whatever the case may be, this duality still echoes the ancient division.

The article ‘Folie (morale)’ paints a picture of madness at the time it was not yet the proper business of doctors (this was to the benefit of the anthropological framework described later). For the author, being mad means moving away from reason – not in full consciousness, like a ‘slave to a violent passion’; but ‘in a very confident way, and strongly persuaded that one is following reason’ (D’Aumont, 1765c: 56). However, this persuasion does not seem specific to a category of humans, and can pertain to each of us in different degrees. The fact that in society some are confined and others are free is simply contingent: according to D’Aumont, those whom we confine in hospitals seem to have ‘a less common type of madness’ than others – a type of madness that does not ‘enter into the order of society’. In other words, there is an essential relativity to the concept of madness – a relativity in regard to local beliefs, social norms, clan tastes – which prevents it from becoming an authentic disease concept.

The sceptical point about the relativity of the concept of madness boils down to this insight: madness is essentially excess (‘all excess is madness’), and each excess supposes a point of comparison. However, this vocabulary of excess – which haunts all the literature about madness – justifies here a critical vision of the concept: madness is a question of viewpoint. This is why D’Aumont highlights the Christian reversibility between madness and wisdom: what seems mad to the world is reasonable to the wise man. The world is mad: the order of society is the ‘combination of human follies’, so that madness ‘enters into the order of society’ (1765c: 58).

Consequently, the classic bipartition derived from antique medicine between physical madness and moral madness, between fever or frenzy deliriums and melancholy or sad passions, has no value in itself: within the ‘houses’ (as they call places where madmen are confined), many people are morally mad; while in the world, many are physically mad (like Molière’s ‘imaginary sick’). This bipartition is only discursively useful for the encyclopaedist: it enables him to organize his articles on the subject. The first entry is then followed by ‘Folie (médecine)’. D’Aumont presents madness here as ‘a type of lesion of the animal functions’ (p. 58), and compares it to mania, melancholy and delirium. Such division is not so firm in practice; and in general, throughout all the Encyclopédie it is difficult to extract a true classification of mental illnesses. In the articles he devotes to them, D’Aumont distinguishes ‘delirium’ and ‘frenzy,’ the latter being accompanied by fever (Berrios, 1999; D’Aumont, 1765a, 1765b, 1765d). This is very close to the classic distinction between mania and phrenesis, which is taken from ancient medicine. But whereas the first article, ‘Folie (morale)’, insists on the ‘excess’ aspect – while drawing the relativist consequences that I have highlighted – ‘Folie (médecine)’ suggests that ‘madness’ is the ‘depravity of the thinking faculty’. However, the two approaches are easily articulated: in a very general manner, depravation and excess seem to raise a globally moral approach to mental conditions. Besides this, they also share the same relative character: excess is relative to a certain measure, and depravation is supposed to have identified what is appropriate, or what is common sense; but, within a Christian framework, common sense or common thinking is already corrupted – which means that depravity is in itself only a relative fact.

Whatever the case regarding these nuances, the three types of madness mentioned by D’Aumont – mania, melancholy, delirium – instantiate ‘the error of the understanding which judges falsely, during observation, about things regarding which everyone thinks in the same manner’ (1765c: 56). We can compare this with Boissier de Sauvages (1772: 3): ‘The mad are currently deprived of reason, or persist in an obvious mistake; and this constant mistake of the soul, manifested in their judgements, their imagination and their words, constitutes the character of this class [of diseases].’ At the same time, Cullen (1784: §1529) puts forward an analogous definition: all ‘vesania’ (psychosis) are founded on false judgement; but more precisely, delirium establishes itself ‘in a person awake, a false or mistaken judgment of those relations of things which, as occurring most frequently in life, are those about which the generality of men form the same judgment’ (§1531). In his taxonomy, Boissier de Sauvages (1772: §15) indicates a difference between theoretical error, which is common, and practical error, the only one at play in madness – for example, the madman who imagines his friends are enemies. The criterion here seems external to the content of the belief: simply put, a theoretical error does not have a negative effect on the subject himself, while practical errors concern those things on which our social life is founded: everyday relationships, common beliefs, etc. D’Aumont’s and Cullen’s insistence on ‘what everyone thinks’ leads us to Boissier de Sauvages’ notion of practical error, placing the accent on the presence of social norms. ³

