Popular Science Monthly/Volume 21/October 1882/Delusions of Doubt
I PROPOSE to describe an extremely curious form of mental alienation which does not often occur, except among subjects whose minds have received a certain degree of culture, and the victims of which are seldom consigned to the asylum. It is an affection the subjects of which nearly always belong to the category of free eccentrics. I refer to the singular perturbation of mind which has been described by the elder Falret as the doubting disease (maladie du doute); by the younger Falret as partial insanity, with dread of the touch (crainte du contact) of exterior objects; by Oscar Berger as Grübelsucht, or the mania for subtilties; and by Legrand du Saulle as the folly of doubt, with delirium of the touch (folie du doute avec délire du toucher).
Waiving for the present the consideration of the tactile element, we might, perhaps, designate this mental state, which is always accompanied by consciousness, by the name which has frequently been given it of "metaphysical delirium." The case is really one of a morbid condition that is variable in its manifestations and which deserves, according to the particular forms in which it exhibits itself, all the names that have been given it. One patient, for example, will doubt everything, even his own existence, and will not be able to fix himself to any formal conviction. Another will manifest, besides this psychological state, a real fear of the contact of exterior objects. Another will feel a constant inclination to split hairs into quarters, and to exhaust all the subtilties of the ancient scholastics upon the most frivolous and trite subjects. All of these conditions, apparently so different, are brought together by one characteristic trait of intellectual restlessness.
"The true basis of this mental disease," says M. J. Valient, in his "De la Folie Morale," "is a general disposition of the intellect to return continually upon the same ideas or the same acts, to feel a continuous necessity for repeating the same words or performing the same actions, without ever satisfying itself, or being convinced even by evidence. I have described certain phenomena of this order under the name of intellectual impulsions. I give a curious example of them. A young collegian, who had previously been very regular in his habits, was present at a party where some of his friends were jesting about the fatal influence attributed to the number thirteen. Suddenly an absurd thought occurred to him that, if thirteen was an unlucky number, it would be deplorable if God were thirteen, space thirteen, infinity thirteen, and eternity thirteen; and, to forefend such a woe, he every instant formulated in his mind an ejaculatory prayer thus conceived: 'God thirteen!' or else, 'Infinity thirteen! eternity thirteen!' Yet he was perfectly accountable, for he wrote to me himself that it was absurd to figure God as thirteen for an instant, to prevent his ever being it. But, pursued by this incessantly returning obsession, he kept on repeating his mental prayer at every instant, and ended with not being able to continue his studies, or to devote himself to any serious occupation."
We come now to the history of a patient whose case I have especially in view, who presents to us an example of the delirium in its purest, most elevated, and most metaphysical form, and least complicated with any foreign element. He is a young man of about twenty-eight years, of an agreeable and intellectual appearance and a fine physical development. He is the fifth son of his father, who is still living, and has no other infirmity than a light trembling. No hereditary vice exists in his family, but the patient had convulsions in his infancy, the last of which occurred when he was eight years old; since then he has had no other sickness. The normal soundness of his development is proved by the fact that he is now the support of his family. He is employed in a bank, and his services are much appreciated there. He is very intelligent, but has never received any but a rudimentary education. He has never read Descartes nor the other philosophers, and, when he involuntarily touches upon the most abstruse questions, it may be said that he makes metaphysics without knowing it. He was working diligently and regularly at his desk in the bank, when, one morning in June, 1874, he observed a sudden and curious change occur in the appearance of objects, concerning the nature of which I can not give a clearer idea than by repeating his own description of his impressions:
"In the month of June, 1874," he writes, "I felt quite suddenly, without any pain or giddiness, a change in the aspect of my vision. Everything seemed to me strange and queer, although the same forms and colors were preserved. Under the mistaken thought that the disagreeable sensation would pass away as it had come, I gave myself no more-trouble about it, till a polypus made its appearance in my left nostril. I then went to a doctor and had him remove the polypus, without telling him anything about the new state of my vision. I thought the polypus was the cause of the strange appearance things presented to me, and that, when it was taken away, I would be all right again. But nothing of the kind came to pass. No remarkable change occurred till December, 1880, more than five years afterward, when I felt myself diminishing, and finally to disappear. Nothing was left of me but an empty body. From that time my personality has wholly vanished, and, in spite of all that I can do to get back that self that has escaped, I can not. Everything around me has become more and more strange; and now, not only do I not know what I am, but I can not give any account of what is called existence, reality. What is it that has happened? Does everything around me really exist? What am I? What are all these things that are made like me? Why am I? Who am I? I exist, but outside of real life, and in spite of myself. Nothing, however, has given me death. Why are all these things around me which all present the same aspect? These things should enjoy life. What are these things?