Boissier de Sauvages, whose Nosologie is constantly cited by the Encyclopédie, claims that even though madness is a disease that constitutes the eighth class of diseases (named the ‘class of vesania’), it is understood as depravity: ‘When the principal symptom is a depravity of imagination or judgement, of will or desire, it’s madness, what the Latins called vesaniae because these functions are not sane’ (1772: §351, original italics). This amounts to equating madness and vice: certain people are ‘sick from a vice that the soul has contracted’ (§21, emphasis added). ⁴ In other words, we move from madness as error – thus, essentially, epistemic pathology – to madness as a fault of the will – that is, moral pathology. Although it was the subject of a medical treatise, madness as depravity is still not fully a medical topic.

For all that, depravity according to Boissier de Sauvages is naturally combined with the lexicon of excess: when depraved, the will pushes judgement to lose its sense of proportion and of measure, and instead flounders in imaginary measures. Thus, among the classes of vesanias, Boissier de Sauvages invents a third class named ‘oddities (bizarreries) – morositates’ that is characterized by a particular error: small things are appreciated with too much pleasure; or the inverse: the oddity is ‘too much of a desire for or an aversion towards something’ (emphasis added) – here, the will is depraved since the subject ‘prefers a small good to a large one’ (Boissier de Sauvages, 1772: 192). ⁵

We thus see in these examples taken from the doctors in the Encyclopédie that elements of the religious vision of madness had very much seeped into pre-Pinelian medicine.

The initial medical unification and appropriation of madness

The aforementioned situation changed progressively, however. Within the Encyclopédie itself, the volumes of which were written and published over many decades, the texts by Ménuret de Chambaud are no longer in the conceptual sphere. Author of the articles ‘Manie’ and ‘Mélancholie’, Ménuret de Chambaud (1765a, 1765b) approached madness as a general alteration of the ‘animal economy’ – namely, the set of communications and hierarchies which orders those intra-organic entities (organs, membranes, etc.) that are independently capable of ‘sensing’ their neighbours. This view was taking up the essential scheme of vitalist medicine developed by Bordeu in his Recherches anatomiques sur la position des glandes et leur action (1751) and Recherches sur les maladies chroniques (1755). ⁶ Ménuret de Chambaud (1765c) is also the author of the Encyclopédie entry ‘Œconomie animale (Médecine)’, which in a way synthesizes the framework within which the vitalist physicians of the time thought the aim of physiology lay. In his articles on mania and melancholy, Ménuret thus considers that a disturbance of these harmonious relationships of the sensibility that we call ‘sympathies’ – whether at a distance or nearby – accounts for madness:

Considering all of these observations, and the most ordinary causes of this disease, one would be close to believing that all the symptoms that constitute it are more often excited by some vice in the lower stomach, and especially in the epigastric region. There is every reason to presume that it’s there where the immediate cause of melancholy ordinarily resides, and that the brain is only sympathetically affected; to be sure that the derangement of these parts can excite melancholic delirium, it is only necessary to pay attention to the most simple laws of animal economy, recalling that these parts are pervaded with a large quantity of extremely sensible nerves, considering that their lesion introduces trouble and disorder into all of the machine, and is sometimes followed by death. (Ménuret de Chambaud, 1765a: 309, original italics)

Here, the French physician is in agreement with the use of these same concepts by a Scottish supporter of ‘animal economy’ medicine, William Cullen – who was active at the same time – in the introduction of his Lectures on Materia Medica: ‘Nothing affects more the mind than the state of the stomach, and nothing draws the stomach into sympathy, more than the affections of mind. This is evident by the hypochondriacs’ (Cullen, 1771/1781: 7). ⁷

What is essential here is that the affections and the passions, as modifications of sensibility, are ontologically of the same nature as functional or organic lesions. To grasp the novelty of this vision, we can compare it with a text by Bossuet (first published in 1741), which comes from a slightly earlier state of the discourse on madness:

All the violent passions are a type of madness because they cause agitations in the brain, of which the soul is not master. Also, there is no more common cause for madness than the passions carried to certain excesses. By this, dreams are also explained, which are a type of extravagance. In sleep, the brain is abandoned to itself, and there is no attention, because wakefulness consists in the attention of the mind, which makes it master of its thoughts. (Bossuet, 1861: 165)

In other words, for Bossuet and like-minded philosophers and physicians of his time, madness occurs when the soul can no longer control the brain, which can certainly happen following an alteration to the brain; generally speaking, madness occurs when the triple structure of the body’s dependence on the soul via the brain is damaged (and it is why madness can in this sense be defined as a situation when this tripartite structure has been pushed to the extreme by the passions). In contrast, when we move to Ménuret’s vitalist medical understanding – that of a disruption of the animal economy – insanity is no longer about a flaw in brain control, but rather an internal disturbance of a system in which the senses, the bowels and the brain are equal participants. (Recall that the brain, the skin and the epigastrum were, for the vitalists, the three centres of the animal economy – as Ménuret de Chambaud (1765b) reminds us in his article.) ⁸

Pinel: the end of ‘madness’, the beginning of ‘alienation’

Pinel takes up this medical understanding of madness; fundamentally, as a disease, madness is a ‘disruption of the animal economy’, falling into the same framework as that used by the vitalist doctors. Indeed, any disease ‘represents a particular modification of the animal economy for a certain length of time; considered from its beginning until its end, it constitutes a unique and – in a manner of speaking – indivisible whole’ (Pinel, 1804: 387). Even in mental diseases this disruption has its own laws, the knowledge of which is the object (as well as the justification) of alienism. Indeed, he writes: ‘The constant laws of animal economy considered in mania as in other diseases struck me with admiration because of their uniformity’ (Pinel, 1802 [hereafter TMP]: §25). With this, Pinel accomplishes the medicalization of madness that had emerged in the Encyclopédie in the tension between the texts by Ménuret and by D’Aumont analysed earlier. Madness brings the expertise of the doctor into play – even that of a specific doctor, the alienist. ⁹ The traditional division of competencies between the moralist and the physician has disappeared; ¹⁰ if madness is a group of regular disruptions within the animal economy, if frenzy like mania instantiates such disruptions, dividing this group into two distinct areas of competence would be just as absurd as to divide the mechanical world into that of the celestial bodies and that of the terrestrial.

What happens then to the essential dimensions of the religious understanding of madness discussed in the first section? As a start, the importance of the comparison with a social norm disappears: an animal economy is or is not troubled, whatever the social context (which can certainly lead to such trouble, but cannot define it). The reversibility of madness, within the Christian perspective, that gives rise to the essential relativity of madness, no longer fits into the alienist conception. It is significant that Pinel gave up the term ‘madness’ (‘folie’), preferring the expression ‘mental alienation’ or ‘mania’ (moreover, the term ‘madness’ even disappeared from the title in the second edition). Indeed, madness is a word from common language: it is used in a relative fashion and can essentially be applied to anything. Pinel justified this important lexical modification in the following way:

The fortunate influence recently exerted by medicine on the study of other sciences can no longer also allow alienation to be given the general name of madness, which can have an indeterminate latitude and can stretch out over all errors and quirks to which the human species is susceptible, which, because of the weakness of man and of his depravation would no longer have a limit. Should we not then understand in this division all of the false and inexact ideas that one forms about objects, all the prominent errors of the imagination and the judgement, everything that irritates and provokes fantastical desires? This would be the erection of a supreme censor over private and public life, embracing history, morality, politics, and even the physical sciences – whose domain has been so often infected by shining subtleties and daydreams. (TMP: 128–9)

In other terms, alienation as a medical category must be clearly demarcated, insusceptible to variations in viewpoint. More generally, Pinel’s argument definitively broke with the religious traces on the perception of madness to the point of banishing the word itself. There are, in effect, two aspects to this justification. First, in the spirit of Condillac and the French Idéologues, to whom Pinel was close, it was necessary to have precise scientific terms that are unaltered by the usual social preconceptions – and defined so that the group of objects falling under the concept designated by the term can be demarcated without confusion. Next, and more specific to psychiatry, the word ‘madness’ itself is muddled in the sense that it presupposes the idea of an aetiology through error (epistemic aetiology) or through fault (moral aetiology). When this is added to the anthropological fact that error is universally widespread, it implies that the demarcation of the group of mental illnesses within the group of errors and faults (which can occur with any human being) proves itself to be necessarily arbitrary – and is thus purely defined by social considerations like taste, fashion, culture, everything extrinsic to medicine. Against this, from a Pinellian viewpoint, the reversibility of madness, founded on the idea that humans are intrinsically mad in essence (whether for theological reasons due to corruption of human nature, or on the basis of anthropological or epistemic scepticism) no longer applies. Some are mad, others are not – just as some are sick and others are not; and in both cases an aetiology explains this difference, and in both cases one must consider a course of therapy. Standard uses, widespread beliefs, social norms count for nothing in all of this; they certainly allow for one to say whether someone is odd or not – which implies that anyone can, at a given moment, for a given group, be odd and thus be seen as ‘crazy’. But ‘mania’, the object of the alienist, must not suffer from this arbitrariness, which affects Boissier de Sauvages’ concept of ‘oddity’ itself. Of course, society is considered by Pinel, but through the medical lens: being mad is not a social category, but a medical category that can sometimes have a social aetiology. For instance, Pinel opened up the question of the psycho-pathogenic effect of the Revolution (see Rosen, 1968).