"Although in this cruel condition, I have to do as I did before, and, without knowing why, something that does not appear to reside in the body urges me to continue as formerly; and I can not realize that this is true, that I really act. Everything is mechanical with me, and done unconsciously.
"When I experience a physical sensation, the substance that produces it, which is without any significance to me, is a blank. I feel a pressure on my temples and a stress between my eyes at the top of my nose, with a twitching of the nose to the top of my forehead. My ears hear well, but appear stopped up. My left nostril is sometimes obstructed, then free, then closed. Besides this strange sensation I remark that when any one speaks to me I answer immediately, and the answer is a reasonable one.
"My work has so far been done properly and without any mistake; and yet, when I say to myself, as I am saying continually, ' I am doing this, I am doing that,' I can not bring myself to realize that it is true.
"I may describe my condition in brief by saying that my personality has wholly disappeared; it seems to me that I have been dead for two years, and that the thing that exists does not recall anything that has a relation with any former myself. The manner in which I see things does not give me any realization of what they are, or that they exist, whence the doubt, etc.
"In view of this painful mental condition I come to ask you now whether I am not about to become mad, or whether I can do anything to deliver myself from a disorder which has continued so long, and which has so far only been modified. Without being able to enjoy life in any way, for I do not comprehend it, I am obliged to suffer everything that others, who are in their normal state, suffer."
The dominant fact in the psychological condition of this man is the absolute loss of the sentiment of reality. He compares himself to an empty paper sack. There is nothing in him. Nothing is left of him but an envelope which preserves a kind of external appearance, but which is in fact perfectly empty. He calls himself "a thing." Other men are "things" like him, but he does not believe in their real existence. He does not believe in what he sees, and when he puts out his hand to touch any object he is convinced in advance that he will find nothing but a phantom that will vanish. Although he really touches the object, the tactual added to the visual impression is still not enough to overcome his incredulity. The world, in his eye, is nothing but a gigantic hallucination. He continues, in the mean time, to exercise the different functions of life. He eats, but it is a shadow of food that enters a shadow of a stomach; his pulse is only a shadow of a pulse. He is perfectly conscious of the absurdity of his ideas but can not overcome them. Along with this profound intellectual trouble the physical functions have remained perfectly normal. He complains of nothing but a slight pressure on his temples, and about the root of his nose. Deeply sensible of his moral condition, he is afraid he is going mad, and comes of his own accord to ask for a place in an asylum for the insane.
Facts of this kind have been known for a long time. Examples of them may possibly be found m antiquity, but the first authentic observation of one is given by Esquirol. He tells of a young woman brought up in trade, who was tormented by a scrupulous fear of doing wrong to others. Whenever she drew up an account she was apprehensive of making a mistake to the prejudice of some other one. One day, coming out from her aunt's house which she visited frequently, she was distressed lest she might involuntarily carry off in her pockets something belonging to her relative. Then she began to take much time to verify her accounts and bills, for fear that she might commit some error and do wrong to purchasers. At a later stage she was afraid, when she handled money, that something valuable would remain in her finders. It was of no use to tell her that she could not keep a piece of money without perceiving it, or that the contact of her fingers could not change the value of the money she touched. "That is true," she would reply; "my anxiety is absurd and ridiculous, but I can not help it." She had to withdraw from trade. Gradually her apprehensions grew till they domineered over her whole life. Yet she was reasonable, intelligent, and lively.
The subject has since been studied and examined in all its aspects by Parchappe, Trélat, Baillarger, the two Falrets, Delasiauve, Morel, and Marcé. M. Legrand du Saulle published a monograph on it, embodying the results of the labors of his predecessors, in 1875. My colleague, M. Ritti, has published an interesting study upon it in the "Gazette Hebdomadaire," and a very complete article in the "Dictionnaire Encyclopédique"; and Griesinger and Dr. Oscar Berger have published essays upon it in Germany.