Asylum institutions/religious institutions

It is too soon to say that all things religious disappear from madness with Pinel. Foucault insisted on the rhetoric of confession, the resurgences of the director of conscience, etc., within the Pinellian ‘moral treatment’ (Foucault, 1961). Before this, Pinel himself refers to The Retreat – an institution founded in England by Quakers to take care of Quakers, and whose foundations are explicitly based on Protestant ideology, as one can see in the description given by the son of the founder, Samuel Tuke (1813). ¹¹ When reading Tuke, one sees how The Retreat is one of the first institutions planned not only in order to shelter, but also to care for the mad, in its spatial as well as institutional organization. But with Pinel, the conceptual change towards approaching madness sketched earlier implies that the nature of the institution was going to disentangle itself from the religious imprint.

Generally, the hospital is built on the basis of the hospice and separates religion from the management of disease. During the eighteenth century, the idea of the hospice giving help to the sick and the poor was replaced by the idea of the hospital as a place of healing (Ackerknecht, 1967; Foucault, 1961; Gelfand, 1980; Goldstein, 1987; Weiner, 2001; Weisz, 2006), and this resulted in a progressive movement away from religious personnel. It began with entrusting the direction of hospitals to secular figures, before these secular attitudes filtered progressively into the staff (not without clashes, negotiations and conflicts, as has been shown; Gelfand, 1980).

But things are still more complex regarding mental medicine: on the one hand, madness, as we have seen, has continuously been understood within religious frameworks; on the other, with the rise of alienism, its care required a specific type of hospital institution. Pinel gives flesh to this idea: the hospital imposes a regulated, ordered environment which facilitates the curing of madness; it superimposes onto nosology a sorting out of the alienated into this space by pathology – while being careful not to mix categories for which the company of one with the other would be detrimental.

There is thus a consubstantiality between alienist medicine and the asylum: the asylum gravitates around a man with undeniable ‘moral qualities’; in turn, this doctor is an effective physician only if he establishes around him a ‘well-ordered hospice’ (rather than possessing medical knowledge or a set of explanatory theories) (TMP: 57). ¹² In this sense, while the invention of the asylum based on the charismatic person of the doctor suggests a connection with the idea of the religious minister, its institutional programme can be understood within the general process of the medicalization/secularization of hospices. ¹³

The competence of such an alienist doctor, which underpins his capacity to rule a hospital, is a particular knowledge – specific in that it cannot be reduced down to the mastery of a taxonomy or to a broad and empirically-based knowledge of the animal economy. Instead, it embodies a knowledge by acquaintance of each individual’s ‘principle of mania’ – meaning the precise configuration of the disturbed animal economy hidden behind the sequence of symptoms that the subject displays. Regarding a certain case, Pinel indeed writes: ‘Through the incoherence of his ideas, one glimpses the principle of his mania’ (TMP: §23). ¹⁴ Unlike ordinary medicine, this ‘principle of the mania’ is individual – in this sense, alienist medicine cannot consist in applying a general physiological knowledge.

Depravity, excess, division: a change in the dimensions of madness

What, then, about the categories of excess and depravity proper to the religious vision of madness? In a certain manner, to see a melancholic subject as someone expressing a a proper ‘principle of mania’ through all of his activities, and to identify this principle through its manifestations, excludes the idea that this melancholy could simply be an excess in one manner or another. Regarding the nature of this excess when it occurs, what could be the measure, how can one discriminate normal subjects who exaggerate certain points from the alienated – a fortiori from those alienated who remain moderate in everything? According to Boissier de Sauvages, ‘oddity’ was simply an excessive consideration given to small details; which ultimately goes back to the imbalance of excess in self-love – that is, the essential corruption of the will. On the other hand, in Pinellian terms, excess is sometimes the appearance of the symptom; but it is neither its essence nor its explanation. Thus, other pathologies, unexplainable in terms of excess, can be perceived as forms of madness that are subsumable under similar principles.

In the same manner, forms of depravation are also rendered obsolete by the configuration that links together principles of mania, troubles in the animal economy, and the disciplinary specificity of the alienist. Neither alteration in the will nor disorder in the functions of the understanding are enough to define madness, according to Pinel: one or the other can stem from the type of disturbance in the animal economy as a whole that defines madness, but the depravation of the will is not the original metaphysical fault that establishes madness. This is one of the recurrent observations in Pinel’s Treatise (hereafter TI; see Pinel, 2002): outside the subject of their madness, maniacs are somehow normal. Regarding a maniac who today we would say was moved by homicidal urges, Pinel writes: ‘In other respects, however, he enjoyed the free use of his reason, even during his paroxysms. He answered without hesitation the questions that were proposed to him and evinced no incoherence in his ideas or any other symptom of delirium’ (TI: 153; TMP: 152). The mind of the maniac is often – as in this example – divided, split between his madness and himself. This is why the experience of madness in the asylum, as Pinel describes it, appears so often in the form of an interior conflict.

To this extent, Pinel shows that madness cannot be reduced to a lesion on the brain: recovery must be considered possible de facto, which is the case if mental alienation is due to a disturbance in the animal economy. This can in principle be rectified, whereas a brain lesion seems irreversible. As the irreducible diversity of ravages to the alienated mind shows, there is not a headquarters, a centre or a unity in what we call the soul: ‘Can this entire group of facts be reconciled with the opinion of a unique and indivisible centre or principle in the understanding? What would then become of the thousands of volumes on metaphysics?’ (TMP: 25). For this reason, when it occurs, alienation must leave certain zones of the mind intact – those with which the doctor must in some way communicate following the procedures of ‘moral treatment’. ¹⁵ Internal division clearly appears here – after ‘excess’ and ‘depravation’ – as the new metaphysical or imaginary mode of madness. Granted, the madman is in the grip of the ‘principle of his mania’, yet something of his rationality, of his sane understanding or of his solid will remains. In the end, without this the animal economy would no longer be functional at all. Scission is thus the cohabitation of the functionality of the animal economy – a little of which still remains, since the madman talks, communicates, etc. – with this principle of mania. Then, one can understand the possibility of cases where ‘confusion incidentally limits itself to everything that concerns religion; because with all other subjects [the madman] seems to enjoy a most sane reason’ and then one is led to question the status of the religious pattern within the psychiatric investigation (TI: 153; TMP: 74).

Example 1: Light religious melancholy

‘Exceedingly affected by the abolition of the Catholic religion in France’, a young man ‘became insane’, and ‘is transferred to Bicêtre’. There, he refuses food in order to imitate ‘the ancient ascetics’. To save him, the staff intends to ‘create the impression of a strong and deep fear’, and fake an armed band threatening to punish him if he does not eat. ‘After an internal struggle of many hours, the idea of the present evil gained the ascendancy and he decided to take the soup’ (TMP: 59ff.). Fundamentally, the subject experiences the division that defines madness. The sick part in him is the religious part; religious faith forms a barrier against the rest of the understanding, which continues its ordinary functioning. In some respects, religion was certainly present in some degree before madness: man was ‘dominated by religious prejudices’. But this religious aspect shows us the tone of the entry into madness, since it explains why the decline of the Church made him a maniac. The cause of his madness includes religion; the contents of the delirium are also steeped in it: he imitates the ‘ancient ascetics’. Religion is implied in the ‘principle of the mania’ of this subject, and forms one of the parts of the ‘interior struggle’; the doctor must in some way play the other part, so that the interior fight can result in a return to a sane and reasonable life. Madness is division, interior struggle, and when the subject is profoundly invested in religion, this struggle will without doubt entail religious faith on the side of alienation and not on that of reason.