Let us pass to the description of the doubting folly (folie du chute). The beginning of the malady is sometimes obscure, but it is rarely abrupt, as in the case we have noticed. Generally the patient, as in the observation of Esquirol, exhibits odd scruples; he attracts attention by his eccentricities, and becomes incapable of any kind of labor; he is afraid of compromising himself, reads and rereads what he has just written, and takes infinite precautions not to make a mistake. A doctor, afflicted with this folly, having carefully examined the patients who consult him, gave them prescriptions that he had compiled with the greatest care; but no sooner had his patient left the office than he would run out to take the paper away, fearing that he had made a mistake, that he had prescribed a poisonous dose of some medicine, or had given some direction inconsistent with the symptoms.
The doubting folly assumes an infinite number of different forms. Without making an excessive use of subdivisions, we must establish a few categories.
We give the first place, in the order of dignity, to the metaphysicians. They are constantly preoccupied with the insoluble problems of philosophy. They are continually questioning about God, about the universe, about the creation of the world. They will ask themselves, Who created the Creator? They seek for the origin of language. They trouble themselves about the end of things, about the immortality of the soul; or, turning their attention to the physical universe, they endeavor to comprehend the phenomena of nature and the fluids that direct them. Our patient belongs to this category. The great object of his preoccupations is self, personality, the real existence of the objects of which he has a subjective perception. He reproduces without knowing it the ideas and often the expressions of the great philosophers who have cast the lead into these abysses. Next to the metaphysicians, we should place those whom I will call the realists. They are occupied with more or less trivial questions that do not permit any elevation of thought. A Russian prince, mentioned by Griesinger, wanted to know why men were not as large as houses; another patient, why the fire-place that warmed his room was fixed against the wall instead of being in the middle of the room; a third, why there was only one moon instead of two. Once started in this course, the patient attaches himself with a morbid tenacity to the most insignificant subjects, and they become for him the point of departure of an intellectual torture.
Next are the scrupulous, of whom Esquirol's patient offers a finished type. They are always reproaching themselves about everything, are tiresome with the precision of their speech, and are constantly afraid that they have not told the exact truth.
The timorous form a fourth class. They are people who, always afraid they will compromise themselves, are incessantly taking exaggerated precautions, and live in a perpetual disquiet. A woman, who was an artist and very intelligent, could never go into the street without a fear that some one would fall down from a window to her feet. She would ask what the consequences of such an accident would be, and saw herself already arrested and taken to prison under an accusation of homicide.
A fifth class, whose mania is really insupportable, are the counters. They are persons who, wherever they may be, are concerned with the number of objects. In the doctor's office, instead of being occupied with the subject of consultation, they are counting the buttons on the doctor's coat, or the books on his table. M. Legrand du Saulle tells of a patient who would say, "Excuse me, it is involuntary, but I must count." Some celebrated men seem to have a similar mania. Dr. Johnson never omitted to step on every stone of the walk as he passed them; and, if by any chance he thought he had forgotten one, he would go back to touch it. Napoleon was in the habit of counting by pairs the windows as he went along the street. Other forms of this madness escape all classification. I have just seen a patient in whom an acute rheumatism has been followed by a special trouble of the will. If he is going into a house, or out of it, he experiences an invincible resistance at the door-sill, and he has to be urged before he can get over the obstacle. Sometimes, on the public road, he can not pass a tree or a stone. He is also persecuted by certain words, and when one of them gets into his head he repeats it through the whole day.
Some of these patients are described as being affected with an exaggerated fear of the contact of exterior objects. This is true. It has been attested by numerous observers, but the doubting folly can exist without such a complication, and our patient, who has no fear of the kind, is a proof of it. On the other side, the fear of contact may exist without the doubting folly.