Example 2: Violent religious melancholy: the fanatic

This may be one of the most fascinating and scary case studies presented by Pinel. A naive winemaker has been impressed by a missionary, and induced to believe in hell. He thinks that he has to kill his family to save them from hell, which he does (but fails to kill his wife). During his trial, he also kills a room-mate for the same reason. He is judged as insane and sent to the asylum of Bicêtre for life. There, he becomes convinced that he is ‘the fourth person of the Trinity’. For 10 years he remains calm, and ‘this persuaded the governor to grant him permission to mix with other convalescents in the inner courts. Four years of freedom and of harmlessness seemed to confirm the propriety of the experiment, when, all of a sudden, his bloody propensities returned’ (TI: 73ff.). He secretly intends to kill all the men in the place, steals a knife and wounds someone, then ‘killed two maniacs who were then on the spot’ and fortunately is captured. ‘It is scarcely necessary to add’, concludes Pinel, ‘that his confinement was now made absolute and irrevocable’.

Here, religion offers a sequence of triggering causes in retracing the aetiology of this case: the ‘ardent’ preaching of the missionary and the reading of the lives of the saints in some way lead to the confinement of the subject within his alienation. Religious stories themselves provide the contents of the delirium; this delirium is an extremely defined one, as if religion and reason were for once purely and chemically separated: ‘his confusion limits itself to everything concerned with religion; because with all other subjects he seems to enjoy a most sane reason’ (TI: 75).

A first essential point here is that a difference is at play between the religious logic of salvation and the medical logic of recovery. Granted, one first applies to the madman a solution that seems to fall within religious ethics: seclusion, for a long time (10 years). Isolation and the absence of contact with the world are actually religious practices, which – by favouring self-reflection and a disinterest in the world – provide penitence and redemption. Since Foucault (1961), people have often noticed that this logic of penitence, of redemptive isolation, resurfaced with the establishment of asylums, as with prisons (curing the criminal through an isolation that promotes repentance, etc.). Nevertheless, a radical difference appears here: in religious logic, the madman would be cured when he came out of seclusion; however, on the contrary, this is not the case in the clinical vignette given here. Recovery thus does not follow the same logic as redemption; and above all, the appearance of mental health misleads all non-expert observers. Only the psychiatrist is able to appreciate the state of the mental health of a subject when coming out of his seclusion, because he sees the principle of mania beyond appearances, and knows that, madness being division, the reasonable aspect can sometimes be the only one visible. The second main point of this case is that the man’s religious madness proves to be incurable. This clinical vignette by Pinel finally indicates the distinctively serious character of religious madness, which Esquirol would examine some years later. Indeed, Esquirol himself also remarks that, regarding religious mania or ‘demonomania’ as he calls it, ‘[it] usually bursts out in a sudden way; its invasion is brutal; it is more or less lengthy; its healing is doubtful (sa guérison est douteuse). Demonomania ends up with dementia’ (MM: 506, emphasis added).

How can we interpret and explain this specific incurability of religious madness?

Tentative interpretations

I will propose three hypotheses – not in any way exclusive of each other – to explain this.

Demonomania

An analysis of demonomania offers three fundamental features.

Monomania, madness, religion

We must note, however, that the presence of religion in the treatise Des maladies mentales is more complex than that. Demonomania includes what one could call cases of possession, and these are examined in a separate chapter (MM: 482–525). But the cases where the object of the delirium is religious are not always included within demonomania. In particular, there exist non-delirious manias within which the conviction motivating the subject has a religious essence, as well as certain cases such as the winemaker that Pinel cited. But in the list of monomanias described in the chapter on this theme, we find no paragraph specifically devoted to religious monomania. However, there are numerous paragraphs in the chapter on monomania in general, and above all in the chapter on hallucination, concerning cases of madness whose object is strictly religious (three of the four cases discussed at length are of this type ²⁰ ). The sentence quoted above about distribution of monomanias seems to explain it: religion provides the material for the ‘most widespread’ hallucinations because of the grip that religion has on hearts and minds, which can only be rivalled by love. Erotomania and religious monomania thus form the largest group of delirious monomanias. Georget, one of Esquirol’s closest disciples, acknowledged the diversity of forms of religious melancholy – well beyond simple demonomanias – and hypothesized that the effect of exaggerated religious beliefs may differ according to the personality of the individuals, yielding various and even contradictory forms of monomania, especially when love and religious drives meet. ²¹

One of the first cases cited by Esquirol is a naval officer who:

enters Charenton asylum in 1825. His delirium is religious and mystical. A thousand hallucinations, a thousand illusions of the senses, play with his reason. M. P. believes himself to be in direct communication with God. The son of God … intimates his orders to his humble servant P., not with words, but through signs that appear in the air. (MM: 166–71, emphasis added)

It is notable here that the alienated individual uses correct reasoning, and one could have mistaken him for a preacher of the Christian religion.