A few additional characteristics will complete our view. The doubting folly is a conscious insanity. Persons afflicted with it are perfectly aware of their condition, and able of their own motive to put themselves under medical care. A second important characteristic is that persons afflicted with it seldom labor under hallucinations. When these occur it is the result of some other form of delirium which may be present in addition to this. A third characteristic is the perpetual desire the patients experience of having their doubts quieted by the affirmation of another person. A woman, cited by M. Ritti, was always afraid that she had said or done something reprehensible. If a person who could inspire confidence in her told her nothing of the kind had occurred, she immediately became calm again. A patient, who came to consult me, expressed doubts as soon as she entered my office as to whether I was really a doctor. Upon my answering that I was, she asked permission to inquire of the persons who were waiting in the parlor if I really exercised the medical profession. Sometimes patients of this class, after having solicited reassuring affirmations and having exhausted all the forms of question that imagination could suggest, add the demand, "Will you write it down for me?"
One of the most curious instances of this whim is related by M. Baillarger: A man about sixty years old had a passion, whenever he went to the theatre, for becoming acquainted with everything relating to the actresses he saw. He would want to know their age, their address, their family position, their ways of life, their habits, and their responsibilities. Tormented by this fixed idea, he had to deprive himself of the pleasure of going to the play. Soon, however, the same idea manifested itself relative to all the women he met, provided they were pretty. He was obliged to have a person follow him, whose duty it was to satisfy him on this point. Every time he met a woman he repeated the eternal question, "Is she pretty?" The attendant would answer "No," and that would cut short the otherwise interminable series of his questions. One day he was starting by railroad for a distant point, and in his hurry forgot to begin his observations on the woman who sold the tickets, and also to ask if she was pretty. When he reached his destination, in the middle of the night, he asked his companion if that woman was pretty. The companion, being for once worried, tired, or forgetful, answered that he had not looked at her, and did not know anything about it. This was enough to cast the patient into such a condition of anxiety that he had to start back immediately for Paris to assure himself as to the truth in the matter!
If I have been able to give a general idea of this curious mental disorder, it will be agreed that, amid all its diversities, it is essentially characterized by a kind of cerebral pruriency which nothing can satisfy, and that the repetition of the same acts, the same questions, and the same thoughts, appertains to an organic phenomenon which brings up unceasingly the same impressions. In away we contend with ourselves laboriously, while dreaming, in a situation we can not bring ourselves out of, because the incessant repetition of the same physical impressions reproduces the same series of ideas. We are not finally delivered from this obsession till we wake.
The doubting folly is hard to cure, but considerable periods of remission sometimes occur, during which the patient seems to be restored to his normal condition. Unfortunately, the amelioration is seldom permanent. The brain falls back into its old habits, and the delirium begins over again. Patients who are attacked by it at the period of puberty have a better chance of recovering than others, for the progressive evolution of the organism may bring them relief from this psychologic condition. On the other side, the malady hardly ever ends in insanity. The subjects, when they have reached the last stage of their malady, remain fixed in their delirium. Incompetent for all work, sad and morose, they retire from society and live in voluntary sequestration. The prognostic is therefore extremely grave, for in the great majority of cases the future is definitely lost, whatever remissions of longer or shorter duration may give birth to slightly founded hopes.
The causes of the doubting folly are quite numerous. Heredity must be placed in the first rank; then comes puberty, which impresses a peculiar stamp on the psychoses that are brought under its influence. Sexual and intellectual excesses may also be included among the causes. Women are supposed to be more subject to the aberration than men. The disease is sometimes developed during convalescence from grave sickness. A certain part in producing it is attributed to moral perturbations, to lively emotions, and sudden frights. Frequently, as in the case of the patient who has been referred to so often, the origin of the disease entirely escapes us.
While suitable medical remedies are no doubt proper in their place, the principal part in the treatment should be given to moral remedies. It is, of course, useless to reason with the patient, or to try to show him how baseless his delusion is; but his attention should be engaged and his mind diverted from the set ideas that tyrannize over it, and a wisely arranged intellectual gymnastics should be prescribed. Physical exercise may also be made of service in turning to the profit of the body a little of the exaggerated activity that torments the mind. A final remedy is sequestration in a sanitary institute. It need not be applied to all patients, but may evidently be of use in cases where the surroundings, the habits of life, and the occupations to which the subject has been devoted, seem to have participated to any extent in the explosion of the psychical troubles.