We next find a seamstress with religious delirium. Last we find Mademoiselle C., whose madness is almost cured, who even helps in the house of the alienated, but who is not, in a sense, cured yet. ‘She remains so convinced of the truth of what has been [divinely] announced to her that she told me one day (1817): “I will be mad another two years, until time has proven to me that what has been predicted to me is only madness” (MM: 182). Here, it is as if the religious idea was unrelenting even when the forms of religious delirium had been treated and disappeared. This leads us to allude to the initial case of Pinel’s winemaker – who was believed to be cured but who ultimately was not, because the conceptual core of his madness had not disappeared.

All of this thus happens as if religion and madness for Esquirol relate to each other within two narratives. In the first, which works beautifully within a positivist, almost Comtian, vision of the world, religion was an initially dominant passion of humanity: its grip held humans in fear; and cases of madness, these ‘demonomanias’, most often bore its colour. But religion loosened its grasp because the fears of men – particularly concerning nature and the social environment – were weakened by science, so that religious ideas no longer provided the dominant mobilizing passion for the construction of monomanias. Today, politics and everything that goes with it – plots, police, conspiracies, etc. – can take this role. However, in the second narrative, there exists more diffuse religious content: it is not about being possessed, but about hearing God, being called by him, and sometimes being his interlocutor, or – more simply and in a more subtle manner – knowing a revealed truth of which others are ignorant. This defines a great deal of positive contents that are not necessarily invested with fear (which was the dominant note of demonomania). Such contents are thus always available for the delirious; in particular, they can provide elements for troubles of perception. There are numerous cases like this, not only in the ‘Hallucinations’ chapter, but also in the ‘Illusion of the Senses’ chapter, following the case of this long-term patient from the mental home that they nicknamed ‘Mother of the Church’ (MM: 211).

Thus, within this second narrative, even if humanity has overcome its fear, religion always remains an available source for disturbances in perception. To this extent, some followers of Esquirol who inherited his theoretical interest in hallucinations as specific symptoms distinct from illusions (Huertas, 2008) investigated cases of mysticism in the past, emphasizing the pathological dimension of hallucination in them. Joseph Lélut’s (1836) treatise on Socrates’s demon interprets this famous Socratic private religious experience as a case of hallucination. More generally, Louis-Florentin Calmeil’s apparently very general treatise on madness, De la folie considérée sous le point de vue pathologique, philosophique, historique et judiciaire (1845), in fact deals with historical cases of religious mysticism, devotion and possession, as attested by its subtitle (‘Description of the major epidemics of delirium that affected the populations, and reigned within monasteries’), and interprets them as varieties of hallucinations. ²² Baillarger, who later pursued Esquirol’s and Georget’s project of systematically ordering mental conditions on a principled basis (Baillarger, 1853/2008), provided at the same time a detailed study of mystical cases of hallucinations (Baillarger, 1845). As Esquirol remarks, religion, because it is capable of claiming the entire being – the entire heart and mind – can thus cover the totality of experience and the whole set of possible perceptions. For this same reason, the psychiatrist will frequently encounter religion, while the specific form labelled ‘demonomania’ is a mere relic of the past (or of this sort of residual past of the least educated class in society, according to the dated social views of the alienist …). Religion can so effectively and profoundly seep into the delusional core of madness that it makes the alienated difficult to treat; and, in spite of appearances, they may possibly always have an untreatable core of madness – so that, according to Georget’s words earlier, one must always ‘fear a relapse at the least occasion’.

Hence, for Esquirol, madness is by no means reversible; it does not indicate the scandal of another truth, nor is it something written in human nature. The madman is sick, and this disease can fixate itself on religious content – even if religion is disappearing. Yet, while religious madness as such seems archaic, the religious colouration of delirium itself is like erotomania: present in a diffuse manner, dispersed throughout all forms of hallucinations, untreatable. If deliriums of possession departed with the Age of Enlightenment and the Revolution, love and love of God go hand in hand in the heart, like downward slopes where it is always possible for the subject to become insane.